Doyle, Joseph B.

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The Linacre QuarterlyVolume 21 | Number 2 Article 35-1-1954The Role of the GynecologistJoseph B. DoyleFollow this and additional works at: https://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationDoyle, Joseph B. (1954) "The Role of the Gynecologist," The Linacre Quarterly: Vol. 21 : No. 2 , Article 3.Available at: https://epublications.marquette.edu/lnq/vol21/iss2/340 THE LINACRE QUARTERLY ============================-The Role of the Gynecologist JosEPH B. QonE, M.D. Director of Infertility Clinic, St. Elizabeth's Hospital Boston, Mass. 0NE of the most poignant problems of modern marriage is invc untary childlessness. One out of every six couples will not 1 e blessed with parenthood unless they avail themselves of tl � remarkable advances in recent years in the science of human reprodu, -tive physiology. God does not necessarily will permanent childlessness for any coupl, In His ordinary providence He usually helps those who help themselve Yet many of these heartsick young people, either through ignoranc, . inertia or false modesty. are reluctant to seek relief. Youth is the talii -man of fertility. Late marriage and delay in seeking fertility studies ha, resulted in a tragic loss of precious years of opportunity for many of ot, · people. It has been estimated that there are three million childle� ; couples in the United States. If they would persevere with medic.: t planning for parenthood, five hundred thousand of these couples woul, l · find their heart's desire.Due to an age old prejudice. it is usually the wife who seeks relie from the "curse of barrenness." Marriage infertility. however, is ; , mutual family problem. At the very first interview both partners shoulc be seen together, and it must be emphasized that often both partner may be at fault. Most infertility is relative. In almost fifty per cent o the cases the husband is in some measure at fault. At the time of th( first interview, this cardinal fact must be stressed-no one is to blame Male pride which often confuses infertility with impotence preventi many couples from even beginning fertility study. Understandably many Catholic husbands resent requests for semen samples, when thf request in non-Catholic clinics involves the use of masturbation or coitu, interruptus-methods which are contrary to the natural law. This i� perhaps one of the major reasons why every Catholic hospital shoul have its own fertility clinic. Since 1948 there has been available to husbands a method of semen sampling which reputable Catholic theolo­gians agree is entirely consonant with moral law and the teaching of the Church. The cervical spoon, a small plastic spoon, is inserted into the vagina beneath the cervix to act as a plastic lining for the vagina and an open receptacle for the seminal pool. It is removed thirty minutes ·after coitus, allowing ample time for much of the sperm to have passed natu-THE LINACRE QUARTERLY 41 rally to the cervix and its contents deposited in a small jar for transport to the laboratory for study. The study of fertility is a relatively new specialty. ( The First ·World Congress for the Study of Fertility was held in New York in May 1953.) The purpose of this symposium is to present the simple standard pro­cedures which constitute modern infertility studies. The general prac­titioner or the isolated gynecologist can conduct fertility studies. But there is no denying that the team work of the urologist, internist and psychiatrist working together with the gynecologist offers more produc­tive opportunity for effective results. It is an extravagant hope which expects a solution for the problem of marital infertility after one or two visits. The first and most important procedure is a careful complete history and physical examination of both partners with special attention to past history of mumps, appendicitis or venereal disease. Complete blood studies including the RH test, a's well as complete urine studies should then be done. The basal metabolic rate of each partner should be determined. Sub-clinical hypothyroid states often underlie relative infertility. The functional tests of human infertility can best be planned if one keeps in mind what is the precise biologic problem. It is this. There is a period in each month when the mature Graafian follicle will expel its liquor folliculi and float the egg down the side of the pelvis where if .tubal motility and patency are unimpaired one of the tubes will siphon it up and propel it toward the uterus. If coitus has been timely, sperms will have ascended through the mucus cascade, which exudes from the cervix at this time even though third degree retroversion of the uterus is present. A few sperms will have reached the distal end of the tubes. where one of their number will penetrate the ovum. If the endometrium has been properly prepared in response to ovarian hormones after a three day journey through the tubes the conceptus will nidate and develop. It is obvious that since we cannot know whether the ovum escapes nor in a given instance how it makes its way into the tubes, any data that help to determine even approximately the time of follicle· rupture is of cardinal importance. We have presented evidence that the ovarian cortex is the first hazard to the escape of the ovum, there being several hours of intrafollicular and