Experiencing IVF in a Prepared and Calm State
IVF is a lengthy multi-step process very commonly used these days for many different reasons, including but not limited to infertility, ageing, poor genetics, and egg freezing for those not yet married. That means that in any given IVF facility you will see a broad range and large number of frum patients daily. I would like to provide a mini guidebook to some of the elements of IVF that have the potential to be unnecessarily aggravating and stressful.
I am going to be overly concrete in this essay because those concrete areas are where I feel that I as a clinician can help the most. When it comes to the pain of wanting a baby and not knowing if you’ll get one, there is little I can professionally say. I frequently tell my clients “I can help you with everything but willingness.” What I mean by that is that in matters we have no control over, matters that have already been decreed (and we are blind to what the decree was), the choice of being joyful and calm in daily life versus making joy and calm dependent on that baby is one that is entirely up to you. It’s a choice that has to be made over and over on a daily basis and takes a lot of work. Taking six months to do some intensive spiritual work with a Rav or Rebbitzin around issues of relationship with Hashem and control is the only suggestion I can make. This is all I can say about the distress of wondering if there will be a baby or not, besides pointing out that worrying does not have magic power to it. The rest of this article will deal with how to steer clear of the many additional potential sources of distress along the IVF road.
Please note that the processes and time frames described are approximate and can differ from clinic to clinic.
Choosing a Doctor
This decision can take weeks, because it involves consulting with organizations that have years of experience with IVF. It isn’t necessarily true that the doctors that take your insurance are the “less good ones” and the ones that are out of network are “the good ones.” Generally, a counselor at the organization you are consulting with will have the latest word on how much success they have been seeing from a specific clinic. It’s ultimately up to the patient to decide whether to go with insurance or cash. Meeting a few doctors and getting a feel for what interacting with them is like might be helpful. You will be interacting with them a lot in the process, so you want to feel comfortable. Other factors include distance (as you will be traveling there daily in the morning darkness for many days- more on that later) and wait time. To this I will add that if you go for non-insurance and you don’t have the money available, this can potentially add many many weeks to the process, as most facilities will not proceed without a solid financial plan in place and approved by their finance department.
Getting a Counselor
Getting a counselor from one of the frum organizations that deals with IVF is recommended but not crucial. If you do take one, make sure they are:
- A) Reachable and Responsive
- B) Knowledgeable and able to answer questions without hesitation
- C) In an active regular relationship with the doctor you have chosen
- D) Vastly and readily knowledgeable of the IVF medications, with access to pricing and pharmacy staff
If you are not finding your counselor to be smoothing the process, ask for a different one right away. Just because someone volunteers for an organization and has been doing so for many years, it does not mean they will be as helpful as you need. Ask peers which counselor they used.
Mental Health Suggestion: If assertiveness is a struggle, I suggest working with a therapist on this issue several months in advance. Staying with a counselor who is unhelpful or misguides you can result in the failure of an entire IVF cycle.
Initial Consult and Homework Phase
Following an initial education and evaluation session with the doctor, you will begin the “homework phase.” There are those for whom this is the absolute hardest phase of IVF, and I wouldn’t blame them for saying so. It can be very anxiety-provoking and take many many many hours. At least 2-3 weeks of long hours on the phone can be involved. If your doctor is in network with your insurance, your “homework phase” will be infinitely easier. If you are paying out of pocket, you will now embark on a two-fronted process that is harder than applying to university. Part 1 is working with a frum organization for loans, discounts etc. Your counselor should be equipped to walk you through this process.
Part 2 is researching medication prices. Each IVF injection has a different price at different compounding pharmacies, and in all, the price of your medications can be upwards of $4000. Your counselor should have access to a pharmacy list, and you will have to call around and price out all possible medications separately, as you won’t know which ones the doctor will want until you are in the middle of the cycle and these daily decisions are being made. Luckily the pharmacies involved in IVF compounding deliver some distance; say from Brooklyn to Monsey on a nightly basis. Your counselor should also be able to direct you to any government programs (such as offered at Refuah Health Center Monsey, NY). This could result in free medications, but may require an in-person appointment to get approved. Getting a timely appointment for this approval is half the battle. You cannot begin an IVF cycle without a solid game plan for where you will be purchasing each medication. This plan has to be submitted to your clinic nurse.
