Infertility
Infertility affects millions of people – and has an impact on their families and communities. Infertility is a disease of the male or female reproductive system defined by the failure to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. In the male reproductive system, infertility is most commonly caused by problems in the ejection of semen, absence or low levels of sperm, or abnormal shape (morphology) and movement (motility) of the sperm. In the female reproductive system, infertility may be caused by a range of abnormalities of the ovaries, uterus, fallopian tubes, and the endocrine system, among others.
Infertility as a medical condition affects many aspects of human life. It affects one’s relationship with oneself and consequently influences one’s identity as a mother or father. Individuals who resort to Assisted Reproductive Technology (ART) methods experience emotional, physical, social, and financial hardships, impacting their families. Infertility rates have increased over the past several decades due to better forms of contraception, thus decreasing the rate of earlier unplanned pregnancies. Today, one in every 80 to 100 births in the U.S., 1 in 60 births in Australia, and 1 in 50 births in Sweden are created through some form of in vitro fertilization (IVF).
No matter what causes infertility, in vitro fertilization offers the highest chance of pregnancy per treatment cycle. Since its inception in 1978, there has been a remarkable increase in the number of IVF cycles worldwide. IVF is now the treatment that leads to the highest pregnancy rate per cycle. Egg donation was introduced in the 1980s, increasing the possibility of pregnancy and childbearing for many women. These women, and those who had illnesses for which treatment affected their fertility, were then able to have children. Still, egg donation brought up a great deal of controversy.
Implanting more than one embryo increases the likelihood of having a viable pregnancy. It also increases the likelihood of multiple births, which carries greater risks. In addition to ethical dilemmas, egg donation presents issues such as parental identity confusion and a compromised sense of social group belongingness.
Donor Eggs
For women with premature ovarian failure, advanced age, lower ovarian reserve, autoimmune disease, failed IVF, or concerns about genetically transmitted diseases, donor egg IVF may be considered. Demand increases have contributed to the growth of the egg market in the U.S., where women willing to donate their eggs can earn between $4,000 and $10,000.
A new trend of increased openness and transparency for egg and sperm donors has taken place, following a similar trend that took place several years ago with adoption. Anonymity and secrecy are becoming outdated. Many families have initiated this trend of openness about using donors, with some even forming relationships with their child’s biological parent. More and more heterosexual parents have also voiced their preference to tell their children how they were conceived—a modern version of the “facts of life.”
When and how to tell a child about their biological origin depends on the child’s developmental and cognitive capacity to understand the meaning of the information they receive. Dishonesty can affect a child’s sense of trust in their parents. It creates a potential disequilibrium in their psychic function and object relations.
Sperm Donor
Some men must confront their own infertility issues like their female counterparts. In approximately 40% of infertile couples, the male partner is either the sole or a contributing cause of infertility. Male infertility may be related to the volume or amount, motility, and morphology of the sperm. A male fertility workup can involve genetic testing and other hormonal testing. In some cases, no apparent cause of poor sperm quality can be found.
Treatment for male factor infertility may include antibiotic therapy for infection, surgical correction of varicocele (dilated or varicose veins in the scrotum) or duct obstruction, or medications to improve sperm production. In some men, surgery to obtain sperm from the testis can be performed. Intrauterine insemination (IUI) or in vitro fertilization (IVF) may then be recommended.
When male infertility is the cause of the problem, couples have the option to use a sperm donor. Direct injection of a single sperm into an egg, called ICSI (intra-cytoplasmic sperm injection), may be recommended as a part of the IVF process. In men with deformed or absent sperm, the use of this technique can carry some risks. The physician may recommend using a sperm donor. Insemination with donor sperm may also be considered if IUI is not successful or if the couple does not choose to undergo IVF.
Surrogacy
The use of surrogates—women who carry a pregnancy for another individual or couple – generates further possibilities for women unable to conceive. The baby can have the genetic identity of the couple—that is, the ovum can be obtained from the woman in the couple and be fertilized by the man’s sperm and then implanted in the woman who has agreed to be the surrogate, or the surrogate can supply the ovum, and the sperm can be the husband’s or come from a donor. This has made having a genetically related baby possible for gay couples, as well as for women who, for some reason, such as repeated pregnancy loss, cannot carry a baby to term but have viable ova. It is possible to freeze sperm, eggs, or embryos for later use.
