生育镜在不孕症诊治中的应用

目的探讨生育镜用于不孕症诊治的价值。方法用生育镜[包括经阴道注水腹腔镜（THL）与宫腔镜]对115例不孕症患者进行盆腔检查,观察内容包括输卵管通畅性、盆腔粘连情况等,以及盆腔完全评价率（即盆腔器官是否能被生育镜全部观察到）及术中、术后并发症。同时行THL下输卵管通液术和宫腔镜下输卵管口插管通液术。穿刺套管针成功从后穹窿穿刺入子宫直肠陷凹110例,其中原发性不孕（原发组）49例,继发性不孕（继发组）61例。既往输卵管检查为双侧阻塞者,原发组21例,继发组22例。结果术后输卵管双侧或一侧通畅者原发组34例（69．4％,34／49）,继发组42例（68．9％,42／61）,两组比较,差异也无统计学意义（P〉0．05）;既往输卵管检查为双侧阻塞者,术后双侧或一侧输卵管通畅者原发组10例（47．6％,10／21）,继发组11例（50．0％,11／22）,两组比较,差异无统计学意义（P〉0．05）。盆腔粘连者原发组21例（42．9％,21／49）,继发组37例（60．7％,37／61）,两组比较,差异无统计学意义（P〉0．05）。两组总的盆腔完全评价率为69．1％（76／110）,其中原发组为77．6％（38／49）,继发组为62．3％（38／61）．两组比较,差异无统计学意义（P〉0．05）。术后需行常规腹腔镜手术者20例（18．2％,20／110）,原发组与继发组分别为4例（8．2％,4／49）和16例（26．2％,16／61）,两组比较,差异有统计学意义（P〈0．05）;其中17例接受了微型腹腔镜手术。术中无盆腔脏器损伤、出血、直肠损伤或穿孔,术后无穿刺部位出血及盆腔感染等并发症发生。结论生育镜用于不孕症的诊治,操作简单、微创、安全、患者依从性好;对于临床或超声检查均无明显盆腔疾病证据的不孕症患者,生育镜可以取代经腹腹腔镜,成为一步到位的盆腔检查方法。     

经阴道注水腹腔镜在输卵管妊娠保守治疗中的应用

目的:探讨经阴道注水腹腔镜(THL)下甲氨蝶呤(MTX)注射对输卵管妊娠保守治疗的可行性、临床效果和安全性.方法:选择25例要求保守治疗的输卵管妊娠患者实行THL下输卵管注射MTX治疗(研究组),记录阴道后穹隆穿刺成功率、手术时间、保守治疗失败率,与单次肌内注射MTX组23例(对照组)比较术后7天血β-HCG下降率、住院时间、治疗失败率.观察研究组术后并发症.结果:研究组22例穿刺成功,穿刺成功率88.00%(22/25),3例严重盆腔粘连和1例术中出血患者,转行经腹腹腔镜手术,手术失败率16.00%(4/25),平均手术时间为25.54±2.50分钟.研究组术后7天血β-HCG平均下降率为(52.90%),与对照组(33.61%)比较,差异有统计学意义(P<0.05);两组平均住院时间分别为11.91±3.53天、16.00 ±6.40天,差异有统计学意义(P<0.05);治疗失败率分别为16.00%(4/25)、17.39%(4/23),两组比较差异无统计学意义(P>0.05).21例THL下MTX输卵管注射患者术中无直肠损伤,无术后穿刺部位出血、盆腔感染等并发症发生.结论:THL下MTX输卵管注射治疗输卵管妊娠是安全、可行、有效的方法.     

