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Published online by Cambridge University Press
 Fertility Counseling: Case
Studies
Second Edition
Edited by
Sharon N. Covington
Shady Grove Fertility, Rockville, MD

Published online by Cambridge University Press

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DOI: 10.1017/9781009030175
© Sharon N. Covington 2023
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First published 2015
This second edition published 2023
A catalogue record for this publication is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Covington, Sharon N., editor.
Title: Fertility counseling. Case studies / edited by Sharon N. Covington. Other
titles: Case studies | Fertility counseling.
Description: Second edition. | Cambridge ; New York, NY : Cambridge University
Press, 2022. | Replacement in part of Fertility counseling / edited by Sharon N.
Covington. 2015. | Includes bibliographical references and index.
Identifiers: LCCN 2022024069 (print) | LCCN 2022024070 (ebook) | ISBN
9781009014304 (paperback) | ISBN 9781009030175 (ebook)
Subjects: MESH: Infertility – psychology | Reproductive Techniques, Assisted –
psychology | Counseling | Case Reports | BISAC: MEDICAL / Mental Health
Classification: LCC RC889 (print) | LCC RC889 (ebook) | NLM WP 570 | DDC
616.6/92–dc23/eng/20220615
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ISBN 978-1-009-01430-4 Paperback

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Every effort has been made in preparing this book to provide accurate and up-to-
date information that is in accord with accepted standards and practice at the time
of publication. Although case histories are drawn from actual cases, every effort
has been made to disguise the identities of the individuals involved. Nevertheless,
the authors, editors, and publishers can make no warranties that the information
contained herein is totally free from error, not least because clinical standards are
constantly changing through research and regulation. The authors, editors, and
publishers therefore disclaim all liability for direct or consequential damages
resulting from the use of material contained in this book. Readers are strongly
advised to pay careful attention to information provided by the manufacturer of
any drugs or equipment that they plan to use.

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 Case studies are based upon relationships and teamwork that exists with both our
clients and our colleagues. I am eternally grateful for the many patients I have
worked with over the years who have entrusted me with their care, some for a
single meeting and others for 30+ years. I am also profoundly indebted to the
trusted colleagues who have supported, educated and guided me along the way.
Too numerous to mention by name, these mental health professionals as well as
the physicians and staff at Shady Grove Fertility have provided me the “wind
beneath my wings”. With deep appreciation, I dedicate this book to all of you: It
has been an honor and a privilege to be on this journey with you.
The secret of change is to focus all of your energy, not on fighting the old, but on
building the new. Socrates

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Published online by Cambridge University Press
 Contents
Preface ix
List of Contributors x

I Introduction 10 Counseling Nonidentified Gamete Donors 54

Laura Josephs and Uschi Van den Broeck
1 Collaborative Reproductive Healthcare Model: A
Patient-Centered Approach to Medical and 11 Counseling Embryo Donors and Recipients 59
Psychosocial Care 1 Maya Grobel and Elaine Gordon
Nancy Kaufman and Loree Johnson 12 Special Considerations in Gestational Surrogacy
2 Reproductive Psychology and Fertility Assessments and Arrangements 65
Counseling 10 Mary Riddle and Tara Simpson
Susan Klock 13 DNA and the End of Anonymity: Disclosure,
Donor-Linkage and Fertility Counseling 70
Kate Bourne
II Therapeutic Approaches
14 Family Life After Donor Conception 76
3 Fertility Counseling for Individuals 15
Jane Ellis, Marilyn Crawshaw and Astrid
Linda Applegarth and Arabelle Rowe Indekeu
4 Fertility Counseling for Couples 20
Kristy Koser
IV Addressing the Needs of Diverse
5 Fertility Counseling with Groups 25
Rachel Rabinor and Landon Zaki Populations
6 Sexual Therapy Primer for Fertility 15 The Male Experience with Fertility and
Counselors 31 Counseling 83
Erika Kelley and Sheryl Kingsberg William Petok and Brennan Peterson

7 “It’s Complicated”: The Intersect Between 16 Counseling Lesbian, Gay, Bisexual and Queer
Psychiatric Illness and Infertility 38 Fertility Patients 88
Katherine Williams and Lauri Pasch Sarah Holley and Lauri Pasch

