Lori Gottlieb on Fertility Counseling

Finding Strength and Resilience

Psychotherapy Networker
Magazine Issue
July/August 2020
A smiling woman sitting on a couch

Lori Gottlieb is the author of the New York Times bestselling memoir Maybe You Should Talk to Someone, currently being adapted as a television series with Eva Longoria. She’s also the writer of the popular weekly advice column “Dear Therapist” for The Atlantic magazine. A practicing psychotherapist, she has a specialty in fertility counseling and speaks frequently on mental health topics for media outlets, such as The Washington Post, The Today Show, Good Morning America, and NPR’s Fresh Air.

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Psychotherapy Networker: In your memoir, you write about your experience using a sperm donor service to have your son. What was that process like?

Lori Gottlieb: I had my son 15 years ago, and a lot has changed in the fertility world since then. But at the time, people didn’t really talk openly about using sperm or egg donors, so I was surprised when a friend, knowing I was getting into my late 30s and didn’t have a partner, suggested I look at a sperm donor site. I didn’t even know what that was, and when she explained it to me, I couldn’t wrap my head around what it would be like to choose the genetic material for my child from a stranger off of a website, not only for me, but for a kid who was conceived this way.

The more I explored it, though, the more comfortable I got with the idea. Then the next step was actually choosing a donor, which is a really strange experience. You’re given a donor’s height, weight, hair color, eye color, and SAT score. Usually, they’ve written a short essay about themselves, and you can listen to an audio file where an interviewer is asking them questions like, “What’s your favorite season?” or “What’s your idea of a romantic date?”

The idea is to give you a sense of the person you’re choosing, some kind of human connection—except you’ll never meet this person, let alone go on any romantic date with him. But going through it, I found I was listening for particular qualities. Did he seem to have a sense of humor? Did he sound like a person who was generally satisfied in life? Did he sound resilient, optimistic?

Did these qualities even have a genetic component? I didn’t know. It took me several months to choose because there were so many factors going into the decision beyond just the health history. I’m a short Jewish woman, so if I chose, say, a tall Danish person, would it just add an extra layer of complication to a kid’s life to keep hearing, “Well, gee, you look nothing like your mother”?

Of course, now that my son plays basketball, he’s said, “Why didn’t you pick the tall guy?” I tell him, “But if I picked the tall guy, you wouldn’t have been you.”

Anyway, I finally found someone I was really excited about, but when I went to purchase the vials of his sperm on the website, a notification popped up that said: “Out of stock.” I immediately called the sperm bank and asked, “What does this mean, out of stock?!”

“Well, you picked a very popular donor, and he’s on backorder,” they told me. After all the time it took to find a donor that felt right, I was crushed. At that point, I asked someone I knew in real life if he’d be my donor, and it seemed like it might work out, but ultimately he decided not to go forward with it. Luckily, the donor that I chose from the sperm bank became available again.

PN: What were some of the other challenges you faced that people just starting this process might want to keep in mind?

Gottlieb: There are challenges at every stage. For me, the issue wasn’t having trouble getting pregnant: it was not having a partner. Most people who want to be parents imagine that when the time comes, they’ll have a partner; they’ll be in a loving relationship. If they’re heterosexual, they probably expect they’ll have sex and get pregnant relatively easily.

I see a lot of people in my therapy practice who are coming to terms with a change in their story. Maybe it’s that they’re going to have a baby on their own, or they have a partner but are going to have to use IVF. Or maybe they’ve done several rounds of IVF that haven’t worked, and they’re going to use an egg or a sperm donor, even though they wanted to use their own genetic material. Maybe they’re going to use a surrogate with their own genetic material. Maybe they’re going to use somebody else’s genetic material and use a surrogate. Maybe they’re going to adopt. There are so many different ways to become a parent.

