Infertility

INFERTILITY, the inability of a mature organism to produce offspring. The cause of I. may be abnormalities either in the sex glands or in the reproductive ducts. I. is observed in cases where abnormalities exist only in the male or only in the female, as well as when these abnormalities are present in the reproductive organs of both sexes. Abnormality in the sex glands may manifest in the testicle failing to develop spermatozoa at all (see Apermatism) or forming improperly formed spermatozoa, and the ovary failing to develop eggs at all or developing improperly formed eggs. In cases where there is an absence of sex cells in one or both sexes, I. occurs due to the inability to fertilize, although in many cases the ability to copulate is preserved. In cases of abnormalities in the reproductive ducts, copulation is often possible, but the meeting of fertilization-capable germ cells is impossible (inflammation of the fallopian tubes or sperm ducts, often as a result of gonorrhea, or inflammation of the fallopian tube as a result of infection during or after childbirth, during or after abortion). In other cases, abnormalities in the reproductive ducts make not only fertilization but also copulation impossible (for example, in general underdevelopment of the reproductive ducts, underdevelopment of the vagina or penis, injury to the penis, or in the absence of erection). The absence of erection may be the result of an abnormality in the secretory function of the testicle or a disruption of the reflex function of the nervous system. Infertility due to the testicle's inability to develop spermatozoa is often observed in cases of cryptorchidism, when the testicles, not descending in humans or other mammals into the scrotum, remain in the body cavity or get stuck in the inguinal canal. The conditions causing cryptorchidism remain unclear. Very often, infertility due to underdevelopment of sex cells occurs in hybrids. In some cases, only individuals of one sex are infertile, for example, males (hybrids of zebu × yak, bison × cow, and many others); in other cases, both sexes are infertile (horse × donkey, horse × zebra). In some cases of hybridization, not only the germ cells but the entire sex gland fails to develop (hybrids of various species of ducks, pheasants, pigeons). In humans, cases of I. due to infection of the sex glands (tuberculosis of the testicles or ovaries) are known. In animals, cases of I. due to parasitic castration (parasitism of the barnacle Sacculina in the sex gland of the crab Inachus and others) are known. Very interesting experiments have shown that the underdevelopment of spermatozoa may also be related to a deficiency in the diet of specific vitamins. Mason fed rats food consisting of casein, fat, milk fat, starch, yeast, and salt mixtures. Rats on this diet grew well, but their testicles did not develop spermatozoa. The latter developed when small amounts of lettuce leaves, which contain vitamin E, were added to the specified food. As a rule, I. occurs in old organisms on the basis of the cessation of activity of the sex gland (secretory and spermato- and ovo-genic). Animal breeders often encounter I. of wild animals placed in captivity. Thus, to this day, only exceptional cases of reproduction in captivity are known for such commercially valuable animals as sable, mink, and others. Many birds (e.g., flamingos, red-breasted geese, etc.) are also infertile in captivity. The causes of I. in a wild animal in captivity are in some cases related to the presence of a strong inhibitory influence on the reflex apparatus of the sexual act from the unfamiliar environment, in other cases related to the inactivity of the sex gland, which in turn may depend on improper care and feeding. For some animals (e.g., worker bees or ants), I. is known not as an exception but as a rule. I. due to the use of artificial contraceptives during copulation is based on preventing the possibility of the fusion of egg and spermatozoon; contraceptives, for example, condoms, in some cases create mechanical obstacles for the spermatozoon to reach the egg, in other cases, such as poisons (acids, sublimate, alum, etc.) kill the spermatozoa. The fight against I. may have greater or lesser success depending on the sources of the condition. It is easier to deal with I. if it depends on defects in the reproductive ducts, whether these are mechanical injuries (surgical intervention) or disorders in the reflex mechanism (psychiatric intervention). In cases of I. due to defects in erection in the male or due to a slight malposition of the uterus, the fight against I. is possible through the use of artificial insemination. It is significantly more difficult to provide help if I. has its source in general underdevelopment of the reproductive ducts or a defect in the sex glands. The most recent successes in transplanting sex glands open up certain prospects here for restoring the lost function of the reproductive ducts and even in cases of underdevelopment of the ducts from birth. There are certain prospects (but not yet real achievements) also in the matter of replacing an unfit sex gland with a healthy, properly functioning one. The search for ways to combat I. in old organisms, caused by the fading of the function of the sex gland, has given good results, especially in the work of Steinach on rats and guinea pigs. When the spermatic