Addressing infertility as part of educating, orienting, and assessing prospective adoptive parents is an ongoing part of my clinical practice in adoption.  While I began my work in the adoption field by directly counseling birth/first parents and writing adoption home studies, as I moved into management roles within the organization I began to expand our programming, service lines, and clinical practices to incorporate infertility work within and beyond our adoption work, after realizing the crucial intersection of the two. In shifting my approach to adoption work, I also began to look critically at the education and knowledge I received in training, and realized that only recently had I begun to see trauma and challenges related to infertility being addressed in relation to adoption. 

In my clinical practice, as I became more seasoned, the connection between adoptive parents addressing their infertility and having a smoother road in their adoption journey became clear. In doing post-adoption counseling, families often came in with a concern, with no realization it could connect back to their infertility trauma until the suggestion was made to them in therapy. In doing matching for an infant or older youth, families struggled to understand why every time they were not chosen it felt like a huge loss, sometimes reporting that it felt like having a miscarriage. In matching for families who wanted to adopt from foster care, it became clear that families with infertility struggled with rigidity in matching and dealing with unforeseen information that surfaced during pre-placement or after placement, more so than families who had not experienced infertility. Just as I was not trained well on addressing infertility with families when I began my career as an adoption professional, families looking to adopt were not educated on the impact infertility had on their adoption journey. In the last few years of my practice, I have strived to change our pre-service trainings, train staff in working with families who have experienced infertility, grow infertility supports at my organization, and educate the professional and public community on the impact of infertility on adoption.

The State of Infertility and Adoption

Research related to infertility and adoption supports my anecdotal experience: 12.2% of women in the United States use medicalized fertility treatment^[1]. Among those with infertility, women ages 18-44 are four times as likely to be considering adoption compared to women in this age range without infertility^[2]. Of the children adopted each year in the United States, 11% are adopted after infertility^[3]. Most significantly, research shows infertility is the primary reason an individual reports wanting to adopt an infant, and many individuals with infertility view adoption as their back-up plan if fertility treatment fails^[4].

Let us pause here and consider the statement “view adoption as their back-up plan if fertility treatment fails.” If adoption is a “back-up plan,” are families able to fully embrace their adoption journey and their child? What does it mean for the child they bring into their home, if the child is joining as a “back-up plan”? Are families equally committed to a “back-up plan” as they would have been to their primary plan? This language alone indicates the significance of this conversation to adoption professionals and the adoption community at large.

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If adoption is entered as a “back-up plan,” are families able to fully embrace their adoption journey and their child?

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Infertility also impacts the wellbeing of families, who are often just ending this phase of family-building before jumping into adopting, or may be simultaneously completing medicalized fertility treatment while also embarking on an adoption journey. Couples experiencing infertility are found to have lower levels of psychological wellbeing, sexual satisfaction and marital satisfaction, and some experience significant financial strain due to the cost of medical fertility treatment, a cost that will occur prior to considering costs for adoption and parenthood^[5]. Furthermore, 41% of individuals with infertility report depressive symptoms and 87% report anxiety symptoms^[6]. Alcohol and drug addiction are also more prevalent among individuals with infertility^[7].

Pregnancy loss is also important to consider, as miscarriage rates in the general population are 15-25% of all pregnancies^[8]. The connection between miscarriage and infertility is more complicated. While many research studies do indicate a correlation between infertility and miscarriage, no causal effect has been identified^[9]. Furthermore, those who experience pregnancy loss experienced an increased risk of diagnosed depression and anxiety, similar to those who have infertility; 20% of those experiencing pregnancy loss have these symptoms for one to three years post loss^[10], which may overlap with the time when a couple also begins to pursue adoption. Even more noteworthy, those who experience pregnancy loss report symptoms of Post Traumatic Stress Disorder (PTSD), including re-experiencing, avoiding, and hyper arousal^[11]. These PTSD symptoms are more common when combined with the experience of infertility^[12] and in 4-10% of the population, PTSD symptoms are described as chronic^[13].

Consider This Scenario: 

A couple comes to you to begin the adoption process. They have experienced years of infertility, and one year ago finally became pregnant, only to lose the pregnancy. The couple was devastated, and made a quick decision to be done with fertility treatment and begin the adoption process. They present as in a hurry to complete the process as they feel they have already waited long enough to be parents. You complete the home study, find no safety or stability concerns, and approve them to adopt. As they begin their wait, you start to notice how hard the wait is for the couple. They present as anxious, and are awkward and uncomfortable when meeting prospective birth parents. When processing this with them, they share with you that it is still hard for them to see others who are pregnant when their pregnancy did not make it to term. They also share that they constantly think about how the birth parents, in the situations being presented, cannot care for their babies yet still make it to term, while their pregnancy which was well cared for did not. As such, it is hard for them to be positive towards birth parents and even harder for them to conceptualize an open adoption relationship. They cannot imagine looking at the birth parents and not thinking about these things. You suggest that the couple receive counseling, which they are not open to at this time, as they do not want to spend any more time thinking about their past. As time passes, you become more and more concerned about the family and wish that you had seen this prior to approving them. 

