Pills, needles, tests, procedures — wait — pregnancy test…. Repeat.

This is in-vitro fertilization, or IVF, described in a nutshell. IVF is billed as a simple, straightforward process that ends with good news. But for many women, it’s an arduous, stressful and daunting emotional journey. And it usually starts even before couples land in the office of a fertility specialist.

Like Seema Tiwari, a 37-year-old author, says, “I didn’t know the process of conceiving naturally was so complicated.”

Diagnosed with polycystic ovary syndrome (PCOS) and endometriosis – both conditions that can affect fertility — Tiwari found conceiving a challenging and frustrating experience.

“For five years I tried to conceive naturally, often enduring well-meaning but ill-timed queries on ‘good news,'” she says. “Each query made me wonder, ‘What’s wrong with me? Why me?'”

After some research, she was introduced to the world of intra-uterine insemination (IUI). IUI, like IVF, is a fertility treatment, but it’s usually a first step for couples having difficulty conceiving but no obvious fertility issues. It involves placing sperm inside the uterus for a chance at quicker fertilization within the woman’s body.

“I took the plunge by trying three IUIs — less invasive and expensive compared to IVFs, but accompanied with horribly painful cramps,” says Tiwari, who says she always dreamed of becoming a mother. “Still the desire to have one kid helped me brave them all, through all the failures — hoping and praying I will get lucky with the ‘next one.’ But after being third time unlucky with IUI, I decided to go for IVF.”

Dr Manjiri Mehta, a consultant gynecologist at Mumbai-based Fortis Hospital, explains IVF as a more complex and technically demanding process than IUI. In IUI, fertilization happens in the woman’s uterus. In IVF, a female egg (ovum) is retrieved from the ovary, and sperm from a semen sample, and fertilization takes place in a laboratory. The fertilized egg (zygote/embryo) is then transferred into the woman’s uterus.

For Tiwari, the IVF experience also involved taking birth control pills to regulate her menstrual cycle. Then, egg retrieval, embryo transfer into her uterus, followed by injections to trigger her production of HCG, a hormone produced by the placenta after implantation to help a pregnancy ‘take.’ Then two weeks of waiting and pregnancy tests.

In India, nearly 10 to 15% of couples, or 27 million couples, who are actively seeking children have fertility problems, but is likely to increase as infertility attributable to male factors is on the rise. To assist these couples with reproduction, there are roughly about 1,500 to 2,000 fertility centres across the country touting ‘test tube babies.’ Success is seldom discussed; reports suggest that 10 to 15% of IUIs are successful, while the success rate for IVF stands at 30 to 35%.

“But it’s best to be mentally prepared that it may be a long journey, and not feel too disheartened if it is not successful,” Dr Parul Tank, consultant psychiatrist with Fortis Hospital, says she advises her patients.

But coping is not that easy.

“My patience, faith, endurance — physical and emotional — and finances, everything was put to test,” says Tiwari. “I was filled with optimism. But I would be lying if I said the failures didn’t affect me — emotionally. It broke me every time the pregnancy test was negative.”

Typically, a cycle of IUI or IVF could cost anywhere from Rs 60,000 to Rs 200,000. “The cost doesn’t guarantee pregnancy, but it does give a lot of physical and emotional stress in return,” says Tiwari.

Agrees Surbhi Patel, a 37-year-old PR professional. It’s the hormone injections that actually play havoc with your mind and body, she says. “I am in the throes of a mess of hormones. Always exhausted, have heavy and painful breasts, bloating, headaches and abdominal cramps,” says Patel, who is on her sixth IVF cycle currently. “The worst thing about the procedure is that your body behaves pregnant—stomach jutting out, hormones playing games—even when you’re not.”

For many patients like her, the journey is overwhelming and completely isolating.

“All around, everything seems so normal, people getting pregnant so easily, having one baby after the other, and all I feel is a sense of loss of something I never had, emptiness and am always seething anger,” she says.

The stress of IVF colors all aspects of life. “You pay a fortune and put your life on hold — job, sex, social gatherings — for something that has a good chance of not working out,” Patel says. “But then, yet again, you do it, like I am.”

For Tiwari three failed IUIs, five failed IVFs, changing many doctors and one country finally led to a successful pregnancy. (She is now a mother to a 2-year-old daughter.) Coping with the stress of IVF — especially after a failure — meant continuing her normal hobbies and focusing on her work. It also came down to one unique factor: whom she was trying to conceive with.

“I remember once, I was bitterly crying after a failed pregnancy test and my husband said to me that ‘If the cost of having a child is your tears, I don’t want a child. I want you and your happiness. Nothing else matters,’” she says.

Dr Mehta says this emotional journey – which Mehta describes as a roller coaster — is not uncommon among couples undergoing IVF, who often experience stress, anxiety, depression, and anger. “Feeling of inadequacy to procreate, fear of failure, uncertainty of the outcome and financial overload are some reasons that could explain the change,” she says.

Dr Tank is more blunt. “What will decide your mental status is the relationship one shares with their spouse. The couple needs to be strong and emotionally supportive at this critical juncture.”

Dealing with the stress can be difficult even for hitherto supportive partners. “The decision to undergo the treatment marks the beginning of the blame game depending on who is infertile or unfit,” says Dr Tank.

“But what breaks down women the most is the feeling of guilt, as socially there are expectations on them to procreate,” she adds.

For Patel, this is her last try. “I feel like I’ve lost the endurance, it’s time to give my body some rest,” she says. “The day I feel like I’ve accepted I can’t have a baby, I’ll be strong enough to not take any more treatments. We’ll think of other options, but I’m certainly not putting my body through this mess,” she adds.

For Tiwari, the ordeal was worth it. “The process is tough, but remember you are tougher,” she says. But even with her dream come true, the experience has left her more practical than idealistic.

“Do it for as long as you feel good,” she says of IUI and IVF. “Stop the day you don’t.”