A critical appraisal of hysteroscopic tubal fulguration for sterilization

A

CRITICAL

APPRAISAL

OF

HYSTEROSCOPIC

FOR

Charles

M.

Robert

Section Department University

TUBAL

FULGURATION

STERILIZATION

March, Israel,

M.D.

M.D.

of Reproductive of

Obstetrics

of Southern

Biology

and Gynecology

California

School

of

Medicine

and the Los Angeles

County-USC

Los Angeles,

Medical

California

Center

90033

ABSTRACT Twenty-seven vestigational local

anesthesia.

hysteroscopy, Follow-up and

women who

method all

laparoscopy

of such

Until

tubal

patients

was available

and uterine

magnitude

necessary

before

Accepted

for

MARCH

were in 23

was performed

defects

were that

this

requested

had hysteroscopic

publication

in

could

be verified

three

instructed in

16 patients.

modification

December

of

1975 VOL. 11 NO. 3

In 69%

with

a high

of

technique

transuterine

30,

geneml

to five

these

patency and/or

sterilization

clinic

months

contmceptive

anesthesia, of

to the use of an in-

the outpatient

to use an additional Using

Coupled

method

and agreed

fulguration

patients.

found.

further

new

closure

sterilization

tubal

repeat

under

postmethod.

hysteroscopy

16 patients,sinus rate,

these

tracts

findings

instrumentation

are

are

can be used clinically.

1974

261

CONTRACEPTION

INTRODUCTION As it necessitates never

achieved

uterine

approach

Attempk

at

cryosurgery (7,

to the

instillation

9) or plugs

of a substance

the

(11)

Recent

advances

development intrauterine

diagnosis

be inserted

into

by Quinones

Guerror

of hysteroscopic procedure

rate

et

even Our

reqest

Neuwirth

and easily

clinic

serves

than

were

considerable

of

feasibility

population The

demands

upon

of outpatient

and

the

The

vision,

accurate

electrodes

Preliminary the

can reports

ease

and safety

experience

especially

when

the expected

bilateral

closure

by most individuals improved

Neither

permitted

documented

and

(17);

rates,

delivery

with

experience

coagulation

in per-

endpoink

were

re-

anticipated.

a large

sterilization.

places

95%

have

direct

with

failure blind

2),

adhesives

in hysteroscopy.

performed.

et al. (16)

(1,

6),

junction.

cavity

improved

5,

be controlled.

interest

Under

(4,

relatively

could

uterine

performed

As equipment

results

the

has

a trans-

simplicity.

considerable

the

the uterotubal

revitalized

Efficacy

and

agents

from

electrocoagulation

and

to be more

better

surgical

the

have

and

al.(15)

(18).

of

14) and surgery.

ostia

was quickly

hysteroscopy

fined,

13,

region

sterilization Ideally,

electrocoagulation

of sclerosing in common

to distend

tubal_uGuration.

was estimated

forming

media

tubal

this safety

suffered

have

female

vasectomy.

numerous:

of tissue destruction

in fiberoptics (12,

the

to the

extent

of appropriate

been

have

All

cavity,

with

provide

have

methods

probe

nor the

might

of a variety

or both.

or thermal

associated

occlusion

These

(10).

of application

the abdominal

tubes

(3) and

complications

the

fallopian tubal

8,

into

and simplicity

transuterine

serious site

penetration

the safety

of multiparous

performance

women,

of numerous

the surgical

faciiities.

hysteroscopic

tubal

many

of whom

sterilization Therefore,

fulguration

under

procedures an

investigation

local

anesthesia

was undertaken. MATERIALS Twenty-seven in a study multiparous were N.

within the All

19,

with

surgical

authors electrode vaginal * Karl

262

with had

period

immediately

anesthesia

placement

were

was

and

tubal A rigid

Endoscopy-America,

physical

early block

themselves

electrocoagulation

Inc.,

to participate

All

patients

in all and

27

cultures

device

had

were

patienk for it removed

HTF. November

follicular

consisted

7 mm Storz

cytology

an intrauterine

between

to the

volunteered (HTF).

examinations

cervical

preceeding

Analgesia

of age,

fulguration

wearing

of a poracervical

and

44 years tubal

performed

limited

familiarized

METHODS

instance,

Women

of menses.

previously

hysterectomy. Storz

In every

procedures

cessation

23 and

History

negative.

Hysterascopy

days after venously

limits.

were

menstrual

1974.

between

of hysteroscopic

one exception.

normal

gonorrhoeae

during

women,

of the efficacy

AND

20

the using

ml of

techniques patient

hysteroscope*

Los Angeles,

1973 of the

and

with

February

cycle,

of 50 mg of meperidine

using

with

6,

phase

l-3

intra-

1% xylocaine.

