By Eileen Farrelly Conway
For the involuntarily childless couple infertility is a major life crisis. As Raphael Laff ¹(1991, p.36) points out ‘the repeated failure to conceive arouses self-doubts, erodes the couple’s sexual and emotional resources … and poses a threat to each partner’s personal and gender identity and to their mutual future legacy’. The scope of the problem is vast. The World Health Organisation estimates that globally some 40 – 80 million people experience infertility problems.2 Yet the cultural milieu of the infertile couple does little to prepare them for the deprivations involved in childlessness. Lack of more autonomy is part of their cultural script.3 While children have ample opportunities to play at mammies and daddies, they have no role-play to prepare them to be involuntary childless couples.
Understanding Infertility as a Life Crisis
Barbara Eck Menning, founder of ‘Resolve’, the national self-help organisation for infertile couples in the U.S., outlines some of the motivations for parenthood. These include parenthood as a way to conform to societal pressures, as a rite of passage to adulthood, as a reliving of one’s own childhood, as a desire to compete with one’s own parents, as role fulfillment and lastly, parenthood for its own sake.
She says that some infertile couples are very child oriented and some are very pregnancy oriented although most express a desire for both pregnancy and a child. Common motivations for wanting a pregnancy include: desire to experience the bodily changes of pregnancy; desire for genetic continuity; pregnancy as proof of virility; pregnancy as recapitulation of a previous lost pregnancy and pregnancy as a way to experience breast feeding a child.4
Johnston says that in working toward resolution of their grief, infertile couples need to determine which of these losses each is feeling most deeply.5 For the couple who mourn the loss of parenting most deeply, alternative routes to parenthood such as adoption or use of donor gametes can avoid the finality of loss. On the other hand these routes to becoming parents will not fulfil the couple who yearn for genetic continuity or the pregnancy experience. Recognising such individual reaction in one’s partner requires sensitive communication since, ‘for the grieving person, communication channels with the spouse are closed for fear of hurt and reproach’.6
Stages of Grief
When infertility is diagnosed the classical stages of grief as described in the literature on bereavement,7 will be experienced by the infertile couple. In this case the ‘beloved object’ is potential and anonymous but the grief is no less acute.
Shock and Surprise
This is the most common initial reaction when the couple find there is a problem in conceiving. People assume they will have a baby when they choose and may indeed spend years studiously avoiding a pregnancy while they decide if and when they want a child. When a subsequent diagnosis of infertility is delivered, the couple can be struck by the irony that the decision to become parents was never really theirs.
Many couples deny there is a problem for some time. Family, friends and even medical personnel may encourage this by suggesting they are young and healthy and just need to wait. Sometimes this defence mechanism is helpful as it allows the couple to gradually absorb what is happening to them.
This can be directed at self, spouse, physician, God or fate. It is rooted in feelings of helplessness or loss of control. People in control of other aspects of their lives now experience deep frustration at their inability to do what the rest of the world appears to do so effortlessly. Anger can well up at the sight of young pregnant unmarried women, abandoned or abused children or in discussion about unwanted pregnancy or abortion. Usually this anger is repressed as it can feel socially unacceptable to express such bitter feelings.
This can take the form that pregnancy is being withheld by God as a punishment. It can include guilt about forbidden thoughts of jealousy over a sister’s new baby or secret pleasure when a friend miscarries. For many couples a cause and effect relationship may be seen to exist between infertility and what they have done or not done in life. The couple may link events such as premarital sex, having an abortion, using contraception with being unworthy to become pregnant. There may be a regression to the magical thinking of childhood as the infertile couple goes through a process of bargaining with God or Fate. If this atonement goes unheeded, further anger is experienced at how unfair is life. This can extend into self-destructive behaviour, such as abuse of drugs or alcohol, feeling there is no point in trying to be worthy.
This can be a normal part of moving from anger to acceptance. It signals that loss has occurred and grief is immanent. There is a sort of ‘doomed’ feeling for those involved.
This stage is characterised by many physical symptoms such as weeping, sobbing, loss of appetite, choking or sighing.
Finally the infertile couple hopefully begin a new stage of recovery where there is renewed ability to function, re-establish social relationships and experience pleasure once more.
Barbara Eck Menning8 summarises the feelings of these stages as follows:
Denial – ‘No, not me!’ Anger – ‘Why me?’ Bargaining – ‘Yes me, but…’ Depression – ‘Yes me’ Acceptance – ‘Yes me and I accept it’
When Grief Fails
Not all infertile couples grieve the loss of childbearing successfully. Some get stuck at a stage in the process. One of the reasons this can happen is that there may be no recognised loss. Family and friends may be unaware of what the couple are going through and so do not offer the normal support they would if there had been a recognisable loss of a child through death.
There may be uncertainty over the loss, such as the case where medical uncertainty reveals no known cause for the infertility. Such uncertainty may hinder normal grief work as the couple grapple with the hope that they may yet have a child.
