Fertility Medicine & Downton Abbey

-Spoilers for season 3-

Apparently, I’m a big fan of Downton Abbey.

I started watching 3 weeks ago and now I’ve seen every episode. Now, I only wish I’d waited until they finished the whole series because after watching three years worth in three weeks, I feel like I’ve sprinted into a brick wall, having come to a sudden halt.

So now I have nothing to do, except dissect the episodes just watched.

Anyone who has seen the drama series knows what an important role medicine has played on the show. Medicine has helped establish characters, and it has affected their lives, for better or for worse.

Of course, anyone in the medical field can find fault with the portrayal of medicine according to the entertainment industry. Some are merely dramatic devices with little resemblance to real life.

Through the first three seasons, we have seen, we have seen:

Heroic / successful therapies:

• Mrs. Crawley directing the withdrawal of fluid from around the heart of a local farmer
• Mrs. Patmore’s successful cataract surgery
• Mary’s fertility surgery

Failed therapy:

• Mr. Bates’ miserable experience with a leg brace

Missed diagnoses:

• Mrs. Crawley telling Molesley that he has erysipelas
• Dr. Clarkson diagnosing Matthew with a severed spinal cord
• The famous Doctor, Sir Philip saying Sybil did not have early signs of eclampsia

Sudden tragedies

• Cora Crawley’s miscarriage induced by soap
• The Spanish flu conveniently eradicating the lovely and loving Lavinia Swire

And even this is not a complete list… However, for the purposes of keeping this short, I’m only going to discuss a few of these events, the ones that have something to do with infertility — things which can disrupt the family lineage.

First…. We’ll talk about Matthew’s spinal bruising missed diagnosis.
Second…. Miscarriage by soap? What’s up with that?
Finally… Exactly what was the surgery Mary had that suddenly rendered her fertile?

Matthew’s Spinal Cord Bruising

Background: Matthew Crawley, a distant cousin to Lord Grantham, has his life changed dramatically when the original heir and son both die in the icy Atlantic waters when the Titanic sinks. Matthew learns that he is heir to the title of Earl of Grantham and all the wealth that comes with it. There are only a few things that stand in his way to perfect happiness including, but not limited to: 1) the woman he loves hates him (but not really), 2) there is a war to survive, 3) this guy claiming to be Patrick shows up again, 4) infertility.

Keeping up? Good.

So Matthew, now Captain Crawley, is bravely serving his country in the trenches and leads his troops on a valiant charge toward the German lines. Running toward the German guns, Matthew and William (Matthew’s war servant – a whole topic in of itself) are critically injured. William will die and Matthew will learn he has a severed spinal cord, meaning he will never walk again…. and worse…. he will never have children or even be able to “fully” be a husband.

Despite the tragedy and his feelings of uselessness, Matthew learns something about the enormous capacity of others to love him. Lavinia pledges her love for him, the same pledge Mary would make … if she could.

Love saves Matthew from total despair.

Then what seems like a miracle happens. He regains his ability to stand, to walk. And Dr. Clarkson is forced to admit that he’d made a mistake about Matthew’s diagnosis. The spinal cord was merely bruised, and not severed. It seems Matthew has been fully restored. The only lingering concern, for Matthew, is whether this injury will have affected his ability to have a child.

So what about this?

Medical Reality: First off, at the end of World War I, there was no adequate therapy to help Matthew achieve a pregnancy. Some men with paralysis are able to achieve orgasm with vigorous stimulation. However, this varies with the level of the spinal injury and Matthew’s injury seemed too high to make this likely, and even if he could have had an orgasm, artificial insemination was vanishingly rare during the 1920’s. So Matthew’s prognosis was correct.

As for the paralysis and recovery itself…. it’s highly improbable that Matthew would be paralyzed for so long and then return to normal. (And by highly improbable, I mean…. inconceivable.) Spinal cord bruising results in short-term paralysis, hours to days – not the months depicted in the series.

If I were going to write a board examination question about this case, it would read:

Despite the improbability, I’m sticking with D.

Cora Crawley’s Pregnancy and Miscarriage

Background: Despite what must have been at least 15 years of unprotected intercourse, Cora Crawley had not conceived a child after her daughter, Sybil was born. In fact, she was transitioning to menopause, when she was discovered to be pregnant! This is just what Lord Grantham had been hoping for, another chance at a male heir of his own.

