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Operative Procedures for the Treatment of Sterility and Ovarian Dysfunctions*
OPERATIVE PROCEDURES FOR THE TREATMENT OF STERILITY AND OVARIAN DYSFUNCTIONS* JAMES
L.
(f:lrom the Department of
REYCRAFT;
M.A., M.D.,
CLEVEI,AND, OHIO
Obstet~·ics
and Gynecology, Western Beser·ve University, and The University Hospitals)
HE gynecologist who is primarily a clinician is constantly confronted with T problems bearing on ovarian dysfunctions. Some of these problems are satisfactorily answered by the judicious use of gonadotropes and estrogens. Many patients are seen whose complaints refer to faulty menstruation or complete amenorrhea. They give a history, oft repeated, of having been treated by one or many physicians with hormone therapy, sometimes of questionable value and without results. A woman who menstruates seldom, if at all, is greatly concerned as to her future happiness, first as a wife and secondarily as a mother. She becomes alarmed over her supposed lack of femininity and is besieged by many fears, some of them justified, of the future in store for her. It is a well-known fact that many women have polycystic ovaries and, as a result of that condition, they may have menorrhagia or almost complete amenorrhea. Fundamentally, the disease is due to functional disturbance, the result of imbalance between the endocrine glands. In 1937, we described six cases in a paper entitled "The Surgical Treatment of Ovarian Dysfunctions," in which it was emphasized that, inasmuch as many patients do not respond in any way to endocrine therapy, a surgical approach was considered justifiable in some instances. The cases presented consisted principally of those treated by excision of a portion of the cortex of one or both ovaries, with very favorable results. In most of the pathological specimens, it was found that there was thickening of the tunica albuginea, increased fibrosis of the ovarian cortex and follicles in all stages of development and atresia. Hypothetically, it was thought that the thickening of the ovarian cortex due to long-continued endocrine dysfunction made it impossible for the follicles to rupture and, consequently, there was a mechanical impediment which we were able to overcome by decortization. Since that time, we have operated upon eleven other similar cases and will present the results. 'l'he operation consists of one of two procedures. In those instances where the ovary is large, hut not a neoplasm, a wedge of substance is taken in its longitudinal axis, the defect lwing closed with interrupted m· figure-of-eight sutures of No. 00 plain catgut. •Presented at the Fifty-Ninth Annual Meeting of th<> American Association of Obstetricians, Gynecologists and Abdominal Surg€ons, Hot Springs, Va., September 9 to 11, 1948.
1069
1070
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i\m. 1 Obst. & Gynec. June, 1949
In most of the cases which we are about to present, however, the process eonsisted merely of denuding a portion of the cortex, and controlling small bleeding points with mattress sutures of ~o. 00 plain catgut. R.t>eently, W(' have used Gelfoam on the eut surface with satisfactory results. CASE 1.--S. V., aged 2G years, married 3 year~, gravida 0, \Y:ts first seen on April 17, 1937, complaining of sterility assoc.iated with menstruation every 6 to 8 months, free, with clots and much pain. Previous estrogenic treatment was unsuccessful. Rubin's test showed patency of tubes, and pelvic examination showed the uteru.9 to be moderate in size and in good position. Both ovaries were large, firm, and very tender, especially the left. May 8, 1937, curettage, insertion of stem pessary, resection of a part of the cortices of both ovaries and appendectomy were done. She menstruated regularly, at 30-day intervals, after the op· eration and removal of stem, until April 14, 1939, when she was found to be pregnant. She was delivered of a living baby in January, 1940. Pathological diagnosis: Simple CJ"Sts of ovary. CASE 2.-H. B., aged 22 years, single, gravida 0, was first seen on Jan. 14, 1937, com· plaining of amenorrhea.· Last menstrual period, July, 1935. Examination showed both ovaries large, low, and tender. Jan. 18, 1937, curettage and stem pessary insertion, without results. She menstruated once, after estrogenic stimulation, June 6, 1937. Stem removed in September, but no menstruation followed until after operation, on Oct. 27, 1937, consisting of excision of two-thirds of the cortex of each ovary, with incidental curettage and ap· pendectomy. Both ovaries were polycystic, but not sclerotic. Menses continued to be ir· regular at 2- to 3-month intervals. Pathological diagnosis: Polycystic ovaries. CASE 3.-D. H., aged 28 years, gravida 0, was examined on Sept. 22, 1942. She complained of a bearing down sensation when on her feet, and of having menstruated only three times in her nine years of married life. Examination showed a small uterus, displaced to the right by a cystic left ovary, estimated to be 8 em. in diameter. Oct. 8, 1942, operation was performed, consisting of curettage, left salpingo-oophorectomy, resection of cortex of the right ovary, and appendectomy. She has menstruated regularly every 26 to 28 days since that time, but never became pregnant. Patholog·ical diagnosis: Theca cell tumor, left ovary. Follicular cysts, right ovary. CASE 4.-C. D., aged 35 years, married, para i, was first seen on Feb. 7, 1944. She had menstruated but once, in August, 1942, since the delivery of her first baby, in 1941. Examination showed her to be healthy, but overweight (180 pounds). Pelvic examination showed a relaxed vaginal outlet and ovaries which seemed sclerotic. She was operated upon April 4, 1944. Curettage produced no material. Perineorrhaphy was done. At laparotomy the ovaries were found to be small and sclerotic. The cortice!' were excised. She menstruated slightly after the operation, but only once (April 25, 1944). This lasted 5 days, but she has never menstruated since. This is thought to have been a case of Chiari 's syndrome. Pathological diagnosis: None. CASE 5.-N. L., aged 20 years, single, was examined on Aug. 28, 1944. She complained of menstruating every two weeks, for a year. She was found to have a left ovarian tumor, 6 em., which was solid and thought to be a dermoid cyst. She was operated upon Sept. 25, 1944, and found to have a thecoma of the left ovary. Curettage was performed and the left ·ovary removed. The cortex of the right was partially removed and incidental appendectomy performed. After this procedure menstruation occurred every 30 days. She married and was last seen in .June, 1945, at which time she was found to be pregnant. Pathological diagnosis: Thecolll<"l. of left ovary. Right ovary, normaL
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CASE 6.-~M. L., aged 26 years, manied 4 years, para O, was first seen ou April 3D, Complaint was that of no menstruation since 1942. Prior to that time, she had bet>n regular, every 28 days. Basal metabolic rate recently, -29%, taking thyroid regularly. Pelvic examination showed the uterus to be small and anterior; left ovary seemed large, probably polycystic. She was given courses of gonadotropes and estrogens, without results. On June 11, 1946, curettage, stem No. 2, left cortectomy and partial wedge excision of the right ovary were performed. She menstruated in August, 1946, and not again until April 26, 1948. With cyclic therapy she has menstruated regularly since that time. Pathological diagnosis: Multiple small simple cysts of ovaries. L!J46.
