Last of all, we have to speak of conception without copulation, of artificial fertilization. In consequence of the mechanical hindrances which in many cases prevent the entrance of the semen into the interior of the uterus, the idea has arisen to introduce the semen by means of instruments directly into the cervical canal, dispensing with the natural act of copulation. Experience long ago gained in artificial pisciculture, no doubt gave rise to this idea. Spallanzani and Rossi by means of a syringe injected the semen of a dog into the vagina of a bitch, the procedure resulting in impregnation. Girault appears to have been the first,[[47]] in the year 1838, to introduce semen artificially into the human uterus, if we leave out of consideration the experiment of Léseurs, who introduced a tampon moistened with semen into the interior of the vagina. The procedure employed by Girault is thus described: The patient having been placed in the position usually employed for gynecological examination, a canula resembling a male catheter with the eye in its point, and with a funnel-shaped enlargement at the opposite extremity, is introduced into the uterus, this instrument having first been prepared by moistening its interior with mucilage and filling it with semen; by insufflation, the semen is now expelled into the uterine cavity. It is stated that neither uterine colic nor any other dangerous symptom has ever been brought on by this procedure. The experiments were made at various periods between the year 1838 and the year 1861; they were ten in number, and of these eight proved successful, two unsuccessful. In the ten cases, the total number of insufflations made was twenty-one—the minimum number in any single case being one, the maximum five. In one case, the insufflation was effected immediately after the cessation of menstruation; in the majority, from one to four days after the cessation of menstruation; in one case twelve days, in one case twenty-three days, after the cessation of the flow. Gautier, instead of insufflations, has employed injections of semen, using two injections in each case, one just before menstruation was expected, the other a day or two after the cessation of the flow. Marion Sims endeavoured in twenty-seven cases to bring about conception by the injection of semen into the uterus; in one of these cases only was the desired result obtained. In this latter instance the patient was twenty-eight years of age, had been married for nine years, but had remained barren. Throughout her menstrual life, she had suffered more or less from dysmenorrhœa, often accompanied by severe constitutional disturbance, such as syncope, vomiting, and headache. Local examination disclosed the existence of retroversion of the uterus with hypertrophy of the posterior wall, an indurated, conical cervix, with stricture of the cervical canal, especially in the region of the os uteri internum. In addition to all these mechanical obstacles to conception, it was found that the semen was never retained in the vagina after coitus. Sims examined the patient immediately after coitus had taken place, but never found a single drop of semen in the vagina, notwithstanding the fact that this fluid had been ejaculated in abundance. Sim’s first care was to bring about reposition of the uterus, and to keep the organ in its proper place by the insertion of a suitable pessary. Injections of semen were then undertaken, and were continued throughout a period of nearly twelve months. In two instances, the injection was effected immediately before the onset of the menstrual flow; in eight instances it was effected at varying times (two to seven days) after the cessation of the flow. At first, three drops of semen were injected, but later only half a drop. The semen (first ejaculated into the vagina during normal intercourse) was injected by means of a glass syringe, which was kept in a vessel of warm water at a temperature of 98° F. Since during the removal of the instrument from the water and its insertion into the vagina, some fall in temperature necessarily occurred in the vagina, Sims allowed the syringe to remain for some minutes in the vagina before he drew the semen into it, in order that he might feel assured that syringe and vagina had regained the temperature most adapted to the vital activity of the spermatozoa. The nozzle of the syringe was then carefully introduced into the cervical canal, and half a drop of semen was slowly injected into the uterine cavity. For two or three hours after the operation, the patient remained lying quiet in bed. After the tenth experiment, conception ensued—the first recorded case of artificial fertilization in the human species.
With right, however, this case of Sim’s was not regarded as conclusive, since both before and after the injection, ordinary coitus had been effected, and it is therefore impossible to determine whether the fertilizing spermatozoön was one of those introduced by means of the syringe, or in the antecedent or subsequent coitus—more especially in view of the fact that by the insertion of a pessary Sims had, previously to undertaking the injections, restored the uterus to a position more suited to the occurrence of conception in the natural manner.
In a case which a priori seemed exceedingly well adapted for the performance of artificial fertilization, one of marked hypospadias in a man whose semen was abundant and contained a large number of vigorously moving spermatozoa, I saw this experiment fail, in spite of all possible care in its performance. In fact, not a single conclusive instance of successful artificial fertilization in the human species is known to me, though I have seen reports of numerous disagreeable and even dangerous results of attempts to effect it. Both parametritis and perimetritis have occurred in such cases; and semen, being a material in a state of most intense molecular movement, may be regarded as extremely liable to noxious transformations.
