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Psychogenic Sterility
Psychogenic Sterility Carlo 80S, M.D., and R. A. Cleghorn, M.D.
WE
ARE UNDER NO ILLUSIONS that we have the answers to the problems posed by our title; it is our intention to highlight some aspects of psychogenic infertility as we see it and hope that this may provide the basis for profitable discussion. In examining the problem we propose excluding the consideration of those organic factors with which you are so familiar, and speak of certain neuroendocrine mechanisms set in motion by psychologic processes. The psychologic or psychodynamic permutations and combinations are many, while the endocrine and neurologic mechanisms, the final common paths by which these may be expressed, are few. Anger, fear, guilt, and hostility may be difficult to disentangle psychologically, but physiologically they most often exert indistinguishable effects.
HISTORICAL ASPECTS Rites and rituals designed to aid fertility have their origins in antiquity and presumably bespeak the presence of the problem of unsatisfactory fecundity then. Accounts of these practices with their SOciologic and gynecologic interest have been described by Guttmacher.14 Speculative explanations and therapeutic recommendations of medical advisers of the eighteenth century came closer to defining and divining the real nature of the causes. William Buchan5 said, in 1779: "Barrennness is often the consequence of grief, sudden fear, anxiety, or any of the passions which tend to obstruct the menstrual flux. When barrenness is suspected to proceed from affections of the mind, the person ought to be kept as easy and cheerful as From the Allan Memorial Institute, Montreal, Canada. Presented at the Thirteenth Annual Meeting of the American Society for the Study of Sterility, New York, N. Y., May 31, June 1-2, 1957. Received for publication July 2, 1957. 84
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possible; all disagreeable objects are to be avoided, and every method taken to amuse and entertain the fancy." Modern knowledge which forms the basis of the present point of view began in the late nineteenth century with advancement in three areas: (1) the endocrines;7 (2) the autonomic nervous system;6 (3) that area we might now term psychophysiology, namely, the importance of emotions in the psychologic and phYSiologic life of man. 53 The increasing refinements of our knowledge of these subjects in the last three decades and the development of psychosomatic concepts set the stage for our knowledge as it is today. In the gynecologic field this has been ably summarized by Kroger and Freed. 23 STATEMENT OF THE PROBLEM Sterility in the female has been variously defined. One categorization describes it as a failure to conceive in the absence of contraceptive measures during a minimum of 1 year of marital interoourse. 2o , 28 To refine this to the narrower realm of psychogenic infertility one must add that there be absence of demonstrable organic pathology unconnected with psychic states, and evidence of the adequacy of the sperm of the male partner. The problem of male fertility is being ignored at this time although there is evidence that psychogenic factors may be influential there too. PSYCHOPHYSIOLOGY The effector mechanisms concerned in psychogenic infertility are those two major homeostatic mechanisms, the endocrine and autonomic nervous system. The first, through the pituitary, controls ovulation and ovarian hormones, and the second, certain other functions of the genital tract essential to conception. Let us examine them in turn. Neuroendocrinologic Control of Ovulation
Some of the phYSiologic mechanisms concerned in the control of ovulation are well understood, and have been described in some detail by various authors.4, 8, 12, 16,41 For present purposes the following summary will suffice. Release of luteinizing hormore (LH), which is apparently the ultimate stimulus to ovulation, must be through a vascular mechanism from the hypothalamus because there are no secretory nerves from the brain to deliver the message to the adenohypophysis. The vascular channel is the hypothlamo-hypo-
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HISTAMINE -( IN VENTRICLE) ACTS VIA LIMBIC LOBE
<
STALK SECTION BLOCKS ALL STIMULI MEDIATED BY HYPOTHALAMUS
2 Fig. 1. Factors causing release of LH (and, consequently, ovulation) by the anterior pituitary in the rabbit.
Fig. 2. Factors preventing release of LH (and, consequently, ovulation) by the anterior pituitary in the rabbit.
physial portal vessel system. In the rabbit, which ovulates only after copulation, the control of the release of LH has been profitably studied, most intensively by Markee and his associates. 32 It has been found that the following procedures may cause ovulation experimentally (Fig. 1): picrotoxin- or Metrazol-induced convulsions; electrical stimulation of the posterior hypothalamus; epinephrine injected into the anterior lobe or third ventricle; histamine injected into the ventricle of the rabbit lightly anesthetized with Nembutal,4° Certain procedures prevent ovulation in the rabbit after coitus or after the majority of the experimentally induced gonadotrophic release (Fig. 2). These are: atropine or Banthine within 15 seconds of the stimulus; dibenamine within 1 minute, or barbiturate anesthesia or stalk section prior to the stimulus. Epinephrine-stimulated ovulation is not inhibited by atropine but by the anti adrenergic drugs. HistamineNembutal-induced pituitary activation is prevented by olfactory bulb lesions or by drugs which prevent the occurrence and transmission of olfactory bulb activity, e.g., atropine and D-ol (SKF 501) also blocks coital and
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epinephrine release without interfering with the electrical response. 40 One may conclude that there is cholinergic function activated within 15 seconds of mating that sets off a train of events linked to an adrenergic mechanism that is activated within 1 minute. Presumably an adrenergic substance is the final chemical messenger which passes to the anterior pituitary by way of the stalk portal vessels. Once there, an hour is required for the elaboration of enough LH to cause ovulation. The reaction of the ovary is still longer-of the order of 10 hours. Studies of animals such as the rat, which ovulates spontaneously, indicate that blocking agents such as atropine and dibenamine will prevent ovulation if given at the estimated time of neurohypophysial activity some 11 hours before ovulation. 32 This is also true for barbiturates, morphine, and chlorpromazineY Both the latter upset reproductive cycles in humans,5o which is of some importance in view of the widespread use of tranquilizers. In an extension of the above studies, Sawyer has demonstrated the involvement of rhinencephalic pathways implicating especially the median forebrain bundle and/or the basal ganglia in experimental pituitary gonadotrophic activation elicited by intraventricular histamine in the lightly Nembutalized rabbit. This is of relevance to the importance assigned to the limbic system in the integration of emotion, as emphasized by MacLean. 26 • 27 Clinical Significance of Neurophysiology of Ovulation. This concerns various degrees of failure of ovulation. In its most dramatic guise, disturbance of ovulation may extend to complete amenorrhea. When this is psychogenically induced the term "hypothalamic amenorrhea" has been used. 21 • 37 The following list summarizes the pertinent situations, but certain aspects deserve detailing. HYPOTHALAMIC AMENORRHEA
1. Novel social situations in the young 2. Dramatic circumstances: Feared pregnancy Wartime experiences 3. Complicated emotional situations Fear, grief, anxiety, hostility (anorexia nervosa)
Psychogenic or "hypothalamic" amenorrhea can be induced by mild situations-debutantes, or girls going into nursing training-but generally rights itself quickly. It is also observed following more stressful circumstances, for example, in 10 per cent of a large series of women exposed to attempted
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rape. 42 Prison camp led to amenorrhea of 3 months or more duration in half of a group of 450 women in Hong Kong in 1941. This was at a time when dietary factors could not have been responsible. A second wave occurred in these women in 1944, when a drastic cut in protein occurred. 46 A similar experience was observed at an internment camp at Manila. 48 Four women who missed a period due to emotional shock showed on biopsy an endometrium at the stage expected for the time of the shock, suggesting that the emotion had interrupted honnone release at that time. 25 By way of explanation, one must assume that the disturbances led to an interference in the elaboration of LH and, secondarily, of estrogens by the ovary.37 Disturbance of LH secretion may also be an accompaniment of electroshock therapy, which sometimes leads to menstrual cycle disturbances. 34 Fear and depression seem to be the affective state most commonly associated with amenorrhea. In 26 patients with depression, 17 were amenorrheic but only 1 of 17 in a manic phase. 1 Time and removal from the threatening situation rectify many cases of psychogenic or hypothalamic amenorrhea. Simple psychotherapy or hypnosis suffices in others. 23 . 35 This is rarely true for its occurrence in that refractory disease known as anorexia nervosa,9 in which cachexia is so marked. An intensive analytic study made in such a case with eventual pregnancy has been reported by Jacobson. 19 The incidence of prolonged suppression of ovulation as a factor in psychogenic sterility has not been estimated in many series. MacLeod 28 assesses poor ovulation at 12.6 per cent in his group. It is given as 28 per cent in 1000 cases by Stallworthy,45 though he minimizes this figure by saying: "It is known [that] it is not a common cause of sterility." This is in concordance with C. V. Smith's44 statement: "Actually, all the endocrine causes of sterility make up but a small percentage of couples with this complaint." The truth is that we do not know. Endocrine disorders of the thyroid and adrenal can also affect fertility and their alleviation precede conception. Autonomic Nervous System Influence on the Genital Tract
The close central connections of the autonomic nervous system with those areas of the brain concerned in emotional expression have been described in various texts. How or why certain efferent branches become involved in the expression of certain psychosomatic syndromes is not understood, but it seems clear that the autonomic can mediate a variety of motor and secretory
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genital disturbances because of altered psychic states concerned with genita) function. Genitally Centered Factors in Psychogenic Infertility. These, therefore, are an expression of autonomic system disturbances. Consideration of structural pathology of the genital tract, which in practice is important, has been omitted. Viewed teleologically, nature has provided certain methods for the prevention of conception in the ovulating female, given a fertile male. Item 1 of the list below may be considered as a somatically expressed manifestaGENITALLY CENTERED FACTORS IN PSYCHOGENIC INFERTILITY
1. 2. 3. 4. 5. 6.
