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Methods and Devices

CATHETERISATION OF THE FALLOPIANTUBES FROM THE VAGINA

ROBERT P. S. JANSEN JOHN C. ANDERSON

Fertility Laboratory, Royal Prince Alfred Hospital, Camperdown,Sydney 2050, Australia

FERTILISATION of oocytes by spermatozoa normally takes placeat the ampullary-isthmic junction (AIJ) of the fallopian tube. Mostcases of infertility result from failure of fertilisation, because eithersuitably capacitated spermatozoa or the ovulated oocyte in itscumulus mass of granulosa cells do not reach the AIJ. We describe amethod by which the fallopian tubes can be catheterised from thevagina, through the endometrial cavity, in order to transfer

spermatozoa, oocytes, or early embryos directly to the region of theAIJ without the need for an operation or anaesthesia.

THE DEVICE

The system is composed of (1) a soft ’Teflon’ 3-french openended inner catheter 33 cm long, tapered to 2-french (0-66 mm) forits distal 3 cm; (2) a firm, but still flexible, opaque-Teflon 5 ’5-frenchouter cannula 28 cm long, bearing a lateral curve for entering theuterine angle; and (3) a malleable metal obturator, which overridesthe outer cannula’s laterally directed curve during transit of thecervix (fig A). We established by in-vitro culture that an oocyteobtained from follicle puncture at laparoscopy with its cumulus andpassed through a fallopian catheter ten times experimentally hadbeen fertilised and had cleaved normally.The catheter set was made to these specifications by William A.

Cook Australia Pty, Melbourne. Transvaginal echography wascarried out with an RT3600 ultrasound scanner and a 7 MHz

phased-array intracavity transducer (General Electric Company,Sacramento, California).The metal obturator has a curve in the sagittal plane for

negotiation of the endocervical canal (fig A). The outer cannula isused with its curve in the coronal plane (which can be directed to theleft or right). Withdrawal of the obturator once the endometrialcavity has been reached allows the cannula to regain its naturallaterally directed curve (fig B). The cannula is advanced to theuterotubal junction (UTJ), where its presence is confirmed byscanning of the parasagittal plane from the lateral vaginal fornix andimaging of the cannula in the lateral angle of the endometrial cavity.When resistance is felt, the patient usually experiences mildlateralised discomfort in the pelvis.

When the inner catheter is advanced through the UTJ (fig C), thepatient again experiences mild lateralised discomfort. The systemlimits the force that the soft inner catheter can exert on tissues in theevent that its passage is obstructed: failure to progress is ac-

companied by displacement of the outer cannula away from theobstruction. Earlier observations with hysterectomy-salpingectomyspecimens showed that the catheter could negotiate tortuous tubalpaths without apparently damaging the tube.During advancement of the catheter through the UTJ and tubal

isthmus, the operator usually encounters transient resistance, whichis then smoothly overcome and the patient senses its passage.Nevertheless, to confirm that the catheter is placed among theadnexa, bubbles of 5 % carbon dioxide in air suspended in sterileculture medium from a gamete incubator can be injected down thecatheter: the moving reflective interfaces that result can be

displayed with real-time ultrasonography during scanning of theadnexa in the coronal plane (fig C).

COMMENT

The extrauterine portion of the fallopian tube has an averagelength of 11 cm, the medial 2-3 cm of which forms the tubalisthmus.2 The medial isthmus is the narrowest part of the tube, withan average diameter of 0-4 mm (range O’l-l 0 mm), mucosa thatoccupies 3-6 primary folds, and a firm thick muscular wall.2 Theinterstitial or intramural portion of the tube links the isthmus to thefunnel-shaped3 angle of the endometrial cavity. Lateral to theisthmus, the tubal ampulla is wide and thin-walled. The ampulla,through its outer fimbriated end, receives the ovulated cumulusmass and its enveloped oocyte. 1We had little difficulty in passing the 06 mm soft Teflon inner

