SART Fertility Experts - Navigating IVF as a Couple

My name is Daniel Grow and I'm a professor specializing in reproductive endocrinology and infertility at the University of Connecticut School of Medicine and director in the fellowship program here. It is a real pleasure that I get to introduce our featured guest Casey Jacob today. Casey and I for years have had the privilege of taking care of patients, planning one of the most important steps of their lives, starting a family.

Many of the couples we see and saw because they had trouble getting pregnant, they thought that this would be easy and natural as there are so many babies around them and when it wasn't easy and they discovered that some treatment was required, we saw the stress that infertility can cause in their lives. Fortunately, there are many treatments available today to help couples conceive. Also fortunately, there are some coping mechanisms to deal with stress.

Dr. Casey Jacob received her Ph.D. in counseling psychology in 1989 from the University of North Carolina at Chapel Hill. She got involved with the American Society of Reproductive Medicine in 1991 and served as a member of the mental health professional group for most of its existence. I knew her best as a psychologist embedded in the IVF program at the University of Connecticut and the Center for Advanced Reproductive Services providing counseling for couples going through fertility treatments.

However, her professional career was so much deeper than simply counseling infertility patients. She served as a Senior Associate Dean for Faculty Affairs at UConn and as a professor in the Department of Psychiatry and a professor in the Department of Obstetrics and Gynecology. She has many peer-reviewed publications, book chapters, and serves as a consultant to many organizations.

Casey, you've touched the lives of thousands of couples in a very positive way and we're thrilled to have you with us today to talk about helping couples deal with the stress of infertility. I really appreciate that you've asked me to do this and I want to say to those of you who are listening, first of all, thank you for joining us and secondly, what I would encourage you to try to do is just to find one or two or three tidbits to take away today. In a talk like this there will always be suggestions that don't sound right for you and you should feel free to just reject them right off the bat but try to listen with an open mind in case things are suggested you haven't thought about before that could work for you and your partner if you're doing this with someone.

You know, Casey, I wanted to share a quick story. The first patient I saw this morning was a new patient consult and I typically ask a patient to open by having her tell me how I can best help her and tears started running and you know, it's this is a very emotional business we're in, helping couples get pregnant and then, you know, it doesn't matter if they've been trying for, you know, one year or four years, who's, you know, if it's a male factor or female factor, it's an emotional diagnosis and, you know, so we know that patients are, patients are suffering. Right, they are.

And so, you know, one of the themes we talked about when we were planning this a little bit is, you know, when a patient is having stress around her diagnosis of infertility, you know, who should he or she tell? Who is their support circle? Is there a way to counsel them on that? I think there are things we can ask people to think about because what might make intuitive sense to them right off the bat may not be what turns out to be most helpful and very importantly, what helped you the first time you thought, oh dear, this isn't going very well compared to way down the road if you've been trying for quite a while, what helps often changes and so your willingness to try a different strategy can be helpful. And we also know that although we always have to be careful when we're talking stereotypes, if I may take the risk of using a stereotype, I would say commonly early on in fertility challenges, women often tell many people about it in excruciating detail sometimes and men are less likely to do this. And I would argue that that early approach often has nothing to do with fertility.

It has to do with how people deal with privacy in their lives. That many times women don't see any reason not to share and they go ahead and do it. And many times men are not interested in sharing.

And as a psychologist, I would say if you are not very interested in sharing in general, really whether you're a male or a female or somebody who doesn't identify either way, if you are someone who in general is not that interested in sharing private information with other people, one reason may be because it doesn't make you feel better to do so. So you decline. It's not necessarily that you think it would be the end of the world if somebody knew the information, but the process of sharing it may not be comfortable for you.

Whereas if you are somebody who commonly shares information, you may find the process of saying things out loud and talking them through is helpful. So as we go through this talk today, I'm going to stop periodically and say so one very specific suggestion is, and you can think about whether it would be helpful for you, one very specific suggestion is that you practice asking yourself, is that helping me? When you do something and especially if your partner does it very differently, we want to recognize that what helps people cope varies from individual to individual. What each of us individually need to be willing to do is to say, is this helping me? And that is a more important question than am I right? Or do I have a right to do this or say this? We can get very caught up in the black and white and the right and wrong of things.

But as a psychologist, I would say, what comforts you and what soothes you? So early in a fertility challenge, many people, women especially, will find it comforting to tell others, I'm trying, I'm excited, I'm worried, here's what we're doing. We're going to try something new. Hopefully this will work.

And commonly, men are less likely to want to talk about it because it causes discomfort and not comfort. Again, it's not a right or a wrong thing. It's a, you know, what soothes me thing.

You know, and I hate to just keep bringing up examples, but I had another couple today where the man, young man, 30 years old, had non-obstructive vasospermia, no sperm, high FSH. And he asked, you know, he, I, my perception is that he's not a person who has told any of his contemporaries. But he asked if I would refer him to a counselor because he wants to talk about it, you know, but he's not comfortable talking about it with his peer group.

Good for him for asking for help. This raises a really important issue. You know, I said earlier on, sometimes it can be helpful to change your strategy as time goes on.

And when you're expecting to have success quite soon, there's no reason to change your strategy necessarily, right? But if it can go on for quite a while, and if you are somebody who has not been talking about it, the problem is that if other people don't know you are suffering, and if other people don't know that you really wish to become a parent, you have to pretend that you're thrilled when they have babies and you have to go through life as if there's no problem. And that just gets harder and harder as time goes on. But what you can learn to do, everybody can learn to do, is to disclose in a limited way.

So, for example, many people who have talked very openly early on, and again, this is more likely to be females than males, people who have talked very openly early on often wish they could take some of their privacy back. And I have a suggestion for how to do that. But people who've been super private early on can think about how can I disclose to others that something's going on, but I don't want to talk about it.

So, you know, for example, I would say the next time somebody says to you, so when are you guys going to have kids? And you're used to just diverting the conversation or not answering the question, you could choose to say, I wish I knew. We've been trying, it's not going well. It's, you know, maybe the hardest thing I've ever done.

And it's very painful. And I don't want to talk about it. And person's still going to ask you a question.

You just said you don't want to talk about it. But that's powerful. Person is still going to ask a question.

And you have to say, no, really, it doesn't help me to talk about it. But if I sometimes seem kind of bummed out, or the reason we didn't stay long at the family party, it's because this is so hard for us. So all prayers and fertile thoughts are welcome.

But I don't want to talk about it. Just being honest. Right.

So you're letting, this is what I call letting the tip of the tail of the cat out of the bag. You are not saying, what's the diagnosis? Or how long have you been trying? Or how many cycles have you been treated? You're not talking about any of the gory details. But you are not pretending that everything is a okay.

Now, if you're the one who's been telling everybody everything, and you're maybe approaching your first IVF cycle, you might be wishing you could take some privacy back. You know, I would say to you, seriously, how many people do you want to have on the telephone tree on pregnancy test day? You know, you've got you've really got to think how many people am I going to have in this loop. And if you have already told a zillion people, there are two main strategies for taking some privacy back.

So one is ask yourself, do I know people who seriously want to be helpful to me and who keep saying what can I do? And they're likely to listen to you if you ever answered the question. Those people you say to them, thank you so much for being there for me all this time and letting me talk about our fertility struggles. It's been incredibly important and helpful.

And yet we are finding that what's helpful is starting to change. And so as we begin IVF, maybe you'll disclose that far. We've decided to go into our caves and not talk about the details.

We really don't want to be asked every day. How did your ultrasound go? What's your FSH? You know, we just don't want all these detailed questions. And you've said you want to be helpful.

So the way you can be helpful now is to talk to me about everything except infertility and to trust that I will tell you if I have something important to share. In the meantime, could you compliment my dress or ask how work is going or tell me about your family? Treat me like a regular old person. I think that would be helpful now.

So you might have some people in your life who would say, thank you for telling me I can do that. But we all have people in our lives who won't listen to that. And there's no point in saying it to them because they're going to always ask questions.

And I would suggest you think about the role models you have in your life who really hardly ever answer questions. I have three brothers and I have three sisters. And I think about how different we are when people ask us questions.

You ask my brother, what are you doing tonight? And he says, I don't know. You asked my sister and she says, Oh, I can't wait to get home from work and get out of this bra. And then I'm going to do this.

And then I'm going to do, you know, like there's really different ways of answering questions. And so if you have commonly been somebody who has shared, and now that feels like too much sharing, you could practice saying, I don't know, not sure they haven't told me yet. And, and just be vague.

You know, my favorite is when they say to you, so, you know, when's your egg retrieval, you would say, if my ovaries were behaving, I wouldn't be doing any of this. I don't know what my egg retrieval is. Just use your, you know, share the frustration instead of the medical facts.

