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Hysteroscopic tubal sterilization
Hysteroscopic I. A preliminary
ROBERT
NEUWIRTH, U.
RALPH New
report
S.
RICHARD M. York,
New
tubal sterilization
LEVINE,
RICHART,
M.D M.D. M.D.
York
Seventeen multiparous patients underwent a sterilization by cornual cauterization at hysteroscopy with 30 per cent Dextran. There were no complications and the procedure was simple. A patient failure rate of 25 per cent as determined hysterosalpingography three months postoperatively was obtained.
A L. L 1‘ 1~ B A L sterilizations have two phases : ( 1) the agent or act which will producr tubal closure and (2) the delivery to some portion of the tube. The search for simplified transcervical procedures to produce tubal obstruction was first undertaken by Dickinson,l using cautery. This method was refined and additional experience collected by Hyams.’ Variations of transcervical electrocautery are still being used,” but other methods have also been studied. Martens’ has tried cryosurgery; Rakshit” and Richart and associates6 have tried chemical agents. All of these methods have suffered in part from the problem of precise delivery to the tube. Zipper and associates’ have been working with quinacrine, which may be delivered
by simple irrigation of the uterine cavity but requires repeated patient visits. With the favorable experience of Levine and Neuwirth* in the use of 30 per cent Dextran for hysteroscopy, it was decided to attempt to treat a small series of patients by means of electrocautery and surgical removal of the interstitial endosalpinx to produce tubal blockage at this point. This report presents the results in 17 patients treated done by this method between October, 1971, and June, 1972, at The BronsLebanon Hospital. Materials
for
publication
November
September
and
methods
The hysteroscopy was performed as rcported previously” with the exception of the use of an ACM1 foroblique hysteroscope of 6 mm. total diameter. Preliminary testirlg confirmed that 30 per cent Dextran was not a conductive solution, and that a predetermined diathermic injury could be delivered under visual control to the uterotubal junction without injury to the uterine serosa. All patients were post partum within two to foul months except two. One of these underwent a preliminary hysterosalpingogram to demonstrate tubal patency before operation (Figs. 1 and 2). The patients were told that results would be unpredictable and that a hysterosalpingo-
From the Department of Obstetrics and Gynecology, Bronx-Lebanon Hospital Center, and the Department of Obstetrics and Gynecology, Columbia College of Physicians and Surgeons. Partially supported by the Population Council, Inc., of New York, Contract No. M71.138/ICCR/C-I. Received 1972. Accepted
b>l
28,
6, 1972.
Reprint requests: Dr. Robert S. Neuwirth, Department of ObstetricsGynecology, Columbia Presbyterian Medical Center, 622 W. 168th St., New York, New York 10032. 82
Volume h’umher
116
Hysteroscopic
1
tubal
sterilization.
I
83
Fig. 1. Control hysterogram.
Fig. 2. Three months following gram would be necessary to determine effectiveness postoperatively. All patients had normal uteri and normal menses. Patients were admitted to the hospital for the procedure and all procedures were done in the operating room. Initially all patients were given general anesthesia, but the last three operations in the series were done under analgesia and local cervical block. Postoperative observa-
hysteroscopic sterilization. tion was mainly overnight. Two patients I vere hospitalized for three nights due to asth ma. Two patients were discharged the aftern loon of the operation. Two patients were stucdied for plasma Dextran levels postoperatively for 48 hours. Blood samples were obtained immediately pre- and postoperatively, and 1then five, 24, and 48 hours later. The plasma was frozen and subsequently measured b) the
84
Neuwirth,
Levine,
and
Richart
Fig. 3. Diverticulum turbidimetric method of Jacobsen and HanThis method is sensitive to levels as low as 1 mg. per milliliter of Dextran. In none of these blood specimens could Dextran be detected. Operating time was generally brief-five to ten minutes. Localization of tubal ostia was accomplished in all cases, although mucus, bubbles, and small clots occasionally prrsented a problem in localizing the tubal ostia. A special serrated electrocautery tip was used on a modified ureteral electrode for the electrosurgical instrument.” The diathermic current was coagulation type and 30 per cent of maximum output of our Rovie unit was used. Cautery was performed until superficial charring occurred. sen.”