经阴道注水腹腔镜盆腔粘连松解术治疗不孕症的临床观察

目的 探讨经阴道注水腹腔镜盆腔粘连松解术(THLPA)治疗不孕症的安全性和有效性.方法 自2007年5月至2008年9月,对30例不孕患者进行THLPA,术中同时行输卵管染色通液术及宫腔镜检查与宫腔镜输卵管口插管通液术.盆腔粘连评分按照美国生育学会(AFS)1985年修订的子宫内膜异位症分期法(r-AFS)标准进行.按总分将盆腔粘连分为轻度粘连(24例,1～9分)、中度粘连(5例,10～19分)、重度粘连(1例,≥20分).记录手术时间与术后离院时间、盆腔粘连评分与粘连松解情况、输卵管通畅性、并发症及术后妊娠情况.结果 (1)THLPA:除7条输卵管近端周围的少量薄膜粘连未松解,5个卵巢的固有韧带处的少量薄膜粘连未松解外,其余所有盆腔薄膜粘连均被松解.全部患者中有4个卵巢存在致密粘连,未能松解.(2)输卵管通畅性:输卵管染色通液术中发现,35条输卵管近端阻塞,经宫腔镜输卵管口插管通液术治疗后,有21条(60%,21/35)输卵管被疏通,另有4条(11%,4/35)输卵管部分被疏通.(3)手术时间:轻度、中度和重度粘连患者的总手术时间分别为(32±6)、(52±6)和83 min,其中THLPA时间分别为(11±5)、(35±7)和62 min.(4)离院时间:全部患者的术后离院时间为120～175 min.无并发症发生.(5)妊娠率:术后随访(15.8±4.3)个月,妊娠率为45%(13/29),1例失访.结论 THLPA可行、有效、安全、不需住院,非常适用于经阴道注水腹腔镜检查中发现的薄膜粘连、特别是轻度盆腔粘连的治疗.     

宫腔镜和腹腔镜联合诊治不孕症104例分析

目的:探讨应用宫腔镜和腹腔镜联合诊治不孕症的临床价值.方法:对104例不孕症惠者行宫腔镜和腹腔镜联合诊治,观察术后妊娠率.结果:104例患者中发现94例有盆腔病变,76例有子宫腔病变,80例输卵管不通.盆腔粘连、子宫腔粘连致输卵管堵塞是不孕症的第1位病因,继发不孕均较原发不孕的发生率高(P<0.01).宫腔镜和腹腔镜联合手术后妊娠率63.5%.1例发生异位妊娠.结论:宫腔镜和腹腔镜联合应用,已成为女性不孕症必不可少的诊治手段,具有重要的临床应用价值.     

宫腔镜下输卵管口插管疏通术在不孕症诊治中的应用

目的 探讨宫腔镜下输卵管口插管疏通术在不孕症患者诊治中的应用价值。方法 2001年9月至2003年1月对122例原发性不孕患者(原发组)和185例继发性不孕患者(继发组)行宫腔镜检查及镜下输卵管口插管疏通术，记录输卵管疏通情况。结果 与术前比较，术后两组的输卵管通畅病例增加；术后原发组左侧输卵管通畅的病例较右侧多。而继发组左侧和右侧输卵管间的通畅性的差异无显著性意义；两组术前为输卵管阻塞的病例，术后输卵管双侧通畅与一侧通畅病例分别达60．0％和47．0％，而术后仍双侧阻塞的病例分别减少至30．0％和37．8％。结论 宫腔镜下输卵管口插管疏通术对不孕症患者的诊治效果非常理想，原发性不孕患者的左侧输卵管较右侧输卵管的疏通效果好。     

阴道注水腹腔镜宫腔镜联合手术在不孕症诊治中的作用探讨

目的:探讨阴道注水腹腔镜宫腔镜联合手术在不孕患者诊治中的作用及其临床意义.方法:对于208例经输卵管造影与通液提示通畅,术后助孕治疗1年仍不孕的患者作为观察对象.106例实施阴道注水腹腔镜宫腔镜联合手术,作为研究组,再次评价输卵管功能及相应治疗;102例直接采用助孕治疗,作为对照组.比较并分析两组患者妊娠成功率.结果:研究组106例联合手术证实34例输卵管解剖异常,占32.1％;72例输卵管通畅,占67.9％.34例输卵管解剖异常患者行经腹腹腔镜手术及助孕治疗后妊娠率23.5％,72例输卵管通畅患者经助孕治疗后妊娠率为44.4％ (P ＜0.05).研究组总妊娠率为37.7％,对照组经助孕治疗后妊娠率为24.5％ (P ＜0.05).结论:阴道注水腹腔镜宫腔镜联合手术不仅能准确诊断评价输卵管性不孕,指导治疗方案选择,而且能够改善盆腔与输卵管内腔的微环境,提高不孕患者的妊娠率.     

