Sterility is Now Being Overcome (Jan, 1937)
Sterility is Now Being Overcome
There is new solace for empty arms as science helps the limping stork
By Lorine Pruette, Ph.D
DYNASTIES have been changed and the course of history affected by the failure of particular unions to be fruitful. Catherine the Great took a lover because of the necessity to provide the throne with an heir and introduced entirely new strains into the royal family of Russia. Henry the Eighth of England made his numerous excursions into matrimony, in part at least, out of the desire for a male heir. As a by-product of his excursions we have the break with the Catholic Church, the establishment of the Church of England and vast changes in England’s internal affairs and in her relations with the continental countries.
Henry’s children mounted the throne in succession, but all three died without heirs. Had his daughter Mary borne a child to her husband, Philip of Spain, much history might have had to be rewritten and certainly England would have been returned for a time to the bosom of the Mother Church.
Mary married late and her husband was not at all interested in her; nevertheless when she assured him proudly that she was pregnant Philip put off his affairs in Spain and Holland and remained in England. Mary’s yearning for the importance which a child would give her in the king’s eyes as well as in affairs of state was so great that she counterfeited the symptoms of pregnancy. At one time the bells of London were rung announcing the happy issue, but time passed, all normal limits were exceeded, with the king growing impatient and the queen frantically clinging to the notion that soon she would be delivered of an heir. We can imagine the poor woman’s desperate unhappiness and the tragedy of her situation when she had to accept the fact of her sterile condition. Napoleon put away the Empress Josephine and contracted an alliance with the Austrians in his determination to found an empire; he secured the heir but lost the empire.
Napoleon and Josephine illustrate the situation in which two persons, both capable of parenthood, are without issue; Josephine had children by her first marriage, Napoleon had a child by his second.
Reproduction is a complicated process which was in earlier ages surrounded by a vast amount of misinformation and superstitious notions. For a long time in the history of the world, everyone was ignorant of the part that the father played. The woman was thought to be fertile under the influence of supernatural powers, and the fertility of the husband was not discussed because it was not assumed that he had anything to do with the creation of new human beings. Many persons in the modern world have swung completely to the opposite extreme, so that instead of denying the capacity of fertility to men they insist that it is inevitably possessed. Even today women submit to operations in the hope of becoming mothers while the defect is actually in the husband.
Nevertheless, the discoveries of science are beginning to give us a control of reproduction never dreamed of in other ages. Marriages are now held together and children produced in marriages which would at any other time inevitably have remained unfruitful. Women used to pray for miracles to give them a child, and now the sober miracles of science sometimes answer their prayers. Man began to understand something about the process by which the race continues. As the new science of endocrinology developed, attention passed from a study of the organs of reproduction to a study of the things which make the organs useful, to the hormones of the endocrine glands which are essential to the process of carrying on the race. Surgery, irradiation and the use of endocrine products are the methods by which children may now be produced by many couples who had thought themselves hopelessly sterile.
Dr. Arthur First has said that “we feel that the future is very promising indeed in the treatment of sterility associated with endocrine disturbances”; his clinic in Philadelphia reports fifty-three conceptions following a study of one hundred and fifty women with glandular disturbances. Dr. Rubin reports eight pregnancies as a result of thirty-five tubal operations. Thus from surgery and endocrinology there begins to come the answer to a question which has baffled human beings since the days of primitive men.
One of the tests made in the study of sterility is that of tubal insufflation, as for various reasons the Fallopian tubes through which the ovum travels to the uterus may become congested or sealed over. Such a mechanical cause of sterility should be ruled out before glandular treatment is undertaken. Titus reports thirty-five cases of tubal obstruction in one hundred and thirteen women, as contrasted with twenty-seven cases of glandular imbalance in the same group.
In spite of many successes through the use of surgery, strenuous warnings are sounded against too ready resort to surgery in the correction of sterility. Where it is necessary to make an incision in the abdominal wall the risks associated with this cannot be denied, while in case of infection, tubal insufflation is a danger to the woman. It would seem obvious that no surgical interference should be undertaken before the fertility of the husband is investigated, nevertheless Dr. Meeker’s records show thirty-two women who had undergone abdominal operations in hope of correcting sterility which was later found due to the husband. Today the emphasis is upon the study of infertile matings, rather than upon investigation of the woman alone. It has been estimated that about twenty-five per cent of infertile matings are due to the husband, while one investigator declares that there is an astonishing number of men who belong in the category of low fertility. One clinic reports that in fifty per cent of the cases it has been necessary to treat both husband and wife.
In both men and women, three of the endocrine glands are now considered to be involved in the failure to have a child; it is possible that further investigation will add to this number. The glands whose deficiency may lead to sterility are the pituitary, the thyroid and the gonads. In both men and women it is more common to find a deficient production of the hormones of the pituitary and the thyroid responsible for sterility than a deficiency of the sex hormones of the gonads themselves.
