Hot Flashes Warm Bottles: First-Time Mothers Over Forty  [Chapter 4 online] by Nancy London Purchase at:  Amazon.com  Format: Paperback, 204pp.  ISBN: 0890879710 Publisher: Ten Speed Press  Pub. Date: May 2001

Chapter 4 - Midlife Moms and the Infertility Mill

Reprinted with permission

My Eggs
I sit across from the brooding young man
and examine the brush of his eyebrows
the unruly whiskers that shoot
over the rim of his glasses.
I hate this doctor whom I've paid exorbitantly
to give me bad news.
I twirl my rings, lick my lips, straighten
the seam of my sweater sleeve
as I line him up in the crosshairs of my gaze.
He shuffles my test results absently
across his desktop.
"Your eggs are old," he muses,
tapping his fingers in an A-frame
of protection in front of his paisley tie.
"The good ones are gone.
You're not like the young, who simply
throw their ovulations away.
They never miss a dozen eggs."
He chuckles at his little grocery joke.

I picture myself at 15, frizzed and barefoot
plucking 12 eggs from an egg carton
recklessly tossing them one by one
each month of my cycle into fields
of lush green expanse.
Where each egg lands, a flowering magenta plume
shimmers, surrounded by bluebells.
The earth is fertile, the babies abound.
My young eggs have fallen, spent
in my heedless youth.
"A few good eggs are all you need."
His words hang in the interval between us,
a black cloudbank of news reshaping my landscape.

A large, frail egg sails off my lap
pale dirigible drifting out into the dark universe
between our chairs.
Cracked like raku porcelain, hundreds
of tiny silver lines thread their way
across its pearly expanse, this egg the last
and the best of my collection.
It hangs between the young doctor and me
daring him to say more.

"You could surely consider an egg donor," he squeezes
through tapping fingers. I imagine my womb
a rental unit for the juvenile eggs
of another, and feel the lines of age
deepen on my face.
I watch the insulted dirigible
dart back and forth along the pathway
of my doctor's words and feel rain in the air.
There will not be a baby.
I stand and carefully scoop my prized egg
into my bag, where it roots
around a bit before settling down
on a nest of loose kleenex at the bottom.
I leave the office bent forward,
older, careful not to swing the bag
as I climb the three sets of stairs
to the street.
 
-Christy Shepard

Nothing quite compares to the shock, disbelief, humiliation, and outrage an older woman feels when she discovers that no matter how young she may look or feel, she can't conceive because her eggs are, simply put, too old. She was born with her lifetime quota of eggs-about three hundred thousand of them-already inside her ovaries, but this supply has been systematically reduced by ovulation and has deteriorated because of environmental pollutants, X rays, chemicals, medications, drugs, additives in food and water, and the toxins to which she has been exposed. Because of these factors, a woman who has planned on becoming pregnant later in her reproductive life may find that, past a certain point, she is unable to do so because the viability of her eggs has been compromised.

What follows learning of her infertility may be a period of sadness, anger, frustration, and isolation, combined with a profound sense of grief for what will never be. She may revisit her past and try to determine when, where, and why she made the decision to postpone motherhood. All her past decisions concerning education, career, and personal opportunities come up for reexamination. Guilt and remorse may surface now over an earlier abortion, and her infertility may seem like "punishment," no matter how right the decision may have been at the time. Working through all of these painful feelings may take a month, a year, or a lifetime. Many women close this chapter of their lives by moving forward with plans to adopt a child. 

She submits to these daily invasive procedures because she knows it is her last chance to bear a child. She submits because all of the competency, training, education, and success she has achieved cannot help her attain her goal. She submits because either suddenly, or over many years, her longing for a child has grown and now nothing else seems worth wanting. Perhaps she has had several miscarriages, a string of all the wrong partners, a failed first marriage, or no partner at all. Now as she faces the beginning of perimenopause and the end of her childbearing years, she is looking at the distinct possibility that she will live the second half of her life childless and is willing to move heaven and earth to alter this unacceptable outcome.

