The sexual life of woman in its physiological, pathological and hygienic aspects

by E. Heinrich Kisch

Displacements of the Uterus.

With less justice than in the case of the pathological changes in the cervix above described, it is maintained that displacements of the uterus form a very frequent cause of mechanical hindrances to conception, and thus give rise to sterility.

It certainly cannot be denied that displacements of the uterus are found very commonly in sterile women; and, on the other hand, among women with pathological flexion of the uterus, the percentage of the sterile is far higher than among women with a uterus normal in position and shape—but from these facts it would be erroneous to infer the general conclusion that displacements of the uterus offer a mechanical hindrance to conception. The casual connexion is less simple than this as a rule. In most cases in which displacements of the uterus are associated with sterility, there are additional pathological states of the uterus and its environment, relics of previous inflammation in the uterus, the uterine annexa, or the parametrium, or displacements of the uterine annexa; these changes may be either the cause or the result of the existing displacement of the uterus, and it is upon them, and not primarily upon the displacement, that the sterility depends. The accuracy of this view is proved by the experience, by no means an uncommon one, that in such cases, when the actual cause of the sterility is removed, the woman will become pregnant, although the displacement of the uterus persists.

How difficult it is, in a particular case, to determine whether the pathological anteflexion is the true obstacle to conception, or the antecedent parametritis posterior and the concomitant metritis and endometritis! How can we decide whether a retroflexion is the simple mechanical cause of sterility, or whether the latter condition does not rather depend upon complicating perimetritis and oophoritis?

On the other hand, we must not fly to the other extreme, and absolutely deny that a displacement of the uterus can be the mechanical cause of sterility. We meet with cases in which we are forced to assume that the flexion interferes both with the outflow of the menstrual blood and with the ingress of the seminal fluid. And this is true, not merely of flexion to an acute angle, often associated with infantile dimensions of the cervical canal or of the external or internal os, but also of those advanced degrees of flexion in which, doubtless in part also from the accompanying catarrh, complete stenosis of the os uteri externum has resulted. The combination of displacement of the uterus with stenosis of the cervix, is in these cases the essential hindrance to conception. When the os is reasonably large, a moderate flexion of the uterus forwards, backwards, or to one side or the other, will not often prevent conception, for the action of the muscular bands in the various ligaments of the uterus will retain the os in a sufficiently favourable position. But if a contracted os is associated with flexion, sterility is very likely; and almost inevitable, if fixation of the flexed uterus has occurred from inflammatory exudation and fibrosis in one of the broad ligaments.

That the belief that displacements of the uterus constitute an obstacle to conception is a widely diffused one, is shown by the fact that among certain nations a means employed for the prevention of pregnancy is the artificial production of displacements of the uterus.

Of the displacements of the uterus, the versions, anteversion, retroversion, and lateral version, have a more pronounced influence in hindering conception than the flexions; for, in the case of version of the uterus, the uterus moves as a whole round a horizontal axis, so that when the fundus moves in one direction, the portio vaginalis moves in the opposite. When the neck of the uterus is thus displaced, the tip of the glans penis fails during coitus to come into contact with the os uteri externum, as it normally should do, and passes into a vaginal cul-de-sac, in retroversion, the posterior fornix, in anteversion, the anterior fornix, and in lateral version the lateral fornix of the side opposite to that towards which the cervix uteri is directed. In high degrees of this malposition, the vaginal fornix covers up the os externum as with a valve. (Beigel.)

Von Scanzoni has especially insisted upon the frequency with which sterility results from chronic metritis complicated with anteversion. In 59 sterile women affected with chronic metritis, he found in 34 instances more or less pronounced anteversion, and hence was led to infer that this particular combination of disorders plays a great part in the production of sterility.

Especially frequent is sterility in cases of anteversion of the uterus, if in addition there is some contraction, even though moderate in degree, of the os uteri externum; this combination of disorders is one extremely unfavourable to the entrance of the spermatozoa into the uterus.

Flexion of the uterus offers less hindrance than version to the entrance of the spermatozoa, for the reason that in the former condition the relations between the vaginal portion and the glans penis during coitus are not affected. But when the flexion is extreme in degree, the cervical or uterine canal may at some point become absolutely impassable for the spermatozoa; and further, extreme flexion is apt to lead to the occurrence of parametritis and perimetritis. But, generally speaking, flexions of the uterus are far less often the cause of sterility, than was formerly supposed. It used to be believed that flexion of the uterus was followed by stenosis of the os uteri externum, by which the outflow of the menstrual blood and the ingress of the semen were equally prevented. It is true that infantile acute-angled flexion of the uterus is often associated with infantile stenosis of the cervical canal or of the internal or external os; and it is also true that extreme degrees of flexion associated with uterine catarrh, favour the occurrence of stenosis and obliteration of the external os; but B. Schultze rightly insists that in most of the cases in which a diagnosis is made of stenosis of the uterine canal associated with a flexion of the sexually mature uterus, the supposed “stenosis” merely represents the difficulty which has been experienced in passing the customary rigid uterine sound past the angle in the uterine canal. Still, the fact remains, that among women with uterine flexion there is a larger percentage of sterile individuals than among women whose uterus is normal.