When Is It Time ImageWhether you have done three cycles of the same treatment or ten cycles of a variety of treatments, when you are not successful in conceiving and bringing a baby home, you will be asking yourselves what to do next. How are you to know when enough is enough?

First, consider taking a break from treatment if you are feeling extremely overwhelmed. This will give you a chance to recuperate from the daily doctor visits and medication injections. It will also allow you to experience what it feels like to not be on the infertility rollercoaster. You may decide that you do not want to get back on it or you may find yourself enthusiastic to begin the next step.

When you find yourself at a crossroads about what to do next, start by assessing how much the treatment process has affected you up to this point. What’s the status of your resources – finances, time, emotional energy, physical energy, social support? Are you morally, ethically or religiously comfortable with the next treatment options offered? Maybe you do not really know anymore how you feel and need to check in with a mentor, a trained counselor or a support group member? Be sure to take into consideration the diagnosis and prognosis you have received from your physician. It is not necessary to have tried everything available but to know you have given it your very best effort respecting your physical, emotional and financial resources.

How do I know when to stop?

There’s good news and bad news. Assisted reproductive technology (ART) is in a period of amazing change today. It is certainly good news for those of us who will ultimately be helped to achieve a pregnancy. But for those who do not readily benefit from these medical interventions, there is a down side as well. It may be harder to move on to a resolution other than pregnancy and biological parenthood when there seems to be an endless array of treatments that one could try. In this world of seemingly limitless options, each of us needs to choose the degree of intervention (how much) and the extent of intervention (how long) that feels most suited to us.

So, how do we know when to stop? Each infertile couple is different – in emotional resources, financial resources, and psychological, social, and religious comfort with various options. We are different in how much time we have to invest in trying to achieve a pregnancy, different in physical abilities to undergo complex and sometimes painful interventions, and different in the ingredients which go into the wish for a child.

There is no one right way to reach such a decision. For one couple, eight IVF cycles may define enough; for another couple, adoption or childfree living may be a preferable route to any invasive procedures at all. But first let us examine the process of treatment itself.

What are the emotional challenges of treatment?

First, by their very nature, infertility treatments are all consuming. It can be a relief to remember this, as we sometimes tend to blame ourselves for our one-dimensional focus at this time, wondering whether we are unduly obsessed and whether we will ever regain our perspective and our normal range of interests. With high-tech treatment, our monthly and even daily schedules are regulated by forces outside our own control, interfering with jobs, travel and vacations, social lives, family responsibilities and planning of all sorts.

Secondly, mood swings are a routine part of undergoing treatment. Each month can become a roller coaster ride of hope, anticipation, fantasy, elation, anxiety and, often, disappointment and grief, all timed to the events of the menstrual cycle and heightened by the effects of hormone manipulation. For instance, ovulation can bring feelings of infinite promise and excitement. If the interventions proceed well, the next two weeks can bring alternating feelings of well-being, pleasure, anxiety, and suspense. If a pregnancy is confirmed, the response can be elation, numbness, denial, or anxiety about future problems. For those who have experienced many previous disappointments, the need for self-protection may outweigh the ability to feel joy. And of course, a canceled cycle, negative pregnancy test or the arrival of the menstrual period bring feelings of loss, despair, futility, and anger.

Anger is an inevitable and understandable feature of infertility and infertility treatment. Anger may be directed, or misdirected, at doctors, nurses, insurance companies and spouses. We may turn our disappointment and anger inward against ourselves, perhaps berating ourselves for lifestyle choices (sexual choices, abortion, late marriage, deferred attempts to conceive) which may play a role in our infertility. Friends or relatives may elicit our anger by their tendency to get pregnant effortlessly or to say all the wrong things. This may be a time to give ourselves greater permission to feel these so-called negative feelings, rather than unrealistically expecting perfect grace under fire.

Isolation is a frequent consequence of infertility and infertility treatment. Infertility and involuntary childlessness may carve an often unspoken, hopefully temporary rift between us and our closest friends and relatives. This is an issue for both men and women. Men may, in fact, suffer more from this isolation, as there are greater cultural prohibitions on talking about infertility for men. Also, because men typically cast themselves in the role of the supportive, rational partner, they may be deprived of the opportunity of expressing their own disappointment and fears, feeling locked into the burdensome role of “cheerer-upper.” Paradoxically, women often feel that their husbands could be more supportive if they would share their own pain and uncertainty.

