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.

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

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

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

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

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

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

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

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

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

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

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

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