腹腔镜手术治疗输卵管扭曲性不孕的临床分析
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摘要
不孕症(infertility)是指婚后同居,有正常性生活,未避孕一年而未妊娠者。它是一种比较常见的病症,且病因复杂多样。多数学者认为输卵管功能异常是导致女性不孕的主要因素之一,而由输卵管扭曲引起的不孕症约占输卵管性不孕症患者的30%-40%。由慢性输卵管炎、输卵管周围炎或输卵管发育异常等因素造成的输卵管扭曲改变了输卵管的正常走行,降低了它的蠕动功能并影响了输卵管液的流动,从而影响拾卵及配子(卵子和精子)的运输,引起不孕。目前腹腔镜是诊断输卵管病变的金标准。在输卵管性不孕症的治疗方面,腹腔镜手术作为其常规治疗手段,效果确切,可以使一部分患者自然受孕,有伦理学顾虑和轻中度输卵管病变患者也更容易接受。
目的
通过对输卵管扭曲性不孕症患者行腹腔镜下输卵管整形术,分析术后妊娠结局及输卵管扭曲程度对其影响,探讨腹腔镜手术治疗输卵管扭曲性不孕症的临床价值以及输卵管扭曲程度与术后妊娠率的关系,为治疗输卵管扭曲引起的不孕症提供指导。
方法
选择2008年01月～2010年10月在郑州大学第三附属医院妇科二病区行腹腔镜下输卵管整形术的输卵管性不孕症患者,排除含有男性不育因素、免疫因素、子宫因素、排卵障碍等因素的病例,经筛选共268例。术中镜下对盆腔粘连及输卵管情况进行评估,以单纯性输卵管扭曲引起的不孕症患者为研究对象,即输卵管扭曲、管壁柔软、伞端正常、子宫直肠窝正常者,共77例。
根据术中所见,行腹腔镜下输卵管整形术。对单纯性输卵管扭曲性不孕症患者,术中牵拉输卵管尽量恢复其正常形态后目测法测量输卵管扭曲处所成角度,记录其最小成角,并根据最小成角大小将患者分为最小成角<45°组、450-900组和90°-1450组。以单极电钩行粘连松解术分解扭曲处浆膜。宫腔镜检查了解宫腔情况及输卵管插管通液术了解双侧输卵管通畅情况。
术后确诊妊娠标准为HCG阳性且超声检查见妊娠囊。统计研究对象的临床资料和术后6-24个月随访资料,采用SPSS17.0软件进行分析,统计方法采用χ2检验以及Logistic回归分析,以a=0.05作为检验水准,分析术后妊娠结局及输卵管扭曲程度对妊娠结局的影响。
结果
1.腹腔镜下输卵管整形术后,248例输卵管性不孕症患者术后总妊娠率48.9%,宫内妊娠率44.4%,宫外妊娠率4.5%。
2.单纯性输卵管扭曲引起的不孕症患者共77人,占输卵管性不孕症患者的28.7%。输卵管扭曲最小成角<45°者22例,术后妊娠5例；最小成角45°-900者49例,妊娠24例；最小成角90°-145°者6例,妊娠3例。最小成角<45°组与45°-90°组术后妊娠情况比较,经χ2检验尸值为0.037,即两组患者术后妊娠率有明显差异。最小成角90°-145°组与45°-90°组术后妊娠情况经χ2检验尸值为0.962,两组患者术后妊娠率的差异无统计学意义。
3.单纯性输卵管扭曲引起的不孕症患者,腹腔镜下输卵管整形术后妊娠32例,宫内妊娠为30例。其中25例为术后6个月内妊娠,占妊娠人数的80.6%；6例为术后7-12个月内妊娠,占妊娠人数的18.75%；1例为术后13-24个月内妊娠,占妊娠人数的3.125%。结论
1.对输卵管扭曲最小成角大于450的单纯性输卵管扭曲性不孕症患者,腹腔镜下输卵管整形术是其有效治疗方法。
2.腹腔镜下输卵管整形术后6个月内为妊娠的高峰期,受孕人数的构成比随时间推移而下降。
Infertility is to point to living together after marriage, having a normal sex life without contraceptiion a year, without pregnancy.It is a relatively common disease, and the etiology is complex and diverse.Most scholars believe that the fallopian tube abnormalities is one of the main factors leading to female infertility, and infertility caused by tubal distortion accounts for about30%to40%of patients with tubal infertility.The tubal distortions caused by chronic salpingitis,tubal phlogistic surrounding tissue,congenital tubal abnormalities change the normal walking of the fallopian tube,reducing its peristaltic fuction and affect the flow of tubal fluid,thus affecting the transport of ova and sperm and cause infertility.At present, laparoscopy is the gold standard for diagnosis of tubal disease. In terms of treatment, laparoscopic surgery as a routine treatment for tubal infertility,it can make part of patients conceive naturally.For ones who have ethical concerns and in patients with mild to moderate tubal disease,tubal plastic surgery is more acceptable.
