The compexity of intergenerational psychic transmission in medically assisted pregnancy (MAP): Extrneousness into familiar

“My belly has been a hotel”

The therapist meets Margherita and Marco in the hospital after the diagnosis of infertility that the gynecologist had communicated to the couple. The therapist sees them in the hospital. The couple are invited by the gynecologist to ask for an interview with the psychotherapist.

In the first session they both appear tried and confused. They seem to have to justify themselves, “We’re not even 35 years old!” they repeat, “This was just not planned.” The therapist’s first response is also one of surprise and sorrow: a concordant countertransference (Racker, 1960). He thinks they feel scared and guilty for having waited too long before deciding to have children but, as the interview goes on, the initial countertransferential response turns into one of urgency of having to buffer their pain.

The therapist offers them a second interview which they miss without notice. The therapist’s second countertransference response seems to link to the couple leaving the therapist waiting, which results in a mixture of anxiety, anger and guilt. The urgency to buffer the pain with actings runs throughout their entire journey. We know that “doing” anticipates the possibility of thinking, allowing us to experience what is happening through action.

The therapist next meets the couple almost two years later at a “pre-partum class”. Margherita is in an advanced state of pregnancy, in a group meeting she declares that she is expecting twins. Very surprised, the therapist thinks that the diagnosis of infertility had been wrong. Finding it hard to concentrate throughout the meeting with them and with an internal feeling of amazement and perplexity, he finds himself curiously fantasizing about what might have happened.

The amazement and perplexity which the therapist feels are linked to a sense of the uncanny and the “extraneousness”.

When the group meeting is over, the therapist discreetly acknowledges the couple. They ask him for an appointment to “tell him the news”. At the appointment they appear beaming, in a state opposite to the one he had observed in the first meeting. They tell him that after the initial shock of being told of the infertility diagnosis, they had been very upset for a few days. Following this they contacted a clinic abroad, where they subsequently underwent a donor-donor heterologous fertilization process. The speed with which they found a solution to their infertility diagnosis was an acting about how they responded to frustration and disappointment, by buffering pain and guilt.

“My belly has been a hotel”, Margherita says, expressing something between emotional detachment and embarrassment. She adds that only her mother-in-law, a health care provider, had been made aware of the matter. They had decided to keep it a secret from everyone else. When asked by the therapist if they had any fantasies about the twins, they replied that they had none, but that they hoped the girls would not look too different from them so as not to raise “embarrassing” questions. Their answer seemed to speak of a block about the possibility of fantasizing and “dreaming”, not only about daughters, but also about couple relationship. Their response thus raises the question: What happens with the diagnosis of infertility that dissociates sexuality and procreation irreversibly?

We cannot fail to emphasize that the term embarrassment also refers to fecundity.

What could have been the embarrassing questions for each of them and for each other? The therapist tries to understand what motivates them to keep the secret Their response indicates that they believe that their parents would have suffered greatly from knowing about their infertility as they were both only children. They also feared that they would not become as attached to the girls as they would if they were their natural granddaughters. What they say to the therapist indicates a number of issues:

1. The displacement of their suffering onto their parents (the projective identification of their suffering) seems to speak about their need to take time to process the events leading to their pregnancy.
2. The fear of not becoming attached to their daughters as extraneous factors

related to their pregnancy seems to lead them to maintain a detachment in the link, which prevents them from fantasizing and dreaming about them.

3. The need to maintain secrecy about their infertility seems to have a close relationship with the transmission of a fantasy that children are made for parents, grandparents, and the continuation of the family’s genetic line plays out. How does the inescapable presence of extraneous factors in their pregnancy impact on inter- and trans-generational psychic transmission?

The therapist seeks ways to help them integrate what they have projected, but encounters rationalizing responses, particularly from Marco.

The couple seems to have jumped into heterologous fertilisation as a way of avoiding the difficulty in thinking through the complexity of the situation which emerged when they received the upsetting diagnosis of infertility.

