This blog addresses various emotional aspects of experiencing infertility. It is written by a clinical psychologist who specializes in infertility counseling. Thank you for reading, and best of luck with your journey!

Thursday, February 24, 2011

The role of anxiety in infertility treatment

Anxiety is an unavoidable part of infertility treatment, and it is probably one of the main reasons that the process often is so traumatizing. After all, there are so many opportunities for worry during every treatment cycle, from successfully being cleared to begin treatment, response during treatment, embryo fertilization and survival, and of course, the outcome of the pregnancy test. Many of these things are out of our realm of control, and worrying about how it will all turn out is sometimes all we have left to "do". In addition, treatment cycles usually stretch out over a month or more, with long periods of time in which we must simply wait to get more information. Thus, much of the time, we look at the anxiety we experience during infertility treatment as something we must manage and work around, rather than something to which we need to directly respond.

However, there are times when anxiety can play a positive role in infertility treatment. Anxiety can function as an important signal that there is something in the situation that is not safe or good for us. In such cases, if we don't respond to our anxiety, we can be missing opportunities to improve our situation.

From an evolutionary perspective, anxiety functions as a protective mechanism. Because we must take in a large amount of information from our environment quickly, we often respond to threats on an emotional, rather than a cognitive basis. As soon as a threat is perceived, our emotional response of anxiety and fear, such as "Oh no! Hungry tiger over there!" quickly helps our bodies respond to the situation, providing the energy to do what must be done to ensure our survival (in this case, running away).

Although most of us no longer spend lots of time in the jungle keeping our eyes out for tigers, the protective mechanism remains the same. Thus, if during the course of your infertility treatment, you suddenly find yourself experiencing intense anxiety, I think it is important to take some time to figure out why. Did something just happen with your treatment that you found concerning, even if your doctor or nurse didn't? If so, it may be important to investigate this further--it has been my experience that even the best of medical professionals can occasionally miss a detail that might turn out to be very important in the case. For example, a friend of mine became anxious during her IVF cycle when she noticed that the time of retrieval, her lining was only 5.5 mm. She raised this issue with her RE, but he wasn't concerned about her lining and did the transfer anyway, which resulted in a chemical pregnancy. Her anxiety about her lining persisted, and she decided to get a second opinion. During that consultation, the new RE agreed with her concerns about her lining. As she pursued treatment with him, it turned out that she indeed had huge lining problems--causing her cycle to be canceled twice until they finally figured out the winning combination of medications to get her lining to the proper thickness. However, once her lining was good, she was able to get pregnant and carry her baby to term.

I think another important type of anxiety that often goes overlooked is rooted in the physical, body sensations that women often have during infertility treatment. Although I think most doctors don't put much stock in these perceptions, I have found that women who are infertility treatment tend to be so aware of their bodies they can often tell that something is awry before it appears in lab results or on a medical exam. For instance, they may be able to discern that their bodies aren't responding to medication in the desired way. Also, on several occasions I have observed that women have been able to sense when an early pregnancy isn't going well, even before their HCG levels start dropping. If you are in treatment and you have anxiety due to the persistent sense that your body is just not feeling right, I would encourage you to report that to your doctor and investigate it further if need be.

In sum, although anxiety during infertility treatment is usually never pleasant, it can sometimes provide us with useful information. Learning to discern whether or not an anxiety signal is a response to a potentially threatening situation, or whether it is in response to merely feeling out of control, is an important aspect of managing--and surviving--infertility treatment.

Thursday, February 17, 2011

Disclosure and secrets in infertility treatment: or how I became a sneaky liar

Some weeks ago, a few readers asked me to discuss the topic of disclosure in infertility treatment. This is an extremely important topic, and yet I have found myself procrastinating in terms of writing about it. I think this is because I myself have struggled with the decision of how much, and to whom, to reveal about my infertility treatments and decisions. With both disclosure and secrecy, problems arise, making a clear-cut choice between the two options difficult at best.

As I have written about previously here, I was actively involved infertility treatment for several years before we adopted our older daughter, and then again a few years later.

When I was first diagnosed with infertility, I was fairly open with my friends and coworkers about my situation. The decision to do so was concordant with my personality and outlook on life in general—I have always lived my life as an “open book”. At first, it was great, as I could talk about my infertility whenever I wanted to, and I had lots of support from the people around me. However, as things began to drag on, and treatment cycle after treatment cycle failed, I started to regret my decision to be open. It felt like it was my responsibility to inform the many interested parties that my cycle had failed—again. Each time it happened, I dreaded this process of going down the list and making those calls (no Twitter back in those days!) more and more. After my first miscarriage, these calls were downright excruciating. Further, as my friends and coworkers were predominantly women in their late twenties and early thirties, they were all starting to get pregnant. Consequently, many worries and discussions about how to tell “poor Lisa” the news ensued. Sometimes I would hear about their pregnancies through the grapevine, sometimes I would guess, and sometimes I would be told directly--occasionally with kindness and finesse, but often not. As you would probably expect, after a certain point, I had difficulty coping with this situation, and I withdrew from many people who were otherwise lovely friends and acquaintances.

