People Australia

Alan Grant, 1942

Dr Alan Mostyn Bradford Grant (1905-1987) was an Australian gynaecologist and researcher into the aetiology of infertility. A graduate of Sydney University, he pioneered the first male infertility clinic and the second female clinic in the world at The Women’s Hospital, Crown Street, at the time the largest maternity hospital in New South Wales; both infertility clinics were the first in Australia. Commissioned in the Australian Army Medical Corps in 1942 for service in the Pacific, he returned in 1945 to pursue pioneer research in three fields: blocked fallopian tubes, endometriosis and hormonal therapy. He was a founder member of the Fertility Society of Australia and at its inaugural meeting in 1982 his career in this speciality, which extended over a half a century, was honoured with life membership.

Early years
Dr Alan Mostyn Bradford Grant (1905-1987) was born at Parramatta, New South Wales, on 8 February 1905, eldest of three children of the Rev. William James Grant (1878-1949) and Annie Gwen Ellen Miles (1888-1951). William had graduated from Sydney University with a BA honours in Moral Philosophy and also from Camden Theological College in 1903. Having served at churches throughout Sydney, William moved with his family in 1922 to Randwick, where he served the large Randwick Presbyterian Church for twenty-six years. During this period he was Moderator of the Presbyterian Church of New South Wales, and Grand Chaplain of the United Grand Lodge of Freemasons.  Known for his radio broadcasts, he found time to teach Greek and Latin at North Sydney Boys High School, which his son attended. Rev. Grant was also later chaplain and Classical Master on the staff of the Scots College until 1929.

Alan Grant graduated in 1929 with honours from the Faculty of Medicine at Sydney University, where he later was a tutor and examiner in gynaecology and obstetrics. As a newly graduated doctor, he held an appointment at the Royal Prince Alfred Hospital as a junior resident for one year, then as a senior resident for another, after which he joined the staff of the Women’s Hospital, Crown Street, Surry Hills. However, in order to join the permanent hospital staff, he needed a specialist qualification, necessitating more years of study for postgraduate examinations, which were at that time exclusively held overseas. Thus he needed to go to Edinburgh to sit for a Fellowship of the Royal College of Surgeons (FRCS). The economic effects of the Great Depression shaped his immediate future.  Australia did not have free tertiary education and he had first to repay his parents for the years at university. The ethics of the time also dictated that no doctor could simply open a clinical practice but could only purchase an established one. Because of this, and to repay his debt, he first took the position as Government Medical Officer, Acting Magistrate and Administrator on Nauru in the South Pacific in 1932, accompanied by his wife Lily Martha Alice, née Bastin (1909-2001), whom he married that year.

The British sea captain John Fearn, a whaler, had been the first European to visit Nauru in 1798, naming it Pleasant Island. In 1888, the island was annexed by Germany, remaining a German colony until 1914, when it was captured by Australian troops. A League of Nations mandate gave its administration to Britain, New Zealand and Australia in 1923. A phosphate rock island with no natural harbour, it was mined by the British Phosphate Company; the phosphate had been discovered in 1900 by a prospector, Albert Fuller Ellis. Seven hundred Chinese workmen from Hong Kong dug out the phosphate earth, leaving a landscape of pinnacles. The Nauruans were paid per ton of phosphate mined and many owned motor cycles or cars. Grant looked after the health of 141 Europeans and 1500 Nauruans, the latter examined every six weeks for evidence of leprosy as the island’s leper colony fell under his jurisdiction, which he described in his Medical Survey of the Island of Nauru.

Nauru was 186 miles from the nearest island, and was itself tiny—only eight miles square—yet the Europeans dressed for dinner, extending formal written invitations to each other delivered by their houseboys on foot. Grant produced many typed accounts of his experiences and impressions, and these are currently in the author’s possession. In his account of Nauru Grant recorded that homes were mostly veranda, twelve feet wide with coconut mats, palms and hanging baskets of ferns. Evenings not spent reading were occupied with billiards, small bridge parties and night tennis by electric light.  The favourite drink was lime juice and soda water, sold at one halfpenny per bottle by the factory on the island.  The Nauruans were bemused by the presence of two different mission denominations, both established in 1888, whose teaching they could only differentiate with practical logic as the ‘can fish Sundays church’ (Catholic) and ‘no can fish Sundays church’ (Protestant). Grant’s parents had wanted him to be a medical missionary, but he decided against this because of what he believed were inappropriate policies of the missionaries at Nauru. The Nauruan women habitually wore skirts and coated themselves with coconut oil so that rain from the intermittent short tropical downpours would run off their skins. Missionaries, however, insisted that they refrain from using oil and wear modest ‘Mother Hubbard’ garments covering them from neck to foot. The result was that the wet clothing clung to the body: many caught pneumonia and died as a result.