duct of one testicle is ligated, it is possible to observe the revival of spermatogenesis in both testicles. With the awakening of the secretory activity of the gland and the restoration of the sexual instinct, it was possible to obtain offspring from old males who were infertile before the experiment. Such a revival of the function of an aging sex gland was also achieved by transplanting a sex gland from a young organism into an old one. In relation to females, the second method gave good results. Females infertile before transplantation due to old age again acquired the ability to reproduce. The methods of ligating the spermatic duct (according to Steinach) and transplanting testicles (according to Voronov) have found fairly wide application in medical practice, but the effect of these methods in combating senile I. has not yet been sufficiently demonstrated. In the fight against infertility in captivity of valuable fur-bearing animals, measures for preliminary taming of young animals should be considered advisable to eliminate the inhibitions created by the captive environment in animals taken from the wild; moreover, measures to ensure animals with vitamin E are advisable.

M. Zavadovsky. Infertility of marriage. Infertility of marriage (female and male) is a phenomenon by no means rare. According to old statistics by Simpson, Spencer-Wells, Duncan and others, 8-10-11% of all marriages remain absolutely infertile. If we take the number of all fertile and infertile marriages in the age group between 15 and 45 years, then according to Duncan (cited by Winckel), in various localities in England and Scotland, one infertile marriage occurs for every 6-10 fertile marriages. Other authors have approximately the same data. Thus, according to the statistics of the Prague clinic (1891-1902), infertile marriages constitute 7.5%. According to Hofmeier-14.7%; according to Lier and Ascher, out of 2,500 married women, 9% turned out to be sterile; Baisch, Kakushkin and Gimmel'farb generally accept 10% of infertile marriages. The percentage of infertile marriages is not the same everywhere. In Basel, for example, among married couples, 15.5% were childless. In Holland, Verris and Stuart out of 9,443 marriages found 13.1% infertile. In Great Britain, on average, Simpson considers 11.7%, in Glasgow and Edinburgh Duncan found 16.3%. According to French statistics, infertility of marriage is observed in 20%; according to data from Rochard (cited by Engelmann), in France out of 10 million marriages, 2 million have no children at all, and in 2 million there is only one child each. In the outpatient department of the Kyiv obstetric clinic, in 1923, out of the total number of patients with female diseases, 16% complained of infertility; in 1924-19%, in 1925-21%. In 1923, in the same clinic, 502 patients were treated as inpatients, of which 10.3% specifically for infertility; in 1924 for the same reason 16.8%. From the foregoing it follows that the already too high percentage of infertile marriages apparently has a tendency to progressively increase. Not so long ago, infertility was blamed almost exclusively on the woman. Meanwhile, the cause of infertility often lies not in the woman, but precisely in the man. Winter assumes that in one third of cases the man is the direct cause of infertility; in another third of cases - the indirect cause (infecting his wife with gonorrhea and thereby making her infertile) and finally, in the last third, infertility can be attributed to diseases and abnormalities in the development of the sexual parts in the woman. Such approximately the same figures are noted by Shuvarsky and Gimmel'farb. According to materials from the Kyiv obstetric clinic, the man is the cause of infertility in 29.7% (azoospermia-23.7%, necrospermia-6%). L. Davidson (Kyiv), developing materials from the outpatient department of the Kyiv obstetric clinic (Pisemsky), in 295 examinations of seminal fluid found azoospermia in 69 cases, i.e. 23.3% of absolutely infertile husbands. Female infertility. Under the name of female infertility (sterilitas) one should understand a condition in which a woman of childbearing age lacks the ability to conceive. For practical purposes, it is necessary to distinguish between absolute, most often congenital, and relative infertility. Absolute infertility is spoken of when conception is generally completely impossible (with congenital absence of the uterus, vagina, after removal of both ovaries, etc.). Non-absolute infertility is understood as the inability to produce a viable child (infertilitas), despite repeated and even frequent conceptions, as is observed, for example, in cases of habitual miscarriage. If a woman gives birth to one or more children and then, due to a pathological condition, becomes infertile, this is called relative, or acquired infertility. Gimmel'farb determines the number of such marriages as 5%. This includes both involuntary and voluntary (facultative) infertility. A distinction is also made between primary infertility, when fertilization of the egg has never occurred, and secondary, or acquired, infertility when a woman loses the ability to fertilize after conception. This form of infertility also includes infertility after one child (Einkindersterilitat). It is sometimes quite difficult to establish the time from which a marriage can be considered infertile. Duncan gives