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Kymographic studies of the Fallopian tubes after insertion of intrauterine contraceptive devices using the Lippes loop and the nylon ring
Kymographic studies of the Fallopian tubes after insertion of intrauterine contraceptive devices using the Lippes loop and the nylon ring ALY
MARE1
MAKHLOUF,
A’HMED
FAWZY
Damanhour,
United
M.D.
ABDEL-SALAM, Arab
M.D.
Republic
One hundred women attending the Family Planning Centers at Damanhour, U.A.R., fitted with the Lippes loop in 50 instances and the nylon ring in 50 instances, were submitted to kymographic tracings, before, immediately after, and for 5 months following insertion of the devices. It was found that a definite increase in the initial rise of pressure, in the basal tonus, and in the range of oscillation occurred. Spasm of the uterotubal junction occurred after insertion and was also recordable during the 5 months’ follow-up. The results obtained suggest that the possible mode of action of ZVCD in preventing pregnancy is through an increase in the tubal motility, accelerating the transport of ova through the Fallopian tubes, so that they pass through in one day or less instead of taking 3 to 4 days, so they reach the uterus, even if they have been fertilized, in a stage not ready for nidation or the uterus itself is not yet ready for conception.
TWE MECHANISM by which IUD’s prevent pregnancy is still not clear. This mechanism has been the subject of many studies. The assumption that the IUD may prevent ovulation or impair sperm migration was found to be untenable. The suspicion that the endometritis may interfere with implantation of the blastocyst has not been confirmed. Margulies10 assumed that the IUD stimulates peristalsis of the tubes to such an extent that the ovum, even fertilized, reaches the unprepared uterus prematurely. Mastroianni and Rosseau,‘r found that in the macaque monkey the presence of IUD was associated with rapid discharge of ova from the uterine tube into the uterus. However, in a study on the action of IUD in parous, regularly cyclic rhesus monkeys, Kelly and From the Departments Gynaecology, Faculty Ain Shams University General Hospital.
Marston’ found that the pattern of tubal transport is not markedly disturbed in the presence of the IUD and in another control group no significant difference was found in the number of eggs recovered from the uterine tubes. Definite changes in the peristaltic pattern of the Fallopian tubes in women using the device was observed by Mann.9 However, Johnson, Masters, and Lewis“ did not observe changes in uterine motility using intrauterine recordings before and after insertion of IUD%. Kamal, Kandil, and Talaat,4 assumed that the IUD causes spasm of the uterotubal junction. Kymography has long been recognized as a proved way of recording tubal motility that is why it was adopted as a method of choice in this work to evaluate the tubal factor as a possible mode of contraception in users of IUD’s. Our experimental study is based on 100
Obstetrics and of Medicine, and Damanhour
759
760
Makhlouf
and Abdel-Salam
Amer.
women attending the Family Planning Center at Damanhour. Each woman in our series selected the IUD as an acceptable method of contraception. The users ranged in age from 19 to 45 years, and in parity from nullipara to para 12. Selection of patients was done by the authors. A complete and gynecologic exgeneral, abdominal, amination was carried out. All had normal pelves on examination, and those who expelled the device or who had pelvic complications were excluded from the study. In this study we have used the Lippes loop size “B” (27.5) in 4 women, in 8 per cent of our patients, and size “D” (30) in 46 women, 92 per cent of the first 50 patients, and the nylon ring in another 50 patients. E,ach of the 100 patients was submitted to a kymographic study as follows: A control tracing was done first before inserting
Table I. Statistical
data rise in pressure
initial
regarding
the
March J. Obstet.
I, 1970 Gynec.
the device. This tracing was done by starting the insufflation for one or 2 minutes according to the tolerance of the patient. Another tracing was done immediately after insertion for the same period of time. Then a monthly tracing was made for 5 consequent months at the same time of the cycle, that is to say 5 days postmenstrual. By this method we were able to obtain 700 tracings. The apparatus used in our experimental study is the Grafax Model RT Kymoinsuflator with Alka-Seltzer effervescent tablets as a source of the CO, gas and a cervical cannula as an inflow of the gas. AS Alka-Seltzer effervescent tablets are not readily available, we used diluted hydrochloric acid plus sodium bicarbonate as a source of the gas. The rate of flow was fixed at 30 C.C. per minute and the maximum pressure at 200 mm. Hg in 30 seconds. This precaution was taken to prevent any modification in the initial rise in pressure as found by different authors. The kymograph drum was driven by an
Control patients before insertion
Immediately after insertion
20-40 40-60 60-80 80-100 100-120 120-140 140-160 160-180 180-200
20 32 28 2 6 4 4 2 2
0 0 18 36 24 12 i
Total
100
Pressure (mm. Hg)
0 2 12 24 36 24 2 0 0
3 100
Table II. Statistical range
During the 5 months’ follow-up
data
( lz$;;L,
basal
as regards
the
1~~~~~
Total
Table IV.
