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Diagnostic Value of Oil Salpingography in the Study of Sterility
•
Diagnostic Value of Oil Salpingography in the Study of Sterility Paul T. Topkins, M.D.
THis PRESENTATION usEs THE TERM "salpingography" because it is limited to a consideration of the fallopian tubes. Uterine abnormalities such as myomata, polyps, adenomyosis, synechias, and congenital deviations are deliberately omitted because their relationship to sterility and infertility remains to be clarified. In addition, salpingography is discussed only from the diagnostic viewpoint, inasmuch as its therapeutic value is not well supported by scientific evidence. It is generally accepted that tubal patency is determined most easily and safely by insufflation with carbon dioxide, precisely expressed as a kymographic tracing. The appearance of rhythmic waves at average pressure, followed immediately or later by shoulder pain, indicates patency of one or both fallopian tubes. This is taken as an indication of their anatomic and functional normalcy. Consequently, many patients with postive insufflation results are not subjected to salpingography for many months, or even years, later. For this. reason it seems logical to investigate the possibility that fallopian tubes may reveal definite abnormalities despite normal insufflation results. If such inconsistencies do exist, how often do they occur and what is their significance?
PROCEDURE Salpingograms obtained on 412 sterility patients during the past 6 years From the Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, and the Kings County Hospital, Brooklyn, N. Y. This paper was presented at the Thirteenth Annual Meeting of the American Society for the Study of Sterility, New York, N. Y., May 31 to June 2, 1957. Received for publication June 7, 1957. 215
216
Fertility & Sterility
TOPKlNS
TABLE 1.
412 Cases of Oil Salpingography
With normal salpingograms With abnormal salpingograms ToTAL Negative insuffiations Positive insuffiations ToTAL Tubal diverticula Unilateral fimbrial occlusion Bilateral fimbrial obstruction TOTAL
66 17 83 3
O."T
7 7
1.7 1.7
17
4.1
No. cases
%
329 83 412
80 20
80 20
by using iodized oil were reviewed. Salpingograms revealing normal fallopian tubes were discarded, and those showing abnormal tubes were retained. The kymographic records of patients with abnormal salpingograms were then observed. Negative tracings were put together with their corresponding salpingograms. Positive tracings were set aside with their complementary salpingograms for special consideration. Thus, by a process of exclusion, there remained for study a group of abnormal salpingograms belonging to patients whose insufflation tests were positive, as demonstrated by rhythmic kymographic waves followed by shoulder pain. RESULTS Clinical evidence of infection or oil embolism did not appear in any patient. There were, nevertheless, 4 instances of intravasation, an incidence of almost 1 per cent. Repeat salpingography, which was done frequently, revealed no deleterious effect on normal fallopian tubes. It did, however, disclose an occasionally harmful effect on previously diseased tubes, in that obstructed fimbria actually became occluded. Unilateral nonvisualization caused by cornual spasm occurred often. If the visualized tube filled and emptied properly, the nonvisualized tube was regarded as normal. In 329 cases ( 80 per cent) the salpingograms were normal, and in 83 instances ( 20 per cent) they revealed some degree of tubal abnormality (Table 1). In the abnormal group, insufflation tests were negative in 66 patients ( 80 per cent), and positive in 17 ( 20 per cent) (see Table 1). In all 17 patients the kymographic tracings were normal and were followed by shoulder pain. Such results, found in 4.1 per cent of the patients, were classified as "misleading positive." The 17 cases with abnormal salpingograms
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•
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Figs. 1-4. Case 2. Fig. 1. Tubal di~erticula. Fig. 2. Tubal diverticula under magnification. Fig. 3. Tubal diverticula under magnification. Fig. 4. After 24 hours, showing normal dispersion. TABLE 2.
..
~
Tubal Diverticula
Case
Age
Race
Attempting pregnancy
Salpingography
Other Factors
1 2 3
Pregnancy
34 36 26
Negro Negro Negro
8 yrs. 7yrs. 5 yrs.
