LIE GREAT IMPORTANCE of the tubal factor in the etiology of female

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1 Salpingostomy Treatment of Female Sterility A. C. Comninos, M.D. LIE GREAT IMPORTANCE of the tubal factor in the etiology of female sterility has become evident in the last few decades as a result of the improvement achieved by the application of modern methods in testing tubal patency, which proved that tubal occlusions occur in more than 4 per cent of the cases of sterility in women. Considering that almost half of the tubal occlusions are permanent, and that conservative treatment alone is not sufficient to re-establish tubal patency, we can understand why, since the first operative procedure was performed for this purpose, there has been a continuous endeavor to modify the old and to invent new methods of plastic operations to re-establish the patency of fallopian tubes. In spite of our efforts to check the 148 cases of salpingostomies performed in our Department, because of enemy occupation and civil war, we only managed to follow 37 such operations in the last 5 years. MATERIAL The majority (24 or 65 per cent) of our patients were women with primary sterility. The rest had secondary sterility. The age, important in all cases treated for sterility, varied between 21 and 40 years, which covers almost the whole period of reproductive life. Almost half (17 or 46 per cent) of the women were between 26 and 30 years, a similar number (16 or 43 per cent) were over 30, and only a very small number (4 or 11 per cent) were between 21 and 26. From the Department of Obstetrics and Gynecology, University of Athens, Greece. 334

2 Vol. 5. No SAL PI NGOSTOMY 335 There were certain diseases reported in the past history of the patients which may have some connection with the obstruction of the tubes. Infections of the alimentary canal were reported in 12 cases (24 per cent). On the contrary, infections of the reproductive system were less common (4 or 11 per cent). Gonococcal infection occurred only once, pulmonary tuberculosis was reported by 3, and pelurisy by 4. Of the 13 cases of secondary sterility, 3 (23 per cent) had spontaneous abortions, and 8 (65 per cent) had induced abortions. Six of the patients also reported previous attacks of appendicitis, and 5 had had appendectomies. The duration of sterility varied from 1 to 15 years. Less than half of the women (17 or 46 per cent) were sterile from 1 to 5 years, 15 for more than 5 years, and 5 for more than 10 years. From the point of view of indication of operation, we divided our patients into two groups: those who were operated upon primarily for the relief of sterility (20 or 54 per c~nt), and those for whom sterility was a secondary problem (17 or 46 per cent), and who therefore were operated upon for relief of other gynecologic complaints. Separation of the two groups was necessary, because in the cases of the second group the purpose of the operation was not the relief of sterility, and thus no other effort was made to achieve conception. The preoperative patency control of the tubes, which was performed by repeated hysterosalpingography, showed bilateral tubal occlusions in 31 cases and unilateral in 3. If we add to the number of bilateral occlusions, 3 more cases of recent tubal pregnancies where both tubes were found occluded during the operation, the total number of bilateral tubal occlusions is 34 (92 per cent). The great variety of abnormalities found at operation sometimes forced us to perform, in association with salpingostomy, many other operative procedures, which aggravated the postoperative result from the point of view of re-establishment of tubal patency and the sterility treatment. There were as many as 22 retrohexions and retroversions of the uterus. In 5 patients, multiple intramural fibroids were present, and therefore myomectomies were combined with salpingostomy. In 2 other cases in the primary sterility group, we performed the Strassman operation for uterus bicomis besides salpingostomy. It is also significant that there were 6 large ovarian cysts, not including the small follicular ones. This forced us occasionally to totally remove one

3 336 COMNINOS Fertility & Sterility ovary or the whole appendage. Gross pathologic inflammatory changes of the appendix were found in 19 patients, and consequently a large number of appendectomies were performed. In 2 patients, tuberculous salpingitis was macroscopically diagnosed and verified later by pathology examination. There were also 3 cases of recent tubal pregnancy, from whom we removed one tube and performed salpingostomy in the other. Thus, in the majority of cases, there was present, besides the tubal obstruction, another abnormality of the reproductive system. The variety and nature of these abnormalities often produced not only considerable difficulties in the ideal performance of the operation, but was also one of the main causes of postoperative obstruction of the tubes. On the other hand, it is evident that the nature of some of these abnormal conditions was responsible for the permanence of sterility, in spite of the fact that the tubes remained patent postoperatively. METHOD The operative method used was vertical salpingostomy, with resection of the obstructed portion of the tubes by circular slight oblique incision, followed by a slight eversion of the lips of the new ostium, fastening the mucosa to the serosa by four fine, atraumatic, plain #0-00 surgical sutures. The instruments used were all fine ophthalmologic ones. In all our cases, ventrosuspension by the modified Doleris-Bumm method was also performed, because this, in our opinion, helps the tubes to hang away from the raw surfaces of the pelvic peritoneum and Douglas' pouch. We would like to note here that suturing of the vesicouterine fold on the posterior surface of the uterus, which we always perform during ventrosuspension, permits us to place the tubes in an ideal position. On the ninth postoperative day, the first hysterosalpingography is performed, which helps in the maintainance of the patency of the newly reconstructed ostium by the dilatation produced by the passage of the oily opaque medium. At the same time we also have the first information about the operative result. The hysterogram was usually repeated after 3 months if no pregnancy took place by then. If an occlusion of the ostium was diagnosed during the first postoperative hysterogram, we tried alternatively uterotubal insufflation and hysterography. Bilateral salpingostomy was performed on 21 patients, of whom 14 belonged to the primary, and 7 to the secondary sterility group.

