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Each advance in assisted reproductive technology (ART) such as the in vitro fertilization raises the question of whether scientific knowledge alone provides an adequate basis for understanding our fertility and its vicissitudes. The issues which emerge from ourselves as fertile/infertile beings have arguably not become simpler through 'miraculous' and expensive procedures on offer from infertility clinics, but yet more complex. The contributors of the study have asked whether experiences of infertility can be advanced by the scientific refinement of techniques which take place in the laboratory, and whether identifying infertility as primarily a medical problem remains the best way forward. They highlight the interface between the medical and the experiential and also the borderland where fertility and infertility cannot readily be differentiated.
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The diverse approach of the contributors opens up dialectic between the scientific knowledge of clinical practitioners and the multilayered psychology of a complex human experience that we label infertility. Unlike other studies on the subject of infertility it has been written from multiple perspectives.
Most of the studies on the issue of infertility, fertility and in vitro fertilization are psychotherapists that were drawn to the psychology of IVF when they found that a new category of patients was consulting them. These were men and women who, in addition to dealing with the traumas of infertility, were now faced with the confusion of all the complex issues associated with IVF. The multiplicity of these procedures, and the dilemmas and choices associated with them, can exacerbate areas of anxiety about an individual's failure to reproduce. Within the last twenty years there have been such radical advances in reproductive technology that a couple who experience difficulties in conceiving are now confronted by a vast area of choices and associated dilemmas which may preoccupy them for the remainder of their reproductive lives.
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Before the advent of the birth pill most women were more concerned about an unwanted pregnancy and the terrors of back street abortions than they were with fears about their fertility. With the medical of reproduction some people have more intense experiences of loss and ambivalence about issues concerning their fertility. It is now accepted that 15 per cent of couples who want to have a child will seek specialized advice from a fertility clinic. Statistics also indicate that one in eighty babies is born as a result of IVF (Saffron, 1994).
With the arrival of in vitro fertilization (IVF) in the late 1970s, an underlying assumption about the divine act of creation proved erroneous. The idea that Man was created in the image of God, which implies that there is something perfect about the creation of man or woman, no longer prevails. The explosion of technological knowledge that followed IVF has revealed a different truth. We now know, through laboratory research, that every act of procreation carries a possibility that up to 40 per cent of eggs may be chromosomally abnormal. On the male side 25 per cent of sperm may also be chromosomally abnormal. For every perfect human being born there has always been a concealed price to pay in natural waste and imperfection. So many difficult issues have been raised by the revolution in IVF that many medical practitioners decided to approach their subject through as many different professional apertures as possible.
This decision will become evident in the studies conducted as each section and result presents the subject from another perspective. Hence, it has become vital not only to be represented professional voices but included first-person accounts of some of the vicissitudes of fertility. It is indisputable that in vitro fertilization has encouraged a destructive split between mind and body; all the studies conducted agree about this and want to restore a balance. The primary concern that the body has become an object of professional scrutiny while the mind, and its emotions, become neglected and isolated in anxiety is the main topic as well. In vitro fertilization is neither a science of fertility, nor a science of infertility -it is about isolating, refining and juggling the mechanics of conception.
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It is not a method by which to understand the Eleusinian mysteries of fertility, or their absence. The individual diagnostic tools of psychotherapy and medicine have both failed, by themselves, to provide a coherent understanding of the experience of infertility. For those who are unable to have a child there are different categories of infertility:
1. Unexplained infertility-infertility for which no physiological causes can be found, and which has failed to respond to any interventions by in vitro fertilization.
2. Infertility as a result of a diagnosed medical condition which does not respond to in vitro fertilization.
3. Infertility which does not arise from a failure to conceive but a failure to carry a baby to term.
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Each of these conditions constellates a different set of psychological issues for the specific individual, or couple, with which they may have to wrestle for a lifetime. It is the subtleties of such differences that we hope to address. For those couples who are unable to conceive, despite medical help, the medical failure can impact on their difficulty in mourning the unsuccessful accomplishment of a family. A diagnosis of infertility can result in a couple becoming deskilled in their procreativity and increasingly reliant on medical experts to bring about conception and live birth. Failure can compound the couple's feelings of impotence, and often affects spontaneous expressions of sexual desire. Procreation and creativity become bound together so that some people may fail to separate the two; unable to mourn their lack of procreativity they struggle to regain some confidence in their other creative powers. The medical of procreativity can create its own obsession pathology and prevent an exploration of loss and destruction which may be crucial to creative recovery and renewal. For those successful couples who achieve parenthood through in-vitro fertilization these issues may no longer seem relevant.
