INTRODUCTION TO INFERTILITY
Not everyone has the goal of becoming a parent, but for those who do, being unable to conceive a child is an exquisitely painful reality. Many of us spend a portion of our lives attempting to avoid unplanned pregnancies, and assume that once we are ready to conceive, it will happen with little difficulty. We tend to think that shifting gears from preventing pregnancy to planning conception and childbirth will proceed in a relatively smooth and orderly fashion. A failure to conceive, then, is a major life stressor, which can wreak havoc on otherwise well-adjusted couples.
Even in today's society, we tend to assume that individuals in committed relationships have the goal of procreation. Women are often identified with their ability to give birth. Both men and women are supposed to pass on their genetic and generational legacies. Failure by either party to "fulfil their end of the bargain" can be devastating, humiliating, and emotionally destructive. The continuing taboo against discussing the subject of infertility compounds these reactions. Even though tremendous strides have been made in treating this relatively common condition, infertility is typically not openly discussed.
Infertility is typically defined as the inability to become pregnant after one year of sexual intercourse without contraception. For women over age 35, this condition is diagnosed after 6 months of an inability to conceive. Using this threshold, there will be women, albeit a minority, who meet the criteria for "infertility" but who go on to conceive without medical intervention. However, this definition is used to ensure that people who are experiencing problems that can be remedied will seek timely medical intervention.
Having trouble conceiving is more common that you might think. Despite what we were taught in our sex education classes in school (if any such class was offered), in any given month a typical couple has a 20% chance of conceiving. In a lifetime, 10-15% of couples will experience infertility. This number jumps to 33% in couples with a woman is over 35 years of age. In about 45% of cases there is a male-origin for the infertility, female-origin infertility accounts for 30% of cases, and 20% of the time both partners are the source of difficulties.
BACKGROUND OF THE STUDY
Infertility has been a major medical and social preoccupation since the dawn of human existence and women have always been the symbol of fertility. Since antiquity, couples have been prolific and difficulty with conception was a real problem. In Egyptian society, women were equal to men, and difficulty with conception was not considered divine punishment but an illness that had to be diagnosed and treated. As far back as 1900 BC, there are recorded documents discussing the treatment of gynecologic disorders. Although the Egyptian's understanding of anatomy was somewhat sketchy, there are references to the female reproductive tract (Lefebvre, 1952), and sperm were considered to originate in the bones (Sauneron, 1960). Medicine was permeated with magic; physicians were priests to the goddess Sekmet, who was responsible for disease. Thus the gods played a fundamental role in treatment of childbirth (Morice, 1992). Infertile women had their own infertile goddess, Nephtys. Male infertility was also discussed in Egyptian records. Since it was important to tell if a women was fertile or not, the Egyptians developed elaborate methods of diagnosis. Examinations were based on the concept that the genital organs were in continuity with the rest of the body and, in particular, with the digestive system. This way of thinking remained in place for hundreds of years and was adopted by Hippocrates and many medieval physicians (Labat, 1951). Concubine figures of naked women in bed with a baby lying next to them in the fetal position is more proof of the Egyptian's interest in infertility (Baines, 1986). These figurines, found in the tombs of women, were hoped to at least insure their fertility in the next world; and for men, the figurines were to guarantee their sexual potency after death. Although, Egyptian medicine probably had very little successful treatments for infertility, it does show a very real preoccupation they had for femininity and womanhood.
One of the main sources of knowledge concerning Jewish medicine in ancient times is the Bible. The notion of original sin predominated and women had very few rights or liberties. “Be fruitful, and multiply, and replenish the earth” was the command from God to Adam and Eve at the beginning of the Book of Genesis. In this context it can be understood that infertility would be a divine curse, and in a time where male infertility was unrecognized. In the Book of Genesis, when Jacob is angry with his wife Rachel, he went as far as saying: “Am I in God's stead, who hath withheld from thee the fruit of the womb?” But pregnancy is above all a gift from God. Eve says: “I have gotten a man from the Lord”. Thus children were desired and conceived by the will of God and consecrated to be His servants.
