Sex, Science, Society, and Reproduction

"The Pill" that changed America

Barry Verkauf

• Publisher: Palmetto Publishing Group
• Year: 2020
• eBook ISBN: 9781649900364
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

We all tend to get involved in our work, put our noses down, try to do it diligently, and are sometimes not aware of what is happening around us. Often what is happening around us influences our work, and clearly our work sometimes influences what is happening around us. By reviewing the history of contraception and its inverse--infertility, appreciating recent advances in them and potential future ones, and by gaining heightened awareness of societal changes as they relate to family, work, economics, and reproduction which have occurred over the last 50 years, we will understand that though science and society have their own determinants of change, they can intermediate and impact each other. This book describes an example of this. Sex is at the center of it all.

CHAPTER 1

THE BEGINNINGS

Sixty years ago, talking about sex in mixed company was simply not acceptable, but sex is everywhere today! It is on TV, it is in movies, and it is in much of our discourse; however, I was a little bit surprised when I went downtown to the Straz Performing Arts Center recently in Tampa, FL and saw this advertisement for the next opera, Romeo and Juliet.

(FIG 1)

I then opened the South Tampa News and noticed the advertisement for a new plastic surgeon moving into town. (FIG 2)

(FIG 2)

Not that I don't think sex is important! For most people sex is highly enjoyable and it is certainly a way of expressing intimacy and meaningfulness to another person. However, probably its' greatest significance on earth has to do with reproducing our species. We really do not know exactly how life on earth began. There is no unanimity of opinion about that. Those who are religious accept the creationist view, the Biblical view, where God created animals and Man from dust in the Garden of Eden. Apparently, Adam was not satisfied so God created Eve out of Adam's rib. He made Eve to look like Adam except for certain differences between them, which you are aware of in those areas which came to be known as reproductive organs! ¹ In the Bible it says that God told Adam and Eve to be “fruitful and multiply and replenish the earth”. I am not certain whether God gave them a handbook or they figured it out on their own, but they did as God directed.²

During the Age of the Enlightenment, people started taking a different view of how life evolved. Charles Darwin was not the first to think about it, but in 1859 in his book “On the Origin of Species”³, he published his observations and codified the fact that it seemed one species evolved from another. He suggested that the changes which occurred in each species were adaptations to the environment and necessary to endure changes which were occurring in the world or in the region of that species. Thus, we have the phrase the “survival of the fittest” and natural selection in science has come to be the accepted way by which life evolved on earth, probably from a single cell made up of substances which are unknown from which all other species over the millennia have evolved. Shortly before Darwin published his book in 1859, Gregor Mendel, a priest who was a botanist as well as having some training as a physician, started dealing with reproduction in peas. From observations he made in the way peas transmitted one characteristic from one generation to another, he hypothesized what has become known as Mendelian genetics.⁴ Though first identified in the 1880s in lower species as vectors of heredity, in 1923 chromosomes were microscopically visualized in humans, marked as 48 in number incorrectly - later shown to be 46. In 1953 Watson and Crick identified the structure of DNA from which chromosomes are constructed for which they subsequently received the Nobel Prize.⁵ We know now in modern science that chromosomes are made up of genes which are of great biologic significance, and it appears that genetics, genomics and related fields may become the dominant specialties in Medicine in the future.

From a societal point of view, reproduction has always been very important. As Man evolved into an agrarian society from the “hunter/gatherer” phase, people organized and worked collectively in the fields and for other purposes. Occasionally they needed to provide armies to protect their properties and to fight other developing societies on earth who might want to overtake them. Thus, adequate reproduction was important to them, but in former times it was inefficient. Until recently women often died in childbirth as did many newborns. Many children did not live to adulthood. Infectious diseases killed many people as did warfare. The average lifespan even in 1900 was only 47 years of age.

