Infertile and ringing in the new year: anxious or hopeful?

If you have been grappling with infertility in 2010, and perhaps for months or years before that, ringing in the new year is a time that is symbolically and practically filled with both hope and anxiety. Symbolically you are facing the new year without a baby in your arms, without a healthy pregnancy, and perhaps without much conviction that medical intervention is going to lead to parenthood. On the flip side of this coin, you also may have learned some lessons from your infertility experience and decided in the new year to try some new strategies. This leads to the practical dimensions of how 2011 can be different: can you and your doctor get clearer about medical expectations? Can you find ways to nurture yourself better through the inevitable anxiety of infertility? Can you and your partner discuss timeframes and begin to explore options in case a healthy pregnancy is not in your future?

There's no question that months of medical interventions can take a serious toll on your hopefulness. All too often doctors will continue with the "same old, same old" without re-engaging you in a discussion of possible future steps to consider. So for the new year, why not make an appointment with your physician to discuss a treatment time frame for 2011. This would include future treatment options, for how long to continue them, costs involved and statistics on healthy pregnancies for women of your age and with similar health conditions. Having this conversation will alert your physician to your expectation that you expect ongoing assessments of what treatment options are open after a reasonable time period of trying standard medical interventions. If you are currently being treated by your local ob-gyn, this might be the best time to discuss whether an infertility clinic could offer more comprehensive medical services (and more flexible days of the week for medical procedures and lab tests).

And while you're thinking about timely medical interventions, the new year also is a time to think about whether you are getting enough emotional support, as the months or years of infertility take their inevitable toll. In my just-published book When You're Not Expecting: An Infertility Survival Guide, I offer a number of suggestions for how to access emotional support, ranging from how to communicate differently with your partner to ways of identifying a therapist or a support group. Even if you are not feeling a compelling need for an extra shoulder to lean on, now might be a good time to check out potential resources in your community, since it is best to have this information in advance of being assailed with feelings of desperation. Prevention is what you'll want to aim for in terms of your emotional health, since you will always cope better with your infertility journey if you have the capacity to absorb ongoing news with a resilient emotional perspective.

So what if 2011, like 2010, progresses with no signs of a healthy pregnancy? Here, again from the perspective of your trying to exert some control, is the opportunity to discuss the "what ifs?' with your partner. Would you be open to adoption? Working with a surrogate? Learning about donated eggs, sperm, or embryos (please see my earlier blogs for information on these options). Whereas you might be saying "yes, maybe" now, some more research on your part will let you know how viable these options are. For example, some countries only accept applications from prospective adoptive parents in good health, of certain ages, in first marriages, etc. Some sources of donated eggs/sperm/embryos are highly questionable or ethically inadvisable. Some attorneys specializing in services for infertile individuals and couples have strong professional reputations, where others do not. Rather than wait until you are ready to take the next step towards parenthood, 2011 might be the year to investigate costs, restrictions and waiting lists. You may not be ready immediately to pursue these options, but you'll feel more in control if you begin your initial investigations (both emotioal and practical), so you can be aware of how much time and money you want to invest in current medical procedures.

So, as you ring in the new year, admittedly with both hope and anxiety, perhaps you can take comfort in knowing there are some proactive ways that you can move into 2011 with new and informative resources. The key word for this new year is "resilience," as you strive for the best outcome possible in your quest for parenthood!

Infertility and the Holidays: A "Double Dose of Hectic"

December holidays are busy for almost everyone, and those of us who grapple with infertility feel especially challenged at this time of the year. Those challenges are both practical and psychological. So let's see what we can do so as not to become overwhelmed by the "double dose of hectic."

In terms of practical challenges, not only do we face the expectable tightness of our schedules as we shop for presents, wrap gifts, send out cards and holiday letters, attend (or host) various parties and events, bake special goodies and decorate our home for the holidays. In addition to the usual holiday tasks, our infertility may place unique pressures on us at this time of the year. Is our doctor's office going to be open around the clock during the holidays? If not, does that mean missing treatments, being delayed in hearing lab results, or needing to be seen by unfamiliar medical personnel as the clinic copes with absences of key staff during the holidays? If your physician also sees women without infertility concerns, does this mean infants, children and pregnant women in the waiting room, many of them dressed in holiday garb and reminding you of what you'll be missing this year -- sharing the holiday excitement with a wide-eyed child? Perhaps you have the opportunity to be out of town during the holiday period. Does this mean that you need to schedule blood tests in a distant location, feeling all the while that there's no escaping your infertility? Or maybe the costs of infertility are becoming especially apparent at this time of the year, when you have less to spend on holiday celebrations?

These practical challenges are aggravating for some of us and downright depressing for others. At a time when we have so little control over the one thing that matters so much -- our dream of becoming a parent -- it especially hurts to have additional losses of control because of unexpected schedule juggling during the holidays. So what can you do? One thing to consider is to scale down on your expectations for yourself in terms of your productivity or activities related to the holidays. This is probably good advice for anyone at this time of the year, but if you feel extra pressure from infertility concerns, then for sure you need to reduce your stress wherever you can.

Think about what could be dropped from your "to do" list; enlist your partner or friends to do tasks that can be shared; hire some help; alert family and friends that you're striving for a restful holiday this year. Next, in the spirit of being restful, think about how you can psychologically take some time out from holiday pressure. A good book? a funny DVD? some time on the treadmill? tea or eggnog with a few close friends? a nap? Undoubtedly you can think of what works for you -- and your challenge then becomes putting yourself first at a time of the year when it is easy to get caught up meeting others' expectations. Just remember, you're experiencing the "double dose of hectic," so you, especially, are entitled to take some quiet time to regain your perspective.

Now, remembering that I also mentioned the psychological challenges of this time of the year, let's see what that might mean for you. Since several of the December holidays have a major focus on children, there's no escaping their excited presence -- whether enjoying school vacations, playing in the snow, sitting on Santa's lap at the mall, or being wheeled everywhere in carriages and strollers. This, often combined with harried parents' complaints, can set our teeth on edge. It is such an emotional reminder that we don't yet have a child and, when and if we do, that we will be accepting, not resentful, of the inevitable stress of parenthood. So, whether you encounter the excited children head on when you venture out to malls and restaurants, or whether you consciously choose to avoid those locations as much as possible over the holidays, be purposeful about how many doses of childhood excitement you can psychologically absorb. When you are reaching your limit, try to find a quiet place to regroup, consider postponing your tasks for another day, and head for a peaceful place where you can focus on more calm thoughts.

But what if leaving the scene isn't an option? Here I am thinking of family gatherings, holiday meals, and traditions where your presence is expected. Here is where some anticipatory planning can provide a safety net. You and your partner are probably aware of what is likely to occur at these various family events and how those occurrences may push your buttons. Make a plan, and clue your host in, that if it all begins to feel "too much," you will retire to a quiet bedroom, or for a short (or not so short) drive, or excuse yourself with a headache (yes, I know it's really a heartache...), and head for home, or your hotel room, or a peaceful place you've identified in advance as emotionally safe. Once there pull out a book, listen to music, light a fire in the fireplace, meditate, or do whatever you can to feel more calm and relaxed.

Holidays are a mixed blessing, and infertility makes them even more mixed, as holidays often mark another year that has passed without a baby. You are entitled to feel the sadness that accompanies these yearnings, and you also are entitled to make whatever conscious efforts you can to soften the impact of your infertility at an emotionally vulnerable time in the calendar year.

Even as you are feeing vulnerable, remember that you also are loved and that your loved ones deserve the opportunity to support you through this season. Clue them in. Let them help.

Infertility: How to Brighten the Holidays

Many of us find our struggles with infertility are especially difficult during the winter holidays. Perhaps our medical specialists have curtailed their office hours; perhaps we are overwhelmed at the mall with the numbers of children sitting on Santa's lap or the number of parents pushing strollers; perhaps last year we had looked forward to being pregnant by this holiday season, and we're not; and very likely it is hard to get excited about holiday gifts and celebrations when the only rejoicing we could imagine would be to revel in a positive pregnancy test or having our own baby to cuddle under the holiday lights.

