It's spring break week and my family has been traveling through Washington DC and Virginia, visiting family and sightseeing, predominantly at historical sites. This simultaneous emphasis on my own personal history while learning more about American history has reminded me of the importance of creating a narrative about one's life. By telling your own story, you often integrate separate parts of your life, creating a more coherent sense of self.
Integrating your experiences with infertility into your life narrative is an essential part of understanding how it has affected you. For example, as we drove through the area of the country my mother's ancestors lived, I found myself thinking about how in retrospect, past generations of my female relatives have also struggled with infertility, although it may not have been diagnosed or treated. I also found myself wondering how surprised (most likely pleasantly) my relatives might be to learn that a beautiful, self-possessed girl born in India was now a member of their family.
In addition to my own story, I also discovered another narrative of infertility in a place I didn't expect to find it. During our visit to Mount Vernon, George Washington's home, I heard repeated references to his raising of his wife's children and grandchildren (Martha was a widow when she met George and had two living children prior to their marriage). However, I didn't hear any mention of any children he and Martha had together. My "infertility antennae" went up, and so when we got to the hotel, I started Googling. Sure enough, it seems that George Washington himself most likely suffered from infertility. There was article published in Fertility and Sterility in 2004, which can be found here, which reports that George Washington was most likely infertile due to a prolonged infection with enteric tuberculosis. Like most men of his time, he blamed his infertility on his wife. However, it seems that Martha's prior history of four successful pregnancies suggests that George Washington's own fertility was most likely compromised. Further, the article describes evidence that George Washington had wished to have children and was saddened upon the realization that this probably would never happen for him. By all reports, he loved children and enjoyed the time he spent raising Martha's children and her grandchildren.
The article's author, John Amory, also speculated on how George Washington's infertility may have affected his professional career and the development of the United States. Did his disappointment about not having any children of his own fuel his ambition and resolve? Was George Washington more motivated to nurture talented young men, thus strengthening the new country and its emerging government, to fulfill some of his own parenting needs? Although we may never know for sure, it stands to reason that George Washington's infertility must have shaped his emotional and professional life in many ways. Freud's concept of sublimation, in which unfulfilled desires are channeled to more socially appropriate goals (or in this case perhaps goals that are possible to achieve) may be relevant here.
Interestingly, the author noted that in historical and medical discussions of George Washington's life, his lack of children and probable infertility is very rarely mentioned. He theorizes that some historians may feel that discussing his infertility might "lessen" his image. However, to me, it only makes George Washington an even more impressive person. He was able to accomplish incredible things and change the course of history, all while struggling with his own feelings about not being able to have his own children--a struggle that most readers of this blog know is a profound one. In addition to being a hero and a great leader, he also has provided us with a model of resilience and coping. Despite his bad luck with infertility, he led a successful, rewarding, and incredible life. In the end, I think that is the best outcome for which we can hope--regardless of our circumstances.
Thursday, March 31, 2011
Monday, March 21, 2011
Do feelings about infertility ever go away? Long-term psychological implications of infertility treatment
As an infertility therapist, I think the question that I am most commonly asked is whether or not the pain from infertility ever goes away. During those dark periods during infertility treatment, it can seem as if things are always going to feel as bad as they do at that moment.
I can always offer reassurance that things will indeed eventually feel better, but I cannot say with confidence that the pain of infertility goes away completely. In my experience, people do generally go on to resolve their infertility issues in one way or the other, and lead happy and rewarding lives. Even within those lives, however, there are moments in which the pain of infertility resurfaces. I will never forget feeling that familiar, bittersweet pain and envy upon hearing a friend was pregnant--except that I myself was actually pregnant at the time! It is almost as if the pain and envy had become a reflexive response, conditioned over the years. A few months of pregnancy had done nothing to extinguish it.
The above example highlights one of the ways feelings about infertility may reemerge--through exposure to familiar situations and cues. Certain dates, times of year, people, and places may all be evocative of painful experiences, events, or realizations. Although in retrospect such painful feelings are completely understandable, they often take people off-guard if they are not prepared for them.
Another time infertility-related feelings commonly resurface is during major life transitions. For example, perimenopause and menopause bring up feelings about reproduction for almost all women, but if there is a history of infertility there may be more intense feelings about closing this chapter in their life.
