Longing for the "wished for child" can be every bit as distressing for women with secondary infertility as it is for those with primary infertility. Most all women and couples have a long-standing dream of what their family configuration will be like--with one, two, three, or more kids. So if they aren't able to achieve it, their family can feel incomplete even though they have a child (or children), which others may not understand or sympathize with.
And you are right that women with secondary infertility often feel more isolated as they can feel like they don't fit in (or feel excluded from) the "infertile world" of those going through treatment or the "fertile world" of friends who have no trouble conceiving. What can also be difficult is that they may be facing treatment decisions to be able to expand their family, such as needing to use donor egg due to their biological clock running out, and struggle with what this will mean for their family with different genetic connections. What is important to know is that there are some great support resources available online for those struggling with secondary infertility through patient support groups, such as Resolve [https://resolve.org], so it is important to seek them out and know you are not alone.

Absolutely! When faced with any life crisis, which infertility certainly is, there is an opportunity for regression and also for growth. While infertility may be the most difficult experience a couple has faced in life together, it likely will not be the only challenge they face in the years ahead. I tell couples about this being an opportunity to work on communication skills that will last them a life time, such as active listening and empathic reflection. And the good news is that research has shown that for many couples their relationship is strengthen through improved communication and consequently greater emotional intimacy as a result of their infertility experience.

The simple answer is "yes", whether this is an opposite sex or same sex relationship. If two people are wanting to create a family together and there is difficulty, then it is a couple problem. While one partner may be experiencing more distress, which often happens in relationships, both feel the pain, although often expressing it (or not!) in different ways. It is important to recognize these differences and use it as an opportunity to grow and strengthen your relationship as you deal with infertility.

That is a very big question! For most people, the goal of having a child is driven by strong social, psychological, and cultural drives and influences that have occurred over one's lifetime. When that goal is thwarted, enormous feelings of grief and distress occur and the longer it goes on, the harder it gets. It has been said, "A feeling shared, is a feeling diminished". Thus, seeking and receiving support from chosen friends and family members and/or trained fertility counselors is crucial. To identify a fertility counselor in your country, you may start with the International Infertility Counseling Organization [http://www.iico-infertilitycounseling.org/]. In addition, learning cognitive-behavioral techniques (CBT) to deal with the feelings of anxiety, sadness, and overall distress is an important coping skill. There are some wonderful free apps available today specific to coping strategies for infertility distress that can helpful: Ferticalm is developed for women [http://ferticalm.com/] and Fertistrong is for men [http://fertistrong.com/].

"When is enough, enough" is a highly personal and complex decision. Recent research on the psychological burden of infertility indicates that the #1 reason people drop out of treatment is due to running out of emotional energy and not due to what many people believed, the financial costs of treatment even in countries with full insurance coverage. Studies have shown that the process of ending treatment and moving on without having a child takes approximately 3.5 years and involves disengaging from the pain of infertility treatment, processing the feelings from past, and reworking and reengaging with how the future will look. So "the right time" to stop trying and move on is hard emotional work, takes time, is evolutionary, and can't be speeded though.

Grieving is the hardest work we ever do in life, yet is a testament to the one we loved and lost. It is made all the harder when the grief is invisible to others and, thus, an internalization of all our hopes and dreams of a baby that is longed-for but not here. We call this "prospective grief" versus "retrospective grief" when we mourn a living loved-one who has died and, yet, real memories and experiences can be shared with others who knew this person. Research has shown that in fact prospective grief over invisible losses, such as with infertility, a miscarriage, or death of a baby before or shortly after birth, are far harder to grieve and take far longer to resolve. Something that can help is to find ways to ritualize and mourn these invisible losses in more traditional ways. One thought would be to write a letter of goodbye to the child you never were able to have, and then releasing the letter in a stream, burning it in a fireplace on a cold evening, or planting under a tree in your backyard. Finding creative ways to express you grief and loss, such as writing a poem or creating a work of art that reflects your feelings is also helpful.

Infertility can stain even the strongest of relationships and it is important for couples to pay attention to changes they are feeling. Some questions to ask yourselves: Are you feeling more distant from your partner? Do you find that you are arguing more or seeing things differently about issues you previously agreed on? Can you still find ways to laugh and have fun, separating from the all encompassing nature of infertility and its treatments? Are you feeling that you partner isn't understanding, supportive, or seeming more critical? Or are you being this way towards your partner, thinking the worst of him/her rather than the best?! As a couple, are you isolating yourselves from friends or family because it is too painful to with them? More than likely, a couple knows when fertility issues are impacting the relationship and should seek out help and support sooner rather than later. As has been said, "An ounce of prevention is worth a pound of cure!"

Books could probably be written on the stupidest things people have said to someone going through infertility! While I believe most of the time these comments are made with the intent to be helpful or supportive, they can still be enormously hurtful to someone who is vulnerable and struggling with infertility. I think it can be very useful to think about common things people have said in the past to you, and work on answers that reflect who you are. For example, do you want to educated about stress and infertility (a common myth) or do you want to use humor to deflect? Having a list of responses and comments, which you have practiced saying in front of a mirror or with your partner, can have you ready and prepared for the next time it comes up.

Cognitive Behavioral Therapy (CBT) has been found to be very effective as a psychological intervention in helping people cope with the stress and emotions from infertility. That being said, I believe many fertility counselors like myself take a more eclectic approach in helping our clients struggling with reproductive loss, as one size doesn't fit all. Grief therapy, crisis intervention, EMDR, and other stress and coping models, to name a few, should be in a therapist's tool box as they are also helpful interventions. What is most important is that you find a therapist who has specific training and training in the highly specialized area of fertility counseling as well as an ongoing commitment to professional standards. Both the American Society of Reproductive Medicine's (ASRM) Mental Health Professional Group (MHPG) [https://connect.asrm.org/mhpg/home] and the European Society of Human Reproduction and Endocrinology's (ESHRE) Psychological Special Interest group [https://www.eshre.eu/], as well as Resolve, The National Infertility Association keep listings of fertility counselors [https://resolve.org/support/professional-services-directory/].

It is so difficult to see a child suffer and feel helpless in taking the pain away. When one in the family is struggling it effects the whole group, especially when the pain is expressed in a way that pushes people away. Being able to to acknowledge and empathize with your daughter's pain is very important, as well as not responding with platitudes that may diminish or negate her feelings. A number of years ago, Dr. Linda Hammer Burns and I co-wrote an article for Resolve, the National Infertility Association, on "When Infertility Strikes the Family". I have attached the article as the information is timeless and provides some important things to consider as a family as well as things that might help you get through this experience.

Shame is a core feeling in the experience of reproductive loss, over the failure of one's body which is not able to procreate as well as not being able to regenerate and be seen by society as an adult vis a vis parenthood. Shame is when we feel we are inherently defective and creates extraordinary vulnerability. Social Work Professor and researcher, Brené Brown, has spent a career on this subject and she talks about "shame resiliency" in repairing one's sense of self. Being able to name the feeling, understand the origins (role of women, femininity, motherhood roles), and developing compassion and empathy for oneself will promote resiliency. Connections with others is, also, important as feelings of shame grow in a vacuum but cannot survive exposure. Thus, talking to others can help!