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In the course of the study there some negative aspects of medical successes that are also reflected on. Even in fairy stories there is a price to pay, and the society are reminded of the Grimm's fairy story Rumpelstiltskin. In this story the Miller's daughter is prepared to give Rumpelstiltskin anything in return for his skills in spinning her straw into gold. When she has nothing material left to give, he agrees to complete the task for her on condition that when she falls pregnant she will give him her firstborn child. The Miller's daughter, being naive, acquiesces. The tragic consequences of her uninformed actions are only experienced when, having fallen in love with her baby, Rumpelstiltskin returns to demand his reward. In the course of ART many women, or couples, will go to any lengths to spin straw into gold and achieve their golden fantasy of a baby. They do not always take heed of the long-term consequences, or implications, of their decisions. Some couples will change consultant, or even country, to obtain a baby, regardless of ethical, medical and financial implications (Yeats, 1952).
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It is only retrospectively that they may be confronted by the Rumpelstiltskin consequences of their actions. In the same way that the Miller's daughter is willing to transfer responsibility for her dilemma on to Rumpelstiltskin it is not uncommon to find patients who imbue their medical advisers with magical properties. Many doctors are honest enough to admit that amongst the greatest pressures they are heir to is an uncomfortable godlike transference from their patients (Ellis, 1994).
Psychotherapists do not have a patent on the psychology of transference, which is ubiquitous in its energies. The study considers that familiarity with its phenomenology-by which we mean the ways in which historical events in the life span of an individual may transfer responsibility for themselves, or unconsciously project themselves, on to contemporary relationships-may throw some light on the intense feelings which become constellated around medical interventions. Whenever a doctor facilitates a live birth for a hitherto infertile couple, she/he is at risk of becoming godlike to them. (She/he has spun straw into gold where they have failed and now it is likely that they will transfer, through projection, their own sense of divinity on to the doctor.) One of the medical consultants who were interviewed said that a contributory factor in his divorce was that his wife was unable to tolerate the ways in which his female patients perceived him as perfect! In a similar fashion doctors who fail to provide the correct formula for conception and live births may become demonized by their patients. Whatever the outcome, there can be little doubt that the doctors and staff of all infertility units are subjected to stress as a result of their patients' changing and polarized perceptions of them as people and professionals.
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Regardless of whether someone is fertile, or infertile, the area of reproduction is redolent with symbolic meaning. Since recorded time menstrual blood has been associated with contamination and the diabolic, and it is of no surprise to find that generations of women have perceived their menstrual cycle as 'The Curse'. One can be cursed with being over-fertile or under-fertile and the whole area is alive with superstition and ignorance. Although the ancient concept of Mother Nature, as the mysterious source of all life, was officially cast aside by the Age of Enlightenment, the archetypal imagery of Mother Nature as a living womb, originator and sustainer of life continues to be a powerful symbol of the feminine. One of the contributors reminds us that classical mythology provides us with archetypal examples of the reproductive dilemmas of gods and goddesses which amplify the issues and compulsions of reproductive technology. Many young women who begin to menstruate have not yet separated out their own fertility and sexuality from their mothers' bodies. After becoming sexually active they may still feel that their mother holds their body in thrall. Giving birth to a child can act as a rite of passage into separation, and entry into womanhood. For some women a negative experience of this sense of fusion with their mother can be disastrous, particularly if the young woman goes on to experience reproductive difficulties. It is not uncommon to find, in the course of psychotherapy, that the infertile woman can feel as though she has been cursed by her mother. One woman, undergoing complicated and painful treatment for frequent miscarriages, who felt that her pain remained invisible to her mother, said that she felt as if she had been cursed when she was a difficult adolescent (Donnison, 1998).
She recalled an occasion when she was chatting to her friends about what it would be like when they all became mothers and her mother rebuked her, saying, 'What makes you take it for granted that you deserve to ever have a child?' At the time she experienced her mother as spiteful and it was only later, when she experienced repeated reproductive failure, that she felt that the words were a curse. Another woman said that she felt so afraid of her mother's envy that it wasn't until she was in her forties that she became sufficiently individuated from her to become a mother herself. Her own conception of a child was followed by her female sibling becoming pregnant within a matter of months. Whilst it is well recognized that maternal ambivalence may be a contributory factor to non-biological post-natal depression, many of the contributors to this book also consider that it may be a contributory factor in non- explainable infertility. The revolution in in-vitro fertilization means that professionals cannot feel easy about their applications of technical knowledge without being concerned about ethical and legal aspects of their specialization. If in vitro fertilization is changing the ways in which the society thinks about fertility, then this also revolutionizes our relationships to kinship patterns and genealogy. Society is now faced with a discrepancy between what can be artificially made and what can be created, and the age-old question of the relationship between body and soul demands new debate. Whether we are ready for it or not, we are now forced to take responsibility for our hubris in over-reaching the boundaries of what it once meant to be human.