Dr. Mastrominas interview

Dr. Minas Mastrominas MD, PhD, obstetrician-gynecologist specialized in IVF and director of the assisted reproduction unit “Embryogenesis”, discusses with Lida Bitrou the psychological aspects of IVF and the doctor-patient relationship

Let me begin our discussion by asking you which characteristics would you say should govern the relationship between the doctor and his patient.

The doctor-patient relationship is generally characterized as a relationship of trust. If I could put a label on this relationship it would be “TRUST” in capital letters. I think this is a prerequisite. And this relationship of trust is built from the first moment, when the patient visits the doctor. It is characterized by the personality of both the patient and the doctor –but I would saymore of the doctor- and has to do with the time that the doctor will devote to the patient and the personal interest with which he will deal with his problem. This way a healthy relationship is built. What I hear as a complaint from patients is that many times we doctors are distant, perhaps impersonal, and we spend very little timewith them. The truth is that we are usually pressured by our daily schedule and it seems that the result is that the patient doesn’t feel unique for his doctor. And this is important, namely the feeling that as a patient you are a unique case and not one of the dozens or hundreds of cases that the doctor sees every day. So I would say that the basic ingredient of a healthy doctor-patient relationship is the building of trust.

Following what you say about the trust in the doctor-patient relationship, could we say that there are special characteristics in gynecology in comparison with the other medical specialties, i.e. the gynecologist’s-patient relationship presents particular characteristics?

It is a somewhat more particular relationship. Clearly, trust is the basic ingredient here as well as it is in the other medical specialties, but because the woman feels quite vulnerable with regard to her pregnancy, her fertility and her “gynecological essence”, it’s a much more sensitive relationship, more special and needs much more attention from the side of the doctor. He must be able to fend off any feelings of shame that may occur. In other words the doctor must be comfortable – and that takes great art to accomplish since he is of the opposite sex, he is a man – and in his relationship with the patient his gender must be “neutral”. In other words, when he examines the woman, his behavior must be such that his gender, his “manliness”, won’t come out. This is something that has to do with the personality, with the professional consciousness and education of the gynecologist. This needs much attention because when the woman is naked on the examination table she certainly feels ashamed and is very vulnerable. So the doctor must maintain through the “medical blouse” his medical identity and his gender shouldn’t be underlined. Now how this is achieved. Personally I have several ways, like the way I look at the patient. In other words, your gaze must be clear and show nothing else than interest in the problem and the reason for which the patient is there. There should be no suggestive face expressions or body postures; the way you look at the patient, the way you are standing. So to keep the distance from the woman, to look her in the eyes so that she doesn’t feel uncomfortable, these are points to whichat least I pay close attention to in my daily practice. And I think that this is what a gynecologist should do. When I am examining a patient, I “lose” my male identity and my gender becomes “neutral”. And I am saying that because, occasionally, I hear women complaining about dealing with a sexist behavior from the doctor. I have heard very serious things from patients that I hope aren’t true but unfortunately I have also seen colleagues flirting implicitly with their patients. I find that totally unacceptable because your role as a doctor is sacred and this is one of the basic principles of Hippocrates. Just think that two and a half thousand years before, Hippocrates included in the principles of his oath and the exercise of this profession this point; that the doctor should never use his status to achieve a sexual relationship with the patient.

It’s interesting that you would say that because I read recently that the medical specialties that form sexual relationships with their patients more frequently are gynecologists, psychiatrists and, abroad, general practitioners. In England, for example, the general practitioner is a member of the community in which the patient lives and the relationship with him is a lifelong relationship.

Yes, because you go to the general practitioner very often and intimacy develops; he knows everything about you. The psychiatrist knows your most intimate matters, he knows a side of you that is very well hidden from all other people; and the gynecologist is also involved in a very special situation for the woman such as pregnancy, child birth, the process of childbearing. These are very delicate and personal matters and in fact the only people to whom you allow access are these three doctors. You don’t allow that to anyone else. Even to the people who are very close to you like your mother, your brother, your father, you put up “walls” regarding your very personal matters.

Let’s go to IVF now. Of course it is difficult and perhaps dangerous to generalize, but concerning the women who come for IVF, what do you observe more often in these patients from a psychological point of view?

I observe some neurotic situations. The basic feeling they have, the one I see first, is guilt. Even if it is not their fault but their husband’s, they feel guilty because they have failed in what society considers the core mission of women i.e. motherhood, and therefore they feel undervalued and guilty because they have failed in their primary role. I also see anger. They become angry and say “why is this happening to me” and that’s why they express anger. And if they fail in their effort they also express despair. So I would say guilt, depreciation, anger and ultimately despair. As if they are saying “I am not capable of accomplishing my main task that is motherhood”.