Women who have successfully undergone infertility treatments come to First-Time Moms over Forty support groups with a bittersweet mixture of awed gratitude for the child they eventually bore and enduring issues about the toll-physical, emotional, financial, and spiritual-the treatments took on their lives. Some feel betrayed by their biology and angry that while they pursued the dream of "having it all," their fertility was in steady, stealthy decline. If they were used to being in control, they remember how helpless they felt to affect the outcome of their treatments as they submitted to doctors with no sense of urgency or a false sense of optimism. They tell stories of spending a lifetime's savings on a year's worth of treatments and recount their grief when they faced the probability that, at best, one child is all they would bear. They talk of the shock they felt when they learned that because of multiple implants that "took," they were carrying twins or triplets.

Even for these women who bore children after infertility, there is a lingering aftermath. They have lost time and resources that can never be recaptured. They may always feel different from other women for whom conception came easily, and they may fear retribution if they forget to be grateful even for a moment. But while the experience of infertility doesn't go away, while these women may never "get over it," they do learn to "get on with it," to heal and restore those parts of themselves that have been impacted by infertility and to find acceptance and resolution for the life they now live.

A Race against Time

Many women over forty falsely believe that as long as they are still menstruating, they can easily get pregnant, but, as we've seen, the ability to conceive declines with age. For a woman under thirty-five, approximately four out of every five of her eggs has the potential to create a healthy baby. A woman over forty will experience a 50 percent decline in the quality and quantity of her eggs, and by the time she is forty-five, most of her eggs will be defective.

Barbara came to a First-Time Moms over Forty support group and talked openly about her experience with infertility. "I'm a scientist and I didn't know a thing about my eggs aging," Barbara told the group. Now in her mid-forties, she earned her doctorate in geology when she was thirty-three, and then enjoyed working and traveling for the next several years. She married her husband at thirty-eight, and then tried to have a baby for two years before she went to a fertility specialist. "He explained that not all eggs are good eggs and that mine were simply too old. He recommended using in vitro fertilization [IVF] because he said there was no time to waste." Barbara and her husband did choose to use IVF and after two cycles successfully conceived and delivered a healthy baby boy. "It was a race against time. I would have been devastated if I had been unable to conceive," she said. "How could I have spent all that money on my education and not learned a thing about my declining fertility rate? Everyone needs this information to make an informed decision."

Michelle, who is typical of many women of her generation who grew up believing motherhood was second best, spoke next. "The two things I heard my mother say a million times were, 'Don't grow up to be just a mother,' and 'Don't grow up to be just a secretary,' which sounded like the worst fate in the world." Michelle decided on a career as a clinical psychologist, and after spending six years in graduate school, she threw herself fully into her work. When she was thirty-five, she joined a dating service and met her husband quickly. "We got married when I was thirty-six, and then we thought we had enough time to wait a couple of years to have kids while we got to know each other. By the time we seriously started trying to have a family, I was thirty-eight. That's when all the infertility problems began, and I started years of treatments. I went through all the standard tests and it turned out I had several things that needed fixing: scarring from an IUD I had when I was younger, a blocked tube, and fibroids. I had two surgeries and then I finally conceived, but it was an ectopic pregnancy. After that I had two miscarriages. There was no single factor that kept me from conceiving-it was the combination that made it difficult."

Michelle paused for a moment before she continued. "As I got older, it got harder and harder," she said. "By the time I was in my early forties, having gone through these surgeries and still not carrying a pregnancy to term, they couldn't find anything else wrong with me. Their final diagnosis was old eggs. The thought that I was never going to have a baby because my eggs were too old was like a death sentence hanging over my head. I even began to wonder why my husband didn't go off with a younger fertile woman."

Michelle and her husband went on to have two children using an egg donor, choosing this option because it meant that their children would be genetically connected to at least one of them. "It never entered my mind that I was sacrificing motherhood for my career," she said later. "I felt like I was doing the right thing, and looking back I don't know what I would have done differently. I was programmed to be the way I was."

