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!

Friday, December 14, 2012

Infertility treatment, and being social pioneers

Recently, I had occasion to listen to the famous semi-autobiographical book Little House on the Prairie by Laura Ingalls Wilder.  I hadn't read the book in over thirty years, and it was interesting to come back to it again from the perspective of an adult.  As a child, I took in the Ingalls' adventures and travails as they settled in Kansas at face value.  As an adult, I couldn't help being a bit shocked by all the chances that "Pa" took with the lives and the fortunes of his family.  Luckily, most things turned out alright in the end, but there were certainly many instances in which disaster was a likely possibility.  As I listened to the book, one thing became clear to me:  I would have made a lousy pioneer, because I am naturally risk-adverse, and I don't feel lucky.

And yet, it also occurred to me that because of my medical condition of infertility, I became a social pioneer without really thinking about it.  By creating a family through international adoption and IVF, my husband and I essentially got the covered wagon ready and started heading west.  We aren't alone, as there are many in a similar situation.  But the social territory in this new land has yet to be fully settled.  Also, even as we try to put down our roots, the terrain keeps changing, making it difficult to feel secure, and competent in this new land.

For instance, when we adopted our daughter, now ten, from India, it was in the height of a wave of international adoption from a number of countries, such as Russia, China, and Guatemala.  At the time, we lived on a street with four other internationally adopted children.  Whenever I went to the doctor's office or grocery store, I almost always saw other families built through international adoption.  Because the world of international adoption has changed so much, I almost never see babies or young children adopted from other countries anymore. It seems odd to me that there was a large generation of children who found their families in this way, and yet now, there is only a small one to follow them.

In my opinion, the changes in international adoption, and the declining US birthrate in terms of babies available for domestic adoption, have pushed more prospective parents in the direction of third-party reproduction.  I was once interviewed by Scott Simon, the NPR journalist who wrote an excellent book on adoption.  During the interview, he asked me which I thought would "win"--adoption or infertility treatment.  I responded that I thought that due to the changes in circumstances, infertility treatment had already "won".  I got the sense he didn't like my answer very much, but the fact remains that there are more babies being born with the help of egg donors, sperm donors, and gestational carriers than ever before.  I can't help but wonder what this will be like for this new generation of children in terms of their psychological and social identity.

Much has been made of the problems that these children will encounter because of their often unknown genetic origins.  Because the stories of their beginnings are different from the the norm, it is assumed that these children will encounter problems.  And perhaps that may be.  After all, there is a certain reality to the situation--these children may not have access to genetic information, may look different than their parents, and have come to be via different means.

The thing is, though, that in the end, societal viewpoints and norms are plastic.  They change over time, and in response to events and situations.  People define them, and they change them. 

As infertility pioneers, it seems to me that we have a good opportunity to help redefine social norms and values in this regard.  Why can't we help shape what all this means for ourselves, and for the children of the IVF generation?  Instead of just reacting to others' negative opinions, we can put forth our positive opinions instead.   For instance, just because something is different, it doesn't mean that it is bad.  Perhaps the differences actually just make things more interesting.

Of course, by the time we really accomplish all this, I predict the landscape of infertility will change again.  I believe that the donor egg/sperm era is but a temporary one.  Science is advancing at a rapid rate, and I think that in my lifetime, scientists will discover a way to revitalize damaged eggs and sperm or restart their production.  Then we will have a whole new set of issues with which to struggle.

Such was the case with the Ingalls family in Little House on the Prairie.  After spending an arduous year building a homestead on the Kansas prairie, the family learns they must leave their farm because they settled 3 miles over the boundary into Indian Territory.  All of their hard work and investment was lost.  On the way back East, the family encountered a lone wagon stranded on the prairie.  The couple inside had lost their horses  to horse thieves, but refused the Ingalls' family offer of a ride into town because they didn't want to leave their worldly possessions behind.   As the Ingalls family rides away, Pa comments that the couple are "tenderfeet"--they didn't use chains to tie up their horses, preventing their theft, and they had no watchdog to watch over their things.  Even though Pa had made a huge mistake in picking the wrong spot to settle, he had still learned a great deal about life on the prairie. 

And so have those of us dealing and struggling with infertility.  Although our landscape will most certainly change, I hope that we can use our knowledge and experiences to change things and make it easier for those who will follow after us.

Friday, November 16, 2012

The fantasy of closure in infertility treatment

By the time a person enters into infertility treatment, they have already experienced a significant loss in terms of their expectations of having a family.  They have had to come to grips with the fact that they could not start their family the "normal" way, without medical intervention. However, for some infertility patients, this is just the beginning of a journey that involves numerous losses, disappointments, and other twists and turns. Every once in a while, the reality of the situation is revealed quickly and definitively; for most, however, the real nature of the problem only becomes clearer in slow motion--one failed treatment at a time.  To me, it's like freefalling down through space on an elevator, but agonizingly slowly, but without any idea of where the bottom floor is.

This is one reason that infertility wreaks such havoc with our emotional life.  While it's going on, it can feel like a constant stream of torture, filled with the worst kind of suspense.  Hope alternates with fear and despair, and of course, there is no definitive ending that can be reliably predicted. Time seems to slow down to a standstill. When looking at others' lives, I can see that these things do come to an end, and usually happily so; but while I was myself living in the midst of it, I had no confidence that those days would ever be done.  I try to share this with my clients, that their struggle will most likely end, and happily so too; and while I am always thanked for my reassurance, I think I am very rarely believed.

Although many problems do tend to resolve themselves over time, infertility is not usually one of them.  To overcome it, you have to actively address the problem, and this is even more difficult when you don't know exactly what the problem is.  Many times, we never really get true clarity, and are forced to guess, making finding a solution difficult.  We usually don't have unlimited time, money, or treatment options.  Plus, as described above, we are usually in an emotionally upset and fatigued state when we must make these incredibly important decisions.

Thus, many of us find ourselves in situations where we cannot know what the best course of action would be--and yet we must, in spite of this, act anyway.  As my grandfather used to say, "You pays your money and you takes your choice!"  Whether it ends up to be a good or bad choice is many times also impossible to determine.  You may have embarked on exactly the right course of treatment for yourself, and it could still fail, just due to bad luck that time around.  Or not.  Too often, there is just no way to know.

All of these observations lead me to the conclusion that that because of the many unknowable variables inherent in infertility treatment, true closure is frequently impossible to obtain.  I have heard many clients long for this closure, understandably feeling that this would help them get over their trauma and losses, and move on with their lives.  However, the frequent impossibility of obtaining closure is yet another one of the traumas and losses those struggling with infertility may have to experience. Thus, sometimes we have to give up our quest for explanations, diagnoses, and certainty, because otherwise we will become even more exhausted and depleted.

The good news is that learning to live with this kind of ambiguity is a skill, and it can be learned.  It's not only helpful with dealing with infertility; life is full of situations that present little clarity, logic or fairness.  The key to to getting over something without clear closure is to accept that you are always going to have some sad and angry feelings about the situation.  Over time, these feelings will dim in intensity, and they will not unduly interfere with your life.  Too often in our culture, I think we feel a pressure not to experience our negative emotions.  If we aren't "happy" all of the time, then there is something wrong with us.  However, I think this is a fairly American and western concept, and an unrealistic one at that, given the trials and travails that can life can offer.  Once we accept that sad and angry feelings are a normal response, and a normal part of life, we don't feel as intense of a need to quell them with explanations and understanding. 

Thursday, November 8, 2012

The aftermath: The effects of infertility once the dust settles

I often hear from clients in the midst of a battle with infertility that they can't wait for their children to come so they can "just put this thing behind" them.  I suppose some people, perhaps who are more skilled at this denial than myself, may be able to do so--but the majority of us find that our infertility is something that we simply can't leave behind.  Even if our infertility is eventually resolved in a manner we feel good about, it still has long-reaching effects in our lives.

As an experiment, this week I tried to keep track of the different ways my own personal infertility came up even though our family is (finally!) complete.  Here's what I discovered:

1.  Having to tell the nurse at our pediatrician's office (again) that I don't know my adopted daughter's birth family's medical history.
2.  Fending off questions from a neighbor about whether I had used infertility treatments and/or donor eggs in the procurement of our youngest child, who is one year old, due to my elderly age.
3.  Having to justify to the school principal and school administration officials why my middle daughter should be "grandfathered" in and not have to lottery in to gain admission to her older sister's school, as they are "too far" apart in age.  Luckily, the school officials didn't really want to deal with my argument that because of my medical problems, I couldn't control the age spacing of my children, and they agreed to let her in the school.
4.  Listening with incredulity to the story of a woman who managed to get pregnant twice while faithfully taking birth control pills.

To me, I think that's a pretty typical week.  Even if I wanted to "put it behind" me, the world has a way of bringing it right back around to the forefront.