Conscious rejection of sex act or contraceptives Vaginismus preventing intercourse Vaginal pH changes lethal to sperm Cervical canal changes Endometrial changes incompatible for implantation Fallopian-tube dysfunction
tion of a disturbed attitude. The remaining five presumptively involve disorder of the autonomic nervous system and imply considerably more unconscious though not necessarily more refractory attitudes. No effort will be made in this presentation to explain the involvement of one or another part of the genital tract in this autonomic dysharmony, but brief consideration will be given to the topics of tubal spasm and vascular congestion with which secretory disturbances are so commonly associated. Isthmotubal Spasm. This was described by Rubin in 1932. In this and later series,38 the incidence of tubes blocked to insuffiation or lipiodol was approximately 25 per cent. This does not represent a permanent state, for conception may occur without the establishment of patency and a figure of less than 10 per cent comes closer to the actual absolute blockage. 45 Atropine does not reliably abolish spasm here any more than in other instances of spasm of smooth muscle, nor does anesthesia. Emotional distress precipitates and reassurance and amyl nitrate may relieve spasm. Studies with this and other muscle relaxants indicates that something like 50 per cent of tubal blockage is due to uterotubal irritability.45 It is perhaps not surprising that this richly innervated area is susceptible to dysfunction similar to that seen in other smooth muscle areas throughout the body. By the same token genital tract secretions may be just as much deterred by fear as salivation. Vascular Congestion and Hyperemia. These are presumably referable in large part at least to dysfunction of the autonomic nervous system. Associ-
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ated autonomic complaints in other parts of the body used to be ascribed to the pelvic vascular disturbance. Now we are more prone to assign priority for both to psychologic factors such as unsatisfied sexual arousal, fear, hate, conflict, and anxieties. It is possible that partial sexual arousal without orgasm may be more deleterious for the health of the genital tract vis-a-vis conception than absolute frigidity because of the chronic effects of autonomic nerve activity. Intensive study of large groups of patients with vascular and secretory disorders by Taylor47 and others indicates a high incidence of sterility. One is reminded by the multiplicity of complaints of the similarity to the syndrome of "irritable colon."49 There is probably also a close similarity to the nasal congestion seen in certain neurotic patients. One could hope that the same careful type of controlled observations might be made as reported by Holmes et al. 18 for the nose. In the foregOing sections we have endeavored to visualize for ourselves as well as for our audience those mechanisms probably involved by physiologic processes which lead to infertility. It is now appropriate to turn to a closer consideration of the pertinent psychic processes. In the time at our disposal it is not possible to do justice to many of the able articles in this field, but we trust we may be able to stress certain salient points for your consideration. PSYCHIATRIC ASPECTS At the outset, it may be well to remind ourselves that when we as physicians speak of a sterile woman, we are speaking of the woman who has sought us because she is dissatisfied with her lot. The sterile woman who is satisfied with being sterile does not consult a physician. Personality Factors
A list of disturbed personality factors in female psychogenic sterility, collected from the literature of recent years, is shown below. The~e were defined PERSONALITY FACTORS IN FEMALE STERILITY
1. 2. 3. 4. 5. 6. 7. 8.
Physical and emotional immaturity Aggressive-masculine types (resents female role) Combination of 1 and 2 Hostile mother identification Motherly type Feminine erotic type Obsessive-compulsive type Disturbed, impoverished, and chronic worriers
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by Deutsch,lO Wittkower,51 and elaborated by other authors.22, 31, 33, 39, 51 Careful study of the various types shown reveals that actually, basically, the affective attitudes involved are two: (1) fear of impregnation, and (2) a rejection of impregnation. As to the psychologic conHicts which bring about these two emotions, these are infinite in number. Actually, this list could probably be multiplied many times. We must remember that psychologic conHicts are individual for each patient. It is impossible for two individuals to have exactly the same basic make-up and to have exactly the same experiences during their lifetime. It is therefore impossible for two people to have exactly the same problem of a psychologic nature, though these can be expressed in the common denominator of psychodynamic terms. It should be remembered also that not all women who reject the feminine role are sterile-indeed some have a compulsion to produce large families. 19 The second important observation to be made from an examination of the standard works on the psychology of women and of the all too few investigations, both systematic and statistical of series of cases and of individual patients, reveals that the psychologic conHicts surrounding impregnation are manifestations of disturbed total personalities. This observation is important because of what it implies with regard to the treatment of this fonn of sterility. The sterility itself may be a defense of the disturbed personality against the stresses of pregnancy and motherhood, with which it is either unwilling or incapable of coping. It is one of the commonplaces of modern psychiatry that the patient's conscious desires and aspirations are not infrequently quite different from, and opposite to, the unconscious or really pervasive wishes. Every married woman is exposed to culturally determined pressures from her husband, relatives, and friends with regard to childbearing. There is a stigma attached to the word sterile. The tenn itself denotes empty, worthless, superHuous, vain, unserviceable, stale. It is little wonder, then, that the conscious strivings of the majority of women are away from any desires or wishes which are contrary to the role assigned to her by society. Our culture assumes that infertility is undesirable; this is one of the reasons for the existence of your Society. The emphasis on the investigations up to now has been on the reasons why a sterile woman, whose problems are at an unconscious level, does not wish to have a child. It would seem to us profitable if some emphasis were placed upon the reasons why a woman who is sterile wants to have a child. We feel also that it is of extreme importance that the conHicts surrounding
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sterility in a woman be examined in the context of her total personality. We are struck by the possibilities of damage to personalities caused by overcoming inhibitions of this nature which may actually serve as a defense against much more serious difficulties for the woman personally, and, as a consequence, for society.3. 20, 30 The Problem of Organ Choice
The task of establishing the connection between psychologic problems and the physiologic manifestations is the eternal problem of psychosomatic medicine, and here in the particular context of our study again we encounter a key difficulty of all psychosomatic medicine-the problem of organ choice, or specificity. This has been thoughtfully discussed at length by Kubie,24 who honestly submits that there is currently no available answer. It is quite unclear how a psychologic confl~ct becomes translated into a specific goaldirected negative neurophysiologic pattern. In other words, we do not know what happens when emotional concern over sexual role, sexual relations, and the bearing, giving birth, and raising of a child are translated into inhibitory neuronal influences that prevent ovulation, or into exaggerated autonomic action that interferes with the conjunction of sperm and ovum. At present, the diagnosis of psychogenic sterility is made primarily by exclusion. We feel that one can be justifiably suspicious of a diagnosis which can be arrived at only on this basis. This is the important, and perhaps the most important, point to be made with regard to psychogenic sterility, as indeed is the point to be made of any so-called «psychosomatic condition," and that is that it should be possible to make the diagnosis in a positive fashion with a minimum of exclusion procedures. Unfortunately, this we cannot do at present. Influence of Therapeutic Procedures