The therapist can’t work consistently on this issue due to resistance, so he tries to help them through some critical moments, such as the conflicts about breastfeeding. In one session the therapist learns that the daughters have different hair color to their parents, which elicits ironic jokes from the family. Marco’s reaction is extreme: when the children begin the kindergarten, he “falls in love” with a separated colleague with two children. He abandons Margherita and their daughters and moves to live in the new partner’s house. He buys a new apartment without consulting with anyone. This behaviour results in his exclusion from the family clan: his own parents support Margherita and the granddaughters.

In an interview following the separation, Marco says that his new partner was unaware of his infertility, and comments: “She already had two children anyway and wasn’t intent on having more, so I didn’t need to tell her my business.” Consequently he is able to deny his own infertility, but a denial is by definition a denial of something that exists; as with the integration of projection, so with denial Marco says that he needs time.

At this point the diagnosis of infertility overshadows the issue of heterologous fertilization, and the move to the new partner turns out to be an acting that allows him to “hold in abeyance” (Nachtraeglichkeit) everything that had happened to them. The enactment of this mechanism confirms that the diagnosis of couple infertility had been traumatic for them.

The therapist continues to work with Margherita and the girls on what happened, but the “secret” issue remains unaddressed. After some time, the kindergarten teachers repeatedly report that one of the girls is beginning to show sadness and a lack of appetite.

The therapist helps Margherita to talk it over with Marco, who promptly breaks off the relationship with the other partner and asks Margherita if he can return  home.

Margherita accepts with much difficulty and binds the return to a therapeutic path of couple therapy. Marco agrees, but on the condition of finding a new therapist: theirs had seen “too much shame” and he did not feel like meeting with him.

Countertransferentially, the therapist feels devalued and experiences much anger. Is he being used as a depository of the group-family issues moved with the infertility diagnosis?

Do the child’s sadness and lack of appetite speak of a depressive element present throughout the family of which the child is emergent? Do they speak of the difficulty of emotional contact present in the two families of origin? On a manifest level there appears an emotional distance among everyone, which controls curiosity and sexuality and prevents any differentiation or relationship of intimacy.

Through sadness and lack of appetite, the familiar which is present in the extraneousness, that the daughters introduce into the situation with their birth, comes to the foreground.

The term extraneous (from Latin extra, outside), relates to the semantic field of foreign, strange, outlandish, external, onto which unrecognized parts of the self are notoriously projected because they are felt to be unacceptable.

1. Langer (1951), an Argentine psychoanalyst, notes that anxiety and excessive hatred towards the mother seriously affect children’s fertility. She makes a connection between a bad relationship with the mother and subsequent fertility problems in children; she describes family scenes with very demanding and often devaluing mothers and a passive father, somewhat in the background, or a domineering father and a depressed mother. In each case, M. Langer stresses that the crucial factor is that the other spouse is unable to mitigate or block the harmful influence of the frustrating parent.

Marco describes his mother as a very authoritarian woman and his father as totally subservient to his wife. The authoritarian style of his mother was experienced by Marco as a pressure for perfectionism. Margherita recounts that, when she was 16 years old, her parents separated and were separated for 10 years. She was not aware of the reason for their separation, other than “couple fatigue”. Her parents re-united when her father was diagnosed with a neurological disease. Subsequently her mother decided to devote herself to caring for her husband. Margherita never asked or talked about this because she imagined them as too vulnerable. Of course, if one cannot speak of the situation experienced as shameful, the situation itself remains stuck in a repetition that is transmitted to successive generations.

In reviewing the case, we focused on the therapist’s countertransference not as a response to a neurotic transference but as something more akin to reverie, to dreaming (Bion, 1962), where the image does not translate into a thought but rather introduces a possibility of thought, which begins to give form to undifferentiated elements in both the intergenerational and the transgenerational transmission.

The couple in MAP

Usually, infertility is seen as an issue attributed to one member of the couple not to the couple. In this way it becomes difficult to enter fertility/sterility from perspective of the relationship.

What does it mean to enter the question conceptually looking at infertility from the perspective of the couple relationship? It means that the “sterility” symptom becomes the emergent issue of the couple’s affective-sexual conflict and of the difficulty of differentiating themselves from their families of origin.

