Evaluation of Tubal Function

Transcription

1 Evaluation of Tubal Function C. Lee Buxton, M.D., and Luigi Mastroianni, Jr., M.D. f INVESTIGATIVE TESTS of physiologic function should be scientifically concise. Unfortunately, this is as impossible in tests designed to evaluate the physiologic capabilities of the fallopian tube as it is in any other kind of biologic or physiologic assay. One would assume that the development and perfection of technics of tubal insuffiation both with carbon dioxide and contrast media over the past years would present a test which would be susceptible to little or no enol' in diagnosis. That this is not true, at least in our hands, is indicated by Table 1. Approximately one fourth the patients who had only tubal insufhation and in whom tubal patency could not be demonstrated became pregnant, and 8 of 71 patients having tubal closure demonstrated by salpingogram, but not treated surgically, also became pregnant. There are undoubtedly various reasons for these possible mistakes in diagnosis. One may be faulty technic, although these tests were done by experienced physicians interested in infertility problems. Another may be that the test had a therapeutic value although we have never been able to prove this statistically. A third may be that we may be considering tubal closure to be a permanent condition whereas occasionally it may be transitory. Tubal pathology in many cases may be constantly changing, and we may find tubal closure when a patient is either undergoing a resolution of a previously active pathologic process which has caused the closure, or is actually in the throes of a diseased condition which is resulting in temporary but not necessarily permanent impermeability of the tubes. The other great source of enor in the use of tubal-patency tests as an From the Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Conn. Received for publication July 1,

2 562 BUXTON & MASTROIANNI Fertility & Sterility TABLE 1. Relationship of Insufflation and Salpingogram to Conception Evaluation of Tubal patency InsufRation only Patency demonstrated Patency not demonstrated Salpingogram Patency demonstrated Questionable patency Patency not demonstrated No surgical procedure No evaluation of tubes -----~ No. cases No Pregnant Within 3 mos. of test % No. % indication of tubal function is, of course, the fact that these tests evaluate tubal patency only, whereas unquestionably the tube has other responsibilities in the physiology of reproduction. Continued nonnal tubal physiology may be fully as important a requirement as tubal patency, and it is extremely hard, if not impossible, by present diagnostic technics to identify abnormalities in tubal or fimbrial peristalsis, ciliary or enzymatic activity, or other tubal activities about which we can as yet only conjecture. Furthermore, there is a crucial and important segment of the process of ovum transfer and progress about which CO2 insufflation can tell us nothing, and insufflation with contrast media gives us only a suggestive clue concerning the possibility of abnormality (Figs. 1-4). This is the segment of ovum progress not yet fully understood-from the time the ovum leaves the ruptured follicle until it is safely in the more secure "throughway" of the fallopian tube itself. Present evidence indicates the possibility that the fimbriated extremity of the tube actually almost wraps itself around the ovary so that the ovulated egg proceeds directly from the ruptured follicle into the tubal lumen. If this is so, the ovum is spared what must otherwise be the most perilous part of its journey-that time when it is thrust from the sanctuary of the follicle and wanders like an errant pilgrim until the tactile fimbria find it and enfold it within the tubal mucosa. Regardless of the fashion by which this seemingly miraculous transfer is carried out in the human being, it presupposes the existence of reasonably normal tubal physiology unhampered by either intramural or peripheral disease, which may prevent its

3 Vol. 8, No.6, 1957 TUBAL FUNCTION TESTS 563 Fig. 1 (GNHH-C46082). Salpingogram indicating probability of tubal patency at time of injection of contrast medium in a patient subsequently proved to be normal (see Fig. 3). Fig. 2 (GNHH-E3948). Salpingogram indicating probability of tubal patency at time of injection of contrast medium in a patient subsequently proved to be abnormal (see Fig. 4).

4 564 BUXTON,& MASTROIANNI Fertility & Sterility efficient activity even though the tube itself may be wide open. It is on this type of case which we desire to particularly focus our attention in this paper. Within the past year, the authors have had occasion to culdoscope or operate on 13 patients who fall into this category, and who have had surprisingly similar histories. They have all had infertility problems of at least 2 years' duration, and all except 3 have had a history of 6 to 17 years of infertility. They had all been investigated extensively elsewhere with the exception that, because their C02 insuffiations had been presumably normal, they had had no x-ray salpingogram. Some of these patients had a history of previous pelvic surgery. Others had a history of what might be considered pelvic infection, either of a specific variety or of peritonitis following ruptured appendix in childhood. Three patients, for instance, had been Fig. 3 (GNHH-C46082). A twenty-four-hour plate showing contrast medium (oilsoluble, low viscosity) spread fairly evenly over pelvic viscera. This patient is now pregnant.

5 Vol. 8, No.6, 1957 TUBAL-FUNCTION TESTS 565 operated on for a ruptured appendix between the ages of 7 and 10, and had long histories of subsequent wound drainage for periods of from 3 to 6 months. Two had negative past histories., X-ray salpingogram on these patients disclosed tubal patency (Fig. 2), but 24-hour films indicated that the contrast medium had not spread itself over the pelvic viscera the way it normally should as in Fig. 3, but seemed to have accumulated in blotchy areas which led the authors to suspect, at least, the presence of pelvic peritoneal adhesions as the residue of old infection, as in Fig. 4. It was felt that such adhesions might impair the Fig. 4 (GNHH-E9348). A twenty-four-hour film showing accumulation of contrast medium in areas of pelvis, its spread having been prevented by pelvic peritoneal adhesions. Subsequent laparotomy verified the impression of extensive pelvic pathology.