THE endocrine glands form an interlocking system, with influences from one gland upon another, both to inhibit or to encourage activity. From the pituitary comes at least one hormone whose function is to stimulate the sex organs to appropriate activity, and possibly more. From the pituitary there also comes a hormone to stir the thyroid to activity in producing its hormone. The hormone from the thyroid likewise affects the sex glands. In cases of male sterility the following factors were found operating: defective thyroid in eighteen cases, inactive spermatozoa with defective numbers in seven cases, sluggish spermatozoa with defective numbers in seven cases, abnormal forms of spermatozoa in five cases, anemia in three, excessive frequency of coitus in seven and excessive use of alcohol in one case.
The use of thyroid has shown brilliant results in correcting sterility in both men and women. The treatment for pituitary failure is handicapped by the chemical problem of the production of a potent extract, but much research is under way to meet this problem. One investigation reports that while only ten per cent of the women treated responded to the pituitary-like gonadotropic hormone, considerably better results were secured when this was combined with a small amount of extract from the pituitary itself. Insulin has also been found helpful in some cases of primary ovarian failure. This secretion, normally produced by the pancreas, and used in the treatment of diabetes, improved the body weight of the women and caused a distinct improvement in genital functions.
When the ovaries or the pituitary are inactive, good results have been secured by irradiation with low doses. This seems paradoxical, since large dosage of X-ray treatments results in sterilization and is used for this purpose in case of disease. But low irradiation stimulates the endocrine glands to activity in the production of hormones and has been found to clear up menstrual disturbances in a large number of cases, with a resulting increase in fertility. In one investigation, irradiation of women with functional sterility and menstrual disturbances made conception possible in fifty per cent of the cases.
The discovery that ovulation, that is, the ejection of the egg from the ovary, is a process distinct from menstruation shed new light upon reproduction. Women may menstruate regularly and yet be deficient in ovulation. Ordinarily, the egg ripens and is discharged from the ovary about midway between the menstrual periods. If the egg encounters live spermatozoa within the few hours of its life, conception takes place. This is the only time in the month when conception can take place, hence occasional failure in ovulation cuts down the opportunities of conception. Likewise failure to have sexual relations at the time of ovulation makes conception unlikely, as the spermatozoa also live only a short time. In cats and in rabbits, ovulation takes place under the stimulation of the sex act, and only then. It is thought that some women also have a tendency to ovulate under conditions of sexual excitement or of coitus, in which case they would seem to be repeating an earlier evolutionary pattern.
HOWEVER, in most women it seems possible to establish the time of ovulation, and this is important both to questions of conception and of contraception. Instead of there being a brief period of infertility, as used to be thought, it now seems that most of the month the woman is infertile; this has given rise to the so-called “rhythm” method of contraception. Very careful records should be kept for a number of months to determine the woman’s sexual cycle and this should be supplemented by analysis of the hormonal content of the urine. Even after the time of ovulation has been determined for the individual woman, this may be upset by illness, excitement or after a pregnancy, and so it cannot be relied upon as a method of contraception under any unusual circumstances.
Knaus of Vienna and Ogino of Japan have made very careful studies of the menstrual cycle. They believe that in women with a twenty-six day cycle, with ovulation normally on the twelfth day, conception is most likely during the period from the ninth to the thirteenth day. In women who have a twenty-eight day cycle, with ovulation on the fourteenth day, the favorable period is from the eleventh to the sixteenth day.
The woman whose sterility is primarily gonadal may suffer from a deficient product of one or both of the ovarian hormones. The estrogenic hormone operates in the ripening and release of the egg from the ovary while the corpus luteum prepares the uterus to receive and to hold the fertilized egg. Treatment may include the use of both substances as well as thyroid medication. Women who show marked under-development of the generative organs have commonly suffered from glandular derangements during the critical period of adolescence, derangements which were not recognized at the time. When they are recognized in adolescence, the estrogenic hormone of the ovary, known as theelin, estrin or progynon, is sometimes helpful in stimulating development of the genital organs and in establishing the menstrual rhythm. Such treatment is also used with mature women who have an insufficient supply of the hormone.
In one investigation, attention was centered on the sterility of regularly menstruating women. A curettage of the uterus was made to see if the endometrium lining provided a suitable nest for the fertilized ovum. When this is not the case, the woman may conceive easily enough but she may not be able to retain the fertilized egg. In fifty sterile women who menstruated regularly, less than half, twenty-three, showed the normal changes in the uterus which are necessary for nesting. The absence of these changes showed the women suffered from a deficiency of the corpus luteum hormone from the ovary. In addition, thirty-seven of these women, or seventy-four per cent, gave no evidence of estrogenic substance in the blood just before the menstrual period, thus indicating a deficiency of this hormone.
