just how many investigations should be carried out as a routine in sterility patients. I do not .... efficiency in cases of sterility and in certain other circumstances. ... !t will be appreciated that there can be no excuse for the use of any gas other than ...
Edinburgh
Medical April
1951
THE TUBAL FACTOR IN By G.
When
I first took
D.^MATTHEW, a
Journal
FEMALE STERILITY
F.R.C.S.Ed., M.R.C.O.G.
real interest in the
subject
of female
sterility
some
three and a half years ago, I soon realised that there was a great deal to learn about the function, and the investigation of function, of the various organs concerned with reproduction. Of these, and of outinterest and
standing
importance,
are
the
fallopian
tubes.
The first
Method of acquiring knowledge is to study the writings of others and to absorb the benefits of their observations, experiences and deductions.
From such a study two facts were quickly discovered : firstly, the enormous literature which has accumulated concerning this single factor in the aetiology of sterility and, secondly, that the ability to arnve at a sound evaluation of the state of the fallopian tubes in each
individual patient must be acquired by the second method of learning, which is by personal experience. The value of this experience can be assessed only by pausing to take stock, to study a series of records to determine whether the methods of investigation employed so far have, in fact, fulfilled their purpose. The invitation to give this lecture provided the necessary stimulus and impetus to make this effort and thus the subject-matter of the lecture is based upon the experience of the last three and a half years. From the inception of the Sterility clinic within the Royal Infirmary in 1946 to the Present day, 600 patients have attended of whom 400 have been investigated by tubal insufflation on a total of 540 separate occasions. 110 patients examination of the genital tract has been made by X-ray visualisation, and 36 patients have been subjected to laparotomy. "
In
"
times there has been much controversial discussion as to out as a routine in sterility patients. I do not recollect, however, any difference of opinion as far as the necessity of investigating the fallopian tubes is concerned, n this case the argument has centred around the method of investigation and this particular battle continues to be waged fiercely in certain
just
recent
how many investigations should be carried
Before entering into any discussion of the available methods, Would be wise to consider firstly what is the precise aim and object
Quarters. *t
?f this
investigation. A
Honyman Gillespie
yOL. LVIII.
NO.
4
Lecture delivered in the 153
Royal Infirmary,
1950. L
G. D.
154
If "
MATTHEW
accept, at its face value, the commonplace phrase patency we would be misled into believing that mere
we were to
tests of tubal
"
This patency of the tubes constitutes proof of tubal efficiency. far from the It must be remembered be would truth. interpretation
that the function of the tube is to transmit the spermatozoa from the uterine end towards the abdominal ostium, and to collect the ovum from the ovary and transmit that ovum, preferably fertilised, from abdominal ostium to uterine cavity. It is still a matter of speculation as to how the ovum passes from the surface of the ovary into the lumen of the tube. Perhaps the fimbriae reach out like the tentacles of an octopus to ensnare the liberated ovum which is brought within reach by rhythmic rotatory movements of the ovary, or maybe the ovum is attracted towards the lumen of the tube by suction or by some chemical affinity. That the fimbriae are not essential for this process is proved by the occurrence of conception following tubal circumcision. The
anatomical and histological structure of the tube has received a good deal of attention in recent years and, as a result, it is realised that the passage of a foreign body, such as ovum or sperm, cannot be entirely dependent upon the ciliated epithelium as this is present only in patchy distribution and in certain selected sites in the tube. A second mechanism must play an essential role and this additional propulsive force is provided by the action of the tubal muscle. Rhythmic contractions produce waves of peristalsis passing from outer to inner ends but these are capable of reversal when the sperm enters the uterine end and requires assistance in pursuing its onward journey. There is
now ample evidence to support this contention of muscular and direct evidence can be obtained by the observation of tubal contractions during laparotomy with tubal insufflation carried On several occasions, in such circumstances, out under direct vision. I have noted alternate tubal contraction and tubal dilatation, during
activity,
flow of gas,
to be synchronous with oscillations on the Thus it is evident that tubal function entails not only patency but also activity, and I would suggest that the expression tests of tubal patency should be replaced by the more tests of tubal function." accurate phrase It is obvious that any test
constant
kymographic tracing. "
"
"
which is limited to establishing patency alone is of little value in assessing real efficiency of the fallopian tubes. That the tubal epithelium is influenced by the ovarian hormones is The cyclical changes affect all constituent now an established fact. cells of this coat, including the ciliated cells which are seen in their active state around mid-cycle, at the time of ovulation. It is reasonable to suppose that the tubal muscle is similarly subjected to most
hormonal influences which lead to alterations in sensitivity and activity during the different phases of the menstrual cycle with maximum power of propulsion occurring at the time of reception of the ovum. There is good evidence to show that the administration of cestrogens will influence the character of tubal
contractions,
but
kymographic
THE TUBAL FACTOR IN FEMALE STERILITY
records have so far failed the pattern of the
155
definite and constant change in the succeeding phases of a menstrual cycle. Tubal muscle action is also dependent upon the nerve supply, sympathetic and parasympathetic. Through this medium normal stimuli will cause normal contractions and abnormal stimuli will precipitate tubal spasm. Summing up, it can be stated that, in health, the tube as a whole, and in its constituent parts, will be influenced by various hormonal and nervous stimuli and the effect of abnormality or disease upon this ability to react will determine its to
reveal
a
graph characterising
functional
value. Tests
of
Tubal Function
Although alternative methods have been suggested from time to time, the two original tests, tubal insufflation and hysterosalpingography, have alone withstood the test of time and are universally employed at the present day with the object of determining tubal efficiency in cases of sterility and in certain other circumstances. Tubal Insufflation This test was first performed by Rubin in 1919 and so rightly his name. Originally oxygen was utilised as the medium for
bears
msufflation but this soon gave way to air and then to carbon dioxide and for many years the term " Rubin Test " has implied the use of this gas. Air and oxygen cause considerable pain from peritoneal and are associated with the grave On the other hand, the introduction of carbon dioxide causes little upset and it is rapidly absorbed and its use does not involve the danger of embolism. In view of these comparisons, !t will be appreciated that there can be no excuse for the use of any
irritation,
are
very
slowly absorbed,
risk of embolism.
