输卵管妊娠腹腔镜保守手术改良方案的临床研究
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摘要
[研究背景和目的]
异位妊娠(ectopic pregnancy, EP)是早孕期间威胁孕妇生命的主要因素之一。其中以输卵管妊娠(tubal ectopic pregnancy, TP)最多见,约占95%,近年来发病率有明显增高的趋势。由于高敏感度放免测定人绒毛膜促性腺激素(human chorionic gonadotrophin,β-HCG)及高分辨B超和腹腔镜的开展,异位妊娠早期诊断率显著提高。药物治疗、内窥镜手术已被普遍接受,剖腹手术已很少应用。在手术治疗中,自20世纪70年代中期已从传统的根治性输卵管切除术发展至各种不同的保守性手术,为年轻及未生育妇女保留了生育功能。
腹腔镜技术的迅速发展,使输卵管妊娠由创伤较大的剖腹手术向微创的腹腔镜手术转化,成为异位妊娠手术治疗的第三次突破。电视腹腔镜下对输卵管妊娠未破裂或破裂型行保守性手术最适合于年轻、要求生育的患者。由于卵巢的血供60%-70%来自子宫动脉的上行支经输卵管系膜进入卵巢,故现多主张保留输卵管以保证卵巢的血供不受破坏。目前对输卵管妊娠多趋向于腹腔镜保守性手术治疗,尽量避免输卵管切除,除非有严重出血及组织破坏。
输卵管妊娠腹腔镜保守术式常见有伞端挤压,负压吸胚、切开取胚及镜下囊胚注药法等。无论上述何种手术方法,成功的关键在于胚囊着床部位的止血及预防和正确处理持续性异位妊娠,避免再次手术和切除输卵管。此外,术后对患侧输卵管通畅度进行正确有效的评价是保障生育功能恢复的前提。
输卵管具有复杂而精细的生理功能,在一定的时间内能将精子与卵子从相反的方向输送至壶腹部,创造适宜环境使二者结合为孕卵,并在其内发育、分裂直至子宫内膜已发育至孕卵着床时,进入宫腔,完好的伞端能拣拾卵子进入输卵管,而壶腹部的纤毛摆动是输送卵子不可缺少的,输卵管之所以能完成如此复杂的生理过程,其本身各部位的完整性是其重要的物质基础;保留了输卵管将有利于卵巢的血供,维持女性生理特征,尤其是对未产妇女以及生育功能低下而又需要保留生育功能的妇女。因此输卵管的完整性及其功能日益受到关注。这正是本课题的研究意义所在。
本课题基于输卵管妊娠保守手术的基本操作,结合微创手术特点,重点解决取胚过程中止血和术后预防PEP两大问题,总结出一套改良方案运用在腹腔镜保守术中：1、结扎输卵管系膜血管；2、垂体后叶素局部注射；3、剔除妊娠黄体；4、术后口服米非司酮巩固杀胚；5、经宫腔镜选择性输卵管插管通液配合斑马导丝疏通术评估患侧输卵管通畅度。通过研究组和对照组的临床研究,探讨以下问题：1、改良方案的技术操作要点及其目的和意义；2、改良方案中结扎输卵管系膜血管对同侧卵巢血供的影响；3、宫腔镜下选择性输卵管插管通液检查输卵管通畅的意义；4、改良方案在输卵管妊娠保守术中的应用指征和禁忌症。
本课题通过以上几方面的综合探讨,期望能为临床开展输卵管妊娠腹腔镜保守治疗及术后输卵管功能的恢复提供新的依据和参考。
[方法]
1.研究对象：2008年10月～2009年10月我科因输卵管妊娠行腹腔镜保守手术治疗的患者62例,随机分为两组：其中38例采用改良方案,设为研究组(A组),24例采用一般的保守手术,设为对照组(B组)；所有入选病例均符合以下指征：(1)病人有生育要求；(2)不能耐受药物保守治疗；(3)术前血流动力学控制稳定；(4)患侧输卵管无严重粘连导致难以分离、坏死感染等。
2.临床资料采集：收集患者的病史,临床症状,体格检查和妇科检查,实验室检验结果,功能辅助检查等临床资料。明确手术适应症排除手术禁忌症。
3.手术方式：所有病例均在腹腔镜下操作。B组常规式保守手术采用伞端挤压法或负压抽吸法,对壶腹部、峡部妊娠者采用输卵管切开取胚术；A组联合式保守手术在此基础上采用①结扎妊娠部位输卵管系膜血管；②垂体后叶素局部注射；③剔除妊娠黄体。附加手术：对侧输卵管伞端闭锁者均行造口术或输卵管伞端整形术修复。盆腔粘连者行粘连分解术。
4.术后处理：术后均常规予米非司酮100mg QD口服巩固杀胚,术后第1天复查血β-HCG,以后每隔3天复查一次,出院后每周测一次,直至转阴(血β-HCG<5IU／L)后停药。
5.围手术期资料记录：术中探查输卵管妊娠部位、类型,盆腔粘连分级,对侧输卵管情况；术前盆腔积血量；术中取胚出血量；手术时间；术后血β-HCG下降情况、住院时间及手术并发症(包括PEP)等资料。
6.手术随访：①A组病例于手术后第3个月月经周期第5天行经阴道彩色超声多普勒检查,记录患侧和对侧卵巢血流。②两组病例于术后第2次月经干净3-5天,勿同房,行宫腔镜下输卵管选择性插管通液术检查,记录患侧和对侧输卵管通畅情况。
7.统计学方法：所有数据均采用SPSS13.0统计学软件进行统计学处理,计量资料变量值以均数±标准差(X±S)表示；描述两组间差异采用两独立样本t检验或秩和检验或x2检验,描述A组病例左右卵巢动脉血流参数差异采用配对t检验。P<0.05具有显著统计意义。
[结果]
1.62例输卵管妊娠腹腔镜下保守手术全部成功完成,两组患者的年龄、妊娠次数、术前血β-HCG值、盆腔包块直径比较,差异均无统计学意义(P>0.05)；在停经时间上两组之间差异有统计学意义(t=2.429,P=0.018)。
2.两组术中所见输卵管妊娠部位、类型、盆腔粘连以及对侧输卵管情况两组比较差异无统计学意义(P>0.05)。其中输卵管妊娠破裂A组有4例,B组有1例,这些病例术中所见输卵管破口不大,且不伴有明显的活动性出血,我们通过术中修补也顺利完成了对患侧输卵管的保留。
3.术中出血量A组(44.21±14.45)ml和B组(73.75±15.48)ml之间有显著性差异(t=7.627,P=0.000),且我们通过手术对比的体会是：A组术中使用电凝明显少于B组；术前盆腔积血量、手术时间和住院时间比较,两组差异均无统计学意义(P>0.05)。
4.两组患者术前血β-HCG水平比较无显著性差异(t=0.662,P=0.511),血β-HCG下降率术后第1天(t=2.194,P=0.032)和第3天(t=6.198,P=0.000)及其降至正常水平的时间(t=2.183,P=0.033)均有统计学差异。
5.A组中1例出院后血β-HCG回升,考虑诊断PEP,在B超引导下局部注射MTX,血β-HCG14天内转阴；B组中2例术后1周复查血β-HCG缓慢不降反升,1例加用MTX50mg肌肉注射,血β-HCG于21天内转阴；1例因再次腹腔内出血而改行输卵管大部分切除术。
6.A组38例中有32例(其中30例双侧输卵管均健存,另2例为对侧输卵管缺如)预期随访检测双侧卵巢动脉血流；30例双侧输卵管均健存患者的患侧和对侧卵巢动脉血流参数值Vmax (t=1.533, P=0.136)、Vmin (t=0.352, P=0.727).RI(t=1.831,P=0.077)、PI(t=0.792,P=0.435)之间的差异均无统计学意义;2例既往因宫外孕行对侧输卵管大部分切除的患者,其缺如侧卵巢动脉血流(病例1Vmax47.7、Vmin11.5、PI0.76、RI1.63;病例2：Vmax 45.8、Vmin 10.4、PI 0.77、RI 1.58)均显著低于结扎侧(病例1Vmax10.7、Vmin3.9、PI0.64、RI1.16;病例2:Vmax9.7、Vmin2.9、PI0.70、RI 1.35)。
7.术后共36例回访输卵管通畅度情况,其中A组23例(22例为双侧输卵管均健存,1例为对侧输卵管缺如者),B组13例为双侧输卵管均健存。先行宫腔镜下选择性输卵管插管通液术检查双侧输卵管通畅度：两组的患侧输卵管通畅度(Z=1.721,P=0.361)及对侧输卵管通畅度(Z=0.358,P=0.749)均无显著性差异。对不通畅侧输卵管经斑马导丝疏通后再通液,患侧输卵管通畅度两组之间亦无显著性差异(Z=0.183,P=0.721)。A组中1例对侧输卵管缺如和1例对侧输卵管不通的患者在随访过程中自然受孕成功。
[结论]
腹腔镜下改良方案治疗输卵管妊娠不仅具有传统微创手术的优点,争取了最大限度地保留输卵管的完整性和功能性,值得我们继续推广和深入研究。我们的研究表明：切开取胚前结扎输卵管系膜血管配合垂体后叶素局部注射止血迅速有效,更适用于较复杂的异位妊娠；与电凝创面止血方式相比,输卵管系膜血管结扎法不会造成输卵管内膜损伤和术后疤痕形成,减少了管腔狭窄或周围组织挛缩的机会,也不会损伤同侧卵巢血供；剔除妊娠黄体利于术后血β-HCG下降,配合术后口服米非司酮有效预防PEP；宫腔镜下选择性输卵管插管通液配合斑马导丝疏通提高了术后输卵管通畅度的检查效率,对有效评估患者术后的生育功能有积极的临床指导意义。
[Background and Objective]
