Adventures of a Misbehaving Uterus

I had considered writing about abortion laws and their potential impact on infertility and miscarriage management long before last night’s news about the draft Supreme Court opinion overturning Roe v. Wade, but I’ve been afraid to open myself up to potential anger and criticisms. I don’t want to debate when life begins or the merits of pro-life vs. pro-choice, that’s not what this blog is about.  However, those debates and resultant legislation have real and potentially serious implications for the infertility and pregnancy loss communities, and I think it’s important to discuss how. That’s what this post will focus on.  If this is a non-starter for you, stop reading now. For the rest of you, I’ve broken this down into three areas.  There are others, but these are the ones I’ve spent the most time exploring and which I feel would have directly impacted my own fertility journey.  First is the issue of “personhood,” second is the legislation restricting access to the “abortion pill,” and the third is the question of fetal harm and maternal responsibility.

**Please remember that I’m not a lawyer nor a constitutional scholar. This is simply a summary of my own research and personal opinion on the subject.

• Personhood legislation could limit assisted reproduction

Several states have already introduced legislation stating that human life begins at the moment of conception/fertilization (“personhood legislation”).  If passed, these types of laws could severely limit reproductive research as well as assisted reproduction procedures like IVF.  As stated in RESOLVE: The National Infertility Association’s policy position (I encourage you to read the whole thing), “with personhood legislation, the legality of pro-pregnancy fertility treatments would be called into question: if microscopic fertilized eggs/embryos are full humans, anything that puts an embryo at risk could be a criminal violation.”

Were a personhood law to pass in my state, it would mean that my remaining frozen embryos were PERSONS, persons with rights. I have four embryos remaining – 400 cells.

Currently, the decision about what to do with them lies with me.  I can use them to try and become pregnant, I can have them destroyed, I can donate them to science, or I can donate them to another couple or individual. But if my embryos were considered persons, my options become limited. I could try for more children.  Although, given my pregnancy history and current maternal age, one might argue that a transfer into my uterus would be reckless endangerment.  Or I could donate them to another couple, essentially giving my embryos up for potential adoption. I find neither of these appealing.

Personhood legislation could also limit scientific research.  Already no federal funds can be used for research involving the creation or destruction of embryos. Personhood legislation could further restrict privately funded research as well, limiting potential advancements in both reproductive research and embryonic stem cell research.

• Restrictions on medicated abortions impact miscarriage management

Movies and TV shows often depict miscarriages as happening all at once – a woman wakes up and her bedsheets are soaked with blood.  Sometimes it happens like this.  But often, a woman finds out her pregnancy is no longer progressing before her body starts to physically miscarry. In these situations, there are generally three choices: (1) wait for the body to naturally pass the pregnancy, or “expectant management”; (2) undergo a surgical procedure called a dilation and curettage (D&C) to scrape the uterine lining and remove the pregnancy tissue; or (3) induce a miscarriage using medication. 

Over the course of my six miscarriages, I have personally selected and experienced each of the above options.  They all have pros and cons, and they all generally suck.  Expectant management is unpredictable; you can wait for weeks for your body to pass the pregnancy and often you still need to have follow-up treatment to remove “retained tissue.” Medical management is more predictable but can also result in an incomplete loss and require retreatment.  Surgical management is predictable and complete, but it is invasive and (for me) resulted in post-operative uterine scarring, twice. I should also note that these are the options for managing early losses, later pregnancy losses are handled differently.

The American College of Obstetricians and Gynecologists (ACOG) recommends a combination of two drugs to medically manage an early miscarriage – an oral dose of a drug called mifepristone followed by a vaginal dose of a drug called misoprostol. However, this is the same drug regimen that would be used to induce an abortion in the first trimester.

Several states have now introduced legislation limiting the availability and use of mifepristone, calling it the “abortion pill.” And while, it is possible for a miscarriage to be managed with misoprostol alone, the combination therapy is more effective, there is a lower possibility of retained pregnancy tissue, and thus a reduced need for further treatment (see the NEJM study here). What this means is that after already suffering the trauma of early pregnancy loss, women are now receiving less effective medical treatment for their miscarriage because of abortion laws that restrict doctors’ ability to prescribe mifepristone. 

• Fetal protection laws risk criminalizing pregnancy loss

Fetal protection laws are similar but different to personhood.  Fetal harm legislation already exists in many states, and while it is usually used when a pregnant person is the victim of a crime, it also has been used to prosecute pregnant women whose actions contributed to their pregnancy loss.

As stated in a Kaiser Family Foundation (KFF) policy brief, “by granting full rights to a fertilized egg, embryo or fetus, or by failing to provide sufficient exemptions to pregnant women in fetal harm laws, the rights and protections of the pregnant individual may inevitably decrease. Because the pregnant person and their developing pregnancy can be regarded by the law as two separate entities, if a person experiences a pregnancy loss and they are thought to be at fault in any way, they could be charged with a crime using fetal protection legislation.”

If you read that and groaned because you think it’s ridiculous, think again.  That same KFF brief references this analysis which identifies numerous cases in which women who experienced miscarriage or stillbirth were charged with crimes because state prosecutors believed them to be responsible for their pregnancy losses.