The duration of the menstrual cycle is also of importance in the study of sterility. During the month the ovaries produce the two hormones in varying amounts, rising to a high tide considerably before menstruating and falling off very sharply just before the onset of the menses. The estrogenic hormone and the egg have been produced in the middle of the month, followed by a high production of corpus luteum hormone which makes it possible for the uterus to retain the fertilized ovum. Menstruation is the reaction of a “disappointed uterus” which has been prepared to receive the embryo. It is like a house which has been prepared for an expected guestâ€”when the guest does not appear the furniture of the house is moved out as no longer necessary. Women whose menstrual cycle is short are less likely to become pregnant, according to Dr. A. G. Campbell. They have a deficiency of the corpus luteum which is necessary to prevent the sloughing off of the endometrium cells in the menstrual flow. Since they have not enough of this hormone to postpone menstruation to the full period, it is unreasonable to expect them to have enough to sustain the endometrium for the nine months of pregnancy. The reason for the ability of the fertilized ovum to nest in the uterus and to adhere to and develop within this organ is because the hormone of the corpus luteum inhibits and checks the hormone of the posterior lobe of the pituitary gland. This is why pregnancy can continue and abortion does not take place.
WE have here the explanation of spontaneous abortion, which prevents a number of women from carrying their children to term. Folklore is full of stories of women who lost their babies because of some dreadful sight or shocking experience, but medical experience discounts this. Women are known to produce their babies under all sorts of disturbing conditions, such as wars, cyclones, deaths of loved ones, etc. Spontaneous abortion is held to be extremely rare when a healthy child is properly attached to a healthy uterus. But the woman who aborts frequently is like the woman who receives the expected guest but has no place prepared to receive him. Until the last few years there was very little that could be done for such women, but now there is great hope for them. In order for them to carry their babies
to term, it is necessary to supply them with the corpus luteum hormone which their ovaries should be producing. This is necessary through the fifth month, after which time the normal ovary stops producing the hormone in large quantities.
The desire to have a child, coupled. with the sterility of one of the partners, has led at times to odd and dangerous attempts to remedy the situation. With the great strides made in recent years, through endocrinology and surgery, more reliable and less emotionally disturbing methods have become available for many childless couples. When it becomes possible, as apparently it soon will, to separate the various active agents of the pituitary, some of which are known to be involved in the stimulation of the sex glands, many cases which now appear hopeless will probably be cured.
THE importance of further research in this field is indicated by the fact that in one hundred sterile women with irregular menstruation, sixty-four were found suffering from pituitary deficiency. At present authorities differ as to the value of using the estrogenic factor from the ovary in cases of deficiency of this hormone, but here again it is possible that improvement of therapy waits only on further research of the bio-chemists. Treatment of women who are able to conceive but who, through deficiency of corpus luteum, cannot carry the child through the nine months is already giving striking results. Most impressive of all, at present, is the successful use of thyroid medication.
When a man and woman have been married for a year and conception has failed to take place, their mating is considered sterile and they are urged to submit themselves to a thoroughgoing study before any more time is lost, as a condition may be remedied in its early stages while hopeless in later ones. The complete study advocated by Meaker, which requires more than a week and involves the services of a number of specialists, has resulted in pregnancies in fifty per cent of the cases. When a man and a woman are really in earnest about their desire for a child, there are now many tests available for investigating the failure to produce offspring. In a recent article, Dr. Paul Titus has listed the following essential steps:
1. A history and general physical examination of the wife, including a blood count and urinalysis, followed by
2. A pelvic examination.
3. A history and general physical examination of the husband. .
4. Examination of the husband’s genital organs.
5. The estimation of the basal metabolic rates of husband and wife.
6. Examination of the spermatic fluid from a condom-to-bottle specimen, as well as later postcoital examination of spermatic fluid recovered from the cervical canal of the woman (Huhner test).
7. Tests for tubal potency by insufflation (Rubin tests).
8. Such other measures as may be necessary, including injection of uterus and tubes with opaque mediums for roentgen visualization and the Frank estimation of circulating estrogenic hormone and follicle-stimulating factor or excretion of these in urine as determined by Kurzrok’s method, as well as galactose tolerance test as gage of pituitary function.
A deficiency in the production of healthy sex cells does not necessarily imply any deficiency in the hormones which affect the femininity or masculinity of the individual, nor any deficiency in sexual desire. Very passionate individuals may be sterile, just as very fertile individuals may have weak sexual desires. A further complication is seen in the fact that fertility appears sometimes to decline in a given couple after a number of years of marriage. It is thought that a new mating may revive this. Also, a man may be fertile and so may his wife, and yet they may fail to produce children.
A theory has been developed to account for this, that after a time an immunity is set up between the husband and the wife. This conception of immunization against the spermatozoa of the male has been made the basis of research in Russia in birth control technique. The cells are injected into the female, just as is done in developing immunity against a disease by injecting the germs of this disease. A considerable period of immunity in the rabbits, corresponding to immunity of several years in human beings, has already been reported from these studies of spermatozoa injections; this may offer to the future the safest and least objectionable form of contraception.
Science has gone a long way in the investigation of the world of nature, in protecting mankind against the elements and in making it possible for men to live under climates and conditions once fatal to life. Now through the study of the glands of internal secretion we are coming nearer than ever before to an understanding of the processes of life itself. If man can come to the point of controlling his reproductive processes he will have achieved a startling triumph over the compulsions of nature, only second to the triumph not yet achieved of a genuine postponement of senility and of death.