Ectopic pregnancy (EP) is one of the life-threatening conditions during the first trimester,95% of which is most commonly implant in the fallopian tube. Unfortunately the incidence of ectopic pregnancy has shown an increasing trend in recent years。However, our ability to diagnose an ectopic pregnancy at an earlier gestation (prior to rupture) through the use of highly sensitive pregnancy tests (Beta-HCG), ultrasonography, and diagnostic laparoscopy, has significantly altered our approach in treatment. Drug therapy, endoscopic surgery has been widely accepted.Traditionally-ectopic pregnancy has been dealt with by surgical removal of the affected fallopian tube. This may be done at the time of laparotomy or laparoscopy (an abdominal operation).However, since the mid-70s in the 20th century,many hospitals has been treating the affected fallopian tube more conservatively with a diverse array of surgical management which protect reproductive function for young patients and woman without children.
With the development of laparoscopic techniques rapidly, Our ability to diagnose and treat a tubal pregnancy at an earlier gestation (prior to rupture) being attributed to availability of microsurgical techniques, finer suture and minimal surgical trauma by laparoscope instead of laparotomy, which lead to the third breakthrough of surgical treatment for ectopic pregnancy..Laparoscopic conservative surgical treatment of unruptured or ruptured tubal pregnancy is best suited to young patients who require fertility. Furthermore,60%～70% of the ovarian blood supply comes from the ascending branch of uterine artery, and go into the ovary through the mesosalpinx. To retain the integrity of the fallopian tube have a positive meaning to keep the blood supply of the ovary from damage. Currently,conservative operations (ie, salpingotomy)are selected as much as possible instead of salpingectomy in cases of tubal pregnancy,unless there is severe bleeding and tissue damage.
There is a diverse array of technical procedure of laparoscopic conservative surgery for tubal pregnancy treatment. Such as fimbria extrusion, Vacuum aspiration, salpingotomy and blastocyst injection under laparoscopic etc.No matter which kind of operation were taken, the key point that affect the success of the surgery.is to control haemorrhage efficiently when removing the product of conception and to prevent PEP. In order to avoid further surgery and removal of fallopian tubes.In addition,correct and effective evaluation of the treated side tubal patency is precondition for the recovery of fertility.
Physiologic functions of the human fallopian tube are multiple and subtile, then, these facts are correlated with clinical considerations as they relate to tubal factor infertility. Anatomically the human oviduct is a tubular, seromuscular organ attached distally to the ovary and proximally to the lateral aspect of the uterine fundus.The intact fimbriated extremity of fallopian, whose terminal end contains the tubal ostium and picks up ovum into the tube. The ampullary region,whose cilia seems uncritical in gamete transport and embryogenesis.Clinically, the role of the the fallopian tube in sperm transport, its part in sperm maintenance and capacitation, and the tube's function in ovum transport, fertilization, and embryo transport may be essential to normal conception. Fallopian tube has been able to complete such a complex physiological process, its own segments of anatomy are an important material foundation.Tubal conservation will contribute to ovarian blood supply and the maintenance of women's physical characteristics, especially for a younger population, older nulliparous patients, and patients of reproductive dysfunction who desire future fertility. This is the significance of this research.
