Mary Beth Golden dissertation

In Vitro Fertilization and the Adult Daughter and Mother Dyad

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment for the Degree of Doctor of Philosophy By Mary-Beth Golden, LCSW, MT-BC

Chicago, Illinois October, 2012

Abstract This research explored how the adult daughter and mother relationship changes when needing the assistance of IVF to get pregnant. Twenty women participated in this mixed methods research in which the Mother and Adult Daughter questionnaire was administered to evaluate quantitative data and a semi-structured interview was used to evaluate qualitative data. The adult daughter’s perspective was used to assess how she understood the complexity of the relationship with her mother and whether the IVF process changed that dyad. Theoretical concepts found in developmental psychology and psychoanalytic theories were chosen to inform the findings. Results indicated that the adult daughter felt that going through the process of IVF did change the relationship with her mother. If she had a close relationship with her mother when younger, that relationship continued to be close through the process of IVF despite unexpected disappointments in mother. If the relationship with mother was distant and strained when younger, the adult daughter did not look to her mother for emotional support when trying to get pregnant via IVF.

For my mother, Harriet Evansgolden Derezotes, who always encouraged me to find the next big “mountain to climb�

ACKNOWLEDGEMENTS

I would like to recognize my dissertation committee at the Institute for Clinical Social Work. Thank you to my chair, Joan DiLeonardi, PhD., for her ending guidance, patience, and persistence in helping me achieve this body of knowledge. I would also to thank Marie Davidson, Ph.D., who facilitated a greater learning about the socio/cultural and psychological dynamics involved in the area of infertility. I especially appreciated my work with Constance Goldberg. M.S., who helped me provide a sensitive and rich psychodynamic understanding to this study.

Secondly, thank you to my readers, Joseph Cronin, L.C.S.W. and Peter Shaft, L.C.S.W., for taking the time to read my work and provide critical and useful feedback. I would like to also remember the late Marilyn Silin, M.A., who was an original reader, but had unfortunately passed away before the completion of this study. Marilyn provided an important role in helping to support my educational endeavors at the Institute for Clinical Social Work.

I am grateful for all the women who participated in this study as well as the individuals, associations, and clinics who helped me locate research.

Lastly, I must acknowledge the love and support received from my husband, Sherman, and children, Miles and Maggie. They never stopped believing in me and for that, I am immensely grateful.

M-BG

TABLE OF CONTENTS

ABSTRACT........................................................................................................................ii ACKNOWLEDGEMENTS…………………………………………………………… iv

CHAPTER I. FORMULATION OF THE PROBLEM………………………………….. 1 Statement of Purpose Significance of the Study for Clinical Social Work II. REVIEW OF SIGNIFICANT LITERATURE………………………………7 Becoming a Mother When to Have a Child Infertility The Experience of Infertility Infertility Treatment Issues The Woman and Her Mother III.

THEORETICAL AND CONCEPTUAL FRAMEWORK………………19 Self Psychology Developmental Model of Psychology

IV. METHODOLOGY……………………………………………………

Type of Study and Design Sample Selection Theoretical and Operational Definitions of Major Concepts Statement of Assumptions Statement on Protecting the Rights of Human Subjects Limitations of the Research

26

IV.

DATA COLLECTION………………………………………………..32 Mother and Daughter Questionnaire Semi-Structured Interview

V.

FINDINGS…………………………………………………………. 37 Introduction to the Findings Summary of the Quantitative Findings Summary of the Qualitative Findings

TABLE OF CONTENTS Continued

Category I- The Historical Nature of the Mother and Daughter Relationship Category II- Conversations Category III- The Introduction of IVF Category IV- The Grieving Process Category V- The Dynamic of Change VI.

THEORETICAL IMPLICATIONS…………………………. 85 Introduction The Sustaining Qualities of the Daughter and Mother Relationship Narcissism and IVF Cohesive Elements and the Adult Daughter/Mother Relationship Conclusion Implications for Further Research Final Thoughts

CHAPTER 1 Introduction Formulation of Problem The relationship between a mother and her daughter is unique and oftentimes complex. The attitude of a mother towards her daughter differs from the attitude toward her son (Klockers & Sirola, 2001). This difference remains relevant through life.

Klockers & Sirola (2001) write, “Gender is our fate-it influences how the mother will react to us (p. 221)”. This actual as well as imagined relationship begins even before the mother is pregnant with her daughter and continues to evolve over time. While this exceptional dyad has been studied and researched within the parent/child model, less has been written about the parent and adult child model.

As the daughter matures, the relationship with her mother changes. In terms of generational differences, daughters have more choices and opportunities than their mothers. For example, more young women are going to college, pursuing careers, choosing to marry later, and delaying starting a family (Petok, 2006). It was more common for the women in the mother’s generation to marry younger and begin childbearing sooner. Prior to the 1970s, if the mother had a job, she usually did not have a career before starting a family (Layton, 2004).

Currently, women are having their first child at a later age (Centers for Disease Control [CDC], 1994), citing as reasons going to college, attending graduate school, establishing a career, marrying a second time, and/or meeting their significant other at a later age. For many women, postponing having children results in age-related fertility obstacles (Petok, 2006). Initially they may go through a period of time known as “wait

and see” in which they try to get pregnant “the natural way” for six to twelve months before pursuing medical assistance to achieve pregnancy (Keye, 2006).

When a primary care physician feels he/she can no longer help a woman become pregnant, she is referred to a fertility specialist who may recommend assisted reproductive technology (ART). In vitro fertilization (IVF), a common form of ART, has become an appropriate treatment for many infertility diagnoses in men and women (Keye, 2006). IVF is still a relatively new procedure; the first baby born through IVF was in 1978. It offers no guarantee of success and has a 41.5 percent success rate resulting in live births for women under 35 years old using their own eggs (CDC website, 2010).

Success lessens significantly for women whose age is 35 and over.

The desire to have a child but needing ART can affect a woman and her mother.

For the woman over 30, the experience of infertility treatments and IVF is unlikely to be familiar to her mother, especially if the mother was able to conceive her daughter without medical intervention.

Just as the daughter desperately wants a child, so may her mother

desire a grandchild. The developmental rite of passage of a mother witnessing her own daughter having a child is meaningful for both the woman and her mother.

While it is known that women benefit from increased social support when trying to become pregnant via IVF (Petok, 2006), there is limited research on the impact that infertility has on the relationship between a woman and her mother. Additionally, there is little research that focuses on how the daughter’s fertility treatment(s), specifically IVF, affects the perceived relationship she has of her mother within the context of the mother/daughter dyad.

Statement of Purpose The dissertation topic was focused on the woman’s perception of change in the relationship with her mother when trying to become pregnant via IVF. The purpose of this study was to explore how the adult daughter perceived changes in the relationship with her mother when trying to become pregnant via IVF. The study focused on and explored the adult daughter’s perspective. The objectives of this study were to: (1) Assess the woman’s historical understanding and perception of the relationship with her mother, (2) Assess whether the adult daughter’s feelings about the relationship with mother changed with the infertility diagnosis and eventual need for ART, (3) Assess the dynamics of the mother and daughter relationship once treatment for IVF had begun. The theoretical understanding was informed by self psychology and concepts found in a developmental model of life stages.

Significance of the Study for Clinical Social Work When a woman seeks psychotherapy for infertility related issues, either individually or within a couple, she is often looking for assistance in coping with mood fluctuations, anxiety, and relationship issues (Burns & Covington, 2006). She rarely seeks long-term treatment that may focus on more deep-seated characterological concerns. Leon (1996) writes, “People who seek emotional help in the midst of reproductive loss are not looking ‘unconsciously as well as consciously’ to change in fundamental ways who they are” (p.

345). There is a difference between treating a woman who comes to see a therapist solely for support surrounding fertility issues and treating a woman who is in ongoing treatment for anxiety and depression when the challenges of infertility arise.

The social environment has changed considerably in the past 50 years; more women are waiting longer to get married and have children (Arnett, 2004). Women’s fertility is also a current “hot topic”, with numerous stories of women being able to conceive well into their 40s and sometimes 50s. There is less publicity and emphasis on the means of achieving conception, such as having a gestational carrier (surrogate), using a donated oocyte, and enduring endless cycles of IVF. Current research explains that a woman’s fertility drops subtly in her late 20s to age 35 but then declines more rapidly as she approaches age 40 and older (Choi & Rosenwaks, 2010). There is a tendency for women to think that they can” have it all,” meaning a well-defined career and motherhood (Chodorow, 2003). For many women this is not an concern, but for other women, by the time they reach their career goals, their fertility is on the decline. An estimated 1/3 of women who delay pregnancy until the age of 35 or older will have problems with conception. If a woman waits until 40 to attempt conception, she faces a difficulty of 50% in achieving a pregnancy and carrying the fetus to term without fetal abnormality (Keye, 2006).

The first baby born with the assistance of IVF was in 1978 (Burns & Covington, 2006). Given that reproductive technology is still a relatively new science, there is much that is unknown. Doctors sometimes cannot explain why IVF might be successful or why a woman cannot conceive despite the fact that both she and her husband have normal test results. Despite no guarantees, many couples pursue ongoing infertility treatments with the woman bearing the brunt of physical examinations and procedures.

Treatments for fertility problems are far more researched and available for today’s women compared to the women of their mother’s generation. Unless the mother is

curious about IVF and/or knows someone who has gone through IVF, she may not be familiar with the personal and physical aspects of this procedure. A woman undergoing IVF is aware that her biological mother most likely conceived her without this level of medical intervention. Knowing that the desire and quest to have a child was different for her mother may impact a woman’s perception of her mother and the relationship with her. Notman (2006) writes, “The rapid social changes within the past generation can create some particular dilemmas between mother and daughters that are analogous to the conflicts between parents of immigrant generation and their children” (p.139). No doubt the relationship between mother and daughter remains relevant and significant because, “… with many individual variations, the power of the mother daughter relationship persists, even when the daughter may be independent, geographically separate, in her own family or alone” (p. 39, Notman, 2006).

The mother/daughter relationship is worthy of investigation because there is little research that focuses on the normative functioning of the mother-daughter relationship.

Indeed, Shrier, Thompsett & Shrier (2004) validate that even after consulting psychoanalysts, psychiatrists, psychologists and sociologists, they were unable to locate bibliographies on research and theory about normative adult mother-daughter relationships. There is little to no research about how a daughter’s fertility treatment(s) affect the relationship between her and mother. Clinically, this study is relevant because most women in therapy or analysis spend considerable time understanding and working through this pivotal dynamic (Reed, 2006). Additionally, few multi-generational studies of infertility, IVF, and psychological factors exist (Apfel & Keylor, 2002). Finally,

another benefit to this study is the exploration of how women cope with differing societal opportunities and expectations from one generation to the next.

Review of Significant Literature Girls internalize gender roles and caretaking functions from their mothers beginning at a very early age. Freud (1931) spoke about how early awakened femininity could be observed in, “… the fondness girls have for playing with their dolls” (p.237).

By taking care of their favorite baby doll(s) in rocking, hugging, feeding, and soothing them, girls practice mothering at a young age. Girls internalize how their mothers mothered them and they often replicate and practice some of the same methods with their dolls and others. Less obvious, but nonetheless important, are the ways young girls and their friends pretend to be the mother and/or wife within a family. What becomes apparent in these examples is that, in many cases, women fantasize scenarios of being a wife and mother from a very early age. As adults, making these fantasies a reality contributes to a more mature level of functioning.

Chodorow (2003) explains that motherhood does not begin once one is pregnant or after the child is born. Rather, “Motherhood begins internally in the conflictual, intense cauldron of childhood sexuality and object relations, and is overdetermined, filled with fantasy, and complex: any woman's desire for children, whether immediately fulfilled, fulfilled belatedly, or never fulfilled, contains layers of affect and meaning” (p.3). In particular, Klockars & Sirola (2001) state that women especially imagine what it might be like to have a daughter. They (2001) write, “The mother-daughter love affair exists in the mother’s fantasies long before the daughter’s birth. Every little girl imagines that she will one day give birth to a daughter. She has memories and fantasies of her love with her own mother, and perhaps of her grandmother’s love as well” (p. 220). These ideas highlight that women imagine themselves as mothers whether or not they try to become a

mother in adulthood. There is just as much meaning in these fantasies for a woman who attempts to become a mother as for a woman who cannot achieve motherhood or who decides not to become a mother. Additionally, women imagine what it might be like to mother their own daughter.

In order to become a mother, the majority of women attempt to have a child through a natural pregnancy. Pines (1990) states that, “Pregnancy, the final stage of identification with her own mother, rooted in a bodily identification with her, contributes to the fulfillment of a girl child's ego ideal which contains her own maternal self in identification with her fertile mother” (p. 2). This concept emphasizes the importance of the daughter’s ability to become pregnant just as her mother did with her. Moreover, a woman’s confident development of her sense of femininity, sexual identity and selfesteem are contingent upon her ability to become pregnant (Pines, 1990). This developmental process of becoming pregnant, for the daughter, cannot help but revive unresolved conflicts between mother and daughter from previous developmental periods.

As the unresolved conflicts come to the surface, “…the young woman has to achieve a new adaptive position within both her inner world and the outer object world” (Pines, 1990, p. 3). The transformation can be psychologically disruptive as described by such clinicians as Benedeck (1959); Lazarre, (1976); and Stern, (1995). Not only must internalized ideals be modified and reconsidered, but one’s sense of self and relation to others is impacted and changed. Additionally, “The woman’s fantasies have a special effect on the interaction between mother and child when the waited for baby is a girl, since every mother has , in addition to her fantasies, memories of her relationship with her mother, and fantasies color her expectations for the future” (p. 220, Klockars &

Sirola, 2001). Steinberg (2005) writes, “Becoming a mother is, or can be, an act of reparation with one’s own mother or it is inevitably a reworking of one’s relationship with her” (p.180).

The Wish to Have a Child Burns (2006) writes about the trends in having children in America starting in the 19th century. Before the Industrial Revolution, the value of children was based on their ability to contribute economically to the family. After the passing of child labor laws, children’s emotional contributions to the family became more relevant and important. Burns (2006) says, “By the beginning of the twentieth century, reproduction had become less a matter of creating more hands to work than of having children who would enhance their parents' self-worth and social position” (p. 460). May (1995) discusses how the center of American society transitioned from community to family as “… the ideological center of happiness” (p. 23). This focus on family, specifically on children as the source of happiness and emotional investment, is even more apparent today. Rosen (2002) writes “Americans pursue happiness in the private areas of their lives, and children are their central focus in this pursuit” (p.2).

Brazelton & Cramer (1991) describe how the motivation to become a mother is influenced by the woman’s relationship with her own mother. For example, they explain that women are motivated to become a mother because it allows them to identify with their mother and with women in general. Having a child provides the opportunity to repair or revitalize the relationship she has with her mother. Becoming a mother also allows the woman to “…both replace and to separate from one’s own mother by matching now her own all-powerful mother” (p. 67).

While the trend to be more family and/or child focused has occurred in the past 50 years (Burns [2006]; May [1995]; & Rosen [2002]), the age at which a woman becomes pregnant has also changed in the past 50 years (CDC, 2008). Chodorow (2003) points out that, “In the last half century, women and men choose not to have children, and women are typically older at the time of the first birth” (p.4). Just as child labor laws impacted the value of children, the women’s movement of the 1960s “… challenged a generation of women to step out of the traditional roles of wife and mother” (p. 14, Rosen, 2002). Chodorow (2003) has observed these trends and its consequences. She writes, “We have moved from having children as a necessity to option” (p.4).

The societal implications are that, “The more choice is exerted, the more power women have. Conversely, the more power women have, the fewer children they choose to bear” (p.2, Rosen, 2002). Rosen (2002) has studied this topic in depth and indicated through her research that fertility rates decrease when women have multiple sources of power from education, careers, money, or political representation. Apfel & Keylor (2002) discuss how this societal trend has impacted their young adult patients. They state, “Patients are frequently in conflict between career goals and desires for parenthood while years of higher education delay parenthood as an agenda” (p.2).

“What has complicated this is that there is a belief that motherhood and professional life are incompatible for women” (p.4, Chodorow, 2002). Today many women want to establish careers first. Rosen (2002) writes, “Unfortunately they do this and still have faith in their reproductive capacities” (p. 14). While delay of childbearing can occur for many reasons, many women remain uninformed about the consequences of this action” (p.14). Describing a more extreme scenario, Sauer (1998) writes, “Most

women are shocked to discover that by the age of 40, when many for the first time are serious about trying to begin a family, ovarian functions may be compromised and the likelihood of pregnancy significantly reduced” (p. 275).

We live in a country and society where popular media impacts our thoughts about a woman’s professional life as well as her family life. Rosen (2002) indicates that within our society, fertility rates are impacted because “… aging is often perceived as a personal failure, our lines and lumps are airbrushed away, women denied or never really knew the consequences of their decisions” (p. 14). There are examples in the movies and television shows of the driven business woman who suddenly realizes that she is in her late 30s and should, perhaps, start to look for a man or sperm bank that would allow her to get pregnant. These shows are usually comedic in nature and usually end with the woman getting her baby. The message is that as a woman, you too can wait till your mid to late 30s and still have time to have a child. It is only recently that women have become more vocal in discussing their fertility woes, which may include needing the assistance of ART, requiring the assistance of an egg donor or a gestational surrogate in order to deliver a healthy biological child.

The sense of time standing still from one’s early 20s to late 30s is written about by both Chodorow (2003) and Arlow (1984). Chodorow (2003) says, “… this unconscious sense of time standing still is a potential in any time and place, but it may be more likely in a culture like ours with its emphasis on youth, no aging, longer lives, later fertility, and a family life cycle that seems to have no fixed routine and to be a voluntary rather than a taken-for-granted option” (p.6). She (2003) believes that the experience of time begins to progress cyclically rather than linearly.

For a woman who deliberately delays having children, it is a painful reality when she discovers that she is physiologically running out of time to conceive a child.

Additionally, she may be devastated when she learns that she cannot conceive a child either as the result of preexisting medical reasons or as a result of time delay. Pines (1990) writes, “Lack of control over the reproductive capacities of one’s own body is an enormous personal crisis, a blow to the individual’s narcissism, a diminuation of pride in the mature self-representation, the relationship to the self and to the sexual relationship which may seem to become mechanical, especially if fertility techniques place constraints on its spontaneity” (p.2).

Infertility RESOLVE: The National Infertility Association defines infertility as “A disease or condition of the reproductive system often diagnosed after a couple has had one year of unprotected, well-timed intercourse, or if the woman has suffered from multiple miscarriages” (p.1, www.resolve.org). According to the Centers for Disease Control and Prevention, more than 7.3 Americans or 1 in 8 couples of childbearing age are infertile (CDC.gov). Approximately 40% of infertility is due to a female factor and 40% is due to male factor. In the remaining 20%, infertility results from problems in both partners or the cause of fertility cannot be explained (RESOLVE website).

