Parental coping with sudden infant death after donor insemination: case report

Rupert Conrad1,2, Guntram Schilling1 and Reinhard Liedtke1

1 Department of Psychosomatic Medicine and Psychotherapy, University of Bonn, Sigmund Freud Str. 25, D-53105 Bonn, Germany

2 To whom correspondence should be addressed. Email: cr.bonn{at}t-online.de


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
We report the case of an artificial donor insemination couple experiencing sudden infant death of their 8-month-old child. Six months after the incident, the couple were investigated by means of an extensive interview, a repertory grid investigation and the Family Assessment Measure, as well as at 6 years after the incident by an extensive interview. The results show the importance of the diagnosis of male infertility and the preceding fertility treatment for coping with the death of their child. Six months after the incident, acute feelings associated with bereavement are mixed with feelings of anger and shame, apparently due to the experience of infertility. However, secrecy and shame associated with male infertility and donor insemination make it impossible for the couple to communicate their feelings to each other or to friends and relatives; furthermore, they decline psychological counselling. Repertory grid investigation and the Family Assessment Measure point to significant problems within the partnership. Six years after the incident, the couple's relationship is destabilized and both partners plan to divorce. We suggest a possible link between donor insemination secrecy and difficulties with coping. We discuss implications for couple counselling and emphasize the necessity for an improved legal framework for donor insemination in Germany.

Key words: coping/donor insemination/psychological counselling/secrecy/sudden infant death


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
The decision to agree to donor insemination (DI) is often achieved only after years of frustration because of unsuccessful medical treatment. The infertile husband may give his approval because he is highly motivated to satisfy his wife's desire for a child, and he may see DI as a possibility to hide his physical defect from others. However, he has to face the fact that there will be no genetic link to the child. The female partner may see DI as the last chance to experience pregnancy and to bring up a child in the partnership (Wright et al., 1991Go).

Both partners may consider DI as a chance to consolidate their partnership and to give their relationship a new perspective. Thus, the arrival of the DI child might have a significant effect on the improvement of the couple's relationship (Durna et al., 1995Go; Daniels et al., 1996Go) and several studies show good marital adjustment in the majority of couples even years after successful DI (Klock and Maier, 1991Go; Klock et al., 1994Go; Brewaeys, 1996Go).

In view of these facts, sudden infant death (SID) after DI might have an even deeper impact on the couple's relationship than on the relationship of those having conceived in a natural way. In the light of the taboo surrounding male infertility and DI, it may also be extremely difficult to share the experience of SID with others.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
We report on a DI couple experiencing SID of their 8-month-old child. (The couple were investigated in the course of a study at Marburg University Hospital, in which 57 DI couples were included consecutively. The study aimed at investigating the relationship of DI couples and their attitude towards the DI child. For legislative reasons there is no DI at the Department of Andrology in Marburg (Head W.Krause) and most other hospitals in Germany.) The case report is based mainly on the thorough examination by an extensive interview, the Family Assessment Measure (Skinner et al., 1983Go), and a repertory grid investigation 6 months after the incident, and a further interview 6 years after the incident. Asked about their motivation to take part in the study, the couple said that by communicating their experiences they wanted to help other couples in the same situation.

At the time of the first examination, the couple had been married for 12 years. The 46-year-old husband worked as a toolmaker and his 30-year-old wife worked as a secretary.