gas other than carbon dioxide for this test at the present day. The test can be carried out, without anaesthesia in the out-patient department, m the large majority of cases. Utilising the lithotomy position, and
after adequate preparation and examination, the cervix is exposed' by speculum and grasped by a volsella. The uterine sound is passed
a
and this is replaced by the uterine cannula, already connected to the gas cylinder and tested. With the cannula in position and an air-tight junction with the cervix assured, the volsella is removed. After an mterval of at least three minutes and when all initial pain has subsided, gas is allowed to flow and results are observed. The way in which be observed will depend upon the type of instrument employed and nowadays there are many varieties, simple and complicated but all modifications of the original Rubin instrument. In my opinion, an instrument which permits of a regulated rate of flow of gas with controlled pressure and with kymographic recording apparatus has immeasurable advantages over any other type. In such
results
can
circumstances
not
only
evidence of tubal patency may be obtained
G. D.
156
MATTHEW
but in addition a detailed picture of tubal activity will be provided. With this record, additional information is, as a rule, not necessary, but confirmation of patency may be obtained from abdominal auscultation and percussion, and the presence of shoulder pain. During the test, the nature, site and distribution of abdominal pain is noted and considered in conjunction with the graphic record. In this way valuable information concerning the site of partial or complete obstruction is provided. These are the essential steps in the technique of insufflation but one or two additional points demand special attention. The use of antispasmodic drugs as a routine to prevent established spasm, is favoured others. by Amongst the preparations by associated with varying degrees of popularity may be mentioned pethidine, octyl nitrite and nitroglycerine. My experience of the first suggests that it is valueless whereas the other two may cause so much systemic upset that their use is undesirable particularly as it is very doubtful if they have any real value in preventing or relieving spasm. I believe that genuine spasm can be overcome in most cases spasm,
or
some
in certain cases to and discredited
overcome an
by maintaining a high pressure of gas for several minutes. In some cases of prolonged spasm a repeat insufflation may be required to establish tubal patency. Until such time as a reliable and innocuous tubal antispasmodic becomes available I have discontinued the use of all drugs of this sort. The use of anaesthesia as an aid to insufflation and in preventing and overcoming spasm has been condemned as useless
by
many authors.
My experience
is
entirely
to
the contrary.
Anaesthesia has been used in 25 patients with completely satisfactory results. Non-patency under anaesthesia has been found only in cases of proved pathological blockage whereas normal patency and activity have been revealed in several cases where previously there had been non-patency. It seems to me that two facts point to the definite value of insufflation under anaesthesia. Firstly, insufflation during laparotomy has demonstrated actual tubal contraction when the patient is
anaesthetised,
as
previously mentioned, and secondly, certainly induce spasm,
such as pain and fear, which an anaesthetic.
Results
of
emotional factors are
eliminated
by
Insufflation
The results of insufflation are assessed by a study of the kymographic record viewed in conjunction with any clinical features noted during the test. It is not always easy to interpret such findings but for the sake of description an attempt has been made to group kymographic tracings into four standard patterns. In many cases, however, there will be found an inevitable and significant variation from these standards insufflation record may well incorporate the characteristics than one pattern. (1) Normal Patency with Normal Activity.?With an initial rate of flow of from 40 c.c. to 60 c.c. carbon dioxide per minute a pressure
as
of
a
single
more
THE TUBAL FACTOR IN FEMALE STERILITY
157
of 60 to 120 mm. mercury is attained. There may then follow a fall in pressure of some resistance to up to 60 mm. mercury suggesting the initial flow of at a pressure of around flows the Thereafter gas gas. from 3 to 9 per minute 60 mm. mercury with oscillations varying in rate and with range of oscillation of from 10 to 40 mm. mercury. In such circumstances a flow of two minutes will be adequate for diagnostic Purposes and will also provide sufficient gas to cause shoulder pain. This may be experienced on either side or on both sides, but the distribution is not necessarily related to the side of tubal patency, if unilateral. If shoulder pain is severe it can be eliminated immediately
by placing
the
patient
in the prone
IG- I?"?Case ^IGNormal patency I.?Case 185. Normal normal normal activity.
and
JTjq 3- Case ?Fig- 3-?Case 336. High normal patency 336. High with with normal normal activity. ls a
or
Trendelenberg position.
