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!

Monday, May 30, 2011

The great divide? "Us vs. them" feelings and infertility

Sometimes when things get ugly, your real feelings reveal themselves.

Such was the case during an argument I had with my husband when I was pregnant. I had my 20 week ultrasound coming up, and I really wanted him to attend the appointment--I was nervous I would find out something was wrong with the baby, and I also wanted him to be part of the experience. He wanted to go too--but his boss at the time had different plans. Although he had blocked the appointment time on his calendar out for a month, his boss was insistent that he go out of town that morning, and only that morning, to soothe the worries of a nervous client. To my husband, attending the meeting didn't seem like a good idea in any case, because he would not be available to work with the client permanently. When my husband explained both his general reservations, and that he had a personal obligation and could not attend the meeting because he had a medical appointment, his boss was not pleased. He repeatedly pressed him to reveal the reason for the appointment. When, under duress, my husband told him about the ultrasound, his boss was quiet for a moment. Then he said, "You know, I have four children, and I never went to any of their ultrasounds. I don't think that's very important. What's the big deal anyway?" He told my husband he needed to go home and think about his priorities.

You can imagine the argument that ensued later that evening. I was shocked that my husband began to question his own decision to go the appointment. "Is it really that important?" he asked. "Are you kidding me?" I responded. "Don't you remember what we've been through all these years? And what it took to get to this point? Half a pregnancy under your belt, and you are already thinking like a breeder!" The word, ugly, fell off my tongue.

Now it was his turn to look shocked. He paused and said angrily, "Don't you ever, ever, call me that again!"

That's when I realized it--"breeder" was now the most vile thing we could say to each other. It was the ultimate throw-down in our relationship. It was clear even though we were not conscious of it, because of my infertility, we both felt like we were in a minority group, separated from the rest of the fertile world.

To me, that's a real problem, because most of the people whom I love have no fertility problems whatsoever. I don't want to feel separate from them. On the other hand, I can't deny the fact that infertility is often painful and unfair, or that many times, people without fertility issues say insensitive and thoughtless things. Or worse, that some people, like my husband's former boss, take their fertility and good fortune for granted.

In my conversations with others with infertility, I know that my husband and I aren't alone in this struggle. Too often, the infertile folks feel left behind, out of sync, and separated from the rest of the world. While they are undergoing treatment and enduring disappointments, the rest of their peers are, seemingly effortlessly, having babies. The situation, by its nature, is divisive, with its "have and have not" undertones.

I have come to realize that one of the great tasks of life, at least from a psychological perspective, is to be able to honor your own unique experiences while simultaneously recognizing the different experiences of others. It takes a lot of emotional energy and maturity, and it is hard to do when we are in pain. However, I feel that even in the throes of infertility treatment, it is vital to try to do so. Although others may never be able to understand us and our experiences, we must still try to understand them. Without this, we risk being permanently cut off from the 92 out of 100 couples who do not struggle with infertility, even if it is in unconscious or subtle ways. This can keep us from fully dealing with our feelings of anger, grief, and loss, and can prevent us from moving forward after our infertility issues have been resolved.

Thus, although it is doubtful that my husband's boss could ever understand my feelings about my ultrasound, I realized I must try to understand his emotions. It seemed that he hadn't considered that there was anything to be nervous about during his wife's pregnancies, and that he was lucky enough that everything went well. That he didn't seem to fully value his own good fortune, and that he would clearly pick a client above his family, struck me as sad. I wondered whether or not, in the long-term, he would feel good about these choices. Seeing him as a person struggling with his own issues, and not just a "breeder", helped me to bridge the divide between myself and the fertile world.

I would love to hear about other experiences with this issue. Do you feel separate somehow from the fertile people in your life? If so, how did you deal with it?

Thanks so much for reading, and as always, if you have any questions, or have any ideas for future blog posts, please let me know!

Thursday, May 26, 2011

Do mind/body programs significantly raise IVF success rates? A new study.

