Riflessioni sugli interventi di Procreazione Medicalmente Assistita
Dott.ssa Livia Agresti
Cosa succede a una coppia che desidera un figlio quando il figlio non arriva?
Dopo almeno un anno di prove naturali il medico invita la coppia a fare le prime indagini per individuare le eventuali cause della mancata fertilità. Ci sono i primi controlli medici, più o meno invasivi, i primi monitoraggi dell’ovulazione, l’ isterosalpingografia, il controllo del liquido seminale … in modo più lato si controlla tutta l’attività sessuale della coppia.
Si continua così fino al sopraggiungere della proposta, fatta in vari e progressivi livelli, di avvalersi delle tecniche di Procreazione Medicalmente Assistita. Tecniche di fecondazione Omologa, con i gameti della coppia, o di fecondazione Eterologa, con uno o con entrambi i gameti di un donatore. Gameti che possono essere sia freschi che criocongelati. Tecniche di I livello: inseminazione semplice; o tecniche di II e III livello: inseminazione in vitro con sedazione parziale, nel II livello, e totale, nel III livello.
Inizia un primo ciclo di PMA, che si considera iniziato quando la paziente è sottoposta a stimolazione ovarica, o alla somministrazione di ormoni per preparare l’utero in caso di eterologa per donazione di ovociti, e comprende: stimolazione ormonale, controlli ecografici, aspirazione ovuli, inseminazione in vitro Fivet o Icsi, attesa dell’avvenuta fecondazione, trasferimento in utero.
Le coppie si trovano sempre più coinvolte in un lungo e logorante iter medico dagli esiti incerti, dove tutte le risorse fisiche, emotive, mentali ed economiche sono investite in questo progetto e spesso per diversi anni. Considerando che i tassi di successo sono di circa il 23,9% per le pazienti con meno di 35 anni per poi diminuire linearmente fino ad arrivare al 4,5% di successo per quelle con più di 43 anni, le perdite e i fallimenti con cui fare i conti sono molteplici.
Vorrei prima di tutto riportare l’attenzione su un importante cambiamento di paradigma in atto su cui è opportuno riflettere. Da sempre la procreazione è stata frutto di un rapporto sessuale tra un uomo e una donna. Adesso si può parlare di una riproduzione asessuata, ove c’è una disgiunzione tra sessualità e procreazione.
La contraccezione aveva separato il sesso dal concepimento ora la PMA separa il concepimento dal sesso. Nel 1953 è riuscita la prima inseminazione con sperma congelato separando così nel tempo e nello spazio i protagonisti dell’accoppiamento. Nel 1983 con la donazione degli ovuli si è separata la madre biologica da quella genetica. Nel 1984 con il congelamento dell’embrione si è separato il concepimento dalla nascita dopo i nove mesi. Nel 1997 è iniziato l’uso degli ovociti congelati, dando la possibilità anche a giovani donne di congelare i propri ovuli per un uso successivo.
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La PMA porta la coppia a uscire dalla camera da letto per coinvolgere nel processo procreativo altri luoghi e altri soggetti quali la clinica, i medici, gli operatori del centro… fino ad arrivare ai donatori. La propria attività sessuale è messa in mostra, si devono raccontare inadeguatezze e fallimenti, sono discusse e ridefinite le modalità e i tempi della sessualità della coppia.
Il primo evento da elaborare è la diagnosi di sterilità che mette a dura prova l’immagine di sé, l’autostima, la fiducia nel proprio corpo e nella vita, e poi anche la relazione con il partner e il senso della continuità genetica.
Avrà caratteristiche diverse per l’uomo che si sente colpito nel suo vissuto di potenza sessuale, mascolinità, adeguatezza, e nella donna più soggetta a sentimenti di perdita, ansia, depressione, invidia verso le altre donne madri.
Da questi vissuti portatori di un senso profondo di impotenza e inadeguatezza, si rischia di passare facilmente ad un’illusione di onnipotenza offerta dalla scienza, da tecnologie capaci di superare ogni difficoltà e così ci si tuffa in un turbine di azioni da compiere.