1951 and 1957 1953 and 1955 1951 and 1953
Normal Normal Normal
None None None
and positive insu:Hlations (see Table 1) consisted of the following: tubal diverticula-3 cases (Figs. 1-4); unilateral fimbria! occlusion-7 cases (Figs. 5-8); bilateral fimbria! obstruction-7 cases (Figs. 9-12). DISCUSSION Tubal diverticula (Table 2) occurred in 3 patients, all of whom were Negroes. The original diagnosis, made 4 to 6 years ago, disclosed a long
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218
6
5
8
7 Fig. 5. Unilateral fimbrial occlusion (Case 4). Left tube normal, right abnormal. Fig. 7. Fig. 6. Case 4 after 24 hours, showing unemptied abnormal right tube. Fig. 8. Unilateral fimbrial occlusion (Case 5). Left tube normal, right abnormal. Case 5 after 24 hours, showing unemptied dilated right tube. TABLE 3. Case
4 5 6
7 8 9 10
Age
30 31 24 32 35 30 24
Attempting pregnancy
2 yrs. 8 yrs. 5 yrs. 12 yrs. 7 yrs. 7 yrs. 2 yrs.
Unilateral Fimbria! Occlusion
Salpingography
1951 and 1952 1950 1953 and 1954 1956 1956 1952 and 1957 1954
Confirmation
Cesarean sect. 1953 Cesarean sect. 1951 Cesarean sect. 1955 Culdoscopy 1956 Culdoscopy 1956 Culdoscopy 1953 Salpingo-ophorect. 1954
Pregnancy
One One One None None None None
history of sterility in every case. Contrary to the reports of Madsen1 and Bertelsen,2 there was no radiologic evidence of fimbria! involvement. In all 3 patients the 24-hour film showed good dispersion of the iodized oil (Fig. 4). Tubal diverticula occurred in 0.7 per cent of the 412 patients, an incidence less than half of that mentioned by Siegler. 3
...
~
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219
9
10
11
12
Fig. 9. Bilateral fimbria! obstruction (Case 16). Fig. 10. Case 16 hours, showing perifimbrial collections, negligible dispersion. Fig. 11. fimbria! obstruction (Case 11). Three positive insufflation tests. Fig. 12. after 24 hours, showing perifimbrial collections. Dispersion is present pronounced. TABLE 4. Case
Age
Attempting pregnancy
11 12 13 14 15 16 17
26 30 37 28 26 30 28
3 yrs. 4yrs. 11 yrs. 3 yrs. 7yrs 10 yrs. 8 yrs.
after 24 Bilateral Case 11 but not
Bilateral Fimbria! Obstruction
Salpingography
1951 and 1952 1955 1957 1951 and 1952 1952 and 1953 1953 and 1956 1954
Confirmation
Pregnancy
Culdoscopy 1953 Culdoscopy 1955 Not yet obtained Culdoscopy 1953 Fimbriaplasty 1953 Culdoscopy 1956 Culdoscopy 1954
None Ectopic 1956 None None None None None
Unilateral fimbria! occlusion (Table 3) was found and verified in 7 patients, an incidence of 1. 7 per cent. The opposite fallopian tube was entirely normal in every case. Although the average duration of sterility in this group was 6 years, 3 patients did become pregnant. They all had full-term babies delivered by cesarean section because of cephalopelvic dispropor-
220
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Fertility & Sterility
tion. Although none has conceived since then, it is nevertheless possible that the other 4 patients will also become pregnant. Therefore, it is questionable whether unilateral fimbria! occlusion should justifiably be considered a cause of sterility or infertility. Bilateral fimbria! obstruction (Table 4) was present in 7 patients and confirmed in all except 1 who is still under observation. In every case in which culdoscopic examination was done, perifimbrial adhesions were seen. Nevertheless, in 3 instances injected indigocarmine was visualized beyond the limit of perifimbrial adhesions on one side or the other. This emphasizes the difficulty of diagnosing fimbria! obstruction by means of an aqueous contrast medium. In 1 patient an ectopic pregnancy occurred at the fimbria. In another, bilateral fimbriaplasty was done almost four years ago, but no pregnancy followed the operation. SUMMARY 1. A review of the salpingograms of 412 patients has been presented. It reveals normal fallopian tubes in 329 cases ( 80 per cent) and tubal abnormality in 83 cases ( 20 per cent). 2. Examination of the corresponding insuffiation tests of the 83 patients discloses negative results in 66 instances ( 80 per cent) and positive results in 17 cases ( 20 per cent). The latter are designated "misleading positive" results and are found in 4.1 per cent of the patients. 3. The 17 patients with abnormal salpingograms and positive insuffiations are made up of the following groups, which are discussed briefly: tubal diverticula-3 cases; unilateral fimbria! occlusion-7 cases; bilateral fimbria! obstruction-7 cases. CONCLUSIONS Salpingography performed with iodized oil reveals a certain number of abnormal fallopian tubes not identified or suspected by insuffiation with carbon dioxide. These abnormalities are tubal diverticula, unilateral fimbria! occlusion, and bilateral fimbria! obstruction. They are present in 4.1 per cent of the patients. If cases of unilateral fimbria! occlusion are excluded from consideration, there remain 13 per cent of patients with tubal pathology incompatible with uterine pregnancy who show positive insuffiation results. Similarly, in
Vol. 9, No. 3, 1958
OIL SALPINGOGRAPHY IN STERILITY STUDIES
221
all patients who show positive insufflation results 2.4 per cent have tubal disease inconsistent with the possibility of uterine pregnancy. Oil salpingography is a valuable supplement to tubal insufflation, and should be performed before the patient is told that her fallopian tubes are normal. 1141 Eastern Parkway Brooklyn 13, N. Y.
