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Uterotubal Insufflation and the Kymogram
Uterotubal Insufflation and the Kymogram An Analysis of 12 Cases at Laparotomy ALVIN M. SIEGLER. M.D.
as well as investigations by Jeffcoate, Ostry, Stabile, and Scharf and Peretz have cast some doubt upon the reliability of the diagnostic interpretations based on Rubin's insuffiation patency test. Therefore, a study was made at laparotomy to evaluate some of the variations and to assess how accurately the kymogram can portray tubal health or disease;
PERSONAL OBSERVATIONS
MATERIAL
The ages of the 12 patients who were explored varied from 24 to 56 years, with a median of 40 years of age. Parity varied from 0 to 4, with a median of 2 live births. The indications for surgery were: endometrial hyperplasia, 4 cases; ovarian cys.t, 3; myoma of the uterus, 2; and endometriosis, endometrial polyps, and tubal sterilization, one case each. METHOD
A Grafax ModelS Kymoinsu:ffiator 0 was employed for all determinations. The carbon dioxide issued from the apparatus at an average rate of 45 ml.jmin. With the gas passed at this rate the pressure rose to 200_mm. Hg in 1 min. The horizontal distance between the vertical curved lines on the chart paper was one half inch and was traversed in one minute. The length of the rubber connecting tube was 3 feet. A Dartigue uterine holding forceps for compression of the isthmus (Fig. 1) was employed during the direct-vision tubal patency tests. The patient was insu:ffiated in the operating room after premedication and e
From the Department of Obstetrics and Gynecology of the State University of New York, Downstate Medical Center College of Medicine and the Beth El Hospital, Brooklyn. Presented at the 18th Annual Meeting of the American Society for the Study of Sterility, Mar. SO-Apr. 1, 1962, Chicago, Ill. *Grafax Instrument Company, New York, N.Y.
465
466
SIEGLER
FERTILITY
&
STERILITY
prior to laparotomy and the record obtained then was used as a base line for comparison. The preoperative tubal status, as reflected by the kymogram, was compared with the gross anatomy of the oviducts at laparotomy. The uterine tubes were measured in situ and a 17-gauge needle was inserted
Fig,l, (left) Application of Dartigue uterine holding forceps for compressing isthmus while carrying out direct-vision tubal patency tests. Fig. 2. (right) Indigo-carmine instilled into uterine cavity and seen to pass to points of patency and/or obstruction.
through the fundus into the uterine cavity. Then a dilute solution of indigocarmine was instilled to confirm the presence of the needle in the uterine cavity, to test the integrity of the cervical occlusive clamp, and to observe by direct vision (Fig. 2) the response of the oviducts to a fluid medium. A second insuffiation test was performed through the previously placed 17-gauge needle and results noted, especially in regard to the time of release or bubbling of carbon dioxide, the initial pressure, oscillations, and tubal motion. RESULTS (Fig. 3)
In 8 patients the preoperative tubal status was determined by insuffiation and in 6 of these the results were interpreted as normal. In one of the 6 there was an initial pressure of 180 mm. Hg, but a rapid fall with normal oscillations at 100 mm. Hg. In 2 patients there was occlusion at 200 mm. Hg for 3 min. At laparotomy the length of the normal tubes varied from 7.5 to 12 em. There was no significant difference in length between the tubes. They were grossly normal in 6 patients, 4 of whom had had a normal preoperative tubal insuffiation test. One of the remaining 2 who had had a normal insuffiation test had abnormal tubes characterized by multiple dense adhesions of one
r
l
e
[)
1
VoL. 13, No. 5, 1962
467
UTEROTUBAL INSUFFLATION
tube with torsion and gangrene in the opposite one; the other patient had densely adherent oviducts and normal fimbria. The tubes grossly were normal in 2 patients who had had occlusion kymograms preoperatively. On the ·'basis of indigo-carmine instilled into the uterine cavity via the
•••••• NORMAL
Pre-op Patency Test
Fig. 3. Comparison in 8 patients of results of preoperative insuHlation test, examination of gross anatomy, the indigo carmine test, and insufllation at laparotomy. Numerals are patient numbers.
