Sunday, March 27, 2011

Infertility: Do You Wear A Scarlet Letter?

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.

Sunday, March 20, 2011

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

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.

Friday, March 11, 2011

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

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.

Friday, March 4, 2011

The Stress of Trying to Conceive

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.