Fertility patterns after appendicectomy: historical cohort study
BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7189.963 (Published 10 April 1999) Cite this as: BMJ 1999;318:963
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
No conflict of interest.
1 Andersson R, Lambe M, Bergstrom R. Fertility Patterns After
Appendicectomy: Historical Cohort Study.BMJ 1999; 318:963-967
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests