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Infertility: What's God got to do with it?

Having children is an important part of most religious traditions, and in many of them, parenthood is th every embodiment of a life of faith.

Beatrice Schnell had her life mapped out: She would marry her boyfriend after college, and they would raise a large family, just as their parents had. Sure enough, she married right out of Wellesley College in 1981 and soon became pregnant. But then something happened that wasn't in the plans: She suffered a miscarriage when she was four months along, and the doctors had no explanation. She and her husband were devastated.

For the next three years, Schnell concentrated on getting her master's degree from Harvard University, then the couple began trying again to have a baby. In their native Venezuela, having babies, and lots of them, was considered a birthright. Even in Cambridge, it seemed that everywhere you looked were babies. Sometimes Schnell felt she was the only person in the world without one.

Pregnancy after pregnancy followed, and miscarriage after miscarriage - seven over the next 10 years. Schnell's life became a nightmare of charts, tests, needles, and ultrasounds. Finally, a specialist found that she had an abnormally high level of platelets - blood cells that aid in clotting - that compromised her ability to carry a baby. He was not optimistic about her chances.

To complicate matters, she had begun having problems even conceiving. She endured months of fertility treatments, starting with intrauterine inseminations, in which sperm is injected into the uterus during ovulation. When that failed, she went through three cycles of in vitro fertilization, in which the egg and sperm are fertilized in the lab and the embryo placed in the uterus. Still no luck.

"My husband was the oldest son, and he had his father's name. So I felt that pressure very keenly," Schnell recalls. And her own four siblings were turning out kids at a steady clip. Within 10 years, Schnell had 20 nieces and nephews and was the godmother of several. She looked into adoption and surrogacy programs. And throughout the ordeal, she had been meditating and praying. "I grew up believing in God and that you got married and had a family," says Schnell, who comes from a religious Lutheran background and had always relied on her faith to see her through tough times.

Nearly a decade of increasing despair, though, had eroded Schnell's faith. For her, as for many others, a fertility crisis turned into a spiritual crisis. "I got so angry at God," she recalls. "Why was this happening to me? I adore children ... I felt God had abandoned me." Schnell stopped going to church, even stopped praying. For the first time in her life, God seemed a distant concept.

The ordeal put a strain on her relationship with her husband, too. They divorced in 1995, after 14 years of marriage. The next year - on her 35th birthday - she heard that her former husband, who had remarried, had fathered a baby girl. "I fell apart," she says simply. "I could not get out of bed. Religion was always a source of strength for me, in terms of calming me down and keeping me going. But, I have to say, in those last few years of my marriage, I totally rejected it."

Schnell's response to her fertility problems was not unusual, say religious and mental health specialists: The inability to produce a baby often precipitates the first spiritual crisis in a woman's or a couple's life. "Be fruitful and multiply" is a key tenet of Judaism, Christianity, and Islam. But when one can't follow the command - and 1 in 9 couples can't - it can generate a crisis of huge proportions. "For many women, it's the first time in their lives that their prayers have gone unanswered," says Ali Domar, director of the Mind/Body Center for Women's Health at Beth Israel Deaconess Hospital. "It's the first time they feel God has left them."

But nobody knows how the stress of infertility affects religious faith, and vice versa, because it has never been studied, says Domar. Though medical research abounds on the issue of infertility, there is nothing on the link between religiosity and infertility distress. (As a group, religious people do tend to have higher fertility rates than nonreligious ones, says Domar; the likely reasons are not spiritual but mundane: "They're probably younger when they try, they also tend to smoke and drink less, and they have more social support.")

As for the psychological aspects of infertility, "there's no research ... period," says Domar. "Mix in the religion issue, and it's a very controversial area" - one she believes many people, the clergy included, would rather avoid because the questions are complex, the answers few.

Domar, who has counseled hundreds of infertile women over the past decade, was intrigued by the interaction of faith and fertility. "I believe depression hampers fertility," she says. "I worry that if these patients are getting shoved from different stages of spiritual development, a lot of them are getting depressed." To test her hypothesis, she launched a study of how religiosity correlates with distress and depression during infertility. "We're looking at whether religious women are more or less distressed than women who aren't religious," says Domar.