In the interview, Mr S. reported that he was shocked after having been diagnosed as being infertile. ‘The diagnosis was a severe blow to my self-esteem...I could hardly believe it.’ However, immediately the couple made every effort to fulfil their desire for a child. The couple applied more than 130 times for adoption. [In Germany, the adoption law emphasizes that there should be a natural relationship between the adopted child and the parents. In practice, adoption agencies conclude from this law that parents who want to adopt a baby should be not older than 35 years. Older parents (Mr S. is 46) are allowed to adopt older children (from the age of 6). However, Mr and Mrs S. wanted to adopt a baby.] There was a general couple counselling by the fertility practitioner before DI treatment. However, Mr and Mrs S. were afraid that the couple counselling might be a kind of intrusion into their marital relationship, especially after the disappointing experiences with regard to adoption. ‘We just wanted to solve this medical problem; at that time we weren't really interested in other issues. We always thought that, without any reason, our suitability as parents was questioned. Therefore, we declined further counselling’ Mrs S. explained. Altogether Mrs S. underwent 18 cycles of DI at different fertility clinics, until she became pregnant. Between the 4th and 5th month of pregnancy, sonographic examination showed that the fetus was too small for its gestational age. Mrs S. was admitted to hospital in the 6th month of pregnancy and shortly afterwards the vaginal delivery took place (30th of week gestation, birth weight 520 g). Suffering from respiratory problems, the infant was in intensive care for 4 months. ‘Every day we went to hospital, the nurses and doctors were very friendly, they gave us hope...they suggested talking to a psychologist. However, we could not imagine that this could help. At home we avoided talking about the child, it was a very difficult time...I felt lonely’ Mrs S. said. ‘So did I’ Mr S. said. ‘If we had talked about this it would have made things worse.’ Mr S added. After having achieved a normal weight of 3500 g the infant was discharged from hospital. About 3 months after discharge, Mr and Mrs S. had found their child lifeless in the crib. ‘I was intensely shocked...I just could not believe it’ Mrs S. described her feelings in this situation. ‘We talked to the doctor...he told us that there was nothing we could have done to prevent it.’ Being asked how they had coped with the intense grief in this situation, Mr S. said: ‘We simply carried on...There was nothing we could do about it.’

Mr and Mrs S. reported that they hardly talked to friends or relatives about the death of their infant, because they had the impression that no one could understand their situation. Advice from relatives such as ‘Another baby will be the best remedy’ made them feel even more helpless. Mr S. explained that he had been anxious not to tell any of their friends or relatives of his ‘infertility problem’ because he was too ashamed. Therefore, he reported he had felt a certain ambivalence towards the child. On the one hand, he had loved the child intensely, while on the other he had always been painfully aware of not being the biological father. Mrs S explained that she was always aware of her husband's ambivalence. This made her also feel ambivalent towards the child: feelings of intense love towards the child were mixed with feelings of guilt towards her husband, whom she could not help in his grief. After having experienced the death of their child, they decided not to make any further attempt regarding fertility treatment.

During the whole course of the interview, neither Mrs nor Mr S mentioned the name or the sex of their dead child, thus distancing themselves from the past experience of bereavement. Mr and Mrs S. repeatedly emphasized that they had only had excellent experiences as far as medical treatment was concerned. ‘There is no one to blame for the death of our child...it is fate’ Mrs S. uttered.

Mrs S. appeared to be very lively and spontaneous during the interview, whereas her husband appeared overtaxed and sickly.

In the second part of this investigation, we examined the couple by means of the repertory grid technique. This technique is based on the assumption that individuals interpret the world in terms of their own personal set of constructs which are bipolar abstractions (i.e. stupid–intelligent) an individual uses to distinguish between similar and different elements in the world (Kelly, 1955Go; Winter, 1985Go). The repertory grid technique aims at quantifying the relative distances between the self (‘How I am’), the ideal self (‘How I would like to be’) and other significant persons (i.e. partner, child) within a set of personally relevant attitudes for the individual under scrutiny. First, a set of personally relevant bipolar characteristics (i.e. lazy–successful) is developed for the individual. Secondly, for each characteristic, scores ranging from 1 to 6 are given to each person (i.e.1=very lazy to 6=very successful). From theses scores, distances between significant persons can be calculated as can be seen in Figure 1. These distances are depicted for Mr and Mrs S. The self-ideal-object plot is used to demonstrate the relationship between the self-concept and between other significant persons (Norris and Makhlouf-Norris, 1976Go).



View larger version (40K):
[in this window]
[in a new window]
 
Figure 1. (A) Self-system of the husband (Mr. S.). (B) Self-system of the wife (Mrs. S.).

