Assisted reproduction and its emotional cost

“It’s day nine. I’m not taking a test. I’m not going to notice whether there’s a pulling feeling low in my belly. I’m not reading the forums.” Then she opens her phone and types “cramps nine days after transfer” into the search bar.

If you have ever been through assisted reproduction, or stood beside someone who has, you know this scene. From the outside it looks like a lack of discipline. From the inside it is something else entirely: an attempt to hold on to at least something during the weeks when the most important question of your life is being decided without you.

The medical side of treatment is something to discuss with your gynaecologist and the team looking after you — that is where the answers about medication, options and test results are, and that is where to look for them. This piece is about the other side, the one that never appears in a report: what treatment does to a person, to a couple and to the relationships around them. And about why that cost deserves a name.

A cycle, not a single event

When people hear the word “treatment”, they often picture a procedure: something that happens on one day and is then behind you. In reality, assisted reproduction is a cycle with its own rhythm — scans, medication, egg retrieval, waiting, result. If it ends without a pregnancy, it often begins again. And each new cycle carries the memory of the last.

It is this repetition that wears people down most. One disappointment can be survived. A disappointment that returns every few weeks, with stretches of hope in between, is experienced differently by the body and the mind: as a state with no real way out, because the way out keeps opening and closing again. People describe to me how they live “in intervals” — from scan to scan, from transfer to test. Life waits in between.

The uncertainty that people already know from months of trying is not removed by treatment. Treatment simply gives it a timetable.

Why it is so hard: the body, time and control

When I talk with people who are going through treatment, three layers come up again and again.

The body becomes a work site. Injections at a precise hour, hormones that shift your mood, examinations in which the body is measured and counted. Many women say they began to experience their body as a machine that “doesn’t work the way it should”. This estrangement from your own body is one of the quietest losses of treatment.

Time narrows. Plans for holidays, for work, for a new flat start to bend around the cycle. You don’t sign up for a course because “I might be pregnant by then”. You don’t say yes to a friend’s wedding because you don’t know where you’ll be. Life goes on pause, and the pause has no visible end.

There is no control. You can do everything you are told — and the result can still be negative. People who have been used to effort bringing results meet, perhaps for the first time, a question that effort cannot answer. That is why they so often look for the fault in themselves: “Maybe I didn’t rest enough. Maybe I was too stressed.” Guilt hurts, but at least it promises that something was in your hands. I have written more about this mechanism in Guilt: the feeling that gives us a false sense of control.

And here is something worth knowing. In 2011, Jacky Boivin and colleagues published a meta-analysis in the BMJ of 14 prospective studies including 3,583 women undergoing treatment. They set out to answer the question women hear most often: does emotional distress before treatment lower the chance that it will work? The answer was no — distress before starting treatment was not associated with a worse outcome. So the line “just relax and it will happen” is not true. Nor is its darker version: that a negative test is the result of not having been calm enough.

Two weeks that last longer than a month

If you ask people which part of treatment was hardest, many won’t mention the injections or the procedures. They will mention the waiting. That stretch after the transfer, when everything has been done and there is nothing left to do but wait.

Jacky Boivin and Deborah Lancastle have written about what makes medical waiting periods like this so particular. Waiting is hardest when the outcome matters a great deal, when you cannot influence it, and when you don’t know what is happening in the meantime. The two weeks after a transfer meet all three conditions at once. No wonder anxiety, hope and fear take turns from hour to hour.

During this time many people get caught in a loop: noticing every sign in the body, interpreting it, looking for confirmation online, calming down for a moment, and then feeling the unease return even stronger. This is not a sign of weakness. It is a mind trying to soften uncertainty by checking it constantly — and by doing so, keeping it alive. I describe a similar dynamic in A single thought can ruin your whole day — if you believe it.

It helps if the waiting isn’t left empty. Not in the sense of forcing yourself to stay busy, but having a few small things ready for the days that will be hardest — that is what the exercise below is about.

What happens to the relationship

Treatment happens to two people. But it often doesn’t hit them in the same way. The woman carries the physical part — the medication, the procedures, the examinations. Her partner often stands to one side, not knowing what to do with his own helplessness. Some respond by taking over the organising: schedules, bills, lifts. Others withdraw into work or silence because they “don’t want to add to the burden”. Up close, both can look like distance.

A conversation after a negative test might go something like this (composed, not a real person):

“You keep asking when we’re going to try again. As if it’s just the next step.”
“I don’t know what else to say. If I tell you it hurts, you’ll have to comfort me as well.”
“I’d rather comfort you than be alone with this.”
“I thought my sadness would only drag you down further.”

This short exchange holds the core of what often happens to couples during treatment: each tries to protect the other, and in doing so, each ends up alone. A male partner who is “solid” throughout treatment is often not without feelings; he hides them, because he thinks grief isn’t his to claim when he is not the one suffering physically. I have written more broadly about how infertility tests a relationship and what a couple can do in Infertility as a test for a couple: what happens to the relationship. Here I will add just one thought: a couple who can acknowledge grief together is not weaker than a couple who “holds it together”. Often it is stronger.

In relational family therapy, in which I am training, we also look more widely — at the family each partner comes from. Infertility tends to wake up whatever is passed down in a family: parents’ expectations about grandchildren, old patterns about who is “to blame”, who has to be strong, what is never talked about. If there was a loss in the family that nobody spoke about, the silence can repeat itself. This is not fate, but it is worth seeing.

When those around you don’t know — or know too much

People in treatment often have to decide whom to tell. If they tell no one, they are left alone and have to explain absences, odd schedules and their mood. If they do tell, they get questions — “So, any news?” — that are then repeated at every meeting. And advice nobody asked for.

