Hopefully yours, Connie

Soothing holiday sadness as you remember absent loved ones

2011-12-14T09:02:00.000-08:00

This is the time of the year when holiday shopping, decorations and celebrations exude an aura of happy anticipation: of family togetherness, of shared traditions, and of connecting through cards and other messages with far-flung friends and family. Why, then, does this time of the year bring feelings of yearning and sadness for some of us?

As we contemplate times of the year that revolve around family and memories of loved ones, it is natural for our thoughts also to turn to those loved ones who are unable to be with us. Whether because of illness, military duty, financial stress, conflicting obligations or other reasons, the absence of a loved one on a family oriented holiday can have a poignancy that is difficult to ignore. So what do we do with those thoughts of longing that cannot be satisfied?

Perhaps it would be helpful to distinguish between the different kinds of loss that we experience. I’ll focus especially on ambiguous loss, anticipatory loss and anniversary reactions, as a way of communicating that each loss is unique and may need different kinds of comfort and self-soothing in the midst of the surrounding holiday happiness.

Ambiguous Loss, first conceptualized by Pauline Boss of the University of Minnesota, is loss that is not complete. She identifies that in mourning some losses, we may have the person physically present but emotionally absent (examples of that would be a loved one with Alzheimer’s disease; chronic mental illness; addictions; brain injury or unconsciousness). The person’s physical presence, while a poignant reminder of the loved one’s previously more healthy self, is also a jarring disconnect from the person they have become. Likewise, another form of ambiguous loss occurs when the person is physically absent, but emotionally present (such as a person missing in action or in a natural disaster; kidnapped; incarcerated; or a runaway). In this kind of ambiguous loss the person, although not physically present, occupies a significant part of emotional devotion from those people who mourn that person’s physical absence, and the waiting that is necessary before learning of a safe return.

Since I write this blog with special attention to people experiencing infertility and pregnancy loss, let me say that ambiguous loss is especially familiar in these circumstances: when you have built in your own mind an image of the baby you hope to have, which I think of as a “fantasy baby.” This baby, although not physically present, is very real to you, but as each month passes without a pregnancy, your grief at feeling this fantasy baby slip away grows stronger. Conversely, a newborn baby can be present without the expected joyful emotional bonding. This might occur when a baby is born prematurely, since it is not the healthy, dimpled baby you had dreamed of cuddling and nursing but, instead, this infant is tiny and vulnerable, with its early life restricted to tubes and incubators. Under any of these circumstance, it is difficult to put a finger on what deserves to be mourned, especially as there is fear of loss, but no real closure or future yet to the relationship that you have been yearning for.

So ambiguous loss, especially during the holidays, represents both uncertainty and a changed perception from what we had anticipated as we looked to the future. In a sense we are relinquishing our hopes and dreams, sometimes putting our lives on hold, and trying to nourish relationships with friends and family who have some appreciation for the emotional dilemma that has become a part of our lives. Holiday time can be especially challenging, as we are aware of the “missing persons”, either physically or emotionally, who are not with us as are so many other family members celebrating the holidays.

Anticipatory Loss refers to the mourning we begin to do when learning of a serious diagnosis for ourselves or for a loved one. Terminal illnesses can evoke anticipatory mourning, both for the patient and for loved ones. Other serous diagnoses, such as macular degeneration, loss of limbs, or mastectomies, can alter physical mobility and physical appearance while also increasing dependence on others. As we continue to anticipate the loss and its effect on our relationship with loved ones, we often are assailed with feelings of helplessness and hopelessness. It is not unusual to begin to withdraw emotionally from the loved one who is given a serious diagnosis, because it is so painful to contemplate the future. In truth, this mourning has some therapeutic strengths, in that we are not denying reality, so much as trying to make sense of it emotionally. We may reach out to others to vent our sadness and frustration, we may join support groups where others can share their own struggles and support us in ours. But as the loss becomes more inevitable, those of us who have had the courage to express our love in the midst of impending loss will feel the emotional load evolving, rather than imprisoning us.

Couples grappling with infertility face the issue of anticipatory mourning as they are told that a pregnancy is not healthy or viable, as they receive a diagnosis that means they will not be able to conceive a healthy child, and as they are told by infertility specialists that they have idiopathic (or “unexplained”) infertility. They may gradually find themselves mourning the loss of the roles of birth parents and, instead, assessing whether they want to pursue other means of bringing children into their lives.

Holiday time, with so much emphasis on children, play, frivolity and fantasy, can grate on the hearts of people with infertility. In addition to the pain of not having a child to indulge at this time of the year, many people with infertility feel an undeserved sense of isolation, coupled with the fearful anticipation that birth parenthood may not be an option. Holiday time, with the coming together of distant friends and relatives who may not have seen one another for some time, also creates the awkwardness of questions about when you plan to have children or well-meaning warnings to be careful not to “wait too long.”

Anniversary Reactions: This is a reminder that on the anniversary of a loss, we possibly will have some kind of emotional reaction. Whenever I find myself feeling unexpectedly gloomy or inexplicably introspective, I have learned to ask myself whether I am approaching or in the midst of the anniversary of an emotional loss. Ninety percent of the time that what is happening. Sometimes the anniversary will be of a loved one’s death, birthday, wedding anniversary, or other special occasion when I would have picked up the telephone or sent a cheerful card. Other times, the anniversary may be a celebratory holiday when the loved one would have gathered with family in the days he or she was alive and healthy. I have learned over time that what works best for me is to anticipate an anniversary that may be associated with the loss of a loved one. I try to be especially kind to myself at those times, sometimes sharing my thoughts with friends or family members, or other times just creating quiet times for myself to be contemplative and to dwell on happy memories. For people who may not have completed their grief at the loss of a loved one, it is more likely that an anniversary will evoke feelings of sadness. This is especially true if the loss is an ambiguous loss, with closure feeling impossible and memories feeling unresolved.

For couples with infertility, anniversary reactions can mark such times as the beginning of infertility treatment (and accompanying disbelief that so much time has passed without a conception); a pregnancy loss (which, for many, will represent a continuing emotional attachment); a failed adoption; or a decision to move on to a child free life. The importance of being aware of these emotionally-charged anniversaries is that one can honor the past hopes and dreams while, at the same time, feeling invested in the new directions life may be taking. Holiday time tends to be felt as a reminder of last year’s anniversary, when one or both members of the couple held out hopes that by “this time” next year they might be cuddling an infant in their arms. As they watch nieces and nephews grow older with each holiday, it reinforces for them the passage of time and the diminishing likelihood that any baby born to or adopted by them will have current nieces and nephews as age-mates.

So, just as we may now understand the mix of holiday joy with the flip side of remembering absent loved ones, what do we do with that awareness? Of course each of us will handle the emotion of sadness differently. First it is important simply to acknowledge to yourself that joy and grief can co-exist. It is also helpful to find some quiet time to indulge your memories of the loved ones who are not able to share the joys of the holidays with you. Perhaps this also can include a more public sharing, such as reminiscences with others of the absent loved one, the baking of that person’s favorite holiday goodies, or the displaying of a photograph or possession that evokes memories of happier times together. And then, in the midst of what can become a hectic holiday, it is helpful to slow down enough to absorb the memories in a calm way. Playing soothing music, soaking in a warm tub, getting a massage, getting extra sleep, taking a peaceful walk, or doing a kindness for another person all constitute opportunities to change the rhythm of the holidays to a more calm and reflective time.

So in the spirit of finding some emotional balance in the midst of busy holiday celebrations, I wish you peacefulness as you find a path, and perhaps some company, to soothe your emotions in this celebratory season.

He Just Doesn't Get How To Comfort Me!

2011-10-31T13:13:00.000-07:00

How many times have you found yourself frustrated that your significant other is unable to offer comfort at the very time you need it the most? Is he unable to see that your eyes are bloodshot? Is he incapable of empathizing with your pain? Or is he just afraid of your inevitable tears?

Well perhaps all three, in various combinations, could account for what feels like a loved one’s insensitivity. But is it really insensitivity? In today’s blog I’ll offer some suggestions for how you might encourage your partner to offer support when you need it most. For the sake of pronoun simplicity, I’m going to assume that you are a female and your partner is a male; but, if you are in a relationship where the genders differ from my examples, just substitute the genders that work for you.

The first thing is to do a bit of detective work. Are there times that your partner is immensely supportive? Are there circumstances when he does “get it” and doesn’t hesitate to offer emotional support? If so, you’re in luck, because that suggests that certain situations are ones that he shies away from, rather than every circumstance where you’re emotionally needy. So the next step in your detective work is to find a quiet time to raise with him your feelings of confusion. But first you’ll want to say something like “You know, I’m always so grateful when you give me emotional support. Like when I was so bummed out last month when I didn’t get the raise I expected, or earlier when I was frustrated that my boss was imposing unrealistic deadlines. It feels so good when you find just the words to comfort me. Have I ever told you that?” Hopefully he’ll respond with appreciation, which allows you to continue with something like “That’s why I’m so confused at those times that you seem oblivious to my sadness, like earlier this week when you had to have known I had been crying when I got my period or when the infertility clinic called to tell me they’d have to change our appointment, and I was frustrated to the point of tears. Both of those times you were just matter-of-fact when I really needed you to be more comforting.”

This level of inquiry moves you closer in several ways to understanding what could be going on. You want to be non-confrontational about this and ask for your partner’s help in understanding his perspective. You want to let him know that you do notice and appreciate those times that he offers emotional support. And you want to ask why there are times that he doesn’t offer the support that you need.

So here are some possible answers he might offer:

1. “You know, it’s a lot easier to offer support when you’re angry about something. You’re usually willing to talk about it, and even if you rant and rave, I feel like I’m doing something to help by letting you get it out of your system.”

2. “Well, in the examples you mentioned from your office, I felt frustrated on your behalf and, as I recall, after you settled down I offered several suggestions of strategies you might try with your boss.”

3. “Now that I think about it, I realize that any time you have a problem that brings you to tears, I feel pretty inadequate. It’s easier for me when you’re angry than when you’re sad.”

4. “Our infertility is such a source of sadness for both of us. I know I shy away from encouraging you to talk about it because it will bring up such sadness in me.”

5. “I know I can comfort you with talk about how to use different strategies. But when a problem like our infertility has defied both us and our doctors, I don’t know how to comfort you.”

So where does this detective work leave you? Actually, in quite a good place. You’ve learned in response #1 that your partner is comfortable with your anger and that he knows that being a good listener is something he can do. In response #2 he shows that he can empathize with your frustration and that he can mobilize his comforting techniques to include strategizing with you about possible next steps. In responses #3, 4 and 5 his reaction shows that he doesn’t know how to comfort you when you’re sad, especially over an issue that doesn’t have a clear solution and, even worse, if it arouses his own feelings of sadness. So we now know that there is a toxic issue that blocks his capacity to comfort you, and whether that issue is infertility, a chronic illness, a health problem, an emotional loss, or something else, the challenge you both face is how to share more fully the impact of this in your lives.

The good news is that (hopefully) there are either issues or emotions that your partner feels adequate to respond to in a comforting way. The challenging piece is to identify what issue(s) are red flags that make your partner feel inadequate or emotionally vulnerable. Once both of you can talk about his feeling more adequate and more emotionally supported, you are on your way to finding mutual comfort in your relationship.

So, for example, when your partner says he doesn’t know how to comfort you when you’re sad, what he really is saying is that none of his old behaviors (good listening, strategizing) seem up to the challenge. I often have been amazed to watch my female clients tell their partners what would comfort them when they’re sad (hugs, cuddling, some chocolate, undivided attention), only to have the partners say something like “You’re kidding! That’s all?” Some guys feel that if they can’t “fix” the problem there’s nothing more to be done. They don’t fully appreciate until you tell them clearly that there are ways to comfort you in your sadness, and that their very efforts to do so will be immensely reassuring. It also is possible that, in their own childhood homes, tears were toxic and comfort was never modeled. Helping your partner to understand what he can do to comfort you will be a gift to him. And, of course, once he begins to show his capacity for responding with empathy to your tears or emotional despair, your feedback and appreciation will help him to feel more adequate.

So next we need to think about the issue of emotional vulnerability that your sadness may evoke in your partner. The suggestion here is that the toxic issue is a shared issue, raising mutual sadness and perhaps some anticipatory mourning in each of you. And what we know about mourning is that it proceeds on different pathways for different people. So you and your partner may be in different places in your efforts to grieve, to make sense of a loss, or to make decisions about your future. There are several things for both of you to consider if emotional vulnerability is getting in the way of offering comfort. One is that, in spite of all the gender stereotypes that guys have grown up with, it is not the male’s responsibility always to be strong for his female partner. Here is where you need to say to him “This is a shared sadness and it would help me a lot if you could talk with me about the emotions it is bringing up in you.” Or “I feel lonely being the only one to share my feelings. I’m sure you have feelings too, and I really wish you would talk with me about them.” This effort to give one another mutual support can go a long way toward making both of you feel less vulnerable.

Another aspect of emotional vulnerability is the way in which it seems to stretch to fill every moment and every room. The worry is that once you bring up the toxic issue, it will overwhelm you. So there are two ways of trying to contain the emotionality associated with this issue (and the inevitable related ones) in your lives. One way is to agree to set limits on when and where you discuss the issue. I usually tell my clients to agree on a time limit they will respect: perhaps 15 minutes three times a week (with exceptions for crises and emergencies), and to identify a place in the house where these conversations can occur: absolutely not in the bedroom and preferably not in a place with frequent distractions or interruptions). Once you and your partner know that there will be times set aside each week for discussions, decisions and emotions, it becomes easier not to feel overwhelmed. A second way to address issues of emotional vulnerability is to talk with a therapist about constructive ways of coping (see my blog of 1/27/11 on “how to find a good psychotherapist”). This can be a good investment of both time and money, as it will set the stage for additional ways of being emotionally responsive to one another as partners, as well as helping both of you to understand any issues of grieving that you may be grappling with in different ways.

So when hoping to sensitize your partner to how to give you emotional comfort, your quest may actually have the effect of making your relationship mutually stronger. Not only will you have learned how to initiate good emotional detective work, but you also will have engaged your partner in sharing with you his feelings around whatever toxic issues you may encounter together in your lives.

Do you have kids? How toxic a question is that?

2011-10-03T11:23:00.000-07:00

For many of us with a history of infertility, the prospect of meeting someone new carries with it a blip of apprehension, as we wonder whether we will need to respond to the inevitable question about whether we are parents. Of course new acquaintances intend it as a “getting to know you” question. We can feel it like a stab in the heart. And our answers can range from the factual to the emotional:

“No.” That answer is certainly an option, perhaps followed by a quick change of topic, to move conversation away altogether from this sadness. You won’t elicit any concern or sympathy, but perhaps you’re not ready for that from a new acquaintance – or maybe you’re so saturated that you want to be known for other things in your life besides your non-parent status.

“No, but we’re ever-hopeful.” So this answer leaves the door open to a quizzical glance, perhaps an inquiry about how long you have been trying, and some awareness that parenthood is not something you take for granted. Other new acquaintances will decide not to be intrusive with someone they have just met, and will change the subject, perhaps a bit awkwardly.

“No. We’ve been grappling with infertility, and we would love nothing more than to have a baby in our lives.”
Okay – now it’s out in the open, feelings and all. It doesn’t mean your new acquaintance will have an empathic response on the tip of his/her tongue, but at least you’ve given a clear signal that these topics (oh, yes, several of them!) are open for discussion.

“No. We’ve experienced a/several pregnancy losses, but we’re still hoping to become parents some day.” This honest answer, like the previous one, suggests a readiness to talk further if your new acquaintance follows through with some empathy.

“Not yet. But we’re/I’m in the process of pursuing IVF because 1) we’ve had difficulty conceiving 2) at my age, the doctor has suggested we will have our best luck with donor eggs 3) my lesbian partner and I want to have an embryo from her egg and donor sperm transferred to my uterus 4 ) I’m single and eager to become pregnant 5)my husband’s sperm need some extra help connecting with my egg.” WHOA! This puts any new acquaintances on notice that a conversation with you will be honest, as detailed as they ask for, and may stay on the topic of your reproductive status for a long time.

“Not yet. But we’re in the midst of investigating whether we can adopt a child. So we’re hoping for parenthood; we just don’t know when it might happen.” This is likely to be a conversation starter, since so many people know adoptive parents. If you offer information about your infertility, the conversation can go in that direction, but chances are that your decision to adopt will provide ample information about how your new acquaintance views this dimension of parenthood that you are trying so hopefully to pursue.

“Not yet, but my partner and I are working with a surrogate and hoping that she is successful in conceiving and giving birth to our first baby.” This is a unique enough way of bringing a child into your family that your new acquaintance either will be tongue tied (with ignorance or awkwardness) or full of questions. In any case, you’ll get a sense of whether this is someone you’re interested in getting to know better!

“Yes.” And here you are likely to offer a brief list of children’s genders and ages. This offers itself as a way of saying “I’m in ‘The Club’ ” without providing any information of your pathway to parenthood. This works well for many previously infertile parents, who want to close the chapter of their life devoted to infertility and fully engage in the new chapters of parenthood. That having been said, most of us know we look at parenthood differently with a history of infertility in our background.

“Yes. We have two little boys, and we had a pregnancy loss/ stillbirth/ infant death of our daughter two years ago.” Here you are honoring the loss of a hoped-for child who still may occupy a psychological presence in your home. It seems impossible to leave her out, yet you know that mentioning her loss may trigger some awkwardness. Since this loss has left you forever changed, you feel it is important to share this dimension of yourself.

“Yes. When they say ‘Be careful what you wish for’, we never dreamed our infertility treatment would result in triplets!” Certainly this will be a conversation starter, but probably more with an emphasis on the challenges of parenting than on the challenges of infertility!

There are probably other responses to the question about you and parenthood that have occurred in your experience. The question itself arises so informally in meeting someone, and yet it leaves you wondering how much to share about your circumstances. And since we all evolve over time in our readiness to talk openly about our infertility, you may find that several of the responses in this blog have been ones you have chosen at various times when meeting a new acquaintance.

That in itself reminds us that infertility is an unanticipated detour on our journey through adulthood. Much as we might have wished not to travel this infertility pathway, most of us try to do it with strength, with integrity, with partnership and with courage. We want friends who understand us and the challenges we face. At the same time we want friends who do not define us via our infertility, but who are reciprocal in our relationships, allowing us to help them when they too fall on difficult times. And it is that wish for reciprocity that poses the challenge as we “size up” a new acquaintance and decide how much to share, how much we can trust a compassionate response, and how much we want to confide how soon. The answers are different for each of us. The important thing is that we understand why a single, inviting question can sometimes feel so toxic…..

Pregnancy at 40 -- How realistic is it?

2011-09-08T14:33:00.000-07:00

Why is it that some women wait until they are 40 to begin trying to conceive? Is it that finally their lives have settled down enough to contemplate children as the next step? Are they in a new marriage that they hope will be blessed with parenthood? Is the tick of the biological clock getting louder and louder? Are they feeling out of sync as some of their friends are anticipating grandparenthood? Or, as a recent New York Times article posed, do women who physically look much younger than their age actually believe their 40-year-old eggs are up to the challenge of conceiving a healthy baby?

Certainly there are many reasons and circumstances that cause a woman to try to become pregnant. But waiting until age 40 is risky, no matter what one’s motivation. Particularly worrisome is the belief that it’s just fine to wait until the time “seems right.” I would be the last person to advocate trying for a pregnancy when the timing is all wrong – that’s risky in a different sort of way, as the consequences of adding a new baby to an already stressful life can be devastating for all concerned. But if there is a guiding assumption that becoming pregnant at (or after) 40 is a breeze for a healthy woman, then we need to challenge that assumption.

Let’s start with the information most of us were given in eighth grade health class: females are born with all their eggs, as opposed to males who begin producing sperm at puberty and continue to do so into old age; neither old eggs nor sperm of older men are as healthy as those of younger adults. Defective sperm or eggs can be at the source of infertility, pregnancy loss, or congenital defects in newborns. The most healthy fertile years for women are in their twenties, when their bodies are mature, when their eating habits (hopefully) are healthy, when they can understand what they are reading about good reproductive health, and when they are capable of restricting behaviors known to harm developing fetuses, such as smoking, drinking, or substance use.

So how is it that some women reach their forties assuming that conceiving and carrying a pregnancy to a healthy birth will be a smooth process? Some of these women have forgotten their eighth grade health class lessons and haven’t brushed up in the intervening years; others have never initiated a discussion with their ob-gyns about fertility and the risks of first trying to conceive in their late thirties; and still others, who have done everything to keep their bodies supple and young-looking, believe mistakenly that their bodies contain young and healthy eggs. In fact, their eggs are aging, with higher risks for chromosomal abnormalities, and their hormone levels are progressing closer to those of menopause with each passing year. By the time a woman is 40, most doctors would agree that her chances of getting pregnant each month are approximately 5 percent.

But women are increasingly being influenced by the sensationalist magazines in the grocery store, the Hollywood stars celebrating birthday number 40 with a baby (or multiples) in arms, and the television coverage given to sex-symbol actresses who, at age 40, are embracing new parenthood. No longer are woman and their partners being guided by the factual information about aging eggs and infertility. Or aging eggs and pregnancy loss. Or aging eggs and birth defects. Now only a prolonged inability to conceive or unexpected news from prenatal tests may be what shocks them into conversations with their ob-gyns or propels them to an infertility clinic.

That is when they are likely to learn the news that the Hollywood coverage never revealed: that donor eggs, donor sperm or a surrogate may be necessary for a woman in her 40’s to have a baby. This then becomes a new pathway that some couples decide to pursue. And for couples with determination, energy, patience and a significant amount of money, they may yet be able to bring a baby into their lives. But others may be deterred at the immense disruption that medical, legal and financial efforts will introduce into their relationship, their health and their work lives. For those women and their partners who once believed it was possible to use Hollywood as their guide in matters of fertility, the wake-up call may have come too late. And with more and more domestic and international adoption agencies placing age limit restrictions on prospective parents, the feelings of loss become even more profound.

