Fertility following perforated appendicitis in girls

Fertility Following Perforated Appendicitis in Girls By P. Purl, E.P.J. McGuinness, and E.J. Guiney

Dublin, Ireland 9 A study was undertaken to determine fertility status in a group of adult females w h o as children had been operated on for perforated appendicitis b e t w e e n 1957 t o 1975. The 3 8 9 girls operated on for perforated appendicitis w e r e reviewed. Their ages ranged from 10 months t o 13 years at t h e t i m e of appendicectomy. Of these girls, 2 7 6 w e r e n o w 2 0 to 43 years old, and they w e r e contacted by means of a mail questionnaire, and personal interview w h e r e v e r necessary. It proved possible to contact 181 w o m e n ; 102 of them w e r e married and 79 w e r e unmarried. Eighty-four of the married w o m e n (82%) had one or more children. Nine unmarried w o m e n also had one or more children. Eighteen married w o m e n w h o have no children w e r e studied in detail. Five w o m e n w e r e on contraceptives, t w o desired pregnancy but had not conceived, and one patient was separated from her husband. T w o patients had conceived and aborted, and t w o w e r e married to infertile men. Of the remaining six patients w h o had been investigated for infertility, no demonstrable cause of infertility was found in three. Of t h e o t h e r t h r e e patients, one showed evidence of bilateral tubal occlusion secondary to pelvic inflammatory disease, one has had a right ectopic pregnancy followed by t w o abortions, and the third patient was found t o have a p i t u i t a r y adenoma. Our data show t h a t perforated appendicitis before puberty has little if any role in the aetiology of tubal infertility. 9 1989 by Grune & Stratton, Inc. INDEX W O R D S : Appendicitis, perforated; fertility.

T R I N S I C anatomical abnormalities of the fallotube or extratubal distortion of tubo-ovarian I Npian relationships are the major aetiological factors in infertility. Recently, a multicentre WHO study, comprising 7,570 patients, reported that tubal disease was the most common cause of infertility in 31% of patients. ~ Salpingitis is the most common cause of intrinsic tubal involvement. The incidence of intrinsic tubal disease as a cause of infertility varies, and depends largely on the prevalence of salpingitis in a given geographical region. 2 Extratubal disease produces peritubal or periovarian adhesions that distort the relationship between the ovary and the fimbriae, and may cause infertility through interference with ovum pickup mechanisms. It has been stated that perforated appendicitis in childhood is associated with an increased risk of tubal infertility) '4 This belief is based on often repeatedly appearing statements in textbooks, without proof, that a perforated appendix in childhood results in increased incidence of infertility. In a preliminary follow-up study of women who had undergone appendicectomy in childhood for perforated appendicitis, we found no evidence to suggest that a perforated appendix increases the risk of infertility.5 The present study was Journal of PediatricSurgery, Vol 24, No 6 (June), 1989: pp 547-549

designed to review a larger number of women from whom perforated appendices had been removed during childhood, and to document in detail the aetiological factors of infertility in childless women. MATERIALS AND METHODS

From 1957 to 1975, 389 girls under 13 years of age underwent appendieeetomy for perforated appendix at Our Lady's Hospital for Sick Children, Dublin. Two hundred seventy-six of these were now 20 to 43 years old, and an attempt was made to trace these women. The detailed follow-up data was collected by means of examination of hospital records, questionnaires sent to all the patients, and personal interviews wherever necessary. The questionnaire requested information regarding marital status and the number of births and miscarriages. Women who had been involuntarily infertile were asked whether they had attended any hospital for investigations and treatment for infertility. RESULTS

A total of 181 women (66%) returned the questionnaire. Age at appendicectomy had ranged from 10 months to 13 years (mean, 8.9 years). The duration of hospital stay ranged from 7 to 63 days (mean, 18.7 days). The operative findings included generalised peritonitis (29), localised peritonitis in (117), pelvic peritonitis in (16), and an appendix abscess or mass (19). Appendicectomy was performed in all patients except eight who had drainage of an appendiceal abscess followed by appendicectomy at a later stage. Drains were employed in 15 patients. All patients were given antibiotics post-operatively. Post-operative intraperitoneal abscesses developed in 23 patients (pelvic abscess in 20 and intra-abdominal abscess in three; one patient had a pelvic as well as a subdiaphragmatic abscess). The ages at follow-up in 181 women ranged from 20 to 43 years (mean, 27.3 years). Of the 181 women, 102 were married and 79 unmarried. Eighty-four of the married women (82%) had children ranging in number from one to seven. Nine unmarried women also had one or more children. There had been three cases of

