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An Investigation of Tubal Implantation for Cornual Block
AN INVESTIGATION OF TUBAL IMPLANTATION FOR CORNUAL BLOCK E. I.
OSTRY,
M.B.E., D.P.H.,*
LONDON, ENGLAXD
T
HERE have recently been considerable discussion and interest about the repair of bilateral cornual block by tubal implantation. Reports have been publh;hed1 - 5 of high rates of conception following this operation. The terhniques recommended involve some form of boring, or coring, through the cornu and implanting the proximal portion of the tube, previously strung with a tube or rod of polyethylene, into this artificially formed tunnel. This polyethylene rod is removed from within the tunnel in the following three to twelve weeks. The experience with this operation at the Samaritan Hospital for Women has been sadl.v at variance with all published figures seen and may be of some interest. To evaluate this procedure, 1,830 consecutive case records from our infertility clinic were taken, covering the years 1!l48 to 1955. All r<:<·ords showing bilateral cornual occlusion on hysterosalpingography at on<: or mor<> tests were set aside for investigation. There was a total of 240 cases. Cases of reopening of normal tubes that had previously been tied as a deliberate sterilizing procedure were not included in this series. A letter was sent to each patient. Our usual response to letters of enquiry sent to patients 0\'('1" the last five years has been about 60 to 65 per cent. In this instance the response was much greater and 209 patients either wrote or appeared at our clinic. Here follows the fate of these 209 patients. Twenty-seven wrote that they had had one or more pregnancies since their last hysterosalpingogram. This reduced the number of cases for further im'estigation to 182. Thirtythree patients wrote or came to say that they no longer desired further investigation as they were ''too old,'' ''too tired,'' widowed, separated, divorced, or that social circumstances had changed since their last visit. This left a residuum of 149 cases. In every case the endometrial biopsy showed a normal seeretory endometrium and no cases fell by the wayside on this aceount. Our standard of .::ubfertility in the male on the basis of semen analysis was less exacting than many; nevertheless, even with a generous interpretation in favor of the patient, 14 cases of oligospermia were found where the sperm count and morphology ruled out any reasonable prospect of eonception. 1 ms reduced the number of our cases to 135. A further 11 cases showed complete *Senior Registrar, Sama.-itan Hospital for Women, and St. Mary's Hospital. London. Present address, 108 Medical Arts Bldg., Calgary, Alberta, Canada.
409
410
OSTRY
Am.
J. Obst. & Gynec. · February, 1957
azoospermia, reducing our numbers to 124. One ease was discarded as intercourse now took place only once a year and one case as intercourse took place every six months, Our number was now 122. It was decided to operate on each of these patients if they showed no patency at two insuffiations and bilateral cornual block on two more hysterosalpingograms. At repeat insufflation, 26 were found to have one or both tubes patent, reducing our number to 96. At repeat hysterosalpingography 22 showed one or both tubes patent, reducing our number to 74; and a further 24 eases now showed a block not at the cornua but this time at the ampullary ends. We now had 50 cases. This final group of hardy patients were again interviewed, and it was explained that we proposed operating on them. Our plan was to do a final insufflation under anesthesia and if this showed no passage of carbon dioxide a laparotomy would be done. On opening the abdomen a retrograde insufflation would be done, and if this showed bilateral cornual block then a repair would be undertaken. A picture of minimal mortality rates was presented, but no assurance of success in rendering the tubes patent, or of pregnancy inevitably following should the tubes be made patent was given. Six patients refused operation when we could give no absolute guarantee of success. This reduced our number to 44. Over a period starting in October, 1952, and ending in July, 1955, these 44 patients were admitted to hospital. All of these dauntless women had had at least one endometrial biopsy, two and usually more hysterosalpingograms showing bilateral cornual block, and two or more unsuccessful insuffiations with or without anesthetic. At final insufflation under anesthesia prior to laparotomy 26 of these patients were found tl) have one or both of their tubes patent and were discharged home. The remaining 18 patients did undergo laparotomy. Five of these were found to have both tubes clearly patent on retrograde insufflation and the abdomen was closed. At this stage 15 patients remained. Four of these were found to have both tubes completely disorganized along their whole length by old inflammation. In 2 of these it was necessary to do a bilateral salpingectomy, while in the other 2 cases a combined salpingostomy with cornual implantation with little or no hope of success was performed. Our numbers were reduced to 9. The remaining H patients had bilateral cornual occlusion with the remainder of the tube clinically normal in appearance and patent as far as the cornua on retrograde insufflation. Five surgeons using 3 slightly varying techniques with polyethylene operated on these 9 patients and implanted the tubes into the cornua. There were no deaths. The postoperative morbidity rate was nil. The polyethylene tubes were remoYed in from three to twelve weeks, usually the latter. A hysterosalpingogram was done on each of these cases three to six months after the polyethylene tubes were removed. In 8 cases the films showed bilateral cornual block. In one case the tubes were shown as patent. We did
Volume 73
Nt•mber 2
TUBAL IMPLANTATION FOR CORNUAL BLOCK
411
not repeat this or any other test for patency as the ordeals of these patiPnts had already almost amounted to martyrdom, and our experience as to thr reliability of these tests when negative, as evidenced in this seriE>,s, was not such as to give us confidence in their value. By May, 1956, there was no record of any pregnancy.
References 1. 2. 3. 4. 5.
Castallo, M. A., and Wait1er, A. S.: AM. J. OBST. & GYNJ!:O. 66: 385, 1953. Green-Arm.ytage, V. B.: Proc. Roy. Soc. Med. 48: 87, 1955. Moore-White, M.: Proc. Roy. Soc. Med. 48: 89, 1955. Palmer, R.: Bruxelles rued. 33: 1449, 1953. Rock, J., Mulligan, W. J., and Easterday, C. L.: Obst & Gynec. 3: 21, 1954.
