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Souvenir Children: Death and Rebirth

Michal Braun, Lea Baider

From the Sharett Institute of Oncology, Hadassah University Hospital, Jerusalem, Israel

Address reprint requests to Michal Braun, PhD, Sharett Institute of Oncology, Hadassah University Hospital, POB 12000, Jerusalem 91120, Israel; e-mail: bmichal2{at}hadassah.org.il

The Narrative of M

Miriam was a 28-year-old woman who came to my office (M.B.) in the psycho-oncology unit, seeking advice and support. Her husband, Jonathan, had died of cancer 2 months earlier in a nearby hospital. I thought that this would be another case of bereavement counseling, with her loss at such a young age. However, I had no idea how this woman was about to challenge my worldview and to raise significant ethical, philosophical, and psychological quandaries.

One year and 3 months before their wedding, Jonathan had been diagnosed with angiosarcoma of the heart. The prognosis was clear to both of them. However, Miriam did not think that her husband's life expectancy would be so short. Jonathan commenced chemotherapy; and, except for the hair loss, he tolerated the treatment well. After hearing the diagnosis, he talked with Miriam about canceling their wedding. She refused, and they were married during the same period that he was undergoing chemotherapy. They had been friends for 2 years before deciding to marry, and she described their relationship as "two lonely wolves who had found one another." They loved each other very much, had created a small, insulated world for themselves, and both had difficulty with external social interactions.

Miriam revealed that during her husband's illness, they had been undergoing in- vitro fertilization (IVF) to try to have a baby. When Jonathan died, she was in the middle of an IVF cycle and actually had completed it at the time of the Shiva (Jewish ritual of mourning during the first week after the death of an immediate family member). Miriam was the only one who knew about it, besides Jonathan and the medical team. She still had his frozen sperm, and it was clear that she would use it in order to become pregnant with Jonathan's baby. Miriam and her husband had never talked about this possibility. In retrospect, she felt that Jonathan would have opposed it. While listening to Miriam's story, I questioned the inequitable paradox of going through fertility treatments while facing death and the offer to bank sperm to newly diagnosed cancer patients with a poor prognosis.

The Paradox of Fertility and Advanced Cancer

For a young man diagnosed with cancer, treatments may cause infertility. However, with advances in oncology and fertility treatment, the possibility of becoming a father is real. In the case of infertility, cryopreservation of sperm cells enables parenthood through intrauterine insemination (IUI) and IVF. The intracytoplasmic sperm injection (ICSI) technique allows successful freezing and future use of a very limited and/or low quality sperm count.^1,2

Lass et al,³ in their review article, conclude that "sperm cryopreservation should be offered routinely to all cancer patients less than 55 years old, and especially to young men who have not yet completed their family."

In a survey by Schover and her colleagues⁴ of young cancer survivors, 66% declared that they would want to be a parent even if they died prematurely. In the same survey, 66% worried about living to see their children grow up and 73% would not want to die and leave their spouse to face single parenthood. It should be noted that cancer was not found to hinder the motivation for having children.⁵

In a separate survey by Schover et al⁶ of oncologists' attitudes and practices regarding banking sperm before cancer treatment, 91% of the oncologists agreed that sperm banking should be offered to all eligible men. The authors conclude that "any male cancer patient should ...have at least one semen sample cryopreserved as long as there is any chance that he may desire children in the future," but what if there is no cure and the future is questionable? "Cancer with a chance of a cure" was considered by only 4.2% of oncologists (2 of 46) as an important factor when deciding whether or not to discuss cryopreservation with a patient. However, lymphoma and testicular carcinomas, which are associated with relatively good prognoses, were listed as the most important cancers for which cryopreservation should be considered.⁷

In one of the very few reviews dealing with the effects of cancer and cancer treatments on male reproduction, emphasis was placed on the need for the oncologist to initiate a pretreatment discussion with the patient so that the patient might "recognize both the possibility of a cure... and the risk of infertility."¹

Cryopreservation is a medical procedure in which life and death might coexist, giving rise to ethical, legal, cultural, and religious dilemmas. Should it be offered to all patients regardless of their prognosis and the possibility of short-term parenthood, with one of the consequences being posthumous sperm use?

Legal Implications of Posthumous Sperm Use

From an ethical point of view, as well as a legal perspective in some countries, the last will and testament of the deceased has tremendous significance for posthumous sperm use.^8-10 The current legal positions internationally regarding posthumous sperm use vary widely. Some countries, such as Germany and France, do not allow posthumous sperm use; while others, such as the United Kingdom, permit the procedure on the condition that the deceased will have left an informed consent or specified it clearly in his will.^3,8,11 Israel allows posthumous sperm use without requiring an informed consent; and the widow becomes the owner of the frozen sperm.^12,13

In a report by the American Society of Clinical Oncology, ¹ it was recommended that the oncologist discuss the potential legal implications connected with fertility preservation with the patient, such as ownership of embryos and reproductive tissue in the case of the patient's death, risk of infertility, and issues concerning posthumous disposal or use of the sperm.

Shover et al⁶ suggested that patients obtain legal advice. In their survey, 96% of the oncologists agreed that men who bank sperm should discuss posthumous disposition of the tissues, but they were not asked about posthumous use of the sperm. Oncologist-patient discussions about fertility normally take place before treatment; and as a consequence, hasty decisions are frequently made about sperm banking at a time when the patients are overwhelmed by the cancer diagnosis.⁶

Reflections on Miriam's Narrative

During the course of the counseling, Miriam expressed her concerns and confusion about many questions which remained unanswered. We wondered about the significance of going through cryopreservation and IVF treatments while her husband was facing life-threatening disease with such a poor prognosis, about the value of continuing the fertility treatments after a death of a spouse, and about the meaning and consequences of giving birth and raising the child of a dead husband.

