Ok, last time I posted here, I promised I'd write about how to get the most out of a second opinion. To do this, I did something a little novel - and so it took me longer than I expected. While I have pretty strong opinions on how to get the most out of a second opinion, I queried a lot of doctors from around the country to see what they would advise.
I have to say, overall, I was a little disappointed. Most of the responses were some variation of "send the patient to me."
Most advice was also not very helpful. A lot of the advise was almost opposite from the advise of other physicians.
To be fair, not all the people who responded were reproductive endocrinologists, so they may be quite in tune with the issues infertility couples face.
However, of the people I polled, there were some excellent points and issues to consider.
Why Get a Second Opinion?
There are many reason patients consider a second opinion. Frequently, in our field of medicine, it’s because a person did not have success with their previous provider, because they were given difficult news with few acceptable options, or simply because they did not mesh with their first provider. Sometimes, it seems some people get a second opinion because it’s just what they do… they like more than one opinion.
How to prepare for a second opinion:
1) First identify why you are seeking a second opinion (be aware of your agenda).
2) Be aware that your first and your second doctor may have an agenda, too.
3) Gather your records and get them to the physician ahead of time if possible.
Agendas are critical.
Agendas may completely alter the advice you receive.
First, the patient’s agenda: Almost every patient has a reason for getting a second opinion. Nearly every doctor I polled said that patients should know why they want a second opinion. If it’s because they just didn’t get the answer they were looking for from the first doctor, the patient needs to recognize this and keep this in mind when seeking a second opinion.
It has been said that the very poor and the very wealthy are at greatest risk for receiving the worst medical care. The poor have no access. The very rich can doctor shop until they find physicians who will do whatever the patient wants. Michael Jackson could always find yet another surgeon to carve him up or help him sleep. If you're just looking for someone to tell you what you want to hear, you should be aware that this can lead to sub-optimal treatment.
My advice to patients is, to the best of your ability, don’t tell the doctor your agenda until he or she gives his opinion.
Here is why.
There have been many times when patients come to my office for a second opinion and it is very apparent that they simply did not like what they heard from their first physician.
If I realize that the patient is very unhappy with the first doctor because of the opinion, I have a tremendous advantage compared to the first doctor. I already know what information, or what type of information that a patient does not like to hear. Simply agreeing with a patient’s preexisting biases may strongly influence the way the patient feels about my advice.
I would like to think this knowledge does not influence my opinion or how I relay information to a patient. I hope that’s not wishful thinking.
If I don’t know a patient’s agenda, then there is no opportunity for me to be influenced by this.
Knowing which advice is the best is not always easy. These are not fool-proof clues to which advice is best, but here are my suggestions:
*Did each doctor support their opinion, with evidence from the medical literature?
*Did each doctor explain the diagnosis to your understanding?
*Were you given a full range of options and the likelihood of each being successful?
*Does the doctor’s advice make sense?
The Doctors’ Agendas
Dr. Deane Waldman, of the University of New Mexico Health Science Center said that physicians providing a second opinion would ideally just be providing an opinion and not be gaining financially from such an opinion.
I frequently tell patients this, too. If a physician has nothing to gain from giving the opinion, he or she, is less likely to be influenced by his or her own gain. This kind of opinion is least likely to be biased.
So how does the patient learn if the doctor has an agenda?
In general, physicians in our field of medicine should really be providing you with information to help you make the very best choices. If their advice is good, they should not be threatened by the thought of you getting a second opinion.
Red Flags
There are certain circumstances when a first or a second opinion should cause you concern. (Preston Parry, an REI at the University of Wisconsin pointed out some of what follows below.)
1) False choices: I have encountered patients who have been told they either need donor sperm or in vitro fertilization. One couple had actually had two previous pregnancies over the past two years. In this case, the recommendation was made on the strength of a minimally abnormal semen analysis. (Clue 1: this advise didn't make sense, based on the patient history. Clue 2: a minimally abnormal result, even a moderately abnormal does not always mean extreme measures need to be taken.)
2) Only the positives are discussed. Every treatment has advantages and disadvantages. If you are offered only one treatment and the physician does not volunteer the disadvantages and advantages of all the options, then be wary. This is not to say the doctor is incorrect. But unless you really understand the upsides and downsides to all treatments, how can you make an informed choice?
3) It's Natural: the doctor suggests an array of supplements/holistic medicines. (Trying to prove that their practice is more thorough; the reality is if these things had a dramatic effect, everyone would be using them.)