You may examine those cases and find the prosecutors’ arguments reasonable.  But what does that say about me? I transferred two pre-screened, top-notch embryos, and I lost them. At this point, neither my doctors, nor I believe I was responsible for my losses, but what if I was?  What if down the road, it’s found that I have a genetic predisposition for miscarriage (this, by the way is not outside the realm of possibility).  If I intentionally got pregnant with the knowledge that I would likely miscarry, would that constitute fetal endangerment? If I did miscarry, would it be considered feticide? Where do my rights end and the fetus’s begin? If I skied or hiked while pregnant and had an accidental fall which resulted in loss, could I be held responsible or deemed criminally negligent?

I recognize I’m being hyperbolic, but there is a slippery slope here, and laws like these can have serious unintended consequences.  My father told me that overturning Roe would never happen and was simply a fear tactic used by the left to increase voter engagement leading up to elections, but here we are.  You tell me what’s hyperbole. And, even if you are pro-life, even if you support all the aforementioned legal restrictions, I still think it’s important to recognize how such laws might affect the entire spectrum of family planning not just whether or not a woman has the right to choose.

I’ll close by saying that one might imagine after everything I’ve gone through in my efforts to have a child, I’d be offended by those who elect to terminate their pregnancies.  In fact, it’s exactly the opposite. After enduring the physical and psychological trauma pregnancy loss and considering the virtues and vices of unanticipated (and often undesirable) fertility treatments, I feel more than ever that all women should have all family planning options available to them.

I’m sorry I haven’t posted for a while.  I’m sorry because I have so much I still want to say (so much I still need to work through), but I haven’t made the time to write.  Or maybe I’ve avoided it.

As many of you were aware, my husband and I had been going through the gestational surrogacy process. I am now pleased to report that we are the proud parents of an 8-month-old baby girl.

I am overflowing with words on the experience of her birth, the surrogacy journey, and the transition to parenthood.   But I’m also not done sharing or working through everything it took to get us here. 

I don’t intend for this to turn in to a mommy-blog, but I also cannot avoid my current context or keep it from influencing my outlook on the future or reflections on the past. Moreover, recurrent pregnancy loss undoubtedly affected my parenting experience, and I think it’s important to discuss that.     

I know there may be some readers who are still struggling through infertility and loss.  If you need to stop reading, please do.  You won’t hurt my feelings at all.  I know your pain well. 

My sensitivity to past my triggers is acute, so much so in fact, that I almost didn’t post a birth announcement on my social media feeds.  When I was going through my losses, I found birth posts distressing, and I didn’t want to cause similar unease for others.  In the end I did announce her birth on Instagram and Facebook.  Having been open about our journey and our decision to pursue gestational surrogacy, I decided it was more disingenuous to hide the truth.  But as it stands, I haven’t posted anything about my daughter since her birth announcement. 

I’m not entirely sure why.  There still is sensitivity around not wanting to share images that will cause others pain.  But I also feel a strange desire to protect my former self and former identity – as if by not transitioning my social feed, I’m keeping that version of myself in some sort of pre-parent time capsule. 

For years, having a baby was the primary objective of my life – the goal around which all other goals were organized – and grief was the primary theme.  Grief was my filter for life; it became the explanation and justification for everything. 

This experience altered me. In some unexpected ways it served me.  It made me humbler. More compassionate. It motivated me to leave a job that was unfulfilling and fueled me to start Recurrent Pregnancy Loss Association. I found a community. I found my voice.  I know I need to change my filter, but it’s not quite as simple as changing my outlook, it’s changing my perception of myself.  Perhaps this is akin to a someone getting remarried?  They transition from “divorcee” or “widow” to “bride” and “wife.” But it’s not like the past gets washed away.

I think part of me is afraid to release my pain.  I don’t have anything from my pregnancies.  I didn’t keep ultrasound images or pregnancy tests.  I don’t have burial plots or keepsakes.  If I completely let go of my grief, I worry there will be no record of what I went through.  No proof.  At least no proof that anyone but me would recognize.

This yearning to hold on is elicited (for me) by the final stanza of E. E. Cummings’ poem I Carry Your Heart with Me.

here is the deepest secret nobody knows
(here is the root of the root and the bud of the bud
and the sky of the sky of a tree called life;which grows
higher than soul can hope or mind can hide)
and this is the wonder that's keeping the stars apart

i carry your heart(i carry it in my heart)

Because in the end, who will remember my pregnancies but me? Even if they were only imaginings, they were mine. For Christmas last year I bought myself a gift – a necklace. It has six, intertwined golden rings surrounding a peridot – our daughter’s birth stone. The six rings are for my six pregnancies. I carry them with me (I carry them in my heart)… and around my neck.

My maternal grandfather, my Papa, died yesterday.  He was 100 years old, so it was not entirely surprising, but it is still a loss.  The loss of our family patriarch, the loss of one of my life-long role models, the end of an era for me and my cousins.  I find myself in a very philosophical place today, pondering life’s big questions and the very nature of grief.  

But let me start with him.  Two words come to mind when I think of my grandpa: family and faith.  He was an accomplished businessman—starting, growing, and selling his own company.  He was a veteran, and a golfer, and a fisherman.  But his two great loves were my grandma and God.  His proudest legacy was the family they built, and his happiest moments were when we were all together. 

While death at age 100 is not shocking, his passing yesterday was unexpected.  In the morning he woke up, ate breakfast, got dressed… and then died.  My grandmother, his wife, passed away two years ago.  Her health had been declining for several months, so her death was anticipated if not welcomed.  In some ways it was a relief for us to see an end to her pain.  My grandpa’s death was not a relief, but there was a sense of rectitude and rightness to it.  I was happy to imagine his soul reunited with my grandma in some other space and place. 

I spoke with cousin of mine who was conceptualizing the loss in a very similar way as I, but said he wasn’t feeling grief over Papa’s passing.  His phrasing struck me because I did think I was grieving.  I began to wonder how each of us was defining the word “grief.”

I am not anguished by my grandfather’s passing.  I am not angry about the circumstances.  I am not shocked, nor am I wishing for a different outcome.  I have had tears in my eyes and a lump in my throat, but I don’t feel broken open.  I am upset, but I am not sad, at least not in the traditional sense.  I feel nostalgic.  I feel the Earth has lost something in his passing.  I wish I could relive many of our family reunions and holiday celebrations.  I miss that foundational stage of my life when my grandparents became my role models.  I’m grieving memory—the memory of the grandfather of my youth—but I don’t feel robbed of a future.  Perhaps that is the gift of long life.  There isn’t a sense of injustice or things left undone.

The loss of unrealized things is the grief of pregnancy loss.  It’s the opposite of what I’m experiencing now, and yet in some its ways similar.   Nostalgic memories and unfulfilled futures are both just thoughts in our heads.  We can’t get to either one, and both leave us wanting.   

Months after my grandma passed, my mom shared that there was a part of her that felt like she wasn’t allowed to grieve because her mother had lived a wonderful life until 99, as if age negated the fact that my mom missed her mother.  My mom is remarkable.  She is a person you want around in times of crisis.  She is a bit unflappable, she’s compassionate, and on top of that, she’s an ordained minister.  She is very comfortable with death.  She has a very clear idea about where we go after all of this.  She organized and officiated her own mother’s funeral.  She showed gratitude, and grace, and strength, but she didn’t feel she had permission to be in “grief.”  I think she and my cousin were both thinking of grief as sadness and tears.  My mom grappled with whether sadness was acceptable, my cousin was equated its absence with a lack of grief entirely.  But both their experiences were an effort to come to terms with loss.

My definition of grief has broadened over the past years (perhaps too much).  Grief always recognizes itself in others, and now I see it in so many ways.  For me learning to grieve has been learning the human condition.  We are all of us, all the time, managing feelings of loss or disappointment.  We are constantly reckoning our feelings of anger, or guilt, confusion, or lack of control, with feelings of joy and acceptance.  We worry when our feelings about a situation don’t square with what we think we should feel, and that makes us feel alone.  The irony, of course, is that we are all together in this collective confusion.

Last night I received what I believe was a message from my grandfather. It’s a long story, but one that lead me to Second Corinthians, Chapter 12, Verse 9 (sorry to get biblical, but I did say my grandpa had an extremely strong faith).  In the chapter, Paul describes a thorn in his side that torments him, and his repeated pleas for God to remove the pain, but God answers “My grace is sufficient for you, for My power is made perfect in weakness.”  God doesn’t remove the pain but gives Paul the grace to bear it.  It is a beautiful metaphor for the experience of grief and other human sufferings.  We are all pricked by different thorns in different ways at different times, it cannot be avoided. But we are given the power and grace to move through it.

There is a movement in pregnancy loss community about “redefining motherhood” and challenging the standard ideas about when someone becomes a mother. 

Does motherhood start at birth?  What if your child is stillborn or passes shortly after birth?  Are those women still mothers?  Is motherhood defined by the act of raising your child, or birthing them, or conceiving them?  If it’s the later, how long does someone need to be pregnant before they are considered a mother? Is it a kick?  A heartbeat? Does an early miscarriage count?

I won’t pretend to know the answers to these questions.  I don’t believe one answer exists. 

Many women who have experienced pregnancy loss feel they are already mothers.  There are hundreds, if not thousands, of social media accounts recognizing “loss moms” and “angel babies.”  Commemorative boxes and plaques can be purchased for named or unnamed and unborn babies.

I am incredibly supportive of this movement to redefine motherhood.  I want to acknowledge the pain and grief of pregnancy loss at any stage and honor each person’s self-expression and self-identification.  But I do not feel like a mother; that’s not how I see myself.

I recently participated in a vlog (video blog) conversation with Michelle Valiukenas, Co-Founder of the Colette Louise Tishdal Foundation, a nonprofit that provides financial assistance to families dealing with the impact of pregnancy loss.   The plan was to discuss the various ways to commemorate pregnancy losses.  In her introduction, Michelle said she is the mother of three: one living child and two in heaven.  In my introduction I said I’d had six pregnancies… because I simply don’t feel like I have six children.