So with this acute awareness that the holiday lights seem dimmer this year, I'd like to offer some thoughts on ways that you can turn up the wattage. Of course, being infertile does not make you the only person feeling some disappointment in the holiday hecticness. We all tend to have inflated expectations of family togetherness and spreading joy at this time of the year. But infertility does present itself as a reminder of reproductive sadness to couples, and it also is an unresolved issue that keeps tugging at your heartstrings. So how can you get beyond this emotional disappointment at a time of the year when others seem so effortlessly to be celebrating the joys of the season?

Perhaps one thing to consider is to decide with your partner how you want to acknowledge the holidays this year. Would you like to host a party or to go to lots of holiday gatherings? Would it be soothing to spend some peaceful time together before the fireplace or hiking outdoors? Would it bring you satisfaction to do some volunteer work in health care facilities or soup kitchens where regular staff would appreciate having time off during the holiday season? Do you enjoy baking holiday goodies to share with friends and family? If the local shopping scene is stressful, might you consider home made gifts or ordering from catalogues instead of braving the crowds? Rather than getting swept up in the hectic pre-holiday rush, think purposefully about what will bring you pleasure among the many choices available and then indulge yourself in these activities.

Another aspect of the holidays to consider is which rituals have meaning for you. You may decide that you no longer want to participate in familiar family rituals, like watching nieces and nephews open their presents, if this now feels more obligatory than joyful. Now is the time to absent yourself from rituals that no longer are satisfying and to invent or participate in new rituals that are more uplifting. How about a midnight walk in the snow, or a nighttime stroll to enjoy the holiday lights, or a peaceful cup of eggnog before a crackling fire? Or maybe a try at ice skating after many years off the rink or a visit to a local nursing home or watching some favorite DVDs with loved ones? There's nothing magical about inventing rituals -- just an opportunity to let your imagination travel in creative directions!

So what if your family objects that your new holiday rituals prevent you from participating in their favorite familiar ones? Every family is different, and you know best how to counter their objections, but keep in mind that you have every right to assert your belief that change can be good, new rituals will bring you happiness, and you would appreciate family support as you move forward in seeking happiness during the holidays.

Since we're in the midst of the holiday season, now is a good time to rethink what can make this time of year more uplifting for you. Let your imagination soar, let your creativity flow, and get in a holiday spirit that offers a chance for your infertility to co-exist with love, with embracing unique rituals, and with discovering new aspects of yourself as you move forward into the new year!

Infertility: Creative approaches to Thanksgiving

Thanksgiving causes many people with infertility to pause and re-evaluate the meaning of this U.S. holiday. Not only do we feel distinctly unthankful for what have become elusive and unsuccessful efforts at parenthood, but we also feel apprehensive at the prospect of sitting at the holiday table with pregnant women, nursing mothers and infants in high chairs.

So what can we do to anticipate new ways of approaching and getting through this particular holiday? For starters, it may help to figure out just what is likely to cause the most emoti0nal difficulty this year. Is it the tradition of family togetherness when your family of two feels especially small next to the burgeoning families of your fertile adult siblings? Is it the expectation that you will need to pitch into meal preparation and clean-up with more energy as the parents in the group attend to their offspring? Is it the anticipation that enthusiastic conversation at the table will focus on the children, a recently announced pregnancy or, worse yet, that there will be complaints about the exhaustion of parenting or the discomforts of pregnancy? The list could go on and on, but we all know our most vulnerable issues connected with our infertility and how they change over time.

So, in the spirit of trying to be creative about those vulnerabilities, what are some things to consider? I know some couples who decide to make Thanksgiving less about tradition and more about celebrating in a new way: volunteering time in a workplace that could free up some of its employees to enjoy the holiday with their loved ones; serving food and offering conversation at a homeless shelter; or delivering Thanksgiving baskets to families who have requested them. Other folks without children may choose to enjoy nature through hikes, renting canoes and kayaks, camping out or preparing their gardens for the winter. All of these may very well be done before or after the traditional family Thanksgiving, and they will give you the opportunity to carry the conversation in interesting directions for others around the table.

But what if you are at a point where the length of time or effort others expect you to devote to Thanksgiving is already feeling like a burden? There's nothing that says this year has to be like other years. If you are feeling emotionally depleted and not celebratory, figure out what you are willing to do to contribute to the holiday, let the hosts know far enough in advance so they needn't count on you for your famous stuffing/pie/gravy or whatever, and offer to do only as much as you can comfortably. Try to arrange to be seated near people whom you enjoy, and arrange a signal (and a prearranged excuse) with your partner if you need to make a retreat from the celebration in favor of some peace and quiet.

For some people grappling with infertility, Thanksgiving may represent a wish to be absent from family altogether. The prospect of an extended weekend out of town, or with distant friends or relatives, or submerged in a favorite city, activity or indulgence just hits the spot. Do it! Explain in whatever way you choose to the usual Thanksgiving crowd, perhaps contribute some homemade desserts for the meal, and then disappear to enjoy yourself without the reins of tradition holding you back.

Creating your own traditions is a valid an approach to the holidays. Although your infertility may be the catalyst to your creativity, this also represents resilience on your part to taking care of yourself, to expanding your horizons and to thinking about the continuing holiday season in new and more fulfilling ways.

Infertility and Halloween: Cheers? Jeers? Tears?

Halloween, as the ultimate children's holiday, may evoke your own childhood memories of that magical day and evening. Or it may have a darker side as children fill your yard, just for this one evening, with joyful anticipation. What's so dark about that? Well, for one, they're not your children, even though they may stimulate your fantasies about how much fun it would be to create imaginative costumes for your own little one(s), usher a child through the neighborhood on that night, and sort through the goody bag once all the treats have been collected.

So what is this holiday like for those who yearn for parenthood? To many of us it serves as a reminder of the cheers that children echo again and again in the weeks before Halloween as they shop for or create their own costumes, visit pumpkin patches, carve the pumpkins and stock up on sweets. There's lots to cheer about if you're listening to the kids, but I often found myself feeling emotionally sidelined as other parents shepherded their little ones through the anticipatory preparations. Then when Halloween actually arrived I could put on a happy face at my front door, but at the end of the night I knew it had been just that - a happy face covering the wistful emotions in my heart.

Emotional jeers would jab at me too. I would grouse at the huge amount of sugary snacks being purchased, knowing that the money spent on them could better have been donated to a local food bank so low income children could have nutritious food available. Or I would mumble to myself that the last thing any child needs these days is extra calories -- and for several years I followed the example of a neighbor dentist who passed out toothbrushes to trick-or-treaters (my virtuous choices ranged from pencils to apples to raisins, evoking surprise but not enthusiasm from the local kids, who clearly viewed me as a kook!)

And inevitably there would be some tears shed. Sometimes they were an over-reaction to smashed pumpkins or T.P.'d trees the next morning. More often, though, my tears were in response to the feeling of not being in The Club, to which I devote an entire chapter in my book When You're Not Expecting. This feeling of being left out of parenthood, of being deprived of cuddling a child each day, of missing the opportunity to re-live aspects of my own childhood if only I could share them with my child...these were the precipitants to my misty eyes as Halloween approached, peaked, and life moved forward again.

And, of course, as I came to learn and dread over the years of my infertility, Halloween was just the beginning of a long series of family holidays (more of this in future blogs). So each year I would view Halloween as a testing ground to prepare me for how I would try to reconcile my infertility with others' celebrations of holidays that often had children, pregnant relatives, nursing mothers and infants in attendance.

Having begun this blog with some reference to "cheers," I will end it by sharing a personal "cheer." After three years of battlng infertility, my daughter was born in late October, and we arrived home from the hospital the morning of Halloween. With no time to carve pumpkins and barely enough sense to purchase some candy bars, we welcomed trick-or-treaters with genuine joy and enthusiasm. Many of the neighborhood kids had been curiously observing my swelling abdomen, so they considered themselves very privileged to get a first introduction to "the newest kid on the block" that evening. My husband and I had decided to dress her in the most symbolic of costumes: a Red Sox hat and bib. To us, as loyal Red Sox fans who met during the World Series season many years earlier, who had cheered the Red Sox on for countless years without a World Series victory, we knew what it was like to hold out hope eternally. We had held out hope for our child's birth for what felt like an eternity, never knowing we would have the joy of a baby to cuddle on this special children's celebratory holiday.

Infertility: So Now What Do I Say To My Pregnant Girlfriend?

