输卵管造影和插管术在输卵管手术中的应用

目的:在妇科输卵管手术中采用非血管介入手术-输卵管造影和输卵管插管术放入支架,以提高术后输卵管的通畅率及术后妊娠率.方法:回顾性分析61例输卵管整形手术患者,31例观察组术中应用输卵管造影和插管技术,在输卵管狭窄处或端端吻合处放置微导管作为支 架,头端置于腹腔或输卵管腔,尾端置于宫腔内,术后1～2月后月经来潮时取出;30例对照组自输卵管伞端至宫角放置支架,尾端固定于腹壁切口,术后3～4天取出.观察、随访两组术后输卵管通畅率和妊娠率.结果:观察组31例共59条输卵管中,术后3个月53条输卵管通畅,占89.83%,2年内19例妊娠,占61.29%;对照组30例共58条输卵管,术后3个月27条通畅,占46.6%,2年内9例妊娠,占30%.两组对比,观察组术后输卵管通畅数、两年妊娠数明显高于对照组(P＜0.001、P＜0.01).结论:在输卵管整形手术中应用输卵管造影和输卵管插管,置入输卵管支架至创面愈合后取出,明显提高了术后输卵管的通畅率及再妊娠率,为输卵管再通提供了一种新的有效的治疗方法.     

腹主动脉球囊阻断在不同植入程度凶险性前置胎盘剖宫产中的应用效果

目的:研究腹主动脉球囊阻断术在不同植入程度凶险性前置胎盘(PPP)剖宫产中的应用效果。方法:选取2014年3月至2016年3月在山东省立医院产科行手术治疗的PPP伴植入患者115例。其中伴穿透性植入者60例(深植入组),非穿透性植入者55例(浅植入组)。根据是否行腹主动脉球囊阻断术,将两组再各分为阻断组和非阻断组。回顾分析患者的术中出血量、输血量、手术时间、子宫切除、膀胱损伤及新生儿窒息情况,以及腹主动脉球囊阻断的术中和术后并发症。结果:深植入阻断组的术中出血量中位数为1000ml,较非阻断组(2000ml)明显减少(P0.05);浅植入患者阻断组与非阻断组的术中出血量比较,差异无统计学意义(400ml vs 350ml,P0.05)。深植入阻断组的子宫切除率[7%(3/41)]低于非阻断组[37%(7/19)],差异有统计学意义(P0.05);浅植入组均无切除子宫者。深浅植入患者中,阻断组和非阻断组的膀胱损伤率、手术时间、新生儿窒息情况比较,差异均无统计学意义。64例腹主动脉球囊阻断术中发生导管打折1例,股动脉血栓20例,下肢深静脉血栓2例,术后穿刺点渗血2例,股动脉-股静脉瘘1例。结论:腹主动脉球囊阻断术可明显减少PPP伴穿透性植入患者的术中出血、降低子宫切除率,但对非穿透性植入的应用效果不佳。腹主动脉球囊阻断术后可发生较严重的并发症,应严格掌握其适应证。     

输卵管阻塞性不孕症宫、腹腔镜术后治疗方法的探讨

目的:探讨输卵管阻塞性不孕症宫、腹腔镜术后阻止再次粘连和阻塞的诊疗方法。方法:将宫、腹腔镜术后至少一侧输卵管通畅的不孕症患者随机分为治疗组和对照组,治疗组和对照组分别术后第1次月经干净后3~7 d应用欣可聍或注射体积分数20%甲硝唑氯化钠注射液进行彩色B超监测下宫腔镜输卵管插管通液;观察术后1年的妊娠情况,术后1年未孕者,于月经干净后3~7 d行子宫输卵管碘佛醇造影检查,了解输卵管通畅度。结果:术后1年治疗组妊娠率(68.75%)高于对照组(51.25%),差异有统计学意义(χ2=5.104,P=0.024);异位妊娠差异无统计学意义(P0.05);未孕者治疗组双侧输卵管通畅率(40.9%)高于对照组(14.2%),差异有统计学意义(χ2=5.168,P=0.023)。结论:输卵管阻塞性不孕症宫、腹腔镜术后第1次月经干净后3~7 d用欣可聍注射液进行彩色B超监测下宫腔镜输卵管插管通液,可以降低盆腔的再次粘连,维持输卵管的通畅,提高受孕率,值得临床推广应用。     

