‘Cycling Through’ -

Counselling in the area of Fertility and ART

Julia Cernaz

www.jcernaz.com

juliacernaz@gmail.com

0432 747011

Carla and Vince

ART

• Medical definition of infertility usually includes length of time ttc

and/or physical factors but we can also consider a social definition, “active but frustrated desire for a biologically related child” (Throsby.)

• Most common treatments include;

-IUI Intra Uterine Insemination (Artificial Insemination)

-IVF (In Vitro Fertilisation)

• ART treatments also include the use of donor gametes, donor embryos and surrogacy arrangements.

ART because...

Heterosexual couples • Time...trying to conceive • Male/Female factor • Unexplained • Sexual issues • Secondary infertility Solo women & same-sex couples • Social infertility Fertility preservation • Health diagnosis • ‘Insurance’ to use when

able/ready • Trans people

Some Numbers: VARTA Annual Report 2016-2017

• 12 495 women had 22 963 ART treatment cycles in Victoria 2016-2017 financial year.

• Resulting in 4502 clinical pregnancies.

• 1785 treatment cycles for recipients of donor gametes -egg/sperm (10% increase from previous year)

donated embryos (32% increase from previous year)

resulting in 672 pregnancies.

• 40 women involved in surrogacy arrangements (local) resulting in 15 pregnancies.

Legal Context

• A counselling session is mandatory for all people in Victoria proceeding with ART treatments (ART ACT 2008).

• Key Guiding Principles of legislation;

“…the welfare and interests of persons born or to be born as a result of treatment procedures are paramount”.

“children born as the result of the use of donated gametes have a right to information about their genetic parents”

• The Victorian legislation distinguishes between being a parent and being a donor and ensures that children born have a right to access identifying information about their donors.

The ART Experience

Emotional and Psychological • Prolonged treatment associated with

increased stress. • Mental health risks particularly where

hx of depression/anxiety/trauma. • Continual cycles of grief and loss and

re-exposure to source of distress through repetitive procedures.

Relational • The couple relationship can

experience significant stress on multiple levels including changes to sexual intimacy.

• Relationship challenges with family and friends, sometimes reducing sources of support.

The ART Experience

Developmental

• Life stage transitions – a sense of developmental ‘stuckness.”

• Living in limbo and inability to plan for a desired future.

‘Patienthood’

• The impact of assuming a patient role and being subjected to a medicalisation of baby making.

• The centrality of clinic and reliance on others/staff to the process.

Existential Awakenings

• Life’s randomness and unfairness – discontinuity and life plans not as expected.

(Raphael-Leff 1991)

Bodies • Women in fertility treatment can see

their bodies as a site of inadequacy and failure.

• Language reinforces this view; ‘old eggs’, ‘bad eggs’, ‘poor responders’ -the uterus as a ‘hostile environment.’ • Women - self surveillance and

policing of the body, it’s performance and success or failure.

• Male fertility strongly associated with

sexual potency (virility/fertility) and masculinity.

Starting Treatment

For heterosexual couples;

• ‘Finally’... IVF as relief that something is happening.

• What’s present - relief, worry, excitement, anticipation, hope.

• Challenge of how to ‘position’ oneself - hopeful / cautious.

• Adjusting to the demands of the treatment cycle and waiting.

• Time moves from calendar to cyclical time of treatment.

For solo/same-sex women;

• ‘Finally’…after thinking, planning, deciding how to proceed.

Further on- holding patterns

‘ • Focus on treatment and why not working/searching for answers.

• Relationship challenges - within couple and broader network.

• The emotional toll - possible anxiety / preoccupation / rumination.

• Treatment options may extend and open possibilities not previously contemplated.

• Negotiating the fear of the potential of not becoming parent/s.

• Contextual stressors – financial, social, career difficulties.

Ending Treatment, Without a Baby

• “…while there are well-trodden paths into IVF, the routes out of treatment are more obscure.” (Throsby)

• Confronting the idea and social/medical construction of ‘giving

up’. • The move towards a different identity; ‘not a mother/father’

• How will relationships reorganise around a different future?

• Emerging long term literature on post treatment experience for

those who remained childless post ART - mixed results -20 year post treatment follow up ‘grandchildlessness’ and grief -10 year post treatment follow up good psychological adjustment

Loss and Grief

• The experience of cumulative and disenfranchised grief.

• Echoes of the past – the legacy of other losses. • Other types of losses -

eggs/embryos may have profound meaning.

• Rituals - noticing/acknowledging cycles and losses

(Mizuko Japanese ceremony).

