Potential Infertility in Young Women

Potential Infertility in Young Women Medical Alertness vs. Patient Anxiety

Leona M. Bayer, M.D.

THE

of the words "potential" and "infertility" suggest two other ideas-"prediction" and "prevention." Whether any of the concepts of potential, prediction, and prevention are appropriate to the problem of infertility depends upon a consideration of the causes. Obvious causes of female barrenness are usually classified under such headings as constitutional and structural defects, specific diseases, and nutritional deficiencies. The effects of most of these are predictable. Furthermore, they are either preventable, easily remedied, partially responsive to treatment, or clearly beyond help. These will not be discussed here. More obscure causes include the less precisely defined endocrine imbalances, and psychic conHicts. To these I would like to add spinsterhood. Recent census figures show that 8 per cent of the American women retain their single and statistically childless status past the age of menopause, and only twice as many, 16 per cent, remain childless despite marriage. Vague endocrine imbalances, psychic conHicts, and spinsterhood share several attributes besides their poor delineation. While originating earlier, they tend to herald themselves in adolescence. None exerts effects which are surely predictable or definitely preventable. All three have psychosomatic implications which shade into each other. Since the psychosomatic point of view encourages a total approach, it appears that the problem of the prevention of sterility properly includes the prevention of spinsterhood, as well as the preservation of physiologic JUXTAPOSITION

From the Stanford University School of Medicine, San Francisco, California. Presented at the Regional Meeting of the American Society for the Study of Sterility, Palm Springs, California, November 6-8, 1953. 461

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fecundity and the desire to procreate. This brings us into the twilight area of somatic and psychic sexuality, and of somatic and psychiC motherliness. It is this area which I wish briefly to explore. ANDROGYNOUS PROFILES Most of the ambiguous endocrine imbalances described in studies of female infertility involve constitutional somatic sexual deviations which can be sorted into three main groups. The first comprises various degrees of hyposexual development, of which ovarian agenesis and eunuchoidism are the extreme and unequivocal examples. The second comprises various degrees of virilization, of which, again, the adrenogenital syndrome and pseudohermaphrodism are the extreme examples. The third comprises syndromes characterized by obesity and menstrual disorders, often in women in whom one can demonstrate no clear-cut endocrine deviations, but who can be said to be somewhat overdifferentiated in a feminine direction. If one assesses the body build of these patients on an androgyny (masculine-feminine) rating profile,s they fall away from the normal feminine form in divergent directions. They may be underdeveloped (hypofeminine), developed in a masculine direction (virile), or overdeveloped (hyperfeminine). One tabulation of the distribution of the age of menarche in these four groups, 1 shows that the first menstrual periods of the normal group occur remarkably close to the mean age of 13 years, whereas all others are more widely scattered. Insofar as the age of menarche is accepted as one index of harmonious sex function, this observation lends collateral support to the idea that normality of body form and body function tend to go together. PERSONALITY TYPES Turning to psychologic studies of infertile women, the published sketches of personality types likewise fall into three main groups. The first is the woman who is emotionally immature,1 the second is the woman with masculine strivings and identifications,7.8 and the third is the woman who is still involved in developmental conflicts with the mother4 and in a hostile identification with her.9 The latter descriptions could also be subsumed under the general category of emotional immaturity. PSYCHOSOMATIC SYNDROMES It is the belief of this author that there tends to be some correlation

r

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between these observed somatic and personality profiles. The point is not susceptible of direct proof here, since, in most reports, patients are described with regard to either their physical or psychologic characteristics, but rarely with regard to both. In a study which I made with Dr. Reichard,2 we sought to describe both aspects of our patients in more comprehensive psychosomatic syndromes. The symptoms we dealt with, however, were obesity and leanness, rather than infertility, so that our records are only tangential to the subject at hand. But the somatic and psychologic groups which emerged from our analyses are in many ways similar to those already described. An attempt will therefore be made to apply the insights gained in the weight study to observations recorded by others in the studies of infertility. The working premise of our weight study was that "when certain constitutions undergo certain life experiences, disease and personality pictures will result which are explainable with reference to their origin."2 Our observations and analyses led us to an hypothesis concerning the role of androgyny in the complex interplay between constitution and parentchild experiences on the one hand, and the resultant factors of weight and personality on the other, namely:

1"

... that the degree of somatic sexuality is related to the strength of the life instinct. According to Freud's final formulation, this instinct, with its associated energy or libido, serves both the establishment of love relationships and the preservation of the self. Where, in our patients, the sexual constitution is adequate, the life instinct tends to triumph over the death instinct. Compromises are sought in favor of the maintenance of love relationships and oral gratifications. Where the sexual constitution is deficient, the libidinal endowment is also weak, love relationships and oral gratifications are more readily sacrificed. The direction of sexuality is related on the psychological side to the amount of drive for muscular activity and independence. It is also related directly to adiposity in that characteristic fat deposits delineate the form of the normal adult woman. When the environment is favorable, variations in androgyny express themselves in variations of weight and personality which are within the normal range. Confronted with frustration, however, individuals react with pathological syndromes which reflect their constitutional sexual endowment. Obesity and leanness are translations back into somatic form of the fate of the life instinct in its conflict with environmental forces. In this chain of reasoning, at least one implicit link is self-evident: acceptance or rejection of oral needs, insofar as their gratification involves the taking or leaving of food calories, is a crucial factor in the development of obesity or leanness. 2

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If we now use this same general hypothesis to link together the commonly reported descriptions of somatic and personality pictures associated with . infertility, we can indulge in the following speculations: 1. Hyposexual women may not only function below par on the physiologic levels of ovulation, nidation, and pregnancy, but they may also be psychologically less capable of achieving the degree of heterosexuality and motherliness which is described as essential to the successful conclusion of pregnancy-to say nothing of the successful conduct of parenthood. 2. The virile woman may not only be inhibited from the fulfillment of childbirth by the honnonal antagonisms in her endocrine system, but it is also possible that her associated drives for muscular activity and personal independence intensify the purely psychologic conflict between masculineactive and feminine-passive strivings. 3. Finally, the description in the sterile woman of developmental conflicts with the mother are similar to the mother-daughter relations described in our obese women. It is therefore possible that this mother-daughter fixation is the common denominator in the weight gain and in the sterility manifested by some overweight, deceptively "hyperfeminine" women with vague menstrual disorders. This general line of reasoning can be both simplified and extended by taking as a starting point the idea that somatic sexuality gives some indication of the capacity for social relatedness. The hypofeminine constitution is the one which has the lesser capacity, whereas the virile constitution works out heterosexual social relatedness as competition, and the wellendowed feminine or hyperfeminine constitution has not only a great capacity to relate, but also a greater need. The greater need can be more easily frustrated in early childhood, and can thus contribute to fixation of the mother-daughter conflict at a primitive level. If the thread of somatopsychic inferences is thus far not too tenuous, it can lead to the notion that spinsterhood, functional sterility, and parental inadequacy may be successive points of arrest in the capacity for interpersonal perfonnance. A further deduction is that certain constitutional deviations may predispose to such arrest. ROLE OF THE PHYSICIAN We shall tum now to the role of the physician who deals with adolescent girls and young women.

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The alert and qualified physician will have many opportunities to detect danger signals in the great upheaval of the second decade. Again, putting aside the diagnosis of obvious pathology and frank endocrine disorder, he can profitably direct his attention to the potential obstacles to fruitful maturity implied in the various deviations from average feminine development. Certain associations between the tempo, degree, and direction of sexual differentiation make identification easier. The hypofeminine girl tends to mature more slowly, as well as less completely; the hyperfeminine girl may reach puberty while chronologically still young; and the slightly virile girl may give early evidence of her bisexual endowment in her muscular build and athletic prowess. The physician's long-range opportunity to help his adolescent patient, however, may depend less on his diagnostic acumen than on his understanding of her psychologic intricacies. This is because the medical appraisal of her sex functions will usually be her first social experience in which sex is frankly faced and dealt with, rather than repressed. In this connection, understanding the interfamilial relations of individual patients may give an important clue as to whether a man or woman would be the preferable physician. Deutsch has given an invaluable and comprehensive picture of the tortuous route by which a girl grows up. However, even without a total grasp, there are a few practical points about adolescence which are particularly relevant to the doctor-patient relationship. First, the adolescent's overt complaint is rarely complete. Usually it withholds at least as much as is expressed. The presenting complaints of the "teen age" are most often those of qualitative variations: too tall, too short, too fat, too thin, too late, too soon, too much, too little, and, of course, acne. What is not expressed are the questions: "Will I ever achieve the right size, shape, and function?" "Am I queer?" The second point is that the adolescent girl never comes to the doctor alone. Almost always she is accompanied by her mother, and always by her mother-daughter conflict. The final point derives from the others, and notes that the dominant mood of the adolescent is anxiety about the capacity to accomplish the complicated physical and emotional metamorphoses which are her task. If we accept the interdependence of physiologic and psychologic factors in the process of normal maturation, it becomes clear that the physician

