How to Cope with Infertility

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Even though the stress of infertility is often unavoidable, there are many steps that you can take to decrease the pain. First of all, both of you must recognize that you'll have different feelings and different reactions at different times. If you expect your partner to behave in a certain way, you may create additional stress. Together, you should become informed about infertility and its treatment. Learn to focus on those factors which are within your control ( for example,, stopping smoking ) than those over which you have no control ( for example, your age). As you examine the treatment options and emotional stages, you can identify in advance the times that you will have difficulty. Then, as a couple, you can plan to make them easier. Talk about your feelings concerning infertility and its treatment. Determine if your expectations of one another are realistic, and accept differences of opinion that your partner may have.

Sharing Your Feelings

Sharing your feelings is essential when dealing with the emotional aspect of infertility. At times, valued friendships are especially important, but friends and family may not understand what infertility means, and they will sometimes make insensitive remarks. As a result, feelings of isolation may increase, and this could lead to depression and loneliness.

Although it is true that many people do not understand infertility, it is important to remember that others don't know what you're going through unless you tell them. If friends make discouraging comments, try not to close them out. You may want to attempt to let them know how you feel and how they can help. Some of the following tips may be helpful.

• Don't assume that everyone understands your needs and what you're thinking.
   
• Don't always put on a brave front. Friends and family may think that you are not distressed and don't need emotional support.
   
• Try to identify your feelings and share them. Putting your thoughts down on paper is often a helpful exercise.
   
• Offer friends and family reading material concerning infertility. Articles or books with quotes from individuals who are infertile are especially beneficial.
   
• Become aware of your own anger directed towards your body, your partner, and your friends. It is important to recognize its effect on you and your ability to communicate with others.
   
• Examine your expectations of yourself and try to understand that infertility can lead to feelings of helplessness and loss of control.
   
• Examine your expectations of others. You will be disappointed if you expect others to always be there for you.
   
• Accept your own feelings and acknowledge that there may be a time when it is okay for you to avoid certain emotionally painful situations.

Coping with infertility in everyday living

Undergoing treatment can "eat up" into your entire day - waiting to talk to the doctor, waiting to take your injections, waiting to do scans, waiting for blood test reports - it's endless and all you do is wait! The treatment seems to take all day - and you don't seem to have time to be able to do anything else. You need to take control of your time. While some waiting is unavoidable, a lot can be minimised. Can your husband learn to give you the injections so that you don't have to come into the clinic for them? Can you get the blood tests reports on the phone? Also, learn to make good use of the waiting time - you can read more about your problem ; and also talk to other patients in the clinic - this often become the place for an informal "support group" meeting!

The waiting to get pregnant also makes you put the rest of your life on "hold" you find you cannot make plans for the future because you do not know what lies ahead. Should you plan to go on a holiday next month - what if you get pregnant? Should your husband accept the new job, even if it means a transfer to another city and you will have to find a new doctor? This can be frustrating - not only are you not getting pregnant, but you also cannot get on with the rest of your life! You need to try to separate infertility from other important aspects of your life - and remember that you are a worthy person irrespective of your fertility. Women often have a harder time, because they have been taught that their life revolves around their family - which has yet to be started! Often getting a job is helpful, because it keeps you occupied and bolsters your self-esteem by confirming what you know - that you can accomplish useful things with your life irrespective of your fertility.

Talking to relatives and friends can be difficult when they ask awkward and thoughtless questions about infertility. Some typically painful questions include:

• So when are you going to start a family? You two aren't getting any younger!
• When are you going to stop concentrating on your career and start on a family?
• Well, I guess we'll never be grandparents.
• Oh, I have just the opposite problem - I get pregnant so easily.
• I wish you'd take one of my kids - they drive me crazy!
• I hear they're having tremendous success with test-tube babies. Why don't you try it?
• You can always adopt.
• Any good news yet?

Questions and comments from others can be turned into opportunities for you to explain your situation more fully to close friends; or you can discourage further discussion. Be firm and pleasant - and don't let yourself be put on the defensive. After all, just because a question is asked does not mean it deserves an answer, so with a smile, you can let them know that it's none of their business without being rude yourself.

Think about how you will respond to these questions - and plan ways in which you can successfully manage the conversation. There are emotional barriers between the fertile world at large and infertile couples - and you need to work to overcome this!

Dr Epstein has described activities which you can use to help yourself at  http://www.mindspring.com/~yepstein/activ.htm. Check this out - it's a very valuable DIY resource !

Times that may be especially difficult

Social gatherings such as weddings where the conversation focuses on pregnancy and children can be difficult to cope with. You'll also inevitably have friends who become pregnant during your infertility treatment. The news that infertile friends have conceived with treatment can be bitter-sweet - you are happy for them, and know that this also means there is hope for you; but you feel it's unfair that you are not the one pregnant, and sometimes despair whether you will ever be able to have baby. Furthermore, holidays and birthdays may bring added stress by reminding you that time is passing by without children.

