"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!

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!

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.

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.

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!

Common emotional pitfalls when choosing an infertility clinic or doctor

Making good decisions about infertility treatment is crucial because the stakes involved are incredibly high. Having, or not having, a child is arguably one of the most life-changing decisions a person can make. In addition, infertility treatment is incredibly expensive—not just financially, but physically and psychologically as well. Being in infertility treatment (as you have probably already realized) can be quite physically uncomfortable and emotionally stressful. Most of us don’t have unlimited financial resources, and perhaps more importantly, none of us has unlimited physical and emotional energy to endlessly devote to treatment cycle after treatment cycle. So every cycle, every attempt must really count; every decision about what to do next is very important and must be treated as such. To make our very best decision in such a complicated situation, we must be functioning at our highest levels. If our emotions, as valid as they may be, are clouding our judgment, it can make it difficult to make the choices best for us.

In addition to having to make the best decisions for ourselves in the present, we also have to make sure we don’t look back at our current decisions years or decades from now and regret them. Infertility treatment, especially with your own eggs, has a time stamp on it, and we usually can’t go back years later and try again. So we must also think about what our future selves will feel about the decisions we make now. In my own case, I have done many rather difficult and unpleasant things so that 50-year-old Lisa won’t be upset, angry, and regretful (I sure hope she appreciates it!) I feel the regret factor is one of the most important decision-making variables we must include when making treatment decisions.

One of the most important infertility treatment decisions is choosing a reproductive endocrinologist or clinic. However, in my practice (as well as my own life experience) I have observed that this is one of the most common areas in which emotions may have a negative impact on the final decision. Too often, I see that the main criterion that people use to select an RE is that they want someone that really like and connect with emotionally. They want someone who is empathic and sympathetic, and who gives them a feeling of hope even if their diagnosis does not usually have a positive outcome. This is, of course, absolutely understandable. Usually, when we visit a RE, we are feeling sad, anxious, angry and scared, and finding someone that can understand, tolerate, and address these feelings feels good. However, (and I can’t stress this strongly enough) the purpose of your reproductive endocrinologist is not to make you feel better emotionally, but to provide you with the best information and treatment currently available. Thus, the main variables you should be looking for are how successful a particular RE or clinic is in treating your particular diagnostic, treatment, or age group category. Period. Anything else, like a nice relationship with that person, is a bonus.

Okay, so I know that seems like a pretty strong statement for a psychologist to make—that it shouldn’t matter if you like your RE or if you feel he or she cares about you. It’s a vastly different approach than I would suggest for choosing a therapist or an internist, because in those relationships you spend a lot of time with the person with whom you are working, and trust is a vital factor to successful treatment. But there are two reasons behind my thinking here. The first is that there is such variance between the number of cycles performed and the success rates of different treatment clinics. If you haven’t done it already, check out the success rates of the clinics in your area at http://www.sart.org/find_frm.html . You’ll see what I mean. In most cases, you are going to want to go a place that runs a lot of cycles and has good success rates. The RE’s who staff these clinics may, or may not be the type of person you’d love to hang out with, or wish lived next door. But again, that’s not really the issue--getting the best treatment possible, so you don’t waste your time, tears, and money, and don’t have regrets later, is the most important issue at hand.

The second reason I feel that it doesn’t matter too much if you don’t have a warm and fuzzy relationship with your RE is that you probably aren’t going to be spending a lot of time with them anyway. In most cases, you are going to have a lot more contact with the nurses, technicians and other staff, and often, these clinicians are more overtly empathic and understanding.

I should add that I think that getting emotional support about your infertility from someone who understands what you are going through is extremely important. But that support can come from a variety of other sources, like family, friends, support groups, and clinicians specializing in infertility like myself. In my opinion, it is unrealistic to also expect it from your RE, who should be focusing on the medical and scientific aspects of your case.

Another common problem I see is that sometimes people want to make the decision about treatment providers based on other variables like geographic proximity, because they want to lessen the “inconvenience” of infertility treatment. While nobody likes to have to commute out of their way morning after morning to go to monitoring appointments, or even cycle at a clinic in a different town, sometimes it may be a short-term but necessary evil in order to ensure that you are getting the best treatment and the best chances for having the family you desire. I once talked to a friend who was having difficulty getting pregnant. She was quite distressed that she had two failed IVF cycles at Clinic X, which had very poor success rates and did not do many cycles. When I suggest she move her treatment to Clinic Y, which had much higher success rates for her age group, she was very resistant initially because Clinic X was close to her house. Clinic Y was not, and she didn’t have a car, so she would have to take a taxi to her retrieval and transfer. I think she was a bit shocked by blunt question about what was more inconvenient to her—taking a few taxi rides, or not having a baby at all. But she did take my advice and switch clinics, and now a few babies later, I think she’s glad she did.

I think one of the reasons such seemingly irrational decisions occur is that people may not want to acknowledge the far-reaching impact of infertility on their lives. Somehow, commuting across town or even across the country for infertility treatment makes it seem all the more real and painful. The unfortunate truth, however, is that infertility affects us deeply, whether we consciously acknowledge it or not. And the consequences of our decisions are profoundly life-altering events which, one way or another, will shape the future course of our lives.

