Incidence of Residual Intraperitoneal lodochlorol after Hysterosalpingography

Transcription

1 Incidence of Residual Intraperitoneal lodochlorol after Hysterosalpingography A Radiologic Study of I 00 Infertile Women Who Subsequently Became Pregnant Abner I. Weisman, M.D. STUDIES by Brown, Jennings, and Bradbury 1 2 have pointed to certain disadvantages in the media commonly used for hysterosalpingography. Iodochlorol, an iodized oil, is among those evaluated by these authors. Retention of the oil for prolonged periods and its subsequent ill effects were among the disadvantages cited. They encountered foreign-body reactions, peritoneal inflammations, and retention cyst formation. In view of the encouraging results obtained by the present writer using iodochlorol for hysterosalpingography in a large number of cases during the past fifteen years, the conclusions drawn by Brown, Jennings and Bradbury in their series of 16 cases are somewhat perplexing. Findings quite different from those reported by Brown and his colleagues will be presented in this and subsequent papers. Brown and his associates report that from 8 to 12 cc. of the medium were usually injected. Since 3 or 4 cc. of iodized oil will fill both the uterus and the normal fallopian tubes, 3 the use of a much larger amount is unnecessary and is probably unwise. If 10 cc. of oil is used for hysterosalpingography, it is probable that from 5 to 7 cc. will spill into the peritoneal cavity, and the remainder which fills the uterus will probably be evacuated through the cervix into the vagina. Six or seven cc. of iodized oil is a large quantity for the pelvic peritoneum to deal with, and probably is excessive for a peritoneum previously damaged by inflammatory processes. It is therefore not 290

2 Vol. 3, No.4, 1952] IODOCHLORAL AFTER HYSTEROSALPINGOGRAPHY 291 surprising that Brown found complications following the use of 8 to 12 cc. of oil. In addition to using what the writer considers to be an excessive amount of oil, their injections were done without fluoroscopic control. When hysterosalpingograms are made under fluoroscopic control, the volume of oil can be minimized, for as soon as it begins to "spill from" the fimbriated end of the tubes, the injection can be stopped. TECHNIC EMPLOYED IN HYSTEROSALPINGOGRAPHY One must be sure that no active pelvic inflammatory disease exists. A preliminary bimanual examination should be made, and in most cases a leukocyte count and sedimentation rate should be secured. In addition to FIGURE 1. The apparatus in place. The switch from gas to oil and return is accomplished with ease in this position. the usual local preparation, I employ pre-medication with pavatrine as an antispasmodic. I employ the Gynograph, a specially constructed apparatus to simplify gaseous and radiologic evaluation of the genital tract (Fig. 1). This instrument consists essentially of a closed gaseous circuit under constant manometric control. 5 The pressure of the carbon dioxide, rather than the usual piston, forces the fluid through the cannula and into the uterus. The facility with which one can change from injection of gas to injection of oil, and back again to gas, without removing the cervical cannula, recommends the instrument. 6 The patient is placed in the lithotomy position directly on the x-ray table. The cervix is grasped by a tenaculum, and the author's self-retaining cannula

3 292 WEISMAN [Fertility & Sterility is introduced. When attached, the cannula and tenaculum virtually become one unit, maintaining correct cervical traction automatically. The Gynograph is then placed on the x-ray table between the patient's thighs, and the cannula is attached directly to the apparatus. Step 1: Preliminary Gaseous Insufflation The instrument is adjusted so that the carbon dioxide flows at 20 to 40 cc. per minute, and when this rate of flow is established, the gas is allowed to enter the cannula and, through it, the uterus. Once patency is established, the examiner can switch to hysterosalpingography with impunity, no longer apprehensive about the possibility of uterine intravasation or embolic phenomena. Step II: Hysterosalpingography Under Manometric and Fluoroscopic Control As soon as the uterine cavity is filled with iodized oil, the first radiograph is made. When the oil fills the fallopian tubes to their distal ends, the second film is exposed, revealing the outline of the entire uterotubal tract. Usually only 3 or 4 cc. of oil have been required, and if the tubes are well filled, no additional oil need be injected. Step Ill: Secondary Tubal Insufflation and Final Radiograph While the uterus and tubes are still clearly visible under the fluoroscope, the oil reservoir is removed from the Gynograph and the procedure continues with ordinary gaseous insufflation. The gas, entering the uterus at about 30 cc. per minute, rises to the uterotubal junction and forces the oil already in the fallopian tubes out of the distal ends into the peritoneal cavity. The dispersion of oil is thus accomplished readily, the vis a tergo being gas and not oil. The final x-ray film is now exposed. This final plate obviates the need for a twenty-four-hour plate and eliminates a return visit for the patient. By employing this technic, the least possible amount of oil, namely that already present in the fallopian tubes, has been introduced into the peritoneal cavity. This small quantity is usually absorbed, leaving no radiographic residue after a few weeks. Records of the last 100 patients who became pregnant following successful uterosalpingograms with iodochlorol are the basis of this report.