interesting research regarding the period in which pregnancy usually occurs after the beginning of marriage. The average interval (for Edinburgh and Glasgow) he calculated as 17 months, in 2/3 of cases pregnancy occurred within the second year; only 1/3 of women gave birth to a living child for the first time after 4 years of married life. Simpson also found that after 4 years of married life, only in exceptional cases is the first child born. According to Winkel, a married woman who does not have a child every 20 months during her childbearing age already shows a certain degree of relative infertility. Kakushkin for primary infertility considers a period of 3 years, and if fertilization does not occur within 5 years, then infertility can be considered absolute. According to old Russian legislation, a lawsuit for dissolution of marriage due to the inability of one of the spouses to marital cohabitation could not be initiated earlier than three years after the marriage was concluded. Diagnosis of infertility. To determine the cause of infertility, it is necessary to conduct a systematic objective examination of all parts of the woman's sexual apparatus, and if no definite data is obtained, it is imperative to examine the sexual capacity of the husband as well. Some (M. P. Bushmakina) recommend the method introduced by the American physician Huhner-"Spermatozoa test" (sperm test). The examination should be performed as soon as possible post coitum. The cervix is carefully exposed, and the contents of the cervical canal are aspirated with a long pipette, which is examined immediately under a microscope. If living spermatozoa are found in this content, then for this case it does not matter neither ejaculatio praecox nor absence of orgasm in the woman, nor changes in the vaginal content, and thus there is no need to examine the vaginal secretion. Next, with the help of a Brown syringe, mucus is taken from the uterine cavity. If living spermatozoa are also found here, then the assumptions about mechanical obstacles from the cervical canal fall away, and the woman is spared the unnecessary operation "dilatatio et excisio colli". In case of a positive result of the Huhner test, it is necessary to proceed to the examination of the tubes, then to the clarification of constitutional-biological and secretory causes of infertility. In case of a negative result, the lower part of the sexual tract is examined, first of all - the contents of the vagina and cervical canal, which can have a detrimental effect on spermatozoa. In parallel, spermatozoa in a condom are examined: if they are alive there, and not found in the cervical canal, then the cause of infertility is in the quality of the cervical secretion. Huhner's proposal, of course, has practical significance, but obtaining mucus from the uterine cavity with the help of a Brown syringe hardly guarantees the accuracy of the examination. - The method of isolated examination of the contents of various parts of the sexual canal was thoroughly developed by Shuvarsky as early as 1895, and for extracting the contents of the uterine cavity, a special cannula was constructed, representing a simple curved probe 3-4 mm in diameter, in which a small spoon with blunt edges is hidden. To extract the contents, the cannula in the closed state is inserted into the uterine cavity: here the spoon is extended and, after the cannula makes several movements, it is hidden back. Then the instrument is removed, and the contents are examined under a microscope. With this method, it is completely possible to examine the contents of the cervical canal in isolation. - Anamnesis can give very substantial data. Special attention is paid to menstruation. Its absence or late appearance indicates poor development of the sexual apparatus. Too early appearance of menstruation often indicates some disease of the ovaries (tumors). If the menses came late, scanty (oligomenorrhea) or are completely absent, this indicates developmental defects. Profuse menses are most often observed in diseases of the uterus (myomas, catarrhs, inflammation of the appendages). - It is very important to establish whether we are dealing with primary or secondary infertility. In both cases, treatment and prognosis are different. If a woman has given birth, then male infertility is usually excluded, although the possibility of subsequent illness of the husband is not excluded. Detailed questioning about the sexual act can explain much. The cause of infertility and in general the ability to perform the sexual act are sometimes the subject of forensic medical research. Usually it is necessary to resolve the question - is the woman capable at all of sexual intercourse and childbirth. Infertile women often complain of lack of sexual feeling (frigiditas sub coitu), as well as early or late appearance of orgasm (dyspareunia). The role of orgasm is reduced to creating conditions favorable for the onset of conception, which in a woman is expressed in periodic contractions of the uterus with the expulsion of the mucous plug of Kristeller, which, due to its alkaline reaction, has a vitalizing effect on spermatozoa and serves as a kind of ladder or bridge for spermatozoa to penetrate into the uterine cavity (Shorokhova, Shtrasman and others). Some (Keppeng) attach great importance to this in fertilization. Others (Shuvarsky) consider this unproven.