How can we move beyond this gulf of misinformation and move women and couples more realistically in the direction of planning for parenthood? Clearly it would help if the Hollywood new 40-something parents would come clean and be open about the extraordinary means (including financial) they have pursued to welcome children into their lives. It also would be an important medical contribution if ob-gyns and Planned Parenthood staff would routinely query their patients about whether and when they are thinking about conceiving. And if those same reproductive health care offices had literature about infertility and pregnancy loss on their tables that are too often crowded with parenting magazines, it might lend a bit of balance to the way women view the issues on which their doctors can advise them.

Women have worked far too long for reproductive freedom to be thwarted by an unexpected twist of fate in our late 30’s and early 40’s. We need to talk with our peers, to encourage balanced reading material in ob-gyn waiting rooms, to raise with our sons and daughters the issues we hope they remember from their health classes, to advocate for insurance companies to cover costs associated with infertility, and to remember that reproductive advances come with many costs at many levels that just may be too much for the prospective 40-something parent to afford.

Pre-Parenthood Perspectives of IVF Couples

2011-08-18T12:25:00.000-07:00

Social science researchers (Fishel, A.K. et al) at Massachusetts General Hospital have completed an interesting study with couples who have given birth to a healthy baby following IVF treatment. Comparing these couples to what is known about couples who conceive without medical interventions, this study provides a unique lens into the pre-parenthood perspectives of couples who desperately want a healthy birth child.

Married couples who conceive without medical intervention have been studied for years. Generally, what is known about their transition to first-time parenthood is that (especially for couples who had not planned their pregnancy) there is a spike in divorce, a decline in marital satisfaction and the frequency of sex, increased depression in both men and women, a shift to a more traditional division of labor, and less time available for the couple after the baby is born. Generally these transition issues are less problematic for couples who had planned their first pregnancy and who had anticipated both their needs and their babies’ prior to the birth.

With the 16 couples interviewed in their last trimester for this study, the focus was on the impact of IVF on the couples’ expectations of parenting, on their work life, and on their marital relationship. Of course, we also must remember that, in addition to the disruption of IVF treatment, the shadow of months of infertility (and perhaps pregnancy loss) also may have taken a toll on self esteem, interpersonal relationships and the couple’s sexual relationship. These infertility issues, which I portray from the perspectives of several hundred women with infertility in my recent book When You’re Not Expecting, form a backdrop over which the additional tensions (and hopes) of IVF build and play out.

So what did the research find with this particular sample of IVF couples? First, we must keep in mind that they are a group not typical of all IVF couples. The 16 highly educated dual career couples interviewed were relatively young (average age of women was 34 and of men was 36). Most couples had conceived this pregnancy after only one IVF cycle and had experienced infertility for a relatively short period of time. Half of the men in the sample had an infertility problem, as compared with 30 percent in large studies. Yet, even as this small group may not be typical of IVF parents-to-be, the six themes that emerged from the interviews provide a unique window into how these couples are beginning to think about themselves as parents:
• A truncated view of the future. Few of the individuals said anything about what they imagined their lives to be like once the baby had arrived, nor did they have elaborated fantasies about the baby. It seemed as though they could not risk imagining they would really have a baby. Instead, they placed their focus on living from one medical appointment to another, very much as they had done during their IVF experience.
• Health fears. Almost all the couples talked about their fears about the baby’s health, and one quarter of them were concerned about the mother’s health. When a pregnancy has been medicalized via IVF, it is understandable that medical problems are a high priority for these couples.
• Gender of infertility factor. With the higher than usual percentage of these couples where the male factor contributed to the couple’s infertility, the men expressed guilt that their wives had to bear the brunt of IVF treatment.
• Multiple disruptions to work, particularly for women. Women, in particular, noted that IVF had required them to take time off for appointments, meaning that they needed job flexibility and a compassionate boss. Finding or remaining in a job where the health insurance covered infertility treatment was a factor for some women. More than half the women anticipated working less after the baby’s birth and already were aware of a loss of interest in their work.
• Unequivocal attitude toward parenting. The emphatic wish to become parents was accompanied by a lack of complaining about the pregnancy, the anticipated delivery and parenthood.
• Infertility as relationship strengthening. Almost half of the couples stated that the process of going through IVF had strengthened their relationship, though a small number said that their sexual relationship had been negatively impacted.

So what can we learn from this study, even as we recognize its small sample size that is not representative of IVF couples in general? The medicalization of their IVF experience seems to have focused couples on the present (rather than encouraging hopefulness and planning for new parenthood), and also has placed health issues in the forefront of the couples’ minds. The couples’ lack of ambivalence about the much-relished hope of parenthood has caused all of them to have a positive focus, which might benefit from some anticipation that less positive feelings like frustration, anxiety and exhaustion will probably accompany early parenting and should not be a cause for guilt. Yet, the emphasis on infertility as having been a source of growing strength in their relationship provides many IVF couples with a good foundation on which to build their new parenthood experience, hopefully reaching out to family and friends for the support all new parents need.

I have found in my counseling experience with infertile couples (whether their parenthood is achieved by good fortune, by reproductive technologies, by surrogacy or by adoption) that continuing counseling, although less frequently, is a good idea during the first year of new parenthood, as the joys and the challenges often have infertility as a poignant backdrop. Couples who understand the impact of infertility and medical treatment on their parenting experience often find that counseling enables them to sort out those complexities in creative ways. Issues such as rebounding from months of medicalized sex, deciding about birth control, discussing the timing of a subsequent pregnancy, or dealing with the urge to be over-protective can benefit from using a counselor as a sounding board.

In vitro fertilization: What's realistic to expect?

2011-07-11T10:18:00.000-07:00

I’m a big fan of realism when it comes to infertility, because operating on false hope can get in the way of making realistic plans for parenthood. So many people view in vitro fertilization as an expensive and effective magic wand to wave to make pregnancy possible. In today’s blog I’ll try to present the facts, as well as the emotional considerations, about how soon (and for how long) to rely on IVF for fulfilling hopes of a healthy pregnancy.

Last week, at a meeting of the European Society for Human Reproduction and Embryology in Stockholm, scientists discussed new research into how eggs and embryos develop and how to predict and prevent miscarriages in infertile women. However, scientists there agreed that even that knowledge is unlikely to radically boost the chances of most infertile couples trying to achieve a healthy pregnancy.

So let’s first look briefly at why IVF carries such a hopeful aura. Hollywood is a good place to start, with many starlets crediting IVF for their pregnancies – and, if we look closely at the ages of many of these women becoming pregnant (sometimes with multiples), we also know that IVF may deserve the credit even if they don’t share that information with the public. So Hollywood IVF babies get lots of publicity, leading the reader to believe that it’s a procedure that can bring happy parenthood after months or years of infertility.

And, speaking of multiples, publicity attached to octomoms Nadya Suleyman and Kate Gosselin has grabbed and held the public’s attention for months on end. Exhausting as their lives are, anyone touched by infertility yearns for the physical exhaustion of new parenthood as a welcome replacement for the emotional exhaustion of infertility. So IVF has moved into the mainstream of family-making in ways one couldn’t have imagined just a few decades ago.

On July 25, 1978, Louise Brown became the first baby born as a result of IVF. Since that time the number has swelled to several million babies born worldwide from IVF and other assisted reproductive technologies. Yet, despite these large numbers, the success rate of IVF has climbed only modestly since 1978. About 15 years ago the IVF success rate was about 10 percent; today it is about 25 percent. Some clinics will calculate their statistics according to the age and health of the prospective mother, so data exist showing that the rate can be as high as 50 percent. However, even those impressive rates don’t usually reveal the hidden issues, such as costs, number of IVF procedures before a healthy pregnancy and life/employment disruption in general.

So, if you or a loved one is considering IVF, here are some things to think about before the Hollywood bandwagon sweeps you aboard.

• Many people move too quickly into IVF, when less costly procedures can be highly effective. I always encourage people with infertility issues to become affiliated with an infertility clinic (which will view the couple as the patient and will offer services 24/7 instead of being closed on holiday s and weekends when carefully-timed procedures may need to be scheduled). But this does not mean the infertility clinic will immediately offer high tech interventions when more basic procedures may be successful. Ideally a clinic’s goal is to be efficient and effective, with a variety of specialists available to offer treatment options.
• As you are selecting an infertility clinic, you are likely to be drawn to those that are geographically nearby. You will want to ask about their IVF success rates. Keep in mind that many clinics “adjust” their success rates to reflect high numbers. The number that matters to you is the number of healthy births (not chemical pregnancies or unsuccessful pregnancies) for women of your age. Some clinics restrict admissions to healthy couples within a certain age range which will optimize their likelihood of success with all reproductive technologies. This is why some clinics will be able to claim a 50 percent success rate with IVF.
• Whatever treatment you are receiving, be sure that you and your infertility specialist have a game plan for how long to continue that particular intervention before advancing to the next one. This will maximize the likelihood of being efficient and not staying with a particular treatment past the number of times it is likely to be effective.
• Not everyone has the money or the stamina for what is involved with IVF: the woman must take drugs to suppress and then to stimulate her reproductive system, and this involves taking pills and giving yourself shots each day. Daily blood tests and ultrasounds are necessary before eggs are retrieved, sperm are added and the embryos develop in a petri dish, and after three to five days the embryos are either implanted into the womb or are frozen for later use. In the last few years, doctors in the U.S. aim to implant only one or two embryos in most women, cutting the risk of multiple births to about 2 percent, the same risk as in the general population.
• Although the medical treatment is physically disruptive, emotional disruption is an issue for most couples as well. Employment juggling, exhaustion, depression and dealing with feeling out of control are all common issues during infertility treatment. Be sure to check to see whether your infertility clinic offers counseling, and don’t hesitate to explore whether counseling can take the edge off of your emotional life.
• You need to be paying attention to your budget and savings account throughout the period of your infertility treatments. Remember that there is only a 25 percent chance of a healthy pregnancy in most cases using IVF, yet each IVF cycle will cost more than $12,000. Check with your insurance provider to find out whether any costs of infertility diagnosis or treatment (including IVF) are covered for you.
• One reason you need to be highly aware of your dwindling savings account is that individuals and couples considering adoption if a healthy birth never happens, will need to have money and emotional energy for domestic or international adoption. Early on in your infertility treatment you may not feel open to considering adoption, but as month after month of regular periods diminish your hopes for a birth child, your personal perspectives on parenthood may expand to include adoption. And you’ll want to have enough money to pursue that dream.

So that leaves U.S. couples aware that good health and a woman’s age are crucial factors that increase the likelihood of having a successful pregnancy. And, as efforts to become pregnant deplete your savings account and your emotional energy you may find the voices of women in my recent book helpful as you consider other options (When You’re NOT Expecting: Chapter 10: Ending Treatment: when enough is enough; Chapter 11: Different Dreams: opening new doors to life). I’m a great believer that joining hands and hearts with others who have experienced infertility can sustain you emotionally during your creative, yet realistic, efforts to pursue parenthood.

When Hopes for a Happy Pregnancy are Disrupted

2011-06-30T09:36:00.000-07:00

It happens. The early joy of a much-wanted pregnancy is suddenly shattered by something unexpected. Whether your partner (imagine former US Congressman Anthony Weiner) reveals some giant stupidity that makes you question whether you want this person in your life anymore; whether your physician delivers some troubling news (imagine a Down Syndrome diagnosis) from a prenatal test; or whether a family catastrophe (imagine being laid off from your job and losing your health insurance) takes over your life, stifling the joy that had nourished your spirit, you feel as if you are in the midst of an emotional balancing act with no acrobatic training.

So how do you cope when a joyful pregnancy is no longer in the center of your life because your partner has demonstrated an emotional betrayal, an act of extreme stupidity or some other unexpected dimension of behavior that you never would have thought possible? As you are re-grouping, you could be weighing whether to remain in the relationship, whether to continue the pregnancy or whether to consider placing the baby for adoption. Each one of these issues feels life changing and overwhelming. And, given the betrayal exhibited by your partner, you may feel reluctant to confide in close friends and family, since you don’t want to face yet more pressure from them about what actions you “should” take. You also need desperately to vent, but hopefully are careful about saying too much too soon. So here is where an excellent option is to seek counseling from a professional who practices marriage and family therapy. This could be a psychologist, a social worker, or a marriage and family therapist. Some pastoral counselors will have this training as well. As I have said in earlier blogs, as well as in chapter 7 of my book When You’re Not Expecting, there are several ways to locate a therapist: recommendations from friends or clergy, names provided by your county mental health clinic, suggestions from a hospital social worker, or contacting your local family service agency. Plan to present yourself as someone who is experiencing a crisis, which will minimize the likelihood of being placed on a wait list. And be persistent in asking for services – if you are concerned that you cannot afford them, ask whether the agency or the therapist has a sliding fee scale. But the bottom line here is that it is important to receive emotional support and guidance in this difficult time from someone who appreciates the complexity of your dilemma AND who has the professional perspective to guide you through the decisions you will face in the months ahead.

Troubling medical news from prenatal tests can be immensely disruptive emotionally. Although the opportunity to learn early about genetic or other developmental disorders is important to expectant parents, the flip side of this opportunity is that often tests cannot predict the extent to which a particular abnormality will affect the developing fetus. This places many parents in an immensely difficult position. Clearly the first goal is to learn as much as possible; medically this may involve more specific tests or a consultations with specialists; emotionally you may very well want to meet parents of children born with the disability (being sure to include children both severely affected as well as minimally affected); and you will want to learn about community support services for children with the special needs that your child may have. All of this information presents a particular challenge to prospective parents who may be considering terminating the pregnancy or placing the baby for adoption. And, of course, your view of your pregnancy is forever changed; you now are apprehensive, anxious and fearful at the same time you also may be feeling protective and hopeful. Prospective parents who make the decision to terminate the pregnancy often choose to present the loss as a miscarriage, in large part to protect themselves from the judgmental reactions of others. Some will be forthright with close friends and family about the careful thought they gave to this wrenching decision. And all will be very careful in subsequent pregnancies to receive early genetic counseling and prenatal testing, as a way of being informed about any risk factors.

In addition to partner woes or worries about the health of a developing fetus, other life catastrophes can take a huge toll on the happiness initially associated with a pregnancy. These days financial issues, unemployment, home foreclosure, family illnesses and other unanticipated crises can be a significant source of worry and uncertainty. Sometimes we have some control or influence over these situations, and other times there is little we can do. Given that anxiety is usually associated with loss of control, perhaps the one antidote is to remain as calm as possible in the figurative “eye” of the situational storm. Since it is known that the cortisol associated with stress can enter the fetus’s bloodstream via the placenta, remaining calm is for the health of the fetus as well as your own. In addition to considering counseling as one path to take in addressing sources of stress, relaxation efforts and mindful behavior also can help you to feel more centered as your pregnancy progresses. The kind of counseling that is most appropriate in dealing with situational stress is cognitive behavioral therapy, where a therapist will help you to re-frame your tensions differently and more manageably. After helping you to think about constructive ways to address the stress, the therapist will offer support and encouragement each step of the way. Not only are you learning about problem management, but you also are learning skills that will be excellent for future difficulties that initially seem overwhelming. Deep breathing exercises, yoga, and mindful relaxation are additional skills you can learn to help you calm your body and your mind when tension intrudes. It can be empowering to learn that even when you cannot change a particular situation, you can exert some control over how you respond to it and the extent to which you allow its stress to affect you.

An initially happy pregnancy can be threatened with worry or misery for a wide variety of reasons. Often our initial reaction at such a time is to turn to friends and family for help and support. After all, haven’t they been there for you in other times of stress? Perhaps. But the examples in this blog go beyond the skills and knowledge that our informal networks typically possess. So, in addition to dealing with the current disruption to the joy in your pregnancy, you also will need to stretch yourself to consider how to access necessary support and skills. Use the web, use the yellow pages, use your spiritual leader or health care professionals, and do it in the spirit of moving forward to learn the acrobatic training for this uninvited interruption in the joy you deserve to nourish.

Fathers' Day: A holiday of gratitude or yearning?

2011-06-13T11:39:00.000-07:00

Fathers’ Day is a holiday that is so visible you can’t miss it! Advertisements, greeting cards, gift ideas, restaurant (or home grilling) choices… everywhere is filled with the importance of this holiday. But fatherhood is complex. Some of us can genuinely express gratitude to our father on this holiday. Others may have several fathers or father figures, with each representing a unique relationship. And then there are the men who yearn to be fathers but, because of personal or partner infertility, lack of a female partner or singlehood, cannot easily attain that coveted role.

So for those readers who have a positive relationship with a father, this holiday is just one day to express your love and caring to this special man in your life. It’s easy to focus these feelings on a holiday, but it’s important to know that spontaneous expressions of gratitude or sharing special memories can occur whenever the spirit moves you. Count yourself very fortunate to have this father in your life.

For many readers, Fathers’ Day is a time to weigh the differing relationships you have had with fathers and father figures. Complexity can be a challenge when a highly visible holiday suggests one father, positive feelings, and a life of shared experiences. If you have had various father figures in your life, this holiday is a time to decide how (or, perhaps, whether) to connect with them. Whatever you decide, aim to be genuine in your expression of what each relationship has meant to you over the years. This may include references to your differences, disappointments and difficulties, but even with the challenges, you may have emerged at a place where your gratitude is genuine. Relationships with fathers are an evolving experience, so hopefully you can capture some recollections to share even if the relationship may have become distant over time.

Likewise, fathers themselves may use this holiday to renew ties with birth children, adopted children, foster children, adult children and other folks of a younger generation with whom you have had a special relationship. If these relationships are ones that are valued, then think about shared meals, shared time together, or shared plans for getting together in the future that both of you can look forward to. There’s nothing magical about the holiday itself, but if it serves as a reminder that you would like to be more connected, then go for it!

But it is the men who yearn to be fathers for whom I have a special empathy on Fathers’ Day. They are the forgotten guys in the shadows of elusive parenthood. They are the ones who don’t yearn for cards or gifts but, rather, for a son or a daughter to cherish. And they feel invisible, except to their partners, on this day when their incapacity to father a child reminds them sharply of this missing role in their lives. So how to turn Fathers’ Day into something other than a day of yearning? That question will depend somewhat on your circumstances.

If infertility is the barrier between becoming a father or not, hopefully you and your partner are being diagnosed and treated at an infertility clinic, where each couple is assessed carefully by a team of health care professionals. That team should be sharing with you a timeline and a game plan for treatment, so that you don’t linger unnecessarily in the same treatment and can move to another level as medically appropriate. However, be careful with your finances, since infertility treatment can be enormously expensive and, for some couples, reduces their savings so that other choices, like adoption or surrogacy, are not an easy option economically.

Lack of a female partner is another barrier to fatherhood. For gay men wanting to become fathers, adoption and surrogacy are the major options to pursue. The “Resources” section of my recent book When You’re Not Expecting has listings of agencies that gay men will find supportive and informative in their quest for parenthood. The challenges posed by surrogacy are finding a reputable agency, handling the expenses, and deciding whose sperm will be used to conceive the baby. Some men request that their surrogate to use sperm from both of them to fertilize her eggs, while others will be more specific about which man’s sperm will be used during the insemination procedure(s). Men who choose surrogacy as an option usually identify genetic connections as important, prefer to adopt an infant, and may wish to use the same surrogate for future pregnancies, so the siblings would have a genetic connection. Adoption, which is likely to be a less expensive option than surrogacy, also should be pursued using a reputable agency. Many gay partners say that healthy infants are more likely to be matched with heterosexual couples, whereas older children, children with special needs and sibling groups are likely to be available for adoption by single parents and same sex partners. International adoption may widen the availability of adoptable infants and children, although some countries are very strict about such issues as marital status and heterosexual couples when releasing children for adoption. It is good to inquire about the average waiting time from application to adoption, learn whether travelling to the country is expected by the agency, and to understand fully any hidden costs or requirements associated with an international adoption.

Many of the same issues will pertain to single men wishing to adopt that I have indicated in discussing the challenges and rewards of gay couples adopting. However, there is one caveat I will offer. If you are a single gay male wishing to adopt, do not present yourself as heterosexual in the hopes it will enhance your chances of being matched with a child. Complete truthfulness is essential in the adoption process, in order not to risk voiding the adoption if later there is proof that deception occurred. This sounds harsh, I know, but any lawyer would tell you the same information. As with any single parent planning to adopt, you will want to assess your financial security, as well as your emotional support network who will join with you in loving your child and providing experiences and a sense of “chosen kin” that will be so important to both of you.

For further reading on the challenges of Fathers’ Day faced by men who are trying to become parents, I encourage readers to view the website of RESOLVE, the national infertility association (www.resolve.org). This week there is a focus on Fathers’ Day that is both sensitive and encouraging for men who are yearning to become fathers.

Can We Learn Anything From Tornadoes About Resilience?

2011-06-02T11:04:00.000-07:00

As coverage of tornadoes across the US has filled pages of newspapers and hours of newscasters’ time, I find myself speculating about the larger lessons that may lie beneath the shattered landscape left in a tornado’s wake. Issues of coping with loss, recovering from devastation and seeking support are universal in many tragedies we face over the course of our lives.

None of us invites tragedy. Sometimes it comes upon our lives slowly; other times it strikes like a bolt out of the blue. Yet when tragedy touches us or our loved ones, it may be helpful to have thought about how people salvage their lives and move forward with resilience. In reading about the recent tornadoes in the US, a few of which have caused me to retreat to a cramped crawl space in my own basement as sirens screamed in the distance, I have felt relief at being spared from the damage that people in nearby communities have experienced. Sometimes I have felt survivor’s guilt. And other times I have felt like a ghoul as I find myself riveted by news reports in the aftermath of the wreckage. So I’ve tried in my own mind to think about how I might sort out my life if it were upended by a tornado – by which I could mean a violent act of weather, but I also could mean any event that rips me from my psychological moorings.