There is no right answer. But one thing often helps: deciding together, as a couple, who will know and how much, and having a short sentence ready to close the topic when you can’t bear to open it. For example: “Thank you for thinking of us. When we have something to share, we’ll tell you.”

The people close to you often don’t know what to say. And because they don’t know, they say something that hurts. A few of the most common sentences, and what lies behind them, are shown below.

Back in the 1990s, Alice Domar and colleagues compared the distress of women with infertility with that of patients with other chronic and serious illnesses. The level of psychological symptoms was similar. This does not mean that infertility is the same as a serious illness. It does mean that what you are going through is not an overreaction — and that “it’s only a procedure” is a long way from reality.

Exercise: a card for the waiting days

This exercise is simple, and you can prepare it today, before the next wait begins. It is inspired by a brief intervention that Lancastle and Boivin developed for the wait before a pregnancy test — a card with a few sentences that a person reads when the unease takes hold.

1. Take a small card or a note on your phone. At the top, write: “When it grabs me.”
2. Write two sentences that are true whatever the result. For example: “I did everything that was in my hands.” “Whatever happens, I won’t be alone.”
3. Write three small things you can do in ten minutes that take your mind off it, even a little: a walk to the end of the street, a call to a friend who won’t ask questions, a chapter of a book.
4. Agree with yourself or your partner on a “worry time” — say, fifteen minutes in the evening when you are allowed to read, search and worry. At other times, when the thought comes back, tell it: “Come back at eight.”
5. Read the card when you notice yourself reaching for your phone to look for signs. Not to forbid the worry, but to give it a frame.

The exercise won’t take the anxiety away. But it can make it manageable — and in those days, that is a lot. If you want to sort out what is within your influence and what isn’t, the circle of control tool in the knowledge base may also help.

When the result is negative

A negative test is a loss. It is not “just another unsuccessful attempt”. You have lost something that already existed in your mind — a possibility, a date, an image. There is no funeral for this loss and often not even any words. People who know about the treatment may say “next time it will work”, which is meant as encouragement but sounds like skipping over what has just ended.

Allow yourself to call this grief. Perhaps not the same as grieving a person, but grief all the same. Why some losses are not acknowledged by those around us is the subject of The grief nobody acknowledges. When losses pile up — cycle after cycle, year after year — what I describe in When everything comes at once: cumulative loss can happen: one loss has not yet been worked through when the next one arrives.

Research on why people end treatment paints a similar picture. In a 2012 systematic review, Sofia Gameiro and colleagues found that psychological burden was among the most common reasons for stopping — not only medical circumstances or cost. This is not failure. It is a sign of how hard this cycle is to carry.

Deciding when enough is enough is a subject of its own, and it is covered in When is enough enough? Deciding to end fertility treatment.

When to look for more support

Distress during treatment is to be expected. But there are some signs that suggest it makes sense to look for more help:

• when your mood has been pulling you down for weeks and nothing else interests you,
• when you can’t sleep, can’t eat or can’t manage work,
• when you hardly talk to the people around you any more,
• when the only topic left between you and your partner is treatment — or no topic at all,
• when it feels as if your life has no meaning without a child.

Talk about physical questions, and about how medication affects your mood, with your gynaecologist or the team running your treatment. If low mood goes on for a long time, it is also worth seeing your GP. If thoughts appear that it would be better if you weren’t here, reach out to someone straight away: in Slovenia, the crisis line Klic v duševni stiski is available on 01 520 99 00 (every day from 7 pm to 7 am), the Samarijan helpline on 116 123 (24 hours a day), and in an emergency call 112.

The European Society of Human Reproduction and Embryology (ESHRE) has issued guidelines that expect healthcare staff to treat the psychosocial side of treatment as part of care, not as an extra. If you need more, that is not an exception, and it doesn’t mean you “can’t cope” with treatment.

Where this piece doesn’t apply

I want to be honest about the limits of what I have written.

Not every treatment is a trauma. Some people go through treatment fairly calmly, trusting the team and without feeling that their world is falling apart. This is not denial. People differ, and so do circumstances — the first cycle is different from the fifth. If it isn’t as hard for you as I have described, there is no need to look for what is wrong with you.

Psychological support does not increase the chances of pregnancy. This needs saying clearly, because therapy is sometimes sold as a route to successful treatment. Research does not support that. Therapy can help make the path more bearable, help a couple stay connected and help a person not get lost in the cycle. It has no effect on the test result and does not promise one.

Some distress has a physical side. Hormonal medication can affect mood. So don’t interpret every swing as a psychological matter — tell the doctor who is looking after you.

There is no single right emotional path. Some people are helped by talking about treatment a great deal, others by keeping it as private as possible. Some need hope; others deliberately give it up so that the fall isn’t so deep. What I have written are observations, not a prescription.

What to remember

• Assisted reproduction is a repeating cycle, not a single event — and it is the repetition that wears you down most.
• A meta-analysis of 14 studies did not show that distress before treatment lowers the chance of success. A negative result is not the consequence of not having been calm enough.
• The two-week wait is hard because it combines great importance, uncertainty and helplessness. Worry is helped by a frame, not a ban.
• Partners often protect each other and end up alone. Grief acknowledged together often brings a couple closer.
• A negative test is a loss that has a right to be grieved. Psychological support doesn’t promise a pregnancy, but it can make the path more bearable.

If treatment has brought you to a point where you don’t know how to go on, the short explanation of infertility and distress in the knowledge base may also help.