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must keep in mind throughout his medical management that an integral part of his purpose is to give the girl every warranted reassurance about her development, to relieve parent-child tensions, and to alleviate anxiety. On the diagnostic side, this may mean that he will defer certain procedures, such as a vaginal examination, until confidence is established. Where there are alternatives, he will choose the test which is the least disturbing, or will least focus the patient's attention on herself. For instance, a determination of hormones in the 24-hour-urine sample may be preferable in an adolescent girl, whereas in a married woman he might request basal body temperatures, serial vaginal smears, and endometrial biopsy. Once an evaluation is made, the total picture should be explained to the patient, or to the patient and her mother, in the least alarming phrases available. It is helpful if the doctor is conversant with the wide deviations which characterize the range of normal adolescent patterns. He can then allow the maximum realistic latitude with regard to variations in such attributes as weight, height, and menstrual history. Furthermore, if he avails himself of modern technics for prediction of height from skeletal age, and of weight from bicristal breadth, he will often be able to give great reassurance about these two important measures. Nor is he lacking in candor if he leans to the considered optimistic view. Because in this vague sky of psychosomatic constellations, as in the society of Anatole France, "everything is not known, although everything is said." When the time for treatment comes, he is wise to choose the less aggressive method, the less authoritarian manner. Pills are preferable to injections. A diet worked out as a co-operative project, in which an adolescent seeks to achieve her own ego ideals, can provide a healthy reality-testing experience. The same number of calories dogmatically prescribed may lead to the same or greater weight loss, with the young woman meanwhile slipping far back into childish docility. But these are enough examples to illustrate the simple theme, that in dealing with adolescents it may be good medicine to take certain calculated risks of omission and procrastination on the physiologic side in the interests of sturdier psychologic growth.

SUMMARY There are seen in adolescents and young women certain psychosomatic deviations in the degree, tempo, and direction of maturation which can

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be characterized as hypofeminine, hyperfeminine, and masculine. These slightly deviant constitutions may carry within them potential hazards in terms of future adult function. Spinsterhood, functional sterility, and parental inadequacy may be thought of as successive points of arrest along the route of full feminine realization. Since the second decade of a young girl's life is a time of great upheaval, it offers the physician inviting opportunities to detect and correct. His task, however, is to handle the total situation in such a way as to enhance the chances for ultimate somatopsychic sexuality and somatopsychic motherliness. He must manage the physiologic problem so that his activity is not perceived as aggressive, nor experienced as anxiety producing. He can only help his patient along the road to maturity, marriage, and motherhood if he does not frighten her into a psychologic retreat. REFERENCES 1.

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4. 5. 6.

7. 8.

9.

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L. M.

Weight and menses in adolescent girls, with special reference to build. J. Pediat.17:345, 1940. BAYER, L. M., and REICHARD, S. Androgyny, weight and personality. Psychosom. Med. 18:358, 1951. BAYLEY, N., and BAYER, L. M. The assessment of somatic androgyny. Am. J. Phys. Anthropol. 4:433, 1946. BENEDEK, T. Infertility as a psychosomatic defense. Fertil. & Steril. 8:527, 1952. DEUTSCH, H. The Psychology of Women. New York, Crune & Stratton, 1944. FREUD, S. New Introductory Lectures on Psychoanalysis. New York, Norton, 1933. KROGER, W. S. Evaluation of personality factors in the treatment of infertility. Fertil. & Steril. 8:542, 1952. MARSH, E. M., and VOLLMER, A. M. Possible psychogenic aspects of infertility. Fertil. & Steril. 2:70, 1951. RUBENSTEIN, B. B. An emotional factor in infertility. Fertil. & Steril. 2:80, 1951. BAYER,