The

of hysteroscopy,

volunteers an ACM1

undergoing 150 watt

Calif.

MARCH

1975

VOL. 11 NO. 3

CONTRACEPTION

fiberoptic a

10%

light

solution

of

of

dextran

solution

alone

availability

and

the

ml infusion

After

Three

for the

and

the

excellent under

glucose

solution

of electrodes

2 x 4 mm was used in seven

electrode

with

teflon

in

one side was

and

the

#701*

of electrode

until

Patients formed ceptives,

the

upon

tubal

group

was originally

serious

complications

pregnancies

were

obstruction

(19), for

reported the

sterilization

and

cided

to have

and

1.5

fulguration electrode

x 6 mm cylindrical electrode

with

electrode Each

other.

electrode

by a Birtcher

the

a on

was visible

within

Hyfreca-

Coagulating

regulator.

the

tissue around

procedure

patients

the

and

point

were was per-

used oral

received

contra-

intramuscular

medroxy-

of

sterilization

laparoscopic

tubal

of

these

sixteen

P8 foley

catheter

+

American Cystoscope Abbott Laboratories,

++

The

1975

27 one

16 were

patients. fitted

with

Makers, Inc., North Chicago,

Corporation,

were

time

had a vaginal studied

with

an adapter

Pelham Manor, Illinois

into have

hysteroscopy four

hysterectomy,

detwo

concomitant potency,

was performed into

were

were

advised

To assess tubal blue

comual

putients

a repeat

When

cornual

for follow-vp:

Chromopertubation

Los Angeles,

VOL. 11 NO. 3

new

procedure

patients

sterilization. of methylene

and

of bilateral

the

returned

end-

100 subjects.

No

at which

of the and

a solution

Birtcher

study

laparoscopy,

with

y in

demonstration

acceptance

coagulation

intrauterine

was altered.

All

patient

and

to include

had undergone

complications.

rates,

electrodes

perforation,

a hysterosalpingogram,

with

pregnancy

scheduled

design

chromopertubation laparosco

and

radiographic

Twenty-three

only

laparoscopy

MARCH

ostium,

a hysterosalpingogram

one

(media,

those who

by means

be performed.

hysteroscopy

after

investigative

the study

would

**

system

the ball-tip

in

after

until and

such as intestinal

of the reported

a

flow

a ball-tip

supplied

voltage

hour

closure

the study

inserting

a high

12 seconds.

foam

points),

had

obtained.

acetate.

investigation

tubal

tubal

a

Twenty-four

under

formed

a 5%

was used The a 50 ml

via

on the

appeared

one

variables

accepted

40 via

cylindrical

were

contraception

pwt-operatively.

Depending and

ring

about

two used contraceptive

progesterone

cavity

and

pressure

only a thin rim of metal

by an in-line

discharged

the

using

electrode

of power

usually

were

months

clarity

utilized:

a modified

until

a white

to use additional

3-5

visual

into were

was performed

watts

controlled

placement,

instructed

in four;

ostium

Thirty

was delivered

uterine

Dextran

moderate

procedures;

cylindrical

tubal

cavity.

tor Model

tip

procedure

modified

into

the uterine power

a ceramic the

inserted

the

procedures

two.

continuously

of an electrode

types

15; one

in 25

remaining

intermittently

measuring tip

To distend

was utilized

bottle.

introduction

was performed.

was used.

in water+

was instilled

syringe 100

supply**

40

in water

its ready

hand-held a

power

Dextran

of dextrose

because

using

carrier

solution

the

the

time

was performed

by

uterine

at

cavity,

N.Y.

California

263

CONTRACEPTION

and

instilling

pressure

the

from a

methylene

blue

solution

in 2-3

ml increments

with

minimal

10 ml syringe. RESULTS

Hysteroscopic

Fulguration

Patient except

when

ranged

from

3-37

prolongation occurred and

acceptance

the operating minutes

resulted

secondary

uterine

the

the cavity, necessitating dextron

acceptance

in contrast

In four

findings

and

visual

to 5%

dextrose

dextrose were

The

and

volume

delay

clarity

in water

solution.

cramping

high

procedure,

distention

dextran

uterine

one

to both

was superior

uterine

to the

time the

in water. was used

poor,

causing

technique

increased

instillation

of

patient

of the

5%

electrode might

have

was difficult

uterine

facilitated

included

others.

Neither

Intro0

erative.