The study was carried out to take use of a modified protocol in laparoscopic conservative surgery,which based on the conventional operation previously described in the management of tubal pregnancy and combined advantages of micro-injury surgery, focused on solving hemostasis when removing the product of conception and prevention of PEP.The modified protocol was perfomed by the following laparoscopic procedure and postoperative management:(ⅰ)mesosalpinx vascellum ligation,(ⅱ)Local injection of hypophysin,(ⅲ)stripping corpus luteum verum,(ⅳ)oral application of mifepristone postoperation,(ⅴ)selective tubal catheterization assisted hydrotubation with zebra-guide wire deoppilation under hysteroscope to evaluate tube pregnancy.In this research,we compared the study group and control group for investigating the following questions:(ⅰ)The key points of technical operations in modified protocol underwent laparoscopic procedure and its purpose and significance; (ⅱ)the postoperative impact of mesosalpinx vascellum ligation to the blood flow of the ipsilateral arteriae ovarica;(ⅲ)clinical significance of selective tubal catheterization assisted hydrotubation under hysteroscope to evaluate tube pregnancy.; (ⅳ)indications and contraindications of the modified protocol application in laparoscopic conservative surgery for tubal pregnancy treatment.
The present study was undertaken to approach several aspects of the above problems,hoping to provide a new basis and reference to evaluate the safety and the feasibility of laparoscopic conservative procedure for tubal pregnancy treatment and post-operative recovery of tubal patency and future fertility.
[Methods]
1. The study object:From October 2008 to October 2009, a total of 62 cases of tubal pregnancy were treated in our department of gynecology randomly by laparoscopic conservative surgery. Of these,38 cases with the new allied process were assigned to be the study group(group A; n= 38) and 24 cases with the conventional process were assigned to be the control group(group B; n= 24).We selected laparoscopic salpingotomy on the basis of following criteria:(ⅰ) the patients' desire for future pregnancy; (ⅱ) intolerance of drug treatment; (ⅲ) haemodynamically stable preoperation; (ⅳ) no severe adhesions in the tubal wall or necrosis and infestation of the ipsilateal oviduct.
2. The clinical data:The data of the disease history, clinical manifestations, physical check-up and gynecologic pelvic examination, laboratorial reports and assistant examination such as transvaginal B-scan ultrasonography must be carefully collected for determining the operation indication and contraindication.
3. The surgery protocol:All patients were operated under laparoscopic successfully. In group B, The laparoscopic procedure was perfomed with conventional process according to that previously described (fimbriated extremity of fallopian pressurization or aspiration underpressure, and salpingotomy for the treatment of Oviduct ampulla oristhmus pregnancy). In group A, The laparoscopic procedure was perfomed with the new allied process (mesosalpinx vascellum ligation, Local injection of hypophysin and corpus luteum verum rejection). Both of the groups undertaken an additional surgery if necessary, such as fimbriae-neostomy or plasty when the contralateral fimbriae tubae atresia and lysis of pelvic adhesions.
4. Postoperative management:Take oral administration of mifepristone 100mg QD routinely to consolidate the effect on elimination of reliquus trophoblastic cell. Recheck serumβ-HCG on the first day after surgery and once every three days afterward and once a week post-discharge until serumβ-HCG step down to negative(serumβ-HCG<5IU/L).
5. The perioperative data:The data of the laparoscopic surgery such as the distribution of anatomic location of the ectopic pregnancy, tubal rupture or not, grading of pelvic adhesions, the condiction of contralateral tubal, post-and intra-operative blood loss, operation time, changes of serum human chorionic gonadotropin levels, hospitalization time, postoperative complications and so on must be correctly recorded.
6. Follow-up:(ⅰ)Transvaginal Color Doppler sonography(TV-CDS)can be used to monitor the ovarian artery blood flow of group A at the fifth day of menstrual cycle 3 months after the operation.Record the parameters Vmax、Vmin、PI、RI of the ipsilateral and contralateral ovarian artery. (ⅱ)Selective tubal catheterization assisted hydrotubation under hysteroscope can be used for tubal patency examination 3 to 5 days after the end of the second menstruation whiout sexual intercourse after the operation, record the tubal patency outcome of the two groups.
7. Statistic analysis:All results were analysed by using a SPSS 13.0 software package. All measurement datas were expressed as means and standard error (SE) of multiple measurements. Analyze the contrast between the groups with the new allied process and the groups with the conventional process by using either Independent samples T-test (a Student's t-test), Wilcoxon rank sum test or x2 test. In group A, the difference of the blood flow between the ipsilateral and contralateral ovarian artery was evaluated by paired t-test. For all analyses, the criterion of significance was set at p< 0.05.
[Results]
1. All of 62 tubal pregnancy cases were treated successfully by laparoscopic conservative surgery. There was no significant difference between the two groups in patient age, gravidity, history of ectopic pregnancy or tubal microsurgery, preoperative serum HCG levels and the mean maximum diameter of tubal pregnancy mass. Meanwhile,the only significant difference was gestational age(t=2.429, P=0.018). (Student's t-test)
2. There was also no difference between the distribution of anatomic location of the ectopic pregnancy, type (tubal rupture or not), grading of pelvic adhesions and the condiction of contralateral tubal in the two groups (Wilcoxon test or X2 test). Tubal rupture was observed in four cases in group A and one case in group B, and these ruptured cases displayed a small ruptured hole and there was no massive bleeding. We tried to approach these cases by conservative surgery.
3. As shown in laparoscopy, we did not observe any difference in the means of intraoperative blood loss and operation time between the two groups. The only significant difference observed was in the amount of intraoperative bleeding, which as expected was lesser in group A (44.21±14.45 ml) compared with group B (73.75±15.48 ml) (t=7.627, P=0.000). The mean hospitalization time was not significant difference between the two groups.
