When You're Not Expecting Part 5

Loss in a Multiple Pregnancy Couples who have grappled with infertility and who have sought treatment through ART are often dumbfounded with the news that the woman is carrying multiple fetuses. It seems unreal to move from a place of barrenness to a place in which two, three, or even more embryos have implanted in the woman's uterus.

After the initial shock, the couple will discuss with the medical 141team the risks a.s.sociated with carrying the pregnancies to term.

Those couples who believe that multiple births will provide an instant family, or those whose funds would not have allowed them to continue infertility treatment, may discuss the risks optimistically. Other couples, who feel overwhelmed at the prospect of multiples, will be apprehensive as they weigh with the health team the issues they now face. Once a couple comprehends the potential complications during pregnancy, the possibility of premature delivery, and the higher risk of birth defects in multiples, discussions with the medical team focus on how to maximize the health of both mother and babies.

Loss in multiple gestation can occur as an early miscarriage; as a result of fetal reductions; as a loss later in the pregnancy; or may be detected as an ultrasound reveals a change in the number of gestational sacs. The uniqueness of pregnancy loss with multiples is that there still may be the delivery of at least one baby, which leaves parents with the haunting feeling that their family is not quite complete. Another more tragic possibility is that all the fetuses are lost, leaving the couple grief-stricken and bereft. The feelings of loss mirror in many ways those of previously infertile women carrying single pregnancies, but the loss is compounded by unique factors: the extent of medical monitoring of this high-risk pregnancy; the extent of accommodations that the woman has made to ensure the health of the pregnancy; and the emotional capacity of the couple to mourn the loss of each of the babies.

A unique issue that couples carrying multiples face is whether to reduce the number of fetuses. This choice is devastating. The couple must decide whether to abort one or more fetuses to enhance the health and safety of the remaining fetus or fetuses or to keep them all, but with much greater risk to their health and survival. The backdrop of infertility is a constant reminder to couples of how they cherish each fetus and are unable to view 142 Pregnancy Loss: A Shattered Dream A Shattered Dream their decision strictly in terms of medical risk. Couples inevitably feel guilty if they decide to reduce the numbers of fetuses in the pregnancy. Since they never can know whether their decision ultimately contributed to the health of the mother and the remaining fetuses, they are faced with nagging doubts at having made an irreversible decision. In the following stories women talk about their experiences of loss while carrying multiples: "Larry and I were blown away when the doctor told us I was carrying triplets, but we had a lot of confidence in the doctors to monitor the pregnancy and to continue to take good care of me. Imagine our dismay when, at one of our ultrasound appointments, the doctor concluded there was only one heartbeat. As we looked at the monitor we could see three embryos, but two of them were still, while the third clearly had a heartbeat. We barely heard the doctor as she explained that this sometimes happens. All we could feel was that we had lost two of our babies before we even could hold them in our arms. And then, to add to our grief, all our families did was focus on the health of the remaining embryo - altogether ignoring the fact that we were still shedding tears for the babies we had lost."

"The prospect of having twins brought joy into our lives after four years of infertility treatments. I followed the doctors' orders to the letter - I rested, I meditated, I ate carefully. And then at three months I had a miscarriage and lost both of our babies.

We're devastated, and I feel so empty with no flutters of life, no dreams to dwell on. I'm overwhelmed by the feeling that this may have been the only time I will ever become pregnant.

Everyone tries to comfort us by saying that at least IVF worked, but I can't even begin to contemplate another IVF until I've mourned for these babies."

143."When I miscarried one of our twins at 10 weeks, I was overwhelmed with emotions. I was grief-stricken at losing one baby, and I was also terrified that I might lose the remaining twin.

So at the very time that I knew I should focus on being calm for the sake of my ongoing pregnancy, I was crying myself to sleep each night and having a lot of trouble focusing during the day. Dave tried to be comforting, but he was also scared that dwelling too much on our loss would endanger my ability to bond with our baby who was still growing inside me.

Finally we decided to see a therapist, since we just couldn't get past the sadness of one loss and the worry that it might happen again. The therapist helped us to focus on our grief for a little time together each day, which was very soothing for both of us. She also helped us to decide what questions we needed to ask our doctors about the health of our remaining baby. Once we learned more clearly from the doctor the answers to our questions, we used that approach on each prenatal visit to get a sense of some control. Even though we were always aware that the pregnancy was high risk, being able to talk about it with our therapist gave us the ongoing sense we were doing all we could do. Heaven forbid that anything more should happen, but if it does, at least I'll be comforted knowing that we did everything possible to take care of ourselves and this baby."

"When the IVF clinic called to say I was pregnant, Jerry and I were ecstatic. We had spent our savings on earlier IVFs and we couldn't believe that I was pregnant on what would be our last try. But soon we learned that all five embryos had implanted, and both of us were on the verge of heart attacks! There was no way we could possibly raise five children born at the same time. The doctors, who were looking at my pregnancy more 144 Pregnancy Loss: A Shattered Dream A Shattered Dream from a medical perspective, suggested that we reduce some of the fetuses to give the remaining ones a better chance to develop to full term. At first this made sense but, pro-choice as I am, it just felt wrong to make such a matter-of-fact decision about 'reducing' the number of babies that I would have. Since I am small boned to begin with, the doctors said that even if I carried twins there was a likelihood of premature labor. So Jerry and I told the doctors that we wanted them to select the embryo that looked the strongest and to abort the others. Once the procedure was over, we both felt so sad. I keep wondering if we were being selfish about wanting to maximize our chances of having at least one healthy baby. I keep thinking that after our child is born, I'll probably see four phantom siblings playing on the swing set in our backyard."