Before there was any sort of treatment for infertility, childless couples had the option of either adopting someone else’s child or the eventual acceptance of not being able to conceive. Once the legalization of abortion occurred as well as the development of contraception in the 1960s, adoption has become more complicated and difficult; there are fewer newborns to adopt. Couples experiencing infertility woes continue to face

many challenges; according to Pines (1990), infertility is a failure couples cannot deny and the acceptance of infertility is never final. She (1990) writes, “… shame and guilt are an inevitable part of their emotional predicament, shame that they cannot conceive as so many of their friends do and guilt that they cannot give grandchildren to their parents and in this way continue the generations of the family and their blood relationships” (p.1).

The Experience of Infertility Infertility is a deeply emotional experience for each affected couple. Apfel & Keylor (2002) write, “Psychological conflicts involving infertility reach into the deepest layers of the individual psyche, invade the interpersonal space of the couple, and radiate into the cultural surround and its definition of family” (p. 3). Rosen (2002) states that “Infertility is experienced as a most basic betrayal of one’s body” (p.7). Apfel & Keylor (2002) highlight common feelings couples experience. They write, “In common are feelings of anxiety, despair, rage envy of others with babies, futility and magical thinking, all of which follow from being deprived of parenthood…” (p. 3). Rosen (2002) adds that, “Infertility profoundly influences self-esteem, self-worth, and the sense of bodily integrity” (p.7).

Apfel & Keylor (2002) write, “The loss of parenthood is multifaceted and involves more than the loss of fertility; there is a loss of spontaneous sexuality, of the pregnancy experience itself, of children and genetic continuity” (p.2). Infertility can cause problems within the married couple causing disruption and/or sexual dysfunction.

Relationships with family and friends can also be affected.

Infertility causes stress and mental anguish for many women and their partners; the experience is considered traumatic. Jaffe & Diamond (2011) developed the term

“Reproductive Trauma” which is based on their many years treating individuals and couples around losses associated with infertility. They (2011) write, “Over the years of listening to patients dealing with infertility or reproductive loss, we realized that no matter what has gone wrong on the road to parenthood, the underlying psychological anguish is similar for all-it is traumatic” (p.10).

Irving (1996) states, “Infertile people, in particular, learn to number their days not only in terms of the menstrual cycle but their time on earth. Not only does the biological clock become louder, but a more insistent and less forgiving clock registers their understanding of mortality much earlier than their procreating peers” (p.4). Rosen (2002) writes that infertility “… renders its sufferers helpless and thrusts them into the middle of existential issues surrounding meaning, life, and death” (p. 7).

Within the couple, the woman and man may deal with infertility differently.

Rosen (2002) states that “Men are more likely to focus on work and other timeconsuming activities” (p. 7). According to Newton & Houle (1993), “Women are more likely to be affected earlier, to take personal responsibility for the inability to bear children, and they are more likely to experience self-image and self-esteem problems and report distress” (p.52). Both men and women describe diminishing sexual satisfaction (Rosen, 2002).

Infertility Treatment Issues Couples that are referred to infertility specialists often come in feeling shame and guilt. It is a deeply emotional experience for each affected couple. Pines (1990) writes, “… the couple that has resorted to artificial reproduction, has had to come to terms with their failure as a couple to conceive and create life as their parents did” (p.1). Apfel &

Keylor (2002) write “A couple’s pain is then compounded belying their involuntary childlessness by invasive procedures and ethical dilemmas created by recent technological opportunities” (p.90). Pines (2002) writes, “These couples are preoccupied with monthly success or failures in conception, at the cost of much of their adult investment in life” (p.3).

Despite being a couples’ problem, infertility is still considered a female issue.

Infertility organizations are largely run by women and therefore appeal to women and perpetuate female involvement at the expense of male participation.

Apfel & Keylor (2002) write, “Reproductive medicine is about life and death within a community of people who are in despair” (p.87). Burns & Covington (1999) state, “Reproductive technologies have increased the notion of perfect “designer” infants available to an increasing array of infertile, childless and even repeat parents” (p.5).

“Greed and narcissism, competing economic interests, medical valorization, religious agendas define this ever shifting terrain” (p. 2, Rosen, 2002). Infertility clinics rely for their reputation on their number (i.e. take home baby rate) of successful pregnancies that have resulted in a live birth. Additionally, many infertility clinics cater to middle-class or upper-class clientele because they either do not contract services with lower reimbursing insurance panels or they may accept reimbursement for only one round of IVF per calendar year.

Unfortunately, increases in assisted reproductive technologies provide treatments that create challenges, emotional stress and outpace psychological preparedness of patients and mental health clinicians. Apfel & Keylor (2002) state, “Some patients come with such medical problems that parenthood would have been out of the question in the

pre-ART era” (p. 9). Ideas of parenthood that had been laid to rest earlier are now being revisited. Rosen (2002) writes, “Now the cultural and social pressures on the infertile couple are not simply the consequences of their childlessness, but pressure to use (or at least consider) assisted reproductive technologies” (p. 5).

“In vitro was originally designed to overcome irreversible discords of the fallopian tubes, it has become an appropriate treatment for virtually all forms of infertility in men and women” (p. 32, Keyes, 2006). While this treatment has given many couples hope, research shows that 1 in 4 IVF trials may lead to a successful pregnancy and that live birth rates can be as low as 25%” (p.55, Petok, 2006). In vitro is an invasive treatment which consists of several steps. It involves taking multiple medications, obtaining blood tests, undergoing extensive pelvic ultrasound examinations, intramuscular injections, etc” (p. 32, Keyes, 2006).

“The longer the duration of infertility, the more protracted the medical intrusions, the higher anxiety about eventual outcome, the greater distress, which in turn affects women emotionally and physically” (p. 1684, Greil, 1997). Apfel & Keylor (2002) write, “Before, during and after the intervention, patients have strong psychological needs that may be minimally acknowledged by those performing the procedures” (p.98). Moreover, it is not just the medical intervention that has a strong impact on the couple but the “… expert doctors who administer them, giving or refusing permission for intercourse, and thus becoming vital figures in the intimate aspects of the couple’s lives” (p.22). Apfel & Keylor (2002) write, “When the duration and time spent in IVF programs are taken into account, it is clear that coping ability deteriorates over time, reflecting the erosive effect of years of infertility and of organizing life around technological conception” (p. 91).

Their research shows that those undergoing infertility treatments report significant changes in mood and sexual functioning which are indistinguishable from major depression.

The Woman and Her Mother While it is known that women benefit from increased social support, there is little research which discusses whether infertility impacts the relationship a woman shares with her mother (Jaffe, [2008] & Petok [2006]). One can conclude that there might be complex matters at stake assuming a woman takes responsibility for the couple’s infertility and that the act of becoming a mother is the woman’s final identification with her own mother.

Jaffe (2008) writes, “Many people not only consider grandchildren a gift, but a real necessity in their lives” (Jaffe 2008, eons.com). Moreover, “Some people view grandkids as having a second chance at parenting” (p. 2, Jaffe, 2008). The generational transmission of the mother-daughter dyad is especially poignant as Klockars & Sirola (2001) write, “A granddaughter represents a repeat of a woman’s own childhood and that of her daughter which she is now able to enjoy. Her life continues in her daughter and granddaughter. Joy and sorrow, receiving and yielding, go hand and hand” (p.237).

Few authors (Jaffe [2005]; Petok [2006]; Jaffe & Diamond [2011]) discuss how the woman’s mother might feel when her daughter does not become pregnant. Jaffe (2008) writes, “People who expect to be grandparents suffer a great loss when their children can’t have their own kids” (p.2). “Producing a grandchild can provide evidence of true adulthood and in some cultures the birth of a child signifies another rite of passage” (p. 51, Petok, 2006). As more time passes, prospective grandparents feel less

and less like they fit in socially just as the infertile couple begins to feel less a part of their baby-producing contemporaries. Just as there is no finality in accepting one’s infertility, Jaffe (2008) says that for the infertile couples’ parents, “… there is no real ending or closure to this grief because they’re continually reminded of their “loss” when their peers’ grandchildren reach certain milestones” (p.2, Jaffe, 2008).

There is very little that is known about how an adult daughter’s relationship with her mother is impacted by infertility and the eventual need for IVF. What is known is that the mother and daughter relationship is powerful, resilient and can withstand life’s journey. Bernstein (2004) writes, “Once we recognize that the course of development is not linear, we should expect to see the woman revisiting, reexamining, and resynthesizing representations of the self-versus mother and self-with mother over her lifetime” (p.603).

Bernstein (2004) illustrates that many analysts tend to pathologize or infantilize the woman’s ongoing tie to her mother and tend to misunderstand the intense ambivalence between daughter and mother. It is useful to recognize that the “…fundamental closeness between mother and daughter is multidimensional, self-enhancing, and contentious from the very beginning” (p. 604). “For a girl, the mother is the object of both love and identification, and the girl never abandons either of these relationships, although their quality and manifestations vary from one developmental phase to another” (p. 219, Klockars & Sirola, 2001).

Theoretical and Conceptual Framework for Proposed Study Self Psychology Self psychology informs both the developmental and clinical data explored in this study. At the heart of this theory is the self, conceptualized as a mental system that organizes a person’s subjective experience in relation to a set of developmental needs (Wolf, 1988). According to Kohut (1971, 1977, 1984), the self is the essence of a person’s psychological being and consists of sensations, feelings, thoughts, and attitudes toward oneself and the world” (p. 225, Banai, 2005). Wolf (1988) comments that the self “…endures over time and changes comparatively slowly; therefore, the self has a historya past, present, and future” (p.13, Wolf, 1988).

The idea of one’s self or sense of self not only possesses the inborn tendency to organize experience but the self continues to change as time goes on. “Each new phase of development provides the opportunity for further deepening and firming up self structure, for improving resiliency” (p. 19, Elson, 1986). The presence of others is required and is technically designated as “…objects who provide certain types of experiences that will evoke the emergence and maintenance of the self called self object experiences (p. 11, Wolf, 1988). The selfobject concept affirms the significance of others and experiences.

Moreover, selfobjects are required for the creation and consolidation of the self and for sustenance of the self throughout life. This study focused primarily on the adult daughter’s sense of self and how the relationship with her mother contributed to various dynamics during the period of needing the assistance of IVF to get pregnant.

Kohut (1971) devised three central selfobject needs that correspond to the three axes of self-development. The self object need for mirroring is a need to be admired for

one’s qualities and accomplishments. The self object need for idealization is a need to form an idealized image of significant others and to experience a sense of merging with the resulting idealized selfobjects. The selfobject need for twinship is a need to feel similar to others and be included in relationships with them. “Proper self object experiences favor the structural cohesion and energic vigor of the self; faulty self object experiences facilitate the fragmentation and emptiness of the self” (p. 11, Wolf, 1988).

“As the individual grows to mature years, there are many transitions which severely test the cohesiveness of the self, resulting in periods of lessened vigor, loss of purpose, discontinuity” (p. 19, Elson, 1986). A mother can meet an adult daughter’s selfobject needs for mirroring when moving through the struggle to get pregnant as well as celebrating her daughter’s pregnancy.

The central ideas of cohesion and/or coherence of the self were found to be relevant in this study. In this regard self cohesion is described as “…a sense that all features of one's personality are facets of a single, well-integrated structure” and that it is “….achieved when people possess a stable, positively valued, and congruent set of qualities, ambitions, ideals, and values, and are able to accomplish their goals without being rejected or isolated from significant others and important reference groups” (p.226, Banai, 2005). Self-structure can usually be sustained under duress, but the development and maintenance of a cohesive self depends on the availability and responsiveness of necessary selfobject experiences. Although the nature of dependence on significant others changes over the lifespan, the need for selfobjects is present especially during transitions and traumatic experiences.

Kohut’s emphasis on empathy was a valuable contribution to the theory of the self. It is most often the mother who provides early and necessary empathic responsiveness which contributes to the fundamental process of building a child’s ability to self regulate. Kohut (1971, 1977, 1984) described how the caregivers’ empathic responses contribute to the meeting of selfobject needs and to the development of a cohesive self. Banai (2005) describes this experience, “Caregivers' empathic responses to children's narcissistic needs foster the development of an inner state of stability, security, and self-cohesion. On the other hand, consolidation of this sense of self-cohesion makes selfobjects less necessary, because the individual's own cohesive self becomes the major agent of self-regulation. That is, with satisfaction of selfobject needs, a person's feelings of healthy grandiosity, idealization, and connectedness are strengthened, and he or she gradually acquires self-regulatory capacities. Specifically, the person can internally regulate self-esteem and ambitions instead of requiring admiration from others (p.227).”

As a result of this experience, individuals can depend on their own capacities to self regulate rather than to depend on other experiences to provide necessary selfobject experiences.

Kohut (1966/1978b) posited a line of healthy narcissistic development that “…moves toward consolidation of a cohesive self-structure, providing a sense of identity, value, meaning, and permanence and promoting the actualization of a person's potentialities (native talents and acquired skills)” (p.225, Banai, 2005). Elson (1984) describes how an individual’s narcissism changes over time and attempts to adapt to getting older. “Each critical period in the lives of children may intensify the thrust toward mature forms of narcissism or may precipitate fragmentation, and feebleness, or disharmony within the parental self” (p. 311, Elson, 1984). She goes on to recognize that society and changing norms encroach upon parent and child dynamics. Elson (1984) writes, “The transience of the parental generation and now even the transience of their

children's lives, add stress and must be mastered by accepting its reality more directly”(p.

312).

Developmental Model This study also understands data and phenomena through a developmental model of life stages. The developmental perspective is of great clinical relevance as it incorporates biological, intrapsychic, and environmental influences on the human experience. Bernstein (2004) writes, “The developmental perspective postulates that the individual, from birth forward, actively constructs her representational world of self and others, in interaction at first with her primary caregivers and before long with her broadening world, in an open-ended process that continues through the life cycle” (p. 4).

Erik Erikson (1959) was one of the first analysts to attempt a developmental theory for the entire life cycle. He highlighted the interaction between the person and her environment and considered the influence of culture and society on identity formation.

His epigenetic theory stated that each developmental stage was built on the previous stage and affected later stages. Personality development was no longer viewed as being fixed in childhood; rather, it evolved as an unfolding of psychological tasks over the life cycle. Until then, many theoreticians saw adulthood as a somewhat static time in one’s life. This psychosocial theory was new for its time but was mostly developed through seeing adults in analytic treatment. One of the drawbacks of using this theory is that “they are nodal ideas needing considerable elaboration because they were formulated in a near vacuum of analytic treatments with adults” (p. 2, Colarusso & Nemiroff, 1979).

Therese Benedek’s (1959) paper, “Parenthood as a Developmental Phase- A contribution to libido theory” was published the same year as Erikson’s, “Identity and the

Life Cycle.” Benedek’s paper was significant both historically and theoretically because she conceptualized parenthood as a developmental phase, emphasizing yet another way in which developmental experiences have a pronounced and lasting impact on adult personality formation. Moreover, she conceptualized that parenthood, specifically motherhood, was an agent for growth and change.

Pine (1998) wrote about the usefulness of a developmental perspective in respect to adult treatment. The core idea of the developmental perspective is that “… life-aslived is a developmental process continually presenting each of us with age-related adaptive tasks: these tasks are often approached by bringing to bear old styles of defending and mastering and along with these, old wishes, repetitions, and enactments” (p.199). Pine writes, “We never feel for more than a moment, ‘Here I am, now I can stand still” (p. 199).

In 1979, Colarusso and Nemiroff hypothesized a psychoanalytic theory of adult development. They suggested that development in adulthood is dynamic in nature and that it is not only impacted by one’s childhood but also one’s adult life. They felt that the ongoing dynamic process in adulthood pertains to the unfolding of existing psychic structure and its ‘use’. Colarusso (1992) states that “… for both child and adult development the psychopathology results from failure to engage in and master developmental tasks during the phase of development in which they are a central issue” (p. 150).

In Colarusso’s (1992) theory of adult development, he mentions that there are some gender differences when moving from one developmental task to the next.

Moreover, biological and physical changes have an impact on how an adult copes with a

specific developmental task. For example in the young adulthood phase, he writes, “The biological determined loss of procreative capacity in females in their 30s and early 40s is the most striking developmental difference between the sexes in young adult development, affecting almost every other developmental line” (p.150).

As indicated, the environment plays a crucial role in moving through and adapting to the different demands each developmental period presents. Arnett (2004) coined the term “Emerging Adulthood” to describe a relatively new developmental phase related to the older age of entering marriage and parenthood, the lengthening of higher education, and prolonged job instability during the 20s. Arnett proposes that adulthood no longer begins immediately after one finishes schooling and gets a job. This is especially true for women who have considerably more opportunities compared to “… 50 years ago where there was a great deal of social pressure to catch a man” (p. 27, Modell, 1989). Notman (2006) writes, “The wish to please, to fulfill mothers’ fantasies, or to conform to new societal expectations can lead young women to career ambitions that can then stand in the way of traditional goals of children and family” (p.141).

“That the mother in adulthood remains an important source of conflicts but also attachments may be surprising to a daughter who sees herself as independent, strong, resourceful and mature” (p. 139, Notman, 2006). Arnett (2004) writes, “The lives of young American women today have changed almost beyond recognition from what they were 50 years ago” (p.7). A woman must cope with differences in generational and societal expectations that may impact her relationship, or more specifically, her perception of her mother. Moreover, vast environmental and developmental factors may

have a significant impact on her personality formation and vulnerability to psychopathology.

Methodology Type of Study and Design This study sought to understand a woman’s feelings in regard to her perception of change in the relationship with her mother during the stressful and emotional experience of IVF. The research project was exploratory in nature, as there had been little research focused on how a woman’s perception of her mother might change when undergoing IVF.” Cherry (1999) writes, “The exploratory approach is very useful when we know little about a new phenomenon or a group of people that begin to emerge” (p. 12).

The

design of this research project was a concurrent mixed methods study where, “… the researcher converges quantitative and qualitative data in order to provide a comprehensive analysis of the research problem” (p. 16, Creswell, 2003). The research design was chosen so that both quantitative and qualitative data could be collected at the same time and integrated so that possible linkages between the various facets of adult daughter and mother relationship could be examined during the crisis of trying to become pregnant via IVF. Quantitative data, the Mother-Adult Daughter (MAD) Questionnaire (Rastogi, 2002), was completed and collected by the researcher before participating in the semistructured interview. The MAD contained 24 closed ended questions which examined both demographics and three subscales: Connectedness, Interdependence, and Trust in Hierarchy. The participant was given the questionnaire 24 hours before meeting for the semi-structured interview as it was relevant to collect both quantitative and qualitative data at roughly the same time. It was estimated that the questionnaire took less than 10

minutes to complete. The participant answered questions about how she felt about the relationship she had with her mother.