In Biblical times having children was considered to be a gift from God. There is reference in Genesis of Abraham and Sarah being unable to have children. It was suggested that because they were both old in their late 80s, that Abraham have sex with Sarah's handmaiden, which he did, and they had a child.⁶ That may have been the first instance of surrogacy in history, but 3 years later Sarah apparently conceived spontaneously at age 90!⁷,⁸ To my knowledge, in modern times, the oldest woman who has given birth to a baby was at the age of 66. Even the ancient Egyptians had a goddess, Nephthys, who was the goddess of infertility to whom they prayed. In Grecian times despite the presence of the goddess of fertility Aphrodite, Hippocrates started applying rational thinking to the process of reproduction but he did not make much headway. In Roman times, once again the gods were important regarding fertility. There was very little respect for infertile women; the inability to bear children was grounds for divorce. You were not treated very well if you were an infertile woman in Roman times. In medieval times, infertility was thought to be a consequence of the actions of witches and devils. Sometimes infertile women were even considered to be witches. The woman was always seen as the problem and, thus, they were sometimes asked to drink urine from pregnant animals! Religious connotations were associated with the issue of infertility. It was sometimes thought to be punishment for sins committed by either partner.⁹

CHAPTER 2

CONTRACEPTION - ITS EVOLUTION

Reproduction has always been key to every society on earth for all of history to this point in time. Despite societal needs, preventing pregnancy on occasion has been important to individuals throughout history.¹ The earliest methods of preventing pregnancy, abstinence and withdrawal, are still intermittently used and relatively useful. Another method in the past to space children was continued lactation which prevented ovulation and simultaneously prevented additional pregnancies. In the Middle Ages, the average age for menarche (and thus opportunity to conceive) was probably around 20 years of age, but by 1940 that had dropped to age 14 and today is about 12.5 years. This change occurred for a variety of reasons, including improved nutrition and other societal advances, but it also accompanied changing views about virginity, marriage, and sex, and heightened the need for adequate contraception.

Throughout history various roots and plants were used for contraception some of which apparently did have some effectiveness. Barrier methods of contraception have been known since prehistoric times. The earliest known illustration of a man using a condom is painted on the wall of a cave in France from approximately 15,000 years ago. Various materials were used for this purpose over time and rubber condoms began to be mass-produced in the mid-1800s. In the early part of the 20th century, the condom was the most commonly prescribed method of birth control. Throughout history women have used a variety of substances intravaginally such as seaweed or moss to absorb semen and block its entry into the uterus. A contraceptive sponge was introduced into the American market in 1983. It was withdrawn in 1995 then reintroduced this century. Another was introduced in 2005 as the Today Sponge. Contraceptive foams, creams, and jellies also date back to ancient times and led to similar products today. They ultimately led to the introduction of diaphragms and cervical caps which were principally marketed to married women in the mid-1800s. In the 1870s the Comstock laws were enacted by Congress to suppress the dissemination of contraceptive devices and was not completely repealed until 1971! By the early 1940s most doctors recommended the diaphragm as the most effective method of contraception. Diaphragms continue to be widely available and used for contraception but U.S. companies no longer produce cervical caps.

By the 1960s, post World War II, a population explosion with perceived serious long-term risks to Society from overpopulation on Earth was becoming an Academic and Societal concern.² Interest in elective contraception heightened. Barrier methods of contraception fell into disfavor after the introduction of the birth control pill in the United States in the very late 1950s. Initially developed for treatment of female disorders such as dysmenorrhea and menstrual irregularity, “the Pill” was found to be an effective contraceptive and was approved for use as such in 1960.³ Hormonal contraception evolved as a consequence principally of the efforts of Margaret Sanger and Planned Parenthood Federation of America supporting the efforts of Gregory Pincus at the Worcester Foundation for Experimental Biology and the clinical trials led by John Rock, a prominent Harvard gynecologist. The first birth control pill, Enovid, was manufactured by G.D. Searle and was made from progestins extracted from yams and estrogens first synthesized by chemical companies in the 1930s and 1940s. The birth control pill more effectively and efficiently enabled women to take charge of their reproductive planning. Along with the second wave of the feminist movements happening concurrently, it increased their sexual freedom and autonomy (and the incidence of sexually transmitted diseases) during and subsequent to the time of the “Sexual Revolution” of the 1960s and 1970s. Dr. Ruth burst onto the radio waves with her program “Sexually Speaking” in the 1980s! Remember” Sex and the City,” the toast of television in the 1990s?

