Secondary Infertility: When having more children is an unexpected challenge for parents

In earlier blogs, I've mentioned the fertility challenges faced by such public figures as Celine Dion and Sarah Jessica Parker, both of whom grappled with secondary infertility (and, earlier, with primary infertility). So, what exactly is secondary infertility? Statistically the most common form of infertility, it is the inability to become pregnant or carry a pregnancy to term following the birth of one or more biological children to the same couple.

The unique dilemma of a couple with secondary infertility is that everyone presumes them to be fertile, unless they had an earlier child with the help of reproductive technology. And, just as primary infertility often is referred to as an invisible disability, secondary infertility seems even more invisible, since it occurs in the context of a couple who are birth parents and very much enjoying that phase of their lives. And that's where one difficulty lies: friends and family may "blame the victim," urging the couple to be grateful for the child(ren) they already have, and admonishing them for taking up emotional time and energy in seemingly futile efforts to conceive again. With that as a backdrop, the couple feels socially isolated in their grief and often question whether they even are entitled to grieve. Their sadness comes amidst an increasing feeling of being left behind, as their siblings and friends have increasing numbers of children, complete with baby showers, christenings, brises and celebrations of their expanding families.

Another source of social isolation may be felt by mothers who took time away from employment to devote time to their child and, hopefully, to enjoy another pregnancy. These women now may be cut off from sources of support by their former co-workers, whom they see far less frequently. Ironically, they find themselves preoccupied with finding sitters to care for their child while they pursue doctors' appointments and infertility treatments. Even as they are eager to indulge themselves in the joys of parenthood, those very joys reinforce for them how special it would be to be able to have more children. Feeling at psychological loose ends as they figure out how to be parents of an only child, couples may find themselves mourning for their intended children as they see their family evolving quite differently from the fantasy family they created.

Secondary infertility, in addition to being a source of anguish for the couple, can also be a concern for their child. It is not unusual for children to ask their parents when they will bring a new sibling home, or whether "mommy is sick," given her sadness and the number of doctors' appointments she may be juggling. Added to the direct inquiries of the child is the parental question of how much they can invest in their infertility treatments, feeling strained as they divide their financial and emotional resources between the child they have and the child they long for. If their infertility diagnosis results in the couple learning that any future pregnancy will be the result of using donor sperm, donor eggs or surrogacy, they face yet another level of decision-making, as they assess whether they can accept a child who is biologically a half-sibling of their existing child. If adoption is contemplated by the couple, they also will confront their capacity genuinely to embrace a new child who has no genetic ties to the family, and whose arrival in the family is known by its members and probably the entire community to be different from that of the big brother or sister. And if the couple decides to end treatment, not pursue adoption, third-party reproduction or various forms of pre-natal adoption (e.g., donor insemination, embryo donation) their resolution to their secondary infertility may be to remain a smaller family than they had hoped for.

Couples struggling with the emotions and the decisions associated with secondary infertility will find some responsive "voices" in my book When You're Not Expecting, as well as by contacting RESOLVE (www.resolve.org ) or the Infertility Awareness Association of Canada (www.iaac.ca ).

No Life Partner? Some women become single moms by choice

In my recent blogs I have been revealing the many faces of infertility. Most of us are familar with individuals and couples diagnosed with a medical condition that prevents them from becoming birthparents. However, also included among the faces of infertility are same sex couples (see my most recent blog) and single women hoping to become parents, the topic of today's blog. These folks, often medically capable of conceiving and bearing children, have what is called "social factor infertility," or the lack of a male partner.

In past years, whenever a single woman became pregnant, most people assumed that this was an unplanned pregnancy. However, today many women are becoming "single moms by choice," believing that their life dream of being a parent shouldn't be derailed by the absence of a life partner. Single Mothers by Choice, a 25 year-old support group, took in nearly double the number of new members in 2005 as it did in 1995. And the California Cryobank, the largest sperm bank in the U.S., owed a third of its business to single women in 2005. So these women, who are as dedicated to becoming parents as many of their married peers, reflect the face of social factor infertility.

Whereas medically infertile individuals and couples tend to evoke sympathy from their peers, people with social factor infertility may face stigma and disapproval from people who are convinced that heterosexual couples are the best parents. However, research shows that children raised by same sex couples have no negative outcomes related to their parentage and, in fact, are often especially accepting of diversity in relationships. Since the current divorce rate of couples is about 50 percent, we also know that many children are being raised in single parent homes, even though that had not been their parents' plan when they were conceived.

So what is the special challenge faced by women who, typically in their 30's and 40's, decide to become single mothers by choice? First is the question of how to bring a child into one's life. Some women may accidentally become pregnant and discover that they are thrilled at the prospect of becoming a mother. Many others will seek medical assistance for donor insemination, and they will need to understand the pros and cons of using a known donor vs. an unknown donor. They also will need to decide how long to pursue donor insemination before considering adoption as a potentially more satisfying way to bring a child into their lives. Women considering adoption will need to learn which countries and agencies are more "single friendly," and how to handle the inevitable adoption bureaucracy.