以宫腔镜手术为主的综合治疗在宫腔粘连性不孕中的应用

目的:探讨以宫腔镜手术为主的综合治疗在宫腔粘连性不孕中的应用价值。方法:回顾性分析67例宫腔粘连患者的治疗效果,均经宫腔镜下机械性粘连分离术及输卵管间质部插管通液术,术后宫腔放置宫内节育器及雌、孕激素周期治疗。结果:67例宫腔粘连中轻度粘连24例,中度粘连25例,重度粘连18例。46例1次手术成功重建宫腔,21例2次手术。术后88.1%宫腔形态正常,79.1%月经恢复正常,输卵管通畅率72.1%。术后妊娠率50.7%,活产率85.3%。无手术并发症。结论:宫腔镜对于不同程度宫腔粘连的宫腔重建微创、有效。术中注意保护子宫内膜;疏通阻塞的输卵管对提高妊娠率至关重要。     

宫腔镜下输卵管插管通液术与子宫碘油造影诊断输卵管性不孕作用的研究

目的:比较宫腔镜下输卵管导管通液术与子宫输卵管碘油造影(HSG)诊断输卵管性不孕的临床价值。方法:对2008年1月至2009年12月880例不孕症患者行宫腔镜下输卵管插管通液术,术前均常规行子宫输卵管碘油造影术,比较两者诊断的符合率并分析两种检查方法在评价输卵管通畅度方面的特点和应用价值。结果:子宫输卵管碘油造影和宫腔镜插管通液均诊断输卵管不通784条,通畅799条,通而不畅65条,两者符合率93.6%(1648/1760),不符合率6.4%(112/1760)。HSG检查输卵管通畅度的假阳性率为11.8%(107/906)。结论:宫腔镜下输卵管导管通液术能更精确地判断输卵管的通畅度,患者未接触有害物质,同时可以直接观察宫腔情况并治疗。在判定输卵管梗阻部位方面HSG优于宫腔镜检查。     

腹腔镜与开腹手术治疗异位妊娠术后受孕率对比

目的:探讨腹腔镜保守性手术与开腹保守性手术治疗异位妊娠术后宫内受孕率的差异。方法:回顾性分析有生育要求的83例异位妊娠病例,其中行腹腔镜保守性手术43例,开腹保守性手术40例,术中配合患侧输卵管系膜处注射甲氨喋呤,比较两组手术术后输卵管通畅率和术后18个月内宫内受孕率。结果:腹腔镜组术后输卵管通畅率(88%)、宫内受孕率(61%)、再次异位妊娠率(7%);开腹组术后输卵管通畅率(73%)、宫内受孕率(48%)、再次异位妊娠率(8%)。结论:输卵管保守性手术后宫内妊娠率高,而再次异位妊娠率不增加,适合要求保留生育功能的年轻患者。     

三种输卵管疏通术治疗后发生输卵管妊娠的临床分析

目的 :了解输卵管疏通术后发生输卵管妊娠的危险因素及其相应对策。方法 :回顾性分析 6 9例输卵管性不孕者分别经三种输卵管疏通术后发生输卵管妊娠 (TP)的患者 ,分成 3组 ,比较 3组疏通术前子宫输卵管碘油造影(HSG)结果和疏通术后通畅与非通畅输卵管的TP发生率。结果 :疏通术前 ,示输卵管柔软 5 7条 (34例 ) ,发生TP 2 1例(6 1.8% ) ,而欠柔软 /僵硬 79条 (5 6例 ) ,发生TP 4 8例 (85 7% ) ,两者差异有显著意义 (P <0 0 5 ) ;输卵管周围有无粘连者TP发生率差异也存在显著意义 (P <0 0 5 )。无论畅与不畅 ,3组术后TP发生率间差异无显著意义 (P >0 0 5 )。结论 :疏通术前HSG提示输卵管欠柔软、僵硬以及存在周围粘连者可能是疏通治疗后输卵管妊娠发生的危险因素。对于此类病变严重的输卵管不宜选择疏通术治疗。     