I don't think my experiences in this regard are atypical, either.  I am frequently struck by women telling me, that despite the many traumas they may have experienced, their infertility is the problems that still continues to haunt them.

Thus, although wanting to put infertility into the past is an understandable wish, it may not be a realistic expectation.  My personal recommendation is that it may be better off to expect that infertility will continue to be an issue, although hopefully in a less urgent and intense manner.  That way, when you get the insensitive questions or difficult situations, at least you won't be surprised, disappointed, or filled with self-blame.

Friday, October 19, 2012

"Fertility envy", infertility and friendships

I came across this article about "fertility envy", written from the perspective of a woman without fertility issues who felt hurt and isolated when her closest friends distanced themselves during her pregnancy.   The author describes feeling disappointed and dismayed when her friends, who had not yet disclosed their infertility struggles, did not react with excitement to her pregnancy announcement.  As her pregnancy progressed, she felt increasingly isolated and unable to talk about her pregnancy and preparations for her children.  Instead, she felt burdened by having to spend time talking about her friends' infertility treatments.  In the end, she found herself spending more time with her friends who already had children or who were not interested in having children, and grew apart from her friends with infertility.

For me, the article stirred up a myriad of feelings.  On the one hand, I guess I couldn't help experiencing a little bit of "fertility envy" myself--after all, the author had no problems conceiving and carrying  beautiful twin girls.  Is it fair of her to be upset that her infertile friends, because of their own pain, couldn't be as excited about her pregnancy as she was?  On the other hand, though, it was an interesting perspective,  and one that as a therapist specializing in infertility, I don't often hear.  I suspect that many friends of mine may have felt similarly during their own pregnancies, but I don't think they would have ever felt comfortable admitting it to me.

I believe that disruptions in friendship and family relationships are one of the most painful aspects of infertility.  It seems that they are incredibly common and perhaps unavoidable.  However, what I find makes a pregnancy a "fatal blow" to a relationship is a preexisting problem in the relationship prior to the pregnancy.  Once a pregnancy occurs, the issue surfaces, and because emotions are so high, the issue is usually unable to be resolved.  For instance, in the article mentioned above, the author only learned upon disclosure of her own pregnancy that her friend had been struggling to conceive for three years.  To me, the fact that her allegedly closest friend did not feel comfortable sharing this with her prior to her pregnancy announcement was a sign that her friend was already having mixed feelings about the relationship.  It is also interesting that the author turned out to have several friends undergoing infertility treatment at the same time, none of whom shared this with her.  Rather than bemoaning the fact that her friends weren't available to her, she might be better served questioning why people she felt close to didn't feel comfortable opening up to her.  In a sense, what she really discovered is that her former friendships weren't really all that close anyway, and thus they were unable to withstand the emotional pressure of her pregnancy.

Much has been written about the difficulties that individuals struggling with infertility have when their friends and family members become pregnant.  I agree that this is often very difficult, but I think much of the difficulty comes from the attitude and expectations of the pregnant persons involved.  The pregnant person's reactions usually fall in one of two camps: either their is complete insensitivity to the feelings of the infertile person, or their is a high level of guilt and oversensitivity, which can then become burdensome for the infertile person to manage. 

Last year I had a relatively unique experience in this regard when I became pregnant (as a result of a frozen transfer from a prior IVF) somewhat unexpectedly, in the midst of working with several clients struggling with their own infertility.  I must say I was repeatedly impressed with how well my clients handled my pregnancy.  Perhaps knowing my long history of infertility, I got a "pass", but I think it had more to do with my willingness to understand and tolerate the fact that they would have negative feelings about my pregnancy, and that I didn't expect them to be excited for me.  In my own personal life, when I was embroiled in IVF, I found that I was able to tolerate, and to some extent enjoy the pregnancies of friends who understood that I was going to have my own feelings about it.  It helped that they listened to my feelings when I brought them up, but didn't force me to talk about it when I didn't.

As for the author's feelings of pregnancy isolation, I find this hard to believe.  It seems that our culture worships pregnancy and its related rituals and material goods, so it seems nearly impossible to me that she couldn't have found other women (other than the old lady in the checkout line) that would have been excited to share in her experiences with her.

I am curious to hear what your experiences with pregnant friends or family members and "infertility envy" have been.  Where there responses or attitudes that you found helpful, or that were less than ideal?

As always, thank you for reading, and please feel free to contact me with any questions or suggestions!

Sunday, October 7, 2012

The September curse

If you are reading this post, I hope you are well and have had a great month.  Unfortunately, it's been a challenging month for my family in terms of medical problems.  At beginning of September, my son became acutely ill and required hospitalization for several days.  That was followed by a long but ultimately successful recovery at home, after which he caught some sort of horrible virus and was quite sick for another ten days or so.  In the meantime, there have been broken hands and sprained ankle, and today's arrival, a family case of stomach flu.

I can't think of a time since I was in throes of infertility treatment that I have had such a hard time doing what needs to get done, and consequently I haven't had the time or mental energy to post anything for the last month.  However, as soon as I and everyone else around here recover from this latest virus, I plan to be posting regurlarly again!s

Take care everyone and check back soon!  In the meantime, I wish you much luck and success on your road to having your family!

Wednesday, September 5, 2012

Time management and infertility treatment: the "half-a&$" principle

Infertility treatment is a very expensive endeavor.  It costs a great deal of money, a great deal of emotional energy, and a great deal of time.  The time requirements involved in a treatment cycle can be one of the most difficult aspects of managing infertility treatment.  Add in the requirements of a job or home life, and it can create a pressure-cooker situation.

To make matters worse, it seems that those of us with overachieving tendencies have a particularly difficult time trying to apply our coping skills (such as perfectionism) to both our life situations and infertility treatment at the same time, causing added stress, anxiety, and guilt.  During a treatment cycle, you have relatively little control about when your presence at the infertility clinic will be required, so you cannot really plan around it.  Thus, conflicts are sure to arise.

In addition, we all have finite amounts of physical, mental, and emotional energy.  Because infertility treatment requires so much of our energy, it leaves us with less energy left over for work, relationships, and even the laundry.

In my practice I have seen many clients struggle with this problem, and of course I myself struggled with it too during my own treatments. These experiences have led me to draw the following conclusion:

 For most people in most situations, infertility treatment is the most important thing you are doing right now.

 Okay, so you might be saving puppies from a burning building, or be governing a country on the brink of international disaster, in which case, my remarks do not apply to you. But otherwise, you are probably embroiled in one of the most important periods of your life right now. The act of having children, or not having children, drastically affects the future course of your life. Thus, in my opinion, it should take precedence over the other aspects of your life, like your job, your social relationships, and your housework. It's not that these things aren't important, because of course they are. It's just that if you have to make a decision about which thing to cancel or to give, as my Grandma used to say, "a lick and a promise", it shouldn't be your anything related to your infertility treatment.

 The main reason I feel that infertility treatment should be given first priority is to prevent the possibility of profound and long-standing regret later in life. If for some reason treatment fails, you don't want to be in the position of looking back at your efforts and blaming yourself if you didn't do everything you possibly could do to achieve a positive outcome. In order to ensure the possibility of having future closure, you may need to make your absolute best efforts now. In order to make the time and emotional energy for the effort that treatment involves, you usually need to cut back on doing other things, such as work or social obligations. This can be difficult, especially if you are a high achiever, used to coming as near to perfection as is humanly possible. To help in these situations, I have delineated what I term as the "half-a$& principle":

 Only do what is absolutely necessary. Then, only if you have time and energy to spare, go back and do some of the optional stuff--but if you start getting tired or stressed out, you MUST STOP.

 For many individuals, this is a real paradigm shift. Not completing a task, and letting things go, feels almost like an anathema. However, by doing only what is absolutely necessary, you will have saved considerable time and energy you will need for your infertility treatment. Many clients, who have been rather initially resistant to this idea, have nonetheless tried it and have discovered that in most situations, things go just fine. After that, they have come to embrace the half- a$& principle. I suppose if you apply this principle forever, problems will eventually crop up. But I feel safe in recommending it is most situations because infertility treatment usually only lasts for a finite time period. When the dust settles, you will be able to catch up on all of the little details left by the wayside. If you are in the midst of a treatment cycle and feeling overwhelmed, try to see if you can use the half- a$& principle to prioritize your to-do list, in order to ensure you have the time and energy to comfortably move forward.

Saturday, August 18, 2012

Loved this article about magical thinking and adoption

I just wanted to share this article I came across, thanks to Dawn Davenport at Creatingafamly.org, which is a wonderful resource.

Here is the link to the article:  Adoption, Destiny, and Magical Thinking

Happy reading!

