Part 77

The fertilization of the ovum is, as previously described, probably effected in man, as in other mammals, in the upper third of the Fallopian tube. The fertilized ovum is then swept down into the uterus by the action of the cilia which line the tube, assisted by the peristaltic movement of the muscular wall of the canal. The uterine mucous membrane at this time is thickened and thrown into folds, and in these latter the fertilized ovum is entangled; by its presence the ovum now exerts a reflex stimulus leading to a still greater proliferation of the cells of the uterine mucous membrane, which grows up over the ovum and soon shuts it off completely from the uterine cavity. Thus the ovum comes to be entirely imbedded in the substance of the mucous membrane.

Thus for the implantation of the ovum, it is first of all necessary that the uterine mucous membrane should be in a normal condition; pathological changes in this membrane, and indeed any morbid structural alteration in the uterine tissues, may prevent the implantation and incubation of the ovum, and may thus give rise to sterility.

The uterine cavity is normally lined with ciliated epithelium, the cells of which have an elongated elliptical form. The movement of the cilia is directed downwards. The epithelium is perforated by the orifices of the uterine glands; these glands are simple tubular glands, passing through the mucous membrane with an S-shaped or corkscrew curve; between the glands lies a rich germinal tissue, made up of rounded cells. The rounded connective tissue cells have processes which build up the scaffolding of the mucous membrane. Among the connective tissue cells of the uterine mucous membrane, wandering leucocytes are almost always to be seen. Menstruation is characterized by a swelling of the mucous membrane, and by enlargement of the uterine glands. At the same time, blood extravasations appear between the more superficial layers of the membrane, and on its free surface, and various portions of the surface of the membrane are cast off.

Very numerous are the morbid states of the uterus and its annexa whereby the implantation and incubation of the ovum are prevented; and incapacity of the uterus for the fulfilment of these functions is therefore a common cause of sterility in women.

That developmental defects of the uterus, even when they are not such as render conception impossible, may yet often give rise to sterility, has been already explained in writing of the conditions of the uterus which prevent the contact of ovum and spermatozoon; for defects of development which are not sufficiently severe to prevent this contact, may yet suffice to render the uterus unfit for the implantation and incubation of the fertilized ovum. Inflammatory disorders, such as perimetritis and the formation of exudations in the parametrium, may render the uterus unable to undergo the enlargement necessary to pregnancy. Tissue changes in the uterine musculature may likewise prevent the implantation of the ovum, or the proper development of the uterus during pregnancy. New-growths of the uterus or its neighbourhood may bring the development of the fertilized ovum to an untimely conclusion. Above all, however, it is diseases of the uterine mucous membrane which unfit the organ for the implantation of the ovum, and thus give rise to sterility. All those inflammatory states which lead either to softening or to induration of the uterine parenchyma, or to swelling and thickening of the endometrium or parametrium, may offer a hindrance more or less serious to the normal incubation of the ovum.

The diagnosis whether in an individual case we have to do with sterility dependent upon impotentia gestandi, is often difficult, because the conditions which cause it are frequently associated with those which cause sterility by preventing the contact of ovum and spermatozoon. In any case, a careful examination of the pelvic organs must be made, not only to determine whether there is any displacement or enlargement of the uterus, chronic metritis or perimetritis, parametric exudations, or new growths of the uterus or of neighbouring organs, but also, if necessary by dilating the cervical canal, to ascertain the condition of the uterine mucous membrane, and whether there is hyperplasia or atrophy thereof. In this connexion, examination of the uterine secretion is of especial importance: a purely mucous, transparent, vitreous, tenacious secretion in the os and in the cervical canal, indicates the existence of catarrhal endometritis; a markedly haemorrhagic secretion signifies hyperplastic endometritis; profuse purulent secretion containing gonococci, indicates gonorrhoeal endometritis; the discharge of pieces of membrane shows that there is exfoliative endometritis; the discovery of fragments of carcinomatous tissue indicates the breaking down of a malignant tumour of this nature; etc.

