The art of being infertile in the internet age: When not to pay attention, and why

Last week there seems to have been a little bit of a kerfuffle about Dolce and Gabbana's expressed opinions on children born via IVF and on non-traditional families.  I'm only hazily aware of what they said, and I think I'm going to keep it that way, for the sake of my own mental health.  This is an acquired skill, ignoring comments made by anyone from important celebrities to random strangers.  I have a long history of being what my parents called "overly sensitive"-- being hurt by what others have said, and consequently of nursing a grudge.   Naturally, this made the experience of being infertile and an adoptive parent more painful than it might have been otherwise.  If I've learned one thing through my infertility, it's that people feel comfortable sharing their thoughts and opinions, even if they are uninformed, unwelcome, and painful to hear.  

What I realize as a result of these experiences is that I was putting too much value in the thoughts and opinions of others. I think this resulted from my own insecurity about myself.  I frequently have walked around thinking, "That doesn't make sense....I must be stupid because I can't understand why so-and-so said that!"  However, as a result of hearing so many stupid opinions and comments, I came to see that on certain topics. I should privilege my own thoughts and opinions.  Now, I feel that if someone is an expert in an infertility-related field, or has a lot of life experience with infertility, I will seriously consider what they might have to say, even if it differs from my own initial thoughts.  If they don't have that experience, their thoughts and opinions are most likely irrelevant to me.  This is why I don't care if Dolce and Gabbana might feel that two of my children are "synthetic".  They haven't experienced the same things as me, and it isn't their area of expertise.  So they don't get to have an opinion on it that I value!  

I do try to be fair about things.  So please don't take any fashion advice from me.  I don't know anything about it.  Seriously, my fashion goals are to be able to wear my pajamas to work and to find only marginally ugly shoes that will fit my clunky custom orthotics.  Any clients of mine who might be reading this will back me up on this one.   Dolce and Gabbana are your go-to folks on that subject. 

It used to be that we just had to worry about the uninformed opinions of those we might run into in daily life.  Now, with the internet, we are bombarded with the opinions of everyone, whether they be famous or anonymous.  And it seems that the more outrageous they are, the more they will be promoted, so that we will click on them and generate advertising revenue for someone.  If I see something that looks especially controversial, I try not to click on it.  I don't want to encourage that sort of behavior, and I certainly don't want anyone to profit on it.  

Ruth Bader Ginsburg spoke at my graduation commencement.  She said something that I have increasingly come to see the value of as time has passed.  In referring to marriage, she said, "Sometimes it pays to be a little deaf!"  I think this is true not only in relationships, but increasingly true for the world in general.  Ignoring things can go a long way in terms of saving us some anguish.

Consider the source before you roil yourself into a fit of self-righteous outrage!

I  hope you all have a great week and welcome your opinions and experiences in the comments section or at lisarouff@gmail.com.

"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!

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 light at the end of the tunnel: aging out of expectations of fertility

When I was in the throes of infertility treatment, I remember often reading and hearing that infertility was just a life phase, and that over time, it would resolve itself one way or the other. Life would go back to normal. Of course, this was intended to give me hope, and strength, but instead of finding it comforting, it just made me want to throw up.  I could already see then, as I can confirm now, that there was no way I was ever going to be the same person after going through all of that pain and disappointment.

In that way, it seems that infertility never ends--even when the struggle is over, our perspectives and relationships have changed.  However, I can say that one of the silver linings of getting older is that now no one is expecting me to be able to have babies anymore!  As I approach my mid-forties, I no longer am asked whether or not I am going to have children, or have more children.  People just assume that it's all done with, and because of my age, I am not very likely to become pregnant--and here is the important part--JUST LIKE EVERY OTHER WOMAN MY AGE.  Yes, I've found myself back in the "normal" group again.  It took a decade or two for everyone else to catch up with me, but now we are all in the same boat.

I can't tell you what a sweet relief I have found this to be.  It almost takes the sting out of my encroaching wrinkles and grey hairs--almost.  Now that the book is closed and the dust is settled, it occurs to me that most women my age had their children quite some time ago, and that they haven't defined themselves by their ability, or inability, to get pregnant for quite some time.  They have left all that behind and have moved on to other aspects of their lives.  Perhaps that's one of the problems with infertility--it can imprison us in the "reproductive phase" of our lives for extended periods of time, but without the easy ability to complete the phase successfully.

