腹腔镜和宫腔镜在不孕症诊治中的应用

本文对320例不孕症患者行腹腔镜检查,其中47例同时行宫腔镜检查及治疗。腹腔镜检查结果表明,盆腔炎症和子宫内膜异位症是本组病例中最常见的病因,占77.5％,由此引起的盆腔粘连和输卵管阻塞占71.33％,而这些病例56.9％(110/255)没有临床表现,因此腹腔镜检查是诊断盆腔炎和子宫内膜异位症的可靠方法。47例宫腔镜检查发现异常占21.3％,其中27例49条阻塞输卵管在宫腔镜下加压通液及行插管术,其中8例11条输卵管通畅,占29.6％,4例妊娠。因此对HSG或腹腔镜检查发现的输卵管阻塞,特别是近端阻塞,可在腹腔镜监视下,行宫腔镜加压通液或输卵管插管再通术以减少误诊。     

预测宫腔镜内膜切除成功的手术外因素

宫腔镜子宫内膜切除已成为治疗妇女月经过多的基本手术之一 ,但手术的成功率报告有很大差异。对患者而言 ,预测内膜切除的成功率在术前咨询中是有价值的。手术以外的影响因素有 :术前应用GnRHa及年龄较大患者术后闭经多 ,曾有输卵管结扎史者则最终行子宫切除者较多 ,宫壁肌瘤、宫腔内病变如息肉及子宫大小均对结果造成影响。作者对 4 3例子宫≤ 10周的月经过多经药物治疗无效的妇女行宫腔镜内膜切除 ,所有患者均作阴道超声检查及子宫内膜活检 ,结果均正常。术前 1个月均用GnRHa 3.75mg。要据宫腔镜术中发现 ,33例内膜不太厚者用热球作粘…     

宫腔镜下输卵管双层插管治疗输卵管梗阻108例效果分析

目的 :为进一步提高宫腔镜下插管治疗输卵管严重梗阻的疏通率及术后妊娠率。对象和方法 :本文对 1 0 8例患有输卵管完全或部分梗阻导致不孕的妇女 ,在宫腔镜窥视下经第一次插管注液不能疏通者 ,进行双层插管疏通治疗。结果 :经第一次插管注液完全疏通的输卵管由术前的 3.30 %上升到 33.0 2 % (P<0 .0 5) ,在此基础上进行双层插管 ,完全疏通率 33.0 2 %上升到 57.59% (P<0 .0 5) ,经第二次宫腔镜检查 ,完全疏通率略有下降 ,但 P>0 .0 5。术后一年随访 ,怀孕 33例 (30 .56 % )。结论 :宫腔镜下输卵管双层插管对输卵管严重梗阻有较好疗效 ,可提高术后怀孕率     

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。     

不孕症腹腔镜联合宫腔镜检查的临床价值

目的了解不孕症患者行腹腔镜检查同时作宫腔镜的临床意义。方法对2004年8月至2005年4月因不孕症在我院行腹腔镜和宫腔镜联合检查的患者进行回顾性分析。共232例患者入选。按术前超声和造影检查的结果分为术前宫腔正常组144例、异常组41例,术前未作宫腔检查组47例。将宫腔镜检查术中发现结合病理结果,与术前的超声和子宫输卵管造影(HSG)的结果作对比。结果患者年龄(32.4±3.8)岁(23～43岁)。其中原发不孕症113例(48.7%),继发不孕症119例(51.3%)。不孕症年限(4.9±3.0)年(1～18年)。术前宫腔正常组144例中,宫腔镜诊断宫腔异常21例(14.6%);术前宫腔异常组41例中,宫腔镜诊断宫腔异常17例(41.5%);术前未作检查组47例中,宫腔镜诊断宫腔异常16例(34.0%)。三组之间宫腔异常率差异有统计学意义(P0.01)。以宫腔镜作为金标准,超声诊断宫腔内病变的灵敏度40.0%,特异度81.4%,阳性预测值36.4%,阴性预测值83.6%;HSG诊断宫腔内病变的灵敏度30.0%,特异度90.8%,阳性预测值50.0%,阴性预测值80.8%。提示在不明显增加患者经济负担的前提下,辅助的宫腔镜检查对于发现和治疗宫腔异常具有超声和造影不可替代的作用。结论在腹腔镜手术同时行宫腔镜检查有助于发现和治疗不孕症的原因。     