10
to
More 20 Total
20
10
90 8
2 88
7:
than 2 100
10
23
100
100
as regards
the
More Total
During the 5 months’ follow-up
8 0
7; 21 0
100
100
st
Statistical data as regards of oscillations per minute
No. or waves per minute From
Less than
data
Immediately after insertion
mm. Hg
frequency
1 Zmyf;;W
Statistical
tonus
Less than 10 Between 10 and 20 Between 20 and 30 More than 30
100
of oscillations
mm. Hg
Table III.
Before I insertion 2 : 4 68 5: 8 32 9 : 12 0 13 : 16 than 16 i 100
Immediately after 20 60 20 0 0 100
the
5 months’ follow-up 0 0 18 70 12 100
Volume Number
106 5
Kymography
of Fallopian
tubes
Fig. 1A. This figure represents the tracings of the Fallopian tubes: A, before inserting the IUD; B, immediately after insertion; C, one month after insertion; and D, 2 months after insertion. The distance between each two vertical segments is passed by the writing pen of the kymograph in one minute. The numbers 0, 20, 40 . . ., etc., represent the pressure (mm. Hg) . Note that before insertion that the initial rise in pressure is 80 mm. Hg. Peristalsis rate is 4 per minute (A in the figure). In B there is initial spasm (pressure 190 mm. Hg). No peristaltic waves. In D the initial rise of pressure is 120. Peristalsis rate is 10 waves per minute.
Fig. 18 This figure shows the initial rise of pressure per minute, the range or inserting the device).
the tracings in the third, fourth and fifth months (E, F, G). Here is 80 mm. Kg, the- number of peristalsis is from 13 to 16 waves amplitude is also increased, compare with (A in Fig. lA, before
761
762
Makhlouf
and Abdel-Salam
electric timing motor. The chart paper passes the pen at a rate of one vertical division per minute, although this caused the peristaltic waves recorded to be somewhat condensed, yet the exact number of oscillations per minute was calculated taking the
Fig. 2A. In this figure the number of per&takes pressure, the basal tone,
Fig. 23. This from insertion meaning that
Amer.
peak as indicative of one traction of the tube.
March J. Obstet.
peristaltic
1, 1970 Gynec.
con-
Analysis of the results The tracings obtained in all experiments were studied and analyzed according to the
if C and D are compared with A we notice that after increased from 3 in A to 8 in C and D. Also and the range or amplitude have all increased.
figure represents the tracings obtained in the third, of the device. The same changes previously described there is no accommodation occurring.
inserting the IUD the initial rise of
fourth, and Sth months in 2A are aIso apparent
Volume Number
106 5
Kymography
following: (1) changes in the initial rise in pressure, (2) range or amplitude of oscillations, (3) basal tone, and (4) frequency of oscillations per minute. By the initial rise of pressure we mean the maximum pressure reached before the kymographic tracing starts to drop. This dropping of pressure coincides with the point at which the gas flows through the uterotubal junctions; we observed that in almost 80 women (80 per cent) of the control tracings, the initial rise of pressure was between 20 and 80 mm. Hg and only 4 of patients (4 per cent) experimented higher pressure (initial spasm) probably due to instrumentation and fear because the pressure immediately dropped in less than one-half minute. Immediately after insertion of the device there was an increase in the initial rise of pressure ranging between 10 and 6,O mm. Hg in 80 women (80 per cent of the paGents). A rise as high as 140 mm. Hg was observed in 8 patients (8 per cent), and in 3 patients (3 per cent) this rise reached as high as 180 mm. Hg (Table I). This increase in pressure required to open the uterotubal junction indicates a spasm of the sphincter. This was maintained and even increased in the patients throughout the 5 months’ follow-up tracings. Eighty-four women (84 per cent) showed this persistent rise between 10 and 60 mm. Hg (Table I). This could be taken as evidence that the IUD causes impaired tubal function from the physiologic point of view, in the form of spasm of the uterotubal junction, and this spasm is a permanent phenomen and not a transient one that is abolished by accommodation of the uterus to the irritation produced by the foreign body. Range or amplitude of oscillations means the pressure changes that occur between
REFERENCES
1.
