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An Integrated Approach to Psychosomatic Infertility
296
PSYCHOSOMATICS
JULY-AUGUST
An Integrated Approach to Psychosomatic Infertility WILLIAM
S.
KROGER, M.D.
PART II Psychodynamic Factors in Female Fertility
Common attitudes responsible for psychosomatic infertility are deeply repressed hostility against motherhood and all that it implies. This usually occurs in women whose sub-fertility is associated with marked emotional insecurity and immaturity. Therefore, the emotional maturity of the patient, that is, her ability to meet adequately the demands of pregnancy as well as the healthy acceptance of the mother role should always be taken into consideration! In order to understand the psychodynamics responsible for the ambivalent attitudes related to psychosomatic infertility the following facts should be ascertained: 1. Is the patient a cold, selfish, demanding person, or is she a warm, giving woman?
2. What is her motivation for becoming pregnant? 3. Is the absence of so-called "motherliness" due to environmental factors, permanent or temporary, and if so, can they account for her infertility? 4, How much does her emotional past (reaction to parents, siblings, menstruation, sexual and marital relationship) influence her attitudes toward motherhood? 5. What deeply repressed psychologic factors aTe behind her surface attitudes toward sex, pregnancy and motherhood?
Psychodynamic Interrelationships in Mak and Female Infertility
The male is responsible in almost 50% of barren marriages. Unfortunately, little is known about the relationship of disturbed emotions to semen quality and moThis is the concluding section of Dr. Kroger's two part article. The first appeared in the May-June, 1962 issue.
tility. These, rather than the total sperm count are important factors to the ease M conception." Psychosomatic infertility In the male also may be a defence ,,-gainst certain hazards, as for instance a passive_ dependent husband who cannot and will not be adequate in the father-role. Therefore, unconscious conflicts and motiva_ tions of the husband should always be investigated when treating infertility in the female. These emotional factors, together with the anxiety associated with the female's acceptance of motherhood are pertinent to this discussion. Deep hostility toward the male may be a primary factor in psychosomatic infertility in one marriage, although the same woman may be fertile with a different sexual partner or in the same marriage after adequate psychotherapy. Psychological changes, therefore, obviously have a reciprocal effect on the partner; hence, the wife's reaction to her husband's attitudes should always be evaluated and vice versa. Deutsch" notes that pregnancy often follows renunciation of a career; that a change of living conditions, even for the worse may paradoxically result in conception for many psychosomatically infertile women. She thinks that expiation of old guilt feelings through suffering and sacrifice relieves inner tensions; that the physical procedures used by gynecologists serve as punishment which is the real reason for successful therapy of infertility. Relationship of Metabolism To Sperm Defectiveness'
The genesis of a mature sperm, capable of establishing adequate relationship with ·1 am indebted to the late Milton Gross, Ph.D., Margaret Hague Hospital, Jersey City, for his assistance in the preparation of this section.
1962
PSYCHOSOMATICS
297
. a mature ovum, and together initiating determine the size, shape and geometry the sequence of events which will result in of a cell) and the functional proteins a viable embryo, is one of the most com- (these determine the metabolic machinery plex processes of differentiation and re- of a cell) which are found in a given cell, organization. The characteristics of the depend on the orienting influence of geoutward structural morphogenesis from netic factors on protein synthesis. This undifferentiated germ cells have been can be demonstrated by altering the norknown for many years. However, with mal genetic pattern of a cell by the use of the introduction of cytochemical tech- radiant energy which is ahsorbed by the nics, it is possible to investigate some as- cellular nucleoprotein elements. Such pects of the metabolic structure in an ef- cells are deficient in one or more enzyme fort to determine the enzymatic compo- systems and cannot function normally. nents of normal sperm and its progenitors. The clinical implication in fertility is ob,An important implication of such studies vious. Individuals with germ plasm that is eventually to be able to better differen- has been injured by radiant energy, or by tiate and thus diagnose the deficiency in specific or non-specific stress or any other cases of infertility. several exampIes of noxious agency which can interfere with the direction this work has taken follow. nucleoprotein metabolism cannot produce normal fertilizing sperm. The quality of 1. It has been shown that the sperm has good sperm produced, of course, can range from stores of glycogen and that these must be adcomplete loss of fertilizing ability to that equate for maIntenance. just below normal. A sperm may appear 2. The sperm has a powerful cytochrome-cytochrome oxidase system and associated with normal in every way, but yet be grossly it a powerful succinic dehydrogenase system. deficient in its fertilizing power. The rate Large concentrations of these important of fructolysis as assessed by the colorisources of metabolic energy are found in the metric assay of the disappearing fructose mid·piece, which suggests that they may not is a simple and convenient measure of the be directly concerned only with motility but other functions. This brings up the signifi- metabolic activity of spermatozoa as it cance of motility in estimating ferttlizability. has been found to correlate closely with Motility may not be a good index. It may cell count and motility of the sperm. designate wasteful dissipation of energy which might better be directed to fertilizabillty. Motility, at best, is a sign of spenn life. A "metabolic regulator" has been isolated. Inhibition of certain enzymes stops motility. If the inhibition is reversible, the addition of a reversing agent will re-establish motility. S. The sertoli cells are considered as the sources of nourishment for spermatogenesis. Under normal conditions these contain adequate stores of lipids. Hypophysectomy or large doses of estrogen reduce this lipid and thus diminish the energy supply necessary for normal spermatogenesis. The result is improperly constructed sperm cells with various. degrees of impaired fertilizability and motility.