Similarly, several years ago, after sharing that I’d lost multiple pregnancies, a colleague of mine assured me that I was “still a mother.”  I smiled politely but inside my head I was screaming, “NO, I’M NOT!”  I’m an awesome aunt, a supportive friend, a loving wife, a sister, a daughter, and a dedicated professional.  But I’m not a mother.  Not by my definition.  Not yet. So, I’d prefer the movement to redefine motherhood instead focus on broadening the definition, because I don’t feel like the new definition applies to me.  If fact, I find it pretty uncomfortable. 

I am sharing my feelings on this topic, because there is so much guilt and shame associated with pregnancy loss, the last thing I want anyone to feel is more guilt thinking they haven’t conceptualized their child correctly. 

I was very invested in each of my pregnancies.  My losses were devastating.  But I don’t feel like I lost children.  And while I have tried to find ways to honor my journey, I didn’t feel the need memorialize my specific losses. 

And that’s OK. 

We get to define ourselves in this life.  We get to choose our thoughts.  We grieve and process in our own imperfect ways.  So rather than trying to agree about when motherhood begins, rather than focusing on redefining the word, let’s work on broadening our definition.  Let’s simply “undefine” the word motherhood (thanks Katy Harrison). 

Hey friends! I’m interrupting my personal ramblings to talk to you about some Pro Family Legislation. Yup, it’s that time again for RESOLVE’s Federal Advocacy Day. This Thursday, June 17th, more than 500 volunteers from across the country – all 50 states – will meet with Congress to discuss the following legislative issues:

Access to Infertility Treatment and Care Act: Provides infertility treatment coverage to those who receive their healthcare through government health plans like TRICARE, the VA, or the Federal Employee Health Benefits Program. It also provides access to fertility preservation services for people like cancer patients, who risk infertility because of their medical treatments.

Veteran Families Health Services Act of 2021: Permanently allows veterans access to reproductive medical treatments like IVF and ensure that veterans’ and service members’ spouses and partners are included in eligibility rules.

Veterans Infertility Treatment Act of 2021: Makes infertility care a part of VA healthcare for enrolled veterans with infertility regardless of marital status or service-connection, and removes the ban on donated sperm, eggs or embryos.

Every Child Deserves a Family Act: Bans discrimination against foster and adoptive parents, families of origin, and foster youth, based on sex, sexual orientation, gender identity, marital status and religion.

Adoption Tax Credit Refundability Act of 2021: Encourages adoptions, especially of children with special needs and those from foster care.

Infertility Resolution: Recognizes that infertility is a widespread problem and affirms Congressional commitment to address its causes, diagnoses, treatment, and costs.

PCOS Awareness Month Resolution: Designates September as PCOS Awareness Month and recognizes the need for more education and research on PCOS, which is the leading cause of infertility in the US.

Stephanie Tubbs Jones Uterine Fibroid Research and Education Act of 2021: Increases research funding for uterine fibroids and improves awareness and training.

Medical Research Funding, FY 2022 Appropriations: Requests funding of $1.7B for NICHD, the division of the NIH that conducts reproductive health and infertility research.

If these bills appeal to you, you can help by sending a letter to your representatives HERE. It takes about 30 seconds.

For more information on these bills or infertility legislation in your state, visit: RESOLVE: National Infertility Association

Last week I had the opportunity to speak at a Fertility Rally group support meeting.  Fertility Rally is a wonderful support group/ membership community for anyone who struggles with infertility or chooses to build their family in a non-traditional way. 

After sharing my story and talking about Recurrent Pregnancy Loss Association one of the attendees asked me how I knew it was time for me to move on from trying to conceive.  I answered honestly – that after my sixth miscarriage it was immediately and abundantly clear that I was neither capable of, nor interested in trying again.  My husband and I were experiencing treatment fatigue well before our final IVF transfer.  We were exhausted and had been for a long time.  Before even starting IVF, we began considering other options.  So, for us, it was less a question of whether to move on, but howto move forward.  We chose surrogacy; but that didn’t mean we were happy about it. 

I’ve been hesitant to write much about my surrogacy experience because I’m still in it. However, the conversation last week made me realize that my mixed feelings about surrogacy are worth sharing. 

Let me be clear up front: I adore my gestational carrier.  She has positive energy, a warm heart, and an openness that makes her impossible not to like.  Honestly, she reminds me of my sister.  We have developed a lovely relationship and I am looking forward to going through the birthing process with her. But it took me some time to get this emotional place, and I also still wish I were able to carry my child.

Surrogacy is a long process, and in the beginning, it feels a bit like online dating… if you were forced to choose online dating because you’d tried everything else and couldn’t find a partner. My husband and I answered a bunch of questions about our values and preferences and then put together a profile that could be shared with potential gestational carriers. 

It was damn near impossible for me to write that profile – I finally had to have my mom compose a first draft in order to get started.  It felt like I was being asked to justify why we deserved to be parents, when biology and the universe had determined otherwise.  And I was angry.  I didn’t want to sell our story to someone who I would be paying to have our child.

