Operative treatment of sterility

OPERATIVE TREATMENT OF STERILITY* FRANCIS

W.

SOVAK, M.D., F.A.C.S.

Clinical Professor of Obstetrics and Gynecology, New York University College of Medicine NEW YORK

F

REQUENT reports of new and improved procedures, and a rapid advance in the operative technique of plastic surgery on the adnexa for the treatment of absolute female sterility have produced an increased interest in its application and treatment. The end results are becoming increasingly more satisfactory. The trans uterine insufflation as developed by Rubin and hysterosalpingography have definitely contributed to the essentials of the successful plastic operation. The Patient. It is necessary of course, that the patient be within the childbearing age and have no developmental anomalies. The husband must· be known to have normal spermatozoa. The operations hereinafter described would be contraindicated by the presence of acute or subacute pathology or tuberculous salpingitis. Sterility is classified as absolute when it is caused by the patient having bilateral occluded oviducts. Relative sterility or the occlusion of a fallopian tube on one side . and a patent one on the opposite side would not justify operative procedure since the initiation of the reproductive process is still possible. The patient with chronic adnexal disease should have no operative intervention until at least three menstrual periods have been observed, and that after bimanual examination there is no variation in the sedimentation rate, temperature and leucocyte count. These procedures should be considered of value in such cases where castration ordinarily might be performed in connection with operations for marked pathologic

conditions of the adnexa not associated with the sterility. Where other factors, such as kinks, adhesions or pressure by tumors are obviously the cause of the occlusion, these conditions can be rectified by the correction of the extratubal pathology and the operative procedures herein would not be applicable. Preoperative Preparation. In operations of this character all local foci of infection in the cervix, Bartholin glands and Skene's ducts must be eliminated. Where the history of the patient discloses a pelvic infection a course of heat treatments such as the Elliott method per vaginum as developed at Bellevue Hospital, or diathermy or heat developed with short-wave radio apparatus is given the patient in order to assist the diseased pelvic tissues to recover by a process of resolution and regeneration. At Bellevue Hospital the number of Elliott treatments in a series of cases ranged from twelve to twenty-eight, fortyfive minute treatment at I2soF. being given daily for a period of at least three or four weeks before operation. Decrease in the size of the adnexal masses or no palpable adnexal pathology which had previously been manifest, provide the criteria in the determination of the number of treatments to be given. A Rubin insufflation test to determine the patency of the tubes which may have been opened as a result of the medical treatment, should be performed before undertaking operation. The most suitable time for operation is during the intermenstrual period.

'''From the Department of Obstetrics and Gynecology of the Third Surgical Division, Bellevue Hospital and the Department of Obstetrics and Gynecology of New York University College of Medicine.

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FIG.IA.

FIG. lB.

FIG.

IA.

Salpingitis isthmica nodosa; inner two-thirds occlusion. B. Occlusions due to kinks caused by adhesions. (Davis'. Gynecology and Obstetrics. Vol. III, W. F. Prior.)

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FIG.lc.

FIG.ID.

Occlusions caused by adhesions with prolapsed adnexa. D. Occlusions occurring in outer third of tube, so-called clubbed tube. (Davis', Gynecology and Obstetrics. Vol. III, W. F. Prior.)

FIG. IC.

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Classification oj Adnexal Pathology to Determine Operative Procedure: Due to the variance in the diameter of the tubal lumen

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able depending on the site of the occlusion of the oviducts, and the existing tubal and ovarian disease. Such methods may be

Intrapelvic tubal insufflation syringe for testing tubal patency at time of operation following original suggestion of Arthur Curtis. (Davis', Gynecology and Obstetrics. Vol. III, W. F. Prior.)

FIG. 2.

from 4 mm. to 6 mm. in the outer third to about 2 mm. in the inner two-thirds, different methods of procedure are advis-

classified as follows:I. Where the occlusion occurs outer third of the oviduct;

III

the

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FIG·3 A •

FIG·3B• FIG. 3A. Line of amputation proximal to site of occlusion. B. Testing patency of remaining portion of tube. (Davis', Gynecology and Obstetrics. Vol. II I,

W. F. Prior.)

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2. Where the occlusion occurs within the inner two-thirds of the oviduct including the interstitial portion; and

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Types oj Operations. I. Oviducts which are occluded in the outer third are reconstructed by the

FIG. 3C. Insertion of silk bougie and application of Bonney clamp 1.5 to 2.5 cm. from amputated end. Circular incision down through muscularis. D. Cuff anchored to serosa. Reconstruction complete. E. Turning back cuff over clamp, everting tube, mucosal cuff being brought back to serosa. (Davis', Gynecology and Obsterics. Vol.

