"Just relax"...again? Does a reduction in anxiety levels increase pregnancy rates? Summary of a new meta-analysis

As a former infertility patient, and as now as a psychologist working in the area of reproductive mental health, the oft-repeated statement, "Just relax, and it will happen (referring to pregnancy)" has always made me cringe.  It has always seemed overly simplistic and somewhat pejorative--as if the woman's feelings were somehow preventing her from conceiving.

Thus, I did a double-cringe when I first read the abstract for the following article:

 Frederiksen, Farver-Vestergaard, Gronhoj Skovgard, Ingerslev, and Zacharaie (2015) Efficacy of psychosocial interventions for psychological and pregnancy outcomes in infertile women and men: a systematic review and meta-analysis--- which can be found here.

In this study, the authors conducted a meta-analysis of 39 different studies.  The studies looked at the effect of psychosocial interventions on mental-health symptom reduction and clinical pregnancy rates in research subjects undergoing infertility treatment.  A meta-analysis uses other clinical studies found in the literature as its source of data.  Studies were only included in this meta-analysis  if they studied infertile participants, presented data regarding some sort of psychosocial intervention program (such as cognitive-behavior therapy, group therapy, etc.), measured outcome variables such as stress, distress and pregnancy outcome, both before and after the psychosocial intervention occurred, and used a quantitative research method.  The data for the 39 studies were analyzed for a number of variables.  Interestingly, they found that women who had received any type of psychosocial intervention were twice as likely to become pregnant than women who had not received psychosocial treatment.  Although they found that the psychosocial interventions were effective at decreasing both symptoms of anxiety and depression, only a reduction in anxiety levels was significantly correlated with an increased pregnancy rate.

On the face of it, this is a quite dramatic finding.  The authors theorized that increased anxiety levels could have a negative effect on the uterine environment, and could thus negatively impact pregnancy rates.  However, they also reported a number of limitations to their study that might also explain their results.  For instance, there was no distinction made as to type of infertility diagnosis or type of infertility treatment received among the different studies.  Obviously, the level of severity of the infertility diagnoses involved among the different studies would have a large impact on pregnancy rates, as would the types of medical treatments offered.  Secondly, the authors of the meta-analysis had no access to the pregnancy outcomes for women who dropped out of the studies.  Without this information, it is hard to obtain a complete picture of what really happened.  In addition, the authors had to contend with "publication bias"--meaning that usually only studies with statistically significant results are likely to be published.  Although information that disproves a hypothesis might be just as important from a scientific perspective, it often is not considered as desirable for publication, leading to the "drawer effect"--it gets left in a desk drawer and never sees the light of day again.  For this reason, looking merely at published research can give a skewed perspective on an issue.  The authors did attempt to find unpublished studies to include in their meta-analysis, but as you can imagine, this is a difficult task.  Thus, the results of their meta-analysis might be skewed in a positive direction towards the positive effects of psychosocial  intervention.

As a mental health clinician, I would love to believe that the psychosocial interventions I offer would double the pregnancy rates among my clients.  Not only would it be great for business, but I would love it if I could have that kind of positive impact on helping people solve such a difficult problem.  However, I have my doubts.  To me, I think the key problem with this study is its inability to distinguish between the types of infertility diagnoses among research subjects.  Imagine Patient A, who has a mild but correctible type of infertility diagnosis.  She receives the appropriate medical care along with a psychosocial intervention.  The psychosocial intervention helps her to better cope with her situation, but as she learns more about her diagnosis and her medical treatment commences, she feels less anxious because she is justifiably optimistic about her prognosis.  And as things go according to plan, she becomes pregnant, and there is a nice, happy ending.  Now imagine Patient B.  Patient B has an unexplained infertility diagnosis with some indications of a larger, more serious problem (let's say her AMH and FSH levels are borderline, for example).  Patient B might not get assigned a psychosocial intervention treatment due to luck of the draw.    As her infertility treatment progresses, it doesn't go well, with failed cycles, and her prognosis looks poor.  Naturally, she's not going to get pregnant during the study, because she has an underlying medical problem which prevents it, and she's also going to understandably get more anxious and distressed as she realizes what her situation truly entails.  But we can be pretty sure that her anxiety isn't at the root of her problems getting pregnant.  As you can see from these two examples, diagnosis and situation makes all the difference--but the study isn't able to pick that up.

Thus, I don't think this study really can tell us with any certainty that decreased anxiety levels are associated with increased pregnancy rates.  I believe that psychosocial interventions, such as therapy, relaxation training, or support groups can be helpful during infertility treatment, in that they can provide support and coping tools during a difficult time.  I think that is an incredibly valuable thing in and of itself.  But I don't think that the data support the idea that a psychosocial intervention is going to increase pregnancy rates.

I also think we can all still be justified in getting annoyed the next time someone tells us to "just relax".

Thank you as always for reading, and I look forward to any comments and questions you may have!

Hello Again!

Back to blogging after a long absence!

I don't know exactly where all the time went between my last post and this one!  Actually, to be honest, I do know.  Things got really busy with clinical practice, and at the same time, things became somewhat challenging personally as well.   For a long time, the act or writing seemed to require more emotional energy than I had to spare.  And of course, there is the classic snowball effect.  The longer you let something go, the more difficult it is to get back to it.  So the months turned into years...and here we are.

Although I'd stopped writing about infertility and it's discontents, I certainly haven't stopped thinking about it, and there are so many times that I've had moments that I wanted to share in this blog.  But to begin with, I want to relate this clinical vignette that recently occurred, which I feel best exemplifies my experiences in the meantime:

I was having a session with a client who does not have a history of infertility.   What she does have is a long history of anxiety.  She has lived her life constantly afraid; afraid of natural disasters, afraid of storms, afraid of criminals, afraid of car accidents, afraid of an airplane crashing on her head, etc., etc.  We were discussing the recent changes in her situation, which of course have her feeling unsafe, when it occurred to me: she has the fantasy that there will be a time in which none of these threats exist, in which she will feel safe.  Thus, she keeps trying to do whatever she can to make this possible.

