It is shown by statistical data that the age at which puberty occurs, the age, that is, at which the menstrual flow begins, has a relation to sterility; and the same is true as regards the age at marriage. In the former connexion, women in whom puberty is comparatively early, are less often sterile than those in whom puberty is comparatively late. Emmet, in an investigation embracing 2330 cases, showed that in our climate the average age at which the first menstruation occurred was 14.23 years, and that in the case of women who subsequently proved fertile, the first flow took place on an average 26 days earlier than in the case of women who subsequently proved barren. We also learn from Emmet’s tables that the mean duration of menstruation and the mean quantity of the flow are larger in fertile than in barren women.
As regards the influence of the age at marriage upon fertility, in women who marry between the ages of 20 and 24 years, sterility is most infrequent; it is commoner in women who marry between the ages of 14 and 20; after the age of 25, the proportion of sterile women increases with each year to which marriage is postponed.
Premature atrophy of the ovaries, with consequent incapacity for ovulation, may occur in a great variety of conditions; it has been observed in scrofula, diabetes, rickets, phthisis, and malarial cachexia; it also occurs in certain chronic intoxications, as from the long-continued use of opium or morphine, and from the abuse of alcoholic beverages. According to the observation of Burkart, Levinstein, and Erlenmeyer, morphinism is a condition which may be relied upon to bring about amenorrhœa and temporary sterility from cessation of ovulation. It has been asserted but by no means proved, that the long-continued administration of quinine hinders ovulation. As a result of various acute and chronic disorders, a simple atrophy of the ovarian follicles can be detected, dependent upon simple fatty degeneration; this has been seen by Grohe in children as a result of general atrophy, and also following caseous and suppurative diseases of the respiratory organs; by Slavjansky in children after chronic pneumonia and chronic dysentery, and in adults as a sequel of typhoid, and in one instance as a sequel of puerperal septicaemia.
Hyperplasia of the ovarian stroma, in slighter degrees of the affection, leads to menstrual disturbances, partly of nervous and partly of inflammatory nature, and in more severe degrees leads to sterility dependent upon the hindrances which the thickened tunica albuginea offers to the bursting of the mature follicles. Klebs believes that this anomaly is always due to a disposition acquired very early in life, and perhaps at the time when the ovaries are first developed.
Follicular cysts of the ovary, which are formed mostly at the time of puberty, and originate under the influence of menstrual congestion, from graafian follicles near to ripeness, are competent to cause sterility, owing to the pressure they exercise upon the superficially placed rudimentary follicles, leading to the atrophy of these latter. Other new-growths of the ovaries have similar effects, such as adenomata, carcinomata, dermoid cysts, cystomata, sarcomata, and fibromata. In many cases of these disorders, however, the ovarian follicles may for long periods remain unaffected; and in these instances, ovulation, menstruation, and even conception, may proceed undisturbed. Even in cases in which a neoplasm attains a great size, if it affects one ovary only, ovulation may occur normally in the other, and conception may ensue; and even in the diseased ovary, if small portions of its tissue remain unaffected, ovules may be discharged from these portions. The minutest portion of healthy ovarian tissue, though all the remainder has been destroyed by disease, may suffice to bring about conception.
Ovarian tumours appear with considerable frequency to be complicated with sterility; but in such cases the question always remains open, whether in the majority of instances the sterility is to be regarded as the cause or as the consequence of the ovarian disease. Boinet’s figures dealing with this problem are the most striking of all. He states that of 500 women with ovarian tumours, 390 were childless. But these results are challenged by other observers. Veit’s estimates, based upon a compilation of the figures of Lee, Scanzoni, and West, is that 34% of women with ovarian tumour are sterile. On the other hand, Negroni’s collection of 400 cases of ovarian tumour, including both married and unmarried, contained 43 only who had never been pregnant. Other lists show: 13 sterile women among 45 suffering from ovarian tumour (von Scanzoni); 1 sterile among 21 (Nussbaum); 8 sterile among 63 (Olshausen). Winckel, among 150 sterile married women, found 32 suffering from ovarian tumour, which in two of these cases only was bilateral. Atlee, in 15 cases of ovarian tumour, observed premature cessation of menstruation at the ages of 30, 39, 40 and 42, respectively.
