By Iréné Celcer, MA, LCSW
A Crisis of All Times
Infertility is a formidable crisis to confront. It challenges unspoken rules about when and how adults should build a family.
But the challenges posed by infertility are nothing new.
Three matriarchs of the Judeo-Christian tradition, Sara, Rebecca and Rachel suffered tremen- dously. Their stories illustrate how they handled infertility
, both individually and within the context of a couple. Although they finally conceived, there were significant complications. In the ancient polygamist world, childlessness robbed women of important social status. Still today, the painful feelings experienced by women (and men) who confront infertility remain excruciating.
Sara did not take into account the complexity of a surrogate arrangement. Consequently, she lashed out at her husband “The wrong done me is your fault. I myself put my maid in your bosom; now that she sees that she is pregnant, I am lowered in her esteem. G-d decide between you and me!” And Abraham, as modern man, tried to avoid further confrontation by deferring: “Your maid in your hands”.
Rebecca had a troubled twin pregnancy. But she did not let her husband know about it.
Rachel demonstrates her anguish and her pain to Jacob. “Give me children or I shall die!”
The Many Facets of Infertility
For the religiously committed patient, his or her faith is an important facet of the crisis: “Has G-d decided for me not to have chil- dren? Should I pursue treatments?” “Will my child born through ART (Artificial Reproductive Technology) be an outsider within my own faith?” “Does this — infertility/being Gay/Being Lesbian/Having Cancer—mean G-d’s will is for me not to be a mother/father?” Every day we hear the echo of the matriarch’s pain in our patients’ voices.
From a sociocultural perspective, the reality of infertility resonates differently depending on one’s personal circumstances: What country is the patient from? What family does he belong to? Who is her partner? Are they legally married? An infertile lesbian experi- ences her partner carrying the pregnancy due to her infertility differently than a heterosexual couple experiences their surrogate’s pregnancy. A Hassidic Jew experiences secondary infertility differently than a Swedish woman. The sociological differences among people are enormous. Therapists must be sensitive to the culture and subculture they are working within.
The therapeutic dyad faces many foreseen and unforeseen challenges, like gender issues that are as old as the Bible stories: “Hannah, why are you crying and why are you not eating? Am I not more devoted to you than ten sons?” 3 says the husband, El- kanah, maybe missing the point of her pain, or just anxious to console her.
Furthermore, the months and years that go into identifying and treating infertility may strain the patience of extended family waiting for children, commonly seen in prospective grandparents. Even sisters and brothers may be yearning for a child if the continuity of a line is in jeopardy, bringing echoes of extinction, extermination and death to a family, depending on their worldview.
Addressing the complex sociocultural puzzle of infertility poses special challenges for clinicians. One quickly learns that infertility is not just a woman’s problem, not even just a couple’s problem. For better or worse, dealing with infertility begins with family and in- evitably extends to the broader community.
The Patient’s Experience of Infertility
Patients who suffer from infertility face daunting tasks, such as an endless nightmare of daily temperature charting, scheduled sex, needles, altering mood drugs, invasive medical procedures. They feel broken and faulty, like second goods while witnessing the (continued from page 10)
world getting what they feel they ought to have and cannot achieve.
Tougher yet, they must carry on with daily activities that require the posture and decorum of not falling apart during office parties or family events. The pressures of internal wishes and desires gone awry must go underground. As therapists we need to help without compromising the patient’s true feelings, their working alliances or, family relationships when possible. Is it okay not to attend a child-centered function? Is it okay to take a break from treatments even when it feels like one is running out of time?
Clinician’s validation of the patient’s personal reality is crucial. Patients benefit from a therapist who can say, “The deprivation of a preg- nancy and a child truly sucks.” They benefit from the acknowledgment that child-free living is a valid choice. Patients feel liberated when informed during a treatment cycle that that lovemaking is not only for baby-making, but for togetherness and pleasure too, as well. A thera- pist who understands the added stigma that exists when infertility is wrongly equated with impotency will help her patient.
The Different Meanings of Infertility
There are many ways to theoretically understand the development of personality: psychodynamic, cognitive, and humanistic are but a few examples. However, it is especially important to not fall into extreme dogmatic approaches when trying to understand infertility — one size does not fit all. Patients have a varying range of thoughts, feelings and beliefs about why they are infertile. They routinely carry guilt, fears and love into our office.
Despite our understanding of the psychological diversity of our patients, an understanding of personality and its dimensions may be helpful when clinically assessing a patient, donor, or surrogate. An extraverted individual who is excitable, social, talkative and expressive may or may not suffer from hysteria or hypomania. Someone high in neuroticism (emotionally unstable, anxious, moody and irritable or sad) may be under the effects of stress and hormones from a treatment cycle. Because agreeableness is a dimension that includes attributes such as trust, altruism, kindness, affection, and other prosocial behaviors that are important in a donor or gestational carrier or surrogate, they should not be confused with false self or pathology.
Since families are about building, fostering and constructing attachments, the reality of a barrier to building a family with child will resonate with troubling experiences from the past for those with problematic attachments. The music of the reverberations in our patients’ psyche will sound differently depending on their attachment styles as well as their personalities. A preoccupied patient might feel devastated about the loss of a cycle and show it in a different manner than a dismissive patient. Attachment styles could even impact the choices of treatments — the type of treatment selected as well as how long the patient is willing to repeat the treatment. For one patient, a cancelled or failed cycle may mean that she will not stop IVF treatments until viably pregnant, even when such treatment is iatrogenic. For another patient, the failed cycle might mean she will go straight to adoption, ignoring and submerging any desires she might feel for a genetic connection to her off- spring.
Part 2 will be continued with the next issue of the Clinical Page.