Rahina had hung back from participating in the discussion and now chose her words carefully as she began to speak. "Learning that my eggs were too old left me with a long-lasting combination of shame and humiliation," she said. "Even though I had no particular feelings about the doctor up to that point, I suddenly felt very exposed and humiliated in a way I hadn't anticipated. I felt like the way I looked changed in an instant, like I suddenly aged right on the spot. The minute I walked out of his office I felt old and wizened and dry. I started having all these thoughts about the women in the Bible who were barren, women who couldn't bear children. It was really the first time in my white middle-class life that I was confronted with something I might not be able to overcome. I remember getting really angry and thinking, 'Oh yeah? You don't know what you're talking about. I'll take your fertility drugs and I'll show you.'"

Thirty years ago the diagnosis of old eggs would have meant that a woman either chose to adopt children or found other ways to nurture the next generation. Now science offers women-of almost any age-an array of technologies to help overcome infertility and to produce biological children in response to the powerful maternal longing of the human heart.

The Ten-Thousand-Dollar Choice

The new reproductive technologies offer all the blessings and curses of a genie let out of the bottle. On the one hand, they help women who would otherwise be unable to have them bear biological children. On the other hand, they involve varying degrees of invasiveness into a woman's emotional and physical being, and seriously impact her partnership and individual lifestyle.

An older woman entering the world of ART usually undergoes a complete medical evaluation. This may include stimulating her follicles-the fluid-filled sacs that contain the eggs within the ovary-with hormones to determine her "ovarian age" and indicate the probability of a successful pregnancy using any of several fertility options. Treatment recommendations may first include a hysterosalpingogram (HSG) test, which is an X ray of the uterus and fallopian tubes used to diagnose possible tubal blockages and uterine abnormalities. A laparoscopy-a surgical procedure that corrects pelvic adhesions, tubal abnormalities, or endometriosis (a condition in which the cells that normally line the uterus grow on or within the ovaries or fallopian tubes)-may be recommended as well. Once these obstacles to conception are cleared, women may proceed to using fertility drugs like Clomid, Metrodin, and Pergonal, which stimulate egg production, alone or in combination with intrauterine insemination (IUI), an in-office procedure that places sperm directly inside her uterus, or in vitro insemination (IVF). IVF involves inducing ovulation with fertility drugs for the first ten to twelve days of her cycle and then, using the guidance of ultrasound, retrieving these eggs, fertilizing them with the chosen sperm in a sterile dish, incubating them under laboratory conditions for two to three days, and then transferring viable embryos back into the woman with the hope of a successful pregnancy and birth. Since not all embryos successfully implant, multiple embryos are transferred in the hopes of obtaining one live birth, with the consequence that multiple births are always a possibility. This procedure, plus the ten-day wait until pregnancy can be confirmed, is often described as a torturous emotional roller-coaster ride for those involved.

Other techniques include Gamete Intrafallopian Transfer (GIFT), which involves the same procedure as IVF, but implants the egg and sperm in the woman's fallopian tube for natural fertilization; Frozen Embryo Transfer (FET), which involves the transfer of previously fertilized and subsequently frozen embryos; and Egg Donor IVF, which follows the procedure for IVF but uses an egg donated by another (often younger) woman.

But even this astonishing display of technology has its limitations. A woman who chooses IVF has at best about a 20 percent chance of a successful pregnancy in a given cycle. The cost per cycle is about $10,000, and she may need to undergo treatment for several cycles. Insurance coverage is poor or nonexistent.

"When I got to the place of finally knowing that I was infertile, there really wasn't that much choice," one client who successfully conceived with IVF told me. "I was going to spend $10,000 whichever way I looked at it. Ten thousand dollars for IVF, $10,000 for an international adoption, or $10,000 to take an extended trip because I chose to be childless and I couldn't stand to think about it."

Cycles of Hope and Despair

When women share their stories of infertility clinics-invasive procedures that extract and insert, hormone shots with needles big enough for horses, young male interns who haven't got a clue-they swap them with the grim humor of a war story, one survivor to another. "My husband was in the clinic bathroom trying desperately to fill a specimen jar with sperm when a helicopter flew by the window." "When I had run out of money and couldn't afford to do IVF again, the clinic told me I could get frequent flyer miles if I put it on my credit card. That's 10,000 miles!" The timed sex when ovulation is occurring, the mad dashes to clinics over bridges, through tunnels, in sunshine, in snow, these are all part and parcel of the infertile woman's experience. The waiting, the hoping, and the despair are often followed by the decision to try just one more time. These are the stories women tell each other, glad for someone who understands.