不同防粘连剂在输卵管介入再通术中预防术后再粘连的对比研究

目的 探讨不同防粘连剂在输卵管介入再通术中预防术后再粘连的临床价值.方法 将508例输卵管阻塞患者随机分为对照组(245例)、几丁糖组(108例)、透明质酸钠组(113例)、碘油组(42例).对照组输卵管介入再通术后输卵管内灌注松解液,其他组输卵管介入再通术后输卵管内分别注入几丁糖、透明质酸钠、碘油,每侧输卵管注入量均为2～3 ml.术中观察输卵管阻塞的部位、介入再通率,术后3个月随访各组患者输卵管通水通畅率,术后12个月随访妊娠率.结果 508例共计1016条输卵管,其中峡部阻塞输卵管330条,间质部阻塞输卵管563条,因异位妊娠切除输卵管37条,输卵管通畅86条.(1)介入再通率:几丁糖组、透明质酸钠组、碘油组及对照组输卵管介入再通率分别为95.7%(179/187),97.9%(191/195),98.7%(75176)和97.7%(425/435),各组分别比较,差异均无统计学意义(P＞0.05);(2)术后3个月输卵管通水通畅率:术后3个月输卵管通水通畅率几丁糖组(91.7%,99/108)、透明质酸钠组(88.5%,100/113)通畅率明显高于碘油组(71.4%,30/42)和对照组(74.3%,182/245),差异有统计学意义(P＜0.05);(3)术后12个月妊娠率:术后12个月内妊娠率几丁糖组(48.1%,52/108)、透明质酸钠组(41.6%,47/113)高于碘油组(23.8%,10/42)和对照组(24.1%,59/245),差异也有统计学意义(P＜0.05).结论 几丁糖和透明质酸钠均能有效地减少输卵管介入再通术后输卵管再粘连的发生,提高妊娠率.     

子宫内膜异位症患者术后不孕原因分析

目的 :分析子宫内膜异位症伴不孕患者腹腔镜术与开腹手术后仍然不孕的原因。方法 :选择 10 3例有手术指征的子宫内膜异位症伴不孕患者 ,分为腹腔镜与开腹手术两组进行手术治疗 ,术后口服孕三烯酮 3～ 6个月 ,随访患者 2年内妊娠情况 ,分析术后不孕的原因。结果 :子宫内膜异位症伴不孕患者腹腔镜术后 2年内妊娠率为 5 5 .2 0 % ,开腹手术 5 0 .0 0 % ,总妊娠率为5 2 .74 % ,两组妊娠率差异无显著性 (P >0 .0 5 ) ;子宫内膜异位症分期程度与输卵管通畅程度差异无显著性 (P >0 .0 5 )。术后不孕原因中 ,输卵管不通占 37.2 1% (16 / 4 3) ,子宫腺肌病 13.95 % (6 /4 3) ,子宫内膜异位症复发 9.30 % (4/ 4 3) ,子宫内膜异位症合并子宫肌瘤 6 .98% (3/ 4 3) ,既往有两次开腹史者 4 .6 5 % (2 / 4 3)。另外还有 2 7.91% (12 / 4 3)输卵管通畅但不孕原因未明。结论 :治疗子宫内膜异位症伴不孕应选手术治疗 ,有条件首选腹腔镜手术 ;术后不孕与输卵管不通关系密切 ,子宫内膜异位症合并子宫肌瘤及腺肌病等也是不孕的原因。     