But, as with so many things, it’s clear now that my anger and disinterest were not really about the profile.  The profile was emblematic of the process, and I wasn’t excited about the process.  After our profile was selected, there were dozens of other steps – a face-to-face match meeting, the contracting process, our gestational carrier’s medical examination, and of course, the embryo transfer.

I was committed to surrogacy, but it felt like a committed resignation.  Recurrent pregnancy loss gave me a supreme lack of confidence.  So even when things went well for our gestational carrier, I didn’t trust it.  I kept waiting for the bad news.  When friends, doctors, or family would ask “aren’t you excited” I’d nod, but I wasn’t.  It was as if my heart refused to get invested. 

My therapist encouraged me to join a support group to talk to other intended parents, so in an atypical demonstration of bravery from my introverted self, I attended a virtual social through our surrogacy agency.  I told the group I was feeling disconnected from the pregnancy and that I was struggling to open up to our gestational carrier.  And then something amazing happened – I learned that I am totally normal!!  Some parents shared that they never felt invested in surrogacy until they were in the hospital holding their baby.  Others said their excitement grew in the second trimester as the baby developed. Some felt involved and connected from the start, but not the majority.

I’ve been listening to a bunch of life coaching podcasts recently and one discussed the difference between confidence and courage.  The coach explained that when we’re doing something new, we need courage, not confidence.  Confidence about our ability to do the new thing grows as we experience success.  If we wait to be confident before starting something, we’ll never start. 

Oddly, this made sense to me in the context of surrogacy (or really any stage of my infertility journey).  If I’d waited to be confident or excited, I’d never have moved forward.  A forward step in my journey meant my prior step hadn’t worked, and any hope that I’d built up was lost.  Taking a next step was only achieved through courage. I had to choose to move forward; I didn’t have to confident it would work. 

For me, anticipation and excitement around surrogacy has grown steadily through the second trimester – helped along by the fact that Covid restrictions have lessened, and my husband and I have been able to attend key appointments with our gestational carrier.  The more milestones we hit, the more confident I am that we’ll be parents.   

There is still a part of me (sometimes a large part) that wishes I were pregnant.  But now there’s also a part that’s grateful I’m not experiencing heartburn, or constipation, or migrates; or that when I’m nervous about parenthood, I can have a glass of wine.  There’s a part of me that thinks it’s kind of cool that I will get to see my baby being born when most mothers don’t. 

So, to that Rally support group member, or to anyone who is sitting in ambiguity or on the cusp of a big decision, I think when you’re ready to move forward, you’ll know.  Don’t wait to be “sure,” don’t wait to be “excited” or “happy,” just move when you’re ready.  All it takes is courage; the other stuff will follow in time.

I feel the need to start this post by sharing my recent learning that “jealousy” and “envy” are not actually synonyms – they mean different things – and apparently, I’ve been misusing them for years!!  Envy is wanting something someone else has.  It involves only two people.  Jealousy is worry that someone is going to take something you have.  It involves three people.  This post is about envy.

Regardless of my vocabulary ignorance, I was brought up and conditioned to believe that both these emotions fell into the “bad” category.  I mean, haters gonna hate, right?  It was bad to feel envious – it meant you were ungrateful or unsupportive.  It was bad to feel jealous.  It meant you were insecure or untrusting.  But it doesn’t work like that.  Jealousy or envy – just like any other feelings – are neither good nor bad, they just are.  What matters is how you think about the feelings and what actions you take because of those thoughts.     

Women trying to conceive often lament that it feels like everyone around them is getting pregnant when they’re not.  Of course, everyone around them is not actually pregnant, but when you’re hyper-focused on something you tend to pay more attention to that thing and less attention to other things.  (This is actually called “attention bias.”)  And, when your perception is that everyonearound you is pregnant and you’re not, it creates an overwhelming sense of missing out – envy. 

I experienced frequent and often intense envy throughout my fertility journey.  I tried to put boundaries in place to protect myself (and my friends) from these feelings, but it was often difficult. 

Vicki Tidwell Palmer, author and host of the podcast “Beyond Bitchy: Mastering the Art of Boundaries,” describes boundaries as “the practice of creating physical, intellectual, emotional, and spiritual safety through protecting ourselves and others.”  She explains that “at the extremes of boundaries, we are either boundary-less (too vulnerable) or walled off (invulnerable).”  I admit, I oscillated a bit between these extremes based on the nature of my relationships and my personal context.

For me, pregnant women fell into three groups: strangers, acquaintances, and dear friends. Can you guess for which group it was hardest to establish self-protective boundaries?  Hint: It was not strangers.

Pregnant women on the street bothered me, for sure.  Every time I saw one, I experienced a pang of sadness, a wave of indignation, a slurry of unkind thoughts.  But there were no meta-emotions tied to these reactions.  I didn’t feel bad being envious or angry at these strangers.  They annoyed me, but I’d recite an internal “eff you” and move on.  No relationship boundary needed to be set because no relationship existed.  I was invulnerable to them.