8 “Be Fruitful and Multiply”: Addressing Spirituality 17 Transgender Assisted Reproductive

in Fertility Counseling 44 Technology 94
Megan Flood and Eileen Dombo Karen Wasserstein
18 A Racially and Culturally Sensitive Approach
to Fertility Counseling 99
III Third Party Reproduction: Assessment Kimberly Grocher
and Preparation
9 Counseling Recipients of Nonidentified Donor V Special Topics in Fertility Counseling
Gametes 49
Carol Toll and Patricia Sachs 19 Resilience in Reproductive Loss 105
Irving Leon

vii

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 Contents

20 Reproductive Trauma and PTSD: On the VI Practice Issues

Battlefield of Fertility Counseling 109
Janet Jaffe 25 Telemental Health in Fertility Counseling 137
Carrie Eichberg and Lauren Magalnick
21 Pregnancy Loss Counseling 114 Berman
Irving Leon
26 Nuts and Bolts of Fertility Counseling:
22 “A Little Bit Pregnant”: Counseling for Recurrent Legal Issues and Practice
Pregnancy Loss 120 Management 143
Mia Joelsson William Petok and Margaret Swain
23 Pregnancy and Postpartum Adjustment 27 Ethical Platform of Assisted Reproduction 149
in Fertility Counseling 125 Jeanne O’Brien and Julianne Zweifel
Laura Winters
24 Walking the Tightrope: The Pregnant Fertility
Counselor 130
Laura Covington and Janet Jaffe Index 156
Online resources are available for download at www
.cambridge.org/covington-case-studies
Password: CaseStudies2023

viii

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 Preface

A case study approach to learning is one of the most field as a result of their own personal experience with
effective tools in many fields, including medicine and reproductive loss. Every patient we see has a reproductive
mental health counseling. It provides a link between history and story that influences the course of therapy, as
theory and practice, allowing for an in-depth, multi- does the therapist.
faceted exploration of complex issues in real-life settings. I am grateful for and deeply appreciative of these
I have heard consistently over my many years of teaching vibrant case studies and the authors’ willingness to
that clinicians relate best and often learn more from the share their feelings about the impact of this work. Their
stories we tell about our work with patients than from all personal experiences enrich the case material, making it
the didactic material they read. Bridging clinical concepts highly relatable for the reader. An essential element in
and real practice is essential in internalizing knowledge. every case is the importance of the therapeutic relation-
The Case Studies volume of Fertility Counseling inte- ship, and as psychologist Carl Rogers noted, the
grates the foundational material of the Clinical Guide empathic, genuine and unconditional positive regard
with common situations that arise in clinical practice. the therapist brings to it. As I went through each of
While the cases presented in these chapters are made up these cases, there were so many that resonated with
from a compilation of clients rather than individual stor- patients I had seen over the years as well as the thoughts,
ies, they nonetheless represent key components and reactions, feelings I had about them and their struggles.
issues that occur in fertility counseling. The authors are I felt I learned a great deal from the concepts and case
all highly skilled clinicians with years of knowledge and analysis presented in both volumes, which is one of the
have generously shared not only their experiences in things I value most in my almost 50 years as a clinician: to
working with fertility patients, but also how they felt have the honor and privilege to continue to learn and
about these experiences. Transference and countertrans- grow from all those I work with.
ference are key counseling concepts discussed in both
volumes and are critically important to address in these Sharon Covington
cases, because many fertility counselors come to the December 2021

ix

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 Contributors

Maya Grobel, MSW

Linda Applegarth, EdD
Licensed Clinical Social Worker, Private Practice,
Clinical Associate Professor of Psychology
CEO of EM•POWER donation LLC,
The Ronald O. Perelman/Claudia Cohen Center for
Los Angeles, CA, USA
Reproductive Medicine
Weill Medical College of Cornell University Kimberly Grocher, PhD
New York, NY, USA Clinical Social Worker, Independent Practice, NY, NJ,
Lauren Megalnick Berman, PhD MD, and FL
Lecturer, School of Social Work, Columbia University;
Licensed Psychologist,
Lecturer of Social Work in Psychiatry, Weill
Fertility Psychology Center of Atlanta, LLC,
Cornell Medical College; Adjunct Professor, Graduate
Atlanta, GA, USA
School of Social Services, Fordham University,
Kate Bourne, BSW NY, USA
Private Practice, Melbourne, AU
Sarah Holley, PhD
Laura Covington, MSW, PhD Professor, Clinical Psychology, San Francisco State
Clinical Social Worker, University, and HS Assistant Clinical Professor,
Shady Grove Fertility and Covington & Hafkin and Department of Psychiatry and Behavioral Sciences,
Associates, University of California, San Francisco, San Francisco,
Washington, DC, USA CA, USA