III, W. F. Prior.)

3. Where there is a total occlusion of the oviducts, or where the oviducts present extensive pathology, although different portions may be patent, reconstruction is impossible.

"circumcIsIOn" operation by everting the mucosa ofthe tube for 1.5 to 2.5 cm. and retracting it to the serosa, thus raw surfaces at the newly constructed ostium are eliminated and adhesions and occlusions

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which generally follow operations of this character are a voided. 2. Where there is occlusion anywhere in

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their entirety or where the extensive diseased conditions show that plastic operations are inadvisable. The procedure

FIG.4A• FIG. 4A. Suspending tube and ovary from side wall of pelvis. Small bite of peritoneum being taken

from side wall of pelvis with linen suture. (Davis', Gynecology and Obstetrics. Vol. I I I, W. F. Prior.)

the inner two-thirds of the oviducts treatment by the "circumcision" procedure is not feasible because the lumen of the tube is too narrow. These cases are suitable for the implantation operation which tries to preserve the normal anatomic and physiologic relationship of the tubes to the uterus. (Figs. IA to n.) 3. Neither the circumcision nor the implantation procedures are suitable in cases where the oviducts are occluded in

as described by Estes which calls for removal of the markedly diseased tube or tubes and the transposition of the ovary would apply in cases coming under this section. Depending upon their pathologic condition, one or both, or portions of the ovaries with their intact ovarian ligament may be transposed and the normal nerve and blood supply maintained. A combination of these methods of procedure may be adapted in cases where

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the pathology found at the time of the celiotomy shows it to be advisable. In other words a "circumcision" operation may be

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suitable by the operating surgeon. Determining the Site of Occlusion. The Rubin insufHation test will determine the

FIG·4B. FIG. 4B. Small bite taken through hilum of ovary in order to suspend tube and ovary. This suspension

prevents tube and ovary from prolapsing into culdesac. (Davis', Gynecology and Obstetrics. Vol. I I I,

W. F. Prior.)

done on one side and a transposition of the ovary on the other, or implantation of the inner two-thirds of the oviduct on one side and the "circumcision" operation of the outer third of the other tube, or any such combination as might be deemed most

patency or occlusion of the oviducts but it is not possible thereby in the event of a negative result to estimate the site of the occlusion. This may be revealed by a hysterosalpingogram. However, this procedure may cause an exacerbation of the

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tubal pathology; moreover, if a large quantity of the lipiodol leaks into the peritoneal cavity it may cause severe

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hysterosalpingogram and instead use an intrapelvic insufflation syringe which I have devised to be able to determine the

FIG·5B. FIG. 5A. Amputation of tube proximal to site of occlusion. Site determined by use of intrapelvic insufHation syringe. B. Freeing uterine portion of occluded tube from its attachment to the broad ligament. Also freeing patent portion of tube from broad ligament from a distance of 0.5 cm. (Davis', Gynecology and Obstetrics. Vol. lII, W. F. Prior.)

peritoneal irritation, or an encapsulation of the lipiodol may result. This procedure, therefore has its drawbacks but the hysterosalpingogram has proved of great value in developing the technique of. the circumcision and tubal transplantation operations. However, I have since discontinued the

site of the occlusion at the time of operation. (Fig. 2.) Salpingostomy. At Bellevue Hospital a new method of salpingostomy has been evolved from the operative procedures discussed. It was almost universally noted that the previous methods, many of which

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even attempted eversion of the fimbria or passage of foreign bodies such as catgut into the tubal lumen, were unsatisfactory.

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introduced into the lumen of the outer third of the tube. A Bonney clamp is then placed over them about 1.5 to 2.5 cm. from

FIG·5C. FIG. 5C. Reaming instrument applied over occluded stump of tube. With a circular movement of the instrument, stump of the tube and its intramural portion is reamed out. (Davis', Gynecology and Obstetrics. Vol. III, W. F. Prior.)