Chang, M. C., and tion of Intrauterine
Marston, Foreign
J. H.: The Bodies in
Acthe
of Fallopian
tubes
763
each oscillation. This similarly showed an increase ranging between 10 and 30 mm. Hg in 98 women (98 per cent of the patients) immediately after the insertion and reaching to the same percentage in the 5 months’ follow-up (Table II). The basal tone is the tonus of the musculature of the tubes. This has shown a rise of 10 to 30 mm. Hg. This has been observed in 96 women (96 per cent of the patients) immediately after the insertion and in almost the same percentage during the 5 months’ follow-up (Table III). The importance of frequency of oscillation per minute is to show if there is any actual increase in the number of tubal peristaltic waves as a response to the presence of the IUD in the uterus. We found that there is no relevant increase in the number of the peristaltic waves immediately after insertion of the device (Table IV), where as in the 5 months follow-up there was a definite relevant demonstrable excess in the number of the peristaltic waves ranging from 9 to 16 in 88 women (88 per cent of the patients) (Table IV). However, 12 women ( 12 per cent) showed a number of peristaltic waves reaching 16 or more per minute (Figs. 1 and 2) . Comment IUD’s are to be considered one of the most suitable contraceptive techniques both in urban and rural areas in the United Arab Republic. In this study we tried to put an end to the argument about intrauterine devices as being abortifacients, a thing which is not accepted by religious couples. We also gave an explanation of a possible mode of action based on physiologic action which is acceleration of tubal peristalsis. This alleviates the worry and fear from any pathologic or irreversible side effects of intrauterine contraceptive devices.
Rat and Rabbit, Proc. ference on Intrauterine York, 1965.
II
International Contraception,
ConNew
764
2.
3.
4.
5. 6. 7. 8.
Makhlouf
and
Abdel-Salam
Grafenberg, F.: Die intrauterine methods der konzeptions ver verhutung, in Haire, N., editor: Sexual Reform Congress, London, 1930, Keegan, Paul, Trench, Trubner & Company. Hawk, H. W., Conley, H., Brinsfield, T. H., and Righter, H. F.: Contraceptive Effect of Plastic Devices in Cattle Uteri, Proc. II International Conference on Intrauterine Contraception, New York, 1965. Kamal, Ibrahim, Kandil, O., and Talaat, M.: Gaz. Egyptian Sot. Gynec. Obstet. 15: 2, 1965. Ishihama, A.: Yokohama Med. J. 10: 89, 1959. Johnson, V. E.: Masters, W. H., and Lewis, K. Cl.: West. T. Sure. 70: 202. 1962. Kelly, W. A.: and -Marston, J. H.: Nature 214, 735, 1967. Malkani, P. K., and Sujan, S.: AMER. J. OBSTET. GYNEC. 88: 963, 1964.
Amer.
9.
10.
11, 12. 13.
14. 15.
March J. Ohstet.
1, 1970 Gym.
Mann, E. C.: Cineradiographic Observation on Intrauterine Contraceptive Devices, in Proceedings on IUCD Conference, 1962, Excerpta Med. Int. Cong. Ser. No. 54. Margulies, L. C. : In Tietze, C., and Lewit, S., editors : Intrauterine Contraceptive Devices, Excerpta Med. Int. Congr. Ser. 54: 61, 1962. Mastroianni, L., Jr., and Rosseau, C. H.: AMER. J. OBSTET. GYNEC. 93: 416, 1965. Oppenheimer, W.: AMER. J. OBSTET. GYNEC. 78: 446, 1959. Parr, E.: Studies on Mechanism of Action of Intrauterine Foreign Bodies in Rodents, in II International Conference on IUCD, New York, 1964, The Population Council. Rubin, I. C.: Surg. Gynec. Obstet. 90: 3, 1950. Rzin, S., and Schwartz, A.: Obstet Gynec. 30: 6, 1967.
