A Theory of Psychic Condition in RPL Final Dissertation

Institute for Clinical Social Work

A Theory of Psychic Condition in Recurrent Pregnancy Loss: Self, Body, Relationships, and the Imagined Future

A Dissertation to be Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy

By Jessica L. Vaidya

Chicago, Illinois

Abstract

Using a psychoanalytic case-study methodology, this study explored the lived experiences of five participants undergoing recurrent pregnancy loss (RPL) through extensive psychoanalytically informed interviewing and case-study analysis. While RPL has been studied primarily through medical and symptom-based approaches, this study examined how repeated pregnancy loss is experienced intrapsychically, relationally, and developmentally over time. Data analysis occurred in two phases. First, the researcher conducted within-case analysis, developing five case studies and corresponding categories of meaning. Second, the researcher conducted cross-case analysis to identify shared patterns across cases. Findings suggest that RPL is experienced less as a series of discrete losses and more as an ongoing psychic condition of recurrence, characterized by prolonged uncertainty and repeated reactivation of attachment and dread. Across cases, participants described living within repeated cycles of hope and fear, medical intervention, bodily vigilance, and interrupted mourning. Five cross-case meta-themes emerged: defensive organization under uncertainty; the body as a site of betrayal, trauma, and meaning; isolation, nonrecognition, and longing to be seen; negotiating identity, worth, and the “realness” of loss; and the work of hope, mourning, and reimagining motherhood. The findings indicate that recurrence pressures self-cohesion, intensifies shame and superego attack, complicates bodily trust, and strains relational life— particularly under conditions of minimization, proceduralization, and disenfranchised grief. This dissertation proposes a Theory of the Psychic Condition of Recurrence in RPL organized across four interrelated domains: self, body, relationships, and the imagined future. By centering inner experience and meaning-making under sustained uncertainty, the study offers a psychoanalytic framework for understanding how recurrence reorganizes psychic life over time and highlights clinical implications for holding not-knowing, working with shame and self-attack, and supporting mourning under conditions of chronic reactivation.

For my husband

And for our daughters.

Not everything is lost in waiting.

Statement of Purpose

Significance for Clinical Social Work

Statement of the Problem and Specific Objectives

Research Questions Explored

Definitions of Major Concepts

Statement of Assumptions

Epistemological Framework

Foregrounding

Table of Contents-Continued

Chapter

II. Literature Review…………………………………………………………16

Introduction

Understanding Perspectives on Grieving, Grief in the Context of Pregnancy Loss,

Pregnancy Loss, and Recurrent Pregnancy Loss

Psychoanalytic Theory: Self Psychology notions of Grief and Loss, and Object

Relations Theory as it Relates to Mourning

Research and Literature on Mental Health and Recurrent Pregnancy Loss

III. Methodology………………………………………………………………33

Introduction

Case Selection

Overview of Information Needed

Research Design

Data Collection

Plan for Data Analysis

Ethical Considerations

Validation Strategie/Issues of Trustworthiness

Limitations of the Study

Chapter Summary

Table of Contents-Continued

IV. Results………………………………………………………………….47

Introduction

Within-Case Analysis

Case Study #1: Sally

Case Study #2: Jennifer

Case Study #3: Allison

Case Study #4: Shelly

Case Study #5: Rebecca

Results of the Cross-Case Analysis

V. Discussion………………………………………………………………...172

Implications for Theory

Implications for Clinical Practice

Implications for Research

Conclusion

VI. References

Chapter I

Introduction

Statement of Purpose

The aim of this qualitative study is to uncover a deep understanding of a cisgender woman’s lived experience of recurrent pregnancy loss (RPL), specifically to examine the unconscious contents of the RPL woman’s thoughts and fantasies about herself, and her physical body. This case study research project will focus on how participants think and feel about themselves throughout this conception journey. Recurrent pregnancy loss is defined as a disease distinct from infertility involving the spontaneous loss of two or more consecutive pregnancies (ASRM, 2020). For the purposes of this study, fantasy is defined as scenes and images conjured up by one’s imagination and shaped by unconscious fears and desires (APSAA, 2009). The intent of this study is to explore an RPL patient’s unconscious thoughts, feelings, and fantasies as it relates to her self. This research study will use a case study methodology (Tolleson, 1996) as a means of capturing an in-depth understanding of the unconscious fears and fantasies involved with struggling with RPL.

Significance for Clinical Social Work

The aim of this study is to gain deeper understanding and meaning of the RPL patient’s subjective experience of her recurrent losses and struggle to carry a healthy baby to full-term. This objective will be fulfilled by the analysis of unconscious thoughts, feelings and fantasies obtained from both unstructured and semi-structured interviews with a small sample (n=5) of this population. Presently much of the research on this topic focuses on women experiencing infertility. These studies are mainly quantitative in nature, surveying large groups of infertile

women and drawing correlations between this disease and struggles with anxiety, depression, and complex grief. There is a paucity of research regarding this specific population of women who experience recurrent pregnancy loss, and there is an overall lack of in-depth, qualitative research focusing on their lived experiences (Hogan, 1994). The data gleaned and interpreted from this qualitative study will offer ways of understanding the lived experience of these women, which will help suggest clinical implications and build deeper theory.

Statement of the Problem and Specific Objectives

During the initial review of existing research on this topic, far more studies and dissertations populated on the topic of infertility or single miscarriages. It was challenging to find much research on recurrent pregnancy loss. The existing body of research regarding recurrent pregnancy loss is sparse (Hogan, 1994). The current body of research predominantly focuses on the broader population of infertile individuals or on women who have experienced one miscarriage (Hogan, 1994). Furthermore, the studies that do exist on infertility are primarily quantitative studies that draw broad correlations between women suffering with infertility and anxiety and depression. Research studies such as the Joelsson et al. (2017) study use certain anxiety and depression scales to gather data on women with infertility. This study and many others like it demonstrated that sub-fertile women suffer from increased levels of anxiety and depression when compared with both women who became pregnant after infertility treatment and women who conceived naturally. While this information is meaningful and useful, it says very little about the lived experience of the woman suffering with infertility and provides no insight about the unconscious processes that shape their self-view. What does their depression and anxiety entail? What fears of the past or the future drive the anxiety? What feelings about loss shape their depression? The existing research also provides quantitative data regarding grief and

depression symptoms following one single miscarriage (Volgsten et al., 2018). While this is also useful information, a single miscarriage followed by the ability to have healthy children differs from women who suffer reoccurring pregnancy losses and are failing to successfully have a live birth of a baby. Moreover, these studies also tend to focus on the heightened presence of grief and depression in miscarriage. The studies provide little in-depth exploration or detail about the lived experience of this type of grief and depression. For example, in the Volgsten et al., (2018) study, three validated questionnaires were administered to couples following a miscarriage. The findings demonstrated that for women the emotional experiences of miscarriage, grief, and depressive symptoms were more pronounced than their male partners. While grief and depressive symptoms resolved with time, the study highlighted that resolution was not reached regarding the emotional experience of miscarriage. The study is unable to capture what these “emotional experiences” look and feel like based upon data collected via a scaled questionnaire. Concepts such as guilt were categorized under emotional experiences but that is the scope of the depth and detail of the data collected. What does the miscarrying woman’s guilt involve? What unconscious thoughts and fantasies shape this guilt? The present study intends to examine these kinds of questions.

Thus, not only is more in-depth, rich data lacking from the broader body of research, but more importantly there is little to no studies done specifically on recurrent pregnancy loss. The infertility research and the single miscarriage research are not capturing the unique experiences of the RPL patient. The American Society for Reproductive Medicine (ASRM) clearly distinguishes that recurrent pregnancy loss is “a disease distinct from infertility.” (ASRM, 2020). According to ASRM, one in four pregnancies will end in a miscarriage or about 25 percent, whereas fewer than five percent of women have two or more consecutive miscarriages and one

percent will have three or more. This study assumes that the experience of consecutive miscarriages is unique and distinct from experiences of infertility or single miscarriages.

The purpose of this study is to describe and understand the unconscious thoughts, fantasies, and wishes of the RPL patient’s experience. The stated objectives at the outset of the study are to:

1. Observe and describe the contents of the RPL patient’s unconscious thoughts, feelings, and fantasies to learn more about their psychic experience.

2. To provide significant insights which can help psychotherapeutic professionals better attend to women actively struggling with RPL.

Research Questions Explored

The aim of this qualitative study is to describe and understand the contents of the RPL woman’s unconscious thoughts, feelings, and fantasies about her self. The goal is to obtain data that captures the unheard voices of these women.

The primary question to be explored is:

What are the unconscious thoughts, feelings, and fantasies of women experiencing RPL, specifically in relation to their process of recurrent loss and lack of a healthy, sustaining pregnancy?

Sub-questions include:

1. What kinds of fears, wishes and fantasies do RPL women experience as related to themselves?

2. How do women experiencing RPL observe and relate to their fantasies?

Definition of Major Concepts

For the purposes of this study, the major concepts below were defined as follows:

Fantasy: According to the American Psychoanalytic Association (2009), fantasy “refers to an imagined situation that expresses certain desires or aims of the imagining individual. It can occur at the conscious level, also known as a daydream, or unconsciously, sometimes referred to as phantasy.”

Infertility: The inability to get pregnant and/or stay pregnant after 12 months of trying to conceive

Unconscious: According to the American Psychoanalytic Association (2009), the unconscious is “the part of the mind that stores feelings, thoughts, and urges unaware to the individual. These mental contents and processes often influence the conscious experience even though we are unaware of their existence.”

Recurrent Pregnancy Loss: two or more documented consecutive spontaneous pregnancy losses

Statement of Assumptions

The following assumptions are shaped by clinical and theoretical research:

1. People have fantasies that are driven by certain conscious and unconscious fears, desires and aims.

2. For many women, the act of having a child is experienced as a milestone of their adult development. “Having a child is essential for the development of an adult identity in many cultures” (Alamin et al., 2019).

Epistemological Framework

This study will use qualitative methodology to better understand the present, lived experiences of women living with Recurrent Pregnancy Loss (RPL). According to Bloomberg and Volpe (2019), “Qualitative research is suited to promoting a deep understanding of a social setting or activity as viewed from the perspective of the research participants” (pp. 38-39). Thus, this approach fits this study’s aim to both uncover and understand the voices and unconscious thoughts of women experiencing RPL. Additionally, a qualitative methodology is aligned with psychodynamic theory which tends to emphasize the unfolding of emerging phenomena in the treatment room rather than focusing on diagnosis. As aforementioned, this study hopes to fill in gaps in the literature where there is emphasis on diagnosis of depression and anxiety but otherwise limited information on what these conditions feel and look like for women with RPL.

This study will use a case study methodology (Tolleson, 1996) to explore the content of RPL women’s unconscious thoughts, fantasies, and feelings. A case study methodology was primarily selected as it lends itself to rich, in-depth data collection. According to Yin (2018), case studies are the preferred research strategy when the following conditions are present: 1. “how” and “why” research questions are being asked, 2. there is little to no researcher control over events, meaning the relevant behaviors being studied cannot be manipulated, and 3. The study aims to provide information about events occurring contemporarily within a real-life context.

According to Yin (2018), case study methodology is most appropriate when contemporary phenomena are being investigated “in depth and within their real-world context” (p.15). Case Study methodology fits well with this study’s aim to explore in-depth the unconscious mind of women actively struggling with RPL.

I will conduct unstructured and semi- structured interviews in concurrence with my own journaling, and the collection of participants’ journal entries.

Foregrounding

I graduated from Columbia University with a master’s in social work in 2011. I began working immediately as a discharge planner in a hospital in East Harlem, New York. The work was challenging, and fast-paced. I worked with diverse populations ranging from wealthy UpperEastside Manhattanites to undocumented individuals residing in Harlem, the Bronx, Brooklyn, and Queens. Initially, I assumed this work would not be heavily clinical as discharge planning entails a lot of concrete servicing. My assumptions were proven wrong as I learned that solid clinical knowledge forms the strong foundation for all relational interactions, even brief and time-limited ones between a discharge planner and patient or patient’s family. I quickly found myself overwhelmed by the amount of trauma my patients encountered daily, and my own lack of sufficient clinical supervision. Eventually I transitioned from a discharge planning unit to working in Palliative Care. It was in this area that I had the opportunity to spend longer lengths of time with patients and their families, and to support them as they grappled with the existential issues of death and dying. I relished this meaningful and more in-depth relational work, however, I felt ill-equipped to provide the sound clinical care I felt they needed.

I knew I was searching for something that could ground me in this work and I decided that it was further training in psychotherapy. This realization led me to begin psychoanalytic training at the Institute for Contemporary Psychotherapy (ICP) which eventually led me to ICSW. Through both ICP and now ICSW, the combination of coursework, and clinical supervision has been transformative. The transformation has been both professional and personal. These psychodynamic educations have grounded me in my work and provided me with

a quiet confidence to trust in myself and the relationship with the patient. Personally, these trainings have developed my understanding of the interpersonal and intrapsychic forces that influence us both on an intrasubjective and intersubjective level.

In 2019 my husband and I embarked on the journey to try and conceive our first child. I was excited and naively assumed this would be a relatively easy and happy process for us. I was filled with hope and many expectations about what the process would look like. I read articles about the most effective ways to conceive and like the diligent student I am, I bought all the necessary tools and set to work on being the “perfect” conceiver. These hopes and expectations about what this process would be like could not have been further from my eventual reality.

Despite the supportive words of reassurance that miscarriages happen to many women and that this was “not my fault,” in my more private contemplations, I blamed myself. My husband and I experienced three pregnancy losses back-to-back before we sought help from a fertility doctor. Throughout the process of these losses, and our experiences at the fertility clinic, I felt a deep sense of shame and guilt that my “poor quality” eggs were the reason we were in this situation. I worried that there was something terribly wrong with me, and in my darkest moments I wondered if we would ever be able to conceive a child. Throughout the fertility treatment process, I felt I was constantly being measured and assessed and that my body was falling short of each test. This was the first time in my life that I had set a goal, attempted to do everything in my power to achieve it, and had repeatedly failed. I became obsessive about this goal, and it permeated every aspect of life. My inability to carry a healthy pregnancy to term became an awful partner that never left my side and despite a very supportive and loving husband as well as family and friends, ultimately, I felt quite alone.

It was after my third pregnancy loss that I sought help from a psychotherapist who specialized in infertility and miscarriage. This therapist was supportive and helpful but also fell short of what I was needing. Much of our treatment focused on tools for managing my anxieties and fears. It also reviewed many of the things I already knew about the stigma around miscarriage and infertility. I was searching for something else, something deeper but at the time I could not describe what that looked like. In retrospect, there were very dark thoughts and fantasies about my body’s failings and about the future that I needed to communicate but did not quite know how.

Through the process of eventually conceiving, a long, arduous process involving assisted reproductive treatment (ART), I discovered that the experience of understanding and making meaning out of the suffering was essential to my emotional survival.

As a result of this transformative journey, I became fascinated with the intersection of recurrent pregnancy loss and the ways in which psychoanalytic theory conceptualize many of the facets related to this type of human experience.

More specifically, I want to study the lived experience of this journey that is often less talked about, the one related to fears and fantasies about one’s physical body, feelings surrounding isolation and control, and the complex process of grief and loss.

It feels significant and important to give voice to this lived experience and dig deeper to uncover unconscious processes impacting women living with this type of loss. This is why I want to use Case Study Methodology to gather data that can uncover RPL patients’ unconscious fears and fantasies about themselves in relation to RPL. Presently, there is an abundance of information and treatment targeted at tools and exercises to help women cope with the anxiety

and stress of infertility and single miscarriage events. However, inherent in this “tool-building” approach is that the responsibility and even blame is on the woman to cope better and improve upon herself to obtain what she wants. There seems to be a paucity of research and information about the less talked about and perhaps more emotionally primitive, darker aspects of this journey. My hope is that by providing valuable insight into this lived experience, providers can better understand and support this population of women, and for these women to also have greater access to the process of making meaning of their suffering and feeling less isolated. This project aims to shine a light upon these darker psychic processes at play. The hope is that through doing so, this recurrent pregnancy loss journey can be far less isolating and lonely.

Chapter II

Literature Review

Introduction

The following review of literature and research reflects the researcher’s collection and integration of theoretical and research literature identified as both pertinent and helping to shed light upon the research question: What are the unconscious thoughts, feelings, and fantasies of women experiencing RPL, specifically in relation to their process of recurrent loss and lack of a healthy, sustaining pregnancy?

This chapter will outline theory and concepts relevant to the subjective, lived experiences of women experiencing recurrent pregnancy loss. More specifically, this chapter will explore theory and concepts related to the grieving process, pregnancy loss, recurrent pregnancy loss, and expectations around life milestones, namely that of having a biological child. In this chapter, I review relevant psychoanalytic theory as it pertains to the intrapsychic and interpersonal experiences of individuals with recurrent pregnancy loss.

I. Perspectives on Grieving

For the purposes of this research project and this review of literature, grief is defined as a “painful, complex emotional state,” that changes over the course of time. These changes occur as an individual in the grieving process confronts the loss via yearning for and acknowledging the lost relationship/object. Grief work, i.e., yearning for and recognizing the loss occurs in “service of a gradual detachment from the lost person or object. (Beutal et al., 1995, p. 518).

Traditionally, psychology and psychoanalytic schools of thought have viewed successful mourning as the process of disengaging from the deceased. In his seminal work titled,

“Mourning and Melancholia,” Sigmund Freud (1917) theorized that grief work is the process of freeing the ego from the attachment to the lost object. He states, “when the work of mourning is completed the ego becomes free and uninhibited again.” Thus, the overall goal is to detach from the deceased and accept the finality of loss. Freud (1917) explained that the mourning process could be considered complete when reality testing has shown that the “love object no longer exists, and it proceeds by demanding that all libido shall be withdrawn from its attachment to that object” (p. 253).

Post Freudian ideas about grief have sustained the idea that the main goal of the grieving process is to sever the relationship and attachment with the deceased in order for new, healthy bonds to form. Some theorists have reasoned that if one does not end the ego’s attachment to the deceased, one is trying to hold onto the relationship by fighting against the reality that the loved one is gone. From this perspective, fighting against reality is destined to fail, since eventually one must accept that death is real and final (Klass et al., 1996). There is significant cost to the ego when it does not let go of the lost object. The ego becomes impoverished, and the individual begins to turn on themselves which Freud eloquently points out in his famous quote, “the shadow of the object fell on the ego” (Freud, 1917, p.159). This is one of the main features of Freud’s melancholia and what distinguishes it from mourning or “grief.”

In addition to Freud, there are a number of theorists who examine ideas around the bereaved disengaging from the psychic energy previously devoted to the deceased in order to create emotional space for new relationships and new experiences as well as to heal from the loss. Some of these more recent theories use terms such as complex grief, however, in many ways they echo Freud’s ideas on how an unresolved mourning process can become a prolonged type of melancholia. Shear et al., (2018) states that complex grief can be identified by administering the

Inventory of Complicated Grief more than six months after the death of a loved one. A core feature of complicated grief is “recurrent pangs of painful emotions, with intense yearning and longing for the deceased,” as well as “preoccupation with thoughts of the loved one” (p.2).

According to this reasoning, maintaining a relationship with the deceased does not allow for the emergence of new relationships in the present and isolates the bereaved when they need support the most. Continuing the bond with the deceased could also impede the mourner’s ability to find different ways to fulfill needs previously met from the deceased in the pre-death relationship (Root and Exeline, 2013). In the context of this study, it will be interesting to think about how these theories on the mourning process can be understood in the context of the varying types of loss one experiences. For example, do these theories take on different meaning and shape when we are studying the loss of an existing relationship and person compared with the loss of a hope or dream i.e. a future unborn child?

II. Grief in the context of Pregnancy Loss

According to Klier at al., (2002), it is important to better understand how we define and distinguish grief and depression in order to predict and understand an individual’s long-term emotional experience and prognosis as related to pregnancy loss. Klier et al., (2002), reviews past literature that subdivides bereavement into four parts: (1) shock and numbness, (2) yearning for and preoccupation with the deceased, (3) depression and disorganization, and (4) anxiety. Interestingly, Klier et al., (2002) states that yearning may be of greater prognostic value than depression levels with regard to long term adjustment following bereavement. Prior research suggests that preoccupation with the deceased and searching and yearning for the deceased are predictive of long-term functional impairment (p. 140). Consequently, Klier et al., (2002), asserts that it is specifically important to parse out and study the level of yearning in women

experiencing pregnancy loss. There are numerous lived experiences that pregnant women go through that indicate yearning such as thinking of a name for the baby and making changes in one’s home to accommodate a baby (Klier at al., 2002, p. 140). Much of this more recent research on bereavement, grief, depression, and pregnancy loss echoes elements of Freud’s ideas on mourning and melancholia. The yearning that Klier et al., (2002) refers to can be directly linked to ideas about the ego’s attachment to the lost object.

III. Pregnancy Loss

This section will define pregnancy loss as well as explore existing literature related to this topic. Subsequently, connections will be drawn between the aforementioned ideas about the grieving process and what that looks like when the lost object is one’s pregnancy. It is important to note that for the purposes of this literature review and overall study, the term pregnancy loss will be used in place of miscarriage, except for when quoting other texts. The act of “miscarrying” may carry implicit ideas that the person suffering the loss has “miscarried” or that the loss was “self-generated” (Gorfinkel, 2015). Gorfinkel (2015) states,

The term miscarriage is comprised of two words: mis-, meaning “mistakenly, wrongly, or badly” and carriage, a “means of conveyance.” While the -carriage part of the term miscarriage is reasonable accurate, the mis-portion is inaccurate and potentially harmful. Most miscarriages do not represent a mistake, wrong, or bad action on the part of a woman’s body’ most are caused by spontaneous chromosomal anomalies that render human development impossible…In fact, miscarriage is more often a healthy body recognizing a pregnancy that is incompatible with life. (p.1)

Thus, this research has chosen to use the terminology of pregnancy loss. According to Mayo Clinic (2022), pregnancy loss is the spontaneous loss of a pregnancy before the 20th week of gestation. According to a longitudinal study conducted by Volgsten et al., (2018), grief and depressive symptoms as well as emotional experiences related to isolation, loss, and a devastating event are all present and more pronounced in women than in men following pregnancy loss.

In order to better understand this specific type of object loss (which can seem and feel quite different from loss of an existing loved one such as a spouse, child or parent), it can be helpful to review Donald Winnicott’s theory of maternal preoccupation which helps describe how the unborn fetus can still take on a very real and alive shape in our minds. Winnicott (1975) theorizes that a woman enters a “special state,” specifically a psychological condition which he named Primary Maternal Preoccupation during and in the initial weeks following pregnancy. Winnicott (1975) suggests that one can think of this state as a special psychiatric condition that develops during pregnancy and involves “a state of heightened sensitivity,” (p. 350).

Characteristics of this state involve a certain degree of dissociation from the world around them and a more intense focus on the life growing inside of them. According to Jones (2015), Winnicott’s primary maternal preoccupation during which a pregnant woman identifies with her baby, underscores the potential crisis she will grapple with when the unborn baby with whom she is preoccupied and identified with dies. Related to Winnicott’s early ideas about primary maternal preoccupation, a more recent study conducted in 1995 by Beutel et al., found that the fetus achieves mental representation in most women by 10 weeks of gestation which can be observed through dreams, daydreams, internal dialogues, and preparations for the child’s arrival (Klier et al., 2002).

While the pregnant woman is likely engaging in some degree of mental and physical preparation for her future child’s arrival, there may not be structures in place for the pregnant woman to process that unborn child’s death. While religion, community, and society have developed various rituals and customs designed to help individuals accept and process the finality of loss, there is little to no ritual or custom around loss of a pregnancy. Pregnancy loss is uniquely distinct in that it does not lend itself to those healing mourner experiences. This further highlights the complexity of this type of loss and why it might be difficult for the ego to detach from the lost object. According to Grathouse (2016),

The experience of loss in miscarriage is unique from other losses in several ways. For one, the loss is prospective rather than retrospective (Carter, Misri, & Tomfohr, 2007). One is not grieving the absence of someone once present in the world, but rather, experiencing the loss of someone who was anticipated with great hope and meaning. Secondly, there is no protocol for acknowledgement, support giving, and mourning. Symbolic rituals like funerals or memorial services are not part of the process following a pregnancy loss. (4)

IV. Recurrent Pregnancy Loss

Recurrent pregnancy loss is defined as a disease distinct from infertility involving the spontaneous loss of two or more consecutive pregnancies (ASRM, 2020). During the initial review of existing research on this topic, far more studies and dissertations populated on the topic of infertility or a single pregnancy loss. It was challenging to find much research on recurrent pregnancy loss. The existing body of research regarding recurrent pregnancy loss is sparse (Hogan, 1994). The current body of research predominantly focuses on the broader population of infertile individuals or on women who have experienced one pregnancy loss (Hogan, 1994). There are vague references to implications in single miscarriage study

findings that suggest that recurrent pregnancy loss is distinct from experiencing a single loss. These findings suggest that these differences significantly impact the psychological experience of the individual living with recurrent losses. Volgsten et al., (2018) states,

Previous children made the miscarriage easier to endure while a previous miscarriage had the opposite effect. Women with a previous miscarriage are more vulnerable…Lack of previous children, a previous miscarriage, and infertility diagnosis could increase negative emotional experiences after miscarriage, this was especially pronounced for grief reaction. (p. 23, 27)

It appears more in-depth exploration and study of this population of individuals experiencing recurrent pregnancy loss is needed to better understand what their experience is like. According to Grathouse (2016), “Recurrent pregnancy loss has received little attention in the research literature despite being recognized as a source of distress.” (p. 1).

In the qualitative study titled Experiences of Recurrent Pregnancy Loss Through the Perspective of United Arab Emirates Women: A Qualitative Study, the findings demonstrated a theme of individuals with RPL feeling as though pregnancy is “endless.” Recurrent miscarriage gave women a sense of endless pregnancy that was similar to the study’s emerging theme of going back to “square one” (Ibrahim et al., 2018). This theme of endless suffering and ongoing pregnancy also supports the previously mentioned idea that the mourning of a lost pregnancy is complicated and vulnerable to a more pathological type of grieving that can become a depressed state of being.

Additionally, it is important to note that this qualitative study concluded that cultural and social expectations create challenges for women suffering with RPL as well.

V.

Expectations of Life Milestones

Cultural and social expectations help shape individuals’ own expectations regarding expectations of life milestones. Existing literature and research highlight the impact certain societal norms around life milestones have on women who experience recurrent pregnancy loss and struggle to have a baby. Even in the year 2026 as family compositions and values shift and change, parental experience remains a common and expected life milestone. It is often still thought of as a measure of personal satisfaction, social acceptance, and social identity (Alamin et al., 2019). One of the primary struggles of the inability to conceive a healthy child is the infringement on one’s own expectation of generativity as a fundamental norm of the human experience. Joan Raphael- Leff (1992) encapsulates this well, stating, “Being branded ‘infertile’ constitutes an existential shattering of naïve trust in natural universal order, unquestioned since infancy” (p. 279).

When viewing infertility (and/or any processes such as RPL that interfere with one’s ability to conceive) through a psychosocial lens, the developmental stage of generativity is often experienced as disrupted. Irving G. Leon (2010) goes into more detail to describe the impact of the deprivation of generativity that some adults may feel when struggling to conceive. He states that in Erickson (1963)’s classic study of the eight stages of human development, he underscored the critical adult stage of generativity— “the process of nurturing, mentoring, and guiding the next generation. This is typically, though not inevitably or necessarily, realized through parenthood” (p. 57).

According to Leon (2010), individuals struggling to conceive frequently describe, feelings of getting nowhere, being stuck or even paralyzed, and not being able to get on with their lives. They report being out of synchrony not only with their child-raising peers

and families but departing from their own schedule of where they envisioned themselves to be at this point. (p. 58)

Leon (2010) emphasizes this image of “getting nowhere” by sharing a case vignette of a woman who had a dream of getting off a highway which she was unable to get back on. The failure to accomplish these developmental life goals may cause “a pervading sense of stagnation and personal impoverishment” (Erickson, 1963, p. 267). The disappointment, frustration, anomie, and restlessness arise not only from the month-to-month sadness of failed efforts and interventions, but also from the overall feeling that they are being shut out from achieving a fundamental life goal. Sometimes infertile individuals describe this feeling as though “their future is being taken away” (Leon, 2010, p. 58).

The reason that certain experiences in life are labeled “milestones” is often because not only are they a social norm or expectation, but they may also signify a meaningful event in life that ushers in various forms of growth, evolution, and change in one’s life. Thus, in addition to some of the feelings of failure and stagnation that adults struggling to conceive may experience, there are also important growth processes and changes that can result from moving through the life milestone of becoming a parent. Leon (2010) talks about the process of separationindividuation from one’s own parents, as well as resolving past conflicts and/or trauma from one’s own childhood. He states,

Despite differences in nuance and detail, most psychoanalytic theorists describe pregnancy as a new developmental phase in the process of separation-individuation erected on earlier advances in separation-individuation in toddlerhood and adolescence…Through an integration and reconciliation of conflicting needs including the inevitable ambivalence arising from unmet dependency, a greater degree of individuation may be achieved in

becoming a new mother than was previously experienced…A new parental identity is built on past and present imagoes, integration and supports. (p.58)

Building upon this idea that parenthood may support further separation-individuation, Leon (2010) also believes that it involves a new phase of development which provides space for individuals to revisit and overcome earlier childhood conflicts through the respective challenges that that individual’s child navigates (p.60). Leon (2010) asserts that infertility prevents this reparative process from occurring. Deep-rooted wishes to redeem childhood hurts and disappointments or even abuse and loneliness by creating a different family life for one’s own child are denied. Thus, one can see that there are numerous intrapsychic and interpersonal repercussions as a result of struggling to have a child due to issues such as recurrent pregnancy loss. The next section will explore in greater detail these intrapsychic and interpersonal repercussions through the lens of psychoanalytic theory.

VI. Psychoanalytic Theory

Self-Psychology notions of Grief and Loss

Self-psychology offers ways to understand how experiences of loss can undermine an individual’s sense of self. Heinz Kohut’s theory of self-psychology focuses on the idea that a healthy self evolves within the developmental milieu of three distinct selfobject experiences. Selfobject is defined as an object which is used in service of the self or experienced as part of the self and provides a function for the self (Leeming & Smothers, 2020). The earliest example of a selfobject is a caretaker during childhood who responds to and fulfills the child’s needs in such a way that the child experiences that caretaker in terms of their need fulfilling function rather than an entity that is separate in their own right (Siegel, 1996, p. 206).

The first impactful experience that contributes to a healthy development of self is the process of selfobjects responding to and confirming the child’s innate sense of greatness and perfection. Kohut labeled this a mirroring experience. The second developmentally necessary experience requires the child’s connection with strong others whom he or she can look up to and merge with that other’s sense of calmness and infallibility. This encounter is titled the idealizing experience. Lastly, the child should experience an essential likeness between themselves and the selfobject by way of the caretaker’s openness and demonstrated similarities known as a twinship experience (Mitchell and Black, 1995, pp. 159-161). Through encountering and readily having these three early developmental experiences Kohut believes that healthy, normal development will ensue and be reflected in what Mitchell and Black (1995) describe as,

A feeling of internal solidarity and vitality, the ability to harness talents and reach steadily for goals, self-esteem that is reliable and durable in the face of disappointments and that allows for expansive pride and pleasure in success. (p. 158)

The infertility experience consists of a tidal wave of narcissistic injuries including, disruption to self-continuity, assault on self-worth, loss of bodily control, derailing one’s reproductive narrative, heightened sense of mortality, deprivation of crucial forms of psychosocial and developmental fulfillment, disability status, stigmatized identity, profound social estrangement, damaged self-representation, and loss of important opportunities for self-validation in one’s marital, sexual, and social life. (Leon, 2010, p. 65)

Although an individual struggling with recurrent pregnancy loss and the inability to conceive a healthy baby may have had a childhood filled with the healthy experiences that Kohut talks about, the adulthood experience of recurrent pregnancy loss can be damaging to one’s sense of self. Certain self-functions that self-psychology views as a part of a healthy existence may be

flailing or challenging to feel and enact while going through something such as infertility and/or recurrent pregnancy loss. Joan Raphael-Leff (1992) provides a raw image of what the injury to the self can be like for the person struggling with the ability to conceive a healthy child. She states,

Each partner suffers corporeal disillusionment in relation to the lack of control over their own body, no longer ‘normal’ and taken for granted as a working creative component of self-image, but now proved ‘inferior’, non-functioning, sterile. Confusion between the inner world of the psyche and the inside of the body often leads to a generalized sense of being stuck, impotent and non-productive, which may affect work and social accomplishment. (p. 280)

There are significant challenges to one’s sense of self, what they can achieve, and belief in their own capabilities when that individual is struggling to carry a healthy pregnancy to live birth.