"I felt like I had bought a one-way ticket to hell," Diana, a forty-six-year-old writer confided to the group. "My moods shifted between hope and despair within days, sometimes within hours. Not only were the drugs affecting me, but the two weeks after an IVF treatment and before I got the results were brutal. I was on a ragged roller-coaster ride. I went up, allowing myself to feel hopeful, and then I'd come crashing down into despair, dreading the next negative test result. I became reclusive and envied every pregnant woman I saw." Diana went through four IVF cycles before she conceived her son, Nick, who is now two.

Rahina continued telling us her story. She began taking fertility drugs once she learned that her eggs were too old to conceive naturally. A single lesbian woman, she had tried for several years to conceive using artificial insemination with sperm from the local sperm bank before she made this decision. "I never thought I'd need to use drugs. I thought it was just a matter of time before I got pregnant. But once I realized I couldn't, I decided to try Clomid. I had a very bad mood disturbance from it. I kept calling the doctor and saying, 'I have no libido. I'm too paranoid and anxious to go out of the house. I'm depressed and crying all the time.' He'd say, 'Keep trying, you want to have a baby, don't you?'" Rahina took Clomid for several more months. Ultrasound confirmed that she was producing eggs, so she continued testing her urine and inseminating when there was a surge of hormones. When no pregnancy resulted, she chose to progress to Pergonal, an ovulation-inducing hormone that she had to inject twice a day. "I was scared to take Pergonal because it was stronger than Clomid. It didn't affect my moods as badly, but I could tell that it was throwing me out of whack. I didn't have my usual energy and my body ached like I had the flu for half of the month. I felt so driven during that time, giving myself these shots twice a day and then going for an ultrasound to check my follicles in the middle of the month. I was completely caught up in the machinery of the fertility specialists, and I couldn't face the disappointment of not being pregnant if I stopped trying. I couldn't imagine what else I was going to do with my life."

Rahina knew that she had to stop the treatments for her emotional and physical well-being, and she promised herself that she would, after one last try. She conceived her son on her final round of insemination when she was forty-four.

Barbara, the geologist who ultimately conceived with IVF, described having her follicles retrieved at the infertility clinic with "a guy in the next room yelling 'egg' or 'no egg' as he inspected each one of them under a microscope. She returned home and kept in touch with the clinic on a daily basis to follow the progress of her embryos. "I felt like I had, not real babies, but these things of mine living outside my body in a test tube somewhere. My husband and I followed the growth, and it was as if I were pregnant, but not really, which is funny because when I was growing up my mother always said you couldn't be just a little bit pregnant."

Unlike many of the women in my support groups who chose to postpone motherhood, Jenny, who is now forty-two and the proud mother of a nine-month-old daughter, started trying to get pregnant when she was thirty-one. After two years, her doctor recommended IVF but she was appalled; she felt too young and the procedure was too invasive. She spent the next several years changing her diet, going for acupuncture treatments, and coaxing her husband into drinking bitter Chinese herbs. When that didn't work, she tried Clomid for four cycles, then a laparoscopy, then Pergonal, and several inseminations, all of which failed. "Every time I went to the clinic I saw a different doctor," she told us. "They weren't familiar with my case, they never really knew who I was, and I didn't feel like they were able to handle a lot of my emotional issues. It was stressful talking to someone different every time; I didn't really feel like I could connect with any of them. They kept encouraging me to do IVF, which I just couldn't afford." She explained to us that her husband had two grown children from a previous marriage and "was just going along with what I wanted. I was the one who was intent on getting pregnant. Early on if I had gotten pregnant, it would have been fine with him, but once we started having problems he felt like, 'Well, let's just not have a kid.' But that wasn't okay with me."