Fig.
2
(a).
Fig. 2
Case 320. Eleventh day of cycle.
Fig. 4.?Case
560.
Fig.
1
(b).
Case 320. Twentieth day of cycle.
Under anaesthesia.
Normal
patency and normal activity.
of normal patency and activity. It will be noted the tubes can tolerate an increased rate of flow up to 100 c.c. Per minute without resistance. Minor differences in the appearance ?f the normal curve may be related to different phases of the menstrual tycle but the uncertainty of these findings has already been noted. resent day opinion suggests that in the first half of the cycle oscillations are Sequent and shallow and in the second half they are less frequent ^nd of greater excursion. Fig. 2, (a) and (b), indicates these differences ut it must be stressed that this variation is by no means a constant ndmg. From time to time a higher pressure is found necessary to establish and maintain flow through the tubes but as the record reveals Activity in no way differing from normal, the assumption is that the
that
typical example
rj~sistance ls
of a non-pathological nature. Fig. 3 is an example of " with normal activity. The record was normal high patency ? tained from a patient with the history of unilateral salpingectomy. eference has already been made to the effect of anaesthesia on this test. Fig. 4 is a record obtained from an anaesthetised patient and it "
shows perfectly
normal tubal function.
vol. lviii. no. 4
l 2
G. D.
158
MATTHEW
this group gas enters the somewhat raised pressure but the curve is characterised by markedly deficient, or a complete lack of, oscillations. Thus the presence of patency is established but the conclusion reached is that function is seriously impaired. Fig. 5 is an instance of total absence of contractions in patent tubes and it is believed that such a picture might be the result of one of two mechanisms. Either the power of muscular contraction is completely lost as a result of disease, with normal
(2) Patency
tubes
at
a
Impaired Activity.?In
or
the tube is incapable of responding to stimuli as a result of loss of sensitivity associated either with total ovarian dysfunction or extreme genital hypoplasia. Fig. 6 again demonstrates patency but contractions
or
Fig.
Fig.
Fig. 6.?Case 374. Normal patency with impaired activity.
Normal patency 5.?Case 387. Normal patency with no no activity. activity.
7.?Case 264. Normal patency with impaired activity.
and 31.5.48. Patency Patency and complete inactivity. inactivity.
Fig. 8.?Case 180.
are infrequent and of negligible range. This type of record is consistent with either muscular activity partially destroyed by the effects of disease or external tubal adhesions or the partial loss of sensitivity associated with oestrogen deficiency and lesser degrees of underdevelopment. Fig. 7 is a similar record obtained from a patient with extensive adhesions involving both tubes which, at
otherwise
laparotomy, appeared
healthy.
With normal tubes the rate of flow of gas may be increased to at least 100 c.c. per minute without any alteration in pressure. If an element of stenosis is added to the post-inflammatory changes then an increase in rate of flow will be accompanied by a steadily rising absence of pressure. Figs. 8, 9 and 10 show a picture of
complete
contraction with inability of the tubes to accept an increasing rate of flow. It will be noted that the repeated insufflations produced an almost identical series of records. At this stage it must be stressed that if any abnormality is discovered at the first insufflation a final
opinion
on
the state of the tubes should
is obtained from
repeated
tests.
not
be
given
until confirmation
THE TUBAL FACTOR IN FEMALE STERILITY
159
(3) Patency
with Initial Obstruction.?This term implies a rise of of normal before patency is established. It mayinvolve a rise to the maximum safety level of 240 mm. mercury before the obstruction is overcome. In some cases there will be an immediate fall in pressure whereas in others high pressure is maintained for a varying period of time before patency is produced. When the gas ultimately passes through the tubes the subsequent record may conform to either type I or type II dependent upon the functional efficiency ?f the tubes. The correlation of these records with findings at pressure in
excess
laparotomy ?r to
indicates that the initial obstruction is due either to spasm pathological blockage caused by slender adhesions within the
9-~ Case 180. 28.6.48. ^IG- 9-?Case Repeat insufflation. 180. Patency with complete inactivity. Patency with
Fig. io.?Case 180. 15.11.48. insufflation. 15.11.4S. Repeat insufflation. Patency with complete inactivity.
E3
jTlG 1lx*?Case !??Case 255. Initial obstruction followed obstruction followed by normal normal patency and activity. activity. patency and '
Initial spasm followed normal patency and activity.