Acquaintances who were unaware of what I was going through (and some who knew but were a bit tone deaf) activated a slightly larger emotional response.  These were friends I followed on Instagram, people on my holiday card list who I didn’t speak to regularly, work colleagues, etc.  When they got pregnant or had a baby, I experienced a greater amount of envy, but it was still relatively easy to ring-fence.  I’d unfollow them on social media, decline invitations, throw out birth announcements (yes, I really did this) or not return phone calls.  This wasn’t always possible.  I remember one time while travelling, my husband and I attended a birthday dinner for an old school friend.  Before dinner I said to him “if she’s pregnant, I’m leaving.”  Wouldn’t you know, she walked in at 8.5 months… and, as a birthday “gift,” her sister-in-law announced that she too was pregnant.  I drank a lot of wine and didn’t say much.  But aside from these occasional annoyances, overall, my relationships in this group weren’t really impacted.

Then there were my good friends.  My dear friends.  The friends who warm my insides like a sip of hot tea.  When they got pregnant it was incredibly hard because I had to decide if – at my life’s current juncture – their friendship created more joy or more hurt.  I didn’t want to feel envious of these friends.  I didn’t want to begrudge their happiness.  Having unkind thoughts about women I loved made me feel horrible.  But these were also the women I shared my life with – the friends I wanted to understand me and likewise relate to.  So, their transition to parenthood ahead of me felt like abandonment.  It was another of the many faces of grief. 

I wish I could say that I found simple ways to navigate the pain, but I didn’t.  Sometimes, I pushed myself beyond what was comfortable with.  There were a couple of baby showers I probably shouldn’t have attended (to the credit of these women, they all gave me permission to decline).  But I chose to be there.  I didn’t want to miss out on their lives.  It would have made me feel even more left out and disconnected.  Other times, I chose to let friendships slowly fade with the intention to reconnect again once my fertility journey had ended.  I just didn’t anticipate that it would take this long.

But boundaries have consequences, and relationships are two-way streets.  I had every right to decline baby shower invitations.  But I had to accept that doing so might hurt feelings – even if it would have been understood.  I could ask my friends not to talk to me about their pregnancies.  But I had to accept that it meant they were shielding me from one of the most momentous events of their lives and, at least in the short term, our friendship might suffer.  I could request to socialize without children.  But I had to understand that it meant some of my friends would decline out of necessity or preference.  I was constantly reassessing and adjusting… No, I can’t talk to her today.  Yes, I’d rather see her, and her kids than not see her at all.  Should I or should I not ask how her pregnancy is going? How much will it hurt if I do? 

Over time, it has gotten easier.  I don’t feel as vulnerable, though I can’t explain why.  I think it is a combination of things.  For some reason it was harder when my friends were pregnant or when their kids were babies. As their children aged, the envy faded a bit.  Also, my own life circumstances changed.  A global pandemic, a relocation, and situations that have happened to people close to me took some of my focus away from family building.  It was all consuming for a long time, but eventually it became tiring to be constantly on guard and always thinking about motherhood.

Additionally, my own fertility challenges have made me appreciate just how difficult it is to have a successful pregnancy as we get older.  As most of my friends now fall into the “advanced maternal age” group, when someone gets pregnant for the first time, my initial reaction is more “atta-girl” than “traitor.” 

Finally, I’m also getting better at recognizing envy for what it is – a normal feeling rather than a personal failing.  It’s ok to feel envious of your friends.  It doesn’t mean you don’t support them.  It’s ok if you need to put boundaries in place to manage your feelings.  Relationships can adjust or be rebuilt.  As my therapist constantly tells me – let go of the meta-feelings (the feelings about your feelings).  They don’t serve you.

When my husband and I moved to Seattle we needed to establish care with a new fertility clinic.  We selected our doctor because she is an expert in treating recurrent miscarriage. 

I was stunned when I entered the lobby of the our new clinic.  It’s located on the 10^th floor of a medical tower which faces south east, so I walked into a perfect view of Mount Rainier in all her glory.

I have found there to be a marked difference between private fertility clinics and university clinics.  Our doctor in Chicago worked at a University and was a researching clinician.  Her facility was decked out with all the best equipment – hi-def ultrasounds, doppler imaging, etc.  But the rest of the clinic was sparse; it felt understaffed, it wasn’t inviting, and it wasn’t comfortable.  It was functional.  The two private clinics I’ve been to were the opposite.  The waiting rooms were chic with comfy sofas, nice views, free teas, and candies.  They dripped with support staff… and color coordination… and branding. I want to be clear that I received excellent care in both settings, they were simply different.  One clearly prioritized the science, the other the patient experience. 

Anyway, after checking in for my appointment, I remember being led back to a small, shaded office.  I was by myself, because I’d accidentally scheduled the appointment for the same day we were supposed to move into our house.  But, since it takes months to get a first appointment with a new fertility clinic, rescheduling seemed out of the question.  The lights weren’t on because the sun was beating in through the windows, and the blinds were slightly drawn.  When my doctor arrived, she drew them down further, telling me that after seven years in Seattle, she’d turned into a vampire.  I don’t know why this stuck with me, but it did.

I remember thinking she seemed nice.  She was young, but older than I was, which seemed important at the time.  We went through my medical history, each of my losses, my prior test results, and my family building desires.  I told her I was exhausted.  I confessed that I had little hope I’d ever be able to deliver a child and wondered openly if it was time to move on to other options.