Coping with loss: I have lived enough years by now, and counseled enough grief-stricken clients, to have more than a passing familiarity with the emotional devastation that loss can bring. Although each person handles loss differently, I have found that North American culture often communicates the expectation that people should get on with their lives after a loss. And yet, for most people, it takes time to absorb the meaning of any loss. A year after a loss, when anniversaries have passed without the loved one, most survivors will say that it has been the comfort of family and friends that has enabled them to face each day. Some also will say that a ritual following the loss or a memorial to a loved one has helped to sustain them during their time of grief. But, most of all, grieving people will say that they have needed a shoulder to lean on, someone to talk to and a chance to review the circumstances leading to the loss to try to make some sense of the tragedy. And they will feel relief if their support systems are willing to be good listeners, neither judging nor hastening them to get on with their lives. Sometimes, as in the case of chronic health problems, terminal illnesses or infertility, the impact of loss grows heavier over time; conversely, when someone dies unexpectedly or there is a pregnancy loss, it is the suddenness of this event that leaves us emotionally adrift. So, whether for ourselves or loved ones, it is important to respect the unique pace each person needs in the process of healing, as well as the importance of support during the months and years that follow.

Recovering from devastation: At the memorial service of a friend a few years ago, one eulogy mentioned the decreased person’s frequent proclamation that “It’s just ‘stuff’”! As this friend had coped with his terminal illness, he was reminding others around him about what mattered, and it wasn’t the material possessions they were fussing over. We hear of tornado survivors who celebrate that they are alive and that their friends are alive, while proclaiming that life is what matters most as they contemplate rebuilding their lives. In watching coverage of families who have lost their homes, their scrapbooks, and their treasures of a lifetime, only to reclaim shreds of their possessions, I find myself wondering about what I value in my life and how I would tolerate the loss of a valued object. With this tornado mindset, I have donated many bags of clothing to charity, tried to simplify my life so I am able to spend time doing what brings me joy, and remained thankful daily that life in the moment is worth celebrating. I would hope that if/when devastation strikes, I could separate “stuff” from substance, lean on loved ones, and fortify whatever resilience I could muster in the wake of any personal storm.

Seeking support: In both of the earlier paragraphs I have emphasized the importance of leaning on others, even in a society that expects we should be able to bounce back quickly from catastrophes. And, since these catastrophes may very well have touched the lives of loved ones, I have found that it is wise to maintain relationships with a diverse network of caring people. Whether professionals (clergy, therapists, health care professionals), friends, mentors, neighbors, co-workers or distant folks who care about you, it is important to stay in touch or to extend emotional support when needed, in part because you may need to ask for such support in return some day. Not all folks will be available or emotionally able to connect with us on every issue, so it pays to think over the months and years about which people we feel most ready to confide in on which issues. As life changes, we change. But remembering to stay in touch with caring people of all ages is one way of being able to be responsive to their requests for help, as well as to call on them when your own life’s storms are just too much.

In writing today’s blog, I hope I am striking a responsive chord in some readers who, like me, are aware that, actually or figuratively, tornadoes can appear without warning on the horizon. If they strike, hopefully we can feel empowered to honor our emotions, to rebuild our lives and to seek support of various dimensions from the caring and concerned people in our lives.

Rebounding from Springtime Stress!

2011-05-19T09:15:00.000-07:00

Even as bright flowers, longer hours of sunshine and gradual warmth abound in the spring, many of us have encountered emotional potholes in this otherwise cheerful season. Whether you are rebounding from the stress of Spring holidays, winter weight gain or infertility, here are some thoughts on how to set your sights on moving forward!

HOLIDAYS are a time when we are expected to be celebratory. But the gathering of families, complete with familiar roles and lurking conflicts, can contribute to tension of spring holidays like Easter, Passover, Mother’s Day and Father’s Day. Not surprisingly, these spring holidays have a theme of life and reproduction running through them, which can be haunting for families who have lost a loved one or whose infertility prevents them from being celebrated as a mother or a father. If you are rebounding from feelings of disappointment or regrets associated with any of these holidays, you may want to spend some quiet time thinking through what you would like to have done differently this year. Perhaps you might have been involved with more supportive family members? Interspersed a family gathering with some quiet time or a stroll with a loved one? Called a friend who shares your sadness associated with a holiday so you could offer support to one another? It’s a challenge to feel entitled to emotions of regret when others around you are celebrating. But if you have these emotions, try to talk about them with a loved one. And, in addition to considering that you are rebounding from some stress now, also keep in mind for next year what strategies you might plan in advance as spring holidays approach.

HEALTHY WEIGHT is always a goal to strive for, but as spring approaches and our heavy sweaters no longer disguise the pounds we wish we could lose, stress can be one response to that realization. But if you’re trying to rebound from that stress, find a friend who can join with you in some healthy resolutions. Perhaps you can plan a brisk walk on a regular basis. Or join a gym and take some classes. Or sign up for a weight loss program. All of these possibilities give you the support of others, as well as the motivation to “stick with it.” Then there are some more solitary behaviors that may feel more possible to embrace now that spring fruits and vegetables offer opportunities for healthy eating. Brian Wansink, a professor at Cornell University who focuses on food psychology, reminds us that mindless eating causes people to consume far more calories daily than we are aware. He and other food experts encourage people not to include eating as a part of their multitasking but, rather, to focus clearly on being aware of food in all its dimensions: its taste, texture, color, flavor and deliciousness. As someone who researches the size and shape of our serving dishes, Wansink encourages us to use smaller plates and glasses for our food and drink as a way of controlling portions. And, in the spirit of mindful eating, many nutritionists stress the importance of focusing on food as it is being consumed at the meal table, rather than in front of the TV, while multitasking with our mobile devices, and to avoid sampling food while preparing a meal or nibbling a few last bites of leftovers before washing the dishes. For many people, specific medications may contribute to weight gain. This can be a side effect of some antidepressants. Hormone treatments used by women being treated for infertility may also cause weight gain and mood swings. So it is useful for everyone to try to pinpoint the underlying cause of unwelcome pounds before you make a plan to rebound toward a healthier weight in the spring months.

INFERTILITY can feel especially emotion-laden in the spring. Heavy clothing is coming off of both close and casual acquaintances, sometimes to reveal baby bumps. Mothers are pushing strollers everywhere outdoors, so it no longer is enough to avoid the local mall if infants bring envious tears to your eyes. And, then there have been the spring holidays, replete with pregnant and nursing relatives, flowers and eggs as celebratory reminders of fertility, and (we take a deep breath here) Mother’s Day and (yet to come) Father’s Day. So how can you feel you’re rebounding when reminders of your infertility are lurking at every turn? For starters, we can remember that Spring is also a season of “beginnings.” So now is a good time to think about taking new action in addressing your hopes for parenthood. If you’ve been relying on local physicians, now might be a good time to seek the services of an infertility clinic which, among its many advantages, diagnoses and treats both the male and the female as time-efficiently as possible. Another service provided by many infertility clinics is individual, couple and group counseling. You may feel that you’re coping okay, thank you, but keep in mind that counseling can offer new coping strategies that you might not have considered or tried. So even if you’re not a patient at a clinic that offers counseling, think about going to some support group meetings in your locale (consult the RESOLVE website at www.resolve.org) or seeking out a counselor in your community who can help you over the inevitable rough spots, as well as suggest strategies that will strengthen your emotional resilience. And, as readers of my recently-published book know (When You’re Not Expecting), emotional support during infertility can also be offered between the covers of a book – mine captures the words of a sisterhood of several hundred infertility survivors, each of whom shares her own strategies of coping across the entire spectrum of infertility diagnosis, treatment and pregnancy loss. And as I mention pregnancy loss, let me say that many couples who have had this emotion-laden experience and later grief over shattered dreams find that counseling can ease the pain, especially as a counselor will be the first to understand when you confide that loved ones seem to want you to “get back to your old selves,” rather than giving you support as you strive to rebuild your lives. One way many couples use the springtime is to plant a memory garden to honor a lost pregnancy or a stillborn infant. Although you will want to be aware that you may, at some point, move away from your current home with its memory garden, the very designing of it, as well as the process of planting, can feel therapeutic. Should you move, you may decide to preserve the garden in a photograph or painting you hang in your new home or to re-create the garden at your new residence. So spring flowers can be both an emotional tribute and a poignant reminder of dreams deferred. Lastly, in the spirit of rebounding, now is a good time, before Father’s Day arrives, to think about how you have coped with the challenges of your infertility this spring, and what you might try to do differently next spring with its reminders of fertility at every turn.

So, as we think of rebounding in the spring, whether it is from the stress of spring holidays, unwelcome weight, or infertility, the real issue is how to think about the stress as an ongoing learning experience. Stress is with us in all seasons, for lots of different reasons. What matters more than the existence of stress is how we use those experiences to move forward rather than to get emotionally bogged down with anger, regrets and self-blame. So, whatever issue in this blog resonates most strongly for you, take the rebound perspective (start with small steps) and see whether you can feel empowered to use the spring as a season of positive change. Good luck!

Am I A Mothers' Day Grinch?

2011-04-22T12:26:00.000-07:00

Am I a Mothers’ Day Grinch? Not exactly, but today I’d like to present a perspective that is different from that depicted on Hallmark cards: the perspective of families who need some extra compassion on this holiday.

With Mothers’ Day falling this year on Sunday, May 8, now is a good time to think through how the meaning of this holiday for you may differ from the meaning it holds for some friends and family members.

Families without mothers. Even as I write this title, I feel some personal sadness. My own mother died over 30 years ago, after many years of my celebrating this holiday to honor her. Not only would I send flowers and, if distance prevented our spending the day together, we’d have a long phone conversation in which I’d tell her how much she meant to me, and I’d also remind my younger brothers to be sure to connect with Mom. In those days, Mothers’ Day was about MY mother. Following her death it became a holiday with mixed emotions, as I cherish her memory while, at the same time, wishing that her life could still be a part of my life.

In my early 30’s I was diagnosed with infertility. All of a sudden Mothers’ Day was “in my face” for at least a month before the actual day occurred. Every time I opened a newspaper or a magazine I would find stories of mothers. Every time I turned on the TV or radio, there would be some attention to the approaching Mothers’ Day and the opportunities families had for celebrating it. And in all the media would be reminders to make reservations at a favorite restaurant for a Mothers' Day meal. And there I was, wishing like anything I could be a mother. Not so that I could celebrate this holiday so much but, rather, to satisfy my craving for cuddling an infant in my arms. My husband and I did find ways of escaping the holiday hoop-la, but even with our efforts to plant a garden or play some golf or take a leisurely walk in a nearby state park, I still knew that others were celebrating a holiday I could not call my own. It wasn’t fun in those days.

As many of you know from my recent book When You’re Not Expecting, I have counseled hundreds of individuals and couples with infertility. Each year as Mothers’ Day approached I would ask my clients to anticipate this holiday, think through its meaning for them, and try to find creative ways of deciding how to spend it. Some celebrated the holiday with their mothers or their mothers-in-law. Others used the day to connect with nature in some way, to indulge in a short trip, or to have a potluck dinner with other infertile friends who, like them, dreaded this particular holiday. So, while I won’t go so far as to think of myself as a Mothers’ Day Grinch, I do own up to my role in helping my clients to figure out how this holiday could be less painful for them.

Another group for whom Mothers’ Day is poignantly painful includes those individuals and couples who have experienced a pregnancy loss or an infant death. Since, with regard to pregnancy losses, there are no rituals to memorialize the pregnancy loss (and often no mementoes to save, except perhaps a sonogram photo), the mourning parents may feel especially emotionally vulnerable on a day that honors mothers. If an infant has died, there may have been a service, sympathetic loved ones, and a gravestone in a cemetery, but in American society there often is the assumption that emotional recovery equates with putting the loss “to rest.” So loved ones may not be at all aware of the emptiness of a Mothers’ Day for parents who, even years later, are grieving the death of their infant.

In my life more recently, I’ve needed to extend comfort on Mothers’ Day to my two nieces, ages 12 and 14, whose mother died unexpectedly just 16 months ago. It was especially difficult to comfort them last year, their first Mothers’ Day without her, but this year as well they remind me that Mothers’ Day will never be the same for them. And they’re right. So I talk with them and their dad (my brother) about how they can embrace Mothers’ Day in a different way than their friends’ families are doing. This year they have decided to lay flowers on her tombstone, and then to go hiking outdoors, away from the visible celebrations in restaurants. If the weather is too inclement, they have a backup plan – a movie followed by takeout food they can enjoy at home. For them, as for other families without mothers, having a plan for the family to enjoy themselves gives them an emotional cushion when faced with families in their community who are celebrating the holiday that will never be what it once was in their family.

Families whose mothers are at a physical or an emotional distance. These families could include grandparents raising grandchildren, children in foster care, children whose fathers have custody of them, children who perceive their mothers as abusive and adolescents who have left home because of family conflict. Mothers’ Day is likely to touch these family members in different ways, often with considerable ambivalence and wishes for greater closeness with this parent who does not live with them.

Another family where mothers may be physically separated from their children could include immigrant families, either because the children have not yet come to the United States to join their parent(s) or because, in the case of some undocumented Chinese immigrants, their infants are sent back to China to be raised by the grandparents until the immigrant parents in the US have enough economic security to provide a home for their young child being raised in China. Another immigrant group where parents and children may be separated for periods of time includes agricultural workers who travel entire geographical regions sowing or harvesting seasonal crops. Living circumstances can be very chaotic for these families, with low wages added to the uncertainty of living quarters.

Childfree families: In couples who have decided not to have children because they are infertile and unable for various reasons to bring a child into their family, Mothers’ Day can be bittersweet. Many couples have ultimately made their peace with being childfree, whereas others still carry feelings of sadness and regret for the door to parenthood that has closed in their lives. Other couples have a firm commitment to remain childfree, a decision they reached after careful thought and, perhaps, after bucking their parents, in-laws and loved ones who urged them to consider the joys of having children in their lives. Indeed, many childfree couples do have children in their lives, but not as offspring; they are likely to look at Mothers’ Day as an observance they can share with friends and relatives who invite them to their holiday meal.

Where do we go from here? So now I’ve elaborated on those families where Mothers’ Day evokes feelings of sadness and regret rather than the glow of happiness most people anticipate from women of childbearing age. And, as you may have gathered, my hope is to encourage readers to think about how we can be sensitive to those women who are not mothers.

I think a great deal of grief could be avoided by not wishing every female in sight a “Happy Mothers’ Day!” It doesn’t pay to assume they are mothers and, if they are, chances are they have figured out how to enjoy this day.

Be on the lookout for well-meaning folks who are possessed with the Mothers’ Day spirit. I am thinking particularly of religious leaders who, with the best intentions in the world, decide to honor the mothers in their congregations on Mothers’ Day, either by giving them corsages, having them stand for recognition, or by having a special reception after the service. I cannot tell you how many of my clients and friends have been blindsided by a religious service in which they felt invisible, not honored and generally discounted. If your place of worship is one with the tradition of honoring mothers on Mothers’ Day, perhaps you could encourage your religious leaders to revise their message by reminding their congregations that families come in many shapes and sizes, that not all families include living mothers, and that families who have experienced the loss of a mother, the loss of a pregnancy, the death of an infant or infertility deserve to feel emotionally safe when they come to worship, including on Mothers’ Day.

So, as May 8 approaches, and as you and your family think of how, or whether, you will celebrate this day, please also take some time to be thoughtful about your interactions with others. Don’t make assumptions, offer comfort when it would be appreciated and, when in doubt, ask what you can do to make May 8 a positive experience for a friend or a loved one.

How to Adapt Stress-busting Strategies for Really Tough Problems

2011-04-18T12:28:00.000-07:00

When life is filled with too much pressure, we either cave or we decide to deal with it. If you’re on the “deal with it” team, you may feel apprehensive about how to identify strategies that will work. In today’s blog I’ll suggest some ways you can gather strength and resources to reduce the stress that threatens to become a way of life.

In my most recent blog (Life Happens – But what about the stress it generates?), I offer some strategies for identifying and dealing with the small-time irritants in your life. These strategies are good practice for the time when you need to take on larger sources of stress, our focus for today. These larger sources of stress could have to do with health (cancer), life dreams (infertility), finances (debt), work (too much of it), or any number of other issues that have you in a stranglehold. The common thread these diverse issues share is that they have claimed more of your time and energy than you want to give – AND that they seem too tough to tackle successfully.

So here is where we need to get clear about a few things: How do we define the issue we want to change? What kind of change do we want? What do we call “success?” What resources are available to help with the issue?

Defining the issue. This is actually very important, since it’s easy when we’re overwhelmed to lump together a whole variety of issues. Sometimes defining the issue clearly places it in manageable proportions – but not always, for sure! So, using the issue of infertility, let’s define the issue as “I want to have a baby.”

What kind of change do you want? First you’ll need to consider how you have already tried to address the issue that is causing you stress. You don’t want to keep banging your head against an unyielding wall. So deciding on the kind of change you want amounts to looking for a previously invisible gate in that wall. In that effort, you’ll need to look more carefully at whether your definition of the issue could be broadened, allowing for more flexibility in the changes you are willing to consider. It also is a time when you should open your mind up to possibilities you may not have been willing to consider before. So, using the infertility example, you might re-visit your definition in #1 and reframe it as “I want to be a parent.” By doing that, you move beyond your initial issue of becoming a birth parent and broaden the kind of change you want to “parenthood,” which could come about through your willingness to consider donated eggs, donated sperm, donated embryos, surrogacy, adoption and, maybe, foster parenthood.

What do you call “success?” With a clearer and more flexible idea of changes that would be acceptable, you may want to identify more than one measure of success that would bring you relief or satisfaction. Ideally, “success” specifies something over which YOU have some control. Success can be in mini-steps, with you feeling satisfaction each time you move forward even a bit. So, let’s say that, using our infertility example, you define success as completing the paperwork for an international adoption. The mini-steps could include reading books on adoption; sharing your hopes with close family and friends; becoming acquainted with some adoptive families in your community; deciding the country from which you hope to adopt; identifying an reputable adoption agency; increasing the funds in your adoption savings account; meeting with the agency staff to learn their expectations for prospective adoptive parents and, finally, completing the necessary paperwork to move the adoption forward. Taking these small mini-steps has made it possible for you to feel small successes and increasing confidence in your decision to pursue adoption as the previously invisible gate in the wall leading toward parenthood. When setbacks occur, as they inevitably will, it is important to have a foundation of some mini-successes to bolster you as you regroup and take a new route.

The resources you identify will be very important as you encounter the inevitable setbacks that may be associated with your issue. In my earlier blog, I mention partners, loved ones, religious leaders, physicians and counselors as possible resources. Here is where you need to look at the issue as you have defined it and decide what network of helpful people you need to consult as you move forward. Ask trusted and experienced people for names of the professionals they would recommend.

And don’t try to do too much! It is better to move slowly and carefully than to get tangled up in frustrating details associated with your issue. Remember that your goal is to make progress in moving through that once-invisible gate in the wall. Take your resourceful colleagues along with you so you and they can feel like partners-in-success. There’s nothing as joyous as being able to celebrate mini-successes together! So, with infertility as our issue, possible resources could include family members, local adoptive families, a financial advisor, adoption agency professionals, travel agents, pediatricians, attorneys and language tutors.
There’s no question that feeling stressed and pressured is emotionally exhausting. And it is worse when you have been working for months or years on trying to grapple successfully with an issue that just won’t yield to your persistent efforts to bring about change. So today’s blog shifts the emphasis from “try harder” to “look for the invisible gate in the impenetrable wall.” And remember to recruit friends and experts, since their partnership in opening that gate can be invaluable!

Life Happens -- But what about the stress it generates?

2011-04-11T14:17:00.000-07:00

Feeling overwhelmed happens to all of us. For some of us it’s occasional, for others it seems like a way of life. The causes can range from relationship problems to chronic health concerns like infertility or cancer, with hectic lifestyles usually weighing in with their share of stress. So what to do when life is filled with just too much pressure?

As I’ve counseled people over the years, the one thing I’ve learned is that troubles arise from a whole variety of complex situations. Being able to be as clear as possible about the source of stress can go a long way toward getting it under control. And, if you’re feeling overwhelmed, it’s likely that there’s more than one source of stress to contend with. Many people find it’s helpful to make a list of what is stressing them out, and then putting that list in some order, with the most stressful situations as the top, working down to the least stressful ones at the bottom. As you review your list, very likely you’re saying “No wonder I feel overwhelmed!” And just that admission can go a long way toward helping you feel less crazy and, hopefully, more ready to take the proverbial bull by the horns and work on the issues like a skillful matador.

So, once you’ve named your troubles, another step is to think through the resources you have available to grapple with them. Are loved ones available to help in any way? If they’re part of your stress, are they feeling troubled enough that they’d cooperate in seeking some relief? Could you brainstorm with a good friend who has your best interests at heart? Is your religious leader someone who might help you sort through some of the challenges you’re facing? Would it be a good idea to see your family doctor, either for relief from physical symptoms or for a referral to a specialist? Could a counselor be helpful? In my recent book When You're Not Expecting, as well as in earlier blogs, I provide information on how to find an appropriate therapist, including ways of doing this without a significant outlay of money.

So, now that you have your list of stressors, as well as a list of resources, what’s next? I’m a great believer that success breeds success, so unless you are feeling completely unglued by the issues at the top of your list, my first suggestion would be to tackle two items toward the bottom of your list. These should be items that are troublesome and irritating but, at the same time, capable of showing some improvement. Do one at a time, involve friends, loved ones, or others if they’re willing, and hopefully in a week or two you’ve been able to calm down some troubling issues and feel some mastery over them. Notice, I didn’t say you’d removed them, because some sources of stress aren’t removable so much as they are improvable. Now, keep an eye on these lesser troubles (or ask someone’s help in monitoring them so they stay stable), and go to the middle of your list. Choose one issue there, figure out what resources are available to call on for help, emotional strength, financial assistance or whatever, and make a plan to address this problem.

• What does it mean to make a plan? The most important thing will be to identify what your goal is. (What changes do you want to see? Who needs to make these changes? What changes will you need to make? When will you know you have reached your goal?) You also need to ask yourself if your goal is realistic; if it isn’t, then you’re setting yourself up for feelings of failure and frustration. A goal isn’t necessarily a full solution to the problem if that’s not realistic; it can be a change in the problem that makes it more bearable. Just remember that every change you are able to make lightens your load emotionally and gives you more energy to give to other problems on your list.

• Another important component of a plan is a timeline. Don’t ask too much of yourself or others too soon. Remember, this issue took some time to develop, and it’s going to take some time to unravel it. So try to set a realistic timeline, and be prepared to revise it to a faster or a slower pace depending on how your change efforts are working.

