Rapid Responses to:

PAPERS: Roland Andersson, Mats Lambe, and Reinhold Bergström Fertility patterns after appendicectomy: historical cohort study BMJ 1999; 318: 963-967 [Abstract] [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Fecundity not fertility

Jonathan Cowie   (15 April 1999)

Freud, birth fantasies and appendicectomy

Chris McManus   (15 April 1999)

Surgeons Responsible for Increasing Teenage Pregnancies

Gareth Tervit   (16 April 1999)

Fertility patterns after appendectomy: historical cohort study

Ronald Tam   (20 April 1999)

Perforated appendicitis and infertility

Peter F Jones   (21 April 1999)

Evidence based management of suspected appendicitis

Roland Andersson   (27 April 1999)

Fecundity not fertility 15 April 1999
Jonathan Cowie Send response to journal: Re: Fecundity not fertility	Dear Sir Sorry to keep harping on about this (which I seem to have every 18 months or so for the past decade (to little avail)) but 'fertility' is not synonymous with 'fecundity'. The paper entitled Fertility patterns after appendicectomy: historical cohort study (BMJ vol 318 pp963-967) actually looks at the fecundity of the cohort and then makes the (reasonable) assumption that this might be an indicator for its fertility. That the mis-use of this term is common by those in some specialisms is no excuse. That this mis-use has the potential for confusion I contend should mean that biomedical editors ought to ensure correct usage. In this instance rates of ovulation (one aspect of fertility) were not measured, rather "the rate of first birth" (a measure of fecundity). An illustration of why this distinction is important might be that the fecundity of many nations (especially developed ones) is declining and this is most welcome. On the other hand the sperm counts of men in some countries (again mainly some developed ones) has (it has been reported) been declining and this might mean that male fertility is declining which is not welcome. (And the BMJ has published papers on both these issues and will probably do so in the future.) This should not be a continuing point of debate, however I suspect that I will still be occasionally drawing the BMJ's attention to it in years to come. A shame really considering otherwise the BMJ's high standard on the whole. Yours faithfully Jonathan Cowie CBiol MIBiol MIEnvSc Charlieville Rd North Heath Kent
Freud, birth fantasies and appendicectomy 15 April 1999
Chris McManus, Professor of Psychology and Medical Education CHIME, Royal Free and University College Medical School, London Send response to journal: Re: Freud, birth fantasies and appendicectomy	The study by Andersson et al (BMJ, 10th April, p.963) is principally concerned with the question of whether appendicectomy in girls and young women might reduce subsequent fertility, and the evidence seems convincing that it does not. A finding that was unexpected to the authors was that women who had a histologically normal appendix removed had a higher subsequent fertility. The authors speculate that removal of a normal appendix may reflect misdiagnosed ovarian pain and hence "well functioning ovaries", although they refute their own hypothesis by pointing out that the effect is present in pre-menarchic patients, and they provide no other explanation for a very large effect. Although the authors probably did not consider it, their data may instead be surprisingly strong support for a little known piece of Freudian theory. In his case history of Dora of 1905, Freud speculated that "Her supposed attack of appendicitis had thus enabled the patient ... to realise a fantasy of childbirth" [1]. In the only empirical test of the claim in the literature (Medline and PsycLIT search), Eylon [2] carried out a case-control study of clinically diagnosed appendicitis and found a highly significant (p<.005) excess of birth events. An example might be a case in which an older child is admitted to hospital with appendicitis at the same time as the birth of a younger sibling. The data of Andersson et al seem also to fit with Freud's hypothesis. Could it be that birth fantasies of later childhood are transmuted into actual births after age fifteen? Certainly a 1.37 times increased rate of first birth at that age in with a non-perforated appendix, and particularly a 2.57 times increased rate in those with a normal appendix are remarkable and highly significant statistics. They cannot be discarded lightly in a theoretical sense, particularly given Eylon's previous study and their close match to Freudian theory. Of course it would be desirable if other psychosocial factors such as social class were also taken into account, but such confounders seem unlikely to reduce what is a large effect. An obvious control group would be the subsequent fertility of young boys with appendicitis. In his critical review of empirical tests of Freudian theory, Kline [1] described Eylon's results as "suggest[ing] strongly that psychogenic factors influence appendicitis .... This is striking support for the Freudian claim" (p.291). Andersson et al's data are even more striking support, and certainly justify further research. Bibliography 1 Kline P. Fact and fantasy in Freudian theory. London: Methuen, 1972. 2 Eylon Y. Birth events, appendicitis and appendectomy. British Journal of Medical Psychology 1967;40:317-332.
Surgeons Responsible for Increasing Teenage Pregnancies 16 April 1999
Gareth Tervit, SPR General Surgery Princess of Wales Hospital, Bridgend Send response to journal: Re: Surgeons Responsible for Increasing Teenage Pregnancies	Editor- Regarding the study by Andersson et al investigating fertility patterns post appendicectomy it is comforting to know (as surgical trainees) that when removing normal and non perforated appendices we have been responsible for significantly ( p < 0.001 ) increasing the number of teenage pregnancies in our area. We wonder whether we should take the opportunity to make available information regarding contraception to our younger patients? Andrew Yeoman Surgical House Officer Gareth Tervit Surgical Specialist Registrar Department of General Surgery, Princess of Wales Hospital, Coity Road, Bridgend. CF31 1RQ. Gtervit@hotmail.com No conflict of interest. 1 Andersson R, Lambe M, Bergstrom R. Fertility Patterns After Appendicectomy: Historical Cohort Study.BMJ 1999; 318:963-967
Fertility patterns after appendectomy: historical cohort study 20 April 1999