From the Children's Research Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin; and Coombe Maternity Hospital, Dublin. Presented at the 35th Annual Congress of the British Association of Paediatric Surgeons, Athens, September 21-23, 1988. Address reprint requests to Mr P. Purl, Children's Research Centre, Our Lady "sHospital for Sick Children, Crumlin, Dublin 12, Ireland. 9 1989 by Grune & Stratton, Inc. 0022-3468/89/2406-0009503.00/0 547

548

PURl, McGUINNESS, AND GUINEY

ectopic pregnancy, eight of miscarriage, and one of hydatiform mole in the 84 women with children. Eighteen women who were married but had no children were studied in detail (Table 1). Six had been married <2 years--four were taking family planning precautions and two desired pregnancy but had not conceived. One patient who has been married 21/2years had used family planning precautions until 6 months ago. One patient is separated from her husband and does not desire pregnancy. Two women who have been married 4 and 7 years, respectively, have had miscarriages indicating that they were able to conceive. One woman who has been married 6 years had an ectopic pregnancy 11/2 years after marriage, and as a result, underwent right salpingectomy. Subsequently, she had two first-trimester abortions. A laparoscopy was performed, which showed extensive adhesions around the left tube and ovary involving the bowel and omentum. She underwent left salpingolysis and bilateral ovariolysis 18 months ago. A post-operative hysterosalpingogram was reported as normal. She has not conceived since her operation. Two women who now have been married 15 and 13 years, respectively, were investigated in detail for infertility. A tubal patency test in both women showed the tubes to be patent. Laparoscopy in one showed no evidence of tubal disease, and the other patient was not laparoscoped because of peritoneal adhesions caused by four operations for subacute intestinal obstruction. The husbands of these two patients had an abnormal

semen analysis resulting in a diagnosis of male infertility. One woman who has been married 7 years had a past history of pelvic inflammatory disease. She underwent left ovarian cystectomy 3 years after marriage. One year later, she was found to have bilateral tubal occlusion, and underwent microsurgery. She was laparoscoped a year ago and found to have bilateral tubal occlusion and extensive endometriosis. Another patient who had been married 6 years underwent left ovarian cystectomy 2 years after marriage. Six months later, a hysterosalpingogram confirmed bilateral tubal patency. One year later, as a result of a raised prolactin, a computed tomography scan was carried out, which showed a pituitary adenoma that was treated-by Bromocriptine. The patient is currently on an in vitro fertilisation programme. In the remaining three patients, no demonstrable cause of infertility could be found after detailed investigations for infertility. DISCUSSION

Various published studies on the relationship of complicated appendicectomy and infertility from tubal damage have produced conflicting results. Most earlier studies that examined the frequency of infertility in women who had undergone appendicectomy for perforated appendix in adult life were based on smaller numbers of cases and lacked detailed investigations of infertility.6,7

Table 1. Childless Married W o m e n (n = 18)

Patient No.

Age at Appendicectomy (yr)

Age at Follow-up (u

Duration of marriage(yr)

Remarks

-Pelvic __

FP--pill FP--pill FP--pill FP--pill FP--none FP--none FP--pill 2 yr

1 2 3

5 8 11

24 26 29

4 5 6 7 8

4 7 2~h 10 8

29 26 25 26 29

1 11/~ 2 21,~ Separated

Pelvic __ ----

9 10

12~ 3

35 31

7~ 4

--

35

6

Pelvic

11

71/2

1 1 11~

Post-Operative Abscess

12 13 14

9~ 11 3

39 37 28

15 13 7

Intra-abdominal ---

15

12

26

6

Pelvic

16 17 18

8 4 6

28 29 28

4 4~ 4

Subphrenic ---

3 miscarriages 1 miscarriage Rt ectopic preg, 2 miscarriages, (L) salpingolysis, bilateral ovariolysis HSG-NAD Male sterility Male sterility PID, (L) ovarian cystectomy, bilateral tubalocclusion, microsurgery, endometriosis (L) ovarian cystectomy, HSG-bilateral tubal spill, pituitary adenoma, IVF No demonstrable cause No demonstrable cause No demonstrable cause

Abbreviations: FP, family planning; PID, pelvic inflammatory disease; HSG, hysterosalpingography; IVF, in vitro fertilisation.

