Psychoanalytic Aspects of Assisted Reproductive Technology

Mali Mann

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781780491967
• eBook ISBN: 9780429917899
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book stems from the author's clinical experience working with infertile women in psychotherapy and psychoanalysis. It highlights the crucial importance of integrative work of psychotherapists and psychoanalysts with reproductive medical specialists in assisted reproductive technology (ART).

PART I
CLINICAL PERSPECTIVES

CHAPTER ONE


Psychoanalytic understanding of repeated in-vitro fertilisation trials, failures, and repetition compulsion

Mali Mann

Recent advances in reproductive technology and the increased use of techniques based upon it have created a need for psychoanalytic thinking and understanding of the psychological implications of in-vitro fertilisation (IVF) and other similar procedures. The recent and rapid advances in medical technologies confront us with the mandate to understand their complex impact on parents and their children.

As a physician and psychoanalyst, I became aware of my patients’ trouble accepting their infertility after drawn-out, repeated attempts to have their own children. The acceptance of their failure in conceiving is more of a challenge for some patients than others, although sometimes there can never be a final acceptance. The denial of their failure as a couple to conceive can become a long process with unfinished mourning throughout their life cycle.

The two cases in this chapter in particular illustrate how infertility traumata were re-experienced. The unconscious self-induced traumatisation resulted from the compulsion to repeat an earlier repressed trauma.

Freud inferred the existence of motivation beyond the pleasure principle. In 1919, he postulated “the principle of repetition compulsion of the unconscious mind, based upon instinctual activity and probably inherent in the very nature of the instincts—a principle powerful enough to overrule the pleasure-principle”. Building on his 1914 article “Remembering, Repeating and Working-Through”, Freud highlighted how the “patient cannot remember the whole of what is repressed in him, and is obliged to repeat the repressed material as a contemporary experience instead of ... remembering it as something belonging to the past: a compulsion to repeat”.

Those individuals who can better accept their infertility without significant psychological complication resort to other methods of becoming parents to fulfil their life-long expectation. Some may take an alternative step and adopt someone else’s child. Some infertile individuals whose infertility is related to their advanced age use alternative procedures such as in-vitro fertilisation (IVF). In today’s world, many women want to establish themselves in their careers and choose to postpone reproductive goals until later. When they face reproductive failure, they become extremely anxious, especially when the biological clock is ticking away faster and faster. The narcissistic injury is deep and debases their belief system about self-representation and their body image. Women are affected profoundly by fertility failure. They carry with them the identification linkage with their primary preoedipal maternal object, wanting to become a parent. We see clinically girls who play mother roles in fantasy. Once a woman’s pregnancy wishes are frustrated, the denial of an infertile self-image could potentially lead to crisis.

The way in which these women react to the trauma of their infertility will determine a number of factors, including how they choose to use a donor egg, donor sperm, or surrogate mother. The character of their traumatic experience also influences the process of deciding who will donate their egg, their sperm, or their womb.

Though the reasoning varies among theories, experts agree that the ability to become a mother is essential to believing that one is viable as a woman. Freud (1940a) made passing reference to the subject of human reproduction and pregnancy. The primacy of sexuality in human life for Freud is reflected in his belief that the wish for a child in the woman represents the symbolic substitution for the missing penis; a wish for reparation and completion.

Helene Deutsch (1945) questioned the reparative function of the woman’s procreative life. She made it clear that the woman’s urge to become pregnant and bear a child represents the essentially feminine quality of receptiveness, a bio-physiological concept, the bedrock of femininity.

Benedek (1952), and Bibring and colleagues (1961), pioneers in the study of women’s reproductive drive, saw pregnancy as a developmental crisis, and subsequent writers seem to accept this view (Lester & Notman, 1988).

In severely traumatised women, the wish to be pregnant is not necessarily connected to the wish for a child, as seen by Pines (1982). Pregnancy, instead, is simply seen as an effort to repair the narcissistic injury of early life.

Pines (1982) elaborated on the mother-daughter relationship as the locus of psychic conflict in women who abort habitually. Pre-oedipal dynamics were discussed and identified by Lester and Notman (1986, 1988) as causing anxieties during the early stages of pregnancy.

In her paper “Infertility in the Age of Technology” (1999), Zallusky highlighted the effect of infertility on the analytic process. She elaborates on the permeability of the boundaries between analyst and patient, and between fantasy and action, in psychoanalytic work with women who are infertile and resort to assisted reproductive technology (ART).