Ronald Tam Send response to journal: Re: Fertility patterns after appendectomy: historical cohort study	Editor- Andersson et al(BMJ No 7189 April 1999 pages 963-967) concluded that perforated appendices in childhood(under 15 years of age) do not adversely influence the long term fertility of female patients. Consequently, the recommendation of a liberal attitude to exploration in women with suspected appendicitis for the purpose of avoiding impaired fertility should be viewed with skepticism. As an Attending Specialist Surgeon in private practice, my personal experience is that impairment of fertility rarely, if ever, comes into my consideration when I am confronted with a case of suspected appendicitis in a young female patient. Most surgeons adopt the "liberal" attitude of exploration for the simple reason that the overall complication rate would rise frm 5% with cases WITHOUT perforation to 30% with cases with perforation.[1] The hospital stay is prolonged and the cost of treatment will go up. I have not met or heard any surgeon who would be "liberal" to explore a case of suspected appendicitis on the grounds of avoiding impairment of fertility of young female patients as suggested in the last statement of the article. Ronald Tam FRCS DABS FRCS(Canada) Attending Specialist Surgeon Lane Crawford House Queen's Road Central Hong Kong Reference: 1. Shackelford's Surgery of the Alimentary Tract Vol.4 4th edition, editor: George D. Zuidema, page 147
Perforated appendicitis and infertility 21 April 1999
Peter F Jones Send response to journal: Re: Perforated appendicitis and infertility	Editor All surgeons strive to operate on the inflamed appendix before perforation takes place but when, as Andersson et al suggest1, the resolve to play safe results in 20 - 30% of excised appendices proving to be normal, then the question has to be asked whether "the Gordian knot of appendicitis diagnosis (should be) untied with the scalpel " 2. Studies over the past 30 years have shown that only 30 - 40%of patients admitted with acute abdominal pain need an emergency operation. Another 30%, sent in with possible appendicitis, settle without treatment, and others prove to have medical or non-surgical causes for pain. To identify these groups - and so avoid operating on them - investigation and "active observation" is required. This regime has now been thoroughly tested in children and adults, and shown to be practical and safe. In 8 reports on over 1000 patients having an appendicectomy for possible appendicitis (either on admission or after observation) the negative appendicectomy rate was 6.8%. Where perforation rates were given, 92% were diagnosed on admission: the other 8% were recognised after observation and all made a good recovery 3. In a previous study Andersson confirmed that low numbers of negative appendicectomies are not associated with a high perforation rate 4. As in many situations in medicine, a balance has to be struck here between undue haste and unwise delay. It is reassuring to know that infertility rarely follows perforated appendicitis. This finding, taken with the results of careful observation of the patient with debatable signs, should allow many unproductive laparotomies to be avoided. Peter F Jones Emeritus Clinical Professor of Surgery University of Aberdeen 1 Andersson R, Lambe M, Bergstrom R. Fertility patterns after appendicectomy: historical cohort study. BMJ 1999; 318:963-7. (10 April). 2 Hoffmann J, Rasmussen OO. Aids in the diagnosis of acute appendicitis. Br J Surg 1989; 76: 774-9. 3 Jones PF, Bagley FH. Acute appendicitis. In: Jones PF, Krukowski ZH, Youngson GG, eds. Emergency Abdominal Surgery. 3rd edition. London: Chapman and Hall, 1998: 49 - 52. 4 Andersson RE, Hugander A, Thulin AJG. Diagnostic accuracy and perforation rate in appendicitis: association with age and sex of the patient and with appendicectomy rate. Eur J Surg 1992; 158: 37 - 41.
Evidence based management of suspected appendicitis 27 April 1999
Roland Andersson, Registrar Dept of Surgery, Ryhov hospital, J÷nk÷ping, Sweden Send response to journal: Re: Evidence based management of suspected appendicitis	The present principles of early appendicectomy in patients with suspected appendicitis were formulated at the end of the 19-th century. At this time perforation certainly was associated with an increased risk of mortality and morbidity. With modern surgery the risk of has almost disappeared an there is certainly a need for a more modern and evidence based approach to this problem, as mentioned by dr Jones. It is obvious to most readers that Yeoman and Tervit falls into the trap of making causal inferences from the observed increased fecundity in women that were exposed to negative appendicectomies in childhood. This is however interesting as it demonstrates the difficulties in interpreting epidemiological research. This is probably most common when the observed result is in line with the expected. Very few would hesitate to blame the appendicectomy as responsible had a decreased fecundity been found. A biological cause of the increased fecundity after negative appendectomy can not be categorically excluded but other explanations are more probable. Howver, the explanations proposed by McManus that ”birth fantasies of later childhood are transmuted into actual births” seems too spectacular. The negative appendectomies are related to the care-seeking behaviour and it seems likely that this and the fecundity may be determined by common factors like the levels of anxiety and psychological dependency. Because of the existence of sponaneous resolving appendicitis the identification of non-perforated appendicitis may also be dependent of the careseeking behaviour which may explain the increased fertility among the patients with non-perforated appendicitis. Dr Tam expresses his doubt if impairment of fertility is considered when confronted with a case of suspected appendicitis in a young woman. However, the cited references in the paper gives evidence that fear for infertility is used as an argument to defend the high rate of negative appendectomies as well as motivate the use of laparoscopic techniques in these patients. Because of the diagnostic difficulties negative appendicectomies may not be completely eliminated but they are never beneficial for the patient and should be avoided by all means. It is exactly the reasoning that dr Tam makes that our paper tries to defeat. Our paper shows that the common opinion of an increased risk of infertility after perforation is unfounded. Where is the evidence that support dr Tam´s figures of a six- fold increase in complication rates in perforated compared with non- perforated appendicitis? Where is the proof that this morbidity can be prevented? Roland Andersson, MD PhD, Registrar Dept of Surgery Ryhov hospital, SE-551 85 Jönköping Sweden.