Most people I see are grateful for the opportunity to become a parent, but the story they tell themselves throughout the process affects how they go through it. Maybe they’re not getting pregnant, and suddenly every time they step outside the house, they see pregnant women and babies in strollers everywhere. Every time they get on the computer, a Facebook friend is posting baby pictures or announcing a pregnancy. Their story becomes, I’m the only person in the world who’s not having a baby; I’m alone in this. But if you walk into any fertility clinic, you’ll see it’s packed. A lot of people are going through it, but it can still feel like a very isolating experience, even if you have a partner.

When I got pregnant, it felt to me as if every other pregnant woman had a partner to go through the pregnancy with. I imagined they all had loving, supportive relationships. Pregnancy is such a vulnerable time anyway, because you’re taking care of yourself, and you’re taking care of this person growing inside of you, and you want someone to help take care of you too. But I’ve come out the other end of that, and I’m so happy as a parent.

PN: How has your personal experience informed your work with clients around fertility issues?

Gottlieb: I really empathize with people who are going through that process. I was thrilled to have the opportunity to have a baby in this way, but it was hard at times. Couples who come to see me because they’re having trouble getting pregnant, and have gone through all sorts of treatments, are struggling emotionally. I was lucky to get pregnant on my second attempt through IUI. But I remember the first attempt, when I assumed I’d get pregnant but didn’t. I worried that I’d have to go through more invasive (and expensive) treatments, or that it might take a long time to get pregnant. I remember the anxiety of waiting for results the second time.

For a lot of people, every month is rife with a new round of anxiety and uncertainty. You have hope, of course, but you don’t want to get too hopeful, because you know there’s a chance you won’t get the news you want. So people will start teetering on the tightrope between hopefulness and managing expectations.

It’s especially hard for couples when one partner is dealing with it differently than the other. One person might want to be optimistic about it, while the other is thinking, “I don’t want to talk about it. I don’t want to think about it. I’m going to go through all the steps, but I don’t want to imagine the outcome right now.” You have two people dealing with their own loss, fear, and uncertainty in different ways. How do they work as a couple around that?

”Well, you picked a very popular sperm donor, and he’s on backorder,” they told me. After all that time, I was crushed.

PN: How is fertility counseling different from day-to-day psychotherapy? Is it just applying basic therapeutic tools in a more specific context?

Gottlieb: A lot of people feel like they’re in crisis when they’re going through this, so whatever preceded the fertility crisis will be amplified. In other words, if you’re an anxious person, your anxiety will come out in all kinds of ways. If you’re a person who has a lot of negative stories about yourself, that’s going to affect how you go through it. If you’re a couple who doesn’t know how to support each other or tolerate each other’s differences well, that’s going to make this process even more challenging.

The main difference is that therapists who deal with fertility often are more comfortable in this territory. They know the language, the customs. That’s important to clients, who often feel with family and friends—if they share it with family and friends—that they’re going through something no one really understands in quite the same way. So when they’re talking about their FSH levels on the last test, or that they’re at odds over whether to do genetic PGD testing of the embryos, the therapist should have a general understanding of the lingo and what’s at stake. Clients don’t want to spend their sessions explaining what they’re referring to.

Therapists working with fertility issues don’t need to have experienced them personally, but they should be knowledgeable enough to understand the nuances of what people are going through. Often there’s a lot of shame, or a perceived sense of failure, for having to get assistance to have a baby. Therapists should also understand that many people who might be using an egg or a sperm donor feel that they can’t be open about it because they don’t know how people will react. There’s a cultural element there. Some clients worry that their parents might not treat this grandchild, who doesn’t share the genetic material of that family, the same as other grandkids. So they don’t want to tell their family, even though they might know how toxic family secrets can be.

How do you deal with these sorts of issues? My position is children should be told where they came from, in a developmentally appropriate way, of course. You don’t want it to come out as a surprise later in life, when somebody slips up, or the child grows up and discovers the truth through a DNA test. Although therapists are expected to be objective, and I can’t tell clients what to do, I can certainly help them think about what it might be like psychologically for a child who’s already begun to form their identity to hear, “Oh, by the way, I’m not your biological parent,” or to grow up feeling that there’s some secret lurking in the house.