Being the killjoy that I am, I waited for a pause, and then stated that I thought that there had never been a time in human history when things were safe, or went well.  In fact, right now might just be the safest time, ever.  And she was right, it wasn't too safe--but that perhaps complete safety was impossible.

After a pause, she asked me, "So what you are basically saying is, life is unsafe and it sucks.  And there's nothing I can do about it."  I replied, "Yes, that is what I am basically saying.  And I'm also saying that you probably need to get used to it like that, because it's not going to change."

My client, who was gracious enough to have another session with me after this display of my charm, told me that although she found my words quite upsetting, she also found them liberating.  With the possibility of achieving a safe world off the table, she had more energy to put into enjoying her unsafe world.

I think the same principle holds true for dealing with infertility; for so many of us, the loss of the fantasy of the easily-conceived baby and the the easy, adorable pregnancy is one of the most painful aspects of infertility.  Only by allowing that fantasy to diminish in intensity can we experience any amount of relief.  If there is one thing that infertility reveals to us, it's that our world isn't perfect, and it's never going to be.   

I hope to be writing more regularly in the future, and as always, appreciate your comments, thoughts, and suggestions.

Tales from the other side: setting realistic expectations of life after infertility

When I was struggling with infertility, having a child was almost like finding the "holy grail".  I was convinced that if I could just start my family, all of my problems would be solved.  I must add that most of this expectation was held unconsciously; regardless, boy was it ever wrong!  I am fortunate to be the mother of three (at this moment) reasonably healthy children, but I can't say I have ever approached the nirvana of a relatively problem-free existence.

I know from my clinical experience in working with individuals and couples struggling with infertilty that I am not alone in this belief.  Perhaps it's one of those working fictions that we need to keep us going during difficult times.  If we really recognized that difficult times don't really end, but just lead to difficult-in-a-different way times, we might just curl up in a ball and call it a day.  However, the usefulness of this fiction often dissipates after the infertility struggle is, at least overtly, over.  Often, I see people struggle with the expectation that once their child or children arrive, they should be over-the-moon happy all of the time.  When they don't always feel this way, they worry that they are not grateful enough, or that after they have endured, they are somehow not "doing it right".  Of course, it is their expectation that is inaccurate...most likely, their feelings are completely normal and expectable give their current situation,

In order to create a more realistic picture of life after infertilty, I will describe some of the more common experiences I have witnessed in the lives of others as well as my own life.

1.  Pregnancy after infertility is often filled with anxiety.

Instead of shouting with joy from the rooftops, many newly pregnant infertility patients are riddled with anxiety and fear.  This is usually quite the opposite of what they expected.  They live anxiously from beta to beta and ultrasound to ultrasound.  Every early pregnancy symptom is examined and reexamined.  As the pregnancy progresses, the anxiety dissipates somewhat, but it never totally goes away.

2.  Childbirth and breastfeeding can be difficult and can add to the already negative feelings you may have about your body.

For many infertile women, childbirth and breastfeeding seem like an opportunity to finally be and feel "normal".  That's great if everything works out the way you hoped.  Unfortunately, many women with infertilty are at at higher risk for difficult childbirth and breastfeeding troubles.  For some women, having an unexpected c section or milk production issues can feel like another body "failure", adding to their still painful feelings about their infertility.

3.  Your child isn't going to be perfect, and you aren't going to be the perfect parent, no matter how hard you try.

Of course, this is true of any child and any parent.  However, many parents who have a history of infertility have lingering, unconscious expectations that because they have been so committed to building their family, they need to be perfect parents.  When they fail at the impossible, they can be too hard on themselves.  Sometimes, they may unconsciously  blame themselves or their infertility for whatever difficulties their child might be having, even though chances are, it's completely unrelated.

These are just a few experiences I have noted, and I would love to hear about the experiences and observations of others, so please leave a comment!

Also, even though the parenting experience isn't a perfect one as we may have envisioned, it can be very rewarding--perhaps more so if we free ourselves of unrealistic expectations.

Thanks so much for reading, and as always, I look forward to your comments and questions!

More decisions; medical decisions, emotions, and infertility treatment

I often think that if I ever were to write a book on psychological issues, it would be on how individuals make decisions about their medical care.  I find it fascinating and sometimes frightening how much emotional issues can affect and impair the ability to make good health care decisions.  Unfortunately, I have seen this lead to very sad and perhaps avoidable negative outcomes,  in the area of infertility and in other types of illness as well.

In this post I will discuss some emotional issues that commonly interfere with the ability to make sound medical decisions.  The first, and perhaps most serious problem is an overuse of the denial defense.  We have all heard stories in which a person notices some significant medical change, like a lump, and copes with their anxiety about it by using denial.  They do not seek medical treatment and often don't alert loved ones about the problem until it is too late.  My own father-in-law, a dear, wonderful, and educated man, ignored the warning signs of his colon cancer for years.  When the family finally became aware of and responded to the problem, it was too late, and he died a few weeks after his diagnosis.

In the infertility world, this can occur when individuals fail to seek treatment even though they meet the criteria for infertility.  They often trust that it will "just happen when the time is right".  Meanwhile, the clock is ticking, and if there are ovarian reserve issues at play, time may be running out.  I sometimes see women in their late 30's or early 40's remain convinced of their ability to conceive naturally with their own eggs, despite much objective evidence to the contrary.  Perhaps in some of these cases there is an underlying ambivalence about having a baby, but regardless inaction at this crucial time may ensure that they lose whatever opportunity of using their own eggs that remains.

Another type of emotional issue that can impair medical decision making is feelings about the doctor-patient relationship (or transference as we psychodynamically trained therapists like to call it).  Feelings of loyalty to a doctor may make it difficult for some people to seek a second opinion.  They may have idealized their doctor and be unable to recognize or admit that their doctor has missed something or made a mistake.  Alternately,  they may find it difficult to trust others, especially medical professionals, and therefore are unable to provide a complete symptom picture, leading to under diagnosis or misdiagnosis, which then unfortunately only increases their mistrust.  Even if they do receive the correct diagnosis, their feelings of mistrust prevent them from following treatment recommendations, which can have tragic effects.