Results
Of the 17 patients, one refused to undergo hysterosalpingography postoperatively. She has not become pregnant to date. Of the 16 patients with hysterograms, one had both tubes patent and three patients had one tube patent each (a 25 per cent patient failure rate). Two patients who were in the luteal phase at hysteroscopic sterilization failed to have menses and the pregnancy test subsrquently became positive. Both of these pa-
*Fnhl icated through the courtesy of ‘\mrrican Make, s, Inc., Pelham Manor. New York.
Cystoscopr
of endometrial
cavity.
tients underwent termination of pregnancy by curettage and one had a lapnroscopic sterilization with the termination of pregnancy. At laparoscopy there were no serosal injuries or adhesions noted and the tubal ampullae were coagulated and transected. This patient had one patent tube at tht, isthmus on hysterogram 12 weeks following the hysteroscopic sterilization and ten weeks following the laparoscopic sterilizatiorl, indicating :I biological failure at the intrrstitisl portion of the tube at the time of hysteroscopic tubal cautery. The other patient preynant at the time of hysteroscopy had closed tubes at hysterography. All patients reported normal menstrual function postoperatively. There was no fever: pain, or other morbidity noted. One patient with a patent tube had a small tract from the endometrial cavity to the proximal tube seen on the hysterogram suggesting a fistulous tract between the two structures. This patient underwent repeat hysteroscopy, at which time the tubal ostium was scarred and there was a pinhole tract in the cornu which was rernuterized. The contralateral corm1 was scarrrd and entirely closed at hysteroscop) as well as on the hysterogram. Subsequent hysterosalpingogram showed bilateral blockage. Several cornual diverticula were noted at the postoperative hystrrosalpinSoRrarns (Fig. 3).
Hysteroscopic
Comment The results to date show that by direct visualization and cautery of the tubal ostia. a much higher rate of tubal closure can be obtained than by blind or fluoroscopic control of the same injury. Although a high order of success was achieved at a single procedure, it is probably not high enough at present to compete with other forms of sterilization or the intrauterine device from the viewpoint of effectiveness. Safety has been entirely satisfactory in our hands. No morbidity can be reported. Simplicity is also a significant positive factor for this approach. The failure rate appears to be due to the rapid rate of re-epithelialization of the tubal an d endometrial mucosa resulting in the
tubal
sterilization.
I
85
iatrogenic diverticula observed as well as the endometrial tubal fistula seen. Further studies are under way to augment the effectiveness of the procedure while keeping safety and simplicity at the currently acceptable level. Summary Seventeen multiparous patients underwent attempted tubal sterilization by cautery and mechanical injury of the interstitial portion of the tube at hysteroscopy. The procedure was safe and simple. The patient failure rate of 25 per cent as determined by hysterosalpingography three months postoperatively indicates that this approach alone is only marginally acceptable as a means of tubal sterilization.
REFERENCES
1. 2. 3. 4.
5.
Dickinson, R. L.: J. A. M. A. 92: 373, 1929. Hvams. M. N.: AM. 1. OBSTET. GYNECOL. 28: 98, 1934. B. H.: J. Obstet. Gynecol. Br. Sheares, Commonw. 65: 419, 1958. Martens, F.: In Richart, R., and Prager, D., editors: Human Sterilization, Springfield, Ill.. 1972, Charles C Thomas, Publisher. Rakshit, B.: In Human Sterilization, Springfield, Ill., 1972, Charles C Thomas, Publisher.
6.
Richart,
and Neuwirth, R.: 108: 111, 1971. Zipper,, J., Mendel M., Stachetti E., Pasteur, L., Rivera, M., and Prager, R.: In Human Sterilization, Springfield, Ill., 1972, Charles C Thomas, Publisher. Levine, R., and Neuwirth, R.: AM. J. OBSTET. GYNECOL. 113: 696,, 1972. Jacobsen, L., and Hansen, H.: Stand. J. Clin. Lab. Invest. 4: 352, 1952. AM.
”
7.
8. 9.
R.,
J. OBSTET.
Gutierrez
GYNECOL.