As the first step, she and Barbara Nielsen, an Episcopalcq minister who is a fellow at the Mind/Body Center, designed a spirituality questionnaire for women who come to the center while they are undergoing fertility treatment. Starting this summer, the questionnaire is also being distributed to patients at Boston IVF, a prominent fertility clinic. The survey asks women to gauge their agreement with such statements as, "I don't find that much satisfaction in private prayer with God." "I believe that God loves me and cares about me." "I believe that God is impersonal and not interested in my situation." On the spiritual scale, they must rate statements such as, "I feel that life is a positive experience" and "I believe there is a real purpose in life."

Dr. Alan Penzias, a reproductive endocrinologist at Boston IVF and Harvard Medical School, is also interested in the relationship between people's spiritual orientation and their ability to cope with infertility. Penzias has agreed to give the Mind/Body Center questionnaire to patients coming in to see doctors at Boston IVF. The most troubling cases, he says, are women in their 30s who have had five years of infertility and still have no medical explanation for the problem. (And for all the success stories, assisted conception remains a long shot; only about one-fourth of couples who try in vitro fertilization take home a baby, acccording to the Centers for Disease Control and Prevention, and the rate drops as women age.)

"Not being able to succeed and not knowing why is extremely stressful," says Penzias. "Studies show that people with some spiritual connection use that to help cope with life's stresses," he adds - heart patients and cancer patients are two examples. How does he explain it? "I think it's a grounding in something out there bigger than you. If you feel that you are part of some larger plan rather than just being an isolated person, it may provide an outlet for some of the stresses."

The yearlong study at Boston IVF will look at 250 patients, tracking the women's emotional health but not, at this stage, their pregnancy outcomes. "The really good thing about this study is that no matter what we show, it will be really important," says Domar. "If we show that very religious women have a lot more infertility distress, that's really important to know, and if they don't, that's important, too." Domar expects to compile the results next summer and submit them to a leading medical journal.

Meanwhile, for her doctorate in psychology, Nielsen is continuing to interview and counsel dozens of patients at the Mind/Body Center. Her work has given her some hints, she says, of what the research may show. The most bothersome issues for women tend to fall into four groups:

For religious Catholics, the central conflict is whether to disobey the church's ban on in vitro fertilization, since the pope believes that all conception must take place within the human body. And masturbation, necessary in even the simplest kind of assisted insemination, is frowned upon for Catholics.

Women from all faiths complained of a lack of support from their spiritual communities, which are often centered on families and children. For some, a blocked relationship with God was the most painful effect of infertility; others were finding it hard to let go and accept their lack of control over life.

The most emotional responses were aimed at God: "This has created a terrible interruption with my intimate connection with God."

"It seems that what God wants and what I want are two separate things." "Am I being punished, or doesn't God think I'll be a good parent?" "I have been so angry at God, horribly angry. I felt abandoned as I never had in my whole life."

The very devout of any religion seem to have the most distress over infertility, Domar and Nielsen say, because they feel anger that God has let them down - and then feel guilt over that anger. "Lots of women say things like, `God is punishing me' or `My past sins are causing this,"' says Domar. "Frequently, the first thing people mention is that God is punishing them because they had an abortion or premarital sex."

But nonreligious women may also rank high on the distress scale, say the researchers. Obviously, not everyone going through fertility treatments experience a religious crisis. There are agnostics and atheists who think the issue is irrelevant. Still, these women are stressed, maybe even more than their spiritual sisters. "God and prayer don't enter into the equation for some women," says Domar, "but they are very stressed by infertility, and they are lacking some of the comfort that a religious organization can provide."

It is the moderately spiritual, say the researchers, who seem to handle infertility best. They have religion as a source of comfort, and the solace of prayer, without the accompanying guilt trip that afflicts the most devout.

How the difference in emotional response correlates with fertility outcomes - if it does at all - will demand another study.

But Domar says there is increasing evidence that depression and infertility distress may hamper fertility rates. One study by the National Institutes of Health found the stress levels of infertile couples equal to those of people with AIDS, terminal cancer, and chronic heart disease.

Besides gauging distress, Domar and Nielsen's survey goes a step further into the emotional realm: Was there any lesson the women learned from their ordeal, it asks, anything positive to help them navigate life's rockier shoals?

The answer that came back, in interviews and on questionnaires, had to do with giving up control, sort of a "letting go and letting God" attitude. "You can't control everything in life," said one woman. Added another: "I'm working on valuing myself in a lot of other ways than being a mother."

