Adventures in Human Being Page 15

  Marcus Aurelius spoke of orgasms as the simple product of a timed duration of friction. Aristotle thought that the heat necessary for conception was generated by sex just as a fire can be ignited by rubbing two sticks. But of course the propagation of sexual tension is less predictable than those theories suggest; less a process of ignition than the interplay between storm clouds and an ionizing earth – the lightning flash of a two-way traffic between the mind and bodily physiology. In Western countries where surveys have been attempted it’s been reported that only a third of women regularly experience orgasm during intercourse, the reasons for this being both social and physical. The effect of drugs can play a part: antidepressants like Prozac and Seroxat, some of the most commonly prescribed drugs in the Western world, can so dampen the action of those nerve endings that orgasm becomes difficult to achieve for both men and women. Heroin can do the same, and, most famously, so can alcohol.

  A mirroring tension builds between the nerves within the glans or clitoris and the answering network of nerves in the spinal cord until some final, pivotal change provokes the climax. What the French called la petite mort can be seen on brain scans not as a darkening to oblivion, but as a “lighting up” in the emotional core (cingulate gyrus), reward centers (nucleus accumbens), and hormonal regions (hypothalamus) of the brain. It’s those hormonal regions that in some animals actually provoke ovulation as a response to sex, just as Galen imagined, but in humans that’s not the case.

  During orgasm, pulses of nerve stimulation ripple back out from the spinal cord to the prostate gland and seminal vesicles in men, and the cervix and vagina in women. In men they trigger the prostate, vas deferens and urethra to squeeze sperm and seminal fluid toward the penis in a series of clenching spasms, while coordinated reflexes shut the entrance to the bladder so that semen can go only one way – out. In women those same ripples trigger convulsions in tiny glands around the urethra and anterior wall of the vagina – Skene’s glands – which push out a sort of female seminal fluid similar to the prostatic fluid expelled by men.

  The outlets of Skene’s glands vary between women: on climax they may push a watery fluid out into the urethra as occurs in men, or directly into openings within the vagina – explaining why some women feel as if they “ejaculate” on orgasm, while others do not. An Italian sexologist, Dr. Emmanuele Jannini of L’Aquila University, believes that the area around the urethra on the anterior vaginal wall is a separate erogenous zone in some women, distinct from the clitoris. Like Ernst Gräfenberg, the New York sexologist whose initial “G” gave the name to the “G-spot,” Jannini thinks that there are women who experience orgasms deeper in the vagina than others, as an accident of their pudendal nerve anatomy.

  The vagina in health is acidic, something that helps keep it free of infection. Unfortunately, sperm prefer a neutral environment – neither acid nor alkaline – similar to that prevailing within the womb. The secretions from Skene’s glands and the prostate gland are alkaline, which suggests that they helpfully neutralize the acid environment of the vagina at the moment when sperm are released into it. The secretions from Bartholin’s glands, which lie at the posterior entrance to the vagina and become active much earlier in intercourse, are also alkaline and so do the same thing.

  William Taylor wrote over two centuries ago, “so the poetic orgasm, when excited, glows but for a time”: in men, up to ten seconds; for women, orgasm can last double that. The pattern of female orgasm is different from that of the male: broader and slower to rise as well as fall away. There are several theories, none entirely convincing, which suggest how female orgasm might help in conception.* One theory is that the longer duration of the female orgasm could give the cervix more time to pull in male seminal fluid, which may increase the likelihood of pregnancy, and could help sperm survive by neutralizing the natural acidity of the vagina. But there are others: by encouraging more sex, by secreting the hormone oxytocin from the brain (which may cause the womb to draw in fluid), even that female orgasms help in sexual selection – identifying men who are more likely to prioritize their women’s happiness as highly as their own.

  There’s even a theory proposing that orgasm helps select sperm from a nonregular partner over that of a regular one. See R. R. Baker and M. A. Bellis, “Human sperm competition: ejaculate manipulation by females and a function for the female orgasm,” Animal Behavior 46(5) (1993), 887–909.