4. As shown in labolatory data, there was no significant difference between the two groups in preoperative serum HCG levels (t=0.662, P=0.511),but there were significant difference between the two groups in the decline rate of serum P-HCG on the first day (t=2.194, P=0.032) and the third day (t=6.198, P=0.000) after surgery and the duration of serumβ-HCG decreased to normal (t=2.183, P=0.033)
5. Persistent ectopic pregnancy occurred in one case of group A and two of group B. The case of group A was treated with methotrexate (MTX) local injection through B ultrasound-guided with a consequent smooth decline of HCG levels within 14 days. One case of group B was treated with methotrexate systemic injection with a consequent smooth decline of HCG levels within 21 days.Another case was performed salpingectomy by laparotomy due to coelio-hemorrhea.
6. In group A, thirty-two of 38 patients underwent mesosalpinx vascellum ligation in laparoscopic conservative surgery and then follow-up for checking postoperative ovarian artery blood flow at expectant.These cases include 30 patients with bilateral tubal and the other two patients with unilateral tubal. The other six patients were lost to follow-up. The different of Vmax、Vmin、PI、RI in the 30 patients with bilateral tubal is nonsignificant between the ipsilateral and contralateral ovarian artery(paired t-test, P< 0.05).However,in the other two patients with unilateral tubal,the parameters of Vmax、Vmin、PI、RI in unilateral tubal (patient-1:47.7、11.5、0.76、1.63; patient-2:45.8、10.4、0.77、1.58)is higher than the other half(patient-1:10.7、3.9、0.64、1.16; patient-2:9.7、2.9、0.70、1.35).
7. In total, Thirty-six of 62 patients with tubal pregnancy were followed-up to take the examination of selective tubal catheterization assisted hydrotubation under hysteroscope. In group A,22 patients with bilateral tubal and one patient with unilateral tubal; In group B,all 13 patients with bilateral tubal.The analysis of tubal patency outcome was calculated by Wilcoxon rank sum test and indicated no significant difference both in the treated side(Z=1.721, P=0.361)and the contralateral side (Z=0.358, P=0.749) between the two groups.The impatency tubal was manipulated with the guide wire deoppilation then.There was no significant difference in the tubal patency rate of the treated side between the two groups neither (Z=0.183, P=0.721.Two cases in group A got pregnancy during the follow-up period,of these,one patient with unilateral tubal and the other one with contralateral tubal impatency.
[Conclusions]
We recommend laparoscopic conservative surgery as a useful method in the management of cases with tubal pregnancy. The modified protocol dose not only has the advantages of micro-injury surgery, but also maximizes the integrity and functionality of tubal reservation. Mesosalpinx vascellum ligation and vasopressin injection are safe and effective method haemostasis in laparoscopic salpingotomy, which are more suitable for complicated cases of ectopic pregnancy. Compared to the general haemostasis with electric coagulation, mesosalpinx vascellum ligation will not cause damage and scar of endosalpinx, minimizing the fallopian tube stenosis and surrounding tissue contracture, nor further impair blood supply of the ipsilateral ovarian artery. Serumβ-HCG decreases rapidly with stripping corpus luteum verum. Mifepristone administration postoperation plays a positive role in the prevention of PEP. Selective tubal catheterization assisted hydrotubation with zebra-guide wire deoppilation under hysteroscope improves tubal patency, which has a positive clinical significance to assess reproductive capacity positivily.
异位妊娠(ectopic pregnancy, EP)是早孕期间威胁孕妇生命的主要因素之一。其中以输卵管妊娠(tubal ectopic pregnancy, TP)最多见,约占95%,近年来发病率有明显增高的趋势。由于高敏感度放免测定人绒毛膜促性腺激素(human chorionic gonadotrophin,β-HCG)及高分辨B超和腹腔镜的开展,异位妊娠早期诊断率显著提高。药物治疗、内窥镜手术已被普遍接受,剖腹手术已很少应用。在手术治疗中,自20世纪70年代中期已从传统的根治性输卵管切除术发展至各种不同的保守性手术,为年轻及未生育妇女保留了生育功能。
腹腔镜技术的迅速发展,使输卵管妊娠由创伤较大的剖腹手术向微创的腹腔镜手术转化,成为异位妊娠手术治疗的第三次突破。电视腹腔镜下对输卵管妊娠未破裂或破裂型行保守性手术最适合于年轻、要求生育的患者。由于卵巢的血供60%-70%来自子宫动脉的上行支经输卵管系膜进入卵巢,故现多主张保留输卵管以保证卵巢的血供不受破坏。目前对输卵管妊娠多趋向于腹腔镜保守性手术治疗,尽量避免输卵管切除,除非有严重出血及组织破坏。