I stumbled across this article the other day, which can be found here, describing a new research study by Alice Domar, Ph.D., et al. It will be published in the next issue of Fertility and Sterility. They authors found participation in a mind/body treatment program during IVF cycles significantly improved success rates (52% in the treatment group vs. 20% in the control group). Mind/body treatment is usually offered once weekly for several weeks in a group setting. It combines cognitive behavior therapy, mindfulness and relaxation therapy techniques, and yoga.

At first, I was excited by this news, as I've been a fan of Dr. Domar's work for some time. I think that she has created a very helpful, cost-effective clinical program to help individuals deal with the stress surrounding infertility treatment. However, I was also curious to see the details of the study, because prior research has not consistently demonstrated that participation in a mind/body treatment program is correlated with an increase in treatment success. Further, it often seems that when study results are reported in the mainstream media, they results are often misunderstood or presented as conclusive facts.

The study, which can be found here, was done with 143 women beginning their first IVF cycle at Boston IVF. The women were randomly split into two groups. In the treatment group, the women were offered 10 weekly mind/body sessions. In the control group, the women received spa gift certificates every three months. The two groups of women were not significantly different except for two variables. The women in the treatment group were more likely to work full-time. Also, the embryos of the women in the control group were much more likely to be fertilized using ICSI. This was probably because the women in the control group had a much higher rate of male factor involvement in their infertility treatment (20 percent versus 8 percent in the mind/body treatment group).

The study followed the women over two IVF cycles. In the first IVF cycle, pregnancy rates were the same--43 percent of the women in the treatment and control groups had confirmed clinical pregnancies. However, in the second IVF cycle, the women in the treatment group had a significantly higher pregnancy rate--52 percent--versus the control group, who had a pregnancy rate of 20 percent.

The authors theorized that the reason there was no significant difference in the pregnancy rates during the first IVF cycle was because most of the women in the treatment group had not actually received the mind/body treatment yet. They had predicted it would take longer for the women to start cycling, and the mind/body program is not continuously offered at all times. They argued that the pregnancy rates were higher for the treatment group in the second IVF cycle because by then, almost all of the women had actually attended at least six to ten treatment sessions.

On the face of it, all of this sound pretty good, right? However, when I started really looking at the numbers, I became less convinced. To me, the first troubling issue with this study is that the treatment and control groups were not really diagnostically similar. In the control group, male factor infertility was a much more prevalent cause. Indeed, when the authors reran the statistical analyses to control for male factor infertility, the difference between the second IVF cycle success rates were no longer statistically significant.

Further, the study had difficulty recruiting, and in some cases retaining, participants. This meant that for the second IVF cycle, in which they found their significant results, there were only 21 women in the treatment group left, and 20 in the control group. With such a small sample size, it is difficult to make generalizations to the general IVF population. As the authors point out in the article, it may be that women who are willing and able to participate in a research study, especially those who can attend weekly treatment sessions, may be different than women, who for whatever reasons, cannot. These differences, not the mind/body treatment itself, may be the cause of their higher pregnancy rates.

Thus, I think it is premature to conclude that mind/body programs can significantly improve pregnancy rates for IVF. Further study in this area clearly needs to be done to provide us with more information.

I realize touches on a controversial issue, because there are so many strong and conflicting opinions about whether stress plays a role in causing infertility. For many, the last thing they want to hear is that their own emotions are causing their infertility woes. In contrast, others would love to believe that if they could just change their feelings or mindset, they could transcend the physical difficulties they may have. To make matters worse, the research in this area is all over the map, with some studies showing that stress or depression impairs fertility, others showing it has no effect, and some showing that moderate stress increases fertility rates.

Regardless of the research on pregnancy rates, I still believe that mind/body programs can be very useful during infertility treatment (and probably during a lot of other life difficulties, too). Anything that helps us deal with stress, reconnect with our bodies, and provides support is beneficial. But I wouldn't go into mind/body treatment expecting it to significantly increase your chances of achieving a pregnancy. The way I see it, it might help some people with certain diagnoses to conceive. However, there are also probably some people for whom decreasing stress levels won't change their physical situation, and their chances for pregnancy would remain the same.