'-----vc-'
Gross Anatomy
0
••
ABNORMAL
~
Indigo Carmine
/nsufflofion of Laparotomy
••
fundus in these 8 patients, bilateral tubal patency was found in 5. In 2 cases unilateral occlusion was observed at the cornua and in one bilateral cornual obstruction was noted. When correlations were made of the preoperative kymogram, to the gross appearance of the uterine tubes and to the indigocarmine tests. In only 3 cases were results in agreement on the basis of gross appearance, indigo-carmine instillation, and preoperative kymogram. The tubes were reinsuffiated via the previously placed fundal needle and 4 patients were indicated to be normal and 4 abnormal. All4 of the former had had normal preoperative insufflation tracings and 2 of the 4 with abnormal results on reinsufflation had been abnormal on preoperative insufflation; the records were similar. Yet, in 2 of the cases in which insufflation tests disclosed occlusion on the kymogram the dye and carbon dioxide were seen to come from the fimbria of one of the tubes in one patient and bilaterally in another case. In 2 other women normal preoperative insufflation tests were seen despite the presence of extensive tubal disease. Of 2 patients who had normal preoperative patency, grossly normal tubes, and no passage of carbon dioxide at laparotomy, one had tubes patent to the indigo-carmine and the other had tubal occlusion bilaterally at the cornua. In only 2 women were all observations considered normal. The oviducts were then subjected to the following experimentation:
I
Experiment 1
1
A clamp was placed across both oviducts to occlude their fimbria, and fundal insuffiations were made. In 2 instances normal tubes ruptured after 1
·-~-------
...... - ·-·.
468
SIEGLER
FERTILITY
& STERILITY
min. at 200 mm. Hg. The ruptures occurred into the mesosalpinx and there was a fall in pressure with oscillations. In a third case a tube ruptured after 1 min. at 200 mm. Hg into the mesosalpinx but no fall of pressure occurred until a needle puncture was made into one of the peritoneal blebs. The tube was adherent but previously patent. In the last instance a normal tube ruptured after 1 min. at 200 mm. Hg, but no fall of pressure occurred. Thus in each woman the oviduct ruptured at pressures which hitherto have been considered safe (Fig. 4). Experiment 2
One tube was disconnected at the uterotubal junction and the opposite tube remained clamped at the fimbria in 2 women. Fundal insuffiation disclosed normal kymograms which resembled the preoperative tracings in both instances (Fig. 5).
Fig. 4. (left) Both oviducts occluded at infundibulum; kymogram results in 4 cases. Fig. 5. (right) One tube disconnected at its uterotubal junction, with opposite tube remaining clamped at infundibulum; kymogram in 2 cases.
Experiment 3
In 6 patients the tubes were disconnected at their uterotubal junctions bilaterally; fundal insuffiation resulted in normal kymograms in 5 of them. In 2 women from whom preoperative insuffiations were available the tracings were identical. In one case, although occlusion was registered by the kymograph, carbon dioxide bubbled from both uterotubal junctions. There was a coincidental fall of pressure with the discharge of carbon dioxide from the cornual area'{Fig. 6). ·
VoL.l3,No.5,1962
UTEROTUBAL lNSUFFLA TION
489
Fig. 6. Both tubes disconnected at their uterotubal junction; kymograms in 6 cases.