As you can see, making sound medical decisions requires the ability to deal with your feelings directly, and to be able to acknowledge anxiety-producing situations.  It also involves the ability to trust and value the opinion of others, but not so much so that you cannot examine these opinions critically.  These emotional abilities are not always easy to obtain.  In an emotionally charged situation such as infertility treatment, it is even harder to apply these skills.  Thus, it is important, when you are making treatment decisions, to take a moment and think about whether you are using denial, or if your emotions about your doctor could be interfering with your ability to critically examine their recommendations.

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

Decisions, decisions: a few thoughts about deciding how many embryos to transfer

One of the difficult parts of an IVF cycle comes near the end when the decision about how many embryos to transfer back must be made.  From a medical standpoint, this decision can be difficult because there are no hard and fast rules; every individual situation is different and involves multiple factors such as embryo quality, maternal age, prior treatment history, etc.

From a psychological standpoint, the decision about the number of embryos to transfer can be tricky as. Well.  Usually, these decisions need to be made quickly because the information about the embryos is only available right before the transfer. Further, by this point in the cycle, emotions and hormone levels as running high, making clear and rational thought a challenge.

Perhaps most importantly, however, is the fact that by the time a person is usually facing their IVF transfer, they have been dealing with infertility for a while.  Thus, they are naturally desperate for the whole thing to be over and done with as soon as possible.  The idea that putting another embryo or two back might increase their chances of success, meaning they could be on their way to parenthood very soon, is quite seductive.  If financial issues are a concern, an increased chance of success in fewer cycles is also a strong motivation.

I hear many clients tell me that their ideal outcome of an IVF cycle would be twins.  "Two for the price of one," and "buy one, get one free," are common refrains.  I totally understand that sentiment.  I think I may even have said those things regarding my own treatment at one point or another.  However, part my practice involves working with people who have experienced perinatal loss and/or who have given birth prematurely and whose children have spent an extended time in the neonatal intensive care unit.  Many of these people began their path to parenthood via IVF, and transferred multiple embryos.  There experiences in the NICU are often extemely difficult, traumatic, and of extended duration.  All of them have expressed a wish that someone had really helped them understand the risks associated with multiple pregnancies before their IVF transfer.

In addition, even if things work out medically, my work with the parents of multiples has taught me that having twins or triplets can sometimes be hard on a relationship as well, especially if there are other life stressors occurring simultaneously.

I don't mean to be full of doom and gloom here, as I know many healthy and happy families with twins and triplets.  But I do urge people to really educate themselves about the medical and psychological risks associated with multiple pregnancies before they get to transfer day, so they are prepared.  The good news is that with today's improvements in embryo freezing technology, single embryo transfer is a more viable option with a greater chance of success.

Sometimes the decision about how many embryos to transfer is made for you by the situation; you may only have one viable embryo, or the quality of the embryos may suggest transferring multiple embryos.  If you do end up with a choice, then you need to weigh the risks of multiple pregnancy against the emotional and physical wear and tear of doing another frozen embryo transfer.  After seeing the problems that can arise with multiple pregnancies, I find myself recommending single embryo transfer more often these days.

Of course, the decision about how many embryos to transfer back is a personal one, and can only be made by you and your partner.  Just be sure that you have all the facts, so you can make the choice that is best for your situation.

Infertility, pregnancy, and self-esteem

I was picking up my daughter at a class the other day, when I overheard one of the other mothers talking to the school director.  "Did my daughter tell you our news?" she asked excitedly.  It turned out that this woman was unexpectedly pregnant, after undergoing infertility treatment to conceive her children.  Her face was all aglow, and she went on and on about how she was finally normal, finally experiencing a miracle.  To her credit, the school director told her, "Well, I think all your children are miracles," but that really didn't even slow her down.

I left feeling uneasy, and frankly, a little irritated by what I had overheard.  I was also irritated at myself--shouldn't I be as happy for this woman as she was for herself?  After all, she was experiencing the holy grail of infertility treatment--the spontaneous pregnancy.  As I further considered my reaction, I realized that what was really bothering me was this woman's assertion that now, and only now that she had achieved a pregnancy without treatment, that she was normal.  That now, she could feel good about herself.

The more I work in the field of infertliity, the more I am able to see how much we, as a society, tie the concept of fertility in with our sense of self-esteem.  If a woman can be pregnant and successfully deliver a baby, she's normal and good; if she can't, she's something else--at best someone to feel sorry for, and at worst someone who God/the universe is trying to tell that she doesn't really deserve to be a mother anyway.

The pain that this societal assumption causes is immense.  Further galling, anyone who thinks rationally for any amount of time about this assumption will realize it is patently and ridiculously untrue.  Of course we all know supremely fertile women who are failing miserably at parenting; and we all know (and might well be) supremely infertile women who will make amazing parents once their infertility crisis is resolved.

I guess this is why I felt so annoyed with the woman at my daughter's class-a feeling of "et tu, Brute?"  After all, she is one of us--and yet she still bought into the fertility=normal/good equation hook, line, and sinker.

After a long and protracted battle with infertility and my body in my quest to have children, I have come to realize that I can't let my infertility define how I feel about myself.  It was all beyond my control anyhow, and even if it wasn't, I can't feel worse about myself because of it.  In the same light, I can't feel like I'm a better, normal/good person because today my lungs are functioning well.  That's out of my control too.  Instead, I must judge myself on how I respond to my circumstances, and how I treat others in my life. 

I hope if you are struggling with infertility, you try to do the same; remember that fertility, or infertility is not the measure of a person.  Our efforts, our choices, and our treatment of others are much more valid criteria for self-assessment.

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. 

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.

"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!

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.

 

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.

On loss and miscarriage after infertility

Today, of course, is the tenth anniversary of the terrible events which occurred on September 11, 2001. For all of us, it is impossible to avoid thinking about where we were when we heard about the attacks. But for me, I also can't help remember what I was that day--which was pregnant, for the first time.