联合应用宫腔镜腹腔镜和子宫输卵管通液及子宫输卵管碘油造影检查诊断不孕症110例分析

目的　通过宫腔镜、腹腔镜检查和子宫输卵管通液及子宫输卵管碘油造影检查 ,了解输卵管通畅性 ,探讨引起不孕症的原因。方法　对 110例不孕妇女进行输卵管通液检查 ,子宫输卵管碘油造影 (HSG)、宫腔镜和腹腔镜及镜下通液检查。结果　以宫腔镜和腹腔镜镜下通液 33例双侧通畅为对照标准 ,110例患者中 ,宫腔镜和腹腔镜镜下通液准确率为 30 0 0 % ,输卵管通液检查准确率为 6 5 45 % ,两者间比较有极显著性差异 (P <0 0 1) ;镜下通液与HSG准确率比较 ,宫腔镜和腹腔镜镜下通液 2 1 33 % (16 / 75 ) ,HSG33 33 % (2 5 / 75 ) ,两者间比较无显著性差异(P >0 0 5 )。结论　宫腔、腹腔炎症与不孕症有关 ,宫腔粘连、子宫内膜炎等仍为不孕症的主要原因 ,宫腔镜和腹腔镜通液检查在诊断治疗不孕症中有一定的价值。     

盆腔镜肌瘤摘除术:技术、限度、并发症

内窥镜子宫肌瘤摘除术的困难不在于摘除肌瘤或缝合子宫,而是捣碎及从腹腔取出肌瘤。1991年以来,使用内窥镜可将较大的肌瘤捣碎。1992～1993年对215例子宫肌瘤中的207例(96％)行保留器官的手术。平均年龄36岁(23～54岁)。 全部病例术前均超声检查,以判断肌瘤的大小及部位。巨大肌瘤直接剖腹手术,少数先行盆腔镜检,以决定剖腹手术或盆腔镜手术。月经紊乱者需做宫腔镜检或分段诊刮,不孕者需做输卵管通色素检查。     

输卵管复通术97例分析

输卵管复通术９７例分析张肖欣，俞德祺（温州市第三人民医院）我院于１９８７年１月至１９９３年１２月的７年中，对输卵管结扎术后因子女夭折、再婚或其他原因要求再育者作输卵管复通术１０２例，失访５例，宫内妊娠及分娩者８７例。现将资料完整之９７例总结报道如下。...     

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。     

宫、腹腔镜联合检查在有排卵性不育症中的应用

144例排卵正常的不孕妇女作了宫腔镜、腹腔镜联合检查。112例用于明确诊断,结果发现:宫、盆腔基本正常28例(25%)、盆腔异常58例(51.79%)、宫腔异常12例(10.71%)和宫、盆腔均有异常14例(12.5%);其中68例同时作宫腔镜输卵管插管注染液检查以判定输卵管通畅度。32例腹腔镜监护下作宫腔镜矫治手术,包括:困难的宫腔粘连分离(12例)、不完全子宫纵膈切除术(16例)、子宫内嵌顿的胎儿骨片取出(2例),双侧输卵管间质部息肉摘除和疏通术(2例),对此种检查方法的优点进行了评价和讨论。     