One woman said infertility had initially strained her marriage but ultimately made it stronger. Another said she had found a calling to help others going through the adoption process. And another said her journey mirrored those of the Old Testament matriarchs who struggled with infertility: "Achieving whatever resolution is right for you is your path to enlightenment." Still others said that infertility had forced them to confront issues of abuse or neglect in their pasts.

Nielsen thinks such journeys are essential growth experiences. Many people go through life simply believing in God and attending church, and infertility, like other life challenges, can push them to another stage of consciousness. They may begin asking deeper questions: What is the purpose of my infertility? What am I meant to do with my life? "The question women should ask is, `What is the meaning of my infertility for me?"' Nielsen says. "The woman who can answer that is the woman who has done critical thinking."

"Most Christians have been taught to pray by asking," Nielsen adds. "But we forget to listen for the answer. So we are trying to teach the women through meditation to listen. How does the answer come? Some people see it writ large. Some people hear it. Some just feel it. When we ask, we have to remember it's `Thy will be done,' not `My will."'

Domar has a more practical take on the research they're doing. After the survey answers come back, she hopes to design a program for women in crisis. "If we can figure out who are the most miserable, and if certain religious practices are bringing pain to them, we can pull in appropriate clergy to counsel patients," she says. "My guess is that the concepts of certain religious practices are bringing pain to my patients. I know that's not the aim of the churches. If we can figure out the group most at risk for distress, we can design interventions."

The next step would be another study to look at which infertility patients ultimately have the best success rates for pregnancy: the very religious, the moderately religious, or the nonreligious. "We'll look at the pregnancy rates and psychological states," Domar says, "and see if our intervention is successful."

For Joan Goltz of Milton, who comes from a devout Catholic family of seven siblings, infertility was not only a spiritual crisis, it was a family crisis. "All of my siblings had kids, my sister had five at the time," she recalls. Her mother, one of 11, had three children in three years. Goltz has 40 first cousins on her mother's side of the family alone.

In the beginning, there were the jokes and hints with the underlying message: "Where are the babies?" Then, as those babies didn't appear, everyone said novenas for her. Reluctant to tell her family - especially her aunt, the nun - about the high-tech fertility treatments she was undergoing, Goltz quietly told her mother that she was "seeing a specialist."

She also prayed fervently. "God, I know I'm a good person. My husband, Tom, is a good person. We'll have good babies who will turn into responsible citizens. God, you want people like us to procreate." But month after month, year after year, nothing happened. "I didn't feel anyone was listening," she concluded.

Still, she didn't totally abandon God. "I thought that if I wasn't going to be able to have children, maybe it meant there was some other way I was supposed to contribute to society," she says. "I did a lot of soul-searching. What was going to fill the void? What was I going to do, accumulate money and see the world? I knew there was something else: holding crack babies at City Hospital or completely changing what I do for work. I'd pray to God to show me the way."

After four years of trying, Joan and Tom Goltz had twins - now 5 years old - through GIFT, or gamete intrafallopian transfer, in which the eggs and sperm are put directly into the fallopian tubes for fertilization. "My prayers changed from asking to thanking," she says today. But she is put off by the church's proscriptions against certain fertility treatments, and, along with her husband, is "searching for a religious community that makes sense for me."

Like the Goltzes, many couples with fertility problems not only feel abandoned by God, they also feel shunned by their churches or synagogues. Beginning with Genesis, the Bible is replete with messages such as "go forth and multiply," "be fruitful," and "spread thy seed." Children - lots of them - are particularly valued in the Catholic Church and in conservative Jewish communities. Procreation is a large part of most religious traditions, and to many, parenthood is the very embodiment of a life of faith. At one recent infertility support group, an Orthodox Jew explained that she is considered selfish for producing only two children in a community where six or more is the norm.

And then there are the practical details people must grapple with: What happens when modern medicine conflicts with traditional beliefs? Should a Catholic couple undergo in vitro fertilization even though the church frowns on it? What if an observant Jewish woman needs an egg retrieval on the Sabbath, a day of rest and prayer when devout Jews shun any other activity?

Traditionally, the clergy have not been attuned to the issues of infertility or miscarriage, since they are "invisible losses" that aren't openly acknowledged, unlike, say, the death of a parent. But last fall, at Brookline's Temple Kehillath Israel, Alma Berson, a Cambridge therapist long involved in infertility issues, and Bill Hamilton, rabbi of the temple, founded a group for infertile couples. They call it Kahal Hannah, or Hannah's Community, after the biblical figure who suffered infertility.