We must remember that the research findings show that the narcissistic trauma further impacts the woman’s choice of the surrogate mother above and beyond the original traumas of infertility, which were repeatedly experienced and endured in a conflict-laden psychic structure. The repetition of the previously suppressed trauma leads to an unconscious self-inflicted traumatization.
Here, I describe three cases in psychodynamic psychotherapy that illustrate the complex psychological ramifications of infertility and the impact of ART.
Psychotherapy Cases of Assisted Reproductive Technology Effects
Nelly
Nelly is a 32-year-old married woman who came to psychotherapy treatment for depression. After Nelly turned sixteen, her mother told her that she was created with the help of a sperm donor. Her mother refused to tell her whether she had used a sperm bank or the sperm from a friend or acquaintance. Initially shocked by this tightly kept secret, Nelly became depressed when she could not find out the identity of her biological father.
Her mother explained that she was unsure she could marry at age 34, and the clock was ticking away. She did not think she could attract a man to marry her. She decided to use an anonymous sperm donor. Several years later, once Nelly became aware of the intensity of her chronic anger toward her mother, she decided to get help. She felt frozen in her life and could not move forward. She was in tears one day, feeling she could not free herself from rage. After discovering who her biological father was, she also became angry with him.
In therapy, she started to understand her mother’s anxiety about her biological clock ticking away and uncertainty about her sense of femininity. Nelly became aware of her ambivalent feelings about motherhood and was willing to work through her childhood wish to conceive and bear a child. She learned to value her academic achievement, which was much more significant than her mother’s, without feeling guilty about surpassing her.
Todd
Todd and Sherry are parents of a four-year-old son. Todd presented to therapy because he had difficulty relating to their son, whom Sherry conceived through sperm donation from a family friend. In their mid-thirties, after many years of attempting to become pregnant, male infertility was identified as the main factor in their difficulty conceiving.
After multiple trials, they came to accept the fact that they had to use donor sperm. He wanted to use his close friend’s sperm, and his wife agreed. The pregnancy was uneventful, and they welcomed a healthy baby boy. He was a beautiful boy who bore no resemblance to Todd.
He found himself feeling surprised, having noticed some strange feelings toward his infant son and his friend with whom he had a close friendship and working relationship. At the age of four, his son bore a striking resemblance to his friend Peter. He avoided getting together with his friend because he worried his son would show more affinity towards Peter, as well as Peter towards him.
He wondered if he could ever have the stamina to keep the secret from his son. He worried that disclosing this to his son would make him turn away. Furthermore, he feared his friend Peter would someday reclaim his right as biological father. He kept wondering what would happen to their marriage when all three of them attended gatherings, especially when they also took their son with them.
The internal dilemma that Todd faced caused considerable tension between him and his wife. He experienced mixed feelings, especially when recalling Sherry’s expectation that he play the role of the supportive husband during her pregnancy. He did not know how to come to terms with his own infertility, let alone to play a new role supporting his wife. He was there for her when she went through the wrenching experience of the harvesting of the ova, but now he felt as if his son was a stranger.
In his therapy, Todd was able to discuss all his many fears and self-doubt as a non-biological father, as well as his role as husband to Sherry. His individual therapy helped him to work through his destructive feelings, manage his intense negative affect, develop a better tolerance, and not act out on them. After much individual work, he became interested in starting couples therapy. He felt he was in a much better place since he developed a more consolidated sense of himself. He wanted to work towards better stability in his marital relationship.
From post-therapy contact by phone, Todd described feeling that his relationship with his son had improved. Although his son did not physically resemble him, he seemed to share the same temperament. He learned the importance of openness and wanted to tell his son about the sperm donor when he was at a developmental stage that enabled him to comprehend its meaning. Overall, he was able to enjoy a healthy relationship with him.
Emily
Emily, a married professional in her mid-forties, presented for therapy due to conflicts surrounding her marriage and her desire to become a mother. She postponed her decision to have a child for many years and suddenly realized time was running fast. Emily was the second child in a family of three children. She felt her mother preferred her older sister because they both were brunettes and had more in common. Emily grew up with a pervasive feeling that she was damaged, a feeling that her overanxious mother reinforced throughout her childhood.