Experiment 4
In 6 instances a cannula was placed in the fimbriated end of one of the detached tubes and retrograde tubal insuffiation was performed. In two of the oviducts initial high pressure was followed by good oscillations. Four other tubes registered low initial pressures between 30 and 60 mm. Hg, followed by relatively poor oscillations on the kymogram (Fig. 7). Experinlent 5
In 5 cases both uterine tubes were clamped at their uterotubal junctions, the cervix was occluded with the previously described instrument, and fundal insuffiation was continued through a 17-gauge needle; in addition, a 15gauge needle was placed through the uterine fundus into the endometrial cavity. In 2 of the women the kymograms recorded normal pressures and nor-
Fig. 7. One tube cannulated at fimbriated end, with retrograde insufBation; kymograms in 6 cases.
470
SIEGLER
FERTILITY
& STERILITY
mal oscillations. The other uteri registered high initial pressures of 180 mm. Hg, followed by very frequent waves at lower levels. In the fifth patient there was an initial occlusion and then high patency at 180 mm. Hg (Fig. 8).
Fig. 8. Both tubes occluded at their uterotubal junction, with an additional outflow needle inserted into the uterine cavity; kymograms in 5 cases.
DISCUSSION
The controversy about the source of the oscillations recorded on the kymogram has persisted for many years. These experiments performed in vivo illustrated the complexity of the problem and constituted a preliminary attempt to study some of the possibilities. However, the results which were obtained seemed to confuse even further rather than clarify the nature of these waves. Compared to the work of Stavorsky and Hartman who employed extremely sensitive electronic pressure devices placed in the lumen of the rabbit oviducts, the technic described above is crude. Nevertheless, the clinician not infrequently depends upon the result of the insuffiation test to render a verdict about the physiologic condition of the tube. The evidence accumulated in this study revealed that a significant nu~ber of false-positive and false-negative kymograms must occur clinically. The observation that normal tubes ruptured at safe pressures of 200 mm. Hg, and that this was followed by a normal tracing makes one suspect that tubes previously declared occluded by insuffiation and rendered patent in a therapeutic fashion by high pressures, actually could have ruptured in an avascular area. Another disquieting observation was that tracings indistinguishable from one another were observed whether two tubes, one tube, or in fact no visible oviducts were present. Tubal peristaltic actions were not observed despite the presence of oscilla-
VoL.13,No.5,1962
UTEROTUBAL INSUFFLATION
471
tions, but these changes reflected the intermittent release of carbon dioxide rather than any intrinsic muscular action. The elimination of the uterotubal junction was accomplished by means of the uterine inflow-outflow set-up, and waves on the kymogram readily interpreted as oscillations were observed. These coincided with the intermittent release of carbon dioxide. The main practical point in regard to uterotubal insuHlation is its interpretation. The tendency to infer too much from the character of the oscillations must be avoided. The straightforward issue as to whether the tubes are open or closed is sometimes difficult to determine and the more complex problem of evaluating degrees of anatomic and physiologic abnormality is a greater problem. SUMMARY
1. A se~es of experimental observations at laparotomy were made on a selected group of 12 women to ascertain the origin of the fluctuations in pressure recorded on a kymogram. 2. The diagnosis of tubal health or disease can not infallibly be made from a single or sometimes from multiple insufflation tests. Additional studies to exclude significant tubal pathology are necessary. 706 Eastern Parkway Brooklyn 13, N. Y.
REFERENCES 1. RUBIN, I. C. Collected Papers of Dr. I. C. Rubin, 1910-1954, H. Wolf, New York, 1954. 2. }EFFCOATE, T. N. A. Tubal patency tests. Proceedings of the Society for the Study of Sterility, V. Liverpool Conference, 1953. 3, OsTRY, E. I. An investigation of tubal implantation for cornual block. Am.· J. Obst. & Gynec. 73:409, 1957. 4. ScHARF, N., and PERETZ, A. The diagnosis of tubal patency by culdoscopy as compared with routine methods. Harefuah 58:105, 1960. 5. STABILE, A. Interpretation of manometric oscillations observed during uterotubal insufHation. Fertil. & Steril. 5:138, 1954. 6. STAVORSKY, J., and HARTMAN, C. J. Uterotubal insuffiation. A study to determine the origin of fluctuation in pressure. Obst. & Gynec. 11 :622, 1958.
