Infertility is an experience that strikes at the very core of one's life. Reproduction is considered the most basic of human needs, propelled by powerful biological and psychological drives. When the ability to reproduce is thwarted, a crisis ensues and impacts relationships with others, life goals, social roles, and sense of self. A host of emotions emerge in a somewhat predictable and repetitive process as one moves through medical diagnosis and treatment. Feelings of disbelief, anger, sadness, guilt, blame, anxiety and depression can be overwhelming and finding appropriate avenues to express these emotions is important.
For most people, IVF is not the first course of treatment for their infertility-it is the last, best option for having a child. It occurs after long months and sometimes years of treatment failure, often at tremendous emotional, physical and financial cost. Couples beginning IVF usually do so with the burden of grief and disappointment from infertility, and may feel depressed, angry, tired, and anxious. Although emotionally depleted, couples are attracted to a technology that offers hope where none may have existed. They find themselves drawn into new emotional turbulence of contrasting feelings of hope and despair, which seems to be generated in part by the experience of the technology itself.
The opportunities that IVF creates brings with it significant challenges. IVF is considered by patients to be the most stressful of all infertility treatments. Patients have rated the stress of undergoing IVF as more stressful than or almost as stressful as any other major life event, such as a death of a family member and separation and divorce. While general assumptions may be made about stress levels during IVF, the experience for infertility patients will be personal and unique-each patient will experience the stress differently based upon his or her own personality and life experiences.
The Multifaceted Aspects of IVF
The aspects of IVF that are perceived stressful to patients are multifaceted and affect all parts of their life: marital, social, physical, emotional, financial, and religious. Time is stressful, both in the time commitment to an intense treatment which leads to disruption in family, work, and social activities, and for some, in long waiting periods for treatment services. IVF stress impacts the marital relationship with an emotionally laden experience and, by removing the conjugal act of procreation, sexual intimacy is lost. Couples, also, are stretched financially paying for the high cost of IVF treatment with a relatively low probability of success. Dealing with the medical staff and with the side effects or potential complications of medical treatment has its own stress: hot flashes, headaches, mood fluctuations, shots, sonograms, future health concerns, and decision making about embryos and multiple pregnancies. Religious, social, and moral issues may also make IVF stressful, especially for those dealing with third party reproduction, when these values are in conflict with the choice of treatment.
The first treatment cycle has been found to be the most stressful for patients, with high levels of confusion, bewilderment, and anxiety. This may be due to inexperience with the process or possibly inadequate preparation of the patient by staff in terms of information and discussion of care. While experience seems to help the stress level in the next cycle, if it is unsuccessful the stress level rises again with the third cycle as the "stakes" have been raised. For many couples, IVF can feel like gambling where the stakes are high and the chance of success unknown. Like gamblers, some IVF patients may have unrealistically high expectations of success or feel compelled to try "just one more time" finding it difficult to end treatment after having already invested so much physically, emotionally, and financially to have a child.
Within a treatment cycle, patients view IVF as a series of stages which must be successfully completed before moving onto the next phase of treatment: monitoring, oocyte retrieval, fertilization, embryo transfer, waiting period, and pregnancy test stages. The level of stress, anxiety, and anticipation raises with each stage, peaking during the waiting period. Research has shown that in order of perceived stress for patients, waiting to hear the outcome of the embryo transfer is the most stressful, followed by waiting to hear whether fertilization had occurred, and then the egg retrieval stage. Patients are aware of the importance of these key phases in the IVF process and the uncertainty of the outcome is highly distressing.
Despite the stressful consequences of infertility and IVF, it is important to note that research has shown that the vast majority of patients are well adjusted. Further, there seems to be no long-term impact on the marital relationship and individual functioning. In fact, some research has shown that the crisis of infertility may actually improve marital communication and emotional intimacy. Couples may learn coping skills and communication patterns that provide life-long benefit.
Tips For Preparing For IVF
IVF has the potential to be an emotionally, physically, and financially exhausting experience due to the "high stakes" and "end of the line" nature of this treatment. Thus, patients need to consider thoughtful preparation before beginning the process. If you are a patient about to begin a cycle, here are some tips to help get ready for IVF:
Gather information and plan ahead
Good decision-making involves being well educated and informed about your body, the IVF process, and your clinic/treatment program. IVF is an anxiety-producing experience, and one of the best antidotes for anxiety is information and knowledge. The more you know and understand about the process, the less stress you may feel. Look for articles and other reading materials about IVF. If your practice runs educational IVF classes, attend as a couple and talk to others who have been through IVF.