MAP pushes for a dissociation between sexuality and procreation; a third party may appear in the scenario – the medical team – who at times, as a “powerful male” (Oedipal fantasy), arouses echoes of guilt in the woman and jealousy in the man (Vegetti Finzi, 1997). The scenario is more complex in the case of heterologous fertilization, where it is important to elaborate the fantasies relating to the gamete donors. For example fantasies about ghosts that hover around the conjugal bed. In the first stage of a longitudinal qualitative research project relating to couples who turn to MAP, in 13 cases both members of the couple participated, while in the other 8 only the woman chose to participate, for a total of 34 subjects. Using the graphicprojective tool The Double Moon Drawing³, which taps indicators of the family image that the partners have, the initial results indicate that in 9 cases the nuclear family is not represented, Only the family of origin is represented; in one case the family is designed only by one of the partners. In all the protocols the extended family is drawn. The results highlighted that even in the case of a MAP. there is generational interweaving involved in the desire for a child. The interweaving can be gradually differentiated if the family is offered therapy that allows it to assume its own boundaries with respect to the family of origin.

Biological link and parenthood

Parenthood is developed in a process where the functions – of mother, father and child – gradually become clearer and more complex. The construction of a “mental space for the child” (Carau, 1995), is based on the intertwining of different systems – biological, nurturing-educational, historical, paradigmatic and social – which ensure the newborn the possibility of assuming its own biological link, to receive affection and care, to take root in the family body and to be introduced into the community of origin (Greco, 2001; Greco, Rosnati, 2006). Each system contributes to the construction of the child’s identity: in particular, the resonances of the biological register become clearly evident when it refers to parental figures different from those who perform other parental functions, as in the case of heterologous MAP. On the one

3 The Double Moon Drawing (Greco, 1999, 2006; Greco & al., 2020) is a graphic-projective tool that aims to make explicit how the sense of belonging is experienced by a subject, a couple or a family, when the family situation is structurally complex, (as in the cases of families with children born with MAP, in particular heterologous), where there is a dialectical process between elements that are close or “present” and elements that are distant or “absent”, with respect to which a conflict of belonging may emerge.

hand there is no biological link for one or both parents, on the other hand for the woman there is the physical link that develops during pregnancy, except in cases of surrogacy.

In MAP, parents are defined as “social”, “customer” or “intentional”.

The theme of blood ties is vividly present in the representational scenario of the couple who, after discovering its own infertility, usually refuse to consider adoption precisely because a fundamental value is given, often explicitly, to “blood ties”, that is, to the biological dimension. However, during the long process of heterologous MAP this theme is bypassed, in the implicit fiction of the “as if”. The decision to maintain secrecy is linked to this issue, sometimes only with people outside the family, sometimes with the same family members and even with the child born from MAP. In any case this request, previously denied, is destined to resurface every time the child does not correspond to the desired child and risks being perceived as a stranger: an element that links to the fact that to the extraneousness is always present in the familiar.

An idea of the origin of psychic life: human development and symbiosis

For Bleger (1967) the starting point of human development is a state of primitive undifferentiation between the child and the mother. The process of differentiation passes through the undifferentiated or syncretic mother-child unity in which the most primitive sensations predominate, in particular kinesthetic sensations, motor sensations and deep proprioceptive sensitivity. Differentiation begins directly at the body level. Fenichel (1945) and Wallon (1941) anticipated this view and saw as they at first the object for the babies not clearly differentiated. Perception and motility are almost one, and the perceptions corresponding to the various sensory organs overlap and function in a non-separate way.

There is a basic level of perception, in which the encounter is not perceived as an encounter between two parties, but as a unity which is characterized by some event which qualifies it – a laceration, an emptying, a leap into emptiness, an evaporation, a condensation, a freezing.

The process of differentiation occurs because parts of the undifferentiated structure are elaborated through dissociation (Spaltung), whose function is to separate and differentiate what until then was an undifferentiated whole; the differentiated, separate and identified elements that are produced will gradually build up the more evolved parts of the personality. We can thus distinguish two parts in the psychism: an “undifferentiated part” and a “differentiated part”.

