The Effect of Adoption on Fertility and other Reproductive Functions

THE EFFECT OF ADOPTION ON FERTILITY AND OTHER REPRODUCTIVE FUNCTIONS .B'REDERICK

l\I.

HANSON,

l\I.D.,

AND JoHN RocK,

1\I.D.,

BROOKLINE, MAs>-:

(From the Free llospital for Women)

HYSICIANS and laymen have long thought that it is quite common for couples who have previously been childless to have a child of their own following adoption. Many people can cite one or more cases they know of personally, and when asked will preface their statement with a remark that the phenomenon is well known. Yet we find no report of an accurate survey of how often this sequence oecurs nor, assuming its frequence, of what is its etiology. The theory grows among physieians that psyehogenie disturbances play an important part in reproductive physiology and may influence conception. Proponents of this theory assert that adoption relieves the inhibitng psychogenic factor and allows the eonception. A limited survey of the possible occurrence of this relationship and of what effect adoption may have on other related reproductive funetions has been made and is reported in this paper. The literature contains little that is directly concerned with the cause of these possible phenomena, although several papers have definite bearing upon the subject. None has given any percentage of frequency of occurrence. In 1936 Perkins 1 reported a study made over a five-year period in which he approached people through the medium of a magazine article asking for voluntary responses to his questionnaire. Two hundred seventy-three people reported that having adopted a child they sutsequently had normal pregnancies, ranging from one to fifteen children. No percentage of frequency can be calculatt>d from this study since no onr reportt>d adoption without subsequent pregnancy, although tht> stated purpose of the author was to find "whether inft>rtility is ever or often afft>ctt>d by the dt>cision to adopt.'' He discuss€'~ as provocative decisive factors bringing about the infertility, excessive mental strain, wort·y over financial matters, guilt feelings due to puritanical uphl'inging, or perhaps subconscious guilt feelings because of past indiscretions. 'rhus, in this early- study of the problen1 itself, a psychiatric basis is proposed and discussed. Perkins postulated that perhaps ''an imbalance of endocrine influence may he balanct>d by adoption wht>reas just the desire to adopt is not sufficit>nt." Actual adoption then is the particular factor, according to him, which permits conception and parturition. Dunbar 2 in 1938 summarized the work of Sellheim/ 2 Mohr/ 3 and A. Mayer 14 done between 1925 and 1930, and stated, without acceptable proof, that "psychic influences associated with a vivid but unsatisfied desire for a child, may stimulate the ovaries to pathological growth. It is possible that this may result in premature maturation of the follicles and discharge of tht> ova which are not yt>t ready for fertilization, and consequent sterility. That tht>re are peculiar cast>s of first conception after 15-20 years of married lift> may be explained by tht> fact that as a woman gradually becomes reconciled to her sterility this injurious influence on the follicular apparatus disappears." Orr 3 in 1941 reported a case of "Pregnancy Following the Decision to Adopt," which he attributed in large part to psychosomatic causes. Both members of the couple had had over 500 hours of psychoanalysis which

P

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brought out eYiclences in each member of conflicts dealing with repudiation of f{'mininity and masculinity. Their decision to adopt was followed immediately hy a normal conct>ption, which ended in normal delivery, the last menstrual period occurring eleven days following the time the application to adopt was mad!~. The baby was chosen fifteen days after the onset of menstruation and the wife had no further periods. 'l'he pregnancy followed a period of ten years of infertility, seven of whieh 1vere because of controlled conception. Prior to the \lecision to adopt, a period of three years of infertility without eontraceptiou passed, during which pregnancy was desired and attempted. lt must he stated, however, that associated in this case is a history of pelvic (•ndometriosis fur whielt thr wift> was tt·eated surgically 13 months prior to the normal !'.onception, at whieh time a Fallopian tube and ovary were removed. 'J'lwre an• many eases of infertilt• patients with pelvic endometriosis, however, who, by surgical treatment, have been enabled to conceive, usually within two years following surgery. This must be remembered as a possible cansP of the <·oneeption in this easP, m1option then only incidental. Here, again, howe\'el·, a psychosomatic cause of infertility is proposed. vYc quote at length from Knight; (1941). "\Ne are all aware of the frequew·.y of '!~Onscions' opposition to ha~dng children in married couples, so that they take extreme precautions to avoid conception. This conscious opposition is attributed to the conviction that they cannot afford children, that they do not want io havt> tht>ir :·wcial life aw1 fr·eedom from responsibility interfered with, or so et in order to he acceptable to them.'' Here is proposed the basic question in a study of the effect of adoption on fertility: can a psychogenie faetor~ of itself, ea-use the infertilit:y· that exists before adoption and disappears afteewanl? Knight accepts such a relationship and describes how he thinks the effective cause is made manifest. William .Menninge1··-· statrs that prohahly the most prominent factor in psychogenic sterility is fear of the inability to become pregnant. He lists three cases in his own personal experience which he proposes as cases of psychogenic infertility rt•lieved hy adoption, and lists as well, in verification, Orr's case (previously discussed) stating it to l;e a similar case, making no mention, howt>ver. in his resume of the case history, of the pre-existence of the endometrioHis. Robbins" in 1948 reiterated the possible underlying psychogenic conflicts whieh bring about infertility and stated that'' a promising opening for psychologically oriented investigation of problems relative to conception is the wellknown phenomenon of conception in a previously sterile woman after she has a(1opted a ehild. Unfortunately, aceurate statistics of the frequency of such events are not available but inasmuch as almost everyone knows of one or two such incideuts they must oceur frequently.'' \Ve feel, however, that perhaps those cases that do occur are so well publicized that the relative frequency of the oecurrenee is in tum ovrremphasized. -weiss' discusses these factors as well.

