Few among us are not personally aware of the anguish of infertility, either from our own experience or that of a close friend or family member. Both as a clinical psychologist and a husband who has successfully achieved fertilization with my wife resulting in the birth of boy and girl twins, I have seen the problem from both sides. It is so widespread that in 1998, the Supreme Court ruled that conditions that interfere with reproduction constitute a disability as defined by the Americans with Disabilities Act. In 2002, the Center for Disease Control found that 7.3 million women between the ages of 17-44 had significant impairment conceiving and carrying a baby to term. An estimated 2 million couples were experiencing infertility, defined as failure to conceive despite trying over the previous 12 months. We can be sure those numbers have only risen. It is also important to emphasize that where infertility was previously considered to be a female problem, research has determined that at least half the time, the problems are male in nature.
Fertility treatment typically comprises three distinct phases: 12 months or so of natural intercourse without success; intercourse aided by fertility-enhancing drugs, culminating in intrauterine insemination with a catheter delivering washed, concentrated sperm directly into the ovary; and finally, in vitro fertilization (IVF), a meticulous and complex procedure in which eggs are harvested to be scientifically fertilized by washed sperm and then placed back into the uterus. As a couple moves into not months but often years of expensive, intrusive treatments, a spectrum of severe emotional pitfalls typically emerges. Sadly, my observations pertain almost exclusively to those fortunate enough to have access to quality medical assistance.
-- Accepting the need for help. A major hurdle for couples, who may otherwise be in excellent health, often is to recognize that a problem does indeed require medical attention. Infertility is not something that "only happens to other people." After 12 months or so of trying unsuccessfully to become pregnant, a couple needs to consult a general obstetrician who may identify obstacles that can easily be cured if detected early, such as pelvic inflammatory disease. Delaying a fertility evaluation might well exacerbate whatever problems already exist.
-- Just relax. Particularly for couples who are well along in fertility treatment, such advice is pure nonsense, however well-intended it may be. In the face of impending hopelessness generated by failure to conceive, others may want to brush it off by suggesting ill-informed, easy-breezy solutions. Such advice only makes the couple feel worse by inflaming irrational guilt and shame that they must doing something wrong. Do not expose yourself to those who suggest that the problem is "all in your head."
-- Social isolation and monthly mourning. As infertility continues to persist, there is a strong tendency toward social isolation, as it becomes increasingly painful to be around pregnant mothers and infants. Couples may wish to avoid being blindsided in the grocery by, "So, any news?" Learning of a friend's pregnancy can be fraught with feelings of genuine happiness for the other but now mixed with guilt-ridden envy, sadness, and resentment: "She already has two kids, she's not a particularly good mother, she started trying when she was older than I am -- why does she get to have another?" One or both spouses may steadily withdraw from activities and social connections that were previously enjoyed, sometimes turning to online chat rooms for support. Depression and demoralization gather momentum as feelings become increasingly bottled up. Each unsuccessful cycle hits like a death that engenders monthly mourning.
-- Marital discord. Even more destructive than social isolation is the widespread tension, acrimony, and withdrawal from a spouse. "This is your fault for making us wait so long." "Why don't we just give up? I can't take this anymore." "I can't stand being around you, you're so negative." I have worked with couples where each felt they had to hide their anguish in order not to upset the other, thereby eliminating the opportunity to air feelings and openly support one another.
-- Shame, guilt, resentment, bitterness, demoralization, defeat. In the advanced stages of treatment with no success, people often become overwhelmed by feelings of worthlessness, defectiveness, and unfairness. Those with strong religious leanings may become convinced that "god is punishing me for some reason." "I must not deserve to have a baby." "Why me?" Demoralization, defeat, and dread become increasingly debilitating, often derailing the process altogether.
Just as there are characteristic emotional barriers to enduring the often wrenching process, there are helpful guidelines for couples to consider.
-- Choose a fertility specialist wisely. I cannot overstate the need to seek out the best possible care. All fertility experts are not created equal. I am aware of close friends who were told early on by their specialist, "Don't bother," based on some lab work. Happily, the couple sought out another specialist who assessed the same numbers and advised that their case was far from hopeless. IVF led to the birth of very healthy twin boys shortly thereafter. The former specialist, as it turns out, was predominantly interested in research and publications as an employee of a prestigious Chicago hospital. Clinical work was of secondary interest. Word of mouth in conjunction with internet research can help in finding a specialist with documented rates of success and failure. Although medical expertise is essential, "bedside manner" is also extremely important given the often prolonged and emotionally arduous process. Interview the specialist with a long list of questions to assess whether she is right for you.
-- Avoid withdrawal into yourself. Try hard to find those special friends and family with whom you can feel comfortable opening up, less for their advice than for their genuine listening. The special ones will never be burned out by your need to pour it out. Sometimes infertility support groups can help with the sense of feeling so alone with it all. Similarly, in your marriage, keeping the channels open for mutual emotional support makes everything else easier to bear. When spouses succumb to animosity, withdrawal, and blame, chances of success plummet.
-- You do not have to be childless. In working with couples and individuals struggling with infertility, there comes a time to recognize that the process can no longer be allowed to exact its devastating toll. Nevertheless, I strongly emphasize that when this point is reached, they do not have to accept childlessness. Advanced medical techniques allow for sperm banks, preserved embryos, surrogate mothers and the like. When all else fails, I try to help people to consider adoption. Although it can be stunning even to have to contemplate that route, I have observed wonderful results. But it can take time adjusting to the idea before becoming open to it.
Many couples and individuals have no interest in having children. Others can take it or leave it as circumstances dictate. But for those who would find a childless life ultimately empty and meaningless despite whatever wonderful aspects are present, it is essential to understand that the process can be brutally heartbreaking and draining. Nevertheless, there are indeed strategies for emotionally navigating fertility treatment that optimize the possibility of success.