Reproductive outcome after multiple ectopic pregnancies

Seventy-six patients with two or more ectopic pregnancies treated at the Department of Obstetrics and Gynecology, University Central Hospital, Tampere, Finland over a period of 14 years (1972-1985) were retrospectively analyzed. Conservative tubal surgery had originally been performed in 57% of patients with a repeat tubal pregnancy, and in 41% of control patients with a single tubal pregnancy. After two ectopic pregnancies, 53 patients were actively trying to conceive. Of these patients, 25% achieved delivery, 40% had a third ectopic pregnancy, and 35% did not conceive. Ipsilateral tubal pregnancy occurred in 83% after salpingotomy, in 88% after fimbrial evacuation, and in 47% after tubal resection. Conservative surgery was performed in 16 patients with only one tube where an ectopic pregnancy occurred; 25% had a term delivery, 25% had a repeat ectopic pregnancy, and 50% did not conceive. Follow-up of 19 patients after three tubal pregnancies showed that 16% delivered, 26% had a repeat tubal pregnancy, and 58% did not conceive. There was no significant difference between fertility results after salpingectomy and those after conservative surgery.     

Primary ovarian pregnancy after postpartum bilateral tubal ligation: a case report

BACKGROUND: Primary ovarian pregnancy constitutes <1% of ectopic gestations. Likewise, bilateral tubal ligation failure is uncommon, occurring in approximately 1% of tubal sterilization procedures. Should pregnancy occur after bilateral tubal ligation, of every 3 such pregnancies, 1 will be an ectopic. The incidence of ovarian pregnancy after tubal ligation has not been reported, but must be extremely rare. CASE: A 30-year-old, breast-feeding, white woman 6 months postpartum, with bilateral tubal ligation after delivery, developed acute right lower quadrant pain while excercising. Evaluation in the emergency room revealed rebound tenderness in the lower right abdomen, a positive beta-hCG level and ultrasound findings suspicious for a right ectopic pregnancy. Exploratory laparotomy revealed hemoperitoneum, previously ligated but otherwise-normal-appearing fallopian tubes, and a ruptured and bleeding right ovary. The pelvis was otherwise normal. Histology of the right ovarian wedge resection showed chorionic villi consistent with ovarian pregnancy. Both fallopian tubes were religated, and a review of the original tubal ligation histology confirmed tubal lumen in both segments. CONCLUSION: While ectopic pregnancy is a known but rare risk of failed tubal sterilization, pregnancy involving the fallopian tube is usually reported after tubal ligation failure. The rarely seen primary ovarian pregnancy is usually associated with intrauterine contraceptive devices or occurs in patients with pelvic inflammatory disease. Ovarian pregnancies are associated with massive hemoperitoneum in women unaware that they are pregnant.     

女性下生殖道沙眼衣原体及解脲支原体感染与输卵管妊娠的相关性

目的探讨女性下生殖道沙眼衣原体(CT)、解脲支原体(UU)感染与输卵管妊娠发生的关系以及夫妻双方接受敏感抗生素治疗CT、UU感染的输卵管妊娠患者术后输卵管通畅情况。方法 (1)对暨南大学附属第一医院2009年9月至2011年9月135例手术治疗的输卵管妊娠患者(研究组)和68例卵巢囊肿、子宫肌瘤患者(对照组)宫颈分泌物行性传播疾病病原体检测和药敏试验。(2)对有生育要求的65例CT、UU阳性的输卵管妊娠患者根据治疗情况分成夫妻双方同时接受敏感抗生素治疗的治疗组35例和预防性使用抗生素治疗的预防组30例,两组患者在手术当天均预防性使用抗生素,前者再根据药敏试验结果选择敏感抗生素对夫妻双方进行规范治疗,后者手术24h后不再使用抗生素。3个月后行子宫输卵管碘油造影(HSG),检查输卵管通畅情况。结果 (1)研究组CT、UU、CT+UU混合感染、淋病奈瑟菌(NG)检出率分别为19.3%(26/135)、40.7%(55/135)、8.9%(12/135)、3.7%(5/135);对照组CT、UU、CT+UU混合感染、NG的检出率分别为4.4%(3/68)、17.6%(12/68)、0(0/68)、、0(0/68)。两组CT、UU、CT+UU混合感染检出率差异有统计学意义(均P<0.05)。(2)HSG显示敏感抗生素治疗组患者患侧输卵管通畅31例(88.6%),阻塞或通而不畅4例(11.4%);预防性抗生素使用组患者患侧输卵管通畅20例(66.7%),阻塞或通而不畅10例(33.3%)。两组差异有统计学意义(均P<0.05)。结论以CT和UU为主的性传播病原体感染与输卵管妊娠的发生有关;根据药敏试验结果对CT和UU阳性的夫妻加强治疗,可能有助于提高术后3个月的输卵管复通率及减少输卵管妊娠的再发。     