A history of infertility also is known to increase anxiety during pregnancy and parenthood. Because you have already experienced things not going according to plan, you become more aware of all the frightening, albeit relatively improbable, possibilities during pregnancy, childbirth, infancy and childhood. So many times, I have seen women who had repeatedly fantasied about how happy they would be once they were pregnant become overcome with anxiety once the long-awaited pregnancy occurred. Although this is a shame, I think in a certain way it's probably unavoidable given the types of infertility experiences they had endured.
Infertility is usually a profound, life-changing experience. Studies have shown it to be only slightly less traumatic than the death of a parent and on par with a divorce in terms of the stress it produces. As a striking example, I worked with a woman who experienced infertility, but then went on to have several children. Along the way, she encountered several difficulties. One of her children had a serious, but correctable medical condition. She herself experienced medical difficulties in which her own life was hanging in the balance for months. During this time, she also unfortunately experienced a great deal of interpersonal conflict and disappointment. When I asked her which one of these situations had been the most difficult, she answered without hesitation, "Infertility."
As a silver lining, I have found that each time feelings about infertility reemerge, it is an opportunity to work through them again. This can allow you to have more closure and to better understand your own experiences. With time and distance, you can see things more clearly, and may able to resolve some of the hurt feelings of the past.
So in sum, yes, it really does get better--a lot better! But when something this profound happens to us, we can't expect ourselves not to have feelings about it for a long time to come. However, those painful moments can often often contain the seeds of future psychological growth, and thus our lives may actually be enriched.
I can always offer reassurance that things will indeed eventually feel better, but I cannot say with confidence that the pain of infertility goes away completely. In my experience, people do generally go on to resolve their infertility issues in one way or the other, and lead happy and rewarding lives. Even within those lives, however, there are moments in which the pain of infertility resurfaces. I will never forget feeling that familiar, bittersweet pain and envy upon hearing a friend was pregnant--except that I myself was actually pregnant at the time! It is almost as if the pain and envy had become a reflexive response, conditioned over the years. A few months of pregnancy had done nothing to extinguish it.
The above example highlights one of the ways feelings about infertility may reemerge--through exposure to familiar situations and cues. Certain dates, times of year, people, and places may all be evocative of painful experiences, events, or realizations. Although in retrospect such painful feelings are completely understandable, they often take people off-guard if they are not prepared for them.
Another time infertility-related feelings commonly resurface is during major life transitions. For example, perimenopause and menopause bring up feelings about reproduction for almost all women, but if there is a history of infertility there may be more intense feelings about closing this chapter in their life.
A history of infertility also is known to increase anxiety during pregnancy and parenthood. Because you have already experienced things not going according to plan, you become more aware of all the frightening, albeit relatively improbable, possibilities during pregnancy, childbirth, infancy and childhood. So many times, I have seen women who had repeatedly fantasied about how happy they would be once they were pregnant become overcome with anxiety once the long-awaited pregnancy occurred. Although this is a shame, I think in a certain way it's probably unavoidable given the types of infertility experiences they had endured.
Infertility is usually a profound, life-changing experience. Studies have shown it to be only slightly less traumatic than the death of a parent and on par with a divorce in terms of the stress it produces. As a striking example, I worked with a woman who experienced infertility, but then went on to have several children. Along the way, she encountered several difficulties. One of her children had a serious, but correctable medical condition. She herself experienced medical difficulties in which her own life was hanging in the balance for months. During this time, she also unfortunately experienced a great deal of interpersonal conflict and disappointment. When I asked her which one of these situations had been the most difficult, she answered without hesitation, "Infertility."
As a silver lining, I have found that each time feelings about infertility reemerge, it is an opportunity to work through them again. This can allow you to have more closure and to better understand your own experiences. With time and distance, you can see things more clearly, and may able to resolve some of the hurt feelings of the past.
So in sum, yes, it really does get better--a lot better! But when something this profound happens to us, we can't expect ourselves not to have feelings about it for a long time to come. However, those painful moments can often often contain the seeds of future psychological growth, and thus our lives may actually be enriched.
Tuesday, March 15, 2011
Unpredictability
A few weeks ago, when I returned to my car after work, I found an unpleasant surprise. The passenger side window of the car was smashed in, and glass was everywhere. The contents of the car were tossed about. The thief had apparently tried, and failed, to steal the built in DVD player (although he/she did succeed in breaking it--so probably trying to steal one of those things is not a good idea). Nothing was stolen from the car in the end--not my electronic toll pass, not prepaid parking vouchers, not my daughter's wallet with all of her life savings in it. It did create, however, a big mess, an expense, $2800 worth of damage to the car, and some discomfort and work for me.