Finally, it is necessary to obtain a careful history of the case, asking whether there have been menstrual irregularities, or miscarriages, and the characters of previous labours (in cases of acquired sterility); any pathological conditions in other organs should be investigated; and the condition of the blood and the state of general nutrition should receive attention. Chlorosis, anæmia, and scrofula often give rise to catarrhal endometritis; severe disease of the heart may lead to congestive troubles of the genital organs; after abortion or difficult labour, chronic metritis or endometritis are common. Further, the differential diagnosis between erosion and carcinoma of the portio vaginalis, must often depend upon consideration of the patient’s age and general health, and upon the nature and duration of the haemorrhage. Pain on micturition, appearing soon after marriage, and lasting often a few days only, will indicate the probability of gonorrhoeal infection, etc.

Von Grünewaldt has vigorously insisted upon the fact that the notion of sterility, i. e., impotentia generandi in women, is not coincident with the notion of impotentia concipiendi, and there is an important distinction between cases in which it is impossible that fertilization should be effected, and cases in which, though fertilization may take place, the implantation and incubation of the ovum fail to ensue. In this author’s opinion, the only absolute mechanical hindrance to the entrance of the semen is to be found in atresia of the genital passage, and the role of impotentia concipiendi is of quite minor importance as compared with incapacity on the part of the uterus for the implantation and incubation of the ovum, an opinion, which, notwithstanding the record of exceptional cases in which pregnancy has occurred in spite of the existence of mechanical obstacles to conception, I must regard as altogether beyond the mark. On the other hand, it is indisputable that for the occurrence of pregnancy it is necessary, not only that contact of ovum and spermatozoon should be possible, but further, that the uterus should be in a condition favourable for the implantation and further development of the ovum subsequent to fertilization. For this reason, diseases of the uterine tissues must play an important part in the causation of sterility, though we cannot go so far as to admit with von Grünewaldt that these diseases are the principal cause of reproductive incapacity in women.

Various metritic processes, and also venous hyperaemia consequent upon heart disease, may lead to atrophy of the uterine mucous membrane, which then appears thin and smooth, whilst the uterine glands are destroyed, or transformed into small cysts. The same condition may result from retention of secretions in the uterine cavity—hydrometra and haematometra. In all these cases, the epithelium probably loses its cilia. The process has a serious influence antagonistic to the reproductive capacity inasmuch as the implantation of the chorionic villi is rendered difficult (Klebs).

Hyperplasia of the uterine parenchyma, affecting either the whole organ or a large part, and characterized either by enlargement of the entire organ, or only by thickening and elongation of the cervix, may hinder the incubation of the ovum. It may be due to endometritic catarrhal processes; to venous hyperaemia, especially in cases of valvular heart disease; to subinvolution; and sometimes to excessive sexual stimulation, as in prostitutes. Both the change in the shape of the cervix, and the changes undergone by the uterine mucous membrane in cases of extensive uterine hyperplasia (it commonly becomes atrophic and discharges a watery secretion), interfere with the reproductive capacity.

In all cases of chronic metritis, the hyperaemia and hyperplasia of the uterus may give rise to haemorrhages; these sweep away the ovum, and thus lead to impotentia gestandi. And the nutritive changes in the mucous membrane that occur in chronic metritis also interfere with the implantation and incubation of the ovum. Moreover, it is well known that in these cases, even if conception is effected, abortion is extremely apt to occur, owing to the pathological state of the endometrium, which interferes with the normal development of the decidua. Haemorrhages occur in the decidua, and are followed by abortion. And further, the replacement of portions of the muscular tissue of the uterine wall by fibrous tissue, a change which is apt to occur in long continued metritis, interferes with the proper expansion of the uterus during pregnancy, and thus leads to abortion.

On the other hand, it cannot be denied that frequently enough patients with well marked chronic metritis nevertheless conceive in a normal manner, and give birth to a healthy child; and this not once only, but again and again.

As sterility due to mesometritis, von Grünewaldt classes the numerous cases in which sterility ensues upon a confinement in which the patient reports that inflammation followed delivery—or sometimes in which nothing abnormal was noticed. The results of local examination are negative: there is no displacement, no exudation or swelling, and no relevant affection of the endometrium. But the characteristic feature of these cases is, according to von Grünewaldt, that after her last full-time delivery, a woman has had a miscarriage or a premature delivery, and subsequently has been completely sterile. The degenerative process is at first partial, so that it does not prevent conception, but renders it impossible for the pregnancy to go on to full term; subsequently it extends throughout the mesometrium, and conception is no longer possible.

