Sterility

STERILITY. - The term, collateral to that of impotence, is used in medico-legal language to indicate a particular defect in the efficacy of the procreative function.

Impotence and sterility give rise to the concepts of two different defects and legal situations in both canon law and civil law, while the capital importance of a very clear delimitation of their respective objects appears from the fact that the legitimacy and validity or nullity of marriage is tied to the demonstration of one or the other ("Impotentia... matrimonium ipso naturae iure dirimit... Sterilitas matrimonium nec dirimit nec impedit": CIC, can. 1068). If, however, in common idea and language the difference in their respective conceptual content appears with ease, on legal ground, following the ideas of the different currents and schools, it is not equally easy to set a clear boundary between impotence and sterility. Their boundaries are often confused and almost vanish, exchanging part of their contents; thus, while the meaning of one broadens, that of the other narrows, and the terminology becomes confused, not only in the comparison between civil law and canon law, but within one and the same law. For the question, v. IMPOTENZA.

To keep, therefore, the distinction of the terms exact and thus not to confuse sterility with impotence, it must be said that sterile is not one who is incapable of performing the conjugal act according to the order of nature, but one who can indeed perform it, although from it the effect of generation cannot follow. Therefore the CIC establishes that sterility neither annuls nor impedes marriage (can. 1068 § 3); hence even persons of advanced age can contract marriage, provided they can consummate the marriage itself. In other words: there is impotence when the capacity to consummate marriage is lacking; sterility when this potency is not lacking, but the effect of the potency is lacking, which effect would not be lacking if its cause were found in those circumstances in which alone it could exercise all its power and produce the effect (generation) for which it is destined. Given impotence, the conjugal act cannot take place; given sterility, the act can take place, but without its effect (cf. T. A. Iorio, Theol. mor., III, 3rd ed., Naples 1947, n. 1061).

PHYSIOLOGICAL PERIODIC STERILITY (METHOD OF PERIODIC CONTINENCE ACCORDING TO OGINO-KNAUS-SMULDERS). - For various causes of a morbid nature, which impede the development, maturation, and regular progression of the ovum toward its meeting with the male sexual element, a woman may be affected by sterility that is more or less continuous and lasting. Apart from such conditions, the most modern studies have shown that a woman is periodically sterile, even under perfectly physiological conditions, in relation to the periodicity of maturation of the ova that develop in the ovaries. Such a periodic physiological sterility can serve the question of birth control (v.), according to the method of periodic continence.

1. Periodic physiological sterility as the basis of the method of periodic continence

The period of time between the first day of one menstruation and the first day of the one immediately following constitutes in a woman the "sexual cycle"; in which there take part, with characteristic phenomena, not only the ovary and the uterus, but the entire organism, not excluding its highest psychic functions. With regard to the ovary, what is of interest is the periodic maturation of the ova, which occurs at determined times, nearly constant for each woman. The ova, preformed at birth and arrested in the embryonic state in the number of some tens of thousands, reach their maturation, normally one at a time, cycle by cycle throughout the entire period that runs from puberty to menopause (v. ETÀ CLI-

MATERICHE); therefore only 400-450 ova come to be capable of fertilization, over a period of about 30-35 years, as long as the sexual life of the woman lasts. For this reason, a woman is physiologically sterile before puberty and after menopause; periodically physiologically sterile in the periods that intervene between the maturation of one ovum and that of the next. With regard to the modifications affecting the uterus, what is of interest is the periodic destruction of the uterine mucosa (endometrium) at the close of each sexual cycle in which the ovum was not fertilized; of this a manifest sign is a more or less abundant and prolonged hemorrhage (menstruation) which signifies that the intense proliferation and congestion of the uterine mucosa, preordained for the implantation of the fertilized ovum, was not utilized, owing to the failure of the two sexual elements to fuse and the rapid death of the egg. The appearance of menstruation thus becomes an easy external sign of demarcation between the close of one sexual cycle and the beginning of the next, and of the non-utilization of the ovum.