4 Vol. 5, No.4, 1954 SALPINGOSTOMY 337 RESULTS In 7 of the 21 patients (33 per cent), bilateral tubal patency was found postoperatively after repeated hysterograms. Six of the above cases belonged to the primary, and 1 to the secondary sterility group. In 2 other cases, a unilateral tubal patency was found postoperatively, which raises the total postoperative patency rate to 43 per cent. We also had 6 cases with unilateral (right) salpingostomy with removal of the left tube. From these, 2 have been found patent postoperatively. In the other 7 cases, salpingostomy with removal of the right tube was performed. Two of them were also found patent postoperatively. Finally, in 3 cases unilateral salpingostomy was performed as the other tube was patent, with resulting postoperative patency in 1. Regarding the postoperative tubal patency, we had a total of 14 successes ( unilateral or bilateral) out of 37 salpingostomies performed, a rate of 37.5 per cent. In 3 of the above referred patients, tubal obstruction was due to tuberculous salpingitis; in 2 others there was probably a congenital abnormality of the tubes combined with a uterus bicornis; in 2, previously induced abortions; in 2, chronic inflammation of the appendix; in 1, the presence of an intramural fibroid; and in the remaining 4, unknown inflammatory processes. Regarding the end result of the operation, which is pregnancy, there were 6 women (16 per cent) who conceived after the operation, with a total of 9 (24 per cent) pregnancies. All of these patients belonged to the primary sterility group. Bilateral salpingostomy was performed in 4, and unilateral salpingostomy with removal of the other tube in 2. One of these pregnancies was an ectopic, which occurred one month after the operation, and, in this case, a bilateral salpingostomy had been performed. The other 8 pregnancies were intrauterine. Two occurred in the same woman, and 3 others also occurred in one woman. The other 3 pregnancies occurred in 3 other patients. Five of these 8 pregnancies ended normally at term with 5 living babies. One patient is now in the fourth month, and 2 pregnancies ended in the second month. In one of the above patients, the tubal obstruction was due to tuberculous salpingitis, verified by the pathology examination of the excised portion of the tubes. In 2 other patients who conceived, besides salpingostomy, bilateral ovarian cysts the size of an orange were also removed.

5 338 COMNINOS Fertility & Sterility DISCUSSION There were 6 women (16 per cent) who conceived after the operation, with a corrected percentage of postoperative conceptions of 30, based not on the total number of 37, but on the 20 who were operated upon specifically for the relief of sterility. Taking into consideration all the above mentioned details of the preoperative and operative abnormalities found in almost all cases, and confronted by the many difficulties we occasionally faced, we consider our results as promising. The re-establishment of tubal patency does not always re-establish the function of the tubes. Though the best end results of salpingostomy are achieved when a certain number of prerequisites are taken into consideration before deciding upon the operation, we are of the opinion that when this operative procedure is performed in all women who undergo an operation for another gynecologic cause with which sterility coexists, and in which tubal occlusion (of the abdominal part of the tubes) is present, the chances for cure of the sterility are increased. SUMMARY AND CONCLUSIONS Salpingostomy has been performed in a group of 37 sterile women, of diherent ages during the reproductive period of life, who were suffering from various abnormalities of their genital organs, coexistent with tubal obstruction. Preoperative details, operative findings, and preoperative and postoperative patency of the tubes, checked in all patients by hysterosalpingography, uterotubal insufhation, and pregnancies after the operation, are reported. The total postoperative patency of the tubes (bilateral and unilateral) was 37.5 per cent. Six women (16 per cent) of the total 37 conceived after the operation, with 9 pregnancies. One of these pregnancies was an ectopic and occurred one month after the operation. Five ended normally at term, 1 is now in the fourth month, and 2 ended as abortions. The incidence of living babies was 13.5 per cent.. The resulting pregnancies after salpingostomy (16 per cent) permits us to consider this method as having a definite therapeutic value and to recommend it for the treatment of female sterility.

TUBAL PLASTIC SURGERY is an accepted form of therapy in the treatment

Tubal Plastic Surgery ADNAN MROUEH, M.D., ROBERT H. GLASS, M.D., and C. LEE BUXTON, M.D. TUBAL PLASTIC SURGERY is an accepted form of therapy in the treatment of infertility. However, reports have differed