Assisted Reproduction Techniques (ART) at the 21st century have significantly increased the need for genetic material donation banks. Heterosexual couples, lesbians and single women use gamete donation to fulfill their desire to have a child (François and Bouychou, 2019).

The diagnosis of infertility involves great emotional pain widely studied in terms of anxiety, depression and coping strategies, as well as their relationship with pregnancy rates (Burgio et al., 2022; Flis-Trèves, 1998; Massarotti et al., 2019; Moreno-Rosset, 2000a, b; Muñoz et al., 2009; Oh and Shin, 2025; Rooney and Domar, 2018). It is also described from the clinical point of view as a “grief of griefs” composed of three nuclei of loss: (a) biological fertility, (b) the child project organized in psychoevolutionary development and (c) the asymmetry between one fertile and one non-fertile member of the couple (Camps, 1996, 2007). In male infertility, men have greater anxiety (Boivin, 2019; Hegyi et al., 2019; Öztekin et al., 2020; Patel et al., 2018; Sejbaek et al., 2020).

The elaboration of this complex grief is a vital crisis and behaves according to the organization of the personality, the relational dynamics established in the couple and their degree of vulnerability (Abdoli et al., 2025; Plowden et al., 2025; Espada and Moreno-Rosset, 2008; Camps, 1996, 2009, 2010a, b, 2018; Jeon et al., 2025; Muñoz et al., 2012; Assaysh-Öberg et al., 2023).

This research incorporates the assumption that grief coping strategies to face the loss of biological fertility (GCS) is related to the decision-making process of the communication of genetic origins to children and to the quality of the emotional bonds established during parenting.

The process of communication of genetic origins has been an issue widely discussed with voices for and against in which we observe very opposite positions. Some favor secrecy, but others favor communication (McGee et al., 2001; Schmid and Ehlert, 2025).

Many authors study the issue from the perspective of decision, timing, and how to communicate (Blake et al., 2010; Daniels and Thorn, 2001; Kirkman, 2003; MacDougall et al., 2007), reporting that biparental heterosexual couples present significant difficulties in making the decision.

Our clinical practice shows that when the indication of reproductive treatment with genetic donation is made, most couples have a tendency to refuse to recognize the difference between biological fertilization and assisted reproduction. At this time, they do not see the need to communicate genetic origins to their children and consequently it becomes a conflicting issue for the future (Camps, 2021).

Given the qualitative nature of the problem, the research adopted a rigorous study design from a mixed-methods perspective (Anguera, 2022). The initial phase focused on analysing habitual behavior within a natural context, specifically through in-depth interviews. These interviews were processed following the scientific method (Chacón-Moscoso et al., 2021), which involved: (1) building a non-standard instrument specifically adapted to the object of study, (2) systemizing the information, (3) controlling data quality, and (4) employing adequate analysis techniques, such as T-Patterns, to discover the deep, hidden structure within the data (Anguera et al., 2023a, b).

Interest in the content analysis of verbal data from in-depth interviews is growing rapidly in indirect observation research (Anguera et al., 2018), particularly within clinical and care settings (Arias-Pujol and Anguera, 2020; Del Giacco et al., 2020). However, this methodology has never been applied before in the field of ART.

The main objective of this research is to detect potential regularities in the modality of grief due to infertility (GCS) and patterns related to the communication process of genetic origins, based on an exploratory study of the natural history of infertile couples 25 years after having children with assisted reproduction techniques of donor semen (AID).

We have obtained relevant results in the methodological field, which shows the potential and suitability of the mixed methods that allow quantifying a highly complex experience such as filiation through assisted reproduction from adequately structured qualitative information (Anguera, 2018; Stake, 2006; Yin, 2014). The in-depth treatment of the interview from the mixed methods perspective has allowed us to transform the observed data from a very difficult to quantify experience, into quantitative results rich in qualitative nuances, on the experience studied. At present, there is still little research available with mixed methods in this field (Sandelowski, 1988; Sandelowski et al., 2009).

Anguera (2021) highlights the innovations made on the multimodal perspective of communication applied to the in-depth interview and points out that the transcription of interviews, highly systematized from a more or less molarized or molecularized coding, makes it possible to obtain matrices of codes that, although they contain qualitative information, the degree of systematization makes them already suitable for quantitative analysis. Along the lines described by the author, in our study we have applied this procedure to detect the structure of significant associations in the behaviors/communications of the couples reports; and so we have mapped the interrelationships between the codes/categories that have given us the results of the study.

In line with the mixed-methods approach adopted, neither sample size nor generalizability is a primary concern. The study aims, rather, to generate in-depth insights and enhance understanding of the phenomenon explored.

The results describe five multiple cases based on behavioral patterns that show that the participating couples, in their report, establish a relationship of association between the behaviors related to the elaboration of the grief from the loss of fertility and the communication of the genetic origins; and they show that 25 years after conceiving children, the two behaviors are still significantly connected to each other.

The detailed interpretation of each case provides very valuable information to determine in detail specific aspects of the experience studied on the grief of infertility and that are essential for its in-depth analysis.

Multiple case I shows that the experience of loss caused by infertility lasts over time and that its psychological effects, as highlighted by other authors (Hammarberg et al., 2008), fall on filiation, from the experience of pregnancy, childbirth, to the bonds of attachment established in upbringing.