Fig. 12.?Case 200.
the abdominal ostium. The high gas pressure either overcomes spasm or destroys adhesions. Perhaps the ideal antispasmodic, when it is found, will simplify the otherwise difficult
lumen
of the tube
or
at
differential diagnosis. Fig. 11 shows a case of initial obstruction, followed by normal patency and activity, characteristic (5f tubal spasm. the 12 demonstrates a minor degree of spasm and illustrates initial the once tubes the of essentially normal functional capacity obstruction has been overcome. In Fig. 13 the phase of obstruction the findings is followed by a curve exhibiting deficient activity and with associated are in disease tubal keeping with a diagnosis of adhesions of the endosalpinx.
to rise to a maximum pressure is allowed level for approxithat at remain to mm. mercury and permitted indicates chart the non-patency on line mately five minutes. A straight for which there may be one of two explanations dependent upon whether the obstruction is apparent or real. In the former case, persistent spasm provides the explanation whilst in the latter case
(4) Non-patency.?The gas
of 240
by
160
G. D.
MATTHEW
total pathological occlusion is the underlying cause. Repeated insufflations are essential for confirmation of non-patency and ultimate diagnosis of the cause. In one patient four insufflations were performed
repeated non-patency but at the fifth attempt, carried out under anaesthesia, normal patency and activity were revealed. Fig. 14 is a typical record of non-patency, later proved to be due to postinflammatory pathological changes. During insufflation, the character, position and distribution of pain will indicate the probable site or sites of blockage within the tubes. with
Dangers insufflation
Fig.
of
are
Tubal Insufflation.?Contra-indications to tubal few and are chiefly concerned with the presence of
13.?Case 443. Initial obstruction followed by normal patency and impaired activity.
Fig.
15.?Case 140. Tubal rupture. Obstruction followed by patency.
Fig. Fig.
14.?Case 392. Non-patency confirmed by_repeated insufflation. by^repeated
Fig. 16.?Case 273. Marked hypoplasia. Patency with impaired activity.
infection in various pelvic sites. To minimise the risk of introducing infection during insufflation, cervicitis must be treated before the test is performed and inflammatory disease of the tubes must be completelyeradicated in order to obviate the grave risk of exacerbation. Menstruation or other bleeding is a temporary contra-indication and the majority opinion is against insufflation during the immediate preAt this time the thickened endometrium may menstrual phase. interfere with gas flow through the cannula and it is possible that
particles of the premenstrual endometrium may be detached and forced outwards through the tubes to become lodged elsewhere. The optimum time for insufflation is considered to be between four and seven days after cessation of menstruation. If these precautions are observed,
the risks
of insufflation
are minimal. In addition to consist of embolism and rupture of they no means uncommon when air and by and several fatal cases have been recorded.
exacerbation of infection, the tube. Embolism was oxygen were With carbon
employed
dioxide, rapidity
of
absorption
almost eliminates this
Saw
Ate I.?Case ^Late I.?Case 90. 90.
1
Bilateral Bilateral
ovary. cystic cystic ovary.
Late Pt ATEIIII(?).?case
Bilateral hydrc (b).?Case494_ 494. Bilateralhydro-
film. salpinx?follow-up salpinx?follow-upfilm.
Plate II
494. Bilateral hydro(a.)?Case {a.)?Case 494. salpinx?immediate film.
Bilateral occlusion. 211. Plate III.?Case 211. Venous extravasation.
PlATE IV.?Case Pi-ATE IV,?Case 134. 134.
occlusion. Bilateralocclusion. Bilateral Venousextravasation. extravasation. Venous
Plate V.?Case 19. Bilateral ampullary dilatation and occlusion.
w%.3P, m ?"
Plate lAteVIVI(a).?Case tubal Bilateraltubal ?Case42. 42. Bilateral film. dilatation?immediate dilatation?immediatefilm.
Plate VI
(b).?Case {b).?Case
42.
Follow-up
Minimal patency of right tube.
film.
THE TUBAL FACTOR IN FEMALE STERILITY
161
and no case of fatal carbon dioxide gas embolism has been recorded. If high pressure insufflation is performed with closed tubes, rupture of the tube becomes a possibility and Fig. 15 illustrates this accident. Initial obstruction was overcome and it was believed that and activity were established. Later there was a
danger
satisfactory patency
in the circumscribed over a period of solid tumour which progressively the clinical remained ?ne year. unconfirmed, Although the diagnosis the with consistent to be diagnosis of tubal features were considered
recurrence of shoulder left side of the pelvis.
pain
and
a
boggy
mass was
This gradually resolved into diminished in size
palpable
a
rupture and haematoma formation. Hysterosalpingography visualisation of the tubes was practised in both France and America for some years before the introduction of insufflation. Since then there has been a constant search for the ideal radio-opaque medium. Judging by the large number of substances in present day Use, it is evident that this quest is not yet over. The available dyes are either too viscous, as lipiodol, with slow absorption and perhaps local tissue reaction or else they are too rapidly absorbed, as the water
X-ray
soluble preparations, and thus give unsatisfactory ill-defined pictures. ^ this test is used for the in purpose of establishing tubal activity
must be carried out under of evidence crude this In activity may be obtained. way ^ the for is used examination purpose of determining the site X-ray and nature of tubal occlusion, then a series of films, without screening, ?>Jves all the information. With the same precautions and
addition a
to
patency then the examination
screen.
necessary
in insufflation, this examination is carried out without antispasmodics, and without anaesthesia. With the patient in the position, the volsella is removed after insertion of the cannula t? which a syringe containing dye has been attached by screw connection. A screw plunger fitted to the syringe controls rate of flow and pressure. have found a mixture of fluid and viscous neo-hydriol to be the most is taken after the The first suitable of available
timing
as
lithotomy
picture
preparations.