So you have to decide, do I want to learn how to really not answer all those intrusive questions? Or can I just say to people, please stop asking them because it was helpful. And now it's not. You know, Casey, it's just so fun to listen to you because they're tips for life that all of us can use.

No matter if we have stress from fertility, or stress from our, you know, our, our family talking politics. And so thanks. Thanks for the insight.

I enjoy it. Thank you. And there is one other thing I would say about this, it goes back to the question you asked originally, which is, how do we decide who to tell stuff? Yeah.

And I would say, this is where you practice asking, did that feel good or not? Commonly, if you are somebody who tends to disclose things, commonly, you think there are people you should disclose to. For example, many women will disclose to their mothers if they have good relationships with them. And yet so many women tell me, but it's really not helpful to talk to her because she thinks I should start looking at adoption or she tells me to just relax or, you know, whatever.

So again, you should say to yourself, who really comforted me when I talked to them? It might not be your mother. It might be, you know, in the old days when we all went into the office, I would say it might be the lady you see at the water cooler who just, you know, has a kind word to say and encourage you to, you know, keep the faith. So nobody has a right to this information.

This is private stuff. You know, if you are a heterosexual couple and you were still trying to get pregnant the old fashioned way, how many of you would ring up your mom or dad and say, I'm ovulating today, tonight's the night? Hopefully not very many of you because it's private stuff. And you can take that attitude with you into fertility treatment.

Excellent. Thanks. Hey, I want to change gears.

Let's, you know, many of our patients end up with, you know, doing IVF, right? And in vitro fertilization is, it can be an onerous process. There are, you know, lots of injections, at least 10 days, 12 days worth of injections. They have to be given sometimes in the morning, sometimes in the evening.

There's two or three or four different medications. There's blood work, there's ultrasounds. And I wonder if you have advice for couples trying to negotiate this together.

You know, the husband or partner wants to be supportive. There's a lot of responsibility. There's some shots that have to be given.

There's some technical skills, there's some mixing of medicines. How do you coach couples in dealing with that stress? So the main coaching theme is don't let your doctor's office tell you how to do it. You should talk together about what would help you.

And if you are the woman trying to conceive, don't assume it's all your job because your partner is so busy or has such an important job or, you know, whatever. This, you should really be thinking about yourselves as people. Is one of us more of a control freak than the other? Is one looking for more, you know, is the partner who's not trying to conceive looking for ways to be more helpful? What would be more helpful? Are you fearful of injections and would you welcome assistance with them? Is your partner fearful of injections? You know, there's just all these different things to think about.

I was aware in our practice, we often spoke to patients as if we already knew how it was going to go. We would talk to the woman attempting to conceive as if of course she would give herself subcutaneous injections. And we would talk to the partner as if of course you would give the IM injections.

But I would say to you, don't let anybody boss you around about this. You should think about not just who's technically able and who's going to be in town and that sort of thing, but what would allow you to feel more confident and more comfortable as you go through things. So you may be the woman attempting to conceive and you may be perfectly capable of giving yourself injections.

But if your partner has really been wanting to be involved and you also know they're capable, why not set that up? Even if it's a little bit inconvenient at times or requires more planning. Injections is just one example. I think another great example is how are you going to handle dealing with the insurance company? Should it be all one person or all the other or can you share that information? Who's going to answer the phone on pregnancy test day? Unless you ask for something different to be done, the call is probably going to be made to the woman who's attempting to conceive.

But it doesn't have to be. You could say, I'd really like my partner to get that call. I'm going to go home and hide until the news comes in.

We don't know what's best for you all. So again, keep thinking what would allow me to feel more comfortable. And another way of thinking about this or another question you can ask yourself is what are the things that are predictable that I can have a vote in deciding how we will do them versus what are the things I can't? So I can have a vote in who gives me the injections.

I can have a vote in who gets the pregnancy test results. I can have a vote in how much information I share with others. All of those things enhance our sense of feeling in control.

I think that's helpful and I think that many clinics are willing to accommodate a couple and a patient if they want to do things slightly differently. Unfortunately, the days of hands-on education are gone. We have lots of video instruction and lots of telecommunication.

But in general, the nursing teams are really good and flexible, I think, to help accommodate. It does require good communication from the patient-slash-couple as well. So you can't expect anybody to read your mind about what you want and you can't just say it casually in the hallway as you walk out the door.