So if you find yourself unsure of what to do when choosing a treatment provider, make sure to take the time to try to really understand what you are feeling. Remember that picking your treatment provider is an incredibly important decision with far-reaching consequences, and that you definitely want to try to avoid having long-term regrets later in life. In order to give yourself the best chance of success, you may have to make choices that don’t “feel good” in the short term.

Although you may not be able to use your feelings as the sole basis of your decision, they are still very important to understand and process. It may be helpful to talk to someone else in order to clarify these feelings, such as your partner, a family member, a friend, or a mental health professional. By being more conscious of what your feelings are and how best to respond to them, you will be freer to make the best choices for you in the long run.

Infertility, self blame, and the fiction of doom; why it is probably not your fault

As a clinical psychologist who specializes in working with infertility issues, one of the things I’ve learned is that every person’s story and situation is truly unique. Infertility is one of those life experiences that usually pushes a lot of emotional buttons. Everyone has different buttons, and thus responds differently.

But there is one thing I’ve heard from almost everyone facing infertility at some point in their journey (including myself), and it’s some version of this---that infertility is somehow God’s/the universe’s/karma’s (insert spiritual force of your choice here)’s little way of telling you that you shouldn’t be a parent because you are somehow, or were somehow, bad.

Everyone has their own personal spin on this story, too, when it comes to the details of their alleged horribleness. Often, people seem to struggle to come up with an actually plausible reason for their punishment, because the truth is that they haven’t ever even come close to doing something that would deserve that kind of response. What would, really? Some of the explanations, if the whole situation wasn’t so sad, would actually be pretty funny. Also, almost everyone is able to acknowledge that this is irrational and that all manner of people with glaringly obvious challenges to their parenting skills are able to procreate freely.

But they all still believe that it’s somehow their fault anyway.

Did I mention I myself am not immune to this sort of magical thinking? I remember telling my first RE on more than one occasion that my infertility was a punishment for something I had done in a former life. I also remember being pretty shocked when one day he agreed with me, saying, “I don’t know what you did in that former life, but it must have been really, really bad!”. Not the treatment prognosis you really want to hear, but more on that whole situation another time.

So why do we do this? Why do we torment ourselves even though we rationally know it isn’t, can’t be, our fault?

My theory is that it is our attempt to create meaning and order in a painful, chaotic experience. That somehow it seems more painful to realize that most infertility is probably the product of some random chemical and/or cellular mishaps over which we have no control, because then we must admit that we have, at best, very limited control of the outcome.

This phenomenon is not exclusive to dealing with infertility, however. People often have a very hard time admitting they don’t have complete, or sometimes even partial control over their bodies and their destinies. This purpose of type of defense is to help us function in everyday life. We all walk around every day with all sorts of fictions and denials designed to prevent our realizing, say, that at any second, there is a small but possible chance that we, or a loved one, could be in a car accident, be diagnosed with serious illness, a victim of violent crime, etc. The possibilities for peril are endless even if they are, thankfully, unlikely. But if we constantly hold these possibilities in the forefront of our minds, we would be paralyzed by fear and we wouldn’t be able to function. One way of coping is to create fictional beliefs about our control, such as “I won’t be in a car accident because I’m a good driver.” Although this may not actually be true—being a good driver may reduce one’s chances of being in a car accident, but as accidents can be caused by other drivers’ mistakes, it does not eliminate the risk—it allows us to get behind the wheel and drive to our next destination.

When it comes to situations like infertility, this coping mechanism starts to work against us. Because we have limited conscious control over the inner workings of our bodies when things go awry, we are forced to “go negative” to create a fictional belief that allows us to have the fantasy of being in control. This is where thoughts like “I must be a bad person”, and “I do not deserve to be a parent” come into play. Since we can’t control it physically, it pushes the explanation into the karmic, moral and spiritual realms.

The good news, though, is that once we realize that these negative beliefs about ourselves are not true, but just a misguided way to feel like we are more in control of the situation, we can start to let ourselves off the hook. And being fully aware of the truth of the situation—that we (or our doctors) ultimately have limited control over what our hormones, organs, and cells will do—allows us to take a different perspective on ourselves and our treatment. Once we can get our self-esteem and cosmic self-worth out of the equation, we can make better treatment and life decisions for ourselves. It is so much easier to decide what is best for you, your family, and your future if your worth as a person is not tied into it somehow.

So you if you are reading this, and you’ve been blaming yourself on some level for your infertility, please know that it is very common, and that you are certainly not alone. Try taking a more skeptical view on your own ideas about what you’ve done wrong, or why you think this might be happening to you. Most likely, you will realize that these thoughts and beliefs aren’t so much about your current situation, but instead stem from your wish to have more control over the situation than is possible. It is important to remind yourself, often repeatedly, that your worth as a person and your ability to reproduce are almost always completely separate things. In so doing, you may be able to free yourself from feeling bad about yourself and doomed in your situation, and develop a fresh perspective to help you succeed with the challenges that come your way.