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Female sterilization by electrocoagulation of tubal ostia using hysteroscopy
Female sterilization by electrocoagulation
of
tubal ostia using hysteroscopy RALPH
M.
ROBERT New
RICHART, S.
York,
New
NEUWIRTH,
Bangkok,
M.D.
York
CHARANPAT SUKHIT
M.D.
ISRANGKUN, PHAOSAVASDI,
M.D. M.D.
Thailand
Forty-four women were treated by hysteroscopically directed the tubal ostia to produce permanent sterilization. Thirty-four inserted in the wounded area. Eighty-four per cent of those tubal c!osure as determined by hysterosalpingography.
I N A P R E v 10 u s publication, preliminary experience with tubal sterilization by cautery and partial endosalpingeal excision under hysteroscopic control was rep0rted.l Results were promising and complications trivial. In view of these results a more extended trial of sterilization methods using
Received Accepted
for
publication
May
4, 1973.
May
March
of had a mesh had bilateral
of these
treated
hysteroscopy with 30 per cent dextran was carried out. A different setting was selected in order to evaluate the feasibility of a largescale ambulatory program using this approach. Materials
and
methods
Patient volunteers who wished to be sterilized nonoperatively were recruited from the Family Planning Clinic of the Chulalongkorn University Hospital in Bangkok. NO other selection criteria were used except the local parity guidelines requiring a minimum of three living children prior to sterilization. All procedures were carried out in the clinic area during a five-day period. Five minutes prior to beginning the procedure, 50 to 75 mg. of meperidine and 10 mg. of diazepam were administered intravenously. The perineum was washed and draped. An intracervical local block and cervical dilatation were per-
From the Department of Obstetrics and Gynecology of the Bronx Lebanon Hospital Center, Bronx, New York; the Departments of Obstetrics and Gynecology and Pathology of the Columbia Presbyterian Medical Center, New York, New York; and the Department of Obstetrics and Gynecology of Churalongkorn University, Bangkok, Thailand. Revised
electrocoagulation
12, 1973.
10, 1973.
Reprint requests: Ralph M. Richart, M.D., 630 W. 168th St., New York, New York 10032.
801
802
Richart
November Am. J. Obstet.
et al.
Table I. Results of hysteroscopic
sterilization Occlusion
Failure
of both
Unilateral
tubes Method
10 Diathermic 20 Diathermic 14 Diathermic Plug 44 Total
No.
cautery cautery + Tefdek mesh cautery + mersilene
Table II. Comparison
of results
1
/ #Nzez;, I?&;.;
*See text
for
31 13 44
definitions
of
“easy”
and
tMersilene
mesh. tape.
:Medroxyprogesterone
acetate.
/
%
1 3
10 15
11 37
64 84
3 7
26 16.5
by degree of
94 61 84 “problem.”
formed as described previously2 and a hysteroscope was passed, 30 per cent dextran being used as the hysteroscopic medium. After the tubal ostia had been localized, a probe was inserted and coagulation performed as described previously.2 In randomly selected women, meshes were inserted into the wound following electrocoagulation. Ten women had electrocautery alone, 20 had electrocautery plus insertion of a Teflon mesh* plug into the o&a, and 14 had electrocautery plus insertion of a polyester fiber mesh? plug into the cauterized ostia. The meshes were inserted under hysteroscopic control with the use of a standard cystoscopy biopsy forceps to grasp the precut material and place it in the cauterized o&urn. The forceps and mesh were passed through the operating port of the hysteroscope. All the women in the series received 250 mg. of Depo-Proverag intramuscularly before leaving the clinic. Following the procedure, the patients were transported to a recovery area where they were observed until they were ambulatory. All left the recovery area on the day of *Tefdek
No.
90 85
( cEY;~tc
2 5 7
%
Bilateral
9 17
difficulty
“Easy”* cases “Problem”* cases Totals
15, 1973 Gynecol.
/
No.