4) It's what we do: the doctor suggests protocol modifications, but can’t say why it is appropriate through evidence-based medicine. (“We do it that way for everyone,” is not science, it’s opinion.)
5) Only We Syndrome: the doctor claims that he or his group has a unique procedure that only he can perform.
6) Cherry picking: This is a common concern among REIs (reproductive endocrinology and infertility specialists). There are some clinics which report extremely high success rates by age group. There is a suspicion among some REIs that some of these clinics are only treating good prognosis patients and trying to funnel poor prognosis patients toward egg donation. Without naming them, I will say this: I have referred some young, fairly poor prognosis patients to certain clinics for a second opinion and they have been told things like, "We wouldn't do a better job than your local docs." This is code for "we don't want you to hurt our statistics." Even if you are poor prognosis, a good clinic will give you realistic odds and should still let you proceed with care as long as you understand the chances and the treatment is not overly dangerous for you.
Conclusion:
Second opinions can be tricky. Ultimately it will come down to a matter of trust. If you get a second opinion, be sure that the physician fully explains why a recommendation is being made. If he or she can't explain it to you so that you understand it, then it likely is not the best choice for you.
If an alternative treatment is suggested, the relative advantages AND disadvantages should have been discussed with you.
You can ask your referring provider what their experience has been with the doctor. Ask your friends. Watch for red flags. And, ultimately, if all else fails, you should trust your instinct.
Showing posts with label frustration of infertility. Show all posts
Showing posts with label frustration of infertility. Show all posts
Friday, October 1, 2010
Wednesday, November 18, 2009
Interpret With Caution!
It’s been a while since I’ve written anything here. Quite frankly, I’ve been a bit busy, and no topic seemed particularly inspiring. Until yesterday.
I was asked to make a comment for a local television station, WRCB TV3 Eyewitness News, which was running a story on a New York fertility doctor (Dr. Sami David) who says that too many couple use IVF to get pregnant and that many of those couples should try alternate methods first. He notes that his favorite fertility drug is antibiotics.
What I am about to write may at first sound like a preamble to denouncing this doctor’s claims, or like a build up to a defense of IVF.
It really is neither.
The "Caution" Part...
I am saying there is a lot said about fertility and infertility treatments which should be interpreted with caution. In this post I’m going to elaborate on some of the ways any news story you might encounter can be misinterpreted.
This post is also an expansion of what I would have like to have said if the news station actually had the time to air it. My response to the news story was limited to about 8 seconds and the reporter was only able to highlight a couple of sentences of my response. Such is the nature of broadcast journalism. I am very grateful to Channel 3, the NBC affiliate, that they gave me what time they could spare to my point of view. I am also very happy that they put my entire response on their website.
It appears that the story was filmed by a New York affiliate station and sent to local NBC affiliates from the network. Local affiliates could interview local physicians as time permitted. In case the link above does not work, I’ll give you the skinny on the news story:
Dr. Sami David performed the first IVF procedure in New York and he has not done one since that time. He says that IVF has a high failure rate and that many people who resort to IVF could get pregnant without it. He said doctors need to pay more attention to treating the man and looking for not-so-obvious causes of infertility and treat those causes. The story illustrates the proof of this concept by interviewing a woman who went through three IVF cycles but miscarried all three times. She then saw Dr. David, conceived and now, happily, has a child. Dr. David has now written a book explaining much of this. It is called Making Babies.
Unavoidable Bias
There are several inherent and hard to avoid biases in stories like this. For example, simply by saying Dr. David is offering an alternative, this does not mean many people in our field aren’t also incorporating some of the same treatments. Much of what Dr. David promotes and what your typical fertility would promote will be similar. The implication is that most fertility doctors push a lot of people to IVF.
As a matter of fact, fewer than 10% of our patients ever require IVF. Dr. Scotchie and I try very hard to use IVF as a last resort.
Another unavoidable bias is that simply by reporting this story, makes the information seem like its new. Just because this story is in the news, this does not make it new. The reason Dr. David is in the news is not because of remarkable success rates. The reason he is in the news is because he has written a book. He is promoting the book and he seems to be doing a good job with that. By saying this, I’m not trying to imply that Dr. David wrote this only to promote his practice and to make money. I have not read the book, but until I see proof otherwise, I’ll assume that he wrote it to get the word out that for some people, there are alternatives to IVF. Quite frankly, if I were a reporter, I’d be inclined to write a story about it, because there people who would be interested in it.
