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Section 12
Mediation in Fertility Treatment

Question 12 | Test | Table of Contents

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In the last section, we discussed couple issues in the resolution phase.  These included ending medical treatment, sabbaticals and refocusing.

In this section, we will discuss a therapeutic approach to resolution.  This will include restructuring the couple’s relationship, facing denial of loss and choosing a life without children.

Couples who have been in therapy during immersion begin moving toward the resolution phase as repeated failures and the accompanying distress mount.  As these couples lean more toward the idea of ending medical treatment, you may be alert to cues that the couple is moving into resolution.  Some of the signs as mentioned in the last section include increased resentment of or noncompliance with medical treatments, emotional exhaustion, and perhaps most significantly, a focus less on pregnancy and more on the wish to parent.  Some may also think more seriously about the possibility of life without children.
               
In this phase, one of the tasks that I tend to focus on is helping couples talk about and resolve their losses so they are comfortable with whichever choice they make, whether adoption or a life without children.  Part of this process may include helping the couple grieve their losses through mourning rituals.  As couples are no longer focused on getting pregnant, partners take stock of their lives, including their relationship. 

It may be that during resolution relationship patterns that were tolerated during immersion are no longer acceptable.  If these are not addressed, the couple may move into the future burdened by pain and resentment.  For some, the healing process seems too difficult to tackle, especially after the ordeal of infertility.  They may lean toward dissolving the relationship.

4 Therapeutic Approaches to Resolution

♦ #1 Restructuring the Relationship
First, couples in resolution who opt for a life without children must often restructure the way they had envisioned their relationship.  During immersion, the focus on parenthood may have overshadowed many other aspects of the couple’s life.  Therefore, when medical treatment ends, the couple is left to consider "What now?  Who are we now?  What will we be in the future if there is no child?" 

Because the dyad tends to be the most unstable relationship configuration, as you know, children can stabilize couples in  variety of ways over the course of a marriage.  Three of these circumstances of stability include the responsibilities of parenting, joys, challenges and difficulties to share and being less inclined to separate or divorce in conflict because of concern for the child.

The prospect of life together without this unifying factor can raise uncomfortable thoughts and feelings.  The success of resolution may depend on how well couples have weathered the infertility process itself.  If couples have not been able to work together as a couple or get professional help, there are likely to be lingering resentments about decisions and feelings that were misunderstood or disqualified.  This build-up of pain and resentment is likely to hamper the refocusing process.  Without a child, these unresolved feeling may lead couples to seek out affairs or drift apart.

Bill and Melanie came to therapy on the verge of separation.  They were in the resolution phase, having spent four years in immersion with multiple, unexplained miscarriages.  Bill was having an affair and spoke openly about his wish to have a child with his lover.  I worked briefly with Bill and Melanie to help them with the mourning process, but Bill abruptly left treatment to move in with his lover. 

Subsequently, he left his second relationship when he and his lover were unsuccessful in conceiving, and he wanted to reunite with Melanie.  Melanie, having remained in therapy, had grieved her inability to have a child, and was uninterested in resuming the marriage.

 Many couples, however, intuitively figure out how to redefine or restructure.  The process gradually evolves with the realization that there will not be a child.

♦ #2 Facing Denial of Loss
Second, let’s discuss couples facing their denial of any feeling of loss regarding their inability to have biological children.  Although there are some people who do not feel any regret in connection with their infertility, for most, the ordeal involves losses that must be acknowledged and grieved.  I often try to question the motives of couples who apply to adopt without seeking medical consultation for their infertility, couples who insist that it makes no difference whether they parent a child who is born to them or adopted, and couples who prefer to adopt.

If couples succeed in adopting a child without acknowledging, mourning, and to some extent resolving the losses of their infertility, the child may be burdened by the parents’ implicit prohibition against the child acknowledging any of his or her own feelings of sadness and loss. 

You may make the couple aware that by denying any differences between adopting and having a genetically related child, adoptive parents, in a sense, eradicate the child’s connection to the birth parents and seemingly render it irrelevant.  This, in turn, denies the child a chance to grieve, to work through his or her feelings of being different, and to heal the losses of adoption.

♦ #3 Choosing Life Without Children
Third, in addition to restructuring the couple’s relationship and denial of loss, choosing a life without children can be a difficult decision, as it runs counter to conventional social expectations.  It is often difficult to distinguish society’s dictums from one’s own desires, and couples may feel a certain embarrassment, even shame, about their decision.

If couples are leaning toward a life without children, you may want to ascertain, as with adoption, that they are not rushing ahead and bypassing the process of mourning.  Whereas the active involvement in the adoption process offers and easier escape from grief, couples without children may try to deny their grief by throwing themselves into their work or other activities. 

In the couple’s desperation to keep busy, they may leave little time or energy for their relationships.  Because the partners’ recent experiences of intimacy have probably been filled with pain and loss, they may become increasingly distant and isolated from each other.  A couple that elects not to have children may be taken unawares by the feelings that surface years after the decision is made.

Daphne, age 38, after making the decision not to have children, stated to me, "The other day I was visiting my friend, and we were both playing with her daughter.  The little girl fell down and hurt herself.  I tried to help her up, but she just cried, ‘Mommy!  Mommy!’  What I will miss most is that there will never be anyone for whom I am the most important person in the world, who will come running to me when they are hurt!"

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.  When I ask couples questions regarding the decision not to have children and surrounding issues, my goal is not to challenge couples’ decisions, but to prepare them for the future they may face as the result of having chosen to take a nontraditional path.

7 Questions Regarding Life without Children
Questions I use with clients like Daphne and her husband include:
-- 1. "When you explore this together, what are the pros and cons of this decision?" 
-- 2. "Who is more interested in a life without children?" 
-- 3. "Do you think the decision not to have children will affect your relationship?  In what way?"
-- 4. "How do each of you imagine your individual lives will be different than if you had children?" 
-- 5. "What do you think your family will say?" 
-- 6. "What do you think you might miss?" 
-- 7. "What do you think you would value?"

In this section, we have discussed a therapeutic approach to resolution.  This has included restructuring the couple’s relationship, facing denial of loss and choosing a life without children.

The Emotional-Psychological Consequences of Infertility among Infertile Women Seeking Treatment:
Results of a Qualitative Study

- Hasanpoor-Azghdy, S. B., Simbar, M., & Vedadhir, A. (2014). The emotional-psychological consequences of infertility among infertile women seeking treatment: Results of a qualitative study. Iranian journal of reproductive medicine, 12(2), 131–138.

In the next section, we will discuss couple issues in the legacy phase.  This will include lingering loss, patterns of protection, a changed sexual relationship and infertility as an identity.
Reviewed 2023

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. 

Chazan, L., & Kushnir, T. (2019). Losses and gains of psychosocial resources: Effects on stress among women undergoing infertility treatments and participating in social network systems. Psychiatric Quarterly, 90(4), 717–732.

Crespi, B., & Dinsdale, N. L. (2021). The sexual selection of endometriosis. Evolutionary Behavioral Sciences. Advance online publication.

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.

QUESTION 12
What are three therapeutic approaches to resolution? To select and enter your answer go to Test.

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