Studies in Human Sterility with Special Reference To
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STUDIES IN HUMAN STERILITY WITH SPECIAL REFERENCE TO THE INVEST IGAT ION OP THE PATENCY AND FUNCTION OP THE FALLOPIAN TUBES AND OP THE CONDITION OP THE ENLOMETRIUM. ProQuest Number: 13849840 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 13849840 Published by ProQuest LLC(2019). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 PREFACE. The thesis which is presented here, consists of two parts &nd an appendix. Part I concerns the pathogenesis, diagnosis and treatment of Human Sterility and is an endeavour to give a comprehensive account of this subject, incorporating a study of much new knowledge and of recent advances which mainly concern technical refinements in the investigation of tubal patency and function, the endometrial cycle and the tfsex hormones.” Only slight reference is made to the male aspect of the problem. In effect, this part of the thesis is almost entirely my contribution to the book ”Sterility and Impaired Fertility” (1959), Hamish Hamilton Medical Books, London, (jointly with C. Lane-Roberts, K. Walker and B.P. Wiesner). The few pages which are included here and which were not written by me are indicated in the text. The essential features of important researches, published since 1959, have been added. Part II concerns the results of a detailed study of 500 Gases of "Sterility,” with particular reference to (1) the functional condition of the Fallopian/ fallopian tubes and (2) the uterine endometrium, .normal and abnormal. These cases comprise an unselected series of patients who had never con ceived and who complained primarily of the infertility of their marriage and who were under my observation in the Royal Samaritan Hospital for Women, Glasgow, within the period - July 1953 until February 1943. I am responsible entirely for Part II, which has not as yet been published, although portions of it formed the substance of a paper read at the Annual Meeting of the British Medical Association in 1933. The appendix, concerns the results of original, unpublished researches in cases other than the series above-mentioned. It involves the most recent work, almost entirely done during the years 1941 and 1942. I am greatly indebted to Dr. John Hewitt, not only for facilities in his wards since 1933, but also for his co-operation and encouragement; to Dr. E.B. Morton from 1937 to 1939,and to Dr. D. McIntyre, since 1939, for similar facilities; to the Governors of the Royal Samaritan Hospital fdr Women for providing a Gordon King Kymographic apparatus (the first made in this country); to the British Medical Association for a Research Scholarship at the commencement of this work; and to Dr. I.C. Rubin of New York and Dr. L. Bonnet of Paris for facilities and instruction during visits to their clinics. CONTENTS. P r e f a c e ...... ............................. List of Illustrations ..................... PART I. Page General Survey of the P r o b l e m .......... ' 1 Stages in Investigation ................ 18 Investigation of Specific Functions .... 47 S u m m a r y .......................... 126 Treatment ........ 131 PART II. Introduction........................... 198 Analysis of the Tubal Status ........... 200 Endometrial Biopsy ..................... 231 Examination of the Husband ............. 253 Treatment ............ .258 Results of Follow-up ......... 266 Summary ................ 273 APPEHDIX................. 276 BIBLIOGRAPHY.............. 298 LIST OF ILLUSTRATIONS. Fig. at Page 1 Endometrium removed three d$sys after conclusion of a period ... ... 36 2. Endometrium removed two days before menstruation ............ 36 3 Occurrence of ovulation in menstrual cycle ... ... ... ... ... 39 4 Biopsy specimens of endometrium in three cases of sterility showing characteristics of anovulation 53 5 Siharman & Sheehan’s biopsy curette 57 6 Differing appearances of some endometrium removed a few hours before menstruation ....... 60 7 Specimens of endometrium removed by biopsy curette and by ordinary curette a few minutes later ... 62 ;8 Endometrium removed in premenstrual phase, apparently anovular ... 63 9 Same case as in Fig. 8. Endometrium removed one month later in pre menstrual phase showing normal features ...................... 63 10 Bonnet’s apparatus for kymographic insufflation...... ............. 77 11 Rubin’s apparatus for utero-tubal insufflation ..... ........ 79 12 (Jordon Kingte apparatus for utero tubal insufflation ....... 80. 