When You're Not Expecting Part 4

Seven.

Another Shoulder to Lean On: Support Groups and Therapists You have learned that your life is being redefined by your infertility. It affects your relationships, your finances, your body, your mental health, and your future life choices. Some days your infertility is bearable and other days it is simply overwhelming.

The earlier chapters in this book cover many of the stresses you are trying to cope with, but there are some infertility issues that will make you feel so vulnerable that you wish you had another shoulder to lean on. Since your partner, friends, and family have provided their shoulders already, and you may not want to lean on them too much, you may decide to seek support elsewhere.

Chapter 1 introduced support groups and therapists as additional "shoulders," those people in your community who are committed to helping you feel more empowered. (Different counseling professionals may refer to themselves as "therapists"

or as "counselors," so I will use these terms interchangeably.) This chapter will go into more detail about how to decide what Chapter Seven source of emotional support would be most helpful for you and maybe also for your partner; how you can locate a support group that is a good fit with your needs; how to find a therapist; and what to expect from counseling sessions. It can feel like a daunting prospect but, as you will learn from the voices in this chapter, other people can open up new perspectives on your infertility, provide creative ways of coping, offer information about additional resources, and move you away from a preoccupation with your medical treatment and toward efforts to be more emotionally resilient.

I would like to make a note about the Internet here. Many women enjoy its advantages of being convenient, anonymous, and easy to access. However, it also has disadvantages: it may offer inaccurate information, it may keep you alone at your computer rather than out interacting with people who care about you, and it may prevent you from learning about local resources.

So, if you find the Internet helpful, you should continue to use it, but do consider expanding your network to include local support groups and counselors. They can best help track your ups and downs over time and help you when you are especially vulnerable.

In-Clinic Support Groups Some infertility clinics provide support groups for patients who are undergoing infertility treatment, although, given the distance that many people have to travel, the membership of the group may vary from one meeting to the next. Clinics also provide support groups for patients undergoing procedures such as in vitro fertilization (IVF), which give new partic.i.p.ants an opportunity to learn from those who have undergone a procedure multiple times.

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Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists Also, local hospitals may offer support groups for people who have experienced a pregnancy loss, including miscarriages, ectopic pregnancies, and stillbirths. Such groups usually meet once a month and are facilitated by a mental health professional a.s.sociated with the hospital. Clinic support groups are likely to be led by an experienced professional who understands group dynamics and who is familiar with clinic procedures and the pressures they put on patients. Read on as women share their experiences attending in-clinic support groups: Also, local hospitals may offer support groups for people who have experienced a pregnancy loss, including miscarriages, ectopic pregnancies, and stillbirths. Such groups usually meet once a month and are facilitated by a mental health professional a.s.sociated with the hospital. Clinic support groups are likely to be led by an experienced professional who understands group dynamics and who is familiar with clinic procedures and the pressures they put on patients. Read on as women share their experiences attending in-clinic support groups: "The nurse who led our support group at the infertility clinic was very knowledgeable about IVF, and all the couples attending the group were IVF patients. Some had had as many as five IVF procedures, but many of us were first-timers. It definitely helped to hear the perspectives of the experienced couples.

Even though the nurse knew the medical protocols, the other couples were able to address the emotional aspects of IVF that were becoming such a big part of our lives. They knew what IVF represented to us - the last hope for a birth child. They also understood the financial pressures. The experienced couples knew the anguish of waiting for news about hormone levels after IVF, and they were living proof that if IVF fails the first time, you can try again, a.s.suming that you have the money or the insurance coverage. Those clinic support groups were the emotional glue that helped us through a terribly anxious time."

"One aspect of the clinic support group that I found especially helpful was the support to the partners of the women undergoing IVF. In our group we had husbands and male partners. The facilitator knew how to draw the guys into the discussion. She encouraged the group to offer support not only to the women 117who were being shot full of hormones but also to the guys who had been the stoic rocks for their partners. It helped the guys to feel involved and it also gave them a chance not to be so stoic any more. Most of the men felt apprehensive, since the outcome of the procedure would have such emotional ramifications for their families. The facilitator addressed the issue of temporary impotence caused by the pressure of producing a fresh s.e.m.e.n sample on the day of the procedure. Who would have thought that the men would be willing to speak to such an issue? But in our group, all all the guys were worried about not being able to produce on command. My husband felt the group was a safe and supportive place to go when none of his friends or relatives had a clue what he was going through." the guys were worried about not being able to produce on command. My husband felt the group was a safe and supportive place to go when none of his friends or relatives had a clue what he was going through."