Results of the qualitative data, the semi-structured interview, were analyzed and organized using open, axial, and selective coding techniques. The interview began after the consent for participation was signed and the MAD had been collected. It lasted between 45-110 minutes and took place in the researcher’s private practice office or a location mutually comfortable for the participant and researcher. The semi-structured interview included close-ended demographic questions as well as open ended questions which explored the participant’s “reproductive story” (Jaffe et al, 2005), the historical features of the mother/daughter relationship, how the woman currently understood the relationship with her mother and whether IVF had an impact on that relationship. The interviews were digitally recorded and then transcribed at a later date. Grounded theory was chosen since theory “…drawn from data, are likely to offer insight, enhance understanding, and meaningful guide to action” (p. 12, Strauss & Corbin, 1998).

Information gleaned from the interview was used to a gain a more in-depth view of how the historical features of the mother/daughter relationship influenced the woman’s perception of that same relationship when trying to become pregnant via IVF. Sample Selection Numerous approaches were used to recruit participants for this study. Flyers were posted and made available in multiple fertility clinics, general OB/GYN clinics, and alternative health clinics. Various fertility/adoption support groups also distributed flyers. Social media such as Facebook and Twitter were also used to announce the study and recruit volunteers. The sample was non-random and determined by meeting research

criteria. Additionally, snowball sampling was evident as word of mouth by colleagues and other participants also recruited volunteers (Tashakkori & Teddlie, 1998). An initial phone conversation or email chat was used to determine eligibility for this study.

All participants were required to be married women 20-50 years old, in contact with their biological mothers and in the process of pursuing/trying to become pregnant via IVF using their own eggs. If the woman had achieved pregnancy through IVF, she could only be under 12 weeks pregnant. Twenty interviews were completed with 11 women residing in the Chicago metropolitan area and 9 women residing in the St. Louis metropolitan area. It was not the intention to have an almost evenly divided sample between the two states.

At the time of this study, Illinois had an insurance mandate that required insurance companies to provide for fertility treatment and IVF costs (Illinois fertility insurance law is found Chap 215, sections 5/356m and 125/5-3). Missouri did not have an insurance mandate and as a result, there was no insurance coverage for IVF costs.

This social, emotional, and financial disparity was evident in that in Illinois, there were more IVF clinics per geographical area, more social and community support groups, and more IVF opportunities due to the Illinois insurance mandate.

Theoretical and Operational Definitions of Major Concepts Assisted Reproductive Technology (ART)- “Fertility treatments in which a laboratory handles eggs, sperm, or embryos to increase the possibility of pregnancy” (p. 233, Jaffe & Diamond, 2011).

Dilation and Curretage (D & C)- “A surgical procedure in which the cervix is expanded and then the uterine lining is scraped; often needed following miscarriages” (p. 233, Jaffe & Diamond, 2011).

Infertility: RESOLVE: The National Infertility Association defines infertility as “A disease or condition of the reproductive system often diagnosed after a couple has had one year unprotected, well-timed intercourse, or if the woman has suffered from multiple miscarriages” (p.1, www.resolve.org).

In vitro fertilization: “A method of assisted reproduction that involves combining an egg with sperm in a laboratory dish. If the egg fertilizes and begins cell division, the resulting embryo is transferred into the woman’s uterus where it will hopefully implant in the uterine lining and further develop” (p. 605, Burns & Covington, 2006).

Intraunterine Insemination (IUI)- “A procedure by which sperm are placed directly into the uterus (bypassing the cervix) to increase the odds of fertilization” (p.235, Jaffe & Diamond, 2011).

Polycystic Ovarian Syndrome (PCOS) – “A condition in which there are chronic problems with ovulation, because there are many poorly developed follicles in the ovaries; other symptoms can include obesity, excess body hair, and depression” (p. 235, Jaffe & Diamond, 2011).

Reproductive Trauma- “When you want to have a baby, and it is not as you hoped and dreamed, you are in the midst of a trauma, a reproductive trauma” (www.reproductivepsych.org/trauma/).

Reproductive Story- “A story of how you think your life as a parent will unfold. You begin ‘writing’ your reproductive story when you are a child, and it continues to be modified and ‘rewritten’ as you become an adult” (p. 23, Jaffe et. al, 2005).

Adult daughter-mother relationship: is a bond that maintains the highest intensity, interdependence, and emotional connection in comparison to other intergenerational relationships (Fischer, 1991). It is also a relationship that can provide solidarity and support and one that is significant to all women (La Sorsa & Fodor, 1990).

In this study, the MAD (2002) scale measured the perception of the mother daughter relationship assessed by three subscales: Connectedness: The ability to share feelings and opinions, as well as make sacrifices within the context of the adult-daughter relationship (Rastogi, 2002).

Interdependence: Includes mutual dependence in emotional and practical ways within the mother-daughter relationship. This includes daughters seeking out their mothers’ help and advice, or feeling free to do so (Rastogi, 2002).

Trust in hierarchy: Women who defer to their own mothers regardless of their age. It is assumed that the older woman will know what is best for her daughter even if the daughter does not believe this (Rastogi, 2002).

Statement of Assumptions •

The primary assumption is that going through the process of IVF will change how the adult daughter relates and understands her mother.

•

The secondary assumption is that there is a relationship between the woman’s emotional well-being during IVF and the quality of the relationship with her mother.

•

There are variations in societal expectations and opportunities between generations of women.

•

Reproductive technology has changed since the daughter’s mother was considering pregnancy.

Data Collection (Methods and Instruments) Potential participants were asked to email or call the researcher if interested in participating in this research project. During the initial contact, research eligibility and schedule availability were assessed. Since some women were already pregnant, women were scheduled as soon as possible in order to capture the essence of their IVF experience as well as meet the research criteria of being less than 12 weeks pregnant.

After eligibility and scheduling were established, the consent for participation was emailed along with directions as to how participation would proceed. With regard to scheduling, the participant’s preference of time and location most convenient and comfortable for the in-person semi-structured interview was taken into consideration.

Quantitative data were collected either through email submission or given to the researcher during the in-person interview. The women were asked to complete the MAD before beginning the semi-structured interview. The semi-structured interview lasted between 45-110 minutes, and was recorded and transcribed. Notes were taken during the interview to record impressions, non verbal cues and to keep material organized in the hopes of asking follow up questions later in the interview.

Methods and Instrumentation Mother and Adult Daughter Questionnaire (Appendix A) The MAD questionnaire was developed in 2002 to measure adult daughters’ perceptions of their mothers in a culturally sensitive manner (Rastogi, 2002).

The participant was asked to complete this questionnaire before beginning the face-to face interview. The instrument contained 25 questions total, 18 items of which assessed three subscales: Connectedness, Interdependence, and Trust in Hierarchy. Connectedness

was described as the ability to share feelings and opinions, as well as make sacrifices within the context of the adult-daughter relationship (Rastogi, 2002). Interdependence included mutual dependence in emotional and practical ways within the mother-daughter relationship. This included daughters seeking out their mothers’ help and advice, or feeling free to do so. Trust in hierarchy described women who deferred to their own mothers regardless of their age. Items for the subscales were constructed using crosscultural and mother-daughter literature and were refined after an initial pilot study. The remaining seven questions addressed demographic and geographic characteristics as well as the daughter’s level of satisfaction with her relationship with her mother.

Scoring The demographic questions were ordinal in measurement, assessing more or less the frequency of time living with mother, traveling distance to see mother, communication with mother, frequency of visiting mother, and level of satisfaction with mother. The three subscales, connectedness, interdependence, and trust in hierarchy, were ordinally scored 1-5 (1=very false, 2=somewhat false, 3=maybe, 4=somewhat true, and 5=very true) as well. Women were asked to comment 1-5 based on sentences developed to assess the woman’s feelings about her mother. One subscale question was the exception and that was rating the level of closeness with mother. Women were asked to determine closeness based on a-e (a=very close, b=close, c=somewhat close, d=not very close, e=not close at all). Scores on the 19 items were added to determine a raw score of which women had the highest rating in each of the subscales, felt the highest level of connection interdependence, and trust in hierarchy with their mothers.

Semi-Structured Interview (B) The participant was interviewed once at a location and time most conducive for privacy, self expression, and comfort. It was anticipated that some of the topics and questions might prompt an especially strong emotional response; therefore in order to respect each participant, she was given the option to choose the venue and time as long as the researcher could accommodate the request. Confidentiality was assured before beginning the semi-structured interview.

Information collected at the time of the interview covered close-ended demographic questions as well as an open-ended discussion about the participant’s “reproductive story” (Jaffe et. al, 2005). The telling of the reproductive story allowed the interviewee the opportunity to discuss her own feelings and efforts related to trying to get pregnant and eventually deliver a child. For some women, getting pregnant was not as much of an issue as delivering a healthy baby. Many stories were fraught with painful medical procedures as well as devastating miscarriages. The telling of the reproductive story also identified the point in which the biological mother became involved in the woman’s quest to get pregnant whether that included peripheral or active involvement.

The information collected during the semi-structured interviews was taken in three phases. The first phase covered demographic questions; the second focused on the participant’s “reproductive story” (Jaffe et. al, 2005). This allowed the researcher to discover where in the process the participant was in her efforts to get pregnant via IVF. The third phase of the interview included questions which explored the woman’s impressions and feelings about the historical nature of the relationship she had with her

mother as well as how wanting a child and requiring the use of IVF impacted the perceived nature of the relationship.

Statement on Protecting the Rights of Human Subjects Guidelines were followed based upon a proposal for research submitted to the Institute for Clinical Social Work’s Institutional Review Board (IRB). Informed consent was confirmed based on the participant’s understanding of her written consent. She was asked to explain her understanding of the research project as well as her understanding of her role in the project. If she did not fully understand the project and/or her role, further explanation was provided until her responses indicated that she understood her role in this research.

All participants were voluntary and had the option to decline participation. They were paid $20 for gas money, parking fees, and/or their time. The compensation was not intended to pay for participation in the research study; rather, the payment was an expression of gratitude for the willingness to participate. There were minimal risks and/or side effects, as there was no manipulation of subjects. The only anticipated risks might have been psychological risks because talking about IVF and the relationship with one’s mother could cause distress. .

Information obtained in the questionnaires and semi-structured interviews remained confidential. Identities of participants were removed and/or disguised. All data was encrypted and the computer was password protected. Data were placed in a locked cabinet in the private practice office of the researcher.

Limitations of the Research A limitation of this study was that participants had either average to above average health insurance or the financial capability to afford the costly procedure of IVF. Another limitation to this study was that changes could occur in the mother and daughter dyad across multiple IVF procedures. Lastly, this study interviewed women who volunteered to participate. Their perspective may have been different from those women who chose not to participate. This study captured feelings and assessments during the most current IVF procedure.

Findings

Introduction of the Findings This research integrated a mixed methods approach to data analysis demonstrating how multiple forms of data contribute to discovering all possibilities drawn within the data (Creswell, 2003). Results of the MAD were analyzed using computer software SPSS (Statistical Package for the Social Sciences). The demographic information was identified and categorized into descriptive statistics. The summary scores for the three subscales were computed and compared with demographic information, specifically whether there was any difference in scores between the women residing in Illinois or Missouri. While it was not the intention to have a divided sample, knowing that women from Missouri had the financial obligations that the women from Illinois did not, caused further examination as to whether that had an effect on the women’s MAD scores.

Data from the semi-structured interview was digitally recorded and transcribed after each interview was completed. As the data became available, it was coded using methods found in Strauss and Corbin’s (1998) grounded theory. A variation of open coding was utilized by analyzing whole sentences or answers to a question. The idea and/or concept was named so that a more detailed analysis could ensue. Categories were developed by conceptualizing “…events, happenings, objects and actions/interactions similar in nature or related in meaning” (p. 102, Strauss & Corbin, 1998). Axial coding followed by relating codes, categories and properties to each other, via a combination of inductive and deductive thinking. Subcategories were formed to create more well-defined and complete explanations about the phenomena by defining the when, where, why, and

how of a category. Eventually the categories were integrated using selective coding so that a central explanatory concept could be derived from the data.

Both quantitative data and qualitative data were examined and analyzed using a mixed methods approach, a concurrent triangulation strategy, where the researcher “…uses two different methods in an attempt to confirm, cross validate, or corroborate findings within a single study” (p.217, Creswell, 1998). Equal attention was given to both the MAD and semi-structured interview, but in analysis, the semi-structured interview was prioritized. The results of the MAD illustrated the participant’s current feelings towards her mother while the semi-structured interview enabled the researcher to gain a broader perspective as to whether the experience of IVF impacted those feelings.

Interpreting the integration of both quantitative and qualitative data “…can either note the convergence of the findings as a way to strengthen the knowledge claims of the study or explain any lack of convergence that may result” (p. 217, Creswell, 1998).

Summary of the Quantitative Findings The sample was composed of women whose ages ranged from 29-41. All of the women were in their first marriage. Eleven of the women resided in Illinois while 9 women resided in Missouri. Eighteen women identified themselves as Caucasian and 2 women identified themselves as Asian/Indian. Nine of the women had been married 4 years or less. Nineteen of the 20 women were educated beyond the high school level.

All but one woman were currently working full-time.

Of the 20 women who were interviewed, 16 were suffering from primary infertility while 4 were suffering from secondary infertility. Four of the 20 women were

from 1 day to 11 weeks pregnant via IVF at the time of the interview. Twelve of the women were approaching or just finishing their first IVF; 2 were finishing/approaching their second IVF. Four were approaching/just finishing their 3rd IVF, and the 2 were approaching/just finishing their 4th IVF. Six of the women were diagnosed with PCOS, 2 with endometriosis, 2 with tubal/anatomical, 3 with male factor, 2 with a combination of factors, and 5 with unexplained infertility.

Medical Diagnosis Cumulative Frequency Valid

Percent

Valid Percent

Percent

PCOS

6

30.0

30.0

30.0

endometriosis

2

10.0

10.0

40.0

tubal or anatomical

2

10.0

10.0

50.0

Male Factor

3

15.0

15.0

65.0

Unexplained

5

25.0

25.0

90.0

Combination

2

10.0

10.0

100.0

20

100.0

100.0

Total

The MAD questionnaire was developed in 2002 to measure adult daughters perceptions of their mothers in a culturally sensitive manner (Rastogi, 2002). The instrument contained 25 items, 18 of which assessed three subscales: connectedness, interdependence, and trust in hierarchy. The other seven questions assessed the geographic demographics and frequency of contact between mother and daughter as well as the daughter’s perception of the level of emotional closeness and level of satisfaction.

In terms of physical and verbal contact and proximity, 65% of women saw their mothers at least monthly.

Often see mother Cumulative Frequency Valid

Percent

Valid Percent

Percent

about once a week

7

35.0

35.0

35.0

About once a month

6

30.0

30.0

65.0

About once every few

6

30.0

30.0

95.0

1

5.0

5.0

100.0

20

100.0

100.0

months Once or twice a year Total

The women from Missouri lived slightly closer to and visited their mothers slightly more often than the women in Illinois. Fifty percent of the women lived between 3-30 miles from their mothers.

Travel Mileage Cumulative Frequency Valid

30 miles or less but more

Percent

Valid Percent

Percent

10

50.0

50.0

50.0

4

20.0

20.0

70.0

4

20.0

20.0

90.0

1

5.0

5.0

95.0

1

5.0

5.0

100.0

20

100.0

100.0

than 3 miles 200 miles or less but more than 30 miles 800 miles or less but more than 200 3000 miles or less but more than 800 more than 3000 Total

Eighty percent of the women communicated with their mothers at least weekly and almost all would have communicated this often if they could.

Would Communicate Cumulative Frequency Valid

About the same now Much more Total

Percent

Valid Percent

Percent

19

95.0

95.0

95.0

1

5.0

5.0

100.0

20

100.0

100.0

With regard to the level of closeness, almost half of the sample of women felt very close to their mothers and felt very satisfied with their relationship with their mother.

How close Cumulative Frequency Valid

Percent

Valid Percent

Percent

Very close

9

45.0

45.0

45.0

Close

5

25.0

25.0

70.0

Somewhat close

4

20.0

20.0

90.0

Not very close

1

5.0

5.0

95.0

Not close at all

1

5.0

5.0

100.0

20

100.0

100.0

Total

How Satisfying Cumulative Frequency Valid

Percent

Valid Percent

Percent

Very Satisfying

9

45.0

45.0

45.0

Satisfying

6

30.0

30.0

75.0

Neither satisfying nor

3

15.0

15.0

90.0

Dissatisfying

1

5.0

5.0

95.0

Very dissatisfying

1

5.0

5.0

100.0

20

100.0

100.0

dissatisfying

Total

Assessing their relationship compared to other women’s relationship with their mothers, 35% felt their relationship to be stronger than other mother-adult daughter relationships and 45% felt their relationship to be as close as other mother- adult daughter relationships.

Current relationship Cumulative Frequency Valid

Percent

Valid Percent

Percent

More close than others

7

35.0

35.0

35.0

About the same as others

9

45.0

45.0

80.0

Less close than others

4

20.0

20.0

100.0

20

100.0

100.0

Total

The scores on the three subscales of the MAD were wide ranging. For the connectedness scale, minimum and maximum scores were 9 to 45. Participants’ responses extended from 12-43. For the interdependence subscale, minimum and maximum scores were 3 to 15. Participants’ responses were 3 to 15. For the trust in hierarchy subscale, minimum and maximum scores were 6 and 30. Participants’ responses were 7 to 26.

Descriptive Statistics N

Minimum

Maximum

Mean

Std. Deviation

Connectedness Subscale

20

12

43

32.60

7.022

Interdependence Subscale

20

3

15

10.95

3.017

Trust in Hierarchy Subscale

20

7

26

18.65

4.760

Valid N (listwise)

20

Since there was almost an even split between women residing in either Illinois or Missouri, there was interest in seeing see if there was any difference in the three subscales as well as levels of closeness. There was no statistical significance but the scale did show that women from Missouri felt slightly more connected to their mothers than the women residing in Illinois. There was no difference in how women from Illinois felt about their current relationships with their mothers and their level of satisfaction.

Within this sample, 15 of the 20 women were only or first born children. It was assessed whether this had an impact on the three subscales and it did not.

The Motivation to Contribute to this Study There were many reasons why women chose to participate in this study. Before introducing the semi-structured interview, women were curious about why this phenomenon was being studied. They found the topic relevant and emphasized the significance that their mothers held in their lives whether it was a relationship filled with love and mutuality or a relationship fraught with pain and dysfunction.

