Is it Best to Expect the Worst? Pregnancy after Infertility.


The good news - more and more fertility patients are becoming pregnant, even after many cycles of intervention, some as a result of treatment, and others spontaneously.

The bad news - most are not enjoying this very longed for pregnancy, afraid to be hopeful, expecting the worst. Many worry, "Is this normal? Will I jeopardize the pregnancy? Why can't I just be optimistic? What's wrong with me?"

It is important to understand that a certain amount of anxiety during pregnancy may be inevitable. Having experienced so many disappointments leading up to this pregnancy, many infertile individuals (particularly women) are conditioned to expect disappointment and loss, often pushing anxiety levels quite high, however. When one is anxious, it's easy to see threats everywhere. Statistical probabilities have failed you as you already fell into an improbable category. A struggle with infertility or pregnancy loss can shatter your belief in a just, controllable, and benevolent world. With this prior sense of invulnerability lost, whereas you were once able to believe that "It can't happen to me," now you are more likely to believe, "It will happen to me." Naturally you are afraid to invest emotionally in a pregnancy you fear you might lose.

But, why would women expect the worst during a pregnancy that they worked so hard to achieve?

  • Self-protection. The sensation of hope in and of itself, because of having been hopeful so many times before, may immediately evoke for you memories of loss, disappointment, and pain, resulting in your being afraid to be hopeful. Women who have prior infertility or pregnancy loss experience report higher anxiety and lower attachment scores in a subsequent pregnancy. Emotional cushioning, whereby women attempt to avoid emotional bonding with their baby (Cote'-Arsenault & Donato, 2010), is used to cope with anxiety, uncertainty, and the sense of vulnerability that women can feel in a pregnancy subsequent to either infertility treatment or pregnancy loss. Having a loss of innocence and an increased skepticism, women steel themselves emotionally by acknowledging that pregnancy does not guaranty the birth of a live baby. Not wanting to be blindsided again by disappointment, women believe holding back hope will soften the disappointment should the pregnancy be unsuccessful.
  • Discomfort with uncertainty. Fear tends to actually magnify one's beliefs in the likelihood of loss. Thus, women make fear-induced predictions and assume they are being realistic in their predictions. Although women may believe that if they worry they can eliminate uncertainty and be prepared for disappointment, these negative expectations can magnify anxiety further.
  • Superstitious belief. If an individual was hopeful in the past and experienced disappointment, she may believe "If I don't have hope this time, I will get a better outcome," i.e, superstitious thinking. If she cannot prevent a bad outcome, at least she thinks she can cushion herself from pain. It is also common for women to superstitiously believe that being hopeful can actually jinx the pregnancy.
  • "I'm still infertile." Even once pregnant, women who experienced infertility may still consider themselves infertile, carrying feelings of failure and defectiveness about their reproductive capability. After needing help to get pregnant, a woman may be uncertain of her ability to protect the pregnancy, worrying that her body won't know what to do on its own. Since her visits to an obstetrician are so much less frequent now than they had been to her reproductive endocrinologist, she may feel she is out there unprotected, all on her own.

Thus, expecting the worst and the emotional cushioning that can result is used by women to cope with anxiety, ubiquitous uncertainty, and the sense of vulnerability that looms so large for them.

While engaging in appropriate behaviors to safeguard the pregnancy (e.g., taking prenatal vitamins, not drinking alcohol, attending OB visits), women may hold back from attaching to their pregnancy in various ways. For example, early in the pregnancy she may delay telling others of the pregnancy, not think of the fetus as a baby, try hard not to project down the road and imagine the time of year when this baby will be born, or, later in the pregnancy, and postpone physical preparations for the baby's homecoming (McMahon et al., 1995). She may over-intellectualize the pregnancy, focusing on its physical aspects (e.g., worrying about every pinch and pull she feels in her abdomen) while trying to hold back emotional attachment to the pregnancy.

Unfortunately, recent research has shown that extremely high and/or chronic levels of anxiety during pregnancy can have a detrimental effect on the mother (e.g., greater likelihood of experiencing pre-eclampsia), the baby (e.g., higher risk of miscarriage, preterm delivery, and lower birth weight; Wadwa, 2005), and may even affect a child long after birth (e.g., increased risk of attention deficit hyperactive disorder; Grizenko, Shayan, Polotskaia, et al., 2008; Van den Berg & Marcoen, 2004). Chronic or extreme maternal stress may impact the baby's brain development and may also cause changes in the blood flow to the baby, making it more difficult to carry oxygen and other important nutrients to the baby's developing organs. However, research has also suggested that mild to moderate levels of stress during pregnancy may actually be good for a baby, resulting in a healthier immune system and better motor development, and it is hypothesized to better prepare the baby for later stressors such as birth (Di Pietro, 2004). So, before you get stressed about being stressed, it is important that you understand that not all stress is bad. However, very high levels of chronic stress are probably not beneficial for a pregnancy.

But, does all of this mental posturing work??

The only research available at present, conducted with college students predicting task success or failure, has found little if any beneficial effect of expecting the worst on subsequent success or failure in academic settings. In fact, those students who expected to do badly on a test felt worse when they actually messed up than those who predicted that they would do well but similarly botched their test (Marshall & Brown, 2006). Unfortunately, there is no research available regarding the impact of expecting the worst on adjustment to pregnancy or future adjustment to parenthood. So the answer to the above question can only be conjectured for those experiencing prior infertility or pregnancy loss and probably depends on the criteria you use to determine whether it "works."

