宫腹腔镜联合手术诊治不孕症120例分析

目的探讨宫、腹腔镜联合手术在女性不孕症诊治中的应用优势。方法联合应用宫、腹腔镜对120例不孕症患者进行检查,并对病因明确者行相应治疗。结果盆腔粘连和输卵管阻塞是造成妇女不孕的主要原因。子宫内膜异位症和卵巢疾病也是常见因素。术后妊娠率达43．8％。结论应用宫、腹腔镜联合诊治不孕症患者能直观、准确、全面地明确盆腔、官腔疾患,并予以针对性治疗,提高手术疏通输卵管的成功率,提高女性不孕患者的妊娠率。     

宫腹腔镜联合手术在诊治不孕症中的临床应用

目的:探讨宫腔镜-腹腔镜联合手术在诊治不孕症手术中的要点和临床应用价值。方法:采用宫、腹腔镜联合手术治疗52例不孕症患者,并视术中的不同情况,选择不同的手术方式,术中评价手术效果。结果:52例病人全部明确不孕病因。镜下确诊子宫肌瘤11例,子宫发育畸形5例,子宫内膜异位症8例,结核2例,盆腔炎症31例。梗阻28例,多囊卵巢9例,子宫内膜息肉9例,卵巢囊肿8例。结论:应用宫腹腔镜联合手术可对不孕症做出明确病因诊断。     

Investigation of the infertile couple: should diagnostic laparoscopy be performed after normal hysterosalpingography in treating infertility suspected to be of unknown origin?

Traditionally, a diagnosis of unexplained infertility is established only when all standard clinical investigations yield normal results. When tubal patency has been established by hysterosalpingography (HSG), laparoscopy has been suggested as a mandatory step to preclude the existence of peritubal adhesions and endometriosis as causes of infertility. In women without a previous history suggestive of tubal disease and who have a normal HSG, it was demonstrated that the probability of clinically relevant tubal disease or endometriosis is very low and that laparoscopy does not seem justified or cost effective. In the minority of these cases, laparoscopy might reveal minimal or mild endometriosis or peritubal adhesions. In these cases, either surgery or medical treatment has not been proven to improve fecundity. With the current success rates of assisted reproductive technologies (ART) and the relatively low contribution of diagnostic laparoscopy to the decision-making process of treating patients with a normal HSG, we suggest that laparoscopy should be omitted in couples suspected of having unexplained infertility. These patients should be treated by 3-6 cycles of combined gonadotrophins and intrauterine insemination, and if unsuccessful switched to ART.     

Pelviscopic tubal surgery: the acceptable vogue

A retrospective analysis undertaken at the University of Kiel by the Department of Obstetrics and Gynaecology, consisted of a 3-year study of cases of tubal surgery with operative pelviscopy (laparoscopy). In the period from 1987 to 1989, 529 patients underwent selective operative laparoscopy specifically because of a tubal factor of infertility. The type of surgery performed was aimed at the conservation and salvaging of the tubes whenever possible, according to the principles of 'Minimally Invasive Surgery'.     

Therapeutic strategies in tubal infertility with distal pathology.

Since 1980, various treatments have been proposed for patients suffering from distal tubal infertility. Difficult choices between surgical (microsurgery/laparoscopy) treatments and in-vitro fertilization (IVF) still confront many workers. In this study, we evaluated the cumulative results of both therapeutic methods for this group of patients. From 1979 to 1990, 266 patients with distal tubal infertility were operated in our programme (group M: microsurgery, n = 211; group L: laparoscopy, n = 55). In group M, pathological findings were hydrosalpinges (n = 135) and incomplete distal tubal occlusion, (n = 76) and in group L hydrosalpinges (n = 31) and incomplete distal tubal occlusion (n = 24). After differing time intervals, IVF was proposed for these patients when no pregnancy occurred. The results were as follows: in group M, 35.5% intra-uterine pregnancy (IUP) and 6.6% ectopic pregnancy (EP) after fimbrioplasties versus 28.1% IUP and 11.9% EP after salpingostomy; in group L, 16.6% IUP and 4.2% EP after fimbrioplasty versus 12.9% IUP and 6.5% EP after salpingostomy. Following IVF, 55.7% of patients in group M and 14.5% in group L became pregnant. The cumulative results including both treatment techniques (surgery and IVF) show an average of 70% and 65% pregnancy rates in groups M and L respectively. The best results after surgery and throughout IVF were obtained during the first year. It is concluded that a short delay after surgery, averaging 6 months to 1 year, before involving patients in IVF, is very important.     