MARE1
MAKHLOUF,
A’HMED
FAWZY
Damanhour,
United
M.D.
ABDEL-SALAM, Arab
M.D.
Republic
One hundred women attending the Family Planning Centers at Damanhour, U.A.R., fitted with the Lippes loop in 50 instances and the nylon ring in 50 instances, were submitted to kymographic tracings, before, immediately after, and for 5 months following insertion of the devices. It was found that a definite increase in the initial rise of pressure, in the basal tonus, and in the range of oscillation occurred. Spasm of the uterotubal junction occurred after insertion and was also recordable during the 5 months’ follow-up. The results obtained suggest that the possible mode of action of ZVCD in preventing pregnancy is through an increase in the tubal motility, accelerating the transport of ova through the Fallopian tubes, so that they pass through in one day or less instead of taking 3 to 4 days, so they reach the uterus, even if they have been fertilized, in a stage not ready for nidation or the uterus itself is not yet ready for conception.
TWE MECHANISM by which IUD’s prevent pregnancy is still not clear. This mechanism has been the subject of many studies. The assumption that the IUD may prevent ovulation or impair sperm migration was found to be untenable. The suspicion that the endometritis may interfere with implantation of the blastocyst has not been confirmed. Margulies10 assumed that the IUD stimulates peristalsis of the tubes to such an extent that the ovum, even fertilized, reaches the unprepared uterus prematurely. Mastroianni and Rosseau,‘r found that in the macaque monkey the presence of IUD was associated with rapid discharge of ova from the uterine tube into the uterus. However, in a study on the action of IUD in parous, regularly cyclic rhesus monkeys, Kelly and From the Departments Gynaecology, Faculty Ain Shams University General Hospital.
Marston’ found that the pattern of tubal transport is not markedly disturbed in the presence of the IUD and in another control group no significant difference was found in the number of eggs recovered from the uterine tubes. Definite changes in the peristaltic pattern of the Fallopian tubes in women using the device was observed by Mann.9 However, Johnson, Masters, and Lewis“ did not observe changes in uterine motility using intrauterine recordings before and after insertion of IUD%. Kamal, Kandil, and Talaat,4 assumed that the IUD causes spasm of the uterotubal junction. Kymography has long been recognized as a proved way of recording tubal motility that is why it was adopted as a method of choice in this work to evaluate the tubal factor as a possible mode of contraception in users of IUD’s. Our experimental study is based on 100
Obstetrics and of Medicine, and Damanhour
759
760
Makhlouf
and Abdel-Salam
Amer.
women attending the Family Planning Center at Damanhour. Each woman in our series selected the IUD as an acceptable method of contraception. The users ranged in age from 19 to 45 years, and in parity from nullipara to para 12. Selection of patients was done by the authors. A complete and gynecologic exgeneral, abdominal, amination was carried out. All had normal pelves on examination, and those who expelled the device or who had pelvic complications were excluded from the study. In this study we have used the Lippes loop size “B” (27.5) in 4 women, in 8 per cent of our patients, and size “D” (30) in 46 women, 92 per cent of the first 50 patients, and the nylon ring in another 50 patients. E,ach of the 100 patients was submitted to a kymographic study as follows: A control tracing was done first before inserting
Table I. Statistical
data rise in pressure
initial
regarding
the
March J. Obstet.
I, 1970 Gynec.
the device. This tracing was done by starting the insufflation for one or 2 minutes according to the tolerance of the patient. Another tracing was done immediately after insertion for the same period of time. Then a monthly tracing was made for 5 consequent months at the same time of the cycle, that is to say 5 days postmenstrual. By this method we were able to obtain 700 tracings. The apparatus used in our experimental study is the Grafax Model RT Kymoinsuflator with Alka-Seltzer effervescent tablets as a source of the CO, gas and a cervical cannula as an inflow of the gas. AS Alka-Seltzer effervescent tablets are not readily available, we used diluted hydrochloric acid plus sodium bicarbonate as a source of the gas. The rate of flow was fixed at 30 C.C. per minute and the maximum pressure at 200 mm. Hg in 30 seconds. This precaution was taken to prevent any modification in the initial rise in pressure as found by different authors. The kymograph drum was driven by an
Control patients before insertion
Immediately after insertion
20-40 40-60 60-80 80-100 100-120 120-140 140-160 160-180 180-200
20 32 28 2 6 4 4 2 2
0 0 18 36 24 12 i
Total
100
Pressure (mm. Hg)
0 2 12 24 36 24 2 0 0
3 100
Table II. Statistical range
During the 5 months’ follow-up
data
( lz$;;L,
basal
as regards
the
1~~~~~
Total
Table IV.
