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, April 28, 2011

Does infertility treatment have to take over your life?

It's National Infertility Awareness Week, which is a great thing. Despite much progress, there is still work to be done to help the general public understand that infertility is a medical illness and deserves to be treated as such. Like other illnesses, it should be covered by health insurance. In addition, raising public awareness that infertility is not a result of one's feelings ("Just relax!) or one's choices ("Maybe you should have started sooner!") would be extremely helpful to those experiencing infertility now or in the future.

Still, I can't help but be struck with the irony that although the general public needs increased awareness of infertility issues, those personally struggling with it are usually all too aware of their infertility. Indeed, one of the hardest things about infertility is that it can completely take over your life--psychologically, cognitively, and practically. In this post, I'll discuss some of the psychological implications that arise when infertility is the major focus of your life, and offer some strategies about how to cope with this vexing problem.

During my first IVF cycle, I was overwhelmed by the incessant nature of treatment. Not only was I worried and anxious all the time, but the sheer physical tasks of giving myself several shots a day, and of getting to all my early morning appointments to a clinic an hour away, exhausted me. It was very difficult to fit in, much less concentrate on, that pesky job I had at the time. I don't think I spoke to my husband or friends of much else other than infertility, IVF, and how much Chicago traffic can suck (trust me--a lot). I remember joking that I had turned into an "infertilibot" and was no longer an actual person. Unfortunately, I don't think my experience was in any way unique. Almost all of the clients I have worked with have felt similarly during their cycles, especially the during first one--because everything is new, it take more mental energy to understand and process the experience.

Many times, clients have asked me how to prevent their infertility treatment from taking over their life. My stock answer is invariably disappointing, because to be honest, I think that to some extent, infertility treatment taking over your life is inevitable. Having it as your nearly sole focus is the "cost of doing business" in this situation. No matter how you look at it, the treatment it complicated, and it requires a great deal of careful attention to make sure you are giving yourself all the correct medications at the correct times. Further, it takes time and effort to follow all of your bloodwork and ultrasound results so that you can understand the treatment decisions that are made. In addition to being complicated, infertility treatment takes up a lot of time. There are frequent injections, appointments, and phone calls. So even without any emotions thrown in the mix, you have all the makings of a difficult and stressful time.

Of course, it's very rare to not have a lot of feelings about infertility treatment--so you have the added task of managing your emotions. To make it more difficult, these emotions are usually involve sensitive issues such as self-esteem, social comparison, and feelings about your body. With no extra shots or appointments, managing your emotions about these issues would be more than enough for one person--but in infertility treatment, you must manage both the practical and emotional considerations.

Although I paint a rather dire picture of the infertility "lifestyle", there are a few things you can do to make things a bit easier on yourself. By having realistic expectations, working to prevent your self-esteem from being damaged, and using distraction, you can make this situation more comfortable.

Have realistic expectations

Given the requirements of infertility treatment, in order to do it well, it must be a large focus of your energy. That's why I think it is important to be realistic about what you can expect from yourself during treatment. It's unfair to expect yourself to sail through IVF without stress, fatigue, and the occasional meltdown. Many times, I have seen clients beoome quite upset with themselves during a cycle because they can't perform to their normal level of excellence at work or at home. This only makes an already difficult situation worse. Recognizing that you can only
do so much takes the pressure off of you. I often tell clients that their infertility treatment, because of the importance of having children in their lives, has to be their central focus. All other activities are lower down on the priority level. That doesn't mean that you should stop showing up for work, or that you should let the dishes pile up for weeks, but it does mean that you may need to just do the bare minimum to get by for a short period--knowing you will catch up when it's over.

Protect your self-esteem

Infertility treatment can be very hard on self-esteem, as I've discussed at length in a few other blog posts. That's why I believe it's important, especially during an active treatment cycle, to have the following mantra: "It's a medical illness, and not a commentary on me as a person or future parent." I found myself needing to repeat this to myself over and over during my many treatment adventures. For instance, if you get a disappointing result, it can start to feel like you've "failed", even though you followed all the instructions, went to all the appointments, and did everything you could to ensure success. Keeping in mind that infertility treatment, at it's core, involves medical issues that we often can't control, can be comforting in these situations.

Distraction is your friend

Sometimes, the only way to get your mind off of infertility during treatment is to provide yourself with frequent mental "mini-vacations", whether they take the form of going to the movies, reading books, or fun activities with your partner or friends. It's important to remember that because you are preoccupied, it will be more difficult to distract yourself than normal. That's why you need really, really good distractions--things that are special treats, and things that you absolutely love. Although such distractions can be short-lived (because you have to do that next round of shots at 8 pm, for example) they can be emotionally replenishing. Additionally, they give you something to look forward to, and help pass the time until the cycle is over.

Although being in infertility treatment is difficult and can be all-consuming, if you must continue in treatment, it does get easier. As someone who has actually lost count of the number of IVF transfers I've done--is it 8 or is it 9?--I can say with confidence that the coping skills you develop during the first cycles definitely help you out in later ones. As long as you set realistic expectations for yourself and your cycle, you will survive it. Infertility treatment doesn't last forever, and before long, you will be able to focus on other things.

Thursday, April 21, 2011

Are some types of infertility evolutionarily advantageous?

I read a really fascinating article in the most recent issue of Fertility and Sterility, which can be found here. The article, by Azziz, Dumesic, and Goodarzi, discusses the ancient existence of polycystic ovarian syndrome. The authors investigated how a disorder, which causes subfertility or infertility, could still persist at a relatively high level in modern times--theoretically, wouldn't it have been "bred out" of the species? It appears that increasing rates of obesity in Western cultures has not caused an increase in the rates of PCOS, so it is unlikely that change in diet has increased the prevalence of PCOS in moden times. The authors offered an intriguing explanation--that for much of human history, having PCOS has actually been advantageously adaptive, meaning that women with PCOS were more likely to survive and pass on their genetic material to the next generation.

