When You're Not Expecting Part 1

When You're Not Expecting.

Constance Hoenk Shapiro.

Acknowledgments.

I owe grat.i.tude to so many people who have confided in me, supported me, and contributed to this book.

To my family and loved ones: my husband Stuart Shapiro, my son Daniel Shapiro, Kit Transue, and Kara Otterness, who patiently encouraged me as I juggled the joys of motherhood with offering therapy, conducting academic research, and organizing infertility conferences. I offer special grat.i.tude to my daughter Adrienne Shapiro, whose medical expertise provided incisive input to each chapter.

To my former and current students: Margaret Bane St. Peters, Frances Siegel, Emily Lombardo, and Diana Parry, who provided timely research, proofreading, and social networking efforts.

To my dear friends: Ellen deLara and Ellen Jacobsen, whose unflagging professional expertise and suggestions offered new perspectives for me to include.

To administrators and colleagues at the University of Illinois, whose support ranged from providing me with a sabbatical semester that I used to write many chapters to providing nittygritty a.s.sistance with technology issues, with which Andrea Fierro and Diane Wolfe Marlin were particularly helpful.

To my colleagues at John Wiley and Sons, Canada, who not only believed in this book but also provided the editing input that helped make the book so much better.

To my clients, without whose words this book could never have come into being!

Introduction.

When I embarked on my own infertility journey many years ago, I felt completely lost. I had no map to suggest the pathways that might lie ahead. I knew no infertile women - or at least not any who talked openly about their difficulties getting pregnant or their pregnancy losses. My gynecologist was willing to do some preliminary tests on me, but he never once suggested that I seek help at an infertility clinic. And when I said to my husband and family that I was feeling emotionally under siege, no one knew how to comfort me. Even worse, I couldn't figure out how to solve this problem - after all, hadn't I spent years trying not not to become pregnant? Now that I was ready to be a mother, why wouldn't my body cooperate? For several years my husband and I endured tests and treatments, and still my period appeared like clockwork. I, who once had believed that trying hard was the best path to success, was stymied. Didn't anyone understand how desperate I was to have a baby? to become pregnant? Now that I was ready to be a mother, why wouldn't my body cooperate? For several years my husband and I endured tests and treatments, and still my period appeared like clockwork. I, who once had believed that trying hard was the best path to success, was stymied. Didn't anyone understand how desperate I was to have a baby?

Sound familiar? Although my personal scenario may not mirror every detail of your unique quest for motherhood, I suspect you can identify with the loneliness, the frustration, and the sadness. These are challenging feelings, and no one can appreciate them as well as another woman struggling to conceive and have a healthy pregnancy.

Infertility is a journey that is unique for each person, yet it has some well-traveled pathways. Some experiences will be familiar to almost everyone who is infertile. Others will differ if you have pregnancy losses or IVF failures, if you are single, if you are in a lesbian relations.h.i.+p, or if you are already a birth mother and are trying to conceive again. The chapters ahead discuss all these twists in the road.

The survival strategies in this book come from over 200 women and couples I have known and listened to in my 20 years as an infertility counselor. They represent a sisterhood of survivors, eager to share their emotions, coping strategies, and ultimate triumphs. I have disguised identifying information to protect their confidentiality, but I have retained their wisdom and creativity. Of course, my life too has been shaped by infertility, and you will hear my voice in the therapeutic tips at the end of each chapter, as well as intermingled with the voices of the women whose experiences mirror yours.

A major purpose of this book is to introduce you to these traveling companions who made choices about their infertility that allowed them to gain more control over their lives.You will encounter a variety of spirited and sympathetic women who openly share the wisdom they have acquired.Whatever your current situation, you will find stories that reflect and respond to issues you are dealing with right now. And beyond the empathy extended by the voices in this book, you will also find the practical strategies these women used to take back their lives that had been hijacked by infertility.