输卵管妊娠腹腔镜保守术式常见有伞端挤压,负压吸胚、切开取胚及镜下囊胚注药法等。无论上述何种手术方法,成功的关键在于胚囊着床部位的止血及预防和正确处理持续性异位妊娠,避免再次手术和切除输卵管。此外,术后对患侧输卵管通畅度进行正确有效的评价是保障生育功能恢复的前提。
输卵管具有复杂而精细的生理功能,在一定的时间内能将精子与卵子从相反的方向输送至壶腹部,创造适宜环境使二者结合为孕卵,并在其内发育、分裂直至子宫内膜已发育至孕卵着床时,进入宫腔,完好的伞端能拣拾卵子进入输卵管,而壶腹部的纤毛摆动是输送卵子不可缺少的,输卵管之所以能完成如此复杂的生理过程,其本身各部位的完整性是其重要的物质基础;保留了输卵管将有利于卵巢的血供,维持女性生理特征,尤其是对未产妇女以及生育功能低下而又需要保留生育功能的妇女。因此输卵管的完整性及其功能日益受到关注。这正是本课题的研究意义所在。
本课题基于输卵管妊娠保守手术的基本操作,结合微创手术特点,重点解决取胚过程中止血和术后预防PEP两大问题,总结出一套改良方案运用在腹腔镜保守术中：1、结扎输卵管系膜血管；2、垂体后叶素局部注射；3、剔除妊娠黄体；4、术后口服米非司酮巩固杀胚；5、经宫腔镜选择性输卵管插管通液配合斑马导丝疏通术评估患侧输卵管通畅度。通过研究组和对照组的临床研究,探讨以下问题：1、改良方案的技术操作要点及其目的和意义；2、改良方案中结扎输卵管系膜血管对同侧卵巢血供的影响；3、宫腔镜下选择性输卵管插管通液检查输卵管通畅的意义；4、改良方案在输卵管妊娠保守术中的应用指征和禁忌症。
本课题通过以上几方面的综合探讨,期望能为临床开展输卵管妊娠腹腔镜保守治疗及术后输卵管功能的恢复提供新的依据和参考。
[方法]
1.研究对象：2008年10月～2009年10月我科因输卵管妊娠行腹腔镜保守手术治疗的患者62例,随机分为两组：其中38例采用改良方案,设为研究组(A组),24例采用一般的保守手术,设为对照组(B组)；所有入选病例均符合以下指征：(1)病人有生育要求；(2)不能耐受药物保守治疗；(3)术前血流动力学控制稳定；(4)患侧输卵管无严重粘连导致难以分离、坏死感染等。
2.临床资料采集：收集患者的病史,临床症状,体格检查和妇科检查,实验室检验结果,功能辅助检查等临床资料。明确手术适应症排除手术禁忌症。
3.手术方式：所有病例均在腹腔镜下操作。B组常规式保守手术采用伞端挤压法或负压抽吸法,对壶腹部、峡部妊娠者采用输卵管切开取胚术；A组联合式保守手术在此基础上采用①结扎妊娠部位输卵管系膜血管；②垂体后叶素局部注射；③剔除妊娠黄体。附加手术：对侧输卵管伞端闭锁者均行造口术或输卵管伞端整形术修复。盆腔粘连者行粘连分解术。
4.术后处理：术后均常规予米非司酮100mg QD口服巩固杀胚,术后第1天复查血β-HCG,以后每隔3天复查一次,出院后每周测一次,直至转阴(血β-HCG<5IU／L)后停药。
5.围手术期资料记录：术中探查输卵管妊娠部位、类型,盆腔粘连分级,对侧输卵管情况；术前盆腔积血量；术中取胚出血量；手术时间；术后血β-HCG下降情况、住院时间及手术并发症(包括PEP)等资料。
6.手术随访：①A组病例于手术后第3个月月经周期第5天行经阴道彩色超声多普勒检查,记录患侧和对侧卵巢血流。②两组病例于术后第2次月经干净3-5天,勿同房,行宫腔镜下输卵管选择性插管通液术检查,记录患侧和对侧输卵管通畅情况。
7.统计学方法：所有数据均采用SPSS13.0统计学软件进行统计学处理,计量资料变量值以均数±标准差(X±S)表示；描述两组间差异采用两独立样本t检验或秩和检验或x2检验,描述A组病例左右卵巢动脉血流参数差异采用配对t检验。P<0.05具有显著统计意义。
[结果]
1.62例输卵管妊娠腹腔镜下保守手术全部成功完成,两组患者的年龄、妊娠次数、术前血β-HCG值、盆腔包块直径比较,差异均无统计学意义(P>0.05)；在停经时间上两组之间差异有统计学意义(t=2.429,P=0.018)。
2.两组术中所见输卵管妊娠部位、类型、盆腔粘连以及对侧输卵管情况两组比较差异无统计学意义(P>0.05)。其中输卵管妊娠破裂A组有4例,B组有1例,这些病例术中所见输卵管破口不大,且不伴有明显的活动性出血,我们通过术中修补也顺利完成了对患侧输卵管的保留。
3.术中出血量A组(44.21±14.45)ml和B组(73.75±15.48)ml之间有显著性差异(t=7.627,P=0.000),且我们通过手术对比的体会是：A组术中使用电凝明显少于B组；术前盆腔积血量、手术时间和住院时间比较,两组差异均无统计学意义(P>0.05)。
4.两组患者术前血β-HCG水平比较无显著性差异(t=0.662,P=0.511),血β-HCG下降率术后第1天(t=2.194,P=0.032)和第3天(t=6.198,P=0.000)及其降至正常水平的时间(t=2.183,P=0.033)均有统计学差异。
5.A组中1例出院后血β-HCG回升,考虑诊断PEP,在B超引导下局部注射MTX,血β-HCG14天内转阴；B组中2例术后1周复查血β-HCG缓慢不降反升,1例加用MTX50mg肌肉注射,血β-HCG于21天内转阴；1例因再次腹腔内出血而改行输卵管大部分切除术。
6.A组38例中有32例(其中30例双侧输卵管均健存,另2例为对侧输卵管缺如)预期随访检测双侧卵巢动脉血流；30例双侧输卵管均健存患者的患侧和对侧卵巢动脉血流参数值Vmax (t=1.533, P=0.136)、Vmin (t=0.352, P=0.727).RI(t=1.831,P=0.077)、PI(t=0.792,P=0.435)之间的差异均无统计学意义;2例既往因宫外孕行对侧输卵管大部分切除的患者,其缺如侧卵巢动脉血流(病例1Vmax47.7、Vmin11.5、PI0.76、RI1.63;病例2：Vmax 45.8、Vmin 10.4、PI 0.77、RI 1.58)均显著低于结扎侧(病例1Vmax10.7、Vmin3.9、PI0.64、RI1.16;病例2:Vmax9.7、Vmin2.9、PI0.70、RI 1.35)。
7.术后共36例回访输卵管通畅度情况,其中A组23例(22例为双侧输卵管均健存,1例为对侧输卵管缺如者),B组13例为双侧输卵管均健存。先行宫腔镜下选择性输卵管插管通液术检查双侧输卵管通畅度：两组的患侧输卵管通畅度(Z=1.721,P=0.361)及对侧输卵管通畅度(Z=0.358,P=0.749)均无显著性差异。对不通畅侧输卵管经斑马导丝疏通后再通液,患侧输卵管通畅度两组之间亦无显著性差异(Z=0.183,P=0.721)。A组中1例对侧输卵管缺如和1例对侧输卵管不通的患者在随访过程中自然受孕成功。
[结论]
腹腔镜下改良方案治疗输卵管妊娠不仅具有传统微创手术的优点,争取了最大限度地保留输卵管的完整性和功能性,值得我们继续推广和深入研究。我们的研究表明：切开取胚前结扎输卵管系膜血管配合垂体后叶素局部注射止血迅速有效,更适用于较复杂的异位妊娠；与电凝创面止血方式相比,输卵管系膜血管结扎法不会造成输卵管内膜损伤和术后疤痕形成,减少了管腔狭窄或周围组织挛缩的机会,也不会损伤同侧卵巢血供；剔除妊娠黄体利于术后血β-HCG下降,配合术后口服米非司酮有效预防PEP；宫腔镜下选择性输卵管插管通液配合斑马导丝疏通提高了术后输卵管通畅度的检查效率,对有效评估患者术后的生育功能有积极的临床指导意义。
[Background and Objective]
Ectopic pregnancy (EP) is one of the life-threatening conditions during the first trimester,95% of which is most commonly implant in the fallopian tube. Unfortunately the incidence of ectopic pregnancy has shown an increasing trend in recent years。However, our ability to diagnose an ectopic pregnancy at an earlier gestation (prior to rupture) through the use of highly sensitive pregnancy tests (Beta-HCG), ultrasonography, and diagnostic laparoscopy, has significantly altered our approach in treatment. Drug therapy, endoscopic surgery has been widely accepted.Traditionally-ectopic pregnancy has been dealt with by surgical removal of the affected fallopian tube. This may be done at the time of laparotomy or laparoscopy (an abdominal operation).However, since the mid-70s in the 20th century,many hospitals has been treating the affected fallopian tube more conservatively with a diverse array of surgical management which protect reproductive function for young patients and woman without children.