CASE 7.-R. G., aged 33 years, gravida i, had had one early spontaneous abortion, in 1942. She complained of sterility. She normally menstruated every 4 to 6 weeks, until May, 1945. She had complete amenorrhea, in spite of hormonal stimulation after this time. Exam· ination showed the presence of a large left ovary. On Feb. 6, 1946, curettage was performed and a segment of the left ovary was removed; right ovary was partially decorticized and both were suspended. On March 8, 1946, she had a free menstruation and has continued to men· struate every 28 days since then, but has never become pregnant. Pathological diagnosis: Simple and corpus luteum cysts of ovary. Atypical cystic hyperplasia of endometrium, slight. CASE 8.-V. vV., aged 30 years, married 5 years, a physician, from another city, con· suited me concerning amenorrhea and sterility, on May 6, 1946. Her last menstruation had occurred in July, 1945. Pelvic examination showed that both ovaries were large and sclerotic. Naturally, the tubes were checked and found patent, and the husband was proved to be fertile. On June 26, curettage and stem pessary were followed by resection of a segment of the right ovary, one-third of the cortex of the left, and both were suspended. Three months later, the stem was removed. She menstruated regularly, until Nov. 3, 1946, and ou .Tan. 13, 194i, she was found to be two months pregnant, and was referred back to her local ob· stetrician. Pathological diagnosis: Multiple small follicular and luteinized follicular cysts of both ovaries. CASE 9.-B. J. ::>r., aged 22 years, married 1 year, wife of a physician, was first seen on Dec. 7 1 1942. Menstruations were regular until 1941; now occur every 3 or 4 months. Complaint of constant pain in right lower abdomen. Examination showed the presence of large ovaries, both prolapsed, especially the right. On Dec. 9, 1942, the cortex was excised from the right ovary and a segment of the left was removed. Both ovaries were suspended and incidental appendectomy performed. She menstruated regularly every 35 days until June 14, 1944, and on August 24, 1944, she was two months pregnant. She delivered a full-term baby, in March, 1945.
Pathological diagnosis: Comment: )I'o corpus luteum.
Hyperplasia of tunica albuginea.
Multiple follicular cysts.
CASE 10.-M. W., aged 27 years, single, was seen on Jan. 7, 1946, complaining of amenor· rhea, although she had had some cramps each month, for ten years. Much treatment with· out results. Examination showed fomale. development and hirsutes, but poorly developed breasts. The uterus was infantile, the ovaries not palpable. On }'eb. 12, 1946, curettage was performed and a small stem inserted in the uterus. At laparotomy, both ovaries were found to be very tiny. However, we excised some cortex from the left one and punctured some small cysts in the right. She "'as given large doses of stilbestrol and a course of Squibb's gonadotropic hormone, alternating. She menstruated for 6 days, starting March 28, 1946, and has menstruated every 28 days since then. Pathological diagnosis: Simple follicle cyst of ovary.
Am. J. Obst. & Gynoc. June, 1949
REYCRAF'l'
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CA:;E 11.~-B. L., aged :l5 year~, marrict1 :3 years, gravida 0, was first, st•;m on 8tJpt. J ~1, 1947, complaining of amenorrhea and ~terility. Last mPustmation had ],een in :\
presence of large prolapsed ovaries which seemed thickened and not ttmde1·. 011eration, Oet. 8, 1947, consisted of curettage, insertion of stem pessary, resection half of each large ovary, suspension of both and incidental appendectomy. Curettage at this time ~howed the absence of endometrium. ~fenstruation started on Oct. :lo, 1947, and she was regular until May 5, 1948. The last examination was in July, and she was found to be pregnant.
Pathological diagnosis: None.
A brief summary of these cases shows that two had theca cell tumors, which were removed. A portion of the cortex of the remaining ovary was resected and both menstruated regularly after the operations. One had menstruated every two weeks for a year, before surgery. One, with polycystic ovaries, had a wedge resection of each and menstruated occasionally. All the others complained of menstruating at rare intervals or not at all. One complete failure was in a 35-year-old patient, who had bilateral decortization and has had symptoms of the menopause since then. This was thought to be an atypical instance of Chiari 's syndrome, inasmuch as her amenorrhea followed the birth of a baby with resulting hyperinvolution of the uterus and a long-continued lactation. The remainder, eight in number, had simple cortectomy performed and have menstruated fairly regularly since operation. One unmarried patient, aged 27 years, who had never menstruated in her Iif{•. rrow does so rt:>gularly. Five of the cases have become pregnant. In the past eleven years, we have operated upon twenty cases in which there was pathology complicating sterility, where a major operative procedure seemed justified. The results have been most gratifying, as the following tables will show: TABLE
I.