About half of all infertility is due to male factors, as many of you reading this book are well aware. If you have a male partner, regardless of who is receiving treatment, both both of you are feeling a wealth of emotions a.s.sociated with your collective hope of getting pregnant. However, women and men experience infertility differently. Both feel the apprehension that they cannot easily have children, but women often feel on the outside of what I think of as "The Club." Surrounded by pregnant and parenting peers, infertile women feel awkward and often angry as they are expected to take joy in others' baby showers, birth announcements, christenings, holiday celebrations, and birthdays. Gradually a woman may begin to feel that everyone but her is either pregnant or pus.h.i.+ng a stroller.And whether pregnant friends babble on about Lamaze cla.s.ses or are awkwardly silent in an effort to respect a friend's pain, women's day-to-day lives, as opposed to the lives of men, are intrinsically more tied to conceiving, pregnancy, birth, and nursing, the absence of which can cause a visceral sense of loss. I encourage you to share this book with the men in your life - partners, brothers, fathers, and friends. Men often struggle to understand infertility as women experience it. However, once they have this understanding, men can be very open to suggestions for how they can offer support, and they may need encouragement from you before they can ask for emotional comfort for themselves. Infertility is a challenge to the of you are feeling a wealth of emotions a.s.sociated with your collective hope of getting pregnant. However, women and men experience infertility differently. Both feel the apprehension that they cannot easily have children, but women often feel on the outside of what I think of as "The Club." Surrounded by pregnant and parenting peers, infertile women feel awkward and often angry as they are expected to take joy in others' baby showers, birth announcements, christenings, holiday celebrations, and birthdays. Gradually a woman may begin to feel that everyone but her is either pregnant or pus.h.i.+ng a stroller.And whether pregnant friends babble on about Lamaze cla.s.ses or are awkwardly silent in an effort to respect a friend's pain, women's day-to-day lives, as opposed to the lives of men, are intrinsically more tied to conceiving, pregnancy, birth, and nursing, the absence of which can cause a visceral sense of loss. I encourage you to share this book with the men in your life - partners, brothers, fathers, and friends. Men often struggle to understand infertility as women experience it. However, once they have this understanding, men can be very open to suggestions for how they can offer support, and they may need encouragement from you before they can ask for emotional comfort for themselves. Infertility is a challenge to the couple couple, and it will shape your relations.h.i.+p in unexpected ways. So this book includes the voices of men.You will hear their stories and suggestions about ways to communicate with them more clearly.

An increasing number of lesbians and single women are confronting social biases and declaring their wish to have a birth child. Some may have children from previous relations.h.i.+ps, and some may never have been pregnant. Many have close and supportive networks of friends and family. But social factor infertility social factor infertility, 3 or the lack of a male partner, propels many lesbians and single women to seek the services of infertility specialists and adoption agencies. Although their issues often are not that different from married heteros.e.xual couples who desperately want to become pregnant, lesbians and single women face unique challenges on the pathway to parenthood. This book discusses those challenges, with a range of voices offering creative strategies as well as empathy and understanding.

My own personal anguish during my years of infertility made me vow that if I ever had a baby I would continue to stay connected to the infertile sisterhood with whom I felt such shared experience. I was ultimately fortunate to have two children, but parenthood did not erase the powerful memories of my own infertility. I plunged back into my work as a clinical social worker, devoting my counseling exclusively to infertile couples and individuals. I was amazed that people came from many miles to share their anguish and frustrations, as well as their courage and triumphs.The years progressed, and I found that I was learning more from my clients than my own experience ever taught me. As I spoke with others about the challenges of their infertility, I found myself offering ideas and perspectives that I had picked up from my ever-widening network of infertile acquaintances. And I found my respect growing for the determination and creative solutions demonstrated by my clients and their own infertile friends.

Ultimately, I came to realize that the women who had shared their journeys with me had exactly what every woman struggling with infertility needs, and what you will find as you read on: a wealth of maps, a generous supply of strategies, and an abundance of wisdom to share.

One.