Object Relations

Object relations can be another useful and important theory from which to think about all different experiences of loss. Object relations theory asserts that all people have within them an “internal, often unconscious world of relationships that is different and, in many ways, more powerful and compelling than what is going on in their external world of interactions with ‘real’ and present people” (Berzoff et al., 2011, p. 125). Object relations refers to one’s external, “real” relationships with others, the internal representations that one hold’s of others, and rather importantly the internal images one holds of the self (Berzoff et al., 2011). Internal objects form during infancy through repeated experiences with one's caregiver. The images formed do not necessarily accurately reflect reality but are subjectively constructed by an infant’s limited cognitive abilities. In healthy development, these mental representations evolve and change over

time through various impactful relational experiences; in unhealthy development, they remain at this more immature level. The internal images have enduring qualities and serve as templates for future relationships (Team, 2016). This will be a particularly helpful lens to view RPL through as current research reveals significant processes in which pregnant women are forming internal representations of their unborn child early in pregnancy as well as images of oneself as guilty of wrongdoing once pregnancy loss has occurred (Beutal et al., 1995, and Volgsten et al., 2018).

Within the broader group of object relations theorists, this research project will specifically review Melanie Klein’s theory of object relations as it relates to the processes of grief and loss. Klein’s ideas regarding what she termed “the depressive position,” and mourning will be explored as a framework for thinking about the intrapsychic experience of recurrent pregnancy loss. In Klein’s theory there are two primary positions from which children and eventually adults perceive themselves, perceive objects, and perceive the relationship between themselves and those objects. She named these positions the paranoid-schizoid position and the depressive position. Klein viewed psychological development in terms of movement from an impersonal-psychological experience of the world to a subjective experience of the world. The paranoid-schizoid position is characterized as the impersonal-psychological experience and the depressive position as a more subjective experience. It is important to note she did not think of this development as linear, meaning that first one develops a paranoid-schizoid position and matures into a depressive position but rather that one vacillates back and forth across the life span.

Klein described the depressive position as a developmental breakthrough in which the infant develops a sense of self and subjectivity thereby understanding that their experiences are their own interpretations of events rather than the only reality. Furthermore, recognizing their

subjectivity they also become aware that others have their own subjective experiences as well.

Juxtapose to the primary experience of fear of annihilation in the paranoid- schizoid position, this new way of experiencing the world creates tremendous guilt and fear that one’s own actions could hurt the other and potentially damage or lose them forever.

Ogden (1986) explains that the core anxiety of the depressive position is the fear of the loss of the object. He states, “the lost object is experienced as a whole and separate human being whom one fears one has driven away, harmed, or killed” (p. 75). Klein saw mourning as the working through of depressive anxiety. The working through looks like an evolution from despair at the finality and belief in the permanence of the loss to deepening in connection with inner objects that represent the lost object. Klein explains that the mourner deepens their connection to their inner objects, and there is joy and relief in regaining that relationship with the lost object (Klein, 1940). Klein’s emphasis is on preserving and restoring the object relationship in the mourner's personality (Baker, 2001). Klein (1940) states,

Grief is experienced to the full despair at its height, the love for the object wells up and the mourner feels more strongly that life inside and outside will go on after all, and that the lost loved object can be preserved within. (140)

Therefore, Klein’s view of mourning involves the bereaved person’s relationship with the deceased slowly evolving and changing but continuing on through this internal preservation. One significant outcome of mourning is the creation of an internal relationship that allows the bereaved to maintain an inner representation of the lost object but also leaves space for new relationships. For the purposes of this study, it will be interesting to think about Klein’s logic in the context of recurrent pregnancy loss.

In addition to thinking about how the RPL woman moves through mourning on Klein’s terms, another important element of Klein’s depressive position that is concretely present in the RPL woman’s experience is the anxiety of being the one who damaged and destroyed the loved and lost object. Klein’s principal anxiety in the depressive position of having harmed or destroyed the lost and/or loved object is reflected in the countless research that shows women taking blame and experiencing guilt for their pregnancy losses (Robinson, 2014). Jones (2015) articulates this idea, stating,

When the loss of a loved and wanted fetus is conceptualized in Klein’s terms, it becomes apparent that the dead baby inside could be felt unconsciously as a horrible confirmation and concrete proof of the strength of one’s inner destructiveness…It is not difficult to imagine how this kind of identification might cement or prolong depressed feelings where they could in other circumstances have been more transitory. (442)

In thinking about recurrent pregnancy loss in the context of Klein’s ideas around both how individuals mourn successfully and how they navigate the depressive position, it will be interesting to see what the data in this study reveal regarding the research question of what are the unconscious thoughts, feelings, and fantasies of women experiencing RPL.

VII. Research and Literature on Mental Health and Recurrent Pregnancy Loss

This section of the literature review aims to provide a comprehensive overview of existing research on the relationship between mental health and recurrent pregnancy loss. There are a number of existing studies that primarily look at the heightened prevalence of anxiety and depression within the RPL population. However, there is a lack of qualitative research exploring the lived experiences of this population. There is a difference between awareness that this population faces significant mental health challenges and having an in-depth understanding of

the nuance and intricacy of these patients’ experiences. Numerous studies have identified heightened levels of grief, anxiety, and depression in those affected by RPL. For instance, in a study by Thapar et al. (2018), participants who experienced multiple pregnancy losses reported feelings of sadness, guilt, and anger, leading to significant psychological distress. One study conducted by Kuhlmann et al., (2023) looked at Post-Traumatic Stress Disorder in this population of patients. The study used quantitative methods to administer questionnaires to couples and women at a specialized clinic for RPL patients. Results showed alarmingly high rates of posttraumatic stress in couples affected by RPL, with it being significantly more prevalent in women. The data revealed that women suffered from higher posttraumatic stress if their partner was showing an avoidant, trivializing coping behavior. The man’s reluctance of showing grief openly may result in his partner feeling isolated and left alone with her grief. Additionally, if the woman scored high for anxiety, depression or had a low perceived social support, her partner was found to indicate a significantly higher severity of posttraumatic stress. The overall complexity of these results indicates that there are complex emotional processes occurring when an individual experiences RPL.

In a separate study conducted by Tavoli et al., (2018), the research focused on the quality of life and psychological distress in women with recurrent pregnancy loss. Two different surveys were administered to an RPL group and a control group. The findings demonstrated that women with recurrent miscarriage reported extensive functional disability, and lower level of well-being compared to women without recurrent pregnancy loss. Both of these studies provide important information, namely that mental health issues are prevalent and significantly impact the population of women dealing with RPL. However, Tavoli et al., (2018) identified a limitation of their study as the lack of descriptiveness within the data collected.

Another important study titled Depression and emotional stress is highly prevalent among women with recurrent pregnancy loss, utilized quantitative methods and found that psychological stress and major depression are significantly more common among women with RPL than in those trying to conceive naturally. However, like the other studies mentioned, Kolte et al., (2015) identified a lack of interview data as a major limitation of the study. There was one mixed method study conducted by Jansen et al., (2022) that examined what couples face when they deal with RPL. Although this study used qualitative content analysis to analyze the data, it still used a questionnaire which was administered to a large sample size. Thus, the free text responses were examined using this qualitative content analysis, but the researchers identify a limitation of the study as not being able to follow-up with further questioning in cases of ambiguities since it was written responses and not in-depth individual interviews.

The existing research on mental health and RPL underscores the profound emotional impact RPL can have on individuals. The psychological distress, grief, anxiety, and depression identified by many of these studies drives the interest and focus of this study which is for indepth understanding and description of what these lived experiences look and feel like.

Chapter III

Methodology

Introduction

This qualitative study is designed to describe and conceptualize the contents of the RPL patient’s thoughts and fantasies during the time that she is experiencing recurrent pregnancy loss. The primary question being explored is what are the unconscious thoughts, feelings, and fantasies of women experiencing RPL, specifically in relation to their process of recurrent loss and lack of a healthy, sustaining pregnancy?

This qualitative research project employs a case study methodology (Tolleson, 1996) within a social constructivist epistemological framework. Qualitative research is most fitting for this study for a few different reasons. Firstly, qualitative research is exploratory in nature and lends itself to developing an intricate and more thorough understanding of an issue (Creswell and Poth, 2018). In addition, qualitative research provides space for a variety of responses and explanations, whereas quantitative research tends to try and determine a singular causal explanation or simple generalization (Bloomberg and Volpe, 2008). The final reason for choosing a qualitative methodology is that qualitative research seeks to empower individuals to share their stories, have their voices be heard, and reduce power dynamics that frequently exist between researcher and participant (Creswell and Poth, 2018). These objectives described by Creswell capture the core values and aims of this research project (Goedert, 2015).

Within the broader umbrella of qualitive research, I utilize a case study methodology to ensure that the complexities of each participants’ experience of RPL is heard, described, and understood. The aim of conducting the study in this manner is to produce a body of work that spotlights the contents and meanings of the RPL patient’s thoughts, fantasies, and feelings. The

case study methodology approach allows for greater depth of understanding across multiple cases of participants. Yin (2018) defines a case study as,

An empirical method that investigates contemporary phenomenon (the “case”) in depth and within its real- world context, especially when the boundaries between phenomenon and context may not be clearly evident. (15)

He goes on to explain that case study research deals with distinctive situations in which there are many variables of interest. Case study research will typically encompass multiple sources of evidence and the data will converge in a triangulating fashion (Yin, 2018, p. 15). This definition of a case study appropriately fits with this research project. The study focuses on the lived experience of RPL (i.e., the phenomena being investigated), however, the context of the participants’ lives and histories is significant as well. Additionally, this research project will gather data from multiple sources (in-depth interviews, participant journaling, self- journaling etc.,) and will work to identify where the data converge as part of a larger meaning-making process. The case study methodology allows for a deeper understanding of the lived experiences of women living with recurrent pregnancy loss with careful consideration for the interplay between these patients’ personal narratives and their encounters with these losses, disappointments, and failures.

A major theoretical underpinning of this type of case study methodology comes from hermeneutics. Hermeneutics refers to the theory and practice of interpretation. Systematic empirical research on more interpretive genres of science such as the psychoanalytic process is often seen as providing validity to these areas of practice and study. As this project will be a psychoanalytic study, there may be preference for viewing the findings of this study as more legitimate if it were conducted as an empirically driven quantitative research study. Nonetheless,

I chose to conduct this psychoanalytic case-study within a nonobjectivist hermeneutic paradigm in order to embrace the multitude of RPL lived experiences and ways of interpreting those experiences. Rather than seeking to uncover and excavate existing reasons and rationale for RPL women’s psychological symptoms, this study hopes to engage to in a meaning-making, interpretive process that discovers, explores, and describes the unique lived experiences of these individuals. Hoffman (2009) articulates this point well when describing the drive and pressure to value empirical research over qualitative case study research. One can liken his use of the analyst and analytic patient to that of the researcher/interviewer and research participant. He states,

My thesis is that the privileged status that this movement accords systematic research and neuroscience as compared with in-depth case studies is unwarranted epistemologically and potentially damaging to the development of our understanding of the analytic process itself …The critical constructivism that I have been encouraging replaces a diagnostic, knowing, prescriptive attitude with one that requires responsible, creative, improvised and collaborative efforts on the parts of the participants to make something of the ambiguous, context-dependent reality…In this paradigm, the analyst embraces the existential uncertainty that accompanies the realization that there are multiple good ways to be, in the moment, and more generally in life, and that the choices he or she makes are always influenced by culture, by personal values, by countertransference, and by other facts in ways that can never be fully known. (pp. 1044-1045)

Originally hermeneutics provided a way to interpret biblical texts, however, it has evolved into philosophical underpinning for the interpretation of an increasingly wider range of texts and phenomena (Smith et al., 2009). For the purposes of this research project, two prominent hermeneutic theorists’ ideas will be used to provide a framework from which to

collect and analyze the data. These theorists are Heidegger and Gadamer. In his work titled Being and Time (1927), Heidegger discusses the process of interpretation. He states that the reader, analyst, or listener brings their fore-conception (prior experiences, assumptions, preconceptions) to the encounter and inevitably views the encounter through the lens of their own experience. Nonetheless, he emphasizes that although these prior experiences exist (he refers to them as the fore-structure), when engaging in the act of interpretation “priority should be given to the new object, rather than one’s preconceptions” (Smith et al., 2009). More importantly, Heidegger asserts that while the existence of fore-structures precedes our encounters with new things, our understanding of these actual prior experiences and preconceptions may not emerge fully until we are engaging with the new object. Enhancing and adding onto Heidegger’s ideas, Gadamer emphasized that the “aim is to allow the new stimulus to speak in its own voice,” knowing that one’s preconceptions can “hinder this process” (Smith et al., 2009, p. 26).

Preconceptions are inevitably present and through the dynamic process of what we bring to the encounter and what the encounter brings to us, sometimes we can identify our preconceptions in advance and other times they will emerge during the process of engaging with the new object presented. This is the very heart of the meaning-making process that will lie at the core of this research project. This process requires a “spirit of openness” (Smith et al., 2009, p. 27). This spirit of openness is helpful when thinking about the type of interview process, I will conduct for this study.

In addition to the hermeneutics theoretical underpinning of this study, this case study research project is situated within the social constructivist philosophical paradigm. Social constructivism provides an important framework for how this project identifies, understands, and makes meaning out of the data collected. In social constructivism, individuals pursue an

understanding of the world they are situated in, developing subjective meaning of their experiences. It is important to note that these meanings are diverse and numerous which guides the researcher to look for the complexity of views rather than narrow down the meanings to a few categories or ideas (Creswell and Poth, 2018). Instead of studying or seeking to uncover a single observable reality, social constructivism assumes that there are multiple realities or interpretations (Bloomberg and Volpe, 2019). Creswell and Poth (2018) specify that these interpretations are, negotiated socially and historically…they are not simply imprinted on individuals but are formed through interaction with others (hence social construction) and through historical and cultural norms that operate in individuals’ lives. (24)

The epistemological position of constructivism emphasizes the social construction of reality, viewing the interaction between researchers and participants as open, understanding, and expansive. Thus, in my research, the researcher remains in dialogue with the participant to coconstruct and interpret meaning of the observed phenomena (Jaeger, 2020). This dialectic process is not only happening between participant and researcher but also happening within each participant’s unique sociocultural, developmental, and historical context (Goedert, 2015).

Social constructivism assumes that reality is socially constructed, that individuals make subjective meaning of their own personal experience, and that this unique meaning-making process gives way to multiple meanings (Bloomberg and Volpe, 2019). This not only applies to the participant’s understanding of their own experiences but includes the researcher’s background and how that shapes interpretation (Creswell and Poth, 2018). My own developmental history, as well as social, cultural, and historical experiences unavoidably

influence my questions, interactions, and interpretations (Bloomberg and Volpe, 2019; Creswell and Creswell, 2018; Runyon, 1984). Bloomberg and Volpe (2019), state,

The constructivist researcher’s role is essentially that of the “passionate participant,” as the facilitator of multivoice reconstruction (Lincoln & Guba, 2000). Constructivist researchers recognize and acknowledge that their own backgrounds shape their interpretations, and they thus “position” themselves in the research to acknowledge their own cultural, social, and historical experiences. Rather than starting with a theory… researchers pose research questions and generate or inductively develop meaning from the data collected in the field. (45)

It is important to address value of this type of research. According to Runyon (1984), just because the data in this type of research is shaped by certain personal and particular contexts does not limit its ability to be “rigorously examined” (p. 35). Thus, even with the impactful influence of the sociocultural and historical contexts as well as the acceptance that there are no absolute truths to be uncovered, there is still great value in participating in a dialectical process with individuals to learn distinctive and nuanced understandings of their lived experiences (Goedert, 2015).

In summary, this qualitative research project uses a hermeneutical, case study methodological approach situated within a social constructivist framework, to study the unconscious thoughts, feelings, and fantasies of women experiencing RPL in order to learn more about their psychic experience on their journey to trying to conceive a healthy baby.

Case Selection. General case selection guidelines are used for this project. Yin (2018) recommends using one’s own judgment and discretion when deciding upon the number of

participants, however, suggests that “five, six, or more replications” is useful when trying to obtain a higher degree of certainty with one’s results. After careful consideration it seems as though five cases fits Yin (2018)’s suggestion for a higher level of certainty while remaining small enough to allow for deeper analysis and well-founded observations and interpretations (Tolleson, 2009). I will conduct six one-hour interviews with each participant in an effort to obtain rich and in-depth data about each participants’ experience. I will utilize purposeful sampling which means I will select individuals for study because they can purposefully inform an understanding of the phenomenon being studied (Creswell and Poth, 2018). The purposeful sample allows the researcher to deliberately study a group of people that can “best inform the researcher about the research problem under examination” (Creswell and Poth, 2018, p. 148).

I will use a number of purposive sampling strategies to seek out participants for this study. First, I will partner with a few different, local health clinics that treat and work with patients dealing with RPL. These clinics will include fertility clinics, acupuncture clinics, and pelvic floor physical therapy clinics. These clinics will allow me to advertise recruitment information regarding the project. I will also send an email out to my network of family and friends notifying them of the study and the specifications for the type of participants I am looking for to see if they may know of anyone who might be interested in participating. Lastly, I will network with infertility awareness organizations and groups such as Robyn and Resolve to present my project to them and recruit interested participants who subscribe or belong to those organizations. Although I will reach out to my own network of family and friends, I will only allow participants who might be connected to someone that I know but they do not know me personally. Creswell and Poth (2018) warn against choosing participants that you know personally and for the purposes of this study I believe that boundary holds true.

As aforementioned in chapter one, I have been through my own experience with RPL and have since birthed a healthy baby. For these reasons especially it is important for the participants to not know me personally. I believe this information could have significant impact on how participants answer questions in the interview as well as influence their thoughts and feelings about themselves.

I will screen potential participants with inclusion criteria in mind. The two inclusion criteria will be that the participant has experienced 2 or more consecutive pregnancy losses and that they identify as cisgender female. There will be no specifications on demographics such as race or socioeconomic background. However, the area and locations that I plan to sample from will likely produce a sample that is comprised primarily of middle- and upper-class Caucasians. This is a potential limit to this study and efforts will be made to collect from a more diverse sample population. This will be discussed more thoroughly later in this chapter. The exclusionary criterion for the study will include the following: 1. If an individual is currently pregnant, 2. If an individual has had a healthy baby, 3. If an individual has had a stillborn child and 4. Clinically significant anxiety, depression, or mental illness prior to the RPL diagnosis.

After participants fit the above-mentioned criteria, I will assess willingness and availability to participate in the study. I will provide an overview of the time commitment of six hours over the course of six different interview days. Additionally, I plan to evaluate a potential participant’s interest in their experience of RPL as my hope is to find participants who are invested in thinking and talking about their experiences (Goedert, 2015). Following this thorough assessment, I will select five participants who meet the exclusion criteria and express an eagerness to participate in the study.

Overview of information needed. I will gather demographic information such as age, race, and gender during the early stages of sampling. Additionally, during the initial sampling procedures, anxiety and depression will be screened for in a phone or video conference survey with the potential participant. The screening will involve inquiring about any prior psychiatric hospitalizations or participation in intensive mental health treatment programs.

Important contextual information will include the participants’ individual history with trying to conceive. For example, information such as miscarriages, or whether treatment with a fertility specialist has been initiated will all be important contextual data points to gather about the sample. Additionally, if the participant has initiated fertility treatment, contextual factors such as a diagnosis will be critical information for the researcher to know (i.e., if the RPL is unexplained versus due to a blood clotting or auto-immune disorder.) Participants’ perceptions of their experience with RPL and their treatment or lack thereof will be crucial information to gather as this study is focused on the lived experiences of the population being investigated.

Research design. This project will use a case study methodology (Tolleson, 1996) to explore in-depth the lived experiences of women struggling with RPL. It will involve interviewing five participants six times one hour each time. The participants will have the choice to select the interview location between my office, an outdoor area near my office, or a zoom interview. The interviews with each participant will be conducted within a two-month period in order maintain the participants’ active engagement in the study, to foster rapport and comfort with the interviewer, and to keep participants connected to an ongoing self-reflective process.

Data collection. The data for this study will be gathered from both unstructured and semi

structured interviews as well as the collection of participants’ journal entries reflecting on the interview experience. These interviews will allow the participants to discuss aspects of their narratives that seem most meaningful to them (Yin, 2018). The questions will be mostly open, and general to give participants enough space to consider and discuss information that feels most reflective of their experience. This free and open interview style is designed in such a way to uncover the participant’s lived world and unfold the meaning of their experience (Creswell and Creswell, 2018). While there will be an openness in the interview style that allows the participant to explore their personal experience, I will remain active to keep the material focused on the interests of this research project (Goedert, 2015). I will focus data collection on understanding the world from the participants’ point of view, learning the meanings of the participants’ experiences, and not on fitting their experiences into predetermined ideas about their experiences that fit nicely with theoretical formulations discussed in the literature review (Creswell and Poth, 2018; Goedert, 2015).

The data collection process will involve audiotaping and transcribing the interviews, as well as taking field notes to document my own thoughts, and collecting journal entries from participants that they will have been instructed to keep throughout the process.

Plan for data analysis. I plan to use qualitative and case study methodology guidelines for my data analysis. Bloomberg and Volpe explain (2019),

Analysis and interpretation of case study takes place in an iterative manner. The researcher collects data, analyzes it to see what the data are saying (analysis), and seeks to understand what it means (interpretation)…The centrality of contextualized deep understanding as the ultimate objective is recognized as key. (105)

Additionally, according to Bloomberg and Volpe (2019), When multiple cases are examined, the typical analytic strategy is to provide detailed description of themes within each case (within-case analysis), followed by thematic analysis across cases (cross-case analysis), providing insights regarding how individual cases are comparable along important dimensions to warrant any presumed common finding between them. (pp. 50-51)

I will provide detailed descriptions of each individual case, analyses within those cases, and then analyze themes across cases (Creswell and Poth, 2018; Tolleson, 1996).

Ethical Considerations

The most significant ethical consideration will be for me to be aware of how my own personal journey with RPL and my subsequent healthy pregnancy might influence how I conduct the interviews and interact with the participants. My own journaling process and thoughtfulness about separating out my own experience will be crucial to the project. While it will be impossible to completely remove my own experience from its impact on the interviewing process, it is of utmost importance to stick closely to the participants’ experiences. Creswell and Poth (2018) identify this process as bracketing, stating, “investigators set aside their experiences, as much as possible, to take a fresh perspective toward phenomenon under examination” (p. 78).

Additionally, it is important to note that this study requires participants to spend time thinking about their recurrent pregnancy losses and to talk about it. It asks participants to pay attention to thoughts, feelings, fears, and anxieties on an intense level that they may not have spent time tending to prior to these interviews. As a result, there may be heightened emotional intensity and affect due to the focus on these thoughts and feelings. It is possible that the

interviews and journaling process will be asking participants to observe and relate to their thoughts and feelings in an in-depth way that they have never done before. Regardless of the person or context, RPL is wrought with struggle, suffering, loss, and pain. Consequently, asking individuals to spend intense, focused periods of time thinking about this condition and talking about it has potential to be triggering and to stir up difficult emotions.

In order to address these potentially distressing experiences, I will employ several steps as a means of minimizing risks. The following steps will be taken:

1. Encourage participants to communicate any distressing thoughts or feelings during the interviews.

2. Urge participants to communicate any questions that they are uncomfortable answering.

3. Offer to stop the interview at any time if needed or pause for a break.

4. Be prepared to provide participants with referrals to appropriate resources such as psychotherapists specializing in reproductive health, supports groups and other community support networks if needed.

Validation Strategies/Issues of Trustworthiness

I will implement a variety of strategies throughout this project to ensure validity, credibility, and dependability. The integrity of this study will be established through the methods of Case Study Methodology (Tolleson, 1996). These methods allow for the individual perspective of each participant to be heard. The techniques used as a means of enhancing credibility will include: 1. Semi-structured in-depth interviews that allow participants to discuss aspects of their narratives that seem most meaningful to them (Yin, 2018), 2. Audiotaping and

transcribing the interviews, 3. Taking field notes to document my own reactions, thoughts, and ideas throughout the process, 4. Combining participants’ journaling of their experiences with interviews to collect a fuller picture of the data, and 5. My own self-reflective journaling.

During the interviews, I will reflect and summarize in order to make sure that I accurately understand the material being presented by the participants. I will also reinforce my hope to understand the participants’ stories fully and encourage them to talk as openly and freely as possible about their experiences. Finally, I plan to conduct a sixth follow-up session with the participants where I will ask participants to read what I have written about our five interviews and make certain that what I have written resonates with what they wish to express about their experiences (Goedert, 2015).

Limitations of the Study

Due to the social constructivist paradigm within which this research project has been situated, my questions, analyses, and insights will be influenced by my own life experiences (Creswell and Creswell, 2018). Thus, the findings of this study will present just one specific way out of an immeasurable number of ways of perceiving the participants’ lived experiences (Runyon, 1984). This aspect of the study is a potential limitation. Although I cannot completely remove the influence of my own life experiences, I will still utilize bracketing in an effort to separate my own biases and personal influences from the interview process and data analysis while recognizing the fact that my own experiences still shape this study. Bracketing will involve a process of listing my biases, assumptions and preconceived notions and talking these through with my research advisors. The hope is that through that process these personal influences can be carefully monitored and hopefully have as little impact on the interview process and data

analysis as possible. This will be an ongoing effort throughout the course of the study to pursue meanings directly from the data.

Additionally, another anticipated limitation will likely be a potentially homogenous sample population which I will employ certain efforts to mediate through the diversity of locations I recruit from. However, fertility treatment tends to mostly be accessible to individuals with higher socio-economic background due to lack of insurance coverage and the high expense of these treatments (Smith et al, 2011). Additionally, research has shown strong biases against women of color who report issues with their reproductive health (Chin et al., 2015). As a result, there is an extremely high likelihood of homogeneity in the participant sample. Lastly, not only will the sample likely be homogenous, but it will only be five participants. This sample size will allow for rich, thickly descriptive meanings and understandings to emerge, however, it will also exclude chances to understand the phenomenon on a more broad scale (Goedert, 2015).

Chapter Summary

This is a qualitive study that will utilize case study methodology. It is situated within a social constructivist philosophical paradigm. The study will be comprised of six, one-hour, openended, interviews with each of the five participants who will be selected via purposeful sampling. These participants will identify as cis gender females. The interview data will be studied and analyzed for a depth of understanding as well as themes. The case analyses include within-case analyses as well as cross-case analyses. This methodology will promote deeper understanding and meaning of the participants’ lived experiences.

Chapter IV Results

Within Case Analysis

Case Study #1 Sally

Descriptive Information

Sally is a 35-year-old Caucasian cisgender woman, married and currently working fulltime as a literacy coach in a school setting. She identifies as Jewish but explains that religion is not a hugely significant aspect of her life. She has two master's degrees, one in curriculum and instruction and another as a literacy specialist. She has a background in elementary education and literacy consulting. She reports that she grew up in a loving household and has warm, fond memories of childhood. She shared that she has a sister who is 3.5 years younger than her and parents who remain in a loving marriage to this day. She shared that her mom suffered a stillbirth and a late-term miscarriage (16 weeks) after she had Sally and before having Sally's sister.

Throughout the interviews, Sally intermittently circled back to her mother’s losses. She intermittently discusses this thread of her own mother’s trauma as she navigates through her own experience with RPL.

Sally has a complex fertility history involving two miscarriages, multiple chemical pregnancies, multiple failed rounds of IVF egg retrievals, and numerous other procedures in her efforts to carry a healthy pregnancy and have a baby. At the onset of her reproductive journey, Sally shares that she always knew she wanted to have babies, and she approached this task as one that she needed to plan and prepare for to achieve success (knowing that many people struggle in their 30s to get pregnant).

She shares that she and her husband started trying to conceive on their honeymoon and that she did a lot of physical preparation beforehand (i.e., going off birth control, tracking her cycle, etc.), to give herself the best shot possible at having a baby. She describes a sense of urgency to get started as the messaging around her from society, family, and friends is that this process can be difficult.

The first time Sally officially found out that she was pregnant, she remembers feeling excited to be pregnant but also excited to be able to say "it worked...I can check it off the box. I did my part. I got pregnant." Sally elaborates that she is a "very structured" person who "likes checking off boxes." In hindsight, looking back on that moment, Sally reflects on her own naivete about what it even meant to get a positive pregnancy test.

Sally recalls that as early as her first scan at six weeks pregnant, she felt that something was off about the entire process in the doctor's office. They notified her she was measuring small but that that could still be normal and told her to come back in two weeks to see how things are doing. She states, "Something felt really off. They didn't give me a printout of my ultrasound picture. I didn't really have that joyous feeling I expected to have. I left feeling something in my gut and maybe it was their non-verbal cues but left feeling that something could be wrong."

When she went back two weeks later, there had been no growth of the embryo; however, the medical team informed her that she needed to come back again in another two weeks. They stated that it was possible they had measured wrong initially and that she needed to wait to see how things progressed. Sally recounts this next two-week waiting period as the most difficult time she has endured in this entire process of trying to have a baby. She states, “I left feeling just like this is doomed. My husband was like ‘be positive.’ She didn't say it's definitely going to be bad." The ultrasound tech told me ‘there is still a heartbeat, so I am not going to tell you to go

terminate this. Maybe it will catch up.’ Those were the hardest two weeks that I've really endured through this whole process because I left feeling almost positive in my gut that it was going to end, I knew it. Other people tried to convince me otherwise. It just felt like every fiber in me was saying ‘Just prepare. Just get ready. You're going to be okay. This isn't it.’ It felt like the whole world was trying to tell me it might be okay.”

The mismatch of Sally's intrapsychic experience of her impending losses with what friends and family around her were telling her to feel and think is a recurring theme for her throughout this process. Sally goes on to describe the details of her subsequent losses, her arduous journey with assistive reproductive technology, and the ways in which all of these experiences impact her, her marriage, her familial relationships, and her perceptions of others and her interpersonal interactions. Across the interviews, several core themes emerged that illuminate how Sally makes meaning of her losses and the impact they have had on her sense of self, her body, and her relationships.

Categories of Meaning

Theme I: Control, Achievement, and Self-Worth

A reoccurring theme throughout Sally's interviews is her self-description as a person who always plans and prepares for both personal and professional goals. Sally shares that even prior to getting married, she felt aware of her biological clock, conscious of the issues many people face when trying to conceive and wanted to plan and prepare with her partner in the event that it might take them longer than expected to get pregnant. She was methodical about initially trying to conceive. When she found out she was pregnant for the first time, she reports: "I was so happy

it had worked...I like checking off boxes. And from the start, that's kind of like a gut feeling I got was like, 'Okay, I can check it off the box. I did my part. I got pregnant.'"

Sally's methodical approach to conception—tracking her cycle, discontinuing birth control, and celebrating her first positive pregnancy test as "checking off a box"—reflects her drive to achieve and succeed. Sally never stated outright that her self-worth was tied to achievement, but the way she described her approach to pregnancy, methodical and taskoriented, suggested that success and identity were closely linked for her. Sally had shared that within her family system, she had always been the daughter who was calm, self-regulated, and high achieving.