During my rather cold, windowless drive on the expressway to the repair shop, it struck me that this situation felt very similar to the realization that I was infertile. When I first arrived at my car, I was in a state of disbelief. Even though what had happened was obvious, my mind did not want to accept that someone had broken into the car. "Perhaps someone just accidentally bumped the window in a freak accident," I kept thinking. However, the preponderance of evidence to the contrary forced me to accept the fact that yes, I had just been robbed, and that yes, people can be not-so-nice sometimes. The latter is a fact that even though I know it is true intellectually, I have always struggled with accepting it emotionally. I think the same is true for my infertility. Even when a preponderance of evidence suggested I had big fertility problems, I could still entertain the fantasy of somehow miraculously getting pregnant anyway--which obviously never happened, and isn't going to happen, either. I think it's taken me over a decade to accept that fact--and as those who know me can attest, I am not exactly Suzy Sunshine. Optimism is not my game. I am not a denial-prone person, and could probably use a little more denial in my life. So if even I have struggled long and hard with accepting the finality of my infertility, I think it has to be a pretty common-place event among those who naturally have a sunnier outlook.
Another facet of the break-in situation that felt similar to infertility is that it created a lot of work, delays, and expense. Despite my medical problems, I am lucky to have two wonderful children. However, those children were not easy to come by--both the adoption and IVF journeys they required involved a lot of hard work, physical discomfort and suffering, time, and money. Just like the car, it was doable. It wasn't the end of the world--but it did require marshaling a lot of energy and resources that could have gone to other things, I suppose--like my career, or learning to cook food without burning everything. But we must play the cards we are dealt, and placed in the same situations again, I would make the same choices again, even though they required hardship and sacrifice.
Once I accepted that my car was burglarized, I realized I needed some help--because I had no idea how exactly to manage the situation. I tromped to the parking garage office and told the lady working there what had happened. She sprang into action, filling out forms, and letting me use her phone to make the police report. Two other garage employees worked for a long time in the freezing cold to clean the glass out of my car. The worked endlessly on taping garbage bags to the window, which was an incredibly sweet gesture even though it blew off as soon as I had to drive 30 mph. They all introduced themselves, hugged me, and told me to come by and visit them every week at the office--they were going to "take care of me". They were all such lovely people, and I never would have met them otherwise. To be shown such kindness, after experiencing some of the less desirable parts of human nature, was wonderful. That struck me as the other thing that is reminiscent of my infertility. Because my infertility happened, I have had the good fortune to meet and work with wonderful people whom otherwise I would never have known. I include my blog readers among this list--it's been a pleasure to read your comments and blogs and get to know you a little bit.
Okay, so maybe that doesn't completely make up for getting your window smashed in, literally or metaphorically. But it really does help soften the blow.
Now, if I could just get my car back from the repair shop.....
During my rather cold, windowless drive on the expressway to the repair shop, it struck me that this situation felt very similar to the realization that I was infertile. When I first arrived at my car, I was in a state of disbelief. Even though what had happened was obvious, my mind did not want to accept that someone had broken into the car. "Perhaps someone just accidentally bumped the window in a freak accident," I kept thinking. However, the preponderance of evidence to the contrary forced me to accept the fact that yes, I had just been robbed, and that yes, people can be not-so-nice sometimes. The latter is a fact that even though I know it is true intellectually, I have always struggled with accepting it emotionally. I think the same is true for my infertility. Even when a preponderance of evidence suggested I had big fertility problems, I could still entertain the fantasy of somehow miraculously getting pregnant anyway--which obviously never happened, and isn't going to happen, either. I think it's taken me over a decade to accept that fact--and as those who know me can attest, I am not exactly Suzy Sunshine. Optimism is not my game. I am not a denial-prone person, and could probably use a little more denial in my life. So if even I have struggled long and hard with accepting the finality of my infertility, I think it has to be a pretty common-place event among those who naturally have a sunnier outlook.