Leaving Nauru after two years, the Grants sailed to England, where Alan sat for the FRCS examination in Edinburgh in 1935 and a Licentiate in Midwifery in Dublin in 1936. In another typed account Grant stated that he returned to Australia in 1936 as ship’s doctor on the M.V. Morning Star which departed ‘on Christmas Eve, to the accompaniment of blasphemies from the crew about shipping directors who sent them to sea at such a festival season’. The regulations allowed the ship’s doctor a free passage plus one shilling, a recondite regulation of the Board of Trade.  During the voyage, he was required to perform an emergency operation on a perforated duodenal ulcer with peritonitis, in the midst of a violent storm, on a wooden table borrowed from the cook’s galley. The ‘hospital’ was ten feet square situated over the propeller shaft, with no sterilisers, no gloves and no anaesthetist; in Grant’s words ‘the surgical equivalent of a desert island’.  Fortunately he had brought with him a scalpel, artery forceps and catgut in a glass tube. The fourth officer volunteered to drip ether onto lint over the patient’s face, and the patient not only survived but recovered, to the surprise of the bosun, who called in during the operation to enquire how much canvas would be needed for a decent burial, never before having seen a man recover who was operated on at sea.

In Sydney, Grant re-joined the Women’s Hospital, Crown Street in 1937 as an assistant in gynaecology and obstetrics. The hospital, which had been founded in 1893, was by 1943 the largest maternity hospital in the State, and remained so until its functions were relocated to the new Westmead Hospital. He soon realised that not everyone who wanted children was able to have them. As one woman told him, ‘Doctors tell me that I can have babies – but no babies come – and no-one tries to find out why. I have been waiting two years’. Women reported that they had seen many doctors who had all told them to be patient and relax, reflecting a common assumption that infertility was primarily due to emotional trauma. However, Grant recognised that ‘sterility causes nervous tension but nervous tension alone rarely causes sterility’. This insight motivated him to establish the Sterility Clinic at the hospital in June 1938. The free public clinic was the first in Australia and the second in the western world after the Mayo Clinic in Boston, United States of America. The subject of sterility was not at the time a priority, or even a particular concern for researchers; indeed it was widely considered a backwater of gynaecology. Grant’s clinic initially met with disinterest and disapprobation from the outpatient staff, partly because it represented more work. Projects were financed privately and the cost for steroid chemical tests was paid out of donations from grateful patients. The Hospital Board, for example, refused to allocate funds for the first culdoscope, an instrument to allow telescopic inspection of pelvic organs, so the money was raised instead by the Women’s Auxilliary.

The Army
The coming of the Second World War interrupted Grant’s pioneering work in infertility and marked another change in his career. Commissioned as a Major in the Australian Army Medical Corps (AAMC) of the 2nd Australian Imperial Forces (AIF) volunteers in 1942, he was deployed to New Guinea, the northern coast of which had been invaded by Japanese troops on 3 March that year. His brother joined the Royal Australian Navy in the Mediterranean and his brother-in-law, after the fall of Singapore, was transported to Sandakan Island POW camp off Borneo, where he died. As the Japanese had attacked the end of the Kokoda trail in July and were advancing over the Owen Stanley ranges to within thirteen miles of Port Moresby, it was decided to establish the 2/9 Australian General Hospital.