perifollicular hemorrhage before the follicle exudes a small amount of liq�or. We have observed by culdotomy that the tubes may grasp the ovary but not necessarily precisely over the follicle itself and that in the majority of instances the egg is apparently aspirated from the sides of the pelvis or the cul-de-sac. We have corre-42 THE LlN ACRE_ QUARTERLY lated the relationship of actual· rupture of the follicle with the bas I thermal shift. In the three cases in which actual eruption of the follk ! was observed, it occurred at the lowest temperature of the month in t� ) cases, and on the day following the rise in the third case. A study of s; : recent corpora lutea, however, revealed that ovulation may have pn ceded the lowest temperature of the month by forty-eight hours .. Sine . Barton and Weisner in their large series of pregnancies achieved b · artificial insemination ·obtained no pregnancies beyond forty-eight hoUJ subsequent to the thermal shift, we may conclude that the thermal shif wh'.le a useful indication of the ovulatory phase of the cycle, is not nece, sanly an actual indication of rupture of the follicle itself. Hence, th basal morning temperature shift is the best concurrent index of th ovulatory phase of the. cycle. The recent work of Buxton in datin recent corpora lutea similarly indicates that there is a period of approxi mately five days-two days before and the day of the shift and tw• days subsequent to the shift-which more likely constitute� a span fert_ility phase. We have ourselves observed good temperature shifts i: patients whose ovarian biopsy specimens revealed pseudoluteinization o the follicle. Since fertilization may occur forty-eight hours after coitu b_ecau�e _of the_ known survival of sperm in the tubes for this length 0 t1�e, it 1s obvious that the determination of actual "conception time'will _always be an elusive thing. It is our considered opinion that it i•un:w1se to have patients timing coitus only on the day of the thermas�1ft. Much les� psychic tension will be aroused if patients are simpl) given a four to five day optimum fertility phase and told to exercise thei1 marital right during that period as frequently as they desire. It has been shown th�t too intensive anxiety can actually precipitate utero-tubal spasm which may either prevent conception or lead to tubal pregnancy. �aving determined as far as possible what constitutes the optimum fertility phase by observing basal temperature charts we now plan t e:'aluate the problem of sperm deposition and migration into the cervix smce the cervix mucus is much more profuse, watery and penetrable at the preovul.�t�ry phase. 1:?e study of this phase of the problem has beencalle� the S1ms-Huhner or post-coital cervical mucus test. It is our p�actICe to assay sperm migration by counting the number of sperm per h1g� . power fi�ld an� grading them one to four according to theirmo�1hty. In this fash10n a quantitative as well as a qualitative record wh�ch can be compared from month to month will give us, a time of opt1m�m s�erm penetration of the cervix. Cohen has shown that at ovulation time the sperm routinely survives for twenty-four to seventy­two hours within the cervical mucus. While this test is essentially a THE LINACRE QUARTERLY 43 "straggler" test, nevertheless, it gives us a rough index of the invading forces of sperms that have passed over the bridge of the cervical mucus. If normal coitus at the ovulatory phase results in the ob.servation of only three to five sperm within the cervical mucus, it is our practice to elimi­nate the possibility of sperm deposition defects by having the patient use the cervical spoon, which elevates the protected seminal pool to intimate contact with the cervical mucus and permits mass migration with minimal death of the sperms due to the acidity of the vagina. If the cervical mucus resists the sperm even under these circumstances, it is our practice to give small doses of estrogen ( 0.1 mg. diethylstilbestrol) for one or two months at the preovulatory phase, which will occasion­ally improve the quality and quantity of the mucus. If there is any evidence of infection we give preovulatory antibiotics. Our preference is terramycin in two gram doses daily for four days in the preovulatory phase. We have seen a number of patients achieve improved sperm counts within the cervical mucus as well as pregnancies after each of these types of treatment, particularly after terramycin .. But penetration of the cervix by sperm will not achieve pregnancy unless tubal patency at both uterine and fimbrial ends can be established. Sturgis has shown that even sp�rm invasion of the tube depends upon a?equate motility of the tubes. Freedom of motility of the tubes is quite as important as their patency if the ovum is to be aspirated from the I pelvis. Accordingly, the mere passage of air or carbon dioxide through the tubes does not suffice. Rubin has shown that kymographic tracings of tubal pressure variations will reveal evidence of spasm which may mimic occlusion. We prefer the Kidde apparatus which delivers only 100 cc. of CO2 through a cervical cannula under controlled pressure up to _200 mg. of mercury. Hence abdominal discomfort can be reduced to a minimum. Insufflations of air by old manual pressure methods resulted in. considerable distress. Moreover, the method itself was not infre­quently producing tubal spasm. Stallworthy