With the development of laparoscopic techniques rapidly, Our ability to diagnose and treat a tubal pregnancy at an earlier gestation (prior to rupture) being attributed to availability of microsurgical techniques, finer suture and minimal surgical trauma by laparoscope instead of laparotomy, which lead to the third breakthrough of surgical treatment for ectopic pregnancy..Laparoscopic conservative surgical treatment of unruptured or ruptured tubal pregnancy is best suited to young patients who require fertility. Furthermore,60%～70% of the ovarian blood supply comes from the ascending branch of uterine artery, and go into the ovary through the mesosalpinx. To retain the integrity of the fallopian tube have a positive meaning to keep the blood supply of the ovary from damage. Currently,conservative operations (ie, salpingotomy)are selected as much as possible instead of salpingectomy in cases of tubal pregnancy,unless there is severe bleeding and tissue damage.
There is a diverse array of technical procedure of laparoscopic conservative surgery for tubal pregnancy treatment. Such as fimbria extrusion, Vacuum aspiration, salpingotomy and blastocyst injection under laparoscopic etc.No matter which kind of operation were taken, the key point that affect the success of the surgery.is to control haemorrhage efficiently when removing the product of conception and to prevent PEP. In order to avoid further surgery and removal of fallopian tubes.In addition,correct and effective evaluation of the treated side tubal patency is precondition for the recovery of fertility.
Physiologic functions of the human fallopian tube are multiple and subtile, then, these facts are correlated with clinical considerations as they relate to tubal factor infertility. Anatomically the human oviduct is a tubular, seromuscular organ attached distally to the ovary and proximally to the lateral aspect of the uterine fundus.The intact fimbriated extremity of fallopian, whose terminal end contains the tubal ostium and picks up ovum into the tube. The ampullary region,whose cilia seems uncritical in gamete transport and embryogenesis.Clinically, the role of the the fallopian tube in sperm transport, its part in sperm maintenance and capacitation, and the tube's function in ovum transport, fertilization, and embryo transport may be essential to normal conception. Fallopian tube has been able to complete such a complex physiological process, its own segments of anatomy are an important material foundation.Tubal conservation will contribute to ovarian blood supply and the maintenance of women's physical characteristics, especially for a younger population, older nulliparous patients, and patients of reproductive dysfunction who desire future fertility. This is the significance of this research.
The study was carried out to take use of a modified protocol in laparoscopic conservative surgery,which based on the conventional operation previously described in the management of tubal pregnancy and combined advantages of micro-injury surgery, focused on solving hemostasis when removing the product of conception and prevention of PEP.The modified protocol was perfomed by the following laparoscopic procedure and postoperative management:(ⅰ)mesosalpinx vascellum ligation,(ⅱ)Local injection of hypophysin,(ⅲ)stripping corpus luteum verum,(ⅳ)oral application of mifepristone postoperation,(ⅴ)selective tubal catheterization assisted hydrotubation with zebra-guide wire deoppilation under hysteroscope to evaluate tube pregnancy.In this research,we compared the study group and control group for investigating the following questions:(ⅰ)The key points of technical operations in modified protocol underwent laparoscopic procedure and its purpose and significance; (ⅱ)the postoperative impact of mesosalpinx vascellum ligation to the blood flow of the ipsilateral arteriae ovarica;(ⅲ)clinical significance of selective tubal catheterization assisted hydrotubation under hysteroscope to evaluate tube pregnancy.; (ⅳ)indications and contraindications of the modified protocol application in laparoscopic conservative surgery for tubal pregnancy treatment.
The present study was undertaken to approach several aspects of the above problems,hoping to provide a new basis and reference to evaluate the safety and the feasibility of laparoscopic conservative procedure for tubal pregnancy treatment and post-operative recovery of tubal patency and future fertility.
[Methods]
1. The study object:From October 2008 to October 2009, a total of 62 cases of tubal pregnancy were treated in our department of gynecology randomly by laparoscopic conservative surgery. Of these,38 cases with the new allied process were assigned to be the study group(group A; n= 38) and 24 cases with the conventional process were assigned to be the control group(group B; n= 24).We selected laparoscopic salpingotomy on the basis of following criteria:(ⅰ) the patients' desire for future pregnancy; (ⅱ) intolerance of drug treatment; (ⅲ) haemodynamically stable preoperation; (ⅳ) no severe adhesions in the tubal wall or necrosis and infestation of the ipsilateal oviduct.
2. The clinical data:The data of the disease history, clinical manifestations, physical check-up and gynecologic pelvic examination, laboratorial reports and assistant examination such as transvaginal B-scan ultrasonography must be carefully collected for determining the operation indication and contraindication.
3. The surgery protocol:All patients were operated under laparoscopic successfully. In group B, The laparoscopic procedure was perfomed with conventional process according to that previously described (fimbriated extremity of fallopian pressurization or aspiration underpressure, and salpingotomy for the treatment of Oviduct ampulla oristhmus pregnancy). In group A, The laparoscopic procedure was perfomed with the new allied process (mesosalpinx vascellum ligation, Local injection of hypophysin and corpus luteum verum rejection). Both of the groups undertaken an additional surgery if necessary, such as fimbriae-neostomy or plasty when the contralateral fimbriae tubae atresia and lysis of pelvic adhesions.
