1 Hypnosis: An Additional Tool in the Study of Infertility Ralph V. August, M.D. THE LAST DECADE has seen a number of good papers dealing with the psychosomatic aspects of infertility. 5 6 For the purposes of this presentation we wish to assume that infertility may have an emotional background and that it has an emotional impact on both partners. Similarly, fertility-and what might be termed excessive or unwanted fertility-may also have an emotional impactsometimes undesirable-on both husband and wife. We must always remember that infertility may result from organic or functional causes-or both. We should never credit one causative factor because we have failed to find another. I was among those privileged to hear de Watteville 3 discuss the "psychologic factors in the treatment of sterility" before this Society several years ago. He said: "Summing up, we may state that psychic troubles are capable of causing manifest functional disorders of the genital organs in men and women which lead to sterility." Further, he stated: "We can assume that there are other still unknown ways by which psychic troubles may modify the normal function of genital organs and prevent conception." He agrees with Marsh and Vollmer 7 that the care of such problems may be accepted by the general physician and that those patients requiring deep psychotherapy should be referred to a psychiatrist. Sturgis et al., 10 in discussing infertility studies, state that "the threat of psychiatry will be insurmountable for some." I have made these basic premises. 1. Infertility may involve functional as well as organic factors. This paper was presented at the Fifteenth Annual Meeting of the American Society for the Study of Sterility, Atlantic City, N. J., April 3-5,
2 Vo1.11, No.1, 1960 HYPNOSIS IN STUDY OF INFERTILITY We should never accredit one cause because we found no other. 3. The physician in charge may accept responsibility for investigation and for therapy. I agree with the generally accepted routine of, in order, interviewing both partners, checking the male's semen, examining the male, and making a complete examination of the female, together with appropriate laboratory procedures on both partners. The first interview is the time to advise the couple on the desirable routine. If time permits, psychological factors should be elicited from both partners. Usually, we find this to be more practical after determination of the adequacy of the semen specimen. We make this determination ourselves or have a urologist do it, and if the sperm is inadequate we refer the couple to the urologist. If the specimen is satisfactory, the next consultation snould tell me whether hypnotherapy may be of value. If so, this is suggested to the couple, but is held in abeyance until the physical examinations and laboratory procedures have been completed. The additional contacts with the couple enable me to evaluate their problems further and to judge more accurately my competence in handling their problem. In the absence of organic causative factors, and in the presence of functional problems, hypnosis may offer a rapid diagnostic and therapeutic approach. It should be emphasized that organic and functional factors rarely occur alone, that hypnosis should be considered as just another tool in the physician's armamentarium, and that deep-seated emotional problems are best left to the psychiatrist. We must also remember that the physician in solo practice, outside a clinic or medical center, must, for practical and economic reasons, do as much as possible himself. Only in this way can he help to preserve the private practice of medicine in a small or medium-sized city. Institutional practice has refined infertility investigations to include the combined care and skill of specialists in all the disciplines involved. I dare say that less than half of all these problems reach the men in institutional practice, and many of these only after failure in the hands of their own physician. I refuse to adopt the all-too-often accepted neuro-physico-chemical reasons held responsible in our society for the differences in sexual response between male and female. I hold that two factors are chiefly responsible. One is the obvious anatomic arrangement that readily permits only the male to easily recognize sexual excitement and to achieve its culmination and satiation. The other is a result of generations of teachings and taboos that have relegated