It has been stated that 35 per cent of women coming for treatment of psychogenic infertility become pregnant45 during the course of investigation or therapy. These procedures are, of course, therapeutic in various ways, not least of which is the relationship established with the phYSician. Actually, the general physician is a better psychotherapist than he knows, particularly if he can establish a tender, understanding, and trusting attitude. Under such sympathetic circumstances, as March and Vollmer 3 say: «Physiologic tensions steadily diminish until the pelvis is converted from a sterile battle-
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ground in which hostility and hope have been at cross purposes with each other, into a life-giving bed of fertility." Such beneficial patient-physician relationships have been described in the more esoteric language of psychiatry in terms of the dynamics of transference. One may say in that language that the trust in the interested and understanding physician represents a dynamic transaction which leads to a breakdown in the inhibitory forces. These are presumably the forces giving rise to impulses preventing ovulation or exciting deleterious influences along the autonomic nervous system. Adoption has a widespread and probably justified reputation as a measure which is often followed by conception,36 despite criticism on the shaky basis of a questionnaire. 15 The psychic mechanisms sorted out by the decision to adopt are probably reflected in relaxation of neurophYSiologic tensions preventing conception. This matter is discussed at length by Benedek et al.,3 who also describe the psychical complications surrounding the matter of artificial insemination. In connection with the problem of sterility one must also consider the problem of "one-child sterility," which has apparently a psychodynamic structure of its own. Heiman17 describes this as a motherchild relationship which does not permit the intrusion of a third personhusband or second child. This is in addition to the more obvious rejection after a traumatic first pregnancy. Infertility Studies in Our Culture
Reports which aim at a complete study of infertility vary in their assessment of the incidence of psychogenic factors, partly because patients may be selected differently. One group of reliable investigators found in 100 couples studied only 3 cases with psychologic disturbance alone but in 16 others the maladjustment was accompanied by an organic factor.43 Studies such as that of Ford et al. 13 directed at the psychodynamics of infertility, and including two psychiatrists on the team, disclosed abnormal attitudes in 31 of 38 cases studied. It might be added that their attempt to dissolve the arbitrary borderline between organic and psychogenic sterility is one with which we are in hearty agreement. Their suggestions for detecting Significant emotional conflict warrant incorporation in any comprehensive study. One facet which cannot be expanded upon here but which merits mention is the necessity for the study of the cultures from which the patients come. One is inclined to think and speak in terms of North American cul-
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ture, and there are obviously many pervasive and presumably unhealthy influences which intrude on all our lives, and in particular that of women. 2 It should not be forgotten, however, that there are many subcultures on this hemisphere more or less isolated by virtue of locality, religion, and custom, and these may all have their individual influence on attitudes to pregnancy and child rearing.
CONCLUSIONS AND RECOMMENDATIONS 1. For practical purposes, and with the idea of arriving at a clear understanding of the possible psychogenic factors in the sterility of an office patient, it would be advisable, we feel, to emphasize the reasons why the woman wants a child as much as to seek the reasons why she does not want a child. 2. The total personality of the sterile woman should be studied and one should bear in mind the consequences to that personality from the induction of the pregnancy. 3. Large-scale systematic studies which could be treated statistically should be instituted, and the studies should permit examination and investigation by various technics: a. Of a psychophysiologic nature, such as the type used by Wolff,52 Malmo,29 and others. h. Intensive psychologic examination and psychiatric assessment. c. SOciologic investigation of environment and background. d. Follow-up studies to determine the difficulties, if any, encountered by women who have suffered psychogenic sterility, and who have become pregnant. We are thinking particularly of the incidence of spontaneous abortions, of psychologic difficulties during pregnancy, postpartum difficulties, and conflicts surrounding motherhood. This would be essentially an interdisciplinary study. 1025 Pine Avenue West Montreal, Canada
REFERENCES Psychiat. 13:239, 1933. 4:424, 1956. BENEDEK, T. F., et al. Psychosom. Med. 15:485,1953. BENOIT, J., and ASSENMACHER, I. ]. Physiol. (Paris) 47:427, 1955. BUCHAN, W. Domestic Medicine; or, A Treatise on the Prevention and Cure of Diseases (ed. 6). London, 1779, p. 119. 6. CANNON, W. B., and ROSENBLUETH, A. Autonomic Neuro-EfJector Systems. New York, Macmillan, 1937.
1. 2. 3. 4. 5.
ALLEN, E. B., and HENRY, C. W. Am.]. BENEDEK, T. F. ]. Am. Psychoanalyt. A.
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7. B. 9. 10. 11.
12. 13. 14. 15. 16. 17. lB. 19. 20. 21.
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CLEGHORN, R. A. Internat. Rec. M.166:175, 1953. CLEGHORN, R. A. Psychosom. Med.17:367, 1955. COBB, S. Emotions and Clinical Medicine. New York, Morton, 1950. DEUTSCH, H. The Psychology of Women. New York, Grune & Stratton, 1944. EVERETT, J. W. Ciba Foundation Colloquia on Endocrinology, vol. 4. London, Churchill, 1952. . FIELDS, W. S., GUELLEMIN, R., and CARTON, C. A. Hypothalamic-Hypophysial Interrelationships. Springfield, Ill., Thomas, 1956. FORD, E. S. C., et al. Fertil. & Steril. 4:456, 1953. GUTTMACHER, A. F. Fertil. & Steril. 4:250, 1953. HANSON, F. M., and ROCK, J. Am. J. Obst. & Gynec. 59:311, 1950. HARRIS, G. W. Neural Control of the Pituitary Gland. London, Arnold, 1955. HEIMAN, M. Fertil. & Steril. 6:405, 1955. HOLMES, T. N., et al. The Nose: An Experimental Study of Reactions within the Nose in Human Subfects During Varying Life Experiences. Springfield, Ill., Thomas, 1950. JACOBSON, E. Psychoanalyt. Quart. 15:330, 1946. KELLEY, K. Psychosom. Med. 4:211, 1942. KLINEFELTER, H. F., ALBRIGHT, F., and GRISWOLD, G. C. ]. Clin. Endocrinol.
3:529,1943. 22. KROGER, W. S. Fertil. & Steril. 3:542,1952. 23. KROGER, W. S., and FREED, S. C. Psychosomatic Gynecology. Philadelphia, Saunders, 1951. 24. KUBIE, L. S. "The Problem of Specificity in the Psychosomatic Process." In WITTKOWER, E. D., and CLEGHORN, R. A. (Eds.): Recent Developments in Psychosomatic Medicine. Philadelphia, Lippincott, 1954, p. 29. 25. LOESER, A. A. Lancet 244:1, 51B, 1943. 26. MACLEAN, P. D. "Studies on Limbic System (Visceral Brain) and Their Bearing on Psychosomatic Problems." In WITTKOWER, E. D., and CLEGHORN, R. A. (Eds.): Recent Developments in Psychosomatic Medicine. Philadelphia, Lippincott, 1954, p. 101. 27. MACLEAN, P. D. Ann. Rev. Physiol. 19:397, 1957. 2B. MACLEOD, J., GOLD, R. Z., and McLANE, C. M. Fertil. & Steril. 6: 112, 1955. 29. MALMO, R. B. Anxiety and Behavioural Arousal. Psychol. Rev. In press. 30. MANDY, T. E., et al. South. Med. J. 48:533, 1955. 31. MARBACH, A. H., and SCHINFELD, L. H. Obst. & Gynec. 2:433, 1953. 32. MARKEE, J. E., EVERETT, J. W., and SAWYER, C. H. Recent Progr. Hormone Res. 7: 139, 1952. 33. MARSH, E. M., and VOLLMER, A. M. Fertil. & Steril. 2:70, 1951. 34. MICHAEL, S. T. Psychiat. Quart. 30:63, 1956. 35. O'NEILL, D. "Psychological Aspects of Gynecology and Obstetrics." In WITTKOWER, E. D., and CLEGHORN, R. A. (Eds.): Recent Developments in Psychosomatic Medicine. Philadelphia, Lippincott, 1954. 36. ORR, D. W. Psychosom. Med. 3:441, 1941. 37. REIFENSTEIN, E. C., JR. Med. CZin. N. America 30:1103,1946. 3B. RUBIN, I. C. Am. J. Obst. & Gynec. 50:621, 1945. 39. RUBENSTEIN, B. B. Fertil. & Steril. 2:BO, 1951. 40. SAWYER, C. H. Am. J. Physiol. 180:37, 1955. 41. SAWYER, C. H., and CRITCHLOW, B. V. Annual Rev. Physiol. 19:467, 1957. 42. SCHRANK, P., and KOCH, K. H. Zschr. Geburtsh. Gyn. 130:200, 1949. 43. SIMMONS, F. A., and TAYMOR, M. L. Fertil. & Stenl. 6:320,1955.