4. Postoperative management:Take oral administration of mifepristone 100mg QD routinely to consolidate the effect on elimination of reliquus trophoblastic cell. Recheck serumβ-HCG on the first day after surgery and once every three days afterward and once a week post-discharge until serumβ-HCG step down to negative(serumβ-HCG<5IU/L).
5. The perioperative data:The data of the laparoscopic surgery such as the distribution of anatomic location of the ectopic pregnancy, tubal rupture or not, grading of pelvic adhesions, the condiction of contralateral tubal, post-and intra-operative blood loss, operation time, changes of serum human chorionic gonadotropin levels, hospitalization time, postoperative complications and so on must be correctly recorded.
6. Follow-up:(ⅰ)Transvaginal Color Doppler sonography(TV-CDS)can be used to monitor the ovarian artery blood flow of group A at the fifth day of menstrual cycle 3 months after the operation.Record the parameters Vmax、Vmin、PI、RI of the ipsilateral and contralateral ovarian artery. (ⅱ)Selective tubal catheterization assisted hydrotubation under hysteroscope can be used for tubal patency examination 3 to 5 days after the end of the second menstruation whiout sexual intercourse after the operation, record the tubal patency outcome of the two groups.
7. Statistic analysis:All results were analysed by using a SPSS 13.0 software package. All measurement datas were expressed as means and standard error (SE) of multiple measurements. Analyze the contrast between the groups with the new allied process and the groups with the conventional process by using either Independent samples T-test (a Student's t-test), Wilcoxon rank sum test or x2 test. In group A, the difference of the blood flow between the ipsilateral and contralateral ovarian artery was evaluated by paired t-test. For all analyses, the criterion of significance was set at p< 0.05.
[Results]
1. All of 62 tubal pregnancy cases were treated successfully by laparoscopic conservative surgery. There was no significant difference between the two groups in patient age, gravidity, history of ectopic pregnancy or tubal microsurgery, preoperative serum HCG levels and the mean maximum diameter of tubal pregnancy mass. Meanwhile,the only significant difference was gestational age(t=2.429, P=0.018). (Student's t-test)
2. There was also no difference between the distribution of anatomic location of the ectopic pregnancy, type (tubal rupture or not), grading of pelvic adhesions and the condiction of contralateral tubal in the two groups (Wilcoxon test or X2 test). Tubal rupture was observed in four cases in group A and one case in group B, and these ruptured cases displayed a small ruptured hole and there was no massive bleeding. We tried to approach these cases by conservative surgery.
3. As shown in laparoscopy, we did not observe any difference in the means of intraoperative blood loss and operation time between the two groups. The only significant difference observed was in the amount of intraoperative bleeding, which as expected was lesser in group A (44.21±14.45 ml) compared with group B (73.75±15.48 ml) (t=7.627, P=0.000). The mean hospitalization time was not significant difference between the two groups.
4. As shown in labolatory data, there was no significant difference between the two groups in preoperative serum HCG levels (t=0.662, P=0.511),but there were significant difference between the two groups in the decline rate of serum P-HCG on the first day (t=2.194, P=0.032) and the third day (t=6.198, P=0.000) after surgery and the duration of serumβ-HCG decreased to normal (t=2.183, P=0.033)
5. Persistent ectopic pregnancy occurred in one case of group A and two of group B. The case of group A was treated with methotrexate (MTX) local injection through B ultrasound-guided with a consequent smooth decline of HCG levels within 14 days. One case of group B was treated with methotrexate systemic injection with a consequent smooth decline of HCG levels within 21 days.Another case was performed salpingectomy by laparotomy due to coelio-hemorrhea.
6. In group A, thirty-two of 38 patients underwent mesosalpinx vascellum ligation in laparoscopic conservative surgery and then follow-up for checking postoperative ovarian artery blood flow at expectant.These cases include 30 patients with bilateral tubal and the other two patients with unilateral tubal. The other six patients were lost to follow-up. The different of Vmax、Vmin、PI、RI in the 30 patients with bilateral tubal is nonsignificant between the ipsilateral and contralateral ovarian artery(paired t-test, P< 0.05).However,in the other two patients with unilateral tubal,the parameters of Vmax、Vmin、PI、RI in unilateral tubal (patient-1:47.7、11.5、0.76、1.63; patient-2:45.8、10.4、0.77、1.58)is higher than the other half(patient-1:10.7、3.9、0.64、1.16; patient-2:9.7、2.9、0.70、1.35).
7. In total, Thirty-six of 62 patients with tubal pregnancy were followed-up to take the examination of selective tubal catheterization assisted hydrotubation under hysteroscope. In group A,22 patients with bilateral tubal and one patient with unilateral tubal; In group B,all 13 patients with bilateral tubal.The analysis of tubal patency outcome was calculated by Wilcoxon rank sum test and indicated no significant difference both in the treated side(Z=1.721, P=0.361)and the contralateral side (Z=0.358, P=0.749) between the two groups.The impatency tubal was manipulated with the guide wire deoppilation then.There was no significant difference in the tubal patency rate of the treated side between the two groups neither (Z=0.183, P=0.721.Two cases in group A got pregnancy during the follow-up period,of these,one patient with unilateral tubal and the other one with contralateral tubal impatency.
[Conclusions]
We recommend laparoscopic conservative surgery as a useful method in the management of cases with tubal pregnancy. The modified protocol dose not only has the advantages of micro-injury surgery, but also maximizes the integrity and functionality of tubal reservation. Mesosalpinx vascellum ligation and vasopressin injection are safe and effective method haemostasis in laparoscopic salpingotomy, which are more suitable for complicated cases of ectopic pregnancy. Compared to the general haemostasis with electric coagulation, mesosalpinx vascellum ligation will not cause damage and scar of endosalpinx, minimizing the fallopian tube stenosis and surrounding tissue contracture, nor further impair blood supply of the ipsilateral ovarian artery. Serumβ-HCG decreases rapidly with stripping corpus luteum verum. Mifepristone administration postoperation plays a positive role in the prevention of PEP. Selective tubal catheterization assisted hydrotubation with zebra-guide wire deoppilation under hysteroscope improves tubal patency, which has a positive clinical significance to assess reproductive capacity positivily.
引文
[1]Nama V, Manyonda I. Tubal ectopic pregnancy:diagnosis and management[J]. Arch Gynecol Obstet.2009 Apr;279(4):443-53.
[2]Varma R, Gupta J. Tubal ectopic pregnancy.Clin Evid (Online).2009 Apr 20 pii: 1406.
