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Human tubal motility in vivo
Human tubal motility YAMANDO HECTOR MARIA CHARLES
SICA
M.D.
M.D. REMEDIO,
H.
HERMOGENES Montevideo,
BLANCO,
ROZADA, ROSA
in vivo
M.D.
HENDRICKS,
M.D.*
ALVAREZ,
M.D.
Uruguay
Human evidence
tubal activity can be recorded in vivo. The tubes constantly exhibit of contractile activity. The usual magnitude of contractions ranges between I and 5 mm. Hg, but it may be as high as IO mm. Hg or, in exceptional cases, up to 25 mm. Hg. The frequency varies from 1 to 3 beats per minute. There is much spontaneous variability over long periods of time. The activity between the left and right tubes is not symmetrical and may vary greatly in type. We have been unable to say definitely if the motility patterns change with the stage of the menstrual cycle.
ROLE 0 F TUBAL Contractility in human fertility remains obscure. The characteristics of human tubal motility in vivo remain unknown because it has not been possible to study them heretofore. Nevertheless, much background information, some of it mutually contradictory, has been accumulated. The previous in vivo studies in animals were performed by observation through an “abdominal window” or laparoscopy,1ol I19 27p 28 without proper recording of the phe-
nomenon. Most previous worker+ 27128 coneluded that the tubes have peristaltic waves beginning in the ampulla and progressing down toward the isthmus. Kokll assumed that the peristaltic movements are not constant and that they can start in any segment of the tube. He also described antiperistaltic movements in the tubes. Westman2s described very complicated movements of the Fallopian tube in the monkey, partly similar to the above mentioned, but with the addition of rotation and flexion movements. There have also been described irregular contractions which bear no relationship to peristalsis. During estrus in the rabbit,‘? the contractions are more vigorous and frequently occur every 5 to 12 seconds. The peristaltic activity of the tubes in woman has been observed in vivo through laparoscopy,5p 6* lo radiography,l* 4l I41 15* 18-20 or during surgical procedures53 6* la Nevertheless, some authors have been unable to
THE
From the Clinica Ginecotocoldgica Faculty of Medicine (Director: Hermdgenes Alvarez).
Prof.
“C,” Dr.
This investigation was supfiorted in part by Grants M65-127 and M67-33 from the Population Council, New York, New York. *Dr. Hendricks, from the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, was visiting Professor at the Laboratory of Uterine and Tubal Contractility of the Clinica Ginecotocoldgica “C.”
79
80
Sica
Blanc0
et al. Amer.
corroborate these movements with the same methods. Bunste? could not elicit tubal contractions by direct mechanical stimulation during surgical procedures. Rubinl?? I8 studied what he considered to be human tubal motility through uterotubal insufflation, postulating a consistent tubal activity with contractions ranging from 30 to 40 mm. Hg in intensity and a frequency of 2 to 4 per minute, but he claimed that “the number of oscillations is, to a certain degree, dependent upon the volume of gas which passes through the tubes at a given rate.“lg He also found an increase of tubal motility during the ovulatory period.179 I9 The study method employed by Rubin is very indirect and has been believed to record uterine rather than tubal contractions.2l 14, 25, 26 Stabile, Caldeyro-Barcia, and AlvarezZ6 made an attempt to record tubal contractility directly through the insertion of microballoons in the tubal wall during laparotomy; in a few cases they were able to record contractions of 1 to 2 mm. Hg of intensity with a frequency of 1 per minute. These studies were not continued long enough to give definitive results. Garcia Huidobro and associates7 and Clyman3 have described methods for recording tubal motility in women in vivo, but have not presented any results. In this report we will describe the method
Fig. 1. Method for continuous recording introduced through the abdominal ostium. wall into the tube lumen (see text).
we have recordings Material
January 1, 1970 J. Obstet. Gynec.