To my surprise, she told me there was nothing in my test results to indicate to her that I wouldn’t be able to carry a child and encouraged me to give it more time with a new approach.  She suggested I try IVF.  As we hadn’t tested the tissue from any of my prior pregnancies, she hypothesized that our problem may have been poor egg or sperm quality.  She explained that IVF with genetic prescreening could eliminate those variables and potentially increase our chances of success.  I told her I would think about it.

I think it’s a bit of every patients’ fear that as soon as you enter a fertility clinic, you’ll be prescribed IVF.  I mean, that’s what happened to me.  But, at the time, her logic made sense.   And after trying naturally and getting nowhere, I was willing to give anything a try. 

In retrospect, I have mixed feelings about my decision.  IVF was expensive, hard on my body (both mentally and physically), and ultimately unsuccessful. I’m sure I’d feel differently had it worked.  Since it didn’t, I’m a bit salty.  But that’s the risk one takes when agreeing to a non-standard or experimental course of treatment…

The theory – which has been validated in some data – that IVF with genetic prescreening decreases the risk of miscarriage is based on the fact that most miscarriages are a result of “aneuploidy” (the embryo having the wrong number of chromosomes).  This can be due to poor egg or sperm quality or be a result of random errors during cell division as the embryo forms.  These types of losses are considered “sporadic” and may account for as many as 50-60% of early miscarriages.   By prescreening embryos before implantation, you largely eliminate the aneuploidy risk. 

But here’s the rub, the more miscarriages a person has, the less likely it is that they are a result of sporadic errors.  It’s basic math – its statistically unlikely to get the same roll of the dice over and over again.   If aneuploidy is the cause of someone’s losses, statistically, if they keep trying, eventually, they’ll stay pregnant.  They actually studied this at Stanford.  They compared the live birth rate between couples who’d had unexplained recurrent miscarriages and continued with “low-tech” approaches (trying naturally) versus those who used “high-tech” approaches (IVF).  The life birth rates were similar.  On the flip side, if aneuploidy was not the cause of someone’s losses, IVF probably wouldn’t help anyway.

I don’t know if aneuploidy was the reason for our initial losses. As I said, we never tested. I decided to do IVF because I was pretty hopeless, and it was something new to try that gave me a bit of hope. It was like getting off a jammed highway onto surface roads. It may take longer to get to your final destination, but it’s a more satisfying drive when you feel like you’re making forward progress.

I will write about the full IVF process in more detail later, but we retrieved 27 eggs, of which 22 were mature, 13 were fertilized, 10 grew to the blastocyst stage to be genetically screened, and 7 came back normal. There are many women who would do anything for numbers like these. Some women endure multiple egg retrievals to get one usable embryo. My immediate response to my doctor was “so I guess egg quality wasn’t our problem then.” Please read that as an indication of how desperately I wanted an explanation for my losses, rather than as a complete lack of gratitude. I do appreciate what good news I was receiving, it’s just that the news didn’t bring me any more hope.

My doctor has since told me it was a poignant moment for her as well because it helped her understand the psyche of an RPL patient.  We are small subset of fertility clinic patients.  Mostly fertility doctors are met with excitement at a successful retrieval or a successful transfer.  Not with the RPL patient, or at least, not with this RPL patient. My excitement was tempered.  I would not be fooled. 

For me, IVF proved an unsuccessful exercise.  We got pregnant, but we still miscarried.  Twice.  The only good thing I have to say about it, is that it allowed our surrogacy process to move slightly faster since we already had frozen embryos. It also enabled me to stop trying without shutting the door to pregnancy completely.  My fertility is now frozen in time.  I still have eggs in my basket, and I am grateful for this. 

End Note: I want to caveat this post by saying that I think IVF is a remarkable procedure. For many women, it’s the only way to achieve a successful pregnancy.  But it is not a silver bullet. It’s not the answer for every woman. It was not the answer for me.  

When my mind is feeling busy or overwhelmed, I sometimes pull angel cards for guidance and meditation.  Angel cards are about the size of a quarter Post-It and each has a single word on it, like “gratitude,” or “openness,” or “abundance.”  Before selecting one, I mix all the cards up in a jar, sit quietly, and ask the universe for guidance.  Regardless of whether my selection is a result of divine intervention or utter randomness, the word itself provides me a framework for considering my problem.

Recently, I pulled the angel of “obedience,” and to be honest, at first it really bothered me.  I have a negative association with the word obedience.  To me, obedience means submission – a lack of control and a relinquishment of autonomy.  Dogs are obedient to their masters.  Children are obedient to their parents.  Throughout history woman have been obedient to their husbands.  I don’t want to be obedient.  I want to chart my own course and make my own decisions. 

I couldn’t figure out how to fit my situation into the context of obedience.  I didn’t know who or what I was supposed to be obedient to.  So, I Googled it – the word obedience – and I ended up finding a beautiful Presbyterian sermon about being an obedient servant of God.  The sermon was on the story of Jesus being tested in the wilderness. 