Contrary to what was admitted in the past, when it was held that the liberation of the mature ovum from the surface of the ovary (ovulation) occurred during the hemorrhagic phase of the cycle (hypothesis of Pouchet-Pflüger, 1840, followed by the German gynecologist A. Capellmann, in his Medicina pastoralis, Paris 1893), it is currently recognized with certainty that, under normal conditions, ovulation occurs at about the middle of the cycle, if this has an average duration of 28 days, more generally between the 12th and 16th day preceding the beginning of the next cycle. The credit for this discovery and its demonstration goes to the Japanese Kyusahu Ogino and the Austrian Hermann Knaus, who, proceeding by different paths, at successive times (1924-29), but without each other's knowledge, secured for science the true chronology of ovulation. For the aforementioned reason, in the face of the brief period of fecundability of the woman, which, in the course of the few days in which ovulation can take place, is reduced in substance to two hours and little more, such being the duration of the very brief life of the ovum, there exist for the remaining course of the sexual cycle, before and after, at the beginning and at the end, two periods of periodic physiological sterility of unequal length. The pre-ovulatory period, or period of post-menstrual sterility (from the first appearance of menstruation to the rupture of the Graafian follicle that encloses the ovum on the point of maturing), comprises the phase of development of the ovum; the post-ovulatory period, or period of pre-menstrual sterility, will eventually be occupied by the meeting of the two sexual elements, by fertilization, by the migration of the fertilized ovum toward uterine implantation or, conversely, in it there will be accomplished the death of the ovum that lacked fertilization, the vain waiting of the endometrium, which was ready to receive it and now, unused, moves toward menstrual destruction. To the two aforementioned phases of the cycle there correspond two different endocrine orientations and equilibria (v. ENDOCRINE GLANDS), which influence the entire bio-psychological equilibrium of the woman with modifications both functional and structural. While the first phase is under the dominion of the secretion of the follicle (folliculinic phase of the sexual cycle), the second is under that of the hormonal secretion of the "corpus luteum" (luteal phase) which has organized itself in the empty cavity of the ruptured follicle. A higher regulation of this mechanism is linked to the anterior hypophysis and to the sexual nerve centers of the diencephalon.

The character and the limits of the entry prevent entering into a broader theoretical development and into the scientific demonstration of the facts asserted, which can be derived from the study of the specialized works cited in the bibliography. Here it suffices to say that on the exact knowledge of the course of the female sexual cycle and of the moment of ovulation, on the knowledge of the very brief life of the ovum and of the limited possibility of waiting and survival of the male sexual elements after their emission (the spermatozoa after about 30-48 hours lose their motility, their fertilizing capacity, and die), it is possible to base a system of birth control: the method of periodic continence, improperly called the "Ogino-Knaus method," to which instead more justly belongs the name "Smulders method," from the name of the Dutchman J. M. J. Smulders (d. 1939) who, with skill and long patience from 1930 until his death, elaborated it, spread it, and checked it on the basis of the aforementioned scientific discoveries of Ogino and Knaus. He gathered a great number of observations and practical experiences to render it ever more exact and sure, and it may be said that all the variations introduced subsequently by others do not in the least change its bases and the substance of its practical application.

The method of periodic continence, according to Smulders, posits as its cornerstones: 1) the ovum is mature and free, ready to be fertilized, only between the end of the folliculinic phase and the beginning of the luteal phase, and preserves its vitality only for a very brief space of time (about 2 hours); 2) the fertilizing capacity of the male sexual elements does not exceed 30-40 hours; 3) the calculation of the period of fertility of the woman must always be made backward from the probable date of the future menstruation, which, being an uncertain future event, can be fixed presumptively by determining it from the average of the lengths of a certain number of past cycles. And this is the most delicate and aleatory part of the method of periodic continence, upon which all the skill of its defenders and popularizers is brought to bear, and at which the majority of the criticisms of the enemies of the method are aimed. If the length of the sexual cycle, though different for each woman, were for each one a fixed constant, it would be easy and sure to establish the recurrence of the few fertile days: on the contrary, every woman, though tending to settle on a determined cycle length (between minimums of 20-22 and maximums of 34-36 days, with an average, according to Arey's statistics conducted on 20,000 cycles, of 29 days) undergoes oscillation of her own period, which, following the characteristics of fluctuating variability, shift within margins of 2-5 days' difference. Further on it will be seen how in the application of the method it is possible to compensate for the shifts that the fertile period undergoes owing to the continuous oscillation of the length of the cycle.