Cole of San Francisco regards as the most frequent cause of sterility ensuing upon a single delivery, subinvolution of the uterus, most commonly due to rising too early after delivery. He therefore considers it of especial importance after a first delivery that the physician should satisfy himself that no serious injury has been effected by the process.

Chronic endometritis is a very frequent cause of sterility: in the first place, the catarrhal swelling of the mucous membrane, which often extends from the os uteri externum to the ostium abdominale of the Fallopian tubes, offers an obstacle alike to the downward passage of the ovum and the upward passage of the spermatozoa; and secondly, in long standing cases, the large size of the uterine cavity and the smoothness of the surface of the atrophied mucous membrane, render the lodgment of the ovum in the uterus very unlikely. A further powerful obstacle to impregnation in cases of endometritis is offered by the profuse muco-purulent secretion which usually, though not invariably, accompanies that disease. This secretion, in some cases flowing freely over the surface of the membrane, but in others adhering to it with tenacity, whitish-yellow in colour, rendered cloudy by admixture of pus, or tinted red by admixture of blood, sometimes of a gelatinous consistency with a strongly alkaline reaction, contains globules of mucus, ciliated and cylindrical epithelial cells, pus corpuscles, bacteria and cocci,—and, if the endometritis is of gonorrhoeal origin, the gonococcus of Neisser. This secretion, when profuse and thinly fluid, pours out through the os, and sweeps away the semen; when tenacious and gelatinous, it fills up the dilated cervical canal above the constricted os uteri externum, and constitutes a powerful barrier to the upward passage of the spermatozoa; when purulent, it is destructive to the vital activity of the spermatozoa. The changes in the mucous membrane in cases of long standing endometritis whereby the uterus is rendered unfit for the implantation and incubation of the ovum, are the following. The epithelial cells, as usual in cases of continued catarrh, change in form, the ciliated cells disappear, and are replaced, first by cylindrical cells, later by polymorphic cells, approaching in type those of pavement epithelium. The mucous membrane is swelled, the vessels are dilated, there is hyperplasia of the glands, with a moderate amount of small-celled infiltration of the interglandular tissue (Fig. 83). Ultimately the mucous membrane undergoes atrophy, its glands disappear, it comes to resemble a thin stratum of connective tissue.

FIG. 83.—Uterine Mucous Membrane in Endometritis. (After A. Martin.) ]

Thus, in severe and long-continued endometritis, the changes that occur in the uterine mucous membrane render the implantation of the ovum and the formation of normal decidua impossible; even if conception does occur, the fertilized ovum is speedily discharged. Frequently, in cases of endometritis, there is consecutive displacement of the uterus which acts as a contributory cause of sterility. When endometritis lasts a long time, proliferation of connective tissue in the uterine parenchyma also occurs, leading often to hypertrophy of the cervix, and to stenosis of the cervical canal. Since in so many different ways endometritis may give rise to sterility, the importance that must be attached to this condition is evident.

The great significance of gonorrhoeal infection in relation to sterility in women depends, not only on the changes this disease causes in the Fallopian tubes, leading to interference with the necessary contact of ovum and spermatozoon, but further, upon the occurrence of gonorrhoeal cervical and corporal endometritis, of perimetritis, and secondary parenchymatous metritis. Still, under appropriate treatment, the inflammatory changes consequent on gonorrhoeal infection are in many cases curable, and, after absorption of the exudations and restoration of the normal nutritive conditions of the tissues, conception may take place. Fritsch, who points out that in the woman infected with gonorrhoea, sterility ensues in a manner analogous to that in which it occurs in the male (for in the latter it is not the primary urethritis, the disease of the passage, but the secondary inflammation of the testicle that leads to sterility), states that he has observed cases in which beyond question conception has occurred, notwithstanding the existence of gonorrhoeal endometritis.