"Never in my life have I been so confused as I was when our daughter was born prematurely and her twin brother was stillborn. Within minutes of one nurse asking us if we wanted to hold our son before they took his body to the morgue, another nurse appeared to ask if I was ready to visit my daughter in the nursery. I would have known how to react to the events separately, but having them occur together was just too much. We ultimately sent two announcements to our friends - the first being the birth of our daughter and the second being the birth and death of our son. After we brought our daughter home from the hospital everyone focused on her health and cuteness, and Don and I seemed to be the only ones who remembered that we had lost our beloved son. Within a couple of weeks we had a small service in Matt's memory, and preparing for that helped us begin to heal. But I just know that when we celebrate Sarah's birthdays, it will be a bittersweet time for Don and me."

145.Stillbirth Stillbirth is one of the most devastating experiences that an infertile couple can endure. Whether the baby dies before labor begins, during labor, or during delivery, most couples are completely unprepared for such a tragic outcome to this precious pregnancy. Even though the backdrop of infertility leaves most women very cautious about their capacity to conceive and to carry a healthy pregnancy to term, many women let out a figurative sigh of relief after the first trimester, when most miscarriages occur. Unless she has experienced complications in the pregnancy, or unless she has experienced an earlier pregnancy loss, most women a.s.sume that each month brings a heightened likelihood of a healthy baby. Sometimes it is the woman who identifies the warning signs: too many hours with no fetal movement, spotting, cramping, or the onset of premature labor. In other situations, a prenatal visit is the time at which the doctor is unable to detect a fetal heartbeat and must tell the woman that her baby has died. This news precipitates shock and grief as the couple tries to reconcile their previous hopes and dreams with the reality that they will never be able to welcome this baby into the world with joy. Instead they must prepare for the eventual labor and delivery of their dead child.

At this time most women and their partners are mired in confusion and anguish. When they learn that the baby cannot be delivered until labor begins spontaneously or until it can be induced, they face the specter of returning home still visibly pregnant but carrying a load of grief that seems insurmountable.

The couple must consider how to tell family members, how to handle questions about the pregnancy from people the woman encounters in the days before the onset of labor, and how to think about putting this baby to rest after it is delivered. Many 146 Pregnancy Loss: A Shattered Dream A Shattered Dream women want to seclude themselves from the empathic smiles that a pregnant belly elicits, from the presence of pregnant women and infants that once again are unbearable, and from the expectation she senses that she should greet the world with a joyful smile. Many women experience profound ambivalence about carrying a dead baby. On the one hand, both parents can be prepared for the grief they will experience when labor begins.

On the other hand, the pain of knowing that one's baby did not survive causes many women to wish that the delivery could be over so they can stop dreading it. The following accounts show how some women have experienced and coped with the tragedy of a stillbirth: "Last month I called the doctor's office to say that I hadn't felt the baby move for at least eight hours. Since I was seven months along and this was a very active baby, I was worried. The nurse asked me to come right in and there was something in her voice that made me call Jim and tell him to meet me at the doctor's office. We arrived at just the same time, and the nurse showed us right in to an examining room. She said that the doctor would be right in, but that she would get me prepped for the fetal monitor. As she moved the device across my belly, listening for the heartbeat, she couldn't find one. By then Jim and I were frantic, and we demanded that the doctor be brought in right away. The nurse disappeared and by the time the doctor arrived I was in tears. He tried to find a heartbeat and couldn't.

The rest of the afternoon is a blur. I remember being told that our baby had died and being offered the choice of whether to have labor induced or to wait until it began spontaneously. We were in complete disbelief, but we both knew we needed time to be alone and to call our families. The next few days were pure agony. I cannot describe what it was like to carry a baby 147that I had grown to love, that was a real part of our lives, and to know it was dead and there was nothing I could do to bring it back. When the labor began, my father drove Jim and me to the hospital, while my mother followed in their car. It was such a comfort to have my parents there, both for the birth of our dead baby and for all they did to try to ease our pain. My parents asked if we wanted to have a minister visit in the hospital, if we wanted to have a service to memorialize the baby, and even if we wanted to give him a name. But more helpful than anything, they ran the house and the kitchen while Jim and I lay in our hammock in the backyard trying to figure out where our lives would go from here. As I look back over the past four weeks, I still feel the raw pain. Once I had taken as much sick leave from work as I could afford, I tried to get back into a routine that wasn't too hectic. Mom had left a lot of cooked dinners in the freezer, and she and Dad had left us a generous check with instructions to get out of town for some weekend trips. And with them calling us each day, we were a.s.sured that if we really fell apart they would be there in a minute. To my surprise, I did not fall apart, but I still feel an enduring sadness that I don't think will ever leave. Jim and I have decided to plant a memorial garden in our son's memory in the backyard, and as we draw up the designs, I feel calm. Our due date will be coming up soon, and I have already told Jim we must use that date to begin planting. I hope the garden will become a quiet place for both of us to sit and enjoy the beauty that it brings."