as well as investigations by Jeffcoate, Ostry, Stabile, and Scharf and Peretz have cast some doubt upon the reliability of the diagnostic interpretations based on Rubin's insuffiation patency test. Therefore, a study was made at laparotomy to evaluate some of the variations and to assess how accurately the kymogram can portray tubal health or disease;
PERSONAL OBSERVATIONS
MATERIAL
The ages of the 12 patients who were explored varied from 24 to 56 years, with a median of 40 years of age. Parity varied from 0 to 4, with a median of 2 live births. The indications for surgery were: endometrial hyperplasia, 4 cases; ovarian cys.t, 3; myoma of the uterus, 2; and endometriosis, endometrial polyps, and tubal sterilization, one case each. METHOD
A Grafax ModelS Kymoinsu:ffiator 0 was employed for all determinations. The carbon dioxide issued from the apparatus at an average rate of 45 ml.jmin. With the gas passed at this rate the pressure rose to 200_mm. Hg in 1 min. The horizontal distance between the vertical curved lines on the chart paper was one half inch and was traversed in one minute. The length of the rubber connecting tube was 3 feet. A Dartigue uterine holding forceps for compression of the isthmus (Fig. 1) was employed during the direct-vision tubal patency tests. The patient was insu:ffiated in the operating room after premedication and e
From the Department of Obstetrics and Gynecology of the State University of New York, Downstate Medical Center College of Medicine and the Beth El Hospital, Brooklyn. Presented at the 18th Annual Meeting of the American Society for the Study of Sterility, Mar. SO-Apr. 1, 1962, Chicago, Ill. *Grafax Instrument Company, New York, N.Y.
465
466
SIEGLER
FERTILITY
&
STERILITY
prior to laparotomy and the record obtained then was used as a base line for comparison. The preoperative tubal status, as reflected by the kymogram, was compared with the gross anatomy of the oviducts at laparotomy. The uterine tubes were measured in situ and a 17-gauge needle was inserted
Fig,l, (left) Application of Dartigue uterine holding forceps for compressing isthmus while carrying out direct-vision tubal patency tests. Fig. 2. (right) Indigo-carmine instilled into uterine cavity and seen to pass to points of patency and/or obstruction.
through the fundus into the uterine cavity. Then a dilute solution of indigocarmine was instilled to confirm the presence of the needle in the uterine cavity, to test the integrity of the cervical occlusive clamp, and to observe by direct vision (Fig. 2) the response of the oviducts to a fluid medium. A second insuffiation test was performed through the previously placed 17-gauge needle and results noted, especially in regard to the time of release or bubbling of carbon dioxide, the initial pressure, oscillations, and tubal motion. RESULTS (Fig. 3)
In 8 patients the preoperative tubal status was determined by insuffiation and in 6 of these the results were interpreted as normal. In one of the 6 there was an initial pressure of 180 mm. Hg, but a rapid fall with normal oscillations at 100 mm. Hg. In 2 patients there was occlusion at 200 mm. Hg for 3 min. At laparotomy the length of the normal tubes varied from 7.5 to 12 em. There was no significant difference in length between the tubes. They were grossly normal in 6 patients, 4 of whom had had a normal preoperative tubal insuffiation test. One of the remaining 2 who had had a normal insuffiation test had abnormal tubes characterized by multiple dense adhesions of one
r
l
e
[)
1
VoL. 13, No. 5, 1962
467
UTEROTUBAL INSUFFLATION
tube with torsion and gangrene in the opposite one; the other patient had densely adherent oviducts and normal fimbria. The tubes grossly were normal in 2 patients who had had occlusion kymograms preoperatively. On the ·'basis of indigo-carmine instilled into the uterine cavity via the
•••••• NORMAL
Pre-op Patency Test
Fig. 3. Comparison in 8 patients of results of preoperative insuHlation test, examination of gross anatomy, the indigo carmine test, and insufllation at laparotomy. Numerals are patient numbers.