Years later, when after adopting, I decided to return to infertility treatment, I knew I had to do things differently. So this time, I decided to consciously limit the number of people I told about my plans to two close friends, and my parents, and my brother and his wife. If I didn’t absolutely need the emotional support and/or instrumental help of the person involved, I didn’t tell them. I thought that this would protect me from having to provide disappointing news again. In addition, I wouldn’t have to hear others' opinions, informed or not, about my treatment decisions. As I already had an adopted daughter, no one suspected that I would be crazy enough to try infertility treatment again—so I didn’t get many questions, either.

I was surprised to find that not disclosing what was going on with me was more difficult than I had anticipated. To prepare for my treatment, I had to do a two-month course of Lupron Depot, which threw my body into sudden and severe menopause. I was sweating, forgetful, and miserable, but I couldn’t really tell anyone that—so I had to make creative excuses about why I kept turning red all the time. On occasion, I found myself telling lies about where I had been, or why I couldn’t do certain activities. But perhaps more significantly, I found that if I wasn’t able to talk about what was really going on with me, I basically felt I had nothing to say to people about myself. I didn’t feel good about lying to people, and I didn’t trust myself not to slip some detail into the conversation that would only make sense if you knew the whole story. I felt tongue-tied and I’m sure others noticed my awkwardness. Thus, I became somewhat withdrawn again, from an equally lovely group of friends and acquaintances.

This reticence continued into my pregnancy, when well into the second trimester I found it difficult to disclose that I finally was pregnant. When my precocious young daughter figured out what was going on, she had no such qualms though, and her first step was to share the news at her preschool’s Show and Tell day—and thus I was “outed”. Of course it didn’t help that no one believed that it was possible, so both my daughter and I were met with shock and incredulity at these disclosures. One colleague of mine heard that I was pregnant through a mutual client, and refused to believe him, instead calling me in a panic because he was concerned that our client had suddenly become psychotic.

My withdrawal and reticence began to have a negative impact on my relationships. Several people were hurt that I hadn’t told them what I was going through, or informed them sooner about my pregnancy. I am fortunate that after I explained to them what had happened to me regarding disclosure in my first years of infertility treatment, they all forgave me. To be honest though, one of those friendships really never did recover, and I still feel sad about this.

In sum, I am not sure which was the best approach—telling, or not telling. I don’t think there is a “right answer” when it comes to disclosure. Rather, I think you have to pick your poison—is it more important to you to feel like you can be honest with those in your lives? Or does it feel more important to protect yourself from the reactions and emotions of others regarding your infertility treatment? If you don’t tell people what is going on, will you have other ways of getting the emotional support you need to survive the stress of infertility treatment? If you do, and they don’t handle this information well, will your relationships be able to weather the storm?

As you can see, I’m afraid I have more questions than answers when it comes to the issue of disclosure in infertility treatment. I’d love to hear your thoughts and experiences, and as always, if you have any questions or suggestions, please let me know. Thank you for reading!

Thursday, February 10, 2011

To "POAS" or not to "POAS": psychological implications of home pregnancy tests in infertility treatment

As every person whose ever done an infertility treatment cycle knows, the two weeks spent waiting to see if it worked or not are often excruciating. For the woman involved, the constant self-monitoring of her physical sensations can be overwhelming. Was that a cramp? If so, was it a "good cramp" or a "bad one"? Are my breasts hurting? Do they hurt more than yesterday? And what about that toe-itching? Does that mean anything? Add into the mix the fact that infertility medications usually taken during the two week wait, like progesterone, have their own slew of pregnancy-mimicking side effects, and that early pregnancy symptoms are themselves notoriously fickle, coming and going with no rhyme or reason--and you've got all the makings of a very stressful time.

