Developing a National System: A Series of Failed Attempts?

In the interwar period, the pronatalist lobby integrated the issue of involuntary childlessness into its concerns, even if it still saw this issue as far less important than abortion. However, despite its intense activism during the 1930s, this lobby had little success in forcing the state to introduce public policies to address the problem of infertility. In this respect, 1937 was a turning point: following representations from the Alliance nationale contre la depopulation, the state authorities formulated for the first time the concept of an institutionalized national system. In December 1937, the Health Minister Marc Rucart (1893-1964) sent a circular to the prefects (state representatives) requiring them to ensure that at least one infertility consultation clinic was available in each French departement (an administrative unit between the region and the commune). The Minister also recommended the creation of a national centre for infertility research.33 He even went so far as to provide some public funding. Notably, this made it possible to equip the biology laboratory at the Ecole de puericulture’s infertility centre (part of the Faculte de medecine de Paris).34 After the war, this infertility centre, then headed by Professor Max Jayle (1913-78), was at the forefront of research in hormonology.

However, on the eve of the Second World War, these measures had made little impact on the supply of specialized and accessible services for the treatment of infertility. The official explanation for this failure referred to the shortage, except in Paris, of skilled professionals, rather than to limited financial resources.35 While the government had taken steps to intervene in infertility for the first time, it was neither willing to invest the resources necessary to achieve significant results, nor to acknowledge that further investment was necessary. It seems likely that lack of social demand also contributed to the problem. In 1936, Louis Devraigne proudly announced that he had been consulted by more than 3,000 women since 1925, but other physicians could not boast the same popularity.36 In Suresnes, Jean Dalsace only examined 129 patients in 1939, well below his target, despite the efforts of garden-city social workers in distributing leaflets in the streets to attract new patients to the consulting rooms.37 Among the women examined by Professor G. Cotte in Lyon between September and December 1938, in both his private practice and in his capacity as a hospital consultant, only 23 out of 44 women with ‘primary infertility’, and 5 out of 21 with ‘secondary infertility’, had initially consulted him because of problems in conceiving. Most had instead sought help for habitual gynaecological problems.38 These figures, although illustrative of trends in only a few practices, suggest that the French population still lagged behind the government in perceiving medical intervention as an appropriate or viable solution to the problem of involuntary childlessness.

This story, of official recognition of the problem coupled with failed attempts to resolve it, was repeated in the tumultuous years of the 1940s. Under the Vichy Regime, the pronatalist and eugenic Fondation pour l’etude des problemes humains tried to revive government interest and investment in infertility.39 Physicians and activists felt they could exploit the growing obsession with the ‘French race’.40 The Fondation, also known as the Alexis Carrel Institute after the Nobel Prize-winning biologist who acted as its ‘regent’, brought together physicians with specialist interests in infertility. These included Maurice Lacomme (1897-1986) at the Ecole de puericulture,

Jacques Varangot (1909-85) at the Hopital Port-Royal, Raoul Palmer (190485) at the Hopital Broca, and Louis Portes (1891-1950) at the Clinique Baudelocque. Jean Dalsace, for his part, was engaged in the Resistance.41 The research of the Fondation indicated that 8% of French couples were affected by involuntary childlessness, that 25% of these couples could be treated by appropriate means, and that such treatment might result in 8,000 to 10,000 additional births every year.42 To achieve this outcome, it suggested that it was necessary to open more infertility clinics, and to introduce specific training in the diagnosis and treatment of infertility through the Faculties of Medicine. The Fondation provided some funds for this enterprise, including contributions towards the laboratory of gynaecological physiology at the Hopital Broca, but this did not counteract the repressive spiral set in motion by the Vichy authorities’ policies of national regeneration.43 The dictatorial regime was less interested in measures to stimulate fertility among those unable to conceive than in publicizing its efforts in the fight against abortion, the most spectacular and least expensive sign of state involvement in the ‘preservation of the race’. Again, small steps towards investment in medical provision for the diagnosis and treatment of infertility were countered by official neglect and retrenchment.