Combining B-mode ultrasound with pulsed wave Doppler for the assessment of tubal patency

This study was conducted to determine whether the additional use of pulsed wave Doppler improves the diagnostic capacity in assessing tubal patency by hysterosalpingo contrast sonography (HyCoSy). A total of 210 women with a history of infertility were included in this study. HyCoSy was performed after intrauterine injection of Echovist 200. For the assessment of tubal patency B-mode scanning and pulsed wave Doppler ultrasound were performed in the proximal and distal tubal segments. With the combined sonographic procedure 297 tubes (74%) were rated patent, 35 (8%) incompletely obstructed and 70 (18%) completely obstructed. A total of 252 tubes were additionally examined by laparoscopy for reference purposes. Concordant results for both methods were found in 92% of tubes, nine had been rated false negative and 10 tubes appeared to have been rated false positive. The combined sonographic specificity was found to be 85% with a sensitivity of 95%. Peritubal adhesions detected by laparoscopy were found to be the reason for false positive sonographic results in 60% of cases. In conclusion, the combined B-mode and pulsed wave Doppler examination appears to be a non-invasive and low-cost test for the assessment of tubal patency, which should be performed during diagnostic work-up for infertility.      

Is routine diagnostic laparoscopy for infertility still justified? A pilot study assessing the use of hysterosalpingo-contrast sonography and magnetic resonance imaging

We assessed the value of hysterosalpingo-contrast sonography (HyCoSy) and magnetic resonance imaging (MRI) as alternatives to laparoscopy and dye insufflation with or without hysteroscopy in the investigation of infertility. A total of 19 women had all three procedures, in addition, one became pregnant after HyCoSy alone. The findings were: uterine fibroids (n = 5), minimal-mild endometriosis (n = 4) and moderate- severe endometriosis (n = 3) including one case of bilateral endometriomas, endometrial polyp (n = 1), polycystic ovaries (n = 2), bilateral dermoid cysts (n = 1), haemorrhagic corpus luteal cyst (n = 1) and minimal adhesions (n = 3). At laparoscopy, 31/37 tubes were patent and there was 84% concordance with the tubal patency findings at HyCoSy. The uterine fibroids and ovarian cysts were detected using transvaginal scanning; the endometrial polyp and a congenital uterine anomaly were identified using HyCoSy. These findings were detected using MRI, but in addition the technique distinguished the dermoid cysts from the endometriomas, identified the two other cases of moderate-severe endometriosis, fibroids <2 cm (n = 2) and adenomyosis (n = 5), and interpreted the haemorrhagic corpus luteum as an endometrioma. Our data suggest that women with normal HyCoSy and MRI findings have a normal pelvis and may not need routine surgical investigation.      

腹腔镜诊治输卵管结核性不孕症的临床分析

目的探讨腹腔镜在诊治输卵管结核性不孕中的临床价值。方法对本院7年中经腹腔镜确诊的输卵管结核性不孕症患者42例临床资料进行回顾分析。结果本组患者确诊时平均年龄（29．6±3．5）岁，原发性不孕33例，继发性不孕9例。腹腔镜术前常规行诊刮术排除官腔结核。腹腔镜下双侧输卵管受累者28例，单侧受累14例，镜下主要表现有输卵管肿胀、卷曲、僵硬、表面有粟粒样结节，管腔内有干酪样物质，盆腔存在不同程度粘连。对于轻度粘连者行分离粘连后予以通液治疗，输卵管梗阻严重者镜下作输卵管间质部电凝结扎，术后本组自然妊娠率5．5％。13例患者接受IVF-ET治疗，4例妊娠。结论腹腔镜检查可提高输卵管结核诊断准确性，并行初步治疗。输卵管结核术后复通并有正常功能者较少，术后自然妊娠率低。病变严重者作输卵管电凝结扎并抗结核治疗，通过辅助生育治疗有希望解决不孕症问题。     

Tubal surgery in the era of assisted reproductive technology: clinical options

We reviewed the place of tubal surgery in the era of assisted reproductive technology. Reversal of tubal ligation is one of the main indications for tubal microsurgery. Adhesiolysis has the best results if the adhesion is the only factor responsible for infertility. There are no differences between adhesiolysis by laparoscopy or by laparotomy, and so laparoscopy must be preferred. Proximal tubal obstructions can be successfully treated by microsurgical tubocornual anastomosis. As far as distal tubal lesions are concerned, success rates depend strictly on the pre-existing tubal disease in distal tubal lesions and tubal surgery frequently fails; in-vitro fertilization (IVF) must therefore be considered in such circumstances. In conclusion, we think that IVF and tubal surgery must be considered to be complementary rather than competitive procedures. Adequate selection of patients is crucial to find the best therapeutic approach.     

