PREGNANCY AFTER INFERTILITY: BLISS OR BLUES ?

By Silvia Schneider Fox, Psy.D.

"Honey, guess what! We're going to have a baby."

How many times, in the months or years since you have been trying to conceive, have you fantasized about saying or hearing those words? And how many times have you burst into tears when someone else uttered them, in a movie or TV sitcom or book?

For many of us, who experience long term infertility and infertility treatment, pregnancy becomes an idealized dream. We picture in vivid detail what it would be like to be pregnant, we vacillate between hopeful fantasies of pregnancy and fearful apprehension in the face of yet another disappointment, and we look with painful envy at other pregnant people. For some, the dream of pregnancy becomes focused on one goal: for once in their lives, to obtain a positive pregnancy test. Indeed, most of us imagine that such a positive pregnancy test will lead to an ecstatic response and will usher in nine months of celebration. When we finally do get pregnant, we are often unprepared for, and surprised by, our actual emotional reaction.

In reality, pregnancy after infertility can be a difficult experience. The joy, so long awaited, is often not present in the early phases of pregnancy. Instead, many people feel numb and incredulous or even scared, sad and weepy. As the pregnancy continues, couples frequently go through feelings of loneliness, fear and isolation -- emotions not unlike those aroused by the infertility.

WHAT MAKES PREGNANCY AFTER INFERTILITY STRESSFUL?

THE REALIZATION THAT BAD THINGS CAN AND DO HAPPEN

Infertility causes a loss of innocence. It teaches people, in painful ways, that no matter how good a person one is and no matter how hard one tries, things can still go terribly wrong. It teaches us that we can't always plan the future, and that we are not always capable of meeting our life goals as we had envisioned them. Infertile people are acutely aware of how little control they have over their bodies, their daily lives and their emotions. They know all too well that children do not come easily, and they are constantly anticipating disaster. They do not take their pregnancy for granted and they often envision the occurrence of every possible -- real or imagined -- catastrophe.

THE FEAR OF PREGNANCY LOSS

The most common fear in pregnancy after infertility is, of course, the fear of pregnancy loss. While many couples experience some degree of anxiety in early pregnancy, for most the anxiety subsides as the pregnancy continues uneventfully. For infertile couples, however, the anxiety often endures, intensely, up to the time of delivery. They feel bewildered and in disbelief about the pregnancy and expect it to fail at any time. Some infertile couples believe that they will relax once the first trimester is over, or once they hear a heartbeat, or get positive results form the amniocentesis, or begin feeling fetal movement. The truth is that, while each of these milestones makes the pregnancy feel a little more safe, none of them completely eliminates all the anxiety.

Because pregnancy after infertility can feel so tentative and uncertain, the only confirmation that it is "real" may come from periodic blood tests or ultrasound exams. Between appointments for these tests, people often feel like the time crawls. They may experience a roller coaster characterized by hope and excitement during and immediately after the medical tests, followed by increasing fear and dwindling hope in the interval of days or weeks between office visits, and yet again by renewed optimism after their subsequent appointment.

Understandably, fears of pregnancy loss are greatest for those couples who know that, indeed, they at high risk for miscarriage (for instance, those with prior ectopic pregnancies, tubal surgery, pelvic infections and DES exposure) or those who have experienced earlier pregnancy losses. In an effort to protect themselves emotionally in case of subsequent loss, some couples chose to do things differently in later pregnancies than they had done in the pregnancies that ended in miscarriage. For instance, if they had announced the previous pregnancies right away, they may wait before making the news of the next pregnancy public (to avoid the unwanted questions and attention in case of a loss). Conversely, some couples who, in the past, had kept the news of the pregnancy to themselves, now tell people right away, so that if they miscarried again, their family and friends would recognize their devastation and provide them with support.