Sim’s procedure has been modified by other gynecologists. Thus, Courty’s plan was that during coitus the semen should be collected in a condom, fitting not too closely, from which receptacle it was drawn up into a syringe and carefully injected into the cervical canal. Pajot’s plan was that the semen should be ejaculated into the vagina in natural coitus, and should thence be pressed into the uterine cavity by means of a piston-like instrument introduced into the vagina.
In London, Harley frequently made the experiment of injecting semen into the uterine cavity, but in all cases without any result.
P. Muller, in two cases, on account of extreme anteflexion of the uterus, performed this experiment. Though the general conditions were in both cases extremely favourable, in neither instance was there any result. It must, however, be mentioned that in one of his cases only had there been any preliminary examination of the semen under the microscope.
Fritsch reports a case in which gonorrhœal secretion was injected in place of semen. Peritonitis, which for a month endangered life, was the result.
In Paris, Lutaud has earnestly advocated artificial impregnation in cases of sterility in which all other means have failed. It is obvious that it would be useless to employ this measure after the menopause, or in women in whom menstrual activity has ceased prematurely, with simultaneous disappearance of all menstrual molimina. Equally useless would it be in uterine atrophy and in cases of irremediable malformation of the female genitals. Further contra-indications, according to Lutaud, are offered by chronic pelvic peritonitis, since here, on account of the obliteration of the lumen of the Fallopian tubes, the operation is foredoomed to failure. Chronic inflammatory states of the uterus and its mucous membrane, will also render the attempt useless. Moreover, it is a condition indispensable to success that the semen to be employed shall have been examined microscopically, and shall have been found to be thoroughly healthy. The operation has the greatest prospect of success when undertaken from three to two days before the due date of menstruation. The method employed is that of Sims. If after the first attempt, the due menstruation should begin, the injection should be repeated a week after the flow has ceased; the attempt should not, however, be repeated more than about six times in all, since the probability of success rapidly diminishes with each successive endeavour. Before the operation is undertaken, the permeability of the cervical canal must be ascertained. Further, in order that the spermatozoa shall be placed in conditions in which they have the best possible chance of survival, a weak alkaline solution, such as 1 per cent. of potassium bicarbonate, should as a preliminary measure be injected into the vagina.
Lutaud thus describes the procedure he employs. Immediately after the woman has had intercourse with her husband, a Fergusson’s speculum is introduced into the vagina, the patient remaining in the dorsal decubitus. As the speculum passes in, its margin scrapes the surface of the vagina, and by this means the semen is collected in the vicinity of the cervix. The semen is then drawn up into a Pravaz syringe or an analogous instrument, such as a uterine catheter armed at one end with a rubber ball. The fluid is then carefully injected into the cervical canal, or preferably into the uterine cavity, great care being taken not to injure the mucous membrane in any way, since the slightest bleeding may nullify the whole procedure. Finally, a small tampon of absorbent cotton-wool is inserted into the os uteri externum. For some hours the woman must remain quiet in bed; the tampon is not removed for ten hours. As regards results, Lutaud informs us that he has in this way treated twenty-six cases. In twenty-two of these, failure was complete; in one case, success was partial—the patient was impregnated, but abortion occurred two weeks later; in another case, abortion occurred after three months pregnancy; finally, in two cases, success was complete.
Indications for the employment of artificial impregnation are: first, the existence of stenosis in the upper part of the cervical canal, especially stenosis from flexion, provided, of course, that other measures are contra-indicated or have been fruitlessly employed; secondly, a deleterious character of the secretion of the cervical canal; thirdly, extreme cases of hypospadias in the male. Haussmann recommends the employment of artificial impregnation in cases in which the spermatozoa are found to enter the cervical canal, but fail to pass through the os uteri internum. Whilst artificial impregnation is theoretically a sound measure, yet in the practice the indications for its performance are by no means easy to establish. For, in cases in which there is some mechanical hindrance to the contact of the spermatozoön with the ovum (and it is for such cases only that this method of artificial fertilization can properly be employed), it is often extremely difficult, and may even be quite impossible, to exclude the possibility of there being some failure in ovulation itself, or in the maturation of the ova; or, again, sterility may depend, not on the fact that no ova are fertilized, but on the fact that when fertilized they always fail, for some reason, to find a resting place in the uterus; in a word, in any case in which sterility appears to be due to mechanical obstacles to conception, it may in reality be due to some other disease which has escaped recognition, some organic disease of the uterus, the tubes, the ovaries, of the periuterine tissues.