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Track 2 Two More Beliefs about Infertility
Here are eleven questions I have used with my clients regarding the meaning and value of children and parenting.
"What are or were your ideas about being a mother or father? What are your ideas about parenting together?" "What do you see as the value of children?" "What aspects of parenting matter most to you?" "Is having a genetically related child associated with the way you see yourself as a man or woman?" "What does the genetic relationship to your child mean to you?" "Do you see a difference in how you might parent a genetically related child versus a child who was adopted?" "How do you imagine you would see yourself if you were a parent of a child who was adopted?" "What ideas do you have about adoptive families?" "Have you ever considered what it would be like to choose to live a life without becoming a parent?" "If you had or have only the option of adoption or a life without children, which would seem more fitting to you?"

Once a client has stated his or her beliefs regarding the meaning and value of children, I often talk to him or her about how and when these beliefs were learned and thoughts about alternative ideas they might follow. Four questions I tend to use include:

"Where do you think you learned this particular idea?" "What ideas about children, parenting, adoption, and life without children did each of you bring from your families of origin?" "Do you have family members or friends who have not had children or have adopted? What conclusions have you drawn from their experience?"

Track 3 Facilitating Mourning
I try to help the couple identify and address their losses, asking questions like, "What were you each hoping for?" "What did the treatment failure, miscarriage, afternoon in the park without children…etc. mean to you?" or "How is this loss different from other losses that you’ve encountered?"

Technique: Mourning Ritual
Because rituals can facilitate the mourning process, I often ask my clients to try the "mourning ritual" technique. This involves the couple creating rituals of their own. Most couples need some guidance in order to create a ritual that incorporates elements that address their losses. In suggesting and helping the couple plan a ritual, I try to respect what the partners feel lies within their zone of comfort and to encourage them enough to inspire them to take the risk of trying something unusual. In my experience, I have found that a couple is more likely to feel that creating a ritual sounds "too hokey" if I haven’t spent enough time in helping the couple to articulate their loss. If treated with importance and solemnity, the rationale for a mourning ritual makes emotional sense. Some couples arrive at inventive ways of mourning together without actually realizing they have created a mourning ritual.

Edward, age 35 and Shelley, age 34 had a "Bed and Chocolate Ritual." When Shelley got her period after an insemination, both of them came home from work and cuddled in bed with chocolate and a video. This ritual helped Edward and Shelley to get through another failed attempt.

I have found that some couples prefer to mark their losses with an in-session ritual, especially I have understood their sadness not shied away from their pain. In these instances, I am allowed to be a respectful mourner who amplifies the solemnity of the ritual. Other couples prefer to perform their mourning ritual alone, although a discussion about how it will be executed may take place in the session. In these instances, the discussion of the ritual can activate or intensify the process of mourning.

Track 4 Couple Issues in the Dawning Phase
The following list of questions may help to initiate discussions between partners regarding children and infertility, topics that may have been ignored or avoided by the couple. "Have the two of you thought about if and when you want to have children?" "Have you always assumed that having children was not a matter of choice?" "As you are both interested in having children, when are you planning to get pregnant?" "Are either of you concerned about the possibility of infertility?" "Do either of you have any special medical conditions that cause you to worry about infertility?" "What do you know about how a woman’s age related to infertility?" "Have you discussed any of this with your gynecologist? What has he or she said?" "Would you prefer to work out all your relational difficulties before having children, even if it puts your fertility at risk? Or, would you rather risk having difficulties in your relationship, but have children?"

Track 8 A Therapeutic Approach to Mobilization
Evoking the Future
Regarding levels of intervention, you might ask questions like, "What level of invasiveness are you willing to tolerate, and does your partner agree?" "Which one of you would be more likely to use donor gametes?" "What reservations to each of you have, and how do you deal with these differences?"

Questions regarding expenditures of time, money, and effort might include "Which of you feels more strongly about having children? How long are you willing to keep trying?" "Who is more worried about putting your savings at risk?" "If you find infertility and its treatments very distressing, how much do you think you can tolerate?" "Which of you would be the first to think about ending medical treatment?"

Curtailing Shame
I can engage a couple in discussing ways of curtailing shame by reframing the meaning of infertility. This early intervention the part of a clinician can limit the negative impact of infertility on each partner and the couple. In order to explore these potentially important themes, you may find that you need to ask the couple for their thoughts on a wide range of infertility-related subjects. You might ask questions such as, "What different beliefs do you have regarding the carrier versus the non-carrier of infertility?" "Which one of you feels more affected in your sense of being a woman or a man?" "Who holds the stronger belief that one cannot be an adult without being a parent?" "Which one of you feels more deprived when among family and friends?"

Once these destructive beliefs have been brought to light, you can help to minimize angry, painful, shameful legacies by addressing and reframing them. You might ask, "Would you see yourself differently if you saw infertility as bad luck instead of a sign that you are defective?" "How would that different view affect the way you function in your marriage and in the world?"

Track 8 A Therapeutic Approach to Early and Middle Immersion
Using Metaphors
In exploring meaning and belief systems, clients’ metaphors about themselves and the infertility will often be revealed. Working with metaphors can be especially helpful for couples undergoing this ordeal because metaphors help them describe their experience. After revealing current constraining metaphors by which couples define themselves or their infertility, I can then ask my clients to create a related but alternative metaphor, thus reframing the material in a positive light.

For example, when Sid was diagnosed as being infertile, his wife, Alicia wanted to have a child using donor inseminations. In an individual session, I asked Alicia, "How included or excluded will Sid feel about having a child with donor sperm?" Alicia replied, "Sid feels excluded from everything. He uses this imagery that he’s a lone wolf on the tundra." In a separate session with Sid, he talked to me about this lone wolf metaphor. I asked if he might be able to change the metaphor of the lone wolf to a more inclusive one. In a later session, Sid stated, "I want to be more active, more like a guardian protector role, so I thought about being an English sheepdog whose role is to guard the sheep."