Infertile couples who finally get pregnant often observe the confidence that non-infertile couples have about their pregnancies and they resent it. They envy those people who announce their good news to the world with cheer and certainty, who buy pregnancy books and maternity clothes without hesitation, who speak to their unborn baby and even dare address him or her by name, who allow themselves to enjoy their pregnancy with no fear of "jinxing" it. In turn, other people may not understand infertile couples' apprehension and confusion. They expect them to rejoice in their long-awaited pregnancy and to celebrate their triumph over infertility. They may fail to appreciate the anxiety that accompanies pregnancy after infertility and they may even become impatient with it. As they have at other points in their infertility journey, couples may thus be left feeling isolated, unsupported and misunderstood.

THE FEAR OF BIRTH DEFECTS

Along with fears of pregnancy loss, couples who achieve a pregnancy after infertility often worry that something will be wrong with their baby. These fears are often exacerbated by the couples' feelings about the medical procedures that helped them conceive. People often fear that the means they used in order to get pregnant may have tampered with the natural order of things. This anxiety is particularly acute for those who used procedures that are perceived to bypass the process of natural selection, such as ICSI. Similarly, women who were older when they got pregnant sometimes feel like they have sidestepped a natural barrier imposed by their own bodies and may fear the effect of their age on the well being of their baby.

Couples who have used a collaborative method to conceive, such as those who used a sperm or an egg donor, are also more prone to experience anxiety about their baby. Some feel that they have no control over part of the child's genetic origin and, as a result, they fear that he or she will be born with some unknown genetic defect. Others worry that, if their baby was indeed born with an anomaly, they or their spouses would not be able to accept and love him or her.

Fear of birth defects may be exacerbated by the fact that couples who conceive after long-term infertility are often reluctant to use prenatal diagnostic tests. Non-infertile couples are typically aware of the threat to the pregnancy of such tests as chorionic villlus sampling (CVS) or amniocentesis, but they are usually not deterred by these relatively small risks. In contrast, couples who carry a baby conceived after months or years of infertility treatment or after a previous pregnancy loss may feel that they cannot endanger the pregnancy for the sake of prenatal testing. They are unwilling to take any risks, no matter how small, and are thus left wondering, through the entire length of their pregnancy, if their baby will be born healthy. Those couples who do choose to undergo prenatal testing face the possible tragedy of finding out that, in fact, there is something wrong with their baby. Terribly, some couples find that they may have to terminate the very pregnancy they have spent years trying to attain.

THE STRESS OF A HIGH RISK PREGNANCY

Indeed, the anxiety experienced by couples who conceive after infertility is, unfortunately, not always unfounded. Many of the pregnancies achieved after infertility are truly medically complicated. Some couples achieve a pregnancy only to have it end in miscarriage, ectopic pregnancy or stillbirth. Others are fortunate to have their pregnancies managed and brought to term, but the management itself can become a trying ordeal. Couples who have spent considerable time and money contending with infertility now have to contend with a whole new set of medical problems. After being drained by their infertility, couples sometimes feel too depleted to cope with a high-risk pregnancy.

Some high-risk pregnancies require bedrest. While the idea of spending several weeks, or even months, in bed might sound appealing to some, in truth, the time a pregnant woman spends on bedrest is often trying. Bedrest usually comes as a surprise. Without much preparation, couples find that their lives are suddenly turned upside down. Tasks are left undone, and special arrangements have to be made for those tasks that do need to be accomplished. If they have other children, the couple must immediately find childcare, often at a high cost. More financial stress ensues since the woman loses her income just as the couple's medical expenses are piling up. Women who are usually active find that their mobility is severely limited and that they are dependent on family members and friends to do things they would ordinarily do themselves. As a result, women on bedrest may experience frustration about being dependent on others, along with anxiety, boredom, and guilt. To make things worse, it's not uncommon for other people to react to the news of bedrest by saying, "I'd do anything for a few weeks in bed!" As they have in the past, couples find that not everyone is sympathetic to their plight.

