A 36-year-old patient of mine named Ellen came to me to talk about fertility. She'd been married, happily, for eight years. She and her husband had always known they wanted a family but hadn't felt rushed; they wanted to be settled in their lives first. She spent her late twenties going to graduate school and then developing her career. They'd started "trying" a year and a half ago. At first this meant simply having sex a lot; six months later they bought a basal thermometer; a few months after that an ovulation kit, and finally she was here.
The vibrant, healthy woman I'd known for years looked pale and exhausted. She'd always been thin but now looked unhealthily so. Sex had become a chore -- "like folding laundry," she said. When I asked her how she was coping, she told me she was doubting herself in ways she'd thought she was "above"; she felt unfeminine and was furious with herself for not heeding the tick of her biological clock sooner. Late at night, she worried about the seemingly inevitable diagnosis -- infertility. "What's wrong with me?" she wondered constantly.
"Infertile" is a medical label a couple receives after they've been sexually active for 12 months, without contraception, but haven't conceived. I believe in the power of language, and I think this term does more harm than good. By the time a woman or a couple receives this label, they're often highly stressed, wondering whether an event they thought would happen naturally and joyously will happen at all. So I prefer to describe them as "having a hard time conceiving," which is simply a fact, is less emotionally laden, and lends itself to possibilities.
I started by talking to Ellen about the "biological clock" that haunted her (as it haunts many women). It's true that from a physical perspective, a woman's body is optimally ready to procreate at a young age. The ability to get pregnant decreases and the risk of complications (including birth defects) increases as women age, with a significant jump once they reach 40.
But that's as far as the body goes. What about the "soul clock"? I've spoken to many women who had a baby at a young age and then again years later; they all say that their ability to bring a child into the world, love the child unconditionally, and be present with him or her every step of the way was much more developed as an "older" mother. The optimal time for the soul to conceive, it seems, often comes far later than that of the body.
It would be wonderful if the body clock and the soul clock were always synchronized, but in my experience this is rarely the case -- hence the ironic saying among women trying to conceive: You spend the first part of your reproductive years trying to avoid pregnancy, and the second half chasing it down. What I encourage all of my patients to do is remain conscious of both clocks and try to balance them. In Ellen's case, simply acknowledging her soul clock -- remembering that she and her husband went into the process consciously, at a time when they were emotionally ready, helped her stop blaming herself.
Ellen was considering stepping onto what I call the infertility conveyor belt. After the year mark -- or earlier, if the woman prefers or if her physician recommends it due to her age or other factors -- couples who haven't conceived can choose to begin a fertility workup (again, I prefer this to "infertility workup," the standard medical term). It starts with a number of tests, several of which are typically minimally invasive. Once the physician understands the cause of infertility (or, as is often the case, finds no cause and diagnoses "unexplained infertility"), treatment starts. It varies depending on the diagnosis but generally begins with the simplest treatment and then continues to escalate in invasiveness (and health risks).
There's nothing wrong with committing to the process. But I see many patients who step onto the conveyor belt and feel that they've given their body, and indeed their reproductive lives, over to their doctor. It's understandable; suddenly the most intimate parts of their bodies and lives are the cause for discussion and diagnosis. When a woman undergoes fertility treatment she may, for example, be instructed to have sex within a set time period. She also may have to give herself injections and have frequent ultrasounds. In the case of in vitro fertilization (IVF), minor surgery is required to retrieve the eggs.
The stress of all this -- emotional, physical, financial -- can be enormous, and ironically works against the cause. It's common knowledge that the higher a woman's stress level, the lower her fertility. (This fact prompts the often annoying and unsolicited comment "Just relax, and you'll get pregnant!") Highly stressed women can stop ovulating altogether, and even when they're cycling regularly, a myriad of physiological factors can affect your ability to conceive. And this makes sense. In the hunter-gatherer days, stress probably indicated a lack of food or an imminent threat -- not wise times to bring an infant into the world.
Instead of getting angry or feeling betrayed by your body, it helps to be compassionate with it for doing what it thinks is best, and to start addressing your stress level. Dr. Alice Domar, founder and executive director of the Domar Center for Complementary Healthcare at Boston IVF and author of "Conquering Infertility," has done interesting work in this area. Recognizing how stressed the fertility patients in her clinic were, she began offering mind/body groups, in which patients learned a variety of stress-reduction techniques in a supportive group setting. She noticed something fascinating: These women seemed to be conceiving more frequently. She subsequently studied stress-reduction methods in a research format, finding that both women in support groups and those doing mind/body techniques were more than three times as likely to conceive than women receiving standard care. The studies are small but remarkable. They're not surprising, though; what is surprising is that stress reduction is not integrated into every fertility program.
Ellen and I came up with a plan to help her reduce stress and "befriend" her body. Instead of running daily at dawn, her current routine, she'd walk in the afternoons with a friend or her husband. She'd take a twice-weekly restorative yoga class at her gym and begin receiving acupuncture targeted to both fertility and stress reduction. I also "prescribed" a bowl of her favorite ice cream several nights a week to help her gain some needed weight.
We also talked about the path ahead. What concerns me most about the conveyor belt is that many women check out emotionally, continuing with one procedure after another without ever considering that, at every step, they have choices to make. I encourage all of my patients who go through fertility treatment to stay conscious, to keep asking themselves how they feel, to keep reminding themselves that they have choices.
You can, for instance, have a consultation with a fertility specialist and proceed no further. They can get the workup and not start treatments. They can explore options like adoption sooner rather than later. They can begin treatments and decide to stop before you've exhausted all of your options. And, yes, they can absolutely decide they will do everything possible, for as long as possible, in order to conceive. There's no correct path; what's important for the health of their bodies, their souls, and their relationships is to resist the powerless feeling of being sucked into the big medical fertility machine until "the end" -- i.e., until they get pregnant or give up years down the road after trying absolutely everything.
Ellen pursued treatments, but with a renewed spirit -- the hallmark of which was that she was gentler to herself. Complementing the treatment with acupuncture helped her relax and feel more in control of the situation. And she promised to keep checking in with herself. Six months into treatment, Ellen got pregnant and now has a beautiful little girl.
In my own case, I changed course. I'd done three rounds of IVF, but despite things going "perfectly," I hadn't gotten pregnant. My physicians were optimistic: My ovaries were true champs; I produced plenty of eggs each cycle. (As any woman who has undergone IVF knows, this can be painful. I used to call my hunched post-treatment walk the "fertility shuffle.") It was most likely just a matter of time, my doctors said. I checked in with myself, body and soul, and felt differently. I was glad I'd gone the treatment route, but continuing didn't feel right to me, or to my husband. We decided to pursue adoption, and now I know why I didn't conceive. My son was being conceived in a different way, in a different womb, and I have no doubt that we were destined to share our lives together.
Deciding to become a mother may be the most momentous choice a woman faces; a deep internal shift happens when she makes it. Whatever her path is, if she stays conscious, she'll learn and grow along the way, and feel at peace with the outcome.