Monday, July 30, 2012

The other side of the river: reflections on a first IVF cycle

Geographical landmarks are a funny thing--sometimes being in the same place as you were when something memorable happened can bring you right back to those feelings, as if no time had ever passed. I was reminded of this last night, when I found myself across the Chicago River from the sidewalk where I paced back and forth eleven years ago during my first and perhaps most traumatic IVF cycle. The feelings I experienced then flooded me again, overwhelming me for a moment.

 I always tell my clients that the first IVF cycle is usually the worst, because invariably our expectations entering into the cycle are very high. We have pulled out all the stops and gone for the big guns. How could it not work? For many, the first IVF does indeed work--but for the rest of us, the disappointment of treatment failure is compounded with shock that treatment failed in the first place. In addition, everything is all a new experience, and our anxiety is usually higher when we don't know what to expect.

 My first IVF was an emotional roller coaster ride that was one of the most intense experiences of my life. It started out badly, when on a Saturday morning right after I started Lupron shots my RE called to tell me that our first cycle would be cancelled. I had learned a month earlier that I was a carrier of Tay-Sachs disease, genetic disorder that is usually fatal. This was not too surprising to me because I am of Ashkenazi Jewish descent. However, the cycle was cancelled because my husband had also tested positive as a Tay-Sachs carrier. This was extremely suprising to us, because he is of Southeast Asian descent and Tay-Sachs is not common in this population. "Don't worry," my RE told me, "We can do PGD next cycle to find the embryos where you don't contribute your Tay-Sachs! I've got it all set up for you, and we can do it next month!" And thus, we entered the world of preimplantation genetic testing, then in its' infancy. We would be doing a polar body biopsy, meaning that they would only be able to test the maternal genetic contribution to the embryos.

A few days later, I found myself at the genetics lab, where a nervous doctor who clearly didn't usually do procedures on actual human beings gave me a shot of lidocane, and then without waiting for it to take effect, took a sort of hole punch and removed a large divet of flesh from my arm. My pain tolerance is pretty high, but I can still remember how excruciating that was. I endured it because I desperately wanted things to work. I have a huge scar on my arm to this day to remind me of this misadventure.

 My sample was sent off to determine the exact genetic mutation I carried so that they could identify it during the PGD. I began to prepare for the IVF cycle again, starting BCP and Lupron. Meanwhile, my husband and I kept scratching our heads, wondering how he could possibly be a Tay-Sachs carrier. It just seemed so improbable. Of course, head scratching quickly turned into obsessive internet searching. After a few weeks of research, we found one lab in Philadelphia that ran a test for a "pseudodeficiency allele" for Tay-Sachs; apparently some people carry a mutation that causes their blood to react with the solution in the collection test tube, producing a false positive on the Tay-Sachs test. We took our research to the genetic counselor, who had never heard of the allele or test but agreed to test my husband anyway. It would take weeks to get the results.

 I began the stimulation process of the cycle with very disappointing results. I remember one nurse yelling at me, telling me I needed to have ten follicles on each side. "You are 32 years old; you should be doing better than this!" I began to experience a feeling of panic and dread. When it came time for retrieval, they got 8 eggs, but at day 3, only four were viable embryos. Two were of good quality. Unfortunately, the genetic testing showed that the two good embryos were the ones that carried my Tay-Sachs gene. My husband's pseudodeficiency allele test wasn't back yet. At this point, we had nothing to transfer. I was filled with shock and despair. I was downtown that day, and unable to concentrate on my work, I went for a walk along the Chicago River. I felt hopeless. I couldn't believe that after everything, my cycle ended without anything to put back. I remember thinking, "This is the end of the line." I cried for a while, and then walked back to work to complete the rest of my day. 

 I was wrong, though. It wasn't the end of the line. On the afternoon of day 5, we got a call from the clinic. My husband's results were back--he tested positive for the pseudodeficiency allele, which meant he wasn't a Tay-Sachs carrier after all. We raced to the clinic to transfer the two affected embryos, which were still alive and doing well. Nine days later, I got a positive pregnancy test. It looked like my luck had changed again. My betas were strong, and I had lots of early pregancy symptoms. Unfortunately, there was no heartbeat at 6 and 7 weeks, and I ended up having to get a D & C. I was devastated all over again, filled once more with shock and despair.

 All of those feelings came rushing back to me last night, as I stood across the river. For a moment, I was back in that time again, but my daughter excitedly squeezed my hand and I came back to the present. We were in the process of boarding a architectural boat cruise organized by the American Girl store. It was a beautiful summer night, and there were happy girls and their dolls everywhere. I was struck by what a difference it made to be on this side of the river. When my first IVF was taking place, my adopted daughter was just a few months away from being conceived in a faraway land. That long ago terrible day on the river wasn't the end of the line; it was the beginning of a journey that would span continents and years that eventually would give me so much for which to be grateful. 

 As we toured the city, I basked in the glow of the city lights and in the world of dolls and childhood imagination. I always tell people that infertility is a phase, and although the pain never goes away completely, you can have a wonderful and happy life in spite of, or perhaps because of, the experience of infertility. I say this because it is true; and if I can survive infertility and find some measure of happiness, then I know you can too. If you are reading this and you are having a hard time right now, please remember that one day, you too will be on the other side of the river. I hope that your crossing will be smooth, and happen very soon!

Thursday, July 26, 2012

The RE's waiting room: a world unto itself?

During my eleven on-and-off years as an infertility patient, I logged an impressive number of hours in the waiting room of various infertility clinics, and I have a confession to make:  although I appeared to be calmly reading a magazine and minding my own business, I really wasn't.  Instead, I was watching, listening, and observing everything that went on with the staff of the clinic and the other clients.  And boy, did I see and hear a lot  of interesting things!   Of course many of the things were what you would expect; couples arguing, other clients in various stages of happiness or distress, and the occasional awkward meeting of two acquaintances, both obviously wanting to keep their treatment private, who were now forced to interact.  As interesting as those events were to a nosy nelly like myself, for me the most fascinating occurrences were the subtle looks and interactions between patients.

For instance, when I first began infertility treatment, I was in my very early thirties, and at the time, I looked much younger than my age (unfortunately, I do not have this problem anymore).  On numerous occasions, if a woman in her late 30's or 40's was in the waiting room with me, she would surreptitiously give me the once over, and then start looking really annoyed.  Once, a fellow patient started asking me questions about where I was from and if I went to school, and if I lived with my parents, which all seemed very strange, until it hit me--she thought I was an egg donor! The irony of that situation is that despite my relative youth, my underachieving ovaries were what had me sitting in that waiting room in the first place.  These looks and questions were a little upsetting to me--I kept thinking, "Here we all are in a difficult situation, and we are still making assumptions and being competitive?  Is no place sacred?"

One another occasion, I was in the waiting room during an IVF cycle, and there were a bunch of women who obviously knew each other and lived close to each other. It was as if my RE had offered a discount to their city block.  Apparently they all lived near the RE too, and they were having boastful conversations  for about how many times they had run into Dr. X at the Starbucks, the gym, the grocery store, jockeying for position about who knew him the best.  For his part, I heard Dr. X tell the nurses that this was obviously a waiting room full of his patients, as opposed to the patients of his partners, because his patients were clearly the most friendly and attractive.  Again, I found myself being irritated and annoyed. 

As for me, I spent a lot of the time in the waiting room feeling like the most infertile person in the world.  In my darker days, as someone would walk in, I would find myself thinking that she would get pregnant before me.  My clinic had us sign in with chart numbers that were sequential, and thus I could see that I always had the lowest number--hence I had been going there the longest. 

I'm curious to know about the waiting room experiences of others.  What was your most intresting experience or observation?  And do you have any suggestions about how clinics could make their waiting rooms more comfortable?

Thank you so much for reading for your comments, and if you ever have a question or suggestion, don't hesitate to email me at lisarouff@gmail.com.

Thursday, July 12, 2012

IVF causes stress, but stress doesn't cause infertility: I knew it!

I've said  it before, and I'll say it again:  unless you are extremely and chronically emotionally distressed (and I mean extremely so), it isn't the root cause of your infertility.  I have long maintained that your ovaries do not care about your unconscious, unresolved conflicts or your relationship with your mother.  Your uterus is not swayed by either profound wishes to become a parent, or ambivalent feelings about changing poopy diapers at 3 am.  If this were true, the human race would have become extinct long ago.  We can hardly say that we live in the most stressful time in history--as long as humans have been alive, they have experienced feelings of stress.

Now, however, I can say these assertions with a little more confidence, thanks to some new research.  A study published in the journal Fertility and Sterility (found here) found no relationship between levels of stress women experienced before IVF and their treatment outcome.  As you might expect, they did find a relationship between treatment failure and a higher number of IVF cycles and higher levels of emotional distress.  The study's authors concluded:

IVF failure predicts subsequent psychological distress, but pre-IVF psychological distress does not predict IVF failure. Instead of focusing efforts on psychological interventions specifically aimed at improving the chance of pregnancy, these findings suggest that attention be paid to helping patients prepare for and cope with treatment and treatment failure (Pasch, et al, 2012).