1
%
-
the procedure, most within three to four hours after leaving the clinic. The patients all successfully returned to their regular household duties or jobs the day following the sterilization procedure. Forty-seven patients were scheduled for the procedure. One case was eliminated from the series without cautery because it was believed that uterine perforation had inadvertently occurred. The 46 remaining patients were asked to return in three months for hysterosalpingography. One patient had a vaginal hysterectomy and anterior/posterior repair seven days after the procedure, however, and one patient was lost to follow-up. Of the 44 patients who had hysterosalpingograms, one patient underwent a vaginal hysterectomy and anterior/posterior repair shortly thereafter. Results The raw data are summarized in Table I. Forty-four patients were followed to three months and had a hysterosalpingogram; 37 (84 per centj of these had bilateral tubal obstruction. Seven (eight per cent) of the 88 individual tubes which were treated were patent. The rate of tubal closure was lower in those tubes in which a mesh was inserted, but the number of patients involved is relatively small. The closure rates in Table II were obtained by separating the charts into two groups on the basis of the operative description only without reference to final results. The first group included all patients in whom the entire procedure was easily performed with good visualization and cautery application. The patient failure rate was six per cent; the individual tube failure rate was three per
Volume Number
117 6
Fig. 1. Section is extensive
Electrocoagulation
through
cauterized
necrosis with
local
region
of uterus
inflammatory
of
removed
tubal
seven
ostia
days
response and beginning
using
following
hysteroscopy
injury.
fibroblastic
803
There
ingrowth.
(x250.) cent. The second group included all patients in whom problems arose, such as prior IUD removal obscuring visualization of the ostia or inability to properly place the electrode in the tubes. The patient failure rate in this group was 39 per cent and the individual tube failure rate was 23 per cent. The only problem worthy of note occurred in some patients who complained of bleeding at varying times following the hysteroscopic cautery. The bleeding in most instances was light, however, and hospitalization was not required. The cause of the bleeding was unclear, but the fact that the patients had received Depo-Provera raises the possibility that the bleeding was drug-related, rather than a consequence of the operative manipulation. Similar bleeding did not appear in patients similarly treated in New York but not given Depo-Provera. Histologic examination of the uterus removed seven days after cautery revealed extensive necrosis in both cornual regions (Fig. 1) with a IocaI inflammatory response and beginning organization and repair at the periphery of the injury. Tubal epithelium was not identified in the area of the wound. In the uterus removed 14 weeks following cautery and insertion of Tefdek mesh, the ne-
erotic postcautery wound had largely been replaced by connective tissue, although there were areas still in the early stages of repair and there were many lymphocytes in the cornual regions. The Tefdek mesh had been incorporated into the fibrous tissue and the individual mesh fibers (Fig. 2) were surrounded by a foreign body giant-cell reaction and a local concentration of lymphocytes. Tubal epithelium was not identified in the areas of injury. Comment Among the striking features of this study were the speed and ease with which 46 women could undergo a sterilization procedure and the minimal morbidity which occurred. It is also important that the period of essential contact with professional personnel was short, usually less than 15 minutes, an important factor in the delivery of female sterilization to large populations where physicians may not be in adequate suPPlYThe over-all bilateral tubal closure rate of 84 per cent as determined by hysterosalpingography leaves room for further improvement. The fertility rates in those women with tubal patency is not known, but it is
804
November Am. J. Obstet.
Richart et al.
Fig. 2. Section weeks following mesh fibers are (x625.)
through injury. slightly
area of cautery and Tefdek mesh insertion Fibrous connective tissue infiltrates interstices refractile and surrounded by foreign body giant
probable that it would be reduced because of the extensive tubal damage which the procedure causes, even in those tubes which remain patent. From the point of view of fertility control, the procedure may be more effictive than the 16 per cent failure rate would indicate. The meshes failed to produce a higher closure rate than did cuatery alone. The increased operating time required to insert them and their lack of proved efficacy suggests that meshes should not be used as an
15, 1973 Gynecol.
in
uterus removed 14 of mesh. Individual cells and lymphocytes.
adjunctive measure to electrocoagulation. It is important to note that the patients in this series were unselected and not specifically prepared for the procedure. The high closure rate in those patients in whom the procedure was carried out with ease as compared to the high failure rate in those in whom the procedure was difficult suggests that the results might significantly be improved by a degree of patient preparation and selection.
REFERENCES
1.
Neuwirth, M.: AM.
R.,
Levine,
J. OBSTET.
R.
U.,
GYNECOI..
and Richart, R. 116: 82, 1973.
2.
Levine, OBSTET.
R.
U.:
GYNECOL.
and
Neuwirth, 113: 696,
R. 1972.
S.:
AM.
