输卵管妊娠后再次妊娠的探讨

对输卵管妊娠后有生育要求的５８例行输卵管切除术，１５例行输卵管开窗术，３０例应用药物保守治疗。结果：１０３例治疗后６７例宫内妊娠，９例再次异位妊娠。     

Reconstructive surgery of hydrosalpinx with and without the carbon dioxide laser

Pregnancy rates and surgery-conception intervals were determined in 91 women operated on for bilateral terminal tubal occlusion with different techniques. The intrauterine pregnancy rate following salpingostomy utilizing the CO2 laser was 21.7% (n = 23) and following salpingostomy with the microdiathermy needle was 22.7% (n = 22) at 1 year's follow-up. The pregnancy rate following conventional surgery was 17.4% (n = 46) at 5 years' follow-up. The surgery-conception interval was shorter in the laser group than in the other two groups. This preliminary report suggests that there is no difference between the pregnancy rate following salpingostomy with CO2 laser or microdiathermy needle; however, the surgery-conception interval is shorter. This might reflect the rapid healing of the tube after laser surgery.     

A comparison between laser surgery and electrosurgery for bilateral hydrosalpinx: a 2-year follow-up

The overall pregnancy rate after salpingostomy in women with complete bilateral terminal tubal occlusions was 26.9%. No difference was found in the intrauterine pregnancy rate and the surgery-conception interval between salpingostomy with the CO2 laser or the microdiathermy needle at a 2-year follow-up. The advantage of the CO2 laser in other reproductive surgery remains to be seen.     

Microsurgical salpingostomy is not an obsolete procedure.

OBJECTIVE--A review of the results of microsurgery for bilateral distal tubal blockage. DESIGN--A retrospective review. SETTING--Hammersmith Hospital London and local private hospitals. SUBJECTS--388 patients with bilateral ampullary occlusion treated between 1971 and 1988 by microsurgery. INTERVENTIONS--Full investigation for other causes of infertility followed by abdominal microsurgical salpingostomy. Repeated meticulous follow-up was essential with check laparoscopy one year after surgery. MAIN OUTCOME MEASURE--Successful pregnancy in relation to tubal damage. RESULTS--In 65 women microsurgery followed tubal reocclusion after failed conventionally performed salpingostomy. 74 women (23%) had one term pregnancy after primary salpingostomy and 12 women (18%) after repeat salpingostomy. Over half the women having a term pregnancy subsequently had a second infant. The tubal damage was classified in four stages according to the degree of mucosal damage and tubal fibrosis, the presence of isthmic disease and the quality of tubal and ovarian adhesions. Approximately one quarter of patients had stage I disease and amongst these 39% had babies after primary salpingostomy and 25% after repeat salpingostomy. CONCLUSION--Microsurgical salpingostomy is a specialized procedure. Proper selection of patients, competent microsurgical technique and adequate follow-up appear crucial to success. In selected patients treatment by salpingostomy gives better results than multiple cycles of in vitro fertilization.     

Tubal reanastomosis: an update.

53 self-selected cases of tubal reanastomosis are summarized and followed up. Only patients who had been sterilized by the Pomeroy sterilization method were chosen for this reanastomosis procedure. All but 3 of the cases were performed with a single-side repaired. The longest, least scarred tube with the fewest adhesions was chosen for reanastomosis. The procedure is described. Various techniques were used to confirm patency following the procedure. Follow-up results of the 53 cases are presented in tabulated form. The cases exhibited a high pregnancy rate (64%), a high viable birth rate (47%), and a low tubal pregnancy rate (15%). The high success rate of this series is attributed to the preservation of tubal tissue through a Pomeroy sterilization procedure and a lack of intraluminal material at the repair site. In the 3 cases in which both tubes were repaired, a tubal pregnancy preceded an intrauterine pregnancy.     

Surgical treatment for distal tubal occlusion. A review of 167 cases

Surgery was performed on 167 patients for distal tubal occlusion. In 143 cases a terminal microsurgical salpingostomy was performed and in 24, a cuff neostomy. The overall intrauterine pregnancy rate was 20.4%, and 16.8% of the patients had live births. The ectopic gestation rate was 1.8%. None of the patients with a cuff neostomy became pregnant.     