The modified procedures are described in detail. I. "Circumcision" Technique (Author's Method). No instruments are used on the oviduct so as to avoid any injury to the delicate tissue. If the fimbria are occluded they are freed by blunt dissection; if the oviduct is non-patent an amputation is done proximally to the site of the occlusion, using mosquito clamps and No. 00 plain catgut ligatures to control the bleeding points. By the use of the specially devised intrapelvic glass insufflation syringe the patency of the remaining portion of the tube is tested. If it is opened a gurgling sound is produced as the air enters the uterine cavity and a vibration is felt if the fundus is held. If there is occlusion at any other site the air is not transmitted into the fundus but the tube becomes dilated proximal to the occlusion. If it is found that the remaining portion is patent, a NO.9 to 12 French straight silk catheter is

the amputated end. At the distal end of the clamp a circular incision is made down through the muscularis, (Fig. 3c) applying two fine Allis clamps to the amputated end of the tube. The tube is pulled gently backward at the same time pushing forward the Bonney clamp, thus everting the tubal mucosa to the serosa forming a tubal cuff (Fig. 3E) which is held in place by three interrupted sutures of No. 00 plain catgut, concealed underneath the cuff. The Bonney clamp is then gently released, the catheter removed with it (Fig. 3D) and the reconstructed tube is tested for patency by insufflation of air with the glass syringe (Fig. 3B). The tube and ovary are then suspended following Poole's technique, to the side wall of the pelvis almost level with the round ligament, by a linen suture taken through a bite in the pelvic peritoneum and hilum of the ovary (Fig. 4A and B). This high suspension of the adnexa precludes the possibility of their prolapse and

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A

B

FIGS. 6A and 6B.

FIG.6c. FIG. 6A, B. New opening into uterus following removal of occluded tube and its intramural portion. Patent portion of tube dissected longitudinally by cuticle scissors. Long No. 00 chromic sutures applied to superior and inferior ends of bisected tube. c. Insertion of Reverdin needle I cm. beyond centeroffundus, posteriorly, passing out through the newly created uterine opening in order to bring out the suture previously applied to the end of the superior portion of the bisected tube. The same procedure followed by insertion of the Reverdin needle through anterior surface of the fundus. (Davis', Gynecology and

Obstetrics. Vol. III, W. F. Prior.)

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adherence in the culdesac and by maintaining a more normal circulation relieves the congestion resulting from the stasis for-

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circular motion reaming out the tube and its intramural portion as the instrument enters the uterine cavity, following as

FIG.6D. FIG. 6D. By gentle traction on the previously applied anterior and posterior fundal sutures, the tube is gradually drawn into the newly created uterine opening and its end into the uterine cavity. The sutures are then anchored on the fundus. Two or three fine supporting sutures are passed through the serosa of both tube and uterus. (Davis', Gynecology and Obstetrics. Vol. II I, W. F. Prior.)

merly present. In order to keep the uterus nearly as possible the normal course and well anterior and so prevent any possibility position of the tube (Fig. 5C). The occluded of it retroverting into the culdesac, a one tubal stump and the chronically infected point suspension is done. cornual tissue forms a core which is removed 2. Tubal Implantation Technique (Aueasily upon the withdrawal of the reamer, thor's Method). By air insufflation the site leaving a new uterine opening of approxiof the occlusion in the tube is determined mately 0.5 cm. This reamer, contrary to and it is then amputated at a point proxi- general expectations, does not cause free mally to the occlusion which evidences the bleeding, as the circular movement crushes free passage of air, (Fig. 5A). Occluded the blood vessels but does not cut them and areas may be present in any portion of the the slight oozing first occasioned ceases tube, or at both extremities and both rapidly. The patent portion of the tube is procedures may be indicated for its proper then freed from its attachment to the broad reconstruction. The uterine portion of the ligament for about 0.5 cm. controlling the closed tube is freed from its attachment to bleeding points. A probe is inserted into its the broad ligament as far as the cornu lumen to act as a guide and with cuticle clamping all bleeding vessels and then scissors it is bisected longitudinally, (Fig. ligating them with No. 00 plain catgut 6A) then passing a long suture of No. 00 (Fig ..5B). In order to maintain the ovarian chromic catgut through the superior and circulation, one cuts as close as possible to inferior ends, clamping the ends of the ligathe tube. A reaming instrument of special ture until used later (Fig. 6B). About I cm construction is passed first over the beyond the center of the fundus a Reverdin occluded tubal portion and then by a needle is inserted through the posterior

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surface and passed out through the newly formed opening in the uterus and the ends of the suture from the superior bisected

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gradually drawn into the uterine cavity through the new opening by a gentle tugging of the sutures as they are pulled

FIG.7A.

FIG.7B• FIGS. 7A, B, C, D.

Estes' transposition ofthe ovary (Extra-Uterine). (Davis', Gynecology and Obstetrics.