4 Vol. 3, No.4, 1952] IODOCHLORAL AFTER HYSTEROSALPINGOGRAPHY 293 Table 1 shows that, of 100 patients who conceived following uterosalpingogram performed by the author's technic, 91 showed no late evidence of opaque oil in the pelvis or abdomen. Of the remaining 9 cases, an occasional trace of the opaque substance was still visible in the pelvis in 8 cases; and 1 (Mrs. E.S.) showed moderate amounts of the dispersed oil still remaining in the pelvis when the fetus was at term. Of all the 100 cases studied, this one showed by far the largest amount of iodized oil retained. TABLE 1. Retention of lodochlorol in 100 Follow-up Cases Presence of iodized oil in peritoneal cavity Time since (cases) hysterosalpingography None Scant evidence Moderate Appreciable (months) present (slight trace) amount amount Two years or more ToTAL More than one half of the patients included here became pregnant within six months after hysterosalpingography. The x-ray at term (Fig. 2) illustrates the heaviest deposits of radiopaque substances in the entire series. Some of the patients showed unilateral pathologic conditions of the tubes, others showed bilateral tubal patency with evidence of tubal disease, while still others revealed no evidence of tubal disease or abnormality, by radiographic study. All of these patients had been trying for a year or more to become pregnant. Most of them had been infertile for a longer period.

5 294 WEISMAN [Fertility & Sterility It is interesting to note, in reviewing the antepartum course of these patients, that there were no unusual findings, nor were there any complaints which differed from those ordinarily presented by pregnant women. Deliveries in the 9 cases showing evidence of some peritoneal retention were entirely unaffected by the presence of the occasional spot of retained oil. One patient had a cesarean section for cephalopelvic disproportion, entirely unrelated to her infertility or hysterosalpingography. It should also be FIGURE 2. X-ray of Mrs. E.S. at term. This is the only case which showed evidence at term of more than an occasional flake of retained radiopaque substance. pointed out that Mrs. E.S., in whom retention amounted to more than a few traces, is now pregnant for the second time; she suffers no ill effects from the few particles of iodized oil still visible in her pelvis about three years after the original hysterosalpingography. DISCUSSION From this study it is apparent that in most cases the peritoneum is capable of absorbing iodochlorol from the body cavity in time, leaving no traces

6 296 WEISMAN [Fertility & Sterility played in hysterosalpingography. The instillation, with gynographic and fluoroscopic assistance, of the iodized oil in quantities not exceeding 3-4 cc. will permit its gradual absorption in a normal peritoneum. The instillation of 10 or more cc. of any foreign oily substance may prove an insult to the peritoneum and account for its prolonged presence in the pelvis Fifth Avenue, New York City 29. REFERENCES 1. Brown, W. E., Jennings, A. F., and Bradbury, J. T.: Am.]. Obst. & Gynec. 58:1041, Jennings, A. F., Brown, W. E., and Bradbury, J. T.: Transactions of the Conference on Sterility anil Infertility of the American Society for the Study of Sterility, 1947, p Weisman, A. 1.: Am.]. Obst. & Gynec. 61:202, Weisman, A. 1.: Fertil. & Steril. 1:321, Weisman, A. 1.: Am.]. Obst. & Gynec. 54:145, Weisman, A. 1.: Radiology 56:104, 1951.

7 Vol. 3, No.4, 1952] IODOCHLORAL AFTER HYSTEROSALPINGOGRAPHY 295 (visible by x-ray) of the foreign substance in the pelvis or abdomen. It is my belief that there is a direct relation between the quantity of oil instilled and the ability of a normal peritoneum to absorb it. The greater the quantity instilled, the longer will be its retention. This undoubtedly accmmts for the reports of Brown and his co-workers who found large quantities of iodochlorol retained in the peritoneal cavity after instilling as much as 12 cc. of this oily medium. On the other hand, it is entirely conceivable that a peritoneum previously damaged by infection, inflammation or trauma, will not absorb iodochlorol as readily as a healthy peritoneum. Moreover, if the pelvic peritoneum is distorted by adhesive bands of scar tissue following a previous insult, it is to be expected that iodized oil will be less easily absorbed. In the writer's opinion, hysterosalpingography when carefully performed, instilling the minimal quantity of oil needed ( 3-4 cc.) is a relatively innocuous procedure. Pregnancies following hysterosalpingography were entirely unaffected by retention of particles of iodized oil, in the few cases in which such foreign substance remained unabsorbed. This study of retained iodochlorol in pregnant patients was possible because the author is in the process of making a study of fetal polarity by x-ray throughout pregnancy. No comparable study of residual iodochlorol has been made in that group of patients which has not conceived. Accordingly, while it can be stated with assurance that only 9 per cent of patients who conceive after uterosalpingogram with iodochlorol have any evidence of retained oil, the incidence of such retention in patients who do not conceive is not shown in the present study. SUMMARY One hundred pregnant women were studied by antepartum radiography following previous hysterosalpingography for infertility. In 91 cases no evidence of the iodized oil ( iodochlorol) used in the earlier uterotubal x-rays could be discerned by the tim each pregnancy was able to be visualized ( 4~~ to 5 months of gestation). In 8 cases an occasional spot of radiopaque substance could still be discerned when the fetus was first visible. In only 1 patient was a moderate amount of the foreign material visible just before delivery. However, none of these 9 patients experienced any unusual symptoms or complications during pregnancy or after delivery. These uniformly good results are attributed to the careful technic em-