However, observations show that in women, conception can occur without any sexual arousal (rape, coitus under anesthesia, artificial insemination); in general, women suffering from frigidity become pregnant just as normal women do. Objective examination begins with the external genital parts, the function of which apparently also consists of the fact that, when closed, they help retain the seminal fluid in the vagina. Shuvarsky observed that immediately post coitum the genital slit is covered by slightly swollen lips. The sphincter cunni and the musculature of the vaginal walls are often in a special tonic state that prevents the direct outflow of semen. Sometimes, 2-3 hours after the sexual act, the sphincter cunni, upon first touching the external genital parts, relaxes, and the contents of the vagina are discharged in a relatively large quantity (5-6 cubic cm). Those women who have old ruptures with prolapses of the genital organs constantly complain of the backflow of seminal fluid. This, of course, can be a cause of Infertility. One of the relatively frequent causes of Infertility in women is the spasmodic contraction of the external genital organs and generally the symptom complex which, since the time of Sims, has been called vaginismus. There may be no visible anatomical changes in this condition. In other cases, phenomena characteristic of vaginismus are observed with pointed condylomas, hyperesthesia of the hymen, vulvitis, and generally with inflammatory phenomena (pseudovaginismus). Removal of the hymen or removal of condylomas followed by systematic dilation of the vagina with a Kusco speculum or tubular speculums often brings quick relief. In pronounced vaginismus, the prognosis is worse, and here serious strengthening treatment is required. Infertility in women is sometimes observed with large tumors of the external genital organs, such as fibroma, elephantiasis, with underdevelopment, with adhesion and fusion of the external genital parts, with atresia of the hymen, with kraurosis of the genitals, etc. The mentioned phenomena sometimes make the entrance to the vagina so narrow that immissio penis becomes impossible. Treatment is surgical. It should be noted, however, that immissio penis is not absolutely necessary for conception to occur. Under favorable conditions and with very viable spermatozoa, conception can occur after external coitus. The vagina as an organ intended for the sexual act and reception of semen comparatively rarely serves as a cause of Infertility. The vagina may be absent altogether, which of course leads to infertility. Changes in the shape and size of the vaginal tube, a vagina that is too short and narrow with flat vaults or too long a vagina—all these, as expressions of infantilism, can cause infertility. Pronounced stenoses and atresias, large fibromas, cancers, and other neoplasms can also lead to infertility. A double vagina, cysts usually do not prevent conception. Fistulas, vesicovaginal and rectovaginal, usually lead to infertility. Here, first of all, aesthetically unfavorable conditions for sexual life are created, and then also all sorts of complications, including amenorrhea. The pathological secretion of the vagina is destructive to the spermatozoa and thus prevents conception. The physiological function of the uterus in the act of conception is to give the spermatozoa a free passage into the upper parts of the fallopian tube, and then to prepare suitable ground for the implantation and further development of the fertilized egg. For this purpose, the uterus must first have the correct anatomical structure. It goes without saying that such severe developmental defects as a rudimentary uterus without a cavity or a child's uterus are absolute obstacles to conception. But clinicians attach particular importance to abnormalities in the development of the vaginal part, where conception is generally possible but Infertility is also far from uncommon. Elongation or, conversely, atrophic shortening of this part of the uterus, a long thin cervix with a trunk-like shape of the anterior lip and an eccentrically located os, a hard conical cervix with a narrow os and an anteflexed uterus—all these in one way or another hinder the onset of conception. It is very difficult to imagine that such a menstruating uterus would present a mechanical obstacle (narrowing, thick mucus plug) for the passage of the spermatozoa, the diameter of which is 2-3 times smaller than that of an erythrocyte. S. Rechmensky and Ya. Polonsky found that in a conical cervix, the vaginal secretion has significantly greater acidity than in