Vol. III, W. F. Prior.)

portion of the tube is threaded into the eye of the Reverdin needle and the needle then withdrawn, bringing the sutures without tension, to the posterior uterine surface. The same maneuvers are followed passing the Reverdin needle through the anterior surface of the fundus and drawing the suture through from the inferior portion of the previously bisected tube. (Fig. 6c.) The serosa of each portion of the bisected tube is scarified. The ends of the tube are

through the anterior and posterior fundal wall, where they are anchored. Two or three additional fine sutures for support are passed through the tubal and fundal serosa (Fig. 60). Air is insufflated now to test the patency of the reimplanted tube. Both the reimplanted tube and its ovary are suspended by the previously described Poole technique (Figs. 4A and B) and a one point suspension of the uterus is done. Postoperative Treatment. A Rubin in-

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sufHation test is done forty-eight to ninetysix hours postoperatively in order to ascertain and preserve the patency of the

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for check-up Rubin test; if the tubes show occlusion the patient is instructed to return for further Elliott treatment.

FIG.7C.

FIG.7 D •

reconstructed tubes. If there have been any recent plastic vaginal or cervical procedures, or the patient shows a marked postoperative reaction, the Rubin test should be deferred. To keep the tubes open the insufHation test is repeated prior to discharge from the hospital. If the tubes are found to be patent the patient is instructed to return in three or four weeks

In these operative procedures although there has been a minimum amount of trauma it may be sufficient to cause a temporary occlusion, which will respond very readily to Elliott heat treatments. Therefore one should not become discouraged if the tubes are found to be closed at the time of discharge from the hospital. A patient with extensive pelvic pa-

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thology following a postabortal sepsis and a later complication of a marked gonorrheal infection had a previous unilateral salpingectomy. A plastic reconstruction of the remaining tube was done but it persistently remained closed for eight weeks following operation. She was given a series of fourteen Elliott treatments after which it was found by both the Rubin test and a hysterosalpingogram that the tubal patency was restored. All the cases routinely receive Elliott treatments whether the tubes are patent or occluded for it is our impression that the heat applied by this treatment aids materially in the reabsorption of any postoperative inflammatory tissue reaction. Estes' Transposition of the Ovary. Where there is markedly extensive involvement or complete occlusion of the tube, or extensive pelvic pathology in which castration is indicated, the Estes' transposition of the ovary is the method preferred. Its object is to preserve the function of ovulation and the secretion of ovarian hormone with the possibility of the uterus becoming gravid and ensuing full term delivery. It is essential for the ovum to enter into the uterus and the neurocirculatory supply to the ovary to be maintained. Pelvic drainage is rarely indicated if proper preoperative preparation has been followed. Estes believes that the patency of the uterine cornu is one of the factors which influences the extrusion of the ovum into the uterine cavity. I have modified somewhat Estes' procedure, in that, a cornual portion of the uterus is coned out by a special reamer which makes a larger uterine cornual opening over which the ovary is sutured. Operative Technique. The details of the operation as stated by Estes are as follows: With the patient in the Trendelenburg position and the upper abdomen packed off, pelvic adhesions and the tubes and ovaries are carefully and gently freed. The ovaries are

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thoroughly inspected, and the one more normal in appearance is chosen for transposition. The other may likewise be saved if its condition justifies it. In the majority of cases it must be sacrificed. Operative procedures are given in the order of their occurrence. I. The tube and ovary of the side opposite the site of transposition are removed. The broad ligament and the uterine artery, where it emerges at the horn of the uterus, are tied off. The operation is not completed on this side until the transposition has been made. 2. The tube of the transposition side is then removed, together with enough of the horn of the uterus at the tubal attachment to leave a raw area the size ofthe cut surface of the ovary. Care is taken to preserve the anastomosis of the uterine and ovarian arteries. In the center of this surface will be seen usually the opening into the uterine cavity less than 0.25 cm. in diameter. When the pathology at the cornu is so extensive that there is no visible opening, Estes incises directly through the cornu, extending the incision down into the uterine cavity. The slight oozing which follows can be controlled by pressure after the uterine artery has been ligated just below the operative area. 3. A longitudinal slice is then taken to the full diameter of the ovary, removing usually about one-quarter of it from the surface opposite its ligament and mesentery. The amount of the ovary removed depends upon the amount of cystic degeneration or inflammation that may be present. As much as seven-eighths of the ovary has been removed and the remainder transposed.