The prognostic role of salpingoscopy in laparoscopic tubal surgery

The present study was designed to evaluate the prognostic value of salpingoscopy in patients undergoing tubal laparoscopic surgery for infertility due to periadnexal adhesion or distal tubal occlusion. In addition, the clinical value of salpingoscopy was compared with a current classification system of adnexal adhesions and distal tubal occlusion. A total of 51 patients with either adnexal adhesions (24 patients) or hydrosalpinx (27 patients) were prospectively evaluated. Salpingoscopy was performed concomitantly with salpingo-ovariolysis or salpingoneostomy at the time of operative laparoscopy. There was no significant correlation between salpingoscopic classes and the classification system used for both the salpingo-ovariolysis and the salpingoneostomy groups of patients. The patients had a mean follow-up of 33 months. Patients with a normal tubal mucosa (salpingoscopic classes I and II) had a 71% cumulative term pregnancy rate in the salpingo-ovariolysis group and a 64% cumulative term pregnancy rate in the salpingoneostomy group. No intrauterine pregnancies were obtained in patients with intratubal damage (salpingoscopic classes III to V). There was a statistically significant correlation between the occurrence of a term pregnancy and the salpingoscopic classes, but not with the classification system used. These results suggest that patients with tubal infertility should be offered operative laparoscopy with salpingoscopy as the first step of treatment.     

The value of Chlamydia trachomatis antibody testing in predicting tubal factor infertility

BACKGROUND: The objective of the present study was to compare the likelihood of abnormal Chlamydia trachomatis antibody test results with that of abnormal hysterosalpingography (HSG) test results in patients with tubal factor infertility. METHODS: Anti-C. trachomatis immunoglobulin G antibodies were determined prospectively in 295 infertility patients by means of an indirect fluorescent antibody technique. In 48 of the 295 patients both HSG and laparoscopy with chromotubation were performed. The results of C. trachomatis antibody testing were compared with the results of HSG with respect to their predictive value of tubal factor infertility. Likelihood ratios for abnormal C. trachomatis antibody and HSG test results were determined in infertility patients, as assessed by laparoscopy. RESULTS: The positive likelihood ratio for C. trachomatis antibody testing was 1.8. This was comparable with the HSG, which had a positive likelihood ratio of 1.7. CONCLUSIONS: The predictive value of C. trachomatis antibody testing was equal to that of HSG, but ratios of 1.7 and 1.8 indicate a poor test, so both C. trachomatis antibody testing and HSG have a poor predictive value. C. trachomatis antibody testing causes minimal inconvenience to the patient, in contrast to HSG, and therefore should be maintained in infertility examinations.     

经阴道超声和HSG诊断子宫畸形的对比分析

目的探讨经阴道超声和子宫输卵管造影(HSG)在诊断子宫畸形中的价值。方法收集2009年4月至2010年12月在复旦大学附属妇产科医院因不孕就诊的患者共61例,均进行经阴道超声检查和子宫输卵管造影术(HSG)检查,所有患者进一步做宫腔镜或宫腹腔镜联合检查确诊,从而对比两种检查方法的诊断准确率及误诊率。结果经阴道超声和HSG对单角子宫的误诊率均为7.0%,符合率均为95.1%;经阴道超声对双子宫的漏诊率为0%,符合率为100.0%,而HSG对双子宫的漏诊率为10.0%,符合率为96.7%;经阴道超声对纵隔子宫的漏诊率0%,符合率为100.0%,而HSG对纵隔子宫的漏诊率为15.0%,符合率为91.8%。结论经阴道超声检查对纵隔子宫、双子宫等子宫畸形的诊断符合率高于HSG,是准确、无创的检查方法。对于复杂的、不典型的子宫畸形,上述两种方法诊断还有一定困难,还需要结合宫腔镜或宫腹腔镜联合明确诊断。     

腹腔镜在治疗输卵管、卵巢性不孕症诊治中的应用

目的:探讨腹腔镜在输卵管、卵巢性不孕症治疗中的疗效及影响因素.方法:对35例不孕症患者行腹腔镜诊疗,其中原发性不孕症11例、继发性不孕症24例.结果:35例手术均顺利,无并发症.术后29例获随访,随访3～18个月,术后宫内妊娠率达37.93%(11/29).结论:腹腔镜手术对输卵管远端阻塞、盆腔粘连及肿块导致输卵管扭曲的不孕症有良好的治疗效果,对不明原因的不孕症能尽早明确诊断.     