Objective
By undergoing laparoscopic tubal plastic surgery to tubal infertility patients,intraoperative assessment of tubal morphology and its function,to analyze the outcome of pregnancy and degree of tubal distortion of its impact.To investigate the clinical value of laparoscopic treatment of tubal infertility caused by tubal distortion and the relationship between postoperative pregnancy rate and the degree of tubal distortion,providing guidance for the treatment of infertility caused by tubal distortion.
Methods
Chose268cases who have had laparoscopic tubal plastic surgery in Gynecological ward two of Third Affiliated Hospital of Zhengzhou University, intraoperative assessment of situation of pelvic adhesions and fallopian tubes.There are77cases who were caused by simple distorted tubal infertility of all.
To operate tubal plastic surgery according to intraoperative findings.Try to sretch the fallopian tubes to restore its normal shape,and record the minimum angle of the distortion.Patients are divided into the minimum angle group<45°,group45°～90°and group90°～145°.Then eliminate the distortion by electrocantery.Conduct hysteroscopy for uterine and tubal cannulation for tubal patency.
Patients who have HCG-positive and the gestational sac under ultrasound can be diagnosed pregnant. According to statistics of clinical data and postoperative follow-up6～24months data, analyze the outcome of pregnancy and degree of tubal distortion of its impact by SPSS17.0software,and α=0.05are used as test standard.
Results
1.The total pregnancy rate after laparoscopic tubal plastic surgery of these268cases are48.9%, with44.4%intrauterine pregnancy rate and4.5%ectopic pregnancy rate.
2. There are77patients with simple twisted tube,which account for28.7%of patients with tubal infertility.There are22cases in the group the minimum angle <45°,and5cases got pregnancy after operation.In49cases the minimum angle between45°to90°,24cases of them got pregnancy.In6cases the angle between90° to145°,3cases got pregnancy.Comparing the pregnancy rate of the group the minimum angle <45°and group minimum angle45°～90°,the result of Pearson Chi-Square is0.037. Similarly,comparing the pregnancy rate of the group the minimum angle45°～90°and group minimum angle90°～145°,the result of Pearson Chi-Square is0.962.
3.There are32cases got pregnant in the77patients with simple twisted tube after laparoscopic tubal plastic surgery,in which30cases had intrauterine pregnancy--25cases are pregnant in six months after surgery,6cases in the seventh month to the twelfth month,and1case in the thirteenth month to the twenty-forth month.
Conclusions
1.By laparoscopic tubal plastic surgery to restore the normal shape of fallopian tube is an effective method of treatment of infertility,especially for those cases the minimum angle>45°.
2.The peak of pregnancy appears in the six months after surgery.And the composition of pregnancy declines with time.