I was driving through Chicago gridlock to get my second hcg level drawn when I heard the news that planes were crashing into the World Trade Center. It was following my first IVF, which was a disaster all around, and worthy of a blog post in its own right. I was shocked and horrified all day long as the events unfolded. In addition, I was quite anxious and worried, waiting to hear "the number" from the IVF clinic. When it more than doubled, I was ecstatic, and yet I felt terribly guilty, feeling happy when so much tragedy had occurred.


But my happiness and excitement was short-lived. A few weeks later, my first ultrasound revealed a sac but no heartbeat. After a torturous week of waiting, another ultrasound confirmed my suspicions--I was having a miscarriage. I remember before the ultrasound appointment, I looked online at all the different stages of fetal development, and I had a feeling that my pregnancy would never progress in that way. I remember the way my husband, unable to reach my hand, grabbed my foot when the ultrasound technician told us there was not going to be a baby. I remember crying so hard in my RE's office that he escorted me out the back door of his office, I think less for my own comfort than his fear that I would scare the other patients in the waiting room.


The next afternoon I was scheduled for a D & C. I took a walk in the morning, thinking this was the last thing my "baby" and I would do together. At the hospital, things went worse. As I was waiting to go into surgery, crying the whole time, I heard the patient in the next cubicle, crying herself, only for a different reason--she had just found out she was pregnant, and therefore unable to have her surgery.


After the D & C, my hcg levels would not drop. Every week, I was back at the RE's office for more blood draws. During one of them, one of the nurses (and she was not, unfortunately, one of those great nurses we all know and love) questioned me as to whether or not she should put "pregnant" as my diagnosis--technically I was pregnant, but we all knew the situation. As do so many women who suffer a miscarriage, I desperately wanted to cycle again and get pregnant as soon as possible--but my body was not cooperating. Another ultrasound revealed that fetal matter had been left in my uterus during my D & C, so I had to have another one two months later. All in all, it was not a pleasant experience.


When the chromosomal test results came in from the D & C, the nurse was reluctant to tell me the sex of the fetus, but relented after I pressed her repeatedly--it was a boy, and the chromosomal tests came back normal, leaving the cause of the miscarriage, like so many, a mystery.


Although it has been ten years since these events occurred, I can still feel the sting of them. I am often asked by clients when the pain resulting from miscarriage and loss goes away. My best guess is that it doesn't really ever leave us, although the intensity of the feelings does lessen over time.


I have often thought about writing a blog entry about coping with loss and miscarriage after infertility, but the same thing has always stopped me: I don't have any words of wisdom about this subject. To me, every miscarriage or loss just seems really, really sad. There doesn't seem to be any way to avoid that. Although it is a relatively common experience among women, infertile or no, it still seems a very personal and cutting loss. The best I can offer is to listen to and sit with all the sad feelings that come up, and to pass the Kleenex when needed. A friend of mine, after struggling with infertility, lost her baby to a chromosomal disorder at 32 weeks, and with her, it seemed like she was grieving in some sort of emotional ditch. All I could do is crawl down into the ditch with her, listen, hold her hand, and try to bear witness to her incredible sadness.


The other odd thing about recovering from a miscarriage or loss is that life goes on, and so do we. As I watched my adopted daughter today, participating in a balloon release to commemorate 9/11, I reflected that if I hadn't miscarried my first pregnancy, it was unlikely that she would be here, in this town, on this football field, releasing balloons. I could not have loved her more than at that moment, and yet I still felt sad about the little one that never was to be. So many of my clients have reported a similar mix of happiness and grief, all jumbled together. I don't think there is any way of avoiding those feelings either.


To me, it is even more surprising that on this ten year anniversary of my first confirmed pregnancy, I find myself pregnant again, with a boy, who will hopefully be born healthy and happy in a few weeks. Like all mothers and mothers-to-be, I just hope that my children and I can make it through this day together, and for all
of the days that follow.

Our emotional relationship with embryos created in IVF: some thoughts

I have been having a problem lately keeping the pet fish in our tank alive. Despite my best efforts at following all of the rules (feeding properly, changing the water often, etc), watching the fish closely, and medicating them if necessary, I have somehow become the fish equivalent of the Grim Reaper. All of this has been upsetting, but also has felt eerily familiar. When I noticed the latest victim floating at the top of the tank at 4 am today, it occurred to me that this is because this is very similar to how I have felt about the many embryos my husband and I created through our IVFs--despite all my best efforts, I couldn't seem to keep most of those alive either.

In some ways, the argument about when life begins seems like a nonstarter to me. I know all too well that an embryo is not necessarily a person. True, it contains the potential to become a person--perhaps, if all the conditions are right. But I also know that an embryo can break your heart. When people bemoan the thousands of embryos that are frozen in storage at IVF clinics around the world, it shows me that they haven't spent enough time hanging around with embryos. I know that many of those embryos would never have a chance of becoming a baby in the first place.

It is a interesting side effect of our modern age that we can now develop an emotional relationship (albeit a probably one-sided one) with embryos. During an IVF cycle, it is very easy to develop fantasies about the embryos we create. Looking at their pictures, we can imagine them growing into our beloved children. We pin all of our hopes on them. It seems to be almost a universal psychological aspect of IVF, especially in the first couple of cycles. A friend of mine, during her first IVF, created 24 embryos. She celebrated, sure she would get pregnant with that kind of haul. "It's enough for a baseball team!", she exclaimed, as we popped the champagne. She didn't get pregnant, though, and none of those embryos survived to Day 5. She didn't get pregnant in any of her ensuing IVFs, either. Not to worry, she and her husband adopted two incredibly smart, lovely girls, and are completely happy with their family, as they should be.