Stern (1985) has described the transition between emerging self and nuclear self: the nuclear self arises as a form of differentiation between subject and object, while in the emerging self they are still largely undifferentiated. The adult’s ability to be a reliable depository for the baby and in turn, for the baby to make a more differentiated use of their sensory functions (sight, touch, hearing, perceptivity, visceroreceptivity) will contribute to differentiation.

According to Bleger the underlying perceptive nucleus of the child’s first relationships with the mother is never lost but remains cleaved in an area (agglutinated nucleus) from which it can break out if conditions of crisis, trauma or transformation occur.

One may wonder what characteristics the mother-child symbiosis might have when the development of the embryo takes place outside the woman’s body, with the risk that a sense of extraneousness and anxiety develops during pregnancy, especially when the mother receives a frozen embryo, moreover generated from gametes not her own.

Psychoanalytic aspects of the procreative function

Certain schools of psychoanalysis have long underlined the dialectic between the couple’s relationship and the relationships of each partner with his or her family of origin, inextricably intertwining three generations.

1. Langer (1951) explains the unconscious internal dynamics that sustain this precious passage. The mother-daughter relationship becomes central to unravelling the plot traps of the often complicated, and almost always unconscious, creative function.

She notes that it is an ambivalent relationship, fraught with guilt from the beginning, and for this reason particularly intense and involving. Is it possible to hypothesize that there is a link between guilt, an ambivalent relationship, envy and sterility? Pregnancy or its opposite, infertility, become the stage where this game is played out to the end and the fantasy about who you are having a baby with takes relevance, while, in the case of MAP, the problem could become whose child it is.

Meltzer (1973) enters the question by distinguishing between projective identification and introjective identification, as the dominant modality in the procreative function. According to the author it is a fact of psychic reality that the newborn is, in the sense of possession, only the mother’s child. The father can, in fantasy, support its existence and defend it from persecutors, but the existence of the newborn is coextensive with that of the mother, it is “always” within her. As long as a woman experiences her pregnancy as her own, she can mourn any previous miscarriages or infertility: the pregnancy is perceived and constructed through introjective identification. Conversely, if the physical pregnancy has not been understood in its psychic reality and the dominant quality is that of projective identification, the pregnancy can be felt as belonging to the internal mother. In these cases, what is felt as a “burden” and unconsciously rejected can be unloaded on recourse to medicine.

As in the tale of King Solomon, if the woman is in projective identification with the internal mother, it is not known whose child it is. If the child belongs to the woman, she can decide to give life, but if the child is not hers, he/she can be left to die because he/she is someone else’s child.

In the differentiation between introjective and projective identification, Meltzer seems to create a link between the mother’s aggression towards her son and the daughter’s unprocessed aggression towards her mother.

If she feels her son like her own, he is not attacked and, as in the tale, King Solomon’s proposal to cut him in two is refused, but if her fantasy is that he has been stolen, aggression towards him emerges.

This fantasy is found acted in many cases of MAP and, if active, prevents a gestation and a subsequent peaceful relationship of the mother with the child.

Working through the theft fantasy allows one to get out of the confusion with one’s mother and to include the father. A triangular situation is created which allows us to get out of the confusion between generations and between parental functions in the intergenerational transmission.

Lebovici (1989) distinguishes the imaginary child, “constructed” by the woman for her partner, and the fantasized child, created by the mother’s unconscious as the child of the maternal grandfather.

According to Darchis (2009), becoming a parent is a process that arises from a double movement of identification: on the one hand with the child you have been and with what you would have liked to be, on the other, with the parents one has had and with those one would have liked to have. The representation of one’s own experience as children is one of the crucial areas that is activated in both situations where one begins to “conceive” the idea of a child and when the child is actually conceived.

A challenge for the clinic: accompanying couples in the process of MAP

The birth of a child implies a review of one’s experience as a child which for the woman is played out in the primitive relationship with her mother, a relationship starting from which the woman can have a child of her own. The psychological aspects that can interfere with the partners’ procreative and parenting abilities are destined to remain, if not treated, even when the medically assisted way reaches the finish line, often after painful failures.