Prepare for decision-making
It is important to anticipate decisions that may occur during IVF and discuss your options ahead of time. Sometimes these decisions may have moral and religious implications which you will need to consider and discuss. You will need to decide how many embryos will be transferred while maximizing your chances for pregnancy and minimizing the possibility of multiple babies. You will also need to decide what you will do with extra eggs and/or embryos, i.e. freeze, dispose, or donate them. If there is a possibility that donor gametes (sperm or egg) will be used in the cycle, it is important that you carefully discuss the issues involved in raising a donor-conceived child before starting the cycle. Counseling can assist you in exploring these issues and is a recommended treatment guideline of the American Society of Reproductive Medicine.
Tend to your psyche and your relationships
A long struggle with infertility may have taken a toll on how you are feeling about yourself, your marital relationship, and/or your relationship with others, causing distress and isolation. You will want to be in a good place emotionally and have your relationship on solid ground before starting an IVF cycle. Facilitate communication with your partner by setting a limited amount of time to talk about IVF, possibly 20 minutes every day, and then putting infertility talk aside. Discuss ahead of time your hopes and expectations of each-for example, whether you want to be together at appointments, on the day of the pregnancy test, and when you are expecting a call from the doctor. Counseling can be very helpful when you and/or your partner are feeling depressed, very anxious, emotionally stuck or in a rut. An ounce of prevention is worth a pound of cure, so get help early before problems get too big.
Garner your supports
Friends and family can be your best support or they can be your worst. Decide in advance who you will tell about the procedure by identifying who will give you the support you need. In hindsight, patients often wish that they had not told so many people at the start as it sometimes adds to the pressure. It can be helpful to designate a friend/family member as a "spokesperson" who will let others know, when you are ready, what is going on. In addition, look outside your usual support network to those who truly understand-other infertility patients. If it is available in your medical practice, consider joining an IVF support group, or check out other infertility self-help organizations, such as Resolve. The internet is, also, a ready source of infertility support and information, through various websites and "chat rooms". A great deal of healing can come from others who understand.
Identify your stresses and your coping mechanisms
Each person experiences stress in different ways so it is helpful to identify where yours may come from. For some, it may be in just getting to the clinic in the morning for monitoring, for others it may be injections. Anticipating ahead where your stresses may come from will help in developing coping strategies. Know your own and your partner's styles for dealing with stress and what has helped in the past. For example, women may need to talk and receive support, while men may prefer to be involved in an activity or hobby to cope. Learning to accept differences in the way each of you handles and deals with your feelings can reduce conflict. In addition, exercise is one of the best ways to alleviate feelings of stress, anxiety, and depression although it may have to be adjusted during the treatment cycle. Humor is a great coping mechanism and can help you get through difficult times. No matter how tough things get, you can always find something funny about it and laughing about it is good for your health. Stress management classes, listening to relaxation tapes and other mind/body techniques used regularly can help in handling these feelings and dealing with treatment procedures.
Decide what you have control over and what you don't
To help eliminate any unnecessary stress, you will want to make you life as simple as possible during the cycle. This is not a time to make important decisions or changes in your life, such as a move or job change. If at all possible, avoid major undertakings at work that can add stress to your life. In addition, you will want to think about how to deal with other daily life challenges on the job, at home, and with family and friends. You do have control over the choices you make in your daily life while how the treatment course progresses is usually out of your hands.
Anticipate problem areas
Plan for possible changes and difficult times during your cycle, such as the waiting period after transfer and the day you will get the results. Expect the unexpected, as changes are frequently made in the cycle because of everyone's unique medical situation. There are possibilities for failure at every step of the cycle, from a poor response to medication to no fertilization after retrieval.
The two-week waiting period between transfer and receiving the pregnancy test results is often described as the most difficult part of the cycle. Having had daily contact with your medical support staff during monitoring and retrieval, you suddenly are on your own after transfer and just have to wait. You need to think about how to fill your time during these two weeks, and then consider where you will be when you receive the results (probably not at work) and whether you want to be together to hear the news. To allow some time to deal with what you learn, you may want to consider "fibbing" to family and friends by telling them the results are due a few days later than reality. This will give you breathing space and time to adjust to the news before dealing with others.
Look past this cycle at the beginning
It is important to be looking ahead as you prepare for IVF and to consider your limits as you begin the process. It is easy to know how you will feel if treatment is successful and you become pregnant. However, you must also understand that if you are unsuccessful in achieving a pregnancy, you cannot get away from the sadness, loss, and disappointment that are part of the grieving process. Think about the number of cycles you are willing or able to do, and how much more time and money will be involved in infertility treatment, knowing that you can always reassess later. Remember that with each cycle new information is learned and that it helps knowing what to do next. Consider exploring other family building options, such as adoption, which will give you some control and provide information for future decision-making. No matter what the outcome of IVF, you need to recognize you have succeeded in doing all that is within your power to have a child and can feel good about yourself. Having done so minimizes future regrets.
Sharon N. Covington, MSW, LCSW-C
Director, Psychological Support Services