As a clinician who works with individuals and couples experiencing infertility, I wholeheartedly agree with this conclusion.  To many times, clients come to me with a deep-seated worry that they are the architects of their own misery, and that their desires to have a child have caused their fertility problems.  Of course, it doesn't help that many people hold this mistaken belief, and are constantly telling them to just relax and stop trying.  

I'm afraid my own field of psychology is partially to blame for the theory that emotional conflict causes infertility.  I remember when I first started realizing I had an infertility problem, I did a search in the psychology literature on infertility.  I discovered a case report of an infertile woman, who was allegedly cured of her infertility once she finally worked through her unconscious conflicts about motherhood.  I was upset upon reading this--although I didn't feel I was excessively conflicted about becoming a mother, could my unconscious be keeping me from getting pregnant?  
Luckily for me, a few moments later I had to get back to work, to perform a diagnostic evaluation on a woman who was suffering from mental illness and drug dependence and who had several children, none of whom were in her custody.  She was rife with conflict, conscious and unconscious, about motherhood, and yet her reproductive organs appeared to be working just fine.  That experience, combined with my knowledge about the giant endometrioma that had set up camp on my ovary, allowed me to shake off some of these worries.  I knew somehow that feelings of conflict or mild upset couldn't be interfering with fertility--that just couldn't be right.

Too often, when we don't understand a medical, physiological problem, we tell patients that it is caused by a psychological factor.  For example, until we realized that ulcers were caused by a bacterial infection, we blamed stress and emotional distress for their development.  I predict that the more we come to understand the different underlying cause of infertility, the psychological explanation will fall by the wayside.  Until then, it is important to remember that although there is no conclusive evidence that stress causes infertility, there is a great deal of evidence to indicate that infertility causes stress, anxiety, and depression.  Thus, as the study's authors conclude, our focus should be on treating these "side effects" of infertility, not on subtly blaming infertile individuals for having these feelings in the first place.


Wednesday, June 20, 2012

Infertility treatment and the Type A Personality, Part 2: feelings of failure

In an earlier post, I discussed some of the issues that can occur when a person with a "type A" personality style experiences infertility. In this blog post, I would like to focus on one particular aspect of that experience; namely, the emotional experience of treatment failure. Failure is endemic to infertility and infertility treatment, as the failure to produce a viable pregnancy starts the whole process.
 By the time a person with Type A personality typically gets diagnosed with infertility, they have already been deluged with feelings of failure. Failure to get or stay pregnant is distressing to everyone, no matter their personality style. However, it seems to be particularly stressful for those of us who are more on the type A side of things. To me, this is best expressed by this equation:
 Type A personality + treatment failure = uncomfortable recognition of lack of control.

 One of the biggest motivations for being type A, e.g., worried about the details, anxious about potential obstacles, is that it can provide a faux sense of control. Someone with a more laid-back approach to things may have a basic belief that although things are out of their control, they will work out well in the end. This is not so for people with The A personality style. Simply put, they do not feel lucky. Not only do they not feel lucky with infertility, they do not feel lucky in any aspects of their lives. The underlying assumption is that the world is not a safe place.

It's pretty uncomfortable walking around being anxious and worried about the future all of the time. Thus, if you have this basic belief, you will need to develop a psychological strategy for minimizing these feelings. That's where a type A personality style, with its emphasis on working hard to manage all the details, can come in very handy. You can get so busy organizing, planning and working that you can put your feelings of anxiety about the world out of consciousness.

 The Type A strategy of managing anxiety is usually adaptive in most situations. However, in a situation like infertility treatment, where success or failure usually rest on several factors beyond anyone's control, it all falls apart. A treatment failure isn't just a profound disappointment; it is also an example of the person's worst fear come true. It is a concrete reminder that no matter how hard they might try, bad things happen--and thus, the world is not safe.

Add in some fertility drugs tweaking the emotions, financial stress, and a few insensitive comments from friends and family, and you've got a recipe for the perfect storm in terms of creating an emotional meltdown. Sound familiar? I know I myself have been in that play several times before.

 Although it is painful and unsettling to realize that we feel unlucky and unsafe, there are some advantages to doing so. In reality, your situation is no better or worse off than it was before. The primary loss is actually the fantasy that you had some sort of omnipotent control in the first place. By letting go of this fantasy, you may be able to paradoxically relax a bit more--if it's not all in your power, it can't be all your fault, right? Also, by acknowledging that your fear that you are always unlucky of that the world is always unsafe, you can also realize the ways in which your fears aren't accurate. In reality, a person can't always be unlucky, and not every situation is unsafe. This can allow you to respond more specifically and helpfully to the threats of a given situation, saving your energy for the things that matter most. 

Friday, June 8, 2012

Infertility treatment and the disaster plan: or, another defense of negative thinking

I remember  the moment like it was yesterday; the moment I decided to quit infertility treatment (although, glutton for punishment that I am, I would return two more times).  Another IVF had failed, and the diagnostic explanations as to why were becoming increasingly sinister.  I had a break at work and was agitated, so much so that I couldn't sit still.  I paced back and forth in my office, back and forth, wondering what to do next.  Giving up treatment felt like such a loss, an admission that I couldn't make a baby, and  yet, staying in treatment felt completely hopeless.  I had no confidence anymore in my  body.  I felt so much loss and frustration that things had worked out this way.  And just at the moment when I felt these things most intensely, I felt some sort of shift in myself, a new voice in my head, and I found myself telling myself that although I couldn't get pregnant, I couldn't be unhappy all of the time anymore.  I had to spend my time doing something that I had some hope of being good at, and I felt that I could be a good parent to an adopted child, someone who needed a family just as much as I needed to be a mother.

That was the moment when everything changed for me, and resulted in us joining our eldest daughter five months later. It's all very dramatic sounding, isn't it?  But the truth is that this moment was actually the product of many moments before that, moments that allowed me to reach the clarity of this decision.  Those prior moments were spent constructing my disaster plan, a plan that I could implement if things didn't work out with my first plan of infertility treatment. 

When I recommend that clients create a disaster plan for themselves, I am sometimes not met with enthusiasm.   The truth is that for a therapist, I am actually not that "comforting" of a person to be around.  My way of reassuring myself  has always been to imagine and plan for the worst case scenario.  If I have a concrete plan for surviving that situation, I feel calmer, and I'm more able to focus on the situation at hand.   More than once, I have had  clients react negatively to this line of thinking, for they didn't find considering the worst-case scenario to be comforting at  all, but rather extremely anxiety-provoking.  At these times I am usually asked why I am bringing negativity into the situation.  Wouldn't it be better if I just focused on a positive outcome?

Perhaps it would be better to just focus on a positive outcome, but I know myself well enough to know that I'm not capable of pulling that off.  But more than that, I think that there is great utility in a disaster plan. Having a concrete plan of what you would do if things go badly not only gives you a plan of action, it also aids in decision making and helps you emotionally prepare for the event that things don't your way.

For instance, for me, when I was going through treatment and things were looking increasingly bleak, I started researching all of my options, and in detail.  I learned about surrogacy, and I learned about adoption.  As I considered these options and gained more knowledge, I began to realize how I felt about myself in either of these situations.  In so doing, I decided to focus more on adoption, and then began learning about the different options in the adoption world.  I sent off for information from adoption agencies, signed up for listservs, read message boards, and tried to become literate--fast--in the adoption world.  Some of my family and friends thought I had gone off the deep end.  My IVF treatment was still proceeding, and we didn't know how that would end.  But I felt compelled to keep up with researching and planning.  Pretty soon, my husband and I had decided on a detailed specific plan of action that we would take regarding adoption, including the agencies we would use, if our last treatment failed.

Thus, when I was pacing back in forth in my office that day, I already had a detailed, concrete picture in my mind of what I needed to do should we decide to adopt.  And I think the importance of that detailed picture cannot be overemphasized.  It's basically impossible to feel clarity about an undefined, abstract option.  Everything is so hazy and undefined--how can you possibly know how you really would feel about it?  Having a detailed plan that you can visualize and implement immediately if necessary helps you make a better, more realistic decision.

In addition, the emotional clarity I felt in that moment in my office was the result of gradually working through my feelings about adoption as I read, researched, and talked to others about it.  Instead of jumping in all at once, I had time to imagine myself in various situations.   When the decision was finally at hand, the shock value had gone out of the equation, and I could just focus on what was best for my husband and myself.