!ntroduction of 3 to 4 c.c. and the second after a further 3 to 4 c.c. A third picture is taken after an interval of four hours to demonstrate
spill-over and peritoneal spread. In the normal patient the dye is evenly spread over the peritoneal surface. Plate I shows a variation ?f peritoneal the outline of spread. Some of the dye is seen to form This a pair of spectacles indicating coating of cystic ovaries. lagnosis was confirmed by pelvic examination and laparotomy, lates II (a) and (6) illustrate bilateral tubal occlusion with blockage at the abdominal ostium. The immediate and follow-up films give ue characteristic appearances of bilateral hydrosalpinx. Dangers of Hysterosalpingography.?As in the case of "
lnsufflation,
the main contra-indication
to
hysterosalpingography
is
G. D.
162
MATTHEW
infection and the optimum time for performing this test is between the fourth and seventh day following menstruation. Added to the risk of tubal rupture, the introduction of fresh infection, the exacerbation of existing infection and embolism, there is the
pelvic again
distinct prospect of tissue reaction to the dye which might have the undesirable effect of ultimately occluding tubes which previously were partly or completely patent. Embolism is not uncommon but is fortunately rarely fatal judging by the few deaths from this cause reported in the literature. Bilateral tubal occlusion paves the way for venous extravasation, and minor trauma of the endometrium, which is most liable to occur in the premenstrual phase, is a contributory and precipitating factor. Plates III and IV are illustrations of vascular dissemination. In each case there was bilateral tubal occlusion. In neither of the patients the vascular accident.
was
Insufflation
there any
or
systemic upset
as
the result of
Hysterosalpingography ?
Much discussion has centred around the comparative use of the I believe two classical tests of tubal function for routine investigation. that the case in favour of gas insufflation is much the stronger. From
only is clear evidence of tubal patency obtained but an accurate and precise picture of tubal activity is provided. In the case of hysterosalpingography, patency is readily demonstrated but, even with the help of screening, only crude evidence of tubal activity can be expected. Many will claim that this is sufficient for practical purposes but I believe that a strictly accurate evaluation of tubal function can be made only with the greater knowledge obtained from insufflation. Although the position and distribution of pain during insufflation may indicate roughly the site of occlusion, only X-ray visualisation can establish this point with precision. With the of the nature of the risks attached embolism, important exception to each test are essentially the same with a slightly higher incidence of the other complications in the case of hysterosalpingography, which incurs the added danger of slow absorption with granuloma formationFor this latter reason it is undesirable to carry out repeated X-ray
this
test not
examinations whereas insufflation may be performed on numerous occasions without the risk of this complication. When all these points are taken into consideration the reasonable conclusion would appear to be that there is every justification for the use of both tests in the investigation of the fallopian tubes. Tubal insufflation should be the routine procedure and this should be repeated on two or more occasions if abnormality is discovered. In cases of confirmed tubal occlusion should an X-ray examination be made for the specific purpose of site of actual determining the blockage in order that operative treatment can
be considered.
THE TUBAL FACTOR IN
Effect
of
FEMALE
STERILITY
163
Certain Specific Conditions Upon Tubal Function
Now that the
two classical tests, with their comparative merits, been described and discussed, it is necessary to outline, quite briefly, the possible effects of certain pelvic abnormalities and diseases upon the function of the fallopian tubes. Congenital Abnormalities.?Congenital abnormalities of the tube are not common and include either excessive length or excessive tortuosity. In either case the prospects of fertilisation or successful
have
transmission of a fertilised ovum may be reduced. A typical illustration ?f patently long tubes was obtained from a case of habitual abortion with the history of five consecutive abortions. It is tempting to suggest that the underlying factor in the causation of the abortions was delay xn
implantation Hypoplasia
?ne
of the
of the fertilised and
commoner
ovum.
Deficient Sensitivity.?Genital hypoplasia is pelvic abnormalities found to be associated with
sterility. Evidence of underdevelopment is to be found in the presence ?f tenting of the vagina, a flat button-like cervix and an undersized Uterus. With signs of hypoplasia elsewhere it is reasonable to suppose
that the tubes are similarly affected. In such cases the kymographic record will show the characteristic changes associated with deficient
activity, suggesting an inability of the tubal musculature to normal stimuli. Fig. 16 is a record from a patient with clear genital hypoplasia but no evidence of tubal infection. These were confirmed later at ai*e
nse in pressure.