A.,
ROBERT
NEUWIRTH, U.
RALPH New
report
S.
RICHARD M. York,
New
tubal sterilization
LEVINE,
RICHART,
M.D M.D. M.D.
York
Seventeen multiparous patients underwent a sterilization by cornual cauterization at hysteroscopy with 30 per cent Dextran. There were no complications and the procedure was simple. A patient failure rate of 25 per cent as determined hysterosalpingography three months postoperatively was obtained.
A L. L 1‘ 1~ B A L sterilizations have two phases : ( 1) the agent or act which will producr tubal closure and (2) the delivery to some portion of the tube. The search for simplified transcervical procedures to produce tubal obstruction was first undertaken by Dickinson,l using cautery. This method was refined and additional experience collected by Hyams.’ Variations of transcervical electrocautery are still being used,” but other methods have also been studied. Martens’ has tried cryosurgery; Rakshit” and Richart and associates6 have tried chemical agents. All of these methods have suffered in part from the problem of precise delivery to the tube. Zipper and associates’ have been working with quinacrine, which may be delivered
by simple irrigation of the uterine cavity but requires repeated patient visits. With the favorable experience of Levine and Neuwirth* in the use of 30 per cent Dextran for hysteroscopy, it was decided to attempt to treat a small series of patients by means of electrocautery and surgical removal of the interstitial endosalpinx to produce tubal blockage at this point. This report presents the results in 17 patients treated done by this method between October, 1971, and June, 1972, at The BronsLebanon Hospital. Materials
for
publication
November
September
and
methods
The hysteroscopy was performed as rcported previously” with the exception of the use of an ACM1 foroblique hysteroscope of 6 mm. total diameter. Preliminary testirlg confirmed that 30 per cent Dextran was not a conductive solution, and that a predetermined diathermic injury could be delivered under visual control to the uterotubal junction without injury to the uterine serosa. All patients were post partum within two to foul months except two. One of these underwent a preliminary hysterosalpingogram to demonstrate tubal patency before operation (Figs. 1 and 2). The patients were told that results would be unpredictable and that a hysterosalpingo-
From the Department of Obstetrics and Gynecology, Bronx-Lebanon Hospital Center, and the Department of Obstetrics and Gynecology, Columbia College of Physicians and Surgeons. Partially supported by the Population Council, Inc., of New York, Contract No. M71.138/ICCR/C-I. Received 1972. Accepted
b>l
28,
6, 1972.
Reprint requests: Dr. Robert S. Neuwirth, Department of ObstetricsGynecology, Columbia Presbyterian Medical Center, 622 W. 168th St., New York, New York 10032. 82
Volume h’umher
116
Hysteroscopic
1
tubal
sterilization.
I
83
Fig. 1. Control hysterogram.
Fig. 2. Three months following gram would be necessary to determine effectiveness postoperatively. All patients had normal uteri and normal menses. Patients were admitted to the hospital for the procedure and all procedures were done in the operating room. Initially all patients were given general anesthesia, but the last three operations in the series were done under analgesia and local cervical block. Postoperative observa-
hysteroscopic sterilization. tion was mainly overnight. Two patients I vere hospitalized for three nights due to asth ma. Two patients were discharged the aftern loon of the operation. Two patients were stucdied for plasma Dextran levels postoperatively for 48 hours. Blood samples were obtained immediately pre- and postoperatively, and 1then five, 24, and 48 hours later. The plasma was frozen and subsequently measured b) the
84
Neuwirth,
Levine,
and
Richart
Fig. 3. Diverticulum turbidimetric method of Jacobsen and HanThis method is sensitive to levels as low as 1 mg. per milliliter of Dextran. In none of these blood specimens could Dextran be detected. Operating time was generally brief-five to ten minutes. Localization of tubal ostia was accomplished in all cases, although mucus, bubbles, and small clots occasionally prrsented a problem in localizing the tubal ostia. A special serrated electrocautery tip was used on a modified ureteral electrode for the electrosurgical instrument.” The diathermic current was coagulation type and 30 per cent of maximum output of our Rovie unit was used. Cautery was performed until superficial charring occurred. sen.”