Jenny made the decision to leave the "infertility rat race" and resume her career as a dancer. She went on tour for a year, but the prospect of starting infertility treatments all over again made her depressed and anxious. She returned home and despite her misgivings, did just what she thought she'd never do: she decided to do IVF. "I called my mother and asked her for the money to do it. She was great about it and gave me the money. Since I wasn't limited by my insurance company, I could see the same doctor every time. It made a huge difference. He asked me specific questions that had more to do with my emotional life than my physical life; he asked me where I was at with all I had gone through. I broke down in his office. I told him that I felt like nobody really understood the level of my frustration and disappointment because they never took the time. I told him that we had spent thousands of dollars and needed someone to understand that I didn't have another $10,000 sitting in the bank. Having the treatments not work was devastating. It wasn't as simple as just trying again." Jenny's voice filled with emotion and she sat silently for a moment. "I felt like he really heard that," she continued, "so I did IVF. It was horrible, invasive, and painful, and it didn't work. I said I'd never do it again, but I did, and when I went in for the results the second time I was prepared to let everything go. I had a good marriage and wonderful work, and I just wanted my body back. That's when I found out I was pregnant.

"I'm pretty easy going generally speaking," she said thoughtfully. "But because it had taken me so long to get pregnant, and because it had cost me so much physically, emotionally, and financially, once I got pregnant it was really hard for me just to enjoy the pregnancy. I spent the first three months convinced I was going to miscarry. Every time some little thing happened, I was a basket case. Then when I delivered, there were all these complications-it didn't go smoothly at all. The baby was in intensive care and I couldn't hold her for twenty-four hours. There was not one thing about getting pregnant, being pregnant, or the actual delivery itself that felt 'normal'-it was all totally stressful. Now I look at my baby and say it was worth it. I'm so glad I did everything I could to have a baby because I didn't want to turn around at forty-five and regret not trying harder to have a child."

Two Strollers, Two Cribs

Fertility drugs, which cause multiple follicles to develop, are needed to successfully retrieve multiple eggs during an IVF treatment. They are also one of the causes of multiple births, even when the drugs are used apart from IVF treatment. A fertility doctor using IVF to treat an older woman's infertility will seek to optimize success rates for pregnancy by transferring a large number of embryos, usually more than six, in the hopes of offsetting any problems that might exist in the quality of her eggs. It is increasingly common for a woman to go from the anguish of infertility to the bounty of having more children than she might have planned for or ever dreamed possible.

A 1999 study from the Centers for Disease Control and Prevention documented the unprecedented increase in the twin/multiple birth rate among American women over the age of forty. During the last seventeen years, the twin rate rose 63 percent for women aged forty to forty-four, but the greatest increase in twin rate was among women aged forty-five to forty-nine, with an astonishing rate increase of nearly 1,000 percent from 1980 (when this age group bore only eight sets of twins) to 1999. In fact, mothers aged forty-five to forty-nine bore more twins in 1997 alone than during the entire decade of the 1980s. But lest you think the trend stops here, in 1997 there were fifty twin births and thirteen triplet births for mothers aged fifty to fifty-four. It is worth noting that in England and France, the law restricts to three or less the number of embryos that a woman may have put in her uterus.

"I knew there was a risk that I could have more than one," Karen said, "but it's all just an idea until the reality hits." After three unsuccessful rounds of fertility drugs and inseminations, Karen, a forty-three-year-old environmental lawyer and her fifty-year-old husband, Jay, turned to IVF and conceived during their first cycle. When they went for their ultrasound, Karen remembers that the doctor and nurses were "quite silent. I broke the silence and said, 'It's twins, isn't it?' The doctor nodded and tried to make a joke and said, 'Well, you wanted children, didn't you?'" Karen and her husband sat stunned for a moment. "Then we went out into the waiting room where we had waited all those other times," she said. "Jay's eyes were big and unfocused, like he was trying to register what had just happened. We went home and were in complete shock for about a week. We kept saying, 'What have we done?' We imagined two of everything. Two strollers, two high chairs, two cribs. The turning point was when I woke up about a week after that and had some bleeding. I called the doctor and he said, 'You better come to the hospital right away.' Suddenly we went from, 'Oh my God we're having two', to 'Oh my God, we're not going to lose one, are we?' It had been such a hard road to get to that point and then the reality that we might lose one was awful." Karen and Jay spent six nerve-wracking hours waiting for their ultrasound, which eventually confirmed the beating of two healthy hearts. "From that moment on, our emotional commitment was really strong; we knew we wanted both of them."