CHOCOLATE CYSTS AND 8TERIJ,I'l'Y.
(TUBES ALL PAncN'l')
(No.m•
Mrs.-P. 1943 2. Mrs. D. 1943 3. Mrs. C 1943 4. Mrs. M. 1946 5. Mrs. M. 1942 1.
AGE
DIAGNOSIS
OPERATION
DELIVERIES)
34
Choc. cysts Sterility Choc. cyst Sterility Choc. cyst Sterility Choc. cyst Sterility Choe. cysts Retroversion Sterility
Oophorectomy Salpingopexy Excision cysts Suspension of ovaries Oophorectomy Salpingopexy Oophorectomy Salpingopexy Dilatation and curettage Suspension Resection ovarian cyst Dilatation and curettage Myomectomy Oophorectomy Salpingopexy Freeing of cul-de-sac Gilliam suspension Left oophorectomy Salpingopexy Resection ovarian cyst both
2
28 30 36 26
6.
Mrs. A. 1945
30
7.
Mrs. K. 1946
33
8.
Mrs. A. 1944
27
Fibroid uterus Choc. cy~t Sterility Choc. cyst Retroversion Endometriosis Sterility
None
2
3
>}
OPJ
VnhJitJe 57 Number 6
TABf,E II. FIBROIDS AND STERfLITY (TUBES ALL PATENT) RESULTS (NO. OF
10.
Mrs. D.
34
1945 11.
Mrs. A.
30
1946
TABf,E III.
13.
~frs.
K.
37
Mrs. H.
28
1937 14.
1945 Hi.
Mrs.
1940
c.
32
Submucous fibroid Sterility Fibroid uterus Sterility
17.
1944 Mrs. P. 1943
27
18.
Mrs. 1947
s.
31
1!1.
~Irs.
0.
31
Mrl'. H. 1941
33
1947 20.
1
1
OLD lNFLA:I.lMATORY DISEAS~: AND STERILITY (TUBES CLOSED OR ABSEN'l')
Bilateral Sterility Previous bilateral salpingectomy Sterility Previous bilateral
'rABLE
AGE
ovarian cyst Excision myoma, vaginally Dilatation and curettage Myomectomy Gilliam
rv.
Salpingostomy
None
Canalization, left cornu
None
Estes operation
None
MISCELI,ANEOUS
DIAGNOSIS l·child sterility Endometrioma Retroversion 3 miscarriages Chronic pelvic inflammatory disease Left tubovarian cy>
Sterility Partial tubal obstruction treated 6
OPERATION Gilliam suspension Dilatation and curettage Excision endometrioma in cul-de-sac Gilliam suspension Left salpingo-oophorecto my Suspension rght ovary
Dilatation and curettage Bilateral salpingopexy Suspension ovaries Uterine suspension Dilatation and curettage Gilliam suspension
RESULTS (NO. OF !JELIVERIER)
2
1
Nouc
2
Summary \Ve have presented ten cases in which the patient menstruated seldom if at all, and another who menstruated every two weeks for a year. This was one of those with a theca cell tumor. With one exception the remainder
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HEYCHAJ.'1'
Am. J. Obs.t. & Gyncc June, 1949
were benefited by partial excision of the ovarian cortex, also by using a wedge resection in those instances where the ovaries were unusually large. Suspension of the ovaries has been freely used. Five of these patients have hecome pregnant. We have also presented tv,renty cases where major operative intervention seemed justified for the correction of sterility. Eight of these had cystic ovaries, in which the ovary involved was removed and the tube salvaged and suspended so as to increase the chances of an ovum being received in the fimbriated extremity. Three had myomectomy performed, with good results; four had various operations for closed or absent tubes, all without results. The remaining five were treated by uterine suspension. Of the twenty cases, fourteen have now become pregnant and, to date, have delivered twenty-two full-term living babies. References 1. Allen:
2. 3. 4. 5. 6.
7. 8. 9.
Glandular Physiology and Therapy, Chicago, 1935, A. M.A. Press, p. 169. Berblinger: Klin. W chnschr. (August) , 1932. Goodall, J. R.: Jour. Obst. & Gynaec, Brit. Emp. 40: 640 (June), 1933. Robinson, M. R.: AM. J. 0BST. & GYNEC. 30: 18 (July), 1935. Smith, P. E., and Engle, E. T.: Am. J. Anat. 40: 159 (Nov.), 1927. Smith, P. E., and Engle, E. T.: Curtis' Obst. and Gynec. 8: 287, 1933. Stein, I. F., and Leventhal, M. L.: Am. J. Obst. & Gynec. 29: 181, 1935. Stein, I. F.: AM. J. OBST. & GYNEC. 50: 385, 1945. Reycraft, J. L.: AM. J. 0BST. & GYNEC. 35: 3, 505, 1938.