Prognostic factors of fimbrial microsurgery

From January 1978 to December 1983, 600 infertile women underwent microsurgery for tubal infertility. Only 257 women with the same extent of distal lesions on both sides or with unilateral occlusion (after contralateral salpingectomy) were considered. Patients were classified in four subgroups on the basis of the extent of occlusion. After fimbrioplasty for occlusion of degree I and salpingostomy for occlusion of degree II, the term pregnancy rate was more than 50%. After salpingostomy for occlusion of degrees III and IV, the term pregnancy rate was, respectively, 25% and 22%. The ectopic pregnancy rate was the highest (12%) after salpingostomy for occlusion of degree IV. After microsurgical salpingolysis, the term pregnancy rate reached 64%, whereas the ectopic pregnancy rate was as low as 2%. Ampullary dilatation, as determined by hysterosalpingography and laparoscopy, influences the postoperative pregnancy rate. Fimbrial microbiopsies were taken, and the ciliated cell percentage was obtained. Results suggest that the ciliation index is a valuable method of prognosis of tubal surgery. In conclusion, the pregnancy rate after distal surgery is related to the tubal morphologic findings: ampullary dilatation, fimbrial ciliated cell percentage, and tubal wall thickness.     

Treatment of female infertility due to tubal obstruction by operative laparoscopy.

The advent in recent years of safe endocoagulation (thermocoagulation within the abdomen) has permitted operative laparoscopic treatment of the tubal factor in infertility in selected cases. This paper reviews the results of operative laparoscopy in 223 cases treated for infertility between 1971 and 1976. Tubal occlusion was present in 133 patients before surgical intervention. Following operative laparoscopy, tubal patency was demonstrated in 67% on testing at the time of operation and in 12% at the first postoperative hydrotubation. In only 21% of cases was tubal patency not achieved by these methods. Those cases requiring isthmic salpingostomy, ampullary or isthmic-tubal implantation, or end-to-end anastomosis were further treated by laparotomy and microsurgery. Ninety cases of pelvic endometriosis were treated by a combination treatment of thermocoagulation, ovarian cyst resection, and the antigonadotropin agent, danazol. Ovariolysis, salpingolysis, fimbrioplasty, and salpingostomy can easily be performed using operative laparoscopy as the method of choice with a minimum of complications, shortened hospitalization time (2 days), and the potential for a repeat procedure or a follow-up laparotomy should this be necessary. The pregnancy rate following laparoscopic treatment for the correction of distal tubal occlusion was 30.5% and for endometriosis genitalis externa, 40%. These rates compare favorably with the rates following procedures involving laparotomy and microsurgery for correction of similar lesions.     

Retrospective analysis of laparoscopic salpingostomy and conservative expectant management of tubal ectopic pregnancy

Purpose  To identify predictive factors for successful expectant management of ectopic pregnancy and to evaluate the prognosis for fertility after expectant management and laparoscopic salpingostomy. Methods  Forty-six cases of expectant management and eighty cases of laparoscopic salpingostomy for tubal ectopic pregnancy were retrospectively analyzed. Subjects were classified in three groups: those who underwent laparoscopic salpingostomy, those treated by expectant management only, and those treated by expectant management but requiring additional treatment. Results  The rates of tubal patency, intrauterine pregnancy and repeated ectopic pregnancy in the laparoscopic salpingostomy group were 75, 40, and 16%. The rates in the expectant management group were not significantly different: 72, 42 and 15%. Finally, the rates in the extra treatment group were 75, 39 and 15%. Success rate of expectant management was 54%. In 93% of cases expectant management was successfully completed when the initial levels of urinal hCG were less than 3000 mIU/ml and the levels of hCG 48 h later were less than 80% of the initial levels. However, expectant management alone was insufficient and required extra treatment in 90% of cases when the initial levels of hCG were 3000 mIU/ml and above or when the levels of hCG level 48 h later was 80% of initial levels and above. Conclusions  Expectant management in combination with salpingostomy is not only minimally invasive but also a useful way to preserve fertility. Initial urine hCG levels and their variation over time can help predict whether expectant management will succeed.     

Reproductive performance of women after two tubal ectopic pregnancies

Twenty-four women who had undergone total salpingectomy due to ectopic pregnancy and who subsequently underwent a laparotomy for a second ectopic pregnancy in their opposite tube were treated by the author. Treatment consisted of linear salpingostomy (n = 20) and partial salpingectomy (n = 4). The intrauterine pregnancy rate after linear salpingostomy in women who attempted to conceive was 50%, and the incidence of a third ectopic pregnancy was 27.8%. These findings suggest that linear salpingostomy should be considered in the management of a second tubal pregnancy in women with a single tube. The high incidence of a third ectopic pregnancy, however, is concerning.     