Karen recalled discussing the probability of having multiples with her doctor when she had five embryos transferred. "I remember saying, 'Isn't that a bit extreme?' But he said he had to consider my age and the viability of my eggs relative to the number of embryos he put back. I know these clinics depend upon their success rate," she said. "Their marketability is based on the results they produce, so I knew there was even a risk of triplets. But we had been through so many cycles of dashed hopes that we considered the twins the greatest miracle of our lives. I was glad to play the hand that had been dealt me."

While multiple births may seem at first glance to make economic sense for an older woman, a kind of two-for-the-price-of-one, given the expense of fertility treatments and her race against time, any multiple gestation is a high-risk pregnancy. There is an increased threat of premature delivery, and most women carrying multiples are confined to strict bed rest during the second half of their pregnancies. Those who aren't ordered to bed remain virtually inert, trying to carry their babies as close to term as possible. Multiple births may also mean the spontaneous loss of one or more of the fetuses, with one or several of the others surviving. But perhaps even more difficult is having to make the decision to reduce a high-risk multiple pregnancy to a singleton or twins because of the risk it poses to the health of the mother or because one or more of the fetuses has been determined to be genetically abnormal, or for both of these reasons. This process, called selective reduction, is usually done before the end of the first trimester and involves, under the guidance of ultrasound, injecting a salt solution directly into one or more of the fetuses, which is then gradually reabsorbed into the mother's body.

Having to choose selective reduction can feel like a moral minefield, especially to a woman who has tried so desperately to get pregnant. During her second IVF cycle, Barbara's doctor recommended transferring six of the embryos back into her, but her fears of a multiple birth led her to choose four instead. All four embryos attached. After two months, one of the fetuses spontaneously aborted leaving triplets, two of whom had genetic abnormalities. "We had to decide whether or not to undergo selective reduction," she said. "We stayed up for twenty-four hours phoning about a hundred of our friends and family. We finally decided to do it because my husband's mom said, 'You have one normal child, give him a chance.' There was still the possibility that I'd miscarry the last baby," she said, "so I really didn't allow myself to have very high expectations."

Barbara delivered her healthy baby boy by C-section at thirty-five weeks. "I was so elated and grateful," she said. "But the excruciating part was having to make a life and death decision about the other two babies. It felt like the right thing to do, but my husband and I had to face that decision on our own. It was the hardest choice I ever had to make."

Grieving Our Losses, Healing Our Hearts

And so they lived happily ever after. Or did they? Women who struggled with infertility and beat the odds to become first-time mothers over forty count themselves among the fortunate; most know women who weren't so lucky. They constantly refer to the miracle that brought their children into existence and to the blessing of having a family with whom to share the fullness of their heart. But given all of this bounty, how do they explain lingering feelings of loss and sadness?

The losses are real and they are many. There is the obvious loss of time, resources, and goals put on hold while treatment was pursued. But there are other immeasurable losses, like the second or third pregnancy that most likely will never occur, babies lost in utero or in miscarriage, the loss of the continuity of our genetic line if an egg donor was used, and the loss of our innocence as we face our vulnerability and the knowledge that not all things are within our control.

For some, the consequence of having lived through the infertility experience is a limited ability to express frustration and disappointment. It's as if she made an imaginary bargain: "If I'm allowed to have this child, I promise I'll never yell. I'll always be available. I'll always be giving, gracious, generous, and loving." But what comes along with this promise is the unspoken fear: "If I ever let up on my part of the bargain and admit I'm tired or angry, I'll be punished with the loss of my cherished child."

For all of these women, celebrating life and grieving lost possibilities are the poignant lasting legacies of infertility.

When June bolted from her small Southern town as a young adult, she broke the family pattern of marrying young and having at least a half dozen children. By her late thirties, she had put herself through medical school and established a pediatric practice in a small rural town in New Mexico. When she and her husband tried unsuccessfully for several years to conceive a child, she chose to do IVF and spent two years and all their savings in treatment. June had a healthy baby boy when she was forty-four, and now at forty-seven says, "I feel like I'm just getting started having babies, like I should be thirty-two. How did I suddenly get to the end of the road? My husband has grown kids and doesn't want any more. Last night we stood in the nursery and I wept. I told him, 'Hey, I never got to be young and nest with you. I'm not ready to be old yet. Let's put up the crib and have another baby.'"