• Pause from time to time and pat yourself (and others) on the back for the progress being made. Even little changes deserve attention, encouragement, and ongoing support.

• It’s a good idea to revisit your goal and to reassess whether it remains as realistic as you initially hoped. By now you’ve had a chance to try out various strategies, engage the cooperation of others, and see how committed others are to change. If you decide your original goal needs to be redefined, fine. You’ll base your new goal on new information and behavior, so hopefully you’ll have a better chance of reaching that goal.

• When you believe you have moved as far as possible toward achieving your (perhaps revised) goal, it’s time to decide what needs to happen so that there’s no (or as little as possible) backsliding away from the changes that have occurred. Maintaining these changes may take some energy, but hopefully some of this energy can be supplied by others who have cooperated in making the changes.

• And now it’s time to move higher on your list…

Why didn’t we start here in the first place? For one thing, now you’ve had some practice in problem solving AND you’ve had some successes AND you have fewer problems on your list AND perhaps you already are feeling less overwhelmed. In short, you’ve reached some goals, involved some resources, begun to feel as if change is possible, and hopefully have the energy to take on a tougher problem. So what will be different as you tackle a #1 or a #2 problem on your list? Probably its difficulty.

Simply by virtue of having risen to the top of your list, this is a compelling problem. It seems to you as if it interferes with your capacity to get on with your life. It probably is something that involves other people in some way. And, very possibly, it has resisted earlier efforts to bring about change. So here is where you’ll want to give yourself some “subgoals” rather than just the one big goal of erasing the problem or reducing it considerably.

So, watch out for next week’s blog, when I’ll take on the challenge of problems at the top of your list. In the mean time, how about trying out this blog’s strategies on a stressor or two at the bottom of your list? That way, you’ll already be polishing your problem solving skills and hopefully reducing those feelings of being overwhelmed. Sure, life happens. But you can play a role in steering clear of the worst potholes by strengthening your resilience! Tune in next week….

Craving Parenthood: A New Trend on Grey's Anatomy?

2011-04-04T11:40:00.000-07:00

As I have been watching the medical series Grey’s Anatomy over recent months, I have been struck by how the themes of fertility, unplanned pregnancy and pregnancy loss are interwoven through so many of the episodes. And then after the episode that aired March 31st, I vowed to devote a blog to this thought-provoking series and the way it has humanized so many fertility issues. So, for those readers who may need a quick introduction to the relevant characters, we have these residents and physicians at Seattle Grace Hospital: • Meredith Gray, the protagonist of the show who has been trying for many months to become (and to stay) pregnant. • Derek Shepherd, Meredith’s husband, who was told a number of episodes ago that Meredith had suffered a miscarriage at the same time he had been shot by a gunman in the hospital. She waited some months to confide this to him, hoping that she would become pregnant in the meantime. • Christina Wang, Meredith’s best friend, childless by choice, and a doctor whose life is devoted to perfecting her surgical skills. • Callie Torres, a bisexual physician who has been in an off again-on again sexual relationship with Dr. Mark Sloan, and who has recently renewed her relationship with her estranged lesbian partner, Arizona Robbins. • Arizona Robbins, who has learned in recent months that Callie is pregnant by Mark Sloan. Callie is ecstatic at the pregnancy, but Arizona had said throughout their relationship that she did not want them to become parents. • Mark Sloan, who is also ecstatic at Callie’s pregnancy, since he missed out on raising an adolescent daughter from an earlier relationship, missed out on becoming a grandfather when that daughter decided to place her infant for adoption, and now sees Callie’s baby as an opportunity to become a bona fide dad. So there you have the characters; now for the plot and its infertility dimensions. See how many of these issues resonate with you or your loved ones who are grappling with infertility. • Meredith kept her miscarriage a secret, in part because it paled in contrast with Derek’s life-threatening wounds from the gunman, and in part because denial is one of Meredith’s coping mechanisms. Any reader familiar with pregnancy losses will appreciate that these losses often are not shared (for any number of reasons), and that there are no rituals in North American society to memorialize the loss of a pregnancy and the hopes and dreams attached to that pregnancy. • Meredith, once she didn’t conceive, underwent a diagnostic workup, which she said revealed that she had a “hostile uterus.” Not exactly a medical term, but the message to viewers has been that it will be difficult for Meredith to become pregnant. And, sure enough, over the course of many episodes we can see her and Derek finding private places in the hospital for intimacy, for hormone shots, and for furtive tears. Meredith remains quiet about her infertility, although Christina is aware of her friend’s sadness. However, the hospital provides plenty of opportunity for Meredith to devote herself to her medical practice, perfecting new skills, and participating in research. As most women with infertility are aware, it isn’t unusual to compartmentalize infertility – attending to it when your period arrives or there are medical procedures to submit to, but also trying to keep alive some distractions in your life: career, relationships, being kind to others. • When Callie conceives a baby, certainly without intending to, she realizes she is thrilled at the prospect of becoming a mother, and Mark is equally ecstatic at being the father of this baby. Arizona, recently returned from a medical sojourn in Africa, tries to re-engage Callie in their relationship and, once she learns of the pregnancy, makes her peace with it. Callie, Mark and Arizona ultimately become a threesome emotionally, with all the complications that go with meeting their needs. • When Callie asks Christina Yang to be the godmother of her baby, Meredith quickly moves to action, asking Christina to re-consider her plan to accept the invitation. Ultimately Meredith confides to Christina that she had always hoped Christina would be the godmother to Meredith’s baby, and she wanted Christina to be a special person in that baby’s life. How many times have couples with infertility watched their lives passing by as others live out their dreams: naming their babies the names we dreamed for our baby, inviting a godparent to accept when we had envisioned that person as our baby’s godparent, giving a baby gift that we would have loved to save for our own baby? • And, of course, when the hospital staff celebrated Callie’s pregnancy with a lavish baby shower, we could see the dimensions of feelings playing out: Meredith was on the sidelines; Arizona, ever ambivalent about this baby, was perplexed about why there was such a fuss being made; father-to-be Mark was actively participating in all the shower activities, and the mood was convivial and celebratory, with Callie’s joy being over the top. Seeing this shower was all the reminder infertile viewers needed to know why avoiding showers becomes a high priority the longer it takes to become pregnant. It also was a reminder that no one celebrating at a baby shower has any appreciation for the mixed emotions and depression that some participants will feel, especially if they are being private about their own infertility. • Immediately after the baby shower, Callie and Arizona decide to take a weekend away from the pressures of the hospital (and, for Arizona, from the smothering presence of Mark Sloan). While driving the car, Arizona proposes marriage to Callie, and the resulting discussion causes Arizona, who is driving, to take her eyes off the road. A serious accident results in Callie’s having life threatening injuries, in Arizona (not seriously injured) and Mark arguing about whether Callie’s life or the life of her baby should be given priority, and ends with Mark telling Arizona that, legally, she has no say in that decision. As father of Callie’s baby, he positions himself to be in charge of deciding what Callie would have wanted. All right, so this episode is unbelievably complicated (and made moreso because much of the dialogue is in song, a bit distracting to say the least!). But the take away message comes through loud and clear – that babies are precious, that high emotions cause huge friction, even with everyone professing to have Callie’s best interests at heart, and that the threat of a pregnancy loss is not something one ever anticipates in the glow of a joyful pregnancy. As is typical in TVland, peace is made (Arizona, a gifted pediatrician, cares skillfully for the one pound, one ounce baby; Mark apologizes to Arizona for his cutting words), and we are left waiting for the next episode to see how Callie and baby survive. • The last scene is of Meredith collapsing tearfully in Derek’s arms, protesting the unfairness of it all: Callie’s serious injuries, the baby’s prematurity, and the worry about brain damage for both, balanced against Meredith’s long infertility history of basal body thermometers, ovulation kits, post coital positions, hormone shots and the despair that she will never be a mother. In spite of Derek’s comforting her that they will find a way to become parents, any woman or man experiencing infertility knows this despair, which is highlighted whenever a joyful pregnancy is celebrated on behalf of friends and relatives. So, stay tuned to Grey’s Anatomy if any of these issues resonate with you. And keep an eye on the TV show that follows on ABC, Private Practice, where one of the female characters is deciding that she wants to try for a pregnancy, but her male partner does not share her hopeful enthusiasm. That, too, is all too familiar a dimension of many relationships when the biological clock begins to tick all-too-loudly…

Infertility: Do You Wear A Scarlet Letter?

2011-03-27T08:24:00.000-07:00

We may remember Hester Prynne whose scarlet “A,” sewn to the front of her dress, branded her as an adulteress. But, for those of us with infertility, the letter “I” can be a prominent symbol in our lives, sometime public sometimes not. And we have some choices about how to “wear” that symbol.

When it’s public, here’s what you find. The first sentence out of a friend’s mouth is an expectant “Any news?” The next sentence could be about anything from a friend’s just-announced pregnancy to an invitation to go shopping at the mall, which you’ve been avoiding like the plague, given the number of pregnant women and new mothers pushing strollers who seem to fill every mall in your life. And then, there are inquiries from mothers and mothers-in-law, too embarrassed to speak to your partner directly, but eager for you to know it’s not such a good thing if he’s still wearing jockey underwear or taking long bicycle rides or balancing his warm laptop on his lap. And, then there’s always the awkward pause as you enter a room of chatting friends or co-workers when, out of sensitivity, everyone pauses and hastily changes the subject from babies to something more neutral. And, still more awkwardly, may be your reaction as less sensitive friends or co-workers circulate photos of their sonograms, their newborns or their thriving infants. And, of course, the supreme indignity comes when you receive an invitation to a baby shower and you have to figure out how to respond, convinced that you’re probably the only one reading this invitation with anguish rather than anticipation. Of course you wonder whether it even was worth it to go public with news (limited as it may be) of your infertility. Some friends are super-sensitive, whereas others seem clueless.

And if the scarlet “I” is well hidden, what does this mean for you? Well, like Hester Prynne, knowing that you are different in some symbolic reproductive way may make you feel very alone. It also can raise issues of shame, since you may believe your friends/relatives/acquaintances/co-workers will think less of you if you are not successful in reaching your goal of parenthood. Or you may want to share your situation with others, but your partner isn’t ready for either of you to go public, probably out of those very feelings of shame that can lurk so deceivingly in the background. The hidden “I” forces you to put on a good face when your heart is breaking, especially in the presence of babies and pregnant or nursing women. It may make you question what is wrong with you, now that you are having such awful feelings about these women who are, after all, just doing their best at what you can’t yet experience. Hiding your infertility from others puts you and your partner in the unique roles of being each other’s sole emotional support. In short, staying private with your infertility can feel lonely and solitary, even as it enables you to have some control in figuring out your own issues without unwelcome intrusions by others in your life.

But let’s imagine that your public or private “I” is causing you some distress. If so, there are some things to think about in the way you offer information (or not) about the impact your infertility is having on your life. Let’s first consider how you might want to re-focus a loved one’s well-meaning inquiries about your infertility. In fact, these constant inquiries may make you feel as if the only thing others perceive when they see you is your infertile self. Granted, you spend a good part of each day preoccupied with your infertility, but chances are you’d welcome an escape from this. So, one approach is to give a very brief “infertility response,” followed by a change of subject and an effort to inquire about your friend’s or loved one’s life. Or you could be more direct, by saying something like, “You know, I really appreciate your concern with my infertility treatment, and I’ll be glad to let you know whenever there’s any news. But I also really enjoy it when our time together can be a distraction from my infertility. So I’d love it if we could talk about things that have nothing to do with my reproductive health: current events, girl gossip, work challenges, new movies……That would help me stay in touch with stuff that was important in my life before it got hijacked by not being able to get pregnant.”

There’s another issue in the lives of those of us who have loved ones who constantly express their concern about us. We begin to feel somehow less capable, more vulnerable and, perhaps, less balanced in our relationship with others. After all, they are constantly extending their emotional support in our direction, but we don’t feel as if there is much of an opportunity to reciprocate. How can we, if the major focus of conversation is on us and how we’re coping? So, again, it’s up to us to shift the conversation. Perhaps beginning with “Gee, thanks for asking, but nothing much has changed. How about you? We’ve been so focused on me recently that I really miss feeling caught up on your life. What’s going on?” Or, if you want to be more direct, you could say something like “Susan, you have been such a dear all these months to care about my efforts to get pregnant. But, as I think about it, what I really treasure about our friendship has always been the give-and-take, and the support we both can offer to each other. I feel like I’ve been more on the receiving end lately, which doesn’t give me an opportunity to feel as connected as usual with what’s happening in your life. Can you help me by trusting that I’ll let you know when I need your support, and in the mean time we’ll try to get back to a different balance in our friendship? “ Those strategies can convey your appreciation to others, as well as a wish to refocus your energies back to a more reciprocal relationship. And, while you’re at it, another thing to consider might be to indulge in a new hobby, join a class or a book club, try out some new recipes to share, find some new hiking spots, or in other ways broaden yourself so that you can initiate conversations about things in your life, beyond your infertility, that friends can find interesting.

Now, for those of you who have been guarding your privacy so you can avoid the one-sidedness in relationships I’ve just addressed, does it really seem so difficult to redirect friends away from your infertility when you don’t want the conversation to go there? I have a healthy respect for the need for privacy but, as I say in my new book When You’re Not Expecting, it is a heavy burden for a couple to bear when the two of you have decided to keep your infertility to yourselves.

Other readers who may be reluctant to share news of their efforts to become pregnant include same sex couples and single women, who may anticipate disapproval of their decision to bring a child into this world. However, here, too, there are choices you can make about which friends and loved ones to tell. Keeping silent about your hopes for a pregnancy can sometimes simply reinforce your feelings of being unconventional or different in a society that expects heterosexual married couples to have children and excludes others who cherish the hopes of parenthood.

So, cast off whatever remnants of the scarlet “I” that may have clung to your identity! There are many ways to live with your infertility that need not include being out of balance in your relationships. And, actually, it is those relationships that may be the foundation of strength that help support you emotionally through the especially tough times when you welcome a shoulder to lean on.

"Hey, Remember Me?" Getting Your Partner's Attention

2011-03-20T18:23:00.000-07:00

Whether it is our hectic lives, a conflict in schedules, diverging interests or more serious disruptions in our lives, it can be distressing to feel disconnected with our partner. We began our relationship hoping for a partner who would be “there” for us, who would anticipate our needs, and who would be responsive to our efforts to connect. We are especially sensitive to those feelings of emotional disconnect during unanticipated personal crises, such as infertility or cancer, which may render us unable to cope and reluctant to confide in others. What do we make of it when those connections with our partner feel frayed?

Perhaps the first thing is to see whether the two of you can have a conversation about your perception, to see whether your partner feels at all as you do. If so, then ask whether you can both find a time to talk more about what changes you would like to see in your relationship. If not, you should still propose that you find some time to talk, but be prepared to be the one taking the lead. And in either case, there are a few areas to acknowledge as potentially sensitive:
You do not want to convey to your partner a sense of blame for the distance that you perceive has been growing between you. Instead, you want to enlist creativity and cooperation to draw you closer together.
You do not want to come across as being a nag. “You never…” or “You always…” or “Why don’t you ever…” are key phrases to avoid.
It is possible that the two of you actually have different needs for emotional closeness. So at the very time you are feeling left out, your partner may be feeling as if the closeness/distance balance is just right.

So, starting at the beginning, you already are moving in the right direction if you and your partner agree on making some time to talk about the emotional disconnect that at least one of you is feeling. A caution here: it’s best to have this discussion in a private, neutral space (not the bedroom, not the table/countertop where you eat your meals, not in a place with distractions like riding in the car, and not a place that is physically uncomfortable or where you cannot easily make eye contact). Turn off all ringing, buzzing objects/alarms, so the message you give to each other is that each of you is the other’s priority.

Once the time and place have been set aside, since you’ve taken the initiative, you’ll want to explain why. How about finding an upbeat way to begin? “I’ve begun to realize that I miss the times when we had more chances just to relax and talk/ problem-solve/snuggle/hike/have a candlelight dinner/ be intimate together” would be one way to open the conversation, followed by something like “Do you ever feel this way?”

If your partner agrees, then you both can begin to explore what you would like to do to create more time together. And you’ll also need to figure out what are the factors that have contributed to the emotional disconnect you’ve been feeling. Those factors may be real life issues, like high maintenance family members/friends/co-workers/bosses/or even pets! Other factors may be physical exhaustion, illness, emotional distractions, job or school obligations, work-related travel, or any number of things that have crept unnoticed into your lives. So the combination of a mutual wish to recapture calm time together, paired with a recognition of the factors you think get in your way, should set the stage for a productive discussion on what both of you can do to set the stage for more attention to each other.

But what if your partner doesn’t perceive the emotional disconnect that has been worrying you? You still are entitled to your feelings, but understanding where your partner is coming from becomes especially important. Is it that your partner may be worried that there will be an expectation that some favorite activities will be sacrificed? Perhaps that you may want some changes that would be unwelcome? Maybe that your partner has a real commitment to some of the high maintenance people in your lives and is apprehensive you may demand equal time? As you can imagine, it’s really important to ask your partner’s help in understanding why only one of you is feeling this emotional distance. Here your partner may actually be relieved if you offer your perspective first, which may turn out to be not nearly as difficult to address as your partner initially anticipated.
So if you begin by offering that you find yourself missing the times when you had more time to spend together, and that you want to nurture that closeness and not take your relationship for granted, your partner will hopefully take that as a positive message and not a competitive one. Then, in the spirit of enlisting your partner’s participation, you might ask “I wonder what we could do to recapture some of the special times together that we used to enjoy so much?” Hopefully both of you could begin to explore together your ideas, acknowledging the inevitable demands that have interrupted efforts to spend time together. Trying to figure out how you both can shuffle/reschedule/ re-prioritize those demands will be important. You may need to call on others to help create the space you need for yourselves: parents, siblings, best friends, a religious leader or a counselor all could be resources to consider.

Realistically, we also must consider the possibility that your efforts to re-engage emotionally with your partner may be met with denial, side-steps, avoidance or disregard for your feelings. If you genuinely have avoided blaming or nagging, then your partner’s lack of responsiveness is a serious signal that you are not going to be met half way. This would be a time to encourage your partner to come with you to a marriage counselor to sort out your different perspectives on your relationship. And if your partner is unwilling, then you should seek counseling for yourself (see some of my earlier blogs or my book When You’re Not Expecting for how to find a therapist).

Relationships are sensitive territory, often changing and often needing ongoing attention. And, since the need for attention to the relationship may coincide with life changes, personal crises, family losses or other emotion laden events, you and your partner can potentially benefit if you develop a style of connecting that is open and responsive even in trying times. So if you begin by using your current perception of wanting to nourish your relationship, hopefully both of you will develop and nurture ways of staying emotionally resilient and connected for many years to come.

In-law relationships when you're trying to get pregnant

2011-03-11T08:26:00.000-08:00

In-laws can be in something of a precarious relationship with the couple who is trying to get pregnant. Undoubtedly there will be boundary issues, privacy issues, and life transition issues. Couples may find they can communicate fairly comfortably with their own parents, but this communication can become decidedly more awkward when it is with parents-in-law. What sensitivities will help in-laws from both generations to be more supportive of each other as a pregnancy is being anticipated?

Research shows that boundary issues are present in most families, and that the boundaries shift over time, are heightened at times of crisis, and are made more awkward by lack of familiarity. So, the family who raised you observed its own “rules” for who was considered to be in what roles in the family. These boundaries shifted over time, but you were probably able to keep track of how your family handled emotional closeness, obligations, power, and changes in roles. Likewise, your partner has had the same familiarity with boundary issues in the family that raised him or her. So where’s the problem? Maybe not at all, if the two of you were raised in families that treated family members somewhat similarly with regard to roles and boundaries. But, since most families have their quirks and unique dimensions, getting familiar with your in-laws and their family expectations can feel fairly daunting. And, if you are trying to figure out these boundaries at the very time you anticipate enlarging your own new family, the in-law issues can become pretty sensitive!

If you are a young adult in-law, privacy issues are something that you probably have been trying to figure out for as long as you have known your partner. How much do you tell? How do you handle feedback? What if the feedback is laced with guilt? Or disapproval? Or over-involvement? Or emotional distancing? Decisions about what to tell, how much to tell, and how to tell it are all related to how much privacy you and your partner feel you need. Particularly as you are trying to clarify your own boundary issues with your respective families, you may find that privacy becomes an important measure of how much your families respect you and your partner as a relatively young couple. It may not be unusual for both of you to feel ready to share some news with your own parents but, at the same time to feel reluctant to be as open with your in-laws. So just as you are both trying to figure out the nuances of your own evolving relationship, you are also faced with trying to understand how to include your in-laws in certain aspects of your lives. Privacy may mean more to you than to your partner (or vice versa), so those unique sensitivities will demand some attention as you decide how much information to confide in both parents and in-laws (and heaven forbid that either set of older in-laws should learn they are being left out of the loop!)

Life transition issues tend to be especially emotion laden. So news of your hopes for a pregnancy is not just about reproduction. It also is about anticipating grandparenthood, about family traditions, about geographical closeness/distance, about selecting names, religious rituals, finances and even health care expectations. And remember we are talking about two sets of older in-laws who may have quite distinct opinions in these areas.

And I would like to add some words here for couples who are having difficulties conceiving. If you have shared your hopes for a pregnancy and ultimately begin a medical investigation about infertility, do not be surprised if your parents and your in-laws are inquisitive to the point of being intrusive. This is especially sensitive because you are dealing with your own worries about whether parenthood will even be possible, and the older generation may be both uninformed and awkward about trying to understand what is happening in your lives. What is happening can include diagnosis (how much will you tell?), treatment (how much can you afford?), new reproductive technologies (how will news of donated eggs or sperm disrupt the older generation’s hope for a grandchild that has their genes?), and perhaps the options of adoption (again the issue of genes and family resemblances), or child-free living. Being able to confide in one’s parents can be a challenge for couples with infertility, and that challenge may be even greater with in-laws whose communication style may feel stilted or awkward.