Another benefit of the pre-prepared disaster plan; I didn't have to figure all this stuff out when I was terribly upset, when my cognitive functioning is not at its best.  I  just had to plug away at the steps I had already outlined.  This allowed me to keep going, and not lose time while I processed my feelings regarding ending infertility treatment.
Of course, some disasters cannot be planned for, and the best-made plans may not pan out in actuality.  But if you are in the midst of infertility treatment and things are not looking very positive for the outcome, I would encourage you to give serious thought and time to developing an alternate plan of action.  You might decide to try a different type of treatment, get a second opinion, or go to a different clinic.  You might consider third-party reproduction as an option, or decide that adoption is a path you might take.  Once you decide on a direction, learn as much as you can about that direction as possible, so that if you should need to go that way, you've already got a very detailed map to follow.

Although I did end up using my disaster plan, I am happy to report that in doing so, I soon realized that my new path was anything but a disaster.  Although there were many challenges along the way, they were ones I  could handle.  The paper chase of adoption was a breeze compared to infertility treatment.  For example, though couldn't get my body to cooperate in IVF, it turned out I could assemble our homestudy documents with alacrity, and wade through bureaucratic red tape with efficiency.  In so many ways, adopting our daughter was an amazing experience that I will always cherish, even though it began as my disaster plan.

Thursday, May 10, 2012

Get over it....

As a therapist, there isn't a workday that goes by without hearing the question, "Why can't I just get over it?"   The short answer, of course, is that if it was that easy to get over whatever it was, you wouldn't be here talking to me about it in the first place--you'd be working or laughing doing your laundry or drinking a coffee or taking a nap.  Psychotherapy, like infertility treatment, usually isn't anyone's first choice.

The reason people often go to a therapist in the first place is with the idea that psychotherapy may help them "get over" something, which indeed it may, although not in the way they might initially expect.  In our culture, o there seems to be an expectation that to get over something, you shouldn't have negative feelings about  anymore--your sadness, anger, hurt, despair will all become things of the past.
If that were the usual course of events, that would put me out of a job.  And believe me, I would be fine with that.  Instead, I find myself trying to find way to gently explain that perhaps "getting over it", in terms of no longer having negative feelings, is an unrealistic goal, for that there are some things in life that just can't be gotten over so easily.

Infertility is almost always one of those things that can't be gotten over so easily.  No matter what the outcome, the struggle of infertility almost always changes a person in fundamental ways. The losses endured are often profound and unchangeable.  They have due dates, anniversaries, and countless other reminders.  Other people are reproducing everywhere you look.  In the thick of my infertility treatment, the number of pregnant women I would see on a daily basis was breathtaking.  I sincerely wished the continuation of the human race would just stop for a few minutes, to let me catch my breath, but that wish, like so many others, never came true.

I suppose that is one of the many things I have never "gotten over" about infertility.   And although I have children now, I don't think I will ever lose touch  with how bad that felt.  Thinking about those moments of my life still makes me feel sad, angry, and alone.  When I am around people who didn't have the same struggles I did, I still sometimes feel alienated and shake my head, marveling that children could arrive in their lives with such little fuss.  I don't see how that's ever going to change.

What has changed, however, is my expectation that I am ever going to feel differently.  I have come to accept that there are certain memories and issues that are going to upset me no matter what, and that they probably will continue to do so for the rest of my life.

This is no small thing.  For by recognizing that you can't escape certain negative feelings, you can find freedom in other ways.  First of all, you don't have to feel badly about yourself because you haven't "gotten over it" yet.  And secondly, there is something about accepting how you feel that makes those feelings less intense and more bearable over time.  Once you start processing your feelings, they may not go away; but they may not affect your ability to enjoy the rest of your life.

My rule is that if you keep telling yourself you need to just "get over" something, it is likely that you may be up against an impossible task.  Instead, take some time to explore and process the feelings you think you should just be getting over.  You may be surprised that even though you aren't over it, you still feel better anyway.

Wednesday, April 25, 2012

Don't Ignore Infertility: but don't ignore the power of ignoring!

It is National Infertility Awareness week.  This year, Resolve's theme is "Don't Ignore", reminding us all to pay attention to infertility, its interpersonal ramifications, and its legal and financial issues. I hope that as more people become aware of the issues surrounding infertility, there will be an increase in sensitivity, legal protection, and funding for treatment.

I think the theme of awareness is an extremely important one.  However, I also believe that there are times in which, in order to best cope with your infertility, you may benefit from a little judicious, purposeful ignoring.   I have come to the conclusion that there are certain interpersonal problems and experiences that are better left neglected.  Intervention only makes them worse, and only makes us more miserable than necessary.  As Ruth Bader Ginsberg wisely said during her speech at my graduation ceremony, "Sometimes, it pays to be a little deaf."

For instance, if someone who is not particularly emotionally close to you makes a hurtful or insensitive comment about your infertility, sometimes the best thing might be to just pretend they never said it at all.  Let's say Great-Aunt Mabel gets on your case for not having children yet, observing that after all, you aren't getting any younger.  You could try to correct her--but since she's 97 years old, she's not likely to alter her behavior.  You could allow the hurt of her words to seep inside, stirring up all the painful issues of which you are struggling.  Or you could pretend, as Ruth Bader Ginsberg might suggest, that you just didn't hear that comment at all, and completely change the subject.  After all, Aunt Mabel clearly doesn't have a good understanding of the situation, and she isn't a source of emotional support.  Her opinion is not valid in this situation, and it will not be of any help to you. 

The two rules of thumb I use in these situations are 1) Is the person close to you and typically a source of emotional support? and 2) is this person able to hear and make good use of constructive feedback?  If the answer to both of these questions is no, then thinking about or responding to what they say is often a waste of your energy.

Another example occurs when after you and your partner have carefully considered your treatment options and chosen a path, only to have others, usually less-informed (and in any case, not you) opine about what you should, or shouldn't do.  If considering their opinion isn't going to change the outcome of your decision, then arguing with them about their thoughts on the matter is only going to be detrimental and upsetting to you.
 For example, if you've decided to try IVF, but your always opinionated cousin doesn't understand why you don't "just adopt", there may not be much benefit in responding to or arguing with him.  A blank stare often suffices.

For the most part, the internet has been a blessing to those of us struggling with infertility, allowing us to connect and share information and support.  Unfortunately though, it seems to be another prime source of information and comments best left ignored.  The anonymity of the internet allows people to feel entitled to say things to and about us that they would never have the courage, and many times even the inclination, to say to our faces.  For example, early on in my blog, I wrote a post which contained some of my feelings about the experience of adopting my daughter.  Someone commented that they had featured my blog post on their blog and to click over and check it out.  When I did, I discovered that this person had used my words, which I had thought were filled with love, as evidence that adoption was bad.  Several of her readers commented that I should never have been given a child in adoption, and that I was not a fit parent.   My first response was to get upset and defensive and leave a comment of my own--but I soon realized it wouldn't do any good.  After all, these folks had never met me, and really didn't have any valid information with which to judge my suitability for parenthood.  Any comment that I wrote would be unlikely to change their minds, and an internet fight was not going to be good for my emotional health.  So I decided to leave the situation alone, and it quickly blew over, without any effort on my part. 

Almost any news article about infertility treatment, if one scrolls down to read the comments, seems to invoke a negative, judgmental reaction in some of the commenters.  I've decided to stop reading those comments.  It's impossible to argue with an anonymous, closed-minded, and misinformed person.  I think our energy is better spent going on about our business and working hard to achieve or family building goals.  Instead of fighting with someone who will never be convinced, I think we should focus our efforts on educating and   informing the public as a whole about infertility and infertility treatment.
Another type of interpersonal situation I think it is pretty safe to ignore are those in which someone with an obvious profit motive is trying to tell you to buy something or try something.  If it seems to good to be true, than I'm afraid it probably is.  I would be wary of any product or professional that guarantees that if you do X, Y, or Z, then you will get pregnant. 

Of course, there are a lot of things about infertility treatment that you should never ignore--your bodily sensations, and your feelings about and reactions to important people in your lives.  We should also never ignore the medical facts surrounding our diagnosis, and need to learn about and carefully watch over our treatment.  By letting go of the stuff that people say that really doesn't matter, we can have more energy to devote to attending to the things that do--and thus help ensure we create the most positive outcome for ourselves.

For more information about Resolve, infertility and National Infertility Awareness Week, please visit:

Friday, April 6, 2012

Sex, infertility treatment, and the real purpose of sex

It's no secret that experiencing infertility can be hard on your sex life.  In fact, I don't think I've ever heard a client tell me that their sex life had improved once they realized infertility was an issue. Typically, the scenario goes as follows:  at first, there is great excitement as a couple begins to try to have a baby.  However, if things don't work out relatively quickly, anxiety sets in, and sex becomes a more scheduled and anxiety-fraught affair. By the time infertility treatment begins in earnest, sex has become associated with feelings of failure and unhappiness, and couples sometimes struggle with maintaining a healthy sex life.