Marilyn Crawshaw, PhD, CQSW Astrid Indekeu, PhD

Department of Social Policy & Social Work, Licensed psychologist, sexologist, private practice,
University of York, York, UK Hasselt, Belgium, Fellow at Centre for Sociological
Research, KU Leuven, Leuven, Belgium
Eileen Dombo, MSW, PhD
Associate Professor and Assistant Dean & PhD Janet Jaffe, PhD
Program Chairperson, The National Catholic School Co-founder and Co-director of the Center for
of Social Service, The Catholic University of America, Reproductive Psychology, San Diego, CA
Washington, DC, USA
Mia R. Joelsson, MSW
Carrie Eichberg, PsyD Clinical Social Worker
Licensed Psychologist, Boise, ID, USA Shady Grove Fertility and Independent Private Practice
Gaithersburg, MD, USA
Jane Ellis, BA, CQSW
Donor Conception Network, London, UK Loree Johnson, PhD
Licensed Marriage and Family Therapist,
Megan Flood, MA, MSW Independent Practice, Los Angeles, CA, USA.
Licensed Independent Clinical Social Worker,
Washington, DC, USA Laura Josephs, PhD
Clinical Assistant Professor of Psychology at the
Elaine Gordon, PhD Center for Reproductive Medicine, New
Clinical Psychologist, Independent Private Practice, York-Presbyterian Weill Cornell Medical Center,
Santa Monica, CA, USA New York, NY, USA

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 List of Contributors

Nancy Kaufman, LCSW, LP Departments of Marriage and Family Therapy &

Licensed Clinical Social Worker and Psychology
Licensed Psychoanalyst, Independent Practice, Crean College of Health and Behavioral Sciences
New York, NY, USA Orange, CA USA

Erika Kelley, PhD William Petok, PhD

Clinical Psychologist, Department of Obstetrics Licensed Psychologist, Independent Practice,
and Gynecology, University Hospitals Cleveland Baltimore, MD, USA
Medical Center; Assistant Professor, Departments of
Reproductive Biology and Urology, Case Western Rachel Rabinor, MSW
Reserve University School of Medicine, Licensed Clinical Social Worker, Certified in Perinatal
Cleveland, OH, USA Mental Health
Independent Practice, San Diego, CA, USA
Sheryl Kingsberg, PhD
Clinical Psychologist and Chief, Division Arabelle Rowe, MSW
of Behavioral Medicine, Department of Obstetrics Diplomate Member, Association for Behavioral and
and Gynecology, University Hospitals Cleveland Cognitive Therapies.
Medical Center; Professor, Departments of Greenwich Psychotherapy & Associates, Greenwich, CT,
Reproductive Biology, Psychiatry and Urology, Case USA
Western Reserve University School of Medicine, Mary Riddle, PhD
Cleveland, OH, USA Associate Teaching Professor of Psychology, Department
Susan Klock, PhD of Psychology,
Professor, Departments of Obstetrics and The Pennsylvania State University,
Gynecology University Park, PA, USA
and Psychiatry, Northwestern University Feinberg Patricia Sachs, MSW
School of Medicine, Chicago, IL, USA Licensed Clinical Social Worker,
Kristy Koser, PhD Shady Grove Fertility and Covington & Hafkin and
Licensed Professional Clinical Counselor, Associates
Aporia Counseling & Psychotherapy, PLLC Berlin, OH, Rockville, MD, USA
USA Tara Simpson, PsyD
Irving Leon, PhD Licensed Psychologist,
Adjunct Associate Professor of Obstetrics and Shady Grove Fertility and Covington & Hafkin and
Gynecology, Michigan Medicine, Associates
Ann Arbor, MI, USA Rockville, MD, USA