Infertility: The Journey Begins The reasons for deciding to try to become pregnant are different for each woman, as you will notice when you think about your own reasons. Perhaps you were surrounded by pregnant women and new parents, and the time felt right; perhaps your education or your financial circ.u.mstances were at a place where you were ready to take on parenthood as a new life challenge; perhaps your parents, your siblings, or your in-laws increasingly asked when you were going to add a new member to the family; or, even more likely, perhaps you and your partner began to look at your life together and think about what becoming parents would mean. So, after weeks or months of sharing doubt and antic.i.p.ation, you found yourself perched hopefully on the brink of a new life stage: parenthood.

But if you are reading this book, the brink may be feeling more like a precipice. Your hopes of becoming a mother have not been realized. You are filled with apprehension about why it is taking so long to achieve something that seems effortless for Chapter One everyone else. Your questions about where to go from here have sent you to the bookstore, the Internet, and your gynecologist, and the word infertility infertility is becoming all too familiar. This is not a journey you want to embark on, but you realize the best next step is to face this challenge. is becoming all too familiar. This is not a journey you want to embark on, but you realize the best next step is to face this challenge.

Perhaps you can identify with some of the following scenarios: "Bob and I had stopped using birth control, and after about a year I began to feel worried about not becoming pregnant. Since we are in our twenties, my doctor gave me some charts and told me to keep trying - he didn't seem concerned. But it's been 18 months now, and I'm beginning to think that the word infertility infertility may apply to me." may apply to me."

"As a lesbian I have always known that becoming pregnant would present its own set of challenges. My partner and I have not been able to find a physician in our small community who is willing to work with us, so we're resigned to seeking help in a city that is a three-hour drive away."

"My mother took DES when she was pregnant with me, so I have always known that pregnancy might not be as easy for me as it is for others. When John and I were engaged, I told him that he deserved to know about the medical problems a.s.sociated with DES, so my gynecologist talked with both of us and gave us some literature. John said he loved me and that we would face this together. Now that we've been trying to get pregnant for over a year, I'm really worried that this will be a big struggle."

"I was able to become pregnant for the first time with no problem.

We have an adorable four-year-old daughter. But we've been trying to get pregnant for the past two years and now our doctor 6 Infertility: The Journey Begins The Journey Begins has referred us to an infertility clinic, because she can't figure out what the problem is."

"After two years of being unable to conceive, Jack was referred by my gynecologist to a urologist, while I underwent some preliminary procedures. My test results all came back as normal, but when Jack's s.e.m.e.n a.n.a.lysis results came back, we were both floored to learn that his sperm count is low and the quality of his sperm is poor. When the urologist talked with us about artificial insemination by donor, we felt the bottom fall out of our lives."

Whether infertility creeps more persistently into your worries about why you are not becoming pregnant, or whether you have an inkling of the difficulties you might experience with getting pregnant, it is still a rude awakening to realize that pregnancy will not come easily. As the rude awakening becomes a diagnosis of infertility, women and their partners begin to grapple with the meaning of this diagnosis, in terms of both the medical interventions and the uncertainty now a.s.sociated with dreams of parenthood.

Infertility Testing Most couples are apprehensive but eager to establish the source of their infertility as quickly as possible. The statistics regarding who is physically responsible for infertility are split roughly down the middle between men and women (about 40 percent each). In a surprising 20 percent of cases, both the man and the woman have physical issues or the source of the problem is unknown.

With that in mind, it is important to be prepared for the reality that some couples cannot get the definitive answers they seek, 7even after a comprehensive diagnostic workup. Knowing this ahead of time will prepare you for what is likely to be an ongoing series of tests. Ultimately, a small percentage of couples may never know the source of the problem.

You and your partner will feel more comfortable beginning your diagnostic workup if you have some idea of what to expect. Understanding the importance of these initial tests will enable you to choose doctors who perform these procedures on a regular basis. After all, an appropriate diagnostic workup is the foundation on which to develop a successful treatment plan. So without going into too much medical detail or jargon, here I discuss some of the conditions that can contribute to a couple's infertility and the procedures that are typically used to identify these conditions.