Moving back to the original blog question: what sensitivities will help in-laws from both generations to be more supportive of each other as a pregnancy is being anticipated? An important consideration is that you and your partner need to feel respected by your in-laws. Danger signs would be any evidence of jealousy of the child-in-law, intimations that the child-in-law is not welcome in the family, or constant and unwarranted criticism of the child-in-law. These are signals for you and your partner to be clear that you love and respect one another and you will not tolerate signals by the in-laws to try to create discord between you. Another danger sign could include in-law competitiveness for the time and attention of you and your partner, with the purpose being to exclude the other set of in-laws from involvement with both of you. Here it is important for you to make your own decisions about how to divide your time and energy among various family members and to be firm with parents and in-laws that you are trying to be fair in your decisions, and to be clear that the older generation needs to respect your right to do this. So what else can you do to soothe the ruffled feathers of in-laws? You already are making a good effort when you state clearly that you love each other and expect them to respect that. In addition, there is always the strategy of staying in touch, so the in-laws don’t feel they’ve lost their child to you. Whether through phone calls, or holiday/birthday/anniversary cards and notes, in-laws will appreciate your efforts to stay connected despite busy schedules and geographical distances. And this is important before any pregnancy occurs, because if you think the in-laws are competing for your time and attention now, just wait until the little bundle of joy arrives!

So in-law sensitivity runs between both generations, and perhaps you and your partner will sense that many in-law difficulties stem from a yearning by the older generation to hold tight to their child. This may feel especially pronounced around times of family transitions. Anticipating a pregnancy is an exciting and an anxious time for couples, for parents, and for in-laws. On the one hand you will want to emphasize your own autonomy as a beginning family; on the other hand, you can anticipate that your separation from parents and in-laws is likely to trigger some possessive responses. Try to keep the lines of communication as open as possible, but be clear when you believe parents or in-laws need to back away and give you some space to establish yourselves as a young family.

The Stress of Trying to Conceive

2011-03-04T09:16:00.000-08:00

Should women with infertility just relax? Will avoiding stress increase chances of conception? A study just published online in the British Medical Journal (BMJ) concludes there is no association between high emotional stress and failure of fertility treatment. So does this mean women can stop enrolling in yoga, meditation and mindfulness workshops? In today’s blog I’ll try to sort out the mixed messages of recent research on stress and infertility treatment.

The impact of stress on conception has been under debate for a number of years. In the 60’s women were often advised to “just relax,” or to “take a second honeymoon,” which felt infuriating, especially when it moved the responsibility from the physician to the woman. Furthermore, since about half of infertility is due to a male factor, women resented being targeted as needing to monitor their stress levels. Ultimately, as physicians were able more clearly to diagnose physiological causes for a couple’s infertility, the “relax” advice diminished and assisted reproductive technologies claimed increasing credit for success rates in conception. So, even as folk wisdom may have promoted stress as a cause of infertility, physicians tended to agree that stress, when it was present, was most likely to be an effect of infertility.

So how much stress are we talking about? In the BMJ article, 30 percent of couples in their studies stopped treatment because of the psychological burden. Research also exists citing that the stress levels of infertile women are equivalent to women with cancer, AIDS, or heart disease. So there is no question stress is present in women receiving infertility treatment. But does it contribute to the failure of infertility treatment?

In one of my earlier blogs, I mention that Dr. Alice Domar has conducted research with women who are receiving treatment for female factor infertility. As an adjunct to these women’s medical treatments, Dr. Domar has offered mind-body programs and has conducted research that shows participants in such programs can have significantly higher pregnancy rates than women who receive medical treatment only.

So why would Dr. Domar’s research demonstrate that specific workshops in mind-body relaxation increase chances of conceiving, whereas the BMJ research claims that emotional stress is not associated with failed infertility treatment? Part of the answer may lie in the numbers and in participant diversity. Dr. Domar’s participants, numbering in the hundreds, were enrolled in Massachusetts workshops conducted by her and her staff. The BMJ research reviewed 14 prospective studies from 10 countries covering 3,583 women who underwent a cycle of infertility treatments. So we can presume more diversity in the BMJ international sample than the Domar Massachusetts sample. What we do not know in any of the studies is how many male partners were diagnosed with factors contributing to the couples’ infertility.

But, most significant, is how one measures stress. Dr. Domar’s participants self-defined themselves as wanting to reduce their stress while being treated for their infertility; the BMJ studies considered only those participants who rated emotional distress before treatment. In both cases, subjective self-ratings were used, without any awareness of the physiological presence of stress hormones in the bodies of the participants. In contrast, an August 2010 article in the journal Fertility and Sterility cited pregnancy results from participants whose stress hormones were measured using saliva samples. The findings in that study actually demonstrated that although the stress hormone cortisol had no adverse effect on conception, women with high concentrations of another stress hormone, alpha-amylase, were 12 percent less likely to become pregnant each month than those with the lowest levels. What that teaches us is that not all stress hormones have an effect on fertility and, most important, self-report measures of perceived stress do not enable researchers to measure with any accuracy the physiological presence of stress hormones that affect conception.

So where does that leave us? Hopefully with a healthy respect for the stress caused by infertility; perhaps with a careful eye for how a study defines stress, and ideally with an awareness that consistent collection of physiological measures of stress is more informative than self reports, which cannot easily be standardized. But we also are left with the awareness that many women would do anything to be rid of the stress that accompanies their infertility. So, whether or not stress can be credibly shown to be associated with fertility failure, women being treated for infertility should be offered every opportunity, with their partners, to participate in mind-body workshops and other forms of learned relaxation that can diminish their stress. Infertility is hard enough as we give up parts of our lives to infertility specialists. But we can rejoice (okay, okay, we can be thankful!) that stress management is something we can do for ourselves -- to feel better, to connect with our partner, and to learn skills that will build a strong foundation for facing future life challenges, whatever they may be.

Infertility: "His" and "Hers"?

2011-02-23T12:27:00.000-08:00

Much of the research on reactions of individuals to infertility divides along gender lines. Women often are portrayed as more likely than men to reach out for social support and to use certain escape or avoidance strategies (wishing, hoping, fantasizing and social avoidance). Men, on the other hand, are seen as more likely to distance themselves emotionally by focusing their attention on other issues, carefully regulating their emotions, and viewing infertility as a series of problems that need to be solved. Actually, all of these reactions are developed in an effort to protect yourselves against the emotional dangers of the infertility experience. In their own ways, both males and females are striving for feelings of mastery, as well as searching for opportunities to distract themselves from the inevitable painful realities of their infertility. So what might this mean for you in your relationship with your partner?

I would suggest that one way couples can join together more supportively is to have conversations about how infertility is affecting them, both individually and as a couple. This will prevent falling into the common trap of complaining that “H/She doesn’t understand what I’m going through!” Furthermore, as you and your partner are sharing your separate perceptions of how infertility is affecting you, each of you can use that time to express how you hope your partner could be supportive and comforting. As you have this conversation, it is important to fully concentrate on what your partner is expressing, and to ask for clarification whenever you need to. By the way, I wouldn’t overdo these conversations; once or twice a week for 30 or 40 minutes should be enough time to feel as if both of you are staying connected emotionally. And be sure not to have these conversations in the bedroom – that is a place that should be saved for sexual pleasure and sleep, not associated with sadness and problem solving.

While I’m on the subjects of sadness and problem solving, let me encourage both of you to admit together that sadness is probably an inevitable response to many aspects of infertility: unclear diagnoses, failed treatments, pregnancy losses, dwindling finances, and diminished self esteem. It is important not to discount this sadness for yourself or for your partner; rather, this is the time to ask for support and to ask your partner what you can do to offer comfort. Even though you may not share the same sadness at the same time as your partner, or even the same hopes for comfort, being able to be emotionally responsive to one another is the challenge you are both hoping to embrace. And as for problem solving, which can be initially discouraging, if you can share this time consuming and emotional load, you may find yourselves feeling even more united in your efforts to be resilient against the challenges that infertility poses in your lives. In my book When You’re Not Expecting: An Infertility Survival Guide, I offer a wide range of examples of how couples I have counseled come together emotionally to face the hurdles that infertility has thrown into their path.

Inevitably you and your partner will need to make decisions, whether about treatment options, alternative paths to parenthood, financial planning, or keeping your relationship resilient at each new stage of your infertility journey. Just as earlier you may have had different perceptions about how you responded emotionally to some of the infertility challenges you faced, here too you may find significant differences in your readiness to make decisions or in the outcomes you are valuing. And, here again is my encouragement to share your perceptions about what is important to you now, and then listen very carefully to your partner about where s/he is in being ready to contemplate some decisions. If you hit an impasse, it may be a good idea to invite a trusted third person to help both of you to sort out your differences, clarify your priorities or assess what issues are most compelling right now. What is important is that you as a couple are committed to communicating as openly as possible, to respecting each other’s right to think differently about your infertility, and to seeking resources when you feel “stuck,” either emotionally or practically.

And, remember too, that even as infertility may hover over you like an unwelcome cloud, you both need to seek respite from that cloud. So on your “to do” list, be sure to include hobbies, time with friends, weekend getaways, and other fun experiences to reinvigorate you emotionally and reinforce your commitment to being together, even through the unknowns that your future may hold.

Couples with Infertility: Nourishing Your Love

2011-02-14T11:03:00.000-08:00

Valentine's Day is a special day in the lives of most couples. But what happens after the cards have been opened, the chocolates consumed and the flowers begin to wilt? Every couple faces the challenge of how to keep that spirit of love alive after February 14, and couples with infertility experience unique challenges. Fortunately there are lots of creative ways to re-ignite and nourish those loving feelings 365 days of the year!

Let's begin with the "hectic" challenge. Everyone knows the feeling of having too many things to do and not enough time, but if grappling with infertility is one of those "things," you know the frustrations: scheduling doctors' appointments, balancing responsibilities with c0-workers, balancing the homefront responsibilities with your partner, fitting in fun with friends and enjoyable hobbies, as well as trying to think a few months ahead to see whether a vacation is going to conflict with your treatment schedule. So, with these multiple balancing acts, how do you and your partner find time to focus on your love for each other? Chances are you have fond memories of earlier times in your lives before infertility crowded your psyches and your calendars.

So, with Valentine's Day so close in your awareness, perhaps this is a good time to talk about consciously re-igniting those fond, but distant memories. If both of you share the commitment to bring back into your lives some of the kindnesses that kept your love well-nourished, then you can decide together how to do it again. Some of this will take time, like planning a trip, planting a garden, exploring nearby communities, hiking in the woods, taking a class or undertaking a new hobby. But with two of you, it will take less time, and anticipation can be half the fun! Other nourishing efforts may require conscious effort, but they take no time at all: a good morning kiss, a 15 minute walk together after work, a long hug after dinner, telling jokes or humorous anecdotes, cuddling on the couch while watching TV...the opportunities are only limited by your imaginations!

And while we're on the subject of "hectic," and hugs and kisses, did I mention sex? You know, not the preoccupation-with-babymaking sex, but rather the steamy, spontaneous, joyful sex that was so much a part of your pre-infertility days. I know that once sex becomes associated with conceiving, spontaneity can go down the tubes. And even if you know the only way a pregnancy will occur for you is through medical technology, the tension of infertility can take its toll on your libido. But if you once shared a passion for sex, there are all sorts of ways you can bring this passion back into your lives once you decide to talk about it.

So here are some things that can be a part of that conversation. If you find yourselves too exhausted at bedtime to do more than fall into bed, then you need to find other times of the day when your energy level lends itself to making love. How about a small snack before dinner, topped off with some fun in the bedroom? Or how about having dinner wearing some skimpy undergarments, and leaving the dishes to soak in the sink while you enjoy some after-dinner lovemaking? Or how about going to bed an hour early a couple of times a week, so you can kindle some of the romance with the help of low lights and music? You can use your imaginations to add to my suggestions, once you agree that re-igniting your passion is something you want to try. And each of you can make the effort to initiate your lovemaking in creative ways, so that it is both fun and surprising.

And, in spite of my examples, don't restrict yourself to the bedroom! Creativity may take you to other parts of your living quarters, just for the fun it it! But if you DO plan to enjoy yourselves in the bedroom, please keep in mind some important reminders. Lovemakling in the bedroom is greatly enhanced if you save the bedroom for sleep and for sex. No computers, no food, no TV, no talk about infertility, no reminders of anything except the passion and the relaxation that help to re-charge your relationship.

And, although I seem to be waxing and waning on the topic of re-igniting your sexual passions, let me also say that I fully understand many couples grappling with infertility find themselves shying away from intercourse. That may be because for so long intercourse has been associated with babymaking, rather than with passion. Or it may be that incidents of producing semen samples on demand have interfered with feeling aroused on other occasions. So the take-away message is that passion and love can be expressed in many ways, and intercourse does not need to be an outcome (except, of course, when ovulation is occurring!). So you and your partner should feel fully creative in the ways you express your love as well as your passion, with the emphasis being on mutual pleasure rather than intercourse or even orgasm.

As Valentine's Day, 2011 recedes in our memories, I hope that some of the ideas in this blog will stimulate you and your partner to nourish your love together in as many ways as you can imagine!

Infertility and Stress: Could Yoga be the Answer?

2011-02-07T10:39:00.000-08:00

Yoga is enjoying a broader audience as "yoga for fertility" classes are appearing in various metropolitan areas. Described by some as a support group in motion, these yoga classes draw together women who hope to learn skills that will take their minds off the tension of infertility and reduce their anxiety. In addition, these classes provide the added opportunity to share confidences informally with their yoga-mates. But does yoga increase pregnancy rates in infertile women?

An article in the February 6th Sunday Styles section of the New York Times provides some useful information about these classes, which are called the latest in a succession of holistic approaches to fertility treatment, including acupuncture, mind-body programs, massage, and Chinese herbs. In that list, only mind-body programs have generated research data demonstrating effectiveness. No one leading yoga classes makes claims about increasing conception rates. So what draws women to these classes?

It seems to be several things: The opportunity to learn relaxation skills is a relief for many women who carry a load of anxiety over the uncertainty of whether they will ever become parents. For women who have been reluctant to confide in others, the yoga classes provide a natural gathering where infertility is the common bond in a group whose members fully empathize with each other. And for those women whose doctors have told them to avoid strenuous exercise, especially while they are taking drugs that stimulate their ovaries, yoga enables them to feel that they still can stay lithe and limber.

So, even though there's no evidence to show that yoga classes for infertile women increase rates of conception, there are other rewards that may be highly appealing. Unlike formal support groups, the yoga focus is not on group discussion of infertility issues. Instead, all participants can come together for yoga, share (or not) whatever infertility information feels relevant that day, take away coping strategies learned from their classmates, and feel physically reinvigorated. For many, yoga helps to quiet the infertility chatter in their brains, diminishing the negative messages in this chatter that fuel their feelings of being desperate or hopeless. By learning yoga poses, women force themselves to concentrate and to put their minds and bodies in a good place. And being in the company of others who share the unique condition of infertility, women can develop empathic bonds in what can be a lonely journey.

Dr. Alice Domar, one of the first researchers to advocate stress reduction in infertility treatment, has conducted much of the research demonstrating that mind-body programs can be an important and successful adjunct to medical treatment for infertility. Whether through meditation, deep breathing exercises, bodily relaxation, visualization or other strategies, it appears that de-stressing is therapeutic on many levels for women with infertility. So perhaps the take away message is: even if yoga has not been found to increase conception, are there aspects of a yoga fertility class that might work for you? Might you make new friends? Learn new coping strategies? Quiet your negative brain chatter? Find ways to tone your body when your doctor discourages vigorous exercise? Distract yourself from your infertility preoccupations?

Only you can decide whether this new "resource" for infertile women is something to investigate. But if you're intrigued, give it a try!

Infertility: How to find a good psychotherapist

2011-01-27T11:36:00.000-08:00

The decision to begin therapy usually has a backdrop that can include stress, unhappiness, unfilled hopes and interpersonal difficulties. If infertility is at the source of the stress, there may be additional components: fertile friends and siblings; juggling employment and treatment; monthly feelings of failure; difficulty communicating (verbally and sexually) with your partner and, perhaps, the experience of mourning one or more pregnancy losses. Finding a therapist who can be helpful along all of these dimensions can feel like a huge challenge. So, in the spirit of good problem-solving, let's see how we can approach this creatively.

I am writing this particular blog now, because in my December 31st blog heralding the beginning of the new year I cautioned all readers to take care of themselves emotionally. For some this will mean gathering comfort from friends and family, and for others it could mean seeking a therapist who can help you feel empowered by sorting through the various components of your emotional distress. In my recent book When You're Not Expecting, I devote an entire chapter ("Another Shoulder to Lean On") to finding emotional sources of support. Today's blog will focus on finding a therapist.

If you are beginning this search already in the throes of emotional misery, be aware that you may need to expect some delays as you identify a therapist who feels like a good choice. The therapist may have a waiting list, may not be covered by your insurance, may have a schedule that conflicts with yours, or may have an office that requires more travel than is ideal. So let's begin with how you can initiate your search.

Most of my clients and infertile acquaintances have found that word-of-mouth in their own community often serves them very well. Good therapists acquire good reputations for all the right reasons, and your initial inquiry should include whether or not the recommended therapist has experience counseling infertile clients. Someone with this background is ideal, since s/he will probably be familiar with treatments, side effects, parenting options and resources, and will save you the time of explaining your infertility issues in much detail. If you are currently being seen at an infertility clinic, be sure to ask whether the clinic employs a mental health professional for its patients. But if infertility is not a familiar issue for a recommended therapist in your community, don't despair. Here are some of the most important areas of expertise for a therapist: couple communication, grief counseling, family dynamics, depression and decision-making. Those areas are ones in which many couples with infertility need help, and along the way you can educate the therapist about the particular aspects of your infertility that are important.

So let's imagine that trusted friends, infertile acquaintances and family have not come through for you with names of therapists to consider. Some other resources could include your county Mental Health Association, the social worker at your local hospital, a local RESOLVE representative, your ob-gyn, a mental health specialist at a nearby fertility clinic or your religious leader. You also can contact RESOLVE (the national infertility association) at http://www.resolve.org/ for names of therapists and leaders of support groups in your area. You are likely to be given names of social workers, psychologists, pastoral counselors and marriage and family therapists from these resources.

Once you have several names, it will be up to you to contact the therapist and ask for an appointment. What barriers might you encounter? You should expect the therapist to ask that you and your partner both attend the first meeting, so be sure to have two datebooks in front of you when you have this first conversation. You will be asked to describe your situation briefly, so be prepared to do this, and to ask the therapist whether s/he works with clients using the areas of expertise I mentioned above. If your prospective therapist has a full caseload of clients and offers to put you on a waiting list, you should ask how long it is likely to be before you could be seen (or, better yet, ask whether you could be fit in for an introductory appointment so you at least can determine whether you feel comfortable in conversations with this particular therapist). If the wait seems too long, or if a visit reveals that the chemistry is just not right, ask the therapist to suggest names of other therapists in the community. This process can take a while, but it is time well spent.

Another potential barrier is insurance coverage for the therapist's services. Find out in your initial telephone conversation with your own health insurance carrier what therapists are covered, and begin by contacting them. But if you find, for whatever reasons, that insurance is a problem, you have several options. One option is to ask to be seen by a therapist at your local mental health clinic or at your local family counseling agency (both may have sliding fee scales). Some therapists in private practice also have sliding fee scales. Another option is to look carefully at your savings and decide whether you can afford to pay out of pocket for these expenses. A last option is to seek a financial gift or an interest free loan from loving family members.

In terms of therapists whose schedules are a challenge or whose offices are difficult to reach, those issues are likely to be ones where you will need to adjust your life once you have decided that seeking therapy is an important priority. You can request a more convenient time if one becomes available, but the inconvenience of distance is a challenge. Occasionally a therapist might be open to a Skype session or a conference telephone call, but this is likely to be the exception rather than the rule.

So, the take-away message of this blog is that finding a therapist can take time and energy, but there are very clear pathways to follow in this quest for emotional support. And with this emotional support, hopefully you and your partner will feel increasingly energized and resilient as you face together the months ahead.

Sharing infertility news: How to reach some decisions with your partner.

2011-01-19T08:30:00.000-08:00

From the moment you suspect the word infertility could apply to you, there is an emotional pause as you struggle with how open you will be with your apprehensions. As months pass, as diagnostic tests or pregnancy losses increase your anxiety, the questions still loom: whether or how to take others into your confidence on this very personal matter.

So what are the questions you and your partner will need to consider? Together you have undoubtedly spent hours discussing how both of you are viewing the news you are receiving from medical professionals, from your own collection of information, and possibly from local infertility support group members. But the big question you both need to be clear on is how open to be about your news and with whom. Each of you needs to be respectful of the other's wish for privacy, which initially may include no sharing of any news, and eventually is likely to include what news is acceptable to share. As you discuss this issue with your partner, you will want to focus on why it would be helpful to you if both of you could consider a certain perspective, and why you, in particular are, feeling a strong need to move forward in a new direction. This puts the positive framework of "problem solving" on the discussion, rather than the more negative dimensions of power struggles or selfishness.

So here are some considerations for both of you. Chances are that once a piece of information is shared, it will be shared broadly, even if you have asked your confidante to keep it private. This happens in several ways. Your confidante, with all sincere wishes for your emotional welfare, may want to create a small group of supportive others, alerting them perhaps to only a small piece of the information you have shared, and in the process arousing further curiosity ("I don't think it's just PMS that makes Janet so upset every time she gets her period."). Another possibility is that your confidante may feel somewhat overwhelmed to have learned the information you have shared, and may feel the need for help with the anxiety the news creates ("I'm feeling so helpless since Suzanne told me she is being tested for infertility -- I wish there were some way I could help her."). And then, there's always the possibility that your confidente is a bit of a gossip girl and thinks she will become the center of attention as she shares even a small bit of your news ("I never imagined that infertility is what is making Katie so edgy these days -- what? you didn't know? well, here's what she told me....") So whether it is concern for your welfare or a disregard for your request for privacy, the news will pass among friends and family members once you have begun to share it, no matter with what expectations of discretion you may have.

That brings us to the next question of how you and your partner can come to agreement on what to share, now that you know the word ultimately will circulate to a circle of family and friends. You might begin by asking yourselves what are your own issues of privacy. Is there some stigma associated with thinking of yourselves as infertile? Are you concerned that curious loved ones will pry further to learn more information than you want to divulge? Do you want to avoid well-meaning advice from folks who are not knowledgeable about the medical aspects of your infertility?