 
In the self-ideal-object, plot two orthogonal axes represent self and ideal self. Persons can be located near to self and/or ideal self (distance from 0 to 0.8), neither near to nor distant from self and/or ideal self (from 0.8 to 1.2) or distant from self and/or ideal self (from 1.2 to 2). When a person is situated near to ideal self, it can be interpreted as idealization. When a person is situated distant to ideal self, it can be interpreted as devaluation. When a person is located near to self, it can be interpreted as identification.

For Mr S. the most relevant characteristics in describing other significant persons were ‘healthy–ill’ and ‘obstinate–flexible’, whereas for Mrs S. ‘healthy–ill’ and ‘childless–having children’ were most relevant (i.e. these constructs explain the highest amount of variance within the respective sets of constructs). As it is not possible to describe the method in depth in a case report, we recommend the introduction by Fransella et al. (2003)Go for interested readers or open accessible information on the Internet www.terapiacognitiva.net/record/pag/contents.htm.

As can be seen in Figure 1A, Mr S shows a convergent constellation of his self and his ideal self that means he perceives his actual self as close to his ideal self. He described himself as healthy and flexible. Normally this constellation is interpreted as a sign of high self-esteem, but it completely contradicts the clinical impression of Mr S.'s self-esteem, which is severely affected by his infertility. The dead child is near to himself and to his ideal self, or, in other words, a close and idealized person. His wife has no significant position in the self system.

As can be seen in Figure 1B, there is a discrepancy between Mrs S.'s actual self and her ideal self (divergent constellation); the childlessness deeply affects her self-esteem. In her self system, her husband and the dead child are distant from her self and her ideal self. The partner is characterized as ill, childless and obstinate.

Finally, the couple filled in the Family Assessment Measure (Skinner et al., 1983Go), a self-rating scale that investigates the individual's perception of his/her functioning in the partnership/family. In the Family Assessment Measure, Mrs S. showed no pathological scores, whereas her husband showed pathological scores on the subscale ‘task accomplishment’ (T=66) which can be interpreted as a sign of his difficulty in performing important tasks in family life. Furthermore, he showed higher scores on the subscale ‘affective expression’ (T=65) which can be interpreted as a sign of his inadequate affective communication.

After the first examination, the couple were informed of the possibilities of psychological counselling. However, it became evident that both partners were reluctant to continue consultations in the context of the fertility clinic. They refused further counselling in order to avoid questions from friends and relatives.

In the second interview, 6 years after the incident, the couple's relationship appeared to be destabilized. Mrs S. talked about divorce. She complained that there was not sufficient communication in the relationship.

In the interview, she appeared to be dominant, while he showed a submissive attitude. After the SID, they had made no further attempt to have a child. We were told that there had been no further communication about the loss in the past years. ‘There is no use talking about things you cannot change.’ Mr S. said. Once again, the couple declined any further psychological counselling.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
In our case, the DI couple is traumatized not only by the experience of SID but also by the preceding illness of their child. With respect to Mr S., his coping with the SID is overshadowed by his concern about being infertile. In the interview, Mr S. stated that this diagnosis affected his self-esteem and caused ambivalent feelings towards the child. However, he denied these ambivalent feelings since they were associated with strong feelings of shame and guilt. Thus, he characterized himself as healthy and idealized the dead child. Only by means of strong defence mechanisms such as denial could he keep the experience of infertility from endangering his self-esteem.

The taboo surrounding his infertility even made it impossible to obtain a certain relief by talking to friends or relatives. Furthermore, it became apparent that he was aware of certain difficulties in the functioning of the partnership. However, he insisted on denying a possible link between these deficiencies and his infertility.

Mrs S. said that she was grief-stricken because of the death of their child. However, she attributed it to fate and did not blame anyone. Being aware of her husband's ambivalence towards the child, she felt guilty about her love towards the child. Though she did not verbalize this in the first interview, the position of her husband in her self system—who is characterized as ill, childless and obstinate—seems to be due to her being angry with him and she obviously reproaches him for being responsible for her unfulfilled wish for a child. In her self system, the dead child has nearly the same position as her husband and is distant to her self and ideal self. One might say that 6 months after the incident the dead child stands for his failure.