Infertility in women is often caused by a problem in ovulation or an anatomical problem, such as blocked or damaged fallopian tubes. In men, fertility may be affected by sperm quant.i.ty or quality. It is important to evaluate both partners for conditions that are contributing to their infertility. Typically women are tested before their male partners, but there is no reason for this, especially if you are trying to proceed as efficiently as possible.

Basic testing of both you and your partner could be completed in six to eight weeks.

A urologist, preferably one who specializes in male infertility, will typically start with a comprehensive medical history and physical examination, which may include blood work, ultrasound testing, genetic testing, or specialized tests on the s.e.m.e.n.

A s.e.m.e.n a.n.a.lysis, the foundation for male fertility evaluation, should include s.e.m.e.n volume, sperm count, motility motility (speed), and (speed), and morphology morphology (shape). This test can reveal the most common male infertility factors: (shape). This test can reveal the most common male infertility factors: azoospermia azoospermia (no sperm cells are being produced) and (no sperm cells are being produced) and oligospermia oligospermia (few sperm cells are produced). (few sperm cells are produced).

8.Infertility: The Journey Begins The Journey Begins Sometimes sperm cells are malformed or die before they can reach the egg. Because of the variation that can occur in s.e.m.e.n samples, most doctors will request two separate specimens at least two weeks apart. Do not expect your partner to be thrilled at this, but do express to him how vital his partic.i.p.ation is in the diagnostic workup. Additional testing may be done to measure male hormone levels, since a hormonal deficiency can easily be treated and result in restoring normal fertility.

While your male partner is being evaluated, you should pursue an infertility workup as well. Many of the appropriate tests can be performed by an ob-gyn. Often, however, a reproductive reproductive endocrinologist endocrinologist, a physician who specializes in infertility and hormonal problems, can evaluate your needs more quickly. After an initial history and physical examination, an evaluation of ovarian function is accomplished by examining you at the beginning of your cycle, at the time of presumed ovulation, and again approximately one week later. Pelvic ultrasound studies and serum hormone a.n.a.lysis provide the physician with a picture of whether or not ovulation is occurring properly. Ovarian reserve Ovarian reserve (the potential to ovulate) should be evaluated by measuring (the potential to ovulate) should be evaluated by measuring FSH FSH, one of the two hormones that stimulate the ovaries, and estrogen estrogen, one of the two princ.i.p.al hormones that the ovaries make. Other tests may be used as well to measure ovarian reserve, which is especially important if you are 35 or older. Another area that is essential in your diagnostic workup is an a.s.sessment of your pelvic anatomy, especially the fallopian tubes and the uterine cavity. The two most common methods of this evaluation are a hysterosalpingogram hysterosalpingogram, an X-ray procedure in which a special iodine-containing solution is injected through the cervix into the uterine cavity to ill.u.s.trate the inner shape of the uterus and degree of openness of the fallopian tubes, and/or a laparoscopy laparoscopy, an outpatient surgical procedure that enables the physician to 9see all of the pelvic anatomy through a laparoscope inserted into the abdominal cavity.

Seeking Help from an Infertility Specialist What is most relevant for you and your partner in your beginning medical investigation is to seek the most comprehensive medical care where the physicians are committed to being thorough and efficient. You may already have begun to discuss with your ob-gyn your concerns in conceiving or carrying a pregnancy to term. Some factors may encourage you to remain with your ob-gyn, at least initially, including a positive relations.h.i.+p, proximity to home or work, insurance benefits, and ease in working with office staff.

However, unless your ob-gyn specializes in infertility, works closely with a urologist specializing in infertility, and has established that your diagnosis is straightforward and treatment is not complex, you run the risk of spending money on incomplete or inappropriate diagnostic tests and treatment that may deplete your finances before you are even referred to an infertility specialist (who may require that both of you repeat the very same tests!). Remember that, dedicated as your ob-gyn may be, most of the patients being treated are either pregnant or trying to not become pregnant. Ob-gyns vary in their commitment, training, and ability to provide infertility services.