Thus, although the emotional changes infertility causes never fully leave us (nor, in my opinion, should they) it does seem that society's expectation that we go forth and multiply does, thankfully, come to an end.  As for me, I notice the difference in myself when I am social situations with people I don't know very well.  For years, every time I met someone new, I had been unconsciously bracing myself for the questions about babies and pregnancy, whether they actually arose or not.  Now I can observe myself feeling much calmer and lighter in these situations, knowing that the questions just aren't going to come up.  Although that's not a complete end to the "infertility" phase of my life, it certainly feels much better, and it isn't as much of a constant presence in my mind.

"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.

 

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!

Infertility and third party reproduction in the public spotlight: psychological implications

I think it's safe to say that infertility and third party reproduction is in the public eye now more than ever. For instance, the reality show Guilana & Bill has followed the celebrity couple Guilana and Bill Rancic through 2 IVFs, one ending in miscarriage and another ending in a BFN. Numerous celebrities have announced the births of their children created through some form of third party reproduction. News reports, articles, and documentaries about the growing practice of international egg donation and surrogacy have been published and aired. It seems that when it comes to infertility treatment and third party reproduction, almost everyone has a strong, if perhaps not well-informed, opinion.

In her blog, Dawn Davenport at Creating a Family wrote a really wonderful post, found here, about the media coverage of and public response to Nicole Kidman and Keith Urban's daughter's birth via a gestational carrier. In it, she excerpts some of the many negative comments that can be found on the internet about their use of a gestational carrier. As you can imagine, some folks out there in cyberspace are not supportive of Kidman's and Urban's decision, suggesting that Kidman didn't want to ruin her figure with a pregnancy, or decrying the use of a gestational carrier/surrogate as dehumanizing or morally wrong.

As the spotlight shines on our little corner of the world, I find myself wondering about what all this attention, both positive and negative, means psychologically for individuals experiencing infertility in their own, less public lives. On the one hand, I think that increased public awareness of the issues involved in infertility could be beneficial to those currently experiencing it. Perhaps seeing a couple on television deal with a miscarriage and failed treatment cycle could help watchers become more empathic to their friends, family members, and neighbors who are in the same situation. Also, if the public increasingly understands infertility as a medical condition, there may be more public support for increased health insurance coverage.

However, I think that the negative commentary now floating around out there adds a new wrinkle of difficulty to the already complicated psychological terrain of infertility. The negative comments people feel compelled to make about the family building choices of celebrities seem to fall into two categories. The first is that somehow the celebrity him or herself is personally to blame for their situation, rather than having a medical condition. She waited too long, she is too selfish and vain, etc. The second category has to do with the idea that the celebrity is somehow circumventing God's will or fate--e.g., if it's meant to be it will happen, so using IVF, or a surrogate, or whatever, is therefore wrong.

Although I always suspected that some people felt this way about infertility treatment and the choices it involved, in my own personal and professional life I've never had anyone express these criticisms to my face. Perhaps they were thinking it, but I didn't have to deal with it explicitly. Not so anymore. Yesterday, I read an interview in which Guiliana Rancic repeatedly defends herself against public commentary (presumably from people she has never met) that she has caused her infertility by being too thin. This struck me--I mean, it's bad enough to figure out what to say to your insensitive Aunt Maisy who always suggests you just need to relax, or maybe it's just "not meant to be", but to have to start arguing with people you've never met? Although Ms. Rancic is the star of a reality television show and thus has opened up her life to public opinion, it is hard not to take the negative comments made about her situation, or those of other celebrities, and apply it to ourselves, however obliquely.

Of course, it is perhaps only a minority of people out there in the world who have such intense negative feelings about infertility treatment. But with the cloak of anonymity and the ability to publicly express themselves instantaneously at the touch of a button, they can make a big difference in the psychological climate surrounding infertility--and I would argue it's not a good difference. If people person are already inclined, albeit unfairly, to blame themselves for their infertility (and most infertile individuals struggle with this from time to time) negative comments such as these can be used to support this erroneous belief. Fodder for self-criticism is, after all, only a short internet search away.

Although it is possible to avoid reading negative opinions and comments about infertility, it does take effort. And I feel that even if we ourselves never read a word of this stuff, other people do--and this changes the emotional landscape in which we find ourselves.

I am very curious about others' experiences in this regard. I would love to hear your thoughts and stories about how the increase in news coverage around infertility has (or hasn't) affected you. Please leave a comment if you can! And as always, if you have any questions you think I can answer, or any topics you think it would be helpful for me to address in my blog, I'd love to hear from you.