Hence the need for a space both to explore the psychological factors involved in infertility, and to make explicit fears, desires, fantasies relating to the child to be born, putting thoughts where there is only impatience. This is especially the case for couples who have been looking for a child for years, and investing in expensive MAP whilst trying to sidestep their psychic difficulties?

Extraneousness

In the clinic, we can observe the consequences of the unconscious psychic activity that the couple implements in order to deny, split or forclose the impact of extraneousness influences that relate to relationships, people, places, times, atmospheres that predate not only their relationship, but their own lives. The defensive mechanisms are therefore brought into play in order to cope with possible risks of disintegration and contamination of their identity.

The experience of extraneousness in relation to one’s own and one’s “familiar” can be captured in adolescents towards their parents but also in parents towards their children. Sometimes it emerges in one of the family members in the moments preceding a psychotic break. These are often transient phases, but they are very important as they signal strong changes in progress.

Philosopher Bernhard Waldenfels (2011) points out that extraneousness is not a deficit but «an experience of encounter according to a structure of absence/presence (…) in which the extraneous appears as what cannot be integrated into the whole» (2011, p. 75) and which «becomes relevant only when it comes into contact with an extraneousness of myself» (ibid., p. 73). The paternal function works in this sense as a third extraneous, preventing the mother from reabsorbing the child within herself.  Reference to Freud’s term Unheimlich (1919) here is inevitable, precisely because of its meanings of uncanny proximity, near distance, absence/presence (Curi, 2010). Arising from the lack of an opposition between “home-not-home”, between “familiarextraneous” is a sense of the uncanny whereby the stranger does not come from outside but from within.

Recognizing and accepting this quality of the relationship of extraneousness can activate unexpected processes of learning, enrichment and change in those involved. Sartre (1964) tells us that the extraneous is absence in the flesh and blood, pointing to an experience in which the other is there in the mode of non-being.

This mode of non-being in experience seems important to us in the vicissitudes of the couple in MAP, where extraneousness is buried and made irretrievable giving rise to a perception of nonexistence.

Therefore, we can think of an unconscious misunderstanding of the couple, whereby what is made irretrievable by the processes of denial and foreclosure is mistaken for nonexistence, and everything is understood starting on the common familiar.

We believe that a MAP does not result in a delimited phase of a couple’s experience, but rather is a process in which the experience itself is renewed in certain situations and that the relational dimension of extraneousness reappears and gives rise to movements of disorganization and reorganization of the couple and the family, as shown in the case presented by the father’s acting, who first leaves the family and then returns.

We believe that the inability to recognize and accept the extraneousness present in the context MAP contributes to the fragility of links.

Intergenerational transmission in MAP

The subject is primarily an intersubject, and thus psychic transmission implies more than one other, in the sense that the group precedes the formation of a subject of the group (Kaës, 1993).

What precedes the subject is also transmitted from previous generations. Interestingly, the term betrayal also has the same etymology as transmit and hand down^[3]. To betray means to send, to hand over to the enemy. It is structural for the subject both to receive and to betray, that is, both to receive a “mandate” and to have the freedom to change something of what has been received.

Kaës (ibid.) distinguishes intergenerational transmission, which is passed down explicitly among  subjects, and transgenerational transmission, which is passed down through subjects.

In MAP, especially in heterologous MAP, what is handed down through subjects is likely to be broader and more burdensome because it refers to the dimension of the extraneousness, especially that which is kept secret and/or removed, but for that very reason it is even more pregnant with fantasies and forms a receptacle for projective identifications and fantasmatizations.

Sandler & Sandler (1998) recall how stranger anxiety around eight months of age arises from the dissonance experienced with respect to the external environment with the approach of an unfamiliar person, but also emphasizes the gradual dissonance perceived with respect to the Self as the boundaries between the Self and the Object grow. There is a parallel process whereby the child «scrutinizes and has a dialogue with his own Self (…) for confirmation that his Self is his old and familiar Self, and that it is not extraneous to him» (p. 114).

A diagnosis of infertility can cause a painful collapse of the idealized image of Self and one’s couple as fertile and powerful, and open a wound that at first leads to a lack of recognition of oneself. If this condition can be read as dissonance with respect to the Self, the use of MAP techniques opens a gateway to actors outside the couple, who creep to the core of one’s physical and psychological identity where sexuality dwells, revealing a dissonance with respect to the external environment.