Many times, I've had clients tell me that they feel that because they are infertile, that sex has lost some of its meaning for them.  After all, sex exists for the purposes of reproduction, and if having it can't achieve it's purpose, they experience feelings of loss and failure.

Although this reaction is understandable and predictable, it seems to have more to do with cultural values about sex rather than the realities of the situation.  Although I'm no evolutionary biologist, I would argue that reproduction is only one of the purposes of sex, and perhaps not even its most important purpose.  This is because for human beings, a sexual encounter rarely produces a child.  Even in the case of the Duggars, only 20 or so of their instances of their intimate moments resulted in a pregnancy.  In contrast, many other species only engage in sexual behavior when reproductive potential is at its highest--cats, for example, who only participate in sexual behavior when the female cat is ovulating. 

For humans, then, sex plays another very important role--sexual behavior leads to affiliation.  A couple's sexual intimacy keeps them close to each other.  This had several evolutionary advantages.  Historically,  human beings have survived better when they lived in group.  Their offspring tended to survive more often with more adults available to protect and care for them.  Thus, sex really isn't merely about reproduction.

In the history of Western culture, sometimes the reproductive aspects of sexual behavior have been emphasized over its affiliative aspects.  In recent times, societies' values about sexuality have changed.  Interestingly, from a psychological perspective, when it comes to infertility, we often take a more reductionistic view, focusing only on the parts with which we struggle.

Thus, if you are finding that your sex life isn't what it used to be since infertility, keep in mind that for human beings, sexual behavior isn't primarily about reproduction.  Rather, for us, sex is primarily about forming and maintaining an important relationship.  Even if you are infertile, you can still be successful at feeling close with your partner.  In the end, the survival of the species may depend more on that than on reproduction per se.

Tuesday, March 20, 2012

Is reproduction a virtue? Attribution theory and infertility

I was on Facebook the other day, and one of my friends, who is really a lovely and kind person, posted a status update saying how wonderful Beyonce was for giving birth vaginally. I was taken aback, because not only is it none of my business how a celebrity gives birth, but to be honest I'm not sure how much choice we all have in these matters. If Beyonce had been forced, due to medical reasons, to have a C section, would she be any less wonderful? Of course, this was just a status update, but the sentiment it expressed epitomizes something that has been bothering me for some time. When it comes to fertility and childbirth, there seems to be, in some circles, a cultural assumption that if things go well, it is more than just good luck. It is evidence of the inherent goodness and moral correctness of the person involved. Beyonce is wonderful because she could conceive and deliver her baby the "right" way. Those of us who can't are presumably not. This kind of thinking is usually painful to those struggling with infertility, and it is, at its base, unfair. As I know too well, infertility almost stems from one or more medical issues, which cannot be easily controlled. A lack of infertility is of course a desirable and fortunate thing. It usually occurs, however, without a great deal of effort. It is the same principle as my not being congratulated for possessing working fingers and toes. I'm grateful for them, but they are more an indication of my good fortune in terms of appendages rather than of any inherent effort, goodness, or ability on my part. Why would such an illogical belief system about fertility be so common? I wonder if this is an example of an attribution error. According to Heider,a psychologist working in the 1950's, we tend to explain others' behavior based on internal characteristics, such as their personality traits. In contrast, we tend to attribute the cause of life events in our own life to external circumstances, such as luck or chance. Thus, my Facebook friend attributes Beyonce's birth experience, about which she feels positively, to positive characteristics she believes Beyonce possesses. On the other hand, I might attribute my own infertility to factors beyond my control. I could go on forever about the different types of pain and self doubt that erroneously attributing ease of conception and delivery to internal personality traits causes those struggling with infertility....but I won't because if you have found this blog, you most likely know what I mean. Instead, I will reiterate that it isn't true. When I mentioned this blog post idea to my mother, she told me, "Make sure you write that although some people may think like this, it really is a reflection of their own failings, such as a lack of empathy, or their own thoughtlessness. So often people say stupid things, or just don't think things all the way through!". I suspect that Mom is right. If you find yourself struggling with this issue, it may help to remind yourself that people make these sorts of attribution errors all of the time, and that it really isn't a valid understanding of the situation. By seeing these errors for what they really are, we may be more free to create our own, more positive meanings of our experiences.

Monday, March 5, 2012

Getting "the donor egg talk"

For a women undergoing infertility treatment, hearing that her only or best chance at pregnancy is donor eggs is usually a fairly upsetting experience.  Many times, she senses it is coming--repeated poor response to follicle-stimulating medication lets the realization sink in over time.  In other instances, it comes a shock.  Testing reveals that despite her youth and health, she is entering menopause early.  In either case, getting "the talk" from the RE is a dreaded and painful event.

Of course, learning that one cannot be biologically related to her child is a huge loss, one that takes time to process and to grieve.  In addition to this, I often hear women blame themselves for their situation.  The refrain of "if only I had known" is a common one, even though of course there was no way to predict the situation.  Perhaps more damaging, I also often hear confessions of shame and self-loathing.  A woman may feel terrible that she can't do what other women do effortlessly, and hate herself for being unable to easily give her partner a child.  Again, as it is a completely uncontrollable situation for her, there is no "solution" for these types of feelings.  Using another, presumably more fertile, women's eggs can feel like a slap in the face.

In addition, if the woman decides to go forward and use donor eggs she is now faced with the prospect choosing an egg donor, which is never an easy decision. She must decide whether or not to use an known or anonymous donor, and deal with the complications that result from either decision. Further, she must manage a complicated treatment cycle with many players, including the egg donor, her agency, a couple of attorneys, and of course, the IVF clinic staff. She must also figure out how she is going to pay for the donor fees and for the treatment, often not covered by insurance.

All in all, this situation is pretty overwhelming for most people.  If you are faced with the prospect of using donor eggs and are feeling upset and stressed out, I'd say that most likely, your response is normal and indicative of good mental health.  I often tell my clients that if they were in a difficult situation and were not upset by it, that would be a big red flag for me.  The main thing is to try to deal with your upset feelings in a helpful and productive manner. To that end, I have a few suggestions for how to navigate this complicated emotional situation. 

1.  Give it time to sink in.

Usually, the first reaction to the donor egg talk is often shock and intense emotional distress.  Even though you might see the writing on the wall, it still hurts to hear "officially" that the chances of having a genetically-related child is small.  It is important to give yourself time to be upset about this, and cry if you need to (and you probably will).  Don't expect yourself to go back to work right away, or see people with whom you don't feel comfortable expressing your true emotions.  This is one of those situations in which you may need to press the "pause" button on your life in order to give yourself time to react and recover.

2.  Watch out for denial.

A common reaction to this sort of news is to deny the severity of the situation.  I have often seen women, upon hearing this news, get very angry at the doctor who delivered it, feeling that he or she may have ulterior motives.  Since they might be getting their period every month and otherwise feel normal, they question why donor eggs would be necessary.  Although it is possible for doctors to be wrong, to be honest I have never really witnessed a case where an RE suggested donor eggs unnecessarily.  I suspect that most RE's dread giving the "donor egg talk" as much as their patients dread hearing it, because it feels bad to have to deliver disappointing news to people they want to help.

Sometimes, a women in denial about her fertility potential, in spite of overwhelming evidence to the contrary, persists on, trying to find a doctor who will perform IVF with her own eggs, or pursuing alternative treatments in the hopes of a miracle.  While miracles can happen, they often aren't likely, and pursuing them for too long can exhaust a couple's financial and emotional resources.  This can make the process of infertility treatment even more traumatic and depleting.

3.  Be kind to yourself.

Being faced with the decision of whether or not to use donor eggs is a traumatic event.  It usually prompts what I have come to call an "infertility meltdown".  There will be a period of grief and mourning, as well as times of anger at the situation.  As it is a time of crisis, it is very important to treat it as such and to take good care of yourself emotionally.  Allow yourself time to cry, and to think about your feelings.  It will most likely be helpful to discuss them with a partner or a close confidante.  Recognize that things like going to baby showers or being around pregnant women may be especially painful right now.  In this difficult time, it may be necessary on a temporary basis to protect yourself from events and people in order to cope with your feelings.  Also, keep an eye out for negative self-thoughts.  Try to remember that producing a quality egg is an involuntary act, and that pregnancy is only nine months out of a whole lifetime of parenting.  I feel we cannot judge ourselves just by what we cannot do.  Rather, we also need to take into account all of our strengths and accomplishments, not the least of which is sticking it out in infertility treatment in order to try to create our families.

Friday, February 17, 2012

Not quite free to be you and me: Infertility treatment and the recogntion of our limitations

I have come to the conclusion that it is all Marlo Thomas' fault.