The male staff embarked for New Guinea on the SS Manunda on 14 August 1942, arriving on 23 August to find only a small cleared area in the jungle, seventeen miles from Port Moresby, where tents and hospital equipment had been deposited in huge heaps. The site extended over a narrow terrain of steep hills with erosions between steep slopes with torrents of water flowing from the bursts of rain. The entire medical, technical, kitchen and transport staff worked to knit individual tents together to form the hospital; three grass-roofed huts formed the kitchen, mess and recreation mess. Ablutions were performed in the nearby Laloki River, accompanied by a soldier with a rifle as protection from crocodiles. The AIF hospitals were moveable so as to be near the battle fronts as dressing and casualty clearing stations, their temporary nature designed to cater for the possibility of advance or retreat. Sixty-eight nursing sisters and three physiotherapists, who were initially not permitted to accompany the men due to the primitive jungle conditions of tents, ankle-deep mud and insects, arrived in October, as by then the hospital was averaging 46 admissions each day for patients with tropical illnesses and well as with wounds. The planned 600 beds expanded in three weeks to 1,200 beds. By November over-crowding resulted in ‘stacking’, as 250 ambulance stretchers were placed under the beds. By January there were over 2,000 patients. Working as a general surgeon at the jungle hospital for those wounded by snipers, Grant’s patients also included Japanese soldiers, whose infantry was not accompanied by a doctor. He lived throughout the war in a tent, forming a life-long friendship with his neighbour in the next tent, Trevor Rice, who had also volunteered, leaving a large physiotherapy practice in Melbourne. Had they still been on Nauru, Grant realised that he may have suffered a much worse fate. Invaded on 26 August 1942, the remaining Europeans and Chinese became prisoners, the others having been evacuated by a French destroyer Le Triomphant. After deporting 1,200 Nauruans to the Chuuk islands to work as labourers, the leper colony was exterminated. The 39 lepers were told they were going to another island and loaded onto a boat, which was towed out to sea. At a distance offshore gunboats sank the vessel, killing everyone on board. American planes destroyed fifteen Japanese aircraft on 25 March 1943 and in retaliation five Australian prisoners were beheaded and bayoneted. Later, some Japanese soldiers faced the War Crimes Tribunal for executions of European and native prisoners on Nauru.

Research years
Peace returned in 1945, and Grant, by now a captain, returned to civilian life in Sydney and resumed his work at the Crown Street clinic. His interest in infertility covered three main fields of investigation: blocked fallopian tubes, endometriosis and hormonal therapy. He introduced several investigative procedures, believing that only 5-10 percent of female infertility cases were due to the widely held belief of emotional trauma as the aetiology. Although artificial insemination began in 1946, the Medical Board requested that it be confined to marital donors because of unresolved legal and religious issues.  The first successful IVF in Australia would not take place until 1980. Grant introduced endoscopic procedures to infertility practice in Australia and read the first paper in Australia on the topic in 1955 at the Australian Medical Congress, published in 1956 as Culdoscopy – a New and Telescopic Method of Inspecting Pelvic Organs. The original culdoscopy procedure was finally followed, when the hospital had sufficient finance, by laparoscopy, inserting a cylinder with a light source through a small incision in the abdomen for better viewing.

Blocked fallopian tubes presented the contemporary problem that when cleared by surgery, or by using the gas CO, they frequently blocked again, or the fertilised ovum was not carried all the way to the uterus.  In these women ectopic pregnancies were between seven and eight times more common than in normal pregnancies. Tubal implantations were carried out for blocked tubes, involving the insertion of very fine Teflon rods to keep the passage open. This work earned Grant wide recognition, although because of the low priority given to infertility research in Australia this initially came from overseas. In France, for example, he was regarded as one of the five leading tubal surgeons in the world. In later research, which he reported in 1970 to the Pacific Coast Fertility Association, he recommended that diagnosis of pelvic adhesions by X-ray was preferable and more effective than the previous practice of laparoscopy.

His second major area of interest, endometriosis, is a painful condition and a cause of infertility which was often missed in diagnosis. The condition occurs when cells lining the interior of the uterus are also found in areas outside. As an alternative to surgery, Grant initiated the use of progestogens (hormonal preparations) in a successful cyclical treatment regime for 20 days, which was far cheaper than the continuous regime used previously. His first paper on this subject was written in 1961, and his research with progestogens was developed further by the pharmaceutical firm Schering AG to produce the first contraceptive pill.

The innovation of hormonal therapy for infertility began in 1963 when, returning from a visit to the United States, Grant brought clomiphene to Australia in tablet form to use for stimulation of ovulation, courtesy of the pharmaceutical firm Wm. Merrell & Co. The medication had previously only been used for cases of oligomenorrhoea, infrequent menstruation. A perfectionist in his attention to records, Grant found that clomiphene improved the likelihood of ovulation by up to 84 percent, and the chances of conception by 36 percent, results which were recorded in a 1966 paper on the subject.  Importation of clomiphene from overseas was necessary as at that time, as the Health Department did not allow the removal of pituitary glands from humans at post mortems. Gonadotrophin, a substance produced naturally by pituitary gland, was then produced industrially for the clomiphene tablets (Chlomid). The treatment Grant pioneered in Australia remains the preferred course of action to stimulate ovulation.