Western medicine finds its primary sources in Greece. But the real change came with Hippocrates and his school. Born in 460 BC, Hippocrates wanted to break away from the way medicine of the time was practiced, which was closer to magic, and develop a system of medical reasoning based on rational thinking. Infertility was recognized as a medical problem which needed diagnosis and treatment and women were not subject to exclusion because of it. Hippocrates was well aware of the problems of infertility and theorized a number of causes for it and had formulated numerous treatment options.
“When a cervix is closed too tightly the inner orifice must be opened using a special mixture of red nitre, cumin, resin and honey. Or it could be dilated by inserting a hollow leaden probe into the uterus enabling emollient substances to be poured in”. Despite these “advances”, women in Greek times, were considered as a “chastised male”, an inferior creature. The uterus was considered an irrational soul and to be at the origin of all sorts of ills. Aristotle and Plato both thought that a woman emits a substance during coitus, necessary for fertilization.
The roles of the gods were just as important during the Roman era. During the feast for Mars, the priests to this god would run through the city whipping the bellies of infertile women with a goatskin whip. Many Roman physicians believed that conception took place right after menstruation. The period prior to menstruation was infertile because the uterus was “overloaded”. Galien (130-200 AD), believed that the phases of the moon had an effect on the feminine cycle. There were little advancements in the treatment of infertility during Roman times.
The Byzantine and the Middle Ages also made little progress in the diagnosis and treatment of infertility and the next major advances would have to wait for the Renaissance and discoveries in anatomy for any real breakthroughs to occur. During the Middle Ages, however, it was understood that procreation was a necessity and important to the “continuation of the species”. It was not considered a reason for annulling a marriage. If a couple's sole reason for sexual intercourse was not for procreation, their fertility would be decreased. Infertility could also be the consequence of sins committed; infidelity, and blasphemy could also give rise to infertility. Fertility might be regained with prayer and fasting. Infertility, the mark of divine punishment, was a real fear during the Middle Ages.
The Renaissance marks the period of undeniable scientific progress and advancements in modern day thinking and treatment of infertility. Thanks to da Vince and others, the mysteries of the female body were gradually resolved and scientific thinking and reasoning replaced magic and the gods. In 1562, Bartolomeo recommended that husbands should put their finger in the vagina after intercourse to encourage conception. This was the ancestor of the idea of artificial insemination. De Graaf (1672), refuted Aristotle's theories of fertilization, and described the ovary and follicular function. Sperm was first identified under the microscope by von Leeuwenhoek in 1677. In 1752, Smellie was the first to carry out experiments and describe the fertilization process. Despite the progress that was made during these times, infertility was almost synonymous with the female; and it was rare that the husband was considered as a cause. Even during this age of enlightenment, a real ambiguity existed. Women became the source of continual interest but were considered weak and sensitive and thus unfit to have anything to do with public and professional life; thus they were made to live indoors, to lead a dependent and subjugated life. Although progress was being made in the origins of infertility, because of a woman's apparent fragility, she automatically was at fault when the couple was infertile.
The nineteenth and twentieth centuries were marked by tremendous advances in the diagnosis and treatment of infertility. In 1898, fertilization was described as the union of a egg and a sperm. 80 years later, in 1978, the first “test-tube” baby was born in England and in 1981; her in-vitro sister was born. You know the rest of the story. The first IVF baby born in the US was in 1981, pioneered by fertility specialists at Eastern Virginia Medical School in Norfolk, Virginia. Since those early days, a little more than 25 years ago, tremendous progress has been made in the understanding, diagnosis and successful treatment of so many of the causes of infertility. And step by slow step, infertile women have come to be considered patients in her own right, instead of a curiosity and condemned member of the human society, living in silence and misunderstanding; no longer being considered witches and burned at the stake, but replaced as the center of medical and scientific attention, and possibly lying at the very source of all human survival. Just imagine where we will be by the next 25-50 years.