All that these figures prove to an unbiassed judgment is, however, that displacements of the uterus are apt to render conception difficult; or that, in addition to other pathological states of the pelvic organs, they are frequently met with in sterile women—but in and by themselves, displacements of the uterus do not offer any very serious or very frequently occurring obstacle to conception.
That conception is possible in spite of the very notable mechanical hindrances which certain displacements of the uterus may offer to the occurrence of pregnancy, is shown by many striking examples in gynecological literature. Winckel, Olshausen, and Holst have all seen pregnancy occur in women who at the time of conception were wearing intra-uterine pessaries; and von Scanzoni has published cases in which fertilization took place, notwithstanding extreme anteversion which stenosis of the os uteri, and in another instance, notwithstanding the presence of a polypus filling the external os.
Myoma of the Uterus.
Among the mechanical obstacles to conception which act by preventing or rendering difficult the contact of spermatozoon and ovum, must be enumerated uterine myomata, and these must therefore be included among the causes of sterility.
According to their number, their size and their situation, uterine myomata give rise to different and manifold mechanical disturbances. When there are numerous intramural myomata, even when these are of a moderate size, the uterine cavity becomes bent and narrowed, and retention of the secretions may ensue, often lasting for a lengthy period. Submucous fibromyomata, when situated low down, near the internal os, may occlude this orifice completely; when implanted higher up in the uterine cavity, they are apt to cause flexion of the uterus; large, pedunculated fibromyomata of the uterus may descend into the vagina and narrow this passage.
Myomata interfere with conception in very various ways. Mechanically, they may occlude the uterine orifices of the Fallopian tubes, or may give rise to displacement of either tubes or ovaries, or, again, by blocking the uterine cavity, they may hinder the descent of the ovum and the upward passage of the spermatozoa; their presence may cause catarrhal disease of the uterine mucous membrane, or give rise to profuse hemorrhage, and either of these secondary changes may interfere with the implantation of the ovum; and there is yet another way in which myomata may interfere with conception, and give rise to sterility—this is a subject to which especial attention has been given by Winckel, and to which we may here most conveniently allude. The continued growth of small submucous myomata often gives rise to a hyperæsthetic state of the genital organs analogous to vaginismus, and this interferes with coitus. Large myomata, on the other hand, give rise to catarrhal states of the uterine cavity and to hyperplasia of the mucous membrane, constituting hindrances alike to conception, and to the implantation and further development of the embryo if fertilization should be effected; moreover, the growth of large myomata often causes perimetritis, perisalpingitis, and perioophoritis, and these, partly by abnormal fixation of the uterus, and partly by closing up the tubes and so thickening the tunics of the ovary as to prevent the rupture of the graafian follicles, give rise to sterility.
The existing statistics regarding the relation of the growth of myomata of the uterus to fertility, incomplete as they are and lacking in exactitude, suffice nevertheless to show that the fruitfulness of women suffering from uterine myomata is notably diminished by the growth of these tumours; more particularly, we learn that whilst the number of women with uterine myomata who have one child is sufficiently large, the number of multiparae thus affected falls greatly below the average of fertility. A characteristic feature of the influence of myomata in producing sterility is clearly shown by the statistics, inasmuch as pregnancy is comparatively common in the case of women with subserous myomata, in whom the uterine cavity and mucous membrane are as a rule least affected, whilst fertility is far more seriously impaired in the case of women with submucous myomata.
West, in the case of 43 married women with myomata of the uterus, found 7 childless; the remaining 36 had in all given birth to only 61 children, and 20 of these had only one child each. Of Beigel’s patients, 86 married women with uterine myomata, 21 were sterile; of McClintock’s 21 patients similarly situated, 10 were sterile. Von Scanzoni’s investigation showed 38 sterile women among 60 married women suffering from myoma uteri; Michel, 26 sterile among 127; Winckel, 134 sterile among 415. From a table showing the number of children born to each of 108 women with myoma uteri of whom 46 were observed by Winckel, and 62 were in Süsserott’s collection, it appears that on an average 2.7 children were born to each woman thus affected, whereas in Saxony the average number of children born to each married woman is 4.5.
Many other gynecologists have published statistics regarding this matter, Gusserow, Röhrig, Schröder, E. von Flamerdinghe, and others, some of them dealing with a very large number of cases, and all show that 30% and upwards of married women with uterine myomata remain sterile.
On the other hand, Hofmeier maintains, in opposition to the prevailing view, that in the great majority of cases myomata are not to be regarded as giving rise to sterility. His investigation embraced 313 persons, of whom 25% were unmarried, and 75% married, and of these latter, 25 to 30% were sterile. (It must be pointed out that compared with the average percentage of sterile marriages—about 10%, this figure of 25 to 30% is a very high one.) From a comparison of the age of the sterile married woman with the duration of married life in each case, Hofmeier is led to believe that it is not the myomata which have exercised an influence unfavourable to fertility, and that the occurrence of sterility in these cases is referable to other causes. The origination of myomata he regards as etiologically independent of the exercise or non-exercise of the sexual act. The apparently overwhelming preponderance of the occurrence of myomata in unmarried and in sterile married women is, he thinks, to be explained by the fact that unmarried women and nulliparous married women seldom have occasion to consult a gynecologist, but that the one condition that renders it necessary for them to do so is the growth of a uterine myoma. Generally speaking, pregnancy seldom occurs after the age of 35 years, precisely the age at which the growth of uterine myomata begins to be common. If, however, at this comparatively late age pregnancy does occur, it is so often found to be complicated by the presence of a uterine myoma, that Hofmeier is even led to infer that the presence of such a tumour must have a certain favouring influence upon the occurrence of conception; the facilitation of conception in these cases he explains by the fact that the growth of the tumour renders the blood-supply of the whole reproductive apparatus more active than is normally the case, and protracts the duration of ovarian activity.