Discussion at the monthly meetings often centers on relevant religious texts. While the Bible is replete with procreation messages, it is also filled with stories of matriarchs who had trouble bearing children. "Give me children or I die," says Rachel in the Book of Genesis. In Samuel, Hannah weeps and stops eating because she cannot bear children - just the kind of downwardly spiraling depression Ali Domar is concerned about. In fact, Dr. Isaac Schiff analyzes Hannah's plight in a recent article, "The Biblical Diagnostician and the Anorexic Bride," published in the journal Fertility and Sterility. "Poor Hannah was caught in a downwardly spiraling syndrome - depression due to not conceiving, leading to anorexia, leading to assured infertility!" writes Schiff, who is chief of obstetrics and gynecology at Massachusetts General Hospital. Hannah finally has her baby, though: She prays, and eats, and becomes pregnant with the prophet Samuel.

There is also talk about issues for the temples, such as how congregants can be more responsive to those who are not childless by choice. And each month at Kahal Hannah, a rabbi gives a talk on finding sources of comfort within the Jewish tradition. "It's hard to do because there's a lot of emphasis on procreation, of being in God's image," says Hamilton. "Not only doesn't the religious tradition help, but it actually serves to expand the pain and suffering of those affected by infertility." Hamilton speaks from firsthand knowledge: He and his wife experienced infertility for several years, and Hamilton says it both humbled and informed him. The couple eventually had children, now 2 and 4 years old, using high-tech help.

At a recent meeting of Kahal Hannah, Berson and Hamilton ask the dozen people sitting in a circle how they are feeling. "I keep praying," says one woman, "because God sometimes does answer prayers, and this could be the one he answers." Says another woman: "Kids are beginning to get on my nerves. Being Jewish is quite demanding in dealing with infertility." And another: "I spend most of my time blaming myself. It might be good to blame God."

The guest speaker that night, Rabbi Benjamin Samuels of Congregation Shaarei Tefillah in Newton, says gently: "Rather than blaming God, which may be temporarily cathartic, why not share your anger with God? Take the burden off your shoulders and hurl it to others, and to God." In Hannah's story, he reminds the group, there is despair, but there is also hope.

"Maybe there's comfort in having someone in our tradition experiencing the same pain, the same frustration," Samuels suggests. "I hope that's inspiring."

Rabbi Joel Sisenwine of Temple Shalom in West Newton also hopes to "create a community that welcomes the infertile." Last year, he gave a sermon during the High Holy Days in which he addressed the issue of infertility and revealed that he and his wife, Heidi, had gone through treatments.

His message? "That we're not in control, that we need to learn to live with the fact that we are not the sole arbiters of our future," he says. Afterward, several people thanked him for acknowledging their hidden grief. As for Sisenwine, he believes his infertility journey strengthened rather than diminished his faith. But that might be easier for him to say than for others: A little more than a year ago, he and his wife had a baby girl through their fourth cycle of in vitro fertilization.

"Some people have anger," he says. "For me, it was the exact opposite. I gained a sense of awe that I had never known before for the miracle of life and the divine."

During their infertility treatments, Heidi Sisenwine felt that she couldn't share her sad secret with her congregation. A fourth-grade teacher, she also used to help with the toddler program at the temple. But it became too painful, and she had to stop going to the children's services. People would make insensitive comments: "So when are you two going to have kids?" Or, "You've been married five years already, you guys should be having kids."

She joined a support group through Resolve, the national infertility organization headquartered in Somerville. "We were of several different faiths," she says. "And we would share our beliefs with each other. The women really gave me a lot of hope and strength." Since she and her husband "came out" about their fertility problems at the temple, they have become a sounding board for other congregants.

But the rabbi acknowledges that his temple is very child-oriented. "I'm hoping we can become more fully aware of the childless," he says. "I hope we can create a community that welcomes the infertile and strengthens those going through infertility."

Diane Clapp, the medical information director at Resolve, has counseled couples in fertility and spiritual crisis. "They feel let down, that somehow God is punishing them," she says, and such feelings are reinforced by people who say to them: "Maybe God meant for you not to have a child." Clearly, this attitude annoys Clapp. "I always tell my clients to say back, `Would you tell someone with cancer that God meant for her to have it?"'

