At The American's May meeting in Toronto, a public forum was presented on the psychological, social, ethical, and legal aspects of reproductive technology. The title of the forum, co-sponsored by the American Psychoanalytic Foundation and the Social Issues Committee, was “Infertility: Hopes, Fears, and the Search for Identity in the Age of Technology.” It was the third in a series of discussions of social issues.
The overall theme of the forum was the impact of infertility on parents, on health-care providers, and on the “test tube” babies themselves. Medical progress has surged ahead of ethical and psychological questions. In vitro fertilization is now commonplace. Sperm can be frozen, and soon unfertilized eggs may be frozen. Cloning is on the horizon, as are eggs fertilized from other eggs. A woman will soon be able to give birth at nearly any age.
Stuart Taylor, one of the forum's two co-chairs, connected these developments with the Old Testament. He pointed out that Hagar, maidservant to Sarah, served as a surrogate mother for Sarah when she was infertile. This is one of the first recorded conflicts concerning surrogacy: Sarah and Hagar developed a competitive conflict, leading Hagar to flee with the unborn child. Later, when Sarah did bear a child, Ishmael, the surrogate child was disinherited. Judi Kobrick, the other co-chair, noted that women and men suffer equally from the intrusive and painful procedures to treat infertility and the real chance of failure.
Jane Rosenthal, a psychoanalyst and member of the In-vitro Fertilization Team of Columbia-Presbyterian Medical Center in New York, was the first panelist. She raised a series of questions that remain unanswered. Postmenopausal pregnancies are becoming more common. How old is too old? What is the child's right to a vigorous parenthood? What are the rights of the adult siblings? Should a second marriage justify a pregnancy? Who should donate eggs to whom? Rosenthal brought up a case of a forty-year-old woman who underwent in vitro fertilization, using her husband's sperm and eggs donated by a younger sister. The woman had a successful pregnancy, but the sister was physically damaged by the egg-harvesting procedure and was unable to conceive. An altruistic act had led to lasting psychic damage.
Sharon Zalusky, a psychoanalyst from the Southern California Psychoanalytic Institute, was the second panelist. She presented a case of a forty-year-old woman who remarried and was unable to conceive. She went through several successful in vitro fertilizations but miscarried each time. She had a dream during this process that suggested a shattered identity.
A major psychodynamic issue for her was her relationship with a narcissistic father. She had developed an oedipal fantasy that she would be special to her father by giving him a child and he would be transformed into a loving grandfather. At the same time, she felt she was competing with her mother for father's attention. Her infertility was felt to be a punishment for oedipal triumphs. In working through these fantasies, she was able to come to terms with the possibility of not having a child. She then had donor eggs implanted. In order to have a viable pregnancy, she had to abort four of the fetuses, and had accompanying fantasies of murder. She eventually gave birth to a healthy baby boy.
Eva Lester, a psychoanalyst from the Canadian Psychoanalytic Society, was the third panelist. She presented the case of a thirty-four-year-old woman who had had several unsuccessful in vitro fertilizations and decided to use a surrogate mother. Lester focused on the relationship of the mother to the surrogate mother. The two had frequent contacts during the pregnancy. They had an intense but ambivalent relationship. The mother fantasized merger with the surrogate mother but worried about the surrogate's needs and demands. She identified with the surrogate mother and had the fantasy of being her child. She felt guilty about taking the baby, wondering who it really “belonged” to. During the delivery, both parents stayed with the surrogate mother. The surrogate mother became more emotionally withdrawn at the end of the pregnancy, and her contact with the parents diminished after the birth. Lester raised the issue of the relationship between pregnancy and maternity. Does the lack of the physical experience of pregnancy compromise the quality of early mothering?
Helen Meyers, a psychoanalyst from the Columbia Institute, was the fourth panelist. She spoke of emotional reactions to infertility. Is there such a thing as psychic infertility? It might take the form of oedipal or pre-oedipal competition with the mother, resulting guilt and need for punishment. Meyers pointed out that the motive to be pregnant and the motive to be a mother are different and have different consequences. For example, a mother may have a powerful wish to be pregnant but have little interest in mothering. Partners differ widely on the need for children. Other pathways for adult development are possible and may be preferred by both men and women.
Meyers discussed the variety of conscious and unconscious reactions that can be seen in the woman who is infertile and wants to be pregnant. She may mourn the loss of the experience. Issues of guilt, of failing, of being punished, or shame that the body is defective are common. There can be a fear, sometimes quite real, that the mate will leave, or a more general fear of desertion. The mother can feel defensive relief that something outside can be blamed. There may be an impact on gender or sexual identity, and marriages often break up over such issues.
During the discussion, several points were made about the impact of reproduction technologies on the infertility doctor. Do they help the doctor to distance himself or herself from powerful sexual conflicts? Do the technologies encourage a fantasy of omnipotent creation of babies? Another question was what to tell children about their birth and genetic background. The question should be how and when to tell children, but studies have suggested that when children are born of donated sperm, parents may feel less willing to tell their children of this as they grow older. Studies of child development have found that children conceived through in vitro fertilization may have early separation conflicts but show no differences in development by age three.
Robert White, M.D., is a member of the Western New England Psychoanalytic Society and an assistant professor of psychiatry at Yale University.