Community Support Groups Community support groups may have evolved informally among infertile couples hoping to share resources and information. And some communities may have support groups sponsored through the Infertility Awareness a.s.sociation of Canada (IAAC) or RESOLVE, the national US infertility a.s.sociation. Although some group facilitators may be mental health professionals, many are members of the local community who have a personal history of infertility and who have acquired expertise and empathy by reaching out to newly infertile people.

"When I went to my first support group I was most worried about how much I would be expected to disclose. I'm a pretty private person, and our community is small enough that I expected I might know some of the people who came to the support group.

Cliff simply refused to go. So I felt very alone as I walked in the door that first time. There was coffee and a literature table, 118 Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists so I occupied myself with those until someone came up and introduced herself by her first name, which felt comfortable to me. She said that she had been coming to the support group for the past two years, and we talked a little about her situation, but she didn't ask about mine. After more people arrived, the leader asked us all to find seats, and she welcomed us to the group and reminded us of the confidentiality policy that we were expected to observe. She encouraged people to say as much or as little about themselves as they chose to. About eight people were there that evening. A few gave their first names and a brief summary of their infertility situation. I decided just to give my first name and to say that I was there for my first time and that I didn't know any other people in the community who were grappling with infertility. When we finished going around the group, the leader asked if anyone had an issue to raise. One woman had just had a very unpleasant experience with her mother-in-law, who expected her to attend a baby shower for a family member. The group talked about this, and the leader was very good about providing specific examples of how to be clear and a.s.sertive about our needs, even when dealing with insensitive people. so I occupied myself with those until someone came up and introduced herself by her first name, which felt comfortable to me. She said that she had been coming to the support group for the past two years, and we talked a little about her situation, but she didn't ask about mine. After more people arrived, the leader asked us all to find seats, and she welcomed us to the group and reminded us of the confidentiality policy that we were expected to observe. She encouraged people to say as much or as little about themselves as they chose to. About eight people were there that evening. A few gave their first names and a brief summary of their infertility situation. I decided just to give my first name and to say that I was there for my first time and that I didn't know any other people in the community who were grappling with infertility. When we finished going around the group, the leader asked if anyone had an issue to raise. One woman had just had a very unpleasant experience with her mother-in-law, who expected her to attend a baby shower for a family member. The group talked about this, and the leader was very good about providing specific examples of how to be clear and a.s.sertive about our needs, even when dealing with insensitive people.

Several others shared personal examples of ways that they had addressed similar family insensitivities. The rest of the meeting was a general discussion of how to communicate our needs to our partners, since that was apparently a common issue. That first meeting really drew me in without threatening my privacy.

As I came to more meetings I felt increasingly able to share, and I was just so touched by the thoughtfulness of the people in the group."

"The time that I was most grateful to be in a support group was during my first year of infertility. I came to a meeting saying that I had an awful pain in my abdomen, and that I was really feeling 119rotten. One of the members asked if I had told my gynecologist, and I said I had and that his nurse had told me to wait 24 hours and come in tomorrow if it wasn't better. A woman who had had an ectopic pregnancy told me that I shouldn't wait, and she drove me right then to the emergency room. Sure enough, it was an ectopic pregnancy, and I was rushed into surgery. The doctors weren't able to save my tube, but they did save my life.

That incident catalyzed our support group into sending a few members to visit my clinic to discuss how to prevent such a close call in the future."

"About six months after I began going to support group meetings, I was hospitalized for surgery to clean out endometrial tissue from my abdominal cavity. Members of the support group had asked if I would like visitors in the hospital and at home. We have no family nearby, so of course I did. Not only did someone from the support group come to visit in the hospital every day, but when I got home group members delivered dinners to us for two weeks. Jerry, who had never gone to any meetings, was so touched by their thoughtfulness that now he attends meetings with me, which has really brought us closer together."

"The woman who leads our community support group has two children she adopted after six years of infertility problems. Our community is small enough that all the gynecologists and urologists in town give her name out to any of their patients who are having trouble conceiving. She is so well known now that people from surrounding towns come to the monthly meetings. We get about seven or eight members each month, and she is very good at drawing people out about the issues they're struggling with. She's been doing this for so long that she knows about 120 Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists all sorts of community resources, from counselors to adoption workers. Many of us have needed to go out of the community for high-tech treatment, and she has even given us names of other people who were willing to share the experiences they've had with certain clinics and hospitals. So, in addition to being a really sensitive support group leader, she has a wealth of information about different options to pursue." all sorts of community resources, from counselors to adoption workers. Many of us have needed to go out of the community for high-tech treatment, and she has even given us names of other people who were willing to share the experiences they've had with certain clinics and hospitals. So, in addition to being a really sensitive support group leader, she has a wealth of information about different options to pursue."