developed for making continuous of tubal pressure in situ in women. and
methods
Patients in whom sterilization was indicated were selected for study. The indications for sterilization in nonpregnant women were as follows : multiparity (5 cases), neuropsychiatric indication (3 cases), and chronic hypertensive disease (1 case). In four patients we performed an abdominal hysterotomy along with sterilization. The ages of the subjects ranged from 23 to 45 years. A total of 13 patients were studied one or more times, a total of 45 observation sessions having been carried out. In addition, we studied three patients who did not have sterilization, but were scheduled for a gynecologic laparotomy. During their convalescence, each one was studied on three occasions. Two of them have subsequently conceived and are carrying normal intrauterine pregnancies. With the patient under Pentothal, procaine, and succinylcholine anesthesia, the abdomen is entered through a Pfannenstiel incision, Tubal sterilization is accomplished by excising a short segment of each tube near the cornual region of the uterus. Into each tube there is inserted a sterile salinefilled polyethylene catheter, O.D. 50. The catheter is inserted through the site of a small
of tubal pressure. In the left tube
In the right tube the catheter the catheter is passed through
is the
Volume Number
106 1
Tubal
needle puncture and is pushed into the tubal lumen until approximately 2 cm. of the catheter are lying inside the tube (Fig. 1) . It is fixed to the tube by a fine catgut suture. On some occasions the catheter is introduced into the tube through the abdominal ostium and fixed to the fibriae by a catgut suture (Fig. 1) . The tube is then allowed to drop down posteriorly, at which time the catheter is also sutured to the posterior surface of the uterus. The catheter is brought up over the top of the fundus where it is again sutured lightly. Two more sutures are placed to hold the catheters along the course of the round ligament. Finally, the 8 foot catheters are exteriorized by threading them through a straight 17 gauge thin-walled needle inserted so that it presents along the course of the round ligament within 2 cm. of the final suture which is holding the catheter within the pelvis. Considering the anatomic vicinity of the tubes and the intestinal loops, and that our recording method might register the variations in pressure produced in the tube by the intestinal motility, another catheter was fixed in 6 patients, in the posterior uterine wall for recording the intra-abdominal pressure. A sterile dressing is maintained over the site of
2. Different
tubal
motility
patterns
(see text).
in vivo
81
the catheter exit. The fluid-filled tubes are then connected to Sanborn transducer and recording equipment. Observation sessions last from 2 to 5 hours. Up to five observation sessions can be done on the same patient during her convalescence from laparotomy. When indicated, the catheters are gently flushed with sterile saline containing tetracycline. There have been no instances of infection in any of the subjects studied. It will be noted that the catheters are brought out in such a way that they will not have any effect upon the arrangements of the intestinal loops. In eleven observation sessions we made a simultaneous recording of the uterine motility by Hendricks’g method. Resulfs
In most of the studies, the tubes exhibited constant motility characterized by contractions appearing every twenty seconds. The usual intensity of these contractions is of 1 to 2 mm. Hg (Fig. 2, A, B, C, and B ) . On this basic contractile pattern, contractions of higher intensity (8 to 15 mm. Hg) appear periodically, either isolated (Figs. 2, A and 3, A) or in groups (Fig. 2, C and D) . There may be a progressive rise in the in-
b209
Fig,
motility
b170
82
Sica
Blanca
January J. Obstet.
et al. Amer.
tensity
of
these
basal contractions until they values of 8 to 10 mm. Hg and
reach
average
then
suddenly
recede
(Fig.
2, C) . At
other
is interrupted
A
of denly
B
by
higher
to
the
a variable
to 5 minutes)
and
vious
characteristics
the
the
wave be
previous
D
and/or
In the
all
the
1
:
._ . .
.
.
. . ...”
1
1.
. .... :
i
periods
lowed
by type
(Fig.
On
other
during
the
the
.i
:
:
at
progressive
of
may
increased
fre-
contractions. just
lead
described,
us to suspect
activity,
although
contractions activity
of
are
during time
in the slow
hours
of
tubal
the
comor
pressure
seem to of
tonus
pattern.
$$
.
even
observation,
modifications
in the contractile
i 1 .
minutes 40 years of age. Dysmenorrhea, uterine retroversion; was introduced through the wall into the tubal lumen of both tubes. Note the pressure scale (see text),
fol-
a very
.