normal conditions. This occurs because with a conical cervix, the uterine and cervical secretions enter the vagina in very limited quantities and do not have time to neutralize the vaginal contents. From this, the effect of empirically proposed operations (laminaria, bougies, incision of the cervical canal and os, operation of Defontain, etc.) becomes understandable. By dilating the cervix, they facilitate the secretion of alkaline mucus and thus facilitate the passage of spermatozoa from the vagina into the uterus. Cervical catarrhs, especially of infectious origin, metritis, myomas, metropathies based on irregularities in sexual life (condoms, coitus interruptus, etc.) are often accompanied by Infertility. Diseases of the uterine tubes (mainly their inflammation) are the most frequent cause of sterility in women. The gonorrhea plays the main role here, which in half of all childless marriages must be considered the causative factor of Infertility. Severe pathological changes in the tube with obliteration of the abdominal opening and always accompanying inflammation of the pelvic peritoneum grossly disrupt the functional activity of the tube. With bilateral involvement, absolute Infertility occurs; but even with the disease on one side, the ability to conceive is lost in most cases. If one considers that inflammation of the appendages occurs in 10-30% of all gynecological patients, it becomes understandable that in the vast majority of cases of Infertility, one must take into account inflammation of the tubes and pelvic peritoneum. All other causative factors of Infertility must undoubtedly be relegated to the background. In well-expressed cases, diagnosis presents no difficulties, but cases are also often observed where, besides tenderness in the area of the appendages, nothing else is determined. A carefully collected history confirms the inflammatory origin of the disease. Since the cause of Infertility is often the impermeability of the tubes without visible pathological changes, in all cases where there are no contraindications, it is necessary to perform tubal insufflation, and where this is accessible, also salpingography. Treatment is strictly conservative: heat in all forms, baths, mud therapy, diathermy; with exudates, massage gives excellent results (use with caution). However, a number of cases (20-30%) do not respond to resorption treatment and require surgical intervention. Surgery must also be extremely conservative. Even small preserved parts of the tube can conduct the egg into the uterus. In hydrosalpinx, salpingostomy is indicated. When excising the tubes, some perform the operation of implanting the ovary into the uterus (Pisemsky, Krupsky) by the method of Tuffier and Estes, after which pregnancy and childbirth may occur. Positive results have been achieved so far in individual cases. Diseases of the ovaries prevent conception much less frequently than diseases of the tubes. Fertilization can occur at the highest degrees of degeneration of ovarian tissue. Even bilateral cysts do not exclude the possibility of conception. Generally, in women with ovarian tumors, conception occurs much less frequently than in healthy women (Kogan). The remaining healthy areas of ovarian tissue can produce mature egg cells perfectly correctly. Only malignant tumors (papillary cysts, cancers) comparatively quickly destroy all ovarian tissue. With congenital developmental anomalies, the ovary is reduced in volume, its function is impaired; usually these anomalies are accompanied by various forms of underdevelopment of the uterus. In such cases, absolute infertility always exists. In relation to conception, the age of the woman is important. Before the appearance of menstruation, conception does not occur. But the beginning of menstruation does not yet mean that the girl's organism is fully mature for marriage. Full maturity occurs much later. According to the old Russian law, the age of 16 was considered the lower limit permissible for women to enter marriage; according to the legislation of the USSR, the age of 16 was also retained. But this age is in essence too early. The female organism develops until the age of 20; therefore, one cannot but agree with those (Maryanchik) who consider the age up to 20 years insufficient for entering marriage. Kish explains the fact that Infertility is observed much more frequently in very young women marrying between 15 and 19 years than in those marrying between 20 and 24 years, when the woman's organism is fully formed for the purposes of reproduction, by the insufficiency in the development of the sex glands.

