As a physician and psychoanalyst, I became aware of my patients' trouble accepting their infertility after drawn-out attempts to have their own children. Acceptance of their failure to conceive is more of a challenge for some patients than others, although often there may never be a final acceptance. Over the course of 30 years, from my own clinical experience working with infertile women in psychotherapy and psychoanalysis, I have learned how infertility impacts the inner lives of individuals. Many of these patients struggled to conceive by using various forms of assisted reproductive technology (ART).
Emily* is one of the cases with whom I worked in analysis over the course of many years. A married professional in her early forties, she came to see me because of conflict surrounding her marriage and her desire to become a mother. She was doubtful about her capacity to become a parent. She postponed her decision to have a child for many years and finally realized time was running out.
She was the second of three children. Her sister was five years older and was a very popular girl. She could never be like her sister. She felt her mother preferred her older sister because they both were brunettes and had more in common. Emily was blond and petite. The youngest was a girl who was born eight years after Emily's birth. Emily grew up with a pervasive feeling that she was damaged, a feeling reinforced by her anxious mother. She was maternal toward her younger sister and fiercely competitive with her older sister. Her father drank a lot and used foul language when intoxicated. She learned to avoid him and his abusiveness.
Emily described herself as an obedient girl who never thought of herself as intelligent. Her mother constantly compared her to her older sister, and her father jokingly called her “my little dumb blonde.” She was filled with anxiety and self-doubt. Reinforcing this self-doubt was her family's difficult financial situation, which made her feel inferior to her classmates. After completing high school, Emily entered a prestigious college. She met her husband in college, and after a few months they decided to get married. The couple waited 15 years before deciding to start a family.
For several years, Emily was unsuccessful in becoming pregnant. Eventually, they sought a gynecological work-up for infertility, which revealed multiple calcified uterine fibromyomas. Her mother suffered from the same problem. However, her mother had her three children before her fibromyomas became problematic. Emily's contributing psychological makeup further complicated her problem with infertility. Her difficulty conceiving made Emily feel as though she was “damaged goods.” She could not become a mother like her sister or even her own mother.
She was bitter and could not accept that her uterine abnormality was the cause of her infertility. She felt it was not fair that her sister had children and she could not get pregnant. She was a “virtuous good girl” and her mother relied on her when her family needed help. She felt she was denied something very important. “It was my birthright, it was not fair!” she said one day, trying to draw affirmation from me. After she found out she could not conceive, she thought “there was a big sign on me like in scarlet letters that I was infertile.” The fertility clinic told her she needed to talk to a psychiatrist because her infertility was “psychogenic.” Later, she reported, “I was going full circle. I thought I was grieving. I was so disappointed each time I tried. My husband was not grieving. But he actually was very supportive of me and left me free to make a decision how to go forward. He even was willing to be childless if I wanted to.”
In one of her analytical hours, she said, “I must have made myself infertile by being neurotic. See, I am not smart enough to catch on to things quickly. See, pregnancy may never happen for me. Maybe I wanted it too much, like I wanted my friend's wealth and prestige. I wanted to wear expensive clothes, drive an expensive car, and marry a rich man. It may be wanting everything or wanting too much, being greedy has to do with not getting what I really want, a family is what I have always dreamt of.” She had tears in her eyes. She was in despair and full of doubt. She continued, “I did not even ask why I needed to talk to a psychiatrist. I followed their advice. Looking back, I could tell why I needed to see someone, and now I am here to see you in order to understand my ambivalent feelings about motherhood.”
She felt she needed me to help her learn to accept her fate, or maybe she would regain her stamina to pursue other options such as using an egg donor or resign to the prospect of being childless. She had contemplated using a surrogate mother, but wanted to try the egg donor option with her newly reconstructed uterus.
Mali Mann, M.D., is on the faculty of the San Francisco Center for Psychoanalysis, where she serves as training and supervising psychoanalyst. She is also an adjunct clinical professor, at the Department of Psychiatry and Behavioral Sciences, Stanford University.
(She had undergone extensive myomectomy.) Her two in vitro fertilization and gamete in the fallopian tube (GIFT) procedures were unsuccessful. These failures caused her great anguish, hopelessness and self-doubt. She realized how angry she was with her mother, who did not empower her and instead made her a damaged woman.