Whatever the route toward parenthood, single women are likely to seek acceptance and emotional support from loved ones, as well as from residents in their communities. Prospective single mothers ideally have a strong wish to parent, adequate financial resources, and the emotional resilience necessary for the ups and downs of parenthood. Beyond that they will need to anticipate the circumstances in which they may need to call on close friends for help -- either in an emergency or in more familial events like celebrating birthdays or holidays.

Several organizations exist to offer support to women who are considering becoming mothers by choice. The National Organization of Single Mothers, Inc. (http://www.singlemothers.org/) and Single Mothers by Choice (http://www.singlemothersbychoice.com/) offer online information as well as support groups around the country.

In my book When You're Not Expecting, I recognize the dliemma some women face as they grow older, very much wanting to be a mother, but hearing the ticking of the biological clock with no life partner on the horizon. These women may seek out infertility services or adoption agencies, yet their needs are unique and deserve careful consideration both by professionals and by loved ones.

Stay tuned for my next blog, when I'll explore the face of infertility presented by parents who now find themselves diagnosed with secondary infertility.

No Heterosexual Partner? It's called "social factor infertility"

As I considered what new "face of infertility" to focus on in today's blog, I decided to honor March 3, 2010, a historic day in Washington D.C. where couples waited in line for hours to apply for marriage licenses on the first day same sex unions became legal in the nation's capital. One rarely thinks of same sex couples as "infertile," but the absence of a heterosexual partner means that they must give careful and deliberate consideration to how to enlarge their families. "Social factor infertility" differs in some ways from a diagnosis of medical infertility, and couples facing either will share some familiar emotional territory.

The shared territory obviously includes the anxiety about whether one partner will be able to conceive, and what toll this effort will take on relationships, self esteem, finances, and plans for one's future. The unique territory faced by same sex couples will depend on how open they are about their relationship, whether they have friends and loved ones who support them emotionally in their effort to become parents, whether they are legally married, how they plan to conceive or adopt this child, and whether they live in a state that permits adoption by same sex couples.

Same sex couples who are open about their relationship will have created an environment in which they can be relatively straightforward about themselves and their lives together. In this context, if they choose to share their hopes for a pregnancy or an adoption, they are likely to be able to rally support from many of the people whom they tell of their plans. The details of how they plan to conceive may be shared discreetly: lesbians can choose insemination with sperm from a donor (identified through a sperm bank or a consenting male known to the couple), or intercourse carefully timed to the woman's ovulatory cycle. Gay couples can identify a gestational surrogate, either using her eggs or the eggs of a donor mixed with the sperm from one or both of them. And both gay and lesbian couples can explore adoption as a way of enlarging their families.

Although same sex and heterosexual couples will share many anxious days of waiting for a positive pregnancy test, and some lesbian couples may be treated at infertility clinics, same sex couples must address some issues that never enter the minds of heterosexual couples. Physicians sometimes refuse to inseminate lesbian patients; infertility clinics occasionally refuse to accept unmarried patients; informal acquaintances may assume there is a "husband" in the picture and ask questions of a pregnant lesbian that build on that assumption; and health insurance issues can arise, especially around use of a surrogate.

Adoption is another issue that is different for same sex couples. First, it is important to keep in mind that there are states in which it is not legal for a same sex partner to adopt. Even in states that permit adoption, this very process feels emotionally intrusive at the very time the parents are bonding with their new child. In the case of gay fathers who adopt a child, there will need to be an initial home study and reams of paperwork prior to the legal adoption of their child. If their baby was born to a surrogate, a number of steps must be taken to ensure legal parenthood status for the fathers. For lesbian mothers, the non-birthing mother will need to complete a home study and a legal adoption several months after the baby is born. Also, in same sex couples who wish to pursue adoption as the way to enlarge their families, there are a number of constraints as they encounter some adoption agencies who will only work with married couples or heterosexual couples. In regards to international adoptions, many countries now block adoptions if one person in the same sex (OR heterosexual) couple is over a certain age; has been previously married; is not married; has had treatment for certain mental health or certain physical health problems; and in some countries, adoption of their children by a same sex couple is not permitted. For the occasional gay or lesbian in a same sex relationship who considers presenting as a single person, the legal advice is firm: don't! This is because if you are found to have been untruthful in your application materials, you could lose custody of the child. And for all same sex couples whose travels take them through states and countries that may not recognize them as legal parents of their children, remembering to carry copies of adoption certificates is yet one more reminder of their parental vulnerability.

Even with all of these complex considerations that same sex couples face, there is at least one opportunity for respite from the stress of their infertility: their lovemaking is rarely negatively affected by their "social factor infertility." Since they can separate completely the act of making love from their capacity to conceive, they are far less vulnerable to a familiar dynamic of infertile heterosexual couples: having lovemaking diminished by the emphasis on baby-making.

So, at a time that same sex couples now can look forward to one more location for legal marriage in the U.S., we still must appreciate how "social factor infertility" presents unique challenges for parents-to-be. As you notice from the photo appearing at the top of this blog, it depicts both a couple joined in love as well as a loving individual off to the side. In my next blog (which you'll recognize with the same photo), I'll explore the issues, challenges and joys experienced by single women and men hoping to become parents. They, too, are considered to have "social factor infertility," and are rarely thought of in the broader context of infertility.