of Oxford has shown in a study of a thousand cases by fluroscopy and the passage of an alcoholic radio-opaque medium that tubal occlusion was apparent i� twenty per cent, but was acutal in only thirteen per cen"t. This type of utero-tubal spasm can be relieved by transecting the utero-tubal nerve supply ( Frankenhauser' s plexus) which lies in, around and between the uterosacral ligaments across the top of the vagina. There remains the nidation problem to be studied. Where this defect is suspected ( e. g. in patients having late or profuse periods or who exhibit the problem of repeat abortion with a normal appearing fetus) 44 THE LINACRE QUARTERLY ============================-endometrial biopsies should be done, preferably on day one of the eye e. A prettier microscopic picture will be obtained in the premenstr• al phase, but unless the patient has been instructed not to attempt pre J­nancy that month it is best to wait until the first day of the cycle :o avoid interruption of a pregnancy. The endometrium offers an e ,d organ picture of the response of the tissues to both the pituitary a ,cl ovarian hormones, and is simpler and less expensive than extensi -·e hormone assays. The microscopic picture can be improved by the use )f estrogen and progesterone. We prefer O.I mg. stilbestrol daily throug t­out the cycle. When these agents fail, we must suspect failure of del i ·­ery of these hormones to the endometrium. Since the excellent work of the Smiths with stilbestrol in the preve .­tion of repeat abortion has been seriously challenged by Davis ai d Dieckmann's recent large series, we feel that there is a place for a m e physiologic approach. We have proposed the maximal delivery a: d utilization of the patient's own hormones by the surgical elimination ··if autonomic imbalance and vaso-spasm. A more stable blood_ flow w II deliver more hormones to the tissues. We feel . however, that the pr -cedure should be reserved for patients who abort normal fetuses ar :I have evidence of autonomic imbalance by kymographic demonstration , f utero-tubal pressures of high degree. To utilize the endogenous ho -mones of thEi patient in maximal amount by eliminating vasospasm ar :I improving endometrial circulation we suggest the simple procedure ( f paracervical uterine denervation, which can be done either per vagina .1 or at laparotomy. A series of seventeen patients who had this type c f denervation while under fertility studies conceived fourteen times an:! delivered thirteen live children during a two year study. (Jour. Fertiliiv & Sterility, Mar. 1954) These are the simple standard proc�dures which constitute the stu I of the female partner. If we will only till the barren ground, it will I:;� easier for the Author of life to plant the seed. THE LINACRE QUARTERLY 45 The Function of the Internist FRANCIS w. DRINAN, M.D. T HE function of the medical staff in �he op.eration of an InfertilityClinic is primarily to evaluate pat1errts m order to exclude all systemic disorders that may have a bearing on fertility. At times, a relatively simple examination may reveal abnormalities that are signifi­cant, but equally as likely is that exhaustive studies will fail to supply any explanation of infertility.-The causes and factors are many and varied. The internist's interest will be directed towards extra pelvic disorders bf an organic nature. In general, the search entails an evaluation of the general state of health, endocrine systems, toxic or traumatic factors and metabolic disorders. The relationship between general health and ovarian and testicular function has not been clearly defined, and is a source of considerable physiological speculation. General debility, malnutrition, hypoprotein­emia are well known factors th.at are associated with hypofunction of sexual organs. The mechanism of the hypofunction is not clearly under­stood, but most likely involves several factors, as cellular and enzyme activity, primarily hyaluronidase and glucuronidase and hormonal pro-. duction. No medical disease, excluding endocrine disorders, is inevitably associated with infertility. However, spreading tuberculosis, especially involving the Fallopian tubes, and decompensated liver disease are examples of conditions in which conception is unlikely. Endocrine dysfunctions make up the most likely medical reason for sterility. Several conditions that are almost invariably associated with decreased ovarian or testicular activity below the functioning threshold are: Froehlich syndrome, eunuchoidism, Simmond' s disease, arrheno­blastoma, masculinovoblastoma, Stein-Levinthal syndrome and struma ovarii. These situations are usually suspected and diagnosed after appropriate studies. There is a vast field of glandular disorders that may be significant in sexual gland function. Correction of thyroid defi­ciency commonly results in a return to normal of either the general state of health or hormonal balance requisite for pregnancy. In many cases, administration of thyroid to euthyroid patients has been followed by pregnancy in a couple that may have been barren for many years. Hypo­adrenalism is not per se .gufficient to depress the factors necessary for conception. However, Addison's disease is rarely seen in pregnancy. Cessation of cortisone therapy is known to be followed by a decrease 

The Role of the Gynecologist

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