Another facet of the break-in situation that felt similar to infertility is that it created a lot of work, delays, and expense. Despite my medical problems, I am lucky to have two wonderful children. However, those children were not easy to come by--both the adoption and IVF journeys they required involved a lot of hard work, physical discomfort and suffering, time, and money. Just like the car, it was doable. It wasn't the end of the world--but it did require marshaling a lot of energy and resources that could have gone to other things, I suppose--like my career, or learning to cook food without burning everything. But we must play the cards we are dealt, and placed in the same situations again, I would make the same choices again, even though they required hardship and sacrifice.
Once I accepted that my car was burglarized, I realized I needed some help--because I had no idea how exactly to manage the situation. I tromped to the parking garage office and told the lady working there what had happened. She sprang into action, filling out forms, and letting me use her phone to make the police report. Two other garage employees worked for a long time in the freezing cold to clean the glass out of my car. The worked endlessly on taping garbage bags to the window, which was an incredibly sweet gesture even though it blew off as soon as I had to drive 30 mph. They all introduced themselves, hugged me, and told me to come by and visit them every week at the office--they were going to "take care of me". They were all such lovely people, and I never would have met them otherwise. To be shown such kindness, after experiencing some of the less desirable parts of human nature, was wonderful. That struck me as the other thing that is reminiscent of my infertility. Because my infertility happened, I have had the good fortune to meet and work with wonderful people whom otherwise I would never have known. I include my blog readers among this list--it's been a pleasure to read your comments and blogs and get to know you a little bit.
Okay, so maybe that doesn't completely make up for getting your window smashed in, literally or metaphorically. But it really does help soften the blow.
Now, if I could just get my car back from the repair shop.....
Thursday, March 3, 2011
Can psychological support groups really double your chance of conception during infertiity treatment?
My father was in town last weekend, and was very excited about a clip he had recently seen on the Today show about infertility, which can be found here. He was very impressed to learn that if a woman participates in an infertility-related social support group, it doubles her chance of conception in a given treatment cycle. When I expressed skepticism, he was adamant. "They proved it at Harvard," he exclaimed! How could I argue with that?
And really, why would I want to argue with that? No one would like to believe that providing people with emotional support would fix their infertility problems more than me. Not only is this a problem I could actually do something about, but given my line of work, it would be financially lucrative if this were true. And yet, I had a sinking suspicion that unfortunately, this was just too good to be true.
Thus, I took myself took a look at the study referred to in the Today show interview. (For those of you who are interested, here is the citation: Domar, A. Clapp, D.,Slawsby, E., Dusek, J., Kessel, B., Freizinger, M., (2000). Impact of group psychological interventions on pregnancy rates in infertile women: Presented at the Annual Meeting of the American Society of Reproductive Medicine, October 5, 1998, San Francisco, California. Fertility and Sterility, Vol. 73 (4), 805-811.) And indeed, the study was performed at Harvard Medical School. The lead author, Alice Domar, Ph.D., is a very well-known psychologist in the area of infertility. And yes, the results did show the women who participated in one of two types of support groups had a conception rate of 54 and 55 percent, respectively, versus only 20 percent in the control group.
However, as is so often the case with psychological research, the results are not the whole story. As the authors of the study themselves explain, this study had some serious methodological issues that call into question the veracity and applicability of its results. The researchers had difficulty recruiting subjects for the study, and thus the sample size involved was very small--too small to conduct powerful statistical analyses or to make sweeping generalizations to the population in general. The researchers made no attempt to control for the type of diagnoses with with the women in the study were struggling--so there was no way to tell whether or not the severity of the diagnosis was a factor in treatment success. Further, because they had difficulty recruiting enough subjects, the researchers were unable to randomly assign women into the three groups (cognitive-behavioral treatment, social support group, and no treatment). In addition, they had such large rate of dropout in the control group (which received the 20% success rate) they decided to not run any statistical analyses on the results because they would not be representative or accurate. The authors concluded that it may be that psychological interventions could increase pregnancy rates, but they could not definitively prove it on the basis of this study--further research was needed to clarify the issue. And by the way, further study has not uniformly supported this finding. Dr. Domar's later studies in this area have shown that while being in support groups or mind-body treatment may increase coping skills, quality of life, and a sense of well-being during infertility treatment, it does not appear to significantly increase, much less double, pregnancy rates.
