两种输卵管绝育术式安全性、有效性及可接受性的临床对比研究

目的:通过对局麻单孔腹腔镜双极电凝输卵管绝育术、经腹近端抽芯包埋输卵管绝育术的比较,评估局麻单孔腹腔镜输卵管绝育术的安全性、有效性、可接受性及两种术式术后对卵巢功能的近期及远期影响。方法:在贵州省14个项目县随机抽取2014年1-12月行局麻单孔腹腔镜双极电凝输卵管绝育术妇女914例(腹腔镜组)、经腹近端抽芯包埋输卵管绝育术妇女893例(经腹组),对两组术中观察和术后随访进行评估,同时对两组与未行输卵管绝育术(未绝育组)部分妇女,抽取不同时期静脉血进行卵巢功能评估。结果:腹腔镜组术中出血量、术后并发症发生情况、术后1个月卵巢功能等安全性指标优于经腹组(P均0.05),术中疼痛度、手术时间、术后疼痛感、留观时间、满意率等可接受性指标优于经腹组(P均0.05)。腹腔镜组和经腹组术后1个月基础性激素水平无显著改变,但经腹组术后基础FSH10U/L、基础FSH/LH升高2的比例显著高于腹腔镜组(P均0.05)。结论:局麻单孔腹腔镜手术是一种安全、有效、操作简单、痛苦小、恢复快,更易被手术对象接受的手术方法,对卵巢功能的近期影响小于经腹手术。     

绝育五年以上输卵管复通研究

本文是本科自1980年开展输卵管显微复通术系列研究一部份。临床实践在数次总结论著中均发现绝育5年以上复通受孕率低于5年内。基础研究对绝育者卵巢功能探测和绝育者输卵管近端形态学和超微结构包括扫描电镜和透射电镜,发现绝育者卵巢功能低下,绝育5年以上者输卵管有严重病变。为提高绝育5年以上复通受孕率,于1990年10月至1991年9月随机选择35例绝育5年以上做显微输卵管复通术,给予术前、术时、术后常规改进,术前诊刮,初步排除宫内病变和检测卵巢排卵功能,术时切除全部病变管腔组织和用腹膜代替缺损输卵管浆膜和系膜,使输卵管形态完整,有利于输卵管蠕动,术后加用3个月黄体酮和必要促排卵,补充复通者黄体不足,经1～3年随访,35例复通术后复孕率为100％,全部足月分娩。     

腹腔镜子宫切除术并输卵管切除对卵巢功能的影响

目的探讨腹腔镜全子宫切除术同时行输卵管切除对卵巢功能的影响。方法将子宫良性病变行腹腔镜全子宫切除术的患者120例,随机分为两组,其中观察组(同时行输卵管切除组)60例与对照组(保留输卵管组)60例。两组患者分别于术前及术后第1、3、12个月后相当于月经周期第三天抽血检测血清中抗苗勒管激素(AMH)、雌二醇(E2)、促黄体生成素(LH)、促卵泡刺激素(FSH)的水平,并进行术后随访。结果两组患者各时间点AMH、E2、LH、FSH水平比较,差异均无统计学意义(P>0.05);但两组AMH、E2水平随着时间延长而降低,FSH、LH水平随着时间延长而升高,差异有统计学意义(P<0.05)。结论腹腔镜全子宫切除术同时行输卵管切除并未增加手术难度、手术时间和手术风险。全子宫切除术会对卵巢功能造成不利的影响,但同时行除输卵管切除并未增加对卵巢功能的影响,故如果预防输卵管癌、卵巢浆液性癌或预防输卵管积水可以行子宫切除同时切除输卵管。     