Jeanne O’Brien, MD Margaret Swain, RN, JD

Reproductive Endocrinologist and Attorney in Private Practice,
Chairperson, Ethics Committee Baltimore, MD, USA
Shady Grove Fertility, Rockville, MD, USA Carol Toll, MSW
Lauri Pasch, PhD Licensed Clinical Social Worker,
Professor, Department of Psychiatry and Behavioral Shady Grove Fertility and Covington & Hafkin and
Sciences Associates
University of California, San Francisco Rockville, MD, USA
San Francisco, CA USA Uschi Van den Broeck, PhD
Brennan Peterson, PhD Clinical Psychologist and Family Therapist,
Professor, Chapman University University Hospitals Leuven, Gasthuisberg,
Leuven University Fertility Center (LUFC), Leuven, BE

xi

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 List of Contributors

Karen Wasserstein, PsyD and Director of the Women’s Wellness Clinic, Stanford,
Licensed Psychologist, CA, USA
Shady Grove Fertility and Covington and Hafkin &
Associates Landon Zaki, PsyD, PMH-C
Bethesda, MD, USA Licensed Psychologist
Bloom Therapy
Laura Winters, MSW San Francisco, CA USA
Licensed Clinical Social Worker
Private Practice, Chatham, NJ, USA Julianne E. Zweifel, PhD
Department of Obstetrics & Gynecology
Katherine Williams, MD University of Wisconsin School of Medicine & Public
Clinical Professor of Psychiatry, Stanford University Health,
School of Medicine Madison, WI, USA

xii

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 I Introduction

1
CASE

Collaborative Reproductive Healthcare Model: A Patient-Centered

Approach to Medical and Psychosocial Care
Nancy Kaufman and Loree Johnson

Introduction and medical issues, which she recognized added to her

present feeling state, as did her work as a scientist in an
Nancy Kaufman: I was trained as a psychoanalyst and extremely stressful job. We agreed to work together
have been practicing in New York City for more than 30 weekly in supportive psychotherapy to help her manage
years. When my own fertility struggles went from years of the stress of her impending infertility treatment (see
hopelessness to renewed possibility, this not only changed Chapter 3 in the companion Clinical Guide).
the course of my life, but of my work as well. To help those I immediately felt drawn to her. Highly educated,
struggling through the loss toward a new future became articulate and insightful, she presented as an ideal client.
the focus of my practice. I see individuals, couples and lead Leah understood that her personal history and her partic-
groups for those pursuing family building using donor ular character were responsible for adding to her under-
assistance, which is my particular area of research interest. standable current anxiety. She wanted to know herself
Loree Johnson: I was trained as a systems therapist and better in order to manage through this period. I was
have worked in community mental health and private prac- eager to work with her. Little did either one of us realize
tice during my 25-year career. As with many clinicians, my the long journey we would be embarking on together.
practice evolved as I experienced recurrent pregnancy loss Leah and I formed a working alliance very quickly.
and complicated grief. Initially unaware that infertility and The sessions became a refuge for her – a quiet, safe
loss disproportionately affected women of color, I noticed place where she could let her guard down and her
the shortage of medical and mental health professionals feelings out. Each week, after having contained them
of color within the field of fertility counseling and how in order to function in her life, they came pouring out
that added a layer of struggle to my journey. As a result, in my office.
I am passionate about supporting individuals and couples Initially, I was concerned that I wasn’t offering her
struggling with infertility and loss, especially in commu- enough. But I began to see how the safe space to unleash
nities that feel invisible and are underrepresented within this torrent of feelings with a nonjudgmental listener
the field. enabled her to manage a stressful job and navigate an
The two cases presented in this chapter are a compos- increasingly complex medical situation while remaining
ite of various clients we have seen in our practices that integrated.
illustrate many aspects common to the experience of the Her first IVF was unsuccessful as were several more,
infertility journey. They represent diversity in clinical followed by a very early miscarriage. Her options were
thought, style and training. We think that together they beginning to narrow; her defenses to unravel.
are an excellent companion piece to portray the many Treatment during this phase was first to help her deal
different lenses within the field of fertility counseling and with and recover from each loss and disappointment so
reproductive medical treatment. as not to have them build on each other, as well as to help
her determine what her next steps should be and how
to navigate them. As is often the case with infertility
The Case of Leah patients, each new loss can reawaken prior losses, both
Leah came to see me 10 years ago in my private psycho- fertility-related and life losses in general (see Chapter 21
analytic practice. A 37-year-old, married female, origi- in the companion Clinical Guide).
nally from Israel, she was about to begin her first IVF Leah experienced her infertility as a narcissistic
cycle at a major metropolitan fertility program. injury [1]. Coming from a family that prided itself on
Leah was extremely anxious about the procedure and having many children, she faced the additional burden
reported a long history of anxieties surrounding health of feeling she was letting them down, as well as her