In the course of time, the aggression against her husband becomes obvious; she blames him for his failures and thinks about separation. No plans or ideas for a mutual future became visible.

Most couples experiencing SID are (or want to be) pregnant again within 1 year after the loss of the child (Dyregrov, 1990Go). The complete renouncement of having another child after the loss supports the view of a pathological grief reaction.

In our case, the secrecy due to feelings of shame and guilt because of DI apparently does not only surround the life but also the death of the donor offspring. This secrecy makes it impossible for the affected couple to obtain the urgently needed psychological support. However, emotional support is highly correlated with long-term adaptation to the traumatic experience (Thuen, 1997Go). In an interesting study about the long-term impact of SID (Dyregrov and Dyregrov, 1999Go), most of the 26 parents studied showed a good adaptation in the decade following the event. However, there was a small group of persons showing an increase of psychopathological symptoms. All these parents had separated in the years after the incident. The authors point to the fact that these couples had not been able to discuss the loss either during the first period following the loss, or in the years after because of a lack of trust.

Our couple clearly belongs to this risk group, since they are not able to speak openly about the loss on the one hand, and they decline professional support on the other. In comparison with other parents, the most important difference after SID seems to be that the death of the child intensely evokes past experiences associated with the diagnosis of male infertility.

This case report illustrates a possible link between DI secrecy and the difficulties in parental coping with the traumatic event of loss of a child. As the European study of assisted reproduction families showed (Golombok et al., 1996Go, 2002Go), only 8.6% of the parents had told their adolescent child that he or she had been conceived by DI. The most common reason was to protect the child; however, more than one-third (35.8%) of the parents were worried about the impact of speaking about DI on family relationships, and 44.6% of the parents wished to protect the (social) father.

However, the secrecy may lead to a psychopathogenic communication linked with problems specific for DI constellations. On the one hand, DI couples may be preoccupied with the question of whether to keep the secret or to reveal it. Landau (2003)Go reports the case of a father who kept the secret and got depressed because he was afraid of being considered a fraud. On the other hand, secrecy and late disclosure may negatively affect the development and identity of donor offspring (Turner and Coyle, 2000Go; Schilling and Conrad, 2001Go; Bonney, 2002Go). A quote from a donor offspring whose mother disclosed the DI after the death of the social father illustrates the problem convincingly: ‘I became very depressed for a while. I wasn't the person I thought I was. And my parents, the people I should be able to trust the most in life, had lied to me for 35 years about something so vital: about who I was.’ (Kirkman, 2003Go, p. 2229).

As our case illustrates, DI is not a simple or quick ‘cure’ for infertility (Mahlstedt and Greenfield, 1989Go). Consequently, extensive psychosocial counselling should take place before DI; it should focus on two issues. First, to learn in which way infertility affects patients individually, and as a couple. This issue might recommend psychotherapy. Secondly, to discuss the specific problems associated with DI such as the couple's attitude towards disclosure, and the possible impact of disclosure or secrecy on the children and their well-being (Mahlstedt and Greenfield, 1989Go; Daniels, 2002Go; ASRM Ethics Committee, 2004Go).

However, this kind of counselling needs a legal framework, where the rights of fertility practitioners, donors, recipients and future DI children are clearly defined. In Germany, further legal regulations concerning DI modalities are urgently required (Schreiber, 2003Go).


    References
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
ASRM Ethics Committee (2004) Informing offspring of their conception by gamete donation. Fertil Steril 81, 527–531.[CrossRef][ISI][Medline]

Bonney H (2002) The psychopathogenic power of secrecy: child development and family dynamics after heterologues insemination. J Psychosom Obstet Gynecol 23, 201–208.[ISI][Medline]

Brewaeys A (1996) Donor insemination, the impact on family and child development. J Psychosom Obstet Gynaecol 17, 1–13.[ISI][Medline]

Daniels KR (2002) Toward a family-building approach to donor insemination. J Obstet Gynaecol Can 24, 125–126.[Medline]