As for me, my first IVF was not so fruitful. I had 4 embryos that had any serious chance of success. I remember planting four plants in my garden to commemorate them. The plants later died. One of the embryos got me pregnant, only to miscarry at 7 weeks. To honor him (chromosomal testing revealed it was a boy), I planted a shrub in my garden, only it didn't take root. The next spring, I kept waiting for it to start to grow again, to no avail. I think I finally gave up in July. I planted St. John's Wort in the same spot instead--for its antidepressant properties if nothing else.
It did just fine.

Such experiences, along with the experiences I witness among my clients, make me wonder if getting emotionally attached to embryos is at all wise. However, the same experiences also make me wonder if getting attached to embryos is somehow unavoidable. Even the most veteran, jaded IVF patient seems to harbor secret, unspoken fantasies about his or her embryos, although they are long past the point of celebrating them or commemorating them in a garden. What makes this so hard is that although not all embryos are going to turn into babies, some indeed do--and it's hard to definitively tell which ones are capable of doing that at the outset. In contrast to my first IVF cycle, my last cycle was with our one last, remaining, frozen embryo, created four years ago. We cycled to complete our infertility story, but without expectation that it would result in a baby. Now, at 33 weeks pregnant, it appears this embryo had other plans, and we are hoping for a good outcome in October. But to be honest, I never would have guessed it was possible.

If you are undergoing IVF, I would caution you to try to remember that an embryo is a possibility, not a promise, of a child. However, if you find yourself having lots of feelings and fantasies about your embryos, I think that's probably par for the course. The important thing is to acknowledge how you feel and give yourself permission to process these feelings, no matter what happens in your cycle.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When POASING may be helpful

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

When POASING might not be for you

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

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

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

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

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


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

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

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

Shame, infertility, and why we shouldn't feel that way anymore

Well, it's been quite a week around here in my practice. I don't know if it is the stress of the holidays, the subzero temperatures, or perhaps the near lack of sunlight, but I've been hearing a lot this week about shame.

Shame is a common emotion that occurs when someone is undergoing infertility treatment. Each time I hear a person talk about feeling ashamed of their infertility, this argument presents itself--they feel ashamed that there bodies aren't functioning "normally", and thus they can't easily reproduce and fulfill their alleged biological imperative. In this way of thinking, for women, the ability to become pregnant and produce healthy babies is their most defining feature.

Thus, I hear client after client tell me how ashamed they are of their bodies because of their infertility. The real shame in all of this, from my perspective, is that I’m hearing this from wonderful, heroic people who are doing an amazing job with their infertility treatment. They are doing everything right—working hard to maximize every possible variable they can control.

Here's the other thing I've noticed--the shame doesn't stop at infertility. Even in the fertile world, women struggle with feelings of shame about their reproductive abilities. I recently met a woman who had five children, but felt horrible about herself in comparison to her sister, who had nine children. My acquaintance, although she got pregnant easily, had difficult, high-risk pregnancies and deliveries. She felt ashamed of her body—why couldn’t she do things as well as her sister, who had easy pregnancies and deliveries? Another woman I know feels terribly ashamed of her body because she used an epidural in the delivery of her child, rather than delivering naturally, like her mother did. A friend confided that she felt ashamed that she couldn’t successfully breastfeed her baby, who had severe food allergies.

In all of the above situations, everyone was doing their absolute best, and nobody could do anything else that would change the medical outcome of their situation for the better. So why did feelings of shame have to come into the picture?

I think our society has a lot to do with women’s feelings of shame about their bodies when it comes to reproduction. I've realized that the emphasis on reproduction, although it does have biological elements, is largely a societal construction--and probably, at this point, an archaic one. In an agrarian, monarchy-based society, producing heirs, and children/laborers, is important for the survival of the society.

But things are different now. Given the change in women’s roles in the workplace, not to mention our global overpopulation problems, defining women by their reproductive capacities, on a practical level, isn't such a smart idea anymore. And yet, so many women are still buying into the idea that their reproductive capacities are central to feeling “normal”, or to their self-worth.

The thing about feeling shame about things over which you have no control is that ultimately, it’s a big waste of energy and effort. The shame doesn’t magically improve the situation or provide you with more control. It just makes you feel lousy and therefore less able to function at your highest level. Shame about infertility doesn’t help you, and it doesn’t really help society either.

However, I do have a solution. The great thing about societal constructions is that they are just that—arbitrary constructions—and not actual reality. Therefore, they can, and do change over time. As individuals struggling with infertility, we can simply decide not to buy into the societal values about our bodies when it comes to reproduction. Instead, we can work on not blaming ourselves for things over which we have no control.

So please, please, do me a favor. If you find yourself starting to feel shame, take a moment and think about why. Did you just purposefully run over your grandmother’s pet weasel? Have you recently financially defrauded starving orphans? If so, go right ahead—be ashamed of yourself with my compliments. However, if you are feeling ashamed about your body, your infertility, or anything else over which you have no control—could you please try to stop? Because trust me, you don’t deserve it! And if you hear a friend start down the shame path, could you remind her to stop too? Not only will you be feeling better about yourself, but you’ll also be improving society. And in that, there is no shame at all!

Upsetting things people say, and what to say back: self-protection during infertility treatment

If there is one thing that I have learned from my own infertility, it is that people can say some rather insensitive and mindless things! Enduring countless questions about when you are going to start a family, admonishments that you certainly aren't getting any younger, and other helpful "advice" can wear on a person, especially a person who is already experiencing a lot of stress and disappointment. The holidays, with their many family and social engagements, especially seem to be a hotbed of activity in this regard.

It's hard to know how to respond to these types of comments. I myself still struggle with this issue, and many of my clients describe similar dilemmas. In this blog, I will outline some creative strategies of responding to these situations that may be useful.

Striking a chord

I think one of the hardest aspects of responding to upsetting comments is that they often stir up our own feelings of inadequacy or self-blame about our infertility. As I have discussed in a prior post, it is quite common for individuals experiencing infertility to worry that somehow their medical problems are caused by their actions, beliefs, or feelings, despite all evidence to the contrary. Thus, hearing, "You just need to relax" for the zillionth time can reinforce our feelings that we are somehow doing something wrong, and that is the root of the problem. Our emotional reaction doesn't take into account that rather than a lack of relaxation, there are medical issues at play--and the speaker likely does not have any expertise in this area. In addition, if infertility has already taken a toll on self-esteem, hearing about how so-and-so became impregnated merely by her husband looking at her can heighten feelings of inadequacy.