Discussion DR. FRANK E. WHITACRE, Memphis, 'l'enn.-Dr. Reycraft's report on the surgical treatment of ovarian dysfunctions introduces a debatable subject. The reported eases are a collection of several procedures. It is commonly accepted that myomectomy in some instances may prove to be good treatment for sterility and occasionally for menstrual disorders, anc1 the essayist's success with this group demonstrates careful selection of eases. It is also commonly accepted that salpingostomy in the presence of chronic pelvie inflammatory disease is not often successful in the treatment of sterility, and this also is borne out by his results. I am particularly interested in Dr. Reyeraft 's series of removal of the eortex of one or both ovaries. An explanation of the successful cases might be more than removal of the thickened cortex. The origin of primordial follicles is still an unsettled question. Thnre is some evidence from animal experimentation that follicles may have their origin in the hilum or at its juncture with the mesovarium. It is possible that resection of the cortex of the ovary with the hilum remaining intact may be followed by some degree of regeneration of the ovarian cortex. It is important to study the time interval elapsing between the operation on these patients and the establishment of a more nearly normal menstrual cycle and/or preg· nancy, and also whether or not a future laparotomy on the same patient might demonstrate regeneration of ovarian cortex. My experience with this procedure has been limited, and opinions of my colleagues who have carried out this or similar operations vary from lack of enthusiasm to recommendation. Success in the use of similar procedures has been reported by Stein and also by Jacobson. The degree of success reported by the essayist and other authors presupposes careful study an<1 selection of patients and delicate handling of tissue. In congratulating Dr. Reycraft on hiH results, it must be understood that this meticulous study is mandatory for success and that wide adoption of this and like procedures would lead to a wave of unnecessary surgery on young women over and above what we already have.
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In discussing· this problem ten years ago, Douglas brought up the question of postopcmtivo adhesions, to which the essayist agreed that it is of real danger. Hartman has shown that adhesions may, and sometimes do, result from simple ovulation in the primate. With this in mind, what could one expect after surgical denudation of the ovaryf Perhaps the use of absorbable sponge material would lessen these dangers. We all see young women who have had one or more pelvic operations directed at the ovaries where improvement is temporary and the end result unsatisfactory. It is, therefore, a question of careful judgment. Operations on the ovary in young women should be controlled by the specialist. In recent years agencies authorized to establish the standards of hospitals have compelled the consultation of a qualified specialist before cesarean section is permitted to be done, and this has resulted in general improvement. This principle could be extended with benefit to include the subject under discussion. DR. EMIL NOVAK, Baltimore, Md.-While I have not personally employed ovarian · resection for the treatment of amenorrhea per se, I have been interested in the reports of others. It must be remembered that ovarian dysfunction is not a mere plus or minus affair, as would seem to be the case with the thjToid. Furthermore, ovarian dysfunction is most often only an ovarian reflection of disordered function of the anterior pituitary. There are many cases of amenorrhea in which there is an excess of estrogen, many in which there is a deficiency, so that such a procedure as ovarian resection would be a highly random affair unless' it were very sharply circumscribed by methods of study still highly unreliable. Many years ago Henkel advised resection of the ovaries for functional bleeding, probably on the basis of an assumed analogy with hyperthyroidism. The results of this plan, long since abandoned, were disappointing, although its revival has been suggested from time to time since then. ' I believe it quite probable that ovarian resection might be of value in a small proportion of cases, perhaps of the group in which Stein advocates performance. ~'\.ny benefit in such cases, however, would seem explainable on the basis of pituitary mediation. As far back as 1928, LipschUtz enunciated the "law of follicle constancy," and I believe that this is probably true. According to this, resection of the ovaries would be followed by the concentration of a continuing pituitary gonadotrophic function upon a reduced ovarian surface, with increased follicle maturation and increased estrogen production as a result. This, to my mind, would explain the good results in a small group better than the mechanism suggested by Stein himself. The case reports of Dr. Reycraft do not impress me as good evidence for the wisdom of the procedure. In two of his cases, for example, a thecoma of the ovary was removed, and this tumor not infrequently caus'!s amenorrhea. Another patient presented what appeared to be a Chiari syndrome, and in most cases a curettage was done. This procedure in itself may at times be helpful through the still poorly understood coordination between the uterus and the ovaries. My chief apprehension concerning such a paper is the fact that it might lead to the widespread abuse of ovarian resection for amenorrhea per se. The old dictum of ''Either take out the ovary or leave it alone" cannot be accepted without qualification, but in the main the principle is a good one. While resection is easy, it may do far more harm than good, as secondary operations will often show adhesions and possibly angulation of the intestines, angulation of the tubes, and other unpleasant sequelae. li'urthermore, in most cases of amenorrhea, it is quite certain that no benefit would accrue from the operation. DR. GEORGE W. KOSMAK, New York, N. Y.-Doctor Reycraft stated that the stem pessary is employed. I would like to ask him what the indication was for this procedure. I thought it was pretty well abandoned. DR. REYGRAFT (Closing).-This discussion was really less critical than I expected. It is granted that this is a procedure that should not be done by everybody, as it is very likely
to be abused, and I therefore emphasized the fact that I had done it in only 11 cases in 11
1076
REYCRAF'l'
years, and I felt I had screened the cases very carefully. Dr. Novak has called attention to the fact that one was a Chiari 's syndrome and two had theca cell tumors. We have, doubtless, produced changes in the physiology of the ovarian fuurtion, although of <·onrsc> the ae-tion of the pituitary gland cannot be ignored. As far as Dr. Kosmak's question about the stem pessary is concerned, we are disciples of Dr. Weir, who has used the stem l'C~sary many, many year~, awl in clean cases we feel it has a stimulating effect on the endometrium, and when you are ''throwing the book' ' at cases of this kind you want to do everything you can, and in some instances the use of a stimulating instrument, such as a stem pessary, was perhaps of some benefit.
L.
(f:lrom the Department of
REYCRAFT;
M.A., M.D.,
CLEVEI,AND, OHIO
Obstet~·ics
and Gynecology, Western Beser·ve University, and The University Hospitals)
HE gynecologist who is primarily a clinician is constantly confronted with T problems bearing on ovarian dysfunctions. Some of these problems are satisfactorily answered by the judicious use of gonadotropes and estrogens. Many patients are seen whose complaints refer to faulty menstruation or complete amenorrhea. They give a history, oft repeated, of having been treated by one or many physicians with hormone therapy, sometimes of questionable value and without results. A woman who menstruates seldom, if at all, is greatly concerned as to her future happiness, first as a wife and secondarily as a mother. She becomes alarmed over her supposed lack of femininity and is besieged by many fears, some of them justified, of the future in store for her. It is a well-known fact that many women have polycystic ovaries and, as a result of that condition, they may have menorrhagia or almost complete amenorrhea. Fundamentally, the disease is due to functional disturbance, the result of imbalance between the endocrine glands. In 1937, we described six cases in a paper entitled "The Surgical Treatment of Ovarian Dysfunctions," in which it was emphasized that, inasmuch as many patients do not respond in any way to endocrine therapy, a surgical approach was considered justifiable in some instances. The cases presented consisted principally of those treated by excision of a portion of the cortex of one or both ovaries, with very favorable results. In most of the pathological specimens, it was found that there was thickening of the tunica albuginea, increased fibrosis of the ovarian cortex and follicles in all stages of development and atresia. Hypothetically, it was thought that the thickening of the ovarian cortex due to long-continued endocrine dysfunction made it impossible for the follicles to rupture and, consequently, there was a mechanical impediment which we were able to overcome by decortization. Since that time, we have operated upon eleven other similar cases and will present the results. 'l'he operation consists of one of two procedures. In those instances where the ovary is large, hut not a neoplasm, a wedge of substance is taken in its longitudinal axis, the defect lwing closed with interrupted m· figure-of-eight sutures of No. 00 plain catgut. •Presented at the Fifty-Ninth Annual Meeting of th<> American Association of Obstetricians, Gynecologists and Abdominal Surg€ons, Hot Springs, Va., September 9 to 11, 1948.
1069
1070
HEYCH:Al"r
i\m. 1 Obst. & Gynec. June, 1949
In most of the cases which we are about to present, however, the process eonsisted merely of denuding a portion of the cortex, and controlling small bleeding points with mattress sutures of ~o. 00 plain catgut. R.t>eently, W(' have used Gelfoam on the eut surface with satisfactory results. CASE 1.--S. V., aged 2G years, married 3 year~, gravida 0, \Y:ts first seen on April 17, 1937, complaining of sterility assoc.iated with menstruation every 6 to 8 months, free, with clots and much pain. Previous estrogenic treatment was unsuccessful. Rubin's test showed patency of tubes, and pelvic examination showed the uteru.9 to be moderate in size and in good position. Both ovaries were large, firm, and very tender, especially the left. May 8, 1937, curettage, insertion of stem pessary, resection of a part of the cortices of both ovaries and appendectomy were done. She menstruated regularly, at 30-day intervals, after the op· eration and removal of stem, until April 14, 1939, when she was found to be pregnant. She was delivered of a living baby in January, 1940. Pathological diagnosis: Simple CJ"Sts of ovary. CASE 2.-H. B., aged 22 years, single, gravida 0, was first seen on Jan. 14, 1937, com· plaining of amenorrhea.· Last menstrual period, July, 1935. Examination showed both ovaries large, low, and tender. Jan. 18, 1937, curettage and stem pessary insertion, without results. She menstruated once, after estrogenic stimulation, June 6, 1937. Stem removed in September, but no menstruation followed until after operation, on Oct. 27, 1937, consisting of excision of two-thirds of the cortex of each ovary, with incidental curettage and ap· pendectomy. Both ovaries were polycystic, but not sclerotic. Menses continued to be ir· regular at 2- to 3-month intervals. Pathological diagnosis: Polycystic ovaries. CASE 3.-D. H., aged 28 years, gravida 0, was examined on Sept. 22, 1942. She complained of a bearing down sensation when on her feet, and of having menstruated only three times in her nine years of married life. Examination showed a small uterus, displaced to the right by a cystic left ovary, estimated to be 8 em. in diameter. Oct. 8, 1942, operation was performed, consisting of curettage, left salpingo-oophorectomy, resection of cortex of the right ovary, and appendectomy. She has menstruated regularly every 26 to 28 days since that time, but never became pregnant. Patholog·ical diagnosis: Theca cell tumor, left ovary. Follicular cysts, right ovary. CASE 4.-C. D., aged 35 years, married, para i, was first seen on Feb. 7, 1944. She had menstruated but once, in August, 1942, since the delivery of her first baby, in 1941. Examination showed her to be healthy, but overweight (180 pounds). Pelvic examination showed a relaxed vaginal outlet and ovaries which seemed sclerotic. She was operated upon April 4, 1944. Curettage produced no material. Perineorrhaphy was done. At laparotomy the ovaries were found to be small and sclerotic. The cortice!' were excised. She menstruated slightly after the operation, but only once (April 25, 1944). This lasted 5 days, but she has never menstruated since. This is thought to have been a case of Chiari 's syndrome. Pathological diagnosis: None. CASE 5.-N. L., aged 20 years, single, was examined on Aug. 28, 1944. She complained of menstruating every two weeks, for a year. She was found to have a left ovarian tumor, 6 em., which was solid and thought to be a dermoid cyst. She was operated upon Sept. 25, 1944, and found to have a thecoma of the left ovary. Curettage was performed and the left ·ovary removed. The cortex of the right was partially removed and incidental appendectomy performed. After this procedure menstruation occurred every 30 days. She married and was last seen in .June, 1945, at which time she was found to be pregnant. Pathological diagnosis: Thecolll<"l. of left ovary. Right ovary, normaL
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1071
CASE 6.-~M. L., aged 26 years, manied 4 years, para O, was first seen ou April 3D, Complaint was that of no menstruation since 1942. Prior to that time, she had bet>n regular, every 28 days. Basal metabolic rate recently, -29%, taking thyroid regularly. Pelvic examination showed the uterus to be small and anterior; left ovary seemed large, probably polycystic. She was given courses of gonadotropes and estrogens, without results. On June 11, 1946, curettage, stem No. 2, left cortectomy and partial wedge excision of the right ovary were performed. She menstruated in August, 1946, and not again until April 26, 1948. With cyclic therapy she has menstruated regularly since that time. Pathological diagnosis: Multiple small simple cysts of ovaries. L!J46.