Salpingitis.?The
pf
laparotomy.
minimal and that increase in
It will be
seen
signs of findings
that contractions
rate of flow of gas
various causes, types and
react to
causes
a
slight
pathological changes
well known to warrant detailed description but salpingitis *t is consider the end-results of infection in so far as they to necessary affect tubal function. There may be complete tubal occlusion, unilateral ?r bilateral, at any point in the course of the tube, with or without are
too
dilatation and hydrosalpinx. On the one hand, this occlusion may he due to marked pathological change following gross tubal disease. On the other hand, it may be due to filmy adhesions following upon
puld endosalpingitis. Such adhesions may be broken down by lnsufflation. In other cases patency is maintained but deficient or absent activity is the sequel to pathological change in the muscular eoat of the tube. Finally, involvement of the tubal peritoneum may result in external adhesion formation with kinking, and impairment ?f function. Fig. 17 is a record from a patient with known post-abortal Salpingitis and this shows patency with deficient activity, whilst Fig. 18 ls a record from a patient with the presumptive diagnosis of tuberculous salpingitis and this shows a complete lack of activity in patent tubes. Appendicitis.?That there is some relationship between appendicitis, or more specifically the operation of appendicectomy, and
G. D.
164
MATTHEW
sterility seems to be borne out by the frequent history of Of 600 patients with the appendicectomy in sterility patients. complaint of sterility, primary and secondary, 18 per cent, gave this history. In most cases the operation was in the nature of an emergency
female
in the presence of acute symptoms. In acute infection of the appendix it is reasonable to suppose that the inflammatory process might extend to involve the tubes, especially the right, in one of two ways. Involvement of the peritoneum covering the tubes and other pelvic organs might lead to adhesion formation with distortion of the tubes or there might be a direct extension of infection via the abdominal ostium to
give rise to a true salpingitis. In either case such tubal involvement may not be revealed for many years after the removal of the appendix, in fact, not until the patient seeks investigation for sterility. It is not beyond the bounds of possibility that, although removed by operation,
Fig.
17-?Case Patency
M. A. with
Post-abortal infection.
impaired activity.
Fig. 18.?Case 12.
Patency
Tuberculous
with
no
salpingitis-
activity.
appendix may not have been the origin of the initial symptoms. a suggestion is not a slur on the diagnostic powers of our surgical colleagues but, in fact, amounts to a condemnation of the method of surgical approach to the appendix in the female. I venture to suggest Grid-Iron that the incision should be virtually abandoned in the female and should be replaced by an incision permitting not only removal of the appendix but adequate examination of the pelvic organs. In this way direct evidence of pelvic disease might be revealed which would not only alter the immediate management of the case but also provide knowledge which would be of the utmost value in years to come. So far as the patient with suspected so-called chronic appendicitis is concerned, laparotomy should not be performed by a surgeon without, In these doubtful cases I at least, the opinion of a gynaecologist. be would it to have the abdomen explored by a that preferable suggest the finds removal who of an appendix, should this be gynaecologist For a time indicated by the findings, well within his capabilities. it was my custom to make routine inquiry from the hospital concerned As a rule the replies included a with the appendix operation. of the appendix but, with one exception, macroscopic description The there was never any information about the pelvic organs. was a patient who was already attending the sterility clinic exception
the
Such
"
"
first examination she was found to have bilateral tubo-ovarian for which conservative therapy was prescribed. Unfortunately swellings she developed acute abdominal symptoms and was admitted to a
where
on
THE TUBAL FACTOR IN
surgical
ward where her
appendix
FEMALE STERILITY
was
removed without
waste
165 of time.
Upon asking for operation details I was informed that the appendix looked fairly normal and no abnormality was detected within the pelvis. ^ had the
of examining this woman about ten days after somewhat surprised to note that the tubo-ovarian swellings were still present and, in fact, were considerably larger than Previously. Of the 112 patients who gave a history of appendicectomy 88 were investigated for tubal function. In 50 cases, or 57 Per cent., the record showed some departure from normal. Fig. 19 ls an shows initial obstruction, high patency and impaired and example
opportunity
operation and
was
kymographic
activity.
Endometriosis.?The association of endometriosis with sterility is a major problem, and one which has incurred a great deal of thought, speculation and publicity in recent years. A striking feature in itself
Fig. jqyPt
p,
^ase 19??Case
Adhesions Adhesions following Obstruction, Obstruction, high patency ^ith impaired impaired activity. activity. 410. 410.
Fig. 20.?Case 445.
aPpendicectomy. aPpendicectomy. Wlth
Endometriosis.
Normal Normal
patency and activity.
in cases of extensive involvement the tlibes are frequently patent and active. Recent papers on this subject sUggest, however, that tubal involvement, either by the actual presence endometriotic nodules or by adhesions to surrounding- structures, to be more common than was previously thought. It is difficult as such Understand why certain conservative surgical procedures, of nodules or resection of an ovary, in cases of endometriosis, ?uld be followed so frequently by successful conception. It is easier ^ exPlain the successful results following division of adhesions involving e restore tubal and tubo-ovarian or ovary, as this might well cases nctlon. As the likelihood of adhesions being present in such whom in Very great, laparotomy is advocated in all sterility patients e of endometriosis has been made, and in whom conception
?f endometriosis is that
even
e^cision .