REFERENCES I. 2. 3.
Acta obst. et gynec. scandinav. 23:353, 1943. BERTELSEN, A. Acta obst. et gynec. scandinav. 23:80, 1943. SIEGLER, A. M. Fertil. & Steril. 6:432, 1955. MADSEN,
V.
Second World Congress of the International Federation of Gynaecology and Obstetrics The International Federation of Gynaecology and Obstetrics was founded in 1954 in Geneva, Switzerland, where it held its First World Congress. Meeting every four years, according to its Constitution, the International Federation chose Montreal, Canada, as the site of its Second World Congress, from June 22 to 28, 1958. All scientific sessions will be held and scientific exhibits and moving pictures shown in the newly built Queen Elizabeth Hotel. The main features will be plenary conferences with invited guest speakers, round-table discussions, and free communications. Information and registration forms may be obtained by writing to the Montreal Committee, Second World Congress, International Federation of Gynaecology and Obstetrics, 1414 Drummond St., Suite 220, Montreal 25, Quebec, Canada.
Diagnostic Value of Oil Salpingography in the Study of Sterility Paul T. Topkins, M.D.
THis PRESENTATION usEs THE TERM "salpingography" because it is limited to a consideration of the fallopian tubes. Uterine abnormalities such as myomata, polyps, adenomyosis, synechias, and congenital deviations are deliberately omitted because their relationship to sterility and infertility remains to be clarified. In addition, salpingography is discussed only from the diagnostic viewpoint, inasmuch as its therapeutic value is not well supported by scientific evidence. It is generally accepted that tubal patency is determined most easily and safely by insufflation with carbon dioxide, precisely expressed as a kymographic tracing. The appearance of rhythmic waves at average pressure, followed immediately or later by shoulder pain, indicates patency of one or both fallopian tubes. This is taken as an indication of their anatomic and functional normalcy. Consequently, many patients with postive insufflation results are not subjected to salpingography for many months, or even years, later. For this. reason it seems logical to investigate the possibility that fallopian tubes may reveal definite abnormalities despite normal insufflation results. If such inconsistencies do exist, how often do they occur and what is their significance?
PROCEDURE Salpingograms obtained on 412 sterility patients during the past 6 years From the Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, and the Kings County Hospital, Brooklyn, N. Y. This paper was presented at the Thirteenth Annual Meeting of the American Society for the Study of Sterility, New York, N. Y., May 31 to June 2, 1957. Received for publication June 7, 1957. 215
216
Fertility & Sterility
TOPKlNS
TABLE 1.