重度宫腔粘连分离术后预防再粘连方法的比较

目的评估宫腔镜宫腔粘连分离术后预防宫腔再粘连方法的疗效。方法回顾性分析2004年11月至2007年5月间郑州大学第三附属医院妇科内镜诊治中心122例宫腔镜下宫腔粘连切除术患者的临床资料。术后宫腔内放置节育环(IUD)58例为IUD组,宫腔注入几丁糖并IUD64例为IUD+几丁糖组;根据病程长短将IUD组分为Ia组(病程≤1年)和Ib组(病程1年),IUD+几丁糖组分为IIa组(病程≤1年)和IIb组(病程1年)。观察术后宫腔恢复情况、月经改善及妊娠情况。结果IUD和IUD+几丁糖组术后宫腔再粘连率分别为41.4%和23.4%(P0.05),其中Ia组(19.0%)明显低于Ib组(54.1%)(P0.05);IUD组月经改善率及妊娠率分别为74.1%和29.3%,IUD+几丁糖组分别为92.2%和48.4%,IUD组明显低于IUD+几丁糖组(P0.05),其中Ia组(90.0%、47.6%)明显高于Ib组(64.9%、18.9%)(P0.05)。IIa组术后宫腔再粘连率及妊娠率分别为8.7%和78.3%,IIb组分别为31.7%和31.7%,两组比较,差异均有统计学意义(P0.05);IIa组(100%)月经改善率与IIb组(87.8%)比较,差异无统计学意义(P0.05)。结论重度宫腔粘连切除术后宫腔内放置节育环加几丁糖可有效预防再粘连,提高月经改善率及妊娠率。     

宫腔镜输卵管注药治疗输卵管梗阻性不孕症(附54例临床分析)

本文报道54例(含102条输卵管)输卵管梗阻性不孕妇女,经宫腔镜输卵管插管注药术治疗三次,治疗前、后均作子宫输卵管碘油造影比较。治疗后86条输卵管通畅度改善(84%),与治疗前有非常显著性差异(P<0.01),其中56条输卵管通畅(54.9%),30条好转(29%)和16条无效(16%),按输卵管条数计,此术用于输卵管通而欠畅者疗效最佳(85.7%),宫角梗阻疗效较好(62.5%),而伞部梗阻疗效最差(13.3%)。治疗后输卵管通畅的35例中,随访1～12月已有12例获宫内妊娠。     

HOXA9、HOXA11、LIF在输卵管中的表达及与输卵管妊娠的关系

目的:探讨同源框基因HOXA9、HOXA11以及白血病抑制因子(1eukemia inhibitory factor,LIF)在输卵管异位着床中的作用。方法:用免疫组织化学染色方法分别检测36例异位妊娠输卵管和34例正常输卵管HOXA9、HOXA11和LIF蛋白的表达。结果:①HOXA9、HOXA11强阳性(+++)表达率在异位妊娠输卵管中最高,且输卵管着床部位和非着床部位表达率无明显差异;增生期输卵管HOXA9、HOXA11强阳性表达率明显较低,在分泌期输卵管中表达率为0。②LIF强阳性表达仅见于妊娠输卵管,着床部位的表达率高于非着床部位;增生期和分泌期输卵管呈中低水平表达。结论:HOXA9、HOXA11及LIF蛋白表达增加与输卵管妊娠相关。     

A randomized, prospective, controlled study of laparoscopic dye studies and selective salpingography as diagnostic tests of fallopian tube patency