This example is not uncommon, and illustrates the importance of considering infertility, pregnancy loss and resulting grief, loss, and trauma prior to adoption approval. While adoption professionals know the importance of assessing safety and stability, we also need to delve deeper into a couple’s infertility journey and assess for trauma, mental health needs, and marital stability—through a lens of infertility. If left unresolved, families may move along an adoption path with active trauma triggers, PTSD symptoms, and lingering depression and anxiety that can impact their parenting and the wellbeing of their child. 

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While adoption professionals know the importance of assessing safety and stability, we also need to delve deeper into a couple’s infertility journey and assess for trauma, mental health needs, and marital stability—through a lens of infertility.

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Assessing for Adoption Readiness

Unresolved Grief, Loss, and Trauma

Before we discuss how to look at adoption preparation and approval from a lens of infertility and loss, we also have to further understand what adoption might look like for a family that has unresolved grief, loss, and trauma. For some families, this can look like trouble bonding with an adopted child, or not feeling entitled to be a parent. They might wonder if they even deserve to parent the child or, given their history and trauma response from years of infertility grief and loss, they might be preoccupied with what could go wrong or cause them to lose this child as well, and thus struggle to form a healthy attachment. The family may also be acutely aware that the child does not look like the child they imagined, or as the child grows, does not behave like the child they imagined, which can lead to attachment difficulties. Even if secure attachment is established, feelings of sadness, and then guilt over having these thoughts and feelings about their child, may surface. Some families also experience triggers when maintaining contact with birth family or in talking to their child about being adopted, leading to avoidance of these important adoption parenting tasks. Families who have not worked through their grief and loss occasionally

experience uncomfortable triggers, such as when a child yells “You aren’t my real mom” in the midst of an argument. If parents do not have the skills to understand and respond to their triggers, the child will be impacted. For these reasons, adoption professionals need to consider the impact that infertility and pregnancy loss have on parenting an adopted youth, explore this with families during the initial training, home study, and approval process, and recommend help and support when appropriate. 

But how do we, as adoption professionals, manage these difficult conversations in our work with families? Many of us are not licensed therapists and may feel uncomfortable asking hard questions and approaching families who have had significant family-building trauma. Where do we even start? As with all adoption practice, we start with being trauma informed and understanding the impact that infertility and pregnancy loss may have on the couple entering adoption, as outlined above. We also work to create a relationship based in safety and trust from the first time a family reaches out for information on adoption. There are many ways to create safety, such as strong and prompt communication, reflective listening, cultural sensitivity, and normalizing experiences and emotions. Specific to the task of exploring infertility, transparency is important. We can let families know from the beginning that if they experienced infertility, this will be explored during the home study process. We can let them know in advance which interview session may address this and offer a trigger warning for some questions we are asking. And we can acknowledge to the family that not only do we understand that this is a hard topic to discuss, but we also understand that the family has been through a very long journey and may feel that having to go through the home study process is intrusive and unfair. This is a normal way to feel, and a family needs to be given permission to express their hesitancy. It can also help to debrief with families after interviews. If a triggering topic was covered, processing with families how they will cope after the session helps the family while also helping the adoption professional learn about the family’s supports and coping skills that may also help them as they move forward in the adoption process. 

Once safety is created, the adoption professional can begin to explore infertility with families during the home study process. In assessing adoption readiness through a lens that is informed about infertility, pregnancy loss, and resulting grief and trauma, we want to consider the way that the family views parenthood and the importance of biology. Have they grieved not parenting a biological child, or do they still wish to have a child sharing their genes? Are they able to let go of the control one has when pregnant and embrace a child that comes from a biological mother who may have been unable to get prenatal care, eat well during her pregnancy, and be substance free? In other words, have they been able to move from “I want to be pregnant and have a baby” to “I want to grow my family through adoption, and am ready and able to give love and support to a child in need of permanency.”

As adoption professionals, we want to see families clearly make this shift. While they may always have some sadness over not having a child by birth or experiencing pregnancy, we also want to see that they have spent time grieving and are ready to move forward on a different path to parenthood. Adoption may be their second choice, but it should not be second best.

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Adoption may be their second choice, but it should not be second best.

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Expectations

It is also important to discuss and assess the family’s expectations about the adoption process, and ensure they understand that adoption will not cure the pain from infertility. While adoption may make their family complete, triggers and grief can still surface during their journey. Families should understand this, and have coping skills and support systems in place to handle triggers when they arise so that these triggers have minimal impact on their parenting. 

