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

by E. Heinrich Kisch

Incapacity for Incubation of the Ovum.

The fertilization of the ovum is, as previously described, probably effected in man, as in other mammals, in the upper third of the Fallopian tube. The fertilized ovum is then swept down into the uterus by the action of the cilia which line the tube, assisted by the peristaltic movement of the muscular wall of the canal. The uterine mucous membrane at this time is thickened and thrown into folds, and in these latter the fertilized ovum is entangled; by its presence the ovum now exerts a reflex stimulus leading to a still greater proliferation of the cells of the uterine mucous membrane, which grows up over the ovum and soon shuts it off completely from the uterine cavity. Thus the ovum comes to be entirely imbedded in the substance of the mucous membrane.

Thus for the implantation of the ovum, it is first of all necessary that the uterine mucous membrane should be in a normal condition; pathological changes in this membrane, and indeed any morbid structural alteration in the uterine tissues, may prevent the implantation and incubation of the ovum, and may thus give rise to sterility.

The uterine cavity is normally lined with ciliated epithelium, the cells of which have an elongated elliptical form. The movement of the cilia is directed downwards. The epithelium is perforated by the orifices of the uterine glands; these glands are simple tubular glands, passing through the mucous membrane with an S-shaped or corkscrew curve; between the glands lies a rich germinal tissue, made up of rounded cells. The rounded connective tissue cells have processes which build up the scaffolding of the mucous membrane. Among the connective tissue cells of the uterine mucous membrane, wandering leucocytes are almost always to be seen. Menstruation is characterized by a swelling of the mucous membrane, and by enlargement of the uterine glands. At the same time, blood extravasations appear between the more superficial layers of the membrane, and on its free surface, and various portions of the surface of the membrane are cast off.

Very numerous are the morbid states of the uterus and its annexa whereby the implantation and incubation of the ovum are prevented; and incapacity of the uterus for the fulfilment of these functions is therefore a common cause of sterility in women.

That developmental defects of the uterus, even when they are not such as render conception impossible, may yet often give rise to sterility, has been already explained in writing of the conditions of the uterus which prevent the contact of ovum and spermatozoon; for defects of development which are not sufficiently severe to prevent this contact, may yet suffice to render the uterus unfit for the implantation and incubation of the fertilized ovum. Inflammatory disorders, such as perimetritis and the formation of exudations in the parametrium, may render the uterus unable to undergo the enlargement necessary to pregnancy. Tissue changes in the uterine musculature may likewise prevent the implantation of the ovum, or the proper development of the uterus during pregnancy. New-growths of the uterus or its neighbourhood may bring the development of the fertilized ovum to an untimely conclusion. Above all, however, it is diseases of the uterine mucous membrane which unfit the organ for the implantation of the ovum, and thus give rise to sterility. All those inflammatory states which lead either to softening or to induration of the uterine parenchyma, or to swelling and thickening of the endometrium or parametrium, may offer a hindrance more or less serious to the normal incubation of the ovum.

The diagnosis whether in an individual case we have to do with sterility dependent upon impotentia gestandi, is often difficult, because the conditions which cause it are frequently associated with those which cause sterility by preventing the contact of ovum and spermatozoon. In any case, a careful examination of the pelvic organs must be made, not only to determine whether there is any displacement or enlargement of the uterus, chronic metritis or perimetritis, parametric exudations, or new growths of the uterus or of neighbouring organs, but also, if necessary by dilating the cervical canal, to ascertain the condition of the uterine mucous membrane, and whether there is hyperplasia or atrophy thereof. In this connexion, examination of the uterine secretion is of especial importance: a purely mucous, transparent, vitreous, tenacious secretion in the os and in the cervical canal, indicates the existence of catarrhal endometritis; a markedly haemorrhagic secretion signifies hyperplastic endometritis; profuse purulent secretion containing gonococci, indicates gonorrhoeal endometritis; the discharge of pieces of membrane shows that there is exfoliative endometritis; the discovery of fragments of carcinomatous tissue indicates the breaking down of a malignant tumour of this nature; etc.

Finally, it is necessary to obtain a careful history of the case, asking whether there have been menstrual irregularities, or miscarriages, and the characters of previous labours (in cases of acquired sterility); any pathological conditions in other organs should be investigated; and the condition of the blood and the state of general nutrition should receive attention. Chlorosis, anæmia, and scrofula often give rise to catarrhal endometritis; severe disease of the heart may lead to congestive troubles of the genital organs; after abortion or difficult labour, chronic metritis or endometritis are common. Further, the differential diagnosis between erosion and carcinoma of the portio vaginalis, must often depend upon consideration of the patient’s age and general health, and upon the nature and duration of the haemorrhage. Pain on micturition, appearing soon after marriage, and lasting often a few days only, will indicate the probability of gonorrhoeal infection, etc.

Von Grünewaldt has vigorously insisted upon the fact that the notion of sterility, i. e., impotentia generandi in women, is not coincident with the notion of impotentia concipiendi, and there is an important distinction between cases in which it is impossible that fertilization should be effected, and cases in which, though fertilization may take place, the implantation and incubation of the ovum fail to ensue. In this author’s opinion, the only absolute mechanical hindrance to the entrance of the semen is to be found in atresia of the genital passage, and the role of impotentia concipiendi is of quite minor importance as compared with incapacity on the part of the uterus for the implantation and incubation of the ovum, an opinion, which, notwithstanding the record of exceptional cases in which pregnancy has occurred in spite of the existence of mechanical obstacles to conception, I must regard as altogether beyond the mark. On the other hand, it is indisputable that for the occurrence of pregnancy it is necessary, not only that contact of ovum and spermatozoon should be possible, but further, that the uterus should be in a condition favourable for the implantation and further development of the ovum subsequent to fertilization. For this reason, diseases of the uterine tissues must play an important part in the causation of sterility, though we cannot go so far as to admit with von Grünewaldt that these diseases are the principal cause of reproductive incapacity in women.

Various metritic processes, and also venous hyperaemia consequent upon heart disease, may lead to atrophy of the uterine mucous membrane, which then appears thin and smooth, whilst the uterine glands are destroyed, or transformed into small cysts. The same condition may result from retention of secretions in the uterine cavity—hydrometra and haematometra. In all these cases, the epithelium probably loses its cilia. The process has a serious influence antagonistic to the reproductive capacity inasmuch as the implantation of the chorionic villi is rendered difficult (Klebs).