As a child growing up in the 1970's, I was raised on a steady diet of "Free to Be You and Me" encouragement--women, it seemed, could have it all.  They could be whatever they wanted--being professionally successful and a mother was no problem.  There were no limits. All a girl had to do was to do her best, and work as hard as she could.  This message seems to be permanently woven into every fiber of my being.  Even though I now know this is not always true, it seems like I constantly default back to this belief. I somehow manage to forget that I, like us all, have limitations, some insurmountable. Every time in my life it again proven that hard work can't solve everything, it stings just as much.  Over, and over, it is an unpleasant, and unwelcome, surprise.

Now I understand what Ms. Thomas was trying to accomplish.  For much of our history, women were discriminated against, and discouraged from entering the professional world.  I am enormously grateful that my generation of women received the encouragement and opportunities that we have.  And of course, I recognize much of the wisdom of Ms. Thomas' teachings.  In almost all areas of life, attempting to solve problems through effort and hard work is a very successful strategy.  I also believe that without trying, we may never know what we can accomplish. 

My problem with the "free to be mentality" is this--if for some reason you couldn't do whatever you wanted, then logically you could conclude that you hadn't worked hard enough or tried your best.  A problem that couldn't be solved with hard work didn't exist in this scenario.   If there were no barriers to your success, there could be no other explanations for your failures.  It is all on you.  I'm sure this logical corollary was completely unintended by Ms. Thomas.

Despite this, whenn it comes to infertility, this type of thinking can be extremely problematic.  IInfertility is not a problem that can usually be solved by effort and hard work alone.  Physical variables, and frankly, luck, seem to be the trump card in many cases.  Thus, despite all the efforts made to fix the problem, it is often experienced  psychologically as a profound personal failure.  Lest this just be my issue, nearly every infertility client with whom I have ever worked has expressed strong concerns that their infertility was somehow their fault, and that the reason that they couldn't have a baby was because they had done, or were doing, something wrong.  In all of these cases, the problems, whether they could be fully identified or not, lay outside of the person's sphere of control.

In my case, infertility turned out to be more than the inability to have a child, but realization that my philosophy of living was fundamentally flawed.  I suppose that's a good thing, because it's more realistic. In learning to accept the limitations of our bodies when it comes to creating a baby, we learn that not all things are possible after all.  This is a painful but important realization, for there will be other aspects of life in which we will also be unable to achieve our goals.

On the other hand, my infertility would have been much easier for me to cope with if I had considered the possibility that there were going to be many things in life I wasn't going to have the ability to do, and that was how it was for everyone.  It didn't mean I was a bad person, flawed, cursed, or lazy.  It was just unfortunate that my talents didn't lie in this particular direction.  Based on my clinical experience, I suspect this is the same for others as well. 

As for hard work, I still believe in its value.  When I recently discussed this issue with my mother (the one who relentlessly played the "Free to Be" album, and in many other ways promoted the omnipotence of hard work during my childhood), she was unmoved.  "Look," she said, "You have lots of problems with infertility.  And yet you still have children.  You worked hard to make it happen.  Marlo Thomas was right."  And I really do see her point, especially if you look at the big picture. 

But like most of us, during infertility treatment, I couldn't look at the big picture, mostly because it wasn't drawn yet.  So all I saw were a series of physical failures, despite maximum effort and worry on my part.  It took a while to realize that hard work wasn't going to solve the problem alone.  During that time, my self-esteem was in tatters.  It has taken years to reorganize my way of thinking, and to come to terms with my physical, intellectual, and emotional limitations. 

If you are reading this, I just hope you can learn all of this much faster than I did.  While we all can and should try to achieve our goals, we must forgive ourselves, if through no fault of our own, we cannot.  In that way, I think we can be most free to truly be ourselves.

Thursday, February 2, 2012

Misperceptions, Misinformation, and Infertility Treatment: Psychological Implications

Last week, as part of his campaign in the Republican primary in Florida, Newt Gingrich stated that if he were president, he would appoint a commission to investigate IVF clinics, as embryos (and to his way of thinking, life) are created there.  There are probably some political machinations and implications of this pledge that I don't fully understand.  However, it did get me thinking--what exactly does Mr. Gingrich think that such an investigation is going to find?    Somehow, Mr. Gingrich seems to believe that embryos are being developed for the wrong reasons or capriciously destroyed or mistreated.  The irony here, I think, is that no one values the sanctity of human life more than those who are infertile.  People going through the physical, emotional, and financial hardships of IVF value their embryos, and the children they might possibly create, above anything else in the world. 

But Mr. Gingrich is not alone in his misperceptions of and mistrust in infertility treatment.  A day after his announcement, I found myself explaining to a group of other mothers at a preschool fundraiser that the Octomom was not the norm in infertility treatment.  One woman thought that in IVF, the patient was forced to transfer back all the embryos that had been produced in their cycle, and thus higher-order multiple births were the norm.  A long discussion of embryo cryopreservation and medical ethics ensued.  The mothers seem surprised to learn that the Octomom's doctor was investigated on ethics charges, that most reproductive endocrinologists try to avoid multiple births, and the field is moving towards single embryo transfer.  All they knew about IVF came from sensationalist headlines describing the exception to the rule.

These views are often furthered by inaccurate portrayals of infertility treatment and IVF in movies and on television.  I am often stunned by the countless examples of medical inaccuracy of television shows when it comes to reproductive issues.  For instance, the show Private Practice, which frequently features themes of infertility and infertility treatment, has on multiple occasions depicted infertility treatment incorrectly.  My favorite instance involved a doctor using a microscope in the room with a patient to fertilize an just-retrieved egg, only to immediately transfer it back and pronounce her successfully pregnant, much to the joy of all in the room.  Anyone who has ever actually done IVF knows its just not that simple! It amazes me that television shows wouldn't hire a consultant to make sure they were getting their facts straight.

In addition to getting the facts wrong, television shows and the movies often portray infertility treatment in a more sinister light, pulling from the extreme situations in the news that get all the attention.  Thus, the general public tends to develop a skewed sense of infertility treatment.  For instance, a recent episode of CSI Miami focused on the murder of a sperm donor who fathered over 100 children, all of whom became suspects in the criminal investigation.  Although there have been cases where one sperm donor has produced a high number of offspring, I suspect again this is much more the exception than the norm.  However, if this is the major exposure that most people have to the idea of sperm donation, they will tend to look at it in a more negative light.  I suppose stories about wholesome people with a medical struggle doing the best they can to have a family just don't get the ratings.

My concern about the negative portrayals of infertility treatment in politics and the media is that it perpetuates the already preexisting stigma surrounding infertility.   For individuals undergoing infertility treatment, it is exhausting and demoralizing to continually have to fight stereotypes of their treatment.  The effort involved in managing the reactions of others colors every social interaction involving treatment and infertility, and takes a lot of energy.  When, as in infertility treatment, energy is in short supply, it seems a shame to have to use it to protect ourselves from judgements of others based on misinformation.  Even though I've been around infertility for a long time, and have many opportunities to process my feelings regarding it, it still felt burdensome to set the preschool moms straight about the Octomom situation.

In addition, suggestions like Mr. Gingrich's that some secret evil is going on in infertility clinics can cause individuals in treatment to question themselves unnecessarily--although they can't see how they are doing something wrong.  Almost all of the clients I work with have carefully considered, without any prompting from me, how their infertility treatment plan fits in with their sense of morality and ethics.  IVF isn't the kind of thing that people enter into lightly.   Thus, when someone in a prominent public position intimates that what they are doing is suspect, without specific information to back it up, they spend a lot of energy and time questioning themselves.  If they are already feeling shame about being infertile, they may be especially sensitive about such suggestions.  This adds to the pain of an already difficult situation, and is, as far as I can tell, completely unnecessary.

Thursday, January 26, 2012

Relational Infertility: When partners don't agree

I am part of an email listserv for the Mental Health Professional Group of the American Society for Reproductive Medine, in which mental health professionals discuss psychological issues surrounding infertility.  This week there was a fascinating discussion of what do when there is in impasse in couple therapy, in which one member of the couple wants to pursue having a child, but the other member does not.  Perhaps there is a disagreement about what method of family building to use--one person is against using donor gametes, or adoption.  Other times, the conflict centers around whether or not to have a child, or another child, at all.  On the listserv, there were different suggestions about how to be helpful in this situation, but all the clinicians agreed that these are usually very difficult and painful situations for the couple involved.

I have come to realize that there are actually many different types of infertility.  Of course, there is your garden-variety medical infertility, which in some ways, though emotionally painful, is a bit more clear cut.  There is also situational infertility, in which an individual or couple cannot pursue having a family because of their circumstances, for example, if a family member develops a serious illness, or a financial crisis occurs.  But when the members of a couple seriously disagree about if and how to have a child, then relational infertility occurs.  This type of infertility often coexists with medical and situational infertility. 