  FOR SIGMUND FREUD, “Eros” and the erotic represented the sexual components of life: churning with energy, chaotic and generative. He opposed it to humanity’s drive toward aggression and self-destruction – the Greeks would have called it “Thanatos.” Carl Jung thought the erotic was less about opposing violence, and more about achieving a balance between the rational and the emotional aspects of human nature. “Woman’s psychology is founded on the principle of Eros, the great binder and loosener,” he wrote, “whereas from ancient times the ruling principle ascribed to man is Logos” – from logos comes our idea of logic. For Jung, just as acids and alkalis have to balance to create a neutral environment, so the logical and the erotic had to balance for both men and women to flourish. In counseling infertile couples, Jung might well have characterized a dependency on blood tests and analyses, such as those taking place in an infertility clinic, as too great a focus on Logos, but a concentration solely on the emotional and sexual health of a couple’s relationship as an overindulgence of Eros.

  A few weeks later I met Helen and Rob again. Rob’s semen analysis was normal: I ran through the parameters examined by the laboratory, translating the arid terminology of “motility,” “morphology,” “concentration” and “consistency.” Helen’s hormone tests too had come back as I’d hoped: the LH and FSH were in appropriate proportion to one another, the estrogen as low as it should be early in the cycle. The progesterone level in her blood a week before her period was due suggested that she’d ovulated normally – there was no obvious reason they weren’t conceiving.

  “So the results are all very reassuring,” I told them. “Rob, your tests are normal, and Helen, your ovaries are ovulating at the time in the month we’d expect them to.”

  “So what could be wrong?” she asked.

  “Sometimes the tubes inside aren’t letting the sperm past for some reason, sometimes the immune system prevents the sperm and the egg coming together, often there’s nothing wrong at all.”

  “So what now?”

  “Now I write to the fertility clinic at the hospital, and you two try not to worry about it too much.”

  WHEN THEY CAME BACK to see me a few months later their initial embarrassment had been replaced by dejection.

  “How did you get on at the clinic?” I asked.

  “Don’t ask,” Rob said.

  At their first clinic appointment Helen had admitted to the odd glass of wine, and was told baldly that she must swear off alcohol. Rob was irritated by the suggestion that he should lose a little weight, and by the in-depth questioning about how often, and in what manner, they had sex together. “I suppose they have to ask,” he said, “but it was as if they thought we didn’t know where babies came from.”

  After a further blood test, and an ultrasound scan of her ovaries, Helen was told she had “depleted ovarian reserve”; there were relatively few “follicles” in the ovaries with the potential to ovulate. The couple were likely to need IVF, but even at that their chances of success were small, at around one in ten. “And you didn’t warn me about the ultrasound,” she told me. “I got a shock when the doctor rolled a condom over a plastic truncheon, and told me where he had to put it.”

  Despite the indignities of the clinic they decided to go ahead. The first step in treatment was a series of injections to “reset” all the follicles in Helen’s ovaries, so that all were at the same early stage of development. Then she began a further series of injections, this time to hyperstimulate egg maturation – the development of many eggs at once. “I couldn’t stand those injections,” Helen told me. “My b
um was black and blue from them.” The internal ultrasound scans were by now so frequent they no longer bothered her.

  Helen’s ovaries began to swell with developing follicles, and a further injection provoked the final maturation of the eggs. Within thirty-four hours of receiving the injection, almost to the minute, the eggs were ready to be gathered. For that procedure she was given a powerful sedative and, using an intravaginal ultrasound scanner, a very fine needle was passed through the walls of her vagina and into her ovaries. The fluid within each follicle was drawn carefully out and examined for eggs. Rob had to provide a fresh sample of semen that same morning, then he and Helen were sent home.

  That night Helen slept deeply thanks to the sedatives still soaking in her blood. Rob couldn’t sleep for the thought that, as he and Helen lay together, his sperm and her eggs were being mixed together in a glass dish in some white-walled laboratory.