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44. SMITH, G. V. "The Ovaries." In WILLIAMS, R. H. (Ed.): Textbook of Endocrinology. Philadelphia, Saunders, 1955. 45. STALLWORTHY, J. J. Obst. & Gynaec. Brit. Emp. 55: 171, 1948. 46. SYDENHAM, A. Brit. M. J. 2:159,1946. 47. TAYLOR, H. C. Am. J. Obst. & Gynec. 57:637,1949. 48. WHITACRE, F. E., and BARRERA, B. ].A.M.A. 124:399, 1944. 49. WHITE, B. V., COBB, S., and JONES, C. M. Psychosomat. Med. Monograph I, 1939. 50. WHITELAW, J. ]. CUn. Endocr. Metab. 16:972, 1956. 51. WITTKOWER, E. D., and WILSON, A. T. M. Brit. M. J. 2:586, 1940. 52. WOLFF, H. G. Res. Pub. Ass. Res. Nerv & Ment. Dis. 29:1059,1950. 53. ZILBORG, G., and HENRY, G. W. A History of Medical Psychology. New York, Norton, 1941.
DISCUSSION SPRAGUE H. GARDINER, M.D. (Indianapolis, Ind.): Doctors Bos and Cleghorn have rendered a real service in their comprehensive presentation of the various factors of psychogenic sterility. Since in all psychosomatic studies we must remain biologically oriented, it was particularly appropriate that they should discuss the physiologic background of infertility before presenting the psychogenic aspects. I find myself in agreement with their summary of the current knowledge of the psychologic factors. I am in particular agreement with the authors when they state, "We feel that it is of extreme importance that the conflicts surrounding sterility in a woman be examined in the context of her total personality." Our studies of sterility patients at the Indiana University Medical Center have convinced us that frequently the complaint of sterility, per se, is but one of the problems, and often a minor one, in considering the total personality maladjustment from a diagnostic and therapeutic point of view. On the other hand, follow-up discussions with some of my private infertility patients who have become pregnant following simple diagnostic infertility procedures have evinced the frequency of psychogenic infertility due to emotional conflicts which have not become deeply rooted. In a barren couple, it is almost always the wife who assumes the blame for the infertility. I have always concluded that the reason for this was the anatomic difference between the male and temale. The husband, with his generative organs externally located, can easily verify his normalcy. The wife, however, with her generative organs located in the pelvic cavity, has no way of knowing her status in regard to her normalcy. The positive reassurance given by the physician to these women regarding the complete normalcy of the female organs, as demonstrated by the pelvic examination, the endometrial biopsy, and the uterosalpingogram, has dispelled the dozen and one fears and worries concerning possible disease or abnormality of the female organs which had been mounting month by month and year by year as the barrenness of the marriage continued uninterrupted. I strongly agree with the authors' statement that, "The most important point to be made with regard to psychogenic sterility ... is that it should be possible to make this diagnosis in a positive fashion with a minimum of exclusion procedures." Recently, at the Indiana University Medical Center, we made an intensive psychosomatic study of 14 women whose only gynecologic complaint was infertil-
,
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ity of 1-10 years' duration. Each had had a complete gynecologic and infertility investigation, with all findings being normal. Detailed psychologic evaluation of these patients revealed 7 women in whom no evidence of a psychogenic cause for the infertility could be found, although psychogenic etiology had been assumed by exclusion of other possible causes. Of these 7, 1 patient became pregnant in the subsequent months. In the other 7 women, emotional disturbances of possible etiologic significance were found related to the infertility. Of these 7, 5 women became pregnant in the ensuing several months, 3 after psychotherapy and 2 after detailed psychologic evaluation only. In conclusion, I strongly urge adoption of the suggestion made by the authors that a large-scale systematic and interdisciplinary study be made of the problems of psychogenic sterility.
* * *
J. ROBERT WILLSON, M.D. (Philadelphia, Pa.): Until relatively recently the study of infertility was directed primarily toward the female and consisted of an attempt to detect gross abnormalities that could prevent conception. As our knowledge of reproductive physiology increased, new diagnostic tests and instruments were devised, thereby increasing the accuracy with which both members of an infertile couple could be studied. We can now detect minor deviations in structure and function of the reproductive organs which were often overlooked or unknown a decade or two ago. There are, however, many infertile women in whom no such organic defect can be discovered; these are the ones in whom emotional disturbances may be acting to prevent conception. The size of this group is not immediately obvious because our diagnostic ability has not as yet reached the point of perfection which permits complete accuracy. Therefore, some women now considered as normal may actually have organic conditions which we cannot recognize. On the other hand, a diagnosis of psychogenic infertility cannot be made solely on the basis of the emotional pattern, because an identical pattern can be found in women with structural changes which could prevent conception as well as in those whose reproductive organs appear normal. Because there is so much overlapping of organic and emotional factors, it does not seem advisable, even though it were possible, to attempt to divide infertile patients into two distinct groups. This is particularly true if the diagnosis of emotional infertility is made solely because organic defects cannot be demonstrated. Most gynecologists feel inadequate to cope with emotional problems, and, as a consequence, often deliberately avoid asking questions other than those applying directly to organic factors. This is wrong, because much pertinent information concerning the patient's emotional attitude toward pregnancy can be obtained by a few simple questions which can be asked as part of the usual history. The emotionally normal woman wants children, because to her they represent one of the major goals of womanhood. She even accepts unplanned pregnancies and welcomes the birth of the child in spite of the fact that it adds much to her responsibility. The functionally infertile patient, on the other hand, desires a baby only verbally; on an unconscious level she wants no part of pregnancy and nothing could be more damaging to her than to conceive. Her reason for seeking help is
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often selfish (to have something to love her, to be like other women or because her marriage is tottering), revengeful (to do a better job than her mother did), or because her husband made her go to the doctor. In many instances the husband brings the patient to each of her appointments. Questions concerning other aspects of sexuality and motherhood will also bring forth important information. Most normal women want at least 2 children, whereas those who are neurotic usually are equivocal; they may say "My husband wants three," or "I want one for my husband," but they rarely admit wanting none. The normal woman usually wants a son for her husband and a daughter for herself, while the neurotic individual knows she cannot cope with a female child psychologically and almost always wants a boy. The neurotic woman is aggressive, masculine, and in competition with men, and, as a result, often displays frigidity, dyspareunia, and menstrual abnormalities and may be contemptuous both of her husband and of her role as a housewife and mother. This is in direct contrast to the normal feminine woman who both accepts and enjoys her position. This information can be elicited by asking: Why do you want a baby? How many children do you want? Do you want a boy or a girl? Will you raise your child differently from the way your mother raised you? How could you improve your husband? Would you rather work than keep house? etc. When such attitudes are discovered, the need for psychiatric evaluation is obvious even though definite organic abnormalities also are found. While there is no question that there are women who fit the authors' criterion for psychogenic infertility, "... absence of demonstrable organic pathology unconnected with psychic states ... ," I doubt that it is possible at this time to make such a diagnosis with certainty. As a matter of fact I believe the term "psychogenic infertility" could well be discarded. I would substitute "the psychogenic factor in infertility," which could take its rightful place beside "the tubal factor," "the cervical factor," etc., as one of the things to be considered in each patient who is unable to conceive. This might encourage gynecologists to assume a positive attitude toward emotional problems rather than to consider them as a last possibility after gross organic lesions have been eliminated.
International Federation 01 Gynaecology and Obstetrics The International Federation of Gynaecology and Obstetrics will hold its Second World Congress, from June 22 to 28, 1958, in Montreal Canada. Information and registration forms may be obtained by writing to the Montreal Committee, Second World Congress, International Federation of Gynaecology and Obstetrics, 1414 Drummond St., Suite 220, Montreal 25, Quebec, Canada.