Yet I am thinking about what you said about their main mission being motherhood, and, since I imagine that we are talking about women who are above thirty-five, this awareness apparently came quite late. We are not talking about women who said from an early age “I want to have a child”.

Yes, and that is why they feel guilt for neglecting or postponing a basic task, something that creates regrets in them because if they hadn’t done so and had acted earlier they wouldn’t have these issues (i.e. fertility problems). Also if they were more careful and hadn’t had abortions, they wouldn’t suffer this damage that now hinders their reproductive capacity. The “number one” cause of infertility is abortion which was wrongly considered in the past as a method of contraception. So that is why I put the feeling of guilt first that I see all too often. I also see anger and in the end despair. But what is most impressive is perseverance. A woman persists despite the failures and the difficulties. A man may “bend” during the process; he may say “ok, it didn’t happen, we are unlucky, let’s quit”. A woman doesn’t give up easily. Recently I had a woman whose husband said “I can’t go on, I’m stressed out, I’m tired” and she came up to me and said “I will continue alone with semen from a sperm bank”.  She was that determined.

Now that you mentioned that, recently I was talking with a colleague of yours andhe told me that it is quite usual for a couple to split up after this procedure.

It happens indeed. They either split upduring the procedure or if they fail; but the most impressive is that some couples split up when they succeed in having a child. The truth is that the couple invests a lot in this “chapter”. They think that their relationship will improve automatically as soon as they have a child. So if the relationship isn’t good, the child as we know will increaseany pre-existing problems and this may bring in them the frustration of having invested in the wrong “investment”; so they say “we have a problem and we are splitting up”. In cases where there is a good relationship, the child actually makes it better but if the relationship is mediocreand they invest a lot in the future child, then people usually split up. I have seen many couples separating after succeeding in having a child, because the whole investment in the idea that “the child will bring us happiness and fix our relationship” collapses.

What you are saying is interesting because it seems that it’s not only motherhood that’s in the heart of the process, but the psychological investment in the IVF is also based on the hope that this will make them happier.

Yes, of course. And in order to limit any problems coming from their entourage as well. I have women who tell me “doctor, I have my mother in law who is nagging and I need to have a baby so that she will stopnagging”. It is as if she wants the babymore for her mother-in-law, to make her stop talking, than for herself. What I mean is that usually the relationship is “under attack” by external factors as well, isn’t it? People aren’t alone and especially in Greece they have interventions from the outside. Very often I get phone calls fromthe parents of the couple who say “tell me, doctor, how is my son or daughter doing? Will she have a child?”. And they even make these calls without the couple knowing so they tell me “don’t tell them that I called because they will get angry”.

How do you handle that?

I find myself in a very difficult position; normally I shouldn’t tell them because there is a matter of confidentiality. But what can you do when an elderly person calls you because they worry? It is very difficult and that is why I tell them some general things. I try not to get into details.

Let’s get to the role of the man now. What role does the man play in this process? Is it a secondary role?

Indeed it is secondary. In any case the role of the man in this process is a secondary role by nature and I don’t just mean in IVF but also in natural procreation. Therefore men are usually at a distance. If they have a problem with their semen they feel guilty, and their male status is negatively influenced because Mediterranean men confuse fertility problems with their sexual capacity. And they think that since their semen isn’t “good” they aren’t “100% men”. While in reality, the quality of the semen has nothing to do with their sexual ability. This affects the sexual relationship of the couple and the function of the man in the family.

It is interesting because the truth is that in IVF what is connected by nature becomes disconnected. I mean sexuality and procreation, so I am thinking that it is logical that the sex life of a couple would be affected.

The sex life is affected a lot. Very few couples have a good sexual relationship as I am told. The sexual relationship becomes compulsory; it exists only for this reason(procreation) and it is put into a strict“mould”. In other words, the couples says “now we need to have sex because these are the right days” and they have to ask the doctor questions like “when do we need to have intercourse and how many days of abstention is necessary etc”. So in a sense the sex life of the couple becomes “stylized” and this definitely has an impact on their relation.

Do you ever see the problems of the couple manifested in front of you? I mean if they disagree or fight in front of the doctor. Do they get you involved in this since you are present?

They try to get me involved by asking me about many issues “what do you say?” and this is difficult. They often get angry, usually the women, when the man isn’ t co-operative. Women show their “claws” and this usually involves cases in which one of the two already has children, is in a second marriage, so they are not so eager to have more. This usually happens with women who get married to men who are divorced and have children and aren’t particularly interested in having more children so they come here mainly because their new companion requires that from them. Or even men who are somewhat distanced and put obstacles like “I can’t come (to the IVF center) because I have a meeting, I have loads of work etc”. In other wordsthey behave as if they don’t want that and it is then that the woman shows her claws and the couple gets into a fight. Or in other cases they fight because one of them says for example “I don’t want twins, why do you want twins… let’s not transfer two embryos” and the other one doesn’t agree and there you have again friction and quarrels.