Many women felt it was important for them as well as for others to talk about their experiences undergoing IVF. Some felt alone and ashamed about their fertility woes. Women were surprised to find how many others did not admit to fertility treatments and how other friends, family members, and acquaintances refused to talk about their own involvement in fertility treatments. Moreover, attending fertility support groups did appear helpful initially; later, women realized that they were often the last ones in their group not to get pregnant.

Many of the women from Missouri had no idea that fertility treatments were covered by health insurance in other states. They discussed the anguish they felt over

money concerns, trying to decide whether to get a loan on their house to fund fertility treatments, borrow money from family, or forego fertility treatments altogether despite the strong desire to have a biological child. They felt isolated with limited social or community supports in place.

All of the women in the study expressed great interest in the findings of this research. Many expressed relief in having the opportunity to discuss their feelings with this researcher. They all requested a copy of the findings once the research was complete. Additionally, many voiced interest in participating in future research projects that focused on their experience with IVF.

Summary of the Qualitative Findings The results of the qualitative analysis found five relevant categories which described influences, transitions and adaptations that the daughter made with her relationship with her mother. There is a sequence to these categories beginning with the examination of the way in which the mother influenced the daughter from a young age and how this influence evolved over time. The analysis explores these influences and pays particular attention to how the mother and daughter relationship responded to the crisis of infertility. In particular, the focus will be on how the adult daughter understands and makes use of the relationship with her mother when trying to become pregnant via IVF. Further dimensions of each category will be explored at length. The categories are: -The Historical Nature of the Mother and Daughter Relationship -Conversations -The introduction of IVF -The grieving process -The dynamic of change

The Historical Nature of Mother (Category I) “I love my mom and I would love to be just like her as a mother”

Education The beginning of the open ended portion of the semi-structured interview focused on the woman’s memory and perception of her mother growing up. One of the first things discussed was whether the daughter felt that her mother influenced her with regard to education and schooling. For most women, they felt that college was an assumed “given.” One woman said, “My mom has a master’s degree and all through the years for me, it wasn’t a question of whether or not go to college, it was where and what am I going to study, so that kind of thing. I’m sure that was because of my mom’s influence”.

Another said, “There was no question of whether or not I would go to college. There wasn’t a, “do you want to go to college?” It was,” where you going to college?” And they actually paid for it.”

Almost all the women in this study attended college or post-secondary education.

Daughters indicated that their mothers recognized the change of expectations from their generation to the next. No longer was college a choice, but was deemed essential. For women of middle to upper socio-economic status, college was a culturally reinforced requirement and a necessity in order to “move ahead” and maintain one’s status.

In particular, daughters explained that after high school, college was prioritized over getting married and having children. One daughter remarked, “My mom always wanted us to not rush into marriage. I don’t know if that means she felt that she rushed into marriage or not. But she wanted us to go to college and know what we wanted to do

with our lives. “She actually tried to push me to get my master’s degree since my company paid for it at the time.” Another commented, “I never felt like I was adult enough to have children, to be responsible to be a parent. Education, though, was very important. I was the first in my family to get a college degree.”

Many women felt that going to college was extremely important for their mothers, but more discussed it as the thing to do. Even if the mothers did not go to college or finish college themselves, many women felt that not finishing was not an option. College seemed to represent a necessary milestone in the eyes of the mother. It was an imposed desire by the mother internalized by the daughter.

Daughters discussed the opportunities a college education might give them; a college education created opportunities and incentives. It was one way to protect a woman from being completely dependent on someone for income and/or support. One daughter said, “I think that when I was young, I saw my mom struggle and it was really hard after my dad left. She just basically didn’t have a lot of a career. At an early age, I understood the importance of not relying on anybody else, being able to take care of yourself. She strongly pushed and encouraged me to get an education and in fact, actually paid for most of my college education.” Another woman explained that in her family,”…you need your education just in case you get divorced.” Another participant stated, “My mom felt that if I get an education, I better use it. I want to make sure I’m independent financially. Once I got out of her nest, I never moved back and I promised myself , if I had problems, be like a plant, my seeds and roots and just be independent.”

Many women spoke about the pride their mothers felt in their pursuit of higher education. The daughters seemed to be satisfied in moving through this rite of passage despite not experiencing the same level of pride and enthusiasm that their mothers felt.

A college education also influenced how some daughters regarded their mothers’ choice of careers. One daughter shared, “My mom has been at the same job for the last 20 years and she’s been at the maximum pay scale. She gets a two penny a raise each year.

I wonder if that’s why she always pushed us to get more education so you don’t get stuck where you are.” Another daughter wished her mother had finished college. She said, “I always wished my mom had finished college. It was weird. I also wish she worked more.

I don’t know why. I’m definitely more driven. It was never a question of finishing college or working after kids. I’ve kind of gone in the opposite direction.”

In a few cases, the daughters wished that their mothers had pushed them more to pursue higher education. One daughter stated, “It was always important to have your college education, obviously, she being an educator. But she didn’t push me as hard as maybe I think she should’ve pushed because I think she just saw what needed to be done with education for now. She thought I needed my two year degree, go out, and then figure out if I wanted to go back to school.” One daughter disregarded her mother’s permission to “slow down” her pace in college and instead, kept moving ahead. She said, “I can remember in school, my mom saying things like, if it’s really stressful, you don’t have to push yourself through this. Take a year off and me thinking about my mother’s advice, I think I’ll do the opposite.”

Daughters spoke about the limits and frustration their mothers experienced because of their own lack of education. It was difficult to decipher if the mother was

indeed dissatisfied with her own path or if it was the daughter’s projection. While the mothers did not complain, a few daughters spoke in disbelief that the mother could be satisfied or happy with their own attained education or career/job position.

Career Some of the mothers’ attitudes about education also had a connection with their feelings about careers. Many mothers felt that their careers represented an identity or lifestyle. One daughter explained, “My mom’s work comes first. When my father left, they had just built a house, so obviously that came with a hefty mortgage. I think that was motivation for her. She didn’t want to be one of those mothers that gave up and went on welfare and didn’t have to work. She said, “That’s not me. I chose not to do that. I worked my ass off for you kids.” Another daughter commented, “Going back to work for her was just to have spending money whereas now both people/both parents have to work because they have to.” Another woman expressed a slightly different slant.

She said, “I think in a way, my mom going to work was a way for her to get away.”

Having a mother who worked and also took care of domestic duties had both a positive and a negative impact on daughters. One daughter expressed her admiration for her mother by explaining, “My mom’s amazing the ways she was able to balance her work life and us as kids.” Another daughter said, “My mother took a whole month and a half or two months after she gave birth to me. And then I went to daycare. She was happy to go back to work. It had been long enough. I was definitely a child of daycare.”

For some women, having their mothers return to work did have an emotional downside. One participant stated, “My mom worked the three day weekends while my dad took care of us. I remember feeling like we had more free reign over the house when

my dad was in charge. I was the third child; there are no baby pictures of me or anything.

I think as I got older my brother and sister were doing their things; I was almost an only child towards the end. I think I was starting to not want her to leave because I wanted her all to myself.” Another participant acknowledged, “My mom went back to work when I was seven years old. My grandparents were more present; therefore I didn’t turn to my mom a lot of the time. I went to my aunts or grandma for needs.”

Mothering For many women, having their mothers stay at home brought fond and warm memories. One women commented, “My mom was always home. She was a traditional stay-at-home mom. She was a great cook and loved to bake. She was always there.”

Another woman commented “Seeing my mom at home during the week makes me want to stay at home with my kids. I think it makes a big difference by being part of your kids’ lives and not having to dump them off and let somebody raise them.” Some women recognized the value their mothers placed on being a mother as evidenced by this comment, “Being a mom was where my mom’s identity came from. She was really wrapped up with my sister and myself.”

Daughters reflected that mothers created positive memories by not only being a stay at home mother but also by providing necessary and meaningful maternal functions.

One daughter recollected, “Seeing my mom has made me want to be a mom. She did special things when we were growing up. She would always make heart-shaped cookies for Valentine’s Day. I want to be able to do that. I want to be able to bring goodies to school or whatever.” Another daughter stated, “I have good memories of her being home

and I think about all the stuff she did for us. I had legendary slumber parties growing up.

We had free reign of the basement and we could do whatever we wanted.”

In many interviews, daughters recalled that their mothers were more in charge of the household and that oftentimes, fathers deferred decisions to the mother. One daughter stated, “My mom was pretty good. She was there for us; she was the rock. She was in charge of the family. If we ever went to our dad with a question, he said, ‘go ask your mother’, because he wasn’t going to make any of the decisions. She’s the matriarch, she’s in charge.”

Some women did not appreciate the efforts their mothers made in providing maternal and domestic functions until they became adults. A daughter stated, “I was always very proud of my mom working full-time and still managing domestic stuff. It wasn’t until I was in high school that I started realizing how many things my mom had to cope with and deal with effectively.” Another daughter explained, “I don’t think I appreciated my mom being a jack of all trades. As I get older, I don’t see myself as real versatile.”

Not all daughters had positive and idyllic memories of their mothers. Some described the difficulties and frustrations their mothers experienced when being the primary caretaker. One daughter remembered, “Sometimes my mom was pretty unhappy, so I think I associated having kids with unhappiness. Not that she was always unhappy, but she was definitely frustrated with being a wife as well. She would just get upset about something and throw things, not at us, but she would say, ‘nobody gives a rats ass about what goes on around here’ and then she’d run upstairs.”

Some daughters recalled painful conversations and interactions which seemed to set the tone for future mothering expectations. Comments such as “I was by myself. I had to

take care of everybody” as well as “I struggled to raise you kids. I did this for you” were used as an explanation for why the mother struggled to take care of the daughter. It was during these early interactions that daughters learned of the limitations of their mothers and what they could expect in having the mother meet her emotional needs. One woman stated, “My mom was always physically nurturing, always took care of us, but emotionally, sometimes there was a disconnect.” Another daughter put it succinctly. She said, “I think it was ingrained in me very early. I mean, I knew growing up my mom wasn’t going to be there for me. So it’s just how it is. It’s not a good thing or a bad thing, it’s just how it is.”

In speaking about these painful memories, a few daughters discussed how these memories influenced their adult decisions. One daughter stated, “My mom wanted us to consider her as our best friend. If she can share your secrets, she’s in control of every aspect of you and as I’ve gotten older and been on my own, I realize how unhealthy that is. So, it may sound bad, but I want to do some things she did but mostly I want to be a different type of mom that she was.” Another woman commented, “I would say that some of my decisions were very much influenced by my mom and others were sort of a reaction to her, to be different from her, to not do what she did.” One daughter stated, “I’ve always been extremely independent and very single-minded. I left home early because I just didn’t have any respect for the decisions that my mom was making in regards to her family.”

One daughter realized that her mother still functions in similar ways to how she remembers her to be as a child. She said, “I want to be something different than my mom because my mom is still at home and I think a lot of problems continue because she

doesn’t have anything else going on. My mom makes ways to be needed and I don’t live like that because it is not healthy and that’s why it’s important for me to kind of have other things going on.”

Mother as a wife One of the unanticipated directions of the interview contained daughters’ memories about their mothers as wives. In many ways women found it difficult to compartmentalize their recollections between the how they experienced their mothers as mothers as well as how they considered their mothers as part of a parental union. Some women cherished memories they had of their mothers as a loving partner to their fathers.

Some women spoke about their mothers and fathers and undifferentiated ways. In other ways, their mothers not only provided care-taking functions for them but also for their fathers. In some cases, fathers were mentally ill or emotionally absent in some form.

One participant disclosed, “I think my mom was overwhelmed because she was running the family business. My dad was doing his obsessive type things and there were certain things in the business that dad couldn’t do. He would rely on her, but she was also taking care of us two kids also.” Another said, “My father was kind of a drunk. Nice guy, but not around a lot and my mom had a rough time. As a kid I thought he was a nice guy who never complained. And then later as an adult, I thought my poor mother and all she had to deal with.” One daughter was also enlisted by the mother to help the mother cope with her father’s mental illness. According to the daughter, “My mom and I would talk about my dad, like how to protect him. We wouldn’t watch a certain movie or TV show because he would get upset about it, like conspiracy movies and stuff like that.”

The daughter gave various examples of observing her mother getting little to no respect from her father. One commented, “My dad was never really there. My mom was expected to do her wifely duties and shut her mouth. Another participant revealed, “There was always the question of my dad cheating on my mom. There was a lot of fighting about things like that. I just thought, my God, this is awful. I could not get out of the house soon enough.”

In many ways, daughters relied on their mother for everything despite her parents being married. One participant shared, “My mom was always there for me where my dad, God rest his soul, he wasn’t. He would rather drink or do a lot of things that he shouldn’t have been doing.” Another woman reflected, “I’m pretty sure my father was bipolar. We lived off my mom’s salary and financially, that’s how it was. My parents were really very separate people.”

There were emotional consequences to witnessing the strained relationship between mother and father. Oftentimes the parental conflicts consumed the mothers to such an extent that the daughters felt as if mothers’ judgment about caretaking capacities were not intact. One daughter expressed, “My mom was very emotionally cut-off. Her denial was very high. It would be like talking to a brick wall. Her denial was almost dissociative. It was awful living in a house like that. My mom had chosen my dad, I feel like, for years.”

Another commented, “I always knew from a very young age that what was happening in my house was not normal and not healthy and it was not anything I wanted to be a part of. I just never had a lot of respect for my mom not standing up for her kids who were in a very volatile environment or herself for that matter.”

For women whose parents divorced, that also had lasting negative consequences.

One daughter stated, “My mom never got over my dad leaving her. She basically hates him to this day, which is really sad because they’ve been separated much longer than they were ever together, and it was a really long time ago.” These hurtful feelings were especially evident when the daughter felt the mother paid more attention to her boyfriend’s feelings than her own. She said. “I had friends, but it was just basically my mom, so I felt very lonely. She was dating a man at the time, who was sort of emotionally abusive. I sort of resented my mom for that and I distanced myself emotionally from her.”

Conversations (Category II) “She steps away from our personal issue and speaks globally, ‘It’s natural for people to want to have their own children, and you shouldn’t feel guilty about that”

In exploring the conversations between mother and daughter, part of the semistructured interview asked participants to comment on whether or not they had talked about having children before trying. For one woman, the conversation about becoming a mother has been a constant for as long as she can remember. She explained, “I always discussed it. When I was really young and I didn’t really know where babies come from, I knew I wanted to be a mommy.” For another, the conversations were more global in nature. The daughter described her mother as saying, “Well, it’s natural for people to want to have their own children, and you shouldn’t feel guilty about that.”

The conversations demonstrated the tone and assumptive qualities about having children. For many mothers and daughters in this study, having children was expected with no consideration that it would be difficult to conceive and deliver a healthy baby.

Some of the mother and daughter conversations focused on the daughter expressing ambivalence about having children as well as the possibility of not being able to have a child due to medical complications. One expressed her anger at her mother’s constant prompts at having the conversation. The woman would tell her mother, “I can promise you that who knows what’s going to happen.” Another told her mother, “Someday when I have kids or maybe I won’t even have kids.” One daughter explained that her mother handled her PCOS diagnosis so poorly that the last thing she wanted to do was talk about difficulties in conceiving due to the PCOS. Having children was a choice for the daughters interviewed in this study. The act of trying to become pregnant required intentionality. Daughters described wanting to take responsibility for their own choices rather than succumb to their mother’s desires.

The milestone of marriage prompted the child conversation for some women. One daughter stated, “After I got married, my mom called me all the time in regards to having children. She started the pressure and said, “Come on, let’s go! Do it! When?! Now!” Another woman explained that every time she would see her mother, she was every time about when she would have children.

The daughters highlighted what was evidently a major difference between their generation and their mothers generation, in their opinion, that marriage did not imply immediate plans for having children. Daughters recognized they could be married without necessarily having to move on to having children.

For some of the mother and daughter dyads, the focus was more on the mother becoming a grandmother rather than the woman becoming a mother. One participant explained, “My mom has made no bones about the fact that she wants grandchildren. I would hear about it all the time. She would find ways to bring up random people that I didn’t even know and say that they would be having a baby.” For a few, being an only child seemed to increase the pressure to have a child. One woman stated, “My mom always wanted grandchildren because I’m the only child. She’s always been hopeful and I would say, “I will or I won’t, we’ll see what happens.” Another woman had similar thoughts. She said, “I think she wants me to have a child so bad just so she can be a grandmother. And I’m her only chance to be a grandmother.”

Being a grandmother seemed to represent something to the mothers. While some expressed being the last or only chance to become a grandmother, another also explained becoming a grandmother would provide a distraction for her mother. She disclosed, “I think mom’s living for grandkids now. She’s having a hard time since she’s remarried.

They’re having marital problems. But now her focus is on grandkids because she sees that as a positive thing.” Another daughter said, “She wants this as bad as I do. It’s like her whole life is revolving around this possible child. It puts a lot of pressure on me.”

Turning Points At some point in the discussions between mother and daughter, the fact the daughter was having problems getting pregnant was introduced. For some mother/daughter dyads, this conversation was a turning point so that the difficulties with becoming pregnant were introduced and integrated into dynamic relationship between

mother and daughter. For some women, the turning point occurred after experiencing a medical procedure or suffering a miscarriage. One woman said, “I told my mom when my brother and sister-in-law got pregnant cause I kinda lost it. They were younger than we were. They got married a few months before we did and they decided to tell everyone they were pregnant when they were six weeks along. I called my parents and I was crying, and they asked what was wrong and I told them. I said I wasn’t upset about my brother getting pregnant, I said I’m upset because we lost a baby and we can’t get pregnant. After that, my mom asked what was going to happen next, but if she didn’t understand, she wouldn’t ask many questions.”

Another disclosed “After the surgery for my D and C, was the turning point when I told my mom we were having problems having a child. I did convey a lot, but what I didn’t realize was that they had their own grieving to do for their deceased grandchild. I didn’t realize that I had a cousin get pregnant soon after I lost my baby, before I got pregnant and she couldn’t tell me how hard it was for her not to have a grandchild.”

Another participant described the subtle yet supportive tone her mother expressed after learning about the participant’s miscarriage.

“My mom knew when we were starting to try to get pregnant. I guess I kind of told her as things went on. We had a miscarriage, and I had told her that we had had a positive

pregnancy test. She knew when I started spotting, she was very supportive…just quietly there…very unobtrusively present.”

The daughters who disclosed in these examples conceived naturally but were unable to carry their child to term. They expressed dire grief and mourning for the loss of their child but also experienced a sense of personal failure in the wake (or light) of others’ successes. For some participant’s, the loss and anguish was too much to contain and regulate by oneself and her spouse; the act of sharing with one’s mother was a step indicating the daughter’s need for understanding and comfort. The daughters decidedly invited their mothers into their world of pain.