Starting from 20 years of age, the frequency of infertility increases as women marry at an older age. The most favorable time for conception, according to Siegel, Weisenberg, and others, should be considered the first week after menstruation. Sellheim presents Siegel's table, who, based on his observations, asserts that the possibility of fertilization begins on the second day of the cycle (menstruation), when, however, it is still very small; then this possibility gradually increases until the tenth day. The most favorable chances are from the 10th to the 14th day inclusive, i.e., during the days of ovulation. From the 15th day, the curve begins to fall, reaching its maximum by the 22nd day; and from the 23rd to the 28th day, the chances for fertilization are minimal. The age at which a woman's reproductive capacity ceases has been determined by Winkel as 38 years; according to Ansell, most women stop giving birth between 39 and 43 years. According to data from the Kiev statistical bureau on the age of women who gave birth in 1925 (in Kiev and the Kiev region), it follows that the number of births before 20 years is relatively small, the most being in the age group from 20 to 30 years; after 30 years, the number of births begins to noticeably decrease until deep old age. Most interesting is the fact that births after 50 years are not a great rarity. Inflammations of the ovaries relatively rarely cause disruption of the egg-forming function. Only in infectious diseases (scarlet fever, cholera, etc.) does destruction of the follicular apparatus sometimes occur (Slavyansky). In chronic oophoritis and, especially, in perioophoritis, a delay in the release of egg cells may occur, with the formation of small cysts (small-cystic degeneration) or without them. Amenorrhea naturally occurs in old age (climax) or is observed at a younger age in exhausting diseases (tuberculosis, scrofula, chlorosis), in infectious diseases, during starvation (Bykov: amenorrhea of wartime), from nervous shocks (Vladimirsky), in mentally ill patients, in patients suffering from obesity, and finally, after X-ray irradiation of the ovaries. At present, a special type of amenorrhea that occurs after scraping and the injection of iodine into the uterine cavity, which is so often used to interrupt pregnancy, is of particular interest. The duration of such amenorrhea ranges from 2 months to several years. Cases of complete loss of menstruation (Tsomakion) have been observed. The cause of such amenorrhea may be suppression of the internal secretory activity of the ovary or improper regeneration of the mucous membrane with overgrowth of the cervical canal (false amenorrhea). Treatment—diathermy and X-ray therapy—sometimes gives good results. It remains only to mention artificial insemination as a special method for treating infertility. As a zootechnical method, it has found wide application and has given brilliant results (Ivanov). However, the observations available in medical practice are still very few and, in any case, insufficient for a final judgment on the suitability of this method on a large scale. In Russia, A. Shorokhova published 21 cases of artificial insemination with positive results in 11 (52.3%) cases, and S. Vinogradova—16 cases, of which in 6 (37.5%) pregnancy occurred. The children are born healthy and develop normally. The indication for the use of artificial insemination are abnormalities that make normal fertilization impossible by other means (e.g., developmental abnormalities, husband's impotence). The technique consists in the fact that after proper microscopic and bacteriological research, with the help of a Record syringe with a long thin silver tip, seminal fluid is