Dr. Clarkson explained how all of this happened to the astonished Lord and his wife, saying that age-associated menstrual changes can bring about a sudden “surge” in fertility. He also said there was no reason to believe that the baby would not be healthy.

Then tragedy strikes. O’Brien, Cora’s maid, misinterprets several conversations and wrongly believes that she is going to be fired. In a moment of spite, O’Brien hands Cora the wrong bar of soap during Cora’s bath… and within minutes Cora has lost the baby. We learn that it was a healthy boy.

Medical Reality: By all accounts, Cora would be in her 40s when this child was conceived. Since the 1950s, it has been well known that natural fertility actually declines with age. However, it is easy to understand why Dr. Clarkson might say some women have a sudden “surge” in fertility.

Due to elevations in FSH, some women who did not ovulate frequently on their own, may start to ovulate when this occurs. Elevations in FSH can also increase the chance of twins. So Dr. Clarkson is not completely wrong about this “surge.” His statement was consistent with what was generally known at that time.

Also, during this time, it was not widely recognized that older women had more “dyskyesis” or recurrent miscarriage – probably in part because pregnancies were actually more rare in this age group. So Dr. Clarkson’s assumption that the baby should be healthy was based on general medical knowledge and possibly by the tendency of the time to not alarm patients.

So what about soap and miscarriage?

The soap in question is almost certainly lye soap, which is harsh by today’s standards and thus not used much today. It is true that lye injected into the uterus was used as an agent to induce abortions, but soaping up with lye (even in a tub) would not be the cause of her abortion.

The likely cause of the miscarriage was either genetic abnormality of the baby, or perhaps Cora had developed an incompetent cervix or a uterine fibroid that made her more prone to miscarriage.

O’Brien did not cause Cora’s miscarriage, but certainly her foul heart justifies her horror and guilt over the whole affair.

Mary’s Fertility Operation

Background: So Matthew and Mary were having trouble conceiving. Despite reassurances from Dr. Clarkson, Matthew is worried that the spinal cord bruising that temporarily paralyzed him has affected his fertility. He secretly steals away to London to meet with a fertility specialist. He has just received further reassurance when he sees his wife checking into the same clinic under an assumed name.

It turns out, the problem is not “him.” It is “her.” She’s had an operation and now getting pregnant should be easy. In the very next episode, one year later, she is clearly pregnant and the couple is in what seems like endless bliss.

I’ve got to say that all of this struck me oddly. What was this operation? Why was the doctor so confident? Was he so confident, or was his reassurance the custom of the times? What was really known about fertility during these times?

Medical Reality: As long as women ovulate, her tubes are open, and the husbands have sperm, pregnancy can occur. Given the duration of their relationship, as long as they had those three things, they had a good chance of conceiving.

Tilted uterus: This is not a cause of infertility, but a small abdominal incision could alter the direction of the uterus without much risk to the patient and likely without harming her fertility.

Fibroids: During the 1920s, surgery to remove fibroids was being performed, mainly because of bleeding. A prominent medical text mentions that “sterility” can be caused by fibroids, but the actual association was unclear. Using techniques of the day, two experienced operators reported that only 1 in 94 women became pregnant after myomectomy (removal of a fibroid). Given the high risks and low rewards, this was not likely the surgery.

Blocked fallopian tubes: This could have been diagnosed and treated. But even today, repair of fallopian tubes or removal of surrounding scar tissue does make a patient good prognosis for pregnancy.

Ovarian cysts: These were rightly thought to cause a decrease in fertility. Removal or drainage of a cyst (or even an ovary) might improve pregnancy rates.

The bottom line is that three of these surgeries might have been performed. The best prognosis surgeries at the time would have been tilted uterus (little risk of harm) or ovarian cyst removal. Most likely, all Mary and Matthew needed was just more time.

After all, for many couples, even in the world of infertility — time is the a great healer.

So what now?

Mary has a son. I am no expert in British law, but I imagine this baby boy is now the rightful and most direct heir to become the next Earl of Downton.
There is a lingering medical plot twist that could dramatically affect the Downton lineage. Namely, will Patrick Crawley show back up? Will his amnesia prove to be real? Let’s hope nothing happens to the child, because I don’t want to see that guy again.