OSTRY,
M.B.E., D.P.H.,*
LONDON, ENGLAXD
T
HERE have recently been considerable discussion and interest about the repair of bilateral cornual block by tubal implantation. Reports have been publh;hed1 - 5 of high rates of conception following this operation. The terhniques recommended involve some form of boring, or coring, through the cornu and implanting the proximal portion of the tube, previously strung with a tube or rod of polyethylene, into this artificially formed tunnel. This polyethylene rod is removed from within the tunnel in the following three to twelve weeks. The experience with this operation at the Samaritan Hospital for Women has been sadl.v at variance with all published figures seen and may be of some interest. To evaluate this procedure, 1,830 consecutive case records from our infertility clinic were taken, covering the years 1!l48 to 1955. All r<:<·ords showing bilateral cornual occlusion on hysterosalpingography at on<: or mor<> tests were set aside for investigation. There was a total of 240 cases. Cases of reopening of normal tubes that had previously been tied as a deliberate sterilizing procedure were not included in this series. A letter was sent to each patient. Our usual response to letters of enquiry sent to patients 0\'('1" the last five years has been about 60 to 65 per cent. In this instance the response was much greater and 209 patients either wrote or appeared at our clinic. Here follows the fate of these 209 patients. Twenty-seven wrote that they had had one or more pregnancies since their last hysterosalpingogram. This reduced the number of cases for further im'estigation to 182. Thirtythree patients wrote or came to say that they no longer desired further investigation as they were ''too old,'' ''too tired,'' widowed, separated, divorced, or that social circumstances had changed since their last visit. This left a residuum of 149 cases. In every case the endometrial biopsy showed a normal seeretory endometrium and no cases fell by the wayside on this aceount. Our standard of .::ubfertility in the male on the basis of semen analysis was less exacting than many; nevertheless, even with a generous interpretation in favor of the patient, 14 cases of oligospermia were found where the sperm count and morphology ruled out any reasonable prospect of eonception. 1 ms reduced the number of our cases to 135. A further 11 cases showed complete *Senior Registrar, Sama.-itan Hospital for Women, and St. Mary's Hospital. London. Present address, 108 Medical Arts Bldg., Calgary, Alberta, Canada.
409
410
OSTRY
Am.
J. Obst. & Gynec. · February, 1957
azoospermia, reducing our numbers to 124. One ease was discarded as intercourse now took place only once a year and one case as intercourse took place every six months, Our number was now 122. It was decided to operate on each of these patients if they showed no patency at two insuffiations and bilateral cornual block on two more hysterosalpingograms. At repeat insufflation, 26 were found to have one or both tubes patent, reducing our number to 96. At repeat hysterosalpingography 22 showed one or both tubes patent, reducing our number to 74; and a further 24 eases now showed a block not at the cornua but this time at the ampullary ends. We now had 50 cases. This final group of hardy patients were again interviewed, and it was explained that we proposed operating on them. Our plan was to do a final insufflation under anesthesia and if this showed no passage of carbon dioxide a laparotomy would be done. On opening the abdomen a retrograde insufflation would be done, and if this showed bilateral cornual block then a repair would be undertaken. A picture of minimal mortality rates was presented, but no assurance of success in rendering the tubes patent, or of pregnancy inevitably following should the tubes be made patent was given. Six patients refused operation when we could give no absolute guarantee of success. This reduced our number to 44. Over a period starting in October, 1952, and ending in July, 1955, these 44 patients were admitted to hospital. All of these dauntless women had had at least one endometrial biopsy, two and usually more hysterosalpingograms showing bilateral cornual block, and two or more unsuccessful insuffiations with or without anesthetic. At final insufflation under anesthesia prior to laparotomy 26 of these patients were found tl) have one or both of their tubes patent and were discharged home. The remaining 18 patients did undergo laparotomy. Five of these were found to have both tubes clearly patent on retrograde insufflation and the abdomen was closed. At this stage 15 patients remained. Four of these were found to have both tubes completely disorganized along their whole length by old inflammation. In 2 of these it was necessary to do a bilateral salpingectomy, while in the other 2 cases a combined salpingostomy with cornual implantation with little or no hope of success was performed. Our numbers were reduced to 9. The remaining H patients had bilateral cornual occlusion with the remainder of the tube clinically normal in appearance and patent as far as the cornua on retrograde insufflation. Five surgeons using 3 slightly varying techniques with polyethylene operated on these 9 patients and implanted the tubes into the cornua. There were no deaths. The postoperative morbidity rate was nil. The polyethylene tubes were remoYed in from three to twelve weeks, usually the latter. A hysterosalpingogram was done on each of these cases three to six months after the polyethylene tubes were removed. In 8 cases the films showed bilateral cornual block. In one case the tubes were shown as patent. We did
Volume 73
Nt•mber 2
TUBAL IMPLANTATION FOR CORNUAL BLOCK
411
not repeat this or any other test for patency as the ordeals of these patiPnts had already almost amounted to martyrdom, and our experience as to thr reliability of these tests when negative, as evidenced in this seriE>,s, was not such as to give us confidence in their value. By May, 1956, there was no record of any pregnancy.
References 1. 2. 3. 4. 5.
Castallo, M. A., and Wait1er, A. S.: AM. J. OBST. & GYNJ!:O. 66: 385, 1953. Green-Arm.ytage, V. B.: Proc. Roy. Soc. Med. 48: 87, 1955. Moore-White, M.: Proc. Roy. Soc. Med. 48: 89, 1955. Palmer, R.: Bruxelles rued. 33: 1449, 1953. Rock, J., Mulligan, W. J., and Easterday, C. L.: Obst & Gynec. 3: 21, 1954.