It is important to note that Sally is the baby who came directly after her mother gave birth to a stillborn baby, and Sally is her mother's first healthy, live birth. Thus, inherent in Sally's very existence is being a "fixer" to terrible grief and loss, and to be a "success story." Growing up as the well-behaved daughter—and the "fixer" who arrived after her mother’s losses—Sally seems to carry an internalized pressure to succeed and to make things right. She communicates in her interviews that she holds a deep fear of not achieving her reproductive goals.

This feeling of failure is so overwhelming within her fertility journey with recurrent pregnancy loss that at one point during interviews Sally states, "I cannot even miscarry properly." The meaning behind Sally's statement is that even when she is in the process of losing her pregnancy, her body believes it is still pregnant and holds onto the pregnancy, continuing to produce pregnancy hormones and not allowing her body to naturally dispose of the unviable pregnancy.

This inability to "check the boxes" off and reach her goals is most starkly highlighted by her experience of going through multiple rounds of IVF egg retrievals. As she is going through the multiple rounds and not reaching her goals, others' (namely family members') expectations stir a great deal of inner conflict for her as she begins to experience her own physical and mental limits. Sally struggles with the decision to stop treatments, sharing: "It feels wrong not to do as much as I can, but I know sometimes doing as much as I can is taking a break to take care of myself."

In addition to Sally's fear of not meeting her goal, she also fears being "left behind" while others move on to subsequent pregnancies. She shares, "I feel left out of the fun, joyful parts of life." This fear of being left behind is part of the reason she attempts to plan and exert as much control as she can over her fertility journey. However, this degree of planning and focus makes it that much more disappointing when what she has planned for does not come to fruition. Furthermore, others being able to achieve what Sally is working so hard to accomplish challenges her internal narrative of being the best and most successful at whatever she is doing.

Sally’s struggle with RPL has left her feeling that the freedom and spontaneity she once had—being able to say yes to destination weddings or fun trips—has been replaced by a life organized around fertility treatment. She described having to plan meticulously around injections, monitoring, and possible procedures, while at the same time feeling unable to commit to social plans because she never knew where she might fall in a cycle or when she would need to be near her doctor. In this context, she shared that she had canceled at least five trips, stating, “I’m so ready to not plan out my weekends.”

Theme II: The Body as Both Failure and Worthy of Protection

Sally's relationship with her body throughout her fertility journey is a complicated one filled with feelings of both self-blame and a strong desire to nurture and protect it. Her multiple pregnancy losses are experienced not only as medical setbacks but as personal failures that disrupt her life-goals and plans. Yet despite this feeling of failure at times, Sally also expresses a strong desire to provide love and care to her body for all that she is putting it through.

When Sally comments "I cannot even miscarry properly," she expresses an exasperation with her body that even in the failure or loss process of the pregnancy journey, her body is still not showing up for her in a predictable or understandable way. During her interviews she talks about the questions that go through her mind: "What is going on inside my body? It is scary that I miscarried a 'normal' embryo, can I even carry a successful pregnancy?" When Sally learns that one of the embryos she lost was genetically normal, she views this as a failure on her body's part to carry it to a healthy, live birth.

Sally has experienced significant physical trauma throughout her fertility journey. She developed a serious infection and almost went into sepsis after a D&C. This infection required emergency treatment and a second procedure. She describes physical pain that she feels afraid of, stating: "I've had the same but worse really atrocious stabbing pains in my ovaries, particularly my right one." She wonders aloud to me if it is “crazy” to even be considering another retrieval when she is experiencing that type of pain. She talks about how when getting an IV for an MRI, the technician comments on her extensive scar tissue from previous procedures.

The tension between what her mind wants and what her body can endure becomes explicit when she contemplates another retrieval: "I feel like my mind wants to do the retrieval.

But my body is like, 'No, it's not an option.'" This split she feels between her mental determination and her physical limits challenges her internal ideas about persistence and achievement.

While Sally experiences these disappointments and struggles with her body, she expresses deep compassion for her body despite these perceived failures. She states: "I don't think I've really ever felt mad or disappointed in my own body...I just feel like it was dealt a shitty hand." This perspective is further illustrated when she shares, "I feel like all I want to do is like wrap my own body in support." Rather than anger, Sally feels protective of and in awe of all that her body has had to go through.

Sally's fantasy of putting embryos in a surrogate reveals the depth of her desire to protect her body: "If surrogates weren't like $160,000...I would want 100% to put one of our embryos in a surrogate and go pamper my body, let it workout, let it eat healthy...That sounds like a relief to me, not sad that I couldn't carry my baby at this point." Thus, there is this contradictory experience of a simultaneous need to persist and push her body while also wanting to protect and care for it.

Theme III: Detachment, Shame, and the Search for "Realness"

Later in our interviews, Sally begins to explore her disconnection to pregnancy and to having a baby. She talks about how throughout her losses and treatments, she has not allowed herself to envision herself as a mom or feel connected in anyway to the lost pregnancies she has had along the way or to the future idea of a child. She shares, " All of my losses, I have not once felt like I lost a baby. I've been like, oh God, my whole journey's put on hold. My body's going to go through hell." This detachment extends to her struggle to connect with the possibility of

success: "I can't even remember being pregnant even though I have been so many times...I can't even remember the joy in it if that makes sense." She also describes a moment during a Reiki session she did after her first pregnancy loss where the practitioner asked her to envision space for a baby in her apartment. She describes this moment, stating, “She would try to help me visualize a space a baby could go in in our one bedroom apartment. Because I literally was like, I can’t imagine myself getting pregnant and having a baby because there’s literally nowhere to put one.” This practical limitation in her life also seemed connected to a deeper inability or not allowing herself to imagine her future with a child in it.

She further emphasizes the experience of disconnect with a baby or the idea of a baby by sharing, "I honestly felt like if I were to really reflect, and it's really sad to say I felt like shame that it hadn't worked out...It wasn't that I was sad to lose a baby. I don’t think I even allowed myself to imagine having a baby. " She’s sharing that the feeling of failing felt more pronounced than an experience of a loss of a baby.

Despite some of the detachment that Sally experiences, she also repeatedly expresses a need for her experiences to be validated as real. She shares that finding out the sex of her miscarried pregnancies "made it real" and provided her with a fleeting sense of inclusion in the "mom club." This need for concrete markers of her maternal experience hints at her desire for recognition of her losses.

Sally reflects on her experience after receiving genetic testing results from one of her pregnancy losses: "I remember being like, 'Oh my God, please tell me the sex because that would mean it was real.' I really wanted to feel validated that I had all of these feelings." This desire to have the realness of her pregnancies mirrored back to her seems linked to the experience of feeling shut out of the “mom club” by both the fact that she has not been able to carry a

pregnancy to term and have a child as well as the larger societal messages that say that anything before the second trimester is not worth talking about. She states, “Society tells you don’t tell anyone. Its not really real until you get an ultrasound.” Her own mother reinforces this message stating, “Oh, you’re so early, Talk to me once you have the ultrasound.” Interestingly, when Sally is answering a matter-of-fact questionnaire with the receptionist at a maternal-fetal-medicine specialty office, after providing her history, the medical assistant states, “Oh okay. So this is your sixth pregnancy.” Sally shares that just hearing that and not just thinking about them as chemical pregnancies or early losses provided a certain “realness” to her experience and her identity as a woman who has now carried 6 pregnancies.

This search for "realness" extends to her consideration of finding out the sex of her frozen embryo before transfer, explaining that knowing this detail would help her connect to the process.

Theme IV: Hope, Reality, and the Path Forward

A reoccurring theme throughout Sally’s interviews is how she works to maintain hope when faced with so many disappointments and troubling realities. She talks about how having space to contemplate different paths to parenthood has provided her with hope and comfort rather than feeling like she is giving up on one dream and settling for something less.

Initially, earlier in her reproductive journey, Sally receives reassurances from others during her losses. People say things like, “its common to have a miscarriage, the next pregnancy will work for you,” or during the actual pregnancy that she is in the process of losing, people will say things like “It may still workout, you don’t know yet, just hold out hope.” She describes an internal "gut feeling" that often contradicts everyone else’s optimism. For example, with most of

her losses, she had a gut feeling things were not progressing in the right direction. This contrast between her intuition and what friends and family tell her, leads her to not only feel a pressure to maintain hope but it also leads her to question whether her "negative" thoughts might somehow harm her pregnancies.

Sally's consideration of donor eggs feels like a way in which she is able to reframe hope and possibility during her challenging reproductive journey. Sally talks about how society and people in general view donor eggs as "giving up." Sally sees them differently: "If someone handed me on a platter right now, embryos with like a cute, brown-haired woman's egg, and my husband's sperm, I would be like, 'Praise everything. It's over put it in.' I wouldn't be sad at all."

She explains: "I think the reason I want them so badly is because, to me, they carry a very similar potential to be our children. It's not that I'm giving up on one, it's that I am obsessed with the fact that we could have a hope with these embryos." This perspective gives insight into how Sally’s like experiences with RPL have expanded her definition of motherhood beyond biological connection. She juxtaposes her own expanding ideas about motherhood with a close friend who remarks about Sally’s consideration of donor eggs: “I don’t know how you could do that. I really don’t think I could ever do it.” Sally reflects on this comment, “Yes, you would if you wanted a kid and that was your only avenue you would find the beauty in it and you would get empowered by it.”

Theme V: Navigating External Pressures and Misattunement

Throughout her RPL journey, Sally talks about many moments of misattunement with both her healthcare providers and her community of family and friends, highlighting the isolating nature of RPL.

Subtheme: Medical Dehumanization

Sally describes numerous instances where healthcare providers failed to recognize her emotional needs or seemed thoughtless in their approach to pregnancy loss and fertility treatment. During her initial pregnancy loss experience after her OB told her there was no heartbeat, she said, “I’m going to move you to a different room, and then we’ll talk about what to do.” Sally said that her and her husband switched rooms and proceeded to sit there for a long time waiting and no one came back. Eventually a nurse walked by the room and asked them what they were doing in there. Sally says she responded, “We’re in here because I miscarried and I need to know what to do next.” She said eventually the doctor came back and it felt as though she had forgotten they were waiting for her and the first thing she said was “Do you need the ‘miscarriage talk?” Sally reflects on how this felt, stating, “It felt belittling in a way. Like I’m not a kid. I don’t need some talk. But this feels like, ‘I don’t want this question right now. You should obviously tell me what my options are and how to navigate this. Why are you even asking me if I need that because telling someone, ‘You might have a heart attack tomorrow, do you need a heart attack talk?’ It’s like, ‘Yeah you’re my doctor. It’s your job.” This was a clear moment where the doctor was failed to provide thoughtful, compassionate care and almost seemed like she was missing the proper tools in how to provide care during pregnancy loss.

A different doctor told her during a miscarriage diagnosis, "Well, isn't it great that you got pregnant when you have scarring?" she felt profoundly misunderstood. Sally thought to herself, “No, I am not feeling particularly grateful in this moment and nothing seems ‘great’ about it.” These interactions make an already painful experience even more painful by completely skipping over the complexity of her emotional state and alienating her from the provider.

Even moments that should be triumphant become sources of stress—at her embryo transfer, her blood pressure spiked to 177/100, and she reflects: "I was like, this is the moment I have waited for like 18 months and this is just so typical that this is how it would go down." In that moment as well, none of the nurses or staff expressed any appreciation for the stress of her seeing her blood pressure go up so high during an important moment in her journey.

Subtheme: Social Pressures and Judgment

Sally feels judgment from others when she begins to consider alternative paths to parenthood. When she mentions donor eggs to her mother-in-law, the response is, "Don't say things like that. Think positive." Sally's reflects on this in our interview: "I was like, 'That is positive.' The ability to shell out $40,000 and have a baby...That is positive."

The external voices compound Sally’s people-pleasing nature and desire to ‘be the best, adding complicated layers to her process as she both wants to succeed in having a baby while yearning to be viewed as "doing everything possible and not giving up." The burden of constantly educating others about her experience adds another layer of frustration and exhaustion to her journey with RPL.

Subtheme: Interpersonal Pressures and Triggers

Sally’s RPL journey highlights the challenges of managing social dynamics while going through an experience of such profound loss and emotion. She talks about how so many seemingly benign interactions can feel triggering or lead her to feel misunderstood and they require careful navigation and thoughtfulness. There is a risk of becoming isolated from friendships and familial relationships. More specifically, Sally talks about how she is generally an open person who likes to share and process her emotions. At the beginning of this journey she

shared quite openly with friends and family about what she was going through, however, as the process has become much more complicated and drawn out, she has developed an appreciation for why people do not always share details about pregnancy loss and infertility. She talks about how she wishes she could share information when she feels a need to share and not talk about it when she doesn’t feel like it, however, once she does share even a small detail, she feels pressure from family and friends to continue to provide updates. She further describes the complex decision making around disclosing fertility updates by stating that “it forces you to either be very private about something you want more than anything to open up about, or if you have opened up about it, there is than a pressure to continue to update people even if it is news you no longer feel like sharing or feel up to sharing.”

Sally also talks about how different people with different life experiences trigger or do not trigger her in different ways. She shares, “I think I’m fine once I see the baby. Once the woman gives birth, I feel like I’m okay. It’s when they’re pregnant, that’s what’s triggering to me…a pregnant woman makes me fiercely jealous.” For her its less about the baby and more about this visible, physical reminder of something her body has not yet been able to do but is trying so hard to accomplish. Sally processes even more nuance and complexity to social triggers by sharing that some friends may say offensive things, however, based on their own individual experiences she may give them a “free pass” or just feel less triggered by their words. She talks about a college friend who had two losses and is currently pregnant and will often complain about pregnancy to Sally. She remarks on how this friend “has the right to say these stupid things.”

Lastly, she shares about how some of the challenging interpersonal dynamics have even shown up in her marriage. She states that she and her husband feel different about donor eggs.

For her, talking about donor eggs as a possible path to parenthood is exciting and comforting where for him it feels sad, as if they have given up on the option of having a biological baby together. She explains that at first it was difficult for her to allow space for him to express those feelings, she would get angry, shutdown or upset, however, she is trying to let him have his feelings alongside her own feelings and process them together. She also talks about how sometimes he will comment on what she’s eating or how much she is exercising. She states, “I think the biggest thing is him grasping for control and me feeling like someone is trying to control me by the person that loves me the most…Don’t eat too much sugar. I’m like there are women that don’t even know they’re pregnant that are having eight strawberry daiquiris a day in Cancun.”

Impressions from the Interviews with Sally

Throughout our interviews, Sally entered with palpable warmth and eagerness to discuss her experiences. She often made comments about having her therapy session and the interview in the same week and feeling lucky to have a second opportunity to think through her feelings. Sally frequently used humor, playfulness, and self-deprecation to reflect on the absurdity of all that she is putting her body through as well as disappointing interactions with medical providers.

In our first interview, Sally expressed how good it felt to contribute to research on this topic. Her participation seemed to serve as a way of making meaning out of her suffering and finding purpose in her challenging journey. The combination of Sally's warmth, playfulness, and participation contributed to my perception of an exceptionally resilient individual with a welldeveloped sense of self.

Sally demonstrated a profound capacity for intersubjectivity—the ability to hold both her own experience and that of others simultaneously. She navigates relational tensions with an ability to maintain her own perspective while acknowledging others' feelings as valid. This allowed Sally to hold space for her desire to contemplate donor eggs while providing space for her husband to express his desire to stay the course with their own eggs. It also helped Sally sustain many relationships as she navigated her journey, despite these individuals sometimes unknowingly making hurtful comments.

Perhaps most significantly, Sally's relationship with her own body reflects this capacity for holding multiple truths. She is able to feel deeply sad and frustrated with the disappointments of her fertility journey while simultaneously holding deep appreciation and respect for her body and all that it is enduring.

By the final interview, when Sally is newly pregnant with her transferred embryo, she shares that for the first time throughout this entire journey she could imagine "us in a hospital room, me, like, pushing. And like my body being able to do it." This represents not just hope for a successful pregnancy, but a fundamental reconnection to her capacity to imagine herself as a mother. Her ability to finally allow herself to fantasize about holding her baby with her husband shows the range and breadth of emotional experience, from disconnection and protection to hope and fantasy.

Psychoanalytic Interpretation of Sally’s Case

Sally’s way of organizing both her internal world and the external world around her demonstrates a largely integrated self, one that can hold ambivalence and maintain object constancy despite recurrent narcissistic injuries (Kleinm 1935, 1940, 1946; Ogden, 1986). Her

reactions to the various challenges she faces while going through RPL reflect what Melanie Klein (1940) would term movement toward the depressive position or the capacity to experience both good and bad aspects of herself and others simultaneously. One example of Sally’s capacity to experience both good and bad aspects of herself is in the way she feels deep concern and care for her body despite her disappointment in her body’s performance when it comes to carrying a healthy pregnancy. Sally is also able to tolerate guilt without engaging in persecutory defenses (Klein, 1935, 1940). A powerful example of this is when Sally struggles with the decision to stop doing egg retrievals. She describes feeling guilty, “it feels wrong not to do as much as I can.”

Despite feeling guilt around this decision, Sally does not engage in criticizing herself as inadequate or weak, instead she recognizes that “sometimes doing as much as I can is taking a break to take care of myself.” She holds space for herself to feel both guilt about potentially not doing enough while simultaneously maintaining self-compassion and realistic understanding of her limits. She does not fall into self-persecution or paranoid feelings that she is failing.

Sally’s narrative is largely organized around achievement as a primary source of narcissistic supply and self-cohesion. From a self-psychological perspective, her reliance on accomplishment to secure her self-esteem might mean that somewhere along the way in Sally’s development she may have experienced a deficit of “mirroring,” or recognition/validation (Kohut, 1971; Siegel, 1996). Sally’s high-achieving, methodical approach to trying to get pregnant, “checking off boxes,” demonstrates how she treats pregnancy as a goal to be mastered through effort and planning in order to achieve certain external markers of success i.e. validation.

Nonetheless, its important to note that despite her seeking validation, she can also recognize when this defense fails and respond with self-compassion rather than blame. She states, “ I don’t think I’ve really ever felt mad or disappointed in my own body…I just feel like it

was dealt a shitty hand.” This type of thinking is distinct from how a more narcissistically organized individual might respond to the same life challenge. Furthermore, it demonstrates a meaningful psychological achievement: the capacity to sustain concern and connection with the object despite intense disappointment. Sally maintains concern and connection with the body-asobject even when it has failed to provide what she desperately needs and wants. This is a clear representation of Klein’s concept of reparation or the wish to protect and care for the object (body) that has been damaged, rather than attacking it persecutorily (Klein, 1935, 1940).

Sally’s detachment from her pregnancies (she describes being unable to imagine herself as a mother and also experiencing pregnancy losses more as logistical setbacks rather than actual losses) can be understood as a defense mechanism. Rather than splitting (dividing good from bad, self from other), Sally engages in emotional withdrawal that is designed to protect her from the full impact of object loss. This emotional retreating is not dissociation but a strategic way of minimizing her emotional investment in an attempt to manage repeated trauma (Fairbairn, 1952; Bollas, 1987).

Bollas’s (1987) concept of the “unthought known” is a useful way of conceptualizing Sally’s defensive operation. Sally protects herself from fully knowing the extent of her attachment to these pregnancies because that experience might be psychologically overwhelming. When she seeks “realness” through wanting to know the sex of the lost pregnancies she is looking for concrete markers that her pregnancies/fetuses existed. This is an attempt to create symbolic space for mourning without being overwhelmed by unbearable affect. She needs the pregnancies to be “real enough” to validate her feelings but not so real that their loss destroys her.

Sally’s psychological superpower is her capacity for intersubjectivity. Jessica Benjamin (2004) describes intersubjectivity as the ability to recognize the other as a separate subject with their own experience. Sally holds both her desire to consider and pursue donor eggs and her husband’s sadness with and hesitation to use donor eggs all at the same time. She repeatedly demonstrates the ability to feel frustrated with her medical providers while also recognizing their human limitations. She feels both disappointed in and protective of her body while going through her RPL journey.

Sally has the ability to hold multiple perspectives simultaneously and to preserve the subjectivity of the other people in her life even when their thoughts, feelings, or needs are in direct conflict with her own. This capacity supports her ability to cope with the ongoing challenges in her fertility journey as intersubjectivity provides resilience and counterbalances the tendency to revert toward the splitting or narcissistic rage that something like RPL can activate (Benjamin. 2004; Ogden, 1986). Sally’s unfolding internal process suggests movement toward integration rather than fragmentation with the possibility for RPL to someday become an experience that deepens her self-knowledge and compassion rather than solidifying feelings of unworthiness or failure.

Case Study # 2 Jennifer

Descriptive Information.

Jennifer is a 36 y/o cisgender female who is married and identifies as Caucasian. Jennifer does not adhere to any organized religion but does connect with the idea of being a spiritual person. She has a bachelor’s degree and currently works full-time in IT as a manager of technical engineers. Jennifer’s initial journey with trying to conceive was influenced by pressure she felt to

start having children because that is what all her friends were doing, and she felt that that was the next life milestone she should be working toward. However, she reflects that now looking back on the initial phases of her journey toward motherhood, she really was not mentally and emotionally ready. Although she knew she always wanted children someday, she shared that she experienced significant trauma in her own childhood and felt she had not worked through all of it by the time she began feeling the pressure to have a baby.

Jennifer shared that she has “earlier memories” of childhood that are joyful and happy but things quickly “took a turn for the worse.” Jennifer reports that she was sexually abused by her older brother from the age of five until age 13. In her high school years her dad became physically abusive toward her mom. This abuse eventually led her mother to file for divorce, and for a period of time Jennifer lived in a hotel room with her mother while her dad vacated their home. She reports that during her high school years she became tougher and smarter at fending her brother off and that is why the abuse stopped; however, she did not disclose any of it to her parents until she was out of college. Jennifer shared that her dad did not believe her, and her mother has gone in and out of phases of believing her and not believing her. She shared that “a large capacity of my mental space has been spent trying to process my trauma.” Jennifer went to therapy for many years including during high school when she kept it a secret from her parents that she was even going to therapy. She states that “It really wasn’t until my pregnancy losses where I realized I had spent so much of my life working through that past trauma that I hadn’t given myself space to plan for my future the way other people family plan.”

In addition to not really family planning prior to trying to conceive, Jennifer also reports she had no education about ovulation and timing and later learned that she had been trying for one year with her husband but missing her ovulation window. Eventually she went to go see a

fertility doctor and learned more about timed intercourse. After monitoring her cycles with a physician, she soon got pregnant. Jennifer shared that quickly into her first pregnancy, “I knew things were going south,” because of the frequent bloodwork and ultrasounds. Although the pregnancy did not seem viable, there was a heartbeat and some growth at each scan which forced her to stay in a limbo of waiting for the pregnancy loss to declare itself. She states that the medical team was initially vague, not telling her it was bad but also not reporting anything positive and eventually did directly tell her she was likely going to “miscarry,” but there was still a heartbeat, so they wanted her to continue to have monitoring. Jennifer shared that in the initial weeks of monitoring the medical team kept telling her to “be hopeful,” and she wishes someone had been “more direct and honest,” about where things were heading. Jennifer stated that eventually the heart stopped beating and she was given the options of a d and c, medication at home, or to try and pass the pregnancy naturally. She opted to pass it at home on her own and states it was “absolutely, hands down, the most painful, like physically painful experience I’ve ever had.” In addition to the physical pain, she also reported “it was so traumatic to feel something falling out of you.” Jennifer said that despite all of this pain and trauma she went to work the day afterward.

Jennifer went on to have two more pregnancy losses soon after this first loss. She states that the second loss was one of the more emotionally painful losses for her because she felt very hopeful for it and all her bloodwork and scans initially looked great.

Jennifer shared that the stress and emotional pain of the recurrent losses was a big strain on her marriage, and at one point her and her husband were considering divorce. She now reflects that at the time they were both grieving in different ways, and rather than “turn toward one another and respect each other’s grieving process we grew apart.” She states that they used

an application called Lasting which has various communication exercises that helped them regain their connection.

Jennifer states that despite their marriage being stronger than it ever has been, one of their biggest challenges is the strain that their conception journey has placed on her relationships with her husband’s family, namely his mom and female cousin. She shared that her mother-in-law has never really validated how significant and real their losses are, and the cousin whom she used to be close with now has a baby and it has been difficult to remain connected. She shared that loss of certain relationships because people are having children has been a theme throughout this journey for her. Currently, she is on a break from trying to conceive naturally while she works with a Reproductive Immunologist to try and get her body strong, healthy, and primed to support a pregnancy. Jennifer’s experience is marked by her struggle with internal conflicts, challenging relational dynamics, and the loneliness of going through loss.

Categories of Meaning

Theme I- External Pressures (Keeping up with Everyone Else’s Timeline)

At the beginning of our interviews Jennifer discloses that she didn't start trying because she was ready to be a mom. She started because “everyone else was doing it.” Jennifer explains that her friends were all getting pregnant and she felt like she was falling behind. The pressure to keep up with friends at the same life stage as her pushed her into trying before she'd really thought about whether she actually wanted a baby or was ready for one at that time. She remembers having the feeling that she should be ready for this next step but feels she was not actually ready at that time to have a baby. This external pressure—combined with the implicit societal communication that motherhood is the next crucial milestone—spurred her decision to

begin trying. She states "I felt quite pressured to start trying to conceive...all of my friends were trying to get pregnant at the time." Jennifer recalls feeling a fear of being left behind. As it became more clear that having a healthy baby might take more time and be more challenging than initially expected, Jennifer's perception of her self-worth became more tied with her ability to check certain milestones and societal expectations off her list.

Throughout her journey, Jennifer expresses feeling that she is "waiting for my life to start." She elaborates: "I feel like everybody else in my life...they have the things that they want. Like, a lot of my friends have kids. It's not like a waiting game for them. For me, I'm waiting for my life to start."

Subtheme- Self-Worth Tied to Reproductive Success

Jennifer's identity is closely linked to her ability to have a child. She describes inner voices she hears, one is encouraging and positive when she gets pregnant and the other is punitive and critical when she has a pregnancy loss or sees others who are succeeding at having a baby. After her second pregnancy loss she shares, "At that point, I was just really fucking bitter...I was blaming myself."

For Jennifer, the losses trigger internal critical voices that say, "You are not enough" or "You failed." She states powerfully: "I know it's silly to say but I have felt that my life is not valid or important or worthy unless I am a mother. And I know that's just a self-limiting belief of my own, but like, that's how I feel. I feel like I'm looked at differently because I don't have kids yet. Especially in my husband's family, I feel like such judgment because all of my sister and sister-in-laws or cousin-in-laws, they all have kids, and it's just like, 'Oh, there's Jess. Sucks for

her. She is not a part of the mom group yet.' And it just sucks. I just feel left out of something and that my life is less important because I don't have a child."

When asked what she is doing with her life or life updates, she says her internal thoughts go something like this: "I'm like, well, what do I have to show for myself a job that I really don't like? Right now, that's all I have to show for myself. That's what I have accumulated in my life so far."

Theme II- Living in a Body That Both Supports and Disappoints You

Jennifer's relationship with her body throughout her fertility journey changes overtime shifting from a place of more self-hatred and blame to gradual acceptance and trust. Toward her later interviews she begins to talk about both her body’s vulnerability and its strength.

Subtheme: Initial Self-Blame and Bodily Failure

Initially, Jennifer experiences a high-degree of self-blame and hatred toward her body. She recalls: "I was so hard on myself. I was so hard on myself like, 'I did everything right. What is wrong with me?' I was like feeling so depressed. I hated myself." She describes feeling that "my body was failing me" and questioning whether her childhood trauma had somehow damaged her ability to carry a pregnancy. She wonders whether the trauma created some form of energetic or physical damage that prevents pregnancy: "For a long time...I thought it was, maybe my trauma, maybe my womb trauma from me being sexually abused. Granted, there was no sexual intercourse, it was more of on a spiritual level." This spiritual interpretation of physical trauma demonstrates Jennifer’s search for a reason behind the recurrent losses. However, for Jennifer, despite trying to make meaning and connection out of these two traumas in her life, her physical

body remains a site of mystery and suspicion where she cannot quite explain the causes of her losses and therefore it is difficult to have a sense of control or protect against another loss.

Jennifer compares herself with others who get pregnant easily despite still engaging in "unhealthy" behaviors. This comparison reflects her experience that her body is uniquely damaged or broken. It also reveals a degree of exhaustion and exasperation she feels with all that she is doing in order to try and get her body to cooperate and do what she wants it to do. At one point she asks the question "What kind of person am I?"

Subtheme: Moving Toward Bodily Trust and Compassion

Over time, Jennifer's relationship with her body slowly shifts. She starts talking more about how her body's actions are protective and healthy responses rather than failures. She reflects: "I think after the first one, I realized my body did know what to do and knew how to pass everything. Some women have a miscarriage and it just stays in there and they have to get surgery. Second time, same thing. I passed it...But like, if anything, I feel like my body's like, 'All right, you're not ready to carry yet.' There's something off. Whatever that is, I don't know. Maybe you're just not ready yet, and this is your body's way of protecting you." Jennifer begins to see her body as healthy and intuitively doing what it is supposed to do. The ability to pass non-viable pregnancies naturally becomes evidence of her body's capability and self-knowledge. This reframing doesn't eliminate her emotional pain but it does help her overall meaning-making process and allows space for her to experience her body as strong and protective rather than failing and punishing.

This evolution toward self-compassion is further illustrated when she states: "I have gone back and forth, don't get me wrong. There are some days where I'm just like, 'What the fuck is

wrong with me?' But, for the most part, I just have to be kind to myself and I've really learned that that's like the most important thing. I just have to be nice to myself."

By later interviews, Jennifer expresses pride in how her body has endured and showed up for her: "I am proud that I had three miscarriages because they're my babies and they're not here but like they're very special to me. And I'm only getting emotional because I am just really proud of myself that I am continuing to put myself through this, because I know it's not easy." In the moment that she says that she seems to be holding space for both her suffering and her strength.

Jennifer’s oscillation between self-compassion and self-blame shows the reality of a difficult healing process that is not necessarily linear, however, there seems to be more self-compassion as she moves through her interviews in the study.

Theme III: The Physical Trauma of Pregnancy Loss

Jennifer's describes the deeply physical, lived experience of each loss, and how these bodily processes can be quite dark as well as invisible to the external world.

Subtheme: The Visceral Reality of Miscarriage

Jennifer provides raw details of her physical experience: "It was absolutely, hands down, the most painful, like physically painful experience I've ever had...I was just in the shower bleeding and crying. I've never felt pain this before...it was so traumatic to feel something falling out of you. It was the size of my hand." Jennifer communicates her lived experience of the physical aspects of pregnancy loss. Her descriptions provide a sense of alienation from her own body. She describes an involuntary physical process where her body is doing something that feels foreign and outside of her control.

The second loss brought its own horrors: "I was sitting on the toilet. I went to go pee in it, it fell out. My husband's name is John. I was like, 'John, you need to come in here.' And this is the saddest part, he had to get a strainer, a pasta strainer to scoop it out of the toilet so that we could send it to the lab...So we put it in a Tupperware, wrapped in a black dog poop bag in my refrigerator...I got to fucking look at that in my refrigerator for the next 24 hours." After Jennifer suffers a second loss, more questions arise about whether an underlying issue is being missed which leads her doctor to recommend analyzing the pregnancy tissue for genetic abnormalities. As a result, Jennifer has to find a way to save and preserve her pregnancy tissue after she passes it at home so that it can get sent for genetic testing. This description she provides of what it is like to have to save your own pregnancy tissue reflects the challenges of dealing with everyday life while also coping with the physical/emotional trauma of pregnancy loss. The jarring juxtaposition of her mundane home life and the trauma of having to retrieve her lost pregnancy tissue highlight how pregnancy loss can permeate the household, and yet people on the outside have no clue what she is going through

Subtheme: Working Through Physical Trauma

Despite the physical and emotional trauma, Jennifer returns to work immediately: "I worked that day afterward because I work from home. I felt I couldn't even call out of work." She feels a disconnect between the weight of what she is going through and the pressure she feels to go right back to work. Unlike other forms of physical trauma that might warrant time off or medical leave, pregnancy loss occupies a liminal space—too significant to ignore but not significant enough to pause life's demands. Jennifer's process of deciding to return to work reflects the absence of social scripts for navigating pregnancy loss. Without any established rituals or recognized periods of recovery, she is left to choose her response and what she feels is

appropriate to do. Furthermore, the physical aftermath she experiences extends beyond each immediate loss. Jennifer shares that she has to deal with irregular cycles, and hormonal fluctuations after each loss and each time it takes months for her body to return to its normal, balanced state with regular period cycles. These longer-term physical consequences remain largely invisible to others. Jennifer describes feeling consumed with monitoring her body in hopes for signs that it was returning to normal, and how isolating that feels when others around her don’t know what she’s going through or what that feels like.

