Tubal electrocauterization under hysteroscopic control

TUBAL

ELECTROCAUTERIZATION

UNDER

HYSTEROSCOPIC

CONTROL

Rodolfo Quiiiones Guerror, M.D.* Ram&n Aznar Ramos, M.D.** Albert0 Alvarado Dukn,

M.D.***

Hospital de Gineco Obstetricia No. 2 Centro M&co

National

Av. Central No. 100 Mhxico 7, D.F.

ABSTRACT

A new technique of tubal occlusion by electrocauterization

of the intramural

portion

of the Fallopian tube is described. The electrode is passed into the tube under direct vision control through hysteroscopy and the tissue alterations produced during the cauterization procedure are clearly seen. Prior to cauterization, uterine cavity.

of the tubal orifice and the introduction

*Direct& **Depto. ***Jefe

a 5% glucose solution is injected into the

By injecting this solution with as much pressure as necessary, localization of the electrode becomes an easy and safe procedure.

del Hospital de Gineco Obstetricia No. 2 C.M.N.I.M.S.S. de Investigackk

Cient:fica.

C.M.N.I.M.S.S.

del Depto. de Enzeiianza e Investigaci6n.

Hospital de Gineco Obstetricia

No. 2 C.M.N.I.M.S.S.

Accepted for Publication January 31,1973

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INTRODUCTION

Tubal occlusion by electrocauterization has been attempted for a long period of time. Electrocauterization is usually performed at the cornual region; however on a few occasions direct cauterization of the intramural portion of the Fallopian tubes has been tried. Previous studies with this method usually report both complication and failure of the methods utilized. The first experience with cornual electrocauterization was reported in 1878 when Kocks (1) introduced an electrode through the cervical cornual and described the “crackling sound” heard at the abdominal wall and the steam which came from the uterus after cauterization. Prudnikova (2) applied the same technique on 9 patients. Dickinson (3) devised an instrument for this purpose using a loop wire heated by an electric current. In 1916 he reported its use in 40 patients without complication. Hyams (4) in 1934 described an electrode covered with an insulated sheath; the electrode protruded into the utero-tubal junction so that electrocoagulation current arrived at this portion of the uterus. The correct position of the electrode was controlled by fluoroxopy after injection of iodine dye into the uterus. De Vilbiss (5). Bowers (6). Yasui (7). and Sheares (81, have tried cauterization of the cornual region in more than 500 patients. In more than 59% of them, both tubes were occluded. In a group of 128 patients treated by Sheares (8) in Singapore, there were 46 pregnanciesand several complications including hemorrhage, peritonitis, and one death. Pasricha (9). in 89 patients in which she employed cauterization of the cornual region, reported one case of severe hemorrhage, two casesof salpingitis cured by palliative treatment and three casesof peritonitis with signs of bowel perforation in one of them. In Japan, from 1952 through 1957, permanent sterilization by cornual coagulation was performed on many patients; nevertheless, the method has been abandoned by most gynecologists in that country. Mickulieckz and Freund (10) attempted tubal cauterization under hysteroscopic control without success. Hayashi and lshikawa (11) utilized mainly cornual cauterization controlled through hysteroscopy or fluoroscopy. In their last group of 98 patients in which a curved electrode was employed, 5 pregnancies ensued. Hulka and Omran (12) wrote: “In a population control’tool, more assurancethan clinical FEEL that the cauterizing tip is at the utero tubal junction is needed”.

There is no better technique to place the electrode into the intramural portion of the tube than under hysteroscopic control. Figures 1 and 2 demonstrate this fact. Through hysteroscopy it is possible to localize the tubal orifice, introduce the electrode into the intramural portion, as well as watch the tissue modifications at the moment the electrocoagulating current is passing. At the Hospital de Gineco Obstetricia del Centro M&co National del lnstituto Mexican0 del Seguro Social, we developed a technique for tubal electrocoagulation. The purpose of this manuscript is to communicate this modification of the technique which has resulted in an easier, safer and more reliable procedure.

In 1970 Edstrom and Ferns&m (13) published their experiences with hysteroscopy in which they used a highly viscousdextran solution to dilate the uterine cavity. Since we

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Figure 1. Tubal orifice, endoscopic image.

Figure 2. Electrode partially introduced into the tube.