J.
of
tubal ostia using hysteroscopy RALPH
M.
ROBERT New
RICHART, S.
York,
New
NEUWIRTH,
Bangkok,
M.D.
York
CHARANPAT SUKHIT
M.D.
ISRANGKUN, PHAOSAVASDI,
M.D. M.D.
Thailand
Forty-four women were treated by hysteroscopically directed the tubal ostia to produce permanent sterilization. Thirty-four inserted in the wounded area. Eighty-four per cent of those tubal c!osure as determined by hysterosalpingography.
I N A P R E v 10 u s publication, preliminary experience with tubal sterilization by cautery and partial endosalpingeal excision under hysteroscopic control was rep0rted.l Results were promising and complications trivial. In view of these results a more extended trial of sterilization methods using
Received Accepted
for
publication
May
4, 1973.
May
March
of had a mesh had bilateral
of these
treated
hysteroscopy with 30 per cent dextran was carried out. A different setting was selected in order to evaluate the feasibility of a largescale ambulatory program using this approach. Materials
and
methods
Patient volunteers who wished to be sterilized nonoperatively were recruited from the Family Planning Clinic of the Chulalongkorn University Hospital in Bangkok. NO other selection criteria were used except the local parity guidelines requiring a minimum of three living children prior to sterilization. All procedures were carried out in the clinic area during a five-day period. Five minutes prior to beginning the procedure, 50 to 75 mg. of meperidine and 10 mg. of diazepam were administered intravenously. The perineum was washed and draped. An intracervical local block and cervical dilatation were per-
From the Department of Obstetrics and Gynecology of the Bronx Lebanon Hospital Center, Bronx, New York; the Departments of Obstetrics and Gynecology and Pathology of the Columbia Presbyterian Medical Center, New York, New York; and the Department of Obstetrics and Gynecology of Churalongkorn University, Bangkok, Thailand. Revised
electrocoagulation
12, 1973.
10, 1973.
Reprint requests: Ralph M. Richart, M.D., 630 W. 168th St., New York, New York 10032.
801
802
Richart
November Am. J. Obstet.
et al.
Table I. Results of hysteroscopic
sterilization Occlusion
Failure
of both
Unilateral
tubes Method
10 Diathermic 20 Diathermic 14 Diathermic Plug 44 Total
No.
cautery cautery + Tefdek mesh cautery + mersilene
Table II. Comparison
of results
1
/ #Nzez;, I?&;.;
*See text
for
31 13 44
definitions
of
“easy”
and
tMersilene
mesh. tape.
:Medroxyprogesterone
acetate.
/
%
1 3
10 15
11 37
64 84
3 7
26 16.5
by degree of
94 61 84 “problem.”
formed as described previously2 and a hysteroscope was passed, 30 per cent dextran being used as the hysteroscopic medium. After the tubal ostia had been localized, a probe was inserted and coagulation performed as described previously.2 In randomly selected women, meshes were inserted into the wound following electrocoagulation. Ten women had electrocautery alone, 20 had electrocautery plus insertion of a Teflon mesh* plug into the o&a, and 14 had electrocautery plus insertion of a polyester fiber mesh? plug into the cauterized ostia. The meshes were inserted under hysteroscopic control with the use of a standard cystoscopy biopsy forceps to grasp the precut material and place it in the cauterized o&urn. The forceps and mesh were passed through the operating port of the hysteroscope. All the women in the series received 250 mg. of Depo-Proverag intramuscularly before leaving the clinic. Following the procedure, the patients were transported to a recovery area where they were observed until they were ambulatory. All left the recovery area on the day of *Tefdek
No.
90 85
( cEY;~tc
2 5 7
%
Bilateral
9 17
difficulty
“Easy”* cases “Problem”* cases Totals
15, 1973 Gynecol.
/
No.