Additionally, adoption professionals should have conversations with adopting families to help them understand that the adoption process has ups and downs, and ensure families have skills in place to cope with this. Families often struggle with the lack of control in the adoption process; families who have experienced infertility and a medical infertility journey in which they had no control often struggle with this more than families approaching adoption for another reason. A family’s expectations need to be reframed so that they understand the lack of control in the adoption process, as well as the lack of control over how their child may one day feel about their adoption story. Families entering adoption with realistic expectations are at less risk of post-adoption depression; while not well studied at this time, post adoption depression is found to impact between 8 and 32% of adoptive parents^[14].

Attachment

Another important topic to discuss with families is attachment and any concerns they might have about attaching to a child after experiencing infertility. This also connects to the importance of having realistic expectations, as attachment may not look as a family thought it might if they had a child by birth, as they had initially hoped. This is an especially important topic to tackle when discussing adoption of children from foster care, as families also need to understand that attachment does not happen overnight and most foster and pre-adoptive families have to work to build attachment with children who have experienced trauma and loss. Even with a newborn baby, the nature of the adoption process and a family’s history of infertility may impact early bonding, causing bonding to look different than a family expects. Educating families about attachment during the home study process is crucial to families being prepared to adopt. It will also help families be less at risk of being discouraged during their adoption journeys, experience fewer foster care and adoption disruptions, and lower the incidence of post-adoption depression that might stem from attachment challenges. 

Approval Process

Within this framework, the job of an adoption professional in approving a family to adopt should not only be to check for stability and safety. They should also be assessing adoption readiness and ensuring families have the necessary tools in place to navigate adoption successfully. When interviewing families, we should ask about triggers the family might anticipate in the process, to whom the family turns for support, if the family has completed fertility treatment, and if the family has received any counseling to help process prior losses. While there is no guidebook for how to approve a family who has experienced infertility, a family who has successfully resolved their infertility and is ready to move to adoption can identify future triggers and how they will respond, has realistic expectations on the adoption process and experience, and has shifted from a pregnancy mindset to a parenting mindset. Families should also be able to talk about their loss and trauma openly; while emotion is normal, signs of post-traumatic stress should not be present. Signs of unresolved trauma in reproductive medicine and counseling settings include looking away or limited eye contact, an unwillingness to elaborate on their journey, expressing anger at professionals for asking hard questions, shaking or trembling, self-protective posture, and cycling through emotional extremes^[15]. If a family presents with any of these signs during the interview process, further assessment and support might be needed prior to approval.

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…a family who has successfully resolved their infertility and is ready to move to adoption can identify future triggers and how they will respond, has realistic expectations on the adoption process and experience, and has shifted from a pregnancy mindset to a parenting mindset.

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Delaying or denying adoption approval is one of the hardest parts of this process, and can be devastating for prospective adoptive parents dealing with infertility and trauma. A family can feel especially vulnerable when we create safety, allow them to trust us and open up, and then decide that the family needs more support prior to approving them. Additionally, delaying adoption approval due to our assessment of adoption readiness is not as straightforward as delaying or denying approval for a family who may have an unfavorable clearance returned or have significant financial troubles. Telling a family that you would like them to delay their family-building even longer than they have already been waiting is a hard conversation, but in some cases may be best in the long run not only for the family but also for the child they are bringing into their home. It may be that you feel that the family may benefit from counseling to process their infertility, trauma, and loss prior to proceeding with approval. It may be that you feel that the family can proceed but would benefit from counseling support as they continue the adoption journey. However the adoption professional decides to approach this situation, the conversation is not easy; having an open and honest dialogue—with a family in which safety has already been created—is the most positive approach to these difficult conversations.

In many cases, however, families who have experienced infertility have successfully resolved their grief, loss, and trauma and have skills in place to tackle triggers that may come up, showing us that they are ready to proceed. For any family who has had an infertility journey, we as professionals can be sure to identify strengths in their experience and put these strengths into the written family approval document or home study. For example, families who have gone through infertility may have increased coping skills, resilience, and strength in their marriage from facing hardship, and may have increased supports already in place through family, friends, community, and counseling. These strengths that are built up throughout their infertility journey will no doubt be helpful to them in their adoption journey as well. 

In summary, adoption professionals need to ask themselves if they are thoroughly addressing infertility and pregnancy loss when approving families to adopt. Here are some key questions to help adoption professionals reflect on their current processes: 

• Is infertility, pregnancy loss, and adoption readiness being assessed in the home study process?
• Are resources being provided to families who could use more support surrounding infertility and pregnancy loss?
• Is safety being created from the very first contact?
• Are open-ended questions being asked to allow the family to explore their infertility journey with their worker?
• Is the family asked about both formal and informal support and coping skills?
• Is attachment and its connection to infertility being discussed in the home study process?
• Are adoption expectations being discussed in the home study process? 

As adoption professionals open this dialogue among ourselves and with the families we work with, we will better safeguard against unfavorable outcomes for our families as well as the children they bring into their homes and hearts.