Infertility on Both Sides of the Couch

Earn CE Credit

• Family Planning
• The Family System
• Couples Therapy
• Mystery Solved
• Judging Claire
• Working Through and Joining With
• The Breakthrough
• Different Kinds of Pregnant

Family Planning

"When are we going to start a family?" asked my husband.

I felt a boa constrictor wrapping around my throat. For months now, the topic of children had evoked tension, leaving us powerless and detached from each other. The argument had become a tradition on Saturday mornings. We would sit in the living room in an awkward silence, avoiding eye contact, until my husband pierced the hush with what he deemed a simple question about our future.

My husband was comforted by having a plan. Three years into our marriage—my second—we were in our mid-thirties, established in our careers, and financially stable. For him the next step in our lives was to start a family, but his need for a plan set off a vicious cycle. I felt ignored and disrespected in our relationship and couldn't justify bringing a child into a fractured marriage. I craved connection and love and was not willing to commit to having a child until we resolved our relationship problems. My resistance made him more insecure and unsure of his focus, and he would ask me about starting a family as a way to relieve his anxiety. Unfortunately, his persistence pushed me away, leaving me feeling trapped and controlled and leaving him stranded without resolution.

I felt immense pressure both from him and from society to conform and have children. Gradually, I isolated myself from my husband and emotionally shut down, as my sense of self and my voice vanished. Feeling alone with no one caring about my thoughts and feelings, I believed I was not enough for my husband and that he had married me solely for procreation. Meanwhile, I was inundated with inquiries from our family and friends about when we would be parents.

My mother-in-law often phoned my husband's siblings to convey that her children were failing her since she did not have grandchildren. While growing up, my husband's mother talked a great deal about heirlooms—each piece of jewelry or china was a link between past and future generations. Grandchildren were an essential part of keeping the family traditions alive and to not have them meant the family had failed. She made it clear that my husband was not enough, just as I felt I was not enough as his wife. My resistance to the "plan" was a clear message to him and his mother that I would not conform.

His side of the family was not the only problem. My stepfather had the impression that all couples wanted children. He frequently dropped hints about what a joy they are, pointing to his grandson and saying things like, "See, aren't these fun and not so bad?" For him, family represented connection and closeness. Initially this was endearing but it soon became annoying.

While at a party, I declined an alcoholic beverage, which ignited rumors that I might be pregnant. When I heard the gossip, a wave of heat washed through my body. How dare my friends speculate? It was as if I were starring in the reality show, "When Will Wendy Pop One Out?"

The Family System

In 2005, I started therapy with a psychotherapist who practiced from a Family Systems model, the premise of which is that the family is an emotional unit—systems of interconnected and interdependent individuals, none of whom can be understood in isolation from the system. Over the course of my therapy, I came to understand that my symptoms of sadness, loneliness, and detachment were a consequence of the recurring patterns and interactions within my family. The sense of powerlessness I experienced evolved from my marital dynamics, my family history, and the cultural expectations of a woman in her thirties.

My parents divorced when I was thirteen years old. I was an unplanned pregnancy and the reason my parents had married. It was bad enough that I was a mistake, but I resented my parents even more for their divorce, and the struggles that I encountered during my teens trying to navigate through the turmoil of their divorce played a role in my delaying the start of a family.

During my first marriage, I was enrolled in graduate school and wanted to wait until completing my program to start a family. We would have been in our early thirties by then and my ex-husband wanted to be a father sooner. He had an affair and decided to leave. This time around I wanted to make sure I was in a healthy relationship, that we were not introducing a child into a doomed family. I did not want to recreate my childhood trauma for my own children.

At Christmas in 2006, my stepsister announced over dinner that she was pregnant with her second child. I broke down sobbing at the table. A hush blanketed the room as everyone stared at me. Although embarrassed and humiliated, I could not stop crying.

Two weeks later, my stepbrother shared the news about his wife's first pregnancy. My sister-in-law had planned on not having children but had changed her mind. I was consumed with feelings of betrayal. I was my own childless island in a world that demanded parenthood. I dove deeper into despair.

Couples Therapy

My husband finally realized that our marriage was at stake and agreed to couples counseling, but I wondered whether it was too late, as by this time my rage had evolved into numbness. I recalled our minister's marriage sermon encouraging us never to throw in the towel when things were broken, but another part of me was tempted to do just that. “You don't need a man, you survived a divorce,” the voice said. "Trust me, you’ll be much happier single." I contacted therapists, but they either did not return my calls or have any openings for new patients. Was the universe telling me it was too late for my marriage? The battle inside me grew more crushing until finally after three months, I found us a therapist.