In addition, you will likely have “homework” of taking some initial vitamins and getting some bloodwork. Note: The very first blood-draw can run up to 25 vials. (that’s not a typo). Plan accordingly (like not on Erev Yom Kippur).
Mental Health Suggestion: If you have any underlying triggers around paperwork, homework, making calls, feeling trapped, I suggest working with a therapist months in advance. EMDR is a quick and effective way to desensitize these types of triggers for many people.
Your IVF Nurse
You are about to have a new spouse. Actually, you will probably speak to your IVF nurse much more than you have ever spoken with your spouse. Your IVF nurse will contact you every afternoon during IVF with your results, medications, doses and other instructions, It is crucial to make sure you are comfortable and happy with your nurse. If not, immediately request a switch. Your IVF nurse will be piling more work on you than any teacher you have ever had in your life. You will likely need to have access to a computer, email and the clinic’s app, where you will be contacted daily with your various results and medication doses.
Mental Health Suggestion: If you don’t have a therapist, then your IVF nurse is now your therapist for the duration of IVF. Utilize this person for emotional support; it’s part of her training. Building familiarity with email and using apps is recommended far in advance of starting IVF. Please also make sure your computer or phone can play videos, as instructions for injections may come in the form of videos.
Early Mornings and Commute
This is another aspect of IVF that many will tell you is the worst part. IVF involves being checked almost every morning for up to two weeks. Most clinics require arrival before 8am, and the wait can be up to an hour for your turn. Scheduling with the doctor to be able to skip a check on Shabbos is recommended, though there is no guarantee. Make sure there is a hotel in walking distance before choosing a doctor.
Mental Health Suggestion: Here is the worst comment I have ever heard, from a veteran counselor at a frum organization: “When I got IVF, I still had to get to work by 9am so I got up every single day at 4am to commute over an hour each way and be back in time for a day of work.” Your body is trying to make normal, healthy eggs right now. It is strongly recommended to make sure you get good sleep during IVF. In addition, you may not feel great. This SHOULD mean arranging to be late to work for a couple of weeks and/or taking days off.
Blood and Needles
The basic process, though it will vary per person, is that you will have to do 2-4 nightly injections in the belly (if an embryo is created and implanted later, there will be additional injections in other locations on the body). These injections will go on for approximately two weeks. Training will be given by your IVF nurse in how to mix and give injections. You have a few choices here, but I will start by saying that the needles are TINY. Many people don’t feel them at all. You can inject yourself, you can have your counselor from whichever frum organization you are working with send you a volunteer nightly, you can have someone in your house inject you (you will not be clean for part of the cycle so don’t count on it being your husband), or you can find a friend or neighbor who is a nurse/doctor or who has been through IVF.
Your additional exposure to needles will be a (almost) daily blood draw each morning at your IVF facility. You will alternate arms daily. On the last two days, plan to leave one blood vessel in good shape for the IV you will have during the egg retrieval surgery. Plan this ahead with the phlebotomist.
Mental Health Suggestion: EMDR and Exposure Therapy are recommended well in advance of IVF to reduce any anxiety around needles. Mindfulness Meditation can also be helpful. Asking your doctor to toss an insulin syringe into your belly will give you the gist and eliminate all the imaginings swirling in your mind, so why not do this weeks in advance, rather than wait until the last minute for your IVF nurse to basically do just that.
Internal Exams
In addition to a daily blood draw, IVF involves an internal sonogram daily. This will be done by whichever doctor is on staff that day. It may be a male or a female.