OBJECTIVE: To determine and compare the relative merits of laparoscopic dye (LD) studies and selective salpingography (SS) as diagnostic tests of fallopian tube patency. DESIGN: Randomized, prospective, controlled study. SETTING: University-associated assisted reproduction unit. PATIENT(S): Two hundred seventy-eight women undergoing investigation of infertility. INTERVENTION(S): Allocation to the performance of either LD studies followed by SS or SS followed by LD studies conducted sequentially under general anesthesia. MAIN OUTCOME MEASURE(S): Detection of fallopian tube occlusion, including the site of obstruction and evidence of peritubal or pelvic disease. RESULT(S): When diagnosis was compared by the first test used, 16 (11.9%) of 135 patients had proximal tubal occlusion at LD studies versus 5 (3.6%) of 138 at SS. Twelve (5.6%) of 122 patients had distal tubal occlusion at LD studies versus 14 (10.5%) of 133 at SS. Fifteen (11.1%) of 135 patients had peritubal disease at LD studies versus 3 (2.52%) of 119 at SS. When diagnosis was compared by individual tubes, the results were similar. Among patients who had proximal occlusion and otherwise normal tubes by both methods, endometriosis was present in 72.2%. CONCLUSION(S): Selective salpingography is a better diagnostic test of proximal tubal occlusion than are LD studies. There is no difference between SS and LD studies as a diagnostic test of distal tubal occlusion. Laparoscopic dye studies are a better diagnostic test for assessing peritubal disease than is SS. There may be an association between endometriosis and proximal tubal occlusion. Selective salpingography and LD studies are complementary investigations of the fallopian tubes.     

The influence of patient insemination on the implantation rate in an in vitro fertilization and embryo transfer program

The implantation rates and subsequent pregnancy rates in in vitro fertilization (IVF) programs are lower than those currently seen in the normal fertile population. During IVF treatment regimens, intercourse is not allowed and artificial insemination is normally excluded. This trial, involving the deposition of semen in the high vaginal area, was undertaken for evaluation of the influence of sperm in the reproductive tract on subsequent implantation rates. The results show that the implantation rate, as assessed by a rise in the human chorionic gonadotropin levels in inseminated patients, was 53%, compared with 23% in the control group. The implantation rate of 54% in the group who had tubal occlusion or no fallopian tubes was not significantly different from the implantation rate of 50% in the group with patent tubes, which suggests that the site of sperm influence was on the endometrium and that the absence of the fallopian tube has no significant effect upon this influence.     

End-to-end tubal anastomosis using an absorbable stent.

Using absorbable suture as a stent, end-to-end anastomosis of previously ligated or cauterized fallopian tubes was performed in 15 cases. Luminal patency of at least one fallopian tube has been achieved in all cases, and thus far seven pregnancies have occurred in six cases. The technique for inserting the absorbable suture into the distal and proximal portions of the tube is fully described, and the importance of repeated hydrotubations to maintain tubal patency is emphasized.     

康妇炎胶囊在治疗输卵管通而不畅性不孕中的临床应用

目的 探讨康妇炎胶囊在治疗输卵管通而不畅性不孕中的临床应用效果。方法 2012年1月至2014年1月在天津医科大学第二医院根据子宫输卵管造影结果选择轻度输卵管通而不畅患者143例（治疗组89例和对照组54例）和重度输卵管通而不畅患者120例（治疗组77例和对照组43例）。轻度输卵管通而不畅治疗组采用输卵管通液术联合康妇炎胶囊口服,对照组仅行输卵管通液术。重度输卵管通而不畅治疗组采用宫腹腔镜再通手术联合康妇炎胶囊口服,对照组仅行宫腹腔镜再通手术。记录患者12个月内妊娠的情况并计算宫内妊娠率和异位妊娠率等指标。结果 轻度输卵管通而不畅治疗组宫内妊娠率显著高于对照组（70.8%对51.9%）,差异有统计学意义（P＜0.05）;输卵管妊娠率显著低于对照组（1.1%对7.4%）,差异有统计学意义（P＜0.05）;生化妊娠率两组比较（4.5%对7.4%）,差异无统计学意义（P＞0.05）。重度输卵管通而不畅患者治疗组宫内妊娠率显著高于对照组（37.7%对20.9%）,差异有统计学意义（P＜0.05）;输卵管妊娠率显著低于对照组（5.2%对16.3%）,差异有统计学意义（P＜0.05）;生化妊娠率两组比较（6.5%对9.3%）,差异无统计学意义（P＞0.05）。12个月后轻度输卵管通而不畅治疗组未妊娠患者的输卵管通而不畅率（26.2%对50%）和阻塞率（4.8%对22.2%）均低于对照组,差异有统计学意义（均P＜0.05）;重度输卵管通而不畅治疗组未妊娠患者的输卵管通而不畅率（32.1%对52.2%）和阻塞率（7.7%对21.7%）均低于对照组,差异有统计学意义（均P＜0.05）。结论 康妇炎胶囊在辅助治疗输卵管通而不畅性不孕中具有良好的疗效,可以提高输卵管通而不畅性不孕患者的宫内妊娠率和再通率,同时降低输卵管妊娠率。     