Sympathetic as your girlfriend may have been to your infertility struggles, now that she is pregnant you know your relationship is facing some unanticipated twists and turns. What are some of the issues you'll both need to discuss? What hopes and fears do you share? How can you keep your communication with each other as open as possible? As I mentioned in my blog last week, both of you will need to recognize the imbalance you are facing, as she is potentially experiencing joy and ambivalence and you are likely feeling envy, envy and more envy.

So, let's look at the envy issue head on. It is there and both of you know it. But how you handle it can make all the difference. And it will probably be up to you to broach this subject. You might begin by saying to your friend that you are feeling both happiness and envy as she anticipates the upcoming months of her pregnancy. You may say that you worry about feeling left behind as her life becomes increasingly preoccupied with plans for the baby's birth. And you will want to reach out to her to affirm that this is a friendship you treasure and to ask if both of you can spend some time now anticipating how you can keep the relationship resilient.

Hopefully she will be relieved that you have taken the lead in opening this conversation. And hopefully she will ask for your ideas on how to remain close friends as her pregnancy progresses and as she becomes a parent. So here are the things you'll need to think about as you and she pursue this conversation. What do you think will cause you emotional pain? Conversations that focus on the pregnancy? Seeing changes in her living arrangements as some space is set aside and furnished for the nursery? Seeing your friend with a distended abdomen? Wondering whether she cares to hear about your continuing saga of infertility treatment? Feeling that you are the logical one to give her a baby shower and recoiling at the thought? Recoiling at the thought of even attending her baby shower? Anticipating that she might ask you to be her child's godmother? Knowing that you would be devastated to visit her in the maternity wing of the hospital after the baby's birth? Wondering about how both of you will have time to invest in your friendship after the baby is born?

Those questions and possibly others suggest that you will need to look within yourself to anticipate the experiences you can handle, those you want to avoid, and those you don't even want to hear about. And, of course, when the reality presents itself you may feel differently than you had anticipated, so you and she may need to leave some room for re-discussing some of these issues as time moves forward. But the glue that will hold this friendship together rests with both of you being willing to bring up potentially painful issues and ask each other how you can handle them so both of you feel supported. You both may need to accept that the changing face of the friendship may include sharing discussion on some topics but not on others. It may include more telephone conversations, more texting and less face-to-face time during certain periods, It can include an awareness that your friend is reaching out to others for support and shared happiness when she knows certain areas are just too painful for you.

And this leads to another issue for you. As you find that certain areas of conversations and contact with your girfriend are diminishing, you may decide to fill that potential loneliness, at least temporarily, with other activities or relationships. As I discuss in my recent book When You're Not Expecting, this time when friends and loved ones are pregnant or young parents often propels individuals with infertility to develop relationships with acquaintances who are empty nesters, who are child free, who are infertile, or whose children are away at school or otherwise not a time consuming presence in their lives. In addition to a shift to new relationships, you also might choose to get more involved in activities, social causes, political concerns or community issues that capture your interest or passion. Doing this can offer new relationships, distract you from being overly preoccupied with infertility, and make you a more conversational partner for new and familiar acquaintances.

So this blog is not about how envy may poison a treasured friendship. It is about how relationships evolve over time, how even envy can co-exist with mutual thoughtfulness, how your own insight about a friend's pregnancy and young motherhood can guide you in the way you raise with her your hopes and fears, how your friendship may change but need not deteriorate, and how you can continue to nurture a treasured ongoing friendship at the same time you reach out for new relationships. Resilience is the key here, as both of you seek a new balance in your changing lives.

Infertility: My Best Friend Is Pregnant!

If you have been trying for months (or years) to get pregnant, the news of anyone you know having achieved this triumph can be a real bummer. But when the news comes that your best friend is the mother-to-be, there are lots of emotional issues for both of you. Was hers a planned pregnancy?Did you hear the news from her directly? How open have you been with her about your struggles with infertility? Is she sensitive to your emotions upon hearing her news?

All of these issues will play a part in how your friendship continues to unfold in the coming months. If hers is an unplanned pregnancy, your friend may confide in you as she makes future decisions. Not only will it feel difficult for her to confide her ambivalence about this pregnancy, it may be just as difficult for you to empathize with her at a time that becoming pregnant is at the top of your wish list, without an ounce of ambivalence on your part. Should she decide to terminate the pregnancy, your feelings will be even more painful. You know at one level you should reach out and offer emotional comfort, but where are you going to find comfort for yourself? It is emotionally complex to watch this friend end a pregnancy because she assumes that when she is more ready for parenthood her body will be ready as well. Her decision to end the pregnancy may be one time that you will probably need to offer her whatever comfort you can muster and then turn to others in your life for solace and understanding. If, instead, her decision is to continue the pregnancy, then you and she face a new set of relationship issues as she seeks to resolve her ambivalence and you seek to keep your envy at bay.

So, let's go back to the beginning and explore how you first heard the news. If it was not from your friend but, instead, from a mutual acquaintance, you have every reason to ask her why, as her best friend, you were not among the first to know. Even as you ask, you already know the answer. She could not bear to see the pain in your eyes, hear the catch in your voice, wonder about the genuineness of your hug. So now is the time that both of you must talk about how her pregnancy might affect your relationship, what your hopes and fears are, and how you can keep your communication as open as possible while both of you are treading unexplored territory in keeping your friendship alive.

If you heard the news of her pregnancy directly from your friend, how did she share her news and what was your reaction? If you knew she was trying to become pregnant you had probably already rehearsed a few phrases in anticipation of her news. She, on the other hand, also probably had done her share of rehearsing before breaking this news to you. If you had not known that she was trying, then the news will likely have taken you by surprise, with many mixed emotions. It is a real challenge to receive ordinarily joyful news when both of you know there is more than a tinge of sadness in you, the recipient. Certainly the sadness is not about wishing her anything but happiness -- but you know already that you will be left behind on this particular happiness journey, and you wonder whether your friendship can be resilient or whether it will crumble or wither under the shadow of your friend's upcoming anticipation of parenthood.

And, just as you hope she will have some empathy for your yearning for a pregnancy of your own, it is important to reflect on how familiar she has been with your infertility struggles. Many couples grappling with infertility agree to be fairly discreet with friends and loved ones, preferring (at least initially) to contend quietly as a couple with sadness, with diagnostic test results, and with treatment decisions and outcomes. Others are far more open, both in terms of emotions and medical details. Your friend's capacity to empathize with you now will be affected by how much you have shared in the past about your own infertility, both its medical aspects and its emotional impact. If you need more empathy than she is offering, this may be the time to be more open with her about what she can do to offer emotional support. Both of you will need to recognize the imbalance you will continue to face, as she is potentially experiencing joy and ambivalence and you are likely feeling envy and envy and more envy.

My next blog will focus on how to keep emotionally strong during a friend's pregnancy, along with some tips for how to negotiate expectable pitfalls looming in front of both of you. Stay tuned!

Infertility: A Nobel Prize in Medicine for IVF Pioneer!

There is no question that the perfecting of in vitro fertilization has revolutionized treatment options for millions of infertile people world wide. Today the Nobel Prize in Medicine was awarded to Dr. Robert G. Edwards who, with his now-deceased colleague Dr. Patrick Steptoe, spent years perfecting the IVF procedure while battling controversy, lack of institutional funding and criticism on ethical and religious grounds. For those of us who have faced our own infertility struggles, it becomes easy to bask in the glow of this belatedly-awarded Nobel Prize. Drs. Edwards and Steptoe demonstrated more than medical brilliance in their work together, they also set a high bar for unwavering determination to overcome the many-pronged resistance to their scientific breakthroughs.

The celebration of the birth in 1978 of Louise Brown, the first IVF baby, was the beginning of a revolution in infertility treatment, just as that very birth was met with intense criticism of IVF as subverting the natural order of how conception occurs. Ultimately medical follow-up on IVF babies demonstrated that the IVF technique is safe and does not pose a risk to the healthy development of IVF babies. And most criticism, except that of the Roman Catholic Church, has melted away as some four million babies worldwide have been conceived, to the joy of parents who considered IVF to be their last hope for pregnancy and parenthood. IVF is now used in 3 percent of all live births in developed countries.

Since those of us who have grappled for years with infertility often come to feel singled out for unwarranted reproductive distress, I thought readers of this blog might be interested to know a bit about the multi-pronged battles waged by Dr. Edwards and Steptoe (Dr. Steptoe, who died in 1988, is not being named as a co-recipient of the Nobel Prize, as it is not awarded posthumously). My empathy for their ordeal is only surpassed by my gratitude that ultimately they triumphed so magnificently!

