Tubal Pregnancy Following Uterine Insemination*

LIFVENDAHL : TUBAL PHEGN ANCY

733

by the patient, and the temperature during treatment should be raised only three·quar· ters of a degree per minute. Our conclusion, based upon this large series of treatments is, that when the proper technic is used, we feel it is impossible to get a burn severe enough to cause any damage of the vaginal mucosa. DR. H. F. GRAHAM.-We have used the treatment in about 600 cases. The worst burn was in the third treatment given by an interne before we had a trained technician, and he distended the bag to about four pounds, kept the temperature at 130" and went away in spite of the complaints of the patient, because he understood that was the way the treatment. In that case there was a slough about an inch and a half in diam· to eter which took twelve or fourteen days to heal completely. DR. S. A. COSGROVE.-Dr. Holden has touched indirectly on the purpose of pre· senting these eases. He has said that in his experience they have had only one or two minor burns because the treatments have been given by experts specially trained. It is not to be conceived that any method can be offered to the profession and have every· body that uses it as expert as Dr. Holden's operators are, and therein lies the value of the warning that some very unpleasant results may occur from the use of this procedure.

TUBAL PREGNANCY FOLLOWING UTERINE INSEMINATION*

R. A.

LIFVENDAHL,

M.D.,

CHICAGO, ILL.

(From the Department of Gynecology of the Post Graduate Hospital and Medical School)

REVIEW of the available literature for the last twelve years does not elicit a single case of tubal pregnancy following artificial insemination for the relief of sterility. That other gynecologic procedures, particularly of a diagnostic character, have been followed by pregnancy is confirmed by Rubin:' In 1929 he reported 205 cases of pregnancy out of 2000 cases in which he had done uterotubal insufflation for infertility. In 3 of these 205 cases the pregnancy was located in the fallopian tube. Since this article concerns the question of infertility the discussion is not centered about the subject of ''induced'' tubal pregnancy. The same author, 2 in another writing, regarding the most favorable time for tubal insufflation, states that there is less possibility of displacing an impregnated ovum from the uterine cavity if the patency test of the fallopian tubes is done about one week after menstruation. In our patient, uterotubal insufflation was performed, but the procedure was done some time before artificial insemination, and evidently has very little, if any, import in this case. Untoward results have included those conditions attended with performing the Rubin test, plus the possibility of carrying infected material into the uterus, fallopian tubes, or peritoneal cavity. Before performing the procedure, the above possible complications should be kept in mind. Trauma of the endometrium can occur with the possibility o£ gas embolism and collapse and even death is apt to take place if the method is not used at the proper time has been sufficiently emphasized by Rubin. 1 Also, he has described adequately the subject of dislocation of the endometrium

A

*Presented before the Chicago Gynecological Society, December 16, 1932.

734

AMERICAN JOURNAL OF OBSTE'l'RICS AND GYNECOLOGY

through the fallopian tubes ·with resultant endometriosis of the adjacent pelvic structures. Infection of the fallopian tubes and pelvic structures can occur as the result of several errors in technic or the presence of infection in the genital tract of the male or female. If a specimen is obtained from a container that is not aseptic or if infected from the vagina, the bacteria from these sources can readily produce infection along the course of the genital tract. The following case is of considerable interest because of presenting none of the above mentioned complications. CASE REPORT

