Those who have supported a friend or relative through infertility may also feel more prepared. Shannon Ward took heart because her sister had conceived using donor eggs: “watching her go through it just a few years before me is where I learned a lot about IVF and also the donor egg option… . So, it was very emotional, but … I knew the end result was still possible.”
Patients’ reflections on their initial reactions to infertility diagnoses testify to its strong impact on life stories. But how exactly do emotions shape our adjustment and decision making, and with what consequences?
BACK TO THE FUTURE: EMOTION’S ROLE IN COPING AND DECISION MAKING
A popular saying advises, “When life gives you lemons, make lemonade.” But when infertility sours life plans and threatens bitter disappointment, making lemonade requires us to roll up our sleeves and engage our emotions.
After a diagnosis of infertility, we need to take stock, look ahead to what may come, and choose how to react.15 Here, as in other life situations, our emotions influence our interpretations, judgments, reasoning, and decision making. The conventional wisdom that emotion weakens our ability to make “rational” decisions is far too simplistic; emotion always affects our decisions, whether it helps or harms them. Infertility, a threatening event, can demand our attention and influence how we react, what seems relevant, how much we focus on this issue, how carefully we consider information, and whether we use stereotypes and other shortcuts to evaluate options, or opt for deeper reflection.16 Emotions also affect why we make decisions in the first place and which options seem most attractive. Making decisions about infertility generates additional emotions; time constraints or uncertain outcomes can create anxiety, and time delays can produce anger and frustration.17
Deciding what to do about infertility means working through many highly uncertain and complex choices with great personal and social stakes. We don’t make infertility-related decisions like a computer, mechanically analyzing each option’s mathematical risks and benefits, comparing their immediate and long-term consequences.18 This would be impossible; even if we can identify all possible options, we don’t know what will work or each outcome’s precise likelihood.19 This would also take too long, strand us in impossible calculations, force us to work with impossible amounts of information and chains of events,20 and require us to compare incommensurable outcomes21—and most of us are already notoriously bad with probabilities and statistics to begin with.22
Instead, we rely largely on our gut feelings about infertility and particular treatment options to make these kinds of decisions.23 “Bad” gut feelings can direct our attention toward negative outcomes and serve as “alarm bells” or “red flags”; maybe we don’t want to voluntarily accept childlessness and opt for treatment or adoption. “Good” gut feelings can steer us toward positive outcomes;24 if we have enough money to pursue IVF or adoption, we might opt to adopt, since its outcome is more certain. Our emotions play key roles in forming these gut feelings, and even in making them seem inherently “rational.”25
Thus, when confronting infertility and making decisions, we project ourselves into the future, choosing among options from Clomid to IVF to childlessness. To do so, we weigh possible outcomes, their likelihood, and their financial, emotional, psychological, and social “costs” and benefits. Our gut reactions to each option and outcome help us determine what steps to take. Our emotions usually improve these decision-making processes, so long as they are not extreme or overwhelming.26
Just because our emotions can improve decision making, however, doesn’t mean we always choose well, particularly about uncertain events—not because of emotion, but because we don’t have the right information or simply because we’re human, subject to human biases.27 We might be misinformed, overestimate how intensely certain events (like childlessness or an unsuccessful cycle) will impact our lives, or assume our current wishes will apply to future situations.28 We even selectively remember the emotions that past events generate, remembering only how we felt during an event’s most intense moment and at its end.29 For instance, assume we experience more negative than positive emotions throughout six unsuccessful IVF cycles. But if we conceive on our seventh try and birth a healthy child, we may well remember our treatment experiences quite positively. Nor can we do much to ensure emotion influences our decision making in healthy ways; trying to suppress our emotions often intensifies them.30 It might help to think of setbacks like an unsuccessful IVF cycle as just one step in a longer process of trying to conceive, or as a learning opportunity.31
Medical challenges like infertility and treatment decisions cause especially strong emotions, especially given medicine’s inherent risk and uncertainty.32 Strong emotions can prompt us to make a decision too early, without adequately considering other options, or too late, when treatment becomes impossible.33 At other times, stress may motivate us to carefully research options, knowing we’ve only one opportunity to make the best possible decision. But medical decision making can also be therapeutic, too, when it provides strategies for dealing with infertility.34 Even undergoing testing can reduce anxiety and stress, provide answers, and make us feel as if we’re doing something, and therefore aren’t entirely helpless.
Specific emotions also influence our behavior in particular ways. Anger can motivate us to take treatment risks,35 attempt to change providers, or fight against infertility.36 When we’re sad, we’re more likely to blame fate or situational circumstances, attribute infertility to divinity or destiny,37 believe we’ll never conceive,38 and avoid pregnant women.39 Anxiety, on the other hand, makes us feel that infertility threatens our future and can motivate us to learn more.40 We experience disappointment when our choices turn out worse than we expected,41 and we might withdraw from problematic situations or people.42 Fear renders us more pessimistic about the future,43 makes riskier events seem more likely,44 and prompts us to choose the “sure thing” or avoid a decision altogether.45 When we feel guilty, we blame ourselves for bad outcomes, focus more on the decision at hand, and narrow our choices. Happiness encourages us to expect or even overestimate46 that we’ll get pregnant,47 and hope makes us feel a little personal control over what happens,48 but surprise makes us feel that others are responsible for certain outcomes and that positive outcomes are unpredictable.49 Finally, we feel regret when we realize later that another option was better.50
Making infertility-related decisions can unleash all of these highly charged and interdependent emotions. Understanding how they influence our decisions reinforces that these emotions aren’t random, but linked to particular options and outcomes. Ideally, we’ll choose options that make us feel good and that protect cherished goals, values, and relationships. Once made, our choices become courses of action with real-world outcomes that carry their own emotional consequences.
REASONED EMOTIONS: PROVIDERS’ REACTIONS TO PATIENTS’ AFFECT
With this brief glimpse into infertility’s disruptive and emotional experience, we can step out of patients’ shoes and into providers’ to gauge their reactions to patients’ emotionality. Most providers expect patients’ emotions to affect decision making—“almost everything about having babies is emotional” (Dr. Errol Walter)—and grow concerned only when these emotions effect harm.
Patients’ desires and life goals—like having a family—are both cognitive and emotional, and it’s difficult to contemplate changing them even when odds become slim. “If they’ve thought their whole life they wanted to have three babies and they have two, they just can’t put that away. There’s somebody missing, and I think that’s an emotional type of reaction,” explained Nurse Melanie Simons. Indeed, why should reproductive medicine not be emotional, in keeping with other medical treatments? “I would actually be worried if there was no emotion at all,” opined Dr. Heike Steinmann, “that kind of person, like an automaton, … I mean, it’s not like taking out your gall bladder.” As Dr. Denzel Burke said, “It’s impossible to remove emotion from anything in medicine …