In my own experience, whilst gonorrhoeal endometritis is, among inflammations of the endometrium, the most frequent cause of sterility, the place of next importance in this connexion is occupied by exfoliative endometritis, or membranous dysmenorrhœa. This name is given to a pathological condition in which from time to time, usually during menstruation, fragments of membrane, or even an entire sac-like cast of the uterine cavity, are expelled from the uterus; since this condition is apt to hinder the incubation of the ovum, it is commonly associated with sterility—a fact mentioned already by Denman in 1790, and since then confirmed by numerous observers. I have had under observation several cases of dysmenorrhœa membranacea; in two cases it existed from the time of marriage—in one case 14 years, in the other 8 years—and in both sterility was absolute. In the latter of the two cases, vigorous treatment was undertaken, even curettage of the uterus, but quite without avail. In other cases, the sterility was acquired, the membranous dysmenorrhœa having begun after the woman had already had one or more children; but as I have never seen a case in which a woman became pregnant after the development of this affection, I am compelled to regard it as one of the most severe hindrances to conception.

As a general rule, exfoliative endometritis terminates only with the onset of the climacteric age; in very exceptional cases, however, a cure may take place earlier. In cases in which this premature termination has been observed, pregnancy has been known to ensue, cases of this nature having been observed by Solowieff, Fordyce Barker, and Thomas. And recently, cases have been reported, in which the disease has returned after such a pregnancy. Fritsch, indeed, is of opinion that exfoliative endometritis does not cause sterility, and that in this disease abortion is no commoner than in other diseases of the uterus. Charpignon, Hennig, and Bordier have also observed conception occur in the course of this disease. In 42 cases of membranous dysmenorrhœa collected by Kleinwächter, pregnancy occurred in four during the existence of the disease. Löhlein also reports that, among 27 patients affected with membranous dysmenorrhœa, six became pregnant, after the symptoms had been clear and unmistakable for a shorter or longer period. Two of these patients had been already pregnant before the first appearance of the exfoliative endometritis; subsequently they became pregnant and were delivered at full term. The other four had suffered for varying periods and with varying severity from the affection, before they first became pregnant. In three of these cases curettage of the uterus was performed; but in one only, in which pregnancy ensued very speedily on the operation, could a causal connexion be inferred. In two of the cases the mothers of the patient had also suffered from the affection.

It has been asserted by B. Schultze and others that curettage of the uterus renders it difficult or impossible for pregnancy subsequently to occur. There is, however, no evidence to justify such an opinion.

Especial attention should be given to inflammatory processes in the perimetrium and the parametrium as diseases giving rise to sterility in women. They are extremely common, and at times are so insidious, running their course without giving rise either to pain or to fever, that even when very extensive, and even when they have led to the formation of secondary tumour-growths, they may yet be overlooked. Hence their pathological significance in the causation of sterility in women is still underestimated. Chronic pelvic peritonitis and parametritis may lead to the onset of sterility in various ways: changes may occur in the cervix, this organ becoming indurated, fixed, and retroposed, and painful when the uterus is moved; inflammatory changes may affect the body of the uterus, the ligaments of the ovary, and various portions of the pelvic peritoneum; displacement of the uterus may occur; one or both ovaries or tubes may be dislocated and fixed, either to the side of the uterus, or behind it, in the pouch of Douglas; all kinds of adhesions or inflammatory nodules may result from these processes. Further, in the scarred, contracted, sclerosed parametric tissue, the blood and lymphatic vessels of the parametrium are compressed, and in part obliterated, and the intimate connexion between the pelvic cellular tissue and the uterus readily leads to the onset of endometritis, whereby the implantation of the ovum is interfered with. The occurrence of sterility in cases of pelvic peritonitis and parametritis, depends in part on the indirect effects of the inflammatory exudations, and in part on the direct result of the extension of the inflammation to other regions. The perimetritis, parametritis, and pelvic peritonitis that result from gonorrhoeal infection have thus an especially disastrous influence, for the reason that in these cases cervical metritis and endometritis with blenorrhoea are commonly superadded. This is the principal cause of the almost invariable sterility of prostitutes, in whom, however, we must also take into consideration the influence of the absence of voluptuous sensation in an act which to them has become a mere matter of business. The investigations of Bandl in the post mortem room show that residues of perimetritic and parametritic inflammation are to be found in the bodies of 58.4% of parous women, and 33.3% of the bodies of women (married or unmarried) who have had experience of sexual intercourse but have never had a child. This, he thinks, is the explanation of the great frequency of childless marriages and of relative sterility in women. In the nulliparae mentioned above, Bandl commonly found an indurated, functionless, in places cicatrized, narrowed cervix, paraoophoritic and perisalpingitic residues, and morbid changes in the tubes and the ovaries. In some cases also the husbands of such sterile women were found to be affected with azoospermia. The connexion between azoospermia in men and the discovery of inflammatory residues in their childless wives, is a very intimate one. The husband at the time of marriage was suffering from an imperfectly cured gonorrhoea, and infected his wife. In the other class of cases, in which the women had had children, and subsequently become sterile, the limitation of fertility depended chiefly upon inflammatory residues in and around the ovaries and the tubes. In the majority of such cases, pregnancy is not rendered impossible, but merely difficult, for, notwithstanding the presence of very extensive inflammatory residues, the tubes are often pervious, and the ovaries fully or partially functional. Therefore, even in cases in which intrapelvic inflammation has been very severe, we must be cautious in giving a prognosis that pregnancy has been rendered impossible, for the cases in which both ovaries are imbedded completely in pseudo-membranes, or in which both tubes have been rendered impervious, are unquestionably rare.