Medically, Edwards and Steptoe did their work in England, devoting over 20 years to solving problems related to getting eggs and sperm to mature and unite successfully outside the body. They were denied government funding for their IVF research, but their persistence paid off in their abilities to procure private funds. They were attacked, both by clinicians and by ethicists, many of whom were ultimately won over as their own colleagues became more familiar with the successes of IVF. Dr. Edwards, who filed 8 libel actions in one day, proclamed "I won them all, but the work and worry restricted research for several years."

Edwards's and Steptoes's initial medical research was slowed by a series of frustrations in being unable to get eggs to mature outside the body, then in being unable to get fertilized eggs to implant in the uterus successfully, and ultimately in transferring more than 40 embryos before obtaining their first pregnancy. That pregnancy was ectopic and was aborted before Louise Brown was born from the second pregnancy.

But that was back in 1978. Why has it taken so long for the Nobel Committee to offer much-deserved public recognition to these IVF pioneers? Dr. Steptoe is now deceased, and Dr. Edwards, age 85, is "not in a position to understand the honor he has received today," says Dr. Michael Macnamee, a longtime colleague. Since the prize-giving committee's deliberations are confidential, it is not possible to know for certain about the delay in awarding the Nobel Prize. The New York Times reports that the committee shies away from controversial people and issues. Certainly the prolonged ethical objections to IVF may have contributed to the delay, as may have Dr. Edwards's political views as a committed socialist.

Whatever the reason for the delay, today is a day to celebrate! People with infertility the world over know what it is to wait, we know what it is to be misunderstood, we know what it is to persist through emotional turmoil and medical disappointment. Some of us know what it is to rejoice. In the spirit of empathy for Nobel Laureate Edwards's grit and determination, for his medical persistence and vision, and for his magnificent contribution to the joy of many families around the world, I join with millions of others to salute him!

Infertility and Recipients of Embryo Donation

Last week my blog concerned embryo donation. This blog will focus on the recipients of embryo donation. With the large number of cryopreserved (frozen) embryos available in the U.S., only a small percentage are designated for donation to other individuals and couples. Who might be the recipients of these embryos? Why might this option be more appealing than egg (oocyte) donation or adoption? What psychological issues will recipients face as they pursue parenthood via embryo donation?

Among those individuals who consider becoming recipients are infertile couples whose treatment has been unsuccessful, single and lesbian women, individuals who have experienced repeated pregnancy losses (based on other than uterine implantation factors), and individuals with transmissable genetic diseases, absent or nonfunctional testes or absence of or nonfunctonal ovaries (with a functional uterus). However, the choice to be a recipient may not be available to these populations in all countries, so in this blog I will focus on options in the U.S., where practices can vary by agency/clinic.

So why might an individual or a couple decide to become a recipient of embryo donation, where the embryo is placed in the uterus of the woman recipient, with the hope that it will implant and develop into a healthy fetus? Many recipients pursue embryo donation because it is a less expensive family building option than egg donation or traditional adoption. Also, the process of obtaining donated embryos may take less time than adoption. Some couples are drawn to this option because of their wish to experience pregnancy, delivery and nursing of an infant. Others value that it offers greater control over prenatal care and nutrition than would be likely with adoption. Still others anticipate that future pregnancies using the same embryo donors would allow their children to be genetically related to one another, even as they do not share the genes of their gestational mother and her partner.

So what are the words of caution for individuals considering this alternative form of family building? In one's eagerness to locate a donor, some potential recipients may decide to travel to other countries to receive treatment that would be much less available or more expensive in the U.S. Known as reproductive tourism, this practice shortcuts the education and counseling provided in U.S. agencies/clinics, may not be performed under ideal medical conditions and, in some cases, is both financially and emotionally exploitive to the non-domestic embryo donors.

However, assuming that you remain in the U.S. working with an agency/ clinic whose staff are skilled in supporting both donors and recipients, you and your partner may need to travel for treatment and counseling, will need to have a home study performed in advance of receiving the embryo, and are likely to be expected to explore issues with a mental health professional in several areas: how have infertility and infertility treatment affected you? what are your concerns/fears/fantasies about building your family through embryo donation? what coping strategies do you envision using as you proceed with this option? how will you contend with the knowledge that any offspring born via embryo donation will probably have genetic siblings who are being raised by the genetic parents? will you disclose to any offspring about their embryo donation origin? how "open" or "closed" do you want your relationship with the donor couple to be? (Clinics make every effort to match donors and recipients with the same preferences) and how have you and your partner come to terms with giving birth to a baby not genetically related to either of you?

The World Health Organization recommends that counseling should be made available to all individuals and couples undergoing embryo donation. In the U.S. this is typically provided through embryo donation agencies. In the U.S., RESOLVE, the national infertility organization, has published extensive materials related to embryo donation (see www.resolve.org/) Among other issues, these resources will inform you about a number of financial expectations, which can include the cost of fees for medical examination, blood testing and professional fees that must be assumed for both the donating and recipient couples, psychological counseling before and after the transfer process, shipping of embryos, reimbursement to donors for storage expenses, the agency fee for its work in facilitating the donation, medical and genetic screening, and the home study.

So do you think of yourself as a potential recipient of donated embryos? With this as a relatively new parenting option, there exists some beginning research, an increasing number of agencies serving both donors and recipients, and excellent publications through RESOLVE for U.S. residents who would like to become more fully informed. If you are intrigued by this option for building your family, I hope my blog has pointed you in several directions to explore further!

Infertility and Embryo Donation

Embryo donation does not receive much publicity, yet it is important for people with infertility to know about it, as well as about embryo adoption, which I will discuss in next week's blog. Today I will focus on the donation of remaining embryos from one couple's IVF treatments to another couple, followed by the placement of those embryos into the recipient woman's uterus for the purpose of pregnancy.

When an infertile couple's treatment enables them to produce embryos, they very likely begin by having some of those fresh embryos placed via in-vitro fertilization into the woman's uterus, with the remaining embryos frozen for possible later use. If an implantation occurs, followed by a healthy pregnancy and successful delivery, the couple still have the option to use the frozen embryos at a later date in an effort to have more children. However, at some point the couple will decide that they will not use any more frozen embryos, either because they have been able to have their desired number of children or because IVF has not been successful and they have decided not to pursue future IVF efforts.

So the question becomes what to do with any remaining frozen embryos. The options available to the couple at this point include keeping them in frozen storage, asking that the embryos be thawed and disposed of, donating the embryos to stem cell research or donating the embryos to an adopting couple. There are currently 500,000 frozen embryos in the U.S. and one million worldwide. So why is the option of embryo donation not considered by more couples? For the most part it has to do with their emotional ties to the embryos and the reluctance to address their inevitable grief as they donate the embryos to another couple hoping to become the gestational parents.

Having put a great deal of time, expense and emotional energy into creating the embryos, a couple will want to be very certain they will not seek to achieve another pregnancy. The couple also may consider these embryos to be extensions of themselves, and in that sense have a genuine emotional attachment to each embryo, which could be considered a potential child. Thinking of donating their embryos can feel like letting go of an important part of themselves, and many potential donors resist the inevitability of the grieving that will accompany a decision to donate. Yet to allow their embryos to remain for years in storage presents its own set of dilemmas.

Yet many couples with stored embryos have a very real appreciation for the emotional yearning of infertile couples unable to give birth to a baby with their genes. The empathy they feel for couples whose treatment for infertility has been unsuccessful can promote a willingness to address the emotional grieving process in order to proceed with donation of their remaining embryos.

Well over half of embryo donations are anonymous donations, but the legal option exists for a donating couple to specify that they want an semi-open or an open embryo adoption. In an anonymous donation/adoption, medical information about the donors would be disclosed to a couple adopting the embryo(s), but no other identifying information. A semi-open donation/adoption could include sharing such information as family interests, first names, e-mail addresses, but not a mailing address. An open donation/adoption would typically include an initially signed agreement, specifying the level of contact with which both couples are comfortable.

So, as I find myself moving more toward sharing information about embryo adoption, I encourage you to stay connected and keep your eyes open for next week's blog on that subject!

Infertility Sadness: Is it "the blues" or depression?