CASE 7.-R. G., aged 33 years, gravida i, had had one early spontaneous abortion, in 1942. She complained of sterility. She normally menstruated every 4 to 6 weeks, until May, 1945. She had complete amenorrhea, in spite of hormonal stimulation after this time. Exam· ination showed the presence of a large left ovary. On Feb. 6, 1946, curettage was performed and a segment of the left ovary was removed; right ovary was partially decorticized and both were suspended. On March 8, 1946, she had a free menstruation and has continued to men· struate every 28 days since then, but has never become pregnant. Pathological diagnosis: Simple and corpus luteum cysts of ovary. Atypical cystic hyperplasia of endometrium, slight. CASE 8.-V. vV., aged 30 years, married 5 years, a physician, from another city, con· suited me concerning amenorrhea and sterility, on May 6, 1946. Her last menstruation had occurred in July, 1945. Pelvic examination showed that both ovaries were large and sclerotic. Naturally, the tubes were checked and found patent, and the husband was proved to be fertile. On June 26, curettage and stem pessary were followed by resection of a segment of the right ovary, one-third of the cortex of the left, and both were suspended. Three months later, the stem was removed. She menstruated regularly, until Nov. 3, 1946, and ou .Tan. 13, 194i, she was found to be two months pregnant, and was referred back to her local ob· stetrician. Pathological diagnosis: Multiple small follicular and luteinized follicular cysts of both ovaries. CASE 9.-B. J. ::>r., aged 22 years, married 1 year, wife of a physician, was first seen on Dec. 7 1 1942. Menstruations were regular until 1941; now occur every 3 or 4 months. Complaint of constant pain in right lower abdomen. Examination showed the presence of large ovaries, both prolapsed, especially the right. On Dec. 9, 1942, the cortex was excised from the right ovary and a segment of the left was removed. Both ovaries were suspended and incidental appendectomy performed. She menstruated regularly every 35 days until June 14, 1944, and on August 24, 1944, she was two months pregnant. She delivered a full-term baby, in March, 1945.
Pathological diagnosis: Comment: )I'o corpus luteum.
Hyperplasia of tunica albuginea.
Multiple follicular cysts.
CASE 10.-M. W., aged 27 years, single, was seen on Jan. 7, 1946, complaining of amenor· rhea, although she had had some cramps each month, for ten years. Much treatment with· out results. Examination showed fomale. development and hirsutes, but poorly developed breasts. The uterus was infantile, the ovaries not palpable. On }'eb. 12, 1946, curettage was performed and a small stem inserted in the uterus. At laparotomy, both ovaries were found to be very tiny. However, we excised some cortex from the left one and punctured some small cysts in the right. She "'as given large doses of stilbestrol and a course of Squibb's gonadotropic hormone, alternating. She menstruated for 6 days, starting March 28, 1946, and has menstruated every 28 days since then. Pathological diagnosis: Simple follicle cyst of ovary.
Am. J. Obst. & Gynoc. June, 1949
REYCRAF'l'
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CA:;E 11.~-B. L., aged :l5 year~, marrict1 :3 years, gravida 0, was first, st•;m on 8tJpt. J ~1, 1947, complaining of amenorrhea and ~terility. Last mPustmation had ],een in :\
presence of large prolapsed ovaries which seemed thickened and not ttmde1·. 011eration, Oet. 8, 1947, consisted of curettage, insertion of stem pessary, resection half of each large ovary, suspension of both and incidental appendectomy. Curettage at this time ~howed the absence of endometrium. ~fenstruation started on Oct. :lo, 1947, and she was regular until May 5, 1948. The last examination was in July, and she was found to be pregnant.
Pathological diagnosis: None.
A brief summary of these cases shows that two had theca cell tumors, which were removed. A portion of the cortex of the remaining ovary was resected and both menstruated regularly after the operations. One had menstruated every two weeks for a year, before surgery. One, with polycystic ovaries, had a wedge resection of each and menstruated occasionally. All the others complained of menstruating at rare intervals or not at all. One complete failure was in a 35-year-old patient, who had bilateral decortization and has had symptoms of the menopause since then. This was thought to be an atypical instance of Chiari 's syndrome, inasmuch as her amenorrhea followed the birth of a baby with resulting hyperinvolution of the uterus and a long-continued lactation. The remainder, eight in number, had simple cortectomy performed and have menstruated fairly regularly since operation. One unmarried patient, aged 27 years, who had never menstruated in her Iif{•. rrow does so rt:>gularly. Five of the cases have become pregnant. In the past eleven years, we have operated upon twenty cases in which there was pathology complicating sterility, where a major operative procedure seemed justified. The results have been most gratifying, as the following tables will show: TABLE
I.