I wonder if you consume much time on these issues because I’m thinking about what you said at the beginning about the time that the patient asks from his doctor.

You need some time for that. You can’t see such a matter in a strictly medical manner because it has many social and psychological implications so you have to give it some time. I don’t put much time in that because unfortunately I don’t have a lot, but I certainly devote some time in order to calm the situation down and explain to the couple that they shouldn’t allow their relationship to be affected; that there are some stereotypes that aren’t true like for example the connection between a man’s sexuality and fertility. Quite often the woman becomes aggressive. For example she might say in front of her husband, “tell him, doctor, that we can’t have a baby with one intercourse a month”. So she devaluates her husband in front of the doctor and the man feels belittled. The woman often takes out aggression in her claiming of motherhood which is a very basic and powerful instinct in a woman.

With the mothers that I work as a psychotherapist, I see that at home and in the raising of children the man is very often as if he didn’t exist. And I think that perhaps when it comes to having a child it is not that important how he feels, what he wants, what he is or isn’t willing to dofor that matter. As if his state of mind and his desires weren’t important.

The truth is that in the family the woman has the primary role not only in the upbringing of children and their education but also in the process of having the children (pregnancy, childbearing). She is the main link of everything, the pillar of the family. The man is more distanced, that’s true.

I’m thinking that in most medical specialties there is a dyadic relationship between doctor and patient. Even as agynecologist your relationship is with your patient and you will only see her husband when she gives birth, during her pregnancy etc. Here things are somewhat different since in some way there is a peculiar “triangle” between the doctor, the patient and her partner. What emotions does this evoke in the doctor?

Sometimes you may feel uncomfortable. Some women tell me “doctor, it’s the threeof us that had the child” or one-two said “I had the child with two men, my husband and my doctor”. This puts me in an uncomfortable position since she usually says that in front of her husband. Or some sometimes –something that I never take the wrong way of course- they are particularly expressive in their gratitude towards me. There are women who are more cold, more cautious, but there are others who are very “Mediterranean”, very expressive, and they hug me in front of their husband and this also puts me sometimes in a difficult position because I do not wish to be cold but at the same I want to keep a safe distance because the couple opens the door to you and lets you in their life. When for instance you must know if they have intercourse and how frequent that is, regrettably, this is something that I have to know. So if the woman says that they have sex once a month in my quest to find out what the problem is and she doesn’t get pregnant, unfortunately I have to know that too. Yet isn’t that something very personal? It is. However I need to know in order to be able to help. So the couple opens their “bedroom” to me and I put the spotlight on them. So you walk into their bedroom and definitely that requires much attention and I must keep a safe distance. I don’t want them to say that I am a detached and cold professional who is after their money – which I never am- but on the other hand I don’t want to get so close that my role becomes perplexed. Because, as I have seen many times, many women who want to have a child and have IVF for that, “confuse” the doctor with their husband because they feel very close to him. For the reason that they have the child with their husband but in a way the child is “conceived” in the operating room where they are with their doctor, sometimes they get confused regarding their feelings for the doctor. I believe that when a woman has a child with your help, it is reasonablefor her to feel gratitude since motherhood is the greatest gift, but perhaps the woman has indeed confused feelings for her doctor sometimes.

Psychoanalytic research seems to confirm what you are saying because I recentlyread about cases of women who havepsychotherapy in parallel with the IVF, and many of them develop an erotic“transference” for their doctor. Essentially, these are emotions that exist in them and are eventually projected to the doctor who helps them to have children.

Yes, because at that time the doctor helps them become pregnant and they get emotionally “confused”. I have been told at times “you know, doctor, I had a dream about you… ” and at that point I smile and say “I don’t want you to continue and tell me about your dream, I don’ t want to hearabout that, let’s talk about our medicalissues”. I change the subject immediately. So this is a subject that needs attention from the doctor, a lot of attention. Because there is the “transference” like you said.

I’m thinking about your patient’s statement who said “it was the three of us who had the child”. I think that there are many patients who feel that way since the gynecologist puts the fetus inside the woman’s body so it is very different from what takes place in a normal conception. And the doctor acquires a very special position in the woman’s psyche.

