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Infertility: Interventions for Shame, Mourning, and Feelings of Inferiority
Infertility continuing education psychologist CEUs

Section 10
Dilemmas in Fertility Counseling

CEU Question 10 | CEU Test | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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On the last track, we discussed late immersion phase, the donor decision.  These included genetic loss, egg donation as an "affair," sperm donation as "rape" and feeling like an impostor.

On this track, we will discuss four therapeutic approaches to late immersion.  This will include thinking about the donor option, couple communication about donorship, alienation versus attachment and ongoing "check-in" questions about infertility.

Many of the treatment issues that arise in immersion continue into late immersion.  Donor procedures add their own complications because of the use of another person’s genetic material.  I have found that it can be helpful to clients to acknowledge the choices that are available through new technology.  Saying something like, "Some couples find it difficult to consider having a child in this way" can provide an opening for couples to explore their own thoughts and feelings on the subject.

4 Therapeutic Approaches to Late Immersion

#1 Thinking about the Donor Option
First, let’s discuss helping couples think about the donor option.  Electing to conceive with a sperm or egg donor can have profound implications for a couple’s relationship.  If the partners choose to have a child who is genetically related to only one of them, they must grapple with the future consequences of this disparity.  It is preferable for them to consider such consequences carefully before the decision is made.

Some couples, however, may be so distressed by previous treatment failures and the prospect of infertility that they are reluctant to question any aspects of using a donor.  I have found that in these situations it can be important to raise difficult issues that couples may not have fully considered. 

Two Questions about Using a Donor

I might ask questions like:
-- "Have you each thought about the fact that one of you will have a genetic relationship with your child and one of you will not?"
-- "How do you each think this disparity will affect your relationship with your child?  Your child’s feelings toward each of you?  Your relationship to each other?"

Les, age 42 and Vivian, age 36, agreed to proceed with adoption rather than use a donor because they did not want an imbalance in their genetic relationship with the child.  Les jokingly said, "In the middle of the night, when the baby is crying, I don’t want Vivian to say, ‘Get up and take care of your child!"

Some partners may put premature closure on the donor option in order to protect their spouse.  For instance, the fertile partner may believe it would be too difficult for the infertile partner to parent a child to whom he or she is not genetically related.  Or, for the sake of the relationship, a fertile partner may prematurely agree to adoption, feeling too guilty to refuse the infertile partner equal parental status.  In other couple relationships, an infertile partner might agree to proceed with donor conception rather than prevent a fertile partner from having a genetically related child.

By slowing down the process and encouraging partners to keep talking to each other about their thoughts and feelings, I might enable a partner who is not ready to proceed to voice his or her doubts. 

Questions to Enable a Partner who is not Ready

I might raise difficult questions such as:
-- "Is it wise to make a decision if your partner still has reservations?"
-- "What do each of you think the consequences might be?"
-- "What are the risks and advantages of waiting or proceeding?

#2 Couple Communication about Donorship
Second, let’s discuss helping the couple to communicate their feelings to each other about donorship.  The possibility of using a donor may give rise to disturbing thoughts and feelings, such as guilt, resentment, and fantasies about the donor.  It can be important to encourage partners to express their thoughts and feelings to each other. 

Four Communication Starting-Point Questions
The following questions can be used as a starting point: 
-- 1. "How do you think you will feel carrying an embryo that is the combination of your husband’s sperm and another woman’s egg?" 
-- 2. "How do you think you will feel having your wife pregnant with another man’s sperm?" 
-- 3. "How do you think you will feel being inseminated with another man’s sperm?" 
-- 4. "How do you imagine you will deal with these possibilities as a couple?"

#3 Alienation vs. Attachment
Third, in addition to thinking about the donor option and couple communication about donorship, let’s discuss feelings of alienation versus attachment toward a pregnancy that is a result of donorship.  Although it is expected that bonding begins in pregnancy, in donor pregnancy, with all its complexity, bonding may not occur until late in the pregnancy or after the birth of the baby.  Hilda, age 37, stated, "There were times when I felt like a stranger was growing inside of me…when I first started nursing, I felt like I was nursing someone else’s baby.  But that feeling didn’t last long."