WE
ARE UNDER NO ILLUSIONS that we have the answers to the problems posed by our title; it is our intention to highlight some aspects of psychogenic infertility as we see it and hope that this may provide the basis for profitable discussion. In examining the problem we propose excluding the consideration of those organic factors with which you are so familiar, and speak of certain neuroendocrine mechanisms set in motion by psychologic processes. The psychologic or psychodynamic permutations and combinations are many, while the endocrine and neurologic mechanisms, the final common paths by which these may be expressed, are few. Anger, fear, guilt, and hostility may be difficult to disentangle psychologically, but physiologically they most often exert indistinguishable effects.
HISTORICAL ASPECTS Rites and rituals designed to aid fertility have their origins in antiquity and presumably bespeak the presence of the problem of unsatisfactory fecundity then. Accounts of these practices with their SOciologic and gynecologic interest have been described by Guttmacher.14 Speculative explanations and therapeutic recommendations of medical advisers of the eighteenth century came closer to defining and divining the real nature of the causes. William Buchan5 said, in 1779: "Barrennness is often the consequence of grief, sudden fear, anxiety, or any of the passions which tend to obstruct the menstrual flux. When barrenness is suspected to proceed from affections of the mind, the person ought to be kept as easy and cheerful as From the Allan Memorial Institute, Montreal, Canada. Presented at the Thirteenth Annual Meeting of the American Society for the Study of Sterility, New York, N. Y., May 31, June 1-2, 1957. Received for publication July 2, 1957. 84
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possible; all disagreeable objects are to be avoided, and every method taken to amuse and entertain the fancy." Modern knowledge which forms the basis of the present point of view began in the late nineteenth century with advancement in three areas: (1) the endocrines;7 (2) the autonomic nervous system;6 (3) that area we might now term psychophysiology, namely, the importance of emotions in the psychologic and phYSiologic life of man. 53 The increasing refinements of our knowledge of these subjects in the last three decades and the development of psychosomatic concepts set the stage for our knowledge as it is today. In the gynecologic field this has been ably summarized by Kroger and Freed. 23 STATEMENT OF THE PROBLEM Sterility in the female has been variously defined. One categorization describes it as a failure to conceive in the absence of contraceptive measures during a minimum of 1 year of marital interoourse. 2o , 28 To refine this to the narrower realm of psychogenic infertility one must add that there be absence of demonstrable organic pathology unconnected with psychic states, and evidence of the adequacy of the sperm of the male partner. The problem of male fertility is being ignored at this time although there is evidence that psychogenic factors may be influential there too. PSYCHOPHYSIOLOGY The effector mechanisms concerned in psychogenic infertility are those two major homeostatic mechanisms, the endocrine and autonomic nervous system. The first, through the pituitary, controls ovulation and ovarian hormones, and the second, certain other functions of the genital tract essential to conception. Let us examine them in turn. Neuroendocrinologic Control of Ovulation
Some of the phYSiologic mechanisms concerned in the control of ovulation are well understood, and have been described in some detail by various authors.4, 8, 12, 16,41 For present purposes the following summary will suffice. Release of luteinizing hormore (LH), which is apparently the ultimate stimulus to ovulation, must be through a vascular mechanism from the hypothalamus because there are no secretory nerves from the brain to deliver the message to the adenohypophysis. The vascular channel is the hypothlamo-hypo-
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HISTAMINE -( IN VENTRICLE) ACTS VIA LIMBIC LOBE
<
STALK SECTION BLOCKS ALL STIMULI MEDIATED BY HYPOTHALAMUS
2 Fig. 1. Factors causing release of LH (and, consequently, ovulation) by the anterior pituitary in the rabbit.
Fig. 2. Factors preventing release of LH (and, consequently, ovulation) by the anterior pituitary in the rabbit.
physial portal vessel system. In the rabbit, which ovulates only after copulation, the control of the release of LH has been profitably studied, most intensively by Markee and his associates. 32 It has been found that the following procedures may cause ovulation experimentally (Fig. 1): picrotoxin- or Metrazol-induced convulsions; electrical stimulation of the posterior hypothalamus; epinephrine injected into the anterior lobe or third ventricle; histamine injected into the ventricle of the rabbit lightly anesthetized with Nembutal,4° Certain procedures prevent ovulation in the rabbit after coitus or after the majority of the experimentally induced gonadotrophic release (Fig. 2). These are: atropine or Banthine within 15 seconds of the stimulus; dibenamine within 1 minute, or barbiturate anesthesia or stalk section prior to the stimulus. Epinephrine-stimulated ovulation is not inhibited by atropine but by the anti adrenergic drugs. HistamineNembutal-induced pituitary activation is prevented by olfactory bulb lesions or by drugs which prevent the occurrence and transmission of olfactory bulb activity, e.g., atropine and D-ol (SKF 501) also blocks coital and
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epinephrine release without interfering with the electrical response. 40 One may conclude that there is cholinergic function activated within 15 seconds of mating that sets off a train of events linked to an adrenergic mechanism that is activated within 1 minute. Presumably an adrenergic substance is the final chemical messenger which passes to the anterior pituitary by way of the stalk portal vessels. Once there, an hour is required for the elaboration of enough LH to cause ovulation. The reaction of the ovary is still longer-of the order of 10 hours. Studies of animals such as the rat, which ovulates spontaneously, indicate that blocking agents such as atropine and dibenamine will prevent ovulation if given at the estimated time of neurohypophysial activity some 11 hours before ovulation. 32 This is also true for barbiturates, morphine, and chlorpromazineY Both the latter upset reproductive cycles in humans,5o which is of some importance in view of the widespread use of tranquilizers. In an extension of the above studies, Sawyer has demonstrated the involvement of rhinencephalic pathways implicating especially the median forebrain bundle and/or the basal ganglia in experimental pituitary gonadotrophic activation elicited by intraventricular histamine in the lightly Nembutalized rabbit. This is of relevance to the importance assigned to the limbic system in the integration of emotion, as emphasized by MacLean. 26 • 27 Clinical Significance of Neurophysiology of Ovulation. This concerns various degrees of failure of ovulation. In its most dramatic guise, disturbance of ovulation may extend to complete amenorrhea. When this is psychogenically induced the term "hypothalamic amenorrhea" has been used. 21 • 37 The following list summarizes the pertinent situations, but certain aspects deserve detailing. HYPOTHALAMIC AMENORRHEA
1. Novel social situations in the young 2. Dramatic circumstances: Feared pregnancy Wartime experiences 3. Complicated emotional situations Fear, grief, anxiety, hostility (anorexia nervosa)
Psychogenic or "hypothalamic" amenorrhea can be induced by mild situations-debutantes, or girls going into nursing training-but generally rights itself quickly. It is also observed following more stressful circumstances, for example, in 10 per cent of a large series of women exposed to attempted
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rape. 42 Prison camp led to amenorrhea of 3 months or more duration in half of a group of 450 women in Hong Kong in 1941. This was at a time when dietary factors could not have been responsible. A second wave occurred in these women in 1944, when a drastic cut in protein occurred. 46 A similar experience was observed at an internment camp at Manila. 48 Four women who missed a period due to emotional shock showed on biopsy an endometrium at the stage expected for the time of the shock, suggesting that the emotion had interrupted honnone release at that time. 25 By way of explanation, one must assume that the disturbances led to an interference in the elaboration of LH and, secondarily, of estrogens by the ovary.37 Disturbance of LH secretion may also be an accompaniment of electroshock therapy, which sometimes leads to menstrual cycle disturbances. 34 Fear and depression seem to be the affective state most commonly associated with amenorrhea. In 26 patients with depression, 17 were amenorrheic but only 1 of 17 in a manic phase. 1 Time and removal from the threatening situation rectify many cases of psychogenic or hypothalamic amenorrhea. Simple psychotherapy or hypnosis suffices in others. 23 . 35 This is rarely true for its occurrence in that refractory disease known as anorexia nervosa,9 in which cachexia is so marked. An intensive analytic study made in such a case with eventual pregnancy has been reported by Jacobson. 19 The incidence of prolonged suppression of ovulation as a factor in psychogenic sterility has not been estimated in many series. MacLeod 28 assesses poor ovulation at 12.6 per cent in his group. It is given as 28 per cent in 1000 cases by Stallworthy,45 though he minimizes this figure by saying: "It is known [that] it is not a common cause of sterility." This is in concordance with C. V. Smith's44 statement: "Actually, all the endocrine causes of sterility make up but a small percentage of couples with this complaint." The truth is that we do not know. Endocrine disorders of the thyroid and adrenal can also affect fertility and their alleviation precede conception. Autonomic Nervous System Influence on the Genital Tract
The close central connections of the autonomic nervous system with those areas of the brain concerned in emotional expression have been described in various texts. How or why certain efferent branches become involved in the expression of certain psychosomatic syndromes is not understood, but it seems clear that the autonomic can mediate a variety of motor and secretory
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genital disturbances because of altered psychic states concerned with genita) function. Genitally Centered Factors in Psychogenic Infertility. These, therefore, are an expression of autonomic system disturbances. Consideration of structural pathology of the genital tract, which in practice is important, has been omitted. Viewed teleologically, nature has provided certain methods for the prevention of conception in the ovulating female, given a fertile male. Item 1 of the list below may be considered as a somatically expressed manifestaGENITALLY CENTERED FACTORS IN PSYCHOGENIC INFERTILITY
1. 2. 3. 4. 5. 6.