When you are experiencing negative feelings about yourself, it can be hard to formulate a response to the comment or question right in the moment. This is why I believe it is important to try to anticipate problematic comments or questions in advance. I'm not suggesting getting paranoid about it, but it can be helpful to consider what might be said or asked, and by whom. As you start thinking in this way, you will find that certain situations call for such comments, and that certain individuals can be counted on to say something insensitive or unfortunate. Planning in advance can help you to develop a plan you can implement if and when verbal misfortune occurs.

They started it!

When responding to insensitive or inappropriate comments or questions, it is important to consider that although society teaches us to answer questions when asked, and to try to be polite no matter what, in reality we have much more freedom in terms of our responses. In my way of thinking, if somebody else has already crossed a social line, then all bets are off! We often fear breaking a social rule because we worry the consequences will be severe. After you try it in one of these situations, however, you will realize that in actuality we have much more flexibility than we may believe.

Let's say someone has just said something inappropriate or upsetting to you regarding infertility or family building. How do you respond? I have a few approaches you may not have previously considered that might work for you depending on your needs at the moment.

Stonewall.

Sometimes saying nothing at all says the most. We are trained otherwise, but it is true that just because someone asks you a question doesn't mean you need to answer it. So many times, the questions that people struggling with infertility must endure are very intrusive. For instance, you probably don't go around asking fertile people with whom you are merely acquainted what sexual position they used to conceive their children. So a silent stare, and a change of subject, might be just the trick in these situations to set your boundaries in place.

Educate.

Many times, instead of answering questions or responding to comments, I have found myself giving a little manners lesson to my unfortunate conversational partner. I don't know whether they found this to be a helpful lesson, but I do know it certainly made me feel better. I was especially inclined to do this when someone pressured me about not having children, and not getting any younger. I would tell them, "You know, let me give you a piece of advice. You really shouldn't be going around making these statements or asking people these questions. You never know if someone is having a problem having children or not, and if they are, the things you are saying can be very painful. I'm sure you wouldn't want to cause anyone to feel upset, so this is why I bring this up." This usually shut down the conversation right away, although not surprisingly, I never got the sort of thanks I felt I deserved for imparting this sage wisdom.

Be outrageous

Sometimes in these situations it is most effective to think outside the conversational box. The best example of that I can think of is not infertility related, but does illustrate the point. When I was growing up, my mother provided foster care and adoptive homes for orphaned cats. Sometimes, quite a few of them were with us. Of course, they had to eat, and my mother, being thrifty, wanted to buy the cat food when it was on sale. She would get embarrassed though, buying all the cat food because people would always ask her questions about how many cats she had, why she had them, and wasn't she crazy for having all of those cats? Finally, she got so tired of this that she sent my father to buy the cat food instead. He loaded his grocery cart full of cat food, and as usual, he was approached by a woman who wanted to know how many cats he had. With a straight face, he looked at her and said, "Ma'am, we don't have any cats." He left it at that, and rolled off his cart as she struggled to contemplate what other possible uses there could be for all of that cat food.

I am sure you can come up with similar zingers for your particular situation, especially with a little advance planning. Not only will you be able to protect yourself and effectively end the line of conversation or questions, but you also may enjoy doing so.

Get the heck out of there

Sometimes, none of the above strategies are going to work. You might already be so overwhelmed with emotion that you can't continue the conversation any more. In these cases, if it feels too hard to continue, then simply excuse yourself. Try to do something that will comfort you and help you feel better, whether it's a good cry in the bathroom or hanging up the phone and yelling at the wall. You can always deal with the consequences of exiting the situation later, and hopefully the person will understand. If they don't, then it doesn't reflect well on them, does it? Dealing with the difficulties of your own situation is probably hard enough--you don't need to worry about saving the feelings of everybody else too.

This is your brain on fertility drugs: psychological side effects of medication

Usually, at the RE's office, new patients are told that fertility medications may make them "a little moody". This is not exactly true--ask any IF veteran, and she will tell you that they have the potential to make you VERY moody. At no time was this more clear to me than during my two month stint on Lupron Depot to treat my endometriosis. After throwing my body into sudden menopause, complete with hot flashes and night sweats, I also realized I now felt extremely upset all the time. If something wonderful happened, I still felt upset. If something upsetting happened, I felt inconsolable. I was in a constant state of wanting to yell and/or sob and/or punch someone in the face. Not only is that bad for business in my line of work, it was also extremely unpleasant. Clearly, I needed to develop new coping strategies to avoid jail time--and fast!

William James to the rescue!

When I first studied psychology in my undergraduate days, I learned about William James and his theory of emotion. One of the founders of the field of psychology, James believed that emotions resulted from the experience of a physical stimulus--e.g., you see a dangerous situation, begin running, and then become afraid--rather than the other way around--you see a dangerous situation, become afraid, and then start running. To be honest, this theory never made a great deal of sense to me. I was convinced that my body responded to my thoughts and emotions, and not vice versa. However, that all changed when I started becoming a habitual user of fertility drugs.

As I described above, while taking fertility medications, I had many physiologically-based experiences that caused my emotions to careen out of control. And unfortunately, I know I'm not alone. In my practice I've heard many instances of normally calm and mild-mannered women, once on the "sauce", suddenly finding themselves screaming and harming their normally beloved crystal. Yes, being infertility treatment is stressful--but many of the reactions I've seen are so far away from the person's normal coping strategy that it's safe to assume medication was a factor.

These experiences have made me question my assumption that emotions are always a direct result of our thoughts. Now, I believe that James was really on to something--sometimes are feelings are based on bodily experiences and sensations, and not the other way around. James himself suffered from a great deal of physical illness during his life, so perhaps he experienced this first hand.