Enter the home pregnancy test--loved by some, hated by others, and feared by most. Some women swear by them, saying that they give them the soonest possible information--good or bad. To these women, tolerating the anxiety of not knowing is so difficult that testing seems like the best option. Others regard them as "evil"--whom among us has not seen them referred to as the "evil pee stick" online? These women argue that "POASing' (peeing on a stick) can drive you crazy--test too early, and you've convinced yourself that you aren't pregnant when perhaps you are. If you test at the right time and get a negative result, it might be inaccurate. Regardless, even with a negative, you will still be hoping it is wrong, and then will be just as crushed when the clinic calls to say that your pregnancy test was negative. And regardless of what you feel about the idea of taking HPT's during a treatment cycle, we all share the experience that the few minutes it takes for the test results to appear are some of the longest-seeming minutes of our lives!

From a psychological perspective, is taking home pregnancy tests a good idea or a bad one during infertility treatment? To me, there isn't one right answer to that question. Rather, I think it depends on what I like to call your "defensive style"--the usual methods you use to cope with stress and anxiety.

When POASING may be helpful

If you tend to deal with stress by thinking about the stressful situation frequently, you are probably a person who, for better or worse, tends to experience your anxiety consciously. You may repeatedly go over the situation in your mind, trying to come up with a solution--even when there really isn't one sometimes. You may tend towards impatience, and dislike surprises or the feeling of being taken off guard. In this case, I think that you may find using home pregnancy tests (with a few caveats, listed below) will be helpful in managing your emotions during the two-week wait.

When POASING might not be for you

If you tend to deal with stress by focusing on things other than the stressful situation, and if you find thinking about or talking about them to be difficult, you may want to avoid home pregnancy tests. For you, they might just stir things up too much,causing you to feel unnecessarily traumatized. You may be better off dealing with the results, whatever they are, just once, when you hear them from the doctor's office.

If you are going to POAS--POAS "smart!"

If you find that you are the type of person who may want/need to use home pregnancy tests, I offer the following advice to minimize the chances of getting inaccurate information and the level of emotional turmoil involved. My first suggestion is that before you go to the drugstore or start running to the bathroom, you need to decide, in advance, what your POAS strategy will be for this cycle. What is more comfortable for you--testing as early as is feasible to get information as soon as possible, or waiting to make sure you don't get a false positive or negative? Figure this out, make a plan, and stick to it. Decide what day you might start testing, and how you will proceed depending on the type of results you get. Some women feel most comfortable waiting until the morning of their beta to test--others may prefer to start as soon as possible.

You also must promise yourself that no matter what the results are, you will not stop your medications, or stop following your doctor's orders, until your official test results come back--no matter how hopeless you feel the situation may be. Even if there is only a slim possibility that a home pregnancy test may be wrong, it still exists--and you don't want to have to live with lingering regrets about such a decision later in life.

If you are in the "start as soon as possible" camp, then keep in mind that if you took an HCG trigger shot, it can give you a false positive as the HCG remains in your system for several days until it washes out. So you probably need to wait at least 10-12 days from when you took your trigger shot to start testing. (Although, as a client of mine pointed out, you could POAS every day after the trigger shot, and wait for it to turn negative, and then if it starts turning positive again, you know you might be pregnant. While scientifically interesting, this method is definitely not for the feint of heart!)

Regardless of when or how often you decide to test, you should use a consistent method of urine collection and test administration in order to assure the most accuracy in the results. Take the test at the same time every day--most people find their first morning urine to have the highest concentration of HCG. If your urine isn't very concentrated, you may have to "hold it" for a while and test several hours later in order to get accurate results. Some women find peeing in a cup, and then holding the test stick in the cup for the number of seconds designated in the test instructions, to be more accurate.

Also, please be aware that different brands of pregnancy tests have different levels of sensitivity. If you are wanting an early result, you will probably need to buy one of the more sensitive tests. A list of tests and their HCG sensitivity levels can be found at several sites on the internet, including here.

Regardless of whatever strategy you choose, please keep in mind that a pregnancy test is just one piece of data from one point in time, and it may or may not tell the whole story. Like anything else in life, there are emotional risks involved in using them--but if you keep to your strategy, stay on your medications no matter what, you will hopefully find that there will be no lasting damage to your psyche.

Thursday, February 3, 2011

An inspiration for the hard times during infertility treatment: Ernest Shackelton, Antartic explorer

During the dark days of my own infertility treatment, I came across a biography of the life of Ernest Shackelton, an early 20th century British explorer who attempted to cross the South Pole, but failed to due so, due to a series of bad luck and unforeseen events. Although he was forced to abandon his original goal, he performed another even more spectacular feat--despite the most extreme circumstances, he was able to ultimately lead his men to safety, without the loss of a single life.

In the story of his journey, I found numerous parallels between his experiences and those of individuals forced to take the journey of infertility treatment to try to create their family.