'-----vc-'
Gross Anatomy
0
••
ABNORMAL
~
Indigo Carmine
/nsufflofion of Laparotomy
••
fundus in these 8 patients, bilateral tubal patency was found in 5. In 2 cases unilateral occlusion was observed at the cornua and in one bilateral cornual obstruction was noted. When correlations were made of the preoperative kymogram, to the gross appearance of the uterine tubes and to the indigocarmine tests. In only 3 cases were results in agreement on the basis of gross appearance, indigo-carmine instillation, and preoperative kymogram. The tubes were reinsuffiated via the previously placed fundal needle and 4 patients were indicated to be normal and 4 abnormal. All4 of the former had had normal preoperative insufflation tracings and 2 of the 4 with abnormal results on reinsufflation had been abnormal on preoperative insufflation; the records were similar. Yet, in 2 of the cases in which insufflation tests disclosed occlusion on the kymogram the dye and carbon dioxide were seen to come from the fimbria of one of the tubes in one patient and bilaterally in another case. In 2 other women normal preoperative insufflation tests were seen despite the presence of extensive tubal disease. Of 2 patients who had normal preoperative patency, grossly normal tubes, and no passage of carbon dioxide at laparotomy, one had tubes patent to the indigo-carmine and the other had tubal occlusion bilaterally at the cornua. In only 2 women were all observations considered normal. The oviducts were then subjected to the following experimentation:
I
Experiment 1
1
A clamp was placed across both oviducts to occlude their fimbria, and fundal insuffiations were made. In 2 instances normal tubes ruptured after 1
·-~-------
...... - ·-·.
468
SIEGLER
FERTILITY
& STERILITY
min. at 200 mm. Hg. The ruptures occurred into the mesosalpinx and there was a fall in pressure with oscillations. In a third case a tube ruptured after 1 min. at 200 mm. Hg into the mesosalpinx but no fall of pressure occurred until a needle puncture was made into one of the peritoneal blebs. The tube was adherent but previously patent. In the last instance a normal tube ruptured after 1 min. at 200 mm. Hg, but no fall of pressure occurred. Thus in each woman the oviduct ruptured at pressures which hitherto have been considered safe (Fig. 4). Experiment 2
One tube was disconnected at the uterotubal junction and the opposite tube remained clamped at the fimbria in 2 women. Fundal insuffiation disclosed normal kymograms which resembled the preoperative tracings in both instances (Fig. 5).
Fig. 4. (left) Both oviducts occluded at infundibulum; kymogram results in 4 cases. Fig. 5. (right) One tube disconnected at its uterotubal junction, with opposite tube remaining clamped at infundibulum; kymogram in 2 cases.
Experiment 3
In 6 patients the tubes were disconnected at their uterotubal junctions bilaterally; fundal insuffiation resulted in normal kymograms in 5 of them. In 2 women from whom preoperative insuffiations were available the tracings were identical. In one case, although occlusion was registered by the kymograph, carbon dioxide bubbled from both uterotubal junctions. There was a coincidental fall of pressure with the discharge of carbon dioxide from the cornual area'{Fig. 6). ·
VoL.l3,No.5,1962
UTEROTUBAL lNSUFFLA TION
489
Fig. 6. Both tubes disconnected at their uterotubal junction; kymograms in 6 cases.
Experiment 4
In 6 instances a cannula was placed in the fimbriated end of one of the detached tubes and retrograde tubal insuffiation was performed. In two of the oviducts initial high pressure was followed by good oscillations. Four other tubes registered low initial pressures between 30 and 60 mm. Hg, followed by relatively poor oscillations on the kymogram (Fig. 7). Experinlent 5
In 5 cases both uterine tubes were clamped at their uterotubal junctions, the cervix was occluded with the previously described instrument, and fundal insuffiation was continued through a 17-gauge needle; in addition, a 15gauge needle was placed through the uterine fundus into the endometrial cavity. In 2 of the women the kymograms recorded normal pressures and nor-
Fig. 7. One tube cannulated at fimbriated end, with retrograde insufBation; kymograms in 6 cases.