You may be thinking to yourself (especially if you happen to be taking fertility medications right now), "Okay, Dr. Smartypants, who cares? Why are you telling me this? How is exactly is William James going to help me now?" The important point is this--infertility medications mess with your body's ability to react appropriately to the stimuli around you. So if your body feels physiologically upset--adrenalin and cortisol levels elevated--your brain will look at your current circumstances to try to find a reason. If it can't find a really obvious one, it is just going to assume it's one of the things going on in front of you right now. And if you start reacting to relatively innocuous stimuli as if they are the source of your body's upset sensations, well, that's when the trouble starts. But even worse, if you get into a truly upsetting situation, your body will push the panic button and trigger the flight or fight response. During that physiological experience, it's very hard to stay calm and keep a clear head, which many of our modern-day crises require us to do.


In my Lupron Depot days, I experienced this constantly. My natural reaction was to respond to the events going on before me, as if they were the thing that was causing all my inner turmoil. But after a few weeks, I realized that no matter how I reacted or how I changed things in my life, I still felt just as upset as before. Because of my hormonal changes, I was now in an constant state of flight or fight arousal. The only way I could survive would be to use my brain to overrule my emotions and my body's natural tendency to respond. Otherwise, I was going to be in for countless pointless arguments with store clerks and crying jags at the mall--not to mention alienating my husband, family and friends.

Rule No 1--Don't react!

As a psychologist, I am very interested in feelings, especially initial reactions. I normally advise people to pay close attention to those emotions and try to be true to them if they can. However, when you are taking infertility medications, I recommend the opposite strategy. My first rule of coping with the emotional side effects of being on infertility drugs is this: Don't react! The medications have decreased your ability to appropriately respond to your environment. So you have to try very hard not to respond to any seemingly upsetting event right away. Take a breath, and before you say or do anything, cognitively evaluate the situation. Is it really as big of a deal as it feels like right at this moment? Will getting outwardly upset help this situation in any way at all? If the answers to those questions are yes and yes, then you can take the brakes off and respond. But I think you will be surprised at how many times the answers to those questions will be no's. By putting your thoughts back in charge, you can select a more productive course of action.

Rule No. 2--Enlist the support of others

Another important coping strategy is to get a significant other, such as a spouse or partner, family member, or friend to help you evaluate your emotional responses to current life situation. This should be someone who understands your predicament, and agrees--in advance--to be available to you to process your feelings. When you are upset, they can remind you to calm down and go over the details of what just happened to help you figure out the best reaction. Husbands can be great for this, but sometimes men have difficulty truly understanding how hormones can have such a large effect on emotions. Because they don't typically experience the hormone fluctuations that women do even in a normal menstrual cycle, they haven't lived this "from the inside". So it may be necessary to enlist the backup support of a friend or family member just in case they have a hard time understanding the gravity of the situation.

Rule No. 3--Avoid stressful situations

If you are in a treatment cycle at the moment, chances are you are probably doing this anyway, but I'll add a quick reminder that now is not the time to voluntarily take on anything stressful. So perhaps you might want to postpone that incredibly complicated house renovation, or having the queen over for dinner. In infertility treatment, stress is plentiful, so you can be sure there will be enough stress to keep you occupied!

A final note to all the newbies out there....

If you've just begun infertility treatment, chances are you have taken or will be taking Clomid soon. In my experience, this drug is one of the worst in terms of causing emotional side effects. I frequently refer to it as "suicidal ideation in pill form", and I'm only joking a little. If you are taking Clomid and suddenly find yourself feeling very depressed and upset, it may be a result of the medication. (Of course, if it doesn't resolve relatively quickly after your cycle is over, you should definitely get those symptoms evaluated by a mental health professional.) I hope that Clomid will be the key to your success, but if it isn't, take heart--the FSH drugs don't seem to cause such severe reactions.

The end of the line? The decision to end infertility treatment

A reader asked me to address the issue of how you can tell if you should stop infertility treatment. This is a very important question, and one that is perhaps impossible to answer. However, I am going to try my best to share my thoughts on this subject, for whatever they are worth.

Sometimes the decision to end treatment is basically made for you. A biological event occurs, like being diagnosed with a serious illness, that makes continuing in treatment unwise. In other cases, diagnostic information comes to light that makes the possibility of success so unlikely that continuing in treatment is pointless. Also, financial or practical considerations may arise that make it simply impossible to continue in treatment. However, in most cases, the situation is not so clear cut, and it becomes a judgment call as to whether or not you should continue.

The way I think about the decision to terminate infertility treatment is centered on one of my fundamental beliefs--that we should try whenever possible to anticipate what our future selves will think about our decisions, in order to minimize future regrets. Having children (or not having them) is a very important, life changing decision. Thus, I feel it is extremely necessary to really think about how you will feel about your choices ten, twenty, or thirty years in the future. As an example of what can happen when you do not take your future self into consideration, I would like to tell the story of a lovely woman that I know from my hair salon. She is now in her late 80's and is suffering from some cognitive dementia, so although she has met me several times, she does not explicitly remember talking to me before. Despite this, she always sits down with me and tells me her story, each time with more nuance and detail. In a nutshell, she and her husband had a baby when she was in her early twenties, but sadly, he was stillborn. She wanted to try to have another baby, but her husband was insistent that they should not. He felt if God wanted them to have a baby, he would have let their first baby live. As time went on, she still wanted to have a child, and suggested that they adopt. Again, her husband was adamantly against this--to him, God obviously did not want them to have a child, and besides, he was not interested in raising "someone else's children". She loved her husband and wanted to stay with him, so she put her dreams aside, and stayed with him through thick and thin. Every time she told me this story, she stated that although she is very sad about not having a child, she feels she must come to peace with it. But it seems to me if you are telling this (and only this) story sixty years later to a relative stranger at the hair salon, you may never come to peace with the decision. Although she has led a rich and full life, and has wonderful extended family that make sure all of her needs are met now (including making sure her hair looks fabulous), I am pretty sure that remaining childless was not the right choice for her. And the deep regret that she expresses is the kind of thing I think we all want to avoid.