Most of us who have grappled with infertility will readily admit to hours of sadness, days of feeling rotten and even periods of being emotionally overwhelmed. We may believe that those feelings go with the territory of infertility. But what if the time comes when we feel so unlike our "old self" that we begin to question whether the blue cloud hanging over us is here to stay?

Given the built-in stress of infertility, some sadness is inevitable. Our dreams of parenthood have been up-ended and deferred. We may be on hormones that affect our mood. We now have an unanticipated lurch in our relationship with our partner that makes us both walk on eggshells, first trying to comfort and next suppressing our painful emotions. Many of us find our sad feelings are episodic, perhaps relating to our menstrual cycle, to hormone treatments, to test outcomes or to toxic situations such as baby showers or announcements of a friend's pregnancy. So on the continuum of sadness, situational sadness is the least serious, and profound depression is the most serious.

However, the issue of sadness/depression reminds us that our psyches need more attention that they are getting. In that spirit, let me mention a few things to consider as you resolve to make your mental health a high priority during your treatment for infertility. This is especially urgent if you have symptoms of depression, including persistent sadness, guilt or irritability, sleep and appetite disruption, and the absence of pleasure. Depression is not only a mental disorder, so in addressing some of the physical symptoms you will want to be careful about what you eat and drink (avoid caffeine, which can make you anxious; avoid alcohol, which may worsen depressive symptoms). Since sleep disturbance is a common symptom of depression, it is critical to get an ample amount of sleep.

So what if you are attentive to all of these things and your sadness/depression does not abate? Now is the time to alert your infertility specialist to the ways in which your mood is disrupting your functioning and your life satisfaction. If you receive infertility treatment in a clinic that employs mental health professionals on its staff, hopefully you can consult with them. In addition, your infertility specialist may be able to change your hormone treatments to have a less disruptive effect on your mood.

If your infertility clinic does not have mental health professionals on staff, it still is possible they can suggest names of people whom their patients have used. You will want to have a consultation with a psychiatrist, in an effort to determine what mood disturbances you are experiencing; it also is the time to identify a therapist who is skilled in strategies of cognitive behavioral therapy, which is future oriented, teaching mental skills that address negative thought patterns and challenge feelings of helplessness.

Clearly it is a challenge to think of enlarging your treatment network to include professionals who will focus on your mental health. But if you have identified with the issues I present in today's blog, there is no better step you can take than to make your mental health a top priority. In my book When You're Not Expecting, I have several chapters devoted to seeking and achieving emotional resilience, as well as a Resource section at the end of the book with national organizations that can help you in making connections with professionals in your locality. Take a deep breath and resolve to pursue this additional resource today!

Life with Infertility is Hectic!

Whether your infertility is newly diagnosed or a condition for which you've received long term treatment, "hectic" is likely to be a familiar word in your vocabulary. However, for you, the frustrating aspect of "hectic" is that it is punctuated by periods of waiting -- for test results, for procedures, for consultations, and -- of course-- for a pregnancy. In my book When You're Not Expecting, I refer to this as the period when your life is on hold.

So, what's to do when you feel as if you're dancing to the tune of your infertility specialist, clinic schedules and medical procedures? Undoubtedly you will search for ways to lift your spirits, distract yourself from disappointing news, consider new options and nurture your relationships. These are all components of emotional resilience, a familar theme in my blogs. So, given how hectic your life feels, where can you begin to nourish your emotional self?

Many women tell me that it is soothing (and takes very little time) to have a ritual just before going to sleep at night and just before getting out of bed in the morning. One comforting ritual is to think of two or three things for which you are grateful; another would be to write briefly in a bedside journal ... perhaps about some positive event that has brought you happiness or that you anticipate with hopefulness. This quiet ritual takes you emotionally to a resilient place in your mind where you tap into feelings of strength.

Research cited in my recent blog reminds us that healthy women with low levels of a stress hormone in their saliva conceive in a shorter period of time than their counterparts with higher levels of the stress hormone. So the take away message for any woman trying to conceive is to do what you can to lower your stress. Depending on what appeals to you, think about yoga, meditation, mindfulness, deep breathing, repetitive prayer, muscle relaxation or guided imagery.

There also is research evidence cited by Alice Domar saying that alleviating depression and other psychological distress in infertile women appears to make it easier for them to become pregnant. I will address depression in future blogs, but if you believe this is an issue for you, now is a good time to consider seeing a counselor who can help you. In my earlier blogs and in my book I offer suggestions on how to identify a counselor and what you can expect from the counseling experience. If you think you have no time, just remember that lots of your time is spent waiting and feeling stressed. Better to use that time actively pursuing some emotional resilience with a therapist.

Try to get out of your "infertility rut." This means that you and your partner should spend some time thinking about new experiences. This won't keep you from thinking about your infertility, but it will provide a welcome distraction, and even the anticipation of a new experience can be uplifting. It could be as home-bound as planning a garden and ordering from a seed catalogue or as exotic as an ocean cruise (yes, I know -- you'll have to schedule it around tests and procedures!). You may face the challenge of how to jump from the rut on a low budget, but that can be part of the fun. Remember fun? Now's the time to capture some.

Another rut it's easy to fall into is a social rut, where you either quit socializing with friends (perhaps they're either pregnant or new parents) or you find that your friends are so preoccupied with your infertility that you feel as if you have a scarlet "I" on your chest. So figure out what you want to do about your social supports: nourish relationships with friends who are childfree or whose children are grown? tell your current friends that you'll keep them up-to-date if there's any news, but in the mean time encourage more broad topics of conversation than your infertility? join an infertility support group where some members may have achieved their own emotional resilience? take up a new hobby or volunteer experience that will make you feel capable and needed? The sky is the limit here, and any one of these options will broaden your horizons so your preoccupation with infertility is less intense.

So even as "hectic" and "waiting" are constant companions in your infertility journey, there are new ways to consider introducing emotional balance into your life. Breathe deeply and move forward!

Infertility and Emotional Resilience

Most people who have grappled with infertility have developed their own narratives about this experience and how it has shaped their lives. I often am amazed at how many people have found a silver lining in their infertility cloud. This past week has provided several experiences that heighten for me the connection between infertility and emotional resilience.

My first experience was with a group of about 20 women, ages 25 to 60, who conduct workshops and training sessions in their communities about issues affecting families. They had asked me to speak with them about my book When You're Not Expecting, and I encouraged them to ask questions and offer observations during the course of my presentation. Well, I had only spoken a few moments when the conversation turned quite quickly to their own personal experiences with infertility. Who would have imagined that 15 of these women had difficulties conceiving, pregnancy lossses, or lived in a childfree marriage? No matter what the experience was for each, the way in which they shared their infertility experiences ultimately came down to "It's not what I expected, but I know I am a more understanding and compassionate adult because of learning how to come to terms with my infertility." Personal examples ranged from adapting professional goals so they could be more generous in helping troubled families to ways that they redefined their own families that put them in closer touch with young nieces and nephews. The tone of the meeting was definitely upbeat, although there was a fair amount of Kleenex passed around the table as various women delved into their emotions to connect with the shared topic of infertility. What struck me very poignantly was how each person disclosing her thoughts had moved from emotional pain to resilience as she found a new way of shaping her future than the one she initially had envisioned.

My second experience this week occurred when I was interviewed live on our local public radio station about my book. Call-ins are a part of this particular radio hour and, once again, the callers shared their infertility and adoption experiences. One man expressed with zest how the pain of his infertility was eclipsed by the joy of adoption; a female caller spoke matter-of-factly about medical reasons that she could not risk a pregnancy, sharing her sadness that her husband's curly red hair wouldn't be passed along to their children, then moving on to talk about the emotional happiness her family shared 25 years ago as they adopted their two children.

In both of these experiences I was taken with how easily people could delve into their pasts and retrieve memories of unanticipated reproductive losses, the need to regroup emotionally, the capacity to find a new pathway, and the emotional growth that they now attribute to their infertility journey. I hope this can be especially heartening to any readers who are trying to make sense of your own infertility, since it is clear that emotional upheaval is expectable, but emotional resilience also can be an outcome of infertility.

New research on stress and infertility

For years there has been a dialogue between physicians and their infertile patients about whether stress is a cause of infertility or the result of infertility. Current research has shown that the stress levels of women with infertility are equivalent to women with cancer, AIDS or heart disease, so there is no question about infertility resulting in enormous stress. The breaking news published online in the journal Fertility and Sterility and summarized this week in the Science section of the New York Times, ( Old Maxim of Fertility and Stress Is Reversed ) is that women who stopped using contraceptives took longer to become pregnant if they had higher saliva levels of the enzyme alpha-amylase -- a biological indicator of stress. Specifically, women with the highest concentrations of alpha-amylase were 12 percent less likely to become pregnant each month than those with the lowest levels.

So what are the implications of this new research? The researchers say theirs is the first study to link a biomarker for stress with delayed conception in normal, healthy women, and they suggest that identifying ways to reduce or manage stress may be a low-tech solution for some couples diagnosed with infertility. Alice Domar, executive director of the Domar Center for Mind/Body Health at the fertility center Boston IVF, responded to the research findings by saying "This is one more piece of the puzzle that's adding up to the same conclusion: that stress is not necessarily a good thing for our reproductive system." Her 2004 book, Conquering Infertility, addresses the mind/body connection and suggests practices ranging from mindful meditation to yoga that can help women reduce the stress caused by their infertility.

So we are coming full circle: acknowledging the obvious, that infertility causes stress, and now addressing the scientific evidence that stress delays time of conception in healthy women. The researchers remind us that stress is the one consistent factor that shows an effect on how long it takes to get pregnant, of all the lifestyle factors studied to date. More surprising is that even low levels of stress can have an impact on conception.

Dr. Domar advocates that mind/body techniques can decrease physical symptoms of stress such as insomnia, headaches, abdominal pain and fatigue as well as psychological symptoms such as depression, anxiety, hostility and tearfulness. She cites recent research that has shown that women who participate in mind/body programs in conjunction with treatment from their physician have significantly higher pregnancy rates than women who receive medical treatment only.

With these intriguing studies, if you are a woman hoping to become pregnant (remember that the alpha-amylase study used data from 274 healthy women who had just started trying to conceive), certainly you will want to reduce your stress as much as possible in an effort to enhance conception. If you have been diagnosed with infertility, you are already in the midst of a stressful experience; seeking an infertility clinic that incorporates counseling, mind/body interventions and stress management strategies can provide you with new stress reduction techniques. In my book When You're Not Expecting, I provide information on how to locate a counselor or a support group, as well as lists of resources for help with mental health concerns, including stress.

Each of our responses to the stress of infertility is unique to our particular circumstances. Yet this recent research is a red flag that we should actively try to address our own stress levels in an effort to assist our physicians in their efforts to help us achieve a healthy pregnancy.

A Vacation from Infertility?

In my large library of books on infertility, I could find only one with "vacation" in the index. And, no surprise, that book ("When You're Not Expecting") was written by me! In today's blog I'll offer my thoughts on why a vacation from infertility can be such an important and challenging issue to consider.

The very word "vacation" tends to elicit memories from our earlier lives of restful and restorative times that we have tucked away, simply because they have been memorable in such a positive way. And then all of us have memories, perhaps better forgotten, of vacations filled with stress, mishaps, unmet expectations, and other disappointments. So we begin this blog already aware that the word "vacation" can be a double-edged sword.

On one edge of the sword are the lost vacations. These are the vacations never taken because you need to use your savings for infertility treatment or costs associated with adoption or surrogacy. Or these are the vacations never taken because you need to be close to home for clinic visits and treatments. Or these are the vacations not taken because the family members who would join you all have infants, toddlers and pregnant relatives in their midst. And that would be a lost vacation from your perspective.

So how about the other edge? Is there an alternative to lost vacations?
We need first to consider whether we are talking about a vacation or a vacation from infertility. If we're talking about a vacation, you and your partner need to make time in your crowded lives to decide how to avoid the lost vacation syndrome. One strategy could be to plan an inexpensive vacation (think close to home, bed and breakfasts, camping, new experiences big on spontaneity but low in cost). Another strategy might be to see whether a clinic in the vicinity of your destination could administer straightforward tests and procedures. And still another strategy would be to break the news gently to your family that you and your partner are taking a vacation this year where reminders of your infertility are at a minimum -- much as you love tiny nieces, nephews, pregnant sisters and doting grandparents, you and your partner need some vacation time to restore your own emotional energy.

And it is this issue of restoring your emotional energy that is actually behind the concept of an infertility vacation. This vacation probably will not be on the beach or in some yet-unexplored new environment (although it could be). An infertility vacation is a choice made by couples who feel their lives have been so consumed by their infertility that they have lost sight of themselves in the process. They decide to take several months off from treatment, not to touch adoption applications, not to investigate surrogate possibilities, and not to time intercourse with fertile times of the month.

So why would one come to the point of considering such a vacation? Well, I suspect I really don't need to elaborate on the obvious for most of my readers who are infertile, but in the spirit of hoping that loved ones and health care providers may be reading too, I'll elaborate briefly. Being infertile can consume your life: your schedule is no longer your own (in my book, one chapter is subtitled "When Life is on Hold"), you are constantly facing decisions that relate to your diagnosis or treatment, you may feel as though you are stuck too long in a particular treatment regimen, side effects from treatment (which can include weight gain and mood swings) are debilitating and, to top it off, your sex life is suffering. Who wouldn't need a vacation from this?

Well, yes, but an infertility vacation also means losing valuable months of treatment and medical continuity. Depending on your age, you may be feeling as if each month is a precious opportunity not to be wasted. So now the question becomes whether taking a few months away from infertility might enable you and your partner to rejuvenate your relationship, to see how it feels to be a family of two indulging yourselves with more spare time, more flexible schedules and more focus on restoring your own resilience. This is not a vacation meant for decision-making, but the mental and physical rest from treatment may give you enough new perspective after a few months that you are ready to begin facing new options, new decisions and new support systems.

Dr. Seuss, author of "Oh, The Places You'll Go!" has identified The Waiting Place as one detour that both children and adults face during their travels through life. Individuals with infertility will identify with Seuss's depiction of this involuntary life pause, as well as his assurance that life can move forward in new ways after a wretched waiting period.

So, in the spirit of encouraging you to appreciate that both vacations and involuntary waiting involve double edged swords, I hope you will take time to consider how several months of an infertility vacation might offer an opportunity to open your sensibilities and awareness to new ways of thinking about your life.

And, while I'm on the topic of vacations, I will be taking one of my own for the next month: no computer, no academic reading, but hopefully some time for rest and relaxation. I look forward to resuming my blog and reconnecting with faithful and new readers in mid August.

Infertile? Feeling Left out of "The Club?"

Infertility has many dimensions, and the longer you are infertile the more dimensions you are likely to explore. One of the more challenging is how to handle relationships with good friends who have become pregnant or who are new parents. These women, often very preoccupied with how to anticipate or to juggle the new role of motherhood, seem to attract one another like magnets. Whether through childbirth prep classes, La Leche meetings, playgroups, or just the coincidence of several acquaintances becoming pregnant within months of one another, these women often bond together to form what I refer to in my book as "The Club." Happily (or apprehensively) counting the months until their due dates, new Club members seek out more experienced ones for advice on everything imaginable. All very well, unless you, grappling with infertility, are on the outside looking in.

The first sign of discomfort with Club members may come in an ob-gyn's waiting room. There the literature tends to focus on pregnancy and early parenting. Nothing on infertility. And the conversation tends to focus on pregnancy, nursing, labor and delivery apprehensions. Nothing on pregnancy loss, IVF or adoption. In other words, women with infertility feel in the minority, feel silenced, and feel hurt in the presence of talkative Club members.

In the early 1980's, Helen Hooven Santmyer finished 50 years of writing ...And Ladies of the Club. This 1,334 page novel refers to a small Midwestern town literary club whose members are involved from 1868-1932 in their town's political, cultural and social changes. The author, a determined individual, was in her 80's before giving birth to this book, which subsequently remained for weeks on the New York Times best seller list. So why do I think of Ms. Santmyer as I write this blog?

Well, let's see. She hung in there, as many women with infertility do, hoping that her efforts to produce might ultimately meet with success. She appreciated the support system that women can offer to one another, even as political and social change efforts pre-1932 were couched in the context of a literary club. She poignantly portrayed lifelong friendships, as well as the tensions and difficulties that threatened them. And she depicted women who, for whatever reasons, departed from the Club or never were included in it.