You asked me something earlier about the gender difference i.e. what if the doctor was a woman. I was surprised by that fac twhen I had women gynecologists as work-partners because I thought that a woman can better understand the needs of another woman and in particular regarding motherhood. Let me inform you that they didn’t get along at all! I was greatly surprised. And indeed, as women they didn’t show the sensitivity that I expected them to show towards their fellow-women; from woman to woman. I never understood why and many times the patients asked to change doctors. Well, it seems that they have more confidence in the hands of a man because it involves surgical procedures, but they (the patients) thought of them (the women doctors) as cold and distant. It didn’t work out and in fact I had to stop my collaboration with them and currently I work only with men. Not that I would not accept women as work-partners but in our field i.e. doctors who specialize in IVF, it is impressive that there isn’t even one woman who is distinguished. There are certainly some but no one –at least until today- has exceeded the average. And I think that it is interesting as an ascertainment.

I wonder if you have something in mind that explains it…

They don’t have the attitude that one would expect from a woman. They are perhaps more distant. I am trying to understand what is happening. Perhaps in the relationship between the gynecologist and the patient there is a subtle attraction of the opposite sex which affects the professional relationship positively. While among women competition and aggression come out. Also these women doctors that I have in mind in the field of IVF, they all have children. Just think what it means to have in front of you a woman gynecologist who is successful, she is a gynecologist, and has children, while you on the other hand don’t have any. Immediately this puts you in a defensive position, in an unequal relationship, since you are both women,one with children and the other one without. While as for me, whether I have children or not, it doesn’t matter since I’m a man.

I would go take this thought a bit further in the line of what we call in psychoanalysis “unconscious fantasy” and would say that if the patient is aware that you have children with another woman, your partner, perhaps there is the fantasyin her that you can give her a child as well. So in the case of a man gynecologist not only this isn’t regarded as something bad, but it can be good in fact.

And also with the woman doctor there isn’t a good interpersonal relationship, I see it now, as competition comes out. It is very interesting and worth investigating in the bibliography. Ok let’s say that in Greece there aren’t many women gynecologists but in the conferences that I attend abroad, for example in America where women gynecologists are the majority, there isn’t a prominent woman in the field of IVF.

Now tell me, why did you choose to get involved in IVF?

I didn’t set out to get involved in this subject, I didn’t even intend to do gynecology. But when I was a young doctor I met a girl who told me that she was told that she couldn’t have children, and then I married her and we had two children. She put me in this, let’s say by chance. I believe that most things in life are random, circumstantial. I went to a field of medicine that I knew nothing about, through this process I learned it, and finally I said “This is something that I like; that’s what I’ll do”.

What do you get out of this job?

In IVF it’s the confirmation of victory when you accomplish your task. The recognition of success. But on the other hand, the price is too high because there are failures and just when you feel good, suddenly there comes a failure and it takes you back. For me it’s a daily battle to fight the misery of infertility, to give joy to people –although it may sound romantic or idealistic- to have couples bring their children here for me to see them. But if you don’t do this solely for the money and you do it because you like it, then you get many disappointments as well. Many times a couple who’s in despair will “transfer” the feeling of failure to the doctor –since we were talking about transference earlier. That “it’s you to blame for not succeeding, the IVF center, the laboratory, etc”. The couple seeks someone to blame since it’s never the statistics, orthemselves, it’s always someone else’s fault.

Is there a way for this “blame” to stay in the couple and become the object of a psychological elaboration and perhaps acceptance? Or will the doctor be to blame every time and the couple will change doctors until they get the desired outcome –if they do? In other words, can there be a psychological elaboration of failure since the statistics say that it is most likely than not that the woman won’t become pregnant, that the IVF won’t succeed?

But the couple because they can’t endure the burden of failure, they “transfer” it to the doctor and that’s why they change doctors very often, which I think is healthy to a degree. For instance, the woman might not bear to come back to this place that is reminiscent of her failure, to see my face that also reminds her of that, so she wants to see something new that has nothing to do, that makes no associations with the failure, and that’s why they change IVF centers so often.

But this eventually becomes apsychological symptom. I’m thinking of what you said at the beginning of our conversation about neuroses being frequent in IVF patients. There is a great difficulty in the acceptance of failure and the likelihood of not succeeding with the IVF, isn’t there?

A great difficulty and with the economic crisis now the problem becomes even greater because it co-exists with the financial issue. Before the couple would say “ok if we fail now we’ll try again after three months”. The fact that it is more difficult now for financial reasons brings out greater distress and aggression after a failure.

Can a psychologist help with that?

He might, but I would say that there is a very small percentage of couples who see a psychologist. We urge them to go and in fact there is no charge for that in our center as we offer free consultation to couples who undergo IVF. But they don’t go and actually they get offended sometimes. They tell you “do you see a problem with me, doctor, and you send me to the psychologist?”. To which I answer “no, but it would help you to talk about it”. But I don’t see many going. Less than 10 %.

Then let’s end with the hope that the couples and women who resort to IVF will pursue the psychological elaboration of the issues that are related to infertility and the difficulties they experience in their ef fort to have children. Thank you very much for the very interesting interview that you gave me.