j ; I I I I .L: .I. I. i I ._I 1 .I -.l..iJ ..i.-x: xx-1 I.:I‘.L . . . Fig. 4. Primipara, cycle. The catheter Simultaneous record
this
activity
the
motility
rises subsides
..i:‘:I:
._’ j- ‘R’ig’hi
.
with
E) . On
an
of
of
whole
(4 pre-
which then
often
2, F)
and complexity
i !
tone 2,
occasions,
changes
show
2, D)
basa1
regular
periods
(Fig.
the
muscular of
sudtime its
and
of contraction
some
of
resumes
(Fig.
types
patterns
plex
of
intensity
a coordinated Fig. 3. Continuous recording of left tubal pressure over a period of one hour. The record was made four days after abdominal hysterotomy (fourteenth week of pregnancy) and sterilization in a multipara with chronic hypertensive disease. A shows low basal activity with four isolated contractions of high intensity. B shows the basal activity interrupted by a contractile burst. C and D show the intravenous injection of 5 I.U. of oxytocin increases tubal motility.
lapse
tone,
superimposed,
quency
a burst
these bursts start
level
of increased
activity
of which
tube
a progressive increase steadily up to a maximum to
activity
basal
appearance
On some occasions
c
basal
the
contractions
after
motility
the
times,
intensity
cease
I, 1970 Gynec.
thirteenth day without sterilization.
of
Volume Number
106 1
Tubal
All these observed contractility patterns may be seen in the same case over a period of time. The most consistent behavioral characteristic of the tube seems to be its tendency to vary its spontaneous activity from one form to another periodically (Fig. 3). Relationship between the motility of both tubes. The simultaneous records of the contractile activity in both tubes has always demonstrated a motility which seems to be completely independent. In Fig. 4, the left tube (upper part of the illustration) shows regular contractility with two small bursts of increased activity in which the intensity of the contractions rises as high as 15 mm. Hg. The right tube (lower part of the illustration) shows a regular pattern at the beginning, with a contraction every 40 seconds, but this pattern gives way to a 10 minute period of activity in which the contractions are of a more complex type. Comparable variability is shown in Fig. 5, a record made in the same subject 4 days before. Relationship between tubal and uterine contractility. In 1 I cases, the tubal and
motility
in vivo
uterine contractility were recorded simultaneously. Fig, 6 reproduces an original record obtained in the described way. The uterine contractility is characterized by contractions with a frequency oscillating between 5 and 8 contractions per minute, and the intensity of which varies between 2 and 10 mm. Hg. The tubal contractility shows contractions of 1 to 2 mm. Hg in groups of 3 contractions of higher intensity (7 to 10 mm. Hg) . The two contractility patterns are quantitatively, qualitatively, and temporally different. Relationship between tubal contractility and abdominal pressure. Fig. 7 is a simultaneous recording of the tubal and abdominal pressure in a subject during the postoperative period in which she had colicky pains. Variations of abdominal pressure (upper part of the figure) somewhat resemble tubal contractions. The simultaneous record of both pressures shows that there is no relationship between them. In records taken in the postoperative period, once the intestinal motility has become normal, the intra-abdominal pressure variations are minimal over long periods of
#b 205
Fig. 5. Same subject Note
the pressure
as Fig. scale.
1. Record
of both
83
tubes
performed
at the ninth
day
of the cycle.
84
Sica
Blanc0
Janus, y 1. 1970 J. Obstet. Gynec.
et al. .\mer.
# b $63 . .
L
.
‘.,i
minut*r Fig. and
6. Para xii, tubal pressure
36 years of age. (see text).
Eighth
day
after
operation.
Simultaneous
record
of uterine
#b 204 Abdominal
‘.-x_.