Time becomes the enemy - whether it is the incessant ticking of the biologic clock, or the endlessness of waiting for the next menstrual period. The few days before your next period is due can be hell for both of you. The suspense is killing - and you await every day with bated breath to see if the period has started. Each twinge of pain or drop of discharge is monitored carefully - and if the period is delayed, hopes start rising. Then, when the menstrual flow starts, all the castles in the air come crashing down, and you are inconsolable. You sometimes wonder - is it worth beginning all over again?

Coping with treatment is difficult too - especially when you know that for most treatments, it is impossible to predict what the outcome is going to be. Also, with nature's imperfection and today's technology, the chance of your not getting pregnant in any cycle will always be more than the chance of your conceiving. Often the key to success may be to repeat the treatment several times but this can be pure torture! You need to be realistic about your chances of conceiving - this level headedness can help to buffer the disappointments and tribulations of failure. Some women feel that they must maintain a "positive" attitude, no matter what and put up a brave front to the world - but pretending to be hopeful when you are broken inside increases your burden.

Regaining Control

In order to decrease your feelings of helplessness and to regain control of your emotions, there are several things you can do. First of all, take the time to learn about your infertility. By doing this, you will feel more in control at your doctor's office and you'll be better able to understand the tests and procedures that you're undergoing. Read about infertility treatment, and discuss your ideas and opinions with your physician. It's also important to talk with all of your health care providers. For example, your nurses may be able to help you with troublesome emotions as well as medical questions, or a technician could explain test procedures and results.

You need to make an "action plan" outlining possible courses of action as regards your medical treatment. For each treatment cycle, hope for the best and prepare for the worst. If you get pregnant, that's fine; but you should know what do next if you do not so that you are not shattered when it doesn't work. Many couples refuse to think about the possibility of failure and plan treatment on an ad-hoc single cycle basis. This is unrealistic and you are only fooling yourself. Being realistic allows you to cope with the ups and downs of treatment - and you need to have a time perspective which includes 4 to 6 treatment cycles, so as to give yourself a reasonable chance of success.

During treatment, you need to set your own limits. Sometimes, treatment becomes a merry-go-round, which never stops and you find that you just can't get off. Some patients get "hooked" onto treatment and never give up - at great pain and expense to themselves. Decide when you will stop treatment and which treatments you will try. This is a decision only you can make and it should satisfy you that you have done all that you want to - so that you do not have any residual feelings of regret later! If medical therapy becomes too stressful, consider taking a break. When necessary, make it a point to remind friends and family that these are your decisions and that you know what's best for you.

Little things that you do for yourself can make a big difference in how you handle your infertility. Write down positive things you have done or good things that have happened, and read them often. Plan a special evening, and share your thoughts and feelings with your partner. You and your partner may want to join a support group so that you can meet people who are experiencing infertility. It is also important to become more informed about infertility, so that you can share this information with friends and family who do not seem to understand the stress and pressure surrounding this disorder.

Many patients find religious support at this time is very helpful - and a deep belief and abiding faith in God can help you immensely in tiding over this crisis in your life. Others use meditation to help themselves.

How Infertility Affects Couples

Infertility is a medical problem that involves two people - and both of you remain involved even if only one person needs medical treatment. Attend medical appointments together if possible - it is very lonely and frightening sitting alone in the doctor's office, and the support you give by your presence is very helpful. Sometimes the partner who is undergoing all the tests and treatment ( usually the woman!) may feel resentful and angry at all the poking and prodding. Blow off your feelings - but not at your partner - rage at fate instead. Chances are your spouse would do anything to take this burden from you. If you are the partner who is not being treated, you may feel strangely guilty that you are getting off "free". You may also be upset and blame your partner for the infertility problems - but being upset and giving needless blame are two different things. Some husbands are very upset about all the procedures that their wives have to undergo - and often cannot bear to see the pain they have to go through.

Men and women generally respond to infertility differently. Generally, while men are concerned about infertility, it may be less crucial to their self-esteem and identity. Also, handling the emotional impact of infertility may be more difficult for them because they are not used to voicing and sharing these types of concerns - they are taught to bottle up their feelings. On the other hand, women frequently accept the label of infertile as a key aspect of themselves and who they are. In Indian society, the pressure to conceive is directed towards the woman, and it is often she who has to bear the brunt of its impact.

It is common among infertile couples for the woman to be the much more verbal and emotional partner. This often leads to the wife thinking and talking incessantly about infertility, and her whole world now revolves around how to have a baby. She talks ( or complains or screams or cries ) about it and wishes her husband could feel the intensity of her pain. He tries to be supportive, but never seems to be able to do or say the right thing, so he gets "put off and shut off" and refuses to talk about it - exacerbating the tension even more. In order to help keep infertility from becoming an all-consuming event and to break this vicious cycle of one-sided conversation in which no productive communication occurs, the "20-minute rule" recommended by Merle Bombardieri of Resolve, is very useful. You need to set aside a period of time each evening to talk about infertility. Use a timer to limit each person to 20 minutes and let one speak and then the other. The person not speaking needs to listen intently.