The effect of genetic influences on sperm integrity must also be considered. In order for a cell to possess the normal enzymatic components, it must inherit the norlila! genetic organizer material. Both the characteristic structural proteins (these
Personality Factors in Psychosomatic Infertility Buxton and Southam'· after finding that controls became pregnant as readily as those treated by all known methods concluded that "our present technics of therapy for the major causes of infertility are totally inadequate. Unfortunately personality studies were not performed, especially in those patients who became pregnant without therapy. Such an interdisciplinary approach would have clarified the interplay of emotional and physical forces in all types of infertility. Sharman'" obtained nearly the same percentage of pregnancies in 1500 cases with "nothing done therapy," as in the passing of a sound and bimanual examination, as by insuftlation and hormones. In his opin-
298
PSYCHOSOMATICS
ion, a psychic effect could not be ignored and was present regardless of the type of therapy used. A rather uniform psychopathology is present in psychosomatically sterile patient3 which centers around a hostile mother identification.fi.l-1.,;~ Rubenstein"l remarks, "the hostility was so intense as to make for the unconscious feeling that were they to become mothers they would hate the child enough to kill it." Witthower and Wilson"" descriptively classify these women into certain broad patterns a3 follows: In the first group are the physically and emotionally immature individuals who, because of
strong dependency needs, attempt to make a child-parent relationship of their marriage. Most of these are typically feminine in appearance and behavior, although they may have juvenile facies and physiques. As children they were qUiet, indecisive and easily embarrassed. Because of parental overprotection they usually become poor wives and, if able to bear children, relate poorly to husband and child because of their own exaggerated needs. If they live in a protected environment, they usually present a facade of gentleness and may often succeed in becoming loving and devoted mothers. As a rule, however, they compete with their unwanted offspring for attention and affection. There is a second well defined group who are the aggressive and masculine type; competitive, ambitious and dominating. They "wear the pants" in the family, and are often successful in various careers. Marriage is only a "front" for these women, and motherhood poses a constant threat. They are not frightened by the increased responsibility of motherhood, but what they fear is the child's care which may interfere with their social and business life. Hence, they reject the feminine role, frequently resorting to contraceptive measures which mayor may not be necessary. Many patients have personality features characteristic of both groups. The first group is readily recognized. Those, who fall into the second group are more difficult to recognize because they erect acceptable defenses to cover up their aggressive hostility.
Kroger' recently studied eleven infertility patients to whom such projective tests as the Rorschach had been administered. Nearly all seemed to fit into the above arbitrary classifications. Some were
JULY-AUGUST
extremely obese and amenorrheic. Their overweight, endocrine imbalance and infertility may all have a common psycho_ logic origin-oral regression-an infan. tile-like 3tate where the individual seeks emotional security by retreating to an earlier period of development. Here, oral satisfactions relieved tensions, and since this tension-allaying mechanism is never forgotten, it accounts for the excessive calorie intake, subsequent obesity and the associated secondary ovarian failure. Ford" also noted these neurotic needs in his series. Reproductive functioning was either totally or partially sU3pended in dynamic arrest as the result of the primary emphasis on the incorporative aims of oral gratification. Such women usually remain sterile because the last thing they really desire is weight reduction with resultant normal ovarian function and the possibility of pregnancy. They often 3tate, "I will do anything in the world to get pregnant," yet when given a diet and basal body temperature chart, they find various rationalizations for not dieting and keeping the monthly record. Fertility After Adoption
The question is often asked: Can psychosomatic infertility be relieved by adoption? Hanson and Rock," utilizing questionnaire material, interrogated 202 infertile couples who had adopted children. They concluded that adoption had no psychic effect, and therefore could not be considered a reliable cure for infertility. Their study is interesting, but one must remember that this type of sampling is notoriously unreliable. However, these excel~ lent investigators observed that adoption often relieved dysmenorrhea and frigidity, and that ovulation occurred more frequently. Many couples in the potentially fertile group also had a healthier mental outlook because of better sex relation3hips. One would think that such healthy' factors should lead to more frequent intercourse and increase the likelihood of conception since sperm motility is en-
1962
PSYCHOSOMATICS
hanced by repeated ejaculation even when other defects in semen quality are present. Thus removal of emotional tensions, whether by psychotherapy or by the corrective emotional experiences derived from adoption may often achieve gratifying results through resolution of conflicts in the male and stimulation of motherliness in the female. Turner" et al. found that conception occurred within six months after adoption in 26% of a group having a good prognosis for their relative infertility thus suggesting the influence of psychosomatic factors. Diagnosis and Treatment of p8'!Jchosomati.c Infertility