目的
通过对输卵管扭曲性不孕症患者行腹腔镜下输卵管整形术,分析术后妊娠结局及输卵管扭曲程度对其影响,探讨腹腔镜手术治疗输卵管扭曲性不孕症的临床价值以及输卵管扭曲程度与术后妊娠率的关系,为治疗输卵管扭曲引起的不孕症提供指导。
方法
选择2008年01月～2010年10月在郑州大学第三附属医院妇科二病区行腹腔镜下输卵管整形术的输卵管性不孕症患者,排除含有男性不育因素、免疫因素、子宫因素、排卵障碍等因素的病例,经筛选共268例。术中镜下对盆腔粘连及输卵管情况进行评估,以单纯性输卵管扭曲引起的不孕症患者为研究对象,即输卵管扭曲、管壁柔软、伞端正常、子宫直肠窝正常者,共77例。
根据术中所见,行腹腔镜下输卵管整形术。对单纯性输卵管扭曲性不孕症患者,术中牵拉输卵管尽量恢复其正常形态后目测法测量输卵管扭曲处所成角度,记录其最小成角,并根据最小成角大小将患者分为最小成角<45°组、450-900组和90°-1450组。以单极电钩行粘连松解术分解扭曲处浆膜。宫腔镜检查了解宫腔情况及输卵管插管通液术了解双侧输卵管通畅情况。
术后确诊妊娠标准为HCG阳性且超声检查见妊娠囊。统计研究对象的临床资料和术后6-24个月随访资料,采用SPSS17.0软件进行分析,统计方法采用χ2检验以及Logistic回归分析,以a=0.05作为检验水准,分析术后妊娠结局及输卵管扭曲程度对妊娠结局的影响。
结果
1.腹腔镜下输卵管整形术后,248例输卵管性不孕症患者术后总妊娠率48.9%,宫内妊娠率44.4%,宫外妊娠率4.5%。
2.单纯性输卵管扭曲引起的不孕症患者共77人,占输卵管性不孕症患者的28.7%。输卵管扭曲最小成角<45°者22例,术后妊娠5例；最小成角45°-900者49例,妊娠24例；最小成角90°-145°者6例,妊娠3例。最小成角<45°组与45°-90°组术后妊娠情况比较,经χ2检验尸值为0.037,即两组患者术后妊娠率有明显差异。最小成角90°-145°组与45°-90°组术后妊娠情况经χ2检验尸值为0.962,两组患者术后妊娠率的差异无统计学意义。
3.单纯性输卵管扭曲引起的不孕症患者,腹腔镜下输卵管整形术后妊娠32例,宫内妊娠为30例。其中25例为术后6个月内妊娠,占妊娠人数的80.6%；6例为术后7-12个月内妊娠,占妊娠人数的18.75%；1例为术后13-24个月内妊娠,占妊娠人数的3.125%。结论
1.对输卵管扭曲最小成角大于450的单纯性输卵管扭曲性不孕症患者,腹腔镜下输卵管整形术是其有效治疗方法。
2.腹腔镜下输卵管整形术后6个月内为妊娠的高峰期,受孕人数的构成比随时间推移而下降。
Infertility is to point to living together after marriage, having a normal sex life without contraceptiion a year, without pregnancy.It is a relatively common disease, and the etiology is complex and diverse.Most scholars believe that the fallopian tube abnormalities is one of the main factors leading to female infertility, and infertility caused by tubal distortion accounts for about30%to40%of patients with tubal infertility.The tubal distortions caused by chronic salpingitis,tubal phlogistic surrounding tissue,congenital tubal abnormalities change the normal walking of the fallopian tube,reducing its peristaltic fuction and affect the flow of tubal fluid,thus affecting the transport of ova and sperm and cause infertility.At present, laparoscopy is the gold standard for diagnosis of tubal disease. In terms of treatment, laparoscopic surgery as a routine treatment for tubal infertility,it can make part of patients conceive naturally.For ones who have ethical concerns and in patients with mild to moderate tubal disease,tubal plastic surgery is more acceptable.
Objective
By undergoing laparoscopic tubal plastic surgery to tubal infertility patients,intraoperative assessment of tubal morphology and its function,to analyze the outcome of pregnancy and degree of tubal distortion of its impact.To investigate the clinical value of laparoscopic treatment of tubal infertility caused by tubal distortion and the relationship between postoperative pregnancy rate and the degree of tubal distortion,providing guidance for the treatment of infertility caused by tubal distortion.