Fig. tubal
Pressure
--
7. Same
subject as Fig. 6. Twenty-four hours after operation. Simultaneous and abdominal pressure. The subject was recovering from postoperative ileus.
time (2 to 4 hours), and the variations of intra-abdominal pressure could not be confused with those resulting from the contractions of the tubal musculature. Comment
Our method for direct and continuous recording of the tubal pressure has shown its feasibility for the study of tubal motility. It
record
of
is safe for the patient and permits recording over long periods and on successive days without any complications. Moreover, it can be done without any complications. Furthermore, it can be done without tubal section, and in this way it does not interfere with future reproductive functions of the tubes. We do not know to what extent the movements of the whole tube, described in an-
Volume Number
106 1
Tubal
motility
in vivo
85
40 3, Fig. 8. Fallopian
In
vitro simultaneous recording of motility and tube (after Gonzalez-Panizza and Rozada) .8
An obvious limitation of the method of study in those cases where tubal ligation is performed is the fact that in addition to the surgical trauma there is also physical interruption of the continuity between the tubes and uterus. Furthermore, this method of study does not permit the observation of the tubal activity at the cornual region of the uterus. It should be pointed out, however, that in those cases in which tubal ligation lvas not carried out, the tubal activity does not appear different from that of the sectioned tubes. No differences were found in the records taken with the catheter passed through the ostium or through the proximal tubal wall. With this method, the existence of a continuously changing pattern of contractiIe activity in the Fallopian tubes has been recorded. We do not know whether this variability is provoked by the activity of the circular or longitudinal muscles acting independently or synergically, or if they represent a local or total phenomenon as it has been describedr?, 181 I99 23* 24 by other methods of study. 76, 21, 22, 28, 29
electrical
activity
of whole
human
Our studies have not yet convinced us that there are any specific variations of the pattern in the different phases of the menstrual cycle as has been postulated in some in vitro21-23 and in vivo’7y IQ, 27 works. The finding of a nonsymmetrical activity of both tubes suggests the possibility of some neurohormonal factor with local action on tubal contractility which could also be related to the ovarian cycle. Our present results showing independence of tubal and uterine contractility do not support the idea of the existence of a pacemaker in the tubes controlling uterine activity. Nevertheless, Gonzalez-Panizza and Rozada,8 studying in vitro the spontaneous contractile and electrical activity of the whole human Fallopian tube, found a regular pattern of biphasic spikes of action potentials which suggest the existence of an electrical pacemaker (Fig. 8). These biphasic spikes are very regular in intensity (5 millivolts) and in frequency (one every 12 seconds) ; on the contrary, the observed contractile pattern is very irregular in amplitude and in frequency. Our future work will stress the modifications of tubal contractility through the menstrual cycle, the mechanism of control of this
86
Sica
Blanc0
et al.
motility, and the effects of different drugs which could modify this activity and be used in the control of conception. Attempts are
Amer.
also being made to determine presence of an intrauterine device modifies tubal motility.
January J. Obstet.
1, 1970 Gynec.
whether the contraceptive
REFERENCES
5. 6. 7.
8. 9. 10. 11. 12. 13. 14.
Beclere, Cl.: Enciclop. Med. Chir. Gynec. 1: 64, 1955. Bunster, M. E.: Buenos Aires, 1951, G. Kraft, Ltd. Clyman, M. J.: Pacific Med. & Surg. 74: 119, 1966. Daniel, M. C., Mitescu, A., Soimaru, A., and Georgescu, I. D.: Rev. Franc. Gynec: 28: 421. 1937. Dovle, .J. B.: Proc. I World Congr. Fertil. & SteEil.~ 2: 33, 1953. Dovle. T. B.: Obst. & Gvnec. 8: 686. 1956. Garcia ” Huidobro, M., ’ Gomez Rogers, C., Ibarra Polo, A., Guiloff, E., Faundes Latham, A., Quintanilla, R., Avendano, S., Espinosa; R.: II Reunion Asoc. LatinT . . and Ramirez. oam. Invest. Reprod. Humana, Vina de1 Mar, Chile, 1966. Gonzalez-Pan&a, V. H., and Rozada, H.: Unpublished data. Hendricks, C. H.: J. Obst. & Gynaec. Brit. Comm. 71: 712, 1964. Kok, F.: Klin. Wchnschr. 4: 1543, 1925. Kok, F.: Arch. GynLk. 127: 384, 1926. Palmer, R.: Les explorations fonctionelles gynecologiques, Paris, 1963, Masson et Cie. Pincsohn, A.: Zentralbl. Gynlk. 48: 1209, 1924. Rovalo Gimenez, J.: Insuflacion utero-tubarica quimografica, in Gutierrez Murillo, E., and Vazquez Benitez, E., editors: Temas Selectos de Gineco-Obstetricia, Mexico, 1967, Impresiones Modernas, p. 596.