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Karl Menninger 8 states also (1942) that the unconscious wish not to haYe a child n1ay exist even though consciollS appearances deny it, and elaims the

disturbance may be due to a repudiation of femininity, hut more frequently is based on a tremendous unrecognized fear. Further he states that ''we should logically expect that the significant alterations in functions or strueture related to the repudiation of femininity would be connected with the reproductive organs. Frigidity and vaginismus represent physiological rejections of the feminine role in intercourse and cannot exist over a long period without some corresponding structural changes, such as (at least) the atrophy of unused tissues and glands." This last statement may be seriously questioned. Disuse has not been shown of itself to cause atrophy of the vaginal tissues or any of the reproductive organs or glands. He states further, however, "sterility is somewhat comparable to frigidity: it represents the failure of normal biological functioning. That it occurs far oftener among human beings than among animals, should have suggested before now that something in the spirit of our civilization interfe1·es with a process generally regarded as beyond psychological control.'' He mentions also the reported cases of '' reorganization of the psychic life (e.g. psychoanalysis) of a woman resulting in pregnancy 10, 15, and 20 years after marriage,'' and that ''moreover, pregnancy frequently follows the adoption of a child.'' Evidently he feels that this is a very common occurrence, since he writes that "such phenomena as the occurrence of pregnancy following the adoption or decision to adopt a child are frequent enough to belie the explanation of coincidence for even the most organically minded doctors.'' Statistical evidence of sufficient frequency to ''belie the explanation of coincidence'' is not given. In his book, Love Against Hate, 8 he offers the following statement as possible verification of the existence of psychologic control over reproductive functions as evidenced in the animal world. ''Every ornithologist is familiar with the phenomenon observable in the woodpecker family and in some other birds: if a normal clutch of eggs is, let us say, six, the artificial removal or loss of one of the eggs will result in another being laid to replace it, and this can be repeated many times. It is clear that the fenut!e has some psychologieal c.onh·ol over the number of eggs she produces, the stimulus of the awareness of a certain 'perfect' number.''

\\T e are per1nitted to quote in total a letter received fron1 Ludlovv Griscom, Research Ornithologist at Harvard College, in response to our question about this phenomenon in the woodpecker family and in bird life in general. ''Karl Menninger's statement in his book is an amusing combination of half truths made into glittering generalizations. The ascertained facts would appear to be approximately as follows: The ovaries " (1) The great biological mystery about most birds is roughly this: manufacture a large number of eggs, but only the number needed to eonstitute the normal c.luteh are matured, ripened, and laid. What prevents the development of other eggs and how they are absorbed into the system is entirely unknown. Moreover, in the great majority of birds on earth the normal clutch is far more than three, and as experiment fails to show that any bird ean count beyond three, there can be no 'awareness of a certain perfect number,' to quote Menninger. "(2) Menninger's facts about the woodpecker family are incorrect and distorted. Many decades ago somebody experimented with a female flicker and made the remarkable discovery that if two eggs were laid and one was taken, leaving one, that particular female flieker laid seventy-one in seventy·three days. This experiment has been repeated on four subsequent occasions with four other female flickers. No two of these individuals proved alike, and none

::-~14

HANSON AND ROCK

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Obst. & Gynec. February. 1950

of the four laid more than forty eggs. It should be clear that expc1·imenting with five different female flickers does not warrant a generalization about the woodpecker family, which contains at least two hundre.l Rpe~if's. '' ( :1) All experiments agn•e perfectly that if the normal clutch of eggs is, let us say six, and one egg is taken, no known bird on earth is aware of the loss of the egg. '' ( 4) The experiment performe
Bull., 1917, pp. 188-191."