You want (and deserve) to receive specialized care for you and your partner.

Infertility clinics have teams of specialists, such as reproductive endocrinologists, who address both medical and emotional aspects of female and male infertility. These clinics aim to conduct an efficient series of diagnostic tests and a broad range of treatment options 365 days a year. The following factors could 10 Infertility: The Journey Begins The Journey Begins mean that the time is right to seek infertility diagnosis and treatment from a specialist: * If you are under 35 and have been trying to conceive for 12 months; over 35 and have been trying to conceive for more than six months; or over 39 and have been trying to conceive for three months.

* If you or your partner has chronic health problems or a serious past illness. Diabetes, high blood pressure, or a history of cancer are examples of conditions that can affect sperm production and ovarian function.

* If you want to have your diagnostic workup and treatment performed as efficiently as possible with staff, who view "the couple" as the patient, available 365 days a year.

* If you have experienced multiple pregnancy losses.

* If you have been seeing a physician for six months and an infertility evaluation has not been completed.

* If a significant male factor, tubal factor, or moderate or severe endometriosis is identified and in vitro fertilization (IVF) is not available in the practice.

* If procedures such as intrauterine insemination have been attempted or drug therapy such as clomiphene has been prescribed for six cycles or more and no additional testing or treatment has been considered.

* If a fibroid or tubal damage has been noted on a hysterosalpingogram.

* If you report pelvic pain, heavy periods, and/or bowel or bladder symptoms around the time of menstruation, and the physician does not suggest having a hysterosalpingogram or laparoscopy to determine the cause.

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The factors above, as well as a belief that you are "stuck" in your infertility rut without further options to pursue, should suggest to you that moving to a higher level of medical care would be appropriate. But disengaging from your ob-gyn can be awkward or difficult, and it is good to be prepared for feelings of ambivalence on both your parts: "How am I going to tell my gynecologist that I want to go somewhere else for an infertility workup? She tells me that she will be able to do all the tests here in town, and that is certainly tempting, since the nearest (and maybe not even the best) infertility clinic is hours away. I've been seeing her for years, and if I'm lucky enough to get pregnant, I'd like her to deliver our baby. I sure don't want to alienate her over this, but already it has taken months to schedule the initial tests. And the worst part of it is sitting in her waiting room surrounded by pregnant women with their bellies out to here!"

"I'm going crazy with my local ob-gyn. Several of my tests need to be timed to my ovulation cycle, and wouldn't you just know that the day I needed to have blood drawn last month fell on a Sunday, and his office was closed! So now I need to wait another month."

Rather than agonizing about your wish to change to an infertility specialist, a useful strategy would be for you and your partner to meet with your ob-gyn. In this meeting you will want to say something like this: "Dr. Smith, I have asked to meet with you both to thank you for your efforts to treat my infertility and to tell you that Jim and I have decided to seek treatment at the Jackson Infertility Clinic. You have been wonderful in your care and concern for me, but we both know I am getting older, I still am not pregnant, and I want very much to 12 Infertility: The Journey Begins The Journey Begins look back on this painful period in my life knowing that I have done everything in my power to seek comprehensive treatment.

You have been an important person for me in this process, and I hope I have your support as I move forward. If I do become pregnant, I can't think of anyone I would want to deliver our baby more than you!"

Bringing closure in this way should enable you and your obgyn to acknowledge the positive aspects of your work together, even as you are clear that you now want to pursue treatment in a different setting.

Choosing an Infertility Clinic So you are ready to contact a clinic, but which to choose?

There are a few important things to keep in mind, the first two being location and cost. Many clinics provide statistics of "success," but these stats can be easily manipulated. Some clinics take on only low-risk cases, while others count pregnancies that do not develop into healthy fetuses. The statistics that are the most meaningful are those of healthy, live births.

It is also helpful to learn the costs a.s.sociated with infertility procedures, whether the clinic provides counseling or support groups, how they will schedule the timing of tests and procedures for couples coming from a long distance, and whether they will permit your local physician to do some blood tests or injections. You may be able to relate to the following situations: "I've gone on the Web to check out the nearest infertility clinic.