When evaluating the emotional concomitsnts of infertility, it should be remembered that each case is different and is to be approached and understood, not in general terms, but only on the experiences of the patient's whole past life situation. The actual subjective emotional aspects of ;experience should always be ascertained. Good history-taking, with thorough analysis of important incidents, permits an understanding of the developmental patterns of faulty attitudes toward pregnancy and motherhood and also reveals pertinent .psychopathology. The extent to which these attitudes have their origin in childhood indicates the di1Iiculties of treatment. It is not implied that if a woman ·once hated her mother or identified with her father, or rejected the maternal role, that these factors per se accounted for 'psychosomatic infertility. However, it is of the utmost importance to understand how and why reaction to these attitudes enabled the organism to respond to psychic stimuli. It is obvious that when an emotionally immature woman finally succeeds in hav'ing a child, she is apt to "take out her spite" on the actually unwanted-al:though perhaps consciously desired-offspring, and may, as a result, adversely affect its psychic development. These interrelationships as well as the personality
299
profiles should be considered in the psychological readiness of the infertile patient for pregnancy and parenthood. Such factors are of prime importance to all women undergoing procedures for relief of their infertility. Whenever doubt exists as to the advisability of alleviating infertility, the gynecologist should share this responsibility with a psychiatrist. Kroger' has used hypnosis not only to establish menstruation in amenorrheic women but also posthypnotic suggestions to relax after coitus so that the tubal spasm would be reduced. Gratifying results have been achieved in a small series of infertile patients. Recently, hallucinated progression in the future has been utilized to determine the rationale for sterilization in apparently normal individuals. The experiment is structured in the following manner: Under deep hypnosis, patients are informed that they were sterilized a year ago (chronological time is advanced by one year). If remorse, unhappiness and self-recrimination are apparent from the verbalizations evoked during hypnosis, it would be wise to postpone the surgery until patients are psychologically prepared to accept the sterilization. An amnesia for the ventilated mao terial can be used to protect the patient against the abreacted and deeply repressed attitudes. CONCLUSIONS AND SUMMARY
The social and psychobiologic expressions of the personality in relation to the functioning of the female's reproductive organs should always be considered in the therapy of psychosomatic infertility. Cultural influences often produce changes in personality structure which lead to psychologic defenses against the establishment of motherliness and inhibition of the maternal instinct with subsequent interference with the neurophysiology of ovulation and conception. Neuroendocrine factors responsible for ovulation, ease of conception and tubal
300
JULY-AUGUST
PSYCHOSOMATICS
spasm associated with autonomic imbalance are related to psychosomatic infertility. The hypothalamus through its intimate vascular connection with the pituitary is vitally concerned in regulating hypophyseal activity. The anterior pituitary is probably controlled via neurohumoral and neurosecretory mechanisms which can often be initiated through exteroceptive as well as enteroceptive stimuli. These nervous stimuli are mediated through the corticohypothalamic tracts and the pituitary-adrenal-ovarian axis with local effects on the uterus and tubes via the autonomic nervous system. Our thesis is that infertility is, at least partially, a disorder of adaptation to emotional and/or physical stimuli; originating from without the neo-cortex or from within, carried to the neocortex by afferent pathways. According to this theory these stimuli descend from the neocortex to the phylogenetically older limbic system (rhinencephalon) and from this to the hypothalamus, the pituitary and other effector organs via the nervous (posterior pituitary) or humoral (anterior pituitary) tansmission. Thus stress due to fright, or from stimuli from without the organism, or distressing thoughts and memories from within produce autonomic responses with sUbse~ quent endocrine imbalance as alterations in gonadotropin output, secretion of epinephrine and subsequent increased infertility. These autonomic and endocrine responses are also a source of anxiety and physical stress capable of affecting the hypothalamus and so alter behavior (establishment of motherlinness, desire for mating etc.). Thus a vicious cycle accounting for psychosomatic infertility may be established. Unconscious conflicts may adversely affect metabolic and enzymatic changes in the sperm and alter capacity to fertilize an ovum. This may be an important fac-
tor in the causation of male infertility. Adoption often acts as a corrective emo_ tional experience for relieving infertility by enhancing the maternal instinct or motherliness. A healthier interpersonal relationship between hushand and wife usually results in more frequent sex-con_ tacts, increased sperm motility and the greater likelihood of pregnancy. The psychodynamic factors responsible for infertility are related to functioning of the total personality. Certain personality profiles characterize' infertile women and these should be recognized in the patients undergoing procedures to relieve their infertility. The gynecologist aware of psychosomatic interrelationships will readily recognize the emotionally immature female who rejects pregnancy, and through appropriate psychotherapy will enable his patient to grasp the real meaning of her conflictual attitudes toward her infertility. Only then will he be able to help her decide whether or not she is equal to the demands of motherhood. REFERENCES 1. Stein, C.: Fertil. &; SteriZ.} 1:407, 1951. 2. Rammer, J. J.: West. J. Burg. Obst. &i Gynec.,
55:278-287, 1947. 3. Mandy, T. E., Scher, E., Farkas, R., and Mandy. A. J.: J. South. M.A .. 44:1054.1951. 4. Kroger, W. S., and Freed, S. C.: Psychooo-
matic Gyn-ecology: Including Proble?ns 01 Obstetrical Cure.