https://doi.org/10.1017/9781009030175.002 Published online by Cambridge University Press

 I Introduction

1
CASE

Collaborative Reproductive Healthcare Model: A Patient-Centered

Approach to Medical and Psychosocial Care
Nancy Kaufman and Loree Johnson

Introduction and medical issues, which she recognized added to her

present feeling state, as did her work as a scientist in an
Nancy Kaufman: I was trained as a psychoanalyst and extremely stressful job. We agreed to work together
have been practicing in New York City for more than 30 weekly in supportive psychotherapy to help her manage
years. When my own fertility struggles went from years of the stress of her impending infertility treatment (see
hopelessness to renewed possibility, this not only changed Chapter 3 in the companion Clinical Guide).
the course of my life, but of my work as well. To help those I immediately felt drawn to her. Highly educated,
struggling through the loss toward a new future became articulate and insightful, she presented as an ideal client.
the focus of my practice. I see individuals, couples and lead Leah understood that her personal history and her partic-
groups for those pursuing family building using donor ular character were responsible for adding to her under-
assistance, which is my particular area of research interest. standable current anxiety. She wanted to know herself
Loree Johnson: I was trained as a systems therapist and better in order to manage through this period. I was
have worked in community mental health and private prac- eager to work with her. Little did either one of us realize
tice during my 25-year career. As with many clinicians, my the long journey we would be embarking on together.
practice evolved as I experienced recurrent pregnancy loss Leah and I formed a working alliance very quickly.
and complicated grief. Initially unaware that infertility and The sessions became a refuge for her – a quiet, safe
loss disproportionately affected women of color, I noticed place where she could let her guard down and her
the shortage of medical and mental health professionals feelings out. Each week, after having contained them
of color within the field of fertility counseling and how in order to function in her life, they came pouring out
that added a layer of struggle to my journey. As a result, in my office.
I am passionate about supporting individuals and couples Initially, I was concerned that I wasn’t offering her
struggling with infertility and loss, especially in commu- enough. But I began to see how the safe space to unleash
nities that feel invisible and are underrepresented within this torrent of feelings with a nonjudgmental listener
the field. enabled her to manage a stressful job and navigate an
The two cases presented in this chapter are a compos- increasingly complex medical situation while remaining
ite of various clients we have seen in our practices that integrated.
illustrate many aspects common to the experience of the Her first IVF was unsuccessful as were several more,
infertility journey. They represent diversity in clinical followed by a very early miscarriage. Her options were
thought, style and training. We think that together they beginning to narrow; her defenses to unravel.
are an excellent companion piece to portray the many Treatment during this phase was first to help her deal
different lenses within the field of fertility counseling and with and recover from each loss and disappointment so
reproductive medical treatment. as not to have them build on each other, as well as to help
her determine what her next steps should be and how
to navigate them. As is often the case with infertility
The Case of Leah patients, each new loss can reawaken prior losses, both
Leah came to see me 10 years ago in my private psycho- fertility-related and life losses in general (see Chapter 21
analytic practice. A 37-year-old, married female, origi- in the companion Clinical Guide).
nally from Israel, she was about to begin her first IVF Leah experienced her infertility as a narcissistic
cycle at a major metropolitan fertility program. injury [1]. Coming from a family that prided itself on
Leah was extremely anxious about the procedure and having many children, she faced the additional burden
reported a long history of anxieties surrounding health of feeling she was letting them down, as well as her

https://doi.org/10.1017/9781009030175.003 Published online by Cambridge University Press