At forty-seven, June is struggling to come to terms with the choices she's made in her life. As a thirty-year-old medical student, she conceived a child she felt she couldn't adequately care for. After weeks of agonizing, she made the difficult decision to have an abortion. Now, as she realizes that she is at the end of her fertile years, she says, "I really believed I had to deny one part of myself to get what I thought was important in life. But now when I see young women in my clinic who are considering abortion, I don't try to talk them out of it, but I do tell them about my years of infertility. How could I have been so closed to the beauty and mystery of life? Who decided that the worst thing that could happen to a young woman is to have kids?"

Michelle, who believed motherhood was second best to her career as a clinical psychologist, conceived her two children with the help of an egg donor. "Most of the time I don't think about it at all," she said. "I love them with all my heart. But sometimes I notice how much they look like my husband and not at all like me, and it's a painful reminder that they're not my genetic children. I wonder about the woman whose egg my husband fertilized. Did she have any more children? Do my children have half-siblings they don't even know about?"

Karen, the environmental lawyer and Jay, her husband, became parents of twins after one IVF cycle. Six unused but viable embryos were subsequently frozen. Now at forty-five, Karen feels she is realistically too old to have any more children, especially given the distinct possibility of another multiple birth through IVF, but the issue continues to come up since the birth of the twins: maintaining the embryos in their frozen state requires the annual consent of her and her husband.

"So we get this letter every year, and it's like 'Greetings! Do you want to renew your embryo-freezing contract for another year?' And there are all these boxes to check. If one of us dies, who gets the embryos? Do they get thawed and destroyed? Do we want to donate them to a childless couple? On and on. It feels like we're making life and death decisions over our corn flakes and coffee," Karen said. "If I don't renew and I let my embryos die, it's like admitting that I'll never have another child. So far, we just renew for another year and keep our options open."

Karen knows that growing older is a fact of life, but she is tempted by the new reproductive technologies that seductively promise to extend her fertility time line by at least a decade. This temptation seems particularly endemic in our society that elevates youth to the pinnacle of desirability, shuns its elders as no more than nuisances, and views aging primarily as a disease that can be cured rather than an inevitable part of the life cycle.

Anna suffered four miscarriages before she gave birth to her son. Too old to try again, she and her husband are doting parents to their only child. "But it's odd," Anna said. "Sometimes I say I have to get home to the kids. I think I'm talking about all those babies I lost. I gave them names. I imagined what they'd look like. It's as if my heart and my home still feel a little bit empty without them."

Lingering feelings of sadness and loss are a reality for women who have successfully conceived after infertility. Often, however, they are reluctant to admit to them for fear of sounding ungrateful, though surely these women do not lack for gratitude. Adding to this reluctance is the expectation that "all that is behind you now," which makes admitting to any difficulties all that much harder. But allowing grief into our hearts is like the old Zen proverb: "The way to control a bull is to give it a big pasture." Allowing ourselves to feel our losses without minimizing or judging them is how we heal the wounds we may still be carrying from our years of infertility. Ironically, experiencing grief loosens its grip on us. Feeling our hearts break and then sitting still long enough for grace to find its way in through the cracks is the surest way I know to restore the energy and joy we need to get on with our lives.

If you are partnered, you already know that the infertility experience can take its toll on relationships. After years of scheduled sex, emotional highs and lows, and working so hard for what comes naturally to others, you may have forgotten how to connect with each other as a couple. Can you remember the last time you enjoyed a conversation about something other than your child or children, or the last time you held hands and looked at the moon? Now may be the time to recultivate the pleasure you took in each other before you started trying to have children. If you can afford a sitter or can enlist the help of a friend or relative, slip out for a night away and renew your emotional and sexual relationship in peace and quiet.

If you've been blessed with multiples, look for a local support group for parents of multiples, or if one doesn't exist, put up notices and start your own. Check the Internet for information and resources for families with twins or more (see Resources, pages 196-97). Take advantage of these networking opportunities to meet others who share in the wonder and challenges of the world you have entered.