In the literature thus far quoted we find no definite proof of a psychogenic influence on reproductive functions, and feel that those instances of possible Pxamples are only speculative in nature. Helene Deutsch 9 discusses the role of psychog-enic factors in the production of sterility and g·ives an excellent account of conflict patterns and personality types which one encounters in the psychoanalytic study of these patients. She states, howevt'J', that ''every form of psyehogenic sterility is only relative-that is to say, it can lw eliminated if the psychic conditions are ehanged (provided the organic situation permits), and that the same psychic factors may manifest themselves only in later phases of the reproductive function without disturbing its first phase, fecundation." She continues, "in general it can he said that the most frequent cause of (psychogenic) sterility is unconscious fear. This fear may relate not only to the reproductive function, but to everything sexual, thus eliminating any possibility of physical motherhood by exclusion of the sexual experience.'' Yet, ''seen as a functional disorder, psyehogenic sterility in woman is a very complicated and stuhhom phenomenon; its initial causr is usually difficult to discover, even though modern methods of investigation can find the disturbances in the hormonal messenger seT'Vice. Yet, strikingly enough, the symptom (sterility) frequently persists despite favorahle treatment of the hormonal defect, hec·ause, in our oninion. it contimlf>S to lw fNl hv nsvchic· f>llf>l'!.>'if>s." • Th~t -psychog~~i~ fact<;r~ ~~~~.Y-IXay ~n il~q;ortant part in other aspects of endocrine dysfunction, than failure of conception, also is possibly true. That freque11t anovulation \vith or 'vithout arnenorrhea. affects fertility is self~ evident. Benedek and Ruhenstein 10 have studied and summarized the correlation between psychodynamic processes and ovarian activity in general. Ripley and Papanieolaou11 studied how frequently menstrual disorders are encountered in the various psychoses and found a high percentage. Many cases of amenorrhea following nervous strain or fatigue are reported. Especially during World \Vat· II this was found to oecur in the wives of military men during periods of great anxiety. Thus one may for tht> moment aeeept the prevalent opinion that there E>xists a (1efinite connection hetween psychog·enie factors and endocrine dysfunction in the woman. But how the effect of psyehogenic factors is mediated is yet a matter of speculation. We believe that the rqually prevalent opinion that !H1optionmay relieve infet'tility is questionable.

Description of Study :1/ethodology.-Throug-h the aid of adoption agencies a study was made of 202 rouples who adopted, approximate]~' hetween 1938 and 19..J.R. The cases of adoption in the six to twelve months immediately preceding the surve~' were not included as it was felt that sufficient time had not elapsed since adoption to make evident its possible effect on fertility. The couples were approached l1y mrans of a questionnaire asking whethPJ' m· not they bad hacl ehii
K.

J.

B

--II.--

1 aborted

()

4

I

I

3

I

-±

~

I

Diaphragm yean; None

FTRTHER STUDY A~'TER

ADOPTlON

STERII,I'l'Y seavEvs BF:~'ORE

ADOPTION

.

I

CAl'SE m· PRESFMED INF'ERTILlTY

None

N()Wl

None

1

Juvenile uterus, anovulation ''."rnternal Wl'akness''

None

Tubal oedusion

N oi1e_____ _

/Nillio·----~/Oligospermia

None

None

Coinp!E>te______ IN orto--

--/Complete

None

Oophorocyste(··-------IPartial tomy, preadoption

!Partial

Yes

Very cornpletl' Yes, donor in-/Oligosperm ia Cauterization of ~emination cervix, preadoption

OPERA'l'JONS PR~:- AND POSTADOP'l'JON

l\hythm one year,--!None diaphragm, two

INunc

Diaphragm one B years year :l months Withdrawal one 2 children year 14 monthR, 26 months

4 years

13 months

2 aborted

9 months

(j

11

.