2. Technique of the method

Through the observation of the variability of the sexual cycles over a sufficiently long period (possibly 10-12 months), the maximum limits of the oscillations in their length are established (let it result, for example, that the shortest period observed is 26 days and the longest 30 days); it is understood that this already entails in advance the necessity of a margin of four days (30-26=4) to be added to the period of presumed fertility of the woman, a period constituted as a basis by the five days within which ovulation may oscillate (12th, 13th, 14th, 15th, 16th day before the next menstruation), plus two preceding days of possible survival and waiting of the spermatozoa (17th, 18th), plus one more day (19th) required, according to some, as a further margin of prudence against exceptionally early ovulations or a longer vitality of the spermatozoa, or according to others as a margin of partial compensation for the inevitable differences in timing when establishing the beginning of the cycle with approximation to the day. In all, therefore, eight days during which conception could occur. In the case exemplified, therefore, there results a period of possible fertility of 12 days (4+8) situated in the transitional portion between the folliculinic phase and the luteal phase of the sexual cycle. The placement of this period in the middle of the cycle will lead to a fixed period of pre-menstrual s. comprising the last 11 days of the cycle and to a post-menstrual s. period comprised between the beginning of the cycle and the 19th day (excluded before the future return. While the pre-menstrual s. period always retains a fixed length of 11 days, the post-menstrual one is of variable length, in relation to the different length of the cycle. Thus, for example, while for the 26-day cycle it will be 7 days (26-19=7), for the 30-day one it will be 11 days (30-19=11). Since the length of the next cycle is uncertain, the nearest limit must presumably be chosen, that is, to end the s. period with the 7th day and to calculate the last 11 days of s. on the basis of the longest cycle; therefore to consider fertilization possible from the 8th day to the 19th inclusive counting from the beginning of the cycle currently in progress.

Many objections have been raised against the method, such as to appear gravely to invalidate its basis and the hoped-for results; we recall the principal ones. Very great irregularity of the cycles, particularly in certain periods of a woman's life (climacteric, post-puerperium, lactation, intercurrent illnesses, convalescence, etc.), such as to render the period of fertility very long and uncertain and correspondingly short and indeterminable the periods of s.; sudden physical and psychic traumas, disturbing the regularity of the cycles; the possibility of supernumerary ovulations outside the period established by the investigations of Ogino and Knaus; all circumstances that could be such as to remove all security from the periods of physiological s.

We cannot here enter into a detailed refutation of the aforesaid objections; one can, however, readily affirm (v. the specialized works cited in the bibl.), that the great majority of women, particularly in the central period of their sexual life, are capable of an excellent application of the method of periodic continence, even without resorting to particular advice from a specialized physician, provided they intelligently, exactly and cautiously apply the rules set out in the best books on the method. Without doubt, there exist cases and circumstances in which the application of the rules becomes difficult and even fallacious, not possible on the basis of calendar methods alone: here the work of a specialist in the matter is required, who, from the clinical study of the case, resorting to the accurate examination of the concomitant phenomena (intermenstrual crisis, thermal curve, direct examination of the collateral cyclic phenomena of ovulation), bringing into play the necessary means to restore the possibly altered function, following month by month the anomalies of rhythm and the chance interference of disturbing factors, will be able to succeed in the aim of giving to the method of periodic continence exactness and security.