15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.
27. 28. 29.
Rozin, S., and Schwartz, A.: Obst. & Gynec. 26: 524, 1965. Rubin, I. C., and Bendick, A. J.: J. A. M. A. 87: 657, 1926. Rubin, I. C.: AM. J. OBST. & GYNEC. 37: 394, 1939. Rubin, I. C.: J. Obst. & Gynaec. Brit. Emp. 54: 733, 1947. Rubin, I. C.: Utero-tubal Insufflation, St. Louis, 1947, The C. V. Mosby Company. Rubin, I. C.: Proc. III Congr. Latino-am. Obst. y Ginec. Mexico, 1938, vol. 2, p. 68. Seckinger, D. L.: Bull. Johns Hopkins Hosp. 34: 236, 1923. Seckingkr, D. L., and Corner, G. W.: Anat. Rec. 26: 299. 1923. Seckinger, D. L., and Synder, F. F.: Proc. Sot. Exper. Biol. & Med. 21: 519, 1924. Siegler, S. L.: Fertility in Women, Phila; .rphia, 1944, J. B. Lippincott Company. Stabile, A.: Proc. I World Congr. Fertil. & Steril. 2: 1, 1953. Stabile, A., Caldeyro-Barcia, R., and Alvarez, H.: Proc. I World Congr. Fertil. & Steril. 1: 188, 1953. Westman, A.: Acta obst. et gynec. scandinav. 5 (Suppl. 3): 7, 1926. Westman, A.: Acta obst. et gynec. scandinav. 8: 307, 1929. Westman, A.: J, Obst. & Gynaec. Brit. Emp. 44: 821, 1937.
SICA
M.D.
M.D. REMEDIO,
H.
HERMOGENES Montevideo,
BLANCO,
ROZADA, ROSA
in vivo
M.D.
HENDRICKS,
M.D.*
ALVAREZ,
M.D.
Uruguay
Human evidence
tubal activity can be recorded in vivo. The tubes constantly exhibit of contractile activity. The usual magnitude of contractions ranges between I and 5 mm. Hg, but it may be as high as IO mm. Hg or, in exceptional cases, up to 25 mm. Hg. The frequency varies from 1 to 3 beats per minute. There is much spontaneous variability over long periods of time. The activity between the left and right tubes is not symmetrical and may vary greatly in type. We have been unable to say definitely if the motility patterns change with the stage of the menstrual cycle.
ROLE 0 F TUBAL Contractility in human fertility remains obscure. The characteristics of human tubal motility in vivo remain unknown because it has not been possible to study them heretofore. Nevertheless, much background information, some of it mutually contradictory, has been accumulated. The previous in vivo studies in animals were performed by observation through an “abdominal window” or laparoscopy,1ol I19 27p 28 without proper recording of the phe-
nomenon. Most previous worker+ 27128 coneluded that the tubes have peristaltic waves beginning in the ampulla and progressing down toward the isthmus. Kokll assumed that the peristaltic movements are not constant and that they can start in any segment of the tube. He also described antiperistaltic movements in the tubes. Westman2s described very complicated movements of the Fallopian tube in the monkey, partly similar to the above mentioned, but with the addition of rotation and flexion movements. There have also been described irregular contractions which bear no relationship to peristalsis. During estrus in the rabbit,‘? the contractions are more vigorous and frequently occur every 5 to 12 seconds. The peristaltic activity of the tubes in woman has been observed in vivo through laparoscopy,5p 6* lo radiography,l* 4l I41 15* 18-20 or during surgical procedures53 6* la Nevertheless, some authors have been unable to
THE
From the Clinica Ginecotocoldgica Faculty of Medicine (Director: Hermdgenes Alvarez).
Prof.
“C,” Dr.
This investigation was supfiorted in part by Grants M65-127 and M67-33 from the Population Council, New York, New York. *Dr. Hendricks, from the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, was visiting Professor at the Laboratory of Uterine and Tubal Contractility of the Clinica Ginecotocoldgica “C.”