A link between intrusiveness, theft, unprocessed aggression toward one’s mother and the infertility symptom leading to MAP can resurface. In dissonance there could be the perception of extraneousness returning from outside.

What do couples make of this experience of a double extraneousness?

First of all, it should be emphasized that the presence of actors outside the couple modulates in different forms depending on the type of MAP.

In the case of homologous fertilisation, the extraneous is represented by the medical team. Due to the length of the process, which often includes many failed attempts, the physician may become a privileged interlocutor for the woman. Unconsciously seen as the powerful and fertile partner, he is sometimes felt by the man as a rival (Vegetti Finzi, 1999).

In the case of heterologous fertilization, the actors behind the scenes may be removed but still remain active: they are the gamete donors, perceived as a foreign body inside the maternal body, the couple and then inside the child, carrier of those gametes. In the case of heterologous fertilization with female-only or male-only gametes, the picture is complicated by the explicit asymmetry between the partners, with possible consequences in the relationship with the child, who may be felt more by the biological parent, while the social parent is required to build differently over time the mutual belonging between self and child.

In the case of surrogacy, the extraneous person remains the woman who has held the child, both in the case of the biological mother and when hosting the embryo. Fantasies and thoughts about who she is, about what the child would have been like if he/she had stayed with her, amplify those about gamete donors if the embryo does not belong to the couple.

In the cases of a child born from a uterus transplanted from a living or dead woman, with homologous embryo transfer, most often heterologous, on a symbolic level, with different accents, all the actors in the process remain over time the object of fantasising and projecting themes of fear, anger and envy related to infertility.

When parents conceive a child, their fantasies of the primary scene somehow accompany them. If they did not conceive the child themselves, as in cases of assisted procreation where the act of love is not at the origin of conception, parents are pushed to do an important work of associating conception with a nearby primary scene that says something that allows them to inscribe the child in intergenerational transmission.

It is necessary to help couples to come to terms with these structural extraneousness influences inherent in such situations, without concealing or removing them. Heavy indeed are the consequences of secrecy about the biological mandate for their children.

Testart (1986) argues that children, in particular, have very sensitive antennae to pick up what is not being said and when they cannot formulate questions, often speak through symptoms. When secrecy is a consequence of splitting a particularly painful experience, splitting becomes the pathogenic key to secrets (Tisseron, 2008). Racamier (1995) calls this type of secret “antilibid”; he places emphasis on the silence, the efforts made to keep them concealed, and the block imposed on the possibility of thinking, a block that also induces in the other a fear of asking and an obligation to keep such a secret.

The secret, continually facing the preconscious, exudes through facial or behavioral expressions and bears witness to emotional movements sometimes contradicting words and causing disturbances in communication. The intangible and invisible pain of its custodian ends up intertwined with the suffering of those who ignore its content but perceive its existence.

In this way, the transmitted unconscious fantasies become like shadows of unthought, unprocessed knowledge, charged with an anxiety that can prove fearful and traumatic. Having the opportunity to process the extraneous factors in these situations makes it possible to recover a real recognition of the child by the parents and of the parents by the child. Mutual recognition of the function of each member of the family then becomes a gesture that continues to renew itself every day, in every act, and confirms the constitutive and organizing function of the difference of sexes and generations. Recognition of the other is never perfect and total recognition; it is closer to unresolved enigmas and vital questions that continually emerge.

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The complexity of intergenerational psychic transmission in medically assisted pregnacy (MAP): extraneousness into familiar
Lucia Balello, Angela Barchielli, Andrea Benlodi, Barbara Bianchini, Francesco Biondi, Raffaele Fischetti, Ondina Greco, Anna Rebecca Lovisatti, Fiorenza Milano
https://doi.org/10.69093/AIPCF.2023.29.03

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Andrea Benlodi.

At that time, the therapist was participating as a lecturer in the first meeting of a “Pre-partum classes” for prospective parents at the hospital.

In Italian and in the neo-Latin languages, trasmettere, tradire and tramandare have the same root.