If you're interested in learning more about how you can enter to win a free copy of my new book, When You're NOT Expecting, click here!

The Invisible Face of Infertility

In thinking about the many faces of infertility that I mentioned in my last posting, the most prominent one in my mind, ironically, is the invisible face. Adopted by both couples and individuals, this face comes across as having hardly a hint of the developing anguish felt inside. Of course "face" in this context means far more than eyes, nose and mouth. It really captures how you present yourself to the outside world where infertility merits not a word to loved ones, and you resolve to carry on as usual.

If you are in the early months of an infertility workup or the recipient of a recent diagnosis, or if you are someone who guards your privacy, an invisible face may feel like a safe way of figuring out how, whether or when to disclose news of your infertility. "So what's the big deal?" you may ask. Isn't the invisible face a perfectly good option? The answer is both "yes" and "no." I'll start with the reasoning for "yes."

• An infertility diagnosis is an unexpected and an unwelcome piece of news. You need time to digest it, to gather information, to learn from your doctors and to make sense of this with your partner. During that time it can feel best to remain silent on the topic until you believe you have answers for the inevitable questions that others may pose once you become more open about your news.
• You may feel a sense of denial, mixed with hopefulness that this infertility is temporary and will respond to the recommended treatments. In that sense you see no point in getting loved ones all stirred up about something that you hope will be a mere glitch in your plans to build your family.
• Depending on the diagnosis and recommendations for treatment, you may feel in shock as you contemplate medical interventions, lengthy appointments with infertility specialists, and a diminishing bank account. There are no words to capture this jolt in your life, so you initially choose silence.
• You may perceive a diagnosis of infertility as such an assault to your self esteem that you need your invisible face just to be able to hold your head up each day.
• You and your partner may disagree on whether to tell anyone and, if so, how much to reveal. While trying to figure this out, you both adopt the invisible face until you can come up with a plan for disclosing news of your diagnosis and the emotional reactions each of you is having.

All of the "yes" bullets listed above make sense, at least for a time. But after a while, as you and your partner have only one another to turn to for emotional support, you are likely to experience infertility as an increasingly heavy burden. You also may experience it as a source of conflict. Therein lies the foundation for my list of "no's" that target why an invisible face may not be such a good option in the long run:

• Being in treatment for infertility does not mean your emotional needs are being recognized. Physicians will concentrate on your body, your treatments, and treatment outcomes. The nursing staff often is more emotionally attuned, but that is a brief and temporary response during an office visit or on the telephone after learning disappointing test results.
• Not only does having your partner as your sole confidante place a heavy burden on both of you to meet one another's emotional needs, but you probably face the additional challenge of being at different places emotionally during various stages of your infertility journey. If your energy is on taking care of yourself and your partner, do consider expanding your support system.
• The absence of an external network of comfort means that you have no buffer when friends and family members joyfully announce pregnancies, show off sonograms, and invite you to baby showers, christenings, and other events at which your invisible face threatens to crumble.

So, in the midst of emotional overload, how do you and your partner move forward to share with loved ones the news that you are infertile? In essence, how do you make more visible the face of your infertility? Perhaps the most logical first step is to decide what kind of emotional support you need. If seeking out an infertility counselor is appealing because it enables you to delay disclosure to loved ones a bit longer, then seek out a counselor. In my upcoming book When You're Not Expecting, I devote a great deal of attention to how you can connect with a counselor who is appropriate for you. Working as an individual or as a couple with a counselor can still enable you to bring up the subject of engaging loved ones as a buffer and as a support system.

Perhaps, rather than seeking a counselor, you decide to confide in loved ones. Then the question becomes who to tell and what to tell them. In addition, be prepared to suggest to them how they can be most helpful to you, since that will enable you to get what you need from these relationships. And remember, even as you are leaning on loved ones for help, you do not want these relationships to become one-sided. So offer your help when folks in your evolving support network have their own troubles. It feels much more affirming to be in balance when asking for and offering help.

Loved ones are potentially a fine way of helping the face of your infertility to become more visible. And they can be wonderful in shielding you against events of family and friends that celebrate fertility. However, unless they have experienced infertility or pregnancy loss, they may have empathy for you, but not a visceral response to your emotional pain. So, once you have assessed how satisfied you are by your network of loved ones, you may want to consider joining an infertility support group. Another option is to inquire whether the infertility clinic where you are being treated has any support groups. These groups are likely to make you feel easily understood, and they have the additional advantage of members who can offer important tips about everything from low cost prescription medication to people in the community who have been great as resources on a wide range of infertility issues.

So, if your face is invisible to the infertility sisterhood of survivors, consider why you have made the choice to remain silent. You may not be ready just yet, but when you are, remember that there is a world of kind and concerned people you can invite into your life who will embrace you, at whatever stage of the infertility journey you may be.

If you're interested in learning more about how you can enter to win a free copy of my new book, When You're NOT Expecting, click here!