My First Thought
My first thought upon hearing what Dr. Sami has to say is: I agree that some people get thrust into IVF too quickly. I think some doctors don’t do enough investigation to find out if there is a treatable cause. This is especially true of male factor infertility. I know this because I get to review a lot of medical records as a second opinion, and not just from Tennessee or the surrounding areas. Friends from all over the country refer their friends to me to give them my assessment.
Doctors are partly to blame, and there are various reasons for this. High tech treatments do generate more income for the practice than low tech treatments. Also, high tech treatments are generally far more likely to be successful than low tech treatments. A pregnant patient is usually a very satisfied patient. It makes the patient feel good. It makes the doctor feel good.
It can be difficult for patients to know if a doctor is pushing you too quickly into IVF. Second opinions can be valuable here. However… CAUTION must be exercised when getting a second opinion. (I promise to write about this VERY soon. But this is too big a topic to tackle here.)
Sometimes the doctors push for IVF too quickly and, truthfully, sometimes the patients push themselves into IVF before they’ve tried all other reasonable options.
My Biggest Fear
My biggest fear about this story is that there would be people who would interpret Dr. David’s message in a way that would cause them to delay seeking the advice of a fertility specialist.
I worry especially about women approaching their mid- to late-30s who spend several years trying on their own, or using herbal or homeopathic remedies. By the time they reach my office, they have significantly decreased chances of conceiving due to age, or due to the limited number of remaining reproductive years with which to attempt pregnancy.
Despite treatment, it can take some couples years to conceive. I should know. My wife and I were one of those couples.
Dangers of Interpreting Success
It is sometimes hard for doctors to know if it was treatment or time which cured a patient.
I am careful to counsel my patients that I may not know if it was our treatment which helped them conceive. In some cases, all we can say is that we increased the odds of conception in a given month.
It is a happy reality of my practice that some patients will conceive spontaneously before, between or after an infertility treatment.
In cases when patients get pregnant between treatments, patients usually understand that they did not conceive due to treatment. I will know it, too.
Some practitioners have a difficult time in knowing if a patient got pregnant because of treatment or simply because it was a patient’s time to conceive. For example: Suppose I am a doctor who gives everyone an antibiotic or an herbal remedy. A portion of my patients would have conceived anyway. But since all of my patients are “under treatment” at all times, I would be likely to think that the therapy was what made the difference. The patient would think so, too.
Under a lot of alternative regimens, patients are always technically in treatment. In these cases, it can be very difficult to know what actually caused the pregnancy. In my experience, the assumption of the practitioner and the patient is to give credit to the treatment.
In certain situations, I downplay my role to patients. Still, when they get pregnant, they give me the credit, even when it’s more likely that I was not the difference maker.
Example:
If I do surgery on 12 infertility patients and remove low-grade endometriosis and then do no other treatments, studies have shown that 3 of them will get pregnant within the next 12 months. All three who conceive say “the surgery worked” and that’s why they got pregnant. All three give me the credit.
The truth is, if I had not done surgery, 2 of the 12 would have conceived on their own.
This means, I must do 12 surgeries to get one additional pregnancy than doing nothing. This is called number needed to treat, NNT, to get 1 different outcome.
I tell patients this beforehand. Still, EVERY single patient who has gotten pregnant after surgery remarks something like, “The surgery worked!”
I usually say something like, “Maybe, there’s a 33% chance that it did.”
This example illustrates the point that doctors and patients can be very likely to give or accept credit more often than deserved.
Even when it is more probable that my intervention had something to do with the pregnancy, I am careful to counsel patients that the only thing we did was increase the chance.
For Example:
If I do an intrauterine insemination (IUI) on a patient and the patient gets pregnant, I cannot always say that the pregnancy was due to the procedure or due to intercourse that she and her partner had a few days earlier. All I know is that the IUI increased their chances of conception that month.
The news story used an example of a patient to represent Dr. David's success. In this example, the patient had failed to have a baby after three IVF attempts. She was then treated by Dr. David, and after an unspecified amount of time, she got pregnant. Did Dr. David's treatment get her pregnant? Or was it just her time to succeed? Clearly both the doctor and the patient have given him the credit. In all honesty, neither of them could possibly know.
I am wary when anecdotes are used as evidence that a treatment is successful. It does not mean I don’t try some of those same treatments myself, but both the patient and I must still be wary about interpreting the results.
My Final Thought
I’m sure there is a lot more I could write. But my wife is cleaning the house for family members of mine that are arriving from out of town, and it seems somehow wrong that she is doing all of the work, so I’ll leave it at this.