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have had difficulties

getting this dextran solution, we tried several different

finally decided to use a 5% glucose solution. is less costly.

solutions and

The glucose solution is readily available and

The uterine image is clear with the glucose solution and the only difference

from dextran is the finding that glucose must be injected at a higher pressure. This increase in pressure forces part of the solution into the abdominal cavity, but there is enough experience with this technique to assure us that it is harmless; no more than 150 to 200 ml glucose solution is used in most of the cases. Even though we think this technique is less risky than others, the patient must be studied in the usual way and all precautions must be taken to avoid unnecessary complications. contraindications

Genital infection and malignant tumors are

for performing the procedure.

history, hysterosalpingography,

The patient must have a careful clinical

C.B.C., and cervicovaginal

smears (bacteriological

Papanicolaou) before she is scheduled for electrocauterization. performed in the early proliferative

and

The procedure is preferably

phase of the cycle, since it is easier to recognize the

tubal orifices and probably avoid complications due to hemorrhage at this time. Technique of out-patient

(clinic) tubal electrocauterization

1. The patient is placed in the lithotomy

position, the vulva and vagina are cleaned with

aseptic technique, a speculum is introduced into the vaginal canal to visualize the cervix and the posterior lip is grasped with a forceps. 2. Paracervical block with 1% lidocaine solution is used for anesthesia. After 8 ml of this solution is injected into each uterosacral ligament, 10 minutes is allowed to elapse for full anesthetic effect before beginning cervical dilatation. 3. The uterine cavity length is determined with a sound and the cervix is progressively dilated up to a No. 7 Hegar. 4. The hysteroscope is introduced and the 5% glucose solution is injected through the instrument at a pressure individualized for each patient. 5. A tubal orifice is localized and the electrode is introduced under direct visual control into the intramural portion of the tube for 5 to 6 mm at most. 6. Electrocoagulating

current is passed for 4 seconds at 27.8 watts of coagulating power.

7. The same coagulating procedure is repeated in the opposite tubal orifice. 8. The hysteroscope is withdrawn. This technique was introduced in March 1971, and the results until the present time have been most acceptable.

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The patient must come back for frequent follow-up examinations after the procedure. Each patient is seen on one day, one week and three months after the procedure, and at intervals of every 3 months thereafter for 1 year.

Hysterosalpingograms are taken at three, six,

nine and twelve months to determine whether tubal occlusion has occurred; during this period the patient is maintained on oral contraceptives.

For patients whom oral contraceptives

are not suitable, vaginal contraceptive methods are utilized.

Intrauterine

devices must not be

used.

RESULTS

More than 66 patients have been electrocauterized complications

have resulted.

of electrocauterization

with the technique described.

No

The first 34 hysterosalpingograms performed after three months

show bilateral tubal occlusion in 28 (Figures 3.4).

one tube patent and the other occluded. patency must be regarded as a wrong

Some of these were recoagulated.

The remaining 6 had One case of tubal

case selection because the presence of a congenital

anomaly, uterus arcuatum, prevented both tubal orificies from being clearly visualized. possible in this patient that the electrocoagulating

It is

current was passed in the wrong place. After

this experience, patients with uterine abnormalities were excluded from the study. At the present time hysterosalpingograms have been performed on 5 women 6 months after electrocauterization. months.

All had bilateral occlusion at 3 months, and the occlusions were intact at 6

One patient who had unilateral patency at 3 months and was recoagulated had

bilateral occlusion 3 months later.

DISCUSSION

Blind methods of cornual electrocoagulation

are not reliable because it is impossible

to be sure that the current is passed in the proper place. The longer the current passes the greater the increase in number and severity of complications. and the necessity of a method to control fertility technique described is suitable.

Hospitalization

The scarcity of hospital beds

in most countries are the reasons why the is not needed, the procedure is almost pain-

less, rapid, easy and probably results in less complications than the other electrocauterizing methods.

Nevertheless, a greater number of patients and a more prolonged follow-up is

necessary before this procedure can be considered as the optimal method for electrocauterization of the oviducts.

ACKNOWLEDGEMENT

This work was partially supported by a grant from the Ford Foundation.

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Figure 3. Hysterosalpingogram

before electrocoagulation.

Figure 4. Hysterosalpingogram

in the same patient, three months after

procedure.

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Both tubes are occluded.

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REFERENCES

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R.L.:

Simple sterilization

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