For women who experienced medical procedures when their mothers were present, found out the same time their mothers did that they required ART to get pregnant.

“Last summer, when I had the surgery, my mom and dad were the ones who took me to the hospital. My husband met me there. And so they all knew when I found out I couldn't have children. I basically found out I could never have children if I didn't do IVF because my fallopian tubes don't work and that you need those things to get the egg and sperm together. Since then my mom's been very supportive. I would say conversations are more superficial, but she's very supportive.”

For other women, they disclosed their difficulties when having an active conversation about someone else who was also having struggles to get pregnant. One participant shared her story in a more matter of fact manner. She explained,

“I finally said something at a family party. They were talking about grandma who had blocked tubes and I said, “Oh, that might be my problem too. That was the first time I opened up to my family. My grandmother said something to my mom and she called me the next day. She said, “I didn’t want to ask you, it’s been awhile and I thought you’ve been married for two years, I was kind of wondering if you guys were trying.” I said, “Well, yeah, this is the situation.” I think my approach is to this whole thing has been, I don’t really openly talk about it, but if someone asks me, then I will share, but I don’t bring it up. But I know my mom, she didn’t want to ask, so I just never talked about it.”

Daughters seemed to have a sense of their mothers emotional availability in providing the support and emotional responsiveness they needed. By informing mothers in an informal way, daughters created a certain emotional distance. There were assumptions that the mother would not know how to take the news of her daughters problems; therefore, the daughters prevented opportunities for the mothers to confide in this experience.

Even for daughters who knew their mothers/parents had fertility concerns, finding out they had their own opened up a new dialogue between mother and daughter. In some ways the conversation took on a competitive tone. “I don’t think she means to be

competitive but the way she sees it, is, ‘I never had to do that, so you shouldn’t have to do that’ or ‘I can’t understand why you have to do this, I never had that type of problem.’

Other participants were given information by their mothers in a less stigmatized and straight forward approach. “My mom’s problems have always been on the table. And back then there was less education about it, but I don’t think she truly understood what her problem was. Another participant expounded, “My parents had fertility issues. My mom ended up having all three of us with half an ovary. I think it was endometriosis related. And I learned this all now…” The possibilities, options, and methods were so different from the mothers’ generation to the daughters’ generation. Daughters described their mothers having to “wait” to get pregnant while they are more focused on when, where and how to pursue ART (Assisted Reproductive Technology).

It was a more emotional experience when one daughter divulged her grief about another person’s IVF struggle when she came to realize and find out that her parents had their own fertility struggles which they never disclosed.

“I told my mom about my friend from high school who had to go through IVF. I started crying just telling her about this other girl. Then my mom sort of mentioned that she and my father knew what is was like to monthly wish and hope that her period didn’t start. But it wasn’t until I got the doctor’s questionnaire to fill out, I discovered my parents had problems conceiving too.”

For some women, the turning point occurred when they intentionally decided to delay or not to tell their mothers about their fertility struggles. Their mothers’ responses seemed to vindicate their decisions. One participant shared, “Once we started having troubles conceiving my husband and I made a decision that we were not going to involve our parents or tell them or tell anybody about what was going on. It was not until I got pregnant with my son that I told my mom that it was through IVF. My mom didn't say a word. My mom, she gets mad she stops talking to me. I knew she was upset. I never knew that once she knew, she wasn't going to let it go. It was never about us, it was about her. She likes knowing because she then she had an excuse for us not having kids because people were always asking her. She didn't like not having an answer for her friends.”

Another woman explained,

“Over the summer, when went through with an IUI, I told my older sister and I told her I didn’t tell anyone and to please keep it a secret. The day of the procedure, she told my mom. So my mom started calling me every day and she would show up to my house unannounced to try to figure out what was going on.

She became incredibly intrusive and I wasn't comfortable sharing it. It ended up not working, so it added to the emotional trauma of it all. It just confirmed to me at that point, I just can't tell anyone anything. I don't want everybody to know

because my mom will call all her relatives, her friends, she calls everyone so everybody knew that I had gone through that.

By disclosing fertility difficulties, women experienced a closer relationship with their mother which included a dialogue about alternative fertility treatments. One woman described, “Basically, my thyroid got out of control, and I didn't know it, and I pretty much thought I was going crazy, and I called my mom up crying, and I don't know what I'm going into, and she was like, I can get anxious to, and there are things you can do. I was on the edge, I didn't know what to do anymore, and that got better, and I've definitely talked more to her since. She was like, ‘you can try meditation’.

And so I started looking into some of those things. We went to a class when she came up to visit. We went to one together.”

Another woman stated, “It was never a surprise that I couldn’t get pregnant given my family history, but the diagnosis of endometriosis was a surprise because no one in my family had it. My mom and I would talk about it and she suggested B Vitamins. She was very much into natural cures. She wasn’t ever telling me what to do. Involved but not overbearing.”

In some cases, the conversation went no where much to the daughter’s dismay.

“I eventually said mom, ‘it doesn't appear that we can have any more kids’. She did note that I went to the doctor. I told her I was going to the reproductive

doctor, and she never asked anything about that. I think she would talk about it with me if I'm willing to say, ‘I'm really hurt’. But where is that going to go? If it were anything else, she would be totally there for me.”

The Introduction of IVF (Category III) “These are hard decisions that I've had to make. This is a major life decision, and I really want her to say, “You know, have you thought about this, this, this and this?”

Once women introduced IVF to their mothers, how the mother handled the IVF news determined what was shared. The semi-structured interview asked the adult daughters to reflect on the dynamics once the necessity for IVF was disclosed. There were some daughters who felt as if their mothers could not understand the complicated nature of the medication protocol as well as the side effect of these medications. On woman wrote,

“Even when I was home over the holidays and taking all this medicine, she doesn't understand what the medicine does to you, and giving yourself all the shots, her response even when I was going through IUI or IVF, one of her responses, as sympathetic as she was, she would say, oh, well I never had to do that. So it's almost like since she didn't have to do it, she can't understand. And by saying that, I never had to do that it makes me feel like, well like my infertility was better than your type of infertility type.”

Other women discussed feeling as if their mothers were not sensitive to their feelings. The mother would be more focused on her feelings and oftentimes the daughter felt judged by her mother as evidenced by the mothers expression and tone of voice. “I think sometimes I feel my mom thinks of me as a freak, or maybe that’s my own projection. You know, like, where does this come from? How come? We don’t have any family members that have this problem, so she’s looking at me wondering about me being her child. What a weird anomaly I’m having this problem now. She’s been taking me to the hospital since I was 12 or 16 because of irregular periods.” When we initially told her we were having problems conceiving and we are going through all of this, my mom's response was, well I don't understand I never had trouble, grandma never had trouble, and aunt Susie never had trouble, no one has ever had trouble, I don't understand.”

Another woman commented, “I knew that once my mom knew we were having problems getting pregnant, she wasn't going to let it go. It was never about us, it was about her, but part of me thinks, I think, she liked knowing because then she had an excuse for us because people were always asking her. It became, “poor Liz, doesn't have any grandchildren because you know, Steve and Kathy don't want to try,” and you know, that kind of thing. I think there was a lot of that. They didn't like not having an answer for her friends.”

In other ways, some daughters felt their mothers minimized the emotional pain of each step of the IVF process presented. One participant said, “She doesn’t really give me that much support, I guess. And I don’t think she understands it all. She thinks, “It’s ok,

you’ll just try again,” I think. She feels like the eggs are all there and it will happen.”

Another shared, “There are times where my mother kind of feels like, well you've been upset about this long enough, you just kind of need to get over it and move on. Like sometimes she can be really tough and say, ‘Well, you need to get over it’. And I don't think she understood like the long depression that I had after that (which was a miscarriage).” “My mom can be sensitive to another woman having IVF but she doesn't equate me with it, I went through the same thing too. She doesn't think about it at all about what I went through.”

A daughter described the maddening tone and upsetting experience she had when talking about IVF with her mother. She said, “It frustrates me sometimes and it angers me other times, it just makes you roll my eyes and just not want to talk about it with her.

She’s not the first to call up if something has happened. It's almost more like, ‘okay, well I guess I should tell my mom about that now to just to keep her in the loop’, because like I said, she still is my mother and I do love her.” What is clear is the conflict in taking care of oneself emotionally by concealing IVF progress/lack of progress yet feeling obligated to share personal information with one’s mother because it is the ‘thing to do’.

A mothers response could determine the tone of future conversations and what information and/or emotion would be forthcoming. Having a mother not understand the details of IVF was an empathic failure. Daughters’ reactions ranged from sadness and disappointment to apathy and rage. One daughter recollected a most recent conversation with her mother. She said, “After telling my mother about IVF many times, I told her were going to do IVF soon and she's like ‘ yeah yeah you mentioned something about that’ then she's like ‘now what is this IVF again?’ This is something that we've had a

conversation about and I was like are you kidding me right now? You don't even really remember? I'm like wow okay.”

Follow up questions and displays of curiosity by mothers demonstrated care and interest in the well-being of the daughter. This could be the case for both the IVF as well as adjunct treatments. One participant stated, “My mom is curious, she’ll ask questions but with the acupuncture she never asked follow-up questions because a lot of people are curious. ‘Do the needles hurt? Do you bleed?’ Please ask all sorts of questions, but the fact that she asked no questions on it lets me know, based on who she is, she really doesn’t care for it.”

An interesting twist to that was how one woman described her mother as not knowing the IVF process yet having the education and work setting to do so. By pleading ignorance, the mother could support her daughter’s quest to get pregnant using IVF while the IVF process was something the mother opposed on both religious and ethical grounds. “The process of IVF, I don't think she knows the exact steps of it.. I think she would have had a much different reaction towards me, and I didn’t take the extra step to explain the process to her. We just talked about the shots and the side effects and the pills and everything. The medical staff has always been really easy to talk about with her because she’s a nurse. She deals with patients who are dealing with difficult things everyday and she gets it.” The mother in this example understood that the medical process was indeed invasive but did not acknowledge the functions and purposes of the shots and procedures.

For women who were experiencing both primary as well as secondary infertility, mothers’ responses could be confusing and unempathic. For women suffering with

secondary infertility, the idea that since there already was at least one biological child, there was no reason to go through IVF. One daughter said, “My mom told me a story about a woman who couldn't have a second child and I commented I'm sorry she's not allowed to mourn the fact that she can't be pregnant second time? And my mom said well, I mean she already has a family. And we just went back and forth and finally I said to her, well were obviously going to agree to disagree, and I don't want to continue this conversation with you.” Another said, “In regards to secondary infertility-I think what she's trying to say is be happy with what you have. And we're happy with what we have.

But what I hear her saying is totally different. Because she doesn't understand what an emotional roller coaster it is. I guess I expect her to ask more questions to be more involved in our treatment.”

IVF was not available for the mothers when they were building their families.

IVF promises the hope of a child for these daughters whereas, for their mothers, a child was determined by medication and biology alone. These daughters feel as though they have some element of control in expanding their family by using IVF. “I think a lot of it stems from the fact that she didn't have trouble at all with her getting pregnant the second time. And so she can never understand not having enough any children and wanting more because she got pregnant a second time right away. She never had to go through that feeling of ‘my family is incomplete’. So she never had to think ‘If I were to only have one child, is it okay with only having one child.”

Evolving Communication The role of questions and curiosity seemed to indicate that the mother had some interest and perhaps supported the daughter’s decision to pursue pregnancy via IVF. In

the daughter’s eyes, the dialogue represented a level of care demonstrated by the mother.

In an effort to help and support IVF success, mothers and daughters pursued their own research and quest for knowledge, some of which included alternative or unconventional treatments/supplements. One participant said, “When I couldn't get pregnant, my mom and I went to the Chinese herbalist together. She said, ‘okay, okay, Clare, whatever works.’ She was looking at me like I’m strange, but she was supportive.” Another participant was surprised by her mother’s suggestions. She commented, “My mom is very much into natural cures, which is funny that we go the IVF route and kinds of things that are not very natural. I mean, I was putting all kinds of crazy drugs in my body. My mom would read this and suggest us try things like vitamin B. My mom was involved, but not overbearing. She wasn't ever telling me what to do.”

In other ways, alternative treatments further reinforced a disconnect and unempathic response between mother and daughter. One daughter explained, “The whole diet and acupuncture and all that stuff, I think she thinks it's kind of silly. Like is that really necessary?” By trying another form of adjunctive treatment influenced by the mother’s decision, a daughter felt obligated and resentful of her mother’s financial providing of acupuncture. She said,” After my failed IVF, my mom said I really needed to do acupuncture. She knew someone who did that and that person got pregnant. My mother said ‘I think you need to do that and I’m going to pay for it’. I said ok, fine, I’ll do it. It didn’t work but I felt obligated. She paid for it so therefore I had to tell her things. I’m not doing that again.”

Another form of caretaking occurred when mothers accompanied their daughters during the IVF procedure(s) and recovery period afterwards. Some daughters described

wanting their mothers present during every step of IVF. In fact, the mothers were more active witnesses and significant supports to the daughters than the daughters’ spouses.

“She's been through every procedure, every medical procedure and I want her there.”

Another stated, “My husband is not one that wants to be in the room for the IVF. So my mom is there for all of it. When I got pregnant with the first IVF, my mom was there I said, ‘Mom you were in there when I got pregnant’.” In some ways, daughter’s described the IVF procedure as too invasive and upsetting for the husband to witness. “So she was really excited to be there which is good because my husband kind of freaked out at the last minute. The idea of it… because he didn't understand that it wasn't painful. He just thought ultrasound, catheters, needles, so he went out into the hall and he couldn't even be in the clinic. It really freaked him out. My mom stayed in the room during the transfer.”

Daughters described their mothers as more able to tolerate the IVF procedure than the husband. Additionally, there were assumptions that the mother should physically and emotionally take care of the daughter after the IVF procedure. Daughters spoke as though they welcomed the experience of having their mothers care for them once again after so many years. “After my IVF, I go and stay at my mom's. My mom takes care of me just like I'm a kid again. She cooks and makes me lay down on the couch and do nothing. She's already said, “Now you know your coming to stay at my house”. I say, ‘Oh yeah mom, sign me up. I'll be there. Don't you worry.” Another daughter described a similar exchange between her and her mother. “After the doctor explained that I would have to be on bed rest after IVF and I didn’t say anything. My mom said, “Well, I’ll come stay with you for those three days. And I was like, Really?” She’s like, Of course.

You need someone to take care of you. Your husband will be working.” So I said, “All right.”

Mothers support was evident when they could use their own medical expertise to reassure and guide their daughters in the dosing and administering medications in preparation for the IVF procedure. “My mom's a medical technologist, When I have questions about shots, and I think I messed it up, I will call her and she would tell me what's what and how to draw things and stuff.” Similarly, another said, “My mom knows enough that she can reassure me about dosing medication and bleeding. She says it’s okay, but don’t do this or that.”

After the IVF was introduced in the mother/daughter dialogue and more detailed accounts of medical procedures took place, the mother and daughter reached a new way of interacting which integrated the IVF experience. Because the IVF process requires months of preparation a mother and daughter must find a way to talk about trying to become pregnant via IVF so that it does not consume the entire mother/daughter relationship. “Sometimes it's just you don't want to talk about issues surrounding your fertility/infertility treatments. Other times you want somebody to ask about it (the fertility treatments) because of how sad or emotional you are.” Another daughter described the push and pull aspect of sharing conversations and conveying her need for her mother.

“She's probably afraid because I think I can just be downright defensive, which probably comes across as I can be really mean if you ask me the wrong question, so leave me alone, which it didn't come to that, but she's going to know that there's something she shouldn't push, and she's probably smart not to do that.”

Other women spoke about attaining a balance they share with their mothers. “I kept her up to date with everything that I was doing because it was up and down in terms of suspense, failures. The failures, definitely, I let her know. She got the brunt of my frustrations, like when I was angry, I would tell her stuff. I didn't get mad at her, just mad at the situation.” Another stated, “I never realized how strong I could be, and she helped me to realize that because she just keeps saying, just like when I would go through breakups, ‘This isn't the end of the world. It's so devastating. You will get through this. It will be okay.’ You know, the same thing that every mother should say to their child.”

Feelings did not always have to be specifically communicated verbally for daughters to feel loved and supported. One said, “She's been really supportive even without having to say it. She's tried not to ask me questions. I wish I lived closer and stuff like that. It would be even better if they were closer but I think that e-mailing has helped too. If we didn't have e-mail, I don't know if we’d talk on the phone instead of that. I think that it might have increased more silence between the two.” Additionally, prayer functioned as a substitute for communicating support and understanding which also seemed to reinforce the mother’s defensive intent not to fully acknowledge her negative feelings about IVF. This daughter stated, “ I said it didn't work and then as time continued and it started getting worse and worse and we didn't get pregnant she knew how frustrated I was. She would pray about it. It was expected. I think it was better than hearing responses similar to other people that ‘it will happen when it's supposed to happen’.”

For other daughters, the sharing of the IVF experience reminded them of past disappointments in trying to communicate their needs and establish a dialogue around

those needs. “I tell my mother things out of obligation. I do want her to know, which I guess that's something of an obligation, but I do know that she loves me, and she does want the best for me, so it is support. If she could do anything to help she would type of thing.” For another daughter, it took many other missed opportunities of sharing and ‘getting it right’ until the third IVF attempt. She stated, “Now that this is my third round of IVF, my mom’s giving me space, which is good. When it first happened, she wasn’t giving me space. I just don’t want her to pressure me again, so she’s going to want to know when, what, where all that. I want us to surprise people. You know, that makes sense.”

The Grieving Process (Category IV) “My mom’s responses make me realize how much you can love your child and feel their pain. She does. She feels everything.”

The grieving process between mother and daughter can be both a separate and mutual experience. The times of sadness usually took place when the daughter was given specific news about the viability and possible success of IVF. Whether it was how many eggs the doctor was able to retrieve, how many eggs were fertilized and survived to the blastocyst stage before being transferred, the approximate two week waiting period until finding out if the IVF facilitated a pregnancy, and monitoring hormone levels after positive pregnancy test; all of these stages in the IVF process could deliver unwelcome bad news as well as good news for the daughter. The gradual steps in the IVF process promoted intense anxiety, hopefulness and dread in the daughter. Many mothers sensed

this in their daughters yet had to find a way to regulate their own feelings of anticipation and possible sadness.