Conscious rejection of sex act or contraceptives Vaginismus preventing intercourse Vaginal pH changes lethal to sperm Cervical canal changes Endometrial changes incompatible for implantation Fallopian-tube dysfunction
tion of a disturbed attitude. The remaining five presumptively involve disorder of the autonomic nervous system and imply considerably more unconscious though not necessarily more refractory attitudes. No effort will be made in this presentation to explain the involvement of one or another part of the genital tract in this autonomic dysharmony, but brief consideration will be given to the topics of tubal spasm and vascular congestion with which secretory disturbances are so commonly associated. Isthmotubal Spasm. This was described by Rubin in 1932. In this and later series,38 the incidence of tubes blocked to insuffiation or lipiodol was approximately 25 per cent. This does not represent a permanent state, for conception may occur without the establishment of patency and a figure of less than 10 per cent comes closer to the actual absolute blockage. 45 Atropine does not reliably abolish spasm here any more than in other instances of spasm of smooth muscle, nor does anesthesia. Emotional distress precipitates and reassurance and amyl nitrate may relieve spasm. Studies with this and other muscle relaxants indicates that something like 50 per cent of tubal blockage is due to uterotubal irritability.45 It is perhaps not surprising that this richly innervated area is susceptible to dysfunction similar to that seen in other smooth muscle areas throughout the body. By the same token genital tract secretions may be just as much deterred by fear as salivation. Vascular Congestion and Hyperemia. These are presumably referable in large part at least to dysfunction of the autonomic nervous system. Associ-
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ated autonomic complaints in other parts of the body used to be ascribed to the pelvic vascular disturbance. Now we are more prone to assign priority for both to psychologic factors such as unsatisfied sexual arousal, fear, hate, conflict, and anxieties. It is possible that partial sexual arousal without orgasm may be more deleterious for the health of the genital tract vis-a-vis conception than absolute frigidity because of the chronic effects of autonomic nerve activity. Intensive study of large groups of patients with vascular and secretory disorders by Taylor47 and others indicates a high incidence of sterility. One is reminded by the multiplicity of complaints of the similarity to the syndrome of "irritable colon."49 There is probably also a close similarity to the nasal congestion seen in certain neurotic patients. One could hope that the same careful type of controlled observations might be made as reported by Holmes et al. 18 for the nose. In the foregOing sections we have endeavored to visualize for ourselves as well as for our audience those mechanisms probably involved by physiologic processes which lead to infertility. It is now appropriate to turn to a closer consideration of the pertinent psychic processes. In the time at our disposal it is not possible to do justice to many of the able articles in this field, but we trust we may be able to stress certain salient points for your consideration. PSYCHIATRIC ASPECTS At the outset, it may be well to remind ourselves that when we as physicians speak of a sterile woman, we are speaking of the woman who has sought us because she is dissatisfied with her lot. The sterile woman who is satisfied with being sterile does not consult a physician. Personality Factors
A list of disturbed personality factors in female psychogenic sterility, collected from the literature of recent years, is shown below. The~e were defined PERSONALITY FACTORS IN FEMALE STERILITY
1. 2. 3. 4. 5. 6. 7. 8.
Physical and emotional immaturity Aggressive-masculine types (resents female role) Combination of 1 and 2 Hostile mother identification Motherly type Feminine erotic type Obsessive-compulsive type Disturbed, impoverished, and chronic worriers
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by Deutsch,lO Wittkower,51 and elaborated by other authors.22, 31, 33, 39, 51 Careful study of the various types shown reveals that actually, basically, the affective attitudes involved are two: (1) fear of impregnation, and (2) a rejection of impregnation. As to the psychologic conHicts which bring about these two emotions, these are infinite in number. Actually, this list could probably be multiplied many times. We must remember that psychologic conHicts are individual for each patient. It is impossible for two individuals to have exactly the same basic make-up and to have exactly the same experiences during their lifetime. It is therefore impossible for two people to have exactly the same problem of a psychologic nature, though these can be expressed in the common denominator of psychodynamic terms. It should be remembered also that not all women who reject the feminine role are sterile-indeed some have a compulsion to produce large families. 19 The second important observation to be made from an examination of the standard works on the psychology of women and of the all too few investigations, both systematic and statistical of series of cases and of individual patients, reveals that the psychologic conHicts surrounding impregnation are manifestations of disturbed total personalities. This observation is important because of what it implies with regard to the treatment of this fonn of sterility. The sterility itself may be a defense of the disturbed personality against the stresses of pregnancy and motherhood, with which it is either unwilling or incapable of coping. It is one of the commonplaces of modern psychiatry that the patient's conscious desires and aspirations are not infrequently quite different from, and opposite to, the unconscious or really pervasive wishes. Every married woman is exposed to culturally determined pressures from her husband, relatives, and friends with regard to childbearing. There is a stigma attached to the word sterile. The tenn itself denotes empty, worthless, superHuous, vain, unserviceable, stale. It is little wonder, then, that the conscious strivings of the majority of women are away from any desires or wishes which are contrary to the role assigned to her by society. Our culture assumes that infertility is undesirable; this is one of the reasons for the existence of your Society. The emphasis on the investigations up to now has been on the reasons why a sterile woman, whose problems are at an unconscious level, does not wish to have a child. It would seem to us profitable if some emphasis were placed upon the reasons why a woman who is sterile wants to have a child. We feel also that it is of extreme importance that the conHicts surrounding
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sterility in a woman be examined in the context of her total personality. We are struck by the possibilities of damage to personalities caused by overcoming inhibitions of this nature which may actually serve as a defense against much more serious difficulties for the woman personally, and, as a consequence, for society.3. 20, 30 The Problem of Organ Choice
The task of establishing the connection between psychologic problems and the physiologic manifestations is the eternal problem of psychosomatic medicine, and here in the particular context of our study again we encounter a key difficulty of all psychosomatic medicine-the problem of organ choice, or specificity. This has been thoughtfully discussed at length by Kubie,24 who honestly submits that there is currently no available answer. It is quite unclear how a psychologic confl~ct becomes translated into a specific goaldirected negative neurophysiologic pattern. In other words, we do not know what happens when emotional concern over sexual role, sexual relations, and the bearing, giving birth, and raising of a child are translated into inhibitory neuronal influences that prevent ovulation, or into exaggerated autonomic action that interferes with the conjunction of sperm and ovum. At present, the diagnosis of psychogenic sterility is made primarily by exclusion. We feel that one can be justifiably suspicious of a diagnosis which can be arrived at only on this basis. This is the important, and perhaps the most important, point to be made with regard to psychogenic sterility, as indeed is the point to be made of any so-called «psychosomatic condition," and that is that it should be possible to make the diagnosis in a positive fashion with a minimum of exclusion procedures. Unfortunately, this we cannot do at present. Influence of Therapeutic Procedures