So, although that book is not directly about clubs of fertile women, it is about women supporting other women, juggling roles, sustaining friendships and meeting life challenges head on. And Club non-membership is, both in the Santmyer book and in the lives of women with infertility today,one of the challenges for which there are few road maps.

Non-membership tends to be an issue only for those women not in The Club. Club members assume that their doors are wide open to women who are pregnant; they just don't realize how stifling it can feel to be frozen out of a conversation because you have no reproductive stories to contribute. Or maybe you do, but who wants to hear about a chemical pregnancy, a miscarriage or hormone shots?

So how can women avoid the hurt of being sidelined from the Club because of infertility? If we assume the hurt is caused by unintended insensitive behavior, one strategy is to take your pregnant and parenting friends and co-workers into your confidence. Or, if you don't want to do this, see whether a close friend will pass along whatever details you are willing to share, along with hints of ways others could demonstrate their support. This could include not shouting new pregnancies from the rooftop, not waving sonogram pictures every which-way, not making a big deal about new maternity clothes and swollen ankles, and not expecting your presence (or presents) at baby showers.

Another strategy may be to distance yourself from some Club members, especially those who are unable to contain their pregnancy or parenting excitement and enthusiasm. In their place you can tighten your relationships with empathic friends and make friends with empty-nesters or women who are not setting their sights on motherhood. You may also find that an infertility support group offers the kind of Club membership that you need right now.

Some individuals will benefit from a direct approach. These are the folks who don't "get it" when the grapevine spreads word of your infertility, but who are capable of changing their behaviors if told specifically what they can do to help you feel better supported.

And then there will always be a few people who are so focused on their own needs that they have no plan to consider yours. These folks won't miss you when you close the door on your relationship. Unless they're family members, in which case things get more complex. Under those circumstances you can try the direct approach of speaking about what you need from them; you can write a letter emphasizing your expectation that they will take your needs into consideration; or, as a last resort, you can engage someone else in the family to run interference for you. Whichever route you choose, the takeaway message is that you deserve to protect yourself from selfish and manipulative behavior.

So, even though the subtitle of my Club book chapter is "on the outside looking in," this blog is less about being envious than it is about being articulate. Don't be shy about telling others what they can do to help you feel supported. Be clear about behaviors that are hurtful. Enlist your friends to help with this if it feels too overwhelming. And remember that new friends can be found in many places where the topics of pregnancy and parenting are not on anyone's tongues.

You're Infertile and Your Friend is Pregnant -- How to Cope?

The emotional challenges of infertility increase whenever your support network feels shaky. And, for many of us, either because we have been cautious about sharing news of our infertility, or because our network is fairly small to begin with, the news of a close friend's pregnancy can feel like an especially damaging lightening bolt. It may reverberate through your network, causing everyone to wonder how you're "handling it." It pushes your own buttons about how you can continue to be a good friend as you are aware of your own jealousy and envy. And it stimulates so many questions about your ongoing relationship (Can we remain friends? Can I count on her sensitivity? Will other friends forget about me and my feelings as they celebrate her pregnancy? Will I cringe as I look at her swelling abdomen? Will she be willing to talk with me about how our friendship can coexist with her motherhood?).

Of course so much depends on the history and the nature of your relationship. Let's consider a few scenarios:

This "friend" may actually be your sister or your cousin -- in other words, you go "way back," share many memories, have ongoing ties with other family members, and probably have some experience in ironing out rough spots that have developed in your relationship. But, for now, the uniqueness of this relationship is that she is plunk in the middle of your family. So it feels as if this pregnancy will echo and reverberate around the family system, with other relatives wondering how they can be sensitive to you and attentive to her news. Just keep in mind that if you and she can talk about this between yourselves and vow to be as emotionally open and clear as possible, other family members will take their cues from both of you.

This friend may be someone in your infertility network who, like you, has struggled with her reproductive health. If so, she will be apprehensive for months about whether this pregnancy is a healthy one, and her own anxieties about this may interfere with her capacity to focus on your ongoing infertility concerns. So your relationship with her will be complex: at the very time she may appear as a beacon of hope that pregnancy can happen to someone with infertility, she also will have her own worries about burdening you with her pregnancy concerns. So, the bottom line is that you and she will need to be as aware as possible, both of one another's needs, and of your own needs as you determine how or whether to lean on each other. It is possible that each of you will decide that certain topics are still good to share, whereas the strong shoulders of other friends are more suited for other topics. And, as her pregnancy continues, you will constantly need to revisit your relationship and how you can remain emotionally responsive to each other. Should she experience a pregnancy loss or some unexpected pregnancy complications, you both will learn still more about how resilient your relationship can (or cannot) become.

And then your friend may be "just" a friend. But friends come in many shapes and sizes, so you'll need to think about your shared history, how you have worked through past difficulties, her empathy as you've struggled and coped with infertility, and whether she has plenty of other friends with whom she can discuss her pregnancy and plans for motherhood. And, just as you will do with a sister, a cousin or a member of your infertility network, it will be easier to move forward in your relationship if you and she can be clear as possible about how to keep your communication open.

Although I began this blog with the assumption that your friend is pregnant, we should keep in mind that an impending adoption can bring about many of the same responses between you and your friend. If she is adopting, she may share your experience with infertility. Or she may be a single "mom-to-be" by choice. Or she may be a lesbian. Or she may have chosen adoption as a way to expand her family for a wide range of reasons. However, she is progressing along this adoption pathway with high hopes for motherhood, and it will be challenging for her to contain her excitement as she anticipates the arrival of her child. So you and she, as with any other pregnant friend, will need to be as open as possible about how to move forward in your friendship.

So, what are some of the topics that you and your friend are likely to need to discuss? Here are a few:

• How do you feel about hearing about the details of her pregnancy? How does she feel if you would prefer she keep these details to herself? Does she have other friends with whom she can have these pregnancy discussions?


• Is it difficult for you to be with her as her abdomen swells, as she wears maternity clothes, and as she looks increasingly pregnant? Can e-mails and phone conversations substitute for in-person lunches, coffees and walks in the woods?


• Will it be painful for you to be included in/invited to her baby shower? If so, will she understand and be willing to help other friends and family members to be sensitive about your absence?


• Is it likely you will be asked to be her baby's godmother? If so, you need to think this through carefully. To accept this new role will cause you to have feelings of obligation and responsibility that will guide your connections with this baby for many years.


• If there is a christening, a baptism or a bris, will it be painful for you to attend? Will she be supportive of your decision and help other friends and family to support you in this choice?


• After the baby is born, what sort of contact will be most comfortable for you? This may not be something you can know in advance, but you and your friend should keep all options open, which can include baby-less lunches/coffees/healthy walks as opportunities to spend time with your friend.

At any time during her pregnancy and early motherhood, both of you will want to check in with each other about whether there are things you need to revisit in your evolving relationship. Remember that this is a two way street and each of you wants to understand how to be as thoughtful as possible about the issues that arise, many of which will be unexpected (think of your baby-less times being interrupted by mutual friends descending to ask your friend about the baby, as they compare notes on their own pregnancies and new motherhood experiences. Those of you who have read the chapter entitled "The Club" in my book When You're Not Expecting, will understand this example all too well).

Another decision you may find yourself making, either during your friend's pregnancy or during her months of new motherhood, could have to do with expanding your own friendship network. It isn't to say that your friend will be less available to you (which certainly is very possible), but to emphasize the creativity you can use at this time. Not only may you need more friends without pregnancies or young children, but you also may want to find friends who can distract you from the challenges of your infertility. So, with that in mind, consider befriending individuals/couples who happily think of their lives as child-free, individuals/couples who are empty nesters, and individuals/couples who share interests or hobbies you would like to develop more fully.

A friend's pregnancy may arrive like a bolt from the blue, but once you've caught your breath you can use this new event as an opportunity to think more purposefully about what you need and can offer in a friendship. Remember to keep the emphasis on mutuality, on open communication and also on expanding your friendship network in new ways.

Pregnancy Loss: How to respond with compassion

So, you have just learned of the pregnancy loss of a friend, a relative, a co-worker or an acquaintance. You want to offer an appropriate response, but you're not sure what that might be. In this blog we'll look at the considerations you'll want to keep in mind as you offer a comforting response.