CHOCOLATE CYSTS AND 8TERIJ,I'l'Y.
(TUBES ALL PAncN'l')
(No.m•
Mrs.-P. 1943 2. Mrs. D. 1943 3. Mrs. C 1943 4. Mrs. M. 1946 5. Mrs. M. 1942 1.
AGE
DIAGNOSIS
OPERATION
DELIVERIES)
34
Choc. cysts Sterility Choc. cyst Sterility Choc. cyst Sterility Choc. cyst Sterility Choe. cysts Retroversion Sterility
Oophorectomy Salpingopexy Excision cysts Suspension of ovaries Oophorectomy Salpingopexy Oophorectomy Salpingopexy Dilatation and curettage Suspension Resection ovarian cyst Dilatation and curettage Myomectomy Oophorectomy Salpingopexy Freeing of cul-de-sac Gilliam suspension Left oophorectomy Salpingopexy Resection ovarian cyst both
2
28 30 36 26
6.
Mrs. A. 1945
30
7.
Mrs. K. 1946
33
8.
Mrs. A. 1944
27
Fibroid uterus Choc. cy~t Sterility Choc. cyst Retroversion Endometriosis Sterility
None
2
3
>}
OPJ
VnhJitJe 57 Number 6
TABf,E II. FIBROIDS AND STERfLITY (TUBES ALL PATENT) RESULTS (NO. OF
10.
Mrs. D.
34
1945 11.
Mrs. A.
30
1946
TABf,E III.
13.
~frs.
K.
37
Mrs. H.
28
1937 14.
1945 Hi.
Mrs.
1940
c.
32
Submucous fibroid Sterility Fibroid uterus Sterility
17.
1944 Mrs. P. 1943
27
18.
Mrs. 1947
s.
31
1!1.
~Irs.
0.
31
Mrl'. H. 1941
33
1947 20.
1
1
OLD lNFLA:I.lMATORY DISEAS~: AND STERILITY (TUBES CLOSED OR ABSEN'l')
Bilateral Sterility Previous bilateral salpingectomy Sterility Previous bilateral
'rABLE
AGE
ovarian cyst Excision myoma, vaginally Dilatation and curettage Myomectomy Gilliam
rv.
Salpingostomy
None
Canalization, left cornu
None
Estes operation
None
MISCELI,ANEOUS
DIAGNOSIS l·child sterility Endometrioma Retroversion 3 miscarriages Chronic pelvic inflammatory disease Left tubovarian cy>
Sterility Partial tubal obstruction treated 6
OPERATION Gilliam suspension Dilatation and curettage Excision endometrioma in cul-de-sac Gilliam suspension Left salpingo-oophorecto my Suspension rght ovary
Dilatation and curettage Bilateral salpingopexy Suspension ovaries Uterine suspension Dilatation and curettage Gilliam suspension
RESULTS (NO. OF !JELIVERIER)
2
1
Nouc
2
Summary \Ve have presented ten cases in which the patient menstruated seldom if at all, and another who menstruated every two weeks for a year. This was one of those with a theca cell tumor. With one exception the remainder
.1074
HEYCHAJ.'1'
Am. J. Obs.t. & Gyncc June, 1949
were benefited by partial excision of the ovarian cortex, also by using a wedge resection in those instances where the ovaries were unusually large. Suspension of the ovaries has been freely used. Five of these patients have hecome pregnant. We have also presented tv,renty cases where major operative intervention seemed justified for the correction of sterility. Eight of these had cystic ovaries, in which the ovary involved was removed and the tube salvaged and suspended so as to increase the chances of an ovum being received in the fimbriated extremity. Three had myomectomy performed, with good results; four had various operations for closed or absent tubes, all without results. The remaining five were treated by uterine suspension. Of the twenty cases, fourteen have now become pregnant and, to date, have delivered twenty-two full-term living babies. References 1. Allen:
2. 3. 4. 5. 6.
7. 8. 9.
Glandular Physiology and Therapy, Chicago, 1935, A. M.A. Press, p. 169. Berblinger: Klin. W chnschr. (August) , 1932. Goodall, J. R.: Jour. Obst. & Gynaec, Brit. Emp. 40: 640 (June), 1933. Robinson, M. R.: AM. J. 0BST. & GYNEC. 30: 18 (July), 1935. Smith, P. E., and Engle, E. T.: Am. J. Anat. 40: 159 (Nov.), 1927. Smith, P. E., and Engle, E. T.: Curtis' Obst. and Gynec. 8: 287, 1933. Stein, I. F., and Leventhal, M. L.: Am. J. Obst. & Gynec. 29: 181, 1935. Stein, I. F.: AM. J. OBST. & GYNEC. 50: 385, 1945. Reycraft, J. L.: AM. J. 0BST. & GYNEC. 35: 3, 505, 1938.