"It's really hard around the holidays for these couples," says Clapp, who had fertility problems a quarter of a century ago and who has a 22-year-old adopted daughter and a 20-year-old biological son. Resolve has begun sending letters to clergy just before Mother's and Father's days, reminding them that some couples are not able to have children. The letter, which some ministers read aloud at services, explains that being denied "the blessings of parenthood" can bring on a crisis of faith. "Churches and synagogues may be a natural source of solace, and yet attending services in the midst of laughing children and adoring parents can increase the infertile couple's feelings of sadness and isolation," says the letter, which asks ministers to mention infertility in a prayer or a sermon.

Resolve also puts out a fact sheet about religious perspectives on infertility. In it, several women - Catholic, Protestant, Jewish, Mormon - describe similar spiritual journeys during their crisis. "As a choir member in my parish, I had no advance warnings of christenings," writes one woman. "I dutifully sang my way through these grueling tests of strength." Writes one fundamentalist woman: "Once, I requested prayer from a women's prayer group and was promptly told that maybe it was not God's will for me to have a child."

An Orthodox Jewish woman writes: "A marriage without children is not considered a fulfilled marriage and as such is grounds for divorce." Childbearing is considered key to the survival of Judaism, and the pressure to produce children is great. The woman says that although Orthodox Judaism can be flexible in terms of some high-tech procedures, it frowns on donor insemination and surrogate parenting. ("What do you do if you need an egg donor and the donor isn't Jewish?" asks Alma Berson. "Do you convert the egg?")

The experts seem to agree that the religious crisis generated by infertility comes in several stages: disbelief ("Why me, God?"); guilt ("I must have done something terrible"); atonement ("I'll just be a better person"); and disillusionment ("It's no use ... I will forsake my religion").

It is a process familiar to Kristen and Mark Magnacca. Kristen had attended eight years of Catholic school and grew up believing that things happen for a reason. Then infertility struck. For three years, she and her husband tried to have a baby. They eventually went the high-tech route, but the baby they prayed for ended in an ectopic pregnancy. "It was the day before Thanksgiving," Kristen says, "and I had to go to the hospital by ambulance. They put me on the maternity ward. Those were really dark days."

Kristen Magnacca turned from belief to disbelief. One day, in the shower, she found herself screaming at God: "Why did you do this to me?" In the quiet, an answer came back: to learn from her experience and help others. So the deal-making began. "If you send me a baby, God, I will help people any way I can." Shortly after that, Magnacca began writing a book on infertility called Girlfriend to Girlfriend: An Infertility Companion.

A few months later, just as she and her husband were about to give up on having a baby, she got pregnant. "I think God said, `Gee, if I don't send this woman a baby, she's going to hound me the rest of her life,"' she says with a laugh. The couple's son, Nicholas, is 10 months old.

True to her promise, Kristen Magnacca speaks at patient orientations at the Fertility Clinic of New England in Reading, where she underwent treatments.

"One of the things I talk about is to take abundance," she says. "To think of what you have and not what you're lacking." Magnacca likens life to climbing a mountain. "My religion and spirituality are some of my tools, but for a while I forgot to bring them along," she says. "When I picked them back up, it helped."

After Beatrice Schnell hit bottom three years ago, slowly, through therapy, she worked her way back to her faith. Last winter, when she attended a workshop on infertility, spirituality, and belief, she felt as if she was coming home: "It was so helpful for me to hear other women who had the same feelings toward God that I had. When I was angry with God, I would feel very guilty. I wanted to believe - prayer had given me strength in the past - but it hadn't worked for me when I was going through my problems."

Schnell is now 40, working on her doctorate in psychology and planning to move back to Venezuela. Despite her fertility woes, she still hopes to become a mother. She has left the idealistic 21-year-old woman she was far behind, along with the multiple miscarriages, infertility, and divorce; she has a new partner and is exploring the possibilities of adoption or surrogacy. She and her boyfriend attend church regularly, and she is praying again. She has, she says, found a new peace and a better relationship with God.

"When you are younger," Schnell says, "you feel all your dreams are going to be fulfilled. Then you realize life is very difficult. I have a different relationship with God now. When I was younger, it was more like, `God, please help me, give me what I want.' Now it's like, `Just give me the strength to bear whatever I need to bear.' I think it's a more realistic and more mature position toward God."

And Schnell no longer believes God was punishing her. "I know this is going to sound odd," she says, "but I feel this has made me stronger and more compassionate and sensitive to other people's pain. I really feel that somehow God has helped me realize that my present partner was the person for me, the one I want to have my baby with."