Whatever your issues of privacy may be, you both can probably find ways to deflect inappropriate remarks or to correct misinformation. What may require further effort on your parts is the question of stigma. These days, with infertility being so much in the news, affecting so many well-known celebrities, and being heralded for medical breakthroughs, stigma has much less power than in the late 1900's. So rather than focusing on stigma, you both could consider discussing how you think others may view you differently if they hear your news -- chances are you'll arrive at the conclusion that others will be concerned about how they can help, will share information about acquaintances in their lives who have grapplied with infertility or pregnancy loss, and will want to have some sense about how much you want to talk further about your infertility.

So one major effort you and your partner need to make is how you want to present your news so that you'll minimize intrusive behavior of others while creating compassion for the challenging times ahead for both of you. You'll probably want to decide how much initial news to share and, as you offer medical information, you'll probably also want to offer suggestions for how others can help. This can range from "I'll appreciate some extra thoughtfulness if I tell you I've just gotten my period" to "feel free to ask us about how things are going, and if we don't mention our infertility, then it means either there's nothing new to report or we're not in the mood to discuss it right then." This leaves open the door for ongoing conversations at whatever time those offers would meet your needs.

The topic of sharing infertility information is multi-faceted, and in today's blog I have tried to address some of the most challenging aspects. In my recent book When You're Not Expecting, I devote a fair amount of attention to the issue of how/when/whether to share, and there is a reason for this. The burden of infertility easily can become too heavy for a couple to keep to themselves. It crowds your conversations, it intrudes constantly, it makes you feel "stuck," and it can make you feel emotionally isolated and barricaded. Being able to share information can create a sense of broad support, concern and compassion (okay, so it also can create some unwanted intrusions, but that goes with the territory of having people concerned about you). So I hope this blog will help you and your partner to open discussions about how to begin (or continue) sharing infertility information in a way that generates the emotional support that is so important as you face the ongoing challenges of infertility and pregnancy loss.

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

2010-12-31T08:12:00.000-08:00

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"

2010-12-15T11:40:00.000-08:00

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

2010-12-03T13:04:00.000-08:00

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

2010-11-10T13:07:00.000-08:00

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?

2010-10-29T08:15:00.000-07:00

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?

2010-10-22T09:02:00.000-07:00

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!

2010-10-13T13:11:00.000-07:00

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!

2010-10-05T12:03:00.000-07:00

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

2010-09-27T12:25:00.000-07:00

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

2010-09-17T08:07:00.000-07:00

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?

2010-09-08T11:48:00.000-07:00

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!

2010-09-03T09:46:00.000-07:00

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

2010-08-27T12:36:00.000-07:00

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

2010-08-20T08:37:00.000-07:00

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?

2010-07-16T09:21:00.000-07:00

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?"

2010-07-06T11:02:00.000-07:00

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?

2010-07-01T08:46:00.000-07:00

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

2010-06-23T07:55:00.000-07:00

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

2010-06-16T12:09:00.000-07:00

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.

Infertility Counseling: Getting the most out of therapy

2010-06-09T08:22:00.000-07:00

If you never have been in therapy before, or if you are beginning a relationship with a new therapist, or if earlier counseling experiences have had nothing to do with your infertility, you probably are feeling perched on the brink of a new opportunity and a new challenge. Undoubtedly you already are receiving either a diagnostic workup or medical treatment for your infertility, and your decision to seek counseling is an important step in handling the many emotions that emerge in this process. So, now that you and your counselor are beginning your relationship, how can you get the most out of the therapeutic experience?

Most therapists will initially ask you to be clear about what you hope to gain from therapy. I'm going to make the assumption that you and your partner are going to the first session together, so both of you will need to think about how you would answer this question. It is not unusual for partners to have different perspectives on the challenges posed by infertility (see my video at www.connieshapiro.com/ ), so you both should feel free to speak for yourselves. Also, if some issues are more compelling than others, or if you have tried and not succeeded to make desired changes in your lives, it is good to provide that information as well.

In addition to answering questions posed by your counselor (who, for the sake of pronoun simplicity, I will assume is female), you should feel free to ask her to talk about how she sees her role as a therapist, what expectations she will have of you as clients, how she guides the counseling process with her clients, and how you and she will know whether you have accomplished as much as possible in your relationship with her. You should be listening for how open she is to your input, how she formulates goals for the counseling experience, how familiar she is with infertility, particularly issues of loss and communication difficulties, and how she evaluates whether she is being helpful in moving you toward the changes you hope to accomplish.

For you and your partner, both of you should be prepared to view therapy as work: on your relationship, on your relationships with others in your lives, on your communication skills, on your willingness to strive for insight, and on your openness to considering new options in making decisions about your future. As I have mentioned in an earlier blog, I tend to give homework assignments, and if your therapist follows this practice, it is helpful to be conscientious about the therapeutic learning that takes place both outside and inside the therapist's office. You might think of it as having ongoing practice with new skills or discussing new perspectives, which you then can review with your therapist in your regular appointments.

From this perspective, you can see that I tend to favor a therapeutic perspective that helps you to feel empowered, both in new skills you acquire and in new ways of considering how you will handle the stress and the decisions imposed by your infertility experience. This is not the only therapeutic perspective, and it may not be the most productive one for every client. So the important thing for you and your partner is to assess how you feel about your therapist's way of viewing her relationship with you, her willingness to accept your input and your questions, and her willingness to challenge you to think in new ways about painful issues. Therapy is not a full-time "feel good" experience, but it should be a relationship in which you feel both trust and confidence that your counselor has her finger on your emotional pulse and is keeping pace with your readiness to move forward.

With your infertility physician, there should be times when you pause to assess where you are and what's next. The same is true in therapy. I use every 6-8 weeks as my "pausing point" with clients, partly to check out how they are feeling about the changes we are working on, partly to give them my feedback on their new skills and the work that lies ahead, and certainly to see whether they are satisfied with the direction and the pace at which I'm encouraging them to move. I always welcome critical feedback or discussion of therapeutic frustrations at any point during therapy, but I also am a big believer that a regular pausing point helps my clients and me to be attentive to both progress and pace.

Let me spend some time now on ending the counseling relationship. Ideally this decision is a mutual one, perhaps growing out of a conversaton at one of your pausing points. In the best of circumstances it will be an outgrowth of achieving the goals you set in the course of therapy or, even more hopefully, your success in becoming pregnant (although I confess that most of my client couples have found pregnancy to have its own stresses, so many of my clients continue on a reduced schedule until they have celebrated a healthy birth). In less favorable circumstances you may find that you are dissatisfied with your therapist, efforts to address those dissatisfactions have not yielded changes, and you decide to end the relationship. Then the question becomes whether you believe that it would be constructive to identify a new therapist, in which case you hopefully will have a more successful experience. But if you are ending therapy on a successful note, feel free to raise with your therapist that, if new concerns arise, or if you find yourself needing a "booster" session, you hope that you and she could reconnect to assess next steps.

So, in the spirit of "getting the most out of therapy," I hope my perspective is helpful in your anticipating how you might begin your therapeutic relationship, as well as how to provide input as the relationship progresses.
Infertility is not a smooth road to travel, but the support and skills of a good therapist can help you feel empowered as you face emotional challenges.

Infertility Counseling: What to Expect

2010-06-01T09:06:00.000-07:00

Individuals and couples with infertility often contemplate whether to seek counseling. Some approach this decision with ease, but many others have questions about what is involved in a counseling relationship. In today's blog, I will offer an inside view on the beliefs that have guided my counseling experiences with hundreds of infertile clients.

So when I entitle this blog as "what to expect," I probably should have added "if you seek counseling from me." Since I can only speak for myself, I hope you will gain some familiarity about general principles that guide counselors and therapists (I use these terms interchangeably), as well as questions that you can ask your own counselor in order to clarify your understanding of that person's perspective on your relationship.

In my own experience, my first contact with a client usually is in a telephone conversation. On the telephone I try to learn how the prospective client (almost always a woman) defines the problem(s) she wants to work on; what her partner's feelings are about being involved in counseling; whether she or her partner has ever been involved in counseling before; at what stage of diagnosis/treatment they are; and where they are currently getting medical intervention. I then offer a bit of information about myself, including possible appointment times that I have available; fees and insurance coverage information; my office location; as well as the request that both the caller and her partner come together for this first appointment. I also ask whether she has any questions that she would like to ask me before we meet. Then we set a date and time for the appointment, and I provide directions to my office.

In a while you'll learn enough about my approach to understand why I ask for both partners to come to the first meeting with me; if the woman is not in a relationship, I tell her that I will be interested in learning about her support network. So here are some things that are typical of my first meeting with my new clients. It is not unusual for the person with whom I have spoken on the telephone to take the lead in introducing me to her partner and in saying something along the lines of "I think I'm going crazy!" or "I don't know how much more stress I can take." And my response to that introduction is usually to point to my nearby box of tissues and to say that being upset comes with the territory of infertility. I also try to work in something about the courage it takes to begin a relationship with a counselor, since getting help will involve talking about difficult issues.

I ask both of them if they are comfortable with my taking notes as we speak, since I want to be sure to remember accurately how they portray their situations. And then I say that in my experience, each of them may have their own unique "take" on their infertility, so I will be encouraging both of them to clarify for me the dimensions of this experience that are important to them. This also opens the door for them to see each other's perspective and to learn how important it may be to keep both perspectives on the table. It is here that I say to the partner of the telephone caller how much I appreciate his/her coming to this meeting, and how much I believe that person's presence can help all of us to move forward in working on the issues connected with their infertility.

I also clarify briefly the two important issues associated with confidentiality: first, that if either of them communicates something to me when the other person is not present, I will keep that information confidential until it is revealed between the partners in a meeting with me, and, second, that I observe confidentiality unless circumstances occur when I believe there is the likelihood of a client causing harm or danger to oneself or someone else. Lastly, I say that, although it has never happened in all my years of practice, if I am subpoenaed to appear in court, I might need to reveal information that had been shared with me in counseling.

With those introductory remarks, I remind all of us that we have work to do, that our session will end in "X" minutes (I meet with clients for 50 minute sessions), and I encourage them to tell me how they hope I can be of help. I am careful to have both members of the couple speak about their own perspectives and to summarize my impressions of what seem to be the most pressing issues. I am interested in knowing how the couple has already tried to address their challenges and what successes and difficulties they have encountered. That will more than fill up the first session, and probably will spill over into subsequent sessions as well. Before ending, I ask the couple how they are feeling about the time we spent together today, whether they would like to return and, if so, whether this is a good time for regular future appointments, and whether I can look forward to having both of them at subsequent sessions. I tell them that after a few sessions I should be able to give them some idea of how many meetings we may need in order to address their concerns, and I express my appreciation for their openness in sharing with me today the challenges they are facing. I ask if they have any questions for me, which I try to answer as succinctly as I can. I then give them a homework assignment: for each to draw for our next session a sketch of their sources of support and their sources of stress (I mention family, co-workers, neighbors, friends, spiritual leaders and health care providers as potential people who may appear in their sketches).

Now for some reflections about why I do what I do in the first session. I very much hope that both members of the couple will come to each session, since they can be most constructive in addressing concerns if they each verbalize them and if they each practice the skills that I will encourage them to develop. So I am not shy about emphasizing to both that their presence together is a big help to me. I want to hear the initial information from each of them about how they see their concerns, both so I will understand where each one is coming from, and so they will be able to hear the perspectives that each of them presents. I want to reflect back to them my understanding of their issues, so they can correct any misperceptions. I want to convey that infertility can be filled with difficulties, as they well know, and that they probably have an idea of what has and has not worked in coping with their difficulties. And, in giving a homework assignment, I want to convey that getting help is not just a 50 minute session once a week, but that they need to take away from these sessions new perspectives and return to each forthcoming session prepared to build on the new learning thay have developed. Lastly, many clients are concerned that they may be in counseling "forever." I want in the first session to convey that we can decide together how long to continue to meet and what problems we will discuss, thereby conveying that this is a partnership. Typically I am able to make substantial progress on most of the most troublesome problems over 9-12 sessions. If the clients choose, they can introduce additional concerns (or perhaps their infertility will present unforeseen issues such as pregnancy loss, an unanticipated diagnosis, etc.), and they may choose to embark on additional sessions to deal with these new issues.

Now let me look ahead broadly to how I think about subsequent sessions. In my experience, I tend to think of these sessions in terms of content and process. Content, which is presented by my clients, tends to be dominated by issues of loss and issues of communication. In my new book When You're Not Expecting, I write extensively about both of these, including the ways that they tend to change over the course of a couple's infertility. Process, which tends to focus on interactions, may consist of my asking the couple to discuss a difficult issue, with me ultimately giving them feedback on my observations and some clear feedback on how they can build better communication skills into their repertoire. Then I send them home with homework that will enable them to practice these new skills and report back to me the following week how they were feeling about using these skills. Learning skills in assertive communication can come in handy as well, particularly with health care providers and well-meaning loved ones. A third topic, "resources," tends to weave in and out of discussions, depending on what the couple may have presented on their initial sketches to me regarding their sources of support.

From time to time I ask both clients to revise their sketches of sources of support and stress, so they can see how their communication efforts have made a difference -- OR so they can see that they need to distance themselves from unrelenting sources of stress. One of my goals is to help clients perceive themselves as part of an ecological infertility map, complete with superhighways of support and detours of stress. As a family therapist, I also consider it important to understand and discuss the roles that family members are playing in my clients' lives, especially fertile siblings and eager-to-be-grandparents. The more clients understand ways they can increase their support, the more resilient they become.

I do not think of myself as a therapist who lets my clients entirely drive the counseling process. I tend to be fairly interactive in offering feedback to clients on their skills and resources. I am respectful of the social work edict "Start where the client is and stay with him/her." To me this means that I should be respectful of where my clients want to focus, but it doesn't prevent me from testing whether they are ready to be pushed to new places. If they have had an infertility intervention for months that isn't working, I am likely to push them to ask their physician to make a plan with them that includes how long to continue with one intervention before moving on to a different one. If they have spent many dollars and many years on infertility treatment, I may revisit an earlier statement that they won't consider adoption or a surrogate, by asking if they would consider collecting information about either of their previously rejected options. If I see areas of difficulty on which they have not asked for my help, I may make an observation that such-and-such an issue seems to be an "elephant in the room," and I am wondering whether there is a reason they haven't felt ready to examine it. So, even as I try to stay apace with my clients' issues, I also push and prod a bit, just to see whether new growth and resilience enables them to feel resilient enough to consider new directions. If not, I step back, and I am not surprised when, weeks later, they may raise the question of the proverbial elephant for future examination.

Before closing, I will mention two last areas that are neither process or content related. The first is that, as a social worker, I believe that it falls in my realm to teach and to provide advocacy when clients are treated poorly. Occasionally, clients will report to me behavior in an infertility setting that I consider unprofessional. Often their distress is severe enough that they are considering ending treatment with that provider. In the dozen or so cases I have encountered, I have shared with the client my perception that they are on target in objecting to unprofessional communication, and that I would be more than willing either to help them think about how to address this directly or how I might (with their permission) bring this incident to the attention of their provider. In each case, the resolution has been highly satisfactory, always resulting in an apology to my clients, and sometimes resulting also in in-service training for staff so that they understand rude or dismissive remarks will not be tolerated. The second area I will mention is that, as clients and I are preparing to end our sessions, I make clear to them my continued availability if their circumstances should bring a rise in stress or other unforeseen difficulties. Sometimes clients whom I believe are ready to end our counseling relationship will be more ready to accept that encouragement from me if I offer "booster sessions" every 6 to 8 weeks, simply to reassure them that I'm there if they run into bumps in the road.

So, for those of you who are contemplating seeking counseling for any of your infertility issues, I hope that my own disclosures about the way I think of the counseling experience will help you in your own interactions with a therapist. Keep in mind that not everyone shares my perspective that client partners are the first choice when providing counseling, nor that the families of the couple may be the "elephants in the room," nor that the therapist takes as active a role as I do, nor that assertive behavior with health care providers is a place for therapeutic intervention. But all therapists should be able to be clear with you about areas in which they can offer new knowledge and skills, how they observe confidentiality, and their comfort with the ever-so-present issues of loss and mis-communication.

If you would like to see some youtube webisodes that focus on how infertility affects relationships, check out my Hopefully Yours website at http://www.connieshapiro.com/

And stay tuned for the last in my Infertility Counseling blog series: Getting the Most Out of Therapy.

Infertility Counseling: Getting Started

2010-05-21T08:42:00.000-07:00

Since the recent publication of my book When You're Not Expecting, many people have approached me to ask about the counseling experience: How to know when counseling is a good "next step," how to access a counselor experienced with infertility issues, what costs may be involved, and what to expect of the counseling experience. The common thread that seems to be present in these conversations is " Since I feel like I'm going crazy, is counseling likely to be of any help?"

These are very important questions. Since I have provided counseling to hundreds of couples and individuals grappling with infertility, I know all too well the kinds of barriers that can prevent people from seeking help for the emotional fallout of infertility. In the coming weeks I will devote several blog posts to various dimensions of infertility counseling. Today we'll begin with how to get started in this process.

First, I think readers would agree with me that the infertility experience is filled with stress. Who to tell, how much to tell, how to cope with the fertile world, how to communicate with loved ones and health care providers, how to juggle treatment and personal life and, above all, how to bear the interminable waiting. This list could be much more extensive, but you get the idea: it doesn't take long for infertility to become a ruling force in your life. And this is an experience for which you probably have had no preparation. This also is an experience for which you lack a road map, so looming out there in the future is the fear of the unknown and whether you'll have the emotional strength to emerge from the infertility journey unscathed.

Anyone who has been infertile for any period of time will be quick to say that the experience changes you. The question you will want to ask yourself is: at what point in this process do you want to seek out a counselor to help you cope more effectively with the inevitable stresses? Knowing that infertility will change you, do you want a counselor by your side to help you find new ways to handle the present and to think about the future? And do you see counseling as something for yourself, or is your partner also interested in being involved?

Since I happen to be a believer in keeping a finger on one's emotional pulse, I would first encourage you to discuss with your partner how each of you is handling the stresses of your infertility. What are those stresses for each of you? What do you find difficult to discuss with one another? What are your worst fears about the way infertility will affect you? What sources of support do you have? And there are probably other questions that will come into your conversations once you begin this process. If you find yourself talking pretty openly and honestly with some degree of hopefulness, then you can give yourselves high marks for empathy and self awareness. You should make your own assessment about whether any issues are causing you emotional pain and, if not, there are several options to consider. First, continue to keep open communication with your partner about these topics. Another is to join a local infertility support group. RESOLVE's website http://www.resolve.org/ lists support groups by regions in the US, and the Infertility Awareness Association of Canada (IAAC) http://www.iaac.ca/ does as well for Canada. In addition, many communities have their own peer-led support groups. And, further, many infertility clinics offer support groups for their patients. A third option is to make an initial appointment with an infertility counselor; this will give you an opportunity to check out whether this is someone with whom you feel comfortable and with whom you believe you could communicate about difficulties when they arise. It will give the counselor an opportunity to see you and your partner at a time when you are managing well. It will give all of you an opportunity to discuss the likely future availability of the counselor, as well as practices that you need to know about: fees, insurance coverage, length of sessions (usually 50 minutes), whether the counselor has a preference for working with individuals vs. couples, etc. If this visit does not make you feel as though this counselor is the person with whom you would like to work in the future, then continue your quest until you find someone in whom you have more confidence. Waiting for a crisis is no way to pursue this quest.

So, what if your conversation with your loved one is filled with fears, misgivings, tears or apprehensions on at least some of the topics you are discussing? This would suggest to me that at least one of you is hurting, at least one of you feels inadequate or confused about how to soothe your partner, and at least one of you is feeling emotionally overwhelmed on some level. Whether this means that you rarely discuss these issues with one another (usually for fear that the tears will turn to torrents), or that you are often reaching out for comfort that cannot be met by your partner alone, these are signals that you need more emotional support than you are getting.

Counselors are accustomed to having clients who are tearful on their first visit, who say "I think I'm going crazy!" by way of introduction, and who are searching for coping skills that elude them in the midst of their infertility. So if the description in this paragraph feels familiar, your options would include inquiring about whether your infertility clinic or physician's practice can provide or refer you to infertility counseling services. If the answer is no, then you will need to do some detective work in your community to locate a counselor. Resources to help with this may include the medical social worker at an area hospital, your religious leader, any infertile friends in whom you have confided, as well as listings that may appear on the websites of RESOLVE or IAAC. Even contacting a number listed under "mental health services" in the yellow pages or googling infertility counselors with the name of your town may yield one contact number that could give answers to your questions about whether there are experienced infertility counselors in your community. This can take both time and patience, but it is well worth the effort if you connect with someone who can help you with the emotional burdens you are carrying.

Some individuals or couples are so consumed with sadness and depression that it may take an emergency to jolt them and loved ones into recognizing the depth of their pain. Under these circumstances, when inability to function or a suicidal gesture are clear emergency signals, the path to help must be more immediate. Here is when an initial evaluation by a psychiatrist is an important first step, with the likelihood of prompt follow up by a mental health professional. The initial contact may be through a telephone call to your local mental health clinic where you firmly request an immediate appointment (that very day) or, if that is not successful, a trip to the emergency room of your hospital where a psychiatric evaluation should be available. It is far more important to get immediate services in a crisis, and ultimately to learn about the counseling resources in your community once the initial crisis has been addressed.

So, very briefly, let me tell you a bit about the different kinds of counselors (some will refer to themselves as therapists) , including their titles and their training:

Psychiatrists, who are medical doctors, can offer mental health diagnoses and can write prescriptions for anxiety, depression and other conditions. It is important to inquire of the psychiatrist, and of your pharmacist, about the effects of any prescribed medication on a developing fetus. Some psychiatrists offer counseling, but it is more likely that a psychiatrist will refer you to one of the professionals listed below.

Psychologists, who have master's degrees and often Ph.D.s, cannot prescribe medication. They have counseling expertise gained through their education, internships and post-degree supervised clinical experience.