470
SIEGLER
FERTILITY
& STERILITY
mal oscillations. The other uteri registered high initial pressures of 180 mm. Hg, followed by very frequent waves at lower levels. In the fifth patient there was an initial occlusion and then high patency at 180 mm. Hg (Fig. 8).
Fig. 8. Both tubes occluded at their uterotubal junction, with an additional outflow needle inserted into the uterine cavity; kymograms in 5 cases.
DISCUSSION
The controversy about the source of the oscillations recorded on the kymogram has persisted for many years. These experiments performed in vivo illustrated the complexity of the problem and constituted a preliminary attempt to study some of the possibilities. However, the results which were obtained seemed to confuse even further rather than clarify the nature of these waves. Compared to the work of Stavorsky and Hartman who employed extremely sensitive electronic pressure devices placed in the lumen of the rabbit oviducts, the technic described above is crude. Nevertheless, the clinician not infrequently depends upon the result of the insuffiation test to render a verdict about the physiologic condition of the tube. The evidence accumulated in this study revealed that a significant nu~ber of false-positive and false-negative kymograms must occur clinically. The observation that normal tubes ruptured at safe pressures of 200 mm. Hg, and that this was followed by a normal tracing makes one suspect that tubes previously declared occluded by insuffiation and rendered patent in a therapeutic fashion by high pressures, actually could have ruptured in an avascular area. Another disquieting observation was that tracings indistinguishable from one another were observed whether two tubes, one tube, or in fact no visible oviducts were present. Tubal peristaltic actions were not observed despite the presence of oscilla-
VoL.13,No.5,1962
UTEROTUBAL INSUFFLATION
471
tions, but these changes reflected the intermittent release of carbon dioxide rather than any intrinsic muscular action. The elimination of the uterotubal junction was accomplished by means of the uterine inflow-outflow set-up, and waves on the kymogram readily interpreted as oscillations were observed. These coincided with the intermittent release of carbon dioxide. The main practical point in regard to uterotubal insuHlation is its interpretation. The tendency to infer too much from the character of the oscillations must be avoided. The straightforward issue as to whether the tubes are open or closed is sometimes difficult to determine and the more complex problem of evaluating degrees of anatomic and physiologic abnormality is a greater problem. SUMMARY
1. A se~es of experimental observations at laparotomy were made on a selected group of 12 women to ascertain the origin of the fluctuations in pressure recorded on a kymogram. 2. The diagnosis of tubal health or disease can not infallibly be made from a single or sometimes from multiple insufflation tests. Additional studies to exclude significant tubal pathology are necessary. 706 Eastern Parkway Brooklyn 13, N. Y.
REFERENCES 1. RUBIN, I. C. Collected Papers of Dr. I. C. Rubin, 1910-1954, H. Wolf, New York, 1954. 2. }EFFCOATE, T. N. A. Tubal patency tests. Proceedings of the Society for the Study of Sterility, V. Liverpool Conference, 1953. 3, OsTRY, E. I. An investigation of tubal implantation for cornual block. Am.· J. Obst. & Gynec. 73:409, 1957. 4. ScHARF, N., and PERETZ, A. The diagnosis of tubal patency by culdoscopy as compared with routine methods. Harefuah 58:105, 1960. 5. STABILE, A. Interpretation of manometric oscillations observed during uterotubal insufHation. Fertil. & Steril. 5:138, 1954. 6. STAVORSKY, J., and HARTMAN, C. J. Uterotubal insuffiation. A study to determine the origin of fluctuation in pressure. Obst. & Gynec. 11 :622, 1958.