A number of readers of my most recent blog have written to me, asking how to respond when learning of a pregnancy loss. You have acknowledged the awkwardness of not knowing what is the "right thing" to say, as well as the lack of familiarity with what the term pregnancy loss might encompass. And you are aware that, all too often, the world just turns its head when learning of a pregnancy loss. There may have been no bulging abdomen, no sonogram being passed around, maybe not even a public announcement of the pregnancy. Or there may have been all of these things plus more. What is missing in both circumstances is any ritual whereby comfort can be extended to the grieving couple. There are no Hallmark cards, no funerals, no gravestones, no memories to be shared among the mourners. Only a void. And it is into this void that you may decide to venture, with the hope that you are able to offer some support and comfort.

So let's consider a few things that will influence your thoughts about how to reach out to the couple. Keep in mind that a pregnancy loss may mean something different to each of them; also keep in mind that both are sad, so please do not fall into the trap of asking one partner how the no-longer-pregnant partner is doing. It is true that the woman has lost the pregnancy, but both of them have lost the dream of becoming birth parents to this baby, and both of them deserve a genuine expression of your sorrow.

Although pregnancy loss can mean a miscarriage or a stillbirth, it also can come about as a result of the agonizing decision of the parents to terminate the pregnancy, either because of learning the results of prenatal genetic testing or because a multi-fetal pregnancy reduction has been advised by the couple's physician who fears for the outcome of the pregnancy if the woman attempts to carry all fetuses to term. Some couples are comfortable sharing this decision with others, but many anticipate they will be harshly judged for their decision to terminate the pregnancy and they decide to present the pregnancy loss as a miscarriage. Regardless of how open the couple may be about the circumstances surrounding their loss, you will want to empathize with their sadness and to ask how you can help.

For some couples, the pregnancy loss is a dimension of their infertility. They may have had difficulty conceiving; they may have had earlier pregnancy losses; this may be a loss from an ectopic pregnancy (where the embryo begins to develop outside the uterus, often in a fallopian tube); or they may be told after an IVF procedure that, although they had a chemical pregnancy, the hormone levels did not rise sufficiently to sustain hope that the fetus would develop. For any couple grappling with infertility, a pregnancy loss is a terrifying reminder that they cannot take birth-parenthood for granted. Another, less discussed, form of loss occurs when a couple has made a plan to adopt, and the birth mother either loses the pregnancy or decides to keep the infant after its birth. The prospective adoptive couple has invested so many hopes in this adoption, that the loss will be a devastating end to what may have been years of infertility. So, with infertility as a backdrop, any form of pregnancy loss feels especially devastating.

Some people assume that the attachment to a pregnancy grows in proportion to the number of months the pregnancy was sustained. It is more accurate to let the couple tell you what this loss means to each of them, because that will enable you to understand more fully the emotions they had attached to this pregnancy, regardless of how far along it had progressed. And hearing from the couple will prevent you from saying hurtful remarks like "It's probably for the best," or "You can always try again." Instead it will feel more supportive to say "This is such a difficult time for you. Please tell me how I can be helpful/ let me know when you feel like a visit/ tell me if I can bring over some food (books, flowers) or run some errands for you." And then prepare to be a good listener.

Being a good listener is a gift, since it involves being emotionally present, accepting both anger and tears, and hearing various versions of events time and time again as the grieving person tries to make sense of this loss and what the future might hold. Although it may be tempting to offer what I call "false reassurances" ("I'm sure you'll be a parent some day," "You will begin to feel better soon,"), be aware that this response is more a reflection of your discomfort with the current sadness than it is an accurate prediction of hope for your friend. Try to be patient with the time your friend needs to absorb this sadness and to make sense of it.

Some couples decide that they want to have a quiet service to honor this baby who will never be born. Whether conducted by a spiritual leader or created by the couple and their loved ones, such a service can enable supportive friends to reassure the couple and their family of ongoing emotional support and compassion for their loss.

Some grieving couples appreciate the opportunity to talk about how they can memorialize this child whom they had hoped to parent. Keep in mind that many would-be parents have already discussed (and perhaps chosen) names, selected (or envisioned) nursery colors and decor, and begun to save items for the baby scrap book like congratulations cards and sonogram photos. For them this is not a pregnancy loss so much as the death of their dream child. In my book When You're Not Expecting, I mention couples who plant a memorial garden, donate to a children's library or a day care center, or identify a cause that they commit to in memory of their dream child.

Even months after a pregnancy loss, there can be a number of painful reminders that cause the pain to resurface. The previously-anticipated due date is one symbolic time. Celebrations of others' pregnancies and births can be emotionally difficult. Even the sight of a nursing mother or a father cuddling a newborn can evoke waves a sadness. These and other reminders of lost opportunities may be mentioned by someone who has lost a dream child, and your empathic response will be very much appreciated.

So, the take-away message to the question of how to respond with compassion is

• There are many ways in which pregnancy loss can occur. Communicate your wish to be a good listener so that you can understand the particular meaning this loss has for each member of the couple.
• Remember that the partner of the pregnant woman deserves to be recognized as someone who is entitled to grief, rather than being seen solely as the stoic comforter and protector.
• If infertility is a backdrop to this pregnancy loss, you will want to appreciate the couple's feelings of failure and desperation as they fear they may never become birth parents.
• Be patient, and let the couple know that you understand it takes time to grieve such a poignant loss and to make sense of how their lives have changed.
• Be aware of the mixed emotions couples may feel when being invited to celebrate news of pregnancies, births, or other events associated with successful reproduction.

Pregnancy Loss and Discounted Grief

The grief following a pregnancy loss is unique. Couples often feel uncomfortable sharing information about this loss and acquaintances, many of whom may not even have known of the pregnancy, are unfamiliar with how to respond. Why is this? Typically pregnancy loss can be relatively invisible unless you choose to share this information. There are no rituals to help you mourn this loss. There are no Hallmark cards. Your physician probably relates to this loss in terms of your physical recovery. So what do you do with the feelings that assail you and your partner once you realize that you no longer are "almost parents?"

Each person will experience a pregnancy loss differently, which means that you will need to be clear with relatives and friends about what they can do to be helpful. If you need privacy, say so. If you need people to run errands for you, let them know. If you need emotional shoulders to lean on, patient visitors, good listeners, then choose your loved ones carefully, because people differ in the extent to which they can tolerate your sadness without feeling obliged to cheer you up.

You also need to be prepared for the unexpected: the person who last saw you wearing maternity clothes who expresses surprise that you now have a waistline; the acquaintance who has heard about your loss and seeks to comfort you by suggesting that perhaps this is "for the best," or "you can always try again;" the person who expresses surprise that, weeks later, you are still feeling sad instead of getting back to "normal," whatever that is. And it isn't just people -- how about the advertisements for everything from diaper services to baby gear that continue to crowd your mailbox, your phone calls and your e-mail? It seems as if your pregnancy is on automatic pilot for the retail world.

There is another dimension that also is important to have in the forefront of your awareness. Typically even one's most sensitive relatives and friends will see the person who lost the pregnancy as the one deserving of sympathy and attention. Her partner, on the other hand, tends to be asked "How is she doing?" and "Is there anything I can do to help her?" What's wrong with this picture? Do people not appreciate that the partner also has had life hopes and dreams derailed? Do they not recognize the emotional upset that comes with supporting a formerly pregnant loved one as well as figuring out how to handle one's own grief? Do others really feel that you are not entitled to heart-wrenching sadness unless it was your body that bore the pregnancy?

So, along with sorting out your own emotions when others may be confused or insensitive, you also will want to talk openly with your partner about how each of you is handling this sad time in your lives. And be sure to talk about what you need your partner to do to offer comfort to you. It is important to respect that the two of you may have different ways of working through your sadness, but keeping the channels of communication open is a significant challenge.

And it is important to be aware of sources of support that are probably present in your community: spiritual leaders, professional counselors, support groups (many of which you can learn about from the social worker of your local hospital), as well as books and chat rooms that focus on pregnancy loss. This is a time to indulge yourself in taking time to regain your emotional equilibrium, even if the rest of the world seems to be expecting you to have put this loss behind you. In my book, When You're Not Expecting, I emphasize the opportunity to use pregnancy loss as a time to grow emotionally, to bond more sensitively with loved ones, and to decide how to move forward with life following this poignant jolt to your hopes and dreams. So don't let anyone discount your grief -- you are entitled to it. And, with support, hopefully you will find your own ways of weaving it into a new and more resilient emotional perspective.