Social workers, who have master's degrees, have acquired their counseling expertise through clinical supervision during internships and possibly post-degree experience. Social workers often have skills in individual and family counseling, promoting couple communication, addressing issues of loss, advocacy and helping clients to find appropriate community resources.

Marriage and family therapists, who have master's degrees, have acquired their counseling expertise through clinical supervision during internships and possibly post-degree experience. They provide individual counseling, couple counseling and family counseling.

It is possible that any of the counselors listed above, who are licensed in their state of residence, may be eligible to receive insurance reimbursement for providing services to you. This differs in each location, and a call to your insurance provider should be able to determine whether the counselor is considered a provider in their system. If money presents a barrier, there are several options you can pursue. You can ask a counselor whether s/he can offer you a sliding fee scale (this means fees will be flexible depending on your financial circumstances). If individual counselors in your area cannot offer this flexibility, sometimes agency counselors (at Family and Children's Services and Mental Health Agencies) can offer a sliding fee scale. Should none of these options be available, I would suggest a very open conversation with your counselor about an initial partial payment plan, with a repayment plan built in. Another option might be to see the counselor less frequently than weekly, thereby incurring less cost.

I know for any readers who looked at my "getting started" title and expected to whiz through this blog, you might be feeling as if there's a lot to this process. But remember, what I have tried to do here is to depict the process in enough detail so that you could see your own circumstances in the options I am presenting. So, in truth, you don't need to digest everything in today's blog -- just the parts that apply to you.

And, while you're digesting, I'll mention that my book offers therapeutic tips at the end of every chapter. So while you are considering whether/when to seek a counselor, you may find the book helps to acquaint you with the process of learning effective coping and communication skills over the course of the infertility journey. In my next blog I'll review what you can anticipate from the counseling experience, so you can feel more familiar with what to expect.

Post Mother's Day Reflections

2010-05-11T08:25:00.000-07:00

For many women with infertility, the week after Mother's Day feels like a time to let out a deep breath. We haven't just been holding that deep breath on the holiday itself. No, we took that deep breath some time in early April when the first advertisements from retailers began to remind us that Mother's Day was approaching. And we, unlike the mothers in our midst, began to wonder how we would survive the holiday this year.

So did we survive it? How did we handle it? And why does it matter? I'll start with why does it matter. If you emerged this year emotionally unscathed, then you probably entered the Mother's Day season with a mind set or an action plan that worked for you. If you emerged emotionally wrung out, then this is the very time to sit back, breathe deeply, and reflect on what you can do now to learn from this year's difficulties. I know, I know, you have every hope that by Mother's Day next year you'll be able to celebrate with a baby in your arms. However, we all know infertility can be a long journey, and it's worth it to store this year's reflections as important insights into how you handle your vulnerabilities and how you try to anticipate emotional potholes.

So when you reflect on how this Mother's Day could have been less painful, given your infertility, what thoughts come to you? Over the years my clients and I have discussed everything from being caught by surprise, to feeling "out of place" amidst one's parents and fertile siblings, to feeling smothered by the presence of infants and toddlers at family celebrations, to feeling torn emotionally that you want to honor your mother (or mother-in-law) at the same time you want to bolt from the scene. Couple this with the bouquets of flowers that you send but don't receive, the special attention some religious leaders give to mothers in their congregations, and the impossibility of finding a quiet restaurant where you and your partner can have a calm meal (without being greeted cheerily by a staff person who wishes you a happy Mother's Day), and this day clearly emerges as filled with emotional challenges.

Each year I have tried to find a creative way of sensitizing others to the pain felt by families without mothers on Mother's Day. In an earlier blog I mentioned how, years ago, I spoke with the religious leaders in my community in February to help them be more sensitive in their Mother's Day remarks. This year I approached my local newspaper and asked that they do a feature on how infertile people experience Mother's Day, and the result was a full page spread that I have heard touched many hearts in our community. And in the years in between I have politely reminded well wishers that my infertility makes this holiday difficult (which at least made them aware that infertility hurts, and at best may have made them more cautious about assuming that every female is a mother). Also this year, in the two university courses on family relationships that I teach in the spring, I have included a unit on infertility and used a case study focusing on Mother's Day to bring my points home. So, for those of you who want to take on this holiday in the spirit of public education, there are all sorts of ways you can sensitize others. Begin thinking now how you (perhaps with a few friends) can reach out to make a difference.

But if you, like many readers, are not in the mood to be quite this vocal, think back to what you wish would have happened differently this year. Talk with your loved ones about how you need to approach this holiday differently next year if you do not yet have a child. Make some notes to yourself, so you can remember these reflections over time. Think about how you can reframe this day in the future so that it resonates as little as possible with feelings of loss and, instead, provides opportunities for you to feel hopeful or thankful for some aspect of your life. But DO think about this now, because when next year comes you may want to feel more emotionally steady as you enter the holiday fray. Ideas and strategies that worked for you this year are welcome! Feel free to make a difference by sharing them.

Women with Infertility: We're Everywhere!

2010-05-06T13:54:00.000-07:00

In the last month since the publication of my book When You're Not Expecting, I've been amazed at the number of women who have confided in me their personal stories of infertility: women I know well, women I know only slightly, and women I am meeting for the first time. For some, their infertility is recent. For others their infertility is an indelible part of their past. Yet all of these women told me (even as their eyes filled or their voices trembled) how emotionally isolated their infertility made them feel. In addition to the women who had been diagnosed with infertility, another group of women sought me out after reading my book. These women were students, colleagues, reporters, friends, health care professionals, former college classmates, and relatives, all of whom had read my book and wanted my thoughts on how they could be more sensitive to women who have shared news of their infertility. So here's the dilemma -- how can these two quite different groups come together to have a compassionate conversation about the emotional challenges of infertility?

It seems to me there are several barriers we need to address: defining what is infertility, clarifying what behaviors are supportive, and shifting the conversation's focus as the infertile person's circumstances change.

When most people think of infertility, they tend to think of a couple's inability to get pregnant. But those of us who are deeply involved in infertility experiences know that women with the following circumstances also consider themselves to be infertile:

an ectopic (tubal) pregnancy
a partner diagnosed as the cause of the couple's infertility, even though the woman herself is considered fertile
a molar pregnancy
a pre-natal diagnosis that causes the woman to decide to terminate the pregnancy
a miscarriage or a stillbirth
secondary infertility

So when you share with friends, co-workers or loved ones that you are grappling with the sadness of infertility, they may not grasp that your circumstances fall within their definition of infertility. Broadening infertility to include pregnancy loss, a partner's diagnosis or secondary infertility will help others more fully to appreciate the sadness and frustration of your current situation.

Defining infertility may also involve being clear about the treatments that you/your partner are pursuing. Most fertile people are out-of-the-loop when reproductive technology is the topic under discussion. They may believe that IVF can be affordable and effective for everyone, that adoption "cures" infertility, that taking a vacation is a recommended clinical cure...you get the picture. It will fall to you to be as informative as possible, without offering so much information at once that you confuse your listener. That includes correcting misconceptions, as well as offering educational information about where you are in the diagnostic/treatment process.

A second barrier that may stand between you and a compassionate response is uncertainty about how to respond to your news. Especially around information that is perceived as having a sexual component, listeners are cautious about violating your privacy. This is the time to thank them for being interested in your infertility, to offer to answer any questions, and to suggest ways that they could be helpful now that you have shared this news with them. Depending on whether the person is your boss or your sister, there may be a necessity to have you clarify what you need from this person at this time in your life.

And that brings us to the question about how to handle infertility and your relationships over time. For starters, you are learning as you go along who you can count on for what. Some friends who are great for certain forms of support won't want to offer other forms of support; some who are compassionate early on will get tired or emotionally disconnected over time; some will find their own lives consumed by the joys of their own fertility and feel awkward around you; some will be there for you through thick and thin. In anticipation of this, you'll want to do several things to keep your support system resilient.

Remember to relate to your friends as they've been relating to you: offer help when they need it, keep the flow of information about both of your lives, and allow them to distract you from your infertility whenever you're receptive.
Try not to have your infertility define you in the eyes of others. Express appreciation when they inquire about diagnosis/treatment/waiting/etc., but feel free to turn the topic of conversation away from your infertility to another aspect of your life. Of course, if you've just gotten your period, a discouraging test result, a baby shower invitation, or other news where you need a sympathetic ear, you are entitled to ask for support. But every inquiry needn't turn into a major dialogue about your infertility.
Even though you feel as if your life revolves around appointments, injections, mood swings, medications, etc., do what you can to plan with your partner, friends and loved ones some distractions that you can look forward to: a spring picnic, a new restaurant, a walk in the woods, a weekend out of town, a potluck dinner, a birthday party...you get the picture!
Try to cultivate relationships with infertile friends. These folks won't need much prompting to understand why you are bummed out with a particular piece of medical news or the poor outcome of a medical procedure. In addition, adding to your friends adoptive parents and couples who are childfree by choice will expand your awareness of options these couples have pursued in their lives, perhaps with infertility as a backdrop.
As time passes and you find yourself and your partner facing new decisions about future options, consider which acquaintances may be most helpful in talking about possible new directions. Some will be more helpful than others, and you may want to think about this before asking them to weigh in with their reactions to new choices that you are facing.

So, as we know that infertility affects far more people than would initially be apparent to us, and as we realize that many people are silent or awkward because they need a little help to know how they can help, I hope you can envision yourself reaching out in new ways to people who have the capacity to be supportive, both emotionally and practically. Feel free to weigh in with strategies you have used to generate support from people in your life!

Troubled Adoptions: Why? What to do?

2010-04-29T08:42:00.001-07:00

In recent weeks there has been a fair amount of attention given to troubled adoptions. This has, in turn, been unsettling to individuals with infertility who ultimately are considering adoption as an option for future parenthood. The media's attention to the mid-April return to Russia of 7 year old Artem Saveliev by his Tennessee adoptive mother has ballooned beyond this one situation to a host of articles and TV coverage on "adoptions gone sour." The formal term for the ending of a legal adoption is "disruption," but the stories behind these unanticipated family sorrows are causing many readers to think more carefully about the possible risks associated with adoption. So why might an adoption become problematic? And when it does, what resources do adoptive parents have?

Let's look first at the "why?" factors that can contribute to troubles after the adoption. Whether an adoption is domestic or international, the prenatal care of the developing fetus often is unknown. Alcohol or substance use, poor nutrition, low maternal age and other risk factors may be present in the mothers whose babies are placed for adoption. Life after birth of the baby may include institutional care that is substandard or routinized, with little opportunity for the interpersonal warmth and cuddling that can be so important to building future trusting relationships. For older children or sibling groups, there may be a history of foster home placements or institutional care where those children have, at best, needed to fend for themselves and, at worst, have experienced abuse and emotional rejection. A child's records that are available to prospective adoptive parents may not include this kind of information, and the reports from the examining physician may focus exclusively on obvious health problems. This sets up the possibility that an adoptive parent, eager to provide welcoming arms and a loving heart, may be unaware of the extent of physical and mental health difficulties experienced by a child. Given that the agency adoption process itself can take several years, the conditions in which the child has lived are important for adoptive parents to understand, as there will be more empathy for whatever adjustment difficulties occur post-adoption.

So now, let's consider the "what to do?" question. This is not only for adoptive parents who are experiencing troubles, it also is for prospective adoptive parents who want to know what their options are if their child's adjustment to their home is painful or filled with trauma. This is where the services of the adoption agency need to be evaluated. Is the agency one that offers workshops for prospective parents in which they cover both the joys of adoption and the potential problems? Do such workshops include information about predictable problems (sleep disruption, night terrors, food hoarding, testing behaviors, etc.) that children of different ages might demonstrate as part of the normal adjustment to a new home? Are prospective parents given an opportunity to meet with adoptive parents who have experienced adjustment difficulties, learning from them various ways they coped? And, most importantly, does the agency make itself available for adoptive parents to return for counseling around difficulties that arise after the adoption?

Clearly an agency that addresses possible troubles up front is helping prospective parents to anticipate the special needs that their children may have and to ask themselves if they are "up" for this possible challenge. This is a time when prospective parents need to assess whether they see adoption as "second best" or as a "second choice." Second best is worrisome, in that it presents a sense of disappointment and the belief that having a birthchild is preferred as a route to parenthood. Second choice identifies that the adults had hoped for, and tried for, a birthchild, but when that option was not promising, were sufficiently committed to becoming parents that they turned to adoption as their next (and second) choice.

Since all children at one time or another present unanticipated challenges for their parents, those adults with a second best perspective may be most likely to point to the adoption as the root of the child's difficulties, whereas second choice parents may direct their commitment to parenthood into problem solving strategies. Clearly a problem solving approach is most likely to enable parents to reach out for counseling, for support services, and for mental health treatment. And here is where prospective adoptive parents can do some important homework. Does the agency with which you are working offer that counseling? If not, does it provide referrals to agencies and services that are familiar with childhood adjustment problems and dynamics that families may use in response to these problems?

Clearly prospective adoptive parents are aching to hold a child in their arms and to provide the love and comfort that will nurture this new family member. At the same time, they are hopeful that this child will enable them to feel more fulfilled as adults, opening new experiences to them as they finally join the ranks of their siblings, friends and co-workers who are parents. Yet it is important for adoptive parents to realize that they will need to have a special sensitivity to an adopted child around everyday issues such as "tell me how I was born," assuaging grand-parental misgivings and apprehensions, appreciating how differences in skin color or facial features between the child and parents may present issues (both within the family and in community/school relationships), and deciding how to help their child feel a connection to the country of his/her birth.

So, much as troubled adoptions have been in the news lately, this actually presents an important opportunity to help prospective adoptive parents weigh quite carefully the circumstances under which adoption feels possible, the kinds of questions to ask as you consider what agency to work with, the importance of talking with adoptive parents about how they have weathered hard times in child rearing, and the availability of support services in your community for children and families experiencing adjustment problems. Entering into parenthood requires that each of us ask ourselves how ready we are for this new chapter in our lives; and contemplating adoption requires even more introspection and self awareness about the unique opportunities and possible challenges that adoption can bring into the lives of families. Feel free to share your experiences, both in anticipation and in reminiscing about your own adoptions!

Celebrate Infertility Awareness Week: April 24-May 1

2010-04-22T11:30:00.000-07:00

So, you may be asking, "What's to celebrate?" Infertility is not an experience anyone wants to have, it is something people hope to put behind them as quickly as possible, and it tends to be a somewhat carefully guarded secret for many couples.

So when a week is proclaimed in honor of infertility, this tends to jolt us a bit and provoke some questions in our own minds about how we fit into this week of public awareness. I find myself reminiscing (and not at all warmly) on my early days/months/years of infertility. Given that my children are now young adults, I'm recalling the mid 1970's when infertility was misunderstood on many levels, not very successfully treated, and generally "in the closet" for many affected couples. From that context, I imagine that many people would say that there have been massive medical breakthroughs and successes. This is true, particularly for couples who can afford to pay for medical tests, treatments, and choices (including donor eggs/sperm, adoption, or a gestational surrogate). But, in spite of medical progress, there are areas that have not experienced as much success, and it is especially these areas that will benefit from our voices during Infertility Awareness Week:

Lack of insurance coverage for diagnosis and treatment: This is a significant concern for individuals and couples who want to explore what options are available for becoming birthparents. Insurance companies are reluctant to explore this potential black hole, and yet infertility is a significant concern for 12% of couples in the U.S. population of childbearing age. Even more pressing for some couples is being uninsured altogether, which interrupts their efforts to understand more fully what may be contributing to their inability to conceive or to carry a pregnancy to term.

Lack of attention to the emotional impact of infertility. On the shelves of most book stores we can find a handful of books on infertility, but almost every book focuses on the medical aspects, with perhaps a cursory mention of the stress and anxiety that accompany the inability to conceive or to have a healthy pregnancy. The absence of the emotional factor has significant ramifications: physicians focus solely on the physiological, and their patients have no validation for the emotional challenges they find themselves confronting month by month as pregnancy eludes them. In addition, too few infertility clinics have therapists on staff to help patients with the mental health fallout from their infertility diagnosis and treatment. Of course it has been this emotional component that compelled me to write When You're NOT Expecting, in which I focus specifically on strategies for coping with the emotional challenges of infertility.

Lack of awareness of the full range of populations trying to pursue birth parenthood. In the eighties, nineties and the early years of the 21st century, most infertility support groups were composed of married, middle class Caucasian women, with male partners occasionally accompanying their wives. The populations now trying to pursue parenthood also include people of color, same sex couples and single men and women. Creating face-to-face environments and on-line communities that welcome all would-be-parents is an evolving process. In my book I make a conscious effort to include the voices of these less visible prospective parents, since their emotional struggles are important to recognize as valid.

Lack of sensitivity by some ob-gyns, urologists and infertility clinics to unmarried patients and same sex couples hoping to conceive. Beyond the local "invisibility" of these would-be parents, we may find that specialized infertility services can be insensitive to some patients, either unintentionally or, perhaps, in an effort to attract "typical" clients. These insensitivities can include social history forms asking for the name of a "spouse/husband/wife;" reluctance to have the same sex partner in the examining room; obvious awkwardness of the health care professional when interacting with unmarried patients and same sex couples; and, potentially, an unwillingness to accept input on testing/treatment from the couple (an example here would include a lesbian who requests that her partner's egg be fertilized with donor sperm before being implanted in her uterus).

The above are only the most compelling of the issues that deserve attention from the media, from insurance companies, from health care professionals and from infertile people who may have had a restricted view of people affected by infertility.

So, when you find yourself asking "What's this awareness week all about?" recall the issues above, add some of your own, and consider ways that you might be able to advocate on behalf of under-served folks who, like you, share the hope of some day becoming parents.

Infertility gardens

2010-04-15T12:52:00.000-07:00

As I'm looking out at the glorious spring weather, filled with sunshine and bursting blossoms, my thoughts of infertility take a slightly different turn today. I find myself thinking of the ways that the healing balm of nature has calmed sadness and grief of friends and clients experiencing infertility. For those of us tempted to seek solace on the internet, by reading articles and books, through comfort food, or just seeking some solitude, there's yet another option: creating a garden.

First, I will confess that I do not have a green thumb. Nor do I have any experience designing green spaces. But I do love to walk and hike in natural surroundings, especially in the spring. I have many acquaintances who have shared with me the comfort they have received by designing, planting and nurturing special gardens in their back yards and on their apartment building roofs. Perhaps you can identify with some of these scenarios (I will be changing all names and some identifying information to protect the privacy of my acquaintances).

Janice and her husband Bob experienced three miscarriages over the course of two years. After grieving these losses, they wanted to move forward emotionally, but they did not want to forget the hopes and dreams for these children who would never be born to them. So they decided one winter to spend time designing a back yard garden to plant in the spring. They planned their garden with three sections, each one unique in colors and plantings. Poring over seed catalogs during the winter, they planted some seeds in small pots indoors and purchased others in local greenhouses during the spring. Once the threat of frost was over, they devoted several weekends to tilling the soil, planting the bulbs, seeds and sprouting blooms, and applying fertilizer and mulch. Janice, still hoping for a healthy pregnancy, kept herself at a distance from the fertilizer, as she offered suggestions to Bob. Both of them found the garden to be a source of pleasure and calm during the warm months of spring and summer, and as they weeded and watered, they found their own relationship strengthening as they were able to talk openly about their diminishing grief and their continuing hopes for parenthood.

It had been four months since the funeral for Missy and Joe's stillborn son, Jason. The baby's body had been cremated, and they had been unable to decide where to place the ashes, which remained in an urn at the undertaker's. Both were anguished at their inability to find a resting place for Jason's ashes. In conversations with their minister, they eventually decided to plant a back yard garden and to scatter the ashes there. Having reached that decision, they enlisted the help of loving friends and family to offer suggestions about plantings, manual help with tilling and fertilizing, and especially cherishing a hammock that could be hung between trees nearby with a clear and shaded view of Jason's garden. When the time came to scatter Jason's ashes, their minister joined them and their loved ones for a small dedication of this garden planted in his memory.

When Carla had a miscarriage, she collected the remains and took them to her doctor. He indicated that he would send a small sample for genetic and other tests, and Carla decided to bury the rest of the remains in a rose garden in her back yard. She and her partner Kelly buried the material in a shoebox. To their horror, two days later they found that a mole had tried to burrow into the shoebox, disrupting both the garden and their peace of mind. They responded by placing the shoebox into an airtight metal box, which they reburied without further incident. Both now feel that this pregnancy loss has been softened by the presence of the surrounding beauty of the nearby roses.

Susan and Jared were reluctant to plant a back yard garden in their baby's memory, since they expected to move into a different neighborhood within a few years. It would be too difficult to have invested the emotional energy in planting flowers and bulbs, only to leave that garden behind when another family purchased their home. Instead, they decided to plant a tree, with a bench nearby, in a favorite park where they often spent time. Beneath the tree was a rock with their daughter's name and birth date engraved on it. They both derived comfort from this memorial tree, as well as from seeing other people pausing on the nearby bench to read, rest, or enjoy the natural beauty around them.

After two failed adoption attempts, Sandra and Jeff were in a quandary about whether or not to continue to pursue adoption as a path to parenthood. They lived on a dairy farm with gardens in which they grew fruits and vegetables. One day a friend of Sandra asked if she could bring children from her day care center on a field trip to the farm. As they discussed this plan, Sandra suggested that the children might enjoy a chance to create their lunch from the gardens: some gazpacho, a salad and some strawberry shortcake for dessert. The lunch was such a resounding success that the children begged to be allowed to come back again. Future visits included the chance to milk a cow, to feed baby goats, to cuddle newborn kittens and to romp in the fields. As time passed, Sandra and Jeff found themselves enjoying these short term fun experiences so much that they decided to remain childfree, but to nourish their contacts with several day care centers whose children relished the opportunity to visit their farm in all seasons of the year.

Karen and Chris had buried their stillborn daughter Nora in a cemetery plot near that of her grandparents. When spring came, they realized that the ground was untended near the grave, and they decided to plant bulbs that would bloom annually, as well as wildflowers that would bloom throughout the spring and summer months. They found that the flowers and plantings had a calming effect on them during what they had feared would be tearful visits to Nora's grave site.