At the beginning of our counseling sessions, Miriam was very preoccupied and angry at the doctors who she felt were not in favor of her plan. Each time we met, she diverted the discussion to the more practical and pragmatic issues of the procedure itself. It was difficult for her to talk about the meaning of her decision and the emotions tied to it. In the same way, she focused exclusively on the fertility treatment and was unable to imagine the pregnancy, the birth, and ultimately raising the child. With time, Miriam did acknowledge that her desire for this child was partly to relieve the terrible pain and emptiness she was experiencing and the longing for her beloved husband.

Furthermore, during the timing of therapy, death and rebirth were integrated more in a fantasized mechanism of internal compensation, rather than a clear and objective differentiation of death and new life. Miriam hoped that the expected child will be able to fulfill her life, provide meaning and bring joy and happiness to her life that was now occupied by sorrow and grief. While facing her partner's death, she was simultaneously creating life and reconnecting to her dead husband.

During our sessions, questions were raised that attempted to acknowledge her feelings of sorrow, loss, and bereavement. We discussed how the fertility treatments might be a way of escaping these complex emotions. Gradually she was able to visualize the unborn child, to think about the situation into which the baby would be born, and to explore what this meant for her. We also explored the possibility that she would allow herself 1 year to grieve and to adjust before making any significant decisions.

Journey to Grief

In the literature, the terms "souvenir children"¹³ and "memorial candles"¹⁴ are used to describe children who are born after the death of a parent, implying that they are to replace their dead parent.¹³ Landau¹³ suggests that people, who wish for a child after the loss of a spouse, might not want to accept the finality of the partner's death.

Bereavement is a process in which intense and painful feelings of loneliness and longing play a central role in the life of the surviving spouse. Bereaved individuals may be vulnerable to feelings of futility and despair.¹⁴ Giving birth to a child of the dead partner might be motivated from searching for something that will fulfill the emptiness, reduce the pain, and bring life to a place where death is dominate.

Bereavement literature perceives that widows need time to grieve and time to disengage from the deceased to whom they were emotionally attached.¹¹ Bringing a child into the world from the banked sperm of the deceased partner might be a way to reattach symbolically to the dead spouse. Landau¹³ conjectures whether it might be a solution to the problems of pain and loneliness that come with the loss of a spouse. Bahadur⁸ suggests that giving birth to the child of the dead spouse might be a way to resume normal life.

No matter what significance one may attach to the experience of the birth of a "sperm-bank" child, the timing of the decision is problematic as long as the widow is still embedded within the bereavement process. But...when is the right time?

The End

Miriam continued the fertility treatment, and after two more IVF cycles, she announced that she was pregnant with twins. She was shocked and confused, exuding both happiness and fear. During our counseling sessions, and despite Miriam's own grief and loss, we talked about the embryos as new lives. Moreover, Miriam re-established her relationship with Jonathan's family and moved closer to them so that they could help her.

In our last phone conversation, Miriam said that she had just given birth to a beautiful boy and girl. She sounded happy.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

REFERENCES

1. Magelssen H, Brydoy M, Fossa SD: The effects of cancer and cancer treatments on male reproductive function. Nat Clin Pract Urol 3:312-322, 2006[Medline]

2. Lee SJ, Schover LR, Patridge AH, et al: American society of clinical oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 24:1-14, 2006[Free Full Text]

3. Lass A, Akagbosu F, Brinsden P: Sperm banking and assisted reproduction treatment for couples following cancer treatment of the male partner. Hum Reprod Update 7:370-377, 2001[Abstract/Free Full Text]

4. Schover LR, Brey K, Lichtin A, et al: Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors. J Clin Oncol 20:1880-1889, 2002[Abstract/Free Full Text]

5. Schover LR, Rybicki LA, Martin BA, et al: Having children after cancer: A pilot survey of survivors' attitudes and experiences. Cancer 86:697-709, 1999[CrossRef][Medline]

6. Schover LR, Brey K, Lichtin A, et al: Oncologists' attitudes and practices regarding banking sperm before cancer treatment. J Clin Oncol 20:1890-1897, 2002[Abstract/Free Full Text]

7. Zapzalka DM, Redmon JB, Pryor JL: A survey of oncologists regarding sperm cryopreservation and assisted reproductive techniques for male cancer patients. Cancer 86:1812-1817, 1999[CrossRef][Medline]

8. Bahadur G: Death and conception. Hum Reprod 17:2769-2775, 2002[Abstract/Free Full Text]

9. Ethics Committee of the American Society for Reproductive Medicine: Fertility preservation and reproduction in cancer patients. Fertil Steril 83:1622-1628, 2005[CrossRef][Medline]

10. Robertson JA: Cancer and fertility: Ethical and legal challenges. J Natl Cancer Inst Monogr 34:104-106, 2005[Abstract/Free Full Text]

11. Leonard M, Hammelef K, Smith G: Fertility consideration, counseling, and semen cryopreservation for males prior to the initiation of cancer therapy. Clin J Oncol Nurs 8:127-131, 2004[Medline]

12. Ravitsky V: Posthumous reproduction guidelines in Israel. Hastings Cent Rep 34:6-7, 2004[Medline]

13. Landau R: Planned orphanhood. Soc Sci Med 49:185-196, 1999[CrossRef][Medline]

14. Wardi D: Memorial Candles. Jerusalem, Israel, Keter Publishing House, 1990 (Hebrew)

Submitted March 22, 2007; accepted April 16, 2007.

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