Their statistics are impressive, but somehow it all looks too good to be true. I wish that I could talk to some of their patients to see how satisfied they have been with the treatments."

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"The idea of both of us disrupting our lives to travel out of town for treatment is scary. So I made a phone call to one of the clinics and discussed with a counselor just how we could handle all this travel. She said that sometimes blood work and injections can be handled by local doctors and labs who fax the results to the clinic, and that the clinic tries to fit as many tests in for both of us as it can on the day we travel."

Keep in mind that infertility clinics want your business, so it is up to you to tell them what you need in order to decide to become their patient. If getting to the clinic is difficult because of distance, time, cost, or job disruption, propose ways they could make this more manageable. See how flexible they are prepared to be, ask for their suggestions based on other patients like you, and see whether you can make an arrangement that works. The clinic social worker or psychologist may be the best person with whom to have this initial conversation, as those professionals often see their role as being patient advocates. Then pat yourself on the back for being your own effective advocate!

Communicating with Your Partner and Confiding in Others Many couples keep a tight boundary around their privacy at first, but ultimately it becomes a heavy emotional burden to carry alone. Navigating each person's needs can be difficult, and even talking to one another can be awkward or painful. Here are some examples of situations where couples have found it hard to communicate with each other or with those around them: "When I told Luke that I wanted to talk with other people about our infertility, he about hit the roof! He thinks this is our private 14 Infertility: The Journey Begins The Journey Begins business and he can't understand why I would need to talk to anyone but him about it. So what am I supposed to do at the office when I'm asked to organize a baby shower? Or when I need to come into work late because of blood tests? Or when my best friend, who's pregnant, can't figure out why I'm not all excited about shopping with her for maternity clothes?"

"It came as a real shock to us that Jim is the one who is infertile. My test results seem fine. I almost feel guilty to be the healthy one. But the worst part is that he doesn't want to talk about where we go from here. When the doctor mentioned that I might be able to conceive using artificial insemination with donor sperm, I thought Jim was going to dissolve into the woodwork. I feel like I'm going to burst if I don't talk to someone!"

"My husband just doesn't understand why this is such a big deal for me! If it were up to him, he'd be okay if we never had kids - his hobbies, his job, and his guy friends keep him perfectly happy. I guess he says he wants to begin a family because he knows that will make me happy. But now that I'm miserable, he really doesn't want to hear about it. He keeps trying to jolly me out of my misery. I just want someone who will listen! I really get no comfort from him at all."

Not only do most couples need confidantes beyond themselves, they also need to antic.i.p.ate how others may react to their news. And they also need to be prepared for the varied and often surprising reactions of others to their news: "My mom burst into tears when I told her that I was infertile. I think she wants a grandchild every bit as much as I want to have a baby! I can already tell she feels terrible, and I'd give anything 15not to have to share this kind of news. Frankly, I'm not sure how much I'll be able to lean on her, because my infertility seems to cause her so much pain."

"When I told my sister, I couldn't believe her reaction. Do you know what she said? She has three kids under the age of six, and she told me that if she had it to do all over again, she'd never be a parent! She said I should treasure my vacations, my dinners out, my chance to advance my career, and not make a big deal of not being able to get pregnant! I can't believe she is so unable to understand my pain!"

"Many of our lesbian friends have decided not to become parents. Of course we respect their decision, but we have reached a very different decision for ourselves. We tread rather carefully in deciding how much information to share with these friends about our efforts to become pregnant. Not surprisingly, some are more interested than others about being an informal support network for us."

"My best friend was just wonderful. She let me cry, she brought me books from the library, and she'd always understand that it was a very bad time when I got my period. But as time went on I began to feel a real imbalance in our relations.h.i.+p. She was always eager to be there for me emotionally, but it always seemed as if I was the one leaning on her. Whenever I tried to do something nice for her, she would be awkward about accepting, saying that she knew life was tough for me. After a while I felt that our friends.h.i.+p really was out of balance, and that infertility was to blame."