Thanks for reading, and have a great ICLW!

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.

Infertility treatment, love and courage

In infertility treatment, it's pretty easy to name the negative processes at play. The longing for, and not yet having, a child. The uncertainty and waiting for answers. The invasive, expensive, and time consuming medical treatments. The soul-crushing losses and disappointments. The havoc it can wreak in important relationships. The list goes on and on.

And yet, in my practice, intermingled among the pain and the losses, I can see moments of incredible heroism. Amazing acts of generosity and compassion. And profound expressions of love for an unborn or unknown child, made through hard work, risk-taking, and physical and emotional sacrifice. In order to survive all the difficulties, I feel it is important to step back and acknowledge these amazing moments and the profound impact they can have.

Chances are, your own personal struggles with infertility also contain such positive, love-filled, and heroic moments. But it may be hard at times to see them, because the pain of the situation obscures them from view. In this post, I will discuss the role of love and heroism in infertility treatment.


Love

Infertility boils the desire and love for a future child down to its essence. When a baby doesn't come the easy and fun way, it forces the hopeful parents to really think about what they are doing. Now, in order to have a child, they must give something up, starting with their privacy and intimacy in the baby-making process. As treatment progresses, the sacrifices continue, whether they are physical, logistical, financial, or emotional. And sometimes, if it becomes clear that parenting will only take place through using donor gametes or adoption, they must give up their own genetic connection to their future child.

I feel that at the end of the day, the thing that gets most people through all of these sacrifices is their love for their wished-for child. In a "normal" situation, this love would be taken for granted, as the assumption is something like, "I love my child because he or she is created by and similar to me". But when this is all stripped away, it becomes clear that most people have the capacity to love a child no matter how he or she was created or if the child is genetically similar to them or not. People in infertility treatment, because of their situation, know this first-hand. I feel there is something very powerful in this self-knowledge. Sometimes, people without fertility issues have expressed to me that they doubt they could ever go through the hardships of treatment or be able to love an adopted child. This always makes me feel sad for them, because I think what they are really saying is that they doubt their own capacity to attach to or love a child if the conditions aren't exactly perfect. Knowing for sure that you have the capacity to love and care for a child, no matter how they came to be in your family, puts you directly in touch with the best part of yourself, and the best part of human beings in general.


Courage


It has often been said that being brave is not acting heroically in the absence of fear; rather, it is being afraid and acting heroically anyway. Infertility treatment, if it doesn't work initially, often requires these moments of courage. We must keep trying when the stakes are high and the fear of disappointment is strong. Or perhaps we must muster up our courage to accept an unwanted truth or outcome, and to come up with a new plan to make our dreams of a family come true.
Many times, we must perform these courageous acts even when we are feeling hurt, scared, and angry at our situation. Although it is difficult, I frequently witness "ordinary" people rising to the occasion, and performing profound acts of heroism. Although these acts may be private in scale, they are just as courageous as many of the more public acts of heroism we see on the news.

I feel that experiencing yourself as courageous, even in the face of adversity, is very powerful. It puts you in touch with the best and strongest parts of yourself. Also, it is something you can take with you to the other difficult situations that will inevitably come up in life.

So in those tough and demoralizing moments in your infertility treatment, try to think of the ways you have been courageous and brave, and the ways your love has helped you to transcend significant difficulties. I think that you will be impressed and encouraged by what you have done--and this may help give you the strength to pursue your next step down the path towards creating your family.

Does infertility change you as a person?

Many times, my clients ask me if their experiences with infertility will change them forever. Usually, this “change” isn’t regarded in a positive light. I feel that change is inevitable. Over time, I feel that I myself changed on multiple levels as a result of my experiences with infertility, in ways both large and small. I have also observed similar gradual transformations this in my work with clients dealing with infertility. Although the thought of change can be unsettling, many of the changes I have observed in my clinical work are actually signs of increased personal growth and psychological maturity. To be honest, it may not be the most recommended or enjoyable way of achieving this growth--but as infertility is usually not a choice, we must take from it what we can.

