Among 57 cases of retroflexion of the gravid uterus, E. Martin found that in 6 the patient was pregnant for the first time, from which it may be inferred that the anomaly existed prior to the occurrence of conception.
That in some cases of sterility it is the retroflexion of the uterus that is to blame, is shown very clearly ex juvantibus, inasmuch as reposition of the uterus and maintenance of the organ in its proper position relieves sterility perhaps of long standing, together with all the other troubles secondary to the displacement of the uterus. As an example, I quote one case from among several of the kind of which I have notes. Mrs. N., 25 years of age, married 6 years, childless, suffers from severe dyspeptic troubles, leading to emaciation and profound depression. She has been treated fruitlessly for gastric catarrh, but has not previously been subjected to gynecological examination. I insisted on making such an examination, and found the uterus somewhat enlarged and completely retroflexed. The successful replacement of the organ was followed by the cessation of the previously constant vomiting after meals, and by the disappearance of the other dyspeptic troubles; shortly afterwards the lady became pregnant, and pregnancy ran a normal course. Since then, she has had three children; there has been no recurrence of the dyspepsia.
According to Sims, retroversion of the uterus is frequently associated with sterility. Among 250 married women who had never been pregnant, we found no less than 68 cases of retroversion; among 255 women who had had one or more children, but had then ceased to be fruitful, he found 111 cases of retroversion; and in some of these cases the retroversion was uncomplicated. Grenser and Vedeler also found retroflexion to be a common cause of sterility; the last-named, examining 7 nulliparous married women, found retroversion in 5; in these cases, however, there was associated disease of the uterus or of its environment.
Inversion of the uterus, even in the minor degrees of the affection, in which coitus is still possible, almost invariably causes sterility, owing to the occlusion of the uterine orifices of the Fallopian tubes. Moreover, in inversion of the uterus, the position assumed by the os uteri externum is such as to render the entrance of the semen almost impossible. Finally, when the uterus is inverted, the mucous membrane undergoes changes which render it unfit for the implantation of the ovum; the researches of P. Ruge show that it is thinned and that the epithelium is cast off and replaced by granulation tissue. In cases in which the inverted uterus has long projected through the genital fissure, its surface becomes covered by a multilaminar pavement epithelium; at the same time, the glandular apparatus undergoes atrophy, only the fundi of the glands being preserved, and the muscular substance is hypertrophied. None the less, in exceptional cases, which have been reported by Emmet, Macdonald, and Tyler-Smith, pregnancy has occurred after long-enduring inversion of the uterus. Lauenstein had a patient in whom an inverted uterus was replaced after a year and a half; the following week she became pregnant. Stevens saw a case in which the woman became pregnant six months after the reduction of an inversion of the uterus of nine months’ standing.
Prolapse of the uterus is seldom the cause of sterility, inasmuch as during coitus replacement of the organ is effected. It may even be said that in cases of prolapse, the low position of the uterus and the enlargement of the os uteri externum, favour the direct ejaculation of the semen into the cervical canal (likewise enlarged), and that thus the conditions are advantageous for impregnation. In fact, conception more commonly occurs in cases of prolapse than might have been anticipated in view of the various consecutive disorders apt to complicate this affection—chronic metritis and endometritis, erosion, hypertrophy of the cervix, displacement and laceration of the annexa, etc. The extent to which the capacity for conception is unfavourably affected in cases of prolapse of the uterus, is proportional to the amount of descent undergone by the uterus, for the nearer the os approximates to the vaginal orifice, the farther removed from the os will be the point at which the semen is ejaculated. In cases of complete prolapsus it has happened that coitus has been effected directly through the everted os uteri, and has resulted in conception; a case of this kind is reported by Hervey.
Unbiassed gynecological experience in no way supports the views of Sims and Hewitt regarding the frequency with which displacements of the uterus constitute mechanical causes of sterility. Sims supports his views with the figures previously quoted, from which the following table is compiled:
| No. of cases. | Anteversion. | Retroversion. | Total cases of displacement. | |
|---|---|---|---|---|
| First class | 250 | 103 | 68 | 171 |
| Second class | 255 | 61 | 111 | 172 |
| Totals | 505 | 164 | 179 | 343 |
From this it appears that in the 1st class, among 250 married women who had never given birth to a child, there were 103 cases of anteversion, and 68 cases of retroversion; whilst in the 2nd class, among 255 women, who had had children, but for one reason or another had become unfruitful earlier than the natural age for this occurrence, there were 61 cases of anteversion, and 111 cases of retroversion.
The general result of these figures is to show that two-thirds of all sterile women, without regard to the especial cause of the displacement, suffer from one form or the other of uterine displacement, and that the relative frequency of anteversions and retroversions is reversed in the two classes, the nulliparous married women, and the married women previous parous but latterly become sterile, respectively.
Hewitt similarly regards malpositions of the uterus as frequent causes of sterility. He analysed 296 cases of flexion and version of the uterus treated by him at University College Hospital during the years 1865 to 1869, partly in the wards, and partly in the out-patient department. Of these 296 women, 235 were married; 100 were cases of retroflexion, and 135 were cases of anteflexion. Of the 235, 81 had had no full-term children, 57 of the 81 having never been pregnant, and the remaining 24 having had miscarriages only. Of the remaining 154, married and parous women, a large proportion were sterile at the time when they applied for treatment; though in the years immediately after marriage they had given birth to one or more children, they had subsequently ceased to be fruitful.