Wednesday, May 11, 2011

Regrets and infertility

One of the most difficult issues that individuals struggling with infertility face is that of regret. Whether it is about treatment decisions, or decisions about when or with whom to start trying to have a family, regret can be very difficult to tolerate.

I think I have always been particularly sensitive to feelings of regret because even as a young child, I was very aware of my maternal grandfather's own regrets about his life. He always regretted not pursuing higher education when he had the chance, and expressed bitterness about his choices. In my own life, I have used these memories as a constant warning. I frequently find myself thinking about how I might view my decisions in the future. Although I feel that this has helped me make some good choices, it has hardly made my life regret-free.

I have come to the conclusion that despite our best efforts, it simply isn't possible to avoid having regrets entirely. The cliche that hindsight is always 20/20 is oft-repeated because it is true. But in addition, I think that no matter how much research we might do, and no matter how much we weigh the pros and cons of things, we sometimes only learn things the hard and painful way. There is little more instructive than a profoundly painful experience; we usually learn the complicated nuances of that situation very thoroughly and quickly.

Of course, infertility treatment usually presents all sorts of complicated situations and decisions. The best course of action is often not obvious. So we must make decisions using the knowledge, abilities, and emotions we have at the time. When they turn out to be decisions we later regret, it is usually because we learned so much dealing with the aftermath of those decisions. We are now functioning with a whole new level of knowledge and expertise. With our new vantage point, we now see the better option. So in a way, without making choices that we later regret, we may be unable to develop the knowledge and judgment we will need to ultimately succeed. Feelings of regret are, in actuality, the "cost of doing business".

For me, I have struggled with regrets that I did not pursue IVF right away when I first learned I had infertility problems. My RE at the time told me that I was subfertile, not infertile (history has proven it otherwise), and thus I continued trying on my own, and then tried less aggressive treatments to no avail, for almost 2 years. Little did I know that each month, my FSH was rising and my ovarian reserve was declining at a rapid pace. However, at the time, I didn't really know to even ask about those problems. Once I figured out what was going on, however, I was able to change my attitudes about treatment, and eventually achieved success. Now, of course, in my work with my clients, this is an issue I investigate right away--because I learned about it the hard way, it is almost a reflexive response.

Thus, I think problems with regret arise only when the regretful feelings cause a person to become unable to move forward in their lives. Perhaps they now have a crisis in confidence, and feel unable to trust their decisions. Or as my grandfather did,perhaps they blame themselves for circumstances that were out of their control. In truth, my grandfather could not have pursued college when he was young because my grandmother became seriously and chronically ill, and he needed to make as much money as he could to pay her medical bills.

If you find yourself struggling with feelings of regret about decisions in your infertility treatment or family-building choices, it is important to keep in mind that regret is unavoidable. However, being stuck or paralyzed due to these feelings is something we can change. Forgiving yourself for not knowing then what you know now is an important part of this process.

Thursday, May 5, 2011

Unexpected help, unlikely alliances, and other surprises along the journey of infertility

For me at least, experiencing infertility has been a life changing experience. Perhaps most profoundly, due to my infertility, I found myself traveling down paths in life I would have never predicted. In so doing, I met some amazing people, and developed a greater understanding of myself and the world as a whole.

When experiencing infertility, it is very easy to get stuck in all the negative feelings surrounding it, simply because they hurt so much! It's also easy to focus on all the hurtful things others say and do in regard our infertility. In the shuffle, sometimes the positive, helpful, and supportive things that people do for us can get short shrift.

As a psychologist, who spends her work days helping people deal with their painful feelings and experiences, I am probably more vulnerable to focusing on the negative than most. However, during the last couple of weeks I have been poignantly reminded, due the sudden illness and death of a dear relative, of how profoundly I was helped during my own journey to motherhood.

As you may have read in my other blog posts, we adopted our oldest daughter from India when she was an infant. Our adoption process went unexpectedly quickly, and we took her into custody very soon after we had finished infertility treatment. In fact, while I was in India with her, I was still coming off all the hormones I had taken in preparation for my last-ditch (and failed) FET. Although I was thrilled to be adopting my daughter, I think it is safe to say that I was still in the process of understanding and working through my infertility experience.

