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…..

Pregnancy at 40 -- How realistic is it?

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

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

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

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

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

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

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

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

Pre-Parenthood Perspectives of IVF Couples

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.