Results
Of the 17 patients, one refused to undergo hysterosalpingography postoperatively. She has not become pregnant to date. Of the 16 patients with hysterograms, one had both tubes patent and three patients had one tube patent each (a 25 per cent patient failure rate). Two patients who were in the luteal phase at hysteroscopic sterilization failed to have menses and the pregnancy test subsrquently became positive. Both of these pa-
*Fnhl icated through the courtesy of ‘\mrrican Make, s, Inc., Pelham Manor. New York.
Cystoscopr
of endometrial
cavity.
tients underwent termination of pregnancy by curettage and one had a lapnroscopic sterilization with the termination of pregnancy. At laparoscopy there were no serosal injuries or adhesions noted and the tubal ampullae were coagulated and transected. This patient had one patent tube at tht, isthmus on hysterogram 12 weeks following the hysteroscopic sterilization and ten weeks following the laparoscopic sterilizatiorl, indicating :I biological failure at the intrrstitisl portion of the tube at the time of hysteroscopic tubal cautery. The other patient preynant at the time of hysteroscopy had closed tubes at hysterography. All patients reported normal menstrual function postoperatively. There was no fever: pain, or other morbidity noted. One patient with a patent tube had a small tract from the endometrial cavity to the proximal tube seen on the hysterogram suggesting a fistulous tract between the two structures. This patient underwent repeat hysteroscopy, at which time the tubal ostium was scarred and there was a pinhole tract in the cornu which was rernuterized. The contralateral corm1 was scarrrd and entirely closed at hysteroscop) as well as on the hysterogram. Subsequent hysterosalpingogram showed bilateral blockage. Several cornual diverticula were noted at the postoperative hystrrosalpinSoRrarns (Fig. 3).
Hysteroscopic
Comment The results to date show that by direct visualization and cautery of the tubal ostia. a much higher rate of tubal closure can be obtained than by blind or fluoroscopic control of the same injury. Although a high order of success was achieved at a single procedure, it is probably not high enough at present to compete with other forms of sterilization or the intrauterine device from the viewpoint of effectiveness. Safety has been entirely satisfactory in our hands. No morbidity can be reported. Simplicity is also a significant positive factor for this approach. The failure rate appears to be due to the rapid rate of re-epithelialization of the tubal an d endometrial mucosa resulting in the
tubal
sterilization.
I
85
iatrogenic diverticula observed as well as the endometrial tubal fistula seen. Further studies are under way to augment the effectiveness of the procedure while keeping safety and simplicity at the currently acceptable level. Summary Seventeen multiparous patients underwent attempted tubal sterilization by cautery and mechanical injury of the interstitial portion of the tube at hysteroscopy. The procedure was safe and simple. The patient failure rate of 25 per cent as determined by hysterosalpingography three months postoperatively indicates that this approach alone is only marginally acceptable as a means of tubal sterilization.
REFERENCES
1. 2. 3. 4.
5.
Dickinson, R. L.: J. A. M. A. 92: 373, 1929. Hvams. M. N.: AM. 1. OBSTET. GYNECOL. 28: 98, 1934. B. H.: J. Obstet. Gynecol. Br. Sheares, Commonw. 65: 419, 1958. Martens, F.: In Richart, R., and Prager, D., editors: Human Sterilization, Springfield, Ill.. 1972, Charles C Thomas, Publisher. Rakshit, B.: In Human Sterilization, Springfield, Ill., 1972, Charles C Thomas, Publisher.
6.
Richart,
and Neuwirth, R.: 108: 111, 1971. Zipper,, J., Mendel M., Stachetti E., Pasteur, L., Rivera, M., and Prager, R.: In Human Sterilization, Springfield, Ill., 1972, Charles C Thomas, Publisher. Levine, R., and Neuwirth, R.: AM. J. OBSTET. GYNECOL. 113: 696,, 1972. Jacobsen, L., and Hansen, H.: Stand. J. Clin. Lab. Invest. 4: 352, 1952. AM.
”
7.
8. 9.
R.,
J. OBSTET.
Gutierrez
GYNECOL.
A.,