--1

~-. - - I

3

~

CONTRAmJP'l'IV f: PRACTICES

___ ,Douches araCr-ondom 1 year

TIME LAPSE BE~' WEEN ADOPTION AND PARTPRITION

years 5 inonths ~-----3 years B months ------3 years

12

2

5

EXPOSurm YEARS BEFORE ADOPTION

'fABLE

;.t

>,rj >,rj

C;;)

t:.ll """

'1-1""

""',....'t"'""

~

trJ

":j

~

0

z

0'""

'ij

Cl 0

>

0

>,rj

'""

0

trJ

trJ

w'n

,,

~ ~

::3 t:• o-3

316

HANSON AND ROCK

,\m.

J. Obst.

& Gynec. February, 1950

taken of the opportunity to discover what we could on the possible influence of adoption on some other aspects of reproductive physiology. Eighty-five of the 202 were studied by a more detailed questionnaire as to the etiology of their infertility. Of these eighty-five couples, eighteen wives were within the age group 20 to 29 years, sixty-three within the thirties, and four within the forties, with a high of 44 years. 'l'ABLE II REASONS GIVEN BY ADOPTIVE COVPLES AS TO CAUSE OF THEIR PREGNANCIES FOLLOWING ADOPTION

CASES

A.

B.

c.

D. E. F. G.

H. I. J.

K.

l<'urther infertility study and treatment after adoption (donor insemination) None ''Greatly increased love, unuerstanding, and appreciation of children since hav· ing them in our home.'' None None ''Release of mental strain. Prior to adoption, outside activities had exhausted , me [wife] mentally, was extremely run down.'' 1 ''Tension of wanting baby relieved by adoption-only matter then of pro· ducing ono of our own, once we had adopted and producing one no longer in our minds. '' 1 None None "We were very happy and probably more contenteu. I think that anxiety has a lot of influence in this matter. \Ve have now had two normal children I since adoption.'' ''Complete relaxation from the tensions caused by our great desire for a child.''

I I

Results.-Pregnanc ies were reported in fifteen cases out of 202. Eleven of these fifteen were studied as to the cause of the presumed infertility and how it was relieved. The result is given in Table I and discussed later. Table II in(·ludes those reasons given by the involved couples as to the cause of their pregnancies. Of the Hfi eases studied (including the aforementioned eleven cases from among those in whom pl'egnancy followed adoption), the following facts are of value. Seventy-four adopted because of childlessness alone, two because of a limited number of natural children already in the home, four because of neonatal deaths, three because conception was avoided due to the existence of constitutional disease in the wife, either renal or cardiac, which contraindicated pregnancy, and one because of psychologic disturbance diagnosed before fertility had been tested. 'l'hirty-five of the 85 couples reported pregnancies prior to adoption that failed to reach term. Sixty-five had had sterility surveys of varying completeness. Fifty-one of these sixty-five knew of apparent causes for their sterility. Table III lists these causes. Forty-five of the 85 submitted to operations in treatment of their infertility or of existing pathology. These included the common operative procedures such as tuboplasty, myomectomy, dilatation and rurettage, uterine suspension, and oophorocystectomy . Contraceptive practi(•es included all of the usual devices, the vaginal diaphragm being used in most instances, though only for a relatively short period of time. As evidenced most couples adopted well within the reproductive ages. Occupation seemed to have no effect on fertility in any instanee. Hollowing adoption, nineteen of the 85 eouples reported ehanges in menstr·uation, the most common change being loss of premenstrual and menstrual discomfort. 'fhe next most common ehange was in the length of the cycle, with two reporting change in the amount of flow during menses. One reported more regularity of menses of a twenty-eight-day type with slight pelvic pain and

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midmenstrual spotting on the fourteenth day, possibly denoting in this patient a beginning of ovulation, or at least, more regularity of ovulation. Twentytwo couples reported sexuality changes, mostly on the wife's part, the majority reporting less tension with intercourse, more ease of act, and more enjoyment. Tvvo reported less interest in intercourse, due to, as they describe, ce&sation of interest in having natural pregnancies. The remainder of the 85 reported "no change" in roth menstruation and sexuality, which is of no value in interpretation. TABLE

A. Male l. Oligospermia, orchitis 2. Oligospermia, 3. Azoospermia, 4. Azoospermia, testicles

III.

due to mumps unknown etiology unknown etiology
B. Female 1. Anovulation 2. Tubal occlusion 3. Tubal absence 4. Habitual abortion 5. Juvenile uteri 6. Absence of uterus and ovariPs, operative 7. Rh deaths of child 8. in all sisters of

CAUSES OF STERILITY

2 14 2

1

7

li

n

ti 6 6

C. Those with unknown eanses of :n sterility D. Constitutional diseases found in Male 13 Female il9 ineluding: 1. Hypothyroidism 2. Cardiac pathology 3. Renal pathology 4. Tuberculosis 5. Congenital hypoplasia of genital organs