If it's over, you'll know

So given that you want to make sure that in the future, you do not have profound regrets, how do you tell when it's time to call it quits with infertility treatment? My personal and clinical experience has taught me this: when it's time to quit you will know it. You will feel it, almost as a physical sensation--something like, "I can't do this anymore, it's bad for me." Your self-protective mechanism will kick in, and saving yourself will become the most important goal. I vividly remember the moment of my decision to quit infertility treatment. I had a break at work, and was pacing back in forth in my office when I realized that although I didn't want to stop trying IVF, I had run out of treatment options. If I kept going, it would be sort of like gambling--the odds were stacked against me. I had the profound sense that I would be really hurting myself if I continued, and to no good end. I acknowledged that I was really bad at getting pregnant--but maybe there was something else at which I was good, and it made more sense to put my energy toward that. We turned to adoption, and so far I have never regretted that decision.

But the heart wants what it wants...

However, if you feel in your heart of hearts that you would like to continue, but that maybe you shouldn't because it is expensive, time-consuming, or other practical concerns--then it is a different story. In this case, I think that if you could logistically make it happen, you should probably continue in treatment. Infertility treatment has a time-stamp on it, so you don't want to be looking back 10 or 20 years down the line, when you don't have the option anymore, and wishing you tried when you had the chance. The heart wants what it wants, and if continuing is what is in your heart, I think it is important to try to honor that. Whether or not it results in a baby, at least you will have the closure of knowing you tried everything you could to achieve your goal.

I know that this way of thinking comes at a price, usually financial. I personally hate the fact that money can be such a primary factor when it comes to decision making about creating a family. But money can usually be earned or borrowed, although admittedly not without significant sacrifice. However, having a child is such an important part of life that it may be worth taking on more financial risk or burden in order to maximize your chances.

As for the time, logistical difficulties, and other inconveniences involved with infertility treatment, I would urge you to remember that although it may be difficult in the near-term future, if you avoid these things now, you may be feeling regret later for many years.

As in so many things in life, we must balance our short-term needs with our long-term goals. It is never easy, but I think you should keep in mind that this is one of the most important decisions you will ever have to make. This will help give you the necessary perspective--and courage--to do what you need to do to protect your future happiness.

Ambivalence--its role in decision making in infertiity treatment

Individuals in infertility treatment are often faced with difficult and life-changing decisions. Usually, there is no "right" option involved in these decisions. No one but you can decide, for instance, if you should keep going in treatment or if you should call it quits. Or if you should change RE's, or try a different clinic. Or if you feel comfortable with using an egg or sperm donor, and if so, how you feel about the disclosure of your future child's genetic origins. Or if you should start to pursue and adoption, and if so what type...the list of big decisions goes on and on. For almost all of these decisions, your choices, although they will be limited by your medical and financial circumstances, will be primarily based on your subjective preferences.

Figuring out your subjective preferences, however, may not be so easy. These situations are usually very complicated and involve emotions from many aspects of your life. Further, many of the types of decisions listed above are "workarounds". Already, they involve feelings about the loss of being unable to have a baby without treatment. So naturally, these types of decisions are going to bring up some negative feelings--even if, in the end, they are going to be the "right" option for you.


On the other hand, sometimes our negative reactions are telling us that an option would not be the right thing for us to do. It can be tricky to sort out when we are just experiencing "predictable" ambivalence, and when we should make rule out an option based on our negative feelings. In this post, I'll discuss some of the distinguishing features of the two types of negative feelings.

Ambivalence

in graduate school, a former supervisor once told me, "ambivalence is the hallmark of mental health." At the time, I gave him the same puzzled look that I now routinely get when I say this during a session with a client. But with the benefit of time and experience, I increasingly understand the wisdom of his statement. To be able to be conscious of and tolerate, at the same time, both positive and negative feelings about a person or situation (e.g., ambivalence), and still be able to function successfully, requires psychological maturity and sophistication.

When it comes to the types of decisions that come up in infertility treatment, ambivalence is practically a given. Even so, many of my clients have been concerned when they experienced negative feelings about a family building option,especially initially. They have worried that this means they shouldn't even consider the option, even if it may be the most practical or probable solution. In fact, in my work, if I hear a client express uniformly positive feelings about issues such as the ones listed above, I usually become concerned. My worry is that they aren't consciously dealing with some important feelings--and this might cause them problems in the future.

As an illustrative example, I would not expect someone to be thrilled upon deciding to use a gestational carrier, especially during their initial considerations. So feeling okay about the decision of using a gestational carrier might look something like, "I'm sad that I won't be able to myself be pregnant with my child, but I'm happy that I will be able to become a parent to a newborn". Tolerating feelings of disappointment, loss and perhaps envy along with the excitement of the pregnancy and anticipation of becoming a parent--that's the cost of doing business in this situation.

When no means no

There are times, however, when your negative feelings are telling you something important--that you are fundamentally uncomfortable with the option before you. This will look different than the types of ambivalent feelings I described above. One difference is that in ambivalence, the intensity of the negative feelings tends to lessen over time. Once you start grieving the losses these decisions involve, the benefits of the decision seem more prominent. However, if your negative feelings are telling you that this is not the right decision for you, they tend to remain present, and even increase in intensity--until you respond to them.

Another way to distinguishing factor between the two sets of negative feelings is how you feel after making the decision. I have observed this difference many times in both myself and my clients. If you have made the right decision for yourself, you will tend to feel a sense of resolve and peace mixed in with all of the anxiety the situation produces. Although you are aware of the downsides involved in your choice, you still fundamentally feel that no matter what the outcome, this decision is the best for your current situation.

On the other hand, if you continue to have consistent feelings of unease, repetitive nagging doubts, or continued intense negative emotions, you probably need to take a step back and reexamine your decision. It may be that you have decided to do something (or, as many times is the case, not to do something) that really isn't right for you. The good news is that even though you may have to change course, you can use these feelings to help guide you to a decision that does feel more in line with what works best for you in your life.