输卵管绝育后复通手术十年总评

我们随访１９８２年４月至１９９３年６月在我院行显微输卵管复通手术后的１０２９例妇女，发现宫内妊娠率为９３．２９％（９６０／１０２９），术后第一年受孕率最高，为７３．７８％（７５４／１０２９）；术后第一年内前６个月受孕率５４．８１％（５６４／１０２９）明显高于后６个月者４０．８６％（９０／４６５）；前６个月内的前３个月受孕率３７．４１％（３８５／１０２９）又明显高于后３个月２７．８０％（１７９／６４４）。术后各时期宫外孕的发生率均无明显差别；宫内妊娠率与绝育至复通的时间无关；术后的早期通液反而降低宫内妊娠率；抽芯包埋法及夹绝育后复通的宫内妊娠率较高；输卵管峡部吻合后宫内妊娠率最高。因此，我们认为输卵管峡部的抽芯包埋法或夹绝育在目前不失为一种理想的可逆性绝育方法。     

Microsurgery for tubal infertility

In vitro fertilization/embryo transfer (IVF/ART) results have shown significant improvements during the last decade. In the United States the rate of live births per cycle improved gradually to become 27% in 2001. Assisted reproductive techniques (ARTs) are increasingly being used for the treatment of tubal factor infertility. In this review the data are derived largely from our department, where we have treated sufficient numbers of patients and have maintained substantial consistency in our surgical techniques. This 3-part review demonstrates a high success rate of intrauterine pregnancy (IUP) after anastomosis for sterilization reversal. This rate, for those who are < 35 years of age at the time of reversal, is >70%, with most pregnancies occurring within 18 months after surgery. Those who are 35 years of age or more will have a 55% rate of IUP. We note, too, the satisfactory IUP rate (50%) after tubocornual anastomosis for proximal tubal disease. We document the beneficial role of laparoscopic salpingoovariolysis, fimbrioplasty and salpingostomy performed during the initial diagnostic laparoscopy. The IUP rates after salpingoovariolysis and fimbrioplasty are 60% and 50%, respectively. The rates of IUP for salpingostomy are modest in comparison, yet they are 25% for liberal use of salpingostomy during the preliminary laparoscopy. Salpingostomy also provides a beneficial effect upon embryo implantation in both in vivo and in vitro attempts at conception. This stresses the need for an appropriate preliminary investigation and for the subsequent diagnostic laparoscopy to be performed at a center able to perform these procedures. The evidence suggests that surgery should retain its place in the treatment of tubal infertility. Surgery and ART are complementary approaches that can be used singly or in combination to improve the outcome for couples with tubal infertility.     

经脐单孔腹腔镜输卵管妊娠开窗取胚术19例分析

目的探讨经脐单孔腹腔镜输卵管妊娠开窗取胚术的可行性。方法对2010年3-9月在南方医科大学广济医院住院的20例输卵管妊娠患者行经脐单孔腹腔镜输卵管开窗取胚术。结果除1例术中发现为间质部妊娠改为三孔手术外,其余19例手术全部成功,术后监测血β-绒毛膜促性腺激素(HCG)均未发生持续性异位妊娠。结论经脐单孔腹腔镜输卵管开窗取胚术是一种安全可行、更加理想的微创术式,在实施中应注意正确、严格地选择病例,提高手术技巧,术后严密观察血β-HCG的下降。     

Endoscopy for contraception

Over the past 2 decades, endoscopic methods of tubal sterilization-- including laparoscopic, hysteroscopic, and transcervical techniques-- have been refined so as to be less aggressive. In developing countries, laparotomic, minilaparotomic, and chemical methods of tubal sterilization prevail. Hysteroscopic methods involving the injection of silicone plugs or inert devices and transcervical injections of adhesive and sclerosing substances remain largely experimental at this time. The failure rate of tubal sterilization has remained fairly constant at 0.5%, but there has been considerable progress in terms of safety and complications. The mortality rate has dropped from 4-110/100,000 cases in the early 1970s to 4-57/100,000 procedures. In the US, the mortality rate is 4.2 for surgical sterilization and 0.4 for chemical sterilization, while, in Bangladesh, these rates are 32.6 and 30.2, respectively. The greater safety of sterilization in developing countries is due, in part, to laparoscopy and the use of Falope rings or clips. Early complications requiring surgical intervention occur in 1.1% of laparotomic sterilization cases, 1.4% of minilaparotomies, and in 0.9-3.7% of laparoscopic sterilizations. The advent of microsurgical techniques has led to a drop in the ectopic pregnancy rate from 7-21% to 4-17%. In the US, 1.1% of women request sterilization reversal and 60% of such reversals result in an intrauterine pregnancy. Most successful are isthmo-isthmic and isthmo-ampullar anastomoses performed by skilled microsurgeons. The ultimate aim is to develop a noninvasive method of tubal sterilization that is fully reversible and can be performed in an outpatient setting.     