For those of you unfamiliar with the story, I am quoting a summary from an article by Charles Chappell (2001; link to full article can be found here):

"On December 5, 1914, Sir Ernest H. Shackleton and 27 men under his command sailed from South Georgia Island in the South Atlantic aboard the boat Endurance. Their goal was to land on the Antarctic continent and become the first to cross it. The North Pole had been reached in 1909; the South Pole, in 1911. Shackleton, a veteran of Antarctic exploration who had been knighted for his earlier expeditions, felt that crossing Antarctica was “the last great Polar journey that can be made.” He named his endeavor the Imperial Trans-Antarctic Expedition.
Shackleton and his men failed utterly at the expedition’s stated goal; they never even set foot on Antarctica. Yet the courage and determination they displayed have become legendary.
In January 1915, before they could reach the Antarctic coast, their ship became trapped in the pack ice of the Weddell Sea. For nine months, they and their ship drifted helplessly with the ice. Then, in October 1915, currents and wind drove massive plates of ice in on the Endurance,crushing it. Members of the expedition were forced onto the ice floes surrounding the ship.
They salvaged three lifeboats and whatever equipment and provisions they could extract from the tangled wreckage of the ship before it sank.
The ice became their home for the next six months. Attempts to move their provisions and gear dozens of miles over the ice to land were frustrated by gaps between floes and impassible ridges of ice blocks pushed up against each other by currents and winds. As their food supplies dwindled, they were forced to hunt whatever penguins and other sea life they could find. Although the men initially hoped that the drifting of the ice would carry them toward land, in time it became clear that they were drifting northward toward the open ocean. In late March,1916, cracks began splitting the floe into ever-smaller pieces. On April 9, they were forced to take to their boats in an attempt to reach one of a few small islands off the Antarctic coast. For seven sleepless days and nights, they battled the sea ice and the ferocious weather of the Southern Ocean, finally landing on remote, uninhabited Elephant Island.
Shackleton and five others left that island eight days later in the most seaworthy of the boats, the James Caird, to get help at South Georgia Island, a staggering 650 miles away.
Battling towering waves and weather that made navigational sightings almost impossible, they reached South Georgia 16 days later, only to come ashore on the uninhabited side of the island, opposite from the whaling stations they sought, and with the Caird’s rudder gone.
With no choice but to travel on foot, Shackleton and two of the other men set out to cross the mountainous, glaciated, and uncharted interior of the island. On May 20, 1916, they walked into the whaling station at Stromness Bay. Although the three men on the other side of the island were rescued the next day with help from the whalers, it would be four months and three attempts before a Shackleton-led rescue party succeeded in making its way through the sea ice to reach the remainder of the men at Elephant Island on August 30, 1916. Amazingly, after almost two years of danger and privation, not one of the expedition’s 28 members had been lost."

As you can see, Shackelton and his men did not have it easy! Numerous times, they were forced to change their goals; to endure extreme physical discomfort and deprivation; and to traverse unmapped territory; and to depend on strategies that had at best limited chances of success. Although the conditions Shackelton and his men faced were undoubtedly more extreme, many people undergoing infertility treatment deal with similar challenges. Sometimes, we must abandon our goals and hopes of having children the easy way without medical assistance, or having genetically related children. Also, infertility treatment involves its own physical discomforts and deprivations, and the outcome is never guaranteed.

To me, though, the most salient lesson of Shackleton's experience is that even though he did not achieve his original goal, he did the best he could with the set of circumstances (and they were really lousy circumstances) he was given. He used every bit of his physical, intellectual, and psychological abilities to survive, and to make sure everyone else on the expedition did too. He took great risks, made profound sacrifices, and his accomplishment, the survival of his entire team, still seems nearly impossible. For this, he is rightly considered a great man and a hero.

Although infertility treatment is necessarily more private than a polar expedition, I see similar heroes in my clinical practice with great regularity. And like Shackelton, who unfortunately did not view himself as a success (and in fact died of a heart attack during the launch of his "comeback" expedition), too often my clients do not themselves recognize the magnitude of what they have done. Despite the outcome of their treatments, they have also used all of the intellectual, physical, and psychological resources to give themselves the best chance of success. They have come up with innovative solutions to the difficult circumstances in which they find themselves. They have demonstrated profound endurance, and have tolerated physical and emotional conditions that are inhospitable to say the least. And so in my book, they are heroes too--no matter how things work out.

I think it's important to try to recognize all the different ways you yourself have been brave and heroic in your own infertility journey. This can be particularly helpful during the discouraging and dark moments, and can give you the strength to move forward. And I suppose it's always comforting to remember that at least one other person, Ernest Schackelton, didn't always have smooth sailing either.