Defining the ‘Problem’: Perspectives on Infertility
Introduction: Defining the ‘Problem’: Perspectives on Infertility
Tracey Loughran and Gayle Davis
‘IT’S A GIRL’, shouted the headline of the Daily Express the morning after Louise Brown’s birth. On 27 July 1978, newspaper readers across Britain met the blinking, slightly quizzical gaze of a baby no more than a few hours old, and to all outward appearances exactly the same as thousands of other babies born across the land that day. Of course, appearances can be deceptive. As the first child born as a result of the technique of in vitro fertilization (IVF), at that moment Louise Brown was utterly unique in the history of humankind. The successful deployment of IVF has had manifold consequences, including an irrevocable shift in public debates on reproductive technology, the creation of a discourse of the ‘rights' of couples to biological parenthood, and new possibilities for the configuration of ‘the family' itself. Above all, IVF has made infertility socially visible, but in such a way that involuntary childlessness is now often perceived as inseparable from issues surrounding the development and use of assisted reproductive technologies (ARTs).1
This post-IVF conflation of infertility and ARTs is so ingrained in contemporary Western discourse that Margarete Sandelowski and Sheryl de Lacey have even claimed that infertility was ‘invented’ in 1978.2 This claim rests on some very fine distinctions. They argue that infertility is ‘a medically and socially liminal state in which affected persons hover between reproductive incapacity and capacity' because they believe that modern
T. Loughran (*)
School of History, Classics and Archaeology, University of Edinburgh, Edinburgh,
G. Davis, T. Loughran (eds.), The Palgrave Handbook of Infertility in History, DOI 10.1057/978-1-137-52080-7_2
medicine can eventually bypass ‘virtually any kind of biological or physical impediment to reproduction’. As such, Sandelowski and de Lacey view ‘infertility’ as different to ‘barrenness’, which connotes ‘a divine curse of biblical proportions’, and to ‘sterility’, which implies ‘an absolutely irreversible physical condition’.3
The etymological differences between these terms provide some, albeit limited, support for this claim. Although the English word ‘infertile’ dates from the sixteenth century, it seems that until the mid-twentieth century, it was more often applied to animal and plant than to human life. The Middle English word ‘barren’, on the other hand, was used to describe women incapable of bearing children before it was applied to trees or plants, and the late Middle English term ‘sterile’ and its derivatives seem to have been indiscriminately applied to women, animals, and plant life more or less from their first entry into the language.4 The definite preference for ‘infertility’ over other available terms is a late twentieth- century phenomenon, and it is difficult to disentangle this etymological history from that of IVF.
Yet the claim that infertility was ‘invented’ in 1978 is not only about language. It implies first that the experience of late twentieth or early twenty- first-century ‘infertility’ is qualitatively different to earlier experiences of ‘barrenness’ or ‘sterility’, and second that this difference resides in the indeterminate status of infertility as a condition that sufferers believe can be bypassed (if not cured) by medical intervention. This approach emphasizes ‘infertility’ as a medicalized state, in which the possibilities of reproductive technology keep sufferers suspended in a state of hope. Some scholars implicitly or explicitly accept this definition, but argue that the ‘medicalization of infertility’ began much earlier, whether in early nineteenth-century North America or in ancient Greece.5 However, there are many other potential objections to Sandelowski and de Lacey’s argument: that it privileges a medicalized definition of infertility; that it is Western-centric; and that while it posits a definitive shift in the experience of involuntary childlessness as the result of IVF, it is clear that there are important continuities in the experience of infertility in different historical periods and contemporary cultures (see Introduction for further discussion of these issues).
Nevertheless, this radical statement about the ‘invention’ of infertility should not be dismissed out of hand, even if we ultimately find it unconvincing. Sandelowski and de Lacey’s argument highlights the existence of multiple definitions and concepts of infertility and related terms, and how and why they might change over time. Crucially, it also opens our eyes to the manifold ways in which current concepts of involuntary childlessness are inevitably shaped by our own location in a post-IVF world. It forces us to engage with the implicit and explicit definitions that scholars of infertility adopt, how these definitions shape their approaches to the subject, and the challenges they face in attempting to unpick past and present understandings and experiences of involuntary childlessness.
There are no simple solutions to these thorny issues of definition and method. The chapters in this section explore the variety of ways in which infertility has been defined in different periods and contexts, and illustrate a range of possible scholarly approaches to the condition. Taken together, they invite readers to consider the extent to which the ‘biological’ category of infertility has always been mediated by social and cultural concerns; how initial definitions of infertility help to determine the findings of any study; how changing definitions have shaped the experiences of sufferers; and some of the practical difficulties in researching the history of infertility. These chapters therefore reflect on issues of perennial importance to the history of infertility, controversies which have not been resolved, and methodological problems which remain constant. Like the volume itself, this section is a sustained attempt to resist easy assumptions about ‘infertility’, and in this way to generate more complex and historicized understandings of involuntary childlessness.