1

1

Discussion Is adoption frequently followed by pregnancy? Fifteen, or 8 per cent, of the 202 adoptive parents achieved a subsequent pregnancy. This figure of 8 per c.-nt is not remarkable compared to statistical surveys in general, since ten per cent of spontaneous cures are to be expected. Therefore, we can say adop-· tion is not followed by normal pregnancy to any remarkable degree. One may ask, however: Can adoption in any of these fifteen he considere\l as effecting the sul:sequent pregnancy 1 Unfortunately we know details of sterility in only the 85 cases previously mentioned as having returned comprehensive questionnaires. Eleven of the fifteen pregnancies fall within these 8G. r~et us eliminate from the 85, six cases of bilateral salpingectomy, six of panhysterectomy, and three of azoospermia, a total of fifteen. Of the remaining seventy couples with potential fertility, eleven, or 15.7 per cent, reproduced. It is instructive to consider the available information in these eleven (Table I). Five couples had uncompleted pregnancies )wior to adO})tion. In two of these five there was oligospermia. There exists the very strong possibility that the pregnancies following adoption in these two cases were a matter of chance, not uncommonly encountered in oligospermia. The other three cases could possibly be explained on a similar basis. Whether or not psychogenic disturbances played a part is speculative. Possibly the adoption acting as a cure for psychogenic disturbances allowed in some way a pregnancy to be carried to term. We feel that even less possibly adoption acting again in the same way may have eliminated whatever disturbances existed which caused the oligospermia. Certainly, we have very little if any proof for these speculations. Spontaneous cures in habitual abortion and oligospermia without adoption are not rare. We feel that the burden of proof lies with psychogenic disturbances, since in these five cases adoption is not clearly the curative facto!'.

HAJ\:HON AND RO< :r.;:

Am. ].

Ob:~r. &

Gynec. February, 1950

One of the cases of infertility in this group was reportedly due to a uterus and anovulation. Here, again, we feel that chance plays a part ~inct:> JH'J·haps oYulation had always heen infrequent and only now after a short four-yem· exposure ]Wriod was conception possible regardless of adoption. '\.re could SIWculate again in this case that adoption in some way was reB]lom;ihle for more regular ovulation. It seems that there are many proponents of this theory from the literature reviewed here. We think the theory may he right, hnt we cannot proye it. 'J'he histnl'y most deal'!y suggesting a psychogenic factor involved in pregnancy following adoption would be one in which a long period of infertility existed en>ll though the hushand and wife had heen shown hy presfnt examination methods to have no defeets, alld adoption, only two were reporteithe1· menstnwtion or sexuality that might be considered effective in bringing ahout conception. No greater percentage of changes was reported in the group in which no Jll't'gnaJH'Y followed adoption than in the other group. There sf'<'lllS, in faet. to hf' no sig·nifieant physiologie factors on whieh this phenomPuon eoultl he explailwd. All this then perhaps suggests an underlying undetetted faetor w·hieh posfdhl)r 1na.3r have son1e bearing in psychoson1atic activity. \Ve have pointed out also four cases of pregnancy following adoption in which psyrhogenic faetors may have played a part judging from the evidence given. Most of the menstrua} and sexuality ehanges reported, of course, are psyr:hological hy definition. juv~?nile

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El'FECT OF ADOPTION ON FERTILITY

319

Summary and Conclusions The literature affirming the therapeutic effect of adoption on infertility is quoted and discussed. lt is all speculative and without proof. A survey of 202 aLloptive couples revealed subsequent pregnancy occurring in fifteen (8 per cent). Spontaneous cures of infertility without adoption are generally considered likely in ] 0 per cent. A more detailed study of 85 of the 202 couples was made. In fifteen of these the wife had been sterilized or the husband azoospermic. Eleven of the fifteen pregnancies, or 15.7 per cent, fell in the remaining group of seventy cases. One followed donor insemination because of oligospermia. There was oligospermia in two other cases. Isolated or widely separated pregnancies are not uncommonly achieved hy men with exceedingly low sperm concentration. ln two cases with oligospermia and in three others there had been abortions previous to adoption. Malpas 15 reporteLl successful delivery after three abortions as occurring in 27 per cent of such cases, and in 62 per cent after two abortions. Eastman 16 calculated successful delivery in 16.4 per cent of cases with three previous abortions, and a similar figure to that of Malpas in cases with two abortions. In these five instances then adoption seems not to he the definitive curative factor. Of the remaining five cases, in one there had been previous anovulation. That adoption relieved this condition is purely speculative, for spontaneous inexplicable ovulation often occurs in the habitually anovulatory female. In the residual four cases, adoption was followed by improvement in the wiff' of the emotional tone, and there is no other explanation for cure of infertility. These pregnancies also were conceived very closely following adoption. As these eontribute only 7 per eent of the seventy eases of potential fecundity, we believe they do not prove that adoption is a likely eure for sterility. Of 85 women, twenty-two (26.2 per cent) reported improvement in sexuality, and nineteen ( 22.6 per cent), more normal menstruation following adoption. The causal relationship is problematical. The authors gratefully acknowledge the invaluable aid given in this . research project by Miss Madeleine Hoagland of the Children's Friend Society of Boston and Miss Constance Rathbun of the Children's Aid Society of Boston. This study was aided by a grant from the Committee on Human Reproduction of the National Research Council.