For any non- or lapsed-Christian readers, here’s the re-cap… Jesus went into the desert where he fasted for 40 days and 40 nights.  Then the devil appeared and tempted him three times.  First, the devil told him to use his power as the son of God to turn stones into bread so that he could eat.  But Jesus declined, explaining that faith, not just food is required to sustain us.  Next, the devil taunted him to prove his holiness by throwing himself off the temple roof and forcing Got to save him.  But Jesus responded that true faith does not need to be tested.  Finally, the devil offered him power over all the kingdoms in the world in return for Jesus’s worship.  But Jesus told the devil to be gone and was finally left alone. 

I remembered this story from Sunday school, so it wasn’t the story itself that intrigued me, but how the pastor interpreted it.  The pastor explained that Jesus proved he was an obedient servant of God, but not because of something he did.  Rather, he was obedient because of what he didn’t do.  He didn’t succumb to the temptation of disappointment (not having food), the temptation of doubt (wondering if he would be saved), or the temptation of desire (power over the kingdoms of the world). 

Disappointment, doubt, and desire.  That is what this Christian pastor wrote about, but it struck me as being very Buddhist.  Buddhism teaches the importance of observing our mind and living in the present moment.  From a Buddhist perspective it does no good to wallow in disappointment over things that happened in the past because they have gone.  Neither is it productive to worry about whether you’ll get the things you desire in the future because it is always hypothetical and can never be controlled.  The practice of “zen” is to trust (in other words, don’t doubt) that the present moment will provide everything you need because it’s all that ever is. 

When I started thinking about obedience in these terms, it didn’t feel like losing autonomy, but rather like gaining a sense of security.  Obedience to the now.  Letting go of fear and worry and trusting that I can manage in the current moment. That’s the lesson I decided I needed after my study of the word obedience.  So, for the time being, the angle card of obedience is sitting dutifully by my desk reminding me to stay present.  She’ll stay there until I decide I’m ready for a new lesson and new meditation. 

If my process strikes you as being too “woo-woo” that’s perfectly fine.  We each need to find right tools to quite our minds.  I am a non-linear thinker, so I often struggle to logic my way out of worries or problems when my thoughts go too wide.  I appreciate the imposed structure that angel cards provide. But like everything, there are an infinite number of paths we can take.  Each leads us to the exact same thing. The here and now.

My husband works at Amazon and one of the things they talk about when making decisions is a concept of one-way versus two-way doors.  The metaphor being that you can’t walk back through a one-way door, so you need to be more certain about those types of decisions.  To me, becoming a parent feels like a one-way door.

I want kids.  I want the experience of being a mother.  I want to build family traditions.  I want to teach my child and watch them grow and develop.  I am almost sure.

I think most people have some amount of apprehension about becoming a parent.  What’s different is that with infertility or recurrent miscarriage, you must repeatedly face this uncertainty and weigh the strength of you desire for parenthood against the time, financial, and emotional costs of continuing to try. 

For the Fertile-Myrtles, there may be nerves when trying to conceive, but once pregnant it’s a “train out of the station, better get on board” situation.  I, on the other hand, returned to that place of nerves again and again, each time wondering whether I wanted kids badly enough to continue to endure the process and pain. 

Sometimes I’m nervous to become a mother because of my mental health issues.  I’m afraid I won’t be able to be present during bouts of depression or that I’ll pass on my mental challenges to my child.  In really dark moments, I wonder if this was the reason the universe caused me to lose my pregnancies in the first place

Other times I worry because my infertility has been part of my identity for so long that I can’t picture life without it.  I’ve become accustomed to my grief.  After I become a parent, I am not sure where it will go, or how it will change, or how I will honor it, or if I will want to.   

And I’m uneasy about how parenthood will change me.  My sister has always been incredibly maternal.  Her preschool reports talk about how she sang to the baby dolls and fed them pretend meals.  In middle and high school, she spent her summers nannying. It’s no surprise she’s a phenomenal mother.  But I also see how much her life has changed by having children.  She gained so much, but she has lost some of herself as well.  I worry about what I’ll lose.  I worry that I’ll miss the freedom of this child-free life. 

My fears often make me feel ashamed.   As if my doubts themselves indicate that I don’t deserve to be a mother.  As if because I have worked so hard to become a parent, I’m only allowed to be excited and thank my lucky stars.   

But these thoughts are unfair, unkind, and untrue.  It is perfectly natural to be nervous about changes in our lives.  We can move towards something and still have doubts about it, and that doesn’t have to mean we don’t want it or aren’t ready for it. 

I love downhill skiing, but I’m only ok at it.  Often when I’m riding up the chair lift, I look at the mountain below me and think, “wow, that looks like an awesome run,” only to arrive at the top, peer over the precipice, and think, “oh my god, I can’t do this.”  In these moments, my mental mantra is to tell myself that the only way down is down.  Sometimes I fall.  There have been times where I’ve gotten in over my head and had to take off my skis and walk a bit.  But other times, I handle the scary runs with great ease.   

Anticipating parenthood is like riding up the chair lift and peering over that precipice.  At the top of the mountain, I have no idea what the run will be like.  But rather than assuming my apprehension is an indicator I’m doing something wrong, I can choose to interpret it as an indicator that I’m doing something big. Even if it means I might even have to take off my skis and walk a bit.