79
80
Sica
Blanc0
et al. Amer.
corroborate these movements with the same methods. Bunste? could not elicit tubal contractions by direct mechanical stimulation during surgical procedures. Rubinl?? I8 studied what he considered to be human tubal motility through uterotubal insufflation, postulating a consistent tubal activity with contractions ranging from 30 to 40 mm. Hg in intensity and a frequency of 2 to 4 per minute, but he claimed that “the number of oscillations is, to a certain degree, dependent upon the volume of gas which passes through the tubes at a given rate.“lg He also found an increase of tubal motility during the ovulatory period.179 I9 The study method employed by Rubin is very indirect and has been believed to record uterine rather than tubal contractions.2l 14, 25, 26 Stabile, Caldeyro-Barcia, and AlvarezZ6 made an attempt to record tubal contractility directly through the insertion of microballoons in the tubal wall during laparotomy; in a few cases they were able to record contractions of 1 to 2 mm. Hg of intensity with a frequency of 1 per minute. These studies were not continued long enough to give definitive results. Garcia Huidobro and associates7 and Clyman3 have described methods for recording tubal motility in women in vivo, but have not presented any results. In this report we will describe the method
Fig. 1. Method for continuous recording introduced through the abdominal ostium. wall into the tube lumen (see text).
we have recordings Material
January 1, 1970 J. Obstet. Gynec.
developed for making continuous of tubal pressure in situ in women. and
methods
Patients in whom sterilization was indicated were selected for study. The indications for sterilization in nonpregnant women were as follows : multiparity (5 cases), neuropsychiatric indication (3 cases), and chronic hypertensive disease (1 case). In four patients we performed an abdominal hysterotomy along with sterilization. The ages of the subjects ranged from 23 to 45 years. A total of 13 patients were studied one or more times, a total of 45 observation sessions having been carried out. In addition, we studied three patients who did not have sterilization, but were scheduled for a gynecologic laparotomy. During their convalescence, each one was studied on three occasions. Two of them have subsequently conceived and are carrying normal intrauterine pregnancies. With the patient under Pentothal, procaine, and succinylcholine anesthesia, the abdomen is entered through a Pfannenstiel incision, Tubal sterilization is accomplished by excising a short segment of each tube near the cornual region of the uterus. Into each tube there is inserted a sterile salinefilled polyethylene catheter, O.D. 50. The catheter is inserted through the site of a small
of tubal pressure. In the left tube
In the right tube the catheter the catheter is passed through
is the
Volume Number
106 1
Tubal
needle puncture and is pushed into the tubal lumen until approximately 2 cm. of the catheter are lying inside the tube (Fig. 1) . It is fixed to the tube by a fine catgut suture. On some occasions the catheter is introduced into the tube through the abdominal ostium and fixed to the fibriae by a catgut suture (Fig. 1) . The tube is then allowed to drop down posteriorly, at which time the catheter is also sutured to the posterior surface of the uterus. The catheter is brought up over the top of the fundus where it is again sutured lightly. Two more sutures are placed to hold the catheters along the course of the round ligament. Finally, the 8 foot catheters are exteriorized by threading them through a straight 17 gauge thin-walled needle inserted so that it presents along the course of the round ligament within 2 cm. of the final suture which is holding the catheter within the pelvis. Considering the anatomic vicinity of the tubes and the intestinal loops, and that our recording method might register the variations in pressure produced in the tube by the intestinal motility, another catheter was fixed in 6 patients, in the posterior uterine wall for recording the intra-abdominal pressure. A sterile dressing is maintained over the site of
2. Different
tubal
motility
patterns
(see text).
