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

by E. Heinrich Kisch

Fig. [80].—Anteflexio Uteri. After A. Martin.

As regards anteflexion of the uterus, either the congenital, uncomplicated anteflexion of the uterus, due to developmental anomaly, or the acquired form, due either to subinvolution of the uterus during the puerperium, or to parametritic or perimetritic processes,—may offer mechanical obstacles to conception, and thus give rise to sterility; sterility with anteflexion occurs especially in cases in which the anteflexion is dependent upon parametritis posterior, associated with metritis and endometritis, or when any other complication is present to make the flexion a severe one. In some sterile women, we find anteflexion associated with supravaginal elongation of the portio, and in such cases both states would appear to result from catarrh of the uterine mucosa. How frequent is the combination of anteflexion of the uterus with sterility, is shown by the figures published by Sims, who in 250 cases of congenital sterility found 103 cases of anteversion, and in 255 cases of acquired sterility found 61 cases of anteversion.

Fritsch writes in the following terms regarding the difficulty with which impregnation is effected in women suffering from anteflexion of the uterus: “In cases of anteflexion of the uterus, the vagina is remarkably long, the portio vaginalis often badly formed; the ejaculated semen flows away rapidly from the contracted vagina, without, perhaps, ever coming into contact with the portio vaginalis.” He states it as a fact that women with anteversion conceive less readily than those with retroversion of the uterus (when this latter is moderate in degree); for in slighter degrees of retroversion, the axis of the uterus is a continuation of the axis of the vagina, so that the orifice of the male urethra and the os uteri externum will be in contact during intercourse—more especially because in such cases, owing to the portio vaginalis being low in the pelvis, the vagina is short; in cases of anteversion, on the other hand, the cervix is high up, and the vagina is long and narrow. Fritsch considers that generally speaking the fact that the internal or the external os is small is of little importance; but the serious factors, those leading to sterility in cases of anteversion—apart from all other considerations—are the unfavourable high position of the portio vaginalis, the occlusion of the os by the close application of the posterior vaginal wall, and the presence of glutinous mucus in the cervical canal. Since in cases of anteflexion we very commonly find hypersecretion of the uterine mucous membrane, whilst, owing to the narrowing of the external os, the mucus is unable to flow freely away, but accumulates and becomes inspissated, we have the uterine mucous membrane covered with a tenacious coating, which may perhaps render the implantation of the ovum a very difficult matter, even though the upward passage of the spermatozoa be still possible. The clinical association of pain produced by drawing forward the portio vaginalis, with marked anteflexion of the uterus, dysmenorrhœa, and sterility, is a strikingly common one.

Schröder points out that, although sterility is common in cases of anteflexion, cases are yet seen in which, notwithstanding the existence of extreme anteflexion, conception occurs very speedily after marriage. The fact that in cases of anteflexion we have difficulty, not impossibility, of conception, explains how it is that of two women suffering from anteflexion of the same severity, one will readily become pregnant, whilst the other remains permanently barren.

Retroversion and retroflexion offer obstacles to conception chiefly in cases in which this displacement is a congenital anomaly, or when it has developed immediately after puberty; or when complications exist, especially when the retroflexed uterus is fixed by exudation. In nulliparae, these deviations backwards will not rarely be found to be the cause of the sterility. Much less often does sterility ensue when retroversion or retroflexion occurs in women who have already given birth to several children, i. e., when the displacement is a puerperal disorder; the reason why such cases are not often sterile, is to be found in the fact that the wide cervical canal favours the passage of the spermatozoa, and the softness of the tissues prevents any serious obstacle to their upward progress being offered at the angle of flexion; on the other hand, severe retroflexion in a woman who has not yet borne a child offers a serious hindrance to conception, on account of the smallness of the cervical canal, and the sharp flexion of the more rigid uterus.

In general, then, retroflexion can be regarded as offering but a slight hindrance to conception. In fact, many women with retroflexion become pregnant again and again, and may abort several times in a single year. When in parous women suffering from retroflexion, sterility ultimately occurs, B. Schultze considers that it is not the retroflexion which is primarily to blame, but rather the secondary consequences so common in this disorder: uterine catarrh; the general constitutional debility due to such catarrh, and to the accompanying menorrhagia; perimetritis, and oophoritis.

Fig. [81].—Retroflexio Uteri. After A. Martin.

Retroflexion and retroversion of the uterus occur chiefly in women who have previously given birth to children; the bend is commonly obtuse or right-angled, and above the upper end of the cervical canal; sterility in such cases, usually acquired, has a favourable prospect of cure. As Kehrer points out, sterility appears to be constant only in cases of retroflexion in which the uterus is fixed; the reason probably is that by the backward inflexion of the uterus the abdominal orifice of the Fallopian tube is dragged away from the ovary, and thus the ovum, when it is discharged from the follicle, fails to find its way into the tube.