I have not read Dr. David’s book, yet. My suspicion is that I will agree much more than disagree with it. I do think it is very sensible to not turn your back on any practical ways to improve your ability to conceive.
There are many recommendations out there for stress reduction, optimal supplements, exercise, sexual positions. I’ll try to address some of these issues in future blogs.
I think I’ll write about the pitfalls of second opinions next.
But first, I have to mop.
I was asked to make a comment for a local television station, WRCB TV3 Eyewitness News, which was running a story on a New York fertility doctor (Dr. Sami David) who says that too many couple use IVF to get pregnant and that many of those couples should try alternate methods first. He notes that his favorite fertility drug is antibiotics.
What I am about to write may at first sound like a preamble to denouncing this doctor’s claims, or like a build up to a defense of IVF.
It really is neither.
The "Caution" Part...
I am saying there is a lot said about fertility and infertility treatments which should be interpreted with caution. In this post I’m going to elaborate on some of the ways any news story you might encounter can be misinterpreted.
This post is also an expansion of what I would have like to have said if the news station actually had the time to air it. My response to the news story was limited to about 8 seconds and the reporter was only able to highlight a couple of sentences of my response. Such is the nature of broadcast journalism. I am very grateful to Channel 3, the NBC affiliate, that they gave me what time they could spare to my point of view. I am also very happy that they put my entire response on their website.
It appears that the story was filmed by a New York affiliate station and sent to local NBC affiliates from the network. Local affiliates could interview local physicians as time permitted. In case the link above does not work, I’ll give you the skinny on the news story:
Dr. Sami David performed the first IVF procedure in New York and he has not done one since that time. He says that IVF has a high failure rate and that many people who resort to IVF could get pregnant without it. He said doctors need to pay more attention to treating the man and looking for not-so-obvious causes of infertility and treat those causes. The story illustrates the proof of this concept by interviewing a woman who went through three IVF cycles but miscarried all three times. She then saw Dr. David, conceived and now, happily, has a child. Dr. David has now written a book explaining much of this. It is called Making Babies.
Unavoidable Bias
There are several inherent and hard to avoid biases in stories like this. For example, simply by saying Dr. David is offering an alternative, this does not mean many people in our field aren’t also incorporating some of the same treatments. Much of what Dr. David promotes and what your typical fertility would promote will be similar. The implication is that most fertility doctors push a lot of people to IVF.
As a matter of fact, fewer than 10% of our patients ever require IVF. Dr. Scotchie and I try very hard to use IVF as a last resort.
Another unavoidable bias is that simply by reporting this story, makes the information seem like its new. Just because this story is in the news, this does not make it new. The reason Dr. David is in the news is not because of remarkable success rates. The reason he is in the news is because he has written a book. He is promoting the book and he seems to be doing a good job with that. By saying this, I’m not trying to imply that Dr. David wrote this only to promote his practice and to make money. I have not read the book, but until I see proof otherwise, I’ll assume that he wrote it to get the word out that for some people, there are alternatives to IVF. Quite frankly, if I were a reporter, I’d be inclined to write a story about it, because there people who would be interested in it.
My First Thought
My first thought upon hearing what Dr. Sami has to say is: I agree that some people get thrust into IVF too quickly. I think some doctors don’t do enough investigation to find out if there is a treatable cause. This is especially true of male factor infertility. I know this because I get to review a lot of medical records as a second opinion, and not just from Tennessee or the surrounding areas. Friends from all over the country refer their friends to me to give them my assessment.
Doctors are partly to blame, and there are various reasons for this. High tech treatments do generate more income for the practice than low tech treatments. Also, high tech treatments are generally far more likely to be successful than low tech treatments. A pregnant patient is usually a very satisfied patient. It makes the patient feel good. It makes the doctor feel good.
It can be difficult for patients to know if a doctor is pushing you too quickly into IVF. Second opinions can be valuable here. However… CAUTION must be exercised when getting a second opinion. (I promise to write about this VERY soon. But this is too big a topic to tackle here.)
Sometimes the doctors push for IVF too quickly and, truthfully, sometimes the patients push themselves into IVF before they’ve tried all other reasonable options.
My Biggest Fear
My biggest fear about this story is that there would be people who would interpret Dr. David’s message in a way that would cause them to delay seeking the advice of a fertility specialist.
I worry especially about women approaching their mid- to late-30s who spend several years trying on their own, or using herbal or homeopathic remedies. By the time they reach my office, they have significantly decreased chances of conceiving due to age, or due to the limited number of remaining reproductive years with which to attempt pregnancy.