"My husband tried telling some of his friends about our medical workups, and he was surprised and rea.s.sured to learn that 16 Infertility: The Journey Begins The Journey Begins almost all of his friends had either known someone who was infertile, who had lost a pregnancy, or who had adopted. He had felt very alone before that, and now he really appreciates his friends asking him about how our infertility workup is progressing."

"My friends have mixed reactions when they hear that I am trying to become pregnant with donor sperm. As a single woman with no plans to marry, I guess I stand out as somewhat unusual among my friends and coworkers, most of whom are either married or divorced. But that's exactly why I need to find out who is sympathetic to my situation, because sometimes I feel as if I'm going to burst with needing to talk! The issues of finding physicians who will take me as a patient; the books of donors and their characteristics; the worry about whether I can be a good parent without a husband - I need to talk about all of these things with friends. I've been lucky to find a good number of people who have been both kind and helpful. But I've also b.u.mped into my share of people with whom I'll never raise the subject of single parenthood again!"

Would a Support Group or Therapist Help?

Many women find that they benefit from being in the company of people who are especially knowledgeable about infertility and its emotional dimensions. For you, this may occur in the early months of diagnosis, or it might occur later during treatment.

The two most useful resources that women turn to are support groups and therapists.

Community support groups are available locally, and many are sponsored by the Infertility Awareness a.s.sociation of Canada (IAAC) or RESOLVE, the national organization in the 17US providing public education and information about infertility services. You can also find specialized support groups in clinics across North America where the clinic hires social workers and psychologists to a.s.sist patients in discussions about how they are handling the challenges of their infertility. (See the Resources section of this book for organizations that may offer support groups, telephone counseling, or online chat rooms.) A community support group may be right for you if you are comfortable speaking about your personal situation, interested in getting to know other infertile women and men (groups are usually offered to couples, although most groups have more women than men), and if you have questions about local physicians and clinics that other group partic.i.p.ants may have used.

Some community support groups allow pregnant women to partic.i.p.ate, so if being in a group where some members are pregnant would be distressing for you, ask about this ahead of time. Groups usually meet monthly, and the facilitator may be either a professional or a layperson with a personal history of infertility. Here are some examples of women's experiences with support groups as they were told to me: "The first time I went to a support group meeting, I really didn't know what to expect. I was determined to keep a low profile. Imagine my surprise when I found that everyone was very welcoming, and that no one expected me to share any personal information other than my first name. I went alone to that first meeting. But since at that point Tom didn't know any guys who were grappling with infertility, and there was a handful of men who attended, I brought Tom to the next one.

We both found that the support group was a really strong source of emotional support for us. We became friendly with several 18 Infertility: The Journey Begins The Journey Begins of the people in the group and socialized with them. Finally I had a few friends who genuinely understood my misery when I got my period!"

"The support group in my community was good in some ways and not too good in others. The plusses were the lending library and a couple of really solid friends.h.i.+ps that I made. But, because I'm not very comfortable speaking up in a group, I didn't partic.i.p.ate much in the discussions. It was very very helpful to hear the experiences of others that paralleled mine, but each month I would leave the group feeling that my shyness held me back from partic.i.p.ating as fully as I'd like to." helpful to hear the experiences of others that paralleled mine, but each month I would leave the group feeling that my shyness held me back from partic.i.p.ating as fully as I'd like to."

"The support group I attended was a lifesaver! The members of the group were very forthcoming in talking about their experiences with local physicians, with various infertility clinics, and with how to get a discount on expensive medications. Thanks to the group, I chose a physician who was respectful of her patients and who was willing to spend time with me as we weighed my options. I really benefited from the experiences of women who had gone before me, and I was able to avoid physicians and clinics where the quality of care was lacking."