"When the contractions began, I had no idea what was happening. After trying so long to become pregnant, I was an expert on infertility, but I was still reading the small library that I'd acquired on pregnancy. None of the books on the last trimester of pregnancy prepared me for labor to begin early in the 148 Pregnancy Loss: A Shattered Dream A Shattered Dream seventh month. So when the pains began I thought I might be constipated. I was on the telephone with my sister when one of the contractions. .h.i.t, and she was immediately suspicious. She insisted that I call my obstetrician, which I did, and I was told to come right to the office. When I got there, the doctor said that I was definitely experiencing contractions. He had been my doctor through all our infertility efforts, so he knew how precious this baby was to us. He told me that he was going to hospitalize me and put me on medication that would hopefully eliminate the contractions and allow me to carry the pregnancy until it was closer to my delivery date. But after three days in the hospital with weak contractions, suddenly they became stronger and my water broke. I could tell from the look on the doctor's face that this was the end, and he gently told me that our baby could not survive. Of course I knew nothing about labor and delivery so, although the nurses tried to help me breathe through the contractions, I had a very hard time. I know it was worse because I was overwhelmed with grief. After the delivery, the doctor let Bob and me hold the baby until we were ready to say goodbye, and then to my shock I was moved to a room on the maternity wing. The nurses thought they were doing us a favor by putting me in a single room, but it took hours before we were able to get my doctor to intervene and have me placed on another floor, away from crying babies, nursing mothers, and proud grandparents. The hospital stay was just the beginning of letting go of our dreams. When I got home I found the nursery as yet another reminder of the emptiness in my life. Bob and I agreed that we needed to put the baby things away ('for another time,'

we consoled ourselves), so over the next week we gently tucked away clothes, diapers, and stuffed toys and took apart the cradle and changing table. Dismantling the nursery was heartbreaking, but at some level it was also a concrete acknowledgment that 149our baby had died. I cried more packing up the nursery than I did at the hospital, where my main emotions were anger and frustration about the maternity ward."

"I had been at the obstetrician's office the day before my labor began, and everything seemed fine. Naturally, with our history of infertility, I was feeling anxious as we approached the due date. I was worried about how I'd handle the labor and delivery and whether I'd be a good parent, but those worries were mild compared to what lay ahead. As soon as my water broke, the doctor told us to drive to the hospital. We were both excited and tense. We called our parents on the cellphone on our way to the hospital and told them to wait for our call about their new grandchild. When we got to the hospital and into the labor room, they hooked me up to a fetal monitor. My contractions were getting closer and closer together, so Tom and I were concentrating on my breathing, and we didn't notice the nurses' concern as they summoned the doctor. When he arrived and looked at the readings from the monitor, he said the baby was in serious distress and would need to be delivered by Cesarean section. We were shocked that something seemed to be so seriously wrong, but we told him to do whatever he could to save the baby. The anesthesiologist put me under, and the next thing I remember is seeing Tom's tearful face. I knew then that we had lost our precious baby. When the doctor came in, he explained that the umbilical cord had been wrapped around the baby's neck and strangled her. So in one sentence I learned that our baby had been a little girl and that she had died. I just couldn't stop crying, so they gave me a sedative, and the next time I woke up, my parents were there and Tom's were on the way. Once I was fully conscious, the nurse explained that we could have some time alone with our 150 Pregnancy Loss: A Shattered Dream A Shattered Dream daughter's body, as a way to say goodbye to her. I reminded the nurse that I hadn't even seen my baby yet, so how could I be expected to say goodbye? I felt so inadequate. I would have known what to do if she had been handed to me alive and healthy after she was born. But there's no way to know how to do what we eventually did - hold our dead baby and explain to her that we would have done anything to save her.

We told her how much our love for her had grown during her time inside me and that we would always remember her. But deep inside I was feeling like a powerless mother, not strong enough to save my own child from dying. First I couldn't get pregnant and when I finally did, I delivered a dead baby.

Intellectually I know I had no control over the cord wrapping around her neck, but emotionally I know that as a mother I failed to protect my baby. I have a hard time believing that I will ever deserve to be a mother."

It is hard to believe that, at the very time you are grieving the loss of your baby to stillbirth, you must make decisions. You may be asked if you want some mementos of your baby, such as a lock of hair, a photograph, the hospital wristband, or the blanket in which the baby was wrapped. You may consider whether to name the baby, whether to request an autopsy, whether to have a religious service, and how to notify family and friends of the baby's birth and death. The next stories cover some of these difficult decisions: "The hospital social worker visited with us the day after our son was stillborn. She was very sensitive, and she told us that she wanted to offer herself in whatever way she could be helpful. She mentioned the kinds of decisions that we probably had begun to consider and asked if we would like to talk about them. We 151decided to ask for her help in learning about burial and cremation options and how to write the obituary, which led into whether or not we would give our baby a name. We hadn't made a final decision when I went into labor. Since it was only my eighth month I thought we had plenty of time. But we had discussed some possible names earlier in the pregnancy, and we finally decided to name our baby Paul, after my grandfather. It somehow became easier to talk about Paul once we had named him. And, in a way, having a name gave him membership in our family, even though he died before we could give him all the love we'd been saving for him."