As these stories show, support groups can provide much-needed solace and understanding, as well as information about local and regional resources. However, as I mentioned in Chapter 1, ask beforehand about the group's policy on allowing pregnant women to attend meetings. Those that allow pregnant members recognize that the bonds of the support group are very important to a woman who has achieved a much-wanted pregnancy and who may be fearful of miscarriage.

Those that do not allow pregnant women have established this policy because the members have decided that having a pregnant member in their midst would be distracting and emotionally distressing. Whatever the practice of the group, it is likely that much discussion has gone into the decision to adopt the policy.

Counselors and Therapists As helpful as support groups can be, there also are times that seeing an individual counselor is most appropriate. If you are concerned about privacy, need more personal attention than a group can provide, are overwhelmed by stress, or need special help to think through very personal issues as you grapple with infertility, then seeing someone one-on-one may be the best option for you. Counselors also are able to help couples 121communicate more effectively, make important decisions, or resolve the issues of loss that are so intertwined with infertility diagnosis and treatment.

Let me begin by exploring the different types of professionals who are there to help you. These terms cover a wide range of professionals: Psychiatrists, who are MDs, can provide a diagnosis (especially when you are dealing with feelings of depression and anxiety), and they can recommend and write prescriptions for medication. (Always make careful inquiries about the possible effects of any medication on a developing fetus.) Some psychiatrists offer counseling, but it is likely that they will refer you to one of the other professionals in this list.

Psychologists, all of whom have master's degrees and many of whom have PhDs, cannot prescribe medication, but they have been educated in how to a.s.sess your strengths and limitations in coping. Their counseling expertise has been gained through coursework, clinical internships, and post-degree supervised clinical experience.

Social workers, who will have at least a master's degree, may also have other credentials attesting to their expertise in clinical counseling. Their counseling expertise, acquired through coursework, an internship, and possibly post-degree supervised clinical experience, is often supplemented by skills in promoting couple communication, addressing issues of loss, advocacy, and connecting clients with appropriate community resources.

Marriage and family therapists, who will have at least a master's degree, may also have other credentials attesting to their experience in clinical counseling. Their counseling expertise in marriage and family issues is acquired through coursework, an internship, and possibly post-degree supervised clinical experience.

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Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists You can find a counselor in many ways. Since ideally you want a counselor who has some familiarity with infertility, you might ask any infertile friends if they know of counselors in your area who have been helpful to them. If you prefer to be more anonymous, you can contact the IAAC or RESOLVE (see this book's Resources section) to inquire about finding a local chapter. Other resources may be your local mental health society, your clergy, your ob-gyn, or the social worker at your community hospital. You can find a counselor in many ways. Since ideally you want a counselor who has some familiarity with infertility, you might ask any infertile friends if they know of counselors in your area who have been helpful to them. If you prefer to be more anonymous, you can contact the IAAC or RESOLVE (see this book's Resources section) to inquire about finding a local chapter. Other resources may be your local mental health society, your clergy, your ob-gyn, or the social worker at your community hospital.

Once you have found your potential counselor, you will need to ask a few questions: Can the counselor see me right away, or is there a waiting list?

If you are not feeling a sense of urgency and are willing to wait, at least ask whether you could have an initial interview with the counselor soon so that both of you can a.s.sess if you would be compatible. If you don't feel comfortable with the counselor, keep looking until the fit feels right. If the outcome of that meeting is positive, ask when you can set up regular appointments. If the time frame seems too long, ask the counselor whether she or he can recommend another counselor in the community.

What fee does the counselor charge?

Some counselors have a sliding fee scale, so it is appropriate to inquire about the flexibility of the fee. Counselors charge by the session (usually 50 minutes), and many of them will expect that you pay at the end of each session, even if you need to wait to be reimbursed by your insurance carrier.

Will my health insurance cover counseling? Is there a limit to the number of sessions that it will cover?

Before even committing to a counselor, be clear with your insurance carrier about both of these questions. On your first visit to the counselor, tell her or him what, if anything, your insurance 123will cover, so the counselor knows what you can afford and you don't spend too much time on finances (time that could be spent talking about your infertility issues).

How frequently will my counseling sessions occur?

Most counselors offer weekly appointments. However, in times of crisis, more frequent appointments can be arranged. If you and the counselor decide that less frequent appointments would serve your needs, you can organize that as well.

How can I reach the counselor between regular appointments?

You may have an urgent issue that cannot wait for your next appointment, or you may simply need to cancel an appointment due to illness, a medical appointment, or some unantic.i.p.ated event. Most counselors have answering machines that they check regularly - this is so phone calls do not interrupt them when they're with a client. However, the best strategy is to ask the counselor how she or he prefers to be contacted. (This is also a time to inquire about the coverage that your counselor arranges for clients when she or he is out of town.) What is the counselor's perspective on seeing both me and my partner? What is the counselor's perspective on seeing both me and my partner?