Carcinoma of the uterus rarely causes sterility. In its initial stages, in which there is merely papillary proliferation of the portio vaginalis, or carcinomatous infiltration of the deeper layers of the mucous membrane, no hindrance is offered to conception; but even in the later stages of the disease, when ulceration has occurred, and when there is extensive necrosis of the cancerous masses, there is not necessarily any absolute impossibility of the occurrence of conception, so long as cohabitation remains possible, and no insuperable hindrance has risen to the contact of ovum and spermatozoon. The cases are numerous in which pregnancy has been observed, notwithstanding extensive carcinomatous disease of the cervix, with necrosis of the tumour tissue; and Cohnstein even asserts, though in this he goes too far, that cancer of the cervix actually favours impregnation. Among 127 cases of this kind, there were 21 in which the disease had existed for a year or more before the occurrence of conception.

Winckel summarizes in the three following propositions his experience regarding the relation between uterine carcinoma and sterility: 1. Married women form the very large majority of those affected with carcinoma of the uterus; 2. The marriage of such women has very rarely proved sterile; 3. On the contrary, the women affected with this disease have generally been exceptionally fertile.

Other tumours of the uterus cause sterility, not merely by giving rise to mechanical interference with the necessary contact of ovum and spermatozoon, but also by leading to catarrhal states and hyperplasia of the mucous membrane, which interfere with the implantation of the ovum, even when fertilization has been effected. Uterine polypi give rise to mechanical obstruction of the os uteri externum or of the cervical canal; but they predispose to sterility in an additional way, inasmuch as in a woman affected with such a new growth any vigorous bodily movement is apt to cause profuse uterine haemorrhage.

In cases of myoma of the uterus, apart from the mechanical hindrances to conception imposed by these tumours, there is also interference with the implantation of the ovum. When numerous myomata have formed in the uterine wall, the mucous membrane is usually smooth and atrophied, and discharges a watery secretion, and for these reasons the imbedding of the ovum in the uterine cavity is rendered extremely difficult. But that there is often an additional cause of sterility in cases of myomata uteri, has been shown by the researches of Schorler, who examined 822 patients affected with fibromyoma of the uterus. He found that in most of those in whom sterility was observed, the tumours were not submucous but subserous, and that the sterility was to be explained in these cases by the frequent occurrence of partial peritonitis, with its evil results to the uterine annexa.

Schorler appends the following table:

Sterile. Percentage. Of 85 women with interstitial myoma 21 24.7 Of 92 women with subserous myoma 44 47.8 Of 18 women with submucous myoma 7 38.8 Of 44 women with polypous myoma 4 9.0 Of 14 women with cervical myoma 3 18.7 ——— —— ———— 253 79 31.2