Discussion DR. FRANK E. WHITACRE, Memphis, 'l'enn.-Dr. Reycraft's report on the surgical treatment of ovarian dysfunctions introduces a debatable subject. The reported eases are a collection of several procedures. It is commonly accepted that myomectomy in some instances may prove to be good treatment for sterility and occasionally for menstrual disorders, anc1 the essayist's success with this group demonstrates careful selection of eases. It is also commonly accepted that salpingostomy in the presence of chronic pelvie inflammatory disease is not often successful in the treatment of sterility, and this also is borne out by his results. I am particularly interested in Dr. Reyeraft 's series of removal of the eortex of one or both ovaries. An explanation of the successful cases might be more than removal of the thickened cortex. The origin of primordial follicles is still an unsettled question. Thnre is some evidence from animal experimentation that follicles may have their origin in the hilum or at its juncture with the mesovarium. It is possible that resection of the cortex of the ovary with the hilum remaining intact may be followed by some degree of regeneration of the ovarian cortex. It is important to study the time interval elapsing between the operation on these patients and the establishment of a more nearly normal menstrual cycle and/or preg· nancy, and also whether or not a future laparotomy on the same patient might demonstrate regeneration of ovarian cortex. My experience with this procedure has been limited, and opinions of my colleagues who have carried out this or similar operations vary from lack of enthusiasm to recommendation. Success in the use of similar procedures has been reported by Stein and also by Jacobson. The degree of success reported by the essayist and other authors presupposes careful study an<1 selection of patients and delicate handling of tissue. In congratulating Dr. Reycraft on hiH results, it must be understood that this meticulous study is mandatory for success and that wide adoption of this and like procedures would lead to a wave of unnecessary surgery on young women over and above what we already have.
Volume 57 Number 6
OPERATIVE PROCEDURES FOR STERILI'fY
10'75
In discussing· this problem ten years ago, Douglas brought up the question of postopcmtivo adhesions, to which the essayist agreed that it is of real danger. Hartman has shown that adhesions may, and sometimes do, result from simple ovulation in the primate. With this in mind, what could one expect after surgical denudation of the ovaryf Perhaps the use of absorbable sponge material would lessen these dangers. We all see young women who have had one or more pelvic operations directed at the ovaries where improvement is temporary and the end result unsatisfactory. It is, therefore, a question of careful judgment. Operations on the ovary in young women should be controlled by the specialist. In recent years agencies authorized to establish the standards of hospitals have compelled the consultation of a qualified specialist before cesarean section is permitted to be done, and this has resulted in general improvement. This principle could be extended with benefit to include the subject under discussion. DR. EMIL NOVAK, Baltimore, Md.-While I have not personally employed ovarian · resection for the treatment of amenorrhea per se, I have been interested in the reports of others. It must be remembered that ovarian dysfunction is not a mere plus or minus affair, as would seem to be the case with the thjToid. Furthermore, ovarian dysfunction is most often only an ovarian reflection of disordered function of the anterior pituitary. There are many cases of amenorrhea in which there is an excess of estrogen, many in which there is a deficiency, so that such a procedure as ovarian resection would be a highly random affair unless' it were very sharply circumscribed by methods of study still highly unreliable. Many years ago Henkel advised resection of the ovaries for functional bleeding, probably on the basis of an assumed analogy with hyperthyroidism. The results of this plan, long since abandoned, were disappointing, although its revival has been suggested from time to time since then. ' I believe it quite probable that ovarian resection might be of value in a small proportion of cases, perhaps of the group in which Stein advocates performance. ~'\.ny benefit in such cases, however, would seem explainable on the basis of pituitary mediation. As far back as 1928, LipschUtz enunciated the "law of follicle constancy," and I believe that this is probably true. According to this, resection of the ovaries would be followed by the concentration of a continuing pituitary gonadotrophic function upon a reduced ovarian surface, with increased follicle maturation and increased estrogen production as a result. This, to my mind, would explain the good results in a small group better than the mechanism suggested by Stein himself. The case reports of Dr. Reycraft do not impress me as good evidence for the wisdom of the procedure. In two of his cases, for example, a thecoma of the ovary was removed, and this tumor not infrequently caus'!s amenorrhea. Another patient presented what appeared to be a Chiari syndrome, and in most cases a curettage was done. This procedure in itself may at times be helpful through the still poorly understood coordination between the uterus and the ovaries. My chief apprehension concerning such a paper is the fact that it might lead to the widespread abuse of ovarian resection for amenorrhea per se. The old dictum of ''Either take out the ovary or leave it alone" cannot be accepted without qualification, but in the main the principle is a good one. While resection is easy, it may do far more harm than good, as secondary operations will often show adhesions and possibly angulation of the intestines, angulation of the tubes, and other unpleasant sequelae. li'urthermore, in most cases of amenorrhea, it is quite certain that no benefit would accrue from the operation. DR. GEORGE W. KOSMAK, New York, N. Y.-Doctor Reycraft stated that the stem pessary is employed. I would like to ask him what the indication was for this procedure. I thought it was pretty well abandoned. DR. REYGRAFT (Closing).-This discussion was really less critical than I expected. It is granted that this is a procedure that should not be done by everybody, as it is very likely
to be abused, and I therefore emphasized the fact that I had done it in only 11 cases in 11
1076
REYCRAF'l'
years, and I felt I had screened the cases very carefully. Dr. Novak has called attention to the fact that one was a Chiari 's syndrome and two had theca cell tumors. We have, doubtless, produced changes in the physiology of the ovarian fuurtion, although of <·onrsc> the ae-tion of the pituitary gland cannot be ignored. As far as Dr. Kosmak's question about the stem pessary is concerned, we are disciples of Dr. Weir, who has used the stem l'C~sary many, many year~, awl in clean cases we feel it has a stimulating effect on the endometrium, and when you are ''throwing the book' ' at cases of this kind you want to do everything you can, and in some instances the use of a stimulating instrument, such as a stem pessary, was perhaps of some benefit.