输卵管间质部插管加压通液术诊治不孕症170例分析

我院采用电视宫腔镜输卵管间质部插管加压通液术诊治不孕症 ,取得了较好的疗效 ,现报道如下。1　资料与方法1 1　资料　我院自 1996年 1月至 1999年 6月通过电视宫腔镜输卵管间质部插管加压通液术共 170例 ,其中宫腔镜、腹腔镜联合检查 6 8例。患者年龄 2 1～ 40岁 ;原发不孕5 9例 ,继发不孕 111例 ;患者月经大多正常 ,月经周期不规律 30例。既往有人工流产史 5 4例 ,中孕引产史 8例。曾置宫内节育器 11例 ,时间均超过 2年。盆腔手术史 16例 ,其中宫外孕手术 13例 ,卵巢囊肿 1例 ,巧克力囊肿 1例 ,子宫肌瘤 1例。盆腔炎史 3例。曾发生自然流…     

腹腔镜诊治不孕症患者盆腔病变156例疗效分析

目的探讨应用腹腔镜手术诊治不孕症的临床价值.方法 1997年4月至2004年3月中山市人民医院对156例女性不孕症患者行腹腔镜诊断和治疗,观察术后妊娠率.结果 156例中发现盆腔病变145例,占92.9%.慢性盆腔炎是不孕症的第1位病因,继发不孕较原发不孕发生率高(P＜0.01);其次为子宫内膜异位症、多囊卵巢综合征,原发不孕发生率高于继发不孕(P＜0.01).腹腔镜手术术后妊娠率为47.1%,2例发生异位妊娠.结论腹腔镜手术对女性不孕症盆腔病变的诊治具有重要的价值.     

宫腹腔镜联合治疗输卵管型不孕的疗效观察

目的观察宫腹腔镜联合治疗输卵管型不孕的疗效。方法回顾性分析2014年7月~2015年7月本院收治的不孕症患者148例的临床资料,按照治疗时所用方法分为对照组70例和研究组78例。对照组患者采用宫腔镜下输卵管疏通术治疗,研究组患者采用宫腹腔镜联合下输卵管疏通术治疗,比较两组患者的疗效。结果研究组有38例患者是原发性不孕,经治疗后输卵管通畅36例(94.74%),阻塞2例(5.26%);对照组患者有34例患者是原发性不孕,经治疗后输卵管通畅30例(88.24%),阻塞4例(11.76%),两组原发性患者输卵管再通率比较,差异无统计学意义(P0.05)。研究组有40例患者是继发性不孕,经治疗后输卵管通畅37例(92.50%),阻塞3例(6.50%);对照组患者36例患者是继发性不孕,经治疗后输卵管通畅19例(52.78%),阻塞17例(47.12%),研究组继发性不孕患者经治疗后输卵管再通率大于对照组,差异有统计学意义(P0.05)。结论宫腹腔镜联合治疗输卵管型不孕较宫腔镜下输卵管疏通术的疗效更为显著,患者输卵管再通率更高,具有临床推广价值。     