Effect of endometriosis on IVF/ICSI outcome: stage III/IV endometriosis worsens cumulative pregnancy and live-born rates

BACKGROUND: Women with endometriosis often need IVF to conceive-most women need several cycles of treatment. METHODS: To evaluate the impact of moderate to severe endometriosis on cumulative IVF outcome, we carried out an observational study on 98 consecutive women who underwent IVF or ICSI treatment and had endometriosis diagnosed by laparoscopy or laparotomy and classified as minimal to mild endometriosis (American Society for Reproductive Medicine I/II) (n = 31) or moderate to severe endometriosis (American Society for Reproductive Medicine III/IV) (n = 67). The reference group consisted of 87 consecutive women with tubal infertility. The main outcome measures were cumulative pregnancy and live birth rates. RESULTS: There was a significantly lower pregnancy rate per fresh embryo transfer after pooled cycles (1-4) among women with stage III/IV endometriosis (22.6%) compared to stage I/II group (40.0%) or tubal infertility (36.6%). After 1-4 IVF/ICSI treatments, including frozen embryo transfer, 56.7% of the women with stage III/IV endometriosis were pregnant and 40.3% gave birth. The corresponding values were 67.7/55.8% when endometriosis was stage I/II and 81.6/43.7% in the controls respectively. CONCLUSION: Stage III/IV endometriosis means a worse prognosis for IVF/ICSI treatments compared to milder stages or tubal factors. Lower implantation and multiple pregnancy rates offer some support to our practice to continue two embryo transfers in this group.     

Hysterosalpingography: a potential alternative to laparoscopy in the evaluation of tubal obstruction in infertile patients?

BackgroundEvaluation of the fallopian tubes are important for infertile patients. The two most important diagnostic procedures used to evaluate tubal patency are hysterosalpingography and laparoscopy.ObjectivesTo asses the hysterosalpingography and laparoscopy results of patients diagnosed with infertility and investigate the diagnostic value of hysterosalpingography in patients with tubal factor infertility.MethodsThe hysterosalpingography and laparoscopy results of 208 patients who presented to the Obstetrics and Gynecology Clinic at Dicle University, Faculty of Medicine between January 2014- January 2018 were retrospectively evaluated. Hysterosalpingography and laparoscopy results were compared with regard to the investigation of the presence of tubal obstruction and of the pelvic structures that could cause tubal obstruction. The specificity, sensitivity, positive, and negative predictive values of hysterosalpingography were computed.ResultsThe number of patients evaluated was 208. The ratio of primary infertile patients was 57.2% and 42.8% was secondary infertile. Hysterosalpingography was found to have a specificity of 64.6%, the sensitivity of 81.3%, the positive predictive value of 56.4%, and a negative predictive value of 86% in the determination of tubal obstruction.ConclusionPatients with suspected tubal infertility can primarily be examined using hysterosalpingography in consideration of the invasive nature and the higher complication rate of laparoscopy.     

Investigation of tubal infertility by radionuclide migration.

Investigation of the tubal factor in infertility is limited to an assessment of anatomical structure and tubal patency. No test of ascendant tubal function is currently available. The migration of radionuclide (99mTc-labelled human albumin microspheres) through the genital tract in 96 infertile women was compared with pelvic findings at laparoscopy and chromopertubation. The radionuclide test correlated with laparoscopy in the diagnosis of patency or blockage in 83 cases (86%). In nine patients, where 'blockage' was diagnosed on the radionuclide test but patency found at laparoscopy, a higher prevalence of pelvic abnormality was found, compared to the 78 patients where both tests demonstrated patency (P less than 0.02). The radionuclide test may facilitate detection of diseased but patent tubes and, as an adjunct to laparoscopy and chromopertubation, may provide useful information about tubal function.     

A review of 254 ectopic pregnancies in a teaching hospital in the Trent Region, 1977-1990.