The section opens with Sally Bishop Shigley’s moving meditation on different ‘stories’ about infertility, including her own. Shigley interweaves autobiography with medical, legal, and literary interpretations of infertility. She reflects on the consequences of defining infertility as disease and as disability, and how these definitions resonate (or do not) with the lived experience of infertility. Through examining a range of literary texts, including memoirs, chick-lit and comics, Shigley shows how prevalent modes of narrating stories about infertility can variously unsettle, reassure, or attempt to normalize certain aspects of the experience of infertility. Above all, she demonstrates how these ‘stories’ inflect the experience of infertile women, sometimes to reinforce stigma and self-blame, sometimes to delude with unrealistically neat happy endings, and sometimes to offer comfort through the identification of shared absurdities, indignities, and pain. Her chapter is not only a contribution to scholarly debates on infertility, but a story offering solace and strength to those who suffer now, and need to see how they might survive.
Laurence Totelin’s chapter moves us from the contemporary USA to ancient Greece and Rome, and from personal experience to plant infertility. Totelin shows that ancient medical texts often employed agricultural metaphors to describe human fertility, and then examines how Greek and Roman authors explained plant fertility. She argues that references to plants in medical texts were not only metaphorical. In fact, the ancients extended their conclusions about the causes ofsterility in plants to humans, and there are important similarities in their approaches to infertility in different forms of organic life. They perceived intervention by a human male and the active contribution of the female human/earth as essential to the ‘treatment’ of both human and plant infertility. This analysis of infertility provides new insight into how approaches to infertility were gendered in the ancient world, but even more importantly for our purposes, Totelin provokes radical new ways of thinking about how we might study human infertility by looking at the topic from the unexpected angle of ancient botany. As in Shigley’s chapter, Totelin’s approach and her findings underscore that modes of narration are not incidental to the formation of knowledge about infertility: metaphors and analogies reveal shared origins of understanding across different domains, and both reflect and shape mentalities.
Bridget Gurtler’s chapter picks up on many of the same themes, as she examines understandings and practices of artificial insemination in Britain, France, and the USA in the nineteenth and twentieth centuries. Before the cryopreservation of sperm became possible in the 1950s, eventually leading to the creation of commercial ‘sperm banks’, and especially in the pre-HIV era, artificial insemination was one of the simplest ‘treatments’ for infertility.6 It therefore has a much longer history than most of the treatments still in use in the Western world today. However, as Gurtler shows, shifts in the nomenclature of artificial insemination reflected important changes in the medical and social contexts of the practice. As the diverse vocabulary of ‘artificial fructification’, ‘artificial fertilization’, ‘artificial fecundation’, and ‘artificial impregnation’ (all terms common in the nineteenth century) gradually narrowed to the familiar language of ‘artificial insemination’ used today, medical science gradually established control of the procedure, and its practice became acceptable to shore up crumbling family structures. Alongside readings of medical texts, Gurtler draws on the possibilities offered by new digital technologies such as the Google N-Gram Viewer to analyse changing linguistic practices at the macro-level. This method provides an intriguing hint of one direction in which the histories of sexuality and reproduction might evolve as digital technology becomes more sophisticated, and historians more adept at exploiting it.7
From macro to micro: in the next chapter, Christina Benninghaus explores personal narratives and fictional accounts to illuminate the experience of infertility in nineteenth- and twentieth-century Germany, and to reflect on the challenges facing scholars of infertility. Benninghaus argues that the experience of infertility has left few traces on the historical record, and that this reflects the silences that surrounded infertility in earlier periods (and often still envelop the experience now). She explores the potential resonances of these silences, including the possibility that infertility was taboo or a stigmatized condition (ideas touched on in the previous chapters in this section, and which emerge elsewhere), but finally concludes that silence could be a valuable tool for couples as they sought to maintain their relationship, social status, and mental equilibrium in the face of severe difficulties. Benninghaus’s focus on ‘moments of communication’ reinforces the message of earlier chapters that language (or its absence) shapes experience, but also frankly confronts how historians, forced to rely on textual and material evidence to apprehend past lives, might creatively respond to the challenges posed by such absences in the sources.
The concluding chapter of the section, Angela Davis’s oral history of infertility in postwar England, brings together many of these themes. Davis again emphasizes the importance of certain kinds of narration, suggests ways in which (contemporary) historians might confront silences, and considers how definitions of infertility have affected its study. Davis originally conducted the interviews which form the source material for this chapter for a project on motherhood. All the women she interviewed had at least one child, and she did not set out to probe fertility problems. However, as women narrated their stories, they also revealed difficulties and disappointments in the journey to motherhood. The interview process had unintended outcomes, and generated the unexpected finding that secondary infertility and subfertility remain ‘hidden subjects’ in history. In their ethnographic research on contemporary Bulgaria, Irina Todorova and Tatyana Kotzeva reached similar conclusions about the need to broaden out definitions of infertility in order to fully understand how the condition is lived.8 As Davis argues, these women had difficulty telling their stories of subfertility because their experiences did not match stereotypical images of the infertile woman; we could perhaps go further, and say that historians, constrained by both their own expectations of what constitutes infertility and lack of attentiveness to the silences, gaps, and erasures in historical evidence, have failed to look for these stories.