The daughters spoke about how their grieving did not match the level and progression of their mother’s grieving. One daughter said, “When something wouldn't work I would say, no, I had enough, I don't want to do it anymore. Then she would be disappointed, oh, are you sure? You want to try another one…trying to encourage me to continue. For example, after a failed round of IVF, all of a sudden, she's like, when are you getting back into it? And you should try some more of this or that, so she didn't give me that much room to mourn.” Another participant expressed how the role of sadness was differently metabolized between her and her mother. “I say that I'm concerned about that and notice that, gap (the difference how mother and adult daughter process emotions). I like am ready to move onto the next thing and she's not, I doesn't seem to be.

And then, I wonder ‘Is it because of me that you're sad’? And now I feel better and I'm looking I see that you're sad, whereas before I was the only one sad. I wasn't paying attention to you, which was bad.”

Some women did not have a dialogue about the emotional difficulties associated with IVF. “I never tried to make her understand how challenging or emotional this is.

She knows it’s hard so I don’t know if she knows to the extent of how hard it is. I’ve never had that conversation and I don’t know if I ever will.” Other women conceal their emotions because they do not feel their mother is in a position to cope with strong feelings and affect. “In regards to IVF process, I prefer to not discuss it, my mom can't handle emotional problems, so I don't usually share when I'm very upset. Sometimes, like anyone, I can't keep it from her, and she can tell. But for the most part, if I'm upset about

something, I do not unload a lot of it on her.” Another woman commented, “I don’t want her to worry because she is a worrier and she’s got time to worry about it. There are issues with everyone in our family. So, I just don’t even want to cause more stress to it.”

According to many of the women in this study, their mothers became just as emotional and sometimes more so, especially in regards to the depth and staying power of emotion as they did. Working through the roller coaster of emotions associated with IVF sometimes meant that daughters felt compelled to protect and take care of their mothers emotionally. Daughters projected more emotional strength in an attempt to help their mothers feel better about the IVF situation. “I feel like I’ve been really selfish lately, so I feel like it’s all about me and whenever I’m sad, it definitely makes her sad.

So, I’ve been trying to be more conscious lately. I’ve been feeling better so I’ve been trying to pull her back up with me. She gets sad and doesn’t go out and I worry about her.”

Another stated, “I don't want to give her tension. When I call, it's always the night there and it's morning here. I don't cry or anything on the phone because if I cry now she can’t sleep all night.”

One woman expressed her wish that her mother was more ‘strong’. She said, “I want her to be strong. I can tell she's down. She's coming to see me. She never used to come visit me ever. She comes every couple of months and just stays with me for three or four days at a time. It's really really hard on her. And I can tell.” Some daughters wanted their mothers to be more capable in handling the emotions and yet felt absolutely responsible for bringing heartache to their mothers and pressured to help their mothers feel better, “But yeah, whenever I things going on and things on my mind, if I tell her

about it, she too will be sad. And sometimes she’s sad a day later than I. I wonder to myself, ‘If I feel better now, you should feel better too. Come on’! It might take her longer for different reasons.” Another woman illuminated the dynamic between her and her mother. “In regards to not being able to carry a baby, I know emotionally it's hard on my mom. But I tried to be strong, even though it's me that it's happening to and say, you know, maybe God knew something….I don't want to make light of it, I had to make it easier for me to take: So I just say, it's okay mom.”

Some daughters felt obligated to take care of their mothers given the care their mothers had shown them. “I may feel let down if I didn't take care of her. That comes from my mom because my mom had always been there to take care of me and pick up the pieces. I just pick up the pieces and tell everybody it's going to be okay. My mom is still that way with me too, its okay it's going to be okay. I think deep down it hurts my mom when I've had miscarriages because she's afraid of how it affects me emotionally.”

Sometimes when a daughter sensed that she could no longer care for her mother’s emotional health, because she was trying to take care of herself, she suggested that the mother seek support from other people. Daughters felt this was a healthy and necessary step because it was too difficult to be distracted with their mothers’ well being while trying to regulate their own feelings about trying to become pregnant via IVF. “I didn't realize that soon after I lost my baby, before I got pregnant through IVF, she told me how hard it was for her to not have... She had those angry feelings and stuff and we talked about her maybe needing some counseling too, you know? It was difficult, and so even with these optimistic numbers now when I called her yesterday, I said whoever you've

been talking to is your support through this; go ahead and tell them whoever you've been close to, tell. You know what we’re going through, this is not a big secret.”

Another felt relieved that her mother had sought support from someone other than herself. “One time my mom told one of her friends at work about my fertility problems in confidence because I think she really needed to have support with what were going through. I was fine with that. But it made me realize that we’re not alone. And they probably feel like they're alone whenever we tell them not to tell anyone and that kind of thing.”

Many other women detailed the powerful empathic experience they shared with their mothers when they were able to mutually exchange grief and anguish. The daughters’ experiences of having their mothers feel their pain to the same degree was profound and meaningful. “The first time I e-mailed saying that the IVF didn't work, my mom wrote back a day later saying that it took her this long to stop crying about all this.

So I do feel like she's kind of living it with us. It's almost easier to read as opposed to talking, and my mom even said that in an e-mail. It's really hard to have a conversation on the phone when you're crying.” Another woman stated, “It was kind of hard hearing her cry because I know it was good and probably needed to cry and I cried already but it was hard because hearing her cry makes me cry, you know, cry more so were both on the phone just sobbing. I guess I probably needed to do that too. She knew that I was going in for the ultrasound and I, and then I'm like, “I don't know.”

Crying at the same time gave mothers and daughters the opportunity to mourn in a mutual and connected way. “She cries now when I called to tell her that the tests were negative. She's crying just as hard as I am. And I'm like," mom, stop crying, you always

make me cry harder." She's like," but I know how much you want this. It's not fair." “I started keeping my mom informed after the third IVF. Literally harder this time. I had called her and it was like harder for me to tell her that just me knowing. I think it was-an emotional thing. I think I'm okay, but as soon as I hear her voice and she starts asking me questions, it makes me cry and I get really emotional. I'm like, why, I was so in control 5 min. ago. I don't know if it's a comfort thing with your mom you can just let go, but let it out and be yourself where you don't have to try to have to maintain this hard outer shell.

But then when I talk to her, I cried.”

Coping with infertility was something some daughters had in common with their parents. The parents dealt with the feelings differently in some ways. “I think it was really hard for her because she had been through it herself. And so it was painful to watch me go through it. And that was one of the reasons they gave us the money for IVF because they said they had been through the same thing and they knew how difficult it was and the fact that they were in a position to be able to give us this money to us, they did it without a second thought.” Another example demonstrated how the act of just being available to talk and feel was resonating and soothing for the daughter. She shared, “She's told me about how she remembers how hard it is to go month-to-month waiting and hoping and getting the disappointment. That was part of the time when she was talking about the whole seven-year thing and waiting to get pregnant. She remembers how torturous it was. And it's like losing a baby every month almost. And she actually had a miscarriage between my sister and me. Stuff like had that baby lived, I wouldn't be here. She said that before. So obviously my parents are grateful that I'm here. But I don't know, just like I am right now, whenever I talk about it just my mom, we just sit and cry

together which makes me feel better to know that I'm not just like a psycho crying all the time.”

Other daughters mentioned how they tried to regulate their sadness by expressing grief yet moving through it in a mutual supportive way. “I think she hurts more now when this doesn't work cause she was sobbing and I know it's not like she's making me feel worse, but she just cries just as much as I do. And today she said I prayed two decades of a rosary already for you today you’re the only one who gets two decades you know. I’m like okay.” Another form of coping was the swift moving on to other topics.

“My mom asked me what were your results, and did they come in? I say, well, it’s okay, this time it’s negative, but we’ll try one more time, but I don’t’ want to cry or anything.

And then I quickly change the topic. She does the same to me. She’ll say, “don’t worry, you’ll get it next time.”

The Dynamic of Change (Category V) “I don’t know what I’d do without my mother”

For many women going through the IVF process impacted the relationship with their mothers. In particular, after the shock of the infertility diagnosis and the decided IVF plan, mother/daughter dynamics and ways of interacting changed to some degree.

Daughters reported gaining a certain perspective and maybe insight into the inner workings of their feelings about their relationship.

Daughters expressed that they have come to accept, with its given strengths and weaknesses, the relationship with their mothers. “In regards to the quality of the relationship, I feel like it's fine. It is what it is. I don't feel like she has made good

decisions in her own life, so I don't feel like she's qualified to give me advice, but I do talk to her about general things that are going on, and she tells me general things that are going on in her life. Another daughter stated, “I'm fine with the relationship. It’s not the best we've ever had at this point, but certainly not the worst. She's in my life. She knows what's going on in my life for the most part. I'm glad she's there. I lost my grandma almost 2 years ago, we were really close. It was her mother. It kind of makes you appreciate those in your life more.”

Daughters came to terms with their mothers’ limitations as well as the necessary steps they had to take to not rely on their mothers for a source of unconditional support.

Many of the mother/daughter relationships were fraught with difficulties prior to IVF. The IVF experience seemed to help the daughters gain clarity about what they were comfortable in asking emotionally from their mothers. “But when we see each other, we kiss on the lips, and were always hugging and sitting close on the sofa or laying on someone's lap. It's very physically affectionate. But emotionally, if I'm upset about something, my mom is not the person that I would ever call.” Another daughter recalled, “I really respect my mom in a lot of ways and in a lot of ways, I don’t. She wonders to this day, “why aren’t you close to me? Why don’t you tell me things?” And I don’t know. I just keep things inside.”

Missing elements that daughters could not change from childhood played a part in their desire to reach out to their mothers during the more emotional and tumultuous times. “I respect my mother. I think she's a really good decent person. I really do. She cares about me and everything. What is that little piece that's missing, the stability of my childhood.”

Daughters also explained that preparing and/or undergoing IVF not only helped them appreciate qualities of their mothers but also increased appreciation of the relationships they shared. “She is so loving and generous. She's going to take time off of work. She can do whatever she wants and she wants to take care of me. I can never repay her for everything she's done. It seems so little, but to me it's huge. I can't imagine not having her here. The actual physical effort is what sort of has helped change the relationship. It's one thing to be kind and full of love, it's another to all of a sudden receive that.” Another daughter stated, “I understand my mom more needing to nurture and help with things and maybe I think she's a little less crazy, and I can understand a little bit more as to why. I don't know, some people have a relationship with their mom and it's not a very strong one. Even my friends have children that they don't like they say you're so lucky that your mom is willing to do so much. It hurts them that their moms don't want to be close to their children. So sometimes I think maybe my mom’s just overbearing. Maybe that's a word I should use instead of crazy.”

Daughters highlighted that as a result of introducing IVF into the mother/daughter dyad, the relationship could tolerate more honesty and emotional depth with elements of a more mature adult to adult relationship. The power dynamic between the mother and adult daughter was more respectfully balanced. “The one thing I love about our relationship now is I can say something to her and be honest and she won't go off the deep end and start bawling and think that I hate her. You can say something to me and be honest and I don't take it offensively. I look at it as constructive criticism coming from someone who wasn't necessarily my mother but more as a friend.” “I think the

relationship is good. I do because I can talk to her and I can tell her about things but she doesn’t try to pry it out of me. She gives me the space when I need it.”

Introducing IVF to the adult daughter and mother dyad, reinforced an already close relationship between mother and daughter. “I have a close good relationship with my mom. She's very smart. And she always raised me that way. She talks to me like an adult, not like inappropriately or anything, just like she treats me with a lot of respect and probably assumes that my brain works like hers before it was old enough to. But it stretched me to think.” “I would say I’m really close to my mom even though I only talk to her once a month. I’m thankful for that because there are some people where their mom’s don’t feel like they’re close unless they talk to them every week or whatever. I’m glad my mom understands that she doesn’t want to pester us and we don’t want to pester her either.”

One daughter expressed gratitude and appreciation for her mother. Even as an adult, the daughter could feel her mother’s love as an integral part of daily life. “I can't even imagine not being able to have my mom and my life. I’m thankful I have her every single day. My life would be completely different without her.”

The Pregnant Daughter For daughters who became pregnant via IVF, becoming a mother added insight and peace into her relationship with her mother. “In regards to the relationship with my mother, it's interesting because obviously we didn't tell her about the IVF. She has never asked what the process entailed, what it was like, what shots I did, there was no interest, because ultimately she got what she wanted out of it, getting a grandchild.” Another

stated, “Now that I am pregnant through IVF, it's more peaceful. I guess it's more even private too where I have a voice too, but it's incredibly private.”

A daughter voiced the significance of the worry and how becoming pregnant increased her understanding of how her mother could worry so much about her. “She worries about things and now I understand because I have my own daughter, and yes I worry also, so you can understand a little bit more why they worry and things.”

For daughters, becoming a mother forced them to want to provide for their child the same life experiences their mothers provided for them. “We’re planning on moving in with my mom at some point in this next school year. She's going to be a stay-at-home grandma next year because she’ll be 65, so she can retire and all that stuff. Which is what happened with me, I stayed with my grandma once I was old enough to be with someone besides my mom. I would stay at home with my grandma while my mom finished her PhD.” “I now look at my mom and I look at my daughter and I think yes, your mom’s crazy, she's a nut bag, and you're going to have to deal with the exact same stuff that I dealt with as a child, but too bad, because it's okay. It was okay. Growing up with my mom, I know I'm not the easiest person because I have high standards and I have high expectations of people and it's hard when they don't meet them. I know that because good friends of mine have told me, and dealing with my husband, it's been hard on him.”

Perception IVF caused daughters to have a changed perception of their mothers. Not only did IVF impact the dynamic between mother and daughter, but introducing IVF into the relationship also altered how the daughter thought and understood her mother.

When evaluating whether the IVF process transformed a daughter’s overall perception of their mother, some reflected that, indeed, the process added a further dimension into how she viewed her mother to be. For some daughters, progressing through the IVF process gave the daughters a deeper look at their mothers and the mothering that was provided to them not only during the IVF experience but also spanning the daughter’s life. In some respects, the newer views of mom were positive. “I just see a lot of better qualities in her, I guess I think she is a good friend to a lot of people and not something that I never understood as a kid because we weren't that close.”

Other daughters commented on how the desire to become a mother and have a child impacted the similarities and differences they shared with their mothers. “I mean, I never thought about it for the longest while why it took her so long to have kids. But she didn’t seem like it was that big of a deal why it took that long to have kids. For me, it's a very big deal not being able to have children. It is very much an everyday part of my life, and I think about a lot but again, I think maybe my mom was just different for me.”

Daughters realized they had more fertility treatment opportunities /options than their mothers. They also said that they had more choices regarding career and motherhood combining than did to their mothers. “Yeah, like some days I can’t comprehend having more than one child. It's just too overwhelming, and I think I look back on when I wanted her to work more, or to do the things that she didn't do, and I look at it, and there are days that yes, I wish I could win the lottery, and not have to work more. I bawled the day I had to go back to work for the first time and leave my son under someone else’s care. And so I appreciate the fact that she was home with us as much a she was. When I’m at work,

I’m missing my son and missing all the ‘firsts’ and so there are times where I don't think she understands how hard it is to be the primary bread winner and also be a mom.”

The IVF experience further reinforced the daughter to want a mother/daughter relationship just like the one she shared with her mother. The experience influenced the daughter to value the relationship even more with its own unique qualities of nurturing and caring. “The potential thinking about not having a child of my own in getting to be a mother the way she is the mother, oh, that's kind of the heart wrenching part because we have such a good relationship. The more I think about not being a parent and not having anything like that relationship with a kid of my own, the more sad that is, so the more valuable the relationship with my mom is.”

The overall views and perceptions of mothers were also solidified for some daughters. The IVF experience could have been an opportunity for connection or repair; rather it highlighted the preexisting mother/daughter conflicts. “Yes, I think I perceive her clearly now for who she really is. I always seem to worry about her and the pain she's been battling with depression. It's just one more thing I have to worry about in my life.

And at this point, in going through infertility treatments, I don't want to have those thoughts. I don't want to be wondering is she going to leave her husband.” “Yes, I view her as, I do love my mom but I see her as a manipulator and I go in with a clear vision. I grew up honestly thinking my mom was perfect up until I was maybe 26 and then she started to interfere with everyone else which was interfering with me.”

In some ways, the handling of the IVF experience further damaged the already precarious relationship. One daughter seemed surprised at the length her mother could go in coping with anger and disappointment related to the handling of IVF information

communicated from daughter to mother. She said, “My perception of her changed a little bit, I think withholding the IVF was the trigger for more hurt feelings, and that's what led her not speaking to me after my friend, after calling because there wasn't anything she could do about it. I was mad. I think she was so hurt by the fact that I didn't talk to her about the IVF process that she kind of snapped.”

Daughters also claimed that the IVF experience did not alter their overall perception of their mother. In fact, it reminded them of who they’ve always known their mothers to be. “My perception of her has always been wonderful. I still think that. I don’t really think that changed much except now I know more of what they had to go through; it makes it easier to talk to her about and stuff. If anything the perception is for the better instead of worse.” Another commented, “I wouldn't say perception has changed so much because my mom's always been that caring person, specifically a caring individual mom. I mean she's always been that way even when I had an appendectomy she was there as she's a nurturer.” Additionally, “I'd say maybe we’re a little bit closer now than we were for a while. We kind of had some ups and downs since my childhood so yeah, after that I think were close to the mat, but I don't really think it's changed necessarily.”

The IVF experience is a deeply emotional experience which impacts the relationship between mother and daughter. Daughters described intense and moving stories about how the relationship adapted or failed to adapt to the crisis of infertility and the eventual treatment involved in the IVF process. Dynamics and perspectives caused daughters to reevaluate the importance of their mothers during what many would call a time of emotional and physical need. Daughters recalled recognizing similar

mother/daughter relationships that emerged and offered a greater perspective on the adult relationships they now shared with their mothers.

Theoretical Implications

This study explored data from 20 women who were trying to become pregnant via IVF. Quantitative and qualitative data were used to assess how the women felt about their mothers as well as how they felt about the relationship they shared with their mothers during the time surrounding IVF. Findings indicated that an adult daughter’s relationship with her mother was not static during the IVF process; rather, it continued to evolve over time. The findings also illustrated how the crisis of infertility and pursuit of pregnancy via IVF impacted the adult daughter individually, the mother individually, and the relationship. For some women, the unexpected difficulties in getting pregnant caused an existential and developmental impasse affecting both adult daughter and mother.

The findings of this research echoed pre-existing research (Jaffe & Diamond, 2011; Burns & Covington, 2006; Greil, 1997; Pines, 1990) which concluded that infertility has a major impact on a woman’s self as well as on her developmental life course. More specifically, undergoing IVF gives hope to women who wish to bear a child. This is indicative of a developmental task which many women hope to achieve during the fertile years of adulthood. As the woman attempts to move through the developmental demands of this phase, her relationship with her mother is impacted in various ways. More recent psychoanalytic theory acknowledges the evolving and ever changing relationship between daughter and mother over time. Bernstein (2004) states, “New theories about the vicissitudes of the mother-daughter relationship depict development as interactive and relational throughout the lifecycle- leading not to separation but to autonomy with connectedness” (p.1).