Other people may negate the loss the couple feel. Remarks such as ‘nobody ever died of infertility’ or ‘you could have cancer’ trivialize the pain felt. Yet others may wound the couple with insinuations that the absence of children is from choice. As Humphrey remarks it is ‘understandable that the child-encumbered should take a jaundiced view of the child free, who are not only a reminder of lost opportunities (real or imaginary) but a challenge to prevailing values’.9
The technique of in vitro fertilisation (IVF) is now an established treatment for infertility. Many other techniques have been developed from IVF and Jones charts fifteen new methods of conceiving a child based on IVF.10 These new treatments afford opportunities to the infertile couple but also present them with new dilemmas. These range from religious reservations, ¹¹ to what has been described as the roller coaster effect of treatment, with its recurrent hopes and recurrent disappointments.12 Decision making about jobs, house buying, study and other options regarding parenting, such as adoption, is frequently postponed by the couple whose life revolves around infertility treatment. ¹³ Although some studies found that those whose treatment with IVF was unsuccessful, were at risk for depression 14,15 other surveys of IVF patients showed that most women were satisfied with their experience even if they did not conceive.16 Leiblum (et al) found that a large number of those who failed at IVF would consider further participation in new reproductive options that would enhance the likelihood of a pregnancy.17
Counselling the Infertile Couple
It appears to the writer as a social worker that the majority of those having infertility investigations and subsequent treatment are often afforded little opportunity for counselling. This perception is supported in the literature18 where it is acknowledged that the non-biological context of infertility, the impact on a marriage, family and career is rarely considered significant in medical treatment except where links of stress and infertility are concerned.19 Yet to redefine their lives and move on to acceptance of loss, infertile couples need the presence of empathetic others to help sort out the unique meaning of that loss.
What then can the counsellor do to facilitate the process of grieving? As a social worker I am attracted to the psycho-social perspective of infertility counselling advocated by Daniels,20 which recognises the social dimension of the problem and challenges social workers to offer a more holistic service. This involves not only working with the individual couple but with their network, when appropriate. The counsellor then sees each couple, not as a couple in isolation, but as part of a wider family system and is interested in how the couple are supported in their extended families or perhaps how pressurised they are to have a baby.21
The worker acknowledges for the couple that infertility is a problem which touches many areas of their lives. Their’s is not just a medical problem. It is also a social and psychological one that can diminish social and sexual resources.
Assurance by the counsellor of the normalcy of their feelings is the first step in allowing that couple to give themselves permission to experience where they are in the grieving process. Support can help the couple toward the emotional goal of resolution while recognising the wound caused by the loss can be re-opened at an unexpected time.
Finally, the counsellor must help the couple, if necessary, to say good-bye to the dream of their fantasy child. This is a crucial element if the couple are ever to consider parenting through adoption, a child born to someone else.22
1. Raphael-Leff, Joan (1991) Psychological Processes of Childbearing (p.30) London, Chapman & Hall.
2. Scarria, Dr. John (1994) ‘Infertility: A Global Perspective’ Orgyn. No.3 pp
3. Kirk, H. David (1984) Shared Fate: A Theory and Method of Adoptive Relationships. Ben-Simon Pub., Brentwood, Canada.
4. Menning, Barbara Eck (1977) Infertility: A Guide for the Childless Couple. Prentice-Hall, New Jersey.
5. Johnston, Patricia Irwin (1984) An Adopter’s Advocate. Perspective Press. Indiana
6. Renne, Dianne (1977) ‘There’s Always Adoption: The Infertility Problem’, Child Welfare Vol.11, No.7 pp. 465-470.
7. Kubler-Ross, Elizabeth (1969) On Death and Dying. New York. McMillan.
8. Menning Op. Cit.
9. Humphrey, Michael (1969) The Hostage Seekers. London, Longmans.
10. Jones, Maggie (1989) A Child By Any Means. London, Piatkus.
11. Shenker, Joseph (1992) ‘Religious views regarding treatment of infertility by assisted reproductive technologies’, Journal of Assisted Reproduction & Genetics. Vol.9, No.1, pp.3-8.
12. McWinnie, Alexina (1992) ‘Creating Children – The Medical & Social Dilemmas of Assisted Reproduction’, Adoption & Fostering, Vol.16 No.1, pp.26-39.
13. Strickler, Jennifer (1992) ‘The New Reproductive Technology – Problem or Solution’, Sociology & Health. Vol.14 No.1, pp.111-132.
14. Golombok, Susan (1992) ‘Psychological Functioning in Infertility Patients’, Human Reproduction. Vol.7 No.2, pp.208-212
15. Newton, Christopher, Hearn Margarte & Yuzpe Albert (1990). ‘Psychological Assessment and Follow-up after In-vitro Fertilization: Assessing the Impact of Failure’, Fertility & Sterility. Vol.54 No.5, pp.879-886.
16. Strickler, Op. Cit.
17. Leiblum Sandra (et al) (1987) ‘Unsuccessful In Vitro Fertilisation: A Follow-up Study’, Journal of In-vitro Fertilisation and Embryo Transfer. Vol.4, No.1. pp.46-50.
18. Small, J (1987) ‘Working with Adoptive Families’, Public Welfare, Summer, pp. 33-41.
19. Strickler, Op. Cit.
20. Daniels, Ken (1993) ‘Infertility Counselling: The Need for a Psycho-social Perspective’, British Journal of Social Work. 23. pp.501 -515
21. Brinich, Paul, ‘Adoption, Ambivalence and Mourning: Clinical & Theoretical Interrelationships’, Adoption & Fostering. Vol.14, No.1, pp. 6-17
22. Reitz, Miriam & Watson, Kenneth (1992) ‘Adoption and the Family System: Strategies for Treatment’, New York, Guildford Press.