Methods
Chose268cases who have had laparoscopic tubal plastic surgery in Gynecological ward two of Third Affiliated Hospital of Zhengzhou University, intraoperative assessment of situation of pelvic adhesions and fallopian tubes.There are77cases who were caused by simple distorted tubal infertility of all.
To operate tubal plastic surgery according to intraoperative findings.Try to sretch the fallopian tubes to restore its normal shape,and record the minimum angle of the distortion.Patients are divided into the minimum angle group<45°,group45°～90°and group90°～145°.Then eliminate the distortion by electrocantery.Conduct hysteroscopy for uterine and tubal cannulation for tubal patency.
Patients who have HCG-positive and the gestational sac under ultrasound can be diagnosed pregnant. According to statistics of clinical data and postoperative follow-up6～24months data, analyze the outcome of pregnancy and degree of tubal distortion of its impact by SPSS17.0software,and α=0.05are used as test standard.
Results
1.The total pregnancy rate after laparoscopic tubal plastic surgery of these268cases are48.9%, with44.4%intrauterine pregnancy rate and4.5%ectopic pregnancy rate.
2. There are77patients with simple twisted tube,which account for28.7%of patients with tubal infertility.There are22cases in the group the minimum angle <45°,and5cases got pregnancy after operation.In49cases the minimum angle between45°to90°,24cases of them got pregnancy.In6cases the angle between90° to145°,3cases got pregnancy.Comparing the pregnancy rate of the group the minimum angle <45°and group minimum angle45°～90°,the result of Pearson Chi-Square is0.037. Similarly,comparing the pregnancy rate of the group the minimum angle45°～90°and group minimum angle90°～145°,the result of Pearson Chi-Square is0.962.
3.There are32cases got pregnant in the77patients with simple twisted tube after laparoscopic tubal plastic surgery,in which30cases had intrauterine pregnancy--25cases are pregnant in six months after surgery,6cases in the seventh month to the twelfth month,and1case in the thirteenth month to the twenty-forth month.
Conclusions
1.By laparoscopic tubal plastic surgery to restore the normal shape of fallopian tube is an effective method of treatment of infertility,especially for those cases the minimum angle>45°.
2.The peak of pregnancy appears in the six months after surgery.And the composition of pregnancy declines with time.
引文
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[6]Szabo I,Langmar Z,Fontanyi Z,etal. Selective chromopertubation via hysteroscopic tubal cannulation; Orvosi hetilap 2010 Mar 14; 151 (11):453-6
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[I]The American Fertility Society.Classifications of adnexal adhesions,distal tubal occlusicion,tubal occlusion secondary to tubal ligation,tubal pregnancies,multerian anomalies and intrauterine adhesions[J].Fertil Steril,2006,(49):6
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[4]Muzii L, Sereni MI, Battista C,etal. Tubo-peritoneal factor of infertility:diagnosis and treatment. Clin Ter.2010;161(1):77-85.
[5]Szabo I,Sobel G,Pajor A, etal. Clinical relevance of proximal tubal occlusion--diagnosis and therapy.Orv Hetil.2010 Jul 4; 151(27):1106-10.
[6]Szabo I,Langmar Z,Fontanyi Z,etal. Selective chromopertubation via hysteroscopic tubal cannulation; Orvosi hetilap 2010 Mar 14; 151 (11):453-6
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[16]Watson A, Vandekerckhove P, Lilford R, etal.A meta-analysis of the therapeutic role of oil soluble contrast media at hysterosalpingography:a surprising result?Fertil Steril. 1994 Mar;61(3):470-7.
[17]Jenkins CS, Williams SR, Schmidt GE. Salpingitis isthmica nodosa:a review of the literature, discussion of clinical significance, and consideration of patient management.Fertil Steril.1993 Oct;60(4):599-607.
[18]de Wit W, Gowrising CJ, Kuik DJ, etal.Only hydrosalpinges visible on ultrasound are associated with reduced implantation and pregnancy rates after in-vitro fertilization.Hum Reprod.1998 Jun;13(6):1696-701.
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[27]Luciano DE, Exacoustos C, Johns DA, etal. Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubalblockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients?Am J Obstet Gynecol.2011 Jan;204(1):79.e1-5
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