Couples therapy became our new Saturday tradition. My husband had never been to therapy, hated conflict, and had always made choices with tremendous caution, sometimes over the course of many years. Therapy for him was about finding ways to manage his stress. If he knew when we would have a baby, he could plan accordingly. Should we reserve a slot at the day care now, since there could be a waiting list for a couple of years? Should we start putting money into a college fund? Or should we begin grieving about not having a child?

For me, therapy was about maintaining autonomy and establishing a healthy marriage. I wanted the freedom to make choices within the marriage, but feared he would leave me if I did not have a baby. It felt like an ultimatum. And for my husband, despite his discomfort about the therapy, he began utilizing what he learned about me. He realized that asking questions about starting a family was torture to me, so he stopped asking. As a result the perceived threat of the ultimatum faded.

In my professional life, I had wanted to open a private practice. Should I be saving money for the grand opening of my business or for a divorce? The marriage had to be healed before the practice could be born.

During our treatment, I wrote my business plan. My husband was proud as a peacock and bragged to others that I was making my vision come alive. I opened my practice in mid-2007, feeling finally alive after an emotional coma. When I purchased the new office furniture, my husband questioned the size of the sofa, believing it should be larger. Prior to our therapy, this question would have offended me and I would have felt undermined in my judgment. Instead, I confidently explained that the sofa worked well in the room. Understanding his tendency to err on the side of caution, I did not personalize.

He went ahead and assembled the office desk and filing cabinet and moved the sofa into the suite. To this day, he tells others it was a good thing that I ignored his advice because the sofa barely fit into the space. This was the sexiest thing he had ever done. Life was wonderful. I was enough as a wife and my business was thriving. Without pressure to conform and have a child, I decided to go off the Pill.

For three years we did not get pregnant.

Mystery Solved

From the time I was a teenager, I had a history with difficult menses. Like clockwork I got my period every 18 days and bled for 10 days, uncertain what PMS symptoms I would experience. My blood flow would be heavy, dark and impossible to keep up with, changing my tampons and pads every four hours and during the night bleeding onto my bed sheets. At times to get through my school day, I took over-the-counter pain pills for heavy cramps, lower back pain, or headaches. For my peers and teachers I maintained a pleasant façade, but what I wanted was to retreat into a corner and savagely eat raw meat and growl or be in my bed weeping and eating salty chocolate. I applied copious amounts of zit cream to my face attempting to fight a hopeless battle with breakouts. My bra and pants would restrict my breathing because I was bloated. During my annual exams, a range of doctors had explained these symptoms were stress-induced by my parent’s divorce, my divorce, and graduate school, and had prescribed birth control pills.

Now while off the pill, my life was good and I had no stress on which to blame the problem. I was receiving holistic care and yet was still physically and mentally suffering. Why was I having the same problems I had as a teenager?

I made an appointment with an OB/GYN specialist with little faith that I would find answers, but for the first time, a medical doctor was eager to learn what was going on with my body. He believed my symptoms were pathological and not related to stress and ordered blood work and an ultrasound.

A month later, the OB/GYN nurse escorted my husband and me to the doctor's office for my consultation. He was perusing my test results with a look of concern on his face when we walked in. Gazing up at us, he said, “I am unsure where to begin.” The blood work was perfect. The ultrasound, however, revealed why I’d suffered for decades and had not become pregnant during the past three years. Both of my ovaries were smothered in various types of growths (some were thyroid tissue), my fallopian tubes had blood, my uterus had polyps and was malformed, and as a result I was unable to carry a pregnancy. The doctor recommended a full hysterectomy.

My symptoms were not stress related. They were not my fault. A sense of calm flowed over me; my eyes welled up with tears. My husband took my hand and asked questions while I continued to absorb the news.

Judging Claire

Meanwhile, my professional life was evolving beautifully. I had the satisfaction of seeing my vision coming to life, and I loved owning my own business. For several years I had been seeing Claire*, a married and successful professional in her mid-thirties with a significant history of depression and anxiety. She had a warm sense of humor and loved to learn about herself. During the first couple of years working together, she feared her future children would be genetically predisposed to suffer from similar aliments and struggled between the desire to feel a child growing inside of her and her desire to adopt.