3. Statistical examination of the results

The critical study of practical results represents the most probative element of the value of the method of periodic continence; here one may bring the experience of thousands of favorable cases, with which the statistics of honest and accurate experimenters are rich. In the face of these, the opponents most often bring only isolated cases, often not even personal, badly studied, lacking reliable clinical elements on which a critique of scientific value can be made. Against them can be set, besides the data of Smulders so accurately studied and described, the statistics of Miller, Schultz and Anderson (Conception Period in normal Adult Women, in Surg. Gynecol. Obst., June 1933, pp. 1020-25, Chicago); of Leo Latz (The Journal of the Amer. Med. Assoc. pp. 1241-46, Chicago 1935); of Carvalho Azevedo (Das Problem der bewussten Befruchtung, in Ann. Brasil. Gynec., Rio de Janeiro 1936, pp. 255-83); of J. G. Holt (in Nederl. Tijdschr. v. Geneeskunde, 1941, 8 Nov., n. 45); etc. In Stecher's book (op. cit. in bibl., p. 106 ff.) a long observation made in a married couple over fully 17 years of practice of the method is reported; despite 3000 coitions only three conceptions result: one before the beginning of the application of periodic continence, the other two (at an interval of 16 months and of 3 and a half years) deliberately obtained. Prof. C. G. Hartman, of the Carnegie Institution of Washington, in Birth Control Review (May 1933), affirms, on the basis of experience, that the method of periodic continence well applied gives at least as much security as the most widely propagandized contraceptive methods suggested by American marriage counseling centers. Since these are facts that unfold on the biological plane and therefore subject to all the alternatives of fluctuating variability, and to the interference of all individual, social, cosmological causes capable of acting continuously on the vital manifestations of the subject, there is no doubt that it is not possible to fix in an absolute manner, with a numerical index, the percentage of probability of success of the method. For it one can speak of 100% success, as of 90% (Dickinson) or of 80% (Dervaique and Seguy) or of far higher deviations, if applied badly or in particular conditions, which only the physician can evaluate and master (physical health of the woman, conditions of equilibrium of her sexual, neurovegetative, endocrine, higher neuro-affective functions). One can conclude, therefore, positively on the value of the method of periodic continence and ascribe the failures reported, in some common cases, to the causes mentioned above, outside the guidance of the specialized physician.

4. Moral question

Without any doubt the Church has always condemned all those forms of neo-Malthusianism that aim at birth control by vitiating the natural mechanism of the marital act (v. NEO-MALTHUSIANISMO). But in reality, the method of periodic continence cannot fall directly under such condemnations, given that in it, apart from the voluntary choice of the periods of physiological periodic sterility, the performance of the act takes place according to the natural process, without the intervention of extraneous elements that intrinsically vitiate it. For this reason the morality and the possible licitness of the acts performed, rather than with regard to the particular means employed, turns on the end that the subject proposes to himself, on the motives by which he is moved and the circumstances in which it takes place. Now, granted that the subject makes use of marriage according to the natural order established by the Creator, he may use it even if the end does not coincide with the primary one (procreation), but the one he proposes is objectively honest or corresponds to the secondary ends of marriage (increase of mutual love, mutual help, satisfaction of the instinct, etc.). Such circumstances render without doubt generically licit the use of marriage, indifferently in any period and even in those circumstances in which the woman is certainly sterile, such as pregnancy and after menopause has occurred (and more generically the CIC, can. 1068, states: Sterilitas matrimonium nec dirimit nec impedit). This, however, particularly for some moralists (P. Salsmans in Ephemerides Theologicae Lovanienses, 1934, pp. 562-70) cannot lead straightaway to admitting the licitness of periodic continence, inasmuch as in it there exists the particular positive moment of the choice of certain days and the deliberate exclusion of others, in order to avoid procreation; in this way the hierarchical relations of the ends of marriage would be altered, placing the secondary ones to prevail over the primary.

Already, however, the majority of moralists (I. P. Gury, A. Ballerini, H. Noldin, A. Lehmkuhl, P. Gasparri, I. Ferreres, E. Génicot, J. Ubach, A. Vermeersch, F. Hürth, etc.) admit the licitness of periodic continence, which does not invalidate the object of marriage, but only changes its subjective circumstances, whereby the matter of judgment with regard to licitness becomes the intention, the motives that determine it and the circumstances in which it is carried out (cf. A. Vermeersch, Periodica de re morali, 1934, p. 241). Still for the past, two replies of the Sacred Penitentiary (years 1853 and 1880) must be remembered; in them it is said «inquietandos non esse» those spouses who limit the use of marriage to those periods in which fecundation is more difficult or impossible, provided they do nothing to impede conception.