This question is relevant because many counselors will want to meet - at least initially - with your partner and you together.

If you and your partner have already decided that you want counseling as a couple, it is important to know whether the counselor is comfortable working with couples.

The Counseling Experience If you have not seen a counselor before, you are probably wondering what takes place during a session. The exact approach will vary with each counselor, but it is reasonable to expect that 124 Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists in the initial few sessions, the counselor will encourage you to present your perspective on the issues that you're struggling with. in the initial few sessions, the counselor will encourage you to present your perspective on the issues that you're struggling with.

She may ask what you have done to cope and what problem-solving strategies you have used so that she can understand how you approach problems, as well as know what has worked and what hasn't. She will probably ask about your support network and the sources of stress in your life.

The counselor may give direct advice, but many counselors are more likely to ask something like "I wonder what would happen if . . . ?" or "Have you ever thought about doing X?" In that way the counselor can gauge from your response whether you would be willing to try a new approach, or whether the people in your life would be responsive to different behavior from you.

Because so much of infertility involves issues of loss, there are likely to be times when you will find yourself in tears as you describe the sadness, anguish, and mourning that you are experiencing. Almost all counselors expect that raw emotions will surface in counseling sessions, and undoubtedly there will be a box of tissues nearby. You need not feel apologetic about showing emotion with a counselor; your capacity to feel and to share those emotions allows the counselor to better understand the depth of your pain. All counseling professionals expect that their clients are encountering difficult times, and they do not expect you to be coping well on your first visit. After all, they know that your reason for seeking help is to share your pain, to learn new coping skills, to make important decisions, and to emerge from the infertility experience a more resilient person or couple.

The experience of counseling will differ for each person. With the several hundred women and men whom I have counseled, I have found that some needed a sympathetic ear and rea.s.surance 125that I appreciated how stressful infertility had made their lives.

Some needed to learn new communication skills that could ease their relationship with their partner and other loved ones.

Some needed to weigh the options in undergoing a new medical procedure or to face that, after many tries at the same medical procedure, they needed to move forward in making new decisions. Some needed my encouragement to become more a.s.sertive with staff at their infertility clinic (and in several situations, I got my clients' permission to intervene and alert a clinic that staff was behaving rudely or inappropriately with my clients). Some needed to antic.i.p.ate difficult events and think through how they would handle them, and some needed to be challenged to try new behaviors. But all, at one time or another, needed to hear from me that they were making good decisions, that they were ent.i.tled to the emotions they were experiencing, and that they were coping in constructive ways despite the pain of their infertility.

People who have experienced a pregnancy loss, whether an abortion, a fetal reduction, a miscarriage, an ectopic pregnancy, or a stillbirth, will find that counseling can provide an emotional cushion for grieving. Not only will the counselor not expect you to "pull yourself together" or to "accept that it is for the best," as many friends and families may advise, she or he will be patient and accepting of your grief. Many counselors have had considerable experience helping people work through their grief after a loss, and they will understand that you and your partner may have quite different ways of coming to terms with your loss. Since the losses a.s.sociated with infertility are neither recognized nor ritualized in our society, you may find that the counselor can help you think through how to memorialize your pregnancy loss in a way that has special meaning for you.

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Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists Infertility is a condition that encourages you to focus on your body.Whether you are preoccupied with your menstrual cycle, diagnostic tests, medications, test results, side effects, or your ultimate success in becoming pregnant and delivering a healthy baby, the body and its reproductive capacity are central to every person who grapples with infertility. The health professionals with whom you interact will reinforce this. They may inquire about how you're doing, but their expertise is more with your physical health than your emotional health. So it is up to you to recognize that this journey along the pathway of infertility will require emotional resilience.You have sought the best medical care; now you will also need to remind yourself that getting professional help for your emotional health is critical to your capacity to weather the frustrations, disappointments, and anguish of the infertility experience. Infertility is a condition that encourages you to focus on your body.Whether you are preoccupied with your menstrual cycle, diagnostic tests, medications, test results, side effects, or your ultimate success in becoming pregnant and delivering a healthy baby, the body and its reproductive capacity are central to every person who grapples with infertility. The health professionals with whom you interact will reinforce this. They may inquire about how you're doing, but their expertise is more with your physical health than your emotional health. So it is up to you to recognize that this journey along the pathway of infertility will require emotional resilience.You have sought the best medical care; now you will also need to remind yourself that getting professional help for your emotional health is critical to your capacity to weather the frustrations, disappointments, and anguish of the infertility experience.