Although in many cases sterility develops coincidently with the growth of an ovarian cystoma, yet in many other women such tumours have no influence in diminishing fertility. Martin in a case in which sterility existed in connexion with a unilateral ovarian cystoma, the other ovary being healthy, observed pregnancy as a sequel of the removal of the diseased ovary. In one of these cases, after removal of the ovarian cystoma, Martin punctured in the other ovary a dropsical follicle which had attained nearly the size of a walnut. Pregnancy in this case also followed the resumption of marital intercourse. Müller reports that in his clinique within recent years pregnancy complicated with ovarian tumour has been observed in 7 instances; in one of these cases the pregnancy occurred notwithstanding the fact that the new-growth was so large as almost to fill the abdominal cavity. Holst reports the case of a multipara 43 years of age who died in the 18th to the 20th week of pregnancy; at the post mortem examination the left ovary was found to be transformed into three cysts each the size of an apple, whilst in place of the right ovary was a medullary carcinoma the size of a man’s head; on neither side could a trace of normal ovarian tissue be detected. Spiegelberg, in a woman who died shortly after giving birth to her second child, found that both ovaries were transformed into myxo-sarcomatous tumours; in a woman aged 42, who died four weeks after her eleventh confinement, both ovaries were found to be transformed into nodular carcinomatous tumours each larger than a child’s head; in none of these ovaries was any normal stroma to be found. Ruge reports the case of a woman 36 years of age, who miscarried in the sixth month of pregnancy; she had myxo-sarcoma of both ovaries, one weighing 5620 grammes the other 480 grammes.
All these cases indicate that, notwithstanding the existence of extensive degeneration of both ovaries, some minute remaining fragment of healthy ovarian stroma is competent to produce normal mature ova—a fact which has often been proved also by microscopical examination. That under the influence of pregnancy, existing ovarian tumours often take on extremely rapid growth, is also indicated by some of the above cases.
Castration (oöphorectomy, spaying, Battey’s operation), the removal of both ovaries, naturally results in sterility. If in the literature of the subject cases are to be found in which, after this operation, not menstruation merely, but even pregnancy has occurred, this is to be explained either by the fact that in the stump there was left a fragment of the ovary, still containing tissue capable of producing mature ova; or else by the existence of a supernumerary ovary. Schatz reports the case of a woman in whom pregnancy occurred after double oöphorectomy. In the month of February, 1880, this operation was performed on a girl twenty years of age; she married in April, 1884; and in May, 1885, she was delivered of a mature female infant. The history of the case and the details of the operation showed clearly that the left ovary had been completely removed, with the outermost third of the left Fallopian tube; the right ovary was cut away in such a manner that a strip of tissue of at most two millimetres (one twelfth of an inch) in width was left in the body, whilst the right Fallopian tube was left intact. This case teaches us that the smallest remnant of the ovary is competent to render normal pregnancy possible; and further, that a small size of the ovary no more constitutes a hindrance to the proper reception of the ovum in the Fallopian tube, than does an abnormally large size of the ovary, or an unusual shape of this organ.
Miklucho-Mackay relates that among the indigens of Australia the removal of the ovaries is often practised, in order to create a special kind of hetairæ incapable of becoming mothers. McGillivray saw at Cape York a native girl whose ovaries had been removed because she was a congenital deaf-mute, with the object of preventing her giving birth to deaf-mute infants. In the beginning of the last century there existed in Sayn-Wittgenstein a small religious sect whose custom it was always to conclude their religious services by indiscriminate carnal union among the members of the community; when women and girls were first admitted as members of this sect, an attempt was made to render them unfitted for conception “by means of a painful and dangerous compression of the ovaries.” (Ploss.)