The immense stress of infertility can trigger regressions to earlier stages of psychological development. Intense feelings of envy and shame felt currently conflict with their roots in childhood, bringing about a disturbance to the person’s sense of self-identity. As Freud stated, the ego “is first and foremost a body ego” (1923b, p. 27). The earliest way in which we know ourselves is through our body.

Kite (2009) emphasised the importance of keeping the emotional reality of the patient in view in a panel on “Current Perspectives on Infertility”, in which the motivations for childbearing were discussed in relation to ART.

The entry of a third person—the doctor—into the sexual relationship, as if into the primal scene, is another theme in some of the literature. Also in the context of surrogate mothers and /or sperm donation, Ehrensaft (2008) described the feelings and fantasies of parents in relation to having another, outside party involved in conception. She described a stirring up of fantasies of a menage à trois. She observed that the egg donation or the surrogate could stir up fantasies of the other. Thinking of the sperm as sperm may be defensive against thinking of the sperm as coming from another whole person. Ehrensaft also pointed out the importance of telling children about their origins.

Coming to terms with infertility or mourning can manifest as a problem not only for women, but also for men and for the entity of the couple.

In-vitro fertilisation

In-vitro fertilisation means “fertilisation under glass”, that is, in a test tube. IVF is a technique for removing eggs from a woman, fertilising them outside her body, and placing the fertilised egg, or embryo, directly into the uterus. All IVF procedures have four steps: ovarian stimulation, egg retrieval, fertilisation, and embryo transfer.

Overcoming infertility was unimaginable just a generation or two ago. Since then, scientists have devised a way to remove the sperm and eggs and combine them. Eggs are fertilised, then frozen for future use; sperm strength can be boosted; and even women who lack ovaries may find themselves pregnant. These procedures arouse much curiosity among the general public and within the broad community of infertility and mental health experts.

The first “test-tube baby” was born in 1978. Louise Brown was the first child to be conceived by in-vitro fertilisation and was delivered after a full-term pregnancy. In the few years since, IVF has become an important element in the vocabulary of infertility. It has become the cutting edge of modem reproductive treatment and research.

In-vitro fertilisation requires intact fecundity, normal production of ova. Today, a number of women in their mid- to late thirties and early forties, in spite of their intense desire to conceive, remain infertile. Fecundity is intact in many of these subjects, and advances in reproductive technology make it possible to overcome infertility in some of these cases. New ground continues to be broken as research continues.

Regardless of the cause of infertility, the treatment that leads to the highest pregnancy rate per cycle is in-vitro fertilisation. Since its inception in 1978, there has been a remarkable increase in the numbers of IVF cycles worldwide (Nachtigall & Mehren, 1991). Approximately one in fifty births in Sweden, one in sixty births in Australia, and one in eighty to a hundred births in the United States now result from IVF. In 2003, more than 100,000 IVF cycles were reported from 399 clinics in the United States, resulting in the birth of more than 48,000 babies. IVF is now the treatment that leads to the highest pregnancy rate per cycle (Van Voorhis, 2007).

Egg donation was introduced in the 1980s, increasing the possibility of pregnancy and childbearing for many women. Many of the women receiving these donations were older and had delayed childbearing for reasons such as establishing careers, personal conflict, and ambivalent feelings about becoming mothers. These women, and also those who had had illnesses the treatment of which affected their fertility, were then able to have children. Still, egg donation brought up a great deal of controversy. In addition to the ethical dilemma, egg donation presents issues such as parental identity confusion and compromised sense of social group belongingness. I have encountered many clinical examples of this, but expounding upon them would be beyond the scope of this chapter.

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 fertilised 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.

Implanting more than one embryo increases the likelihood of having a viable pregnancy. It also increases the likelihood of multiple births, which carry greater risks. The decision to reduce one or more embryos to prevent multiple implantations is a difficult one.

In this chapter, I do not focus on the traumatic effect of infertility. Instead, I discuss the use of multiple IVF trials despite repeated failures. One of the cases I discuss, for example, presents a serious narcissistic injury and disappointment at the discovery of infertility, which in turn affected the decision to use and the process of assisted reproductive technology. The delay in decision-making created medical risks during this woman’s pregnancies. She insisted on going through a second pregnancy using her own uterus to carry a foetus that came from the union of her husband’s sperm and an egg donor, her niece.

Unexplained infertility

No matter how sophisticated the technique used to combat infertility, there are cases in which a woman remains infertile. Some causes of infertility remain beyond our understanding, even in these days of enlightened biological technology and modern-day high-tech reproductive procedures. These as-yet unsolved mysteries are very frustrating to those trying to understand why some people can conceive and others cannot.