Phila., W. B. Bau,1lders &; Co.,
1951. '5. Kroger, W. S., and Freed, S. C.: Am. J. 01 Obst.t. <£ Gyn
PSYCHOSOMATICS
gress on Fertility and Sterility, 2:'501-505, Int. Fert. Assn., 1955. 14. Benedek, T., Ham, G. C., Robbins, F. P., and Rubenstein, B. B.; Some Emotional Factors in Fertility. Read before the American Psychosomatic Society, March 20, 1952. 15. Kelley, K.: Discussion to ref. 12.
16. Buxton, L.: Am. J. Obst. & Gynec' 70:741J
.17.
18.
19. 20.
753, Oct. 1955. Israel, S. L.; Discussion to Reference 16. Mazer, C., and Israel, S. L.: Menstrual Disorders & Sterility. Paul B. Hoeber, Inc., New York, 1946. Johnson, W. C., and Marshall, J. B.: South. M. J.) 43 :531, 1950. Sturgis, S. H.: Int. J. Fertility, 1 :311-314, July 1956,
21. Mead, M.: Male & Female. Wm. Morrow & Co., N. Y. C., 1949.
-22. Benedek, T.: Studies in Psychosomatic Medicine: Psychosexual Fwnction in Women. Ron-
ald Press, N. Y., 1952.
:23. Benedek, T.: Am. J. Orthophsychiat.) 19:642-
f~4.
654, 1945,
R.
Jenkins, L.: The Significance of Maternal Rejection of Pregnancy for the Future Development of the Child in Therapeutic Abortion, ed. by H. Rosen, Julian Press, N. Y. C., 1954. 125. Beach, F. A.: Hormones & Behavior. Paul B. ~ Hoeber, Inc., New York, 1948. ;)6. Levy, D. M.: Psycho8omat. Med.} 4:223-227, 1942. ;27. Freed, S. C., and Kroger, W. S.: Psychosoi mat, Mcd., 12:229-235, 1950. ;28. Kluver, H., and Buey, P. C.: Arch. Neurol. &; Psychiat., 42 :979-1000, April 1939. i Kluver, H., and Bartelmez, G. W.: Surg. Gyncc. &. Obst., 92:650, Sept. 1951. '30. Schreiner, L., and Kling, A.: Arch. Neurol. & Psychiat., 72: 180-186, July 1954. 31. Fields, W. S., Guillemin, R., and Carton, C. A.: Hypothalamic-Hypophysial Interrelationships. C. C. Thomas, Springfield, 1956. 32. Gloor, P.: In ref. 31. ,33. Fee and Parkes, A. S.: J. Physiol.} 67 :383, 1929. 34. Hinsey, J. C., and Markee, J. E.: Proc. Soc. Exper. BioI. &; Med., 31 :270, 1933. Also in ref. 31. 35. Green, J. D., and Harris, G. W.: J. Endocrinol., 5:136,1947. 36. Wislocki, G. B., and King, L. S.: Am. J. Anat., 58 :421, 1936. 37. Stein, M., and Mirsky, I. A.: The Relationship Between Anterior and Posterior Hypophysis and the Hypothalamus in Response to Stress. Capt. in ref. 31.
29.
301
38. Sawyer, C. H .• and Markee. J. E.: Endocrinol. 46:177-190, 1950. 39. Marshall, F. H. A., Verney, E. B., and Vogt, M.: J. Physiol., 97 :128, 1939. 40. Brooks, C. M., Beadenkopf, W. G., and Bojar, S.: Am. J. Physiol., 129 :320, 1940. 41. Kasdon, S. C.: Endocrinology) 44 :211, 1949. 42. Koikegami, H., Yamada, T., Vsui, K.: Folia Psychiat.. & Neurology. Japonica, 8:7-31, 1954. 43. Marshall, F. H. F_, and Verney, E. B.: J. Physiol., 86:327, 1936. 44. Markee, J. E., Sawyer, C. H., and Hollinshead, W. H.: Endocrinology, 38:345, 1946. 45. Everett, J. W., and Sawyer, C. H.: Endocrinol, 45 :581, 1949. 46. Cleghorn, R. A.: Psychosomat. Med., 17 :367, 1955. 47. Kent, G. C., and Liberman, M. J.: Endocr'inol., 45 :29. 1949. 48. Isaacson, J. E.: Endocrinol.) 45:558, 1949. 49. Brookhart, J. M., Dey, F. L., and Ransom, S. W.: Proc. Soc. Exper. Biol. &; Med., 44:61, 1950. 50. Bard, P.: Research Nerv. &; Ment. n-isc. Proc.) 20: 551, 1940. 51. Friedgood, H. B.: West. J. Burg. Obst. &; Gyncc., 56 :391, 1948. 52. MacLaen, P. D.: Psycho80mat. Med., 11:338, 1949. 53. Knight, R. P.: Bull. of Menninger Olin., 5: 65-74, May 1941. 54. Fischer, I. C.: Proceedings of First World Congroo8 on Fertility and Sterility, 2 :311, I.F.A., 1955. 55. Stallworthy, J.: J. Obst. &; Gynec. Brit. Emp., 55: 171-180, 1948. 56. Rubin, I.: Uterotubal Insufflation, Mosby, St. Louis, 1947. 57. Doyle, J. B.: Fertility &; Sterility, 5:105-239, Mar.-Apr. 1954. 58. MacLeod, J., and Gold, S. Z.: Fert-ility and Sterility, 4:10-33, Jan.-Feb., Urn3. 59. Deutsch, H.: Introduction to the Discussion of the Psychological Problems of PregnancY. In Problems of Early Infant Care. New Y~rk, Josiah Macy, Jr. Foundation, 1948, p. 12. 60. Sharman, A.: J.A.M.A., 148 :603, 1952. 61. RUbenstein, B. B.: Fertility and Sterility, 2: 80, 1951. 62. Ford, E. S., et al.: Proc. of First World Congress on Fert. &; Sterility, Vol. II, 298·307. 63. Wittkower, E., and Wilson, A. T. M.: Brit. M. J., 2:586, 1940. 64. Hanson, F. M., and Rock, J.: Am.. J. Of Obst. &. GynRc., 59 :311-319, 1 9 5 0 . ' 65. Turner, V. H.: Am. J. Obst. &; Gynec., 70: 1189-1196, Dec. 1955.