Surgical treatment of ectopic pregnancy

In most cases of ectopic pregnancy, medical treatment with methotrexate is successful. However, some cases still require surgery and laparoscopy is an effective approach. The candidates for surgical treatment include women who are not suitable to or have failed methotrexate treatment, those with heterotopic pregnancy, or those who are hemodynamically unstable. In women of reproductive age with tubal pregnancy, salpingostomy is the preferred surgical method. Conversely, salpingectomy is a better treatment for women with severely damaged fallopian tube, recurrent ectopic pregnancy in the same tube, uncontrolled bleeding after salpingostomy, large tubal pregnancy (> 5 cm), heterotopic pregnancy, and for those who have completed their family. Similar to treatment of a tubal pregnancy, cervical and interstitial pregnancy could be treated medically first. Most abdominal pregnancies are diagnosed late in pregnancy. However, when the diagnosis is made early, laparoscopic removal of the pregnancy should be performed.     

Prophylactic methotrexate after linear salpingostomy: a decision analysis

Objective: To compare two strategies for managing women after linear salpingostomy for treatment of tubal pregnancy: observation and prophylactic methotrexate.

Design: Decision analysis.

Setting: Outpatient tertiary-care center.

Patient(s): One thousand hypothetical women treated with a linear salpingostomy for ectopic pregnancy.

Intervention(s): Observation after salpingostomy and treatment of persistent ectopic pregnancy with a single dose of methotrexate (current standard of care) versus treatment with prophylactic methotrexate at the time of salpingostomy.

Main Outcome Measure(s): Number of ruptured ectopic pregnancies, surgical procedures, complications, and cost for each group (observation vs. prophylaxis).

Result(s): Prophylactic methotrexate results in fewer cases of tubal rupture (0.4% vs. 3.7%) and fewer procedures (1.9% vs. 4.7%) at a lower cost ($67.55 less/patient) compared with observation alone. Methotrexate-associated complications occur more frequently with prophylaxis (5.5% vs. 0.8%). Certain conditions change which strategy is preferable. Observation is the best strategy when the persistent ectopic pregnancy rate is <9%, the success of prophylaxis is <95%, the complication rate associated with methotrexate is >18%, or the rupture rate of persistent ectopic pregnancies is <7.3%.

Conclusion(s): Prophylactic methotrexate at the time of linear salpingostomy for the treatment of ectopic pregnancy is preferable to observation as long as certain conditions exist.     

Laparoscopic treatment of extensive pelvic adhesions, including hydrosalpinx

Sixty-seven women with extensive pelvic adhesions, including hydrosalpinx, underwent a laparoscopic surgical procedure over the past eight years. Only cases in which ovum pickup was greatly impaired by adhesions were included. Cases of extensive endometriosis or acute adhesions were excluded. Recent innovations in technique were used, including aquadissection, electrodissection, scissors dissection and laparoscopic suturing. Two women suffered transient unilateral brachial plexus injury; there were no other complications. No laparotomies were required. The viable pregnancy rate was 78% (21 of 27) for women who underwent salpingoovariolysis on the most favorable adnexa and 28.5% (2 of 7) for those with salpingostomy for hydrosalpinx. There was one ectopic pregnancy (3%). The outcome for 34 laparoscopically treated women compared favorably with that for 30 women with similar tubal factor infertility who were treated with laparotomy microsurgery; the viable pregnancy rate was 75% (9 of 12) for laparotomy salpingoovariolysis and 53% (8 of 15) for laparotomy salpingostomy, with an ectopic rate of 13% (4 of 30).     

Rendering follicle tubes permeable again after post-partum sterilization. A report on 25 cases. Should post-partum sterilization be performed or not?