Despite treatment, it can take some couples years to conceive. I should know. My wife and I were one of those couples.
Dangers of Interpreting Success
It is sometimes hard for doctors to know if it was treatment or time which cured a patient.
I am careful to counsel my patients that I may not know if it was our treatment which helped them conceive. In some cases, all we can say is that we increased the odds of conception in a given month.
It is a happy reality of my practice that some patients will conceive spontaneously before, between or after an infertility treatment.
In cases when patients get pregnant between treatments, patients usually understand that they did not conceive due to treatment. I will know it, too.
Some practitioners have a difficult time in knowing if a patient got pregnant because of treatment or simply because it was a patient’s time to conceive. For example: Suppose I am a doctor who gives everyone an antibiotic or an herbal remedy. A portion of my patients would have conceived anyway. But since all of my patients are “under treatment” at all times, I would be likely to think that the therapy was what made the difference. The patient would think so, too.
Under a lot of alternative regimens, patients are always technically in treatment. In these cases, it can be very difficult to know what actually caused the pregnancy. In my experience, the assumption of the practitioner and the patient is to give credit to the treatment.
In certain situations, I downplay my role to patients. Still, when they get pregnant, they give me the credit, even when it’s more likely that I was not the difference maker.
Example:
If I do surgery on 12 infertility patients and remove low-grade endometriosis and then do no other treatments, studies have shown that 3 of them will get pregnant within the next 12 months. All three who conceive say “the surgery worked” and that’s why they got pregnant. All three give me the credit.
The truth is, if I had not done surgery, 2 of the 12 would have conceived on their own.
This means, I must do 12 surgeries to get one additional pregnancy than doing nothing. This is called number needed to treat, NNT, to get 1 different outcome.
I tell patients this beforehand. Still, EVERY single patient who has gotten pregnant after surgery remarks something like, “The surgery worked!”
I usually say something like, “Maybe, there’s a 33% chance that it did.”
This example illustrates the point that doctors and patients can be very likely to give or accept credit more often than deserved.
Even when it is more probable that my intervention had something to do with the pregnancy, I am careful to counsel patients that the only thing we did was increase the chance.
For Example:
If I do an intrauterine insemination (IUI) on a patient and the patient gets pregnant, I cannot always say that the pregnancy was due to the procedure or due to intercourse that she and her partner had a few days earlier. All I know is that the IUI increased their chances of conception that month.
The news story used an example of a patient to represent Dr. David's success. In this example, the patient had failed to have a baby after three IVF attempts. She was then treated by Dr. David, and after an unspecified amount of time, she got pregnant. Did Dr. David's treatment get her pregnant? Or was it just her time to succeed? Clearly both the doctor and the patient have given him the credit. In all honesty, neither of them could possibly know.
I am wary when anecdotes are used as evidence that a treatment is successful. It does not mean I don’t try some of those same treatments myself, but both the patient and I must still be wary about interpreting the results.
My Final Thought
I’m sure there is a lot more I could write. But my wife is cleaning the house for family members of mine that are arriving from out of town, and it seems somehow wrong that she is doing all of the work, so I’ll leave it at this.
I have not read Dr. David’s book, yet. My suspicion is that I will agree much more than disagree with it. I do think it is very sensible to not turn your back on any practical ways to improve your ability to conceive.
There are many recommendations out there for stress reduction, optimal supplements, exercise, sexual positions. I’ll try to address some of these issues in future blogs.
I think I’ll write about the pitfalls of second opinions next.
But first, I have to mop.
Tuesday, June 16, 2009
Hope
If you are like me and my wife, most of the time you’ve got things pretty well covered. The world seems to run better when you’re in charge, and for the most part, things go your way.
I think that’s partly why the diagnosis of infertility was so frustrating to us. It seemed like everything about it was out of our control. To make matters worse, a lot of current medical advice encouraged patients to educate themselves about their condition. While this is a good concept, it has a major pitfall: mainly, it gives you the sense that you do have more control over the situation than you actually do.
The more we tried to gain control of it, the more elusive getting pregnant became. The more frustrated we became.
This frustration and desire for control had many implications. I saw this as a patient and I continue to see this as a doctor.
The first casualty in this quest for control was our self esteem.
Getting pregnant was so easy for other people. We could not go to the mall or the grocery store without feeling like we had stumbled into a stroller stampede. Happy mothers and families were everywhere.