In evaluating the findings, the adult daughter’s affect and reactions to the discussion of her mother varied. Some daughters spoke in a detached manner while others found themselves crying and becoming very moved during the interview. The results of the data gave insight into the daughter’s historical and emotional recollection of her mother and into the present feelings associated with the nature of the daughter/mother dyad. The adult daughter was able to reflect upon significant aspects of the relationship and how those aspects contributed to her journey from infertility to the need for IVF. The adult daughters in this study reaffirmed developmental theory which suggests that, “Throughout the life cycle, situations arise that potentially can be opportunities to facilitate or to compromise the mother and daughter relationship” (p. 2, Hershberg, 2006).

The results from the interviews suggested three relevant themes worthy of theoretical understanding and exploration: The sustaining qualities of the daughter and mother relationship; Narcissism and IVF; and Cohesive elements in the adult daughter and mother relationship. Theoretical concepts found in developmental psychology and psychoanalytic theories were chosen to illuminate and make clinical meaning to the findings of this research.

The first theme, the sustaining qualities of the daughter and mother relationship, describes how the adult daughter’s relationship with her mother evolves, adapts and continues to be a source of great meaning over the course of life. Most of the adult daughters who had emotionally fulfilling relationships with their mothers when they were young were the same daughters who, as adults, looked to their mothers for emotional support. Daughters described how mothers attempted to be emotionally and physically

available for them during the course of their early years, thus leading to a more satisfying relationship with their mother during the time of the research interview. Mothers met necessary selfobject needs for their daughters which in turn, helped facilitate a reliable source of empathy and comfort for the adult daughter.

The second theme, narcissism and IVF, explores how infertility and needing IVF has a significant impact on a daughter’s identity and self esteem as well as on that of her mother. In some ways, the adult daughter’s and the mother’s narcissism and identity were impacted in a parallel fashion and in others, not so. The experience of infertility and IVF caused many daughters to have more detailed conversations with their mothers about difficulties associated with trying to get pregnant. Some adult daughter/mothers reported deeply empathic experiences. Others spoke about their frustrations, disappointments, and losses. The experience of IVF had a negative impact on selfesteem and identity for both daughters and mothers. Empathic responsiveness by both daughter and mother lessened the traumatic blow of infertility and IVF. The third theme, cohesive elements of the adult daughter/mother relationship, illustrates how the experience of infertility and need for IVF challenges both the adult daughter’s and mother’s ability to sustain stable levels of self-cohesion. Daughters described the depressive symptoms they experienced which led to various levels of selffragmentation. Additionally, adult daughters recognized their mothers’ symptoms of anxiety and depression which were not in alignment with their own emotions. Despite these difficulties, most adult daughters recognized the value of the relationship with their mothers and appreciated the reparative acts which occurred along the way that prevented long term relationship damage.

The Sustaining Qualities of the Daughter and Mother Relationship Adult daughters spoke at length about the role their mothers played in their lives evolving from a very young age to the present state of wanting to deliver a healthy baby via IVF. The findings of this research highlighted the necessary selfobject experiences that mothers provided for their daughters through various developmental stages.

Theoretically this is relevant because, “The very emergence and maintenance of the self as a psychological structure depends on the continuing presence of an evokingsustaining-responding matrix of selfobject experiences” (p. 28, Wolf, 1988). Tolpin (1978) agrees and further clarifies that “…parents are not experienced as objects of love and hate in the usually psychoanalytic sense; instead, at one and the same time they are sought for and needed to fulfill developmental requirements and to act in place of selfsustaining and self-regulation in psychic structure which is not yet formed” (p. 175).

The concept of providing necessary selfobject experiences is pertinent to these findings because of its focus on affect and regulation. Stolorow et. al (1987) write, “Selfobject functions pertain fundamentally to the affective dimension of self experience and that the need for selfobjects ties pertain to the need for specific, requisite responsiveness to varying affect states throughout development” (p.67). Moreover, the role of affect is significant because, “Affect can be seen as organizers of self-experience throughout development if met with the requisite affirming, accepting, differentiating, synthesizing, and continuing responses from caregivers” (p.67). It was through the daughter’s affective and cognitive memories of the relationship with her mother that she was able integrate a story of the relationship she shared with her mother from young

childhood through adulthood. These memories and the present nature of the mother/daughter relationship suggest that necessary adjustments and modifications to the dyad have been lifelong pursuits and challenges.

In the findings, a majority of the adult daughters spoke at length about how they respected and sometimes idealized their mothers. The adult daughters admired their mothers’ nurturing qualities and their capacity to be available to their daughters no matter what external events were happening. Daughters felt similarly whether their mother was a stay at home mother or a mother who worked outside their home. “A young woman’s experience of her own mother and of her capacity to mother, and the way that mother has dealt with her own femininity, is of prime importance in establishing her own female identity” (p. 3, Pines, 1990). Mothers provided the selfobject need for idealization which in Kohut’s view, is vital. He (1984) felt that children need to hold an image of one or more idealized parental figures toward whom they can feel admiration and with whom they can identify.

The findings also gave clues as to how mothers provided necessary mirroring selfobject experiences for their daughters. Adult daughters shared fond memories during various chronological ages of their mothers when they were growing up. Mothers celebrated their daughters’ personal and academic achievements. Some daughters who were only children or first born described a special quality to their relationships with their mothers. Indeed, Kohut (1971) agreed that children need a caregiver who admires them, celebrates their progress and applauds their accomplishments.

Some adult daughters spoke about deliberately patterning their lives on those of their mothers. Daughters appreciated the similarities they shared with their mothers, thus

describing twinship selfobject experiences. In Kohut’s (1984) view, children need a parental figure with whom they are allowed to feel similar and with whom they are encouraged to feel part of a group (e.g. family) that surrounds and protects them. Not being able to have a family, though, left many adult daughters missing this selfobject experience as “gratification of this need facilitates the adoption of community codes and the development of social skills, empathy, sense of connectedness” (p. 27, Banai et al, 2005). The participants experienced isolation from their peer group and family due to their inability to get pregnant and a have a child. Additionally, infertility prevented them from sharing the experience of becoming a mother as their mothers had.

Selfobject experiences are significant: they impact the developmental process of ‘transmuting internalization’. The process of transmuting internalization “…depends on the willingness and ability of parents to act as selfobjects and to satisfy the child's selfobject needs. As they do, the archaic needs for admiration, omnipotent figures, and twinship experiences are tamed and transformed into healthy narcissism, as manifested in a cohesive self that is capable of maintaining self-esteem, ambitions, and goals” (p. 228, Banai et al, 2005). “Transmuting internalization allows for the internalization of selfregulation functions that were fulfilled in the beginning of life by parents, with the individual gradually acquiring the ability to perform these functions autonomously” (p.

228, Banai et al, 2005) In category I of the findings, The Historical Nature of Mother, women spoke at length about the effect their mothers had on their emotional lives. The adult daughters felt support and sometimes pressure to take advantage of opportunities they had which their mothers had not at that same age. The opportunities the mothers spoke about and valued

helped guide their daughters in creating a meaningful and satisfying life. Daughters looked up to their mothers regarding what they were doing in their own lives and listened to what their mothers had to share. Even if a mother had not taken her own advice, daughters valued their mothers’ thoughts and advice. The mother and daughter relationship demonstrated that feelings and discussions were instrumental in helping the daughter determine how she would like to live her adult life.

The findings suggest that the adult daughters felt that their mothers encouraged and supported education and career success. In talking about their achievements, daughters recognized that by attaining these goals, they made their mothers proud of them and in fact, reinforced the positive and good feelings they had for themselves. This data reinforces the idea that, “The capacity to fantasize for their child a limitless potential while performing a mirroring, affirming, and controlling function is the very hallmark of maturer narcissism, or responsible parenthood” (p. 299, Elson, 1984). The daughters recognized that their mothers took into consideration who they were and what their social and emotional needs might be.

The results emphasize that a majority of the adult daughters recognized their own significant impact on their mother’s emotional lives spanning different developmental phases. The parent-child relationship is reciprocal, complex, and bidirectional. The child influences the parent to the same extent that the parent influences the child (Cohler, 1980). Elson (1984) writes, “As the child matures, the responsive mirroring, echoing, confirming, guiding function of parents as selfobjects is uniquely transmuted by the child into psychic structure, but it is a two-way process in which parental psychic structure also undergoes transformation” (p. 288).

This study’s theoretical foundations were confirmed: that the ability to transmit thoughts, feelings, and actions in an emotionally sensitive way from one to the other was an essential feature of those dyads who remained close from childhood to adulthood.

Daughters who revered their mothers and looked upon their mothers as a source of guidance, empathy, and comfort were the same daughters who found their relationship invaluable when embarking on the journey from infertility to needing IVF. “As the individual grows to mature years, there are many transitions which severely test the cohesiveness of the self, resulting in periods of lessoned vigor, loss of purpose, and discontinuity. Selfobjects play a role in sustaining an individual during a period of such reverses and in tempering the excitement of success” (p. 19, Elson, 1986). The daughters who felt their mothers were able to sustain needed selfobject experiences during various times growing up were the same daughters who, as adults, felt close to their mothers and still looked to their mothers for necessary selfobject experiences, especially when embarking on IVF. Daughters were able to reflect on the positive and negative aspects of the relationship with their mothers. The findings suggest that some mothers were burdened with stressors related to money, work and marriage when the daughter was younger. The consequences for the mother /daughter dyad were diverse. Elson (1984) writes, “The parental self may be sorely taxed by intrapsychic or interpersonal events, but it is as the parents offer themselves as precursors of psychic structure that the forming self of the child is supported and that the parents may be able to fill in their own earlier deficits or distortions or manage more effectively with what they now learn about themselves” (p.

299). Indeed, “The ongoing tie to the mother through different stages leads to a continual

reorganizing of self and self with other schemas” (p.61, Hershberg, 2006). In some cases, the stress of early life made it more difficult to have a satisfying relationship with their mother in later years.

A smaller number of daughters who felt their mothers were unable to direct their attention back to them experienced a strong level of disconnect with their mothers. The results demonstrated that these adult daughters felt significant anger towards their mothers, especially if these mothers never took responsibility for their emotional neglect and still behaved in a way similar to the mothers they knew as children. The daughters struggled to remember when their mothers were able to provide necessary selfobject experiences. Palombo (1985) discusses these implications and writes, “It is the enduring absence of a loss of a selfobject function that leads to a structural deficiency that is then retrospectively concretized as a “real” loss by the patient” (p. 37). As adults, daughters were able to articulate the losses of childhood or the losses of a meaningful and fulfilling relationship with their mothers. Despite these losses, adult daughters still felt some emotional connection with their mothers even if the connection was based on a sense of obligation.

No matter what type of childhood relationship the adult daughter remembered with her mother, adult daughters were interested in talking about and understanding the unique features of their relationship. These conclusions confirmed that a daughter continues to adjust and modify the relationship she has had with her mother. Indeed, Hershberg (2006) points out that, “Mother and daughter form patterns of interaction, patterns of one another that can be mutually enhancing or not” (p. 2 [dc]). Additionally, this material confirms more contemporary developmental research which states, “The

process of psychic integration of the tie to the mother as an aspect of the self is never fully complete. The hallmark of adult female psychic organization lies in the daughter’s capacity to permit continuing reverberations within herself of the representations of the tie to the mother in her ongoing intrapsychic dialogue with her mother” (Dahl, 1995).

Narcissism and IVF Kohut (1966/1978b) posited a line of healthy narcissistic development that moves toward consolidation of a cohesive self-structure, providing a sense of identity, value, meaning, and permanence and promoting the actualization of a person’s potentialities (native talents and acquired skills). Selfobject experiences play a vital role in the development of healthy narcissism. The findings in this research validate the copious research which indicates that IVF is a direct assault on a woman’s self esteem and identity. Moreover, the adult daughters also indicated that the journey of IVF affected their mother’s identity and self-esteem as well.

Elson (1984) writes, “As the tasks of parenthood grow ever more complex and demanding with each transitional phase through which the narcissism of the child finds expression in thought and behavior, permitting a further deepening and elaboration of the self esteem ideals, and the incentive for further transformation of parental narcissism intensifies” (p. 299, Elson, 1984). The results of the research conclude that IVF had narcissistic implications for both adult daughter and mother which challenged and expanded the selfobject milieu between adult daughter and mother, thus confirming that, “Support of the forming and firming narcissism in the child is the developmental task of parenthood” (p. 299, Elson, 1984). The theoretical implication is that “…the forming and firming narcissism within the child and the further transformation of narcissism in the

parent is essentially a twin process and may be best described as a double helix” (p. 299, Elson, 1984).

In the Conversations category in the qualitative findings, many adult daughters discussed how they had imagined becoming a mother since they were young. Some of the daughters had shared their thoughts and feelings with their mothers; other daughters explained that they had never shared those feelings with their mothers. In fact, a few adult daughters explained that they didn’t have conversations with their mothers because there was the assumptions that they would indeed have children. This confirms the idea that, “Reproduction for the continuation of our species is not only an implied responsibility of each person but also assumed to be an entitlement” (p. 99, Devereaux & Hammerman, 1988). Additionally, by imagining becoming a mother, Elson (1984) points out that, “Even before conception, the thought of producing a child furnishes the impetus for the further transformation of parental narcissism, and, at the same time, exposes it to traumatic injury” (p. 31).

The theoretical findings described unexpected narcissistic injuries that adult daughters experienced from mothers during their course of IVF. This was true for daughters who had a close relationship with mothers and those who did not. Adult daughters spoke about the unanticipated frustrations they experienced at the hands of their mothers. This happened frequently when the mother would not fully understand the IVF process even after the daughter had explained it to her. Some daughters expected their mothers to remember the IVF process and their specific IVF schedule and not need to consult with their daughters on an ongoing basis for information, clarity, and the implications of the test results.

Adult daughters reacted negatively if they felt that if their mothers were not curious enough. Kohut speaks about narcissistic injury and rage. He (1972) states, “…narcissistic rage arises when self or object fail to live up to the absolutarian expectations which are directed at their function—whether by the child who, more or less phase-appropriately, insists on the grandiosity and omnipotence of the self and the selfobject or by the narcissistically fixated adult whose archaic narcissistic structures have remained unmodified because they became isolated from the rest of the growing psyche after the phase-appropriate narcissistic demands of childhood had been traumatically frustrated” (p. 386). The findings of this study described adult daughters’ narcissistic rage towards mothers for their empathic failures and for not providing mirroring experiences that they needed.

Narcissistic rage was also relevant in the adult daughter’s understanding of her mother. Adult daughters described being the victim of their mother’s narcissistic rage.

Daughters recalled their mothers reacting negatively to their neediness as young children.

Mothers were perceived as being angry at the daughter if the adult daughter was not perceived as sharing enough details about her adult life, specifically her desire to have a baby. Moreover, mothers were angry because they felt a loss of twinship experiences with their peers; they felt themselves to be the only ones who did not have grandchildren.

This supports Elson’s (1986) idea that “Each critical period in development may intensify the thrust towards mature forms of narcissism or may precipitate fragmentation and feebleness, or disharmony with the parental self” (p.18).

Kohut (1982) depicts empathy as a “powerful emotional bond between people” (p. 397) and claims that “empathy per se, the mere presence of empathy, has…a

beneficial, in a broad sense, a therapeutic effect-both in the clinical setting and in human life, in general” (p.397). “The selfobject functions which the parents perform include the capacity to remain empathically in tune with the needs and tasks of their maturing children” (p.18, Elson, 1986). At the heart of the selfobject milieu and line(s) of narcissism is the significance of empathy. According to postmodern theorist (Stolorow, 1994), this conceptualization of empathy has a more “unique investigatory stance” (p.44).

He suggests that empathic inquiry is better understood as “…constituting a bond between two persons” where meaning is best understood through the principles organizing the patient’s experience (empathy), the principles organizing our own experience (introspection), and the psychological field formed by the interplay of the two” (p.38).

By defining empathy this way, it is also theoretically important to understand a further dimension of the daughter and mother relationship. The findings indicated that the daughters were able to reflect on their own experiences but also on how their self experiences related to the relationship with mother. This takes the idea of selfobject a step further into an intersubjective approach whose motivational principle “…is not centered on the selfobject but in a more broad based striving to organize and order experience” (p. 78, Trop, 1994).

Daughters were sometimes confused by their more recent experiences with their mothers about their infertility and possible IVF. A significant shift of learning, relating, and empathizing occurred when the adult daughter began her fertility treatments. The timing varied for an adult daughter’s disclosing of her difficulty getting pregnant and of her decision to share that IVF would be a course of treatment in trying to get pregnant. In the findings section of this study, most adult daughters indicated that their mothers were

not especially familiar with IVF; they felt some obligation to teach their mothers about IVF and about their own prescribed course of treatment.

Adult daughters described the length to which their mothers went to support them in their efforts to get pregnant via IVF. They described their mothers’ wishes and yearnings for them to be successful in their IVF attempts. Adult daughters whose mothers took time to understand IVF and ask exploratory questions in a non-intrusive manner felt secure, loved, and supported. Some adult daughters felt that the relationship with their mothers deepened. Adult daughters recounted that they spoke with their mothers more often and communicated more with their mothers if they did not live close in proximity. Their mothers took care of them and in some cases, mothers rather than spouses were active in administering shots and accompanying daughters to important medical procedures. Mothers provided necessary self object experiences by prioritizing their daughters needs by assisting them anyway they could, demonstrating patience throughout the IVF process, and validating that IVF was worth the effort in order to have a child. For some adult daughters, these selfobject experiences allowed them the ability to maintain a stable sense of self during a time of stress and anxiety.

The findings also highlighted how the adult daughter reciprocally provided necessary selfobject experiences for the mother. Adult daughters made their mothers feel important and significant. In response, mothers seemed pleased to help. Daughters understood that they still played a significant role in their mother’s life and they were a source of healthy self esteem and narcissism. Mothers felt confident and competent knowing that their adult daughters still looked towards them for advice, emotional and financial support, and company.

The interview data illustrated that by meeting various selfobject needs, there were many empathic moments which occurred between adult daughter and mother. A few daughters had mothers who had fertility struggles themselves. The dyad disclosed moving discussions of their own experiences; frustration, loss, and the insatiable desire to have a child made the adult daughter feel deeply understood and cared for. Other daughters spoke about how surprising and meaningful it was to have their mothers research endocrinologists, IVF clinics, and alternative healthcare methods which facilitated successful IVF. Adult daughters felt that their mothers understood their psychological states by even going so far as staying by their side during invasive medical procedures as well as during the recovery period. Elson (1984) speaks to the psychological relevance and importance to these implications. She writes (1984), “And so with griefs and fears, it is a mark of parental empathy and wisdom to be able to share such experiential narcissistic deficits and injuries. This in itself further contributes to affirming and elaborating reliable self structure for esteem regulation, calming, soothing, preparing and the younger generation” (p. 312).