Among historians, psychologists, social scientists, and clinicians alike, approaches to infertility often simultaneously invoke fierce dispute about what exactly is being studied and rest on unexamined assumptions.9 As Arthur L. Greil and Julia McQuillan found when they examined the unarticulated beliefs about intent and planning that lie behind the standard biomedical definition of infertility as ‘failure to achieve a successful pregnancy after 12 months or more of regular unprotected intercourse’,10 these unexamined assumptions often arise out of, and reinforce, positions of power.11 As this volume shows, throughout history infertile couples have shown determination and ingenuity in their active attempts to have children; but they have also, both before and after 1978, testified to intense feelings of powerlessness and despair. As historians, we are faced with limited, fragmentary, and often ambiguous evidence of past experiences of involuntary childlessness. If we are unable to look past the assumptions of our own cultures, our own times, then we unwittingly reinforce this powerlessness. This section shows that throughout past ages, individuals nevertheless brought their own understandings, shaped by manifold social, cultural and economic resources, to the experience of living with and attempting to overcome infertility. In doing so, it builds on existing research on the history of infertility, but also interrogates the assumptions of this research, and opens out new possibilities for future histories.
- 1. Naomi Pfeffer, The Stork and the Syringe: A Political History of Reproductive Medicine (Cambridge, 1993), pp. 27-8.
- 2. Margarete Sandelowski and Sheryl de Lacey, ‘The Uses of a “Disease”: Infertility as Rhetorical Vehicle’, in Marcia C. Inhorn and Frank van Balen (eds), Infertility Around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies (Berkeley, Los Angeles, CA, and London, 2002), pp. 34-5.
- 3. Sandelowski and de Lacey, ‘The Uses of a “Disease”’, pp. 34-5.
- 4. See entries for ‘barren’, ‘infertile’, ‘infertility’, ‘sterile’, and sterility’ in Oxford English Dictionary, 2nd edn (Oxford, 1989).
- 5. Margaret Marsh and Wanda Ronner, The Empty Cradle: Infertility in America from Colonial Times to the Present (Baltimore, MD, 1996), pp. 243-55; Rebecca Flemming, ‘The Invention of Infertility in the Classical Greek World: Medicine, Divinity, and Gender’, Bulletin of the History of Medicine, 87 (2013), pp. 567-8.
- 6. Donated semen must now be tested for HIV, which requires deep-freezing for the incubation period for HIV, thawing, and testing. This means that artificial insemination, if conducted via medical agencies rather than informal arrangements, is no longer a low-tech procedure. See Frank van Balen and Marcia C. Inhorn, ‘Introduction. Interpreting Infertility: A View from the Social Sciences’, in Marcia C. Inhorn and Frank van Balen (eds), Infertility around the Globe: New Thinking on Childlessness, Gender, and Reproductive Technologies (Berkeley, Los Angeles, CA, and London, 2002), p. 16. On the development of ‘sperm banks’, see Simone B. Novaes, ‘Semen Banking and Artificial Insemination by Donor in France: Social and Medical Discourse’, International Journal of Technology Assessment in Health Care, 2:2 (February 1986).
- 7. See Tim Hitchcock, ‘Confronting the Digital, or How Academic History Writing Lost the Plot’, Cultural and Social History, 10:1 (March 2013).
- 8. Irina L.G. Todorova and Tatyana Kotzeva, ‘Social Discourses, Women’s Resistive Voices: Facing Involuntary Childlessness in Bulgaria’, Women's Studies International Forum, 26:2 (2003), p. 144.
- 9. For an example of clinical debates, see J.D.F. Habbema, J. Collins, H. Leridon, J.L.H. Evers, B. Lunenfeld and E.R. teVelde, ‘Towards a Less Confusing Terminology in Reproductive Medicine: A Proposal’, Human Reproduction, 19 (2004); and C. Gnoth, E. Godehardt, P. Frank-Herrmann, K. Friol, Jurgen Tigges and G. Freundl, ‘Definition and Prevalence of Subfertility and Infertility’, Human Reproduction, 20:5 (2005).
- 10. American Society for Reproductive Medicine, ‘Definitions of Infertility and Recurrent Pregnancy Loss’, Fertility and Sterility, 90:5, Supplement (2008), p. S60. This definition has since been superseded. See American Society for
Reproductive Medicine, ‘Definitions of Infertility and Recurrent Pregnancy Loss: A Committee Opinion’, Fertility and Sterility, 99:1 (2013), p. 63.
11. Arthur L. Greil and Julia McQuillan, ‘“Trying” Times: Medicalization, Intent, and Ambiguity in the Definition of Infertility’, Medical Anthropology Quarterly, 24:2 (2010), pp. 140-1.