If it was so easy for them, then something was wrong with us. We had a sense that we were somehow not worthy, or that we were being punished.
To make matters worse, during much of our journey, I was an Ob/Gyn resident. Daily, I cared for couples who seemed to take their fertility for granted. I saw women (drug addicts, alcoholic) who made very unhealthy choices for their pregnancies. I saw 13 year old girls who thought that pregnancy was a perfectly normal part of adolescence.
It made me wonder what sin I had committed to make me unworthy of being a father.
This blame made us somehow doubt that any treatment would work. Success seemed so far away.
This blame skewed our ability to interpret what the doctors told us. When we were told that an individual treatment would have a 15% chance of working we somehow focused on that 15% only. That 15% received 100% of our attention. So when the most likely thing happened -- we did not conceive -- our disappointment was out of proportion to what our actual chances had been. We thought each failure was an indictment, or a failure of the doctor.
As I sit here and write this, there are so many tangential directions I could go explore. There are so many examples of how we gradually lost trust that we would ever conceive, but I won’t elaborate on them right now.
I can say that I think I know what kept us going.
First, we kept trying because despite each failure, we would have regretted not trying one more time.
Second, I knew I was not yet ready to adopt. At that time in my life, it seemed like "second best". And as long as I felt that way, I knew that would not be fair to a child. (Of course I felt guilty about this, too, and it only reinforced my doubts about whether I was worthy.)
But ultimately, despite all the guilt, despite wondering if we were being punished, I was hopeful.
I was hopeful that our suffering was a gift.
I didn’t know what kind of gift it would be: compassion and understanding for those in my shoes; a greater love for a child (adopted or otherwise) should we ever have one; a cautionary tale for others.
In the end, I learned that no matter how much I tried, I could not control hope. It controlled me.
This was how I came to realize that hope is at once wonderful… and cruel.
If you are like me and my wife, most of the time you’ve got things pretty well covered. The world seems to run better when you’re in charge, and for the most part, things go your way.
I think that’s partly why the diagnosis of infertility was so frustrating to us. It seemed like everything about it was out of our control. To make matters worse, a lot of current medical advice encouraged patients to educate themselves about their condition. While this is a good concept, it has a major pitfall: mainly, it gives you the sense that you do have more control over the situation than you actually do.
The more we tried to gain control of it, the more elusive getting pregnant became. The more frustrated we became.
This frustration and desire for control had many implications. I saw this as a patient and I continue to see this as a doctor.
The first casualty in this quest for control was our self esteem.
Getting pregnant was so easy for other people. We could not go to the mall or the grocery store without feeling like we had stumbled into a stroller stampede. Happy mothers and families were everywhere.
If it was so easy for them, then something was wrong with us. We had a sense that we were somehow not worthy, or that we were being punished.
To make matters worse, during much of our journey, I was an Ob/Gyn resident. Daily, I cared for couples who seemed to take their fertility for granted. I saw women (drug addicts, alcoholic) who made very unhealthy choices for their pregnancies. I saw 13 year old girls who thought that pregnancy was a perfectly normal part of adolescence.
It made me wonder what sin I had committed to make me unworthy of being a father.
This blame made us somehow doubt that any treatment would work. Success seemed so far away.
This blame skewed our ability to interpret what the doctors told us. When we were told that an individual treatment would have a 15% chance of working we somehow focused on that 15% only. That 15% received 100% of our attention. So when the most likely thing happened -- we did not conceive -- our disappointment was out of proportion to what our actual chances had been. We thought each failure was an indictment, or a failure of the doctor.
As I sit here and write this, there are so many tangential directions I could go explore. There are so many examples of how we gradually lost trust that we would ever conceive, but I won’t elaborate on them right now.
I can say that I think I know what kept us going.
First, we kept trying because despite each failure, we would have regretted not trying one more time.
Second, I knew I was not yet ready to adopt. At that time in my life, it seemed like "second best". And as long as I felt that way, I knew that would not be fair to a child. (Of course I felt guilty about this, too, and it only reinforced my doubts about whether I was worthy.)
But ultimately, despite all the guilt, despite wondering if we were being punished, I was hopeful.
I was hopeful that our suffering was a gift.
I didn’t know what kind of gift it would be: compassion and understanding for those in my shoes; a greater love for a child (adopted or otherwise) should we ever have one; a cautionary tale for others.
In the end, I learned that no matter how much I tried, I could not control hope. It controlled me.
This was how I came to realize that hope is at once wonderful… and cruel.
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