I often talk to clients about the difference between privacy and secrecy. Secrets can be toxic, but how can you ask friends and other family members to keep something private because you want to deal with it in a certain way with your child? How do you get comfortable enough with it so you’ll be comfortable talking to your child about it? Those are the kinds of issues therapists can talk about with people who are going through this process.

PN: What’s the most rewarding part of working with fertility and reproductive issues for you?

Gottlieb: I think that people who go through this find out how strong and resilient they are, no matter the outcome. As with any life challenge, it helps people to get to know themselves better, to understand more about meaning and purpose in their lives. It’s often a long, hard road, and at some point, I’ve had clients say, “You know what? It’s enough. We could keep trying, but at what cost to our psyches? At what cost to our marriage, our well-being?” Maybe they’ve been through six rounds of IVF. Maybe they’ve purchased three rounds of donor eggs, and none of the transfers worked. Or they’ve had repeated miscarriages. Maybe they’ve tried to adopt, and the adoption fell through twice. In other words, they’ve been through the wringer.

Fertility counseling is like any other form of therapy, in that we try to help clients understand themselves better so that they can make thoughtful decisions about what’s best for them. This is especially difficult when partners aren’t on the same page about how much they should try in the service of having a child. That was case with one couple I saw, and it was breeding a lot of resentment.

I remember thinking, “I wish they’d just try this one last thing.” But obviously that wasn’t for me to say. I had to talk to my consultation group about that one, because I felt invested in them not giving up. Eventually, they came to a place on their own, without resentment, in which they agreed, “Enough is enough. We’re good. We’re going to stop trying, and it’s going to be okay.” They’re happy, stronger for having gone through it all.

I’ve seen people find incredible meaning and purpose in their lives after deciding to stop trying. They find ways to give to the community, to children in other ways. The process of infertility treatment often forces people to self-reflect in ways that many people who have babies the old-fashioned way may not. And if they do eventually become parents, they tend to be incredibly self-reflective, thoughtful parents.

PN: What does a successful outcome most often look like for you?

Gottlieb: Fertility counseling is about helping people travel whatever road they’re on, and accept and embrace wherever they might end up. Personally, I’d always imagined not only that I’d have a child with a partner, but that I’d have more than one kid. After I had my son, I was so in love with him that I immediately started thinking about having another. I had extra sperm from the donor and didn’t have fertility issues. But every time I drove to the clinic, I’d end up sitting in the parking lot, unable to get out of the car. I couldn’t imagine how I’d be able to raise two kids on my own.

This went on almost every month for two years, where I’d sit in the parking lot on the day I was ovulating and wouldn’t be able to go in. Finally, I had to go through a process of grieving the idea of having this other child.

I remind myself of this when I’m with my clients: that there can be loss, but also joy and meaning in so many forms. That’s why I don’t like the “success” or “failure” language that you hear a lot through this process. Even with a “successful ending,” there’s been some loss, and sometimes that’s traumatic. I know trauma sounds like a big word here, but it can be traumatic for people to go through so many ups and downs in trying for the one thing that’s so important to them. It can really take a toll.

PN: What’s something you wish every therapist knew about this?

Gottlieb: I want them to understand the depth of the loss for people going through this, and the ambiguous grief. Often, you’re grieving a child that you’ve never met—every cycle. Lots of people don’t get that. Some therapists might say, “Well, you didn’t get pregnant this time, but there’s always next cycle.” Or “It was a chemical pregnancy, but you can always try again.” Whatever the situation, there’s a whole reproductive story associated with an imagined child that they lost. Every single month they lose that.

It’s important too for therapists to scan for strengths as people go through this process—and to help their clients see those strengths for themselves, how they’re managing well, how they’re coping well even in challenging circumstances. Therapists should make sure they’re holding that in the room at the same time that they’re holding all the grief and the loss.