injected into the uterine cavity. In this way, artificial insemination essentially differs from natural insemination, in which only spermatozoa pass from all components of the semen into the uterine cavity. Such introduction of semen can also explain the unsuccessful cases (inflammation) observed in artificial insemination. From all that has been said, it follows that female infertility is not a disease, but only a symptom of various diseases of the woman's sexual apparatus. Among these diseases, the main etiological factor is postpartum infection, and especially puerperal. All other causes of infertility are of secondary importance. The basis of diagnosis lies in the usual gynecological methods of examination. In relation to therapy, the generally accepted gynecological therapeutic means are applied. It is only necessary to emphasize that prevention in women at all periods of their life should be placed in the first place. This can achieve a great deal in reducing infertility. Lit.: Winkel F., General Gynecology, Moscow, 1911; Baisch K., Infertility (Menge C. and Opitz E. M., Handbook of Gynecology, St. Petersburg, 1914); Nakushkin N. M., Basic prerequisites for the study of the problem of female infertility, Proceedings of the VII All-Union Congress of Gynecologists and Obstetricians, L., 1927; Chertok R. A., On the etiology of infertile marriages, ibid.; Bushmakina M. P., ibid.; Polonsky Y. N. and Rechemsky S. S., On the problem of infertility with a conical cervix, ibid.; Krupsky A. I., On the problem of restoring the ability to conceive by transplanting the ovary into the uterus, ibid.; Shuvarky N. K., On the material of the doctrine of infertility, 'Journal of Obstetrics and Women's Diseases', vol. IX, no. 9, 1895; Davidson L., Materials on the problem of infertility of marriages, Kiev, 1913; Mandelstam A. E., Determination of the patency of the Fallopian tubes by pertubation according to the author's method, Proceedings of the VI All-Union Congress of Gynecologists and Obstetricians, M., 1925; Bykov S. G., On the effect of starvation on the sexual apparatus of women, ibid.; Kogan M. I., Pregnancy, childbirth, and postpartum course in ovarian tumors, ibid.; Vinogradova M., ibid.; Vladimirsky I., Amenorrhea as a result of mental trauma, ibid.; Shorokhova A. A., Artificial insemination in humans, ibid.; Kisch, Female Infertility (Eulenburg A., Real Encyclopedia of Practical Medicine, vol. II, St. Petersburg, 1909); Gimelfarb G. I., Infertility (Krivsky L. A., Handbook of Women's Diseases, vol. 3, Leningrad, 1927); Kagan S. S., The problem of population and protection of motherhood in Germany, 'Preventive Medicine', 1927, nos. 8-9; Pisemsky G. F., Diseases of the uterine tubes (Krivsky L. A., Handbook of Women's Diseases, L., 1927); Marianchik L. P., On the course of pregnancy, childbirth, and the postpartum period in young primiparas, dissertation, Kiev, 1901; Tsomakion G. F., Some observations on amenorrhea caused by scraping, Proceedings of the I All-Ukrainian Congress of Obstetricians and Gynecologists in Kiev, 1928; Ivanov I. I., Artificial insemination in domestic animals, St. Petersburg, 1910; Priming F., Handbook of Medical Statistics, Jena, 1906; Muller J., The Decline in Births, Jena, 1924; Winter G., Causes and Treatment of Female Sterility, Deutsche medizinische Wochenschrift, 1921, no. 26; Kehrer E., Causes and Treatment of Infertility according to modern viewpoints, Dresden, 1922; Greil A., Etiology of Sterility, Zentralblatt fur Gynakologie, 1925, no. 5; Sellheira H., Further Advances in Sterility Treatment, Berlin, 1927; Nurnberger L., Sterility (Biology and Pathology of Woman, edited by J. Halban and L. Seitz, vol. III, Berlin - Vienna, 1924).