Therapeutic Tips In the preceding chapters of this book I have emphasized the importance of clarifying your emotional needs and taking care of yourself. In this chapter I broaden my emphasis to remind you of people who are well prepared to work with with you to ensure that you are not overwhelmed by the practical details and the emotional uncertainty of trying to conceive. So perhaps after reading this chapter you're wondering you to ensure that you are not overwhelmed by the practical details and the emotional uncertainty of trying to conceive. So perhaps after reading this chapter you're wondering how how will you know if you need more emotional support than you are getting? Here are some warning signs to watch for: will you know if you need more emotional support than you are getting? Here are some warning signs to watch for: * Your friends relate to you only in terms of your infertility and the anxiety it causes. If you sense this kind of imbalance in your relationships, a counselor or a support group might be a good place to turn.

127.* Your partner avoids talking with you about the emotional issues provoked by your diagnosis or treatment. If so, couple therapy would be one way to constructively open up communication channels. If the two of you had decided to lean exclusively on each other for emotional support, this could contribute to your partner feeling overwhelmed or inadequate to meet your needs. In this situation, too, a counselor can help you find different, more balanced ways to cope.

* Your family is either clueless or downright insensitive to your emotional needs. This is a common topic in support group discussions; however, if you think a more personalized approach to your family is what you need, a counselor should be able to look at these family issues and explore with you how you can handle them.

* You find yourself increasingly depressed and unable to take pleasure in events that used to bring you joy or satisfaction.

Mood swings are a known side effect of some hormone treatments for infertility. Be sure to discuss with your infertility specialist the occurrence of any serious mood swings; it is possible that a change in medications will reduce the severity of any depression. Depression is an understandable response to the losses and out-of-control feelings a.s.sociated with infertility treatment. If you can identify a counselor quickly, do so.

He or she very likely will have a working relationship with at least one psychiatrist in your community who can evaluate your depression. Ultimately the counselor will continue to work with you regularly, and the psychiatrist may recommend medication to address your depression. Just be sure to discuss with the psychiatrist, your infertility physician, and your pharmacist any possible effects of those medications on a developing fetus. Your counselor is also likely to know of 128 Another Shoulder to Lean On: Support Groups and Therapists Support Groups and Therapists other supportive resources in your community that can help you use mind-body approaches as an antidote to depression: yoga, guided imagery, mindful meditation, relaxation breathing, and acupuncture, to name a few. other supportive resources in your community that can help you use mind-body approaches as an antidote to depression: yoga, guided imagery, mindful meditation, relaxation breathing, and acupuncture, to name a few.

* Your group of friends is shrinking because of their dedicated memberships in The Club. An infertility support group can provide both empathy and practical suggestions about how to identify helpful resources, how to bring humor back into your life, and how to keep from being consumed by your struggle to have a baby.

* Your spiritual or religious faith is shaken. This may be a good time to talk with the clergy at your place of worship. If you are not affiliated with a particular place of worship, you may be able to learn from friends about a religious leader who can empathize with issues of loss. If attending several worship services provides you with rea.s.surance that you could approach this religious leader, do so and see whether he or she provides the guidance and spiritual comfort you need.

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Eight.

Pregnancy Loss: A Shattered Dream Losing a pregnancy causes anguish for women and their partners. Infertile women never take for granted the capacity to become pregnant, nor do they a.s.sume that a pregnancy will result in a healthy birth. They've experienced too many disappointments and are highly sensitive to the possibility of bodily betrayal.

For those who go the route of home pregnancy tests, the pregnancy may have represented a triumph that they would not need to seek more sophisticated medical diagnosis and treatment. For those who used a.s.sisted reproductive technologies (ART), this pregnancy followed many medical procedures, disruptions in schedules, financial sacrifices, and always an effort to be hopeful about the outcome. Regardless of the circ.u.mstances of the pregnancy, its loss is an excruciating end to the dreams of a baby, of parenthood, of membership in The Club, and of nurturing the family's next generation.Types of Fetal Loss Fetal loss can occur any time in a pregnancy and in many different ways. A loss before the hCG level has climbed is usually referred to as the loss of a chemical pregnancy chemical pregnancy (hCG, or human chorionic gonadotropin, is a hormone that increases early in the pregnancy); a loss that occurs in the first 20 weeks is known as a (hCG, or human chorionic gonadotropin, is a hormone that increases early in the pregnancy); a loss that occurs in the first 20 weeks is known as a miscarriage miscarriage or a or a spontaneous abortion spontaneous abortion; an embryo that begins to develop outside the uterus (often in a fallopian tube) and requires surgical removal to save the life of the mother is an ectopic pregnancy ectopic pregnancy; the abortion of one or more fetuses in a multiple pregnancy is known as multifetal pregnancy reduction multifetal pregnancy reduction; the death of the fetus between the twentieth week and birth is termed a stillbirth stillbirth. Some women experience multiple losses if they are pregnant with multiples and they lose some or all of the fetuses, or if they have repeat miscarriages or repeat stillbirths.

