For many infertility patients, a longed-for pregnancy is frequently achieved by exhaustive measures involving medical treatments, financial sacrifices and emotional upheaval. There is rarely anything spontaneous or private about the process. For successful patients, a positive pregnancy test marks the unfolding of a new phase. How does pregnancy after infertility differ from other pregnancies and what dilemmas does it present?
Patients anticipating moving on from the distress of infertility and reveling in the joy of pregnancy, may instead find that they have entered challenging new medical and emotional territory. The anxiety of, “Will this work?” shifts to, “Will this pregnancy last?” Many women say that they feel numb, and do not allow themselves to trust their bodies to work properly, sustain a viable pregnancy and produce a healthy child after so many disappointments. While they go through the motions associated with early pregnancy after infertility, checking blood levels, undergoing sonograms and repeated contacts with the fertility clinic, some women protect themselves against the pain of possible loss by being cautiously optimistic, at best. At a time when patients often feel most vulnerable, they successfully “graduate” from a trusted and familiar fertility clinic environment to a new and unfamiliar team of health care professionals.
Women may be surprised that as much as they wished to lose the label of “fertility patient,” they may feel like impostors in the world of pregnancy. Initially, women may feel a sense of isolation and as if they are in limbo belonging to neither the infertile or fertile worlds. Friendships nurtured in infertility support circles may become strained and previous support sources may be off limits.
The dilemma looms of when to announce a pregnancy to family, friends and employers. Early disclosure in the past may have triggered painful situations if a miscarriage occurred. However, when an anxious couple keeps the news to themselves, it can lead to further isolation at a time when the usual social support outlets are unavailable. Couples may also find that their feelings about being pregnant do not conform to the idealized view of pregnancy that they may have carried ever since childhood. There may be disappointment that infertility has robbed them the blissful ignorance of risks that those who did not experience infertility may enjoy.
Pregnancy after infertility involves making the mental shift of changing identity from an infertility patient to a pregnant person and potential parent. During the nine months of pregnancy women move through different stages, including belief in the reality of the pregnancy, altered body image, recognition of individuality and separateness of the baby, and transition to the role of parent. A woman’s normal fears and anxieties may be amplified by her experience as an infertility patient, creating unique emotional challenges. If the pregnancy is proceeding normally, there may be a tendency to mistrust the good news rather than to relax. She may view each new phase or test as a challenge and opportunity for loss rather than confirmation of well-being. Often women describe a sense of vigilance with trying to understand what is going on in their bodies, how best to protect their baby, and how to deal with their feelings. For example, some women will read only one day ahead in pregnancy books, or have rituals and superstitions to protect the pregnancy and manage stressful feelings. Despite these struggles, anxiety will usually lessen when the pregnancy continues to develop without problems. For most women, trust in a healthy outcome increases over time with positive experiences.
Pregnancy after infertility may be further complicated by preexisting conditions related to the infertility diagnosis or related to the process of conception. These include multiple pregnancies, third-party reproduction, older parents and secondary infertility.
Some infertility patients consider multiple pregnancy a desired outcome and a way to avoid future treatment. The inherent risks of the pregnancy, as well as the realities of parenting multiples, may be underestimated during the initial period of joy. On the other hand, complicated situations may arise involving the threat of losing one of the babies or the whole pregnancy, while also potentially confronting painful decisions involving multi-fetal pregnancy reduction. The possibilities of bedrest, prematurity, job adjustments, financial pressures and physical demands grow with the developing pregnancy. Feelings of panic or dismay may arise for a couple who desired one child. The much anticipated pregnancy may instead become too much of a good thing and result in a crisis. Guilt or conflict about decisions made before and after a pregnancy may linger if not addressed supportively with the couple.
Pregnancies conceived using donated sperm, eggs or embryos, or pregnancies using a surrogate or gestational carrier can also complicate the emotional response to a pregnancy. When a pregnancy is the result of donated gametes or embryos, potential parents must have grieved the loss of the dream child together. They must learn to attach to an infant not genetically related to one or both parents, and address issues of secrecy and disclosure and adjust to feelings that may include ambivalence and anxiety. Using a gestational carrier or surrogate involves developing an appropriate relationship with the carrier or surrogate, attaching to the potential child and managing fear, anxiety, and loss of control as well as managing societal attitudes.