References 1. Perkins, H. E.: Eugenical News 21: H5, l!J:lti. 2. Dunbar, H. F.: Emotions and Bodily Changes, ed. 2, New York, 1938, Columbia Um· versitv Press. 3. Orr, D. w.; Psychosom. Med. 3: 441, 1941. 4. Knight, R. P.: Bull. Menninger Clin. 5: 6, 1941. 5. Menninger, W.: Bull. Menninger Olin. 7: 15, 1943. 6. Robbins, L. L.: Bull. Menninger Olin. 7: 41, 1943. 7. Weiss, E.: Human Fertil. 10: 74, 1945. 8. Menninger, K.: Love Against Hate, ed. 1, New Yorl<, HJ42, Harcourt, Brace, and Company, Chap. 4, pp. 95-97.

HANSON AND ROCK

Am. ]. Obst. & Gyner. February, 1950

9. Deutsch, H.: Psychology of Women, ed. 1, New York, 1944, Grune and Stratton, Inc., Chap. 5. 10. Benedek, T., and Rubenstein, B. B.: Psychosom. Med. 1: 245, 1939. Benedek, T., and Rubenstein, B. B.: Psychosom. Med. 1: 461, 1939. 11. Ripley, H. S., and Papanicolaou, G. N.: Am . .T. Psychiat. 98: 567, 1942. 12. Sellheim, H.: Gemiitsverstimmungen der Fra:u. Eine Medizinisch-juristische Studie, Stuttgart, 1930, Ferdinand Enke. 13. Mohr, F.: · Psycho-physische Behandlungsmethoden, Leipzig, 1925, S. Hirzel. 14. Mayer, A.: Psychogen Storungen der Weiblichen Sexual funktion. In: Schwarz, 0.: Psychogenese und Psychotherapie Korperliche Rymptome, Wien, 1925, Julius Springer. 15. Malpas, P.: J. Ohst. & Gynaec. Brit. Emp. 45: 932, 1938. HJ. Eastman, N . .J.: Habitual Abortion, In Progress in Gynecology, edited by J. V. Meigs ancl R. H. Sturgis, New York, 1946, Grune and Rtratton, Inc., pp. 262-268.

Nizza, M.:

On the Ogino-Knaus Theory, Ginecologia 14: 92, 1948.

The author reviews the Ogino-Knaus theory which fixes the period of ovulation betv;·cen 16 and 12 days preceding the next menstrual period. Since the viability of the ~permatozoa is three days, the relative fertility of the female is placed between 16 and 9 c'iays before the next period. Reveral authors are cited who attempt to invalidate the Ogino-Knaus theory with reference to conceptions that have occurred out of the range of fertility as specified by Ogino and Knaus. One mechanism is supposed to be the release of the ovum in a nearly mature Graafian follicle following certain emotional factors. The present author attempts to discount these references after reviewing the menstrual cycle of several women and realizing that, in the event of conception outside the physiological range of fertility, there was a miscalculation. When shorter than twenty-e'i.ght day cycles were considered, the day of ovulation still fell within the period specified by Ogino-Knaus. The constaney of the ovulatory date must be based on its relationship to the beginning of the subsequent menses. Relative to the previous period there is no fixed relationship. In other words, in general, the luteal phase lasts from 16 to 12 days, whereas the duration of the proliferative phase is peculiar to the length of the cycle itself. 'l'hus the author correlates his conclusion with adequate basal temperature and also with the Farris method for determining the time of ovulation. FRANK A. GRACEFFO,