One group whose pregnancies are often high-risk is those pregnant with multiple fetuses. Many of these couples may have had to decide, early in their pregnancies, whether to undergo multifetal reduction. Those who do, often grieve their lost fetuses and may experience guilt, anger and depression. Those who do not, contemplate nervously the implications of a high-order multiple pregnancy and the prospect of parenting three or four or more babies. In addition to the worries about the pregnancy, most of the people who are expecting twins or "super twins" struggle with some feelings of ambivalence about parenting multiples. They may feel like their friends and families expect them to be unequivocal in their happiness about having babies. They may feel that they don't have permission to express their concern or apprehension about their pregnancy or the parenting challenges that lie ahead. At the same time, their joy may be dampened by some of the negative attitudes and myths that people hold about twins and which may be expressed in subtly negative comments; such as " I'm glad it's you and not me!”

THE DIFFICULTY BECOMING AN ORDINARY OBSTETRICAL PATIENT

For couples who conceive after long-term infertility, the transition from a fertility clinic to a regular obstetrician's office can be complicated and replete with a sense of loss. On one hand, the "infertile club" is one that people do not join willingly and that they are mostly happy to leave. On the other hand, many infertile people find that, for better or for worse, through the months or the years that they are in treatment they spend hours in their physician's office. As a result, they build a sense of closeness and camaraderie with their physicians, the clinic staff and even other patients. Often, the clinic team members act as cheerleaders and supporters as they become particularly invested in helping the couple conceive. They usually understand the heights of the couple's hopes and the depths of their disappointments. Leaving these relationships for regular obstetrics practices, where they are just unknown, regular patients can be difficult.

This difficulty is sometimes intensified by the transition from intensive monitoring of the pregnancy at the fertility clinic to widely spaced visits at the obstetrician's office. After getting use to frequent ultrasound exams, which reassure them that the pregnancy is still viable, couples may feel that the transition to low-tech, low key exams is dissatisfying. Women who have conceived after infertility may feel that the staff at their obstetrician's office does not appreciate the pricelessness of their pregnancy and does not attend to it with the necessary care. They feel that they carry a fragile and precious baby, who faces innumerable risks. The office staff, in turn, may feel that, by their criteria, the pregnancy is regular and uneventful and thus act oblivious to the couple's anxiety. Ironically, just as the couple stands at the door of the "fertile club" that they had so coveted, they may feel more different and isolated than ever.

The feelings of isolation continue into childbirth classes. Sadly, long-term infertility treatment robs individuals of the innocence and naiveté with which others experience their first pregnancy. Consequently, they cannot easily identify with other expectant parents. They realize that they cannot sit in a classroom filled with pregnant women without feeling a twinge of envy. They cannot muster the same excitement and the same giddiness about the pregnancy as the young couples in their childbirth classes who have not been robbed of their innocent dreams of parenthood by the nightmare of infertility. As much as they want to stop feeling infertile, they often find that they cannot do so, even after they have conceived.

IN LIMBO: FEELING NEITHER FERTILE NOR INFERTILE

Couples who have achieved a pregnancy after infertility often feel like they are in "no person's land". They do not fit easily anywhere. Not only do they feel isolated from other expectant parents but they are also alienated from their infertile friends. Breaking the news of the pregnancy to friends who are still struggling with infertility is a painful feat, replete with "survivor's guilt". Having been there themselves, couples pregnant after infertility know all too well that their friends feel envious, deprived and even betrayed. In an effort to protect those who are still trying to have a baby, the couple may retreat from the infertile community. Thus, they may find that they are withdrawing from their infertility support system before they are actually ready to do so.

In the end, pregnancy after infertility is a peculiar mix of wonder and worry, of skepticism and hope, of attachment and loneliness. There are times of elation and excitement, punctuated with many many moments of caution and fear. Ultimately, for most people, the story ends well, as they go on to parenting the children for which they had so longed.