For the older first-time mother, pregnancy may represent a last chance to have a child and fulfill a dream. Risks to the mother’s health may be minimized or heightened. Parents may wonder if they are too old or question whether they have the energy to keep up with the demands of young children. In addition to medical risks, social complications may result as remarriage, stepchildren or adult children from previous marriages are considered. On the other hand, women may feel secure in their careers and have the time and wisdom to share with a child who is the primary focus.
People experiencing secondary infertility may have had fertility issues in their first pregnancy or it may come as a shock after getting pregnant easily with their first child. While actively parenting one child, parents may feel set apart from the world of families with many children. Frequent queries from others about another pregnancy can cause such distress that parents commonly avoid social groups that had previously been sources of support.
Thus, pregnancy after infertility presents an emotionally and physically complex experience, while offering unique opportunities for healing that sustain and nurture expectant parents. As mentioned, support during the transition from infertility services to obstetrical care is an important process. It can be enhanced and facilitated by finding caregivers who understand the anxieties involved in pregnancy after infertility and are flexible in interacting with patients. Flexible medical appointments that help to manage anxiety, such as opportunities to hear the baby’s heartbeat in between scheduled visits and telephone contact for reassurance, can calm fears and establish trust in the pregnancy (as well as in the new caregivers). In these situations, the expectant parents feel relieved that they are doing everything possible to ensure a healthy outcome.
Pregnancy after infertility support groups offer another transitional service to couples. These groups can be found through local RESOLVE chapters or may be offered by reproductive medical practices as a service to their patients. The support group forum can provide a safe environment to share the fears and feelings often unexpressed or misunderstood in other settings. Once pregnant, it is frequently expected that previous worries of infertility will be eased. However couples may avoid or delay having faith in the pregnancy or buying maternity clothes and baby supplies. Normal social routines such as baby showers may also be postponed until after the baby is born. Decision-making about prenatal care, testing and life after the baby is born are frequent topics of concern. Having defended against the possible threat of loss for so long, expectant parents may only allow themselves to believe that they will be parents late in the pregnancy. As a result, they may find themselves rushing to make plans for job adjustments, daycare or other accommodations for the baby. Being with others who can validate these experiences and normalize feelings is a powerful tool to help these families have a healthy start.
Coping strategies learned during infertility treatment may also be of help. Mind/body techniques such as cognitive-behavioral interventions, stress and relaxation techniques, keeping a journal or developing e-mail networks are particularly useful for managing anxiety and negative thoughts. Reaching out to organizations such as RESOLVE, Parents of Multiples, and Internet pregnancy resources can also be sources of support. It is especially important that couples be encouraged to find ways to normalize the pregnancy such as attending pregnancy exercise programs, childbirth and preparation for parenthood classes. This will help the transition to the non-infertile pregnancy world. Counseling with a mental health professional who has knowledge and understanding about the unique issues of pregnancy after infertility may also help with this process by providing early intervention and support. Pregnancy after infertility leads to parenting, and raises issues about how these infertility experiences affect families later on. There may be increased risk of depression or anxiety in the post-infertility period, especially in families of multiples or when a woman has a history of depression. Concerns about life adjustments and managing as parents may be heightened. Again, reassurance and support at this time may be essential to building confidence and allowing parents after infertility to also experience the long awaited joys and tribulations common to families everywhere.
Despite the dilemmas presented with a pregnancy after infertility, the vast majority of women do well and in fact often feel better emotionally than non-infertile women. The experience provides the opportunity to grow and heal as a woman and as a couple. The pregnancy can renew feelings of self-worth, self-esteem, as well as relationships with others that were hurt by infertility. Birth of the longed for baby begins a new journey.
Carole Toll, MSW, LCSW-C
Reprinted from Resolve Family Magazine, Fall 2004