Investigation of the uterine cavity and fallopian tubes using three-dimensional saline sonohysterosalpingography.

OBJECTIVE: To compare three-dimensional saline sonohysterosalpingography (SHSG) to X-ray hysterosalpingography (HSG) for the evaluation of the uterine cavity and fallopian tubes. PATIENT POPULATION: Fifteen infertile women on whom X-ray HSG had been performed within 1 year prior to this study. METHOD: Fifteen infertile women underwent three-dimensional power Doppler examination of the uterus and fallopian tubes with three-dimensional SHSG during the follicular phase. Distension was achieved using sterile saline injected through a 5 French HSG catheter. Peritoneal accumulation of free fluid surrounding the ovary and tube was required for a diagnosis of a patent tube. Fluid accumulation in the cul-de-sac without visualization of the tubes was considered consistent with at least one tube being patent. RESULTS: three-dimensional saline SHSG was completed in 14 patients. One patient had cervical stenosis and the procedure could not be performed. No significant intrauterine pathology was identified by either X-ray HSG or sonography. Three-dimensional saline SHSG made false positive diagnoses of tubal occlusion in four out of seven fallopian tubes (57%). The sensitivity and specificity for detecting tubal occlusion was 75 and 83%, respectively, with a positive predictive value of 40% and negative predictive value of 95%. Detection of fallopian tube architecture was not possible with three-dimensional saline SHSG in any patient. Simultaneous use of three-dimensional Doppler did not clearly identify the flow of saline through the fallopian tubes. CONCLUSIONS: Transvaginal three-dimensional saline SHSG provides good visualization of the uterine cavity and myometrial walls in three orthogonal planes. However, it does not diagnose tubal occlusion or depict architecture of the fallopian tube as accurately as X-ray HSG. Although we were able to visualize the distal fallopian tube and fimbria with real-time imaging, we were not able to satisfactorily image the proximal tube with three-dimensional power Doppler. This technique may be reserved as an initial screening test to evaluate the uterine cavity and test patency. Patients at high risk for tubal disease by history or with suspected tubal occlusion on three-dimensional saline SHSG should be evaluated by either X-ray HSG or laparoscopy with chromopertubation. Further improvements of three-dimensional technology and contrast materials will, it is hoped, make this method comparable to X-ray HSG.     

Rabbit fallopian tube reanastomosis using a microvascular stapling device

The 3M Precise Microvascular Anastomotic System (MAS), a microvascular stapling device, was compared with microsurgery for the reanastomosis of rabbit fallopian tubes. Differences in operative time, tubal patency, adhesion formation, and fertility rate were studied in 18 rabbits. Only 17% of tubes repaired by MAS were subsequently patent by chromopertubation, compared with 72% with microsurgery. Mean nidation indices were 0.05 for MAS and 0.22 for microsurgery. Sixty-one percent of adnexae repaired by MAS were adhesion stage I, whereas 83% of microsurgically repaired adnexae were stage I. Mean operative time was 28.2 min for MAS vs 21.6 min for microsurgery. Only the differences in patency rate and operative time were statistically significant, but the trends suggest that fallopian tube reanastomosis by MAS offers no advantage over conventional microsurgical technique.