宫腔镜在不孕症和输卵管再通术后的应用

自1985年1O月至1988年3月对249例不孕或复通术后的病例进行504次宫腔镜检查和治疗,其中镜检前曾作复通术或其他腹部检查手术者132例,宫腔镜发现异常者25例(19.53%);镜检术前曾作子宫输卵管造影者35例,宫腔镜发现异常者17例(48.57%);镜检术前未作其他辅助检查者82例,宫腔镜发现子宫输卵管异常者33例(42.31%)。经在宫腔镜直视下作输卵管插管通液治疗后输卵管的通畅度获得改善者51例,占治疗病例的35.92%。受术者中目前已有33例妊娠且16例已足月分娩,未见宫外孕病例。本组病例宫腔镜术失败者11例(4.42%),但无严重并发症发生。在不孕症和复通术后的检查治疗中,宫腔镜是一种重要而安全的工具。     

Tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy and minihysteroscopy) versus hysterosalpingography in an outpatient infertility investigation.

OBJECTIVE: To compare the acceptance and tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy [THL] combined with minihysteroscopy) versus hysterosalpingography (HSG) for evaluating tubal patency and the uterine cavity in an outpatient infertility investigation. DESIGN: Randomized controlled study. SETTING: University hospital. PATIENT(S): Twenty-three infertile patients without obvious pelvic pathology. INTERVENTION(S): Women were randomly divided into two groups. One group underwent minihysteroscopy and THL with tube chromoperturbation as first investigation and HSG within the following 7 days, while in the other group the investigation sequence was inverted. Women reported pain experienced before and at the end of procedures. MAIN OUTCOME MEASURE(S): Mean duration of procedures, level of pain experienced, diagnostic agreement about tubal patency and uterine cavity normality. RESULT(S): THL and minihysteroscopy took significantly more time but was significantly less painful than HSG. Regarding tubal patency, in 95.5% of cases THL agreed with HSG. In one case, HSG diagnosed a bilateral obstruction of tubes, whereas at THL a bilateral spreading of methylene blue was seen. Agreement on intrauterine pathologies between minihysteroscopy and HSG was poor (43%); the number of intrauterine abnormalities found at hysteroscopy was significantly greater than at HSG. CONCLUSION(S): THL in association with minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation.     

Transvaginal hydrolaparoscopy vs. conventional laparoscopy for evaluating unexplained primary infertility in women

OBJECTIVE: To verify the usefulness and reliability of transvaginal hydrolaparoscopy (THL) as a screening tool for evaluating infertility in women in comparison with conventional diagnostic laparoscopy. STUDY DESIGN: Sixty consecutive women with unexplained primary infertility were prospectively enrolled into the study. After examination of the whole pelvic cavity, tubal patency was evaluated and the uterine cavity studied by hysteroscopy. Immediately after THL, conventional laparoscopy was performed. Main outcome measures were the success rate of accessing the pouch of Douglas, rate of complete examinations, rate of complications and accuracy of THL in comparison with laparoscopy. RESULTS: Success rate of accessing the pouch of Douglas and performing THL was 93.3%. The rate of complete evaluation of all the pelvic structures was 76.8%. In studying tubal pathology, 77.8% agreement was found between the two techniques. Diagnosis of endometriosis was correct in 55.5% of patients. Overall, THL results correlated closely with conventional laparoscopic results in 92.86%, but the diagnostic accuracy of THL was 100% in cases of complete pelvic evaluation. CONCLUSION: THL is a feasible, reliable and safe procedure and can be considered an alternative procedure for evaluating infertility in women. In cases of incomplete pelvic evaluation or abnormal findings, conventional laparoscopy is indicated as the second step in the evaluation.     

Transvaginal hydrolaparoscopy

Transvaginal hydrolaparoscopy (THL) is a modification of culdoscopy that can be used to evaluate the posterior uterus, pelvic sidewalls, and adnexae. Diagnostic THL can be done in the office under local anesthesia. Combined with diagnostic hysteroscopy and chromotubation, it can replace hysterosalpingography (HSG) as the first-line diagnostic test for the infertile woman. Studies have shown high patient tolerability with less pain reported postprocedure than with HSG. THL has been shown to have a high concordance with HSG for tubal patency, but THL diagnosed more intrauterine abnormalities as well as finding adhesions and endometriosis not visible with HSG. In addition, salpingoscopy may be performed during THL to assess the tubal lumen. THL also has a high concordance rate with laparoscopy when a complete evaluation is accomplished during THL. Complications of THL are uncommon and minor. Finally, operative procedures such as ovarian drilling, coagulation of endometriosis, lysis of adhesions, treatment of ovarian cysts, and salpingostomy may be performed via THL.     