"When the hospital minister visited us shortly after Melissa was stillborn, we were still in shock. Our families were coming in from out of town, but we were very much alone. We asked the hospital minister to notify the minister of our local church, and she came immediately. She was very comforting, and she helped us to begin thinking about whether we wanted to have a service to honor Melissa's memory. The three of us, with me in a wheelchair, went to the hospital chapel where our minister led us in prayer, and she did that again when our parents arrived. We decided to have a memorial service in the community church, and the minister offered to plan the service and to ask for our input. She was very sensitive to our needs, and she also encouraged members of the congregation to reach out to us, so we felt embraced and cared for spiritually. It was rea.s.suring for our parents to see how members of the congregation supported us with cooked meals, fresh flowers, and offers to run errands. Although we feel empty in our hearts, our minister was able to cushion our pain. She even made an audiotape of the service, so we have that to add to our box of our memories of Melissa."

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Pregnancy Loss: A Shattered Dream A Shattered Dream "While we were in the hospital following Julie's stillbirth, we decided that we just didn't have the strength for a service. We were barely managing around family members who understood our tears and anger, and we weren't ready to be on good behavior in public. Since the stillbirth occurred after seven months and we weren't going to have a service, my mother reminded us that we probably needed to find a way to notify extended family and friends. We decided to have Stan's and my parents call family members, and then Stan and I composed a very brief announcement that we sent to our friends. It said, 'We are so sad to tell you of the stillbirth of our beloved daughter, Julie Marie, on June 1 at Memorial Hospital in Boise, Idaho.'"

Your Partner's Experience of Pregnancy Loss Although loved ones and acquaintances realize that this loss affects both you and your partner, there is often an a.s.sumption that you need more comfort because your body carried the pregnancy. In fact, your partner's initial emotions may have been lost in the medical events that focused primarily on you.

In the midst of hospital procedures, your partner may have felt the need to be strong for your sake, and even hospital personnel may have treated your partner as your supporter, rather than acknowledging the grief that both of you shared. If this pattern started in the hospital, then your partner may have a.s.sumed the role of the strong supporter and discounted the emotional toll the loss was taking on him or her. Once you are home this role is often reinforced by people asking him or her how you you are doing, with the tacit a.s.sumption that your partner's pain is less than yours. are doing, with the tacit a.s.sumption that your partner's pain is less than yours.

So in the midst of your own sadness, you will want to acknowledge to others that your partner is grieving this loss 153too, and ask them to offer verbal and practical support to both both of you. Although you will, of course, welcome the support that your partner is providing, you will need to look for ways that you, too, can offer support. This may be as simple as initiating some time to hold and comfort one another. It could include asking directly about how your partner's emotions are affecting work, concentration, and relationships. As both of you discuss whether or how to memorialize the baby, it will be important for your partner to take an active part in these decisions. Even if the external world sees your partner primarily in a supportive role, you both can strengthen your relationship by making a conscious effort to express not only your grief but also the ways you can move forward in the aftermath of this loss. of you. Although you will, of course, welcome the support that your partner is providing, you will need to look for ways that you, too, can offer support. This may be as simple as initiating some time to hold and comfort one another. It could include asking directly about how your partner's emotions are affecting work, concentration, and relationships. As both of you discuss whether or how to memorialize the baby, it will be important for your partner to take an active part in these decisions. Even if the external world sees your partner primarily in a supportive role, you both can strengthen your relationship by making a conscious effort to express not only your grief but also the ways you can move forward in the aftermath of this loss.

Therapeutic Tips The sadness of a pregnancy loss is not measured by the number of months of the pregnancy, but rather by the emotional attachment of the parents-to-be. With a history of difficulty in conceiving, you and your partner have carried a unique hopefulness. You have known this to be a precious pregnancy, and you probably have felt apprehensions with every twinge and abdominal pain. If you pa.s.sed your first trimester, you may have even breathed a figurative sigh of relief, looking forward to wearing maternity clothes, to letting others know of this much-wanted pregnancy, and carefully celebrating your new status as "almost parents."

The loss of your baby jolts everyone. You and your partner have needed to decide what loved ones to call immediately, how to make some sense of the meaning of this loss, how to advocate for yourselves in the hospital, how to cope with the enormity of your grief, and how to reach out to each other.

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Pregnancy Loss: A Shattered Dream A Shattered Dream Once home from the hospital, you may find that others want to spare you the grief to which you are ent.i.tled. Perhaps well-meaning loved ones have dismantled the baby's nursery; perhaps friends and coworkers tell you you're looking well and they hope life is getting back to normal; perhaps you are encountering acquaintances who haven't heard of your loss and who ask you expectantly whether the baby is a boy or a girl. No matter what the reaction, it is likely that wherever you turn most people lack the words or the empathy to recognize that this loss has changed your lives forever and healing will be gradual.