catheter through the tubal isthmus in 35 patients. Catheters of thissize are commonly used to splint the tubal isthmus and interstitialportion during fallopian tube microsurgery;l the folded, distensiblemucosa and muscle of the isthmus seems readily to accommodatethe catheter. The tubal isthmus at the time of ovulation producesmucus glycoproteins,1,s and these may be expected to havelubricative and perhaps protective properties. Sweeney6 andRocker’ described the interstitial tube as taking a convoluted coursein most specimens dissected after fixation. We found, as othershave,8 that when intraluminal pressure or fluid-flow is directedlaterally from the uterine angle or funnel there tend to be only minordeviations in the course of the intramural tube. Nevertheless, andalthough the catheter can pass through tubes that take a tortuouscourse, we recommend preliminary hysterosalpingography untilthe operator becomes experienced with the device and the

technique.Gamete intrafallopian transfer, or GIFT, is done by laparo-

scopy ; fallopian catheterisation could allow a more direct approachto be taken to gamete transfer to the AIJ. In six cases, we found thatfallopian catheterisation and transfer of capacitated spermatozoa tothe tube adjacent to a preovulatory follicle was followed by normal

1 A - B r1=l[ C

System for catheterisation of the fallopian tubes.

A, a metal obturator is used to guide the cannula through the curve of the cervix into the uterus; B, as the obturator is withdrawn, theannula regains its lateral curve and is advanced to the uterotubal junction; C, the catheter is passed down the cannula and through thesthmus of the fallopian tube.

310

in-vivo fertilisation, transport of the early embryo through therecently catheterised isthmus, and normal subsequent nidation andgestation in the uterus. Five of these pregnancies followed the use offrozen/thawed donor semen and will be reported elsewhere.Use of this system to transfer sperm, oocytes-in-cumulus, or

perhaps early embryoslO to the fallopian tubes may open newopportunities for the treatment of infertility when the fallopiantubes are normal.

REFERENCES

1. Jansen RPS Endocrine response in the fallopian tube. Endocrinol Rev 1984; 5: 521-25.2. Woodruff JD, Pauerstein CJ. The fallopian tube Structure, function, management.

Baltimore: Williams & Wilkins, 1969: 46-66.

3. Lisa JR, Gioia JD, Rubin IC. Observations on the interstitial portion of the fallopiantube. Surg Gynecol Obstet 1954; 99: 159-69.

4 Winston RML. Microsurgical tubocornual anastomosis for reversal of sterilisation.Lancet 1977, 1: 284-85.

5. Jansen RPS. Cyclic changes in the human fallopian tube isthmus and their functionalimportance. Am J Obstet Gynecol 1980; 136: 292-308.

6. Sweeney WJ. The interstitial portion of the uterine tube—its gross anatomy, course,and length. Obstet Gynecol 1961; 19: 3-8.

7. Rocker I. The anatomy of the utero-tubal junction area Proc R Soc Med 1964; 57:707-09.

8. Rubin IC. Observations on the intramural and isthmic portions of the fallopian tubeswith special reference to so-called "isthmospasm". Surg Gynecol Obstet 1928, 4:87-94.

9. Asch RH, Balmaceda JP, Ellsworth LR, Wong PC. Preliminary expenences withgamete intrafallopian transfer (GIFT) Fertil Steril 1986; 45: 366-71.

10. Devroey P, Braekmans P, Smitz J, et al. Pregnancy after translaparoscopic zygoteintrafallopian transfer in a patient with sperm antibodies. Lancet 1986; i: 1329

Reviews of Books

Clinical Electrophysiology of the Heart

David E. Ward and A. John Camm. London: Edward Arnold.1987. Pp 390. 55. ISBN 0-713145072.