单孔腹腔镜电凝与经腹抽芯包埋输卵管绝育术效果观察

目的:观察单孔腹腔镜电凝与经腹抽芯包埋输卵管绝育术的临床疗效差异。方法:2010年3月—2016年3月本院行输卵管绝育术400例,随机数字表法分两组各200例,分别予以经腹抽芯包埋输卵管绝育术(抽芯包埋组)或腹腔镜双极电凝输卵管绝育术(双极电凝组),记录两组手术情况,分别于治疗前后检测血清性激素水平,术后随访12个月内意外妊娠率和手术满意率。结果:两组输卵管绝育术均取得成功,术中出血量、手术耗时和术后住院时间,以及术后不良反应发生率双极电凝组(12.0%)均低于抽芯包埋组(21.5%)(P0.05);两组手术前后血清雌二醇(E_2)、促黄体生成激素(LH)、促卵泡生成素(FSH)和FSH/LH均未发生变化(P0.05),术后1个月,血清FSH10 U/L和FSH/LH2比例双极电凝组(9.0%、26.5%)均低于抽芯包埋组(17.5%、37.0%)(P0.05),术后12个月内两组意外妊娠率(0.0%、1.0%)无差异(P0.05);手术满意率术后1个月双极电凝组(97.5%)高于抽芯包埋组(92.5%)(P0.05),术后3、6、12个月两组逐渐升高,但组间无差异(P0.05)。结论:腹腔镜电凝与经腹抽芯包埋输卵管绝育术手术成功率高,均可达到有效的避孕作用,且腹腔镜电凝术较经腹抽芯包埋术操作更为简便,医源性创伤更小,康复期更短,术后不良反应更少,对卵巢功能的短期影响更小,妇女手术满意度较高。     

腹腔镜下异位妊娠保守性手术局部注射氨甲蝶呤对卵巢功能的影响

目的探讨腹腔镜下局部注射甲氨蝶呤治疗输卵管妊娠对卵巢功能及输卵管再通的影响。方法 2011年1月～2012年1月我院收治的输卵管异位妊娠84例,随机分为腹腔镜下输卵管开窗取胚术局部注射甲氨蝶呤组40例（试验组）和单纯腹腔镜下输卵管开窗取胚44例（对照组）;比较两组患者术后1个月,3个月和6个患侧卵巢体积、卵泡数量及雌二酮（E2）、卵泡刺激素（FsH）、黄体生成素（LH）激素水平有无差别。术后2个月行患侧输卵管通水试验,判断两组患者输卵管通畅情况。结果术后1个月、3个月和6个月两组患者卵巢体积、卵泡数量及E2、FSH和LH激素水平比较差别均无统计学意义（p〉0.05）;术后2个月时,试验组患侧输卵管通畅率为68%,对照组为41%,试验组明显高于对照组（p〈0.05）。结论腹腔镜下局部注射甲氨蝶呤治疗输卵管妊娠安全可行,可以明显提高术后患侧输卵管通畅率,且对患者术后卵巢功能无影响。     

腹腔镜卵巢囊肿剔除术对卵巢功能的影响

目的:研究腹腔镜采用单极电凝用于卵巢止血对卵巢功能的近期影响。方法:将单侧卵巢囊肿行囊肿剔除术60例随机分成两组,开腹组和腹腔镜组,所有患者于术前、术后1天、术后1个月抽血测定E2、P、T、FSH、LH的水平,并术后随访3个月。结果:两组病例术后第1天均出现E2下降,FSH升高,与术前比较差异有显著意义(P<0.05),但两组间E2、P、T、FSH、LH比较无差异(P>0.05),术后1月两组激素水平与术前比较差异无显著意义(P>0.05)。结论:开腹术和腹腔镜手术均对卵巢功能有一定的影响,但腹腔镜手术使用单极电凝不加重对卵巢功能的损害。     

输卵管绝育手术并发症发生原因及影响因素的前瞻性研究

目的:通过对输卵管绝育术前瞻性研究,分析绝育术并发症发生原因及影响因素,提出相关建议。方法:通过预防干预、诊断干预形成多环节的综合干预措施,分别观察干预组与对照组绝育手术并发症的发生率并分析原因。结果:干预组、对照组近期并发症发生率分别为0.88%、4.56%,两组差异有统计学意义(P(0.0001),远期并发症干预组、对照组分别为1.05%、0.46%。单因素分析结果显示:并发症发生的危险性与妇女年龄、痛经史、人流或流产/产后手术、既往患有妇科病史、输卵管取管指板法、输卵管折叠结扎切断法、术中提管困难等有关。多因素分析结果显示:对照组并发症的发病风险是干预组的7倍;采用输卵管折叠结扎切断法发生并发症的危险是输卵管抽芯近端包埋法的50倍;既往有妇科病史的妇女并发症发生率是正常妇女的4倍。结论:对于高风险人群(如年龄(35岁、既往有妇科病史等),应严格掌握适应证及禁忌证并谨慎手术。建议输卵管绝育取管采用吊钩法。输卵管绝育术术式采用并严格执行抽芯近端包埋法。     