Cohesive Elements and the Adult Daughter/Mother Relationship Kohut (1975) writes, “The healthy wish to conceive a child and become a mother proceeds from the very center of the self, flowing from a clear sense of gender and gender role, and follows upon the capacity to select a sexual partner. It is an act of joyful assertion of a cohesive nuclear self…” (p. 28). The adult daughters spoke extensively about their desire to have a child and the lengths to which they would go deliver a healthy baby. The adult daughters in this research were willing to endure uncomfortable and

sometimes painful procedures that were costly in terms of time and money despite no guarantee that that these efforts would result in a healthy pregnancy. Moreover, the desire for a child was so strong that almost all of the participants in this study had already undergone IVF or other multiple ART measures.

For many women, the discovery of infertility and the need to undergo ART, specifically IVF, resulted in a great loss of self esteem and self cohesion. Indeed, “… a cohesive self depends on the availability and responsiveness of significant others, especially when a person seeks help with distress regulation (p. 227, Banai et al., 2005).

Elson (1986) confirms, “As the individual grows to mature years, there are many transitions which severely test the cohesiveness of the self, resulting in periods of lessoned vigor, loss of purpose, discontinuity” (p.19).” Daily living was impaired as were the relationships with self, spouse, family, friends and work. This was even true for adult daughters who knew they would have to undergo IVF due to preexisting medical involvement. These women had not anticipated that getting pregnant via IVF would be so challenging. With regard to the impact on the self structure, Wolf, (1988) writes that the stability of the self structure “…can be lost gradually or suddenly and there may be rapid changes in function in manifestation, such as an altered sense of self or a lost feeling of well-being” (p. 27). The adult daughters agreed that moving through the IVF journey was taxing and especially devastating for some. The conclusions based on the data were that for many women, IVF caused a change in self structure and self cohesiveness.

Theoretically, some daughters experienced fragmentation which is defined as,” A person whose self regresses from a state of cohesion to one of partial or total loss of

structure experiences this as a loss of self-esteem, or as a feeling of emptiness or depression or worthlessness, or anxiety” (p. 39, Wolf, 1988). The daughters indicated that they experienced these feelings often and sometimes at unpredictable times. Always waiting for test results, having to regulate the reality of the test results, and being forced to usually make a follow up decision demanded seemingly inexhaustible emotional resources. Indeed, “…loss of the sense of selfhood can be the occasion for the greatest panic and horror” (p. 30, Wolf, 1988).

The research indicated that many daughters experienced one form or another of ‘reproductive trauma’. Within the Conversations category, adult daughters divulged emotional and physical traumatic events which precipitated the adult daughter’s disclosure that she was going to have to use IVF to get pregnant; as she was unable to get pregnant and/or deliver a healthy baby naturally. In many of the examples, adult daughters spoke about how a miscarriage, a medical procedure, or a relative’s new pregnancy was the fragmenting tipping point. Daughters described these experiences of great despair and grief. The daughter’s ability to remain self-cohesive especially during ‘turning points’ or ‘tipping points’ exhausted all emotional resources.

In talking about their own difficulties in shoring up emotional resources, adult daughters discussed how their mothers had also struggled to regulate their own emotions.

Adult daughters reflected how their mothers’ sadness outlasted theirs and that they, in turn, felt guilty and responsible for causing their mothers psychological pain.

Additionally, knowing their mothers were struggling caused some daughters to withdraw from their mothers and/or begin to edit what they shared with their mothers. Mothers

were no longer perceived to be the stable source of selfobject functioning these daughters needed during the various critical junctures in the IVF process.

Theoretically this was significant as the daughter, who might already be struggling with depression and anxiety, felt losing a mother’s emotional stability would be a further loss. This ‘depleted state’ occurs when, “… the depressed person experiences a loss of self or the loss of significant selfobject functions. These losses were felt as critical injuries to the self, evoking intense pain. This pain lead to fears of fragmentation and to overpowering anxiety” (p.38, Palombo,1985). Furthermore, Wolf (1988) explains, “Proper self object experiences favor the structural cohesion and energic vigor of the self; faulty self object experienced facilitate the fragmentation and emptiness of the self” (p. 11).

The findings suggested that when an adult daughter was experiencing a sense of fragmentation and could not turn consistently to her mother, she turned to others in an effort find more secure and stable sources of support and selfobject experiences.

Adult daughters who were not emotionally close to their mothers as well as daughters who were close to mothers found themselves relying on husbands, internet message boards, and support groups to meet much needed selfobject experiences. Once adult daughters began feeling as though their mothers were struggling to regulate themselves, they turned to self-cohesive supporting others outside of the adult daughter/mother dyad.

“The subjective experience of a regressing, fragmenting self is so painful in loss of selfesteem and anxiety that emergency measures are instituted to reverse the process.

Attempts to boost one's self-esteem often take the form of some sort of self-stimulation; or one provokes or manipulates the environment to supply the needed self object

experience in order to maintain some structural cohesion to one's self” (p. 42, Wolf, 1988).

Conclusion Despite the empathic failures, narcissistic injuries and selfobject failures, at the time of this research, 80% of adult daughters felt their relationship with their mother was as close if not closer than other adult daughter/mother relationships that they knew.

Moreover, 75% of the adult daughters reported to having a satisfying to very satisfying relationship with their mothers. Adult daughters described reparative attempts made by both themselves and their mothers in order to reestablish boundaries and needed necessary selfobject functioning. Elson (1984) states, “Shortcomings and responsive empathy, each for the other, at times unavoidable, if not too great, further transmuting of selfobject functions of soothing and self-esteem regulation…” (p.301). Indeed, this study confirmed that mothers who are able to “…leave the child free to try her way, to make her mistakes, and to work through errors, sustain relationships with their children so that may be available when needed or asked. They’re affirming support, offered without the eventual reproach, may allow the child to absorb what she has learned in order to find new directions” (p. 20, Elson, 1986).

Adult daughters confirmed developmental research which indicates that a daughter’s relationship with her mother in adulthood is important and that it continues to change. Beebe and Lachmann (2002 ) write, “From the non-linear developmental perspective, perturbations in the continually shifting relationship between parents and child occur microscopically on a moment to moment basis in which change in the individual can change the relationship or vice versa, providing opportunities for self and

interactional regulation�. In this study, the journey of IVF changed the relationship between adult daughters and their mothers mostly for the better. It allowed the adult daughter to gain better clarity and greater acceptance of how the dyad could facilitate and support the daughters efforts to deliver a healthy baby via IVF and move through that important developmental stage.

Implications for Further Research The findings from this research illustrates the gratifying, disappointing aspects as well as the complicated nature of the mother and daughter relationship. Findings confirm clinical and theoretical literature which support the notion that the mother and daughter relationship remains relevant across the lifespan. This study also describes and demonstrates how the adult daughter reexamines and reevaluates the relationship with her mother when trying to become pregnant via IVF. As a result of this research, the section below summarizes possible further areas of investigation:

1. Conducting a two-year follow up qualitative study with research participants A follow up interview with the adult daughters of this study would highlight and describe how the relationship with mother has faired with either the daughter eventually becoming pregnant and having a child, continuing her efforts to get pregnant via IVF, or an eventual cessation of ART. Are there any issues or failures that took place during the period of IVF, where the adult daughter may harbor hurt feelings now? Did the dyad survive and continue to prosper in a closer more mutually satisfying fashion?

2. Exploring whether the adult daughter’s age makes a difference in how much she involves or communicates with her mother about her efforts to become pregnant via IVF The sample of this study contained women whose ages ranged from 29-41, all of whom had different levels of contact and involvement with their mother. Does the age of the adult woman or her mother contribute to greater intimate involvement in the adult daughter’s IVF process?

3. Exploring how the adult daughter and mother relationship adjusts to the daughter delivering a baby after a successful IVF attempt More than three quarters of the women interviewed reported having a satisfying and close relationship with their mothers during their efforts to become pregnant via IVF. Some daughters spoke at length about wanting to be mothers just like their mother had been to them and vice versa. Does the reality of motherhood, once again, change the adult daughter’s understanding and perception of her mother? Moreover, does the relationship with mother continue to be as close and satisfying after having a baby?

4. Researching the adult daughter and mother relationship dynamics in more diverse populations during the adult daughter’s quest to become pregnant via IVF In order to go through IVF, the adult daughters in this study were married and must have had decent health insurance and/or the financial means to afford such treatment. This eliminated a greater sample of socioeconomic diversity. Moreover, this study also eliminated the Lesbian/Gay/Bisexual/Transsexual (LGBT) community who

usually need some form of ART to produce a family and sometimes have more difficulties in getting insurance to cover ART procedures. An investigation into how the family of origin of the LGBT individual/couple adapts to ART could contribute to groundbreaking research. Are the families of these individuals/couples just as involved as the heterosexual families examined in this study?

5. Exploring whether the adult daughter using an egg donor and delivering the baby to term impacts the relationship with her mother This study focused on women using their own eggs to become pregnant. For some women, using an egg donor is one of the sure ways to increase the chance of delivering a healthy baby. How might the daughter understand her own feelings about using another woman’s egg and genetic makeup to create a baby? How might she share this with her mother? What dynamics might be involved between adult daughter and mother knowing that the child will not be biologically related to the adult daughter as well as the mother?

6. Studying how much the IVF process becomes an internalized part of the adult daughter’s psyche This study captures woman’s feelings about her relationship with her mother and her fertility at a single moment of time. IVF occupies a significant amount of the adult daughter’s life during the data collection of this study. How does a woman metabolize her understanding and feelings about IVF after she has a baby or ceases her ART efforts?

Final Thoughts The intention of this study was to explore how an adult woman understands the ongoing relationship with her mother well into adulthood while paying particular attention to the different developmental milestone each woman is trying to achieve: the adult daughter trying to become a mother and the mother adjusting to the period of becoming/being a grandmother. Women’s issues with particular attention to generational differences and expectations sparked a curiosity to understand more fully the impact of ART on women and their relationships with their mothers.

It was during the time of conducting this research that more women, visible by various media outlets, were becoming more outspoken about their fertility woes and needs; thus hopefully, lessening the personal shame and social stigma associated with needing ART. This topic was alive and relevant for many friends, peers, colleagues and patients when developing the methodology and conducting the research. Women were interested in the ongoing process and results of this study as they oftentimes disclosed having their own difficulties and challenges with their mothers. The attention and examination of the various facets of this topic validate the need for further research and study on the complexities of how ART impacts relationships and influences the socio/cultural environment in which we live.

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IVF AND YOUR MOTHER Can undergoing IVF impact the relationship you share with your mother?

If you are a woman between the ages of 22-50, undergoing IVF, and having contact with your biological mother, you are invited to take part in this research study.

WHO IS ELIGIBLE? • Women between the ages of 22-50 • Women who are married • Women using their own eggs to get pregnant via IVF • Women who are in contact with their biological mother WHERE? • At my private practice office or a location most convenient to you WHAT DOES THIS INVOLVE? • A brief questionnaire assessing your current perception of the relationship you have with your mother • An open-ended interview discussing whether IVF has had an impact on your perception of your mother • This study can take between 60-90 minutes and requires one meeting.

BENEFIT? There is no direct benefit to you for participating in this study.

RISK? • Talking about such personal issues as IVF and your relationship with your mother could cause difficult or uncomfortable feelings to arise.

• There are no significant medical risks associated with this study COMPENSATION? $20 CONTACT? Mary-Beth Golden, LCSW, Principal Investigator, (773) 7103636 or MaryBeth@marybethgolden.com for more information.

Individual Consent for Participation in Research INSTITUTE FOR CLINICAL SOCIAL WORK I,______________________________________, agree to take part in the research entitled: The change in a woman’s perception of her mother when trying to become pregnant via in vitro fertilization (IVF).

This work will be carried out by Mary-Beth Golden, LCSW (Principal Researcher) under the supervision of Joan Di Leonardi, PhD (Dissertation Chair). This work is conducted under the auspices of the Institute for Clinical Social Work; 200 N. Michigan Ave., Suite 407; Chicago, IL 60601; (312) 726-8480).

Purpose The purpose of this study will be to determine if a woman’s perception of her mother changes when undergoing IVF. The study focuses on and explores the woman’s feelings and her interpretations of her experiences. Findings will be published in the doctoral dissertation.

PROCEDURES USED IN THE STUDY AND THE DURATION The Mother-Adult Daughter (MAD) questionnaire will be given first. It is estimated the MAD will take 10-15 minutes to complete. After completing the questionnaire, the volunteer will participate in a semi-structured interview which will last between 60-90 minutes. The interview will focus on the woman’s perception of her relationship with her mother. The semi-structured interview will be audio-taped. Participants will be compensated $20 for gas money, parking fees, and/or their time.

Benefits There are no direct benefits for participants in this study. There are anticipated benefits in the acquisition of knowledge in this subject area.

Costs There are travel costs and perhaps time costs associated with participation in this study.

Participants will be compensated $20 for these costs.

Possible Risks and/or Side Effects It is predicted that there will be no medical risks/side effects to participation in this study given that there is no manipulation of subjects. Talking about such personal issues as IVF and your relationship with your mother could cause difficult or uncomfortable feelings to arise. Should this happen, please let the researcher know. If distress arises, participant will have the options of pausing the interview, skipping a question and coming back to it later or stopping the interview completely. This researcher will have therapist referral sources for the participant if one is requested.

Privacy and Confidentiality MAD questionnaire responses and interview responses will be kept confidential; available only to the researcher for analysis purposes. Interview responses will not be linked to your name and other personal identifying information. While quotes may be used in the final report and publications, your identity will not be disclosed. When this research project is completed, all data will be retained, for at least five years, in a locked cabinet by the researcher.

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness.

I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. I will not be forced to forfeit the $20 stipend to cover expenses should I end my participation in this study. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw.

If I have any questions about the research methods, I can contact Mary-Beth Golden, LCSW (researcher) or Joan DiLeonardi (Dissertation Chair at this phone number (773) 710-3636 (day and evening).

If I have any questions about my rights as a research subject, I may contact Daniel Rosenfeld, Chair of Institutional Review Board; ICSW; 200 N. Michigan Ave., Suite 407; Chicago, IL 60601; (312) 726-8480.

Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form. _________________________________ Signature of Participant

_____________ Date

I certify that I have explained the research to _____________________ (Name of subject ) and believe that she understands and that she has agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward. ________________________________ Signature of Researcher Revised 6 Sep 2006

______________ Date

Mother and Adult Daughter Questionnaire

Note: (c)= Connectedness: (t) = Trust in Hierarchy; (i) = Interdependence; * = reversed scored.

To begin with, I would like to ask you some questions about the relationship you have with your mother right now. Please answer all questions and choose the answer that applies best to you. Keep in mind your CURRENT relationship with your mother.

For questions 1 through 5, circle the best answer.

1. I have lived with my mother: a. More than 25 years b. Up to 25 years c. Less than 15 years 2. To visit mother, I have to travel: a. 3 miles or less b. 30 miles or less but more than 3 miles c. 200 miles or less but more than 30 miles d. 800 miles or less but more than 200 e. 3,000 miles or less but more than 800 f. more than 3,000 miles 3. I see my mother: a. Almost every day b. About once a week c. About once a month d. About once every few months e. once or twice a year f. Never 4. I communicate (call, write/receive letters) with my mother at least: a. Daily b. Weekly c. Monthly d. Less than monthly e. Never 5. If cost were not an issue, I would communicate (call/write) with my mother: a. About the same now b. A little more c. Much more

For questions 6 through 22, refer to the scale below and choose the answer that describes you best.

1 = Very False 2 = Somewhat False 3 = Maybe 4 = Somewhat true 5 = Very True 6. I can share my intimate secrets with my mother.___________ (c) 7. My mother can share her intimate secrets with me._________ (c) 8. I can share my personal feelings with my mother. _________ (c) 9. My mother can share her personal feelings with me. _______ (c) 10. I can share my opinions and values with my mother. _______ (c) 11. My mother can share her opinions and values with me. _____ (c) 12. If my mother ever needs anything, I help in whatever way I can even if it means making huge sacrifices.____ (c) 13. If I ever need any kind of help, I do not hesitate to ask my mother for advice. ___ (i) 14. I often depend on my mother for advice. ___ (i) 15. My mother will always love me regardless of what I do. ___ (c) 16. My mother always knows best. ____ (t) 17. My mother always knows what is good for me. ______ (t) 18. I do what my mother suggests because it takes away the hassle of having to figure it out for myself._____ (t) 19. I always trust my mother’s judgment. ____ (t) 20. I feel I can use my mother’s wisdom as a resource when making decisions.___ (t) 21. Sometimes I will give in to my mother out of respect for her.______ (t) 22. I feel the need to consult my mother when making a hard decision. ____ (i)

For questions 23-25, choose the answer that describes you best, and circle your response.

23. I consider my mother and I to be: (c)* a. Very close b. Close c. Somewhat close d. Not very close e. Not close at all 24. Compared to other ordinary families of my culture that I have known, my relationship with my mothers is: a. More close than others b. About the same as others c. Less close than others 25. My overall relationship with my mother is: a. Very satisfying b. Satisfying c. Neither satisfying nor dissatisfying d. Dissatisfying e. Very Dissatisfying

Semi-Structured Interview

Demographic Questions: 1. When is your birthday?

2. What state do you currently reside in & where does your mother currently reside?

3. When did you get married?

4. How old was your mother when she had you?

5. What occupations has she had? Currently?

6. What is your mother’s education level? When did she go to school?

7. Do you have siblings? Ages? Do they have children? If so, ages?

8. Did/does anyone else in your family have/had fertility problems?

Please tell me about your Reproductive Story Starting from when you started considering having a child forward, please include ideas you might have had if you thought it would be difficult to get pregnant even before trying. Include lengths and procedures you tried in the hopes of conceiving.

Open Ended Questions: 1. How did your mother’s ideas and decisions about education, career, and motherhood influence you?

2. Are you aware of any fertility problems your mother might have had? If so, please describe.

3. Did you ever discuss the possibility of having children with your mother? If so, when? Has the course of the discussions changed over time?

4. Did you ever talk with your mom about having difficulties conceiving a child? At what point? How did the conversations go?

5. Was there any change in the dynamics of your relationship with your mom once you began IVF? 6. Has your relationship with your mother during IVF changed your perception of her?

7. How do you feel about the relationship with your mother? More specifically in regards to infertility related issues?