During the course of our therapy, Claire forgave herself for having a diagnosable mental illness; she realized the illness did not define who she was. She began to consider that she had plentiful and warm offerings as a mother and decided to conceive naturally. After a year of not getting pregnant—this was around the same time I went off the pill—Claire was diagnosed with infertility.

By then I was secure in my marriage and waiting to see if I got pregnant, but I struggled to maintain my alliance with Claire. Still vulnerable with my own triggers, I had my own opinion about the infertility treatment process and our sessions evoked strong emotions for me.

One in ten couples struggle with infertility issues. According to the medical model, infertility is a disease of the reproductive organs, and usually the first option in treatment is a daily injection of medication to stimulate the ovaries to develop eggs in the follicles (the structure in the ovaries that contain developing eggs). The side effects can include bloating, weight gain, headaches, and nausea. If this is unsuccessful, IVF (in vitro fertilization) begins, in which eggs are surgically removed from the ovaries and combined with sperm. Weekly ultrasounds and estrogen blood levels drawn twice a week assist the doctors in determining the best time to retrieve the eggs. The last resort for infertility treatment is the egg donor cycle, where an embryo formed from another woman's egg is transferred to the uterus of the woman trying to conceive. More coordination and time is involved since two women are being monitored for transfer.

As I witnessed Claire’s physical and emotional agony and the suffering in her marriage it caused, I began to judge her harshly. How could she brutalize her body from treatments and spend so much money to conceive and carry? I hated her for choosing to participate in the infertility treatment process and holding faith in the medical model. I felt lonely and betrayed that she conformed to society's pressure to attempt pregnancy at all costs. I wanted her to join me in rejecting this awful and debilitating process and to redirect her energies toward adopting a child.

Though I had every intention of becoming a mother, once I realized I was infertile, I never considered infertility treatment or adoption. Both seemed too unpredictable and a setup for repetitive grief and loss. It was disturbing to have such an intensely negative reaction to a client, so I began to repress these feelings and thoughts in an attempt to protect both of us. In the process, however, I became increasingly disconnected from Claire.

What was happening between us put strains on my belief in the humanistic approach, which emphasizes that we are in control of our destiny, our choices, and the discovery of meaning for our life’s narrative, and makes use of the relationship created between the therapist and patient as a catalyst for exploration and change. A safe arena was vital for Claire to share her narrative and to discover the meaning of her experiences—the energy in the room could then provide an atmosphere conducive for healing. Regardless of my opinions and beliefs, I wanted to support her in her destiny and choices. But did I have the freedom to accomplish this?

As a therapist, I participate in a weekly supervision group. While disclosing the pain of my challenges with Claire, I shared about my sensitivity to the fertility topic and my beliefs about the infertility treatment process. My peers validated me and understood why I felt threatened, but also challenged me about my countertransference and helped me to work through it. Other colleagues were offended by the infertility treatment process and called my patient "greedy." A few of them had been adopted, and were exasperated that it wasn't Claire's first choice. Others were sympathetic with her plight and could relate to her need to biologically conceive a child. Through the group process, I was able to witness all the different parts of myself being voiced through my peers, and I felt safe enough and free enough to get to some of my own core fears and doubts about infertility. Ultimately this freed me up to be much more present with Claire in the coming months.

Working Through and Joining With

During a subsequent session, Claire tearfully shared how painful it was to have no control during the infertility treatment process. My inner voice whispered, Ask her if she feels she has the choice to stop the infertility process. Before working through countertransference with my supervision group, I would have suppressed this voice, believing it was my own “stuff" and would not be helpful to Claire. Now my heart pounded; I couldn't help but speak up: “Who says you need to continue to fail with the pregnancy attempts?” Something in the room shifted. After a pause, Claire affirmed, "I could stop." I exhaled. We had finally found a moment of empowerment and connection.

Claire continued to participate in the infertility treatment process, and I joined the emotional roller coaster with her. This freed up much more space to explore her process and mine.

Therapy is not immune to the disruption of the infertility treatment process. The scheduling of appointments revolved around Claire's menstrual cycle and she cancelled appointments due to the side effects of medications and clinic appointments. We had lapses between appointments while waiting for the doctors to contact her for the next treatment cycle. All of this meant that I needed to figure out what would take care of me during her infertility series. That involved answering questions such as: How do I cope with my anger? How do I keep from getting stuck in her holding pattern of waiting? Do I charge for missed appointments?

With the ongoing support of my supervision group, I continued to explore my emotional reactions. Claire and I collaborated about payment for missed appointments—she willingly paid and the joint conversation made her an active participant in an otherwise helpless period. The medical doctors had no clear diagnosis about why she didn't get pregnant for three years and she suffered continuously from a sense of loss. She had always dreamed of being a mom and having a family and now she had to face the fact that it might not happen.