Si entra nei cicli di PMA che si susseguono a ritmo incalzante, in modo attento occorre assumere ogni giorno medicine, fare controlli, sottoporsi a interventi medici più o meno invasivi, e poi sempre speranze, attese, delusioni, lutti, ma non c’è tempo per pensare, elaborare, bisogna andare avanti. Si parla in letteratura di “montagne russe emotive” ed io penso alle mie pazienti e immagino più il gioco della roulette russa a cui le vedo sottoposte e in cui è sempre più alta la tensione per la paura della morte e il desiderio di una vita, il tempo passa e il miracolo atteso non avviene. Arriva la perdita di sangue e segna il trauma di un insuccesso, il crollo delle speranze e del lavoro fatto, ma deve durare poco, anche per questo momento non c’è spazio di pensiero possibile, pochi giorni poi occorre riprendere subito un nuovo ciclo e tornare nella roulette con la speranza che questa sia la volta buona, e così si riprendono le medicine, i monitoraggi, le visite… le speranze, le attese…i dubbi, le paure.
In un accompagnamento emotivo a questo percorso il terapeuta aiuta sin dall’inizio la coppia a sostenere il senso di incertezza e dubbio che il non sapere comporta, evita di cerca delle cause per dare strumenti di intervento attivo, colludendo con tutto il sistema già in atto, ma si propone di indagare i vissuti suscitati dalla storia passata e dal continuo susseguirsi di eventi. Spesso la ricerca di una causa psichica può solo aumentare sensi di colpa dei pazienti, anche se chiedono e sperano di trovarla per sentirsi padroni di se stessi e con la speranza di avere una soluzione da concretizzare. “Se vinco le mie resistenze inconsce o mi rilasso o penso positivo questa volta andrà bene!” Tale illusione porta a restare nell’onnipotenza e evitare il sentimento di sofferenza e paura, di ascolto del limite e del possibile fallimento.
Anche noi dobbiamo sostare nel non sapere e siamo testimoni diretti e partecipi di decisioni difficili da prendere e velocemente, spesso non abbiamo conoscenze puntuali ma siamo coinvolti nell’urgenza. “Quanti embrioni fertilizzati voglio impiantare? Per legge posso massimo tre, ma a me ne spaventano anche solo due.” “Cosa faccio di quelli rimasti li congelo?” Sono dubbi che alcune madri mi hanno posto.
I temi che un intervento di sostegno deve affrontare con la coppia riguarderanno: l’impatto che hanno le tecniche di PMA sulla relazione con se stessi e con l’altro; le implicazioni nel mondo affettivo, nel vissuto e nell’immagine di se stessi, nelle relazioni con il partner, con la società e con l’eventuale figlio; le implicazioni immaginate sullo sviluppo del nuovo nato con il supporto della PMA.
I genitori hanno bisogno di integrare tutta l’esperienza vissuta, nei suoi vari aspetti, per digerirla e poi poterla trasmettere integrata al figlio.
Com’è stato concepito quel bambino, chi ha partecipato al suo concepimento, quali le fantasie sugli altri coinvolti, cosa è successo alla coppia genitoriale in quel momento di vita, cosa ha significato quella nascita per ognuno, cosa e in che modo dico a mio figlio delle sue origini. Tutti i vissuti dei genitori sul percorso di PMA se non sono elaborati e resi pensabili, se non è stata possibile una loro integrazione, lasceranno elementi irrisolti che rischiano di essere depositati nel bambino come nuclei ciechi, dissociati, a cui lui stesso non riesce e non può dare senso, fonti di fantasmi e di elementi estranei.