Theme IV: The Impact of Childhood Trauma on Trying to Conceive

Jennifer's childhood sexual abuse and family dysfunction show up from time to time in her journey with RPL and grieving her losses. The abuse and the ways that it shaped her perceptions of herself and her relationships seems to be a background noise in how she copes and is triggered by her fertility struggles. Jennifer experiences her past trauma as sometimes complicating how she copes and manages her RPL trauma.

Subtheme: Trauma Taking Up Mental Space

Jennifer explicitly connects her childhood trauma to her lack of preparation for motherhood: "A large capacity of my mental space has been spent trying to process my trauma. It really wasn't until my losses where I felt like, 'Wow, I've moved away from the trauma of my childhood, and really...' yes, I processed over the years. I've been in therapy for a long time, but it wasn't until like my losses where I feel like, 'Wow, I have more space to actually think about my future, like building a family.'"

Jennifer’s self- observation reveals the importance of processing one’s own trauma—how one must first create psychological space by working through past wounds before being able to

envision and plan for the future. As Jennifer clears mental space to think about family building, she encounters the new trauma of recurrent pregnancy loss.

The lack of family planning that Jennifer describes, not knowing about ovulation, missing fertile windows for a year, can be understood not simply as poor reproductive health education, but as a manifestation of trauma's impact on future orientation. Jennifer’s ability to progress forward in her life requires an intense amount of emotional and psychological effort. The luxury that some women have had to fantasize about becoming a mother, and to future plan is not something she has had much space for her as much of her energy and effort was put toward initially surviving and then attempting to heal and live in the moment. Her statement "I didn't really family plan like a lot of women probably do" is not a reflection of a person who wasn’t a “planner,” or didn’t want to plan for her future but more so the lack of agency and control Jennifer felt she had over her future plans.

Subtheme: Patterns of Turning Inward

Jennifer's coping mechanisms from childhood—turning inward and self-protection— resurface during her losses. She explains: "When I was younger, going through my trauma. I turned to myself; I didn't have anybody to talk to, so I'm used to solving problems by going inward to myself and just protecting myself. It's just how I function." This pattern of self-reliance continues when she is coping with RPL and leads to challenges in maintaining important relationships in her life.

Jennifer describes becoming quite withdrawn from interpersonal relationships during her family trauma years. This withdrawal appears to have been an adaptive coping mechanism at that time that now seems to be isolating her from potential support. She describes withdrawing from

family gatherings and avoiding interactions with pregnant family members or friends. While these behaviors tend to isolate Jennifer and negatively impact significant relationships in her life, they seem to represent the reactivation of survival strategies that once served her well.

Even in her own marriage, Jennifer initially struggles to turn toward her husband for support. Jennifer’s learned self-reliance that helped her survive childhood abuse seems to limit the emotional sharing and vulnerability she engages in with her husband after the initial wave of losses they experience together. The fact that she and her husband "grew apart" rather than together during their losses reflects how her childhood patterns shape her adult relational dynamics, particularly during periods of intense stress.

Subtheme: The "Dark Side" and Suicidal Ideation

Jennifer shares that she goes through an intense period of despair and hopelessness following her losses. She reveals: "I felt really suicidal. When John and I were fighting, and I never even said this out loud, I can say it out loud now because clearly I'm not in that state of mind, but after the second time, our marriage was really on the rocks...There were days that I straight up sat on the bathroom floor and just cried for hours. I was in just such a bad mental place. I wasn't talking to anyone. I distanced myself from every friend, barely talked to my mom. I was just very suicidal. I would never hurt myself or anything like that, but like there were times that I was like, 'Should I call a suicide hotline? Like, what do I even do?'"

The bathroom floor emerges as a significant space—private, contained, associated with bodily functions and being completely alone with one’s body. The image of hours spent crying on bathroom floors captures the profound isolation of her experience. The bathroom is a space

where Jennifer is forced to experience, feel, and see the physical and emotional changes happening within her body throughout the course of her RPL.

Jennifer's reflects about this time in her life: "I would never hurt myself or anything like that, but like there were times that I was like, 'Should I call a suicide hotline? Like, what do I even do? Who do I talk to?'" Jennifer distinguishes between suicidal ideation and intent and emphasizes that she never had any intention to take her own life. She talks about how she did not have a genuine wish to die but rather a need for the pain to stop and to feel hopeful about a path forward toward reaching her goal.

She describes intense inner conflict: "I just feel like I was at war with myself. Yeah. I just felt like I did everything right. What kind of person am I? I was like, 'Do I deserve this? Was I a real piece of shit to someone before and this is what I'm getting?'" Her description of feeling "at war with myself" captures the internal fragmentation that she was experiencing. The question "Do I deserve this? Was I a real piece of shit to someone before and this is what I'm getting?" seems to point to some of the shame and guilt from Jennifer’s childhood abuse showing up in her fears and worries about her current reproductive failure. The search for karma or punishment provides insight into how Jennifer may have tried to make sense of her abuse at different points in her life, and how that way of thinking seems to resurface in the face of unexplained recurrent pregnancy loss.

Theme V: The Need for Control in the Face of Uncertainty

Jennifer focuses on monitoring aspects of her life that help her feel a semblance of control over her current experience with RPL in which she has felt little to no control. She talks

about various ways she is intervening in her own journey, from dietary restrictions to researching medical interventions, each feels like an attempt to exert some influence over her outcomes.

Subtheme:

Hyper-Vigilance Around Health and Diet

Jennifer details her extensive restrictions: "I don't even eat gluten. I don't really eat dairy. I don't drink alcohol. I feel like I literally only eat organic. I make myself like really nice meals. I have my smoothie, low-sugar. I meditate. I do Pilates five days a week. I don't wash my hair with any shampoos that have fragrances. I use shitty $9 nothing shampoo. I don't get my nails done, wear all natural makeup. I don't eat out of plastic containers. I don't drink tap water."

This list of restrictions and rules hints at the all-consuming nature that this RPL/fertility journey has become for Jennifer . Her day-to-day choice all seem so weighted with significance and how they might impact her goals. The shampoo without fragrance, the avoidance of tap water, the elimination of plastic containers—each restriction is an attempt to eliminate risk of failing but they also seem like sources of anxiety and stress too. The fact that Jennifer has "read every single book to tell me the things that I shouldn't do" shows both the exhaustive research she has done in an effort for control as well as the worry and fear that goes into each choice she makes.

Aside from the potential physical benefits Jennifer might be gaining from imposing these restrictions, there is a deeper, more emotional aspect of adhering to certain rules and dietary recommendations. RPL is characterized by such profound uncertainty, the ability to control variables that might negatively impact her goals and outcomes helps to provide a sense of agency. The restrictions provide an opportunity for her to not only take action in a situation that otherwise offers few opportunities for meaningful intervention, but also provides a sense of

comfort in knowing what variables she is eliminating that could potentially cause harm to a pregnancy.

She contrasts this restrictive lifestyle with others: "John's cousin, who is our neighbor and lives down the street, she literally eats like chicken nuggets from McDonald's...She also has Hashimoto's like me and got pregnant on her first chance and had a healthy baby." This comparison reveals the lived experience of the injustice that pervades the fertility struggle—the lack of correlation between "good" behavior and achieving one’s goal successfully. Jennifer referencing the cousin's McDonald's habit points to her felt experience of the unfairness of it all.

Jennifer's articulates this dynamic well: "I get so angry because, again, I try to control everything. It's like, why? It doesn't help me in three years so maybe I should just stop caring as much and then maybe it'll happen for me."

Subtheme: The Burden of "Positive Thinking"

Jennifer struggles with the pressure to control her results through mindset: "I like tell myself, if you think different, then maybe the outcome will be different this time. Like you need to stay positive. You need to not be worried. You need to not be scared. What can I do mentally within my own brain to change the outcome? That's not reality." There is a culture that exists within the world of infertility that places pressure on women to “think positive.” This pressure to maintain optimism places responsibility for biological processes on the individual's mental state. Jennifer talks about how she struggles with this added layer of suffering, feeling fear and guilt that her thoughts and emotions could be negatively impacting her ability to have a healthy baby. Jennifer's insight that "it's this weird feeling of like, maybe if I just don't worry or stress myself out, then it'll be better and I'll have a successful pregnancy" demonstrates the pressure she feels

to try and remain positive despite disappointments, loss, setbacks, and fear. Jennifer describes experiencing physical manifestations of anxiety—waking at 4 AM with panic attacks, feeling unable to breathe, experiencing nausea from stress. She describes feeling stuck in a cycle where she experiences the anxiety, than feels guilt and fear that the anxiety is hurting her chances of a healthy pregnancy which further exacerbates stress levels.

Theme VI: Medical System Failures and Dehumanization

Throughout her losses, Jennifer experiences repeated misattunements with healthcare providers. Her interactions with her medical team reflect the possibility that the broader fertility healthcare system is unprepared to deal with loss in a trauma-informed way.

Subtheme: Lack of Direct Communication

Jennifer describes her frustration with vague medical communication: "I even got into an argument with the doctor like, 'Why can't you just fucking be serious with me? Tell me.'...at the end, when they told me to stop taking progesterone, they said, 'Listen, you're definitely going to be miscarrying.' Like, 'Why couldn't you have told me that and been direct with me from the beginning?'"

She wishes providers had offered clarity: "I wish they would have just been honest with me, and had good bedside manner, just sat me down and hugged me or just put their arm on my shoulder and said, 'Listen, this is the reality.'"

The lack of clear information and direct conversation demonstrates how Jennifer’s doctors may have been avoiding difficult feelings and conversations. This approach to communicating left her in a limbo state where she sensed something was off but had little to no information. The weeks of uncertainty created by vague communications—"Let's just keep

being hopeful"—are emotionally tormenting. Jennifer's observation that "they just kept stringing me along" captures the ongoing pain of being placed in a position of having to maintain hope despite continuous updates that pointed to a nonviable pregnancy.

Jennifer's wish for a different approach is significant in her lived experience of this journey. This desire for human connection and honest communication highlights how she experienced her medical team failing her in the emotional care aspect of her treatment.

Subtheme: Feeling Like a "Guinea Pig"

Jennifer’s experience with reproductive immunology is another disappointing, and misattuned medical experience. Jennifer describes feeling like an experiment: "I'm feeling like a guinea pig...They keep saying, 'Well, if this medication doesn't work, then we'll try another one.'"

For Jennifer, this trial-and-error approach, feels reckless since there are risks to taking these medications and they have huge side effects. She states, “The medications wreaked havoc on my body…not only was the Hydroxychloroquine really wreaking havoc on my thyroid, like, T4 levels jumped way out of range, I have really bad anxiety and heart palpitations from that...my chloride levels which are to your kidney, like, hydroxychloroquine can affect your kidney. In certain cases, it could, I don't know, cause like acute kidney damage." Although Jennifer does not explicitly remark on this, it is important to note the lengths through which she is willing to go to make her baby, even trying highly experimental treatments that have the potential to harm her own health.

Theme VII: Relational Losses and Betrayal

As Jennifer becomes focused on her treatments and her goals, it is important to note that this fertility journey significantly impacts her close relationships with friends and family

members. She describes both the grief and the shame she experiences as she distances herself from people and withdraws completely from certain relationships.

Subtheme: Lost Friendships

Jennifer acknowledges: "I actually lost my best friend. She's had two babies since I started trying to get pregnant and I could not even be there to support her. And we have not talked in three years." Jennifer communicates self-awareness over her role in these relationship losses and the layer of shame this adds to her grief. She reflects on the shame: " I know that that was really shitty of me but I need to be protective of my emotions. This sounds so fucking terrible. I feel like I don't have enough in me to be really happy for somebody else right now. I just don't have it in me...I have to be selfish, but like, I have to reserve my energy for myself that I can't necessarily go to your baby shower and celebrate you right now." This relationship loss represents more than emotional withdrawal; it is a symbol of the incompatibility between living with recurrent pregnancy loss and living a life with an easy path toward conceiving a healthy baby.

Jennifer reflects on how the shame and embarrassment feels at their peak when she has to encounter these lost friendships or familial relationships at social gatherings. "I'm going to walk in with John and I'm not going to have a baby with me. I'm going to feel embarrassed because she's probably like, 'Oh, well, Jess probably has kids by now.'" The imagined judgment of others creates anticipatory shame that makes social re-engagement feel really difficult.

Jennifer's reflection that "I feel so embarrassed even saying that, it makes me very sad because I know that that's not me being a good person" reveals the shame and jealousy that exist in her relationships and her relational losses. The inability to provide emotional support for

others during their joyful moments is a source of self-criticism that adds to weight of her losses and her grief.

Subtheme: Changes in Familial Bonds

Jennifer describes a particularly painful moment in her relationship with her mother-inlaw, a moment that seems to mark a shift in Jennifer’s closeness to her. She states that her mother-in-law made a comment about how their marriage wouldn't last: "She said something. She's like, 'You know, it seems like you guys are really going through a tough time and that your marriage is not going to last. I wouldn't be surprised if you guys got divorced.'" Jennifer reflects: "You, as a parent, can't even see that your son and his wife are going through pregnancy loss. And it's obviously very hard on the both of us and you're not encouraging your son to talk with me or work through our problems. You're planting in his head that we should get divorced."

Jennifer experienced this as a lack of validation from John’s mother on the severity and trauma of recurrent pregnancy loss. For Jennifer, rather than his mom acknowledge how difficult and painful this time was and recognize pregnancy loss as a meaningful source of marital strain, she frames it as evidence of incompatibility. This failure of empathy and support from her mother-inlaw, someone who she might have been expected to understand and nurture demonstrates how the stress and strain of recurrent pregnancy loss can expose existing family dysfunction.

Subtheme: Selective Jealousy and Triggers

Jennifer talks about how feelings of jealousy or envy seem to be specific to certain life situations while others surprisingly do not trigger those same feelings. "I think I'm fine once I see the baby. Once the woman gives birth, I feel like I'm okay. It's when they're pregnant, that's what's triggering to me...a pregnant woman makes me fiercely jealous." This distinction between

pregnancy and babies shows that it’s the actual evidence of the body doing what hers has not been able to do successfully that feels unbearable. The pregnant body is a reminder of failure, while babies represent a finished process that does not directly threatens her sense of self or her capability. Jennifer makes note that she can maintain relationships with those who've experienced loss prior to having children: "Like my friend Chelsea is my neighbor. She's got two kids and I don't have a problem being there and being with her kids...She had multiple losses. She had to terminate for medical reasons." This shared suffering creates a bond that transcends jealousy and even provides hope and inspiration that there can be success after multiple losses. Those who have experienced loss exist in a different category, their fertility success filtered through the lens of shared grief and pain.

This situation-specific jealousy emphasizes the nuanced nature of fertility-related social navigation and dynamics. It's not a simple matter of avoiding all pregnant women or all babies, but rather a complex emotional experience where shared understanding, perceived support/recognition/validation, and individual history determines which relationships can be sustained and which are often sacrificed for one’s own self-care and needs.

Theme VIII: Multiple Paths and Integrated Hope

As Jennifer's journey progresses, she opens up to the idea of different pathways to building her family. She embraces multiple possibilities of what growing her family might look like. This shift in how she thinks about her journey toward becoming a mom represents profound psychological growth. Jennifer has to sit with uncertainty but also hold hope as she contemplates and initiates different pathways toward growing her family.

Subtheme: Adoption as Active

Choice, Not Consolation

Jennifer's approach to adoption represents a deeply thoughtful way of family planning: "I'm not adopting because we're having issues getting pregnant. I am adopting because I wanted to adopt. To me, they're two very different things." This distinction goes against the societal, conventional hierarchy that places biological parenthood as superior to adoption.and reflects a growing inner confidence and sense of self. She reflects on the adopted child's experience: "Adoption is a very traumatic experience for the child. I would love that child like it is my biological child, but the reality of the situation is that that child is not my biological child...That child is taken from their mother that has been carrying them the entire pregnancy...We're going to be going through a grieving process as a baby." Jennifer acknowledges the potential for the adopted child to experience trauma on the same journey that allows her own desire for motherhood to be achieved. Jennifer creates space for both realities and holds space for multiple truths to be possible. This capacity to honor the child's experience while pursuing her own dreams of motherhood reveals a form of maternal thinking that prioritizes the child's emotional reality.

Subtheme: Holding Multiple Possibilities

By the final interview, Jennifer is both pregnant and having her adoption profile go live. She reflects: "I feel like no matter what, our family is coming and I don't know what way it's going to come first...They do feel different, but it makes me feel more comforted that I have that as well." This comfort with uncertainty represents a shift from her earlier efforts to control the outcome.

The simultaneous pursuit of pregnancy and adoption allows Jennifer to embrace more of her hopeful side and quiet the heavy, fear-based thpughts. Rather than comparing these two journeys (pregnancy and adoption) and valuing one more than the other, Jennifer integrates them into a broader vision of family building. Each path maintains its distinctness, "They do feel different"—while contributing to an overall sense of forward movement. This multi-path approach also seems to provide psychological protection for Jennifer. With both adoption and pregnancy as active possibilities, neither carries the sole weight of her hopes.

Theme IX: The Journey Toward Joy and Self-Permission

Toward the end of our interviews Jennifer explores her newfound ability to experience joy despite all of the uncertainty she still faces in her journey to being a mom and building her family.

Subtheme: Breaking the Silence

When Jennifer shares the news that she is pregnant again in our final interview, she explores a revelation she had about how she wants to move through the early stages of this pregnancy even with the ongoing possibility of things not working out again. "I am feeling really excited for the first time to be able to allow myself to be happy, regardless of the outcome. In the three times I was pregnant...I never told anyone. It always felt like a secret. I always felt like I was going to jinx myself. I said, 'Fuck it.' I told so many people." This intentional mentality embodies Jennifer’s rejection of the superstitious thinking that governs pervades fertility culture. The traditional belief that expressing joy early on might jinx outcomes keeps many women isolated in their hope, unable to access support during the precarious early stages when support is

most needed. Jennifer's choice to tell "so many people" claims space for her experience regardless of outcome.

Her explanation further provides insight into how profound this mental shift is for her: "I don't even care, like however it turns out, I want to give myself the opportunity to be able to hear people tell me 'Congratulations', and it feels really good." This choice to feel the joy of a “congratulations”—for recognition of the achievement of pregnancy itself, regardless of outcome —challenges the cultural silence around early pregnancy. She claims the right to have her pregnancy acknowledged and celebrated in the present rather than later after a "safe" milestone has been reached and she has suffered through the early anxiety alone.

Subtheme: Envisioning Motherhood

Perhaps most significantly, Jennifer allows herself to envision her future with specificity and joy. She shares vivid fantasies: "I can literally envision myself wearing that sweater, sitting on my bed, maybe a three or four-year-old tucked into my sweater and he's like, 'Mommy, can I get in there?' and we're reading a book together...I can envision us laying in the backyard, like on a blanket...I can just see it all."

Impressions from the Interviews with Jennifer

Jennifer responded eagerly to the advertisement to participate in the research study, and made herself readily available for our six, 1-hour long zoom meetings. She seemed to welcome exploring her experience of recurrent pregnancy loss with an openness that suggested both a need for witness and a desire to make meaning from her suffering. Through the course of the interviews, Jennifer added comments such as “Talking to you feels like free therapy,” and

“Talking with you about this has felt way more helpful and real than previous times in therapy when I have tried to talk about this.”

Jennifer initially presented herself with a certain degree of intensity and seriousness that seemed to reflect both the weight of her experiences and a guarded approach to vulnerability. As interviews progressed, however, she revealed increasingly more playful, humorous, and open aspects of her personality.

Throughout much of the interview process, I interpreted Jennifer as a person who experiences there to only be one truth in life or a “right” way and a “wrong” way to do things. This showed up in the ways she experienced her healthcare providers, the way she thought about treatment for her pregnancy losses, and how she dealt with family and friends in her life. As we explored more in-depth about her relationships and social life, she seemed to be exploring parts of her recurrent pregnancy loss experience that she had never looked at. Namely, she seemed to be moving from a “me” versus “them,” or a “right” versus “wrong” framework to an integrated ability to hold more than one truth, and in fact to acknowledge some of the parts of herself that she felt badly about or felt she could’ve acted in a “better” way. The space to talk about sensitive and difficult topics felt more open, and expansive toward the end of our interview process. This is encapsulated in how she discusses the adoption process. She explores the challenges of the process and the potential pain and grief of the adopted child despite so desperately wanting to have her own kid at any cost. She states, “Yeah, so adoption is a very traumatic experience for the child. I would love that child like it is my biological child, but the reality of the situation is that that child is not my biological child. Educating the child on adoption and them knowing their birth mother, that's important to me if their birth mother wants to be in the picture. So I think it's really dependent on the situation. But I know it's not going to be easy. That child is

taken from their mother that has been carrying them the entire pregnancy. It's rational. I have to think rationally in this situation and not emotionally that maybe the child won't be attached to me. Maybe it's going to be like, who the fuck is this person? We're going to be going through a grieving process as a baby. I've educated myself a lot and read books on this scientifically, that child will be feeling grief. I want to give a child a really good life and be a mother to them. I am not their mother in the biological respect. I will be their mother raising them and they will be my child. But I think I just had to educate myself on the 360 degree situation of what is adoption.” I was moved by her ability to hold space for the possibility for her to be a wonderful parent and have a profound impact on her future adopted child’s life as well as acknowledge the potential pains and experiences that child may have as a result of being given up for adoption by his or her biological parent. This openness carried forward into many relational aspects of Jennifer’s life and how she reflected on them in her interviews toward the end of our time together, namely her marriage.

Psychoanalytic Interpretation of Jennifer’s Case

Jennifer’s narrative highlights the significant impact of early relational trauma on adult capacity to metabolize loss and maintain integrated function under stress. Her narrative shows a “splitting orientation” to the world in which she moves back and forth between persecutory and idealized positions, difficulty maintaining object constancy, and a regressive pull toward what Melanie Klein would term the paranoid-schizoid position when under duress Klein, 1946; Ogden, 1986).

Jennifer seems to experience her RPL through a lens of “unfairness” and “injustice” that carries a narcissistic quality to it beyond just ordinary disappointment. There are a number of times where she asks questions such as, “what kind of person am I?” and “do I deserve this?”

These types of questions hint at Jennifer’s tendency to equate outcome with moral worth which is characteristic of narcissistic vulnerability and injury (Kohut, 1977; Siegel, 1996). When good things happen to others who may not “deserve” them (i.e. her cousin-in-law who eats McDonalds all the time and conceived easily) and bad things happen to her despite her clean diet and healthy ways, the world splits into doers and done-to, victims and perpetrators (Benjamin, 2004).

Fairbairn (1952) described this type of splitting as the schizoid-defense, where one divides experience into all-good or all-bad in order to manage the unbearable anxiety of ambivalence. Jennifer sees her providers as experimenters using her as a “guinea pig” without much regard for her humanity, or saviors who might finally rescue her from RPL. Similarly, she views her body as trustworthy (when things go well) or betraying (when she is disappointed by outcomes). Friends and family fall into one of two categories, either they are “free pass” recipients who understand what she is going through or they become relationships she deems no longer viable when she feels misunderstood or disappointed. The struggle to hold the good and bad aspects of objects reflects a fragile internal world where stress and overwhelming experiences threaten her sense of self as whole and integrated (Klein, 1946; Fairbairn, 1952; Ogden, 1986).

This narcissistic quality also shows up in Jennifer’s expectations. There is not necessarily a conscious entitlement to a baby, but there is an unconscious expectation that effort should guarantee the outcome of a baby and that doing things the “right way” should protect against a poor outcome. This intermingling of entitlement and expectation as a result of “doing the right thing,” reflects Kohut’s (1977) idea of a “grandiose self” that has not been adequately balanced out with experiences of empathic failure and optimal frustration. When the very real and disappointing reality of RPL confronts her expectations of having a baby, Jennifer experiences it

as narcissistic injury or a fundamental attack on the self’s coherence and worth (Kohut, 1971, 1977; Siegel, 1996).

Jennifer uses isolation and self-reliance to manage situations where she experiences overwhelming affect. She learned to turn “inward” and “protect myself” during the years she experienced childhood sexual abuse because external others were unreliable, dangerous, or denied her reality. The losses seem to reactive this template of coping where Jennifer withdraws from relationships at moments when she most needs connection (Fairbairn, 1952; Bowlby, 1969).

Jennifer’s ability to hang on to the part of herself that is loving and good, towards herself and others, seems compromised at times. Jennifer’s rage at her situation, with her body, and at others’ successes, threatens to overwhelm her capacity for love and empathy. Klein (1957) termed this “envious attacks on the good object,” or when the subject’s inability to possess what others have leads to destructive impulses toward both self and other.

Jennifer explores inner thoughts in her interviews involving “hating herself,” “feeling at war with herself,” and wondering if she’s “a real piece of shit” who deserves punishment. These types of thoughts highlight the degree of inward rage and self-attack she experiences. The external persecutor (i.e. the body that betrays or the world that’s unfair) becomes internalized as a punitive superego that attacks the self. This self-persecution may also be intensified by her past history with abuse where the abuser’s voice becomes internalized, creating a template where badness is located within the self and punishment is deserved (Freud, 1917; Klein, 1940).

The very fact that Jennifer experiences suicidal ideation, sharing at one point that she “wanted to die,” reflects the intensity of this internal persecution and how hopeless she felt that

anything good could be preserved. The depth of her hopelessness at that point in time is an expression of melancholia, where the shadow of the lost object (in this case the anticipated baby) falls upon the ego itself, creating identification with the lost object and intense rage against the self (Freud, 1917).

Jennifer’s schizoid defenses can be observed in her simultaneous longing for and rejection of intimacy in her own marriage as well as in her friendships and familial relationships. She experiences a core conflict around both needing connection in her relationships and being afraid that connection will lead to feeling taken advantage of or exploited. Jennifer’s withdrawal from her friends, her initial distance from her husband during losses, her struggle to maintain relationships with people who have babies, all reflects this schizoid tendency (Fairbairn, 1952).

Despite all of this withdrawal and emotional distancing, there is an underlying yearning for emotional connection and to stay related to others in her life. At one point in her interviews Jennifer states that the research interviews felt like “free therapy” and were “way more helpful and real than previous times in therapy,” suggesting that she does have a need and a desire for a holding environment where her experience can be witnessed and acknowledged without judgment (Winnicott, 1960, 1965). Her capacity to eventually turn toward her husband, to use that relationship app to help with marital communication shows that there is a part of Jennifer, despite her schizoid defense, that is capable of putting herself out there and risking connection, especially when safety can be established.

Despite this defensive organization, Jennifer demonstrates movement from a more fragmented self to a more integrated self as times goes on in her journey with RPL. She evolves from a place of hatred toward her body to recognizing that it might be “protecting” her. She also moves from experiencing her body as a persecutory object to holding concern for its well-being.

Both of these examples represent a shift from Klein’s paranoid-schizoid functioning to a more depressive state (Klein, 1935, 1940, 1946; Ogden, 1986). Her openness to sharing her current pregnancy with people “regardless of her outcome” demonstrates a growing capacity to feel vulnerable and risk disappointment in exchange for feeling connected to others around her. Her openness to adoption as “not giving up but choosing” suggests developing differentiation between outcome and identity, between having a biological child and being a mother. This flexibility or what Jennifer calls holding “multiple truths” reflects movement toward psychological integration where either/or thinking is replaced with both/and capacity (Benjamin, 2004; Ogden, 1986).

Jennifer’s case demonstrates how early relational trauma creates vulnerability to regression under stress. The combination of childhood abuse trauma earlier in life mixed with reproductive trauma in adulthood creates a fragile psychological space where defenses such as splitting, withdrawal and self-reliance that once aided Jennifer in self-protection are now impediments to helping her get the support and connection she needs to manage the emotional challenges of RPL.

Case Study # 3 Allison

Descriptive Information

Allison is a 44 y/o, cisgender female who identifies as Caucasian. She is a single, selfemployed psychotherapist raised within the United Methodist religion, now describing herself as “borderline between Agnostic and Atheist.” Allison grew up in Maryland with her parents and older sister. She describes her parents as "great in so many ways, but not good with emotional

support." She emphasizes that her parents provided and met all of her concrete and basic needs, however, she feels they lacked in their ability to meet her emotional needs.

Allison talks about different moments in her life where she felt disappointed with her parents emotional support. She describes a time when a close friend died during her college years, she turned to her mother for guidance. She expressed a longing for her mother to say: "Go, be with your friend's family... your internship will understand." Instead, she received the message that fulfilling work obligations was the correct choice. Looking back, Allison regrets missing the funeral, noting, "I don't remember anything meaningful about the internship... but I wish I'd gone to say goodbye to my friend." She reflects that as a mother, she would have encouraged her child to attend the funeral and reassured them that the internship would understand.

Allison shared that she has “always wanted to be a mother” and planned that “if by 40 I am not married or I haven’t had a chance to have a child, that I would explore what options there were.” When she turned 40 in 2019, she was on workers' compensation leave for depression, and therefore it did not feel like the right time in her life to pursue motherhood. The pandemic pushed back her plans further until 2021 when she was 42 years old and reached out to a fertility doctor. At this point in her journey, she shared that she was open to adoption or to fertility treatment as a possible pathway to having a child. She states that “not having a partner relationship is something she spent most of her adult life without,” and so she was mostly excited at the idea of having a child and less focused on the feelings around going down this path alone.

She met with a fertility doctor who informed her that her follicle count was above average for her age and trying to do IUI (intrauterine insemination) was a reasonable option even though the statistics for successful IUIs at 42 years of age are generally not great. She shared that as she heard different updates such as “being above average,” she got “caught up” in the

excitement of the possibility to have a child. She proceeded with selecting a sperm donor and on the second IUI attempt she got pregnant. She describes feeling “so happy and so scared,” especially after an early scan revealed possible complications. Over several weeks, she experienced what she calls a "rollercoaster limbo" where both the heartbeat and measurements of the pregnancy were not quite where the doctor expected or hoped for them to be, but simultaneously the pregnancy kept progressing and therefore she was stuck waiting to see what the outcome would be. At eight weeks, there was no heartbeat. She talks about how the doctors referred to her pregnancy loss as a “missed miscarriage” because she had no bleeding, her body did not pass any pregnancy tissue on its own, and she continued to experience symptoms of pregnancy such as extreme nausea. She states that the missed miscarriage meant that her body did not get rid of the nonviable pregnancy on its own and as a result there was a period of five weeks where she was living life with a nonviable pregnancy inside of her while she figured out her treatment plan moving forward. She dealt with insurance complications, provider networks, and scheduling delays all while carrying the loss inside her. She describes "pleading with my body at night" to release the pregnancy. Allison also makes note of how quickly the fertility doctor launched into options for removing the pregnancy loss and treatment options moving ahead to try and get pregnant again when she could barely even process that she had suffered a loss. After giving herself 3 months to grieve and process the loss, Allison decided to pursue IVF to screen embryos for chromosomal abnormalities. However, her first stimulation cycle was cancelled when she failed to respond to medications—a possibility no one had prepared her for. This represented "another thing I didn't see coming... something else I didn't know could go wrong." After her second egg retrieval, Allison only got four eggs total, three of which fertilized to make embryos and she had all three embryos transferred, but the cycle failed. Allison talks

about how she doesn’t even count the failed transfer in her number of pregnancy losses, however, emotionally she experienced it as a tremendous loss. She talks about how at each step of this journey “you just get more invested and open to doing more things the further down the path you go. At the beginning would you have told me I would’ve done IVF and then eventually like donor egg. I would’ve been like no…But once you get in and out, it shifts your emotions. I think the fact that I knew that I could get pregnant also shifted it.”