13 Gordon King’s apparatus in use 83 14 Kymographic tracing in tubal occlusion .................. 86 Fig. at Page 15 Kymographic tracing in normal tubal patency ... 86 16 Kymographic tracing in normal tubal patency, showing con tractions of gareaf amplitude 86 17 Kymographic tracing showing contractions of low frequency and amplitude ... ... 86 18 Kymographic tracing in tubal spasm 90 19 Kymographic tracing in tubal stenosis ............ 90 20 Salpingo graphs showing normal bilateral patency ....... 97 21 Salpingographs showing right isthmial occlusion and left tubal patency ... 97 22 Salpingographs showing bilateral patency in abnormal tubes 97 23 A. Salpingograph showing hydro salpinx of left tube with incomplete block ... 98 B. Showing salpingitis with pelvic peritonitis............ 98 24 A. Salpingograph four days before period due ... ... ... 93 B. Same case four days after cessation of period ... 98 25 Salpingograph showing uterine fibroids and dilated tubes occluded at fimbrial ends 98 26 A. Salpingograph showing tubes stretched round fibroid at fundus uteri: Both tubes are patent 98 B. Salpingograph showing isthmial block after tuberculous peri tonitis ... 93 at Page 27 Section of endometrium showing incomplete differentiation 102 28 Kymographic tracing from a case in which pressure of gas was raised to 250 mm. Hg. 174 29 Salpingostomy. Formation of circumcision cuff ...... 180 50 Salpingostomy. Preparation for tubo-uterine implantation 180 51 Salpingostomy. Completion of tubo-uterine implantation 180 52' Bilateral obstruction of the tubes in the region of their distal thirds ... 182 55 Same case as in Fig. 52 after excision of right tube and salpingostomy ... ... 182. 54-51 Representative salpingographs 226 52-55 Salpingographs showing tubal blockage ............ 226 56-61 Salpingographs shwoing tubal patency in cases in which insufflation diowed non-patency 229 62-66 Salpingographs showing tubal blockage in cases in which insufflation showed patency 250 67-81 Salpingographs showing very differing appearances when lipiodol injection was repeated,in seven cases - to illustrate difficulty of interpretation 251 82 Salpingograph showing atypical features but tubal patency: conception occurred within four weeks ............ 251 Fig. at Page 85 Same case as in Fig. 82, but in first weeks of pregnancy ... 251 84 Salpingograph showing bilateral fimbrial block - before salpingostomy ............ 251 85 Same case as in Fig. 84, after salpingostomy ............ - 251 86-90 Salpingographs showing unilateral tubal patency ........ .. 251 91-98 Salpingographs showing altered appearances on repetition of test, but diagnosis not contradicted ....... ... 251 99 Endometrium removed one day before menstruation was due - 50th day of cycle ... ... 254 100 Same case as in Fig. 99, endometrium removed four days later (another four days elapsed before menstruation actually occurred) ...... 254 101-159 Biopsy specimens of endo metrium in eleven cases of sterility showing character istics of ’periodic1 anovula tion ....... 256-259 140-171 Biopsy specimens of endo metrium in twelve cases of sterility showing characteristics of (constant{ anovulation 240-244 172-205 Biopsy specimens of endo metrium, in twenty cases of sterility, showing tuberculous endometritis 245-253 204 Endometrium removed two days before menstruation after twfifity injections of gonadotropic hormone; same case as Figs. 148-153 262 Fig. at Page 205 Same case as in Fig. 204, endome trium removed eight days before a period, after six injections of gonadotropic hormone ... 262 206 Endometrium removed several hours before menstruation after six injections of gonadotropic hormone; same case as Figs. 145-147 ... ............ 265 207 Endometrium removed two days before ’period* due (26th day of cycle) after five injections of oestro genic hormone, 50,000 units each: same case as Figs. 122 and 125 265 208 Endometrium removed six days before menstruation after a course of oestrogenic hormone ... 265 209 Same case as in Fig. 209, six days before the succeeding period 265 210 Endometrium removed two days before menstruation, after a single dose of oestrogenic hormone (100,000 units) .................. 264 211 Same case as in Fig. 210, two months later after same treat ment : biopsy two days before menstruation .......... 264 212 Same case, endometrium removed during second day of menstruation 264 215 Same case: endometrium removed two days before menstruation after single injection of gonadotropic hormone .................. 264 Plate I-XIII Kymographic tracings of tubal insufflation ............. 208-224