  “They took the eggs on the Friday,” said Helen, “and then on the Tuesday I had to go back. They had six fertilized embryos, two of which were of ‘good quality,’ whatever that means, and one of those – the one they said was the best – was put inside me.”

  “And then?” I asked.

  “And then it didn’t work.” She looked away, and Rob reached across to take her hand. “They told us the chances weren’t good,” she said, “now we’ll just have to think about whether we can face it, or even afford it, again. They still have some of our embryos in a freezer. Maybe I’m frigid after all … they’ll feel right at home in there.”

  FOR GALEN, “BARRENNESS” was the result of a lack of heat; to treat infertility the answer was simply to find ways of heating up the pelvic organs. This could be done with foreplay or “lascivious talk,” or by rubbing the genitals with herbs to redden and irritate the skin. Avicenna, the Arab physician of the eleventh century who transmitted much of this rhetoric back to the West, agreed that it was necessary to find ways to increase female sexual pleasure: “[when women] do not fulfil their desire … the result is no generation,” he wrote. At the same time, too much heat was thought counterproductive: prostitutes were considered to conceive only rarely because at that time it was believed they had too much ardor for sex, so that their seed was “burned off” by excessive lust.

  In The Sicke Woman’s Private Looking Glass of 1636, John Sadler – one of the first English gynecologists – wrote that the problem was often “the man is quicke and the woman too slow, whereby there is not a concourse of both seeds at the same instant as the rules of conception require.” Rather than blaming women for infertility, Sadler laid responsibility on men to refine their “allurements to venery … that she may take fire and be enflamed.”

  The assumption that women conceived in response to orgasm, which had been around for as long as we have written records, at last began to crumble when in 1843 a German physician, Theodor Bischoff, demonstrated that ovulation in dogs occurred even when there had been no intercourse. That same year a paper appeared in the medical journal Lancet asserting, wrongly, that the cycle of animals going into “heat” was one to which “the menstrual period in women bears a strict physiological resemblance.” Medical knowledge had woken up to the fact that women ovulate cyclically rather than as a response to sex, which not only fed into the new Victorian prudishness about female sexuality (if pleasure isn’t necessary, why bother with it?) but gave rise to the mistaken belief that the fertile time of the month was during menstruation, which was the human analogue of animals “going into heat.” It’s a belief that persisted for nearly a century: in the 1920s Marie Stopes’s bestselling Married Love advised that maximum fertility occurred just after the end of menstruation – more than ten days too soon. According to Stopes, it was midcycle when women were unlikely to conceive – exactly the time when we now know that pregnancy is most likely to occur.

  A FEW MONTHS LATER Helen and Rob tried again, using the second of the two embryos that were deemed “high quality”; but were again disappointed. “Perhaps it seems crazy,” she said when she came to talk to me about the failure of the second treatment, “but I want to have a baby so much; every time I pass a baby in the street, or pick one up, my womb does a spin. I don’t know if I can go on working in a day care.”

  “Do you think you’ll try a third time?” I asked.

  “We can’t,” she sighed. “We’ve already spent all our savings on paying for that second round. By the time we’ve saved more, I’m sure it’ll be too late.”

  We were silent for a moment.

  “And how are things between you and Rob?”

  “Fine, actually, more than fine. It’s a funny thing but …” She paused, as if wondering again how much intimacy to share. “We’re both upset about it, but in some ways we’re closer than ever. What’s that quote – ‘When you can’t change the wind, adjust your sails.’ Things have been much, much better – for me as much as for him.” She blushed. “Now that we’ve given up on trying to make a baby, it’s as if we’ve been able to go back to making love.”

  THERE ARE ASPECTS of our bodies’ workings that even now, in the twenty-first century, remain obscure. It wasn’t until the 1960s that the delicate hormonal weave between brain, pituitary gland and ovaries was unpicked with respect to fertility, and until the late 1970s that the first IVF baby was born. Despite all the advances of the subsequent decades, much remains hidden.