PSYCHOSOMATICS
JULY-AUGUST
An Integrated Approach to Psychosomatic Infertility WILLIAM
S.
KROGER, M.D.
PART II Psychodynamic Factors in Female Fertility
Common attitudes responsible for psychosomatic infertility are deeply repressed hostility against motherhood and all that it implies. This usually occurs in women whose sub-fertility is associated with marked emotional insecurity and immaturity. Therefore, the emotional maturity of the patient, that is, her ability to meet adequately the demands of pregnancy as well as the healthy acceptance of the mother role should always be taken into consideration! In order to understand the psychodynamics responsible for the ambivalent attitudes related to psychosomatic infertility the following facts should be ascertained: 1. Is the patient a cold, selfish, demanding person, or is she a warm, giving woman?
2. What is her motivation for becoming pregnant? 3. Is the absence of so-called "motherliness" due to environmental factors, permanent or temporary, and if so, can they account for her infertility? 4, How much does her emotional past (reaction to parents, siblings, menstruation, sexual and marital relationship) influence her attitudes toward motherhood? 5. What deeply repressed psychologic factors aTe behind her surface attitudes toward sex, pregnancy and motherhood?
Psychodynamic Interrelationships in Mak and Female Infertility
The male is responsible in almost 50% of barren marriages. Unfortunately, little is known about the relationship of disturbed emotions to semen quality and moThis is the concluding section of Dr. Kroger's two part article. The first appeared in the May-June, 1962 issue.
tility. These, rather than the total sperm count are important factors to the ease M conception." Psychosomatic infertility In the male also may be a defence ,,-gainst certain hazards, as for instance a passive_ dependent husband who cannot and will not be adequate in the father-role. Therefore, unconscious conflicts and motiva_ tions of the husband should always be investigated when treating infertility in the female. These emotional factors, together with the anxiety associated with the female's acceptance of motherhood are pertinent to this discussion. Deep hostility toward the male may be a primary factor in psychosomatic infertility in one marriage, although the same woman may be fertile with a different sexual partner or in the same marriage after adequate psychotherapy. Psychological changes, therefore, obviously have a reciprocal effect on the partner; hence, the wife's reaction to her husband's attitudes should always be evaluated and vice versa. Deutsch" notes that pregnancy often follows renunciation of a career; that a change of living conditions, even for the worse may paradoxically result in conception for many psychosomatically infertile women. She thinks that expiation of old guilt feelings through suffering and sacrifice relieves inner tensions; that the physical procedures used by gynecologists serve as punishment which is the real reason for successful therapy of infertility. Relationship of Metabolism To Sperm Defectiveness'
The genesis of a mature sperm, capable of establishing adequate relationship with ·1 am indebted to the late Milton Gross, Ph.D., Margaret Hague Hospital, Jersey City, for his assistance in the preparation of this section.