You really have to like write it down or send an email and say, please put a note in my chart that this is how we want to handle this. It's not that different when people are able to be pregnant from what do you do if you don't want to know the gender of your baby? You have to tell your team and they have to put big notes everywhere because it's not what most people want and they have to remind themselves to be respectful of what you want. So you communicate it clearly and the team can try to accommodate.

Yeah. You know, we touched on this a little bit earlier. There are a lot of different coping styles and, you know, one is not necessarily better than the other.

But, you know, I really like your statement, what coping style works best for you? And it may be that we all have to discover that through some trial and error. I think that's very true. And this is another one of those things that's true in life, not just in fertility land.

What is useful to you may be very different from what's useful for me. And in my experience, it tends to be one of the things where couples are different. One of those mysterious equations and what are we attracted to tend to be connecting to people who are different from us.

So in many couples, there is what I would call a talker crier who wants to talk about it with the partner and not necessarily in what I would call a problem solving fashion. It's really more of a talking about it. And there is somebody else who's not a talker crier.

And I see this in heterosexual couples, but I absolutely see it in same-sex couples as well. There just tends to be one of each. And until you start thinking about it, it's very common for you to think, I'm doing it right and they're doing it wrong.

You won't talk about it. That must mean you don't care. You're not thinking about it as much as I am.

You're not as involved in this as much in this process as I am. You never cry about it. I'm alone in this by myself is what we think when we look at the other person.

And if you're the more stoic person who doesn't find it useful to talk or cry, you're looking at your talker crier partner thinking, oh my God, if I were responding in that way, I would absolutely be at the end of my rope. But those of us who are talker criers know that we can do that and stir the soup at the same time. It's familiar to us.

We're not at the end of our rope. We're very upset because fertility challenges are very upsetting, but we're not unable to do other things. So we have to say to people, this is what helps me.

And then in a couple, if you have one of each, what I strongly encourage you to do is to try to find some ways to connect over that without making the other one crazy. So for example, you might agree. We will talk about this for 15 minutes every night at dinner.

If you have dinner together and I'm the stoic one, I will listen. You're the talker. You could talk, but we will not talk until bedtime.

We will not do this again. First thing in the morning, because if you are the person. So setting aside a dedicated time to talk about it.

Yes. So it doesn't spill into every aspect of your life. Exactly.

Because that's part of what makes more stoic people avoidant. They're afraid if I say, how did your doctor's appointment go today? Then that's what we're talking about until we go to bed. There has to be a way to show that interest and yet not have it take over every moment of life because you have to be finding ways to have a life while you wait to see if you're going to have a baby.

It's got to be a parallel process. Similarly, if you are the person who prefers not to talk about things, but it leaves your partner feeling alone and as if you are uninvolved. I encourage you to find ways to report, but refuse to talk about it at length.

So for example, you might say I was on a zoom call for work this morning and we were all schmoozing at the beginning. And Sally mentioned that she just had her third month of ultrasound and they're all excited about having a baby. And I had the same feeling, sweetheart, that you often talk about it.

I thought, when is it going to be our turn? It was so painful. So I just want you to know I have those reactions like you do, but I don't want to talk about it. So you find a way to do what I call reporting.

Yes, I have those horrible experiences. Yes, this is painful for me too, but it doesn't make it less painful to talk about. Very good.

So this has been really fun and I just, you know, I'm hoping that this podcast, you know, gets wide listening audience and, but we are going to have to close it up and end this. I'm just wondering, you know, is there anything that you think, any parting advice you'd like to give to couples struggling with fertility and working through their stress around it? There are two final pieces of advice I give. So one is really taking responsibility for thinking about what helps me and finding ways then item number two, to communicate that to others, because it is so common that we think people should just know how to help me.

And yet we've all heard friends and patients say, I can't believe so-and-so said such and such. They totally don't get it. We have to find ways to say to people, I know you want to be helpful.

This is what would help me. But first you have to figure out what that is. That's powerful.

It's work, but it can be very helpful. And this is a marathon. You are, those of you listening to this are, or if you're listening because you have family members going through this, this is a marathon.

It's not a sprint. So you have to find ways to, how do I hydrate, keep in shape? You know, you never can control who else is in the race or who's going to win it or what the weather is, but you can control if you have good sneakers and if you did good training and you got to think about infertility like that. Fascinating.

Thank you very much for joining us. This has been a wonderful session. My pleasure.

I hope everybody found something to take away. Good luck. And it's just been really fun reconnecting with you.

Thank you so much. Thank you for having me. You take care.