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

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

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

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

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

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

No Life Partner? Some women become single moms by choice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Invisible Face of Infertility

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

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

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

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

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

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

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

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

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

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

The Many Faces of Infertility

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

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

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

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

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

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

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

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

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

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

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


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


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


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


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


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

Intimacy for Infertile Couples: Lovemaking or Baby Making?

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

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

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

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

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

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