When you get home, with your pain still fresh, there are some steps you can take to be constructive about your emotional healing: * If concerned friends and family are treating your partner as a supportive bystander, encourage them to express their sympathies directly and to ask how they can be helpful to both both of you at this difficult time. of you at this difficult time.

* Remember that there is no one "right" way to grieve, so both you and your partner should be respectful of your differences as you try to make peace with this sadness. Just because it is a shared sadness does not mean that you will grieve the same way, agree on how to move forward emotionally, or even be able to understand where each other is coming from.

The important message here is to be open with each other about your own feelings and to be respectful of your partner's different pace, different perspective, or different needs for comfort.

* Be as clear as you can with others (including your partner!) about how they can offer emotional comfort and concrete support. Maybe you simply need to repeat your experience many times to understanding loved ones; maybe you need 155to have others run errands for a few months in the public places where you know you will encounter pregnant moms and infants; maybe you need help with bills and insurance forms; maybe you need someone to accompany you on your errands so you won't feel so alone; or maybe you need someone to suggest books, Web sites, spiritual sources of strength, or other resources to comfort you. Gather your loved ones around you physically, by e-mail, on social networking Web sites, or by telephone, and let them know how much their love means and how they can support you as you try to heal.

* Antic.i.p.ate that there will be certain dates and events that may trigger grief. The most powerful one is likely to be your due date. Other days that have the potential to catapult your emotions into a sad place include family gatherings, such as christenings and holidays (see Chapter 6), as well as announcements of pregnancies and births. And then there are the events you never could have antic.i.p.ated, for example, the "welcome baby" advertis.e.m.e.nts and small gift samples that arrive in the mail from businesses marketing to expectant moms. Or you could find yourself emotionally unglued with a call from a local diaper service, asking whether you will enroll with them. These events are unantic.i.p.ated reminders of the different course your life has taken since the time of your pregnancy loss. Give yourself time to breathe deeply, take your emotional pulse, pause to honor the memory of your baby, and take special care of yourself as you regain your emotional equilibrium.

* Find ways to memorialize your baby. You have probably saved items that remind you of him or her. Perhaps you have tucked away an ultrasound, letters from loved ones wishing you well in your pregnancy, a small stuffed animal, or a hand-crocheted 156 Pregnancy Loss: A Shattered Dream A Shattered Dream blanket. Then there may be more careful plans to memorialize your baby. If you have buried your baby, you may choose a small headstone for the grave. If you did not have a service when your baby died, you may want to plan one. In a society that has no rituals for the often invisible loss of a pregnancy, a remembrance service can comfort you and your partner and loved ones who gather to validate your feelings of attachment to your child. You might want to have a piece of jewelry made as a special keepsake, using your baby's birthstone. If your home has a yard, planting a special flower bed or a tree is another way to create a memorial, but keep in mind that you may not live in your current home forever, so if it would be too painful to leave a garden created with so much love, this plan might not offer long-term comfort.

* Consider doing something positive for your community. You can honor your baby's memory through donations such as books for the public library, baby furniture for a day-care center, or a scholarship for a preschooler to attend a nursery school.

A donation to an organization that helps parents cope with the grief of a pregnancy loss may seem especially fitting.

* Create a sc.r.a.pbook of poems that are meaningful. It may also be comforting to keep a diary of the weeks and months after the pregnancy loss, both as a therapeutic outlet for feelings and as a measure of how far along you have come in resolving your sadness as you move forward.

* Try working with a religious leader or therapist (see Chapter 7) who is comfortable helping people who have experienced loss.

Mourning takes time, and as you explore this unfamiliar pathway you may find this helps. Names of therapists can come from the social worker at your local hospital or infertility clinic, from your community mental health clinic or family service 157agency, or from friends who have had positive experiences with a particular individual. Some hospitals offer support groups for parents who have experienced a pregnancy loss or an infant death. Remember that many therapists will accept insurance or will have sliding fee scales, so don't let financial constraints hold you back from seeking emotional support.

* Know that eventually, since you and your partner will find that your emotional needs evolve and change over time, your conversations will turn to whether or when to try again to conceive. In addition to involving your therapist, you will also want to involve your infertility physician to ask him or her to guide you through the medical options, costs, and other considerations in your decision of whether to pursue treatment.

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Nine.

Achieving Pregnancy: An Emotional Roller Coaster Waiting to learn the outcome of yet another pregnancy test is all too routine for most infertile couples. Whether the test is at home or in a doctor's office, the wait for results evokes anxiety, dread that it will be bad news, memories of earlier negative tests, and the hope beyond hope that this test will be positive. Most infertile women believe that they will receive the news of a pregnancy with joyful relief and be ready to antic.i.p.ate the remaining months of this much-awaited pregnancy. However, even with the initial joy and relief of a positive pregnancy test (or two!), many women find that the specter of their infertility haunts them in unantic.i.p.ated ways.

Why Your Pregnancy Feels Different from Others'

Delightful as it is to be finally in The Club with the legions of pregnant and parenting women who take pregnancy and a healthy delivery for granted, you may sense that your Chapter Nine pregnancy - after months or years of infertility - is vastly different from the more easily achieved pregnancies of other women.

First are the emotional hurdles Club members never confronted. They never doubted that they could become pregnant.