One concern with donor insemination is that the man, because he is not participating in the conception may have difficulty bonding with the child.  To facilitate this connection, I usually encourage the man to be present at the inseminations.  His presence and support of his partner at this crucial moment can provide a foundation for an attachment to the child as well as strengthening the couple’s relationship.

Four Bonding Intervention Questions
If you find that the couple is unable to bond with the fetus and this feeling is intense and unchanging as the pregnancy advances, you may feel the need to intervene.  While validating the inequality of the process of donor conception, I try to help the parents see the consequences of not attaching to the child by asking future questions such as:
-- A. "Are there any benefits to remaining emotionally disconnected from the fetus?" 
-- B. "If you continue to feel disconnected, how do you think it will affect parenting for you and for the child?" 
-- C. "What do you imagine the impact will be on your relationship if one of you remains feeling disconnected from the child?"
-- D. "If you decide it is important to being to attach to the fetus, what could you do to facilitate this?"

#4 Ongoing "Check-In" Questions about Infertility
Fourth, in addition to alienation versus attachment, let’s discuss ongoing questions to "check in" on a couple regarding their emotional perception of infertility.  As you know, if a client does not feel comfortable talking to his or her partner about distressing thoughts and feelings, future difficulties may arise.  Whether clients are seen individually or together, I find the following questions helpful in probing these areas. 
-- 1. "What is it like for each of you to know that you are not going to have a child that you create together?" 
-- 2. "What is it like for each of you not to have the child you imagined?" 
-- 3. "Even though you are feeling optimistic because you are pregnant, have you each considered that you may experience feelings of loss in spite of this outcome?" 
-- 4. "Are these issues hard to discuss with your partner?" 
-- 5. "What are you likely to do with these thoughts?  Keep them to yourself?  On what occasion would you share them with your partner?" 
-- 6. "Do you feel it is okay to have these feelings?" 
-- 7. "What kinds of circumstances do you imagine will cause feelings of loss to reemerge for each of you?"

Do you have a Vivian or  Hilda who have doubts about donor insemination?  Might he or she benefit from hearing this track? 

On this track, we have discussed a therapeutic approach to late immersion.  This has included thinking about the donor option, couple communication about donorship, alienation versus attachment and ongoing "check-in" questions about infertility.

On the next track, we will discuss couple issues in the resolution phase.  These will include ending medical treatment, sabbaticals and refocusing.

Peer-Reviewed Journal Article References:
Casu, G., Zaia, V., Fernandes Martins, M. d. C., Parente Barbosa, C., & Gremigni, P. (2019). A dyadic mediation study on social support, coping, and stress among couples starting fertility treatment. Journal of Family Psychology, 33(3), 315–326. 

Darwiche, J., Favez, N., Maillard, F., Germond, M., Guex, P., Despland, J.-N., & de Roten, Y. (2013). Couples’ resolution of an infertility diagnosis before undergoing in vitro fertilization. Swiss Journal of Psychology, 72(2), 91–102. 

Diamond, D. J. (2011). Review of Ethical dilemmas in fertility counseling [Review of the book Ethical dilemmas in fertility counseling, by J. Horowitz, J. Galst & N. Elster]. Families, Systems, & Health, 29(1), 73–76.

Omesi, L., Narayan, A., Reinecke, J., Schear, R., & Levine, J. (2019). Financial assistance for fertility preservation among adolescent and young adult cancer patients: A utilization review of the Sharing Hope/LIVESTRONG Fertility financial assistance program. Journal of Adolescent and Young Adult Oncology, 8(5), 554–559.

Papadakis, J. L., Poquiz, J. L., Buchanan, C. L., Chan, Y.-M., Crerand, C. E., Hansen-Moore, J., Kapa, H. M., Nahata, L., Pratt, K. J., Tishelman, A. C., & Chen, D. (2020). Fertility discussions: Perspectives of adolescents and young adults with differences of sex development. Clinical Practice in Pediatric Psychology. Advance online publication.

Online Continuing Education QUESTION 10
What are four therapeutic approaches that can be used with couples in late immersion? To select and enter your answer go to CEU Test.

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