10
to
More 20 Total
20
10
90 8
2 88
7:
than 2 100
10
23
100
100
as regards
the
More Total
During the 5 months’ follow-up
8 0
7; 21 0
100
100
st
Statistical data as regards of oscillations per minute
No. or waves per minute From
Less than
data
Immediately after insertion
mm. Hg
frequency
1 Zmyf;;W
Statistical
tonus
Less than 10 Between 10 and 20 Between 20 and 30 More than 30
100
of oscillations
mm. Hg
Table III.
Before I insertion 2 : 4 68 5: 8 32 9 : 12 0 13 : 16 than 16 i 100
Immediately after 20 60 20 0 0 100
the
5 months’ follow-up 0 0 18 70 12 100
Volume Number
106 5
Kymography
of Fallopian
tubes
Fig. 1A. This figure represents the tracings of the Fallopian tubes: A, before inserting the IUD; B, immediately after insertion; C, one month after insertion; and D, 2 months after insertion. The distance between each two vertical segments is passed by the writing pen of the kymograph in one minute. The numbers 0, 20, 40 . . ., etc., represent the pressure (mm. Hg) . Note that before insertion that the initial rise in pressure is 80 mm. Hg. Peristalsis rate is 4 per minute (A in the figure). In B there is initial spasm (pressure 190 mm. Hg). No peristaltic waves. In D the initial rise of pressure is 120. Peristalsis rate is 10 waves per minute.
Fig. 18 This figure shows the initial rise of pressure per minute, the range or inserting the device).
the tracings in the third, fourth and fifth months (E, F, G). Here is 80 mm. Kg, the- number of peristalsis is from 13 to 16 waves amplitude is also increased, compare with (A in Fig. lA, before
761
762
Makhlouf
and Abdel-Salam
electric timing motor. The chart paper passes the pen at a rate of one vertical division per minute, although this caused the peristaltic waves recorded to be somewhat condensed, yet the exact number of oscillations per minute was calculated taking the
Fig. 2A. In this figure the number of per&takes pressure, the basal tone,
Fig. 23. This from insertion meaning that
Amer.
peak as indicative of one traction of the tube.
March J. Obstet.
peristaltic
1, 1970 Gynec.
con-
Analysis of the results The tracings obtained in all experiments were studied and analyzed according to the
if C and D are compared with A we notice that after increased from 3 in A to 8 in C and D. Also and the range or amplitude have all increased.
figure represents the tracings obtained in the third, of the device. The same changes previously described there is no accommodation occurring.
inserting the IUD the initial rise of
fourth, and Sth months in 2A are aIso apparent
Volume Number
106 5
Kymography
following: (1) changes in the initial rise in pressure, (2) range or amplitude of oscillations, (3) basal tone, and (4) frequency of oscillations per minute. By the initial rise of pressure we mean the maximum pressure reached before the kymographic tracing starts to drop. This dropping of pressure coincides with the point at which the gas flows through the uterotubal junctions; we observed that in almost 80 women (80 per cent) of the control tracings, the initial rise of pressure was between 20 and 80 mm. Hg and only 4 of patients (4 per cent) experimented higher pressure (initial spasm) probably due to instrumentation and fear because the pressure immediately dropped in less than one-half minute. Immediately after insertion of the device there was an increase in the initial rise of pressure ranging between 10 and 6,O mm. Hg in 80 women (80 per cent of the paGents). A rise as high as 140 mm. Hg was observed in 8 patients (8 per cent), and in 3 patients (3 per cent) this rise reached as high as 180 mm. Hg (Table I). This increase in pressure required to open the uterotubal junction indicates a spasm of the sphincter. This was maintained and even increased in the patients throughout the 5 months’ follow-up tracings. Eighty-four women (84 per cent) showed this persistent rise between 10 and 60 mm. Hg (Table I). This could be taken as evidence that the IUD causes impaired tubal function from the physiologic point of view, in the form of spasm of the uterotubal junction, and this spasm is a permanent phenomen and not a transient one that is abolished by accommodation of the uterus to the irritation produced by the foreign body. Range or amplitude of oscillations means the pressure changes that occur between
REFERENCES
1.