They never worried that perhaps the birth control they used (or an earlier abortion) might have contributed to their difficulty in getting pregnant. They never obsessed that perhaps they just weren't "meant" to be parents. They never felt guilty that postponing plans for a family to further their educations or careers had placed them at risk of never becoming parents.

Second are the relationship risks and rifts they never negotiated. They never had to bite their tongues at well-meaning but hurtful remarks. They, unlike you, never had to make up endless excuses why they "just couldn't make" a baby shower, a visit to a new mother, or a holiday event.They never needed to stifle jealousy at a sibling's ease at becoming pregnant.They never needed to experience the awkwardness of a pregnant friend who asked, "So what will this mean for our friendship?"They never needed to ask loved ones for a loan for "just one more"

medical procedure.They never needed to wonder whether their coworkers resented them because of so many absences for medical procedures. And they never had to tread carefully around health-care professionals who held the key to the elusive dream of becoming pregnant.

Third is that they never endured the unpredictable events of the infertility experience: negative test results, bad side effects of medication, and programmed s.e.x. And it is actually the unpredictable aspects of infertility that are so unbearable. These negative events socialize you to expect bad news, and much of your energy goes into protecting yourself from the sadness that has become such an integral part of your life. Once you understand that you have very little control over your efforts 160 Achieving Pregnancy: An Emotional Roller Coaster An Emotional Roller Coaster to become pregnant, you are struck by a unique sense of disbelief when you learn that you are, in fact, pregnant! So what does it mean now that you've received the news you've waited so long to hear? to become pregnant, you are struck by a unique sense of disbelief when you learn that you are, in fact, pregnant! So what does it mean now that you've received the news you've waited so long to hear?

The Many Reactions to Pregnancy Your unique history of infertility will affect your response to the news of a positive pregnancy test. If your history includes pregnancy losses, you may be wary of becoming joyful too soon for fear that you may lose this pregnancy. If you have had many months of treatment during which you have been very vigilant about your body's responses to drugs, procedures, injections, and the like, you may continue this vigilance as you remain alert to every physical sign of discomfort. In a more positive vein, this much awaited news of your pregnancy may cause you to embrace your new ident.i.ty and revel in renewing relationships with members of The Club from whom you had distanced yourself.

"On the one hand, I was just terrified. Since I didn't believe that I had anything to do with my success in becoming pregnant, I was at a loss to believe that I could have any effect on keeping this a healthy pregnancy. Every little thing worried me - morning sickness, exhaustion, breast tenderness, even feeling the baby when it first began to move around. In some ways I think I just transferred all the worries of infertility over to my pregnancy. I was in a worrying frame of mind that wasn't going to stop until I had a healthy baby in my arms."

"This is not my first pregnancy. I've had two miscarriages, and so I know I'm going to be fearful until I pa.s.s the tenth week, 161which is when I lost my other two. I don't dare let myself feel the joy I want to feel. I don't dare let myself become attached to this baby. I don't dare begin to think of myself as a mother.

Everything emotional feels as if it's on hold until I can be sure that this pregnancy will be a healthy one."

"Both Sean and I are so thrilled - this positive pregnancy test has brought our relationship back to where it was before we began trying to get pregnant. Since his sperm count was so low, we just never knew whether it would be possible for me to conceive with his sperm. Now the prospect of having a baby related to both of us is a dream come true!"

"I wanted to shout the news of my pregnancy from the rooftops!

But since I'm single and I've shared my quest for motherhood only with family and close friends, I didn't tell many people about my excitement. But when morning sickness made it necessary to let my coworkers know what was going on, I felt very uneasy - as if I wasn't ent.i.tled to my joy and antic.i.p.ation of being a mother. Happily, once I let everyone know how hard I had been trying to become pregnant, there was a lot of support - mostly from my female coworkers. The guys in the office just seemed confused, but those who have kids seemed more comfortable congratulating me than those who don't."

"The moment I learned I was pregnant, I was determined to savor every minute. I wore maternity clothes long before I needed to, I furnished the nursery with an efficiency that surprised even me, I began going to La Leche League meetings right away so that I would have plenty of time to learn all I could to make nursing a successful experience. And I even began a diary so that, no matter what happened, I couldn't be robbed of remembering the joys of this pregnancy."

162.

Achieving Pregnancy: An Emotional Roller Coaster An Emotional Roller Coaster Prenatal Testing Prenatal Testing In spite of the initial joy of having a positive pregnancy test, you'll find yourself needing to make difficult medical decisions.

After finding an obstetrician or a midwife, one of the next decisions is whether to have prenatal testing. Needless to say, after all the infertility tests you have endured, this decision is one that reminds you that pregnancy does not necessarily result in a healthy baby. And with many previously infertile women not conceiving until after age 35, when they are at greater risk of carrying a fetus with chromosomal abnormalities, the availability of prenatal testing is likely to be presented as an option during the first trimester.

For couples undergoing in vitro fertilization (IVF), there is a procedure that can test embryos in the petri dish for chromosomal abnormalities. And for others, about a dozen fetal tests are now available to diagnose birth defects and disease.

However, a dilemma arises when technology provides enough information to raise concerns, without providing enough information to make a conclusive diagnosis about the health of the fetus.