It has been stated that 35 per cent of women coming for treatment of psychogenic infertility become pregnant45 during the course of investigation or therapy. These procedures are, of course, therapeutic in various ways, not least of which is the relationship established with the phYSician. Actually, the general physician is a better psychotherapist than he knows, particularly if he can establish a tender, understanding, and trusting attitude. Under such sympathetic circumstances, as March and Vollmer 3 say: «Physiologic tensions steadily diminish until the pelvis is converted from a sterile battle-
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ground in which hostility and hope have been at cross purposes with each other, into a life-giving bed of fertility." Such beneficial patient-physician relationships have been described in the more esoteric language of psychiatry in terms of the dynamics of transference. One may say in that language that the trust in the interested and understanding physician represents a dynamic transaction which leads to a breakdown in the inhibitory forces. These are presumably the forces giving rise to impulses preventing ovulation or exciting deleterious influences along the autonomic nervous system. Adoption has a widespread and probably justified reputation as a measure which is often followed by conception,36 despite criticism on the shaky basis of a questionnaire. 15 The psychic mechanisms sorted out by the decision to adopt are probably reflected in relaxation of neurophYSiologic tensions preventing conception. This matter is discussed at length by Benedek et al.,3 who also describe the psychical complications surrounding the matter of artificial insemination. In connection with the problem of sterility one must also consider the problem of "one-child sterility," which has apparently a psychodynamic structure of its own. Heiman17 describes this as a motherchild relationship which does not permit the intrusion of a third personhusband or second child. This is in addition to the more obvious rejection after a traumatic first pregnancy. Infertility Studies in Our Culture
Reports which aim at a complete study of infertility vary in their assessment of the incidence of psychogenic factors, partly because patients may be selected differently. One group of reliable investigators found in 100 couples studied only 3 cases with psychologic disturbance alone but in 16 others the maladjustment was accompanied by an organic factor.43 Studies such as that of Ford et al. 13 directed at the psychodynamics of infertility, and including two psychiatrists on the team, disclosed abnormal attitudes in 31 of 38 cases studied. It might be added that their attempt to dissolve the arbitrary borderline between organic and psychogenic sterility is one with which we are in hearty agreement. Their suggestions for detecting Significant emotional conflict warrant incorporation in any comprehensive study. One facet which cannot be expanded upon here but which merits mention is the necessity for the study of the cultures from which the patients come. One is inclined to think and speak in terms of North American cul-
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ture, and there are obviously many pervasive and presumably unhealthy influences which intrude on all our lives, and in particular that of women. 2 It should not be forgotten, however, that there are many subcultures on this hemisphere more or less isolated by virtue of locality, religion, and custom, and these may all have their individual influence on attitudes to pregnancy and child rearing.
CONCLUSIONS AND RECOMMENDATIONS 1. For practical purposes, and with the idea of arriving at a clear understanding of the possible psychogenic factors in the sterility of an office patient, it would be advisable, we feel, to emphasize the reasons why the woman wants a child as much as to seek the reasons why she does not want a child. 2. The total personality of the sterile woman should be studied and one should bear in mind the consequences to that personality from the induction of the pregnancy. 3. Large-scale systematic studies which could be treated statistically should be instituted, and the studies should permit examination and investigation by various technics: a. Of a psychophysiologic nature, such as the type used by Wolff,52 Malmo,29 and others. h. Intensive psychologic examination and psychiatric assessment. c. SOciologic investigation of environment and background. d. Follow-up studies to determine the difficulties, if any, encountered by women who have suffered psychogenic sterility, and who have become pregnant. We are thinking particularly of the incidence of spontaneous abortions, of psychologic difficulties during pregnancy, postpartum difficulties, and conflicts surrounding motherhood. This would be essentially an interdisciplinary study. 1025 Pine Avenue West Montreal, Canada
REFERENCES Psychiat. 13:239, 1933. 4:424, 1956. BENEDEK, T. F., et al. Psychosom. Med. 15:485,1953. BENOIT, J., and ASSENMACHER, I. ]. Physiol. (Paris) 47:427, 1955. BUCHAN, W. Domestic Medicine; or, A Treatise on the Prevention and Cure of Diseases (ed. 6). London, 1779, p. 119. 6. CANNON, W. B., and ROSENBLUETH, A. Autonomic Neuro-EfJector Systems. New York, Macmillan, 1937.
1. 2. 3. 4. 5.
ALLEN, E. B., and HENRY, C. W. Am.]. BENEDEK, T. F. ]. Am. Psychoanalyt. A.
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7. B. 9. 10. 11.
12. 13. 14. 15. 16. 17. lB. 19. 20. 21.
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CLEGHORN, R. A. Internat. Rec. M.166:175, 1953. CLEGHORN, R. A. Psychosom. Med.17:367, 1955. COBB, S. Emotions and Clinical Medicine. New York, Morton, 1950. DEUTSCH, H. The Psychology of Women. New York, Grune & Stratton, 1944. EVERETT, J. W. Ciba Foundation Colloquia on Endocrinology, vol. 4. London, Churchill, 1952. . FIELDS, W. S., GUELLEMIN, R., and CARTON, C. A. Hypothalamic-Hypophysial Interrelationships. Springfield, Ill., Thomas, 1956. FORD, E. S. C., et al. Fertil. & Steril. 4:456, 1953. GUTTMACHER, A. F. Fertil. & Steril. 4:250, 1953. HANSON, F. M., and ROCK, J. Am. J. Obst. & Gynec. 59:311, 1950. HARRIS, G. W. Neural Control of the Pituitary Gland. London, Arnold, 1955. HEIMAN, M. Fertil. & Steril. 6:405, 1955. HOLMES, T. N., et al. The Nose: An Experimental Study of Reactions within the Nose in Human Subfects During Varying Life Experiences. Springfield, Ill., Thomas, 1950. JACOBSON, E. Psychoanalyt. Quart. 15:330, 1946. KELLEY, K. Psychosom. Med. 4:211, 1942. KLINEFELTER, H. F., ALBRIGHT, F., and GRISWOLD, G. C. ]. Clin. Endocrinol.
3:529,1943. 22. KROGER, W. S. Fertil. & Steril. 3:542,1952. 23. KROGER, W. S., and FREED, S. C. Psychosomatic Gynecology. Philadelphia, Saunders, 1951. 24. KUBIE, L. S. "The Problem of Specificity in the Psychosomatic Process." In WITTKOWER, E. D., and CLEGHORN, R. A. (Eds.): Recent Developments in Psychosomatic Medicine. Philadelphia, Lippincott, 1954, p. 29. 25. LOESER, A. A. Lancet 244:1, 51B, 1943. 26. MACLEAN, P. D. "Studies on Limbic System (Visceral Brain) and Their Bearing on Psychosomatic Problems." In WITTKOWER, E. D., and CLEGHORN, R. A. (Eds.): Recent Developments in Psychosomatic Medicine. Philadelphia, Lippincott, 1954, p. 101. 27. MACLEAN, P. D. Ann. Rev. Physiol. 19:397, 1957. 2B. MACLEOD, J., GOLD, R. Z., and McLANE, C. M. Fertil. & Steril. 6: 112, 1955. 29. MALMO, R. B. Anxiety and Behavioural Arousal. Psychol. Rev. In press. 30. MANDY, T. E., et al. South. Med. J. 48:533, 1955. 31. MARBACH, A. H., and SCHINFELD, L. H. Obst. & Gynec. 2:433, 1953. 32. MARKEE, J. E., EVERETT, J. W., and SAWYER, C. H. Recent Progr. Hormone Res. 7: 139, 1952. 33. MARSH, E. M., and VOLLMER, A. M. Fertil. & Steril. 2:70, 1951. 34. MICHAEL, S. T. Psychiat. Quart. 30:63, 1956. 35. O'NEILL, D. "Psychological Aspects of Gynecology and Obstetrics." In WITTKOWER, E. D., and CLEGHORN, R. A. (Eds.): Recent Developments in Psychosomatic Medicine. Philadelphia, Lippincott, 1954. 36. ORR, D. W. Psychosom. Med. 3:441, 1941. 37. REIFENSTEIN, E. C., JR. Med. CZin. N. America 30:1103,1946. 3B. RUBIN, I. C. Am. J. Obst. & Gynec. 50:621, 1945. 39. RUBENSTEIN, B. B. Fertil. & Steril. 2:BO, 1951. 40. SAWYER, C. H. Am. J. Physiol. 180:37, 1955. 41. SAWYER, C. H., and CRITCHLOW, B. V. Annual Rev. Physiol. 19:467, 1957. 42. SCHRANK, P., and KOCH, K. H. Zschr. Geburtsh. Gyn. 130:200, 1949. 43. SIMMONS, F. A., and TAYMOR, M. L. Fertil. & Stenl. 6:320,1955.