1962
PSYCHOSOMATICS
297
. a mature ovum, and together initiating determine the size, shape and geometry the sequence of events which will result in of a cell) and the functional proteins a viable embryo, is one of the most com- (these determine the metabolic machinery plex processes of differentiation and re- of a cell) which are found in a given cell, organization. The characteristics of the depend on the orienting influence of geoutward structural morphogenesis from netic factors on protein synthesis. This undifferentiated germ cells have been can be demonstrated by altering the norknown for many years. However, with mal genetic pattern of a cell by the use of the introduction of cytochemical tech- radiant energy which is ahsorbed by the nics, it is possible to investigate some as- cellular nucleoprotein elements. Such pects of the metabolic structure in an ef- cells are deficient in one or more enzyme fort to determine the enzymatic compo- systems and cannot function normally. nents of normal sperm and its progenitors. The clinical implication in fertility is ob,An important implication of such studies vious. Individuals with germ plasm that is eventually to be able to better differen- has been injured by radiant energy, or by tiate and thus diagnose the deficiency in specific or non-specific stress or any other cases of infertility. several exampIes of noxious agency which can interfere with the direction this work has taken follow. nucleoprotein metabolism cannot produce normal fertilizing sperm. The quality of 1. It has been shown that the sperm has good sperm produced, of course, can range from stores of glycogen and that these must be adcomplete loss of fertilizing ability to that equate for maIntenance. just below normal. A sperm may appear 2. The sperm has a powerful cytochrome-cytochrome oxidase system and associated with normal in every way, but yet be grossly it a powerful succinic dehydrogenase system. deficient in its fertilizing power. The rate Large concentrations of these important of fructolysis as assessed by the colorisources of metabolic energy are found in the metric assay of the disappearing fructose mid·piece, which suggests that they may not is a simple and convenient measure of the be directly concerned only with motility but other functions. This brings up the signifi- metabolic activity of spermatozoa as it cance of motility in estimating ferttlizability. has been found to correlate closely with Motility may not be a good index. It may cell count and motility of the sperm. designate wasteful dissipation of energy which might better be directed to fertilizabillty. Motility, at best, is a sign of spenn life. A "metabolic regulator" has been isolated. Inhibition of certain enzymes stops motility. If the inhibition is reversible, the addition of a reversing agent will re-establish motility. S. The sertoli cells are considered as the sources of nourishment for spermatogenesis. Under normal conditions these contain adequate stores of lipids. Hypophysectomy or large doses of estrogen reduce this lipid and thus diminish the energy supply necessary for normal spermatogenesis. The result is improperly constructed sperm cells with various. degrees of impaired fertilizability and motility.
The effect of genetic influences on sperm integrity must also be considered. In order for a cell to possess the normal enzymatic components, it must inherit the norlila! genetic organizer material. Both the characteristic structural proteins (these
Personality Factors in Psychosomatic Infertility Buxton and Southam'· after finding that controls became pregnant as readily as those treated by all known methods concluded that "our present technics of therapy for the major causes of infertility are totally inadequate. Unfortunately personality studies were not performed, especially in those patients who became pregnant without therapy. Such an interdisciplinary approach would have clarified the interplay of emotional and physical forces in all types of infertility. Sharman'" obtained nearly the same percentage of pregnancies in 1500 cases with "nothing done therapy," as in the passing of a sound and bimanual examination, as by insuftlation and hormones. In his opin-
298
PSYCHOSOMATICS
ion, a psychic effect could not be ignored and was present regardless of the type of therapy used. A rather uniform psychopathology is present in psychosomatically sterile patient3 which centers around a hostile mother identification.fi.l-1.,;~ Rubenstein"l remarks, "the hostility was so intense as to make for the unconscious feeling that were they to become mothers they would hate the child enough to kill it." Witthower and Wilson"" descriptively classify these women into certain broad patterns a3 follows: In the first group are the physically and emotionally immature individuals who, because of
strong dependency needs, attempt to make a child-parent relationship of their marriage. Most of these are typically feminine in appearance and behavior, although they may have juvenile facies and physiques. As children they were qUiet, indecisive and easily embarrassed. Because of parental overprotection they usually become poor wives and, if able to bear children, relate poorly to husband and child because of their own exaggerated needs. If they live in a protected environment, they usually present a facade of gentleness and may often succeed in becoming loving and devoted mothers. As a rule, however, they compete with their unwanted offspring for attention and affection. There is a second well defined group who are the aggressive and masculine type; competitive, ambitious and dominating. They "wear the pants" in the family, and are often successful in various careers. Marriage is only a "front" for these women, and motherhood poses a constant threat. They are not frightened by the increased responsibility of motherhood, but what they fear is the child's care which may interfere with their social and business life. Hence, they reject the feminine role, frequently resorting to contraceptive measures which mayor may not be necessary. Many patients have personality features characteristic of both groups. The first group is readily recognized. Those, who fall into the second group are more difficult to recognize because they erect acceptable defenses to cover up their aggressive hostility.