^
diagnosis
20
Fig. occurred within the year following investigation. a case of extensive in tubes the ?Ws normal of and activity patency s
not
endometriosis subjected to laparotomy. Uterine Fibroids.?The suggestion
that the state of sterility and growth of or other paves the way for the development within r?ids institutes a knotty problem which fortunately is not and fibroids sterility e that scope of this paper. However, it is a fact which the blame are several ways in there and co-exist requently For 0r example, a fibroid sterility might be ascribed to this tumour. the that canal pathway of the so obstruct the cervical P?lypus
^mehow ,
might
166
G. D.
MATTHEW
sperm is blocked, or a submucous fibroid might cause so much congestion of the overlying endometrium that successful embedding of a fertilised ovum is prevented. Furthermore, fibroids may directly interfere with the function of the fallopian tubes. Large submucous well block the uterine entrance to the tube, or a large growth may so distort the lumen of the tube that the chance of successful penetration by sperm or ovum is seriously reduced. Whatever the explanation of the association of fibroids with sterility tumours may
interstitial
the presence of such tumours is a clear indication for conservative surgery provided that the tubes are functionally sound and that there is no other and absolute factor to account for the sterilityMany successful pregnancies have been recorded following the operation of myomectomy. Fig. 21 shows non-patency of the tubes before removal of uterine fibroids and Fig. 22 is a record from the
provided
Fig. 2i.?Case 26.
Fibroids, before operation. Non-patency.
patient activity.
same
and
Fig. 22.?Case 26.
obtained after myomectomy,
Fibroids,
showing
myomecto111^ myomect011^
after
Normal patency and
activity.
normal
patency
RETRODISPLACEMENT.?Retroversion of the uterus as a possible factor in female sterility has for long provided a tough bone of contention, and, so far as I am aware, continues to do so. There is no doubt that conception can, and does occur in the presence of such
displacement, but pregnancy in such circumstances is associated with On the other hand, this malposition an increased liability to abortion. tends to isolate the cervix from the seminal pool and thus provides the sperm with a much harder task in reaching the cervical canalAssociated prolapse of the ovary might adversely affect the tubo-ovarian mechanism and so reduce the chance of an ovum reaching the lumen of the tube. Furthermore, by causing dyspareunia, a prolapsed ovary might prevent complete penetration during intercourse. These factors alone might well contribute to a lowering of the fertility index but there is another possible effect which concerns the tube. Retroversion of the uterus may cause kinking of the tubes, particularly at the region of the isthmus, and thus reduce permeability to sperm and ovumRetroversion with retroflexion in cases of primary sterility is
frequently
associated with genital hypoplasia, and treatment of the displacement is of little value until the hypoplasia has been corrected. In most cases of secondary sterility and some cases of primary sterility the displacement is acquired and should be corrected as it is a
aetiological
factor.
The method of correction will
potential
depend
on
age
and
THE TUBAL FACTOR IN FEMALE STERILITY
167
length
of time married and functional state of the tubes, but I consider a strong argument for operative treatment in such patients. is a record of insufflation performed with the uterus retroverted, 23
that there is
Fig.
showing
initial obstruction and impaired activity, and Fig. 24 is a the same patient, with the position corrected, showing normal patency and activity. Insufflation has been carried out in 42 patients with retroversion and some abnormality of the kymographic record was noted in 28 cases, or exactly two-thirds.
further record in
Therapeutic Measures A discussion of the tubal factor would be incomplete without some to treatment of the various conditions associated with dis?rdered function. For extrinsic factors, such as fibroids, retroversion and and amounts to conservative treatment is
reference
adhesions,
Pt Gl
straightforward
23-?Case 158. before Retroversion, before correction. Temporary obstruction with with "^paired lrnpaired activity.
Fig.
24.?Case 158.
correction.
Retroversion, after activity.
Normal patency and
?Perative measures, which
are followed by successful results in a good For intrinsic factors treatment is not so clearly ned and, in fact, the outlook in these cases must be regarded as lstmctly gloomy. The reason for this state of affairs is not hard to nd and lies in the undeniable fact that post-inflammatory changes aye taken place within the tubes, and in the majority of cases these
Percentage
of
cases.