With infertility as a backdrop to pregnancy loss, it can be especially devastating, as it not only represents the loss of a baby but also reinforces the woman's perception that her body cannot be counted on to carry a pregnancy to a healthy birth.

Infertile couples have been conditioned not to get their hopes up, but once they get a positive pregnancy test, they inevitably hope for a healthy baby. Since many women have nurtured dreams of a baby for months or even years, a pregnancy provides a joyful focus for those fantasies.

And from that focus grows an attachment to the baby, minuscule as it may be. Ultrasounds and the photographs of the baby in utero have allowed you to see your new little miracle. Although you know at a rational level that not all pregnancies lead to a healthy birth, you still believe that after trying so long and so hard, certainly this this pregnancy deserves to be healthy. Not only 132 pregnancy deserves to be healthy. Not only 132 Pregnancy Loss: A Shattered Dream A Shattered Dream is the fantasy of the baby increasingly powerful, so is the fantasy of becoming a parent.

At whatever point the pregnancy ends, the losses are profound.

The baby is gone; the role of parent will never be experienced with this child; the hopefulness of grandparents- and aunts- and uncles-to-be evaporates, and you must once again face the world with an ache in your heart. Since there are no rituals to mark a pregnancy loss, you are especially likely to feel isolated in your grief. If you had not yet shared the news of your pregnancy, then there may be few people to support you emotionally.

Grief, Guilt, Regret, and Anger Grief over a lost pregnancy inevitably comes with many other emotions. There is desperation, fear of getting older, stress over watching the savings account dwindle, worries over how many more mood swings you and your partner can weather, and questions about how much more medical intervention your body can take.

Many women experience feelings of guilt and search relentlessly to find a cause for the loss of the baby. They often blame themselves. When the baby is lost, it is understandable to examine whether something you did contributed to the loss or whether you might have done something to prevent this tragic outcome.

Especially for women whose pregnancies were achieved through ART, it is tempting to feel at fault, since the medical aspects of the pregnancy were being watched so carefully. So women who earlier reveled in keeping charts and records now find themselves scrupulously examining their every move, every meal, every lift of a heavy object to identify what they did that could have caused the pregnancy to end. It is common to wonder whether using reproductive technologies might have contributed to the 133fate of the pregnancy. This question is especially troubling for women whose religions oppose a.s.sisted reproductive technologies and who wonder if G.o.d is punishing them for not observing their religion's teachings.

Guilt also can extend to past behaviors that you now regret.

If you experienced the termination of an earlier, unplanned pregnancy, your current pregnancy loss is likely to seem like retribution. If a s.e.xually transmitted infection left you with scarred tubes or reproductive organs, you may regret lack of attention to s.e.xual health. If you delayed childbearing to meet other life goals, you may feel it's a cruel irony that a child really would be the most precious life goal to achieve. In some cases, either partner may be in a second marriage, at last ready to begin a family; the regret at time spent in an earlier relationship can also fuel guilt when you and your partner encounter infertility and pregnancy loss.

Anger is an emotion that is closely intertwined with grief.

After enduring the sadness and frustration of infertility, only to be emotionally a.s.saulted with the loss of a pregnancy, you may feel furious that you are being singled out for such thwarted life dreams. Yet a target for your anger is not close at hand. You may feel angry at the health-care professionals whom you suspect did not do everything possible to ensure a healthy pregnancy.

But given the likely dependence on the same medical staff for future conceptions, you probably will not express your anger openly. You may be angry with G.o.d for punishing you, but the result may be a spiritual isolation from your religious leader or friends in the congregation. Your anger may even be directed at the baby who died in utero. As one mother said, "Couldn't he just have hung in there for nine months?" Even though the targets of the anger may not seem especially rational, there is no question that women and men who experience a pregnancy 134 Pregnancy Loss: A Shattered Dream A Shattered Dream loss are ent.i.tled to feel angry and cheated of a life hope that so many take for granted. Just remember that it is important not to displace that anger into relationships with loved ones.

Reactions of Family and Friends So let's talk about the important loved ones in your life - your partner, your parents, siblings, in-laws, and friends, who may have sh.o.r.ed you up during the months or years of hoping for this pregnancy. Not only do you have your own grief to bear, but you also must figure out how you are going to relate to your support network, balancing your need for privacy and your need for empathic listeners and shoulders to lean on.