To illustrate this, let me tell you a story about one of the smaller changes I noticed in myself as a result of my infertility adventures. A year or so after I stopped a two-year course of infertility treatment to pursue an adoption, for no particular conscious reason, I started thinking about progesterone in oil shots. As I mused about the painfulness of those shots, it suddenly occurred to me—they were progesterone in OIL shots. Meaning that, on and off for two years, I had been willfully injecting fat into my derriere, a part of my body that I had otherwise spent my entire adult life incessantly, albeit unsuccessfully, trying to make less fatty. What surprised me was not so much the idea that I had made that decision, but that I hadn’t even considered the oil/fat/derriere issue until a year later. During treatment, I focused so narrowly and single-mindedly on achieving a pregnancy that I had left my prior priorities, however shallow, behind without a second thought.

The above example, although seemingly trivial, demonstrates how experiencing infertility can produce profound shifts in our focus and our willingness to undertake hitherto unthinkable efforts. As we try harder and harder to achieve our goal of having a family, we often become more flexible and open-minded. Many times, when someone begins treatment, they have preconceived notions about what they will or will not do. I often hear people tell me that they would not ever consider IVF, using donor gametes, adoption, etc., at the onset of treatment only to later reconsider and find themselves actively pursuing the very possibilities they originally dismissed—and grateful for the chance to do so.

Such a change usually does not happen all at once—there seems to be a “just one more thing” quality to the process. As each type of treatment fails, the next round is just a little different. For example, going from clomid to clomid plus an IUI is just one more thing. Then it’s off to injectibles and IUI, and it that doesn’t work, IVF “just adds the retrieval and the transfer”, as my RE told me. If you made this shift all at once, you might be shocked by your future choices. However, as the process unfolds, a once unthinkable option may start to seem like the best choice after all.

In addition, as you go through treatment, you start to redefine your goals and distill what is really important to you. One example of when this type of perspective change occurs when it seems unlikely that a person will be able to have his or her own genetically-related children. Of course, this is a profound loss that must be mourned. From that loss, however, often comes a change in perspective about what exactly constitutes a family. Instead of the genetic relationship to the child, the quality of the interpersonal relationship becomes more important—people feel connected and related to their child because they devote themselves to caring for the child and share so many experiences together. Interpersonal relationships then become the defining feature of a family, not genetics.

This focus on the quality of interpersonal relationships can carry over into other types of relationships too, in that people are often better able to overlook surface differences and will be able to form deeper connections with a variety of people. Thus, they may develop a larger and emotionally closer network of social support. Their circle of friends may also become more diverse, allowing them to have access to new experiences and perspectives.

Another change I frequently observe is that people who have experienced infertility tend to have an increased capacity for empathy for others, regardless of the nature of their struggles. As I have mentioned in earlier posts, we tend to walk around with the myth that bad things only happen to other people. When something bad happens to you, this myth is shattered, forcing to you acknowledge that bad things really do happen. With that comes the realization of how profoundly painful such experiences can be, whether they happen to you or to someone else. Even though the nature of the hardship or disappointment may be different, you can still have a pretty good idea about how another person may be hurting. Also, almost everyone who has been in infertility treatment has experienced insensitive comments from others, and thus tries to be more thoughtful about what they say, or don’t say, to others.

Many of my clients have also reported that as a result of dealing with infertility, they have increased confidence in their coping skills. By surviving, and even triumphing over their struggles with infertility, they learn that they can survive difficult times, challenges, and disappointments. Plus, they have now developed more sophisticated coping skills, so that the next time a life crisis occurs, they are more prepared and can handle things more easily.

So let’s see here—increased open-mindedness and flexibility, increased capacity for connecting with others, increased empathy and sensitivity, and an increased sense of personal strength—those all sound pretty good, right? Now I know you may be rolling your eyes right now, and thinking that it isn’t worth it—the current pain of your situation is too great, and you’ve got enough character already! But since we usually don’t have a choice about the medical circumstances causing our infertility, all we can do is try to learn from our experiences as best we can. (For instance, my spending a lot of time futilely worrying about the size of my rump probably isn’t the most productive use of my energy, and it certainly isn’t making it any smaller!)

As long as we try to learn from our experiences, I think that the changes in that result from them will be mostly positive. In the case of infertility, the type of personal growth that occurs better prepares us to be parents—we have more emotional maturity and higher levels of tolerance for the stresses that lie ahead. There are several research studies that confirm this theory, in which parents who had experienced infertility prior to becoming parents scored higher on measures of effective parenting.

So if you are worried that your experiences with infertility are going to change you for the worse, remember that are most likely going to become an even more mature, emotionally sophisticated, and empathic person than you already are!