In many ways, relational infertility can be the most painful type of infertility of all.  With medical or situational infertility, the causes are usually out of anyone's control.  But when the family-building impasse is caused by a choice, the feeling is that things could be different--if only the other person would change their mind.  In a couple, such a conflict can be very difficult on a relationship.  Both partners have to face the dilemma of either having some serious regrets and resentments for the road not traveled, or conversely ending an important relationship.  This is because it is often very hard to create a compromise in these situations--you can't have or not have a baby half-way. 

One of the things that struck me about the discussion on the listserv is that my colleagues, like myself, didn't have any easy answers for dealing with such a dilemma.  I suspect that this is because there simply isn't one.  Having, or not having, children is one of the most important life decisions a person can make.  At times, the importance of these desires can override the desire for being in the relationship.

However, if you find yourself in this type of conflict with your partner, there are some steps you can take to try to resolve the situation.  The most important thing you can do is try to listen to your partner very carefully.  Even if you don't agree with their perspective, it is important to try and understand it.  Try to put yourself in your partner's shoes and see things from their point of view.  If you can develop empathy for what your partner is feeling, you may be able to become less rigid in your own position, and a solution may be possible.

In cases of relational infertility, it is also important to consider whether or not other underlying issues and conflicts you are experiencing as a couple are coloring your feelings regarding having a family.  For instance, if there are problems with emotional closeness and support in the relationship, one of the partners may be more hesitant to add on the additional work and stress of having a child.  Certainly, if one of the partners is already having doubts about continuing the relationship, he or she may not want to make the additional commitment of having a child together.

In addition, at times an individual's psychological issues can contribute to an relational infertility impasse.  For example, one couple with whom I worked was locked in conflict about whether to continue fertility treatments--the wife wanted to stop, whereas the husband desperately wanted to continue to try for a baby.  Over time, it became clear that the wife had deep-seated doubts about her own ability to parent successfully.  These doubts were rooted in her experiences growing up with her own parents.  As she became more aware of these issues, and her husband developed a greater understanding and empathy for her feelings, the couple was better able to decide together what their future would hold.

With relational infertility, the stakes are very high.  I think it must be very hard to be the person who kept a partner from his or her dream of having a child.  Conversely, it must also be extremely difficult to feel that one's partner is resentful about parenting, or not fully committed to a child.  Ending a relationship of long-standing can also be extremely painful. Thus, if you find yourself in this situation, think carefully before you act or make your final decision.  Seeking couples therapy with a therapist knowledgeable about infertility would be very helpful in negotiating such an important and life-changing decision.

Friday, January 13, 2012

Infertility treatment and the "Type A" personality

I can only imagine what must be like to be able to get pregnant and have children easily, without much effort.  The analogy that comes to mind is the ease with which I taught myself to read, at age three.  Watching public television along with my older brother, I learned the letters, their sounds, and how to put them together very quickly.  I had my own library card by the time I was in preschool.  Reading never felt like work--it was just something I did, and I took it for granted that I could read whatever I wanted. I had no idea that this was an exceptional experience, so I couldn't understand, and was probably insensitive to, other children to whom reading didn't come quite so easily. 

Of course, while reading was my strength, other academic struggles presented themselves.  My poor visual-spatial skills have created constant fodder for jokes for my friends and family.  Math, physics, and chemistry did not come naturally.  However, I was still able to achieve good grades in these subjects in school by working hard and pushing myself.

Society seemed to support my view that hard work was the only necessary ingredient for success.  After all, I learned that watching public television too.  In high school, I once remarked to my social studies teacher that a person could do whatever they wanted to in life as long as they worked hard enough.  A wise man, he sighed, took off his glasses, and told me that was completely untrue.  I argued with him, but he simply insisted--a person cannot do whatever they want just by working hard, as different people have different abilities, and there is also the involvement of luck. At the time, I felt he was being negative and discouraging, and I did not believe him.

Well, I believe him now.

Like almost everyone, I assumed that when I wanted to get pregnant, it would happen according to my schedule and my timeframe.  I couldn't fathom that it might not happen when I wanted it to, much less at all--and if so, there might be very little I could do about it.

In the early stages of infertility treatment, I clung to my approach of working hard in order to achieve my goal.  When treatment started going badly, I resolved to fight harder, to do more, and to keep pushing myself.  I felt that if I just tried hard enough, I would get pregnant.

When it finally began to dawn on me that no matter how hard I tried, I couldn't overcome certain biological problems, it caused a great deal of emotional turmoil.  Not only was I very upset about my infertility; my entire world-view had been shattered.

I know that my story is far from unique because I hear it from my clients every day.  In so many cases, infertility is the first real life stumbling block that cannot be overcome by hard work.  Like me, my clients also must grapple with their grief and anger about infertility in the midst of developing a new approach to solving problems.

If you are reading this blog, chances are that you are also a hard-working, high-achieving sort of person yourself.  If you too are struggling with the fact that your typical life strategies aren't working with your infertility treatment, know that you are definitely not alone.

It's important to realize that however hard you work at your infertility treatment, it will not be the deciding factor in whether or not is successful--that ultimately, success is left in the hands of biology, chance, and perhaps fate.  By acknowledging this, you can let yourself off the hook a bit, and see that your don't need to work as hard as you have, perhaps exhausting or depleting yourself in the process.

On the other hand, it's important not to stop working hard altogether.  Although hard work cannot ensure that treatment is successful, it can give you the best opportunity you can have to get pregnant.  By making sure you understand your diagnosis and treatment options, and by following your treatment protocols to the letter, you can at least ensure that you've given treatment the best try possible.  That's important later on--you don't want to feel that you have regrets that you could have done more.

In the end, it's like so many things--a balancing act.  We must work hard enough to make sure we get the best treatment possible, but then we have to acknowledge that there is a limit to what our hard work can achieve.  Once we've done everything we can do to further treatment, then we should rest, and try to focus on other areas of our life.  This, of course, is easier said than done.  But by recognizing that hard work alone doesn't cure infertility (or many other problems, for that matter) we can have more energy to devote to other aspects of our lives, thus making infertility treatment more bearable.

Friday, January 6, 2012

Not-normal is the new normal: Infertility in perspective

I apologize for not posting as much as I would have liked to in the past several weeks.  I've been in a sleep-deprived haze, and had difficulty even thinking in coherent sentences--much less writing them.  Things are better now, thankfully, as I am back at work again.

During my break, I've had another opportunity to think about my own infertility and what it has meant in my life.  For me, the bottom line is this--infertility was a real deviation from the "normal" life I had envisioned for myself.  Like everyone who experiences infertility, I was forced to give up my dreams and expectations about how I would have a family.  This was difficult and painful in and of itself, but on top of this, I had to work extremely hard in infertility treatment and in our adoption.  After all, nobody makes you get IVF, or adopt--it is a choice, and you must make the process happen.  As we all know, these processes are difficult, time-consuming, and sometimes heartbreaking.

Even after I had children, I still struggled with not feeling "normal", and a bit envious of others who were able to take the typical path to parenthood. My adopted daughter, fine now, initially had some health issues that took quite a bit of time to resolve.  In my pregnancies, my body, ever uncooperative in the reproductive arena, continued with its contrary ways.   However, as time has passed, although I still don't feel "normal", I'm around enough parents, kids, and families to realize that pretty much every one of them has some sort of issue or problem that makes them "not-normal" also.  I mention this because when I was undergoing infertility treatment, it was so painful for me to be around babies, kids, and their hangers-on that I didn't get close enough to see the details of the situation.  I imagined that everyone else was having a perfect life--certainly a better life than me.   Many of my clients have echoed similar sentiments. 

Once I started to let go of my expectations of "normalcy", everything started to seem clearer.  It was, emotionally speaking, a much less complicated task to just do what I needed to do in my particular situation to have a family.   I guess if I had to do it all over again, I wish I would have let go of these worries about being normal much earlier in the process than I did.  I think I could have saved myself a lot of anguish, and had more energy left for the formidable tasks that were at hand.

If you also find yourself feeling bad because your situation is not "normal", I hope you can learn from my mistakes, and try to move past this worry, because I don't really believe there is a "normal" way to have a family.  There are just different ways to have a family, and they all have the potential to be wonderful and problematic, all at the same time.  Try to keep in mind that the fertile world has its share of problems too, and that although you must take a different path, it is not a lesser one.

Also, I'd like to wish everyone the best of luck with all of their adventures in the New Year.  If you have any questions, or suggestions of topics you'd like me to address, I'd love to hear them!  Please don't hesitate to comment or send me an e-mail at lisarouff@gmail.com.