This article discusses the success of microsurgical reversal attempts after postpartum tubal sterilization and assesses the risk of later reversal requests after postpartum sterilization. 25 of 37 requests for tubal sterilization reversals received by the authors between January 1977-December 1983 followed postpartum sterilizations. The only criteria were contraindications to another pregnancy, a history of bilateral salpingectomy, and existence of a serious hypofertility factor. No minimal tubal length was required. All reversal procedures were microsurgically performed by 3 operators. The average age of patients was 26.7 years at sterilization and 32.5 years at reversal. Ages ranged from 25 to 41 at reversal. The parity of the women ranged from 2 to 9 and averaged 4.2 children. The sterilization was performed during a cesarean section in 19 cases, of which 8 were emergency procedures. The indication for the sterilization was medical in only 7 cases. 20 of the procedures were tubal ligations and resections, 1 was application of a Yoon ring, and 4 were bilateral salpingectomies. Reasons for reversal requests were change of partner in 16 of 25 cases, death of an infant in 1 case, fear of repudiation by the husband in the cases of 4 Muslim women, and change of mind by the couple in 4 cases. 6 of the 25 women were unacceptable candidates for reversal, 4 because of bilateral salpingectomy and 2 because of poor tubal state and failure of previous surgery. 17 women underwent tubotubal anastomoses and 2 had tubouterine reimplantations. The reversal operations resulted in 12 term pregnancies, 1 spontaneous abortion, and 1 extrauterine pregnancy. The delays to pregnancy ranged from 1 to 18 months and averaged 6.6 months. The intrauterine pregnancy rate was 83% for reversals within 5 years of sterilization and 61% later. Age of the woman appeared to play no role. The postpartum period does not seem to be an ideal moment for sterilization because of its association with later requests for reversal. Several factors seem to be involved in requests for reversal, including young age at sterilization, the unpredictability of death in small children, and haste in making the initial sterilization decision. The policy of automatically recommending sterilization after a 3rd cesarean section should be reviewed since in many cases a successful delivery is still possible. Factors in successful reversal include the length of tube remaining, which is related to the sterilization technique employed, and the site of the sterilization, with ligations at the cornu and fimbriectomies giving poor results. The least mutilating forms of sterilization should be used in young women. Clips, rings, and ligations using absorbable thread with limited resection of the isthmus are reliable methods which have the advantage of not definitively compromising fertility. They can also be done by a simple laparoscopic procedure after the postpartum period.     

Microsurgery of Fallopian tubes]

Microsurgery can be performed on the Fallopian tubes to attempt to induce or restore fertility. Such operations should only be performed if a couple definitely wants a child and if there is at least a 15-30% chance of success. Acute genital or pelvic infections are contraindications to this type of surgery. Various statistics show that the rate of uterine pregnancy is 43.1% after salpingolysis, 34.6% for terminal salpingostomy, 33.3% for fimbriolysis or tubal implantation, and 12-13.9% for salpingostomy and implantation or medial ampullar salpingostomy. The techniques of microsurgery offer many advantages, e.g. the ability to coagulate the smallest capillaries to improve hemostatis, but this often leads to increased operation time. Diagnosis of tubal impassibility is obtained by laparoscopy with CO2 or chromopertubation. After the operation the patient undergoes hydropertubation treatment. As a control measure, CO2 or hydrochromopertubation is performed 4-6 weeks after the operation, if necessary.     

Tubal surgery. Report of 101 cases with special reference to the experience of the surgeon.

A report is given of the results of tubal surgery in 101 cases selected from 851 sterility patients. The follow-up time was 3-10 years. Ordinary surgical technique was applied with the use of prednisolone and antibiotics but largely without the use of polyethylene tubing or other splints. Fourteen surgeons were involved. Since the most experienced surgeon operated on about 30% of the cases, an assessment of the effect of the surgeon's skill was possible. The patients are divided into groups with regard to type of operation, and the result is judged with regard to conception, live birth, ectopic pregnancy and abortion as well as with regard to patency. After salpingolysis the conception rate was 52%, and after salpingostomy 32%. There was, however, a gap between the conception rate and the live birth rate, especially for the salpingostomy cases. The live birth rate was more than twice as high after salpingolysis than after salpingostomy. The small lasting effect of cut adhesions is also demonstrated by the observation that combined unilateral or bilateral lysis did not interfere with the result after salpingostomy. Contrary to this, the patients conceived faster after salpingostomy than after salpingolysis. There was no difference between the results in the patients operated on by the most experienced surgeon and in those treated by the thirteen less skilled gynecologists.