412 Cases of Oil Salpingography
With normal salpingograms With abnormal salpingograms ToTAL Negative insuffiations Positive insuffiations ToTAL Tubal diverticula Unilateral fimbrial occlusion Bilateral fimbrial obstruction TOTAL
66 17 83 3
O."T
7 7
1.7 1.7
17
4.1
No. cases
%
329 83 412
80 20
80 20
by using iodized oil were reviewed. Salpingograms revealing normal fallopian tubes were discarded, and those showing abnormal tubes were retained. The kymographic records of patients with abnormal salpingograms were then observed. Negative tracings were put together with their corresponding salpingograms. Positive tracings were set aside with their complementary salpingograms for special consideration. Thus, by a process of exclusion, there remained for study a group of abnormal salpingograms belonging to patients whose insufflation tests were positive, as demonstrated by rhythmic kymographic waves followed by shoulder pain. RESULTS Clinical evidence of infection or oil embolism did not appear in any patient. There were, nevertheless, 4 instances of intravasation, an incidence of almost 1 per cent. Repeat salpingography, which was done frequently, revealed no deleterious effect on normal fallopian tubes. It did, however, disclose an occasionally harmful effect on previously diseased tubes, in that obstructed fimbria actually became occluded. Unilateral nonvisualization caused by cornual spasm occurred often. If the visualized tube filled and emptied properly, the nonvisualized tube was regarded as normal. In 329 cases ( 80 per cent) the salpingograms were normal, and in 83 instances ( 20 per cent) they revealed some degree of tubal abnormality (Table 1). In the abnormal group, insufflation tests were negative in 66 patients ( 80 per cent), and positive in 17 ( 20 per cent) (see Table 1). In all 17 patients the kymographic tracings were normal and were followed by shoulder pain. Such results, found in 4.1 per cent of the patients, were classified as "misleading positive." The 17 cases with abnormal salpingograms
•
•
*
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Figs. 1-4. Case 2. Fig. 1. Tubal di~erticula. Fig. 2. Tubal diverticula under magnification. Fig. 3. Tubal diverticula under magnification. Fig. 4. After 24 hours, showing normal dispersion. TABLE 2.
..
~
Tubal Diverticula
Case
Age
Race
Attempting pregnancy
Salpingography
Other Factors
1 2 3
Pregnancy
34 36 26
Negro Negro Negro
8 yrs. 7yrs. 5 yrs.
1951 and 1957 1953 and 1955 1951 and 1953
Normal Normal Normal
None None None
and positive insu:Hlations (see Table 1) consisted of the following: tubal diverticula-3 cases (Figs. 1-4); unilateral fimbria! occlusion-7 cases (Figs. 5-8); bilateral fimbria! obstruction-7 cases (Figs. 9-12). DISCUSSION Tubal diverticula (Table 2) occurred in 3 patients, all of whom were Negroes. The original diagnosis, made 4 to 6 years ago, disclosed a long
Fertility & Sterility
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218
6
5
8
7 Fig. 5. Unilateral fimbrial occlusion (Case 4). Left tube normal, right abnormal. Fig. 7. Fig. 6. Case 4 after 24 hours, showing unemptied abnormal right tube. Fig. 8. Unilateral fimbrial occlusion (Case 5). Left tube normal, right abnormal. Case 5 after 24 hours, showing unemptied dilated right tube. TABLE 3. Case
4 5 6
7 8 9 10
Age
30 31 24 32 35 30 24
Attempting pregnancy
2 yrs. 8 yrs. 5 yrs. 12 yrs. 7 yrs. 7 yrs. 2 yrs.
Unilateral Fimbria! Occlusion
Salpingography
1951 and 1952 1950 1953 and 1954 1956 1956 1952 and 1957 1954
Confirmation
Cesarean sect. 1953 Cesarean sect. 1951 Cesarean sect. 1955 Culdoscopy 1956 Culdoscopy 1956 Culdoscopy 1953 Salpingo-ophorect. 1954
Pregnancy
One One One None None None None
history of sterility in every case. Contrary to the reports of Madsen1 and Bertelsen,2 there was no radiologic evidence of fimbria! involvement. In all 3 patients the 24-hour film showed good dispersion of the iodized oil (Fig. 4). Tubal diverticula occurred in 0.7 per cent of the 412 patients, an incidence less than half of that mentioned by Siegler. 3
...
~
Vol. 9, No. 3, 1958
OIL SALPINGOGRAPHY IN STERILITY STUDIES
219
9
10
11
12
Fig. 9. Bilateral fimbria! obstruction (Case 16). Fig. 10. Case 16 hours, showing perifimbrial collections, negligible dispersion. Fig. 11. fimbria! obstruction (Case 11). Three positive insufflation tests. Fig. 12. after 24 hours, showing perifimbrial collections. Dispersion is present pronounced. TABLE 4. Case
Age
Attempting pregnancy
11 12 13 14 15 16 17
26 30 37 28 26 30 28
3 yrs. 4yrs. 11 yrs. 3 yrs. 7yrs 10 yrs. 8 yrs.