In his last report Estes cites an instance of a patient, who following operation had four. pregnancies with delivery of three full-term normal children. This patient later developed endometriosis which required removal of the uterus and ovary. I t was found that the endometrium of the uterine horn was continuous with a small cystic area in the superimposed ovary. Therefore, Estes believes that it would be better to attempt to place a cystic area in the cut surface of the ovary directly over the split mucosal orifice in the uterine horn,

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so that there is a direct anastomosis of the two opposing areas. 4. The cut surface of the ovary is then turned over on the denuded area of the uterine horn and sutured in place by a continuous catgut (chromic No. 0), beginning at the inferior margin and approximating the complete circumference of the ovarian and uterine wounds. 5. The round ligament is then plicated over this entire area by suture to the uterus in order to cover and completely peritonealize it. 6. On the opposite side, the stump of the broad ligament is sutured to the horn of the uterus and in turn, like the transposed area, covered by the round ligament. A culdesac drain, if indicated, may then be inserted. SUMMARY

Pregnancy has occurred following operative reconstructive, or plastic procedures on the oviducts which have been described in detail. Although the incidence has been only 30 per cent in my clinical series and 50 per cent in my private practice, it is a marked improvement over previous end results. The possibility of increasing the percentage of incidence of pregnancies will most probably follow other modifications or improvements in surgical technique.

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In 1932 there were 77 per cent successful results based on the patency of the oviducts, as compared to 90 per cent obtained in a more recent series. Although the incidence of pregnancy is low, plastic reconstruction of the occluded tube has prevented castration and invalidism besides retaining the normal menstrual function and endocrine balance. REFERENCES

BAINBRIDGE, W. S. Am. Jour. Obst. and Gynec., 5: 379493, 1923. COTIE, G. and BERTRAND, P. Gynec. et obst., 15: 182, 192 7. CULLEN, T. S. Bull. Jobns Hopkins Hosp., 33: 344, 1922 • CURTIS, A. A Textbook of Gynecology, Air Insufflation of the Tube, p. 233. 1930. ESTES, W. L., JR. Penn. Med. Jour., 13: 610, 1910; J. A. M. A., 83: 674, 1924; Surg., Gynec. and Obst., 38: 394, 1924; Internat. Clin., 3: 266, 1932. HOLDEN, F. C. and GURNEE, W. S. Am. Jour. Obst. and Gynec., 22: 87, 1931. KENNEDY, W. T. J. A. M. A., 85: 13, 1925. KERWIN, W. Am. Jour. Obst. and Gynec., 16: 641, 1928. MEAKER, S. R.: Ibid., 20: 6, 1930. NORRIS, C. C. Surg. Gynec. and Obst., 58: 741, 1934. PETIT, R. Am. Jour. Surg., 16: 94, 1932. RUBIN, 1. C. New York State Jour. Med., 29: 379, 1929. SCHMITZ, H.: Am. Jour. Obst. and Gynec., 23: 47, 1932. SOVAK, F. W. Ibid., 21: 544-550, 1931. SOVAK, F. W. and HOLDEN, F. C. Ibid., 24: 684, 1932. LETULLE. Presse med., 32: 465, 1924. UNTERBERGER, F. Monatscbr.f. Geburtsb. u. Gyniik., 73: 1,1926.

REFERENCES OF DR. NOVAK*

HALBAN, J. Hysteroadenosis metastatica. Wien. klin. Wcbnscbr., 37: 1205, 1924. HElM. Ueber die Entwicklung der Endometriose an Ort und SteIIe~ Arcb. j. Gyniik., 125: 2~, 1933. IWANOFF, N. S. Driisiges cystenhaltiges Uterusfibrom compliciert durch Sarcom und Karzinom. Monats. b u. Gynii k ., 7: 295, I 89 8 . f . Ge. KEENE, F. E. and KIMBROUGH, R. A. Endometriosis. Curtis Obstetrics & Gynecology, Phila., W. B. S aunders Co., 1933, p. 388. . Ad fib' d Ad M EYER, R . Ad enomyosls, eno I rOSIS un eno-

mucosa in fallopian tube, with discussion of origin of aberrant endometrium. Ibid., 12: 484, 1926. v. RECKLINGHAUSEN, F. Die Adenomyome und Cystadenomyome der Uterus und Tubenwandung, Berlin, A. Hlrschwald, 1896. v. ROKITANSKY, C. Ueber Uterusdriisenbildung im Uterus. Zeitscbr. der K. u. K. Gesellscb. der Artzte zu Wien., 1860. RUSSELL, W. W. Aberrant portions of the Muellerian duct found in the ovary. Bull. Jobns Hopkins U" 8 8 nosp., 10: ,I 99· SAMPSON, J. A. Perforating hemorrhagic (chocolate) myom., Miinchen, Veit-Stoeckel Handb. der Gyn. cysts of ovary, etc. Arcb. Surg., 3: 245, 1921; Life 1930. history of ovarian hematomas. Am. J. Obst. and NOVAK, E. Pelvic endometriosis. Am. Jour. Obst. and Gynec., 4: 451, 1922; Endometriosis following Gynec., 22: 826, 1931; Significance of uterine salpingectomy. Ibid., 16: 461, 1928. * Continued from p. 427.