G. Pisemsky. Male infertility, such a pathological condition in which a man is incapable of fertilization, despite the ability to perform the sexual act. In the legislation of antiquity, which considered the main purpose of marriage to be the continuation of the species, sexual impotence in all its forms served as an obstacle to the conclusion of marriage and a ground for its dissolution. On the other hand, male infertility still plays a major role in many countries in deciding the question of paternity. Over time, when the view of marriage as an institution intended primarily for the continuation of the species ceased to correspond to modern legal consciousness, infertility (no matter from which side it came—from the husband or the wife) ceased to have such important significance. In prerevolutionary Russia, inability to fertilize, conceive, or give birth did not, on the basis of existing laws, serve as a ground for divorce. Among a number of nationalities (Ossetians, Jews, etc.), who remained faithful to religious customs, infertility, especially in the wife, still continues to play a significant role as a ground for the dissolution of marriage. In recent times within the USSR, the question of male infertility has come to occupy an important place in civil law and is very often submitted for resolution by specialists of forensic medical examination authorities, mainly in cases related to alimony matters. Turning to the question of the etiology of male infertility, it should be noted first of all the cases of relative infertility in clinically completely healthy people. The fact of the existence of such infertility is confirmed by the fact that these persons, already having been previously married, have proven their ability to fertilize and bear children, while in a new marriage they remain infertile. Some attempt to explain relative infertility by the presence of antagonism between germ cells, by the negative chemotaxis existing between spermatozoa and the egg cell, making their combination impossible. The occurrence of relative infertility in cases of dyspareunia or when there exists sexual antipathy between spouses has also been noted. Some are inclined to explain this phenomenon by the fact that the occurrence of orgasm in the woman during the sexual act facilitates successful fertilization. The contraction of the cervix and vaginal walls at the moment of orgasm, followed by their relaxation, causes suction of the semen. Furthermore, cases should be kept in mind when semen cannot enter the vagina. In hypo- and epispadias, when the external opening of the urethra is located too close to the root of the penis, the semen flows in front of the vagina. This phenomenon can also occur in cases of markedly expressed scrotal hernias and hydroceles of the testicular tunics, which prevent sufficiently deep introduction of the penis into the vagina. This also includes cases of so-called mechanical aspermia (see), when semen cannot be ejaculated outward due to mechanical obstacles, most often in the form of a marked narrowing of the urethra. In this case, the semen is discharged in drops after the sexual act or is expelled along with urine due to its flowing into the bladder. A rarer cause of male infertility is nervous aspermia, when ejaculation does not occur due to the lack of excitability of the ejaculation center. However, the most common cause of male infertility is azoospermia (see)—in no less than 1/3 of all childless marriages. Infertility can also occur in cases of oligospermia (see). Male infertility can also occur in asthenospermia or necrospermia (see), when the spermatozoa, despite their sufficient quantity in the ejaculate, become as a result of changes in the secretion of the prostate and seminal vesicles little or completely immobile. The cause of male infertility can also be structural defects of the spermatozoa (see). Male infertility, in general, does not cause any subjective disorders. The only complaint with which patients usually come—the absence of children. The diagnosis of male infertility in the presence of developmental defects of the penis is simple. Similarly, the diagnosis of aspermia presents no difficulties. In all other cases, the diagnosis is made on the basis of microscopic examination of the unstained ejaculate obtained immediately after the sexual act. The infertile person is advised to have sexual intercourse with a condom and immediately afterward deliver the latter with its contents for microscopic examination. Semen obtained from the patient after an act of masturbation right in the laboratory was also used for research. However, according to the latest instructions of the Scientific Medical Council under the Narkomzdrav of the RSFSR, obtaining the ejaculate by means of an act of masturbation in cases of forensic medical examination is not permitted. Less reliable is the examination for the presence of spermatozoa in the secretion of the seminal vesicles, obtained by their massage. To judge the motility of the spermatozoa, it is recommended, in view of the vivifying effect of prostatic juice on the seminal threads, to simultaneously massage the seminal vesicles and the prostate gland. The prognosis in male infertility depends on the cause causing it. It is favorable in cases of nervous and, partly, mechanical aspermia. Unfavorable is the prognosis in azoospermia caused by obliteration of the seminal pathways after bilateral epididymitis. In infertility based on necrospermia, the prognosis depends on the severity of the accompanying disease of the prostate gland and seminal vesicles. Prevention of male infertility reduces to the prevention of gonorrhea and careful treatment of its complications, which are the most common causes of azoospermia and necrospermia. Therapy consists in treating the above-mentioned causal factors (see Azoospermia, Asthenospermia, Necrospermia, Oligospermia).