"You know, I think of myself as someone who could benefit from a support group. I've been in various women's groups and have always gotten a lot out of them. But, unfortunately, the support group in our area had one woman who really monopolized each session. I felt sorry for her, and certainly the members tried to be supportive, but after a few sessions it was clear that she was going to dominate the group, so I stopped attending. At that point in my infertility experience, I needed to be able to give and get support, and the group didn't allow enough of that."

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Psychologists and social workers are also available in most communities, either in family service agencies or in private practice. Therapists are ideal if your partner or you do not get as much support as you need from a group, or if you are reluctant to confide personal matters in a group. Therapists are also an excellent choice for women or couples who feel overwhelmed by their infertility, who feel "stuck" in their emotional reactions to their infertility, who are having difficulty talking with others about their needs, and who are having trouble making decisions about treatment, adoption, surrogacy, child-free living, and moving forward with their lives.

Ideally it is best to have a therapist who is familiar with infertility, so that as little time as possible is spent educating the therapist about tests, diagnostic procedures, side effects of medications, and clinic procedures. However, if an informed therapist is not available, then it is especially important to select a therapist who is comfortable and knowledgeable about issues of loss and about couple communication.Those two topics tend to predominate in much of the therapeutic work that infertile women and couples need to do, and a skilled therapist who can address those issues will be a source of support regardless of their level of familiarity with infertility.

You may see a therapist only for a few sessions, while others remain in therapy for months or years, depending on their needs and on how long they have struggled with infertility. The therapy process is different for every woman: "From the minute I learned that I had a blocked tube, I had such a huge emotional reaction that I knew I needed to see someone who could help me focus on its meaning for my future. My therapist was wonderful, both as an outlet for my stress and as 20 Infertility: The Journey Begins The Journey Begins someone who helped me figure out my emotional investment in becoming a parent. We spent some time discussing my feelings of reproductive betrayal before I was ready to make a plan that included some medically invasive procedures. She helped me learn how to be a.s.sertive with my doctor, how to guard against letting infertility consume every waking hour, and how to take care of myself emotionally. She really helped me to work 'with'

my infertility, rather than to use up lots of emotional energy battling it."

"I was pretty reluctant to see a therapist. Somehow, I'd always thought I should be able to manage my own problems. And I wasn't sure what I should talk about! But my therapist asked some questions that got me started, and as we talked more, I got clearer on the issues that were causing me the most trouble.

Some of what we discussed I took home and talked about with Jeff; other issues were more for me to work on. I guess that's one thing I learned about therapy - it's a chance to work on issues that are causing me pain, so those things don't eat away at me. I saw my therapist weekly for a couple of months, and then once a month for the next year or so. By the time we ended I felt as if she had been a real source of support through an emotionally painful time."

"By the time I landed in my therapist's office it was a toss up between a therapist and a divorce lawyer. I know that sounds weird, but life at home had gotten so bad that I wanted out of my marriage. Sam was unwilling to talk about our infertility as much as I needed to talk. He was spending more and more time away from the house, and s.e.x was strictly for baby making. The therapist suggested that Sam and I both come in for some sessions, and that made a tremendous difference 21in our marriage. We were able to realize how infertility had become a wedge between us - that infertility was the enemy, not each other. Once the therapist helped us to communicate more constructively, Sam and I were finally able to move ahead on decisions about medical options. I can't tell you how glad I am to have gone to a therapist - she really helped to save our marriage!"

"Losing my pregnancy after six months was devastating. A friend suggested a therapist in the community who was comfortable with issues of death and loss. From the moment I met her, I felt as though I could really open up. Although she didn't know much about infertility, she showed such empathy in being able to identify with the pain I was experiencing. She also encouraged me to bring Stu to some of our sessions. He had acted so strong and supportive that I hadn't realized how much he was hurting. Our therapist helped us to grieve together. We made a sc.r.a.pbook of memories, and this spring we're going to plant a flower garden in memory of Miranda - lots of pink and yellow flowers - the colors we would have used in her nursery. Stu and I are feeling more ready to try for another pregnancy. If I do get pregnant, I'll probably go back to this therapist again, because she really understands why I'll be feeling anxious and apprehensive."