Three

--++tuba

fu garation.

due

to the

A flexible

cavity. electrode

insertion.

polyps

in two

entity

interfered

patients with

oblique

hysterascope Incidental and

occasional

visualization

Complications. A.

the site

of paracervical

fulguration

of one

fulguration

of these

ostium left

1. had

spotting

intermenstrual

modemte The had

had

ostium.

was mild

complained

involuntary There

Four patients

Bleeding.

Two of three

operatively.

tubal

patient

complications

there

were

bleeding

of pain

spasm of her no sequelae

left from

Post-operative.

post-operatively. experienced

and another

experienced

instance

A second

block.

of her

patienk In one

events.

8.

and

the

cavity

in several

hysteroscopic

leg during

placement

entered

placement.

2.

264

During respect

of 5%

minimal, operating

Occasionally

minutes.

a solution

reduced

oviduct

electrode

fronds

nor electrode

tate

solution

were The

Findings.

in the endometrial

polypoid

any

13.2 With

to the constant,

patients,

the

or an angulated

during

dextran

a change

Operative

at which

from

Cramps minutes.

in water. 1.

during

of

electrode.

in which

delivery

good. 15-20

use of photography.

visualization

intermittent

angle

a mean

the

procedures

to distend

dextrose

with

from

delay

and

exceeded

to a faulty

distention,

In two of four

was uniformly time

patients

during

the

voginal

bleeding

patient

received

last

intermittent

bleeding

who

first

had abnormal were

taking

post-operative

olmost

daily

cycle.

for eighteen

intramuscular

for six weeks

uterine

oral

after

bleeding

contraceptives One

patient

weeks

post-

medroxyprogesterone

ace-

HTF.

MARCH 1975

VOL. 11 NO. 3

CONTRACEPTION

2.

Pregnancy.

Two

patients

became

pregnant

13 and

31 weeks

after

HTF. Follow-Up. Of Of

the 27

23,

hysterosalpingogmm these

women

and

the

Neither

four

performed

tubal

ever,

before

she conceived

intrauterine with

pregnancy

bilateml

tubal

Eighteen performed

weeks

at another

and endometrial vealed

sections complete

until

muscle

were The

remaining

16 of the

methylene

blue.

pregnancy She had were

Abnormal tmted these one

with multiple

cornual patient,

and serosa. in

length

and

broad

tation uterine

of

underwent

as normal; the

taken

time

not have

tubal the

her oml

an eight-week

lumenal

oviduct.

routine Prior

hysteroscopy

bilateral

to the

and

the

pelvic

curettage

for an

sterilization,

19 weeks

incorrectly. pregnancy

cauterwith

and chromopertu-

only

tubal

contraceptives intrauterine

in

of the

had a suction

of laparoscopic

re-

Serial

chromopertubation

cauterization

other

the uterus

normal.

with

HTF.

and

hysterectomy

tissue and smooth

portion

after

patient

Endocervical

diminution

laparoscopy

weeks

of

were

fibrous

intramural

hysteroscopy

two who did

The findings

with

a corpus

ovary.

findings

were

observed

chromopertubation. channels the dye

within

wound

The extent than

ligament.

the

around

of these 10 cm,

regions

11 of the

16 patientswho

patients,

the dye

cornual

portions

communicated the

left

with fallopian

sinuses varied

the

latter

Occasionally,

the comual

in

In these

sinuses apparently

to more

the

laparoscopic at

on the right

roscopy

18 patients

the

described

luteum

of

33

sections

Only

The

bleeding.

areas

How-

She has an

had a vaginal

progressive

in the area

Of

were HTF.

revealed

continued

a vasectomy.

contraceptives.

irregular

cornual

of

cornual

complication.

patient

occurred.

had

viscera

laparoscopy

cornua

patency

oral

Routine

the

18 patients

underwent

after

benign.

11 and

one

at

were

bilateral

be performed.

without

one

Two

obstruction

contraceptives.

to have

to take

persistent

between

bation, unwanted

duration

for

oblitemtion

cauterization

ization,

weeks

Grossly,

of the

present

could

HTF.

with oral

unilateral

vasectomy

post-operatively

curettings

histologic

with

decided

has continued

institution

no abnormalities.

size

tubal

of 20 patency

after

patency.

had a

had unilateral

patient

husband

of tubal

laparoscopy

weeks

one

has continued

patient

Her the

23

One

other

One

foam.

12 and

patency.

investigation

to have

obstruction,

the

conceived.

for

refused

between

while

to use contraceptive

returned who

cornual

had bilateral discontinued

has yet

never

patients

had bilateral

last

obstruction

four

patients,

the remaining

prior

was noted,

from

involving

of

the uterus.

the

broad

tube

less than the

entire

myometrial

Iapa-

peneIn seven,

ligament.

between

to chromopertubotion, suggesting

had

promptly

one

In

the

muscle

centimeter

comua, slight

fundus dilo-

disruption

and

weakness.

