Doctor's Review: Medicine on the Move

September 23, 2017

© Ontdeckte onsigtbaarheeden (1688) by Antonie van Leeuwenhoek

Antonie Van Leeuwenhoek first observed sperm under the microscope, and theorized that within each sperm was a tiny, fully-formed human.

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The art of artificial insemination

How doctors managed to insert hope into the lives of couples worldwide — even if it took a few shady tricks along the way


Rumours of storks and immaculate conceptions notwithstanding, we can assume that even the cavemen knew about the birds and the bees. Still, the actual physiological processes that lead to human reproduction remained a mystery for millennia. To be fair, it wasn't exactly a well-kept secret.

The impetus behind artificial insemination then, as now, was most often infertility. Thanks in part to the hapless Hannah — perhaps the Bible's most famous infertile woman, who was rewarded for her earnest supplications with six bundles of joy — the power of prayer was believed for millennia to be the only true remedy, as well as repentance for whatever character defect or sin led to the shameful condition in the first place. As it turned out, prayer didn’t work so well, and so the quest for a scientific solution was born.

The normally prescient ancient medical cultures of Egypt, China, Greece and Rome were utterly foiled by infertility. Midwives and medicine men grappled with this most fundamental problem of the human condition as they did with most other ailments over the centuries — by simply doing the best they could with the knowledge available to them at the time. Every conceivable approach was considered, to little avail. Animal sacrifice, leaden probes, internal poultices, herbal douches, bloodletting, cupping, electromagnetic shocks — all were employed in the desire to conceive. The Romans were even fond of “stimulating” the bellies of childless women with goat-skin whips. Still, no recorded attempts of any kind of artificial insemination exist in the early annals, save for a few reports of successful interference into the love lives of horses in 14th-century Arabia.

SPERM SPOTTING

A series of key scientific discoveries made the first attempts at artificial insemination become possible. Antonie Van Leeuwenhoek (1632-1723), Dutch scientist and father of microbiology, was part inventor of the microscope and the first human being to see microorganisms such as bacteria. His legendary lenswork paved the way for science to come knocking on the bedroom door. After examining sperm for the first time under a microscope in 1677, he stated: “I have noticed... a large number of small animals, I think it must be more than a thousand, on an area no larger than a grain of sand." Unfortunately, his microscope was not strong enough to prove his theory that there lived within each sperm a tiny, perfectly formed human.

Karl Ernst von Baer (1792-1876), the German-Estonian naturalist and biologist and founder of embryology, was the first to identify an ovum in a mammal in 1826. He posited that both animal and human reproduction sprung from more than the mere deposit of “formative liquid” within a female host, but couldn’t prove it. Where he failed, an unlikely champion of artificial insemination would succeed.

Indeed, the first person to successfully impregnate an animal artificially was probably the last person we might expect today: an Italian priest. But Lazaro Spallanzani (1729-99) was also a successful physiologist, with a thriving research and teaching career. Armed with the relatively new gadget called the microscope, he was the first to describe (correctly, at least) the process of mammalian reproduction in that it involved the necessary union of semen and ovum. He was able to impregnate a dog in 1784, as well as frogs and even fish artificially... an impressive feat considering the minuscule scale of their reproductive systems. Spallanzani had figured out that it wasn’t just the reproductive act that allowed embryos to develop, and that it actually depended somehow on the introduction of male sperm into the female body.

DIY AI?

John Hunter (1728-93) was a brilliant Scottish surgeon known for pioneering research into venereal diseases, child development and the lymphatic system, among many other things. Although he liked to experiment on himself — particularly unfortunate in regards to his research into syphilis and gonorrhea — the official surgeon of England’s King George III was also was known to instill within his patients an equal zeal for self-experimentation.

When a young married man, desperate to have a child with his wife, came to him in 1790 with a grim condition known as hypospadias, in which the urethra basically takes a wrong turn out the underside of the penis, Hunter developed a plan. He equipped his patient with a collection of large syringes and a prescription for frequent masturbation. He was to collect his semen and inject it into his wife’s vagina. Tragically, the exact details of their bedroom antics are lost forever, but the fellow did reportedly follow doctor’s orders over the course of two years. By most accounts, a single pregnancy resulted, and Dr Hunter had proven the possibility of artificial insemination in humans. But it would be a while yet before any physician would formally take up the cause of assisted reproduction.

DR SIMS’S POOR TIMING

Today, the American surgeon J. Marion Sims (1813-1883) is somewhat reluctantly known as the father of modern surgical gynecology, since he culled much of his formidable knowledge from research on unwilling African-American slaves. He was the first to attempt a systematic approach to artificial insemination at his Women’s Hospital in New York City, which he opened in 1855 as the first institution devoted exclusively to women’s health. He devised and used the first vaginal speculum in his procedures. Over the course of several years, he performed 55 inseminations in six women. Only one resulted in a pregnancy, and that ended in a miscarriage. In all likelihood, Sims’s technique was spot-on; his timing, however, was terrible. It was eternally the wrong time of the month for old Dr Sims.