The possibility of testing in the first trimester means that couples choosing to terminate the pregnancy can do so early enough that it is less public. But for infertile couples, the issue is to decide what diagnosis would warrant ending a much-wanted pregnancy. And if the diagnosis is problematic, it is unlikely that your discussions will carry much further than the office of your doctor or genetic counselor. After all, you probably don't know anyone who has confronted this decision. And since it is such an emotionally charged decision - ethically, religiously, and personally - it is difficult to discuss with anyone other than your closest loved ones.

163.One resource for couples who decide to terminate a much-wanted pregnancy is A Heartbreaking Choice, an Internet support group for people who have terminated pregnancies because of the fetus's health.

The bottom line for most couples is how having a child with a particular defect will impact you, your partner, and your family. A closely related consideration is the potential quality of life for the child. The following accounts tell of how some women have struggled with the issues around prenatal testing: "One of our greatest concerns about prenatal testing was that it might increase the chances of a miscarriage. After all these years of trying to conceive, it would break our hearts if we had a procedure that caused a miscarriage. So we weighed the odds, discussed what it would mean for us to have a baby with birth defects rather than never to become birth parents, and we decided to skip the prenatal testing."

"I had a routine ultrasound late in my first trimester that looked suspicious to my obstetrician. So he sent the ultrasound films to an out-of-town specialist who confirmed that our baby would be born without part of an arm and with stunted legs. There was a possibility of other birth defects as well, but those couldn't be confirmed. I went from the initial ecstasy of being pregnant to shocked depression. Even though we might have been able to handle the physical disabilities, I knew that I could not devote my life to raising a child who might also be mentally challenged.

Deciding to terminate the pregnancy was excruciating, and since we presented it to everyone as a miscarriage, I carry that burden with me to this day."

"The toughest thing for me, at age 36, was to imagine what I would do if the prenatal test came back with problems. It 164 Achieving Pregnancy: An Emotional Roller Coaster An Emotional Roller Coaster turned out that the fetus was diagnosed with Down syndrome. turned out that the fetus was diagnosed with Down syndrome.

Jeff and I agonized, and ultimately his experience with a cousin having Down syndrome tipped the scales. This cousin, at age 21, still does not speak, is barely toilet trained, and as her parents grow older, they worry about what arrangements they can afford to make for her when they're no longer able to care for her. If that is how our child would develop, I don't think our marriage could survive. We just couldn't take the chance, and we decided to have an abortion and to call it a miscarriage."

"In retrospect, I'm glad that I decided not to broadcast news of our pregnancy until after the fetus was tested for Tay-Sachs, since my husband and I are both carriers and know that the risks for a fetus are high. Neither of us could have dealt with having a baby who would suffer and die in the first couple of years - I mean, who would wish that on a helpless child? So when the diagnosis came back with the results we had dreaded, I had an abortion. We had an informal service at our home in memory of our unborn baby and we grieved for our little angel with our family. Now we're trying to decide whether to try for another pregnancy, which could have the same result, or to pursue adoption."

"Tom and I hadn't known that we were both carriers for cystic fibrosis until after I became pregnant. To have this worry after our years of infertility was just too much! I had an amniocentesis so that the fetus would be tested, and we were just destroyed to learn that our baby would have cystic fibrosis, with progressive lung failure and an average life expectancy of 35 years. The thought of knowingly bringing a baby into this world with serious, and ultimately fatal, health problems was just too much.

165.We decided to end the pregnancy. We only told close friends and relatives whom we could trust to be supportive, and their love carried us through."

Emotions in the First Trimester In most pregnancies, previously infertile women find that their emotions are closely timed to the progress of their pregnancy by trimesters. For example, in the first trimester, you may feel joy, but often it is tempered with concern that this is no guarantee of a problem-free pregnancy, a routine delivery, or a healthy baby.

Shifting from your role as an infertile person to someone who actually might become a parent feels like a huge leap of faith. Some women take this leap wholeheartedly, believing that to embrace the pregnancy is to confirm their new status for all to observe. Others are more cautious, especially if they have a long history of reproductive disappointments or pregnancy losses. As the greatest risk of pregnancy loss is during the first trimester, many couples are reluctant to share the news, to become attached to the fetus, or to feel joyful, for fear that such emotions might tempt fate. The physical symptoms in the first trimester can also be disconcerting as morning sickness, nausea, and exhaustion replace the side effects of infertility hormone treatments.

The voices of previously infertile women during their first trimesters clearly articulate both their joy and their apprehension as they antic.i.p.ate the future of this hoped-for pregnancy: "I couldn't decide when to share our wonderful news. Fred was all for trumpeting it to the world, but I needed to have some time to think about it more carefully. We had so many friends 166 Achieving Pregnancy: An Emotional Roller Coaster An Emotional Roller Coaster and family who had been there for us during our infertility. If I told them now and, G.o.d forbid, had a miscarriage, I don't think I could bear their disappointment on top of my own grief. A little voice kept telling me to wait until after the first trimester before sharing the news." and family who had been there for us during our infertility. If I told them now and, G.o.d forbid, had a miscarriage, I don't think I could bear their disappointment on top of my own grief. A little voice kept telling me to wait until after the first trimester before sharing the news."