Experience with 109 cases of transvaginal hydrolaparoscopy

We conducted a prospective review of our experience with 109 transvaginal hydrolaparoscopies (THLs) performed in 97 women. The THL was considered complete in 101 procedures (93%) and adequate for management in 105 (96%). Two complications occurred (1.8%), one failed entry and one perforation of a retroflexed uterus. Diagnoses for 67 infertile patients were normal pelvis in 34 (51%), endometriosis in 14 (21%), adhesions in 6 (9%), and tubal obstruction in 10 (15%); 3 THLs (4%) were considered incomplete. Of 17 women with dysmenorrhea, a normal pelvis was found in 8 (47%) and endometriosis in 9 (53%). In 11 patients with pelvic pain endometriosis was found in 4 (36%), normal pelvis in 3 (27%), and adhesions in 3 (27%); THL was incomplete in 1 (9%). Six infertile patients (9%) had operative laparoscopy and 10 (15%) operative THL; 6 (9%) were counseled to seek in vitro fertilization. Pregnancy occurred in 16 patients (24%). Analog pain scores (0 = no pain, 10 = worst pain) were tracked in 39 consecutive patients. Pain during trocar insertion averaged 4.2 +/- 0.5, 2.2 +/- 0.2 at midprocedure, and 1.1 +/- 0.1 at the end of THL. We believe that THL should be considered instead of hysterosalpingogram and laparoscopy in selected patients.     

Vaginal misoprostol for cervical priming before operative hysteroscopy: a randomized controlled trial

OBJECTIVE: To investigate the effectiveness of vaginal misoprostol for cervical priming before operative hysteroscopy and to assess the cervicouterine complications related to cervical dilatation and hysteroscopic surgery in nulliparous women. METHODS: One hundred fifty-two women with definite intrauterine lesions were randomly assigned to receive either 200 microg vaginal misoprostol or placebo. Cervical response and outcome and complications of operative hysteroscopy were assessed. RESULTS: Thirty-five subjects were needed in each arm to detect a type I error of 0.01 with a power of 0.99. The mean cervical dilatation estimated by Hegar dilator was significantly different between the treated group (7.3 +/- 0.7 mm) and the control group (3.8 +/- 1.1 mm, P <.001). In the misoprostol group, 55 (75.3%) patients needed cervical dilation, compared with 75 (94.9%, P =.001) in the placebo group. The median time of cervical dilation to Hegar number 9 was significantly shorter in the treated group (40 seconds) compared with the control group (120 seconds, P <.001). The mean operative time was significantly shorter in the treated group (36.4 +/- 10.9 minutes) compared with the control group (45.9 +/- 14.2 minutes, P <.001). Cervical tears occurred in nine (11.4%) patients in the control group and in one (1.4%, P =.018) in the misoprostol group. Creation of a false tract was more common in the control group. Two uterine perforations occurred in the placebo group. CONCLUSION: Vaginal misoprostol applied before operative hysteroscopy reduced the need for cervical dilation, facilitated hysteroscopic surgery, and minimized cervical complications.     

Hysteroscopy combined with hysterosalpingo contrast sonography (HyCoSy): a new modality for comprehensive evaluation of the female pelvic organs.