Kroger' recently studied eleven infertility patients to whom such projective tests as the Rorschach had been administered. Nearly all seemed to fit into the above arbitrary classifications. Some were
JULY-AUGUST
extremely obese and amenorrheic. Their overweight, endocrine imbalance and infertility may all have a common psycho_ logic origin-oral regression-an infan. tile-like 3tate where the individual seeks emotional security by retreating to an earlier period of development. Here, oral satisfactions relieved tensions, and since this tension-allaying mechanism is never forgotten, it accounts for the excessive calorie intake, subsequent obesity and the associated secondary ovarian failure. Ford" also noted these neurotic needs in his series. Reproductive functioning was either totally or partially sU3pended in dynamic arrest as the result of the primary emphasis on the incorporative aims of oral gratification. Such women usually remain sterile because the last thing they really desire is weight reduction with resultant normal ovarian function and the possibility of pregnancy. They often 3tate, "I will do anything in the world to get pregnant," yet when given a diet and basal body temperature chart, they find various rationalizations for not dieting and keeping the monthly record. Fertility After Adoption
The question is often asked: Can psychosomatic infertility be relieved by adoption? Hanson and Rock," utilizing questionnaire material, interrogated 202 infertile couples who had adopted children. They concluded that adoption had no psychic effect, and therefore could not be considered a reliable cure for infertility. Their study is interesting, but one must remember that this type of sampling is notoriously unreliable. However, these excel~ lent investigators observed that adoption often relieved dysmenorrhea and frigidity, and that ovulation occurred more frequently. Many couples in the potentially fertile group also had a healthier mental outlook because of better sex relation3hips. One would think that such healthy' factors should lead to more frequent intercourse and increase the likelihood of conception since sperm motility is en-
1962
PSYCHOSOMATICS
hanced by repeated ejaculation even when other defects in semen quality are present. Thus removal of emotional tensions, whether by psychotherapy or by the corrective emotional experiences derived from adoption may often achieve gratifying results through resolution of conflicts in the male and stimulation of motherliness in the female. Turner" et al. found that conception occurred within six months after adoption in 26% of a group having a good prognosis for their relative infertility thus suggesting the influence of psychosomatic factors. Diagnosis and Treatment of p8'!Jchosomati.c Infertility
When evaluating the emotional concomitsnts of infertility, it should be remembered that each case is different and is to be approached and understood, not in general terms, but only on the experiences of the patient's whole past life situation. The actual subjective emotional aspects of ;experience should always be ascertained. Good history-taking, with thorough analysis of important incidents, permits an understanding of the developmental patterns of faulty attitudes toward pregnancy and motherhood and also reveals pertinent .psychopathology. The extent to which these attitudes have their origin in childhood indicates the di1Iiculties of treatment. It is not implied that if a woman ·once hated her mother or identified with her father, or rejected the maternal role, that these factors per se accounted for 'psychosomatic infertility. However, it is of the utmost importance to understand how and why reaction to these attitudes enabled the organism to respond to psychic stimuli. It is obvious that when an emotionally immature woman finally succeeds in hav'ing a child, she is apt to "take out her spite" on the actually unwanted-al:though perhaps consciously desired-offspring, and may, as a result, adversely affect its psychic development. These interrelationships as well as the personality
299
profiles should be considered in the psychological readiness of the infertile patient for pregnancy and parenthood. Such factors are of prime importance to all women undergoing procedures for relief of their infertility. Whenever doubt exists as to the advisability of alleviating infertility, the gynecologist should share this responsibility with a psychiatrist. Kroger' has used hypnosis not only to establish menstruation in amenorrheic women but also posthypnotic suggestions to relax after coitus so that the tubal spasm would be reduced. Gratifying results have been achieved in a small series of infertile patients. Recently, hallucinated progression in the future has been utilized to determine the rationale for sterilization in apparently normal individuals. The experiment is structured in the following manner: Under deep hypnosis, patients are informed that they were sterilized a year ago (chronological time is advanced by one year). If remorse, unhappiness and self-recrimination are apparent from the verbalizations evoked during hypnosis, it would be wise to postpone the surgery until patients are psychologically prepared to accept the sterilization. An amnesia for the ventilated mao terial can be used to protect the patient against the abreacted and deeply repressed attitudes. CONCLUSIONS AND SUMMARY
The social and psychobiologic expressions of the personality in relation to the functioning of the female's reproductive organs should always be considered in the therapy of psychosomatic infertility. Cultural influences often produce changes in personality structure which lead to psychologic defenses against the establishment of motherliness and inhibition of the maternal instinct with subsequent interference with the neurophysiology of ovulation and conception. Neuroendocrine factors responsible for ovulation, ease of conception and tubal
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spasm associated with autonomic imbalance are related to psychosomatic infertility. The hypothalamus through its intimate vascular connection with the pituitary is vitally concerned in regulating hypophyseal activity. The anterior pituitary is probably controlled via neurohumoral and neurosecretory mechanisms which can often be initiated through exteroceptive as well as enteroceptive stimuli. These nervous stimuli are mediated through the corticohypothalamic tracts and the pituitary-adrenal-ovarian axis with local effects on the uterus and tubes via the autonomic nervous system. Our thesis is that infertility is, at least partially, a disorder of adaptation to emotional and/or physical stimuli; originating from without the neo-cortex or from within, carried to the neocortex by afferent pathways. According to this theory these stimuli descend from the neocortex to the phylogenetically older limbic system (rhinencephalon) and from this to the hypothalamus, the pituitary and other effector organs via the nervous (posterior pituitary) or humoral (anterior pituitary) tansmission. Thus stress due to fright, or from stimuli from without the organism, or distressing thoughts and memories from within produce autonomic responses with sUbse~ quent endocrine imbalance as alterations in gonadotropin output, secretion of epinephrine and subsequent increased infertility. These autonomic and endocrine responses are also a source of anxiety and physical stress capable of affecting the hypothalamus and so alter behavior (establishment of motherlinness, desire for mating etc.). Thus a vicious cycle accounting for psychosomatic infertility may be established. Unconscious conflicts may adversely affect metabolic and enzymatic changes in the sperm and alter capacity to fertilize an ovum. This may be an important fac-
tor in the causation of male infertility. Adoption often acts as a corrective emo_ tional experience for relieving infertility by enhancing the maternal instinct or motherliness. A healthier interpersonal relationship between hushand and wife usually results in more frequent sex-con_ tacts, increased sperm motility and the greater likelihood of pregnancy. The psychodynamic factors responsible for infertility are related to functioning of the total personality. Certain personality profiles characterize' infertile women and these should be recognized in the patients undergoing procedures to relieve their infertility. The gynecologist aware of psychosomatic interrelationships will readily recognize the emotionally immature female who rejects pregnancy, and through appropriate psychotherapy will enable his patient to grasp the real meaning of her conflictual attitudes toward her infertility. Only then will he be able to help her decide whether or not she is equal to the demands of motherhood. REFERENCES 1. Stein, C.: Fertil. &; SteriZ.} 1:407, 1951. 2. Rammer, J. J.: West. J. Burg. Obst. &i Gynec.,
55:278-287, 1947. 3. Mandy, T. E., Scher, E., Farkas, R., and Mandy. A. J.: J. South. M.A .. 44:1054.1951. 4. Kroger, W. S., and Freed, S. C.: Psychooo-
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gress on Fertility and Sterility, 2:'501-505, Int. Fert. Assn., 1955. 14. Benedek, T., Ham, G. C., Robbins, F. P., and Rubenstein, B. B.; Some Emotional Factors in Fertility. Read before the American Psychosomatic Society, March 20, 1952. 15. Kelley, K.: Discussion to ref. 12.