Can infertility impact my marriage?

Marriages experience some heavy challenges during treatment. Normal patterns of spending time, spending disposable income, and relating sexually may all be disrupted during treatment. An additional problem is that our spouses are dealing with their own unique mix of feelings and reactions, hopefulness and hopelessness, and on their own timetables, which often are on just the opposite cycle from our own. Thus, it may seem that just when you need your spouse to bolster your hope or share your belief that the new technique will be the magic answer, he/she will be having an attack of doubt or despair. Alternately, it can be just as difficult when one partner is feeling increasingly convinced that a pregnancy is not going to occur and perhaps a bit closer to acceptance of that fact while the other partner is feeling a surge of optimism or even denial.

Sometimes we polarize the two sides of our inner debate, with each partner becoming the spokesperson for one side only. We need to bear in mind that our spouses are motivated by their own painful struggles and personal coping strategies and not the wish to frustrate or thwart us.

Hope, time and other things to consider.

Hope is the engine, which keeps us moving forward through the rigors of diagnosis and treatment. Its tenacity is in many ways our greatest resource. Yet sometimes, such as when the promise of treatment is not fulfilled after numerous cycles and interventions, we may begin to wonder whether our hope continues to serve us well or whether it is preventing us from moving on.

Similarly, we may need to regard time differently, as we move into a period of evaluating whether to set a limit, or an end, to treatment. Previously, time may have been largely an enemy, as in “I’ve only got x years to x age,” “This ovarian cyst means I have to lose x months before I can try again,” “My husband is traveling out of town all this week—there goes another month down the drain.” It takes a major act of redefinition to see time as potentially on our side in the process of regrouping emotionally, reframing the question “what constitutes success?” and reinvesting in some new dreams, directions and alternatives.

What is our burnout threshold?

Although medical factors may comprise our doctor’s recommendation to end treatment, there are many situations in which a couple must grapple with the issue of moving on without a single, indisputable external event or medical recommendation. Often the decision to end treatment is made, painfully and reluctantly, from the inside out. The decision to end infertility treatment stands at the intersection of facts and feelings and is always the result of a very personal equation.

Deciding whether to end treatment involves:

  • Evaluating and setting limits on our resources,
  • Listening very carefully to our inner voices,
  • Communicating in a plain and conscious way with our spouses.

We can think of setting limits in terms of four general types of resources: time, financial, emotional and physical. After numerous unsuccessful cycles, we begin to ask ourselves “what are the costs and the priorities for ourselves, our marriage and any other children in the family. How much time are we willing to invest in this?

Changing my perception.

Another part of the process involves separating biological parenthood into its component parts and clarifying the relative importance of each part to you. That is, biological parenthood involves:

  • The experience of pregnancy, childbirth and nursing,
  • The sense of genetic connection and continuity with a child,
  • Creating a biological link with one’s spouse, and Parenting.

Do research on all of your options – third party reproduction, adoption, childfree living. Talk to people who have taken those routes to find out if you can picture yourself in their shoes. Being open to all possibilities does not mean you have to accept all possibilities. It just means you consider them so that you can make a thoughtful and informed decision that fits your life.

Nothing and no one can guarantee that you will not have regrets because every decision we make leaves the decision not followed open for regret. The goal for this moment is to anticipate, as best you can, what your regrets might be when you look back on today’s choices. Fifteen years from now you might say, “I wish we had done one more IVF.” Or “I wish we had tried donor eggs.” Or “I wish we had adopted.” But you might also say, “I wish we could have had children, but we tried our best.” We learn to live with our choices and build a life beyond them.

Knowing whether to stop infertility treatment is a major decision that cannot be made in an instant. When you take into consideration all of the recommended steps discussed here, you will come to the decision that is right for you.

Contributed by: Penny Joss Fletcher, M.A., Joan Rabinor and Eileen Ivey