Needless to say, none of the above limitations mentioned in the study were mentioned in the Today show interview. Rather, the results of this study were presented as Harvard-endorsed gold-plated facts. I don't think there was any malice in this, but rather a good dose of naivete. It does underscore, however, how you really can't believe everything you read, hear, or see on television. As infertility patients, it is imperative for us to all become educated consumers of research. That way, we can go to the studies ourselves and evaluate them critically in order to make the best treatment decisions possible. With the internet, scientific journals and studies are now easier to obtain than ever. Although I did take several research and statistics classes in graduate school, anyone can read and understand the author's descriptions of the problems with the study in question.
I must add that I am a big fan of support groups for infertility. I think that they can provide a great deal of information, camaraderie, and support and I would encourage everyone struggling with infertility to consider joining, creating, or leading one. I just don't think we can expect that in doing so, pregnancy rates among the group members will double. As I've said before, I have a sneaking suspicion that your reproductive system, unless under extremely stressful conditions, doesn't care too much about your unconscious conflicts or how you feel. That doesn't mean that you shouldn't care either, though--and that's where getting enough emotional support is so important, whether it helps you get pregnant or not.
And really, why would I want to argue with that? No one would like to believe that providing people with emotional support would fix their infertility problems more than me. Not only is this a problem I could actually do something about, but given my line of work, it would be financially lucrative if this were true. And yet, I had a sinking suspicion that unfortunately, this was just too good to be true.
Thus, I took myself took a look at the study referred to in the Today show interview. (For those of you who are interested, here is the citation: Domar, A. Clapp, D.,Slawsby, E., Dusek, J., Kessel, B., Freizinger, M., (2000). Impact of group psychological interventions on pregnancy rates in infertile women: Presented at the Annual Meeting of the American Society of Reproductive Medicine, October 5, 1998, San Francisco, California. Fertility and Sterility, Vol. 73 (4), 805-811.) And indeed, the study was performed at Harvard Medical School. The lead author, Alice Domar, Ph.D., is a very well-known psychologist in the area of infertility. And yes, the results did show the women who participated in one of two types of support groups had a conception rate of 54 and 55 percent, respectively, versus only 20 percent in the control group.
However, as is so often the case with psychological research, the results are not the whole story. As the authors of the study themselves explain, this study had some serious methodological issues that call into question the veracity and applicability of its results. The researchers had difficulty recruiting subjects for the study, and thus the sample size involved was very small--too small to conduct powerful statistical analyses or to make sweeping generalizations to the population in general. The researchers made no attempt to control for the type of diagnoses with with the women in the study were struggling--so there was no way to tell whether or not the severity of the diagnosis was a factor in treatment success. Further, because they had difficulty recruiting enough subjects, the researchers were unable to randomly assign women into the three groups (cognitive-behavioral treatment, social support group, and no treatment). In addition, they had such large rate of dropout in the control group (which received the 20% success rate) they decided to not run any statistical analyses on the results because they would not be representative or accurate. The authors concluded that it may be that psychological interventions could increase pregnancy rates, but they could not definitively prove it on the basis of this study--further research was needed to clarify the issue. And by the way, further study has not uniformly supported this finding. Dr. Domar's later studies in this area have shown that while being in support groups or mind-body treatment may increase coping skills, quality of life, and a sense of well-being during infertility treatment, it does not appear to significantly increase, much less double, pregnancy rates.
Needless to say, none of the above limitations mentioned in the study were mentioned in the Today show interview. Rather, the results of this study were presented as Harvard-endorsed gold-plated facts. I don't think there was any malice in this, but rather a good dose of naivete. It does underscore, however, how you really can't believe everything you read, hear, or see on television. As infertility patients, it is imperative for us to all become educated consumers of research. That way, we can go to the studies ourselves and evaluate them critically in order to make the best treatment decisions possible. With the internet, scientific journals and studies are now easier to obtain than ever. Although I did take several research and statistics classes in graduate school, anyone can read and understand the author's descriptions of the problems with the study in question.
I must add that I am a big fan of support groups for infertility. I think that they can provide a great deal of information, camaraderie, and support and I would encourage everyone struggling with infertility to consider joining, creating, or leading one. I just don't think we can expect that in doing so, pregnancy rates among the group members will double. As I've said before, I have a sneaking suspicion that your reproductive system, unless under extremely stressful conditions, doesn't care too much about your unconscious conflicts or how you feel. That doesn't mean that you shouldn't care either, though--and that's where getting enough emotional support is so important, whether it helps you get pregnant or not.
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