Si costituiscono così dei “segreti di famiglia” e il figlio deve fare i conti con un non detto su qualche cosa di importante che riguarda al sua esistenza. Questo è un primo passaggio, fondamentale per le trasmissioni implicite, poi c’è la comunicazione esplicita che richiede attenzione ai vissuti suscitati in quel momento al bambino. Ci potrà essere una certa ansia su una parte sconosciuta della propria origine, rabbia e incertezza sui rapporti di parentela, le fantasie di poter avere fratelli di donazione e potersi accoppiarsi con questi.
Significativa a questo proposito è la storia di Audrey Kermalvezen, una donna avvocato che si è specializzata in diritto bioetico ben sei anni prima di sapere la sua storia di essere nata per donazione anonima di sperma, lo ha saputo a 29 anni prima di sposarsi con un uomo anche lui figlio di donatore anonimo. Ha creato un’associazione per nati da procreazione medicalmente anonima, l’anonimato del donatore era possibile in Francia e in molti paesi del mondo fino a qualche anno fa, e ha lottato per il rispetto dei diritti del concepito. Ha scritto un libro nel 2014 “Mes Origines: Une affair d’état” (Ed Max Milo) dove dice «Ecco perché noi non siamo qui innanzitutto per conoscere le nostre origini, ma per testimoniare quanto sia dura nascere così» Perché a tutta questa sofferenza «non c’è alcun rimedio».
C’è una nuova identità che si va definendo basata sulle origini con il sostegno dalla PMA.
Andiamo probabilmente verso lo sviluppo di un Io più flessibile, capace di integrare esperienze intrapsichiche e relazionali diversificate nel tempo e nello spazio, non più un Io caratterizzato principalmente da forza e stabilità, con alcuni parameri da mettere insieme per il suo senso di interezza e continuità, ma un Io che è capace di accogliere molti dati diversi della sua personalità, della sua storia, delle figure relazionali interne, fantasmatiche, ed esterne, aspetti diversi che convivono e dialogano tra di loro in un movimento vitale e ricco.
Gli adulti oggi che si trovano ad affrontare una scelta di nascita così hanno una nuova responsabilità e ci chiediamo quanto siano in grado di affrontare tale scelta con tutte le sue conseguenze e non solo capaci di agirla. È una scelta di desiderio che viene affermata, ma occorre specificare un desiderio di chi e di cosa. Quali sono i diritti dei genitori e quali quelli dei nascituri. Siamo sempre in grado di pensare responsabilmente all’altro? Quali sono i limiti da accogliere e sostenere e quali quelli che l’uomo vuole immancabilmente superare?
Tutto appare procedere verso un’evoluzione auspicabile e inevitabile. Dobbiamo a mio parere riflettere su tutto questo e ancora una volta non serve emettere solo un frettoloso giudizio a favore o contro una data opzione, ma poter pensare insieme e ascoltare le paure e le sofferenze di ogni storia. Le risposte richieste saranno il frutto di un pensiero nuovo, originale e consapevole, quasi mai possono essere ricercate nel già noto. Senza cedere ancora una volta il passo ad una tecnologia onnipotente che sembra illuderci di poter dare risposte su tutto. Occorre darsi il tempo di una trasmissione culturale e organica complessa, di un’elaborazione necessaria di processi interni, un tempo che è inevitabilmente molto diverso da quello delle macchine. La tecnologia va resa compatibile con i ritmi e i tempi biologici e culturali dell’uomo, nonché dei suoi processi vitali e psichici.
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Nell’ascolto di tutte le storie che incontriamo dobbiamo lasciarci entrare in una dimensione profonda di incontro, riuscire a sostare con l’altro nel non conosciuto, anche noi siamo spesso impreparati, senza risposte e insieme dobbiamo frenare il bisogno di andare nel fare e nel capire a tutti i costi. Non cerchiamo ancora una volta di non il sentire il corpo, il nostro corpo: che ha i suoi limiti, che spesso non capiamo, che provoca sofferenza ma che è anche la nostra fonte più intensa di vita e di piacere, e soprattutto che è capace di contenere e sopportare quell’inevitabile ambivalenza e complessità che ci caratterizza come esseri umani.
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