3 120 AUGUST Fertility & Sterility sexual relationships to a hush-hush area-for the female only. The latter has been promoted, partly at least, by the greater penalty and/or responsibility of pregnancy imposed on the female and partly by our economic order. I wish to present the science of hypnosis as an additional investigative and therapeutic tool in the care of the functional infertility problem. 1 Hypnosis is as old as man himsehy 12 It was introduced to medical practice and popularized by Anton Mesmer in 1776, and was first formalized as a science and its modality explained by James Braid in Its popularity decreased at the turn of the twentieth century by Freud's preference for methods of loose association, but has increased since World War II Hypnosis involves the science of suggestion. It is a function of an interpersonal relationship. A basic trait of human behavior is the desire to influence human behavior. There are four basic approaches. 2 These involve the use of ( 1) force, ( 2) reward and punishment, ( 3) reason, and ( 4) suggestion. Of these, suggestion is the most powerful approach because the person being influenced is least likely to feel he is being influenced, and will most likely believe that he initiates the action himself. Hypnosis has been called mono-ideism, a state of increased suggestibility, and channeled thinking. It is all of these. It is also a state of passive acquiescence to reasonable suggestions, with an increased facility for performance. Hypnosis permits one temporarily to leave the world in which he lives for one in which he might or would like to live. The depth of hypnosis varies, the deepest being called the trance. Hypnosis may be induced by one of three approaches: authoritarian, permissive, or cooperative. Its use has a place in medicine, surgery, gynecology, obstetrics, psychiatry, dentistry, and in the control of certain noxious problems such as enuresis, nail biting, excessive eating, smoking, gagging, etc. Permit me to relate briefly how I use hypnosis in my practice, which is limited to obstetrics and gynecology. I present my patients with a short introduction, and emphasize that hypnosis is a skill that the patient learns and I teach. Then I speak of the three "C's," consent, censor, and curtail; and the three "S' s," suggestions, semantics, and sleep. I explain the significance of each word. Then, with my single gynecologic patient or my obstetric patients in groups of eight, I give them a demonstration by hypnotizing them. Following this, we have a question-and-answer period. I always request my patient's husband to be present at the first induction of hypnosis, and my nurse or secretary is present at all subsequent visits.
4 Vol. 11, No. 1, 1960 HYPNOSIS IN STUDY OF INFERTILITY 121 I use hypnosis as the analgesic-anesthetic agent in approximately 80 per cent of my obstetric patients. In 1958 I delivered over 300 patients with the aid of hypnosis. No other anesthetic agent was used in 94 per cent of these. A personality profile is advisable with the gynecologic patient. The results are similarly favorable. It is said that four classes of patients cannot or should not be hypnotized. These are, ( 1 ) those who refuse, ( 2) the very old and the very young, ( 3) the psychotic and prepsychotic, and ( 4) the person with an extremely subnormal intelligence. There is no mystery or magic about hypnosis. Unfortunately, almost anyone can hypnotize, but too few lmow what to do with this approach. Almost anyone can wield a scalpel. Few have a specialized skill with this instrument. The "trick" is to understand your method. In fertility investigation hypnosis is a rapid method for ( 1) learning the psychologic background, ( 2) removing problems that may prevent consummation of coitus by the male or cooperation by the female, ( 3) reducing female tensions and tubal spasm, and ( 4) aiding in the production of regular ovulatory cycles and permitting other normal chemical responses, such as normal vaginal ph production. Hypnosis is a tool, an intermediate, a means to an end. In itself it cures nothing. It must be used with skill and understanding, and always for the benefit of the patient. So used it adds to the gynecologist's armamentarium. CASE REPORTS Two case reports illustrate the use of hypnosis as both an investigative and therapeutic approach to a single facet of the infertility problem. Case 1 The first case presented a well-defined problem. The initial discussion revealed the husband to be impotent as a result of impaired libido. Prior urologic consultation had established this, by a process of elimination, to be on a functional basis. This couple had experienced satisfactory coitus only twice in the past four and a half years. Their baby was three and a half years old. General physical examination revealed the wife's health to be good. We agreed to search, with the aid of hypnosis, for the etiologic factor in the husband, provided it came to light early, as he refused further psychiatric care. We made this exception to our rule because proper care of the wife hinged on the evaluation and possible therapy of his problem. With the aid of age regression, we learned of an unfavorable sexual episode he