Chang, M. C., and tion of Intrauterine
Marston, Foreign
J. H.: The Bodies in
Acthe
of Fallopian
tubes
763
each oscillation. This similarly showed an increase ranging between 10 and 30 mm. Hg in 98 women (98 per cent of the patients) immediately after the insertion and reaching to the same percentage in the 5 months’ follow-up (Table II). The basal tone is the tonus of the musculature of the tubes. This has shown a rise of 10 to 30 mm. Hg. This has been observed in 96 women (96 per cent of the patients) immediately after the insertion and in almost the same percentage during the 5 months’ follow-up (Table III). The importance of frequency of oscillation per minute is to show if there is any actual increase in the number of tubal peristaltic waves as a response to the presence of the IUD in the uterus. We found that there is no relevant increase in the number of the peristaltic waves immediately after insertion of the device (Table IV), where as in the 5 months follow-up there was a definite relevant demonstrable excess in the number of the peristaltic waves ranging from 9 to 16 in 88 women (88 per cent of the patients) (Table IV). However, 12 women ( 12 per cent) showed a number of peristaltic waves reaching 16 or more per minute (Figs. 1 and 2) . Comment IUD’s are to be considered one of the most suitable contraceptive techniques both in urban and rural areas in the United Arab Republic. In this study we tried to put an end to the argument about intrauterine devices as being abortifacients, a thing which is not accepted by religious couples. We also gave an explanation of a possible mode of action based on physiologic action which is acceleration of tubal peristalsis. This alleviates the worry and fear from any pathologic or irreversible side effects of intrauterine contraceptive devices.
Rat and Rabbit, Proc. ference on Intrauterine York, 1965.
II
International Contraception,
ConNew
764
2.
3.
4.
5. 6. 7. 8.
Makhlouf
and
Abdel-Salam
Grafenberg, F.: Die intrauterine methods der konzeptions ver verhutung, in Haire, N., editor: Sexual Reform Congress, London, 1930, Keegan, Paul, Trench, Trubner & Company. Hawk, H. W., Conley, H., Brinsfield, T. H., and Righter, H. F.: Contraceptive Effect of Plastic Devices in Cattle Uteri, Proc. II International Conference on Intrauterine Contraception, New York, 1965. Kamal, Ibrahim, Kandil, O., and Talaat, M.: Gaz. Egyptian Sot. Gynec. Obstet. 15: 2, 1965. Ishihama, A.: Yokohama Med. J. 10: 89, 1959. Johnson, V. E.: Masters, W. H., and Lewis, K. Cl.: West. T. Sure. 70: 202. 1962. Kelly, W. A.: and -Marston, J. H.: Nature 214, 735, 1967. Malkani, P. K., and Sujan, S.: AMER. J. OBSTET. GYNEC. 88: 963, 1964.
Amer.
9.
10.
11, 12. 13.
14. 15.
March J. Ohstet.
1, 1970 Gym.
Mann, E. C.: Cineradiographic Observation on Intrauterine Contraceptive Devices, in Proceedings on IUCD Conference, 1962, Excerpta Med. Int. Cong. Ser. No. 54. Margulies, L. C. : In Tietze, C., and Lewit, S., editors : Intrauterine Contraceptive Devices, Excerpta Med. Int. Congr. Ser. 54: 61, 1962. Mastroianni, L., Jr., and Rosseau, C. H.: AMER. J. OBSTET. GYNEC. 93: 416, 1965. Oppenheimer, W.: AMER. J. OBSTET. GYNEC. 78: 446, 1959. Parr, E.: Studies on Mechanism of Action of Intrauterine Foreign Bodies in Rodents, in II International Conference on IUCD, New York, 1964, The Population Council. Rubin, I. C.: Surg. Gynec. Obstet. 90: 3, 1950. Rzin, S., and Schwartz, A.: Obstet Gynec. 30: 6, 1967.