  I’ve known women whose immune systems repeatedly mistook the embryo within their womb for an infection – and destroyed it. After suffering recurrent miscarriages they conceived only after suppressing their immune systems with chemotherapy-like drugs. I knew a couple whose recurrent miscarriages spanned a decade until, having called in a plumber for a burst pipe, were informed that they’d been drinking water corrupted by lead. When the ancient piping and cistern was removed they had no more problems. I’ve known couples each of whom was “infertile” until they separated and found new partners – suddenly, both were able to conceive.

  It was only a couple of months later that I saw Helen and Rob on my consulting list again. As I stood up to call them from the waiting room I wondered if they had changed their minds, and had found the money for a third course of IVF.

  Usually when I stood at the waiting room door I’d see them nod, gather their bags, and solemnly get to their feet. But their manner this time was different: Helen’s face shone as she looked up. We walked the few steps to my office, and she skipped the last couple to the door. “You’ll never guess,” she said before we had sat down, “– I’m pregnant!” Without laboratories or relationship counselors they’d found the right balance between Eros and Logos on their own.

  15

  WOMB: THRESHOLD OF LIFE & DEATH

  I see the elder hand pressing receiving supporting,

  I recline by the sills of the exquisite flexible doors,

  And mark the outlet, and mark the relief and escape.

  Walt Whitman, Song of Myself

  THE TV TOOK UP more space than the fireplace, but no one was watching it. A two-bar electric fire glowed in the dark socket behind the hearth. An ashtray shaped like a porcelain Pekingese dog was overflowing, and a confetti of cigarette butts littered the carpet. Along a line between the room’s entrance and the patient’s easy chair the carpet was worn thin, a trail greasy from the passage of dropped food and slippered feet. The sofa was longer than the room was wide, and seated on it were a man and a woman – the son and daughter of my patient. Both of them had to sit with knees splayed, to make room for the sag of their bellies. The son stood up to greet me, hands trembling.

  “She’s bleeding, doctor,” he said, “from down below …”

  Parked outside in the car, before stepping out into the rain, I had read Harriet Stafford’s medical history on the emergency service laptop. It read like a primer in the co-morbidities it’s now possible to sustain through modern Western medicine, beginning with emphysema, coronary heart disease, high blood pressure and diabetes – the four horsemen of the aging society
’s apocalypse. Beyond those usual four there were two other significant entries: “Multi-infarct Dementia” explained her absent manner as she watched me approach, and “Endometrial Carcinoma – Palliative” explained the bleeding – she was hemorrhaging from a cancer of the womb. At the end of the list was the plea, written by her own doctor: “Avoid admission if possible.”

  “Hello, I’m Dr. Francis,” I said to her. “How are you getting on?” Her eyes startled with the customary panic of the demented – afraid she’d answer wrongly, or make a fool of herself. I pictured the circuits of her brain, as worn by routine as her carpet. Instead of the expansive possibilities of social intercourse, she was left with a few reflex replies. Some people with dementia return almost to a preverbal state; like very young children they learn to trust or distrust not through words, but through tone of voice and a speaker’s manner.

  “Nice, yes, fine,” she said, smiling up at me and dropping her guard a little. I picked up her hand and shook it gently. It was cool, her palm clammy, and her pulse was thin and rapid. “I’ve come to help you,” I said. With the flat of my fingers I brushed the skin further up her arm; it was cold as far as her shoulder – she had lost so much blood that there was not enough left in her body to keep her limbs warm. The skin of her face was pale as candle wax, almost translucent. The whites of her eyes were bloodless.

  “I changed her pad half an hour ago,” said her son. “But the cancer … it’s gushing out of her.” He blushed at having to describe two taboos – cancer and vaginal bleeding – to a strange man.

  “I’m going to have to examine her. Can we lie her down somewhere?” Off the hall was a small spare bedroom – she was no longer able to manage the stairs. Her son and daughter helped her up from the easy chair and, taking her arms as if encouraging a baby to walk, half supported and half carried her through. “It’s alright, Mum, it’s alright,” murmured the daughter, like a parent comforting a fretful child, before lifting her with ease and laying her down on the bed.