5 122 AUGUST Fertility & Sterility had experienced while with the Army of Occupation in Germany. He had been unable for the first time since puberty to obtain an erection in order to complete coitus with an overly willing female friend, because of the propinquity of her roommate who was sleeping in the adjacent unlocked room of a two-room apartment. Since returning to his wife in the United States, he had been unable to obtain a satisfactory erection, except for the two aforementioned times. Subsequent explanation of this history, together with suggestions on perspective, corrected this disability. The time involved was four visits, totaling five hours. Case 2 The second case report was presented in some detail at the last meeting of the American Society of Clinical Hypnosis. This case was a 37-year-old white female, Gravida IV, with four living children aged nineteen, fifteen, thirteen, and four. Among the diagnostic studies done, a D&C under hypnosis revealed an endometriosis. At this time she expressed her desire for further discussion of her revulsion for and tension associated with intercourse. (I often ask my patients to verbalize freely under hypnosis administered for the purpose of anesthesia for surgery or delivery.) Subsequent hypnotic age regression revealed that her unfavorable psychologic response to intercourse dated from a period of tension almost four years before. At that time her newborn infant had been hospitalized for a serious illness, and had nearly died. She had spent night and day with him and, as she said, was never the same to her husband since. Explanation of the association of events, teaching of proper perspective, and psychological manipulation resulted in a totally satisfactory adjustment, as described by the patient herself. The time involved was five visits, totaling six hours. In summary, I will again quote Marsh and Vollmer: "Sterility then is not the main problem but is subsidiary to and caused by an inadequate and unsatisfactory mode of living." 7 In those of our patients so affected I suggest hypnosis as one additional approach. AuTHoR's NoTE: The patient listed as Case 2 is now pregnant and expected to deliver about the first of June, REFERENCES 1. Bos, C., and CLEGHORN, R. A. Psychogenic sterility. Fertil. & Steril. 9:84-95, CoLEMAN, J. C. Abnormal Psychology and Modern Life (ed. 2). Chicago, Scott, Foresman, DE WATTEVILLE, H. Psychologic factors in the treatment of sterility. Fertil. & Steril. 8:12-23, 1957.
6 Vol. 11, No. 1, 1960 HYPNOSIS IN Sl'UDY OF INFERTILITY ERICKSON, M. H. Hypnosis: General review. Dis. Nero. System 2:13-18, KROGER, W. S., and FREED, S. C. Psychosomatic Gynecology. Glencoe, Ill., Free Press, MANDY, T. E., and MANDY, A. J. The psychosomatic aspects of infertility. Internat. ]. Fertil. 3: , MARSH, E. M., and VoLLMER, A. M. Possible psychogenic aspects of infertility. Fertil. & Steril. 2:70-79, PLUNKETT, R. J. Publication of council on mental health. ].A.M.A. 168: , ScHNECK, J. M. A hypnosis reading list for professional instruction. Am. ]. Psychiat. 108: , STURGIS, H. S., TAYMOR, M. L., and MoRRIS, T. Routine psychiatric interviews in a sterility investigation. Fertil. & Steril. 8: , VAN PELT, S. J. Hypnotism and its therapeutic value in medicine. M. Press 222: , YELLOWLEss, H. Hypnosis, its uses and limitations in medicine. ]. Roy. Inst. Pub. Health & Hyg. 14: , Peruvian Society of Marital Fertility The Peruvian Government has given official recognition to the new Sociedad Peruana de Fertilidad Matrimonial in which the following officers have been elected: President: Jorge Ascenzo Cabello, M.D.; Vice-President: Rafael de la Puente, M.D.; Secretary-General: Javier Hoyle Cox, M.D.; Secretary of Acts: Robert Ruiz Gonzalez, M.D.; Treasurer: Julio Munoz Valdivieso, M.D.; and Vocales: Julio Injoque Mandujano, M.D., and Gerardo Boisset, M.D.