Fertility following conservative surgery for tubal pregnancy

Eighty seven conservative surgical interventions for unruptured tubal pregnancy were performed on 83 patients. Salpingotomy was performed in 66 cases and expression of tubal pregnancy in 21 cases. In this patient group, 76.7% (56 out of 73) experienced intra-uterine pregnancy following surgery and 71.2% (52 out of 73) had a live birth. The recurrence rate of tubal pregnancy was 12.3%. Of the 42 patients with a normal contralateral tube, 36 (85.7%) had an intra-uterine pregnancy, 80.9% had a live birth and 7.1% had a recurrent tubal pregnancy. Sixty percent of the patients who underwent operation on their single tube, had a live birth and 66.6% had an intra-uterine pregnancy; the recurrence of tubal pregnancy in this group was 26.6%. No recurrence of tubal pregnancy was found in the group of patients who underwent expression of tubal gestation. It is suggested that the expression of tubal gestation (milking) is a safe procedure for conserving future fertility, and that the indications for conservative surgical management in patients with unruptured tubal gestation should be broadened to include all patients interested in future pregnancies, regardless of the current state of the contralateral tube.     

Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy

OBJECTIVE: We investigated the outcome of laparoscopic salpingotomy for tubal pregnancy by follow-up hysterosalpingography (HSG) or second-look laparoscopy (SLL) and reexamined the indication for and limitation of this conservative surgery. STUDY DESIGN: From April 1991 to December 2003, we treated 181 cases of tubal pregnancy using laparoscopic salpingotomy. The tubal patency was assessed by either HSG or SLL performed at 3 months post-surgery. The patients with a successful initial operation and confirmed ipsilateral patent tubes at follow-up were classified as truly successful cases (group I). Even after successful operation, if the treated tubes were found to be occluded, they were considered as unsuccessful cases. Therefore, those cases that were unsuccessful at initial surgery as well as at follow-up were categorized as group II. RESULTS: One hundred and thirty-four cases (74%) were successfully treated by salpingotomy at initial laparoscopy and 85 of them (63.4%) were found to be truly successful at follow-up (group I). The remaining 47 cases (26.0%) were unsuccessful at initial surgery and 18 (13.4%) cases at follow-up (group II). Thirty-one other patients refused to accept a tubal patency test or were not examined for personal reasons or were lost to follow-up. No difference in surgical outcome was observed between these two groups of patients with regard to gestational age, intra-operative hemorrhage, size or anatomic location of the pregnancy mass, and pre-operative adhesions of the fallopian tube. However, pre-operative serum levels of hCG were significantly higher in group II than in group I. In addition, the unsuccessful cases were more frequently associated with positive fetal heart beat (FHB), tubal rupture, and pre-operative serum levels of hCG of more than 10,000 IU/l (p<0.05, chi2 test). The log-rank test indicated a higher pregnancy success rate in group I (p<0.05) than in group II in those who desired future pregnancy. CONCLUSION: Laparoscopic salpingotomy may be practised as conservative surgery for proximal ectopic pregnancy, and gestational mass size is not as important and is not a relative contraindication for conservative laparoscopic surgery, as previously reported. Low pre-operative HCG levels, absence of FHB, absence of tubal rupture initially or minimal rupture may be considered suitable parameters for successful surgery and for achieving future pregnancy.     