At this point in her reproductive journey, Allison considers private adoption versus donor egg and decides to move ahead with the donor egg path. She shared that she felt she did not have the emotional bandwidth to deal with the birth mother’s trauma of giving up her child etc. In the end, Allison ends up with only one healthy embryo after using donor eggs. This is another unexpected disappointment and loss that Allison must process. She struggles with various medical issues in her attempts to get her body ready for embryo transfer, another issue which she felt no one really prepared her for. Eventually the embryo is transferred and she gets pregnant. Allison goes on to lose this pregnancy as well after weeks of normal, healthy scans. Allison explores the “unfairness of it all,” and wonders why she had to go through weeks of getting attached and feeling hopeful when ultimately it was going to all come to an end. At this point in her journey, she decided to end fertility treatment. She also concluded that traditional adoption was not the right path for her, feeling ill-equipped to handle “the birth mother’s trauma…I can barely handle my own.” Allison now wrestles with what she calls a “double grief”: mourning the pregnancies themselves, as well as “the entire future I believed I’d have.” Allison shares that although they are connected, they also feel different to her. At this point she is working through the loss of what this means for her future. She reflects on it, “am I really not going to be a mom and is this really it for me? Just the pain of uncertainty of that…” She examines how this specific

loss has led to an existential struggle to feel purpose and meaning in her life again. Allison is currently working through that in her own therapy.

Categories of Meaning

Theme I: Repeated Unexpected Complications and Their Psychological Impact

Throughout Allison's journey, she talks about feeling taken aback by complications no one had mentally prepared her for. Each setback felt like "another thing I didn't see coming." From failed stimulation cycles to inadequate uterine lining, from missed miscarriages to poor fertilization rates with donor eggs, Allison experiences numerous obstacles that no one has educated her about.

This pattern of unexpected complications leads to frustration with both her medical providers and with her own body. Allison reflects, "I kept beating the odds in good and bad ways. So it was rare that I would get pregnant and then rare that my body would not pass the miscarriage." The unpredictability she experiences is its own form of trauma, as she talks about never feeling prepared or protected from the next setback or disappointment.

She experiences her medical providers as careless or cavalier in how they educate and prepare her for fertility treatment. She feels that there could have been more planning and preparation for the potential setbacks, and challenges that she ends up facing throughout her treatment. Throughout the course of her interviews she expresses frustration with the experience of going through treatment complications that were known risks but were never fully explained to her. This lack of education and preparation leaves her feeling uncared for by her medical providers.

Theme II- Medical Depersonalization and Emotional Dismissal

Allison experiences important interactions with her medical providers as significantly lacking in human connection and attunement to what is needed in specific moments, such as appointments where she is told that her pregnancy is no longer viable or that none of her eggs have fertilized. Repeatedly, she encounters providers who quickly moved toward discussing “next steps,” without allowing space to process devastating news.

After learning there is no heartbeat with one of her pregnancies, Allison shares: “I remember lying there with the sheet over me, and she’s already talking about what I want to do with the remains, or do I want more meds. I was like ‘I just found out there’s not heartbeat…can you give me a minute to breathe?’…I’m sitting there, I’m still half undressed, got the sheet over me and we’re having this conversation…you haven’t even give me a second to absorb the information.” The provider immediately starts discussing ways to remove the non-viable pregnancy while Allison is half undressed and struggling to understand what has just happened to her.

She recalls the doctor delivering the news in quick, technical terms and feeling “like nobody really cared how I was coping- just that I should decide D&C or medication.” Allison recalls the doctor focusing on the practical and wanting to discuss the next steps with her, while she was still digesting the loss in real time and needing space to process the news. Allison experiences this type of treatment as a form of emotional dismissal. Providers are focused on practical decisions and future cycles while Allison needs space to process her loss and acknowledgment of her grief. The one exception is a female doctor who “came running after me” to offer a hug and express genuine sorrow- the only provider to simply acknowledge her pain.

Theme III- Intergenerational Patterns of Emotional Misattunement

Allison’s emotional experiences with medical providers share similarities to her experiences with her parents and how they guided her through challenging moments in her life . She describes parents who were “great in so many ways, but not good with emotional support,” creating a relational script where practical needs were met while emotional needs went unrecognized.

The experience Allison has with her mom regarding her college friend’s funeral highlights this dynamic. Allison’s mother focused on practical obligations rather than emotional significance, leaving Allison to work through her grief alone. Her mother also focused on logistics rather than the emotional weight of what Allison was experiencing which left Allison with unmet needs at that time in her life, and later left her with regret and sadness about the decision not to go to the funeral. A similar type of misattunement repeats again in her life with her fertility providers who focus on medical decisions and logistical planning in place of providing space to process emotions or acknowledge the sadness of her loss.

After one of her pregnancy losses she reflects, “I told my mom once it was too painful to talk, and she said ‘Well, you should get out for a walk.’ I was like, ‘Really? That’s your big supportive statement?’” When Allison finally sets boundaries with her mother after her second pregnancy loss, asking her to stop suggesting walks and instead offer emotional support, her mother’s response was simply “Okay.”

Allison’s past experience with emotional misattunement from her mother seems to magnify her later grief with RPL. There is a built-in, lifetime template for “how care feels.”

Growing up she seems to absorb an implicit message of, “When I’m overwhelmed, no one really

shows up for me.” Even if practical needs are met, there is an absence of comfort, support, and validation. For Allison, there is the repeated experience of a doctor who lists “next-step options,” a friend who states “at least you can try again,” or a parent who advises a brisk walk instead of simply listening. When current caregivers (physicians, partners, family, friends) fail to meet the moment with what she emotionally needs, there is a sense of a familiar pattern replaying itself in Allison’s life. The anticipation of dismissal produces a cycle where Allison: 1) Reaches out cautiously, 2) receives an unhelpful or lukewarm, hurried response, 3) feels confirmed that no one understands or cares to understand, 4) she withdraws further (thinking “why bother?”), and 5) grieves in private, amplifying feelings of isolation and loneliness.

Theme IV- Financial Privilege and Class Constraints in Fertility Treatment

Another undercurrent throughout Allison’s interviews is the role of financial privilege, the cost of fertility treatment, and how that has impacted her decisions and her emotions. Her treatment journey and choices highlight the significant role of economic privilege in determining treatment options. She can only pursue fertility treatment because of a workers' compensation settlement, noting, "I don't think I could have done it without that settlement. I was not making a great income before…a lot of other people in my circumstances or my income level would not have been able to do it.”

The financial pressure Allison experiences throughout her fertility treatment process influences the decisions she makes and is an added layer of stress in the whole process. Insurance coverage not only determines which providers she can see, and which procedures are accessible, but it forces her to choose between an option that might have the “best outcomes” versus an option that cost less money. At one point she has to switch doctors mid-treatment when she realizes her HMO won’t cover her fertility specialist's services. During her missed

miscarriage, she deals with obtaining prior insurance authorization while carrying non-viable pregnancy tissue inside of her, describing the additional trauma of "calling my health plan trying to get it authorized... they didn't even put it in as urgent."

When her fertility doctor suggests surrogacy, Allison experiences the recommendation as out-of-touch with her reality. She recalls feeling frustrated by the assumption that she had unlimited resources: "I'm like, yeah, because I have whatever, $150,000 laying around... especially knowing my circumstances, I'm single." The cost of treatments seems to create impossible choices in her life where she is both aware of the potential to keep trying for a baby but also acutely aware of the debt and other impacts this could have on her life. Allison talks about how she spent a large part of her savings on fertility treatments, approximately $22,000 on donor eggs alone, which not only brought up feelings of worry and frustration inside of her but also fundamentally altered her life trajectory. She reflects on the broader implications: "I had some money that I could have been saving for a down payment... that's gone. It will take me many years to get to that point... what other goals for me personally can I look towards like buying a home?"

The financial pressure ultimately leads to her decision to end treatment, as she was having ambivalence about whether to continue or to stop. She describes the impossible calculation: "I also don't have the luxury to just keep trying, just from a financial standpoint... I couldn't afford to not work. Could maybe take a week but..." The huge expense of continued fertility treatment forced her to make the decision to stop trying which only added another layer of grief about paths not taken.

Allison's talks about how single women deal with a heightened level of financial pressure when undergoing fertility treatment. Without a partner to share costs, she carries the full economic burden of treatment while simultaneously managing the emotional toll alone as well. She notes with some resentment: "Sometimes I do resent a little bit because I'm like, if I had a partner I might be able to... I don't know what I would've wanted to, but it's like, I sometimes think people... don't understand my financial situation."

The intersection of socioeconomic class and fertility treatment emerges in subtle ways throughout Allison’s reproductive journey. Allison feels her friends wrongly assume she has more money than she actually does. When people casually suggest adoption, she has to educate them about the reality that "private adoption costs anywhere from $40 to $50,000... So if you've got that for me, go right ahead."

These financial constraints become a source of internal conflict. Allison wonders if stopping because of the inability to afford multiple treatment cycles means she hasn’t tried hard enough: "Am I giving up too easily? And are other people going to think the same thing?" The economic limitations, although very real and practical, manage to challenge her self-belief about her own strength and commitment to motherhood.

Theme V- The Body as Betrayer and Reminder

Allison shares that she has struggled on and off throughout her life with weight gain, negative body-image, and wishing there were things she could change about her figure. It is evident in her interviews that going through fertility treatments and recurrent pregnancy loss changes her physical body in ways she did not feel good about and adds to a lifetime of complex

feelings about her physical self. She describes having "struggled with my weight, not excessively, but I struggle with not feeling attractive. I didn't really date until my early 20s."

These pre-existing insecurities about her body become magnified and recontextualized through the experience of recurrent pregnancy loss and fertility treatment.

The body changes she experiences from fertility treatments and recurrent pregnancy loss intensify the noise she already struggles with surrounding her body image. Allison reflects on how the process affected her physically: "I'm at my heaviest than I have been in a long time... it's just resurfacing worse, in a sense, because it just feels like another layer of it being so unfair, cruel on top of everything else." The weight gain from hormonal treatments becomes another source of grief, an inescapable reminder of both all that she has been through as well as all that she still does not have.

Through her RPL journey, Allison describes feeling unable to trust her body and wanting to "disconnect from it" because it became "a source of pain" and unwanted reminders. The “missed miscarriage” particularly exemplified this betrayal. Allison's body fails to release the pregnancy tissue, trapping her in an extended liminal state: "I was walking around with a dead baby inside of me for five weeks... I pleaded with my body at night, like 'Let it go, please... don't make me do a surgery.'"

The experience of RPL intensifies her negative relationship with her body and these negative feelings intensify even more after she stops trying to conceive. She describes her body image struggles: "I don't want to look, I don't want to look at my body in the shower and look at it after getting changed. It's like you just want to disconnect from it... because it's just a source of pain." Her period has been a constant reminder of what she lost and what she will never have. In

an effort to explain how much her physical body has become linked to her emotional experience, Allison talks about how she is unable to rest her hands on her lower belly without being reminded of loss.

Post-treatment, Allison's body image struggles take on new dimensions of despair. She explains: "It's just like I went through this and then it affected everything... not only not getting anything good, but some things being worse. It's maddening." The physical changes from treatment remind her of her losses and her inability to achieve the baby she wants, while also intensifying her pre-existing body image issues.

Perhaps most significantly, Allison loses motivation for self-care, describing how she no longer feels purpose in caring for her body: "I don't need my body anymore... I don't need to make it really healthy in an attempt to carry a baby." Her body had served a purpose during her mission to become a mother; without that purpose, maintaining her physical health feels pointless. This represents a significant shift from her earlier relationship with exercise and wellness, highlighting how recurrent pregnancy loss can alter one's relationship with physical self-care.

Theme VI- Investment and Hope (The More I do, the More I keep going)

Allison's talks about how with each step in fertility treatment and with each subsequent pregnancy loss, her emotional investment grows, making withdrawal from treatment increasingly difficult. She explains: "You just get more invested and open to doing more things the further down the path you go. At the beginning, would you have told me I would've done IVF and then eventually donor egg, I would've been like no."

Allison explains how the “early successes” (like achieving pregnancy through IUI) surprise her with her body’s ability to even get pregnant, which paves the way for her to consider more aggressive treatments. Additionally, the money she puts in with prior treatments creates a sense of wanting to continue to try and reach her goal rather than lose money already spent. Allison explains how with each deeper step she takes in the treatment process, she experiences a hopeful feeling that "this time will be different."

Additionally, in a strange way, the very fact that Allison goes through a pregnancy loss in some ways pushes her to keep going with treatment and to continue trying to conceive. Knowing that her body could get pregnant makes her want to keep trying in the hope that the next pregnancy will be viable. Allison feels that she has proof of the possibility and potential which makes stopping treatment feel like giving up when success seems within reach.

Theme VII: Oscillating Between Hope and Self-Protection

Throughout each one of her pregnancies, Allison struggles with conflicting needs to hold onto hope and to protect herself from further devastation. She describes being "so happy and so scared" at each subsequent positive pregnancy test, living in what she calls "rollercoaster limbo." This oscillation between hope and self-protection creates a state of hypervigilance, where she experiences some degree of joy but also guards herself for any possible disappointment whenever she goes to the bathroom and wipes or has to go to doctor for a scan.

This split experience is emotionally challenging for Allison. She explains how "the fear and anxiety of another loss makes it challenging to sit with the hope and joy," creating what she describes as a "relentless uncertainty." Each positive milestone—a rising beta, a visible heartbeat

—brings momentary relief immediately shadowed by the knowledge of how quickly everything can disappear. She reflects: "When I saw the heartbeat, I was elated and terrified in the same breath. It's like the moment I let myself be happy, I was already bracing for bad news."

This oscillation intensifies with her second pregnancy, where her trauma from the prior loss has taught her the risk of unguarded hope. As a result of this devastating disappointment, Allison implements protective strategies: she tells fewer people about the pregnancy and consciously tries to self-protect by always remaining cautious about the future. However, she can’t prevent herself from slowly opening to hope as each scan shows progress, describing how "after I'd had my six-week ultrasound, then I told more friends... I thought this was really going to happen."

Allison's oscillation between hope and protection also manifests in her relationship with her own body during pregnancy. She describes moments of connection—feeling morning sickness as a positive sign because "my mother and my sister both had morning sickness through their pregnancies"—alternating with periods of dissociation and anxiety. This creates yet another split experience for Allison where part of her celebrates pregnancy symptoms while another part feels scared and fearful of losing those symptoms.

The cruel timing of her second loss—at nine weeks, after multiple positive scans and the development of strong pregnancy symptoms—feels particularly devastating precisely because she gradually allowed herself to believe. Allison shares the experience of slowly allowing herself to have more hope as she continues receiving positive updates and feeling pregnancy symptoms. She feels that this growing sense of trust and hope make the eventual loss feel substantially more devastating. Allison describes the "unfairness" of slowing opening yourself up to hope only to

have it "ripped away," reflecting: "I would have rather both times the transfer just not work than to go through being pregnant and then losing it."

The fact that Allison would have preferred a failed transfer over a pregnancy loss reflects on how emotionally draining it is to constantly feel pulled between feelings of hope and feelings of self-protection. By nine weeks, Allison lets go of multiple protective barriers she'd erected, allowing each healthy scan to slowly bring down her defenses. The loss then feels not just like the loss of a pregnancy and her future child, but also like punishment for allowing herself to have hope despite her attempts at self-protection.

Theme VIII: Double Grief - Loss of Child and Future Identity

Allison articulates experiencing "double grief"—mourning both the loss of the pregnancy and the baby growing inside as well as her entire anticipated future as a mother. She explains: "There's the grief for the loss of the actual babies... and then there's the grief of what my future looked like... What's my purpose? How do I make meaning out of life?"

Allison elaborates more on these two separate but intertwined experiences of grief. There is her immediate grief for the lost pregnancies and the loss of life that was growing inside of her and there is the grief for her future hopes and dreams that she had fantasized about. This futureoriented grief encompasses the collapse of a life narrative that had organized Allison's sense of purpose since childhood.

The double grief proves particularly complex because it involves mourning something that never fully existed—not just the pregnancies, but the entire identity of "mother" that Allison had anticipated inhabiting.

Theme IX- Existential Crisis and Loss of Self

Allison’s decision to end treatment is followed by a profound identity crisis. She describes feeling like “a shell of who I was” and experiencing a complete loss of engagement with life: “I’ve lost what feels like years of my life…I feel like it’s not even like a shell but I just guess I’m broken.”

In the absence of working toward the goal of motherhood, Allison describes feeling quite lost and purposeless. She reflects on this disorientation: “ I don’t know what life looks like now. I don’t know what will feel purposeful. I don’t know what to do next. I don’t know how I will find a way to make meaning…that’s the hardest part. And knowing that that’s really going to take probably, I feel for me, a long time for that to shake out.”

This existential void manifests in her resistance to engaging with basic self-care and future planning. Allison explains: "I don't need my body anymore... I don't need to make it really healthy in an attempt to carry a baby... It took my purpose away. So why?" The loss of her reproductive goal stripped away her motivation for maintaining her physical health, exercising, or caring for her appearance. She describes how "the person in me who had goals or would do things that could move my life forward... I got other things I've put off for a long time that are just so unlike me."

Allison's loss of self and purpose intensifies to a point where she describes experiencing passive suicidal ideation, though she's careful to clarify that she never experienced any active intent to end her life. She explains: "I'm not suicidal, but there are moments where I'm like, is this really like how the second half of my life is going to be? I'm like, why am I here? Sometimes

do I want to be here? And the reality is for me, like day to day, the only creatures that care, that would be affected or are affected day to day that I'm here are my cats. Nobody else needs me on a daily basis."

The depth of her crisis is felt most intensely in her struggle with meaning-making. Unlike other forms of loss where meaning can eventually be constructed, Allison finds herself unable to extract any positive significance from her experience: "I don't feel like there's any meaning making for me... I would give anything not to have this way of being able to relate to people. I don't want this." This resistance to finding meaning reflects Allison’s reality that this particular experience and series of losses is difficult to integrate into a coherent, meaningful narrative.

Allison's identity in the last couple of years became organized around her anticipated role as a mother that its absence left her questioning not just what to do, but who she is. She reflects: "I look in the mirror and see someone who put her whole heart into becoming a mom. Now I don't know how to reclaim who I was before, or if she even exists anymore." This fundamental disruption to selfhood represents perhaps one of the more devastating aspects of her journey— not just the loss of future motherhood, but the collapse of the self who begun to organize her future life around that possibility.

Theme X: Social Isolation and Invisible Suffering

Allison goes through her fertility journey and recurrent pregnancy loss experience primarily alone. As a single woman, she carries the full weight of hope and grief without a partner to share the experience. She became "the only one that holds the real grief, the memories... the only person that it really impacts."

The invisible nature of pregnancy loss means that Allison's suffering goes largely unrecognized by her community. Unlike deaths that receive social acknowledgment through rituals, visits, and sustained support, pregnancy loss remains hidden from public view. After each loss, Allison receives what she experienced as minimal recognition of her loss: "After each miscarriage, I got... I had a friend who dropped off a card, I think each time... Each time I had a different friend send me flowers, but then otherwise nothing from anybody." She contrasts this with the support typically offered after recognized losses: "My parents didn't do anything for me after either miscarriage. Not offer to buy me dinner, get me anything, send flowers, send a card, nothing."

This isolation intensifies Allison's retreat from social connections. She finds herself unable to tolerate friends' thoughtless behavior, describing how her patience evaporated: "I can't tolerate that stuff anymore... now I have my own trauma too, you don't get to trump me with your shit anymore... most of the people in my world... nobody else in my particular experience. And then most people don't know what this is like and so I'm like, 'You don't know what this is for me. You don't know how painful this has been.'"

The invisibility of her suffering creates particularly painful moments in daily life. Allison describes avoiding her neighbors who had a baby: "I avoid them like the plague. I hear them going out and stuff. I try not to see them... If I'm in my car, like I do whatever I can to not interact, and they probably think that I'm mean."

Allison’s experience of both her unseen and unacknowledged grief as well as her social withdrawal leads to increased isolation. Allison finds that most friends couldn't maintain the ongoing support she needed and wanted for such a hidden type of loss: "Who do you talk about

this with on an ongoing basis? Somebody might be able to hear it, a friend or family member once or twice... But I don’t have somebody that I could or would want to talk about this with every week or every other week." This practical perspective of others' limited capacity to hold long-term space for her grief leads her to further withdraw, which creates a significant feeling of loneliness in her life.

Theme XI: The Therapeutic Relationship as Primary Holding Environment

Allison's therapy becomes her primary space for processing grief, especially as she begins to feel the burden on friends and family once the initial shock and crisis of a pregnancy loss or her decision to stop trying fades. Therapy provides not just safe space to process her emotions but also practical containment of her grief. Allison describes putting on "a face for other people" while reserving her authentic self for her weekly sessions with her therapist. This splitting of experience—functional in public, authentic in therapy—became necessary for survival but also increased her sense of isolation.

The researcher's relationship with Allison during these interviews seemed to serve a similar holding function. Allison noted that while painful to revisit her experiences, it "felt good to reprocess them and feel seen and heard." This demonstrated the need for witnessed understanding that characterizes her experience.

Impressions from the Interviews with Allison.

Allison entered the interview space tentatively as if guarding against what emotional pain she might experience in thinking and talking about her RPL. I often sensed that she felt resigned to her fate of sadness and helpless to change it. I would periodically check in about her feelings

toward participating. Allison shared that although it was painful to relive the memories through our conversations, it also felt good to reprocess them and feel seen and heard by me.

There were a few moments when I found myself hesitating to share a thought or idea with Allison out of uncertainty about how it might land with her or be received. There were a few times when she pushed back or disagreed with a thought or analysis that I had, however, we seemed to bounce back into an ease and flow of our conversation following these moments.

I had a persistent feeling of fragility in our exchanges, in which I felt that if I mistakenly said something she received as offensive, hurtful, or not empathic, that she might shutdown or pull away. I was very conscious of the words, thoughts, and ideas I shared with her and how I shared them. Perhaps in this sense, I may have been experiencing elements of Allison’s relational template where she initially puts herself out there tentatively, receives a misattuned response, feels confirmed that no one understands, and withdraws. Consistently through the course of the interviews, I found myself coming back to this relational template and wondering how this will impact Allison’s process of meaning-making and moving through her decision to ultimately end fertility treatment. Allison describes herself as someone upon whom certain life challenges and failures tend to happen to. Allison's view of herself as someone upon whom failures and challenges tend to happen appears to perpetuate both her withdrawal from relationships and her reluctance to pursue new directions, whether toward motherhood or alternative sources of meaning. I experienced Allison’s willingness to engage in this research despite her pain as reflective of a continued interest in understanding herself better as well as helping others going through recurrent pregnancy loss by providing useful data to the community.

Psychoanalytic Interpretation of Allison’s Case

Throughout her interviews, Allison’s narrative reflects a combination of depressive functioning and narcissistic injury. Allison demonstrates a genuine capacity for mourning while also experiencing profound narcissistic wounding that expresses itself through resignation, and Allison’s feelings that she has a “bad luck” identity (Freud, 1917; Klein, 1935, 1940; Kohut, 1977). Her repeated sentiment, “no one told me this could happen,” and her reflection that she “kept beating the odds in good and bad ways,” suggest an underlying sense that misfortune seeks her out, that she is somehow marked for disappointment in ways others are not.

Allison’s experience reflects Melanie Klein’s (194) depressive position, or the psychological capacity to recognize the object (in her case, the desired baby or the expected motherhood) as separate and whole, and to experience guilt and concern when that object is lost. Unlike the paranoid-schizoid position’s splitting of objects into all-good or all-bad, Allison maintains a cohesive sense of herself and that she wanted motherhood, took a risk, and was hurt (Ogden, 1986).

This capacity for depressive-position functioning coexists with significant narcissistic injury. Allison experiences a strong sense of unfairness when her fertility treatments fail to respond as expected to her efforts and planning. She also feels deeply disappointed and hurt when family, friends, and her doctors do not respond to her experience in ways that she feels they should or in ways that she would perceive as caring, thoughtful, and attuned to her needs. Furthermore, she experiences a strong sense that her doctors could have better prepared her for possible bad outcomes along the way, and that she was especially unlucky to have experienced many of the potentially bad outcomes. When she states “no one told me this could happen,” it not only emphasizes her feeling that she received inadequate informed consent, but it also carries an

implicit accusation: others should have protected her, prepared her, and warned her. Each unexpected complication is experienced not simply as biological misfortune but as confirmation of a pattern where she is uniquely targeted by bad luck (Kohut, 1977; Siegel, 1996).

It is important to note that Allison’s feelings manifest as disappointment and withdrawal than as anger and aggressive attack. Her active avoidance of the neighbor’s baby reveal protective distancing from triggers. Her recognition that her parents “didn’t do anything for me after either miscarriage,” carries hurt and resentment. She expresses this more as resigned expectation rather than surprised outrage. This quality of resignation, “of course no one showed up for me, that’s how it always goes,” suggests Allison has integrated repeated experiences of disappointment into a stable (if painful) sense of self as someone who endures alone. Allison’s narcissistic injury activates her feelings of resignation, withdrawal, depletion, and acceptance of suffering as her fate.

Allison’s early relational template of parents who were “great in so many ways, but not good with emotional support,” creates a foundational expectation that practical needs will be met while emotional needs go unrecognized.

The story of missing her friend’s funeral is one clear example of this dynamic in Allison’s relationship with her parents. Allison was seeking emotional permission to choose the funeral over professional obligation but instead received the implicit message that work comes first. Furthermore, she didn’t receive any curiosity or exploration around her feelings and what might make her feel comforted in this sad situation. This creates what Bowlby (1969) termed an “internal working model” where emotional needs are secondary and practical concerns take precedence. Allison internalizes this template becoming someone who anticipates that others will respond to her distress with practical solutions (“go for a walk”) rather than emotional presence.

This template plays out with Allison’s medical providers who rush to discuss “next steps” while Allison is still “half undressed” and processing devastating news. These situations with her medical providers confirm her internal model that “when I’m overwhelmed, no one really shows up for me.” Her anger at this is palpable: she describes feeling “talked at, not to” and recalls feeling “like nobody really cared how I was coping.” Her wish for someone to “just say this is awful” rather than immediately problem-solve demonstrates her anger at the repeated dismissal and the degree to which recognition and emotional holding could have helped her process the loss (Winnicott, 1960, 1965).

Allison’s frustration with providers who do not prepare her or potential complications (“no one told me this could happen”) not only demonstrates reasonable anger at inadequate informed consent but also hints at a deeper sense of having been set up for disappointment. Each unanticipated complication or set-back feels not simply like bad luck but like evidence that no one protected her, that she was left to navigate danger alone without adequate warning. This compounds her sense of victimization and confirms her identity as someone who must endure difficulty without adequate support.

Allison identifies herself as experiencing what she calls “double grief,” mourning both the lost pregnancies themselves and “the entire future I believed I’d have.” There is object loss (the babies) and narcissistic loss (the anticipated identity of mother.) Freud’s (1917) “Mourning and Melancholia” similarly differentiates between these different dimensions. In mourning, the lost object is external and known; in melancholia, something in the ego itself is lost, though what is lost may be less clear.

Allison’s grief contains both elements but is primarily more mourning than melancholia. She knows what she has lost (motherhood, purpose, identity) and she experiences profound

sadness but does not turn this into self-attack or identify completely with the lost object. Her statement, “I feel like a shell of who I was” reflects awareness of how her loss has impacted her but it does not contain the self-hatred or rage that goes along with melancholic identification.

Allison grapples with questions such as, “ What’s my purpose? How do I make meaning out of life?” These types of questions reflect what Kohut (1977) called “disintegration anxiety,” the fear that the self will fragment when its organizing ambitions and ideals collapse. Toward the end of her process of trying to conceive, Allison’s sense of purpose had become entirely organized around anticipated motherhood. In the absence of this organizing principle, she experiences not just disappointment but a fundamental threat to self-cohesion. Her passive suicidal ideation (“sometimes do I want to be here?”) reflects the despair and hopelessness she struggles with when thinking about whether life without meaning is worth living.

In the midst of this existential crisis of finding purpose again in her life, Allison still maintains self-reflective capacity. She separates her passive suicidal ideation from intent, identifies her cats as beings who need her care and attention, and she engages in the research interviews as a way of creating meaning from her suffering. These are signs that the self has not fragmented, and there are threads of connection to life.

Another important element in understanding Allison’s experience of grief and loss through this process is the aspect of financial constraints and how class intersects with her reproductive trauma. One factor in her decision to end treatment despite not having been able to conceive a healthy baby, is due to financial limitations. Not only has her body failed her, but her economic circumstances put an end to the possibility of continuing to try. She cannot access what others with more resources can pursue indefinitely. Allison’s statement, “Sometimes I do resent a little bit because I’m like, if I had a partner I might be able to…” demonstrates her awareness

of the systemic inequality built into the system of who gets to pursue motherhood and under what conditions. Her anger and resentment is in response to the injustice she experiences.

She asks out loud, “Am I giving up too easily?” revealing how economic limitations can become internalized as personal failure. Allison cannot have the closure of feeling that she ended treatment on her own terms when a large part of the reason she stops treatment is due to how expensive it is. As a results, she struggles with insecurities about her own commitment and strength. Despite the concrete financial limitations she experiences, Allison still wonders whether the need to stop her treatment is not just due to the cost of treatments but due to individual weakness.

Allison identifies her therapy as her “primary space for processing her grief,” while she puts on “a face for other people.” This recognition of her therapy and what it provides her hints a the depth of isolation she experiences in her RPL journey as well as her capacity to use the therapeutic relationship for psychological work. Winnicott’s (1965) concept of the “holding environment,” is one way of thinking about Allison’s therapy. It provides a containing presence that her early relationships and present-day medical encounters fail to offer.

Allison talks about her ambivalence in participating in the research interviews, stating, “the pregnancy losses are painful to revisit but also good to reprocess them and feel seen and heard.” She’s identifying the healing power of one’s suffering being witnessed by an other and how there is reparative potential in the witnessing experience even when it cannot resolve the underlying loss. Her identification of the power in “feeling seen and heard,” speaks to Kohut’s emphasis on empathy as the essential therapeutic action. Allison does not need solutions, in fact there are no guaranteed solutions for her RPL, but someone bearing witness to her pain without rushing to fix, minimize, or redirect her attention elsewhere is very powerful.

Throughout Allison’s interviews there is a complex intertwining of both depressive functioning and narcissistic injury. The coexistence of genuine mourning capacity with narcissistic injury manifests as resignation rather than rage. Allison demonstrates an ability to remain emotionally present to her pain and to the pain of others, maintain concern for others despite her own intense suffering, and continue the difficult work of attempting to make meaning out of her grief and loss. At the same time, she does carry a “bad luck” identity where she perceives misfortune as seeking her out, where others fail to show up for her, and where the universe confirms her aloneness.

This is not the splitting and projection of paranoid-schizoid functioning, nor is it the entitled rage of narcissistic injury. Rather it represents a depressive organization that has been influenced by repeated experiences of emotional unavailability and disappointment. Allison has integrated these experiences into her sense of self, seeing herself as someone who has taken some risks and gotten hurt, who has reached out and been dismissed, and someone who has endured difficulty largely alone.