in vivo
81
the catheter exit. The fluid-filled tubes are then connected to Sanborn transducer and recording equipment. Observation sessions last from 2 to 5 hours. Up to five observation sessions can be done on the same patient during her convalescence from laparotomy. When indicated, the catheters are gently flushed with sterile saline containing tetracycline. There have been no instances of infection in any of the subjects studied. It will be noted that the catheters are brought out in such a way that they will not have any effect upon the arrangements of the intestinal loops. In eleven observation sessions we made a simultaneous recording of the uterine motility by Hendricks’g method. Resulfs
In most of the studies, the tubes exhibited constant motility characterized by contractions appearing every twenty seconds. The usual intensity of these contractions is of 1 to 2 mm. Hg (Fig. 2, A, B, C, and B ) . On this basic contractile pattern, contractions of higher intensity (8 to 15 mm. Hg) appear periodically, either isolated (Figs. 2, A and 3, A) or in groups (Fig. 2, C and D) . There may be a progressive rise in the in-
b209
Fig,
motility
b170
82
Sica
Blanca
January J. Obstet.
et al. Amer.
tensity
of
these
basal contractions until they values of 8 to 10 mm. Hg and
reach
average
then
suddenly
recede
(Fig.
2, C) . At
other
is interrupted
A
of denly
B
by
higher
to
the
a variable
to 5 minutes)
and
vious
characteristics
the
the
wave be
previous
D
and/or
In the
all
the
1
:
._ . .
.
.
. . ...”
1
1.
. .... :
i
periods
lowed
by type
(Fig.
On
other
during
the
the
.i
:
:
at
progressive
of
may
increased
fre-
contractions. just
lead
described,
us to suspect
activity,
although
contractions activity
of
are
during time
in the slow
hours
of
tubal
the
comor
pressure
seem to of
tonus
pattern.
$$
.
even
observation,
modifications
in the contractile
i 1 .
minutes 40 years of age. Dysmenorrhea, uterine retroversion; was introduced through the wall into the tubal lumen of both tubes. Note the pressure scale (see text),
fol-
a very
.
j ; I I I I .L: .I. I. i I ._I 1 .I -.l..iJ ..i.-x: xx-1 I.:I‘.L . . . Fig. 4. Primipara, cycle. The catheter Simultaneous record
this
activity
the
motility
rises subsides
..i:‘:I:
._’ j- ‘R’ig’hi
.
with
E) . On
an
of
of
whole
(4 pre-
which then
often
2, F)
and complexity
i !
tone 2,
occasions,
changes
show
2, D)
basa1
regular
periods
(Fig.
the
muscular of
sudtime its
and
of contraction
some
of
resumes
(Fig.
types
patterns
plex
of
intensity
a coordinated Fig. 3. Continuous recording of left tubal pressure over a period of one hour. The record was made four days after abdominal hysterotomy (fourteenth week of pregnancy) and sterilization in a multipara with chronic hypertensive disease. A shows low basal activity with four isolated contractions of high intensity. B shows the basal activity interrupted by a contractile burst. C and D show the intravenous injection of 5 I.U. of oxytocin increases tubal motility.
lapse
tone,
superimposed,
quency
a burst
these bursts start
level
of increased
activity
of which
tube
a progressive increase steadily up to a maximum to
activity
basal
appearance
On some occasions
c
basal
the
contractions
after
motility
the
times,
intensity
cease
I, 1970 Gynec.
thirteenth day without sterilization.
of
Volume Number
106 1
Tubal
All these observed contractility patterns may be seen in the same case over a period of time. The most consistent behavioral characteristic of the tube seems to be its tendency to vary its spontaneous activity from one form to another periodically (Fig. 3). Relationship between the motility of both tubes. The simultaneous records of the contractile activity in both tubes has always demonstrated a motility which seems to be completely independent. In Fig. 4, the left tube (upper part of the illustration) shows regular contractility with two small bursts of increased activity in which the intensity of the contractions rises as high as 15 mm. Hg. The right tube (lower part of the illustration) shows a regular pattern at the beginning, with a contraction every 40 seconds, but this pattern gives way to a 10 minute period of activity in which the contractions are of a more complex type. Comparable variability is shown in Fig. 5, a record made in the same subject 4 days before. Relationship between tubal and uterine contractility. In 1 I cases, the tubal and
motility
in vivo
uterine contractility were recorded simultaneously. Fig, 6 reproduces an original record obtained in the described way. The uterine contractility is characterized by contractions with a frequency oscillating between 5 and 8 contractions per minute, and the intensity of which varies between 2 and 10 mm. Hg. The tubal contractility shows contractions of 1 to 2 mm. Hg in groups of 3 contractions of higher intensity (7 to 10 mm. Hg) . The two contractility patterns are quantitatively, qualitatively, and temporally different. Relationship between tubal contractility and abdominal pressure. Fig. 7 is a simultaneous recording of the tubal and abdominal pressure in a subject during the postoperative period in which she had colicky pains. Variations of abdominal pressure (upper part of the figure) somewhat resemble tubal contractions. The simultaneous record of both pressures shows that there is no relationship between them. In records taken in the postoperative period, once the intestinal motility has become normal, the intra-abdominal pressure variations are minimal over long periods of
#b 205
Fig. 5. Same subject Note
the pressure
as Fig. scale.