腹腔镜卵巢良性肿瘤剥除术中不同方法处理残留卵巢对卵巢功能的影响研究

目的比较腹腔镜卵巢良性肿瘤剥除术中不同方法处理残留卵巢对卵巢功能的影响。方法将医院2006年12月-2010年7月行腹腔镜卵巢良性肿瘤剥除术的94例患者按照处理残留卵巢的方法分为两组,采用电凝方法止血的47例作为对照组,采用缝合方法止血的47例作为观察组,以雌二醇（E2）、黄体生成素（LH）和促卵泡激素（FSH）作为观察指标比较分析两组患者术后的卵巢功能情况。结果术后两组患者的E2降低,LH、FSH升高,但以观察组改善更为明显,与对照组比较,差异均有统计学意义（P〈0.05）;其中观察组单纯滤泡囊肿术后E2、LH、FSH情况改善更佳,与其他三种比较,差异均有统计学意义（P〈0.05）。结论腹腔镜卵巢良性肿瘤剥除术中不同方法处理残留卵巢对卵巢功能影响不同,采用缝合止血方法能够更好地保留患者的卵巢功能,应作为首选的处理方法之一。     

卵巢良性囊肿剔除术不同止血方式对育龄女性卵巢功能及生存质量的近期影响

目的 探讨卵巢良性囊肿剔除术不同止血方式对育龄女性卵巢功能及生存质量的近期影响.方法 行卵巢良性囊肿剔除术患者92例,按手术方式及术中止血方式分为三组:腹腔镜缝合止血组(31例)、腹腔镜电凝止血组(31例)、开腹缝合止血组(30例).比较三组患者术前1个月、术后6个月血清卵泡刺激素(FSH)、黄体生成素(LH)和雌二醇(E2)水平,术后6个月随访并进行Kupperman评分以评估生存质量.结果 腹腔镜缝合止血组术后6个月FSH、LH、E2与术前1个月比较差异无统计学意义[(6.22±1.69) U/L比(5.98±1.76) U/L、(6.04±1.27) U/L比(5.45±1.63) U/L、(51.05±13.44) ng/L比(54.98±18.57) ng/L,P＞0.05],腹腔镜电凝止血组和开腹缝合止血组术后6个月各指标与术前1个月比较差异均有统计学意义[腹腔镜电凝止血组:(8.24±2.79) U/L比(6.11±1.58) U/L、(7.63±1.86) U/L比(5.72±1.71) U/L、(41.20±12.09) ng/L比(51.34±21.28)ng/L,开腹缝合止血组:(6.65±1.36) U/L比(5.74±2.03) U/L、(6.32±1.51) U/L比(5.29±1.85) U/L、(44.41±12.52) ng/L比(53.16±23.29) ng/L,P＜0.05],腹腔镜电凝止血组术后6个月各指标与腹腔镜缝合止血组比较差异均有统计学意义(P＜0.05),开腹缝合止血组术后6个月FSH、LH与腹腔镜缝合止血组比较差异无统计学意义(P＞0.05),但E2比较差异有统计学意义(P＜0.05).术后6个月,腹腔镜缝合止血组和开腹缝合止血组Kupperman评分均明显低于腹腔镜电凝止血组[(7.25±4.61)分和(8.34±5.11)分比(13.27±5.32)分,P＜ 0.05],腹腔镜缝合止血组与开腹缝合止血组Kupperman评分比较差异无统计学意义(P＞0.05).患者均于术后8～50d月经来潮,月经周期、经量等较术前无明显改变.术后随访6个月,均未发生卵巢囊肿复发.结论 卵巢良性囊肿剔除术应用腹腔镜下缝合止血对育龄女性卵巢功能及生存质量的近期影响较小.     