A total of 254 cases of ectopic pregnancy were reviewed in a teaching hospital in Sheffield, in three defined periods: I, 1977-9; II, 1985-7 and III, 1988-90. A previous history of infertility was noted in 37% of cases. Overall, the presenting symptoms, clinical, laboratory, operative as well as histological findings, are in broad agreement with other series. The incidence increased steadily from 8.6 per 1000 total births in period I to 16.5 per 1000 total births in period III. A number of changes noted in recent years include: (1) the diagnosis of ectopic pregnancy was made significantly (P less than 0.05) earlier; (2) a significantly (P less than 0.05) greater proportion of ectopic pregnancies had an association with the following factors: previous tubal surgery, the diagnosis established with ultrasonography, laparotomy preceded by laparoscopy and treatment by conservative surgery; and (3) a significantly (P less than 0.05) smaller proportion of ectopic pregnancies had the diagnosis based on pelvic tenderness or pelvic mass. During the period 1988-90 a total of 126 laparoscopies were performed for suspected ectopic pregnancy, of which 82 (65%) were confirmed to have ectopic pregnancy and 44 (35%) were thought to have no evidence of ectopic pregnancy on laparoscopy. However, two of the latter cases were subsequently found to have an ectopic pregnancy within 2 weeks. The clinical implications of these findings are discussed.     

Assessment of tubal patency with transvaginal salpingosonography after treatment for tubal pregnancy

Tubal patency was studied in 32 patients who had previously undergone a laparoscopic or laparotomy procedure (salpingostomy, salpingectomy or tubal resection), or who had received a local injection of hypertonic glucose because of tubal pregnancy. Transvaginal salpingosonography (TSSG) was subsequently performed in the follicular phase of the menstrual cycle, and laparoscopic chromopertubation was carried out as a comparative method after TSSG. Of 32 patients (47 Fallopian tubes examined), the affected tube was observed to be patent by TSSG in 68%. The contralateral tube was patent in 93%. Nine patients became pregnant and were thus not subsequently assessed with laparoscopy. Two of these pregnancies ended in a miscarriage and one in a recurrent tubal pregnancy. A concordance of 86% for Fallopian tubes was achieved between the TSSG and laparoscopic chromopertubation methods. When checking the Fallopian tubes separately, the concordance for the results in the affected tubes was 67%, and 100% for the contralateral tube. Therefore TSSG appears to be a practical method for the primary examination of tubal patency in patients treated previously for tubal pregnancy. Guidelines for the treatment of infertility after tubal pregnancy can also be set out according to TSSG findings.      

Successful oocyte donation after stage 1C serous ovarian cancer

A stage 1C serous epithelial cancer was discovered and treated during laparoscopy performed for infertility investigation. An immediate in- vitro fertilization (IVF) was scheduled to obtain frozen embryos. Oncological treatment was then completed by radical surgery (with uterine conservation) and chemotherapy. Two years later, the thawed embryos were unsuccessfully transferred. However, following oocyte donation, the patient became pregnant and delivered two babies. From this observation, the authors discuss the strategy required in cases of early ovarian cancer associated with infertility.      

Usefulness of transvaginal hydrolaparoscopy in investigating infertile women with Chlamydia trachomatis infection

BACKGROUND: A new technique called transvaginal hydrolaparoscopy (THL) was recently developed for the exploration of the tubo-ovarian structures in infertile patients without obvious pelvic pathology. This study was performed to investigate the usefulness of THL to evaluate Chlamydia trachomatis tubal infertility. METHODS: Forty-one women with primary and secondary infertility participated in this study. Fourteen had past C. trachomatis infection. In 38 (92.7%) of the 41, access to the pouch of Douglas was obtained. In total, 71 (93.4%) out of 76 adnexa were clearly visualized. Thirty-seven patients were analysed and compared their tubal passages and peritubal adhesions using both hysterosalpingography (HSG) and THL. Twenty-four tubes from 14 patients with past C. trachomatis infection and 44 tubes from 23 patients without a history of C. trachomatis infection were compared. RESULTS: For the diagnosis of the tubal passage, there were no significant differences in the discrepancy rates between HSG and THL, in patients with and without past C. trachomatis infection. In 14 (58.3%) of the 24 tubes from patients with past C. trachomatis infection and in eight (18.2%) of the 44 tubes from patients without infection, peritubal adhesion was diagnosed only by THL. There was a significant difference in the discrepancy rates of the diagnosis of peritubal adhesion between HSG and THL in the two groups (P = 0.0007 ). CONCLUSIONS: These results suggest that C. trachomatis infection is highly associated with peritubal adhesion which is difficult to diagnose by HSG. Therefore, in C. trachomatis antibody-positive patients, exclusion of tubal pathology by THL or standard laparoscopy should be carried out to consider appropriate treatments. Although THL is not a substitute for laparoscopy, it can be proposed as a first line procedure in the early stages of the infertility investigation.