It seems likely that PCOS actually had several adaptive advantages. In hunter-gatherer societies, food was often scarce. Women with PCOS, because of their insulin resistance, use food resources more efficiently. Their capacity to store food energy is greater, and they expend fewer calories, making them better able to survive times of starvation.

Further, because PCOS frequently causes subfertility rather than total infertility, women with PCOS had fewer children spaced farther apart in time. This was advantageous in a number of ways. With no or limited birth control, women often spent much of their life pregnant or giving birth. Even in the recent past, childbirth was extremely dangerous for women and was the top cause of female death. Thus, limiting the number of childbirths increased a women's likelihood of survival. In addition, by having fewer children, women with PCOS were more able to secure their children's survival--they more easily garner sufficient resources for them. Furthermore, children were more likely to survive if they were being raised by their biological mother, so the fact that women with PCOS had longer lifespans further enhanced their children's survival rates. In sum, it seems that for most of human history, having PCOS was actually a blessing, not a curse.

I think that looking at PCOS from the evolutionary perspective in this article has some valuable psychological implications. Most importantly, I think it is useful for anyone who is currently struggling with PCOS to realize that the disorder actually has some very important adaptive advantages. This will help them have more positive and less conflicted feelings about their bodies. Too often in infertility treatment, we end up feeling as if our bodies are vexing or failing us. Realizing that our bodies are actually trying to help us, although admittedly in a frustrating way, can be a reparative experience.

Looking at PCOS from an evolutionary perspective also made me wonder if there are other infertility diagnoses that have some of the same survival advantages. For example, could premature ovarian failure similarly enhance a woman's, and her offspring, chances of survival? When dealing with infertility, it is very easy to forget that for many men and women, both throughout history and in the present-day world, fertility has actually made their lives incredibly difficult. Perhaps the grass isn't always greener on the other side of the fence after all.

Monday, April 11, 2011

Does age matter? Psychological implications for women of the age of onset of infertility

Infertility is a label that encompasses a vast diversity of medical diagnoses and life circumstances. Although 1 in 8 couples will struggle with infertility at some point during their lives, their individual experiences can be quite different. One such difference is the age of onset or diagnosis of infertility, as infertility can occur at any point during a woman's reproductive years. In this post, I'll discuss some of the different emotions infertility can produce depending on the age of the woman involved. Although age also plays a role in how men experience their infertility, it seems to be less powerful factor than for women, for whom age and fertility potential are closely linked. Thus, I'll mainly be focusing on this issue from the female perspective.

Psychological implications for being diagnosed while "young"

Although everyone's experience is different, it seems that for the "under 35" set, certain emotional themes are more likely to come up when infertility occurs. The main one I see in my practice is a feeling of shock, especially at the beginning of diagnosis and treatment. In the majority of cases, women who have always enjoyed good health and normal gynecological functioning assume that they will be able to have children without help as long as they don't "wait too long" and start trying in their 20's or early 30's. It is thus often difficult to accept that there is a problem.

Once the knowledge that there is a problem sinks in, it is often accompanied by feelings of failure and low self-esteem. I have heard so many wonderful, successful women tell me that because they are having difficulty conceiving a child, they feel inferior to their peers. They worry that they have done something wrong, often on a karmic level, to cause their infertility. They tend to feel angry at and betrayed by their bodies--why aren't they working in the manner nature intended? Further, these negative self-feelings come at a time when their friends, relatives, and peers are busy building their own families, seemingly without effort. Thus, women in the "under 35" age bracket tend to feel left behind from a developmental perspective, and can often experience social isolation. To make matters worse, because they are in the typical family-building time of life, they are often subject to intrusive questions on the parts of others about when they are going to have children. Additionally, they may be the unhappy recipients of uniformed but perhaps well-meaning lectures about how they shouldn't "wait too long to have a baby or (insert bad outcome here)".

Psychological implications of being diagnosed with infertility when a little "less young"

Women in their late 30's and 40's often have a somewhat different experience of being diagnosed with infertility. For them, the shock of an infertility diagnosis often seems to be less intense. It is fairly common knowledge that fertility potential decreases with age--thus, women diagnosed a little later in life often aren't totally blown out of the water that they must contend with this issue. Instead, they often deal with intense feelings of self-blame and recrimination. "If only I'd started trying when I was younger!" is a refrain I have heard many times, even though for these particular women, starting a family at an earlier point in life was often a difficult or impossible choice for them. In addition, women dealing with infertility in their late 30's or 40's must also endure comments from others that that they waited "too long". These women may also feel developmentally out of sync with other women their age, who now have children or have decided to live child-free.

As an aside, it seems that when a woman is in the "less young" age bracket, it is often assumed that she could have had children earlier if she had chosen to, and thus the cause of her problem is more volitional in nature. However, I suspect that many women may have had preexisting infertility conditions all along, but may have simply been unaware of it. I myself was diagnosed with infertility at age 30; but if my life circumstances had been such that I hadn't started trying until now, in my early forties, I would have no way of knowing that at least for over a decade, I was infertile. As I have a talent for self-recrimination, and seem to take it up at every available opportunity, I am sure I would be focusing on how I made the "wrong choices" right this very minute. But in reality, it would be entirely inaccurate.

No matter what your age when your infertility is recognized, it is important to be aware that the timing of your diagnosis may affect how you experience your infertility. In particular, be try to be alert for feelings of low self-esteem, isolation, and self-blame and recrimination. By better understanding those feelings from a developmental perspective, it will be easier to acknowledge what I consider to be the timeless truth of infertility--that it probably isn't anyone's "fault".