Claire tried to detach from her emotional turmoil and did her best to function at work, but the clock ruled her while she anticipated lab results. Her job performance began to suffer and the cost was guilt, shame, and embarrassment. Work became heavy and dreadful. Her depression ignited, leaving her brooding in isolation and sleeping for 17 hours or more every day. Her “should” cognitions were in overdrive and kept her paralyzed.

The Breakthrough

"I'm afraid you're mad at me for the last minute cancellation last week," she said. "I'm failing at everything." In fact I was angry about the appointment. Missed appointments touch on my vulnerability around not being recognized as valuable. But our agreement for her to pay for missed sessions, combined with my own awareness of the reasons behind my countertransference, made it possible for me to process my response outside of session and bring my full attention to figuring out what she was enacting and what it meant for her. I responded, "You think you should be able to manage life better. But things are dropping all around you: your relationship with your husband, your work, your friendships, and especially not getting pregnant. You're feeling so alone." I watched her reach for a tissue, look down at her lap, and wipe her tears. "What are the tears saying right now?”

In her soft voice, Claire answered, “I'm afraid my husband will be angry at me for not controlling my emotions. My anxiety is through the roof. I want to be in my bedroom with the covers over my head. It's unfair to expect my colleagues to do my work. I want to be with my friends but it hurts too much because they have babies or are pregnant.” She believed she needed to be perfect and worried about disappointing everyone around her, including me.

But this conversation about failure and disappointment positioned Claire to begin healing her marriage and bring her husband, family, and friends back into her life. Through addressing her loneliness, Claire articulated her envy about her friends being pregnant or having newborns. She felt conflicted about whether to maintain her connections or isolate herself because it was too painful to be subjected to swollen bellies and to the innocent scent of newborns. She also acknowledged she pushed her husband away because she did not want to be perceived as a "burden." He had a demanding job that made him unhappy, but it provided them with medical insurance to pay for the infertility treatment. She secretly fantasized about him attending medical appointments with her and being readily available to abruptly leave work to provide comfort when she received bad news. I encouraged her to share her emotional burdens with her husband, to let him feel her burden, as that is part of what it means to be intimate with another person. She began to feel less guilty and apologetic about her struggles and to share the craziness of the process with him. They became closer and her sex life began to thrive again.

Over the two-year period of her IVF treatments, Claire's visits to the reproductive health center would evoke a sense of helplessness and lack of emotional safety. She often felt rushed because she didn't get satisfactory information to her questions, and the clinic became increasingly more uncomfortable and sterile. As our work progressed, she was more assertive and less apologetic about demanding the attention of the nurses and doctors until she was satisfied with the gathered information. To increase her comfort at appointments, she brought her own pillow and blankets.

Unfortunately, Claire was given a lot of unhelpful advice from her own support system of family and friends, even medical doctors. She was told, for example, to "just relax" because her stress could be interfering with the infertility process. In the therapy sessions, we worked on how to handle unwanted and sometime hurtful advice and not absorb the harmful implications. When she deemed it appropriate, she informed people about what would be helpful or harmful.

Different Kinds of Pregnant

When the IVF failed, Claire opted for the final remaining option: an egg donor. Our sessions were spent with her describing how a donor was selected and the various reasons they donated their eggs. It was a surprisingly fun process for both of us.

After her second cycle with the egg donor, she curled up on the sofa in my office, hugging a pillow with a distant look in her eyes. Her lip trembling, she said, "For four days, I was pregnant. Now, I am pissed off.” Her rage demonstrated no guilt. She did everything right but was unable to carry her first pregnancy.

The following month, her third attempt was successful.

One day, well into her second trimester and beaming with life, Claire effused, “My boobs are huge!” She shared her ultrasound pictures of her healthy son and we talked through her stress about finances with the arrival of her baby. In her desire to save money and prepare for the baby's arrival, she requested a break from therapy. I encouraged her to go and create a loving home for her son. Tearing up, she said, “I can’t believe I can hear ‘my son’ after all of this.” Claire would soon be a mother.

Through quite a journey, Claire and I mirrored each other for a couple of years. My marriage and business were at last breathing life. I scheduled my hysterectomy, knowing my body would be cured. I learned a valuable lesson: Psychotherapy is a fertile process.

* Claire's name had been changed to respect confidentiality.

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