"My parents, who love me, were clear for years that they hoped I would end my lesbian relationship and find a husband. But as soon as I became pregnant they indicated in a variety of ways their acceptance of Sherry's and my commitment to each other.

I'm pretty sure it is the prospect of being grandparents for the first time that is making them so involved in our lives. Even Sherry is saying that she feels as if my parents have genuinely accepted her."

"Once I left the infertility clinic and was placed under the care of my local ob-gyn, I actually felt even more fragile. At least the professionals in the infertility clinic have a real understanding of how precious this pregnancy is to me. They saw me through the rough times of negative pregnancy tests, mood swings, hormone shots, and even a lapse of insurance coverage. I feel as if everyone in this local office takes this pregnancy for granted and has no understanding of how special it is to me."

"I suddenly realized that this may be my only pregnancy. At a time when I should be filled with joy, I'm finding myself feeling desperate to do everything I can to ensure the health of this pregnancy. I walk gingerly up and down stairs, I eat fruits and vegetables that are organic, I only watch movies with happy endings . . . you get the point. My friends think I'm overdoing it, but after having been able to exert so little control during my infertility treatments, somehow I have the feeling that there are some specific things I can do to make this a healthy pregnancy."

167."Since I'm going through this pregnancy as a single person, the moment I became pregnant I began making a special effort to involve my friends and relatives more closely in my life. Not all of them understand why I would want to raise a child as a single mother, but most of them want to be supportive now that I've shared the news of my pregnancy. Interestingly, it seems as if it's up to me to ask for the kind of support I need, which is a bit strange since I've always cherished my independence. But I'm realizing that I want more people in my life as I worry about whether this pregnancy will be healthy, and as I antic.i.p.ate ways that I'll need support after the baby is born."

"Once Stan and I absorbed this wonderful news, we began to recapture some of the joy in our marriage that had been so badly eroded by the stresses of infertility. And, wouldn't you just know it, after months of programmed s.e.x, where it felt as if our infertility doctor was in bed with us, we had a completely different issue. My obstetrician advised against intercourse during the first trimester! So now that we actually feel in the mood, the doctor tells us we can't make love."

"This pregnancy is different from what I had expected. I'm constantly nauseous, and keeping food down is a real struggle.

That makes it hard to function at work, and I'm worried that the nausea is a signal that the pregnancy isn't going well. My doctor tells me that many women have these symptoms early in a pregnancy, but it makes it hard to be excited and confident when I'm feeling so rotten physically."

"Every time I experience a typical symptom of pregnancy, like morning sickness or fatigue, I just smile to myself. It is a reminder to me that I'm finally finally pregnant. There's no way I'll complain 168 pregnant. There's no way I'll complain 168 Achieving Pregnancy: An Emotional Roller Coaster An Emotional Roller Coaster about feeling queasy or tired - I've waited so long to be at this place that I'll happily take the bad with the good." about feeling queasy or tired - I've waited so long to be at this place that I'll happily take the bad with the good."

"I'm having such fun being pregnant! I'm reading every book I can find, I'm thinking of what to name the baby, I'm beginning to put together things for the nursery . . . but my one sadness is that Jerry isn't as involved as I expected he would be. He tells me that after our years of infertility he still has trouble believing that we will have a healthy baby. So he is staying emotionally removed so that he can be strong to comfort me if something goes wrong."

Emotions in the Second Trimester For most women, the second trimester brings a welcome respite from fatigue and nausea. In addition to facing less likelihood of a miscarriage, you also have the joyful experience of feeling the fetus move inside you, hearing its heartbeat, and watching your shape blossom. Conversations about parenthood now take on a more realistic tone: finances, day care, work hours, division of responsibilities, and s.p.a.ce issues at home. Parents-to-be who have had little experience with infants may even feel some apprehension about parenting skills.

It is normal for any couple to feel ambivalent as they antic.i.p.ate their new roles and acknowledge some reservations about the changes that a baby will bring. However, given the efforts they have pursued to become pregnant, many couples will avoid acknowledging any ambivalence, not feeling ent.i.tled to anything but joyful emotions after the stress of infertility. The stoicism that had characterized your infertility may discourage you from exploring negative emotions with your partner; consequently, you may shy away from discussing the typical 169adjustments that most prospective parents face. Instead, you focus on positive thoughts about preparations for the baby's delivery and homecoming.

In addition to antic.i.p.ating changes on the home front, your pregnancy also may have changed your relationships with friends.

The first and second trimesters are times that you may need to renegotiate your relationships with infertile friends, as well as resume any ties with fertile friends that may have been on hold during your infertility. During the second trimester, the ghosts of infertility are less visible. As the following stories show, most women find themselves eager to antic.i.p.ate the positive changes that will come once they hold a baby in their arms, while others remain nervous about the future of the pregnancy: "When the baby first fluttered in my uterus, it was the most emotional experience I'd ever had! Better even than the news about the pregnancy test, since the baby's movement makes it real and makes me feel as though there really is is a baby in there! a baby in there!

And now that Chuck can feel it moving too, we are having such a wonderful time antic.i.p.ating being parents."