MARCH 1975

VOL. 11 NO. 3

265

CONTRACEPTION

DISCUSSION Outpatient easily

transuterine

and rapidly

of intrauterine

landmarks

as confirmed

ease,

Although it was first after

indicate

that

that

patency-another

tubal

bbstrudtion

More

later not

by the

follow-up canalize allow

course and

and

20

known. by blind

had

tubal

the second technique in

rate

who

their

266

permit

tubal form

may

resulting

occur

who

sinus tracts

sperm migration of the

the

but

do

tubes

to inaccurate and/or

adjacent

bowel

undermay

tortuous

fallopian

lead

destruction

and

basis

recanalization,

16 patients

could

of

on the

and/or

In addition,

portion

transuterine tubal

misdirected

structures,

perforation,

such as

peritonitis

were

cornual

suggested

tubal “the

series simply

hysteroscopic

of

performed control

pregnancies. precludes

the

and

blockage

failure the

tubal

validity

fairly

the

new

further

tubal of the in the

rate

year

of

However,

closure

technology this

Neuwirth after

to the

mucosa

resulting

tubal

fistula

impressions.

safety,

eliminates technique

MARCH

occurred

year.

to be due

by

this

obtained

transu terine

regarding

by

pregnancies previous

endometrial

these

ostia

sterili-

post-operatively,

as the endometrial

effective,

use of

appears

and

as well

is unpredictable Unless

One

tubal

tubal

in hysterosalpingograms

observed

demonstrates

to the

insufflation.

Three

pregnant.

of re-epithelialization diverticula

(22).

of bilateral

diverticula that

damage

who underwent

by uterotubal

17 had evidence others

thermal

patients

coagulation

had demonstrated

They

presence

30

as determined

only

seveml

Our

subsequent

with

transuterine

closure

While under

may

evidence

pregnancies

These

(21)

incomplete

windows

closure.

occur.

damage

ovum.

intramural

reported

the iatrogenic

seen” .

resultant

following

and seven

et al noted -* HTF (16). in

which

tubal

of

aft&r ‘HTF

11 of the

the same uterus

DeVilbiss

year,

patients

rapid

in

to

pregnancies

we havedemonstrated

will

commonly, tubal

noted

These

death.

Recanalization zation

of the

may be coagulated

possibly

is well

track fertilized

cornual

were

HTF,

tubal

radiographic

chromopertubation.

larger

size

with

Thus,

bowel,

with

within

cannulation

more

fistulous

the

variability

coagulation. small

tracts

prior

with

(19).

indicator

pregnancies

visualized

and diminished

tubal

with

sinus

of

closure

is discontinued

or excessive

becoming

passage

their

of patients

inadequate

laparoscopy

with

following

failures

andchromopertubation,

possibly

performed

in patients

pregnancies

tubal

of hysterosalpingography, and

was

Identification

usually

operative

cornual

If-contraception

importantly

as suggested went

group

following

were

is not a valid

__I,

of hysteroscopy

this series.

occurred

were

and

laparoscopy

(20).

findings

HTF

patients

time

in

time.

demonstrated

I

the

placement

had previously

hvsterosaloinaoaraohv

at

tolerated

operating

intrauterine

diagnostic

tubal

after

well

electrode

these

radiographically

By utilizing

of the

and

pregnancies

thought

fulguration

and

by the short

Thereafter,

patency. occur

tubal

performed,

tubal tubal

these of

HTF.

fulguration closure

and

drawbacks, As an alter-

1975 VOL. 11 NO. 3

CONTRACEPTION

native

to fulguration,

philic

gel

the

or expansile

approach

to outpatient

hysteroscopy

and

transuterine

plug)

under

female

the

delivery

sterilization.

control

of a substance

hysteroscopic

afforded

control

Certainly

by

this

(e.g.,

may

a hydro-

provide

the

the simplicity

technique

warrant

best

of

further

investi-

gotion. ACKNOWLEDGEMENTS This and

investigation

was performed

at Women’s Medical

was supported

in the

Hospital,

World

by a grant

Health

Los Angeles

from

the Ford

Organization

Clinical

County/University

Foundation Research

of Southern

Centre

California

Center. The authors

Los Angeles,

ore

grateful

California,

to the

for

the

Birtcher

loan

Corporation,

of a Model

4371

8701

Valley

Blvd.,

Hyfrecator.

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CONTRACEPTION

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M.B.:

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Historical

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R.U.

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