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44. SMITH, G. V. "The Ovaries." In WILLIAMS, R. H. (Ed.): Textbook of Endocrinology. Philadelphia, Saunders, 1955. 45. STALLWORTHY, J. J. Obst. & Gynaec. Brit. Emp. 55: 171, 1948. 46. SYDENHAM, A. Brit. M. J. 2:159,1946. 47. TAYLOR, H. C. Am. J. Obst. & Gynec. 57:637,1949. 48. WHITACRE, F. E., and BARRERA, B. ].A.M.A. 124:399, 1944. 49. WHITE, B. V., COBB, S., and JONES, C. M. Psychosomat. Med. Monograph I, 1939. 50. WHITELAW, J. ]. CUn. Endocr. Metab. 16:972, 1956. 51. WITTKOWER, E. D., and WILSON, A. T. M. Brit. M. J. 2:586, 1940. 52. WOLFF, H. G. Res. Pub. Ass. Res. Nerv & Ment. Dis. 29:1059,1950. 53. ZILBORG, G., and HENRY, G. W. A History of Medical Psychology. New York, Norton, 1941.
DISCUSSION SPRAGUE H. GARDINER, M.D. (Indianapolis, Ind.): Doctors Bos and Cleghorn have rendered a real service in their comprehensive presentation of the various factors of psychogenic sterility. Since in all psychosomatic studies we must remain biologically oriented, it was particularly appropriate that they should discuss the physiologic background of infertility before presenting the psychogenic aspects. I find myself in agreement with their summary of the current knowledge of the psychologic factors. I am in particular agreement with the authors when they state, "We feel that it is of extreme importance that the conflicts surrounding sterility in a woman be examined in the context of her total personality." Our studies of sterility patients at the Indiana University Medical Center have convinced us that frequently the complaint of sterility, per se, is but one of the problems, and often a minor one, in considering the total personality maladjustment from a diagnostic and therapeutic point of view. On the other hand, follow-up discussions with some of my private infertility patients who have become pregnant following simple diagnostic infertility procedures have evinced the frequency of psychogenic infertility due to emotional conflicts which have not become deeply rooted. In a barren couple, it is almost always the wife who assumes the blame for the infertility. I have always concluded that the reason for this was the anatomic difference between the male and temale. The husband, with his generative organs externally located, can easily verify his normalcy. The wife, however, with her generative organs located in the pelvic cavity, has no way of knowing her status in regard to her normalcy. The positive reassurance given by the physician to these women regarding the complete normalcy of the female organs, as demonstrated by the pelvic examination, the endometrial biopsy, and the uterosalpingogram, has dispelled the dozen and one fears and worries concerning possible disease or abnormality of the female organs which had been mounting month by month and year by year as the barrenness of the marriage continued uninterrupted. I strongly agree with the authors' statement that, "The most important point to be made with regard to psychogenic sterility ... is that it should be possible to make this diagnosis in a positive fashion with a minimum of exclusion procedures." Recently, at the Indiana University Medical Center, we made an intensive psychosomatic study of 14 women whose only gynecologic complaint was infertil-
,
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ity of 1-10 years' duration. Each had had a complete gynecologic and infertility investigation, with all findings being normal. Detailed psychologic evaluation of these patients revealed 7 women in whom no evidence of a psychogenic cause for the infertility could be found, although psychogenic etiology had been assumed by exclusion of other possible causes. Of these 7, 1 patient became pregnant in the subsequent months. In the other 7 women, emotional disturbances of possible etiologic significance were found related to the infertility. Of these 7, 5 women became pregnant in the ensuing several months, 3 after psychotherapy and 2 after detailed psychologic evaluation only. In conclusion, I strongly urge adoption of the suggestion made by the authors that a large-scale systematic and interdisciplinary study be made of the problems of psychogenic sterility.
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J. ROBERT WILLSON, M.D. (Philadelphia, Pa.): Until relatively recently the study of infertility was directed primarily toward the female and consisted of an attempt to detect gross abnormalities that could prevent conception. As our knowledge of reproductive physiology increased, new diagnostic tests and instruments were devised, thereby increasing the accuracy with which both members of an infertile couple could be studied. We can now detect minor deviations in structure and function of the reproductive organs which were often overlooked or unknown a decade or two ago. There are, however, many infertile women in whom no such organic defect can be discovered; these are the ones in whom emotional disturbances may be acting to prevent conception. The size of this group is not immediately obvious because our diagnostic ability has not as yet reached the point of perfection which permits complete accuracy. Therefore, some women now considered as normal may actually have organic conditions which we cannot recognize. On the other hand, a diagnosis of psychogenic infertility cannot be made solely on the basis of the emotional pattern, because an identical pattern can be found in women with structural changes which could prevent conception as well as in those whose reproductive organs appear normal. Because there is so much overlapping of organic and emotional factors, it does not seem advisable, even though it were possible, to attempt to divide infertile patients into two distinct groups. This is particularly true if the diagnosis of emotional infertility is made solely because organic defects cannot be demonstrated. Most gynecologists feel inadequate to cope with emotional problems, and, as a consequence, often deliberately avoid asking questions other than those applying directly to organic factors. This is wrong, because much pertinent information concerning the patient's emotional attitude toward pregnancy can be obtained by a few simple questions which can be asked as part of the usual history. The emotionally normal woman wants children, because to her they represent one of the major goals of womanhood. She even accepts unplanned pregnancies and welcomes the birth of the child in spite of the fact that it adds much to her responsibility. The functionally infertile patient, on the other hand, desires a baby only verbally; on an unconscious level she wants no part of pregnancy and nothing could be more damaging to her than to conceive. Her reason for seeking help is
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often selfish (to have something to love her, to be like other women or because her marriage is tottering), revengeful (to do a better job than her mother did), or because her husband made her go to the doctor. In many instances the husband brings the patient to each of her appointments. Questions concerning other aspects of sexuality and motherhood will also bring forth important information. Most normal women want at least 2 children, whereas those who are neurotic usually are equivocal; they may say "My husband wants three," or "I want one for my husband," but they rarely admit wanting none. The normal woman usually wants a son for her husband and a daughter for herself, while the neurotic individual knows she cannot cope with a female child psychologically and almost always wants a boy. The neurotic woman is aggressive, masculine, and in competition with men, and, as a result, often displays frigidity, dyspareunia, and menstrual abnormalities and may be contemptuous both of her husband and of her role as a housewife and mother. This is in direct contrast to the normal feminine woman who both accepts and enjoys her position. This information can be elicited by asking: Why do you want a baby? How many children do you want? Do you want a boy or a girl? Will you raise your child differently from the way your mother raised you? How could you improve your husband? Would you rather work than keep house? etc. When such attitudes are discovered, the need for psychiatric evaluation is obvious even though definite organic abnormalities also are found. While there is no question that there are women who fit the authors' criterion for psychogenic infertility, "... absence of demonstrable organic pathology unconnected with psychic states ... ," I doubt that it is possible at this time to make such a diagnosis with certainty. As a matter of fact I believe the term "psychogenic infertility" could well be discarded. I would substitute "the psychogenic factor in infertility," which could take its rightful place beside "the tubal factor," "the cervical factor," etc., as one of the things to be considered in each patient who is unable to conceive. This might encourage gynecologists to assume a positive attitude toward emotional problems rather than to consider them as a last possibility after gross organic lesions have been eliminated.
International Federation 01 Gynaecology and Obstetrics The International Federation of Gynaecology and Obstetrics will hold its Second World Congress, from June 22 to 28, 1958, in Montreal Canada. Information and registration forms may be obtained by writing to the Montreal Committee, Second World Congress, International Federation of Gynaecology and Obstetrics, 1414 Drummond St., Suite 220, Montreal 25, Quebec, Canada.