1. Record
of both
83
tubes
performed
at the ninth
day
of the cycle.
84
Sica
Blanc0
Janus, y 1. 1970 J. Obstet. Gynec.
et al. .\mer.
# b $63 . .
L
.
‘.,i
minut*r Fig. and
6. Para xii, tubal pressure
36 years of age. (see text).
Eighth
day
after
operation.
Simultaneous
record
of uterine
#b 204 Abdominal
‘.-x_.
Fig. tubal
Pressure
--
7. Same
subject as Fig. 6. Twenty-four hours after operation. Simultaneous and abdominal pressure. The subject was recovering from postoperative ileus.
time (2 to 4 hours), and the variations of intra-abdominal pressure could not be confused with those resulting from the contractions of the tubal musculature. Comment
Our method for direct and continuous recording of the tubal pressure has shown its feasibility for the study of tubal motility. It
record
of
is safe for the patient and permits recording over long periods and on successive days without any complications. Moreover, it can be done without any complications. Furthermore, it can be done without tubal section, and in this way it does not interfere with future reproductive functions of the tubes. We do not know to what extent the movements of the whole tube, described in an-
Volume Number
106 1
Tubal
motility
in vivo
85
40 3, Fig. 8. Fallopian
In
vitro simultaneous recording of motility and tube (after Gonzalez-Panizza and Rozada) .8
An obvious limitation of the method of study in those cases where tubal ligation is performed is the fact that in addition to the surgical trauma there is also physical interruption of the continuity between the tubes and uterus. Furthermore, this method of study does not permit the observation of the tubal activity at the cornual region of the uterus. It should be pointed out, however, that in those cases in which tubal ligation lvas not carried out, the tubal activity does not appear different from that of the sectioned tubes. No differences were found in the records taken with the catheter passed through the ostium or through the proximal tubal wall. With this method, the existence of a continuously changing pattern of contractiIe activity in the Fallopian tubes has been recorded. We do not know whether this variability is provoked by the activity of the circular or longitudinal muscles acting independently or synergically, or if they represent a local or total phenomenon as it has been describedr?, 181 I99 23* 24 by other methods of study. 76, 21, 22, 28, 29
electrical
activity
of whole
human
Our studies have not yet convinced us that there are any specific variations of the pattern in the different phases of the menstrual cycle as has been postulated in some in vitro21-23 and in vivo’7y IQ, 27 works. The finding of a nonsymmetrical activity of both tubes suggests the possibility of some neurohormonal factor with local action on tubal contractility which could also be related to the ovarian cycle. Our present results showing independence of tubal and uterine contractility do not support the idea of the existence of a pacemaker in the tubes controlling uterine activity. Nevertheless, Gonzalez-Panizza and Rozada,8 studying in vitro the spontaneous contractile and electrical activity of the whole human Fallopian tube, found a regular pattern of biphasic spikes of action potentials which suggest the existence of an electrical pacemaker (Fig. 8). These biphasic spikes are very regular in intensity (5 millivolts) and in frequency (one every 12 seconds) ; on the contrary, the observed contractile pattern is very irregular in amplitude and in frequency. Our future work will stress the modifications of tubal contractility through the menstrual cycle, the mechanism of control of this
86
Sica
Blanc0
et al.
motility, and the effects of different drugs which could modify this activity and be used in the control of conception. Attempts are
Amer.
also being made to determine presence of an intrauterine device modifies tubal motility.
January J. Obstet.
1, 1970 Gynec.
whether the contraceptive
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