Mental Health Suggestion: If you are not yet married or have never had an internal sonogram, you can work with your doctor during that very first visit on getting used to the internal wand. Once you are in the cycle, those morning exams can be a very fast part of a crowded hubbub, so getting exposed and comfortable is recommended.
Effects of Hormones
For some, the hormones used in IVF can trigger strong emotions, mood swings and fatigue. Others may feel nothing. Some people fee great from the extra estrogen.
Mental Health Suggestion: This underscores the importance of A) having a good IVF counselor and nurse who are familiar with the potential effects of hormones B) Taking some time off work and C) Extra self care, which could even include a massage and/or yoga or meditation class.
Male Contribution
For those who are married and making an embryo, your husband will have some discomfort as well, but only emotional, and only for a blink. In addition to making all of the phone calls and doing all of the driving (the division of labor I officially recommend) he will be the patient very briefly. Getting complete halachic instructions on the male sample from a Rav or Dayan before starting IVF is crucial. A shomer must also be hired in advance, most often through Bonei Olam. Fast forward to what an orthodox rav will likely tell you: collection must occur during the course of marital relations. Couple that with what the IVF clinic will likely tell you: It must be done with sterile utensils and delivered to our lab within 30 minutes, no later than 7am, at body temperature. What often has to occur is an overnight at a hotel to guarantee that 30 minute delivery and temperature maintenance. The shomer will meet you there and oversee laboratory labeling and storage.
Mental Health Suggestion: It makes for a harrowing morning, so eat some good dinner, go to sleep very early, and decide to hold on tight to your sense of humor.
Egg Retrieval
After your almost two weeks of waking at dawn and enduring a lot of poking and probing, there is still surgery with general anesthesia and recovery. The surgery itself lasts only minutes, but the pre-op prep, IV, meetings with nurses and doctors, and monitoring can take a couple of hours. For many, the recovery is just a matter of being tired and woozy. For others there can be pain or other side effects.
Mental Health Suggestion: It’s possible that you will not be allowed to have anyone with you in pre-op. Bring something to listen to or read or otherwise distract and relax with. Some facilities have a counselor from a frum organization floating around, and you can ask her for some extra support and attention. If having surgery and anesthesia is new, this should be discussed with your doctor. If there is anxiety about this process, EMDR prior to IVF can be helpful. Find out if they provide kosher food. You will be hungry after a morning of fasting, so if they do not, bring something along. The person who takes you to the surgery should plan on taking a full day off work, as you are not allowed to be alone even after arriving home.
Results
Results come from your nurse in stages over the course of approximately two weeks. Right away you get the number of eggs retrieved. A day or so later you get how many eggs were normal. Then (if you are making an embryo as opposed to just freezing eggs) a few days after that you find out how many fertilized. Then a few days after that you find out how many fertilized eggs stayed alive. And on and on until an embryo has reached the stage it needs to be at for transfer. At that point, you will begin an entirely separate process to prepare your body for embryo implant. I will not write about this because frankly by now being poked and probed has become “old hat,” and it’s a pretty joyful time.
Mental Health Suggestion: Try not to react to each and every report. This is wasted energy. The numbers are going to change in a few days, so it really doesn’t matter that you had 22 eggs, or that 16 fertilized. The numbers will keep going down. Only one thing matters, which is having one normal live embryo, and you won’t know this for several days. Even then, it has to successfully implant, and you won’t know this for many weeks. As a matter of mental health, try to distract and stay off the self-imposed roller-coaster.
Overall Mental Health Advice
Psychologically, advanced preparation to eliminate sources of anxiety is key. Taking each task and stage of IVF as it comes, and remaining in the moment will reduce distress greatly. Physically, getting a lot of rest and sleep and time off work will make IVF much easier on the body. Emotionally, having a lot of support and love and joy will cushion the process. People like to keep things “under wraps,” but being isolated during IVF is not recommended. Try to hold on to some semblance of normal everyday interactions and routine so that IVF isn’t the entire focus of your mind.
Lili Goralnick LCSWR-CCTP