Tracking Losses
At each session, you might try to keep track of how the couple is experiencing and dealing with these losses by posing questions, like the following. "Which one of you experienced the treatment failure, miscarriage…etc. as a greater loss?" "Which one of you is more inclined to speak about it with the other?" "What might be the consequences of not discussing this particular treatment failure, miscarriage…etc.?"

Technique: Mourning a Miscarriage
I often suggest that couples a technique that I call "mourning a miscarriage." Like the "mourning ritual" technique from track 3, "mourning a miscarriage" involves the couple creating rituals of their own. However, where the mourning ritual deals with the general loss of infertility, mourning a miscarriage is more specific. I often suggest that the ritual involve special items like baby clothes or a memorial object of some sort. To help clients prepare for their ritual I might ask a few questions like, "What do each of you need to say?" "What kind of preparation do you need to do?" "Who do you wish to include?" "Does this selected site work for both of you, and does it have a special meaning related to the mourning?"

Two questions that might help in broaching this subject include the following. "Are there unresolved issues related to your family of origin, legacies from your own childhood that affect your wish to have children?" "Is having a child a means of attaining status in your families and in society?"

Technique: Coaching
One way that I have found to help couples deal with the social isolation that is common during immersion is to suggest they try the coaching technique with family and friends. The coaching technique involves talking to family and friends about how to offer appropriate comfort and sympathy. I often suggest to clients that they start by informing their support system that anger and depression are common responses to the stresses of coping with infertility, and also to be clear about what kinds of remarks are particularly hurtful.

An example statement might be something like, "Sometimes we do, and sometimes we do not want to talk about the infertility. Please try to take cues from us, and we will try to be clear about what we want. After we have a treatment failure, we want to talk about our loss. Please, just listen.

Although we realize you are trying to make us feel better by saying such things as ‘Don’t worry, you can try again,’ ‘It’s probably for the best,’ or ‘It’s God’s will,’ it feels better to hear statements like ‘I am sorry to hear what happened,’ ‘This must be very hard for you,’ or ‘I feel so bad for you.’"

Track 10 A Therapeutic Approach to Late Immersion
Thinking About the Donor Option
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. 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?" or "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?"

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. 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?" or "What are the risks and advantages of waiting or proceeding?

Couple Communication About Donorship
It can be important to encourage partners to express their thoughts and feelings to each other. The following questions can be used as a starting point. "How do you think you will feel carrying an embryo that is the combination of your husband’s sperm and another woman’s egg?" "How do you think you will feel having your wife pregnant with another man’s sperm?" "How do you think you will feel being inseminated with another man’s sperm?" "How do you imagine you will deal with these possibilities as a couple?"

Alienation vs. Attachment
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, "Are there any benefits to remaining emotionally disconnected from the fetus?" "If you continue to feel disconnected, how do you think it will affect parenting for you and for the child?" "What do you imagine the impact will be on your relationship if one of you remains feeling disconnected from the child?" and, "If you decide it is important to being to attach to the fetus, what could you do to facilitate this?"

Ongoing "Check-In" Questions About 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. These include, "What is it like for each of you to know that you are not going to have a child that you create together?" "What is it like for each of you not to have the child you imagined?" "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?" "Are these issues hard to discuss with your partner?" "What are you likely to do with these thoughts? Keep them to yourself? On what occasion would you share them with your partner?" "Do you feel it is okay to have these feelings?" "What kinds of circumstances do you imagine will cause feelings of loss to reemerge for each of you?"

Track 12 A Therapeutic Approach to Resolution
Choosing Life Without Children
Because there may be few models of others who have chosen life without children in the couple’s circle of friends and family, you can help couples think about their choice and the issues that might arise in the future. You might ask questions like, "When you explore this together, what are the pros and cons of this decision?" "Who is more interested in a life without children?" "Do you think the decision not to have children will affect your relationship? In what way?" "How do each of you imagine your individual lives will be different than if you had children?" "What do you think your family will say?" "What do you think you might miss?" "What do you think you would value?"

Track 14 A Therapeutic Approach to Legacy
Latent Feelings
Normalizing their lingering feelings of loss allows them to feel more comfortable when discussing infertility’s impact. It may be helpful to probe each partner’s ability to communicate with the other when these painful feelings arise. The following four questions may be suggestive of how to explore this area. "Are there times you still think about the infertility?" "Do you share those moments with each other?" "When was the last time the two of you discussed the infertility?" "What worries do each of you have about sharing your feelings about the infertility?"

A History of Infertility
I use the following six questions to elicit a client’s history of infertility in the legacy phase.

Revisiting Belief Systems
infertility often gives rise to fatalistic world views such as "Bad things always happen to me." In the legacy phase, these perspectives ay have become organizing principles, which can be reinforced by subsequent adversities. I usually try to explore these world views with couples using the following seven questions.

Because the inability to reproduce can raise questions about one’s sexuality, potency, and attractiveness, it can be helpful to stress that although our culture conflates sexuality and fertility, the two are distinct. I use a couple of questions in either separate or joint sessions, including, "Do you see yourself as any less sexy as a woman or man because you were unable to produce a baby? If so, where did you learn that?" and "Can you think of any advantage to figuring out how to see yourself as sexy even though you could not produce a child?"

To assess whether couples have sufficiently dealt with the losses of infertility, you may want to open a discussion about the couple’s comfort with discussing and dealing with loss. Three questions that I use in such discussions include, "How have your families dealt with loss and expression of grief?" "How comfortable were your families in talking about death?" and "Do you think this pattern has influenced the way you handle your sad feelings?"

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