Daniels KR, Gillett WR and Herbison GP (1996) Succesful donor insemination and its impact on recipients. J Psychosom Obstet Gynaecol 17, 129–134.[ISI][Medline]

Durna EM, Bebe J, Leader LR, Steigrad SJ and Garrett DG (1995) Donor insemination: effects on parents. Med J Aust 163, 248–251.[ISI][Medline]

Dyregrov A (1990) Parental reactions to the loss of an infant child: a review. Scand J Psychol 31, 266–280.[ISI][Medline]

Dyregrov A and Dyregrov K (1999) Long-term impact of sudden infant death: a 12- to 15-year follow up. Death Stud 23, 635–661.[CrossRef][ISI][Medline]

Fransella F, Bell R and Bannister D (2003) A Manual for Repertory Grid Technique, 2nd edn. John Wiley & Sons, New York.

Golombok S, Brewaeys A, Cook R, Giavazzi MT, Guerra D, Mantovani A, Van Hall E, Crosignani PG and Dexeus S (1996) The European study of assisted reproduction families. Hum Reprod 11, 2324–2331.[Abstract]

Golombok S, Brewaeys A, Giavazzi MT, Guerra D, MacCallum F and Rust J (2002) The European study of assisted reproduction families: the transition to adolescence. Hum Reprod 17, 830–840.[Abstract/Free Full Text]

Kelly GA (1955) The Psychology of Personal Constructs. Norton, New York.

Kirkman M (2003) Parents' contributions to the narrative identity of offspring of donor assisted conception. Soc Sci Med 57, 2229–2242.[CrossRef][ISI][Medline]

Klock SC and Maier D (1991) Psychological factors related to donor insemination. Fertil Steril 56, 489–495.[ISI][Medline]

Klock SC, Jacob MC and Maier D (1994) A prospective study of donor insemination recipients: secrecy, privacy and disclosure. Fertil Steril 62, 477–484.[ISI][Medline]

Landau G (2003) To reveal or not to reveal a secret. Am J Psychother 57, 122–137.[Medline]

Mahlstedt P and Greenfield D (1989) Assisted reproductive technology with donor gametes: the need for patient preparation. Fertil Steril 52, 908–914.[ISI][Medline]

Norris H and Makhlouf-Norris F (1976) The measurement of self-identity. In Slater P (ed.) The Measurement of Intrapersonal Space by Grid Technique. Vol 1. Explorations of Intrapersonal Space. Wiley & Sons, New York, pp. 79–92.

Schilling G and Conrad R (2001) Secrecy and openness in donor offspring. Hum Reprod 16, 2244–2246.[Free Full Text]

Schreiber G (2003) Current aspects of donor insemination. Andrologia 35, 168–188.[CrossRef][ISI][Medline]

Skinner HA, Steinhauer PD and Santa-Barbara J (1983) The family assessment measure. Can J Community Mental Health 2, 91–105.

Thuen F (1997) Social support after the loss of an infant child: a long-term perspective. Scand J Psychol 38, 103–110.[CrossRef][ISI][Medline]

Turner AJ and Coyle A (2000) What does it mean to be a donor offspring? The identity experiences of adults conceived by DI and the implications for counselling and therapy. Hum Reprod 15, 2041–2051.[Abstract/Free Full Text]

Winter DA (1985) Repertory grid technique in the evaluation of therapeutic outcome. In Beail N (ed.) Repertory Grid Technique and Personal Constructs. Croom Helm, London, pp. 154–170.

Wright J, Bissonnette F, Duchesne C, Benoit J, Sabourine S and Girard Y (1991) Psychosocial distress and infertility: men and women respond differently. Fertil Steril 55, 100–108.[ISI][Medline]

Submitted on May 30, 2003; accepted on December 2, 2004.





This Article
Abstract
Full Text (PDF )
All Versions of this Article:
20/4/1053    most recent
deh705v1
Alert me when this article is cited
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Request Permissions
Google Scholar
Articles by Conrad, R.
Articles by Liedtke, R.
PubMed
PubMed Citation
Articles by Conrad, R.
Articles by Liedtke, R.