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

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

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

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

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

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

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

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

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

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

Hello Again!

Back to blogging after a long absence!

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

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

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

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

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

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

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

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

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

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

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

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

1.  Pregnancy after infertility is often filled with anxiety.

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

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

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

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

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

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

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

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

More decisions; medical decisions, emotions, and infertility treatment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Infertility, pregnancy, and self-esteem

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

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

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

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

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

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

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

The 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.