This situation seemed on the brink of change in 1944 with the Liberation. Although it built on some existing provisions, the emblematic creation and institutionalization of the social security system (Securite sociale) offered new opportunities.44 Securite sociale increased the number of persons covered by health insurance, and encouraged the population to make use of the medical services on offer. At the same time, scientific progress (and especially the development of antibiotics) fuelled social trust in medical cure. Increased access to and use of medical services built on trends evident since the early 1940s. In 1941, the official mission of the public hospitals had been redefined as the provision of medical care instead of the ancient dispensation of charity. In other respects, however, the dismantling of the Vichy Regime meant significant shifts in the direction of policies related to medicine. After the Liberation, the coercive and repressive methods of eugenics, pronatalism, and the fight against abortion were less prevalent. Now, everything possible was done to connect medical actors and social professions. The institutionalization of Mother-and-Child Protection (Protection maternelle et infantile) joined together doctors, midwives, nurses, and social workers, and was supposed to provide support for parents and infants from conception to the first years of the child.45 Universal prenatal and postnatal consultations were available in each departement and, at least in theory, infertility consultations were also available at the same level. The state provision of gynaecological and obstetric care had reached a level never previously achieved in France.

From the mid-1940s, then, official support for the rational organization of reproductive medicine, including provision for the treatment of infertility, gathered pace as never before. In 1946, as an offshoot of the law on Mother- and-Child Protection, a ministerial decree established an official committee on infertility under the aegis of the Ministry of Public Health and Population. This brought together more than 30 participants, including all the most dominant physicians and campaigners for medical provision for the treatment of infertility. Rather than submerging the issue of infertility within one of the other numerous expert commissions created between 1944 and 1946, the government at least temporarily recognized the existence of involuntary childlessness as a specific social problem, and gave it relative visibility. In these favourable conditions, infertility specialists and public health administrators constructed an ambitious and elaborate vision of the future of medical provision for the diagnosis and treatment of infertility, including comprehensive territorial coverage and a solid research infrastructure, structured by multiscale coordination.

Although it is unclear whether the political decisionmakers genuinely intended to implement an actual and consistent public policy on infertility, the medical infertility specialists did not miss the opportunity to express their will. The intervention of one Health Inspector nicely summarizes the ‘Jacobin’ spirit of this brainstorming: he proposed ‘to take a map of France, to identify the main [infertility] centres’ and to determine which geographic zone was ‘under their authority’.46 The medical specialists on the committee imagined a detailed plan of infrastructure development on a national scale, even if this continued the traditional privileging of the Parisian region.47 This plan set out arrangements for a hierarchical network of medical centres and consulting clinics, developed out of existing structures, and involving division of labour between different institutions, more methodical distribution of patients, standardization of protocols and observations, and even the centralization of bibliographic resources. At the apex of this hierarchy were ‘top-level’ centres, which were not ordinary infertility clinics but specialized units containing high-tech laboratories for diagnosis and research.48 This comprehensive plan promised to bring together clinical practice and scientific research at the local, regional, and national levels.

Perhaps most importantly for our purposes, the plan produced by medical specialists on the 1946 committee reflects the strength of the biomedical, and to some extent industrial, approach to reproductive problems. For instance, Professor Max Jayle suggested carrying out mass examinations to increase efficiency. As this ruthlessly rational approach to an intensely sensitive medical issue indicates, doctors were aware that their creative ideas had significant financial implications. The functioning of these laboratories in ‘top-level’ centres would require personnel, new instruments and expensive chemical pro- ducts.49 To carry out standardized hormone tests, huge stocks of animals such as rats, mice, and rabbits would be required; according to a reporter, the cost of these laboratory animals would be equivalent to one-third of the payroll budget for the laboratories.50 It was suggested that medical consultations could be financed by a partnership between the Ministry of Health, the departements, the local hospital administrations, and the national health insurance fund. But this still left the question of funding for research activities unresolved. Should the infertility centres be attached to institutions like the Centre national de la recherche scientifique, the Institut national d’hygiene or the Institut national d’etudes demographiques, or should they operate on a relatively autonomous basis?51 These questions were never settled.