Due to the legal process in India, we were able to take her into custody right away, but could not leave the country until our case was processed. Thus, we decided that I would stay in India with her for the 3-4 months it took for the court case to be completed. My daughter and I stayed with my husband's aunt and uncle, whom I had never met.

As you may imagine, I was completely overwhelmed by this experience. Getting a new baby, new family members, and a new culture at the same time was a lot to comprehend. My husband's aunt was insistent that we not hire a nanny, as is common in India, to help look after the baby, in order that the baby and I bond. I still feel this was the right decision, but being alone with sick infant, I got sleep-deprived, and thus quite emotional, very quickly. My husband's aunt had never had children of her own, so sometimes her expectations of the baby and me were a bit unreasonable. Her husband seemed a little disinterested in the situation, or perhaps a bit unsure of what to do with this fussy baby and crazy American who had suddenly taken up residence in his apartment. One day he had promised to take me to a department store after he came home in the evening so I could buy some things for the baby. I hadn't left the apartment in days because I was intimidated by the streets of Mumbai, and I didn't know where to go, so naturally I was really looking forward to this outing. When he came home, however, he said he was tired and that we would go some other time. I got very upset--and I am ashamed to say I threw a bit of a tantrum, complete with tears and door slamming. To my surprise, he came into my room a few minutes later, and asked why I wasn't dressed to go out. I received no reprisals for my behavior, just a smile.

As we walked through the streets of Mumbai, we came to an extremely busy road that we had to cross, with no crosswalk or stoplights in sight. I stood at the edge of the road transfixed with fear--how would I ever cross it? To my surprise, my husband's uncle calmly stepped into the middle of traffic, staring at the drivers with his arm outstretched--and the cars quickly stopped. Having lived in Mumbai for so many years, I am sure for him this was old hat, but to me, it was magic. Had I been by myself, I think I would still be standing there, eight years later, trying to figure out how to get to the other side. With his help, however, we crossed the road with ease.

Sometimes I think it's just as simple as that--in dealing with infertility, we all get stuck by the side of roads we don't know how to cross. And by having help from just one person, just for one moment, to show us how to do it, and to support us, we can learn how to keep going towards our goal, even if it scares us silly.

After that day, my husband's uncle became my biggest helper and ally. Whenever I needed to go somewhere unfamiliar, or to a doctor for my daughter, he went with me. If there was any sort of ruffled feathers between my husband's aunt and myself, he quietly smoothed them. And at 7 pm, when my daughter routinely started screaming for 2 hours straight, he would come and take her out the porch swing, sit with her on his lap, and sing her songs to give me a break. Of course, I tried to thank him all the time for everything he did for us, but he would have none of it. "You Americans are always saying thank you all of the time! In India, we do not say thank you to our family members, because we are just all doing our duty. Please no more thank you's!"

My husband's uncle died today after a short but intense bout with cancer, and I must say that although I am no longer allowed to thank him, I shall remain grateful to him for the rest of my life. If I hadn't experienced infertility, so severe that it pushed me onto a plane and into a far away new land, I never would have gotten to know him, or appreciate his kindness, much less get across that Mumbai street.

And that's the thing about infertility. While you are in the midst of it, it feels horrible, and often all-encompassing. It feels as if nothing good will ever come out of it. But in retrospect, I can see that it pushed me out of my comfort zone, and into a whole different life, with a higher level of appreciation for the people in my life. I am not one of those people who believes everything happens for a reason, because there are too many awful things that happen for which I can find no justification. I do believe, though, that we must make the best of the circumstances in which we find ourselves, and in so doing, we can learn and grow a great deal.

In your own infertility journey, I suggest that you also be on the lookout for support from sources you might not anticipate--chances are, at some point it will be there for you. Although it won't take away from the pain of infertility, it can soften the blow, and sometimes teach you new ways to approach problems.