If I look at the clinical experience of patients, it seems it may work. Women are able to get through their ongoing pregnancies, even while predicting the worst and being fearful. In addition, research in the field of assisted reproductive technology and third party reproduction has consistently found that parents who became pregnant using IVF either with their own or donor gametes develop appropriate or even especially high levels of attachment to their children. Thus, attachment difficulty does not seem to be present in most of these parents.

However, those individuals who unfortunately experience a pregnancy loss after infertility treatment or a prior pregnancy loss(es) do not seem any less distraught about the loss than those who have taken the leap of faith and allowed themselves to enjoy each day of their pregnancy, though it was short-lived. In addition, they have often reported feelings of regret, having deprived themselves of enjoying the all too short period of time that they had with their baby.

So, what can you do to cope more effectively with pregnancy anxiety?

I have found two primary ways individuals can learn to cope more effectively with the anxiety experienced during a pregnancy after infertility or prior pregnancy loss and they tend to contrast with one another.

1. Learn how to relax your body by learning techniques such as deep

breathing, creating relaxing imagery, progressive muscle relaxation, or meditation, and to relax your mind by learning to re-frame your negative thoughts to provide greater realistic optimism and more self-compassion, any of which you will need to practice regularly to keep you generally calm and relaxed as well as use in any situations in which you find your anxiety level escalating. The primary purpose of these techniques is to reduce negative affect. A recent research study suggested that relaxation, particularly the use of guided imagery, was associated with reduced levels of various physiological measures of pregnant women's stress (Urech, Fink, Hoesli, et al., 2010). Alice Domar's book, Conquering Infertility, can introduce you to many of these mind-body techniques.

  1. Learn how to take a mindful approach to your pregnancy, i.e., being in touch with and aware of the present moment while taking a non-evaluative and non-judgmental approach to your inner experience. This approach can also create a relaxed state, but does so through acceptance of thoughts and feelings rather than specifically attempting to relax and reduce theses anxious feelings. By taking a mindful approach, you can learn to have your thoughts and feelings about this pregnancy, as well as various bodily sensations, and recognize them as a thought, a feeling, or a sensation rather than reacting to them as absolute truths or believing that they actually predict a bad outcome. As you become an observer of how you are feeling and what you are thinking and accept your emotions without trying to control them, you will become less reactive to your internal feelings and thoughts. Three books that can help one learn about this approach are: Full Catastrophe Living by Jon Kabat-Zinn, Get Out of Your Mind and Into Your Life, a workbook by Steven Hayes, and Mindful Motherhood: Practical Tools for Staying Sane During Pregnancy and Your Child's First Year, by Cassandra Vieten. Approaching your pregnancy mindfully can help you accept your feelings of anxiety during this pregnancy without automatically jumping to catastrophic conclusions. This method can allow you to approach your pregnancy, along with all your sensations, thoughts, and feelings about it, with curiosity and, hopefully, compassion. You can even imagine examining each anxiety-producing thought, feeling, or sensation as existing in a bubble outside of your self, or imagine gently placing each such thought on a leaf that you allow to flow gently down a river, obtaining a more comfortable emotional distance from your troublesome thoughts, feelings, and sensations. You can learn to be aware without being fused with your thoughts, feelings, and sensations and return to experiencing your present moment-to-moment state of being without trying to suppress or avoid your internal experience. You may wish to write up your mindful observations in a journal, again describing them, without judgment. This, too, can give you some emotional distance so you can look at the content of your thoughts and feelings rather than viewing the world through them.

You may also want to:

  • Rally support around you, including understanding friends and family.
  • Find success stories. If you tend to read everything that can go wrong in pregnancy, STOP immediately. Get off the internet unless you find it reduces your anxiety (unlikely!). Read light hearted and enjoyable materials instead.
  • And, naturally, try to get plenty of rest, eat nutritious meals and snacks as best you can, and drink plenty of fluids. Have consistent prenatal care, with an emotionally sensitive obstetrician who will allow you to have more frequent prenatal visits should you need them.

While some anxiety during pregnancy is inevitable, chronic worry and obsessive doubt are not helpful. Similarly, sweeping everything under the rug or ignoring what is happening is equally unhelpful when trying to cope. If you can learn ways to make peace with your anxiety, anxiety that is present solely because you do care so much about this baby, this will reduce your neuroendocrine reactions to stress throughout the pregnancy and may benefit both you and your developing child. If you are too afraid to be hopeful during this pregnancy, could you at least consider approaching this pregnancy with greater curiosity rather than fear? Your resilience and ability to cope with the normal ups and downs of pregnancy are likely to be enhanced, as well.

References available upon request.

Joann Paley Galst, Ph.D. is Co-director of Support Services and Chair of the Mental Health Advisory Council of Path2Parenthood and on the Board of Advisors of the Pregnancy Loss Support Program of the National Council of Jewish Women-NY Section.. She is a psychologist in New York City specializing in reproductive health issues including infertility and pregnancy loss and a past chair of the Mental Health Professional Group of the American Society for Reproductive Medicine. She has written extensively in the fertility field and is a co-author with Judith Horowitz and Nanette Elster of the recently published book entitled, Ethical Dilemmas in Fertility Counseling. She can be reached at 212-759-2783 or jgalst@aol.com, http:www.wmhcnyc.org/galst/