Infertility and sadness are intertwined. Yet the beauty of nature can be a cushion against grief associated with the losses of infertility. As the scenarios above suggest, our own creativity in using the bounty of blooms and bulbs to create a garden can be a different approach to healing from sadness. A green-thumbed friend said to me recently, "Gardening tills the soul." In these days of spring, consider whether some plantings could offer comfort to you or a loved one struggling with infertility or pregnancy loss.

Apprehension as Mother's Day Approaches?

2010-04-08T12:48:00.000-07:00

In my informal inquiries of individuals and couples diagnosed with infertility, Mother's Day tends to top the list as the holiday that evokes the strongest emotional reaction. So this year I decided to jump into the holiday fray early enough so that we can think ahead about this particular holiday. With Mother's Day falling this year on Sunday, May 9, hopefully a month's lead time will enable you to think through the unique meaning this particular holiday has for you this year. And, beyond that, it may be possible to help others be more sensitive to the impact of this day on families without mothers.

In my own early years of infertility, I focused on Mother's Day as I always had. I sent flowers to my mother, made a long distance call to tell her how much she meant to me, reminded my younger brothers to be sure to connect with her, and went on about my life. In other words, Mother's Day was about MY mother.

But several years of infertility changed all that. More and more I saw myself as yearning for motherhood, rather than being able to celebrate it. A spontaneous plan for dinner out on Mother's Day met with crowded restaurants filled with happy families. My infertile friends turned tearful as they told of attending religious services where mothers in the congregation were honored, either in the sermon, or by being asked to stand for recognition, or by being offered a flower or a corsage. Others told about excitement of friends, siblings or co-workers whose families were planning special festivities. More and more my friends and I felt like bystanders, still honoring our own mothers on that holiday, but wishing so much that we too could be the mothers in the limelight.

I think of my friends and my many clients over the years as the source of creative conversations about how to approach Mother's Day. Many of us chose different pathways through and around this holiday, with the approach differing as the years progressed. I'll share with you my recollections and (since, after all, we have a month to think about all this) encourage you to weigh in with your own thoughts on this holiday and the celebrations associated with it.

Many women simply decide to focus on their own mothers and grandmothers, choosing not to frame this holiday as being about them. This requires a certain amount of tone-deafness as our own peers anticipate their family celebrations, but we already have learned to tune out heavily maternal conversations to a certain extent. And some of our friends and co-workers have become sensitive enough to know what topics to avoid in our presence.

I've known several groups of women and their partners, drawn together by their infertility, who have planned potluck dinners on Mother's Day, thereby avoiding the restaurant scene and symbolically declaring that "we care about honoring one another on this day when the rest of the community thinks of us as invisible." Others have looked forward to the solitude of a movie theater, a walk in the country, planting flowers in the back yard, or seeking some other form of enjoyment "far from the maddening crowd," so to speak.

And then there was the year that I decided to approach the religious leaders in my community, many of whom had evoked misery in my friends' and clients' hearts by their selective honoring of mothers in their congregations. Luckily for me, many of these clergy met once a month for lunch, and I asked if I might join them. I introduced myself as an infertile woman and said that I hoped we could talk together about how Mother's Day in their places of worship could be approached with sensitivity for families without a mother. This made it possible for them first to say what their practices had been on Mother's Day, acknowledging how blind they had been that their efforts to honor mothers might also have hurt families without mothers. We moved from that to a group conversation about how they could approach this holiday with greater sensitivity. I'm happy to say there was no resistance, they tried hard to be creative, and they ended up inviting me back for one more lunch (happily this was only February!), so they could have time individually to think about how they would re-shape Mother's Day that year.

Ultimately that effort led to more inclusive sermons on Mother's Day, with many clergy reminding their congregations that families come in many shapes and sizes, that not all families include mothers, and that families who have experienced the loss of a mother, the loss of a pregnancy, or infertility hope to feel emotionally safe when they come to worship, including on Mother's Day.

Needless to say, Mother's Day services in my community were changed forever, but several other changes grew from that lunch (where, I will admit, my knees were shaking a bit!). Clergy, sometimes the first person sought out after an infertility diagnosis, became much more aware of local infertility counselors and support groups. They also were willing to be panel participants in our regional conferences, where "loss of faith" or "spiritual betrayal" were topics of well-attended workshops.

So, whether you anticipate Mother's Day this year from an individual perspective, a couple perspective, a larger gathering of sensitive folks, or some way to spread the word about keeping visibility for families without mothers, please feel free to share your thoughts (and your actions!) with readers of this blog. I hope to hear from you!

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

2010-03-18T09:36:00.000-07:00

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

2010-03-10T12:17:00.000-08:00

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"

2010-03-04T08:42:00.000-08:00

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

2010-03-01T11:22:00.000-08:00

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!

The Many Faces of Infertility

2010-02-22T09:43:00.000-08:00

Too often infertility is thought of as an "invisible disability." This is because couples, at least initially, often are reluctant to divulge an infertility diagnosis. To those individuals and couples, infertility may represent failure, it may feel like an insult to their sexuality, it definitely feels daunting with its uncertain outcome, and for most people it is their first time on this new journey and they're not sure how they feel about sharing this part of themselves with others in their lives. My next several blogs will depict the many faces of infertility: "coming out," secondary infertility, social factor infertility, pregnancy loss, prenatal diagnosis issues, and deciding when "enough is enough." For today, I want to feature a well known face, Celine Dion. She was recently featured on Oprah and in People Magazine, as she spoke of her infertility experiences over the years.

As I looked at the photo of Celine Dion on the cover of the Feb 22 People Magazine, I was heartened to see a much-admired person openly proclaiming infertility as an ongoing issue in her life. Clearly with the financial means to seek the very best treatment, she also takes a deep breath as she says, "It's not 'Oh, poor Celine,' but it's a lot." I found myself thinking how much I appreciate her public "coming out" as she faces the many lost hopes and disappointments of this current infertility experience that no amount of money can soften.

Celine's hope for children is undoubtedly rooted in her own family, where she grew up with 13 siblings. Her one child with 68 year old husband Angelil, is nine year old son, R.C.,who was conceived on her first IVF attempt. Now, after four recent IVF attempts, she is planning for a fifth. But she and her husband, unlike many couples with infertility, have the comfort of a birthchild in their lives, which enables her to say quite convincingly..."One way or another we're going to be good." And in her sensitivity to R.C., who is well aware of his mother's IVF attempts, she says "But honestly I'm more than blessed with my son. He is everything for me."

So this very public figure is depicting for all of us in a very public way the various balancing acts that infertility plops into our laps: how/when to disclose and how much to disclose; the emotional and physical challenge of ongoing treatments; the sadness as those treatments don't result in a healthy pregnancy; and the juggling act of career and treatment.

How familiar do these quotes sound and feel? "We go crazy waiting for the results" (Angelil speaking ); "sometimes Dion cries for no reason at all;" "The hormones that help make a pregnancy possible also bring a tidal wave of emotions;" This month's publicity certainly puts a public face on what often is regarded as a fairly private matter.

With that in mind, stay tuned, as I explore in future blogs the faces of infertility that we often don't think of when that word is added to our vocabulary. We may not have celebrity faces to add to each example, but each reader knows this expanding vocabulary all too well.

Can Steamy Sex and Infertility Go Hand-In-Hand?

2010-02-11T10:26:00.000-08:00

Some readers may wonder how I came to devote an entire chapter of my book When You're Not Expecting to the topic of the sex lives of couples with infertility. My answer would have to be that, among the hundreds of couples I have counseled about issues affected by their infertility, well over 90 percent identify their sexual relationship.

And this is now backed up by research just posted on an e-mail of RESOLVE to its members today: "A study conducted at Duke University Medical Center, and presented at the American Society of Reproductive Medicine by Dr. Jennifer Norten examined 'sexual satisfaction and functioning in patients seeking infertility treatment.' The results of this study suggest that women undergoing infertility treatment experience significant changes in various aspects of sexual desire, arousal, orgasm, length of foreplay and frequency of intercourse."

For both male and female readers who have been diagnosed with infertility, this will come as no surprise, although it may be something of a relief to know that you are not alone. As my blog earlier in this week preceding Valentine's Day indicates, scheduling sexual intercourse to coincide with ovulation can take a real toll on spontaneous lovemaking! So, what to do? To be truthful, most of these ideas have come from my clients over the years, as they tried to put the zing back into their sex lives. So read along, and see whether any of these can counter the image of your infertility specialist perched on your bedpost:

Make a real effort to save the bedroom for lovemaking and for sleeping -- no reading, no computer, no TV, no Blackberry, no eating, and especially no talking about problems, including infertility. If you have distractions or unpleasant associaltions with what you do in the bedroom, it will be harder to associate that room with sexuality, with intimacy, with desire and with emotional closeness.

Before even coming into the bedroom, talk to your partner about the changes in your sexual intimacy since you began trying to conceive. Use these converations as a way of blaming infertility for any lack of sexual spontaneity. Affirm how erotic you still find your partner; how much your cherish the closeness, comfort and joy of good sex, and how you want to think of ways to recapture and reinvigorate your love life.

Once you are openly communicating about your wish to welcome lovemaking, as contrasted with scheduled sex, back into your lives, see if you can pinpoint the deterrents and figure out how to work around them.

Be kind to yourselves. Start out slowly, celebate small sexual pleasures, and don't be deterred by inevitable missteps and disappointments. Keep the lines of communication open so you stay on the same page about what brings you joy and what you need to rethink. Be sure to give positive feedback to each other.

Experiment with new sexual strategies. Take turns initiating sex, rent DVDs, read books, wear some sexy clothing -- and remember that this is not a scientific experiment! Laugh, be tender, be goofy, be loving. There's always time to create sexual closeness.

And remember: no pressure! Sexual expression needn't involve intercourse if this reminds you too much of scheduled baby making. You can even forget orgasms if you're not in the mood. Kissing, licking, caressing, snuggling, touching -- the number of ways you can pleasure one another to reaffirm your sexual joy is endless. Don't wait!

Intimacy for Infertile Couples: Lovemaking or Baby Making?

2010-02-08T14:36:00.000-08:00

As Valentine's Day approaches, my thoughts focus in unique directions, given my experience as a therapist working exclusively with infertile clients. Couples who have difficulty conceiving or carrying a pregnancy to a healthy birth often find themselves shifting their love making to "baby making." This shift tends to be gradual, and it builds on a foundation of increasing disappointment and sadness as, month by month, the woman's menstrual period begins just at the time she had hoped for a positive pregnancy test. Or, if a positive pregnancy test is followed by a pregnancy loss, the sadness becomes active grief as hope for this baby vanishes and, once again, efforts to conceive are the focus of the couple's life.

So, with my pre-Valentine's Day postings, I hope to resonate with infertile individuals and couples, as well as to sensitize those readers who may have loved ones who are trying to conceive. Today, I will focus on the impact "baby making" can have on one's love life. Subsequent blogs this week will address how to bring some zing back into your love life (clearly this can apply to all couples, not just those who struggle with infertility!).

The infertile couples whom I counsel are often somewhat shocked when, in our very first meeting, I work in a question about their love making. Yet this provides a perfect opportunity for me to share with them that well over 90 percent of my clients are clear that their infertility has interrupted their pleasure in love making. We can then begin to talk further about their preoccupation with creating a pregnancy, rather than enjoying sexual closeness and arousal as a way of heightening their emotional intimacy.

Sometimes it is the diagnosis of infertility that casts the initial shadow on a couple's love life. A low sperm count can cause a guy to believe he is "less masculine," and if he understands himself to be the cause of the couple's incapacity to conceive, he may struggle with his own image of himself as a desirable sexual partner. In addition, even if his sperm health is not identified as a cause for concern, the man will be less than enthusiastic about having sex on schedule or producing semen on demand for use by an infertility specialist in medical procedures. A diagnosis that identifies the woman as the source of the couple's infertility may very well cause her to think of herself as barren or guilty (perhaps because of having waited so many years to begin trying to become pregnant, or because of a decision earlier in her life to terminate an unplanned pregnancy).

For many couples diagnosed as infertile, this emphasis on conceiving begins with a focus on timing intercourse to coincide with ovulation. Whether it is simply a conscious effort to have intercourse around the time of the month when the woman is ovulating, whether it involves the use of ovulation kits to identify when ovulation occurs, or whether a physician is involved in timing medical intervention with ovulation, there is no question that the couple's attention to conceiving is heightened and focused to the few days each month that the woman stands a chance of conceiving. So what does this do to one's love life the other days of the month? In the words of one couple I quote in my upcoming book, When You're Not Expecting, "Once we began a formal infertility workup, it was as if the doctor was right there in bed with us. Somehow, sex became a very medical thing, and in the process of timing our intercourse, we pretty much let go of being spontaneous."

So, now that we can see "baby making" as an expectable shift in the sexual intimacy of individuals diagnosed with infertility, stay tuned for my next blog on putting the zing back into your love life!

Haitian Orphans

2010-01-22T13:44:00.000-08:00

Since January 12, the world's attention has been focused on the devastating earthquake in Haiti and the many international efforts to respond to the needs of its citizens. And for those of us who see news coverage of homeless children and orphans, both physically injured and emotionally bereft, we immediately begin to imagine how we might help. We know from news coverage that the U.S. and many other contries have mobilized resources and people to aid in the relief effort. The most recent news about adoptions and orphans is mixed. I will first share what I have learned about the current efforts, then I will offer a perspective posted by a children's organization in Haiti, and last I will focus on realistic next steps, especially for readers who may be thinking about adopting a Haitian orphan.

On January 20, Secretary of State Hillary Rodham Clinton announced that the State Department is heading up a joint task force with the Departments of Homeland Security and Health and Human Services to focus on orphans and unaccompanied minors. They hope to streamline the process of adoptions and ensure that these families are united as quickly as possible while still guaranteeing that proper safeguards are in place to protect children. An interagency working group has been established to focus on the humanitarian needs of highly vulnerable children. Also, the Administration is also working closely with the many members of Congress who are understandably very concerned about this process.

On January 18, Secretary Napolitano announced humanitarian parole for certain Haitian orphans. The focus in this effort remains on family reunification and makes every effort to be vigilant not to separate children from relatives in Haiti who are still alive but displaced, or unknowingly to assist criminals who traffic in children in such desperate times. As a result there is active discouragement of the use of private aircraft to evacuate orphans. All flights must be appropriately coordinated with the U.S. and Haitian governments to ensure proper clearances are granted before arrival in the U.S. Already some orphans have arrived in the U.S. as the Haitian government has loosened its policy on visa requirements to expedite the adoption of orphans under special conditions: those who have family members living here in the U.S. and orphans who have U.S. adoptive parents who are already in the process of adopting them.

Clearly the urgency to help is being tempered by a concern that too hasty a rush to action may result in traumatic mis-steps. Even before the earthquake there were 380,000 children in Haiti who lived in orphanages or group homes, reports the United Nations Children's Fund. Now the U.S. State Department estimates there could be thousands more children left without parents.

On this issue, a conservative note is being sounded by a children's organization in Haiti, "SOS Children's Villages," that cautions people against rushing to adopt earthquake orphans. Stating that over 80% of these children (estimated by SOS to be between 5-10,000) will have some traceable family who are in some position to care for them, this organization reminds readers that too vigorous an effort to expedite and initiate new adoptions could misidentify children separated from their families in the quake. One of the issues that always arises with international adoption is losing the child's culture. Even with the lower estimates of numbers of orphaned children, SOS concurs with other sources that "the number of orphans is still horrific and the conditions of them and other children have deteriorated sharply."

So, the question remains of how one can extend help at a time when reaching out to adopt may be premature. At the request of President Obama, former Presidents Bush and Clinton are coordiating private assistance and urging Americans to help at www.clintonbushhaitifund.org
You also can text QUAKE to 20222 to charge a $10 donation to the Clinton Bush Haiti Fund (the donation will be added to your cell phone bill). And you can identify more ways to help through the Center for International Disaster Information (www.cidi.org)

As our hearts reach out especially to the orphans and homeless children of Haiti, we also must respect the importance of every effort to help keep these children close to their culture and heritage, close to extended family members, and close to community efforts to rebuild their lives.

A New Approach to "Happy New Year"

2010-01-01T08:50:00.000-08:00

Ever since my teenage years, I have carried out my tradition of welcoming in the new year at midnight and climbing into bed. Before drifting off to sleep, I would review the happiness and regrets of the past year, wondering about what the new year would bring, as well as tucking in some hopes for the future and a few well-intentioned resolutions.

In my infertile years, this new year tradition no longer brought me comfort. My review of the previous year would be replete with regrets for the pregnancy that never occurred, doctors' uncertainties about what to do next, and the emotional loneliness of the infertility experience. As I have talked with people grappling with infertility, I find similar responses to facing the new year, which can feel daunting rather than hopeful. In my new book When You're Not Expecting, I quote one woman who captured a wealth of emotions about her reaction to welcoming the new year:

"Making New Year's resolutions has been a miserable challenge ever since we were diagnosed with infertility. It's bad enough that another year has passed without a baby to share our lives. The thought that I should focus on changing or improving something about myself is downright infuriating. Somehow, just getting through the year in one piece is an ordeal in itself."

So what do we do with the anger and sadness that may accompany our ringing in of the new year? First we acknowledge our right to these emotions. But we then have choices about how to harness this emotional energy and move it in new directions. In my conversations over the years with women and men who are grappling with infertility, they have offered creative ideas about new directions they have embarked on to relieve the anguish of the infertility journey:

I set aside quiet time to meditate each day. This psychological space belongs just to me, and I focus on becoming calm. It has helped me to feel more emotionally steady when I face the inevitable upset of getting my period, negative test results, friends' pregnancy announcements and office baby showers.

I try not to let infertility hijack my entire life. I try to do more than just distract myself with outside activities -- I really try to become involved in my book club, home improvement projects, sports events and other things that bring me pleasure. Some of these things I do with my partner, and others are more my thing. And I do let myself pay attention to the feelings generated by my infertility -- it's just that I refuse to let these feelings come at me 24/7.

I have found that being aware of others' needs helps to give me a perspective on my own sadness. I've set aside time to be helpful to others that actually gives me a lift -- visiting with an elderly neighbor, tutoring a low income teenager once a week, and helping with some community projects from time to time. All of these help get me out of being emotionally consumed by my infertility and remind me that helping others can bring happiness into my life.

I've always loved being outdoors, and I find that giving myself time to take daily walks, to plant in my garden (or indulge myself in seed catalogues during the winter!), to bicycle, to cross country ski, or even to watch DVD's featuring national parks can give me a feeling of the world as being beautiful even when I'm not feeling fulfilled.

So, as I talked with women and their partners who approach the new year without feeling any need for resolutions or self improvement, I could see that their emphasis was on taking care of themselves, expanding their focus in life beyond their preoccupation with infertility, making room for calm and satisfying thoughts, and honoring all their emotions without having the negative emotions consume them.

May your new year be enriched by any of these perspectives that you decide to try.

Surrogacy: Some Words of Caution

2009-12-19T14:04:00.000-08:00

Surrogacy has been in the news for a number of years. I well remember how early media coverage focused on heart-wrenching problems, such as a surrogate mother who chose to retain custody of the baby rather than to honor the agreement she had with prospective parents. Gradually I have seen the media focus becoming more positive, with recent stories of Sarah Jessica Parker and Matthew Broderick welcoming their second child who was born to a gestational surrogate. Given the desperation felt by many infertile couples, I believe surrogacy has become highly appealing to couples who can afford it. And with the demand increasing, a number of fertility physicians have been responsive to couples’ efforts to pursue this option. However, the legal issues involved in surrogacy have not been clarified to keep pace with the increasing demand by hopeful couples for medical assistance in helping a surrogate conceive. I believe this “legal lag” needs to get just as much media attention as the medical successes in helping infertile people become parents. The following article is an excellent step in that direction, encouraging prospective parents to do careful homework on how they can protect themselves from the legal pitfalls that they could encounter.

A front page December 13 article in the New York Times highlighted the issues potential parents face when turning to surrogacy as a means to bring a child into their lives. The article emphasized what so many infertile people know from experience, namely that there is no legal consistency in how different states handle surrogacy. To illustrate the inconsistency, the article states some real-life examples. On one end of the spectrum, there is California, where courts have upheld the validity of surrogacy contracts. On the other end is Michigan, which holds that surrogacy is contrary to public policy and that surrogacy agreements are unenforceable. In between are about 10 states that allow for surrogacy but preserve restrictions, with the majority of states being “silent” on surrogacy, effectively creating legal uncertainty about how intended parents can proceed when their initial plans with a surrogate are challenged. The article did go on to say that fewer problems occur in those circumstances when prospective parents have a genetic link to the offspring, but also pointed out that potential trouble spots can occur in several situations including: when surrogacy arrangements are handled by for-profit agencies, when a woman has not given birth to her own child before becoming a surrogate, when the prospective parents have not been psychologically screened and when there has been no preapproval by a court in a process that would include a home study. For the approximately 750 babies born each year in the U.S. through gestational surrogacy, the legal limbo has potential ramifications for all the players in the effort to provide a healthy and loving home for these babies.

So, what lessons can we learn from this, given that legal protections will be slow to develop and, even when they do, different states will offer different enforcements? First, it is clearly important to choose a nonprofit agency that utilizes protective guidelines. Second, prospective parents should familiarize themselves with existing guidelines developed by organizations such as the American Bar Association, the American College of Obstetricians and Gynecologists and the Society for Assisted Reproductive Technology. Third, it is important to recognize, as the New York Times article emphasizes, that surrogacy is controlled mostly by fertility physicians who stand to profit financially from the procedures they carry out. Also, many of the 100 agencies in the U.S. that coordinate surrogacy arrangements do not adhere to guidelines that would protect prospective parents in case of a dispute. Given that a successful surrogacy can cost between $80,000 and $120,000, prospective parents are in a position to lose not only that money, but also the hope for a newborn to carry home.

What I have taken from this information is that prospective parents need to do careful homework and proceed with caution before choosing surrogacy as a path to parenthood. As attractive as surrogacy may be at first glance, I believe the bottom line is that prospective parents must be vigilant and legally careful in negotiating this particular path to parenthood -- both to protect their rights and the well being of potential children.