But every discordant opinion of moralists must at present be considered annulled in the face of the clear judgment given repeatedly and authoritatively by the Pontiff Pius XII in the address to the participants in the Congress of the «Unione Cattolica Italiana Ostetriche» (29 Oct. 1951): «If the carrying out of the theory is to mean nothing else than that the spouses may make use of their marital right even on the days of natural sterility, there is nothing to object to; with this, in fact, they do not impede or prejudice in any way the consummation of the natural act and its further natural consequences... If instead one goes further, that is, permitting the conjugal act exclusively on those days, then the conduct of the spouses must be examined more attentively... If the limitation of the act to the days of natural sterility refers... only to the use of the right... the moral licitness of such conduct of the spouses would have to be affirmed or denied according as the intention of constantly observing those times is based, or not, on sufficient and sure moral motives. The mere fact that the spouses do not offend the nature of the act and are also ready to accept and educate the child who, despite their precautions, might come into the world, would not by itself suffice to guarantee the rectitude of intention and the unexceptionable morality of those motives... The marriage contract, which confers on the spouses the right to satisfy the inclination of nature, establishes them in a state of life, the married state. Now to the spouses who make use of it with the specific act of their state, nature and the Creator impose the function of providing for the preservation of the human race. This is the characteristic service that constitutes the proper value of their state, the bonum prolis... Therefore to use continually the faculty proper [to the married state] and licit in it alone, and, on the other hand, always and deliberately to withdraw, without a grave motive, from its primary duty, would be to sin against the sense of conjugal life. From that obligatory positive service serious motives can exempt them, even for a long time, indeed for the entire duration of the marriage, such as those that are had not infrequently in the so-called medical, eugenic, economic and social «indication». From this it follows that the observance of the infertile times can be licit from the moral aspect; and in the conditions mentioned it really is such. If, however, there are not, according to a reasonable and equitable judgment, similar grave reasons personal or deriving from external circumstances, the will habitually to avoid the fecundity of their union, while continuing to satisfy fully their sexuality, cannot derive except from a false appreciation of life and from motives extraneous to right ethical norms» (AAS, 43 [1951], pp. 845-46). And in the subsequent address to the «Fronte della famiglia»: «The Church knows how to consider with sympathy and understanding the real difficulties of married life in our days. Therefore in our last allocution on conjugal morality we affirmed the legitimacy and at the same time the limits, in truth very broad, of a regulation of offspring which, contrary to so-called «birth control», is compatible with the law of God. One may even hope (but in such a matter the Church naturally leaves the judgment to medical science) that this may succeed in giving that licit method a sufficiently sure basis, and the most recent information seems to confirm such a hope» (AAS, 43 [1951], p. 859).

BIBLI: R. De Guchteneers, Les variations cycliques de la fécondité féminine, in Rev. franç. de gynéç. et d'obstr., Parigi 1913, pp. 138-57; id., A propos de la continence pérol., in Saint Luc médical, Bruxelles 1939, n. 3, pp. 194-207; K. Ogino, Conception period of women, Harrisburg (USA) 1934; J. N. Smulders, Periodiche Onthouding in het Huuselijk, 7ª ed., Nijmegen-Utrecht 1934; A. Mayrand, Un problème moral: la continence pérol. dans le mariage, suivant la méthode Ogino, Coublivie 1934; H. Knaus, Die period. Fruchtbarkeit und Unfruchtbarkeit des Weises, Vienna 1935; L. Latz, The Rhythm of sterility and fertility in women, Chicago 1935; A. Gennaro, De period. contin. matrimon., Torino 1938 (trad. it., ivi 1947); L. Oldani, Una questione viva. Ancora della contin. period. nel matrim., in La Scuola Catt., 67 (1939), pp. 363-67; J. Pujula, De medicina pastor., Torino 1948, pp. 58-66; P. Babina, Fecondità et infecondità nel matrim., Milano 1949; L. Seremin, Diz. di morale profession. per i medici, 4ª ed., Roma 1949, pp. 358-68; J. E. Georg, Agenesi e fecondità nel matrim., Torino 1950; A. Boschi, Nuove quest. matrim., 3ª ed., ivi 1950; A. Niedermayer, Handbuch der speziellen Pastoralmedizin, II, Vienna 1950, pp. 1-93 (s. periodica), pp. 95-153 (s.); G. B. Guzzetti, Sguardo stor.-mor. ai problemi della popolazione, in La scuola catt., 79 (1951), pp. 283-343; A. Stecher, Contin. period. nel matrim., Firenze 1951; A. Lanza - P. Palazzini, Theol. mor., Append. De castitate et luxuria, Torino Roma 1953, pp. 69-86; v. bibl. alle voci: MATRIMONIO, uso del; NEO-MALTHUSIANIEMO: NASCITE, controllo delle.

Giuseppe de Nino