6 566 BUXTON & MASTROIANNI Fertility & Sterility efficiency of the process of ovum transfer from the follicle to the tube regardless of the fashion by which nature arranges for this transfer. It is difficult to be positive about these x-ray findings, however, and before suggesting culdoscopy or laparotomy several months were allowed to pass and the x-rays were repeated. In every case except one (which will be discussed later) the impression of pelvic pathology was confirmed and further investigation suggested. Nine of the 13 patients were subjected to laparotomy. Three were culdoscoped and 1 (discussed below) was subjected to no further procedure. In each case extensive pelvic pathology was identified. This pathology in most cases consisted of extensive pelvic peritoneal adhesions which frequently covered the ovary and attached it closely to the posterior surface of the broad ligament; or which involved the tube and the intestine in such a fashion that it was quite apparent that there would be considerable difficulty in the fimbriated extremity of the tube acquiring any approximation to the ovary at the time of ovulation. There was 1 case of active pelvic tuberculosis, which was unrecognized even though the patient had been carefully examined in the infertility clinic on numerous occasions, and had been keeping basal body temperature charts for over a year. The adhesions were caused, in some cases, by endometriosis and in others by previous infection, possibly gonorrheal, possibly a Fig. 5. Salpingogram suggesting nonpatency of left tube and possible right hydrosalpinx.

7 Vol. 8, No.6, 1957 TUBAL-FUNCTION TESTS 567 result of previous septic abortion, and certainly in 3 cases at least, as previously mentioned, due to ruptured appendix. It is, of course, difficult to say whether or not these pelvic peritoneal adhesions were the pathologic condition which prevented these individuals from becoming pregnant. As with all other conclusions concerning infertility problems the number of variables is so great, and our lack of basic knowledge concerning infertility so apparent that all we can attempt to do is to make reasonable conjectures. So far as could be ascertained these patients and their husbands were otherwise normal. For the most part they had long infertility histories of over 5 years. Four of the 9 operated cases had been operated on within the past 3 months, and of the other 5, 3 have become pregnant, but these numbers are so small that they have no significance. Even if the possibilities for salvage are slight, the appearance of disruption of pelvic architecture is such that pregnancy seems extremely unlikely, if not impossible. Like other surgery for infertility the possibilty for cure is unpredictable, yet 9 of the 13 patients desired operation in spite of being told that the chances of success were not good. Three patients in whom the suspicion of this type of pathology was confirmed by culdoscopy decided against the operation. The other patient in the series was found upon the second salpingogram to have undergone such a pronounced change that it was felt that she had been x-rayed, in the first instance, possibly at a time Fig. 6. A 24-hour film confirming impression of right hydrosalpinx.

8 568 BUXTON & MASTROIANNI Fertility & Sterility when local pathology might have been undergoing some type of resolution which left her pelvis in a reasonably normal state when it was x-rayed again 3 months later. Since this is our second proved instance (the first is reported elsewhere) 1 that such a coincidence may occur, we are briefly presenting the pertinent facts in her history and demonstrating the salpingogram. CASE REPORT E. H., a 25-year-old nulligravida housewife with a 3-year history of infertility, had a fairly complete infertility investigation in the summer of 1956, at which time tubal insufflation with CO2 demonstrated tubal patency. Salpingogram carried out on Dec. 14, 1956, revealed nonpatency of the left tube, and a collection of dye at the distal end of the right tube suggested a right hydrosalpinx (Fig. 5) which was confirmed, so far as we were concerned, on a 24-hour film (Fig. 6). A tentative diagnosis of bilateral tubal closure was therefore made, and it was decided to re-evaluate her condition in 3 months, following which tubal plastic operation was suggested should the findings be the same. The test was repeated on March 20, 1957, with the results as indicated in Fig. 7. The 24-hour film demonstrated a diffuse spread of Ethiodol throughout the pelvic peritoneum (Fig. 8), and the immediate film demonstrated reasonably normal bilateral tubal lumena, although there was a suggestion of a certain amount of "beading" in the left tube which has been interpreted by some as indicative of possible tuberculous salpingitis. The considerable change in the appearance of the tubes on the two different occasions indicated the possibility of tubal pathology in the first instance Fig. 7. Salpingogram of same case 3 months later, suggesting bilateral tubal patency.

9 Vol. 8, No.6, 1957 TUBAL FUNCTION TESTS 569 Fig. 8. A 24-hour film with spread of contrast medium through pelvic peritoneum confirming impression of tubal patency not seen in Fig. 6. which, within a period of 3 months, had to a large extent resolved itself. A decision was made, therefore, not to operate on this patient but to give her a 6 months further opportunity for pregnancy, and should the latter not occur consider laparotomy at that time. SUMMARY The unreliability of tubal-patency tests in determining the efficiency of ovum transfer has been discussed. The inability of available tests to give us a concise indication of ovum transfer and progress is probably due to several causes: (1) technical error, (2) inability of tubal-patency tests to identify changes in tubal physiology which might prevent normal tubal and ovarian function, and (3) difficulty in identifring pelvic pathology beyond the fimbriated extremity. Thirteen cases of the latter type have been discussed and evaluated. This paper is not intended to deprecate the obviously enormous value of tests for tubal patency. On the contrary, it is hoped that a realization of the limitations of these tests might even more enhance their value. REFERENCE 1. BUXTON, C. L. Tr. New England Obst. & Cynec. Soc. 9:175, Cedar St. New Haven 11, Conn.