Sims was variously despised as a pervert or lauded as a genius. He also had an interest in women’s cancers, and founded a hospital that would eventually become known as the Memorial Sloan-Kettering Cancer Center. Despite his penchant for performing brutal surgeries on slaves to repair vesico-vaginal fistulae in Alabama in the 1840s – some of his patients were subjected to as many as 30 operations, without anesthesia and with little recovery time – he was named the president of the American Medical Association in 1876.

The powerful and famous Dr Sims failed in his attempts to introduce AI as a viable treatment for infertility, but a relatively unknown American physician would soon succeed.

SILENT SPERM

In 1884, Dr William Pancoast of the Jefferson Medical College in Philadelphia went rogue and decided to have a little scientific fun with one of his patients, a Quaker woman who had long been unable to conceive. After many examinations, he decided that the fault in fact lay with her husband’s low sperm count. The man, an elderly merchant many years older than his wife, was officially shooting blanks.

Rather than inform her and her husband of the sad state of affairs and move on from a point of full disclosure, Dr Pancoast summoned the wife to one final “examination.” As the woman lay unconscious and chloroformed on his table as six of Dr Pancoast’s students looked on, the good doctor injected into her cervix a large syringe full of semen – freshly donated by the student democratically deemed by the group to be the most handsome.

This unnamed woman delivered a healthy baby boy nine months later. Presumably, all were ecstatic. The only problem was that Dr Pancoast never actually informed her about what he did to her on the table that fateful day. Whether it was to spare her the embarrassment of her husband’s sterility, or whether it was simply to see if he could do it at all, Dr Pancoast’s experiment remained a secret success for 25 years.

It was only after Dr Pancoast died — a quarter-century after the successful insemination of his presumably pleased patient — that the truth became known. In 1909, one of the students present that day, the suggestively named and incredibly handsome Dr Addison Davis Hard, fessed up and published a letter in the journal Medical World containing all the dirty details. It is interesting to note that Dr Pancoast did actually inform the woman's husband of what he had done, and that they had decided together to spare her the truth. In addition, before the letter was published, Dr Hard took it upon himself to tell the by-then all-grown-up baby boy as well. Hopefully, his mother was not a subscriber of Medical World in her old age.

A CONTENTIOUS BREAKTHROUGH

As the 20th century approached, medical science teetered on the brink of successful intervention into this most revered of forums. In its infancy, artificial insemination was approached with an innocence that precluded many of the ethical, moral and theological debates that swirl around this divisive topic today. But as the 19th century came to a close, so too did artificial insemination’s age of innocence.

Dr Edward Clarke, a Harvard Medical School professor and a very influential figure at the time, deduced that education in women – and not physiological or even emotional factors – was a serious cause of intfertility. A strong mind leads to a weak body, he preached in his 1873 best-seller Sex in Education, or a Fair Chance for the Girls, for as their brains expanded with knowledge, their wombs would shrivel and die. His proof? Why, that college-educated women had fewer children, of course! Plenty of people were eager to accept what he had to say at face value. Infertility and, by extension, artificial insemination came to be regarded with increasing suspicion. That women might soon come to exert some control over reproduction was a very dangerous idea indeed... and a debate that was more or less successfully delayed until the birth control pill was introduced in the 1960s.

By 1909 – the same year that Pancoast’s case was revealed – the Catholic Church stepped in and gave AI their stamp of disapproval as well. There would be no more physiologist-priests playing God for the foreseeable future, no more laboratory hijinks in a moral vacuum. And so, as the popularity and efficacy of artificial insemination blossomed over the course of the 20th century, the religion and ethics struggled to catch up.

The wonders first witnessed by Van Leeuwenhoek under his microscope led, slowly but surely, to July 25, 1978, when Louise Brown, the world’s first test tube baby, was born to happy parents in Great Britain. From then on, the science virtually exploded. From turkey basters to test tubes and beyond, physicians now hold in their hands the power to create life, to manipulate life, to terminate life.

Cloned sheep, outrageous octuplets, surrogacy battles, selective reduction, frozen embryos, gender selection and all manner of life-and-death drama accompanying assisted reproduction unfolds before us now on the evening news, and the world weighs in on the rights and wrongs of each new high and low. And yet, though the realm of reproductive science will likely always be as controversial as it is thrilling, there remains no greater mystery than the unknowable spark that ignites it all.

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