The year 1946 was an important moment in the history of government interest in infertility, but ultimately the committee had little influence on policy. In the end, the public health authorities decided to do no more than attempt to satisfy existing demand. They made no effort to expand the number of centres or potential patients. A report published in 1958 concluded that ‘the important material needs’ of the 16 infertility centres in Paris and the 15 centres in provincial main towns meant that further centres were ‘not necessary’, even though it later became clear that distance from these centres was an important deterrent to those seeking help for infertility.52 Nor was there much support for teaching or research in the physiology or epidemiology of reproduction: in 1950, Raoul Palmer complained that his unit in the Hopital Broca had not received any research credit for three years.53 In part, the failure of the authorities to heed the calls of infertility specialists for further resources might be attributed to the undertones of some of their demands, which were increasingly out of step with mainstream attitudes towards state intervention in reproduction. As an example, in 1970, Jean Dalsace called for reform in premarital examination. Since 1942, this test had been required by law, with the results of the examination disclosed to the individual but not their future spouse: Dalsace denounced the fact that only syphilis and tuberculosis were detected in existing examinations, and that the doctor was unable to forbid marriage. He proposed instead that doctors should be required to check the quality of sperm and the regularity of menses before every legal union, to ensure that fecundity would follow.54

In all, public interventions in the fight against infertility remained very limited up to the 1970s. Indeed, until 1978 even health insurance funding coverage for infertility treatments remained limited, with full reimbursement for costs not available.55 Why, then, did provision for the diagnosis and treatment of infertility remain situated primarily in the arena of private medicine? It seems likely that the preferences of practitioners and patients converged to produce this result. On one hand, it is likely that many private practitioners had a personal or business interest in developing their own infertility clinics rather than contributing to a public service that was not unanimously approved by the profession. On the other hand, patients had various reasons to prefer private practices: shorter waiting times, the possibility of bargaining over treatment (notably to obtain artificial insemination without undergoing multiple examinations), and, overall, greater privacy, discretion, and choice about what would happen to them.

The entrenchment of medical therapies for infertility in the private sphere had several consequences for researchers, practitioners, and patients alike. At the level of research and clinical practice, testing remained largely in the hands of private laboratories, and reproductive medicine remained largely in the domain of scholarship and professional associations such as the Societe fran^aise de gynecologie, the Association pour le developpement de la lutte contre la sterilite involontaire (linked to the Ecole de puericulture and the Fondation de recherche en hormonologie) and the Societe nationale pour l’etude de la sterilite et de la fecondite, founded in the early 1950s by Jean Dalsace. The latter organization worked hand in hand with the Mouvement fran^ais pour le planning familial, and became the central hub of the professional network of fertility and infertility physicians, connecting all the different clinical and biological specialities involved in the diagnosis and treatment of infertility.

The development of medical treatments for infertility on the margins of the public health care system also underlines the consequences of the absence of a strict regulatory framework. Although physicians complained about the scarcity of resources at their disposal, they also profited from a tolerant legal framework which they viewed as an asset for scientific innovation. Many private practitioners probably made all kinds of arrangements with their patients, including clandestine treatments with donor sperm, as caricatured in Guy des Cars’s 1973 novel Le donneur.56 From the early 1970s, the first banks for cryopre- served sperm were established as private associations, although based in public hospitals. The main organization, the Centre pour l’etude et la conservation des reufs humains et du sperme, created by Dr Georges David (b. 1923), was founded on strict principles of free access, volunteerism, and anonymity, but is nevertheless a good example of how doctors capitalized on the administrative flexibility and the scope for ethical pragmatism offered by lax legal controls. Only gradually did professionals start pressing for a stronger legal framework, both to harmonize the practices of the different centres and to encourage stricter bioethical regulation. These demands became more insistent when in vitro fertilization, and later preimplantation genetic diagnosis, was introduced to France in the 1980s.57 As in other countries, this dramatic change in reproductive technology changed the landscape of medical treatments for infertility completely.

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