绝育术后并发输卵管妊娠82例分析

<正> 绝育术失败造成输卵管妊娠是其严重并发症之一,故应加强防治。回顾我区1986～1992年期间共手术治疗输卵管妊娠128例,其中输卵管绝育术后并发输卵管妊娠占64.06％(82/128)。本文对绝育术后并发输卵管妊娠的发病原因及预防措施进行总结分析。 一、一般资料 1.发病年龄 年龄19～42岁,以25～35岁生育旺盛时期者居多,占86.59％。 2.发病时间 绝育术后发生输卵管妊娠最短半年,最长9年,1～2年者15例,2～4年者48例,4年以上者19例,以绝育术后2～4年者居多占58.53％。     

Contraceptive sterilization use among married men in the United States: results from the male sample of the National Survey of Family Growth

Background

Surgical sterilization has many advantages. Previous information on prevalence and correlates was based on surveys of women.

Study Design

We estimated the prevalence of vasectomy and tubal ligation of partners for male participants in the 2002 National Survey of Family Growth, a nationally representative survey of US residents aged 15-44 years. We identified factors associated with sterilizations using bivariate and multivariate techniques.

Results

The findings revealed that 13.3% of married men reported having had a vasectomy and 13.8% reported tubal sterilization in their partners. Vasectomy increased with older age and greater number of biological children, non-Hispanic white ethnicity, having ever gone to a family planning clinic. Tubal sterilization use was more likely among men who had not attended college, those of older age and those with live births.

Discussion

One in eight married men reported having vasectomies. Men who rely on vasectomies have a somewhat different profile than those whose partners have had tubal sterilizations.     

输卵管注药绝育术有效性及安全性的前瞻性流行病学研究

本文为一项输卵管注药绝育术的前瞻性队列研究。队列1使用显影苯酚胶浆共834例,队列2使用8%阿的平苯酚糊剂871例。二年随访率98.5%。生命表法分析,第24个顺序月每100名妇女的累积成功率两队列分别为91.9%和97.4%。其间有显著性差别。绝育效果主要取决于输卵管注药后X光显影的充盈长度。多元判别分析也显示同样的结论。所有研究对象在术中和术后未见严重并发症。术后发烧,队列2 (8%)高于队列1(4.4%)。本术对月经无明显影响。研究结果表明该术是一种简便、安全、有效的女性绝育术。     

输卵管复通术失败后再次显微复通术效果观察

目的:探讨输卵管绝育后复通失败的原因和再次显微手术复通的效果。方法:对178例输卵管复通术失败者行再次显微复通术时的发现(粘连、炎症等)和再次复通术的效果进行分析。结果:178例再次显微复通输卵管356条,首次吻合部位粘连扭曲呈团状占49·44%(176/356),吻合部位有漏管形成占34·27%(122/356),单纯吻合部位堵塞占26·97%(96/356),输卵管伞端与卵巢粘连占9·55%(34/356),首次手术支架未取出占2·81%(10/356),在首次复通术时结扎术废用部分输卵管未切除占56·74%(202/356)。再次复通手术后随访2年以上,宫内妊娠率64·61%(115/178),其中足月分娩率64·04%(114/178);自然流产率2·25%(4/178),其中3例自然流产后又妊娠足月分娩;异位妊娠率1·12%(2/178)。结论:输卵管结扎后首次复通术造成吻合部位的粘连扭曲致输卵管不通是失败的主要原因,其它原因还有吻合部位漏管形成、结扎部废用输卵管切除不充分、输卵管伞端与卵巢粘连等。再次复通术后的宫内妊娠率较首次复通术明显下降。因此,首次输卵管复通术时的规范操作是提高复通术妊娠率的关键。     

Identifying women who will request sterilization reversal in a military population

OBJECTIVE: We sought to identify the characteristics of women in a military population who are likely to seek a tubal anastomosis after a previous bilateral tubal ligation (BTL). METHOD: A written investigational review board-approved questionnaire was administered to 56 women, ages 18-40 years, requesting evaluation for a reversal of a prior BTL and 52 women of the same age range not seeking reversal. The questionnaire identified demographics and relationship characteristics of volunteers at the time of their decision to have a BTL and at the present time. RESULTS: Age 25 years or younger, sterilization due to pressure from a partner, poor marital relationship at the time of the BTL and a new marriage are highly predictive of tubal sterilization regret and a request for sterilization reversal in a military population. In addition, women requesting a tubal anastomosis reported less preoperative counseling on the permanence of a BTL and of the male alternative for permanent female sterilization, vasectomy. CONCLUSION: Women with these characteristics should have extensive counseling before undergoing tubal sterilization.     

Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy

Objective

Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers.

Study Design

We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively.

Results

With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved.

Conclusion

A revised Medicaid sterilization policy could potentially honor women’s reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds.

Implication

Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.     

Probability of pregnancy after sterilization: a comparison of hysteroscopic versus laparoscopic sterilization

Objective

To compare the expected probability of pregnancy after hysteroscopic versus laparoscopic sterilization based on available data using decision analysis.

Study design

We developed an evidence-based Markov model to estimate the probability of pregnancy over 10 years after three different female sterilization procedures: hysteroscopic, laparoscopic silicone rubber band application and laparoscopic bipolar coagulation. Parameter estimates for procedure success, probability of completing follow-up testing and risk of pregnancy after different sterilization procedures were obtained from published sources.

Results

In the base case analysis at all points in time after the sterilization procedure, the initial and cumulative risk of pregnancy after sterilization is higher in women opting for hysteroscopic than either laparoscopic band or bipolar sterilization. The expected pregnancy rates per 1000 women at 1 year are 57, 7 and 3 for hysteroscopic sterilization, laparoscopic silicone rubber band application and laparoscopic bipolar coagulation, respectively. At 10 years, the cumulative pregnancy rates per 1000 women are 96, 24 and 30, respectively. Sensitivity analyses suggest that the three procedures would have an equivalent pregnancy risk of approximately 80 per 1000 women at 10 years if the probability of successful laparoscopic (band or bipolar) sterilization drops below 90% and successful coil placement on first hysteroscopic attempt increases to 98% or if the probability of undergoing a hysterosalpingogram increases to 100%.

Conclusion

Based on available data, the expected population risk of pregnancy is higher after hysteroscopic than laparoscopic sterilization. Consistent with existing contraceptive classification, future characterization of hysteroscopic sterilization should distinguish “perfect” and “typical” use failure rates.

Implications

Pregnancy probability at 1 year and over 10 years is expected to be higher in women having hysteroscopic as compared to laparoscopic sterilization.     

聚氨酯铋输卵管栓堵术18～24个序月的临床研究

为进一步了解聚氨酯铋输卵管栓堵的效果,采用一次性医用带囊双腔管,经宫腔注入聚氯酯铋行输卵管栓堵术585例,观察18～24个序月的栓堵效果及术后X光片显影,对10例术后检查输卵管通畅者实行补做。结果,随访至18个月者409例(70％);24个月者176例(30％),11例妊娠均发生在18个月内。术后2～3个月行输卵管通畅试验,其中造影者132例,123例堵塞成功;通水试验442例,成功383例。总成功率为86.7％,累积妊娠率为1.8％,无术中术后反应。经宫腔注入高分子材料的输卵管栓堵术为一种简便价廉、无副反应、不经腹部的输卵管绝育术。术后X光片检查双显者可做为成功指标,术后不能肯定者,需做输卵管通畅试验。不成功者立即补做,可提高成功率。     

Improving hysterosalpingogram confirmatory test follow-up after Essure hysteroscopic sterilization

Background

Given the need for a 90-day post-Essure hysterosalpingogram (HSG) to confirm proper tubal placement and occlusion, we examined the impact of dedicating a staff nurse to schedule HSG appointments, call with appointment reminders and track HSG compliance for patients who had Essure.

Study Design

We performed a retrospective chart review for patients who underwent Essure sterilization between October 2003 and January 2009. We compared rates of HSG compliance and confirmed tubal occlusion for patients before February 2008 with rates after the protocol change occurred.

Results

Seventy-eight percent of preintervention patients were compliant with at least one HSG following Essure placement compared to 90.9% in the post-intervention group (p value=.033). Tubal occlusion was confirmed by postprocedure HSGs for 123/173 patients (71.1%) in the preintervention group and 48/55 patients (87.3%) in the postintervention group. Patients followed by our staff after our protocol change were more likely to undergo post-Essure compliance (Odds ratio= 2.7, confidence interval = 1.2–7.1, p=.01).

Conclusion

Dedicating a staff nurse to track patients' HSG follow-up as a multicheck system resulted in an improvement in HSG compliance and rates of confirmed tubal placement and occlusion.