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753, Oct. 1955. Israel, S. L.; Discussion to Reference 16. Mazer, C., and Israel, S. L.: Menstrual Disorders & Sterility. Paul B. Hoeber, Inc., New York, 1946. Johnson, W. C., and Marshall, J. B.: South. M. J.) 43 :531, 1950. Sturgis, S. H.: Int. J. Fertility, 1 :311-314, July 1956,
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38. Sawyer, C. H .• and Markee. J. E.: Endocrinol. 46:177-190, 1950. 39. Marshall, F. H. A., Verney, E. B., and Vogt, M.: J. Physiol., 97 :128, 1939. 40. Brooks, C. M., Beadenkopf, W. G., and Bojar, S.: Am. J. Physiol., 129 :320, 1940. 41. Kasdon, S. C.: Endocrinology) 44 :211, 1949. 42. Koikegami, H., Yamada, T., Vsui, K.: Folia Psychiat.. & Neurology. Japonica, 8:7-31, 1954. 43. Marshall, F. H. F_, and Verney, E. B.: J. Physiol., 86:327, 1936. 44. Markee, J. E., Sawyer, C. H., and Hollinshead, W. H.: Endocrinology, 38:345, 1946. 45. Everett, J. W., and Sawyer, C. H.: Endocrinol, 45 :581, 1949. 46. Cleghorn, R. A.: Psychosomat. Med., 17 :367, 1955. 47. Kent, G. C., and Liberman, M. J.: Endocr'inol., 45 :29. 1949. 48. Isaacson, J. E.: Endocrinol.) 45:558, 1949. 49. Brookhart, J. M., Dey, F. L., and Ransom, S. W.: Proc. Soc. Exper. Biol. &; Med., 44:61, 1950. 50. Bard, P.: Research Nerv. &; Ment. n-isc. Proc.) 20: 551, 1940. 51. Friedgood, H. B.: West. J. Burg. Obst. &; Gyncc., 56 :391, 1948. 52. MacLaen, P. D.: Psycho80mat. Med., 11:338, 1949. 53. Knight, R. P.: Bull. of Menninger Olin., 5: 65-74, May 1941. 54. Fischer, I. C.: Proceedings of First World Congroo8 on Fertility and Sterility, 2 :311, I.F.A., 1955. 55. Stallworthy, J.: J. Obst. &; Gynec. Brit. Emp., 55: 171-180, 1948. 56. Rubin, I.: Uterotubal Insufflation, Mosby, St. Louis, 1947. 57. Doyle, J. B.: Fertility &; Sterility, 5:105-239, Mar.-Apr. 1954. 58. MacLeod, J., and Gold, S. Z.: Fert-ility and Sterility, 4:10-33, Jan.-Feb., Urn3. 59. Deutsch, H.: Introduction to the Discussion of the Psychological Problems of PregnancY. In Problems of Early Infant Care. New Y~rk, Josiah Macy, Jr. Foundation, 1948, p. 12. 60. Sharman, A.: J.A.M.A., 148 :603, 1952. 61. RUbenstein, B. B.: Fertility and Sterility, 2: 80, 1951. 62. Ford, E. S., et al.: Proc. of First World Congress on Fert. &; Sterility, Vol. II, 298·307. 63. Wittkower, E., and Wilson, A. T. M.: Brit. M. J., 2:586, 1940. 64. Hanson, F. M., and Rock, J.: Am.. J. Of Obst. &. GynRc., 59 :311-319, 1 9 5 0 . ' 65. Turner, V. H.: Am. J. Obst. &; Gynec., 70: 1189-1196, Dec. 1955.