 Introduction

husband and herself. In her mind, Leah was not suc- those struggling on similar journeys (see Chapter 5 in the
ceeding in her role as a woman, a wife or a daughter. companion Clinical Guide). Additionally, she began seeing
Because of my own history of infertility losses, I felt an acupuncturist as another means to control her anxiety.
especially connected to Leah and her pain. I often felt the It was also during this time that we had several ses-
desire to offer hope but was aware that helping her stay sions that included her husband (see Chapter 4 in the
with her feelings of despair is what could actually better companion Clinical Guide). Slightly older, from the same
help her heal and move toward her own feelings of hope. country and also in the same high-stress profession,
I was able to “hold” these feelings for her [2], because they Ari had been a kind and supportive partner during their
mirrored my own past feelings of hopelessness. This 15-year marriage. He was, however, more traditional in
familiarity enabled me to understand her rather than his thinking and needed more time to get used to the idea
judge her, and she felt accepted for all of her feelings of using donor gametes.
even when she felt “crazy.” Once they each moved through the various stages
The rollercoaster of hope and despair continued as toward acceptance of using donor gametes, Leah and
another pregnancy was achieved but was short-lived and Ari came to the realization that they wanted to use a
resulted in another miscarriage. After another period of directed/known donor. They wanted to meet the donor
mourning Leah, along with her husband Ari and their and have the experience of knowing her as a person and
team of doctors, determined that the next step would be to understand her motivation for donating. They actually
considering the use of donor eggs (see Chapter 22 in the hoped to maintain ongoing casual contact throughout the
companion Clinical Guide). years to normalize the method of their children’s concep-
The next years of treatment dealt with this realization, tion story, provide answers to any questions as their
which initially felt like an insurmountable hurdle. Leah children grew up and to always have updated medical
spoke openly about her distress and her inability to move information. They saw an ongoing relationship as a way
forward. At the same time, she recognized that while she to express their gratitude to the young woman who would
moves very slowly when it comes to dealing with painful make their family possible (see Chapter 9 in the compan-
changes, in the end, she is always able to proceed. This ion Clinical Guide). As scientists, they also understood
awareness allowed Leah to keep working toward her that recent developments in consumer genetic testing
overarching goal of motherhood. had rendered the notion of anonymity obsolete (see
She anguished over this decision, grappling with Chapter 13 in the companion Clinical Guide).
her fear that she was giving up too soon in achieving Leah and Ari found an agency willing to facilitate this
a pregnancy on her own. She worked through this by kind of ongoing relationship, after which the painstaking
separating the loss of her genetics from her desire to search for the “right” donor began. When they could not
become a mother and ultimately was able to move proceed with their first chosen donor, they once again felt
ahead with donor assistance. heartbroken and unable to imagine finding anyone else. But,
I recognized that her defense system easily became in time, as they moved from seeing the donor as
overwhelmed and her slow approach to moving forward a replacement for Leah, they were able to accept another
was actually a necessity to remain integrated. Defenses suitable donor.
are, of course, constructed to protect fragile parts of the I found that in treating Leah I would sometimes take
ego [3]. For Leah, I understood that her avoidance of a more active role than I normally would in treating
moving too quickly served as protection against a deeper nonfertility-related clients. Sometimes I provided sup-
fear of being psychically weakened and of regressing. port and encouragement, took part in role playing to
Therefore, I supported her defenses rather than try to help her get used to difficult conversations and corrected
break through them and moved at her pace. misinformation. While I continued to work with her on
Like many other infertility patients, Leah felt betrayed a deeper level to understand how her current losses had
by her body and anguished over the repeated failures in re-traumatized her and awakened internalized fears from
achieving a pregnancy. She would often ask, “What hap- her early history, sometimes more active participation on
pened to my child? I can’t find my child,” illustrating, my part proved to be essential.
clearly, that a longed-for child can be emotionally present Leah spoke English fluently, but it was not her first
even when physically missing [4]. language and so was not the “language of her emo-
In order to come to terms with her feelings regarding tions” [5]. After years of working together I became
the use of donor gametes, Leah joined a support group for accustomed to the lyrical rhythm of her speech and