1
%
-
the procedure, most within three to four hours after leaving the clinic. The patients all successfully returned to their regular household duties or jobs the day following the sterilization procedure. Forty-seven patients were scheduled for the procedure. One case was eliminated from the series without cautery because it was believed that uterine perforation had inadvertently occurred. The 46 remaining patients were asked to return in three months for hysterosalpingography. One patient had a vaginal hysterectomy and anterior/posterior repair seven days after the procedure, however, and one patient was lost to follow-up. Of the 44 patients who had hysterosalpingograms, one patient underwent a vaginal hysterectomy and anterior/posterior repair shortly thereafter. Results The raw data are summarized in Table I. Forty-four patients were followed to three months and had a hysterosalpingogram; 37 (84 per centj of these had bilateral tubal obstruction. Seven (eight per cent) of the 88 individual tubes which were treated were patent. The rate of tubal closure was lower in those tubes in which a mesh was inserted, but the number of patients involved is relatively small. The closure rates in Table II were obtained by separating the charts into two groups on the basis of the operative description only without reference to final results. The first group included all patients in whom the entire procedure was easily performed with good visualization and cautery application. The patient failure rate was six per cent; the individual tube failure rate was three per
Volume Number
117 6
Fig. 1. Section is extensive
Electrocoagulation
through
cauterized
necrosis with
local
region
of uterus
inflammatory
of
removed
tubal
seven
ostia
days
response and beginning
using
following
hysteroscopy
injury.
fibroblastic
803
There
ingrowth.
(x250.) cent. The second group included all patients in whom problems arose, such as prior IUD removal obscuring visualization of the ostia or inability to properly place the electrode in the tubes. The patient failure rate in this group was 39 per cent and the individual tube failure rate was 23 per cent. The only problem worthy of note occurred in some patients who complained of bleeding at varying times following the hysteroscopic cautery. The bleeding in most instances was light, however, and hospitalization was not required. The cause of the bleeding was unclear, but the fact that the patients had received Depo-Provera raises the possibility that the bleeding was drug-related, rather than a consequence of the operative manipulation. Similar bleeding did not appear in patients similarly treated in New York but not given Depo-Provera. Histologic examination of the uterus removed seven days after cautery revealed extensive necrosis in both cornual regions (Fig. 1) with a IocaI inflammatory response and beginning organization and repair at the periphery of the injury. Tubal epithelium was not identified in the area of the wound. In the uterus removed 14 weeks following cautery and insertion of Tefdek mesh, the ne-
erotic postcautery wound had largely been replaced by connective tissue, although there were areas still in the early stages of repair and there were many lymphocytes in the cornual regions. The Tefdek mesh had been incorporated into the fibrous tissue and the individual mesh fibers (Fig. 2) were surrounded by a foreign body giant-cell reaction and a local concentration of lymphocytes. Tubal epithelium was not identified in the areas of injury. Comment Among the striking features of this study were the speed and ease with which 46 women could undergo a sterilization procedure and the minimal morbidity which occurred. It is also important that the period of essential contact with professional personnel was short, usually less than 15 minutes, an important factor in the delivery of female sterilization to large populations where physicians may not be in adequate suPPlYThe over-all bilateral tubal closure rate of 84 per cent as determined by hysterosalpingography leaves room for further improvement. The fertility rates in those women with tubal patency is not known, but it is
804
November Am. J. Obstet.
Richart et al.
Fig. 2. Section weeks following mesh fibers are (x625.)
through injury. slightly
area of cautery and Tefdek mesh insertion Fibrous connective tissue infiltrates interstices refractile and surrounded by foreign body giant
probable that it would be reduced because of the extensive tubal damage which the procedure causes, even in those tubes which remain patent. From the point of view of fertility control, the procedure may be more effictive than the 16 per cent failure rate would indicate. The meshes failed to produce a higher closure rate than did cuatery alone. The increased operating time required to insert them and their lack of proved efficacy suggests that meshes should not be used as an
15, 1973 Gynecol.
in
uterus removed 14 of mesh. Individual cells and lymphocytes.
adjunctive measure to electrocoagulation. It is important to note that the patients in this series were unselected and not specifically prepared for the procedure. The high closure rate in those patients in whom the procedure was carried out with ease as compared to the high failure rate in those in whom the procedure was difficult suggests that the results might significantly be improved by a degree of patient preparation and selection.
REFERENCES
1.
Neuwirth, M.: AM.
R.,
Levine,
J. OBSTET.
R.
U.,
GYNECOI..
and Richart, R. 116: 82, 1973.
2.
Levine, OBSTET.
R.
U.:
GYNECOL.
and
Neuwirth, 113: 696,
R. 1972.
S.:
AM.
J.