Unexplained infertility is a “diagnosis of exclusion”. This means that all other known diagnoses must be eliminated before the infertility can fairly be called “unexplained”. Making claims about the causality of infertility and the concept of psychogenic infertility is not a useful argument for us as psychoanalysts. Conscious and unconscious hostility towards a defective male sibling (Allison, 1997), and a woman’s unconscious repudiated femininity or motherhood, can be important dynamics. However, there are couples who are able to conceive naturally in spite of similar dynamics. We need to be careful not to confuse the correlational data with causality.

In recent years, infertility treatment has undergone a genuine revolution, which has raised the possibilities for empirical treatment. Today’s infertility treatment is referred to as “assisted reproductive technology”; most simply stated, ART represents the joining of a hormonal therapy with a form of artificial insemination. ART is most commonly represented by intra-uterine insemination (IUI), IVF, and IVF’s variations.

Case one: Jean

Jean, a married forty-eight-year-old woman, came to see me for analysis after a hiatus in her psychotherapy. During her previous years of treatment with me when she was in her early forties, she saw me twice a week. She did not know why she could not conceive. She decided to wait and try natural methods to get pregnant. She made many attempts over a long period of time to conceive, without any success.

Jean’s professional life was a trying and challenging one and kept her very occupied to the point that she lost track of passing years. She did take pride in her work and wanted to appear to her colleagues as “perfect” and “flawless”.

Jean’s inability to conceive was very difficult for her to accept, since she thought nothing was physically wrong with her. Male factors for infertility were ruled out. It meant to her that she was defective. Jean’s husband, who was in a similar professional field, was very supportive of her; and he was willing to adopt or even be childless if Jean chose not to have any children.

Jean was shame-ridden about being defective and not being able to have children as her mother did. She felt intense envy towards her mother and especially her sister, who was five years her senior and had one son. Her envy of pregnant women was very intense, making her angry when she encountered pregnant women.

Jean came from a deprived background both emotionally and financially. She had memories of not having food and going hungry to school. She was not sure if she was conceived out of wedlock. She believed her sister was so conceived, and in her fantasy she thought her father never married her mother.

Jean’s brother was born when she was eight years old. She remembers her parents were overjoyed because they finally had a son after so many years. Jean devalued her mother for her emotional detachment, but would also show guilty feelings for her rage towards her mother.

In her day-to-day interactions, Jean lacked emotional responsiveness. She tried hard to be friendly with her colleagues, as long as they praised her at work. She had many superficial friendships, but she could not go beyond the surface level in relationships.

At the beginning of our work, this patient had immediate realistic concerns about dying before she could fulfil her dream of becoming a mother. Her resistance to becoming fully involved in the transference was expressed in the form of overvaluing her job, dealing with life and death issues, and considering her analysis “just talking”, a process in which “not much important action was happening”.

Jean related that no matter how much insight she would gain through our work, she still needed to take action by hurrying to have children from her own eggs before it was too late. She wanted her gynaecologist to give her strong fertility medication like Lupron and other infertility medications to make her fertile. She went through multiple IVF procedures during this period. Each time they harvested her eggs, she would come in and boast about how many of her own eggs they were able to harvest. She turned a blind eye to the factual comments that several experts made to her about her age factor, which made her eggs unsuitable for IVF. She knew that the probability of getting a viable embryo using her ovum was very low. She vehemently defended her decision and said, “I just do not want to borrow another woman’s eggs”.

“Borrowing” another woman’s eggs would mean that Jean was inferior to egg donors. After her husband suggested that perhaps they could consider an anonymous donor, though, she assented. Yet she waffled. If she could only find an anonymous donor from another country, perhaps she would follow through. In the end, Jean turned away from making the decision.

At this stage of our work, she was obsessed with going through many cycles of IVF without showing much interest in exploring the meaning of her desperate actions. Only after many failures in conceiving did Jean begin to wonder why she could not get pregnant. She thought she was either being punished or she was just flawed. Her almost total absence of fantasy material towards me gradually gave way to being intensively curious about my personal life after she inadvertently learned that I had a daughter. Having found out through a friend who attended a fund-raising event where I was participating with my daughter, Jean imagined that I must be an attentive mother myself and not like her own mother who was aloof and detached. She would use technical terms to show me that she was psychologically minded and a well-read, intellectual woman. However, she would mispronounce or misuse words and quickly apologise to me for not having used the word accurately.

Jean would come to her sessions punctually, and she would get anxious when I took a break for a holiday or professional travel. She worried that I would never come back and that so...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• About the editor and contributors
• Introduction Psychoanalytic impact of assisted reproductive technology
• Part I: Clinical perspectives
• Part II: Conclusion
• Index