Allison’s resignation both protects against repeated disappointment but also leads to withdrawal and lack of connection. The only way Allison might be able to eventually disconfirm her beliefs and expectations of others is through connection and engaging in relationships. Yet her willingness to engage in the research process, her continued therapeutic work, and her stated wish for things to be different all suggest that beneath the resignation there is hope for a different relational experience, one where her suffering is witnessed, and her needs are recognized.

Case Study # 4 Shelly

Descriptive Information

Shelly is a 29-year-old, cisgender Jewish woman who works full-time as a psychotherapist specializing in eating disorders at a group practice. Shelly describes an emotionally difficult and traumatic upbringing where her parents offered little emotional attunement when she was distressed. “My parents were great in so many ways,” she explains, “but when I was distressed, the message was always, ‘perform better.’” Her mother was a stayat-home parent who placed importance on schoolwork, appearances, extracurricular activities, and social etiquette. Her father worked hard so that Shelly could attend private schools including an Ivy League college. As a result of all this emphasis on external achievements, Shelly feels she grew up linking her self-worth to her accomplishments. She experienced her parents as giving more importance to these external achievements rather than emotional connection. This emphasis on the importance of external achievements, often in place of the importance of emotional connection, shaped Shelly's sense of self-worth and initially influenced her vision of motherhood. When her therapist asked whether she had "the drive to parent," her immediate response was negative because she couldn't afford the private schools and elite education her parents had provided. It was during her first pregnancy loss, when she received nurturing support from friends, that she realized parenting might be fundamentally about emotional presence and less about material items and achievements. "After my first miscarriage I had people, friends and like a family member that were really comforting and really nice and just hugged me and let me talk," she reflects. "I was like oh my god, is this what parenting could be? You just give emotional support and make someone feel loved." One of the therapists was like ,’Yeah, that’s the core definition of parenting for a lot of people.’” Shelly shared that because she “was such a

disappointment to her parents” by not becoming a JD, MD, or PhD, she feels the demons of her own upbringing really impacted her ambivalence around her ability to be a good mom which in turn led to lots of fear and anxiety the first time she found out she was pregnant.

Throughout her childhood and into adulthood, Shelly never envisioned biological motherhood, citing severe medical anxiety and pain sensitivity that made pregnancy feel physically impossible. At age 24, following minor surgery to remove a uterine polyp, a doctor's dismissive comment—"If you're this sensitive to pain for this, how are you ever going to have kids?"—reinforced her belief that biological motherhood wasn't feasible. Despite this intense medical anxiety that she struggled with, Shelly also felt cultural pressure within her Jewish communities to have children, leaving her feeling that "my life wouldn't be celebrated or valued in the way that people value you to have children biologically."

Initially, Shelly and her husband decided they would likely live a childfree life, viewing her pain sensitivity as a big barrier to having children. However, practical constraints around their housing situation—they purchased a walk-up Philadelphia home with layout requirements that disqualified them from foster-to-adopt programs—led them to reconsider biological parenthood. As Shelly began to feel she at least wanted the "option" to have biological children, she began researching medical alternative pathways to giving birth like elective C-sections that might make pregnancy manageable despite her medical anxiety.

Shelly and her husband ended up deciding to try and conceive but assumed they’d have time to adjust to the idea of pregnancy and giving birth, assuming it would take a few months to get pregnant, however, Shelly got pregnant on their first month of trying. The first pregnancy occurring immediately after beginning to try, created panic about readiness that led to a

medication abortion at seven and a half weeks. She and her husband thought of this abortion as a "reversible decision," assuming they could easily conceive again when feeling more prepared. However, Shelly goes on to have a complex fertility journey including the initial termination followed by three pregnancy losses—a blighted ovum, a pregnancy loss of a chromosomally normal embryo, and a chemical pregnancy—each carrying profound psychological meaning beyond the medical facts. The subsequent losses have led to feelings of guilt and self-blame. Shelly shares that she has an overwhelming feeling sometimes that each failed pregnancy is a punishment for terminating what she believes may have been her "one healthy chance."

After working through her assumptions about parenting for six weeks following the abortion, including beliefs that good mothers must move to the suburbs, Shelly felt ready to try again and conceived immediately. This was the pregnancy that ended with a blighted ovum, diagnosed by a radiologist who curtly informed her "there is nothing inside the sac, your midwife will call you to either take some pills or get a D&C." The contrast between her abortion experience—where she was denied pain medication—and this loss, where narcotics were prescribed, highlighted the different moral frameworks applied to voluntary versus involuntary pregnancy endings. Shelly had the pregnancy tissue tested and the results came back all normal which further intensified her self-blame since she reasoned that it was her body and not the embryo that was to blame for the loss.

After experiencing RPL and not just one loss, Shelly now interprets each failed pregnancy as punishment for terminating what she believes was her "one healthy chance." After the second loss, she shares, "It just felt very, very confusing to not know which doctor was right. And I think for me, it felt extra scary because of the abortion. It was after the second loss when I

really started blaming myself hard for that and getting into some intense self-hate around that… Like that was my one chance, and I threw it away."

These losses also reactivated previous body image struggles, leading Shelly to wonder if her body shape indicated hormonal problems: "This sounds really weird but I've had the thought about am I intersex or something? Or, I thought for the longest time, I must have PCOS because my stomach sticks out and I have pretty small breasts." Though PCOS was ruled out, these concerns triggered restrictive eating patterns as she attempted to "fix" whatever was causing her losses.

Toward the end of our interview process, Shelly was preparing for IVF after completing endometriosis treatment with Lupron and Aygestin, Shelly seemed to be experiencing her medical journey as both a punishment for past decisions and a potential path to emotional freedom and self-forgiveness. Shelly talks about how the decision to proceed with IVF has been particularly challenging given her medical anxiety and the finances of it, but she feels as though it will inevitably be her only option toward motherhood as a punishment for the medical abortion she previously had. In her experience with her reproductive health providers, Shelly has felt that her worry about pain and her actual pain itself have been minimized. She also expresses many moments of feeling invalidated by her providers and receiving contradictory or confusing communication. One example of this is the preparation she received for a hysteroscopy procedure. She was told it would involve "just pressure, " however she experienced it as so painful that she had to “grip the table tightly and hold back tears.” This was one of many moments where Shelly felt invalidated in her experience of physical pain.

At the time of these interviews, Shelly shares " I am feeling more like myself" while on a break from fertility treatments. However, she continues to struggle with feelings of self-hatred around the abortion. Shelly’s experience with RPL involves a complex intertwining of her own early family dynamics, medical trauma, reproductive loss, and the emotional toll of pregnancy termination. It is evident in her story that her past experiences and decisions have impacted how she perceives and processes hope, loss, and her medical care.

Categories of Meaning

Theme I- The Abortion as Unforgivable Wound and the Compulsion to Repair

Since terminating her first pregnancy, Shelly speaks of herself as a “killer” who forfeited her one healthy child. The word punishment comes up frequently. She refers to every blooddraw, medical intervention, or financial payment as something she “deserves.” She fantasizes about how having a health baby is the only way to erase the mistake of her abortion. She experiences hope with each new cycle, stating “maybe this will make it right,” but quickly feels worried that another loss will confirm that her mistake is beyond repair.

Shelly talks about how she believes that her journey will eventually lead her to IVF. IVF is a process wrought with extraordinary challenge for her as she has phobia of needles and general medical treatment, and she also struggles with financial worries and guilt. She views this inevitability as a punishment for her decision to have an earlier abortion. She states “I threw away the easy road, so now I have to suffer…IVF is my penance for killing the only healthy baby I’ll ever make.” She even goes as far as to say, “If another loss happens its proof I still haven’t paid my debt…Beggars can’t be choosers- I chose abortion, so I chose this pain.”

The lens through which Shelly views her abortion leads each new pregnancy attempt to carry the weight of not only a hope for a baby but also the only path toward forgiving herself for the abortion and moving forward. When she sees a positive pregnancy test, Shelly initially feels hopeful and excited and then she has the thought, "maybe this will make it right," revealing how each cycle carries the heavy burden of redemption. When these pregnancies fail, the losses confirm her sense of being fundamentally damaged and undeserving.

Shelly’s guilt forces her into a trapped state of being. She can neither fully embrace her choice—which would require accepting her agency and right to make difficult decisions—nor fully reject it, since that would mean acknowledging it as truly problematic and irreversible. Instead, her harsh inner critic remains loud, while she simultaneously looks for external validation to quiet the internal noise around her past actions. Even when her fertility doctor reassures her that abortion doesn't cause miscarriage, she experiences this not as absolution but as evidence that others simply don't understand the magnitude of what she's done. She asks her midwife if the first pregnancy would’ve been viable and she repeatedly asks the fertility doctor things such as, “Did I talk you into this? Tell me if I’ve harmed the embryo.” Shelly finds it difficult to feel validated or reassured by responses that are neutral.

Theme II- Medical Providers as Both Saviors and Persecutors

A reoccurring theme throughout our time together is Shelly’s need for reassurance from her medical providers throughout her RPL and fertility journey, and how she is frequently disappointed with their ability to provide the emotional regulation she seeks in challenging moments. These relationships often begin with hope—each new provider initially carries the promise of being the "good parent" who will finally understand her pain and help her achieve her goal of having a child. However, these positive feelings start to decline when providers minimize

her physical pain, providing confusing and contradicting instructions, or respond dismissively to her concerns. She talks about how one doctor initially told her to combine two medications and then a few weeks later seemed surprised she was taking both. She states, “If even the experts can’t keep it straight, I must be the problem.” She describes double checking her medication protocol with a nurse and being told, “you’re overthinking, trust the protocol.” Experiences like these, or the one where she recalls staff telling her the hysteroscopy would be “just pressure,” but she had to grip the table in tears led to an important reflection that Shelly makes about herself and this entire process. She states, “I don’t need hand-holding 24/7. Just acknowledge the pain is real, explain why plans change, and act like my questions matter. If someone did that, maybe I could stop assuming every misstep is my fault.” These experiences don't simply disappoint— they replay and reinforce her deepest fears about being fundamentally too much, too sensitive, too needy for others to tolerate.

Shelly talks about this theme in her life where she experiences herself as too needy and sensitive. She remembers her parents telling her "don't make a scene" when she was upset about something or having a hard time. Now in her present day interactions with her reproductive providers, when she asks questions or seeks comfort, she hears things like, "take the pills, you'll be fine" or "stop Googling.” There is a familiar experience of having her emotional reality dismissed. In both of these encounters, her feelings complicate other people's agendas, and the solution is for her to need less rather than for others to provide more.

Shelly swings between clinging to directives (“Tell me exactly what to do”) and rejecting them (“They don’t care if they hurt me”), leaving her feeling quite stuck. Each underestimated procedure reinforces the belief that her body is “too sensitive” and uncooperative—mirroring her

eating-disorder narrative that her shape and size are “wrong.” Physical pain without validation cements the idea that her body—and now her grief—must be endured in silence.

All of these interactions and experiences, namely the repeated invalidation, impact Shelly’s behavior and decision-making. Shelly hesitates to choose among treatment options, fearing hidden consequences no one will warn her about. She re-reads clinical notes, crowdsources forums, and double-checks every dosage—yet still feels unprepared. She feels dread before each appointment approaches and she rehearses “safe” questions, then finds herself quiet and unable to think of her questions when actually faced with her doctor. When a cycle fails, she wonders if her emails annoyed the doctor and somehow led to a negative outcome. She questions whether she really is "too sensitive," "overthinking," or fundamentally "the problem." Adapting to this narrative of being “too sensitive,” transforms what should be healing encounters into additional sources of trauma, leaving her more isolated and self-critical after each disappointing interaction.

Theme III- The Body as Battleground

After her second pregnancy loss, Shelly talks about how some of her disordered eating is triggered and reactivated. The return to food restriction emerges as both a symptom of the psychological impact of her recurrent losses as well as an attempted solution to fixing her fertility problems. She describes how each loss leads her to feel a lack of control. She cannot control pregnancy implantation, chromosomal abnormalities, or doctors’ treatment protocols. Thus, restricting food feels like one variable she can still control. She begins logging calories again, lengthening workouts, and weighing herself every morning. The goal is not cosmetic—she talks about “flattening the stomach that must be crowding my uterus” and “making the hormones

cleaner.” In her mind, weight loss might correct whatever “masculine” body shape or hidden hormone imbalance is sabotaging early pregnancy.

The routines Shelly develops to try and control her outcome become rigid overtime. She begins skipping shared meals with her husband to avoid his commentary on how small her portions are and she chooses tele-therapy from home over in-person sessions at her office so colleagues won’t notice when she misses lunch. These behaviors offer short-term relief in that she can see her weight dropping or observe the calories burned in a workout which feels temporarily good in comparison with her fertility treatment efforts which are not yielding the results she is striving for. However, lab work shows her estrogen dipping, and her fertility doctor warns that low body-fat can further disrupt ovulation—information that intensifies her selfcriticism. She thinkd to herself, “Even my coping strategy is backfiring.”

Shelly demonstrates a high-level of self-awareness around this disordered eating, stating, “restricting food is the one knob I can still turn, but every notch hurts me somewhere else.” She restarts therapy with an ED-specialized therapist and agrees to nutrition monitoring in preparation for her next treatment cycle. For now, she describes food rules as a “false sense of agency”—something she hopes to replace with safer forms of control, like detailed treatment questions and clearer pain-management plans.

Theme IV- The Absence of Emotional Holding and the Hunger for Containment

Shelly talks about how throughout her upbringing she didn’t have a reliable place to process her fears and emotions. More importantly she describes an absence of reassurance or help with emotional regulation from her parents. They provided material security and educational opportunities but responded to her distress with advice to “perform better” rather

than with empathy and validation. The pattern appears to repeat itself in medical settings. After each loss Shelly wants her provider to pause, acknowledge the emotional blow, and offer resources—“Just a simple ‘I’m sorry—do you have support?’ would change everything,” she says. Instead, she had one doctor remind her that “we’re not therapists,” and overall she reports experiencing a lack of reassurance or space to talk through her fears and doubts.

The lack of emotional support and space to process her fears and feelings leads to a reoccurring cycle of unhealthy communication for Shelly and her providers. When instructions are unclear, she tries to make herself as overly accommodating and people-pleasing as possible to avoid being labeled "difficult," despite some uncertainty about instructions and follow-up. If contradictions emerge—like being told to take both Lupron and Aygestin, then later being questioned about taking both—she writes lengthy clarifying emails, then worries she has overstepped. After each cycle of wanting to be a "good patient" while also needing more clarity and direction ends with her feeling like her needs are too much, and asking only makes things worse.

The lack of a containing presence also intensifies her anxiety around medical procedures. Before one of her procedure appointments, she asked questions about pain management, but was met with a response of "you'll be fine.” Shelly experienced that same procedure as quite painful and felt she was left with a lot of questions about what to expect, how to manage pain during the procedure as well as post-procedure. Shelly directly links these experiences of uncontained anxiety with some of the unhealthy coping mechanisms she has turned to such as food restriction, late-night research binges, and obsessive symptom monitoring.

Shelly discovers alternate sources of containment in her life which are supportive and helpful through her experience with RPL. She finds a pregnancy loss doula who provides emotional support during her medication abortion, joins a recurrent loss support group, and seeks out clinical supervision at work to help her navigate the complexity of going through this emotionally challenging time while providing therapy for others. These relationships begin to provide what seems to be lacking in other areas of her life (namely with her parents and with medical providers), space to feel difficult emotions without immediate pressure to fix them or perform better.

Theme V- Hope as Dangerous Territory and the Protection of Pre-Grieving

For Shelly, hope becomes psychologically dangerous territory that brings with it the possibility of exposure to unbearable disappointment. After experiencing the cycle of rising excitement followed by devastating loss four times in a row, she develops some defensive strategies in an effort to protect herself from the overwhelming disappointment. "I'm actively trying for a miscarriage," she explains, meaning she enters every new cycle expecting failure as a way to protect herself against disappointment and loss. Shelly talks about how she initially experiences a spark of excitement when she gets a positive pregnancy test, however the excitement is immediately followed by dread.

The strategy of preparing for and expecting the worst-case scenario, i.e. miscarriage, allows Shelly to feel some semblance of control over a situation she has little to no control over. She has even developed "pre-grieving" strategies where she visualizes receiving bad news, rehearses how conversations with doctors will go, and plans what she will eat the night she starts bleeding. These fantasies about how the miscarriage will unfold represent attempts to feel control

and safety through preparing for the worst, however in reality they keep her trapped in a chronic state of anticipatory anxiety.

The relationship with hope creates a bind for Shelly. Living with hope feels scary, and yet she cannot continue with fertility treatment without some underlying hope and belief that she will achieve her goal. When friends or providers offer encouragement, “This protocol looks really good” or “You’re young, odds are on your side,” she experiences increased anxiety rather than comfort, as if believing and joining in their optimism might set her up for more devastating disappointment.

Shelly’s defensiveness around hope and optimism prevents her from fully engaging with the potential joy of pregnancy when it does occur. Since positive pregnancy tests are immediately followed by dread rather than celebration, she is robbed of certain moments that not only feel joyful but might also help sustain her energy and motivation to continue through this long and arduous process.

Nonetheless, underneath some of Shelly’s defense against disappointment, moments of genuine hope occasionally surface. She speaks about her fantasies of being the type of mother who hugs her child when they're sad or feeling excited to one day being use the neighborhood resources for children that she has in her community. These moments show that although her hope is blunted by fear of disappointment and more loss, she still has a lot of hope and allows herself space to imagine what her dream might feel life if it became a reality.

Theme VI- Glimpses

of Healing and the Emergence of “Good Enough” Mothering

Although Shelly talks a lot about her self-criticism and self-punishment that mark this journey of RPL for her, there is also a strong thread of healing and psychological growth throughout our interviews, suggesting possibilities for integration and self-compassion that extend beyond her journey to have a child. These moments often occur in relationships that provide what her original family system couldn't—unconditional presence during difficult emotions without demands for immediate improvement or performance.

The most significant of these experiences occurrs following her first pregnancy loss, when friends and her pregnancy loss doula provide a new and different experience of care and support than Shelly has received in the past. They sit with her in her discomfort and pain and allow her to cry without interjecting to offer solutions or quiet her sad thoughts. "It hit me that maybe parenting is just hugging your kid when they're sad," she realized. "These friends did for me what I always wished my parents had done." This experience has disrupted and shifted her understanding of motherhood from her parents’ achievement-focused model toward parenting as being mostly grounded in the emotional quality and presence of the parent/child relationship.

In her recurrent loss support group, Shelly talks about how other women share stories of how bedtime routines, playful moments, and everyday comfort from their own childhoods were the moments that stayed with them the most. These conversations from her support group and experiences with her friends and community slowly show her that "good enough" mothering i.e. “just being there for your kids,” contrasts sharply with her family's emphasis on things like private school and external markers of success. She begins to believe that emotional availability

might matter more than her ability to provide material things like private school or expensive tutors.

This emerging perspective on parenthood carries over into her own development of internal resources for managing her ongoing medical challenges. When treatment plans change or she has an unexpected and disappointing outcome, she sometimes now asks herself, "What would that caring mother say?" rather than reverting back to self-critical thoughts.

Perhaps most remarkably, Shelly demonstrates growing capacity to hold complexity—to feel both guilt and regret about her abortion as well as recognition that it might have prevented an even more traumatic late-term loss due to the fact that doctors later discovered a fibroid in her anatomy that could’ve caused late term pregnancy loss. She can acknowledge both her strong desire for a child and her fears about medical procedures. This ability to accept ambivalence and contradiction demonstrates her movement away from “all or nothing”, “bad vs good” thinking in her earlier interviews. Impressions from interviews with Shelly.

Prior to our initial interview, when I was assessing exclusion/inclusion criteria, Shelly shared in our initial consultation call that she had suffered in the past with an eating disorder and depression and anxiety. One of the excluding criteria to participate in the study was if the individual had been diagnosed with a severe and persistent mental illness. I also did not specify my criteria about whether or not someone with a past elective abortion could participate. When I reviewed the criteria with Shelly, she shared her honest opinion that elements of the criteria were quite limiting as a large number of people by their adulthood have experienced mental health

challenges and their experiences of RPL are also important. Since, I had in fact specified that the mental illness would have had to require hospitalization to be considered exclusion criteria to participate I decided to move ahead with Shelly participating in the study. I believe that us having a dialogue about these criteria was a meaningful part of the backdrop of our interview process together. For better or for worse, I felt at times, that Shelly felt self-conscious of her emotional reactions and responses to her providers and I wondered if she wondered if I was judging them as “unstable” or excessive. I will explain more about this later in this section of my impressions from our interviews.

At the beginning of interviewing Shelly, she seemed both eager to participate in the study, enthusiastic to contribute to the body of research for this population of women, but also tentative to discuss certain aspects of her unique journey. Namely, she seemed more cautious in exploring her experience with her elective abortion prior to her RPL diagnosis. At times, I observed myself taking extra care and thought into how I phrased questions or commentary to ensure she felt seen in her true experience and not misunderstood or judged. There were a few encounters throughout our interviews where I shared a reflection or an idea that did not resonate with Shelly, however, we were usually able to find a place of deeper understanding of her lived experience and move onto other aspects of the interviews or her story.

In addition, with regard to how Shelly’s past experiences with anxiety and depression came up in the interview process, there were times when Shelly was sharing about an encounter she had with a doctor where she was quite anxious and needing reassurance, and she would have doubts about whether her anxiety and self-doubt were so extreme that maybe she was inappropriate for this study or had “pushed” me into accepting her into the study. We talked

about how she was feeling and how I was experiencing her in our interviews and genuinely moved onto a place of understanding and reflection that her story was an important and meaningful part of the research. At the end of our interviews, I felt that Shelly’s experience of an eating disorder, anxiety/depression, and her abortion provided diversity to the sample which provided rich and important data on the lived experience of RPL.

Psychoanalytic Interpretation of Shelly’s Case

Throughout Shelly’s interviews she struggles with guilt, attempts at reparation and selfforgiveness in the context of her elective abortion and subsequent RPL. Shelly’s super-ego is a dominant force following her abortion. She harshly judges herself, questions her decisions and actions, and perceives setbacks and disappointments throughout her fertility journey as punishments for her decision to end her first pregnancy (Freud, 1917; Klein, 1940, 1946).

Shelly’s characterization of herself as a “killer” who must pay “penance” by having to go through IVF reveals how deeply she blames herself for the losses she has endured. From a Kleinian perspective, Shelly’s superego is persecutory and attacks the ego allowing little to no space for forgiveness or compassion (Klein, 1940, 1946). Each subsequent pregnancy loss is experienced as punishment and is evidence that she “threw away the easy road” and must now suffer the consequences.

The punitive quality of Shelly’s psychic organization and framework for viewing her RPL makes sense in the context of the harshness she experienced from her own parents. She may have internalized this unforgiving judgment and approach when her parents responded to her distress with “perform better,” rather than with emotional attunement. When Shelly falls shot of

expectations (“not becoming a JD, MD, or PhD), she experiences herself as “such a disappointment.” The abortion is another failure confirming her defectiveness and unworthiness.

Klein’s (1946) concept of the “bad breast” is a helpful framework for understanding Shelly’s experience of herself and her abortion in relation to her RPL. Shelly has introjected a harshly withholding and punishing object that she now experiences as located within her own body (the “punished” uterus). The body is both the site of transgression (her abortion) and the executioner of punishment (RPL) creating an impossible situation for her where redemption feels impossible to attain. Each subsequent loss or setback confirms the badness inside (the self or internal object) and justifies further punishment.

Shelly often functions from a paranoid-schizoid position in her relationships with her medical providers (Klein, 1946; Ogden, 1986). Initially she idealizes these providers hoping that they can help “fix” her problem, or maybe even “absolve” her through successful fertility treatment. However, these same providers become “persecutors” when they fail to provide the emotional holding she needs. She oscillates between idealization and devaluation which demonstrates unstable object relations where the good and bad aspects of objects cannot be integrated or held simultaneously.

She engages in a number of actions that reflect the hyper-vigilance she is experiencing throughout her RPL journey. She checks and rechecks instructions from her providers, she writes lengthy clarifying emails to them, and simultaneously worries that she’s “annoying” her doctors. This cycle of behavior demonstrates both her need for her providers to be the “good parent” who finally gets it right and her terror that any mistake on her part will confirm her unworthiness and

result in abandonment. This echoes her childhood dynamic with her parents of needing to perform perfectly in order to avoid the shame of “being too much.”

When providers minimize what the pain of a procedure will feel like, describing it as “just pressure,” or dismiss her questions with a response like “you’re overthinking,” Shelly’s fears that her emotional needs are too much or that she herself is too sensitive are confirmed. This confirmation of her worst fear leads to intense feelings of self-doubt and punitive superego attacks. The split between “good doctor who will help me have a baby” and “bad doctor who dismisses me” does not allow Shelly to hold an integrated reality of providers who are limited in certain capacities such as the ability to be emotionally attuned but are not intentionally cruel and might be helpful from a medical perspective (Klein, 1946; Ogden, 1986).

The triggering of Shelly’s former disordered eating habits after her pregnancy losses demonstrates her attempts to both manage emotional dysregulation as well as restore control. The restriction offers a sense of magical control over the outcome. Shelly believes that if she can just make her body “right,” than the next pregnancy will be successful.

Winnicott’s (1965) concept of the “psyche-soma” split is a useful way to think about Shelly’s reactivation of her disordered eating. When psychological distress cannot be metabolized through mental processes such as thinking, feeling, and relating, it becomes converted into somatic preoccupation. Shelly focuses on “flattening my stomach that must be crowding my uterus,” and achieving “cleaner hormones,” through weight loss. These preoccupations reflect a concrete, body-focused attempt to solve complex, emotional struggles tied to guilt, worthiness, and self-acceptance.

The disordered eating also represents an area of Shelly’s life where she can feel a sense of agency and power when pregnancy outcomes are outside of her control. Shelly states, “restricting food is the one knob I can still turn.” There is a more generalized, broad idea in therapy that eating disorders provide the illusion of mastery and self-determination in contexts where individuals may feel out-of-control, powerless, or chaotic. For Shelly this thread remains true in her process of coping with the powerlessness of RPL, despite the fact that her attempts to master her body weight and shape actually further harm her body rather than optimize it for a successful pregnancy.

Despite the intensity of Shelly’s self-criticism and defensiveness, there are moments across her interviews where she reveals growing capacity for depressive functioning (Klein, 1935, 1940; Ogden, 1986). There is one moment after her first pregnancy loss where she realizes that “parenting could be about emotional presence” rather than providing material things. This is a reconceptualization of her ideas about parenting which she attributes to her friends hugging her and letting her talk about her feelings after the loss.

This discovery allows Shelly to imagine a different kind of motherhood, where reparation is a cornerstone of the parent-child relationship and far more powerful than providing the perfect material things that she herself received in her own childhood. Furthermore, her growing capacity to see both this complex and nuanced version of parenting, as well as hold the mixed feelings surrounding her abortion demonstrates movement toward integration. The ability to tolerate ambivalence and contradiction without splitting into all-good or all-bad signifies important psychological development (Klein, 1935, 1940, 1946). In this example, Shelly

gradually develops a more benign superego that is capable of both holding her accountable and offering compassion for hers or others human limitations.

Shelly’s use of multiple different therapeutic relationships (pregnancy doula, support group, individual psychotherapy, clinical supervision) demonstrate her capacity to seek and use holding environments despite her original family system failing to provide this for her (Winnicott, 1960, 1965). These present-day therapeutic relationships function as what Winnicott called “good enough” holding environments where Shelly can express difficult feelings without being told to “perform better,” and where her emotional needs are recognized as legitimate rather than excessive.

The fact that Shelly can identify these relationships as helpful and different from what her parents provided demonstrates her capacity to reflect on what she needs and actively seek out environments that provide it. This also reveals that despite the harsh superego, there remains a part of Shelly capable of self-care and self-compassion.

Shelly’s case illustrates how moral guilt and punitive superego functioning can intensify the already profound narcissistic injury of RPL. The layering of reproductive trauma on top of her earlier relational trauma and the specific guilt around abortion creates a complex intrapsyhic world that requires the gradual softening of persecutory internal objects. When Shelly demonstrates her ability to reconceptualize parenthood or hold ambivalence, these moments reveal that movement away from splitting and more toward integration is possible. Throughout the interviews, Shelly struggles but seems to be in the process of learning to differentiate between appropriate remorse where she can acknowledge the complexity of her abortion decision from self-persecutory guilt where she experiences her losses as deserved punishment.

As the harsh superego slowly becomes less intense through experiences of empathic attunement with friends, her therapist, and her pregnancy loss doula, Shelly develops deeper capacity to mourn her losses without experiencing them as confirmation of her unworthiness (Freud, 1917; Klein, 1940)

Case Study # 5 Rebecca

Descriptive Information

Rebecca is a 43-year-old cisgender Jewish woman who works as a chef operating a small food business specializing in catering, private chef services, and Jewish holiday meals. She is the daughter of a Holocaust survivor and grew up with her mom, dad, and one brother, Maceo, who now has a daughter. Her parents remain married, though Rebecca describes significant political differences within the family, with herself and her father holding "really radical" views while other family members are "really pro-Israel."

Rebecca reports wanting to be a mom since early childhood, recalling being "such a maternal little kid" with "a baby doll Emma and like a million other baby dolls." She attributes some of her strong desire for motherhood to her own mother's parenting, explaining that her mother "just wasn't like maternal enough for me.” She contrasts her own experience with her mom to the warm, loving, nurturing relationship that her wife Jamie describes experiencing with her own mother before losing her.

She has been married to her wife Jamie for four years. Jamie lost both her parents at age 28, and death, loss, and grief are a significant part of her life. Jamie currently works as a death

doula specializing in medical aid in dying. This presence of grief in Jamie’s life prior to Rebecca’s fertility journey later influences how they navigate recurrent pregnancy loss together.

Rebecca highlights how being a part of a queer couple automatically means that parenthood will require extensive planning and intentionality regardless of one’s reproductive health. Rebecca and Jamie began working with a queer-friendly naturopathic physician in Portland in early 2020, though the COVID-19 pandemic initially disrupted their timeline when both women lost their jobs. By July 2020, around Rebecca's 40th birthday, they proceeded with their first IUI cycle.

Rebecca conceived on their first attempt, a success that initially brought joy and excitement. However, the pregnancy became medically complicated when she developed gestational diabetes around nine weeks, requiring transfer from midwifery care to maternal-fetal medicine for high-risk monitoring. Despite these complications, Rebecca’s pregnancy seemed to be developing normally with regular monitoring and at 11 weeks she received bloodwork showing that her baby was a chromosomally healthy, normal female fetus. After receiving these test results, Rebecca and Jamie announced the pregnancy publicly and began planning for their daughter’s arrival.

At 16 weeks and six days, during a routine appointment, the ultrasound revealed that there was no longer a heartbeat, and the baby had died. The measurements suggested death had occurred around 13 weeks and five days, which made this loss a “missed miscarriage,” meaning that Rebecca’s body had not recognized it. Rebecca describes the medical staff as appearing disorganized and unprepared to deliver this type of diagnosis to her. She states that the ultrasound technician initially said "huh it's not showing anything this is like a bad machine or

this is like the like really simple machine like let me get a better machine and we didn't think anything of it." When multiple machines failed to locate cardiac activity, staff brought in additional technicians and eventually the doctor, creating worry without clear explanation. When they were finally told "I'm so sorry there's no heartbeat," Rebecca recalls feeling like minimal information was provided after that regarding next steps or what to expect physically and emotionally.

She was sent home, and it is unclear whether she was told to follow-up to schedule a D and C or not. She does recall that she was told not to worry about spontaneously going into labor at home, and yet on Thanksgiving eve she ended up with what she describes as significant “contraction-like cramping,” and delivering her baby in her bathroom at home with wife Jamie by her side. She named the baby Birdie. She went to the ER following this traumatic event and describes the ensuing process as “dehumanizing,” and with poor attention to her pain management and symptoms. Perhaps most significantly, she reports that no medical provider informed her of her right to recover Birdie’s remains for any type of burial or cremation. She later learned about this option from a support group, however, it was too late for her to do anything at that point. She shares that Birdie was “disposed of as medical waste,” which has become a huge source of regret, anger, and pain for her.