·white patient, twenty-four years of age, entered the clinic on .Jan. 10, 1931, because of a yellowish-white vaginal discharge which came from an ''eroded'' and cystic cervix. Linear cauterization was performed on ,Jan. 12, 1931, and by Feburary 7 of the same year the treated area was healed :wd there was no discharge, except for a small amount of elear mucus from the cervical canal. On Jan. 12, 1931, she presented the question of sterility but was advised to wait until the cervix healed before performing any tests. She had been married in August, 192:1, and one year and nine months later had an uncomplicated delivery. }'or two years after this they practiced coitus interruptus: but for over three years contraceptive precautions had not been taken. Menstruation began at thirteen years of age, was regular until marriage, and since had been irregular, with bleeding occurring every thn•e to six weeks, six to seven days' duration, moderatP in amount, and accompanied with moderate lower abdominttl cramps. She described herself as a "spitter" in that the semen was always discharged following intercourse. Examination at this time showed a relaxed "levater sling" and a slight cystocele. A Rubin test performed on Feb. 17, 1931, showed, complained of pain and fullness of the breasts, and pain in the left lower quadrant. 'fhe latter symptom had been repeatedly present before and was regarded as being due to a spastic sigmoid. At this time the uterus was very slightly enlarged, firm throughout but colostrum was expressed from the nipples. Three weeks later she stated that she had been nausea ted and vomited daily for a period of two to three weeks. The pain in the left lower quadrant had been especially severe, seventeen days after the insemination, on Dec. 23 and 25, 1931. On examination at this time (Feb. ];{, 1932) the findings were the same as of seven weeks following the insemination, lmt in addition the body of the uterus was softer and to the left of it was a tender mass twice the size of a normal ovary. No vaginal bleeding had occurred. On Feb. 2:1, 1!!32 she acquirt'd a ''severe cold,'' with a temperature of 104 ',and on the twenty-sixth of the same month hegan to bleed profusely from the vagina. Examination, three days later, showed a 3 by 5 em. boggy and tender mass, which had been noted ten days previous. The culdesac was free of any mass or exudate. Bleeding continued from the vagina, until she was again seen on March 12, when the findings were the same. 'rhis period of observation was permitted because of the possibility of an aborting intrauterine pregnancy, associated with a cyst of the left ovary. The latter periodic swellings of the left ovary had been noted in her on one occasion before the insemination had been performed. Although the test for pregnancy was positive, in this case it was of no help. But since no fetal or placental tissue had been passed, laparotomy was advised.

LACK~ER

AND

KROH~

: 'TERATOMA OF UTEHUS

735

On March 14, 1932, thirteen weeks after uterine insemination, preliminary curettement yielded a moderate amount of thin and slightly thickened endometrium of a yellow and red to purple color. Before opening the peritoneum through the Pfannenstiel incision, small dark purple 1 to 2 em. pieces of clots were seen through the peritoneum and the latter were also found between the loops of the ileum. Exploration of the pelvic organs revealed the following: The uterus was 1 'XI, times normal size, ant everted, and moveable. The left fallopian tube was adherent to the posterior aspect of the corresponding broarl ligament and ovary by moderately firm purplish adhesions that were easily freed, permitting the tube to be delivered. The distal one-half of the tube presented a fusiform intact purple colored swelling, having a diameter of 4 em. in its ampullar portion and tapering towards the fimbriated end where its diameter was 2.3 em. Lying in the opening of the fimbriated end of the tube enmeshed and held there by dark clotted blood was an 8 em. long pale yellow embryo. The right fallopian tube and ovary were grossly normal. The left tube was removed.

The possibility of the pregnancy having occurred before the artificial insemination is rather remote because of the size of the embryo, the onset of clinical symptoms and findings and her inability to become pregnant before the artificial insemination had been done. The Rubin test had been done nine months before the insemination, so she should have had sufficient opportunity to become pregnant if the insufflation of the tubes had opened them. Furthermore, no findings were noted when the injection was done to indicate that the tubes had ever been closed. That the infected cervical mucous discharge probably prohibited her from becoming pregnant previous to the cauterization of the cervix uteri is very likely. Against this is the fact that the discharge from the cervical canal had been grossly normal for a period of eight months before insemination was resorted to. ABSTRACT OF DISCl:SSION DR. MARK T. GOI,DSTINE.-I have noted five cases of very severe pelvic infection following insemination, one requiring the removal of a large alJseess of the ovary. We feel this is a rather dangerous thing to do.

REPORT OF A CASE OF TERATOMA OF THE "GTERUS'"' JULIUS

E. LACKNER, M.D.,

AND LEON KROHN,

M.D.,

CHICAGO, ILL.

(From the Departments of Gynecology and Pathology of the Michael Reese Hospital)

are defined by Ewing as a group of tumors composed of T ERATOMAS recognizable tissues and complex organs derived from more than one 1

germ layer. Although teratomas have a distinct predilection for the sex glands, their occurrence in the uterus is an extreme rarity. A review of the literature revealed only very few cases of teratoma of the uterus, the majority of which are of questionable authenticity. Robert Meyer 2 emphasizes the fact that one must make a diagnosis of termatoma of the uterus with extreme caution. *R€