FERTILITY AFTER PERFORATEDAPPENDICITIS

549

Recently, Mueller et al 8 in a study of 158 women with primary infertility, reported that those who had an operation for perforated appendix were five times more likely to have primary infertility relative to women who had never had appendicitis. A critical analysis of their study showed that 20% of their patients with primary infertility had a history of pelvic inflammatory disease, compared with only 3% of controis. Since pelvic inflammatory disease is a wellknown cause of infertility, one would expect a higher incidence of infertility due to tubal disease in this group of patients. Due to the approximation of the appendix to the right fallopian tube, one might expect an appendicectomy to be associated with unilateral tubal disease rather than bilateral disease. Consistent with this was the finding of a recent W H O study that 11% of 7,570 women attending for infertility investigation had undergone appendicectomy, 18% of whom were classified as complicated. ~ It was noted in this study that bilateral tubal occlusion was found significantly less often in those who had had appendicectomy than those who had not. Furthermore, the incidence of pelvic adhesions was not significantly different between those who had had a complicated appendicectomy and those who had an uncomplicated appendicectomy. There are only a few reports in the literature that specifically examined the risk of infertility in women who had undergone appendicectomy in childhood. Puri et al 5 and Geerdsen and Hansen 1~reported that perforated appendicitis in girls was not associated with

increased incidence of subsequent infertility. However, an earlier study reported that six of the 37 women who had undergone appendicectomy for perforated appendicitis in childhood were infertile. ~~Upon close examination of this report, it became evident that two of the six patients had evidence of salpingitis, and in the other four women, infertility investigations were inadequate. The fallopian tubes may be affected by initial inflammation in childhood perforated appendicitis. Nevertheless, this inflammatory process usually resolves completely with appendicectomy and adequate antibiotic treatment, and does not have the implications that salpingitis or endometriosis in the adult patient has. In recent years, with the use of antibiotics directed against anaerobes, particularly bacteroides, the incidence of intra-abdominal abscess after perforated appendicitis is significantly diminished. This should further minimise any risk of tubal damage arising from perforated appendices. It is possible that in women who have borne children, there may have been damage to the right fallopian tube due to its approximation to the appendix. However, the left tube in such cases may function n o r m a l l y - - a situation that arises in cases of ectopic pregnancy in which salpingectomy has been previously carried out, and the other tube retains its normal physiological function. Our data show that perforated appendicitis before puberty has little if any role in the aetiology of tubal infertility.

REFERENCES

I. Cooke ID: Investigationof the subfertile couple. Results from the female partner. WHO Task Force on the diagnosis and treatment of infertility, in Shah Ratnam, S, Tcoh ES, Anandakumar C (eds): Infertility. New Jersey, Parthenon, 1987, pp 143-150 2. Cates W Jr, Rowe PJ: The Prevalence of infertility: measures and causes, in Shah Ratnam S, Teoh ES, Anandakumar C (eds): Infertility. New Jersey, Parthenon, 1987, pp 93-102 3. Cloud DT: Appendicitis, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, Saunders, 1980, p 506 4. Mastroianni L Jr: Tubal occlusion, in Keller PJ (ed): Female Infertility. Basel, Karger, 1978, pp 114-131 5. Puri P, Guiney EJ, O'Donnell B, et al: Effects of perforated appendicitis in girls on subsequent fertility. Br Med J 288:25-26, 1984

6. PowleyPH: Infertility due to pelvicabscessand pelvicperitonitis in appendicitis. Lancet 1:27-29, 1965 7. Wiig JN, Janssen CW Jr, Fuglesang P, et al: Infertility as a complication of perforated appendicitis. Acta Chit Stand 145:409410, 1979 8. MueUer BA, Daling JR, Moore DE, et al: Appendiceetomy and the risk of tubal infertility. N Engl J Med 315:1506-1508, 1986 9. Geerdson J, Hanson JB: Incidence of sterility in women operated on in childhood for perforated appendicitis. Acta Obstet Gynecol Scand 56:523-524, 1977 10. Thompson WM, Lynn HB; The possible relationship of appendicitis with perforation in childhood to infertility in women. J Pediatr Surg 6:458-461, 1971