Because there is such a discomfort with grief in North American society, even loved ones may minimize the emotional pain a.s.sociated with this loss. It is common for friends and relatives to rea.s.sure a couple by reminding them that at least now they know they can achieve a pregnancy. Some people, believing that a fetal abnormality contributed to the miscarriage, will suggest that "this was for the best" or "you can always try again." These remarks, in addition to being ill-informed, minimize the loss of the baby and further isolate you from the support you need. When you experience a number of insensitive responses, you begin to question whether you even are ent.i.tled to mourn.

Early Loss A positive pregnancy test is hoped-for, but unexpected. Since this pregnancy has been so hard to conceive, you are likely to cherish every single day, even as you are aware at some level that the first several months of a pregnancy can be precarious.

135.So you are watchful, tentatively joyful, quietly apprehensive, appreciating each day that the pregnancy continues. But then a day comes when you are no longer pregnant, and your world falls apart. Here are the experiences of women who share the anguish of losing an early pregnancy: "I was ecstatic when my home pregnancy test turned out positive!

But of course I didn't trust it, so I went to Planned Parenthood and had them do a test, and when that one came back positive I just cried for joy. We had been trying for about two years, and we were just on the verge of going to an infertility clinic for a workup. I was relieved that this pregnancy meant we didn't have to go that route. But after a few weeks, when I began to have cramps, my doctor warned me that I might be facing a miscarriage. She suggested bed rest, which I did for two weeks, but the pains kept coming, and late one night I pa.s.sed a lot of blood.

That was it. No drama, no medical emergency, but my life felt so empty. The doctor did a D&C [dilation and curettage] and told me to wait a couple of months before trying again, but I'm so shattered I can't even look that far ahead. Reed keeps saying it is a good sign that I was able to get pregnant, but all I can focus on is how long it took and how I'm not getting any younger.

I'm just consumed with the sadness of losing this baby. Trying to get pregnant again won't erase from my mind and my heart that my baby died before it could even have a chance at life. So how am I coping? It's hard to say, but one thing that helps is talking about my sadness, and I'm lucky that I have friends and family who are understanding and willing to listen. I'm trying to figure out whether I have the patience and optimism to try to get pregnant again before we go to an infertility clinic. I guess I'd like to know from some specialists if there is a biological reason that getting pregnant and staying pregnant is so hard for 136 Pregnancy Loss: A Shattered Dream A Shattered Dream me. Once I have answers to those questions, it will be easier to figure out what next steps to take."

"You know, with all the medical tests and procedures I've undergone, I'd made a big investment in this pregnancy. At some level I guess I felt that since I couldn't do this by myself, perhaps having the best doctors in the city would ensure a healthy pregnancy.

And in the beginning, when they told me I was pregnant, I felt that we had made the right choice to sink so much time and money into IVF [in vitro fertilization]. But as the clinic monitored my hCG levels, the nurses were more and more cautious with each communication. Finally, when the levels fell too low, they told me that this pregnancy would not continue. I don't even feel as if I'm ent.i.tled to mourn, since they say that I only had a 'chemical pregnancy.' But in my heart, even for just that week, I believed I was going to have a baby. And the sadness I feel is more than a chemical mood swing. So now we have to figure out what's next and whether there is anything the doctors learned from this that will make them more optimistic about another IVF attempt. In the meantime, I'm shedding some quiet tears each day, trying to pamper myself by splurging on funky jewelry and some of my favorite comfort foods. I've also joined a RESOLVE support group, and it really helps to be with these women and couples who also are struggling to move forward with their lives."

"The term ectopic pregnancy ectopic pregnancy wasn't anything I had ever heard of. wasn't anything I had ever heard of.

After all these months of trying to get pregnant, both my doctor and I were thrilled when the pregnancy test turned out positive. And, of course, Dan was just ecstatic. He had put up with my worrying and my charts and my calendars for so long.

It was a joy to begin to plan for this baby instead of worrying 137that I couldn't get pregnant. And then out of the blue came this incredible pain like nothing I'd ever experienced before.

I didn't really think it had anything to do with the baby - I thought it was appendicitis. When we got to the emergency room and they diagnosed an ectopic pregnancy, I didn't know what they were talking about. They had to move me into surgery so quickly that I didn't learn until later that I had lost both the baby and my right fallopian tube, which was ready to burst when they operated. The doctor and everyone else kept telling me that I'm lucky to be alive, but I keep asking how lucky is it to have lost a baby and a fallopian tube that could help me to have another baby? So now I'm trying to slow down, to take care of myself, and to do lots of reading on infertility. But my friend who has been trying for years to get pregnant warned me against getting consumed by my infertility. So she and I have a pact that we'll meet a couple of times a month for lunch or coffee and we'll share what we've been doing to have fun, to soothe ourselves, and to be thoughtful to other people who have their own troubles. There's no question that a big focus in the coming months will be on trying to get pregnant, but I also need to work at keeping my perspective."