.
changes
are irreversible. ^ has been noted that high gas pressure may destroy occluding and thus insufflation itself, or repeated insufflation, although Primarily used for diagnostic purposes, must be regarded as a erapeutic measure. Because of the difficulty in distinguishing Ween sPasm and adhesions as the cause of initial obstruction to the ?w ?f gas in some cases, it is not easy to assess the frequency of this aspect of insufflation.
adhesions,
Although frequently
encountered during insufflation, tubal spasm barrier to conception. Admittedly spasm or pain associated with intercourse, but surely ls spasm must have relaxed long before the sperm reaches the Entrance to the fallopian tube. I do not believe that antispasmodic ruSs, administered before intercourse, are either necessary or
Cann?t be regarded as be induced by fear
a
advantageous. With
ln
the realisation of the part played c?ntrolling tubal function, the inevitable
by the ovarian hormones suggestion has been made
168
G. D.
MATTHEW
that oestrogen therapy might be beneficial in patients with patent but inactive tubes. My experience of this treatment has been singularly disappointing. I believe, however, that this therapy might be helpful in certain circumstances. Firstly, prolonged oestrogen administration might rectify the error in mild degrees of hypoplasia, and secondly* this treatment might give just sufficient boost to muscle tone to permit conception in the presence of tubal function partially impaired by disease. Prolonged trials of oestrogen therapy will be necessary before its value can be assessed accurately. Thus in cases of partial disorder of tubal function the only methods treatment at our disposal are repeated insufflation and the administration of oestrogens. As the results are not encouraging, every effort must be made to increase the prospects of conception by correcting other aetiological factors and by giving advice as to the optimum time
of
(a). Salpingostomy. During operation after opening tubes. Fig. 25
Case 166.
Fig. 26
(a).
Fig. 25 (6). (jb). Case 166. Salpingostomy. Twelve days after
Case 42. 2. Salpingostomy. Fourteen rteen days after
operation.
operation.
Fig. 26 (!>)? Fig. 26(b)Case 42. 42. { at &
Salpin?0^ SalpinS0^
days Fifty-six days
operationoperation.
for intercourse. Conception can occur, but is most unlikely, in the presence of muscular inactivity, and by what mechanism the ovum makes its way through the tube in such circumstances remains an unsolved
problem.
pressure insufflation for the purpose of deliberately rupturing tube has been suggested as treatment for total tubal occlusionMy only experience of this treatment was purely accidental but the, result confirmed the opinion that this manoeuvre is too dangerous to
High
a
warrant serious consideration.
Occasionally, high pressure insufflation a blast passage through the abdominal ostium, but may ultimately in patients with total occlusion the main hope of success lies in plastic operation. And, as is well known, that hope is but a slender one, fof
the results of corrective operations on the tube are notoriously poor. Salpingostomy, tubal circumcision, resection with anastomosis or implantation, each has its definite role in the treatment of tubal occlusion. In spite of improved technique, however, such as the use
repeated
of diathermy in controlling bleeding, catheterisation and insufflation to maintain potency, the success rate remains in the region of 6 to 10 per cent., and there is the added risk of tubal gestation to be taken into account. It is certain that the poor results are due to indiscriminate selection of cases rather than faulty technique. I believe that if operation is
performed on grossly diseased
tubes then the chances
, ,
THE TUBAL FACTOR IN FEMALE STERILITY
?f success
169
negligible even although patency of the artificial opening Operation can be justified only if a sufficient reasonably healthy tube remains to render conception a fair are
may be maintained.
length
of
possibility.
If this condition
was
observed in the selection of
cases
then the prognosis following operation would be materially improved. Plate V shows bilateral ampullary occlusion, with dilatation, quite
close to the uterus. This patient was subjected to operation, but I realise now that the result was a foregone conclusion. Fig. 25 (a) and
is
a record of insufflation carried out during operation after of the tubes, and again twelve days after operation. Patency and some activity were present on these occasions, but three months
?Pening
after operation, in spite of repeated insufflation, the tubes were once again closed. Plate VI (a) and (J?) shows bilateral dilatation with
0cclusion of the left tube. Pressure of dye has forced an opening of the right abdominal ostium. Operation consisted of dilatation of the nght ostium and left circumcision. Fig. 26 (a) and (b) are insufflation records following operation, the first after fourteen days and the Second after fifty-six days. Both show patency and activity which Were maintained for three months, when the patient left the district. These illustrations confirm the opinion that the difficulty in patency is not in the immediate post-operative period later when progressive fibrosis seals the artificial opening.
^aintaining
Incidence
of the
Tubal Factor
My final remarks must necessarily be concerned with the incidence ?f the tubal factor in female sterility. Figures in the literature vary Within the wide limits of 10 to 50 per cent., but it is doubtful if the gures quoted are comparable as some include total occlusion only
whereas
others take into account lesser degrees of abnormality. With SUch a small series I hesitate to mention figures but feel justified in quoting three percentages without comment. In patients fully lnvestigated and with findings confirmed : 12 per cent, showed total Seclusion and a further 21 per cent, showed evidence of disordered Unction. This gives a total incidence of the tubal factor of 33 per cent. Whatever the be it is evident that
precise figure
may
lnyestigation of the tubes is an ?f sterility patients. Without 0
thorough
essential part of the routine examination the knowledge of the functional ability the tubes obtained from insufflation with carbon dioxide it is unwise and, indeed, impossible to provide the patient with a reliable opinion ?n the prospects of conception and this, after all, is no more than the
Patient has the right Aly thanks ests
to
expect.
are due to Dr Joan Mackie who has not only carried out but has also assisted in the interpretation and selection of records.
vOL. LVIII.
NO.
4
many of the
M