The Baby, End to Treatment

• The baby who comes after ART is much wanted and anticipated and yet… this may come with a sense of enormous pressure to ‘get it right’.

• Difficult experiences may be concealed for fear of judgement or feelings of guilt and shame.

• Stress on relationship that occurs with ART may not have had time to heal and issues may continue into new parenthood.

• There may be heightened anxiety or worry about the baby related to the challenge in achieving the pregnancy.

• May be the one child if later in age or no further treatment viable.

Parenting Post ART • “In the first few months after giving birth,

women who conceive with IVF have a higher rate of parenting difficulties than women who conceive spontaneously, including anxiety about caring for the baby. However, follow-up studies show that within a few years of ending treatment, there are very few differences in terms of emotional wellbeing and life satisfaction between those who had a baby as a result of IVF and those who did not.”

(VARTA Possible Health Effects of IVF) • Critical role of health professionals in being

able to listen well and to engage in conversations around any particular challenges or experiences that parents are bringing forward.

A Different Story- Donor Arrangements

• Parents of children conceived through donor arrangements have a more complex route to parenthood as involves other parties, further procedures, ethical, psychological and legal considerations and significant financial costs.

• They may experience baby talk differently;

-‘who does the baby look like/take after’

• Disclosure of donor involvement and type of relationship with the donor varies and each family will approach this differently

(child’s right to access information about their donor is protected).

Respectful Relationships and language

Need to position ourselves in a manner that is open and inclusive and we demonstrate this partially through language

• Be gender neutral – ‘they’/ ‘partner’ instead of assuming he/she

“What is your partners’ name?”

“Tell me about who is in your family?

• If told that the baby is ‘IVF’ / ‘donor’, ask gently is there is anything particular that the parent wants you to understand about this information

“Can you let me know what is important about this for you?”

“Is there something that I need to understand about this to better

support you and your family?”

(Jacqui Tomlins 2015– Resource Kit for Rainbow Families)

Doing Inclusivity

What creates a sense of ‘cultural safety’ for LGBT people;

• Create a healthcare environment that is welcoming and demonstrates inclusivity e.g. posters, literature that is visible and conveys a inclusive message

• Create systems that are open, neutral and inclusive

e.g. gender neutral intake forms

• Listen carefully and think about how you demonstrate respectfulness

(Jacqui Tomlins 2015 – Resource Kit for Rainbow Families)

Endings

• ART is more than the medical set of procedures to have a child…it can raise profoundly significant issues for people.

• There are many treatments and ways of forming family through ART.

• We need to be mindful of the experiences of those who undergo these processes without having a child.

• As practitioners who work with parents it is important to be thoughtful and sensitive in our contact and languaging about families who have ART as part of their history.

• Carla and Vince ……

References

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• Berman, A. (2006). Sex at 6pm. A Personal Journey Through IVF. Sydney. New Holland Press.

• Boden, J. (2007). When IVF treatment fails. Human Fertility., 10, 2, pp 93 – 98.

• Couples and Infertility Moving Beyond Loss – The Infertility Project of the Ackerman Institute for the Family DVD psychotherapy. net

• De Lacey, S. (2002). IVF as lottery or investment: contesting metaphors in discourses of infertility. Nursing Inquiry., 9, 1, Pp 43 – 51.

• Diamond,R., Kezur,D., Meyers,M., Scharf, C.N., Weinshel, M. (1999). Couple Therapy for Infertility. The Guilford Press, N.Y.

• Donarelli, Z., Lo Coco, G., Gullo, S., Marino, A., Volpes, A., and Allegra, A. (2012). Are attachment dimensions associated with infertility-related stress in couples undergoing their first IVF treatment? A study on the individual and cross-partner effect. Human Reproduction., 0,0, pp1-11.

• Fisher, J.R., Baker, G.H.W., Hammarberg, K. (2005). Assisted conception is a risk factor for postnatal mood disturbance and early parenting difficulties. Fertility and Sterility., 84, 2, Pp 426 – 430.

• Fisher, J.R., Baker, G.H.W., Hammarberg, K. (2010). Long-term health, well-being, life satisfaction, and attitudes toward parenthood in men diagnosed as infertile: challenges to gender stereotypes and implications for practice. Fertility and Sterility., 94, 2, Pp 574 – 580.

• Galhardo, A., Cunha, M., and Pinto-Gouveia, J. (2013). Mindfulness-Based Program for Infertility: efficacy study. Fertility and Sterility. (in press) pp 1-9.

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• Tomlins, J. (2015). Resource Kit for Rainbow Families.

• Victorian Assisted Reproductive Treatment Authority Annual Report 2017.

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