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 Collaborative Reproductive Healthcare Model

the deeply conveyed emotions she expressed. When During this time, Leah and I continued our work on
she occasionally misused a word, I understood her the telephone (see Chapter 25 in the companion Clinical
intent and felt immersed in her world. If she could Guide). With her permission, I contacted a psychiatrist
not think of the appropriate English word to explain who specialized in postpartum issues so that she would
something I would ask her to say it in her native have someone to consult if necessary (see Chapter 7 in the
language. Rather than a barrier, the flow of language companion Clinical Guide).
in our sessions, which were conducted in English, felt I was also concerned about myself. Would I be respon-
like another point of connection between us. sible if something happened to her? What if something
Leah was a deeply religious woman and often saw her happened to the baby? I found that I was thinking not only
infertility through this lens: “It is up to God to give me of them but also of my own potential culpability in this
a child, when He is ready.” This thinking served to give Leah situation and how best to protect myself (see Chapter 27 in
hope and was a way to explain the injustice she deeply felt. the companion Clinical Guide). Leah elected not to see that
A recurrent theme, however, was that Leah felt she referral, but she did begin to find other ways that helped
was committing a sin by pursuing fertility treatments and her begin to feel more and more in control.
feared she might be severely punished. Despite feeling It was my understanding that during this period
plagued by this thought, she continued to seek out reli- her mother-in-law, who had come to “help,” was actually
gious leaders until she finally found one who understood undermining Leah’s confidence at every turn. Her
her faith as well as her deep desire to become a mother. mother-in-law criticized Leah’s attempts to care for her
When this rabbi gave her his blessing, Leah decided to baby and virtually took over, leaving Leah feeling even
accept his words, but it was years before she felt able to more inadequate. She was so tired and demoralized that
practice her religion again. she could not put up much of a fight. But the stronger she
This religious aspect aroused strong feelings in me. became the more she saw how this dynamic had affected
I did not share Leah’s views but was I helping her her and had always been operating in her relationship
commit a sin? Would I be responsible if she experienced with her own mother as well. This terrible period actually
some kind of “punishment?” Sometimes she wondered began a new awareness for Leah, helping her to establish
whether the repeated failures to become pregnant were a new sense of self as the mother of her child, separate
that punishment. Was I responsible for that? Some of from both her own mother and her mother-in-law.
these feelings were what I believed to be common self- When her second child was born two years later using
examination, but mainly I believed they were “induced the same donor, Leah felt much more confident as
feelings” [6], namely that they were Leah’s feelings a mother and was able to maintain firmer boundaries
rather than mine and were induced in me through the with her mother-in-law, who once again came to help.
powerful transference connection between us (see She was able to carve out space for herself as the mother
Chapter 8 in the companion Clinical Guide). and caretaker of her new baby, while her mother-in-law
After struggling to find a donor with whom they felt was given the role of helping her older child as
compatible, Leah and Ari forged a very positive connection a grandmother.
with Frannie, the donor they ultimately chose. Leah worked For many years, Leah had attended a support group
very hard to keep her fears under control and was able to focusing on disclosure issues in donor-assisted reproduc-
maintain a close and collaborative relationship with Frannie tion. Initially, she worried whether she would be able to
[7]. Talking through each fear with me allowed Leah to tell her children their story without feeling overcome with
voice her concerns without taking them back to the donor grief at the losses she had suffered. Hearing how others in
and potentially damaging that relationship. the group had worked through similar feelings helped her
Following a first failed donor egg cycle and additional feel prepared and empowered. Her primary identity had
heartbreak, they were successful on the second attempt and shifted away from being an infertility patient to that of
began the new journey of finally being pregnant. After an a mother.
anxiety-filled but otherwise normal gestation, Leah’s Leah’s son knew of the donor, Frannie. Although they
mother-in-law came to assist them in taking care of their lived in different states, they remained in contact, just as
newborn son. It was not an easy time. Leah was filled with Leah and Ari had hoped. Their experience together was
panic, anxiety and feelings of inadequacy, finding herself in so positive, in fact, that Frannie was also the donor for
an unfamiliar role while totally sleep deprived (see their second child 2 years later (see Chapter 14 in the
Chapter 23 in the companion Clinical Guide). companion Clinical Guide).

https://doi.org/10.1017/9781009030175.003 Published online by Cambridge University Press