Though a landmark scientific advance, the combined hormonal contraceptive pill required the need to remember to take it every day. Depo-Provera was approved in 1972 as a long acting injectable progestational contraceptive which only needed to be given every 3 months. While avoiding the necessity of taking the pill daily, it did require an injection at office visits and was not widely embraced by women.

A subdermal implant of a progestin, Norplant, was approved in 1993 as an effective and reversible long-term method of contraception. Norplant's use was time-consuming, both upon insertion as well as removal and was not well received by either patients or physicians. It was removed from the market in 2002. Implanon, a single rod progestin subdermal implant using etonogestrel, effective for up to 3 years, became available in 2006 as a long-term method of female contraception and was easier to insert and remove. Subsequently, Nexplanon, which is radiopaque, became the only available implant in 2011 and has action of longer duration.

Hormonal contraception took most of the headlines in the mid part of the 20th century but intrauterine devices (IUD), which required only a single insertion and might have protracted use, were also being investigated. The early IUDs were associated with intrauterine infection but in the late 1920s, Ernst Grafenberg in Germany introduced the Grafenberg ring, an IUD that was widely distributed particularly in Europe. It was reasonably successful because it eliminated the IUD string which could introduce bacteria into the uterus. In 1964, the Lippes loop (Figure 3) was introduced in America and was an instantaneous success, followed shortly by the Dalkon Shield (Figure 4).⁴

(FIG 3)

(FIG 4)

The IUD fell into disrepute in the 1970s as a consequence of introduction of the Dalkon Shield which had extensions on each side meant to prevent expulsion but made insertion and removal somewhat painful. The string on the Dalkon Shield was made of a porous material that also introduced bacteria into the uterus and was associated with the same frequent infections that had plagued the early devices. The Dalkon Shield was removed from production in 1974.

Despite availability somewhat later of other and much safer monofilament IUD's such as the Copper T, IUD's generally remained in disfavor in the U.S. until relatively recently. Currently six IUD's are marketed in the U.S. Five of them, starting with Mirena, approved in 2000, utilize a small dose of levonorgestrel in the uterus and are effective for up to 5 years. The copper-containing IUD Paragard is effective for up to 10 years.

Two other aspects of contraception deserve mention. All methods discussed so far are reversible and temporary, but permanent methods of contraception which are effective and instituted with relative ease are currently available. At the beginning of the 20th century, vasectomy began to be used for birth control. Increasing numbers of men volunteered for vasectomies in the 1960s and 1970s because it was less complicated and less expensive than sterilization for women, which at that time was usually done by laparotomy, an open surgical procedure. By the early 1970s, 3/4 of a million American men a yea...

Table of contents

• COVER
• TITLE
• COPYRIGHT
• CONTENTS
• FOREWORD
• INTRODUCTION
• CHAPTER 1 THE BEGINNINGS
• CHAPTER 2 CONTRACEPTION - ITS EVOLUTION
• CHAPTER 3 SOCIETAL CHANGE: 1960-2000
• CHAPTER 4 SOCIETAL CHANGE: 2000-PRESENT
• CHAPTER 5 WHAT NOW?
• CHAPTER 6 THE EVALUATION FOR INFERTILITY
• CHAPTER 7 BASIC TREATMENT FOR INFERTILITY
• CHAPTER 8 IN-VITRO FERTILIZATION
• CHAPTER 9 ART: THE ASSISTED REPRODUCTIVE TECHNOLOGIES
• CHAPTER 10 RECENT ADVANCES IN ART
• CHAPTER 11 A COSTLY ENTERPRISE
• CHAPTER 12 THE FUTURE???
• DEFINITIONS
• FIGURES
• REFERENCES