CLINICAL cardiac electrophysiology is an example of ascience originating in and largely defined by a techniquerather than by a body system or disease group. Cliniciansaccustomed to discussion of aetiology, clinical features,management options and indications, success rates, andcomplications will find the subject-matter here confinedmainly within the electrophysiological laboratory. Thatsaid, the authors, both distinguished contributors in thissphere, are to be congratulated on distilling the complexitiesof the subject in a clear and coherent account. As Prof A. L.Waldo says in his foreword there has long been a need for amonograph on this subject. The topics covered includeinvestigative methods in adults and children, conductiondynamics and refractory periods, conduction delays andblocks, investigation of tachycardias, drug studies, pacingand surgery for tachycardias, and electrical ablation ofconducting tissue. The references are carefully selected andthe text is particularly well illustrated by original traces withfully explanatory legends.The development of clinical electrophysiology in the two

decades since the start of His bundle recording andprogrammed electrical stimulation has contributed greatlyto understanding of the mechanisms of arrhythmias and ofdrug action. It has improved ECG interpretation. Hopesthat it would immediately simplify and rationalise choice ofantiarrhythmic drugs have not been fully realised and theplace of antiarrhythmic pacemakers is not yet fully defined.However, while the number of patients requiring theseinvestigations is small, countless others benefit indirectlyfrom the knowledge gained.

This book appears opportunely when consensus is

emerging on indications for study, protocols,interpretations, and therapeutic indications. Areas of

controversy such as the prognostic significance of HVprolongation, the place of electrophysiological studies inpost-myocardial-infarction patients and in unexplained

-

syncope, and the assessment of drugs for ventricular

tachycardia by serial electrophysiological testing are

summarised with full references. The book is commendedto all cardiologists, not merely to the minority involved inelectrophysiological studies, and indeed to all who seek

greater understanding of disorders of the heartbeat.

Western General Hospital,Edinburgh EH4 2XU ARTHUR KITCHIN

The Quality of Life of Cancer Patients

Monograph Series of the European Organisation for Research andTreatment of Cancer, vol 17. Edited by Neil K. Aaronson andJoem H. Beckmann. New York: Raven Press. 1987. Pp 320.$68.50. ISBN 0-881672726.

THIS valuable monograph is a collection of reviews bymany of the investigators most concerned with quality of lifemeasurement. Any oncologist wishing to incorporateassessment of quality of life into a study will find much ofvalue, and there are many perceptive discussions of issuesthat will interest cancer specialists as a whole.

Measurement of quality of life comes into its own whentwo treatments have an identical outcome with respect tosurvival but a clear difference in quality of life, or,

alternatively, if the outcome is quite different but thepatients think the treatments are equally tolerable (orunpleasant). Then a choice can be made. But what if onetreatment is rather more toxic but confers a modest survival

advantage? To put it crudely, how much survival would youjudge was worth an increased likelihood of hair loss orvomiting? In these circumstances the measurement ofquality of life can draw our attention to what the total choiceis: it makes us think about the less ’tangible effects of atreatment, not just the survival curve.

In this book you will find excellent discussions on

problems of measurement, on the psychologicalconsequences of mastectomy, on cross-cultural

comparisons, on the long-term effects of treatment of

children, on unproven cancer treatments (one of whichincludes massage of the reflexogen zone of the foot), and onthe troubles of the terminally ill. I particularly enjoyed thereview on methodology by Jones et al, and the description ofthe measurements made in a trial of chemotherapy inovarian cancer by de Haes et al. There is much else of valueand I recommend the volume.

Department of Oncology,Faculty of Clinical Sciences,University College London,London WC1E 6JJ R. L. SOUHAMI

New Editions

Cardiac Anesthesia.—2nd ed. Vols 1 and 2. Edited by J. A. Kaplan.Orlando: Grune & Stratton. 1987. Pp 1135. $124.50.

The Psychology of Childbirth.—2nd ed. By J. Prince, M. E. Adams.Edinburgh: Churchill Livingstone. 1987. Pp 219. £7.95.

Manual of Gastroenterologic Procedures.—2nd ed. Edited by D. A.Drossman. New York: Raven. 1987. Pp 284. $23.50.

The Clinician’s Guide to Diagnostic Imaging.—2nd ed. By Z. D. Grossman,F. S. Chew, D. A. Ellis, S. C. Brigham. New York: Raven. 1987. Pp 287. $26

Dermatology in General Medicine.-3rd ed. By T. B. Fitzpatrick, A. Z.

Eisen, K. Wolff, I. M. Freedberg, K. F. Austen. Maidenhead: McGraw-Hill1987. Pp 2641. £160 (2 vols).