"When I had a miscarriage at four weeks, it was practically a nonevent for everyone but Ben and me. Since we already have a six-year-old daughter, no one has ever taken very seriously that I'm grappling with secondary infertility. They know I'm trying to get pregnant, but they also see the joy that Lisa brings into our lives, so they a.s.sume that I'm fulfilled as a parent. Of course I am in many ways, but my fantasy family always included two or three kids. And now that Lisa has been asking for a couple of years why I don't have a brother or a sister for her, I also feel like I'm not the only one to want a larger family. In retrospect, I'm 138 Pregnancy Loss: A Shattered Dream A Shattered Dream glad that Ben and I agreed not to tell Lisa about the pregnancy so early, because I really don't want to have her involved in our preoccupation with having more children. I've decided that I'm going to try to find a therapist who can help Ben and me sort out our feelings about this miscarriage and the shattered dream it represents."

Loss after the First Trimester Once the first trimester has pa.s.sed, and with it the greatest likelihood of losing this pregnancy, you are likely to relax more fully and to begin to take pleasure in being pregnant. By now you have felt flutters of life, you may be wearing your first maternity clothes, you are sharing your news with everyone in sight, and you are feeling round and maternal. And then your life is shattered as you lose this pregnancy. Women and their partners who share this experience are devastated, as is evident in the following scenarios: "I am still so devastated by this miscarriage that I can barely talk about it without breaking down into tears. After all the tests and treatments and after five months of pregnancy, I had really allowed myself to hope that, at long last, I was going to become a mother. I had been wearing maternity clothes for a couple of weeks, so people were asking me about the due date and how I was feeling, and it was just wonderful to be able to share my joy with everyone from best friends to store clerks. To lose this baby is just more than I can bear. Of course I've spent a lot of time wondering whether there was something I did - something I ate, some toxic fumes I was exposed to, some physical exertion, but I can't think of anything. I took the remains of the miscarriage to my doctor, but he was unable to determine anything.

139.So here I am, with my hopes and dreams in shambles. At first I didn't want to leave the house except to go to work. People at the office were sympathetic, but they have their busy lives and now that a month has pa.s.sed they've pretty much moved on. But now when I go to the grocery store with all the babies being pushed through the aisles, and to the mall with pregnant women and strollers everywhere, I am reminded of the joy that I have lost. So I've told Jerry that I need him to do more shopping, and I am trying each day to take walks in a nearby park where I can steer clear of the playground. I've begun to find some solace in nature and its beauty, and I'm becoming more comfortable with being alone and accepting that this sadness is now a part of me. In a way I say to myself that this baby would not want to have me carry this sadness forever, so I'm gradually trying to shape my life around things that make me smile: music, flowers, chocolate, and nature. I've talked a lot with Jerry about what I'm doing to try to heal, partly because he needs to figure this out for himself and partly because I don't want him to think that he has to cheer me up. We're even discussing getting a dog - not as a baby subst.i.tute, but as something to love and have fun with at home. So, who knows? Even though I still feel incredible emotional pain, I know that we will get through this and hopefully become parents someday."

"One of the worst things about losing our baby at six months has been the number of people who hadn't seen me in awhile and who a.s.sumed I had given birth. So what do you do when someone gives you a big smile or a hug and says, 'Congratulations! Is it a boy or a girl?' Of course my eyes would well up with tears and I'd tell them that we lost the baby, and the whole situation was terribly awkward. I would be a wreck for days, wondering how many more times this was going to happen. I almost 140 Pregnancy Loss: A Shattered Dream A Shattered Dream became a recluse, but my mother insisted that I get myself out of the house each day. She told me to practice in front of a mirror what I would say the next time I ran into someone who a.s.sumed the baby had arrived. I had a whole paragraph memorized, and I did feel more in control with words on the tip of my tongue. My mother knows that being in control is important to me. Her help after the miscarriage was so comforting.

She cautioned me that people would try to comfort me with words that offered little comfort, and she was right. I had to figure out how to respond to thoughtless or painful remarks, because to ignore them felt so false. So now when people tell me they're sure it was for the best or they wonder if it wouldn't be a good idea to adopt, I'm able to let them know that I'm still feeling a lot of grief over this baby and I'd appreciate their sympathy rather than their suggestions. As I think about how I'm grieving, I guess I'd have to say that I'm trying to talk a bit about the sadness and at the same time not to let it drown me.

I can only hope that I am able to get pregnant again, and when that happens I intend to tell my doctor that he should treat the pregnancy as high risk from the beginning. But for today and tomorrow and next week, the best I can do is to stay in touch with my sadness when I feel it and open my heart to new things that will bring me joy."