by Andrea Braverman, Ph.D.
When is enough, enough? This question creeps in at different moments as you pursue treatment. Enough is a judgment that is weighed individually but has common thoughts and feelings. For many, enough is reached when treatment fails to provide the hoped for pregnancy and the doctor is saying there is little else to offer hope that treatment will yield a pregnancy”. This choice is more of a fact-based decision. For others, enough is the moment when the cost of moving forward with treatment is too high. This choice is more of an emotional decision. Finally, there is the situation when the choice is taken away because of the financial reality and this contributes heavily to the decision to stop treatment.
Enough leaves you vulnerable to self-doubt. Am I choosing to stop treatment for the right reasons? Maybe I should see another doctor? Maybe I’m trying too hard and everyone is right and I should just relax? Have I really looked at all the different sides to this decision?
Another part of the decision to stop pursuing pregnancy is the “what next” question – what do I/we do after we stop treatment? For some the decision to stop medical treatment means the choice to live childfree. For others, it is moving on to non-genetic parenting and either adoption, donor egg, donor sperm or donor embryo. Answering the “what next “question has a great deal on the influence of when to say enough. For those who are choosing to live childfree, stopping medical treatment also involves making a new life plan which does not involve raising a child. For those moving on to non-genetic parenting, there is the need to grieve the dreamed of child and the potential for the reflection of one’s own family genetics in the child.
What does research tell us?
Research has shown that there are three main emotional challenges that make ending treatment difficult for couples: fear of not being able to cope; an inability to imagine a life without children; and concerns over survival of the partnership. (1) Research also tells us that there are differences between men and women in how they approach treatment as well as ending treatment. Men are more often willing to end treatment before their partners; conversely women are more willing to start treatment and try new treatments. (2) These differences can easily lead to misunderstandings or disagreements. Regardless of differences, understanding the core feelings also has shown to be important. If one or both partners feel that they could not survive life without children, this can lead to prolonging treatment because the consequences loom so large. Feelings that life would be impossible without the dreamed of child may weigh in with the decision to end medical treatment as the couple crosses over the bridge to non-genetic parenthood. Fears for the relationship need to be expressed so that both partners can actively engage in planning as well as imagining a life beyond the original plan of a jointly genetic child.
Good reasons and bad reasons
There are good reasons to terminate treatment and bad ones. Good reasons involve considering both the practical and emotional. Good reasons involve examining the cost – emotional, physical and financial – that continuing treatment will have. Good reasons involve understanding that goals and needs change as we journey through treatment. Good reasons involve moving on to a new goal and a new vision for one’s life if choosing to live childfree. Good reasons involve moving on to donor gametes, if living childfree is not the choice, because the desire to be a parent is greater than the desire to have a genetic relationship.
Bad reasons are usually ones that are for the moment and not for the long term. Bad reasons can be ones done in haste or anger. If a partner is not being as supportive or enthusiastic, stopping treatment in anger or spite does not usually stand the test of time. Bad reasons involve just wanting to make the pain stop for right now and not considering whether there will be other pain down the road. Bad reasons involve not considering long-term wants and needs.
Relationships: Dealing with being on different pages
Sometimes, partners are not on the same page and one is ready to stop treatment before the other. Added to the negotiation is the fact that treatment is almost always disproportionate in its burden. Women usually have the demands of medications, blood draws, monitoring, inseminations or egg retrieval. If the male partner is not ready to stop treatment, it may be very difficult or impossible to ask his female partner to continue to put her body through more treatment. Men have expressed the frustration and guilt about not being able to have a more direct role in the cycles. Conversely, women may feel that they cannot stop treatment because it is unfair to her partner to deny him the opportunity to be a parent. Or a woman may feel resentful to stop treatment at her partner’s request because it would denying her the chance to experience a very desired pregnancy and, ironically, she may feel her partner is controlling her body. Independent of these issues is still the need to negotiate different needs in the relationship, which may include very open and honest discussions about the need to be a parent or have a genetic relationship to that child.
Decisions to be made
It is important to feel that you have attempted enough treatment and there are minimal “what ifs”. There is no magic to the number attempts or types of treatment that will give that satisfaction but it is clear that terminating treatment to avoid uncomfortable feelings may lead to poor resolution of those feelings and decision-making.
Here are a few non-constructive thoughts to be aware of:
- § the “slot machine” mentality of the “one more cycle”
- § feeling like you are not strong enough or being a wimp to stop
- § being afraid of disappointing your doctor, nurse or other care giver
- § continuing treatment just so you don’t have to deal with making decisions or grieving
Having a treatment plan about how many attempts and how long you attempt can serve as a guide along the journey. The plan doesn’t have to be set in stone but it is a great resource as feelings and thoughts change along the way. If you want to go further or stop earlier, the plan can be a place to start when having the discussion about whether this is a good choice. Ask what has changed in the plan or what have you learned that makes changing the plan a good choice? Often feelings and reactions change along the way and the plan should be altered. But other times the plan is a good reminder of the thoughts and feelings that led to setting that plan and that deviating from the path is more an immediate reactions to being tired, discouraged or frustrated and that this will pass more quickly leaving the needs and desires in the original plan ready to be pursued.
It’s okay to “try on for size” different ideas. For example, if the thought is to live childfree, then you can try living this decision to the fullest. If, after a few months or longer, feelings and reactions are different from what you anticipated, revisit the plan. Don’t be afraid to gather information. Getting informed doesn’t commit you to any particular decision but you can gather information on yourself – on your own thoughts and feelings – as you get information. Don’t be afraid to think and feel “outside the box”. This is a big decision and it deserves the time invested to try out ideas and plans.
The decision to end treatment is complex as well as individual. When working with a partner, discussions must be open and honest about the issues that will arise once that decision is made. Whether individually or as a couple, planning for the next leg of the journey in life requires thought and action based on honestly expressed needs for the moment as well as the future is so very important. Although you may be weary after a long infertility journey, make sure you are in a place where you can explore within yourself and, if you have a partner, with your partner all the possibilities for the future. Start with framing these choices as positive choices even if they were not your original plans. You can make a wonderful future as long as you can be insightful, honest and open.
- 1. Boivin J, Takefman J, Braverman AM. Giving Bad News: Ending Treatment. IVF in the medically complicated patient: a guide to management. Ed. Nick S. Macklon. Taylor Y Francis, 2005.
- 2. Greil AL. Infertility and psychological distress: a critical review of the litera- ture. Soc Sci Med 1997; 45: 1679–704