This technique is useful in achieving the following outcomes:

• The wife will talk less about infertility and will present her feelings more succinctly.
• The husband is more willing to listen because he is assured of an end point.
• The wife feels she has an interested listener and is supported.
• The rest of the evening may be spent in more pleasant pursuits.
• You may both feel relieved to see the other feeling better.
• In all likelihood, as the wife feels she has less need to talk about infertility, the husband will begin to be more expressive - so that the wife no longer needs to "grieve for two".

Communication in your relationship may change as you and your partner deal with infertility and its treatment. Sometimes, you may keep emotions to yourselves as you try to protect one another from painful feelings. This may create especially difficult feelings such as anger, blame, and guilt, and you may find that there is even more pressure in your relationship. You have the right to feel differently about infertility treatments and choices - after all, even though you are a couple, you are still individuals with your own separate identities. Individual responses depend on personality, coping mechanisms, who has the fertility problem, and your relationship with your partner. You may feel hopeful and optimistic, while your partner feels hopeless and despondent - and you may find that you are balancing on opposite sides of an emotional seesaw. You can agree to disagree - but keep your heads and fight fairly, and honestly.

Acknowledge the fact that infertility does put a lot of stress on the marriage. In fact, it is not uncommon for some marriages to break down because of the pressure which infertility subjects them to. However, if you have the maturity to deal with this crisis in your life together, you will find that learning to cope with infertility allows you and your partner to grow and become closer as you share your feelings throughout this difficult time - and your marriage will become much stronger than most marriages because you have weathered a difficult time together successfully.

Stress and Infertility

Most infertile couples are under considerable stress. Personal, social, family, financial. Hardly surprising – when you want to get something and you cannot, this is a perfectly normal and natural response. Thus, it’s obvious that infertility causes stress.

However, what about the converse – can stress cause infertility?

Stress is ubiquitous, and– and in today’s world, stress is something we are all exposed to. It has now become fashionable to blame the "stress of modern life" for all ills – including infertility, and many elders feel that it is the stress which the modern generation is exposed to, which is responsible for the increase in the incidence of infertility. Stress can cause disruption of the body’s equilibrium, and excessive stress can interfere with ovulation, so that women may not produce eggs. While this is a biologic explanation for how stress can cause infertility, it is unfortunately become all too common to blame stress for everything. Often a form of victim-blaming – "You are too stressed out to get pregnant. Just relax and go for a holiday, and you’ll get pregnant". However, while stress can decrease fertility, it is obviously too simplistic to blame the couple for being stressed out. Thus, if a woman has bloced tubes, then this is going to cause her stress – and it’s obvious that in this case it’s the blocked tubes causing the stress, rather than the stress causing the tubes to get blocked! However, for some couples, specially those with unexplained infertility, this relationship can be a complex chicken and egg problem.

It is useful to develop constructive ways of coping with the stress of infertility. Many programs have focused on the mind-body relationship for the infertile couple, and have reported gratifying successes. Useful as a sole mode of treatment; perhaps, even more useful in teaching couples to cope with the stress of taking treatment.

We too encourage our patients to be optimistic – to hope for the best, while preparing for the worst. However, since many patients blame themselves when they do not get pregnant, the backlash of this is that then the wife does not conceive, the husband often blames her further by saying she was too stressed out, which is why she didn’t conceive. This is simply adding insult to injury, and is very unfair!

When Professional Help May be Necessary

If you remain depressed, rather than having "ups and downs" that seem to be related to your treatment, you may need to seek professional therapy. Counseling can help you honestly examine your feelings, determine your priorities, and improve your coping skills.

There are several signs that indicate serious depression. If you find yourself constantly feeling sad, desperate, worthless, or inadequate, professional counseling may help you better understand your situation. Other signs that indicate a need for professional counseling are lack of motivation, withdrawal from social activities, feeling overly sensitive, vulnerable, or guilty, and having suicidal thoughts.

In addition to the emotional signs of depression, there are several biological and physical signs that you should look for. For example, if you're having difficulty falling asleep or staying asleep or if you find yourself waking up early and being unable to go back to sleep, this could signal depression. Other signs are excessive increase in or loss of appetite, loss of sexual desire, and fatigue.

You might also want to seek help if you and your partner are unable to communicate with each other about your infertility and its treatment, and if you're having difficulty coping with extreme anger or resentment.

It is important to select a therapist who has experience in infertility treatment and the difficulties and emotions that go long with it. Remember, you are choosing the therapist. It is acceptable to interview a number of professionals in order to select someone who is familiar with your situation and who makes you feel comfortable.

Dr. Domar has pioneered the development of specialized Mind-Body programs which are specifically designed for infertile couples. These teach couples useful tools, such as yoga and meditation, to help them to elicit the relaxation response which improves their physical and emotional responses to stress; and also behavioral strategies to enhance coping skills. The goals of these programs are to increase sense of control and well-being; and develop skills to ease the infertility treatment process, and has been shown to help many patients.

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