Following Birdie's death, Rebecca recalls feeling profoundly isolated. This isolation was compounded by COVID-19 restrictions that prevented her network of family and friends from providing normal social support. Rebecca recalls feeling disappointed by her brother Maceo and her father for not following through on her request to honor Birdie on certain significant dates. Rebecca reports that her family "thinks we're super crazy… like it was a miscarriage," suggesting a lack of understanding about the significance of their late pregnancy loss. This

minimization of their grief pushed them to further isolate themselves from their community of friends and family during their most vulnerable period.

In December 2021 they moved into the house they had purchased when they first began trying to build a family. Rebecca reports experiencing a mix of emotions as she begins to live in the spaces they had originally designed for their future family to live-in together. Rebecca reports that both hers and Jamie’s grief was further complicated by the complete lack of physical remains or tangible memorials, leaving them with only ultrasound images and a few items they had purchased in preparation for Birdie's arrival.

Rebecca reports that her and Jamie began trying to conceive again within months of Birdie's death.. Over the next two years, Rebecca experienced five additional pregnancies through a combination of IUI cycles and IVF using Jamie's eggs. All resulted in early pregnancy loss, ranging from chemical pregnancies to losses at approximately eight to nine weeks. Rebecca underwent a recurrent pregnancy loss blood panel, testing for potential causes such as antiphospholipid syndrome. However, the blood work yielded inconclusive results, leaving them without clear medical explanations for the pattern of losses.

Rebecca describes the transition from doing IUI’s with donor sperm to embarking on IVF as both a time of immense hope as well as a time filled with emotional and physical challenges. Rebecca shared that after her partner Jamie underwent egg retrieval procedures she developed health complications including PMDD and POTS syndrome that Jamie attributes to the hormonal interventions. The financial, physical, and emotional costs of repeated fertility treatments created ongoing stress, during a time when COVID-19 isolation protocols were still in place and the couple had limited access to normal support systems during these incredibly vulnerable periods.

Rebecca shared that after her sixth pregnancy loss she expressed suicidal ideation to her physician, stating "I'm just gonna go jump off the bridge." During the subsequent D&C procedure, she asked the surgeon to "just take out my uterus and just give me a hysterectomy while we're under." Following these statements, Rebecca’s doctor recommended stopping and/or at least pausing active treatment for mental health concerns. Rebecca remarks on how this moment in her journey was the first time any provider had suggested stopping treatment rather than launching into next steps that included additional interventions.

At the time of these interviews, it had been about 18 months since Rebecca had stopped fertility treatment. She shares that they still have two frozen embryos in storage. She reports that stopping treatment and accepting that she will no longer be trying to conceive and that she does not have a child has been incredibly challenging. Rebecca describes herself as having reached "more of a place of acceptance" where she can function in daily life, though she acknowledges that her sadness has deepened rather than diminished over time. Throughout her interviews, Rebecca alluded to the fact that her and Jamie were in different places about wanting to stop or continue the treatment, namely that Rebecca would have wanted to continue trying and still holds on to those feelings while Jamie did not want to continue with fertility treatment. Rebecca shared that her and Jamie have been in couple’s therapy as the repeated losses created unprecedented strain between them around issues of hope, perseverance, and Jamie's unwillingness to attempt to carry the pregnancy herself. In interviews we briefly touched upon the idea that there is a possibility that Jamie’s body is better able to carry a healthy pregnancy all the way through to a live birth, however, that is not something they have been able to explore as Jamie has had a firm boundary around not wanting to do that. Rebecca describes that presently she continues to work on accepting Jamie’s wishes and finding peace in their life.

Rebecca shares that finding fulfillment and contentment with her life has been difficult not only because fertility treatment did not end with a healthy baby, but also because there have been fundamental changes in their social networks and community connections as a result of wanting children but not being able to have any. She reports feeling increasingly isolated from friends who have achieved parenthood as it can be very painful to spend time around their babies and/or children. She states that her and Jamie have developed new rituals and interests, including annual memorial trips for Birdie's birthday and death anniversary, and birding activities that provide connection to nature and community while honoring Birdie's memory. Rebecca shared that having two remaining embryos that they have not attempted to transfer, remains an unresolved source of stress, representing both ongoing financial obligation and emotionally charged decisions about their reproductive future.

Categories of Meaning

Theme I: The Shattering of Medical Trust and Institutional Betrayal

Rebecca’s experience with medical providers demonstrates how providers can either be sources of hope and comfort but can also have the potential to act in ways that create profound trauma that extends beyond the initial physical or health-related issue. At the beginning of her conception journey, Rebecca makes note of the wonderful care she received from a queerfriendly doctor who she felt provided personal attention, phone access, and genuine investment in her success. Later in Rebecca’s journey she experiences communication with her medical team as confusing, and anxiety-inducing. She describes how during the scan where no heartbeat was detected, the medical staff were scrambling around and not providing any transparent communication or steadiness during a stressful event. She states that it was evident they had no clear protocol in place for how to handle this type of situation. Rebecca feels that even after it

was communicated that there was no heartbeat, the next steps and options for moving forward were unclear and confusing to her. She shared that no one really told her “what to expect next,” and the timing and logistics of what to do next felt vague. She talks about the doctor’s departure from the room without clear follow-up instructions and how confusing that was but she also did not feel comfortable pushing for more clarity.

The lack of communication about what to do with Birdie’s remains seems to have left the longest and most traumatic impact on Rebecca. She states that no one informed her of her rights regarding Birdie's remains. Learning weeks later through a support group that she could have arranged burial or cremation created a source of immense regret. "That's something i have to live with all the time," Rebecca reflects, and it has been difficult for her to move past that.

All of these errors in communication change how Rebecca views medical settings. In her interviews she talks about how doctors’ offices have shifted from places of potential healing to places where trauma happen. Even years later, routine medical care triggers memories of feeling abandoned and uncared for. Rebecca's description of feeling "totally traumatized by what happened there" speaks to how she experiences these institutional failures and how that has fundamentally altered her ability to trust systems meant to provide care and safety.

Theme II: Queer Identity within Heteronormative Medical Systems

Rebecca highlights how the medical system is designed around heterosexual assumptions which she feels lent itself to her experiencing more marginalization and trauma while navigating her recurrent pregnancy loss journey. She initially feels supported by her queer-friendly provider, however, when the actual medical crisis occurs at a different office and she is informed her baby has died, she experiences that provider’s office and the emergency room care as lacking in

cultural competence and basic awareness of LGBTQ+ family structures. Rebecca explains, "from the minute you enter the fertility world, everything is heteronormative. There's no space for queer people." Insurance requirements treat their intentional family building as requiring additional psychological evaluation simply because they are "getting sperm from" a donor rather than a partner. Rebecca notes that "there's certain like things you have to do in order to be eligible for IVF that, you know, like we had to like see a doctor, a psychiatrist to evaluate us, to make sure we knew what we were doing" - requirements that heterosexual couples facing pregnancy loss and infertility would never encounter. She shares that it feels as though her and her partner are suspect or need to justify why they want to build their family.

The medical establishment's heteronormative assumptions become particularly problematic during crisis situations. The emergency room forms only have space for “mother or father.” Emergency room staff seem confused by their family structure, lacking protocols for supporting a non-biological partner during pregnancy loss. Jamie's presence and distress aren’t automatically recognized as legitimate, requiring advocacy and explanation during moments when Rebecca would’ve preferred to focus her emotional resources on herself and on Jamie.

Rebecca feels that there is inadequate language to describe her experience of losing Birdie. Medical providers default to terminology and assumptions that erase her experience. When Rebecca describes giving birth to Birdie as something she didn’t even have words for-“no one gave me language for that until two weeks later.” She feels the medical system fails to provide appropriate language for what has happened to her which leaves her without the tools to understand or communicate her experience. Initially she did not know that what happened was actually “birth” rather than a “miscarriage.” The lack of culturally competent language and protocols suggest that medical systems are not designed with queer families in mind.

Rebecca's experience highlights how systemic heteronormativity can complicate the grieving and healing process. Support groups, medical literature, and even well-intentioned friends often assume certain things about family structures and gender roles that don’t match Rebecca’s reality. Jamie's experience as the non-carrying partner becomes particularly invisible within systems designed around traditional maternal/paternal roles, creating what Rebecca recognizes as "disenfranchised loss" that has no clear place within existing frameworks for understanding pregnancy loss.

Theme III: Loss of Bodily Trust and Physical Safety

Rebecca’s late pregnancy loss with Birdie followed by the subsequent losses that she suffers after Birdie, fundamentally change her relationship with her body. Feelings around trusting her body, feeling safe within her body, loving her body, and caring for her body all change after she goes through RPL. Rebecca shares, “I still struggle with feeling like my body killed our babies.” Not only does Rebecca view her body in this dangerous, betraying form, but she also talks about how she cannot even trust her body to signal to her when she is losing a pregnancy because with Birdie she had what doctors called a “missed miscarriage,” where the body does not signal that the fetus has died. The physical trauma of birthing Birdie at home and seeing so much blood also leads to monthly periods feeling triggering. She states, “I use period underwear and I just feel it coming out of me and it feels like not as much now but especially those first couple of years it felt like how it felt to give birth to her and it was so traumatizing every time.” After the loss of bodily trust and her own body being a source of repeated trauma with monthly periods, basic self-care becomes difficult. Showering requires not only energy and effort (when Rebecca was struggling with depressed mood at the time), but also the emotional pain of being forced to touch, clean, and look at her own body. She states, “Everything felt so

hard and the shower just taking care of yourself in that way I don’t know it felt impossible and sometimes it still does like its really hard for me to shower still.”

This loss of trust in her own body and the distance she feels to her own body extend from fertility issues into other areas of health and safety. Rebecca states, “the unthinkable happened. It was something you never thought could happen. So there’s no way to trust anything anymore. Everything you thought was safe is now potentially threatened.” This type of hypervigilance creates ongoing anxiety about her own well-being as well as loved ones. She elaborates more on her fears, sharing, “I couldn’t leave the house because I was so worried that something’s gonna happen to Jamie. I’ll be out on a run to the grocery store and it’s like I hear ambulance on the way home and I’m like the house is burning down they’re all gonna be dead.” The experience of losing Birdie break any beliefs or assumptions Rebecca had about what was safe and predictable in her life.

Theme IV: Relationship Strain and Different Grief Responses

Rebecca experiences RPL as both a stressor on her partnership as well as something that creates disconnect between her and Jamie. Their different roles during the losses- Rebecca as the carrying partner, Jamie as witness and support- create uniquely different experiences of trauma. The initial trauma of the loss of Birdie is shared but also experienced in profoundly different ways. Rebecca states, “We were both in so so much trauma we didn’t know how to communicate we were just like two super traumatized people just getting by.” While Rebecca endures the painful trauma of physically passing Birdie at home, Jamie suffers a secondary trauma of witnessing the birth and fearing for her partner’s safety. As previously highlighted in an earlier section, Rebecca talks about how Jamie experiences a disenfranchised grief where the current medical and social systems predominantly recognize biological motherhood and subsequently

the pregnancy loss as centered around the carrying partner. Rebecca observes, “she doesn’t feel like she can go to support groups because she’s not the carrying mother it’s like very complicated.”

Rebecca shares that she and Jamie have differing opinions and desires for Jamie to carry their future baby in service of their shared reproductive goals. Rebecca yearns for Jamie to attempt pregnancy herself, and Jamie expresses resistance to this idea. Rebecca shares that one of the primary reasons for not wanting to become the carrying parent was that Jamie fears that Rebecca would forever resent her if she was able to successfully carry the pregnancy which Rebecca had been unable to do. Rebecca states that Jamie said to her, “if I try and I do it successfully maybe you’ll be so jealous and resentful that my body was able to carry it through.”

In addition to this fear, Rebecca shares that Jamie had other reasons for not wanting to transfer an embryo into her own body, including concerns about the physical toll on her body.

Rebecca shares that Jamie worried about weight gain and body changes and that the process of the egg retrieval was very draining for her. Rebecca states, “Her body’s kind of never been the same since.” Rebecca reports that one of the most challenging aspects of this fertility journey has been acknowledging and accepting that her and Jamie have different tolerance levels for continuing fertility treatment. Rebecca describes herself as having an intense, singularly focused determination to have a baby, while she perceives Jamie as sharing that desire but also having emotional and physical limits for how far she will go with medical interventions. Rebecca shared that couple’s therapy was integral in helping her process her resentment and anger toward Jamie.

At the time of the research interviews, Rebecca explores how she is presently in the process of acceptance of Jamie’s limits and overall acceptance that they have stopped trying to

conceive and will live a childless life together. When describing her process of accepting certain limits rather than resisting them she states, “I’ve had to just kind of let that go because otherwise

I’m afraid if I explore whatever resentment I have there that like we won’t survive it I’m really trying to come to like a place of acceptance to our life now.” While this acceptance is an ongoing challenge, Rebecca also reflects on how this level of shared trauma has forced her and Jamie to work on their communication and remain emotionally intimate and honest with one another. She states, “We’ve learned each other in a way that I know my friends will never have to learn each other and they might think that parenting is the hardest job but like to be honest losing six babies is the hardest fucking job.”

Theme V: Social Isolation and Friendship Loss

Rebecca’s isolation after her loss with Birdie (which also happened to be her latest pregnancy loss) is a combination of grief-driven self-isolation as well as peak COVID isolation. Rebecca believes that her isolation likely would’ve been an acute grief-driven isolation, however, since it was also COVID isolation this compounded the alienation and loneliness she experiences in the aftermath of the loss. She states, “Not a single person came over or came in because it was COVID. We were all alone.” The timing of their loss and going through RPL during COVID isolation may have compounded Rebecca’s social withdrawal.

Rebecca talks about the gradual return to social life and needing to navigate a new and complex set of triggers as a result of the RPL and not having a baby. She shares, “I still can’t be friends with anyone who’s pregnant or has little kids it’s just I have lost all those relationships...everyone who kind of stuck around for me kind of had to like relearn me.” She’s not only feeling triggered by pregnant people and young children, but more specifically she feels her grief and loss have changed her in such a way that she has low capacity and tolerance for

relationships that deplete her and do not provide her with energy and support. She explains, "If it doesn't feel reciprocated then I want to give less... I just keep them as more of a not a close friend you know there's people that I love to just have fun with I'm just not gonna like you know I'm just not gonna be close with them unless they can kind of fit these strict requirements."

The loss of specific, close friendships creates a separate, distinct grief that compounds the grief and loss of RPL. Rebecca talks about losing a best friend who was undergoing her own fertility journey and did not meet certain expectations Rebecca had of her during the time of her own losses. She seems to touch upon the experience of grief creating needs inside of us that even well-intentioned friends and family may not be able to meet. She describes this experience when this best friend forgot the anniversary of Birdie’s death, “That was when I look back on it when I physically look back on those emails and I remember how hurt I was that she couldn't step up on those days and just be like I know we're fighting but I love you and I'm thinking of you and this must be a terrible day for you.”

The development of specific avoidance strategies reflects both her need to self-protect as well as the incredibly vulnerable state she was in at the time of all of this loss. Her inability to look at or interact with her neighbor's new baby—"she must think that i'm such a bitch and that's totally fine i like can't be involved I cannot look at her I can't like see her baby I don't want anything to do with them"—demonstrates the challenge of wanting to remain socially connected and relational with one’s community, neighbors, and close friends and family in a world where pregnancy and parenthood are prevalent and celebrated.

Perhaps most significantly, Rebecca describes feeling excluded from social structures that organize adult life around family and raising children. "I don't get to have this like super human experience of getting to be a fucking mom so I mean I still struggle with it daily," she

reflects, recognizing that her losses have placed her outside many cultural experiences centered on parenthood that provide meaning and connection for other adults.

Theme VI: Finding Purpose and Meaning After Loss

In the period following her recurrent pregnancy loss, Rebecca faces the challenge of making meaning out of her loss and trauma while also trying to find new purpose in her life. This process of meaning-making and finding purpose outside of becoming a mother requires ongoing negotiation between her acknowledging and honoring her losses while also finding reasons to continue living. Rebecca talks about how difficult it became to find purpose and meaning in her life when her central life goal of becoming a mother became impossible to achieve.

Rebecca shares that in the period following Birdie’s loss she struggles immensely because the previous purpose of carrying and becoming Birdie’s mom is gone but no new purposes have emerged yet. She states, “I felt like my purpose in life was taken away.” She alludes to an experience whereby the fantasy and dream of becoming a mom becomes so central to her identity during pregnancy that there are tremendous feelings of emptiness after the loss.

The struggle with suicidal ideation that followed all her losses demonstrates how when the sense of purpose (that is deeply tied to becoming a mother is gone), the motivation to continue living is a struggle. She states, “I wanted to die, we both wanted to die we talked about it all the time.” She notes that driving off a bridge was a frequent and intrusive thought she experienced during that time period. She states what ultimately helped her and prevented suicide was her concern for Jamie’s wellbeing.

Rebecca explores how she transitions from living in a heavy, dark, grieving space with no lightness or joy to finding a space where she can experience joy alongside what she describes as

a “permanent sadness.” Rebecca states that finding ways to honor her losses with ritual and acknowledgement while also returning to doing things in her life that bring her joy help her to find a more balanced place to live in. She states, “I think I’m in more of a place of acceptance… there’s a depth of sadness that I think most people will never know and will never think that I have still because I’ve like you know I’m healing I’m moving in different directions but like actually the sadness is maybe the deepest its ever been.” Rebecca describes a complex emotional experience where healing does not mean elimination of grief but rather integrating her loss into ongoing life.

Rebecca talks about developing new interests and finding new activities she enjoys in an effort to find meaning in her life outside of achieving her original reproductive goals. One particular interest, birding, creates space for her to connect with nature and community while honoring Birdie’s memory through symbolism. She ends up organizing a “birding for Birdie” walk with eighteen friends which highlights her ability to create new, joyful experiences while continuing to acknowledge her loss and sadness. Another important element of her journey to heal and find purpose again involves ritual and commemoration. Both acts allow her to maintain connection to Birdie while marking the passage of time. She talks about an annual trip she now takes to the Olympic Peninsula for Birdie’s birthday which provides structured opportunity for grief and remembrance that feels intentional rather than grieving moments that are triggered by unplanned interactions with friends and family or events such as children’s birthday parties. Rebecca has created this ritualized and commemorative space for losses that typically do not have any societal ritual or formal acknowledgement.

Despite all of this meaning-making and grief work, Rebecca shares that the ongoing question of what to do with their stored embryos represents unresolved meaning-making in their

RPL journey. She states, “One day we’ll get rid of the embryos and I don’t know how and I don’t really know how we’ll ever survive that I can’t even think about it.” Nonetheless, while this piece of her journey seems to require eventual resolution, she seems to have found a more comfortable space to inhabit in her life where she can engage in small, daily activities with friends and loved ones without “melting down.” She states, “I can be out in the world because my nerves are not as raw and I’m not as exposed and raw to the world where everything that touches me sends me down a spiral.”

Rebecca finds some meaning in having survived these experiences, though she describes this more as endurance than recovery. Her statement that 'losing six babies is the hardest fucking job' acknowledges the difficulty of what she has been through while asserting that her experience has value, even though it doesn't align with typical life trajectories.

Impressions of Interviews with Rebecca

Rebecca expressed an openness to sharing her story while simultaneously communicating some ambivalence to participate for fear of what might come up emotionally. This occasionally translated to difficulties in scheduling interviews which Rebecca herself identified as her own avoidance at times of thinking about this part of her life. At times, I experienced a mismatch between Rebecca’s affect and emotion while she discussed intensely graphic and painful physical aspects of her losses. She recounted the details of delivering Birdie at home with a directness that I experienced as both courageous but somewhat dissociative. I experienced this as a way for Rebecca to gauge my assessment and reaction to her experiences. Additionally, it seemed as though she had likely told this story a number of times and through that repetitive process some distance from the raw emotion had formed.

Perhaps most striking was how Rebecca connected to her first loss as the loss of a baby rather than the loss of a pregnancy and had named that baby. This detail also reflects the potential difference between a very early loss versus a 16-week loss.

Despite the heaviness of the topic, Rebecca often displayed humor throughout our interviews, laughing at the absurdity of some of the situations she found herself in throughout this process. Her laugher felt like a way for her and I to connect over some of the painful experiences she had such as a nurse’s tone-deaf comments or a radiologist’s dismissal.

Rebecca expressed her anger toward the systemic failures she encountered as a result of her queer background. At times, some of the encounters she shared felt surreal or unbelievable due to how blatantly neglectful they were. In particular, when she was sent home with little to no information about miscarrying Birdie as well as the disposal of Birdie’s remains without informed consent.

Rebecca’s relationship with her story seemed to shift across our interviews. After our first interview she described feeling “destabilized” implying that she felt triggered or activated when discussing and reliving traumatic moments of her RPL experience. However, toward her later interviews I experienced her as stable, settled, and able to reflect on her experiences with more distance and less reactivity. This evolution demonstrated that while her grief was still significant in her life, she also developed an ability to integrate her profound sadness with joyful aspects of her life. Her statement that, “the sadness is maybe the deepest its ever been,” while simultaneously describing improved functioning illustrates her growing ability to move away from simplistic narratives toward a more complex, intricate narrative about her life.

One theme that kept coming up in the interviews was the complexity of Rebecca’s relationship with her partner Jamie. At times, Rebecca did not directly speak about her feelings toward Jamie, with left me with questions in my own mind about their present-day dynamic. As we grew more familiar with one another, I found myself asking Rebecca more probing questions about her feelings toward Jamie and vice versa. Rebecca acknowledged resentment about Jamie’s refusal to try and carry their baby while at the same time identifying her continued love and commitment to the relationship. Her statement, “I’m afraid if I explore whatever resentment I have there that like we won’t survive it,” suggests that this is still a dynamic in the relationship that Rebecca is attempting to cope with.

Similarly, I often felt that Rebecca was indirectly communicating with me about her own mental health by providing matter-of-fact description of suicidal ideation with very little context or further explanation around her current safety and mood. At one point she shared, “I would drive over a bridge and be like I should just fucking drive off this bridge.” This statement was delivered without any apparent distress which felt significant to me and made me want to probe further to assess her current safety but also better understand how she is feeling about everything in the present day. After further exploring these thoughts and feelings, Rebecca explained that Jamie’s wellbeing protected her from ever following through on harming herself. She did acknowledge that intrusive thoughts are still present in her life, however, she feels she has a better handle on managing them. The casualness with which Rebecca referred to these thoughts was both striking but also created space for us to openly discuss them.

I was also struck by Rebecca’s experience as a queer person navigating recurrent pregnancy loss within a heteronormative medical system. I found myself thinking about my own privilege and using that to inform how I talked about Rebecca’s experiences with her. I found

myself hyperfocused on being thoughtful, intentional, and humble when discussing her experiences with her. The additional barriers, required evaluations, and lack of cultural competence felt quite eye-opening to all the ways in which my own heteronormative identity allows me to take so much for granted.

I carried that same focus on intentionality and humility when exploring her decision to stop treatment. The decision to stop treatment without having had a baby is one that also separates and highlights the differences in privilege with someone who has had a baby and someone who cannot and will never have a baby. Rebecca’s doctor waited until after her sixth loss and expressions of suicidal ideation before suggesting stopping treatment. I sensed that it was incredibly difficult for Rebecca to stop treatment which is why it required external intervention from her doctor to truly stop. It seems as though she has been through various permutations of resistance and acceptance, and presently would still be open to trying but recognizes that this could break both Jamie as well as their relationship. Rebecca shared that Jamie’s wellbeing and the relationship itself are her priority and as a result her process has been learning to live with the sadness of no longer trying for a baby while also experiencing joy in her day-to-day life.

When Rebecca spoke about the dynamics between herself and her partner Jamie, the initial interviews hinted at divergence in feelings and opinions about how to proceed forward. However, toward the end of our time together in our final interviews Rebecca more directly discussed how she would’ve liked to continue trying to conceive and she would’ve liked for Jamie to attempt to be the carrier of the pregnancy. This topic felt vague and guarded at the beginning of our process, however, Rebecca and Jamie’s different roles, responses, and

capacities became clearer as our interviewing process progressed. I felt Rebecca’s love for Jamie and the prioritization of their partnership over the continue quest to conceive a child.

Finally, I found myself struck by Rebecca’s ability to continually adapt to life without a child- what she describes as “learning to live with sadness.” She talked about her continued, deep sadness over not becoming a mother, while slowly rebuilding her life. I was moved by her process of adapting and accepting, which for her, did not mean that her grief was diminished but rather she integrated the loss into her ongoing life. The ongoing nature of her grief paired with her genuine capacity for joy and engagement offers a nuanced and complex understanding of healing after recurrent pregnancy loss.

Psychoanalytic Case Interpretation of Rebecca

Throughout Rebecca’s interviews there is a strong sense that she has achieved what Klein termed the depressive position. She shares about her experience of tolerating and accepting profound sadness about not becoming a mother and no longer trying to conceive while maintaining integrated functioning and connection with her partner who is more of the driving force behind stopping treatment. She captures the essence of her mourning work when she states, “I am learning to live with sadness” (Klein, 1935, 1940; Ogden, 1986). Rebecca is in the process of accepting her irreversible loss without defensive splitting, narcissistic rage, or withdrawal from her life.

Klein (1940) distinguishes between the paranoid-schizoid position and the depressive position and the distinction between these two positions is helpful when understanding Rebecca’s psychological organization. Where the paranoid-schizoid position is characterized by splitting the good and the bad, persecutory anxiety (fear of attack), and primitive defenses such

as projection, the depressive position involves integration (holding good and bad together), concern for the object, guilt about one’s own destructive impulses, and the wish to repair damage done to loved objects (Klein, 1935, 1940, 1946)

Rebecca’s capacity to hold multiple truths, specifically loving her partner Jamie while resenting her limits, grieving Birdie while creating joyful birding rituals, experiencing profound sadness while engaging meaningfully with daily life, demonstrates depressive-position functioning. She does not split her experience into all-good or all bad, rather she maintains awareness of complexity, ambivalence, and her own involvement in relational dynamics.

Her statement “the sadness is maybe the deepest its ever been” yet she is also “healing” and “moving in different directions” highlights the paradox of the depressive position, where one can experience intense grief while also remaining engaged with life. This is not splitting (feeling sad in one moment, happy in another) but holding both mourning and joyfulness together in the same space.

Freud’s (1917) distinction between mourning and melancholia is useful when thinking about Rebecca’s journey with RPL. In mourning, the individual gradually withdraws libidinal investment from the lost object, eventually freeing up energy for new attachments and interests. Self-regard remains relatively intact and the loss is experienced as external versus in the case of melancholia where there is identification with the lost object and subsequent self-attack leading to intense self-reproach, loss of self-esteem, and sometimes suicidal ideation.

Rebecca’s experience contains elements of both but ultimately is more mourning than melancholia. Although she does experience an episode of suicidal ideation following her losses, this was not characterized by self-hatred or a sense that she deserved to die because of her own

badness. It reflected unbearable pain and the deeper question of whether life without motherhood held enough purpose and meaning for her. Rebecca’s concern for Jamie’s wellbeing as a protective factor in preventing her from ever acting on suicidal thoughts demonstrates that concern for others remained intact even in her darkest moments.

Most importantly though in distinguishing between mourning and melancholia for Rebecca is that she does not turn her rage inward in melancholic self-attack. Her statement, “I still struggle with feeling like my body killed our babies,” reflects sadness and disappointment but not self-persecutory condemnation (Freud, 1917). She recognizes her body’s failure but does not come to the conclusion that she is defective or deserving of punishment. This allows her to slowly withdraw investment from the lost possibility of becoming a mother and redirect her energy toward meaning-making activities such as birding, ritual commemoration, community engagement, and deepening her relationship with Jamie.

Klein (1940) emphasized the significance of reparation when operating from the depressive position. The wish to repair damage done to loved objects and to create something good from destruction can be observed in Rebecca’s creation of rituals and meaning-making practices that she engages in following all of the loss she endures in her RPL journey. She organizes annual trips to the Olympic Peninsula for Birdie’s birthday, she begins the practice of “birding for Birdie” walks with friends, and the general hobby of birding as a way of honoring Birdie’s memory. All of these acts and practices symbolize her attempt to keep connection with the lost object alive while also creating new sources of meaning and community.

The birding activity in particular seems to hold multiple levels of meaning and significance in Rebecca’s mourning and healing journey. Birdie becomes associated with actual birds, allowing Rebecca to maintain her connection to her lost baby by engaging with the natural

world. Freud might identify this process as sublimation or the transformation of painful affect and thwarted desire into socially valuable and personally meaningful activity. Rebecca is able to channel her maternal energy toward the protection of birds and ecosystems while simultaneously finding some sense of purpose in her loss (Mitchell & Black, 1995).

The tension in Rebecca and Jamie’s relationship demonstrates how even when Rebecca is relating to Jamie from the depressive position, there are challenges in communication and understanding when both partners cope differently with the shared loss. Rebecca’s wish for Jamie to carry their embryos creates a complex relational dynamic where Rebecca is forced to balance her own desire (to continue pursuing motherhood) and her concern for Jamie’s wellbeing and respect for her limits.

The central tension of the depressive position is how to maintain one’s own needs and desires while also recognizing the other as a separate subject with their own needs that may conflict with one’s own. Rebecca states, “I have had to just kid of let that go because otherwise I’m afraid if I explore whatever resentment I have that that like we won’t survive it.” She is negotiating an inner balance between the protection of her relationship with the cost of suppressing some of her own needs and emotions.

From a relational psychoanalytic perspective, there is potential for what Jessica Benjamin (2004) calls the “doer-done to” dynamic to develop in Rebecca’s relationship. The “doer-done to” dynamic represents a collapse in the dyad’s ability to maintain mutual recognition of one another, especially when each person’s needs conflict with the others. Rebecca hints at the idea that earlier on in their RPL journey, she had moments where she experienced Jamie as withholding while experiencing herself as the denied subject. However, through therapy and processing with Jamie, Rebecca is be able to maintain her own subjectivity which involves her

acknowledging her resentment and disappointment while simultaneously holding space for Jamie as a subject with valid needs and limits.

Rebecca articulates this dynamic in the interviews and describes actively working on these issues in couples therapy. Her ability to articulate it and work through it highlights Rebecca’s capacity for what Mitchell termed “enactment and recognition.” She can experience the painful relational pattern while also being able to take space to reflect on it and prevent it from destroying the relationship. This mentalizing capacity, or the ability to think about thinking suggests a high level of psychological maturity within Rebecca.

Rebecca’s case embodies the experience of hope and meaning-making weaved throughout devastating loss and multiple compounding traumas. Rebecca retains capacity for genuine mourning, and continued engagement with life. Her story demonstrates the achievement of the depressive position, or learning to tolerate ambivalence, loss, and complexity without defensive splitting or withdrawal (Klein, 1935, 1940; Ogden, 1986). This achievement allows for what Winnicott (1965) called “going on being,” in that Rebecca’s life continues not because her loss is overcome or forgotten but because she either has always had or develops capacity to hold loss within ongoing experience. Throughout her story she really embodies this notion of continuing being when going on being feels almost unbearable.

The unresolved question of the stored embryos arises when Rebecca states, “One day we’ll get rid of the embryos and I don’t know how and I don’t really know how we’ll ever survive that.” This statement suggests that mourning remains incomplete. These embryos represent biological possibility as well as a remainder of the life she had fantasized about. Eventually when Rebecca and Jamie make a more permanent decision with what to do with the

remaining embryos this will likely require another mourning process and another integration of loss.

Rebecca does not attempt to pretend she is at peace with getting rid of the embryos or convince herself she has reach full closure on her RPL journey. She does not claim to have “moved on.” She acknowledges the permanent nature of her sadness while also claiming space for joy, connection, and meaning. This is the achievement of the depressive position, to live with loss but not be destroyed by it, and to remain open to life while honoring what has been lost.