She also felt I was an impotent analyst and that her problem was far more complicated, beyond the scope of my expertise to be able to solve. She was unsure about the help I could offer her. In the transference, I turned into an “infertile analyst.” She agreed with my interpretation of how she wished I could have had a magic formula to help her damaged uterus, damaged mind, and damaged body. She felt I was letting her suffer in her despair and was being indifferent to her pain. I emerged as a controlling pre-Oedipal mother who expected total obedience and submission.
In the transference, I turned into an “infertile analyst.”
The decision about using an egg donor and who to ask became an obsession that agonized her for many months. She thought of asking her younger sister to become her egg donor but worried that her sister would have second thoughts about going through the procedure. She wanted her child to have her family genes and did not want to go to a stranger for eggs.
After several months of deliberation, she summoned the courage to ask her younger sister Ann to be her donor. Ann was a happily married mother of two and was eager to help her older sister, of whom she was very fond. Emily was ecstatic when her sister agreed to be her egg donor. We tried to explore the meaning of using the eggs from her sister. Her desire to use her sister's eggs was so strong that she was not interested in exploring the meaning of her decision. Her conscious desire was to have her family genes pool with her husband's sperm, rather than using eggs from a stranger. If her sister was willing to give her eggs, it meant those were like her own eggs. “It's like a dress we could both share” was how she gleefully described it.
Shortly after this decision, she started to have fears about her sister's children, who would be her child's half-siblings. How could she bear the thought of keeping it secret, or bear to have it out in the open? One happy thought countering her fear was “why not become a big happy family?” She would carry the baby to term and everyone would understand and support her. She also thought she was being greedy to ask for her sister's eggs, which were not hers. To her, it was like stealing. This self-accusation led to an association to an earlier memory about her mother. She recalled how her mother declared one day, how could she feed her children when there was hardly any food at home. Her father, an alcoholic, was not helping the family when he spent money on alcohol. Food was scarce, and the family had to deal with extreme deprivation. Over time, our analytical work helped her with feelings of envy, greediness and the theme of stealing. She worked hard to overcome her doubt and move forward with her decision to enter into the world of motherhood.
After this unsettling emotional period, she became more hopeful as she anticipated becoming a mother. Emily overcame her disabling doubts. Her pregnancy was uneventful and she gave birth to a healthy baby girl. She brought her infant to one of her sessions. The baby resembled her, and she wanted to hear my reassurance that indeed her daughter looked like her.
One day, I received a phone call from her asking to see me for a follow-up visit. She told me she was caught by surprise when she felt confused about her reaction towards her sister on a holiday family gathering. She felt her daughter seemed to gravitate toward her aunt (the biological mother) at the family party, and she imagined her sister also made her attraction to her daughter obvious through her non-verbal interaction. She told me she never thought about her future encounters within her family circle or her unanticipated and unexpected emotional reaction. She trusted that her sister had kept her promise not to reveal to her own two children that she had volunteered to be the egg donor. Emily was not prepared to talk about it openly with her daughter.
The meaning of her belief in “the promise of anonymity” needed to be explored in our work together. She struggled with her reawakened feelings about her body that had betrayed her. In the course of our work, she could confront her childhood self-doubt, fear, anger and confusion. At the end, she was also able to break the secret of “anonymity” and felt ready to tell her daughter where she came from.
Undoubtedly, the discovery of infertility is fraught with feelings of loss, fear, shame and grief for the individual and for the couple. The fear and unremitting dread can be overwhelming and lead to a feeling of shame for not being able to produce a biological child. When confronted with repeated failure to conceive, a couple may seek medical and in some cases psychological support. The decision to see a specialist is an affirmation of their infertility.
The book, The Psychoanalytic Aspects of Reproductive Technology, which I have edited covers a variety of topics related to the use of assisted reproductive technology and the role of unconscious transaction in analytic process. As analysts, we appreciate the value of in-depth understanding of a single case presentation. Shared themes from these cases are not meant to be generalizations, but could provide a starting point for future research on this topic. Further clinical research on the psychological impact of ART within families is needed.
* Patient identity has been disguised to protect privacy.