This result allows us to affirm the emotional value of the loss of fertility by couples and its significance in the upbringing of their children. For this reason, we find it necessary to consider the recognition and acceptance of the loss of biological fertility as a psychological factor to be taken into account in the first line of the fertility clinic when the diagnostic process is carried out.

Multiple case II yields results along the decision to communicate or not to communicate genetic origins; and if so; how, when and what modality to do it. There are highly polarized voices against and in favor of communication, but most authors agree that the decision of whether or not to communicate genetic origins is a delicate issue that couples do not know how to deal with (Blake et al., 2010; Daniels and Thorn, 2001; Kirkman, 2003; MacDougall et al., 2007).

In the case of two-parent heterosexual couples, clear difficulties have been observed in making this decision. Our clinical practice agrees with Fitó (2010) that the problem of the decision to communicate origins cannot be solved simply by offering information.

The results of this study allow us to affirm that the decision to reveal one’s genetic origins to one’s children is related to the experience of loss experienced by the diagnosis of infertility.

Multiple case II (which establishes a clear relationship between the dimensions of grief coping strategies (GCS) and communication of origins) reinforces the clinical indication of favoring a priori the recognition of the loss of fertility and the processing of the grief that it entails, so as to facilitate the subsequent management of decision-making on the communication of genetic origins, according to the singularities chosen by each couple.

The application of this result in the fertility clinic is crucial, in particular, with regard to the orientation of the interventions that can be offered by physicians and professionals in the first line of consultation.

From the perspective of the first-line care approach, we believe that the counseling function carried out by specialists has a very important educational and preventive role in the adjustment of the dynamics of couples in the upbringing. Kazemi et al. (2021) also highlight the need for mental health programs to improve adaptive coping strategies of men undergoing ART treatment. Likewise, Luca et al. (2021) propose to consider a couple-centered program for the integrated management of psychological and sexual dysfunction in ART programs.

Along these lines, the articulation of the results of multiple case II with those of multiple case I highlight the importance of orienting care objectives to the improvement of parental functions and not only to increase the pregnancy rate.

Multiple case III shows that the therapeutic offer of assisted reproduction techniques, quickly proposed, can have effects on coping with the grieving process, obstructing or facilitating the reparative function.

Multiple case IV shows that, 25 years after treatment, the parent couples continue to associate the emotional experience of the loss of fertility with the decision to reveal the genetic origins and values of the experience of filiation. This multiple case is related to multiple case II, that allow us to highlight again the clinical importance of coping with and processing infertility grief (GCS).

Multiple case V shows the influence that emotional management has had when incorporating the experience of sperm donation in interpersonal ties with the child and family.

The integrated reading of the multiple cases II, IV, and V, in relation to the objectives of the study, shows a significant associative relationship that relates the emotions emerging from the loss of fertility and coping with grief, and the decision to reveal the genetic origins.

This study presents several limitations that should be acknowledged. Firstly, the 25-year interval between treatment and follow-up may have introduced memory biases among the interviewed participants. Retrospectively constructed narratives—particularly those concerning initial decisions about origin disclosure and the subjective elaboration of infertility grief—may be selectively recalled, reconstructed, or aligned with current family narratives.

Although a sequential mixed-methods design (QUAL–QUAN–QUAL) and rigorous coding procedures were employed, such recall effects cannot be entirely ruled out. Nevertheless, considering that the study focuses on grief coping, a retrospective perspective is particularly valuable for understanding how couples have re-signified their experiences over time.

Self-selection bias should also be considered, as only couples willing to be interviewed chose to participate, possibly representing more resilient or motivated cases. In addition, social desirability may have influenced how participants described their parental experiences. The absence of systematic measures of psychological functioning at both baseline and follow-up limits the emotional contextualization of the findings.

Furthermore, the study is culturally situated in Spain, with recruitment conducted within a specific clinical context in Barcelona. Cultural scripts related to reproduction, kinship, and disclosure—as well as the structure of public reproductive services—are highly specific to this setting and may limit the transferability of findings.

Future research would benefit from incorporating the voices of sons and daughters, thereby including the perspective of the offspring. Additionally, conducting similar studies with couples who conceived without donation, single-parent families, lesbian couples, or those formed through other assisted reproduction pathways would offer valuable comparative insights.

The application of these results in the healthcare field strongly supports the clinical recommendation to facilitate the recognition of fertility loss and grief in infertile couples to promote healthier parenting roles (Tavousi et al., 2022). More specifically, in light of the findings of this study, we propose the following practical clinical applications: (1) To promote interdisciplinary collaboration across all reproductive units, whether public or private, by incorporating mental health professionals with specialized training in fertility-related clinical practice. (2) To develop care protocols that, from the initial consultations, include an assessment of the emotional dimensions of fertility and the parental project that leads to the birth of children. (3) To incorporate the semi-structured interview as the primary assessment tool, complemented where necessary by psychodiagnostic scales and/or instruments to detect emotional needs and guide interventions. (4) To include in clinical protocols the design of psychosocial interventions aimed at fostering parental well-being and strengthening the resilience of parent–child bonds, with particular attention to grief processing in cases of genetic donation and to cultural differences in kinship conceptions and diverse family trajectories.