Cross-Case Analysis

Overview of Cross-Case

Patterns

Each woman’s narrative in the study contains its own unique lived experiences as well as their own individual biographical, biological, developmental, and sociocultural backgrounds. Despite these differences, there are several themes regarding lived experiences that emerge that are shared across all five women’s stories. These themes highlight the inner experience of enduring repeated loss. Across all five cases, RPL was experienced less as a singular event and more as an ongoing condition marked by rupture, prolonged uncertainty, and repeat encounters with medical systems that were often experienced as dehumanizing, objectifying, or lacking recognition. Each woman explores her own struggle with negotiating between a need for control while simultaneously wishing she could surrender more to the process, especially because the nature of RPL and fertility treatments did not lend itself to mastery even with the best most dedicated and diligent patient. Each woman’s relationship to her physical body was complicated by conflicting emotions of both body as betrayer and body as an object in need of protection, or body as place for holding grief, and hope. Experiences of isolation and nonrecognition were

common, however the women did seek out more sustaining holding environments through partners, friends, therapists, support groups, and doulas (Winnicott, 1960, 1965). Lastly, the women experienced the reoccurring losses as threatening to both their identities and their selfworth. These threats felt particularly intense in the context of a culture that links womanhood and value to a woman’s ability to bear children.

The following cross-case analysis shifts from within case description to collective, theory-building interpretation, consolidating shared psychodynamic experiences into five metathemes. Each meta-theme synthesizes the overlapping ways that participants metabolized trauma, uncertainty, and mourning.

Meta-Theme 1: Defensive Organization under Uncertainty

All five women described the numerous ways they attempted to control outcomes despite the uncontrollable nature of RPL. Control can be understood as a form of containment or a way of holding the self together when the body and future felt unreliable and uncertain. The participants’ efforts to control functioned as a defensive organization under uncertainty as a means of managing helplessness, fear, and threats to self-cohesion. It is important to note that this struggle between their need for control and the unpredictable nature of RPL all took place within the context of RPL’s repetitive cycle of waiting, monitoring, and living in liminal states where both hope and fear coexisted. This prolonged “in-between” state often increased efforts to create order and predictability in a process that was mostly uncontrollable. For many of the women it seemed as though they were attempting to apply a formula they have used in the past when trying to achieve a goal. The formula being if they worked hard at something and did everything, they were supposed to do they would achieve their end result. RPL disrupts the familiar logic of mastery-through-effort.

Control took different forms across participants. There were several categories of control that all participants engaged in at different times: 1) monitoring bodily sensations, 2) information-seeking and reassurance-seeking through medical data and research, 3) achievement and doing, 4) superego-driven shoulds aimed at preventing recurrence, and 5) managing relational boundaries to protect against nonrecognition. Over time, the effort to control became exhausting and unsustainable for many of the women. The participants described a sense of exhaustion with maintaining their current behaviors which slowly overtime led to actions rooted in self-care and recognition of their own limits.

Control can be understood as a defense to avoid total psychic disintegration in the context of repeated unpredictability and prolonged uncertainty. Engaging in controlling behaviors helped manage helplessness when outcomes could not be guaranteed. Psychoanalytically, it is helpful to think of these efforts as mastery-based defenses or attempts to change an experience of helplessness into activity, agency, and ‘doing.’ Monitoring, researching, changing diet, limiting exposure to plastics and toxins, and pursuing the next medical step were experienced as active and therefore offered a fantasy of preventability and predictability (Kohut, 1977; Ogden, 1986).

Control manages both narcissistic/annihilation anxieties related to threats to self-cohesion when one’s own body could not be fully trusted, as well as depressive anxieties including grief, ambivalence, and helplessness. Furthermore, controlling behaviors often represented anticipatory mourning or an attempt to pre-process expected loss in advance as a form of self-protection. In this sense, participants sometimes seemed to make what Shabad and Selinger (1995) call a “counterphobic leap into the future,” bracing for disappointment in order to reduce traumatic surprise. Yet this kind of pre-grieving often contained melancholic dynamics as well, insofar as

dread became fused with self-attack, omnipotent responsibility, and the fantasy that better vigilance could forestall catastrophe (Freud, 1917; Klein, 1940).

Controlling behaviors seem to temporarily contain anxiety, but over time they can become rigid and exhausting. Across interviews, a gradual shift appeared in which participants began to distinguish between times when their efforts to control that were rigid and not serving them, and times when control felt like true self-care. This shift in control represented movement away from attempts at omnipotence toward a more adaptive stance where the participant could hold effort alongside uncertainty. This change in control can be understood as movement from more paranoid-schizoid and melancholic modes of control - marked by splitting, urgent mastery, and self-attack - toward a more depressive-position stance in which limits could be acknowledged, ambivalence tolerated, and self-care could function as reparation (Klein, 1935, 1940, 1946; Ogden, 1986). From the depressive position, hate toward the failing body was not completely removed, but increasingly mediated by love, concern, and the wish to protect rather than persecute.

Meta-Theme 2: The body as a Site of Betrayal, Trauma, and Meaning

Across participants, the body was a central source of tension, at times the body was experienced as untrustworthy, other times as something to fight with or against, and still other times as something that could be repaired through action and care. Participants’ relationships to their bodies organized into several recurring dynamics, 1) the body was experienced as a betraying persecutory object in that it was experienced as unreliable/threatening and had to be monitored, 2) the body functioned as a site of trauma and somatic memory where normally ordinary sensations such as nausea or cramping because emotionally charged cues triggering feelings of fear and dread, 3) the body was experienced through a medical lens where

participants felt like an object or a number managed through protocols and procedures which contributed to disconnection, and 4) the body was dealt with like a reparable object in which participants focused their efforts on restoring, preventing, or fixing whatever was broken inside (Klein, 1946; Winnicott, 1960, 1965). Eventually, the women’s narratives shifted more toward self-care and feeling in partnership with their body rather than in opposition with it.

The physical body also made it difficult for participants to take a break from their emotions or have space from the emotional pain they were enduring, as the body was frequently the focus of medical attention and intervention and also the place where loss was directly experienced through bleeding, cramping etc. Recurrent pregnancy loss also changed the way the participants related to their bodily functions in that ordinary sensations such as bleeding, nausea, pain, and menstruation became sources of worry, fear, and a reminder of loss or impending loss.

In this sense, the body became an intensely cathected object that was not only related to on a physical and biological level, but was also a psychic site where trauma, hope, dread, and mourning were managed (Freud, 1917; Ogden, 1986).

The participants’ interactions with doctors and medical staff contributed to a feeling of disconnect and distance from their bodies. Participants described the experience of continually being measured, monitored, and managed medically with little to no emotional presence or support. In this context, the body was experienced less as a lived, subjective body and more as an object under medical surveillance which contributed to the feelings of disconnection, or a sense of distance from one’s own embodied experience. At the same time, the women described small ways of working with their bodies rather than against them by either pausing treatment, practicing gentler self-care, using movement or yoga, and seeking providers such as therapists,

reiki practitioners, or doulas who felt emotionally supportive and attuned (Klein, 1935, 1940; Winnicott, 1960, 1965).

This theme suggests that bodily experience in RPL was impacted not only by bodily processes and symptoms, but also by the relational contexts in which the body was treated, acted upon, and responded to. As a result, recognition versus nonrecognition profoundly impacted participants’ ability to mourn. When emotional presence and support were missing from interpersonal interactions, participants described not only feeling disconnected from their own bodies but also a desire for the other person to recognize and hold space for their grief, a frequently unmet need that shaped their ability to mourn.

Meta-Theme 3: Isolation, Nonrecognition, and Longing to Be Seen

In addition to experiencing RPL as loss, participants also experienced it as recurring moments of nonrecognition, objectification, and pressure to manage others’ comfort rather than have their own distress held. These failures of recognition occurred with family, friends, partners, and medical systems. Across these contexts, nonrecognition organized around several recurring forms: 1) proceduralization and medicalization, 2) minimization or disenfranchisement, 3) pressure toward resilience, and 4) communication gaps and informational uncertainty.

There is an additional dimension that further adds to the experience of nonrecognition and that is related to both the varying language that people use to name or symbolize what was lost, and how individuals conceptualize what was lost. Depending on who is speaking, an early pregnancy can be referred to as a baby, a fetus, an embryo, pregnancy tissue, or a “clump of cells,” and these terms carry markedly different meanings. When partners, family members or medical systems use different names for the loss, they are not only differing in wording, but they

are occupying different realities of what occurred, what was loss, and what it signifies. This instability in naming can make recognition difficult, as there is both the absence of shared language for identifying what was lost and certain words or phrases imply that the gravity of what was lost was more or less impactful to the person’s life. The RPL patient’s grief must contend not only with loss itself but with the absence of shared language that would allow the loss to be held, legitimized, and mourned.

In medical contexts, nonrecognition most often took the form of proceduralization, objectification, and vague communication. Participants described encounters in doctors’ offices and hospitals in which providers focused on procedure, treatment, and intervention while loss, trauma, and emotional experience went unacknowledged. They also described vague communication and prolonged waiting periods with little information, which intensified feelings of fear and left them to manage an intolerable degree of uncertainty.

In participants’ interpersonal worlds, nonrecognition frequently emerged as minimization, disenfranchisement, and pressure toward resilience. Participants described comments from family and friends that implicitly treated their losses as less real or less legitimate. They also described feeling pressure to present as emotionally strong or positive, and to reassure or comfort others. These interpersonal tensions shifted the burden of emotional regulation onto the participants at the very moments when they most needed to be held.

These patterns reflect failures of recognition and emotional holding at the points in the RPL journey when participants most needed their grief witnessed. When responses became procedural, minimizing, or prematurely reassuring, distress was treated as something to manage rather than grief to be acknowledged and held. In this relational climate, withdrawal and performative strength can be understood as protective adaptations that reduce exposure to

nonrecognition while also deepening loneliness and complicating mourning (Winnicott, 1960, 1965; Benjamin, 2004). Many participants described isolation as a form of self-protection from disappointment, invalidation, or interpersonal strain. At the same time, several recognized that withdrawal often intensified loneliness and made relationships harder to sustain as their RPL journeys continued.

Meta-Theme 4: Negotiating Identity, Worth, and the ‘Realness’ of Loss

Recurrent loss was experienced as repeated threats to identity and worth that were further intensified by the lack of recognition in society for early loss and the resulting struggle to be seen and acknowledged. Repeated and early loss resulted in the following patterns of experience: 1) narcissistic injury, 2) legitimacy and disenfranchised grief, 3) belonging and social comparison, 4) superego scrutiny and self-attack, and 5) identity negotiation and revised self-understanding (Freud, 1917; Kohut, 1977; Siegel, 1996).

Narcissistic injury appeared in the ways repeated losses disrupted self-image and a sense of being “good enough” and feeling shame for not being able to do what other women seem to be able to do so easily. The legitimacy of early pregnancy loss is often lost because this type of loss and grief is not socially recognized which forces the mourner to defend the reality of both the pregnancy and the loss. Psychoanalytically, the question of ‘realness’ of loss is not only social but intrapsychic: when the outside world does not recognize early pregnancy loss as a legitimate loss, the mourner is left without a stable relational mirror for grief. This lack of recognition intensifies shame and makes it more difficult to symbolize and integrate the loss. In this way, repeated loss functions as a narcissistic injury, meaning it is experienced as an attack on identity, value, and belonging, rather than solely as grief over an external object (Winnicott, 1960, 1965; Kohut, 1977).

Belonging is impacted when the participants attempt to locate themselves in cultural narratives of womanhood and are left feeling “outside” or “less than” those with visible pregnancies and children. Self-attack and a harsh superego result from the lack of external explanation or recognition of the loss. In the absence of a clear reason for the loss or recognition of it, the superego steps in to try and make sense of what is going on. Participants are tasked with proving, explaining, or justifying their grief and their worth. At times this intensifies self-attack, as the participants take on the responsibility for losing the pregnancies. I observed melancholic dynamics when the lost pregnancies could not be fully mourned (in part because they were not fully acknowledged) and thus grief turned inward through self-reproach rather than moving outward through mourning and remembrance (Freud, 1917; Klein, 1940). As time went on and identity and legitimacy were repeatedly negotiated, the participants worked toward reclaiming identity outside of pregnancy outcomes and renegotiated what it meant to be a mother/woman/person. This renegotiation of identity also shaped how hope could be held and whether it remained tied to outcome, or gradually became an internal capacity to live with contradiction

Meta-Theme 5: The Work of Hope, Mourning, and Reimagining Motherhood

Hope was both an energizing force in the participants’ lives as well as the most feared aspect of their journey. Participants oscillated between desiring, believing-in, and working toward their future as a mother, as well as protecting themselves against devastation. The five themes that emerged within the experience of hope, mourning and meaning-making were: 1) the hope-dread oscillation, 2) hope as defense versus hope as capacity, 3) mourning interrupted by recurrence, 4) narcissistic versus depressive anxieties, and 5) reimagining motherhood.

Using mourning versus melancholia as an organizing frame, participants’ oscillation shows that mourning in RPL is continually interrupted by recurrence and prolonged uncertainty. The loss cannot be neatly located in the past because the possibility of loss remains ever-present; grief is continually reactivated by waiting, symptoms, and medical checkpoints. In this context, hope can feel dangerous because it reopens attachment to an imagined future that may again be taken away (Freud, 1917; Klein, 1940).

Over time, I observed hope as transitioning from outcome-focused to hope as an internal capacity to tolerate ambiguity and uncertainty, wanting, fearing, grieving, and continuing simultaneously. Conceptually, this reflects a shift toward a more depressive-position stance, in which ambivalence and uncertainty can be tolerated without relying on omnipotent control or rigid self-protection (Klein, 1935, 1940; Ogden, 1986). This does not eliminate dread; rather, it expands psychic space so that mourning and hope can coexist without one foreclosing the other.

Discussion

This study used a psychoanalytic case-study methodology to explore the lived experience of recurrent pregnancy loss (RPL). Drawing on psychoanalytically informed interviews and a two-part analytic process (within-case analysis followed by cross-case analysis), the findings demonstrate how participants worked through repeated loss, and sustained uncertainty over time. The cross-case analysis yielded five integrative themes that highlight how participants metabolized the recurrent loss, uncertainty, and mourning across time and context.

Across cases, the most significant finding was that RPL was experienced less as a series of discrete losses and more as an ongoing psychic condition built by recurrence. In this psychic condition, uncertainty is prolonged rather than temporary, attachment is repeatedly reopened, and dread is repeatedly reactivated by each new pregnancy and the possibility of another loss. The psychological struggle of RPL was not simply to mourn an “ended” event or lost object, but to live inside a prolonged “in-between” state in which the future cannot be secured and yet must repeatedly be imagined. The possibility of another loss remains ever-present and complicates the rituals that typically support mourning (Freud, 1917; Klein, 1940).

It is helpful to observe the cross-case patterns through a psychoanalytic lens paying attention to the participants’ defensive organization when under threat, the oscillation between narcissistic and depressive anxieties, the ways in which participants present with more mourning or melancholia depending on various circumstances, and the significance of relational recognition and holding. The following discussion moves beyond summarizing cross-case themes and proposes a conceptual model of RPL as an ongoing psychic condition of recurrence. In developing this model, I am arguing that recurrence functions as an organizing psychic environment, not simply as repeated events. I use these psychoanalytic concepts- defensive

organization under threat, oscillations between narcissistic and depressive anxieties, mourning versus melancholic pressures, and the role of recognition and holding- as interpretive lenses for understanding how participants attempted to preserve self-cohesion under prolonged uncertainty. This model is organized across four domains—Self, Body, Relationships, and the Imagined Future—as the main areas where recurrence is felt most intensely and where the adaptations people develop over time can begin to consolidate into more established ways of coping, relating, and making meaning.

Implications for Theory

RPL as a psychic condition of recurrence

The cross-case findings provide evidence for understanding RPL as a psychic condition of recurrence rather than just repeated traumatic losses. For the purposes of this discussion, condition is defined as an organizing context that endures overtime and continually reactivates psychic work. In the context of RPL, the psychic work involves coping with cycles of waiting, self-monitoring, medical interventions, repeated reopening of attachment to a pregnancy or baby, and repeated experiences of uncertainty and potential for failure. The most prominent psychological challenge of this condition is that distress is not only influenced by what has happened in the past, or what is occurring in the present, but is also shaped by the pervasive possibility or fear of what may happen again. The losses are real and devastating, yet the psychological toll of the entire experience is complicated by the demand placed on the psyche to repeatedly re-enter liminal time and re-invest in an imagined future.

Implications for Theory

RPL as a psychic condition of recurrence

The cross-case findings provide evidence for understanding RPL as a psychic condition of recurrence rather than just repeated traumatic losses. For the purposes of this discussion, condition is defined as an organizing context that endures overtime and continually reactivates psychic work. In the context of RPL, the psychic work involves coping with cycles of waiting, self-monitoring, medical interventions, repeated reopening of attachment to a pregnancy or baby, and repeated experiences of uncertainty and potential for failure. The most prominent psychological challenge of this condition is that distress is not only influenced by what has happened in the past, or what is occurring in the present, but is also shaped by the pervasive possibility or fear of what may happen again. The losses are real and devastating, yet the psychological toll of the entire experience is complicated by the demand placed on the psyche to repeatedly re-enter liminal time and re-invest in an imagined future.

Unlike a single traumatic event that can be processed as a one-time occurrence or an event that had closure, recurrence produces a chronic traumatic effect (Khan, 1963; Terr, 1991). Repetition alters the experience of time, it shapes expectation and influences defensive organization. Hypervigilance, compulsive checking, anticipatory dread, and self-attack risk becoming more enduring ways of organizing experience (Herman, 1992). In this sense, recurrence does not only inflict pain on the self continually but it can actually gradually reshape personality by consolidating defenses that were initially adaptive responses to chronic threat (Khan, 1963). Krystal (1988) similarly suggests that cumulative trauma can erode affect tolerance and symbolization, leading to greater reliance on action, numbing, and somatic vigilance to manage overwhelming feeling under chronic threat.

A Theory of Loss in RPL: Self,

Body, Relationships, Imagined

Future

Across the participants’ narratives, recurrence reorganized experience across multiple interrelated domains of psychic life. What follows outlines how the condition of recurrence repeatedly destabilized self-experience, embodied experience, relational experience, and futureoriented attachment—and the adaptations participants used to remain psychologically intact. I begin with the Self domain, because recurrence consistently pressured identity, worth, and selfcohesion, and these pressures often shaped how participants then related to their bodies, relationships, and imagined futures.

Self domain: threats to self-cohesion, legitimacy, agency, and future identity

In this dissertation, self is defined as a person’s felt sense of coherence and continuity over time—feeling like “the same person” across time and feeling entitled to one’s experience, relationships, and place in the world. From this perspective, participants experienced not only grief about external losses (the pregnancies) but also repeated threats to how they experienced and organized themselves internally.

Across cases, recurrence repeatedly pressured identity by threatening: (1) self-cohesion (a felt sense of being intact rather than broken), (2) legitimacy (a stable sense that one’s loss and grief matter and are real, especially when early loss is minimized socially), (3) agency (the assumption that effort reliably leads to the hoped-for outcome—an assumption that RPL repeatedly disrupts), and (4) future identity (the imagined self-as-mother repeatedly interrupted by recurrence). Affectively, these threats often showed up as shame, comparison, and a harsh internal judge. Psychoanalytically, these threats to the self can be understood through dynamics of narcissistic injury and melancholic pressure. In a cultural context that links womanhood and

value to reproductive success, distress often turned inward as superego scrutiny and self-attack.

This inward turn complicates mourning: grief becomes entangled with questions of adequacy, legitimacy, and belonging rather than remaining focused primarily on the external loss of pregnancy (Freud, 1917; Kohut, 1977; Siegel, 1996).

Body domain: bodily trust, threat cues, medical surveillance, and re-embodiment

In the Body domain, recurrence transformed the body from a background of lived experience into the primary site where fear, grief, and uncertainty were felt (physically and emotionally) and managed. The body was experienced as betraying/persecutory and therefore as something that had to be monitored. It also functioned as a trauma-site where ordinarily normal sensations (cramping, nausea, bleeding) became emotionally charged cues that something bad was happening. Many participants described feeling objectified in medical contexts and described efforts to repair perceived bodily “flaws” through hypervigilance and control.

There were also melancholic dynamics in relation to the body: participants lost earlier ways of viewing the body as strong, healthy, and productive; lost the pregnancy the body was “supposed” to hold; and lost a sense of trust and connection they had once had with their bodies.

Experiencing these bodily meanings within sustained uncertainty, participants often turned toward self-scrutiny, making these losses difficult to mourn (Freud, 1917; Klein, 1940). Toward the latter part of the interview process, some participants described a shift toward partnership with the body. Psychoanalytically, this can be understood as movement from a more paranoidschizoid stance (split body-as-enemy / body-as-project-to-fix) toward a more depressive stance in which ambivalence becomes more tolerable and the relationship to the body shifts away from attack and control toward mourning, tenderness, repair, and reparation (Klein, 1935, 1940, 1946; Ogden, 1986).

Relationships domain: recognition, misattunement, and the “chorus of voices”

In the Relationships domain, recurrence repeatedly exposed the limits of recognition and emotional holding across important relationships and institutions. Participants described failures of recognition from medical providers as well as parallel failures in their interpersonal lives. These experiences organized around four primary categories: (1) proceduralization, in which providers and family focused on next steps, treatment, or intervention while bypassing grief and trauma; (2) minimization of the loss, producing disenfranchised grief; (3) pressure to present as strong, positive, and hopeful; and (4) communication gaps, especially in medical settings, which intensified the experience of living in limbo. Across cases, these conditions contributed both to withdrawal/isolation as protection and to the active seeking of alternative holding environments such as therapists, support groups, and doulas (Winnicott, 1960, 1965).

An additional layer of nonrecognition in RPL involves the problem of naming and symbolizing what was lost. Early pregnancy can be referred to as a baby, fetus, embryo, pregnancy tissue, or a “clump of cells,” and these terms carry markedly different emotional meanings. When partners, family members, or medical providers use different names for the loss, they are not only choosing different language—they may be inhabiting different realities of what occurred and what it signifies. In a culture where early loss is already contested, this instability in naming can make shared recognition difficult to achieve and can leave the grieving person feeling alone in the meaning of the loss. In this sense, the mourner must contend not only with loss itself, but with the absence of shared language that would help the loss feel real, held, and mournable.

This also helps clarify an internal “chorus of voices” participants often seemed to be living alongside: medical voices focused on protocol and probability; cultural voices that

valorize biological motherhood; relational voices that minimize grief or demand optimism; and the participant’s own conflicting voices of hope, dread, self-protection, and self-attack. Under recurrence, these voices do not reliably quiet with time; each cycle reopens the same questions— what happened, what was lost, what it means, and what can be hoped for next.

Imagined Future domain: futurity under threat, hope–dread oscillation, and reimagining motherhood

In the Imagined Future domain, recurrence destabilized future orientation and planning. Loss of the imagined future refers either to the loss of imagined motherhood and the future child in cases where participants stopped trying to conceive, or to profound doubt and fear about ever achieving the imagined future after so much loss had already been endured. Hope appeared both pivotal to continuing and terrifying to feel. Participants repeatedly reopened attachment to imagined motherhood and to a potential baby while also protecting against the devastation of another loss. In this domain, mourning was repeatedly interrupted by recurrence.

This domain also raises a question about why repeated reproductive loss was tied to such intense shame. Across cases, biological pregnancy carried dense psychic meaning: proof of bodily adequacy, participation in normative womanhood, access to generativity, continuity with imagined family life, and—for some—wished-for developmental arrival or repair. In this sense, recurrent loss threatened not only the hoped-for baby but a culturally and psychically laden image of the self as capable, whole, and “on time.” Shame thus seemed tied not only to the losses themselves but to what recurrence came to mean about the self (Kohut, 1977; Siegel, 1996).

It is also important to note that participants were not rigidly attached to biology in an ideological sense. Biological pregnancy held particular psychic meaning because it carried

multiple wishes in a single hoped-for outcome: motherhood, bodily trust, social recognition, relational continuity, and repair of narcissistic injury. Consequently, pathways to motherhood such as adoption were not always experienced as interchangeable with biological motherhood, which had been cathected, longed for, and repeatedly lost. Turning toward adoption, donor eggs, or surrogacy could require mourning the fantasy that biological pregnancy would restore the body, repair old injuries, and heal a sense of belonging and adequacy. Nevertheless, some cases demonstrated psychological integration such that there was a widening of what motherhood could mean. Jennifer’s movement toward adoption as an active choice rather than a “secondary option,” and Sally’s growing consideration of donor eggs, reflected processes of differentiating motherhood from biology even while still grieving what biological pregnancy had represented.

It is important to note that these four domains are interconnected. Relational nonrecognition can intensify shame and superego attack, thereby threatening self-cohesion. Medical proceduralization can reinforce disconnection from the body and lead to increased control. Identity threat can intensify the oscillation between hope and dread and make it challenging to hold both together. Conversely, recognition and emotional holding via therapy, support groups, or other attuned relationships can soften superego harshness, support reembodiment, and create psychic space in which mourning and hope can coexist (Winnicott, 1960, 1965; Benjamin, 2004).

Mourning, melancholia, and the issue of recognition

One thing that stood out across cases is that the ability to mourn was shaped by conditions that either allowed or did not allow the mourning process to unfold, particularly whether loss was recognized and held by another person. All participants experienced early loss as minimized or insufficiently recognized. The burden of having to justify the legitimacy of grief

suggests that disenfranchisement impacts both the interpersonal and the intrapsychic. When loss is not mirrored and held by another, grief is left without a relational container that supports symbolization and integration. Consequently, shame and self-doubt can increase, and mourning becomes more difficult to organize (Freud, 1917; Winnicott, 1960, 1965).

Freud’s (1917) ideas about melancholia are a helpful understanding of how RPL grief may turn inward through self-reproach when loss is unacknowledged and repeatedly interrupted. When the loss cannot be resolved because recurrence is maintaining a constant state of threat, and when the external world does not consistently validate the loss as “real,” grief may be more likely to become intertwined with self-attack, guilt, and harsh internal scrutiny.

Narcissistic and depressive anxieties under uncertainty

The cross-case patterns also indicate that RPL activates both narcissistic/annihilation anxieties (threats to self-cohesion, collapse, betrayal) and depressive anxieties (grief, helplessness, ambivalence, guilt) (Klein, 1935, 1940; Kohut, 1977). These anxieties alternate back and forth rather than replace one another, particularly within the condition of recurrence.

This object relations lens helps explain why control and hope feel both necessary and dangerous. Control defends against total disintegration by redirecting feelings of helplessness into action and doing, while hope reopens attachment to a longed-for future that may be lost once again. Over time, participants demonstrated an emerging capacity to tolerate contradiction which is consistent with a depressive-position. Participants talked about their experiences in ways that revealed a growing ability to hold ambivalence without relying on omnipotent control or rigid self-protection.

Implications for Clinical Practice

The findings suggest that effective clinical work with RPL should attend to the experience of recurrence and prolonged uncertainty as a core struggle that patients face when going through this process. The therapist is tasked with providing a holding environment for prolonged uncertainty, repeated reactivation of attachment, and oscillation between hope and dread (Winnicott, 1960, 1965).

First, clinicians should approach control as adaptive and protective rather than simply unhealthy or maladaptive. It is important to recognize that controlling behaviors functioned as a way to shift helplessness into agency and to counteract dread and fear. Therapy can validate the protective function of these defenses while also exploring the ways in which they might be detracting from a person’s life (i.e. rigidity, exhaustion, collapsed life space) and supporting differentiation between rigid control and true self-care. An important task for the therapist in working with RPL is to avoid rushing in to offer reassurance or solutions and instead help patients tolerate not-knowing without falling into self-attack.

Second, clinicians should attend directly to shame, identity injury, and superego attack. When RPL is experienced as evidence of inadequacy or when early loss is socially minimized, shame may intensify and the person may feel the burden of proving the legitimacy of their grief and their self-worth. Clinical work may involve explicitly legitimizing the reality of loss, naming disenfranchised grief, and exploring superego dynamics. When self-reproach and harsh “shoulds” are present, interventions may focus on softening the internal persecutory stance and creating symbolic room for mourning and remembrance rather than accusation (Freud, 1917; Klein, 1940).

Third, the body should be treated as a meaningful and central part of the therapeutic process. Across the five participants, bodily sensations held significant meaning and were experienced as cues of danger and dread. Psychodynamic treatment can include careful attention to the somatic experience, specifically how sensations are monitored, feared, interpreted, and linked to affect.

Fourth, relational nonrecognition and pressure to present a positive outlook should be understood within the context of both relational and intrapsychic dynamics. Patients may feel pressure to manage others’ comfort, remain positive, or minimize their own grief. Clinically, it can be helpful to name this emotional burden, explore withdrawal as a protective adaptation, and support boundaries around sharing updates about one’s fertility journey.

Finally, the therapist should pay close attention to the countertransference. The condition of recurrence may elicit urges to rescue, fix, and reassure, as well as avoid grief by focusing on logistics. Awareness of these urges can better support the therapist being able to sit with the uncertainty of the patient’s situation, maintain emotional presence, and support meaning-making without bypassing grief or falling back into omnipotence.

Implications for Research

This study also has implications for future research on RPL. First, it highlights the value in qualitative research approaches that can capture in-depth, dynamic, meaning-based, and relational aspects of experience that are often missed by symptom-focused quantitative measurement alone. Psychoanalytic case-study methodology is a strong fit for examining

oscillation, ambivalence, defensive organization under uncertainty, and the relational conditions that shape whether grief can be symbolized and integrated.

Future studies could extend this model by examining more diverse populations and contexts, including variation in socioeconomic access to care, racialized experiences, and queer and trans reproductive experiences. Longitudinal research could help clarify how hope, mourning, bodily meaning, and superego dynamics evolve across cycles, and how particular holding environments alter the trajectory of psychic organization. Research that includes partners or relational systems could further illuminate how nonrecognition, pressure toward resilience, and emotional labor shape both individual and dyadic experience. It would also be valuable to study how the meaning of biological pregnancy is psychically organized in different individuals and cultural contexts, and how varying pathways to parenthood are imagined, resisted, or mourned. Finally, intervention-oriented work could explore which clinical and systemic supports most effectively reduce disenfranchised grief, improve communication and emotional presence in medical contexts, and facilitate re-embodiment and mourning under conditions of recurrence.

Conclusion

This dissertation puts forth the importance of viewing RPL as a psychic condition of recurrence, one that reorganizes how patients experience self, body, relationships, and imagined future through repeated cycles of attachment, uncertainty, dread, and interrupted mourning. The cross-case analysis demonstrates that the psychological struggle of RPL is sustaining psychic life within an ongoing condition where the future cannot be guaranteed and yet effort remains directed toward the imagined future.

By offering a theory of the psychic condition of recurrence in RPL across four interrelated domains, this study provides a framework for understanding why control, increased body awareness, nonrecognition and isolation, identity threat, and hope are interlocking responses to the same underlying dilemma. This study also illuminates that RPL is not only experienced as a sequence of discrete traumatic events but may become a more chronic condition of traumatic effect. When individuals experience repeated losses within the setting of prolonged uncertainty, defensive responses such as hypervigilance, compulsive monitoring, anticipatory dread, and self-attack may begin as adaptive efforts to survive repeated threat, yet risk becoming more enduring features of psychic organization over time (Khan, 1963; Terr, 1991; Herman, 1992). In this sense, recurrence does not simply reactivate pain; it may gradually reshape how the self relates to the body, to attachment, to hope, and to imagined futures.

The findings therefore point to the importance of recognition and emotional holding, a therapeutic stance capable of bearing not-knowing, and interventions that soften shame and superego attack. With this therapeutic approach, patients with RPL have a greater likelihood of mourning their losses rather than falling more fully into melancholic dynamics of self-reproach or characterological personality changes shaped by chronic trauma (Freud, 1917; Winnicott, 1960, 1965).

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