AIM: Hysterolaparoscopy is the gold-standard procedure for mechanical evaluation of the female pelvic organs. However, it is invasive and potentially life-threatening. The purpose of the present study was to assess the value of an alternative, minimally invasive technique. METHOD: All consenting women who reached the stage of mechanical evaluation in their infertility work-up were invited to participate in the study. All underwent diagnostic hysteroscopy followed by hysterosalpingo contrast sonography (HyCoSy) performed in a single session on an outpatient basis. Patient clinical data were collected prospectively.RESULTS: Twenty women participated in the study, 6 with primary infertility and 14 with secondary infertility. All procedures yielded satisfactory evaluation of the uterine cavity and uterine and ovarian structures, fallopian tube patency, and relationship between the fallopian tube fimbrial edges and the ovaries. All patients were discharged within 2 h; there were no complications during or after the procedure. CONCLUSION: The combination of hysteroscopy and hysterosalpingo contrast sonography (HyCoSy) can provide a comprehensive, functional and relatively non-invasive evaluation of the female pelvic organs.     

非脱垂子宫阴式子宫全切除术的适应证和禁忌证探讨

目的探讨非脱垂子宫阴式子宫全切除术(TVH)的适应证和禁忌证。方法回顾性分析我院1992年6月至2003年6月间2086例非脱垂子宫TVH的临床资料,按子宫体积、既往有无盆腹腔手术史、有无阴道分娩史、是否同时处理附件等分别进行统计,比较手术并发症的发生情况。结果(1)不同体积子宫比较:子宫体积>16孕周患者的非脱垂子宫TVH手术时间、术中出血量及术后盆腔感染率分别为(73±25)min、(237±86)ml、1.69%(7/413);子宫体积≤16孕周患者的非脱垂子宫TVH手术时间、术中出血量及术后盆腔感染率分别为(42±16)min、(101±58)ml、0.78%(13/1673),不同体积子宫上述各项指标比较,差异有统计学意义(P<0.01)。(2)既往有无盆腹腔手术史比较:既往有无盆腹腔手术史患者的非脱垂子宫TVH手术时间和术中出血量比较,差异无统计学意义(P>0.05),但有盆腹腔手术史患者非脱垂子宫TVH的术中并发症发生率升高;(3)有无阴道分娩史患者非脱垂子宫TVH的手术时间和术中出血量比较,差异也无统计学意义(P>0.05);119例合并卵巢囊肿患者均成功行非脱垂子宫TVH。结论子宫体积≤16孕周患者的非脱垂子宫TVH是安全、可行的,子宫体积>16孕周患者的非脱垂子宫TVH手术难度较大,是否行TVH,需根据术者的经验及患者的情况进行选择;既往有盆腹腔手术史,可增加非脱垂子宫TVH并发症的发生率;对于子宫体积≤16孕周的患者,有无阴道分娩史均不影响TVH的成功率;TVH同时处理直径≤6cm的卵巢单纯性囊肿是可行的。     

Higher Prevalence of Endometrial Polyps in Patients with Fallopian Tube Obstruction: A Case-control Study

Study ObjectiveTo study the association between endometrial polyps and fallopian tube patency diagnosed by hysteroscopy, conventional histology, and 4-dimensional (4D) hysterosalpingo-contrast sonography (HyCoSy).DesignA case-control study (Canadian Task Force classification II-2).SettingA university hospital.PatientsA total of 323 women of reproductive age underwent 4D HyCoSy and hysteroscopy between January 2015 and December 2017.InterventionA retrospective analysis of the association of endometrial polyps and fallopian tube obstruction (n = 154) or patency (n = 169) in patients who underwent 4D HyCoSy.Measurements and Main ResultsThe prevalence of endometrial polyps was significantly higher in patients with bilateral fallopian tube obstruction than in patients with bilateral fallopian tube patency (42.9% [66/154] vs 20.1% [34/169], p <.0001). In univariate and multivariate analyses, the presence of endometrial polyps was found to be a risk factor for tubal obstruction with an odds ratio of 3.16 and 2.59, respectively.ConclusionThe prevalence of endometrial polyps is higher in infertile patients with fallopian tube obstruction than in patients with fallopian tube patency. History of endometrial polyps, ectopic pregnancy, and pelvic inflammatory disease are risk factors for tubal obstruction.