Following the establishment of the clinic for women in 1938, Grant opened the first male clinic in the world in 1946. This produced, in his words ‘a flutter in the dovecot’; due to objections about the presence of men in the outpatients department in a women’s hospital, the male clinic could not open before 5pm daily.  He remained clinical director of the facility until his retirement in 1965, after which he continued his work in a Macquarie Street practice until 1983. The clinic was renamed The Alan Grant Fertility Clinic in 1979.

The term ‘sterility’ had come to mean that the cause of childlessness was irremediable, while ‘infertility’ had the connotation of possible remedy: there was a universal consensus among specialists for this change. In 1982, Grant was a founder member and the first Life Member of the Fertility Society of Australia.  Its logo is the abstract ‘Foetus in Utero’ motif found in Italy on an Umbrian bronze fertility amulet, dated 7-8th century BC. The amulet was a charm against evil and was hoped to ensure personal fertility; for Romans barrenness was a valid reason for divorce.

One international sequel was an influx of visiting specialists from England and America, among them Professor Morris from Manchester, Leon Israel from Philadelphia, Robert Kistner from Boston and Professor Pendleton Tompkins from Stanford University, some of whom stayed at his home, coming to visit the male and female clinics. These were at the time unique, whereas today ‘Well Woman and Well Man Clinics’ for this purpose are commonly attached to most hospitals. Grant’s career in the development of infertility as a medical sub-speciality led to Australia being placed in a leading position in that speciality in the world. 

Secondly, researchers from the pharmaceutical firm Schering AG in Berlin, Germany, frequently came to visit Grant’s clinic: their Medical Science Department corresponded with him for over 30 years due to their interest in the use of hormonal therapy in gynaecology.  He shared his research results with them because for it to benefit a wider public it needed to be produced in tablet form.  As a further development based on his research, although it had not been his particular research interest, Schering AG produced the first oral contraceptive agent and introduced it in Australia and Europe on 1 January 1961. This was the first preparation for hormonal contraception, the ground-breaking ‘norethindrone acetate 4mg + ethinyl estradiol 50 ug’. Schering invited Grant to choose the name for the tablet, which he did, and this was ‘Anovlar’. Later, Schering AG asked him to undertake research for to produce a ‘mini-pill’: to find the minimum dosage required for contraception. However, he declined because he did not agree to experiment by prescribing an ever-decreasing dosage to patients who trusted his prescriptions to prevent pregnancy. This aspect of research using a lower hormonal dose was later studied in Belgium and in 1973 resulted in ‘Microgynon’, which is still in use.

Grant had a deep interest in medical history and literature and often cited aptly both Shakespeare and Confucius. He was awarded the Shakespeare medal for his undergraduate essay maintaining that King Lear was not mad, presenting medical reasoning as his proof. Impressed by the fact that Winston Churchill had begun painting in his seventh decade, he also produced many passable watercolour scenes at that age. His greatest pleasure, however, was the collection of innumerable letters from patients with photographs of their progeny, many with the forename of Alan or Grant, bearing testimony to the hiatus that was filled by these two pioneering fertility clinics. He believed that medical science should not forsake the minority, despite the population explosion in the world.

After his official retirement in 1965 he conducted a world-wide, hand written correspondence and continued to his 85th publication in international journals until his death on 29 April, 1987 from a melanoma, the skin cancer so common in sunny Australia. Survived by his wife Lillian and one daughter Alicia, he was buried in South Head Cemetery in Sydney. The company Schering wrote testifying to his contribution to the development of oral contraceptives. The eulogy of his colleague Dr Struan Robertson, much of which was published in the Medical Journal of Australia’s obituary, described “a man of ideas with a clear and enquiring mind” who liked a challenge, a meticulous record keeper and a perfectionist in his work. The weekly Australian Doctor named him the ‘Father of Infertility Practice’ in Australia.

His research legacy of fifty years within the Alan Grant Fertility Clinic was significant. The establishment of the first male infertility clinic and the second female infertility clinic in the world, both the first in Australia, led to the introduction of endoscopic procedures to infertility practice in Australia and to his advances in existing techniques for blocked fallopian tubes and endometriosis, as well as initiating the use of clomiphene. All were praised internationally, and recognition followed in Honorary Life Memberships of the Pacific Coast Fertility Society (USA), the American Society for the Study of Sterility and election as Vice President of the International Fertility Association of the USA 1953-6. The award of Fellowship of the Royal College of Obstetricians and Gynaecologists came in 1960. He accepted several editorial commitments and was Patron of the Marriage Guidance Council, a Foundation Member of the Australian Society for Reproductive Biology and Foundation Member of the trail-blazing Fertility Association of Australia, of which he was also a Life Member.