after 24 Bilateral Case 11 but not
Bilateral Fimbria! Obstruction
Salpingography
1951 and 1952 1955 1957 1951 and 1952 1952 and 1953 1953 and 1956 1954
Confirmation
Pregnancy
Culdoscopy 1953 Culdoscopy 1955 Not yet obtained Culdoscopy 1953 Fimbriaplasty 1953 Culdoscopy 1956 Culdoscopy 1954
None Ectopic 1956 None None None None None
Unilateral fimbria! occlusion (Table 3) was found and verified in 7 patients, an incidence of 1. 7 per cent. The opposite fallopian tube was entirely normal in every case. Although the average duration of sterility in this group was 6 years, 3 patients did become pregnant. They all had full-term babies delivered by cesarean section because of cephalopelvic dispropor-
220
TOPKlNS
Fertility & Sterility
tion. Although none has conceived since then, it is nevertheless possible that the other 4 patients will also become pregnant. Therefore, it is questionable whether unilateral fimbria! occlusion should justifiably be considered a cause of sterility or infertility. Bilateral fimbria! obstruction (Table 4) was present in 7 patients and confirmed in all except 1 who is still under observation. In every case in which culdoscopic examination was done, perifimbrial adhesions were seen. Nevertheless, in 3 instances injected indigocarmine was visualized beyond the limit of perifimbrial adhesions on one side or the other. This emphasizes the difficulty of diagnosing fimbria! obstruction by means of an aqueous contrast medium. In 1 patient an ectopic pregnancy occurred at the fimbria. In another, bilateral fimbriaplasty was done almost four years ago, but no pregnancy followed the operation. SUMMARY 1. A review of the salpingograms of 412 patients has been presented. It reveals normal fallopian tubes in 329 cases ( 80 per cent) and tubal abnormality in 83 cases ( 20 per cent). 2. Examination of the corresponding insuffiation tests of the 83 patients discloses negative results in 66 instances ( 80 per cent) and positive results in 17 cases ( 20 per cent). The latter are designated "misleading positive" results and are found in 4.1 per cent of the patients. 3. The 17 patients with abnormal salpingograms and positive insuffiations are made up of the following groups, which are discussed briefly: tubal diverticula-3 cases; unilateral fimbria! occlusion-7 cases; bilateral fimbria! obstruction-7 cases. CONCLUSIONS Salpingography performed with iodized oil reveals a certain number of abnormal fallopian tubes not identified or suspected by insuffiation with carbon dioxide. These abnormalities are tubal diverticula, unilateral fimbria! occlusion, and bilateral fimbria! obstruction. They are present in 4.1 per cent of the patients. If cases of unilateral fimbria! occlusion are excluded from consideration, there remain 13 per cent of patients with tubal pathology incompatible with uterine pregnancy who show positive insuffiation results. Similarly, in
Vol. 9, No. 3, 1958
OIL SALPINGOGRAPHY IN STERILITY STUDIES
221
all patients who show positive insufflation results 2.4 per cent have tubal disease inconsistent with the possibility of uterine pregnancy. Oil salpingography is a valuable supplement to tubal insufflation, and should be performed before the patient is told that her fallopian tubes are normal. 1141 Eastern Parkway Brooklyn 13, N. Y.
REFERENCES I. 2. 3.
Acta obst. et gynec. scandinav. 23:353, 1943. BERTELSEN, A. Acta obst. et gynec. scandinav. 23:80, 1943. SIEGLER, A. M. Fertil. & Steril. 6:432, 1955. MADSEN,
V.
Second World Congress of the International Federation of Gynaecology and Obstetrics The International Federation of Gynaecology and Obstetrics was founded in 1954 in Geneva, Switzerland, where it held its First World Congress. Meeting every four years, according to its Constitution, the International Federation chose Montreal, Canada, as the site of its Second World Congress, from June 22 to 28, 1958. All scientific sessions will be held and scientific exhibits and moving pictures shown in the newly built Queen Elizabeth Hotel. The main features will be plenary conferences with invited guest speakers, round-table discussions, and free communications. Information and registration forms may be obtained by writing to the Montreal Committee, Second World Congress, International Federation of Gynaecology and Obstetrics, 1414 Drummond St., Suite 220, Montreal 25, Quebec, Canada.