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。     

Isthmic ectopic pregnancy and salpingitis isthmica nodosa

Two hundred eighty-five charts were reviewed from patients who underwent surgery for ectopic pregnancy. Excluded were patients with previous tubal reparative surgery, linear salpingotomy, or failed sterilization. The incidence of isthmic ectopic pregnancy in the remaining 255 cases was 15.3%. The association of salpingitis isthmica nodosa (SIN) and isthmic ectopic pregnancy was determined by review of resected tubal segments. SIN was noted in 17 of 37 cases (45.9%) of isthmic ectopic pregnancy. SIN places the patient at risk for recurrent ectopic pregnancy or infertility. Recommended conservative management of isthmic ectopic pregnancy is segmental resection with postoperative emphasis on documentation of SIN when present. Postoperative hysterosalpingography is recommended with an abnormal contralateral tube or when SIN is noted in the resected tubal segment. Management options after an isthmic ectopic pregnancy when future fertility is desired are presented.     

Pregnancies with intra-uterine contraceptive device in situ

34 cases of pregnancy with IUD in situ were observed in 715 IUD wearers, i.e. a 4.7% failure. Patients were mostly nulliparous, and between 20-24; IUDs were of several types, both inert and copper; time elapsed from insertion to occurrence of pregnancy went from 6 months to 2 years. Of the 34 pregnancies 3 were tubal; after celioscopy 2 salpingectomies and l salpingostomy were performed. 17 patients requested abortion, while 14 accepted the pregnancy. The IUD was successfully removed in 11 of these patients, while removal was impossible in the other 3 cases. There were in all 7 normal pregnancies and deliveries, and 7 spontaneous abortions. When a pregnancy occurs with IUD in situ it is necessary, after IUD removal, to watch for complications due to infection, for premature delivery, and for hemorrhage during delivery. It has not been proven that pregnancy with IUD in situ can result in malformations of the newborn.     

Conservative surgical treatment of tubal pregnancy: factors affecting future fertility

The results of conservative surgical treatment of tubal pregnancy (salpingotomy in 10 cases, partial salpingectomy and anastomosis in two cases) were compared with radical treatment in seven cases. The subsequent pregnancy rate was 55% and 71% for the conservative and radical groups, respectively. There were no recurrent tubal pregnancies in either group. Prior presence of pelvic adhesions did not have an effect on fertility in these patients. The rate of multiparity was significantly higher in patients who became pregnant after the surgery than those patients who did not become pregnant.     

Can open tubal microsurgery still be helpful in tubal infertility treatment?

In 30 years, 1,669 patients underwent open microsurgery for tubal diseases. Several techniques like adhesiolysis, reanastomosis, fimbrioplasty, salpingoneostomy, proximal reconstruction, isthmo-ostial anastomosis and reimplantation are described. Results were excellent for patients with a favourable prognosis (1,517 patients) and with very high pregnancy rate: 80% pregnancies with delivery for tubal reversal, 68% for proximal diseases, 75.1% for fimbrioplasty and 55% for salpingoneostomy. Risks of ectopic pregnancy were very low: 1.5% for tubal reversal (because the tubes were healthy), 4% for proximal diseases, 4% for fimbrioplasty and 6.7% for salpingoneostomy. Results were very low for patients with a poor prognosis (152 patients): 10% pregnancies with delivery for distal diseases, less than 20% for proximal diseases and 22% ectopic pregnancies. Open microsurgery can still be helpful in treating tubal infertility: results are better than those obtained with laparoscopic reconstructive surgery and better than those obtained with in vitro fertilization for patients with a favourable prognosis. Patients are only operated one time and can have several pregnancies. Open tubal microsurgery is a minimal invasive surgery and saves costs (it requires a small number of instruments and minimises sutures; patients can return home 4 days after surgery, at the latest). Results on fertility are very favourable.