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Joann Paley Galst, Ph.D., Chair of the AFA Mental Health Advisory Council

Part I of this article reviewed some unique aspects of pregnancy loss after experiencing infertility. This week’s article offers suggestions to help you deal with this most painful of losses.

What Can Help with your Grief?

The loss of a pregnancy often leaves few if any memories for any individuals other than the mother and father. Thus, it is often helpful to create rituals to acknowledge the loss and process one’s grief:

For early losses:
• keep a journal, diary, or audiotape describing your feelings
• write a letter or poem of goodbye to your baby
• purchase a necklace or bracelet to wear in recognition of your baby
• reach out for available support from loved ones, your clergy, or a support group

For losses occurring later in your pregnancy, in addition to the above you may also wish to:
• hold the baby
• name the baby
• create mementos (e.g., memory box or scrapbook with sonogram photos; for later losses may include a photo of the baby, wristband from the hospital, a lock of hair, a footprint, the blanket that the baby was wrapped in, a dried flower from a bouquet your partner brought to you, etc.)
• organize a memorial service/funeral or memorial activities either privately or with others (e.g., light a candle at home or at church, plant a tree that will continue to grow in honor of your baby, select a garden statue/brick; donate to a special charity; donate books to a library or support group or items for neonatal or high risk hospital units)

You may wish to consider a consultation with a mental health professional if your grief becomes a major depression which is more pervasive and leaves you rarely able to obtain any relief from your symptoms. If you have serious thoughts or intent of suicide, not solely thoughts of dying (which are common after a pregnancy loss), immediate attention is warranted. In contrast to depression, grief is less pervasive and as it progresses, is more likely to be triggered by, for example, announcements of others’ pregnancies, anniversary dates, or even diaper commercials.

Coping with a Subsequent Pregnancy

Babies are not replaceable or interchangeable. Thus, a new pregnancy often brings complex and conflicting emotions for the couple/individual. Hope and joy for the new baby is frequently coupled with fear of loss and ongoing sadness for the baby that was lost. Couples/individuals often find they need additional emotional support as they experience a subsequent pregnancy, particularly because their family and friends, wanting them to be able to move past their sadness, may hope or expect them to react with unbridled joy at announcing a new pregnancy, which is not what they typically feel after a prior pregnancy loss and infertility treatment. Though usually happy to be pregnant, the anxiety they may experience often precludes unrestrained optimism in a subsequent pregnancy.

Help for the Helpers

A fertility patient’s pregnancy loss after infertility treatment can take a significant emotional toll on the reproductive endocrinologists, obstetricians, nurses, and staff, as well, leaving them feeling guilty, inadequate, or helpless even when they know they did nothing wrong medically. They may mistakenly believe that there is nothing more that they can do, failing to recognize the enormous importance of their emotional response to their grieving patients. Acknowledging these losses, listening empathically so you can determine what this loss actually means to these parents, calling the patient after learning of the loss with follow-up a few weeks later to see how she and her partner are doing, encouraging both emotional expression and problem solving, providing information about support services available in one’s community, and empowering parents through this process can allow patients to feel supported, able to tap in to their resilience, and better able to integrate and eventually heal and grow from their loss experience. From clinical experience, I have observed that heartfelt, comforting words from caregivers can often become a sustaining memory that promotes healing in the vulnerable patient, just as a callous remark or indifference can create a painful scar for the patient which impedes their grief process and may, in fact, irreparably damage the patient-doctor relationship.  Bereaved patients need to know and feel that their caregivers actually do care.
Medical staff confronted with the frequency of loss and IVF failure that those working within an infertility practice experience need to recognize that they may also feel a sense of loss and helplessness. The support of one another may be invaluable to staff members (e.g., bi-weekly or monthly staff support group meetings) in order to avoid compassion fatigue and/or burnout.

Conclusions
A pregnancy loss on top of infertility seems a cruel irony, indeed. For patients, there can be an echoing quality of infertility and pregnancy loss that extends beyond the treatment phase. Both create an interpretive lens through which future life experiences are filtered, resonating and reminding individuals of these earlier losses, but also expanding their capacity to empathize with the suffering of others. The extended grieving of pregnancy loss amplified by infertility, as well as the protracted period of decision-making and potential attempts for a future pregnancy, may increase the need for counseling. Fortunately, most individuals and couples do integrate their loss within a year or two and discover the inner resilience that helps them survive this crisis and continue on in their quest to create their family and live a productive and meaningful life.

Joann Paley Galst, Ph.D., is Co-director of Support Services for the American Fertility Association and Chair of the AFA Mental Health Advisory Council. 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 is also a co-author of the recently released professional text, Ethical Dilemmas in Fertility Counseling, published by American Psychological Association Books.

References

Conde-Agudelo, A., et al. (2006). Birth spacing and risk of adverse perinatal outcomes. Journal of the American Medical Association, 295, 1809-1823.

Harris, D. L. & Daniluk, J. C. (2010) The experience of spontaneous pregnancy loss for infertile women who have conceived through assisted reproduction technology. Human Reproduction, 25, 714-720.

Useful Patient Materials and Resources

American College of Obstetricians and Gynecologists Patient Education brochures:
Early Pregnancy Loss: Miscarriage and Molar Pregnancy (2002),
      Repeated Miscarriage (2000)
Available from the American College of Obstetricians and Gynecologists,
409 12th St., SW, P.O. Box 96920, Washington, D.C. 20090-6920
1-800-762-2264 X 830, or order online at http://www.acog.org

American Society for Reproductive Medicine, Patient Fact Sheet, Recurrent Pregnancy Loss. Available online at http://www.asrm.org/Patients/FactSheets/recurrent_preg_loss.pdf

Brody, Jane. Trying again after recurrent miscarriages, NY Times, March 25, 2008. 
Available online at http://www.nytimes.com/2008/03/25/health/25brod.html?_r=1

Brody, Jane. Seeking answers to stop another stillbirth. NY Times, April 1, 2008.
Available online at http://www.query.nytimes.com/gst/fullpage.html?res=9C07EFDD1230F932A35757COA96E9C8B63

Douglas, Ann, & Sussman, J. R. (2000). Trying again: A guide to pregnancy after miscarriage, stillbirth, and infant loss.

Kluger-Bell, Kim. (2000). Unspeakable losses: Healing from miscarriage, abortion and other pregnancy loss.

Kohn, I., & Moffitt, P-L. (2000). A silent sorrow: Pregnancy loss – Guidance and support for you and your family (Revised and Updated 2nd Edition). 

Lanham, Carol Cirulli. (1999). Pregnancy after a loss: A guide to pregnancy after a miscarriage, stillbirth, or infant death.

Nelson, Tim. (2004). A guide for fathers: When a baby dies.