Eventual Moms-To-Be: Heads Up!

How many of us really know how our age affects our fertility? Judging from a recent study, we shouldn’t be bursting with confidence.

Sure, our doctors and ob-gyns have probably cautioned us in general about keeping healthy: avoiding too much weight gain, stopping smoking, being careful about STD’s and STI’s, getting exercise, eating nutritiously, preventing unplanned pregnancies – we all know the drill. But have any of those doctors asked us about the age at which we may decide to try to become pregnant? Not very likely and, if the question is raised, many of us would feel that we have plenty of time (and plenty of plans to pursue) before stopping birth control. And, frankly, our lives may have revolved for so many years around birth control of one kind or another that actually trying to become pregnant may feel like it is light years away.

But, should we look more carefully at those light years? A knowledgeable physician would offer a resounding “Yes!” And we, watching all the famous Hollywood new moms in their 40’s, may have been telling ourselves that we don’t need to be in any hurry. After all, many of us are looking and feeling younger than our chronological ages. And with exercise, help from a dermatologist or plastic surgeon, and careful use of makeup, we are pleased that we can slow the hands of time with a youthful appearance.

But, here’s the deal. Many of those Hollywood 40-something moms cuddling newborns have not shared the more private details of their efforts to conceive: hormone treatments, in vitro fertilization, use of donor eggs or donor embryos. And the couples who have used a surrogate to carry their baby/ies are so blissful at the healthy births that they focus on the bliss of parenthood rather than dwelling on the anxiety of finding and working with a surrogate. Few of those moms need to count their pennies the way most of us would need to do when seeking help with our infertility (which is covered by health insurance in only a small number of states).

And, then, there are some “eventual moms-to-be” who protect themselves against the emotional sadness of infertility by looking at adoption as another path to parenthood. But here again, being informed is important. There are very few healthy Caucasian babies available for adoption in the US, so prospective parents are being encouraged to consider children of color, sibling groups, special needs children and older children. As far as international adoptions go, some countries and agencies have restrictions on parental age, marital status and length of marriage, criminal history, health factors (including obesity), and/or work status (e.g. requiring one parent to be at home full time). So, attractive as domestic or international adoption may seem in the abstract, the specifics require patience and fortitude (which may be especially difficult as we grow older without yet having become a parent).

So what is the concern around women being uninformed about age and conception? A new fertility awareness survey’s results were presented at the American Society of Reproductive Medicine’s recent annual meeting. The poll of 1,000 women ages 25 to 35 who had talked to doctors about fertility found that fewer than 50 percent of participants could correctly answer seven out of ten basic questions. Women were wrong most often about how long it takes to get pregnant and about how much fertility declines at various ages. The facts? At age 30, a healthy woman has about a 20 percent chance of conceiving per month and by the time she reaches 40, her odds drop to about 5 percent. Yet the women surveyed thought that a 30 year old woman would have a 70 percent chance of conceiving and that a 40 year old’s chances could approach 60 percent! They also believed that a 20 year old woman might get pregnant in less than two months of unprotected sex, rather than the five months that is the average.

We are now suffering the effects of not being proactive about understanding our bodies and the way age affects our reproductive capacities. Many fertility specialists bemoan the fact that many women seek their services only when they reach age 40, by which time the biological clock will be ticking very loudly and their reproductive options are increasingly limited.

With infertility as a condition that affects some 7.3 million women in the US (this is 12 percent of the population of child-bearing age) or about one in eight couples, understanding the fertility facts of Bio 101 is important for all couples. Statistically all women should know that after age 35 their fertility plummets, their chances of genetic abnormalities in pregnancies rise, and the number of pregnancy losses increase. So the take away message for all women is to begin conversations with our ob-gyns no later than our late 20’s to be fully educated about any conditions we might have that could compromise our fertility (e.g. endometriosis, diabetes, hypertension, weight extremes, polycystic ovarian syndrome, irregular periods). Then that conversation should move in the direction of when (or whether) you might feel ready to consider parenthood. Better to educate yourself about your fertility early than to face the stunning news that conception will require expensive, time consuming, energy depleting and anxiety producing fertility treatment. Begin these conversations early!

Banishing your heartache on Valentine's Day

As Valentine’s Day approaches, my thoughts turn to people whose plans for indulging in an evening of love may feel uniquely challenged. I’m thinking of people with an ache in their hearts, with an aura of hopelessness, and with a distinctly non-passionate approach to Valentine’s Day. In short, I’m thinking of couples who are grappling with infertility.

Given my experience as a therapist working exclusively with infertile clients, I’m fairly familiar with individuals and couples who no longer feel passion as the overriding dimension when they slip between the sheets. Couples who have difficulty conceiving or carrying a pregnancy to a healthy birth often find themselves shifting their lovemaking 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. Of, 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 posting, I hope to resonate with infertile individuals and couples, as well as to sensitize readers who may have loved ones who are trying to conceive. Today I will focus on the impact of “baby making” and how to bring the “zing!” back into your love life. The infertile couples whom I counsel are usually 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 may 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, the 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 focuses on the few days each month that the woman stands a chance of conceiving. So what does that do to one’s love life the other days of the month? In the words of one couple I quote in my recent book “When You’re Not Expecting,” “Once we began a formal infertility workup, is 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, with Valentine’s Day as a possible catalyst, let me share with you the ideas my clients and I have discussed over the years to bring back the “zing” into their love life. As you read along, perhaps you can use some of these strategies to banish your physician from the 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 associations 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 conversations as a way of blaming infertility for any lack of sexual spontaneity. Affirm how erotic you still find your partner; how much you 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 love making, as contrasted with scheduled sex, back into your lives, see if you can pinpoint any deterrents and figure out how to work around them.
• Be kind to yourselves. Start out slowly, celebrate 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. Make any day Valentine’s Day!

Soothing holiday sadness as you remember absent loved ones

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!

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?

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…..

Pre-Parenthood Perspectives of IVF Couples

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?

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.

Fathers' Day: A holiday of gratitude or yearning?

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.

Rebounding from Springtime Stress!

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?

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.

"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.

Infertility and Stress: Could Yoga be the Answer?

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

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.

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.