Emily described herself as an obedient girl who never considered herself intelligent. Her mother constantly compared her to her older sister, and her father jokingly called her a dumb, petite blond. She felt anxiety and self-doubt. Perpetuating this self-doubt was her family’s difficult financial situation, which made her feel inferior to her classmates who lived in more comfortable circumstances.
After completing high school, Emily entered a prestigious college. She met her husband in college, and after a few short months, they decided to get married. For several years, Emily was unsuccessful in becoming pregnant. Eventually, they sought a gynaecological workup for infertility, which revealed multiple calcified fibromyomas in her uterus. Her mother also suffered from the same problem. However, her mother had her three children before her fibromyoma became problematic.
In addition, Emily’s contributing psychological makeup complicated her infertility problem further. Her difficulty conceiving made Emily feel like she was “damaged goods.” She could not become a mother like her sister or even her 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 that she had been denied something significant.
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 resigning 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. (She had gone through an extensive myomectomy). Her IVF and GIFT (Gamete in the Fallopian tube) procedures were unsuccessful. These failures caused her great anguish, hopelessness, and self-doubt.
The decision about using an egg donor and who to ask became an obsession that agonized her for many months. She considered asking her younger sister to be her egg donor. She wondered if her sister would have second thoughts about undergoing the medical procedure. She wanted her child to inherit her family’s genes and not go to a stranger for eggs.
After several months of deliberation, she gathered the courage to ask her sister, Ann, if she would be her donor. Ann was a mother of two and was happily married. She was eager to help her older sister, whom she loved. Emily was ecstatic when she heard her sister had accepted to be her donor egg.
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 gene pool with her husband’s sperm rather than using some stranger whom she did not know. She was set to have her child, and if her sister was willing to donate her eggs, it meant that those would be like her own. “It’s like a dress we could share,” she described with glee. Shortly after this decision, she started to have fears about her sister’s children, who were her child’s half-siblings. How could she bear the thought of keeping it secret or opening it?
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 with an earlier memory of her mother. She recalled how her mother asked one day how she could feed her children when there was hardly any food at home.
After this unsettling emotional period, she became more hopeful as she anticipated becoming a mother. Her pregnancy was uneventful, and she gave birth to a healthy baby girl. She brought her baby to one of her sessions. The baby had a resemblance to her. She wanted to hear my reassurance that her daughter looked like her. It was essential for her to listen to it from me.
Two years later, after a hiatus in her treatment, she phoned to see me for a follow-up visit. She was surprised when she began feeling confused about her reaction toward her sister at a holiday family gathering. She felt her daughter seemed to go to her aunt (her biological mother), and she imagined her sister also made it evident through her non-verbal interaction. She said she had never considered future encounters and her unexpected emotional reaction. She knew her sister had not told her two children that she had volunteered to be an egg donor for her older sister. Emily was not prepared to discuss it with her daughter and was unsure whether she would have wanted to disclose it to her.
Although she did not continue therapy, she would have benefited from exploring the meaning of her belief in “the promise of anonymity.” She felt competitive toward her sister and felt inferior to her. She struggled with old feelings about her body that betrayed her.
Discussion
Each case contains many complex social, familial, cultural, unconscious, and conscious elements. These aspects influence how individuals navigate infertility through unexpected challenges and losses. Earlier unconscious conflicts reappear and affect their sense of identity and their relationship as a couple.
For men, infertility does not directly affect their role, although it can be profoundly disappointing. It is often experienced as performance failure—a failure of masculinity. In some cultures, masculinity and femininity are directly linked to being able to produce children. In cultures that value women for their ability to have children, menopause marks a shift away from a position of prominence. Female fertility is a very public experience, displayed by visible bodily changes. Bearing children is a rite of passage for women, closely tied to their sense of femininity and societal role.
Both men and women experience physical and emotional turmoil when confronting infertility, which has unique and complex dimensions for every couple. Although ART has provided many successful pregnancies, the emotional impact of these reproductive methods requires further examination. The experience of a fertility workup, followed by several medical interventions before a successful pregnancy, can psychologically unravel individuals and shake up even the healthiest couples.