Above all I encourage you, single or partnered, to add, one at a time, those things back into your life that nurtured you before you entered the world of infertility treatments. It need not be something that takes a lot of time or money. Are you still in touch with the friends you knew back then? Do you go out dancing any more? Have you tucked away your frilly clothes in favor of more practical things? Have you continued with your favorite sport or musical instrument? My life B.C.-Before Children-always included rock and roll music and an eclectic collection of outspoken female singers. In particular, I adored Joan Armatrading. Her music accompanied me on all of my road trips solo or with friends. So now my road-trip days are severely curtailed, but I still blast her unmistakable deep, soulful voice when I do the dishes at night. It's loud. The cats slink away and my husband rolls his eyes, but it's a part of my previous life that never fails to restore my spirits. If you're having a hard time remembering what you enjoyed before you became a mother, ask an old friend who knew you back then and see if you can manage to squeeze just a little bit of these pleasures and activities, big and small, into your daily or weekly routines.

Some say that women who use ART to conceive are tampering with nature and that if they had been intended to be parents, they would have been. But I have seen time and time again that the women who have the courage to go to these extreme measures are moved by, driven by a longing for motherhood that is powerful, cellular, and in fact hardwired into the survival of the species. From that vantage point, all our judgments seem futile and miss the mark by a mile.

The Journey Book

Grieving Our Losses, Healing Our Hearts

For this exercise, you'll need three pictures. The first is an actual photograph of yourself that represents the life you led before you tried to conceive, maybe yourself when you were a young career woman, musician, traveler, student. This is the image of "Who I Was."

The second picture represents the pregnancy, childbirth, or motherhood experience you hoped for but did not achieve. It might be a pregnant woman about the age you were when you first tried to conceive, or a mother with several children, or maybe it's a picture of a child who is the same age as the baby you miscarried would be. This picture is called "What I Lost."

The third picture is a photograph that represents you as you are now. It is called "Who I Am Today."

Allow about fifteen minutes for each part of this three-part exercise. It is ideal to do all of them at the same time, but if that's not possible, doing one part at a time is okay.

Glue the first photograph of yourself into your Journey Book, and sit quietly and look at her. Allow the memories of that time in your life to surface. Where were you living, who were your friends, what clothes did you wear, what was your favorite music, who were you dating? Did you think about having children? Remember one especially memorable scene from that time and journey back until you are standing with her in that moment.

Begin writing. Tell her who you are today. Tell her where you live now and who you live with. Talk about the experiences you've had since that time in your life. Tell her about your child (or children) and the joys and sorrows involved in becoming a mother. Tell her about your infertility, knowing all too well that her life path has already been irrevocably chosen. Let her innocence melt your heart, and if tears well up, imagine your wounds being washed with them. In closing, let her know that you honor her choices; they have made you the woman you are today.

Next paste into your Journey Book the picture that represents what you expected from life and what you lost. Begin writing about your losses. Maybe you thought you'd be a young mother, bearing several children in your youth. For some women the loss was of time, money, and energy. Careers were put on hold, and all the resources that might have been directed toward a new home, travel, business goals, or school were channeled into fertility treatments. This isn't the time to worry about not sounding grateful; it's a private moment for you to express your disappointment, anger, or sadness. It's okay to feel cheated, betrayed, outraged. You're feeling it in order to heal it.

Finally paste the photograph or image that represents your life now in your Journey Book. Write about how your losses have shaped you. Describe the strengths you've developed as a result of these losses. These may be a reordered sense of priorities, resiliency, the ability to deal with disappointments and make difficult decisions, new coping skills, a greater sense of compassion for others, a stronger relationship with your partner and friends, and an ability to find joy in the small moments of life. Write about the things you give thanks for every day, and what you most trust and admire about yourself now.

Promises and Bargains

Did you make any deals with the universe when you were trying to conceive? Did they involve always and never? Write yourself a formal release from this agreement and affirm that you are doing your best, that your best is good enough, and that you and your family are surrounded by beneficial forces working toward the highest good of all concerned.