[3]Fambrini M, Cioni R, Marchionni M,et al.Macroscopic evidence of ectopic pregnancy associated with mechanical tubal obstruction[J].Obstet Gynaecol. 2010 Jan;32(1):9.
[4]Obed S A, Wilson JB,Elkins TE.Diagnosing unruptured ectopic pregnancy [J]. Gynecol Obstet,1994,45:21.
[5]Yao M, Tulandi T.Current status of surgical and nonsurgical management of ectopic pregnancy[J]. Fertil Steril1997,67 (3):421
[6]Ehrenberg-Buchner S, Sandadi S,etc. Ectopic pregnancy:role of laparoscopic treatment[J]. Clin Obstet Gynecol.2009 Sep;52(3):372-9.
[7]Oelsner G. Ectopic pregnancy in the sole remaining tube and the management of the patient with multip le ectopic pregnancies[J]. Clin Obstet Gynecol,1987,30 (1):225-229.
[8]Diamond MP,Decherney AH, Surgical techniques in the management of ectopic pregnancy[J]. Clin Obstet Gynecol.1987.30(1):200～209.
[9]Farquhar CM. Ectopic pregnancy[J]. Lancet 2005;366:583-91.
[10]Kaser O, IKLe FA, Hirsch HA,妇科手术图解[M].第2版.广州：广东科技出版社,1996.211-212.
[11]Weekes LR,Ectopic pregnancy:current clinical trends, a fifteen year study. J Natl Med Assoc[J].1981 Sep;73(9):823-33
[12]夏恩兰主编.妇科内镜学[M].北京[J]人民卫生出版社,2001.347
[13]Keckstein J, Hepp S, Schneider V,et al. The contact Nd:YAG laser:a new technique for conservation of the fallopian tube in unruptured ectopic pregnancy[J]. Br J Obstet Gynaecol.1990 Apr;97(4):352-6.
[14]Bornstein, et al. Treatment of ectopic pregnancy with laparoscopicresection in a communnity hospital[J]. J Reprod Med,1987,32:59.
[15]Bruhat MA, Manhes H.Treatment of ectopic pregnancy by means of laparoscopy[J]. Fertil Steril,1980,33,411-414.
[16]Mettler L, Semm K. Management of ectopic pregnancy:a Shift from laparotomy to pelviscopy[J]. Inter J Fertil,1998,33(6):389～392.
[17]F. Mol, B.W. Mol, Ankum WM, et al.Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy:a systematic review and meta-analysis[J]. Hum Reprod Update. 2008 Jul-Aug;14(4):309-19.
[18]Templeman C, Davis C, Janik G,et al. Laparoscopic microsurgical anastomosis of the blocked, solitary post-ectopic Fallopian tube:Case report[J].Hum Reprod. 2006Jun;17(6):1630-2
[19]Ding DC, Chu TY, Kao SP, et al. Laparoscopic management of tubal ectopic pregnancy[J]. JSLS.2008 Jul-Sep;12(3):273-6.
[20]Seeber BE, Barnhart KT. Suspected ectopic pregnancy[J]. Obstet Gynecol.2006 Feb;107(2 Pt 1):399-413.
[21]Condous G. Ectopic pregnancy:challenging accepted management strategies [J]. Aust NZJ Obstet Gynaecol.2009 Aug;49(4):346-51.
[22]陈全娘,张晓薇,胡淑君等,输卵管妊娠保留输卵管的腹腔镜手术方法研究[J]中国实用妇科与产科杂志1998,1(14)：37-39.
[23]徐丽珍腹腔镜下异位妊娠保守性手术的临床应用[J].广西医学2006,4(21)： 23-24
[24]Fujishita A, Masuzaki H, Khan KN,.Laparoscopic salpingotomy for tubal pregnancy:comparison of linear salpingotomy with and without suturing[J]. Hum Reprod 2004 May; 19(5):1195-200.
[25]Nutun Jain.State of the Art Atlas of Endoscopic Surgery in Infertility and Gynecology[M]2006.3.114
[26]Bonatz G, Lehmann-Willenbrock E, Kunstmann P, et al, Management of patients with persistent beta-hCG values following laparoscopic surgical and local drug treatment for ectopic pregnancy[J]. Int J Gynaecol Obstet.1994 Oct;47(1):33-8
[27]Giuliani A,Hoenigl W.Reproductive outcome after laparoscopic instillation of hyperosmolar glucose into unruptured tubal pregnancies[J].Fertil Steril,2001,76 (2):366.
[28]Arikan GM,J eline KB, Tamussino K,et al.Local injection of hyperosmolar glucose solution versus salpingotomy for tube-preserving therapy in women with unrruptured tubal pregnancy and a serum HCG level of 2500IU/L[J]. Ferti 1 S teri l,2001,75 (4):826.
[29]Ocal P, Erkan S,etal. Transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose for treatment of unruptured tubal heterotopic pregnancy[J]. Arch Gynecol Obstet.2007 Sep;276(3):281-3.
[30]李光仪,异位妊娠腹腔镜保守手术[J].中国实用妇科与产科杂志2006,4(22)：198-200
[31]Agdi M, Tulandi T. Surgical treatment of ectopic pregnancy [J]. Best Pract Res.Clin Obstet Gynaecol.2009 Aug;23(4):519-27.
[32]Gajewska M,Kaminski.P,etal.Laparoscopicmanagement of ectopic pregnancy[J]. Neuro Endocrinol Lett.2008 Apr;29(2):267-71
[33]Akhan SE, Baysal B. Laparotomy or laparoscopic surgery? Factors affecting the surgeons choice for the treatment of ectopic pregnancy [J]. Arch Gynecol Obstet. 2002Apr;266(2):79-82.
[34]古伟文,张秀俊输卵管系膜血管结扎术在输卵管妊娠治疗中的应用[J]中国实用妇科与产科杂志1993,6(9)：53-54
[35]王雁,吴翘楚结扎输卵管系膜血管在输卵管妊娠保守性手术中的应用(附90例报告)广东药学院学报[J]1998,14(4)：354～355
[36]Young-Sam Choi M.D. Dae-Sook Eun M.D. Jin Choi M.D.et al.Laparoscopic cornuotomy using a temporary tourniquet suture and diluted vasopressin injection in interstitial pregnancy[J].Fertility and Sterility 2009,91(5): 1933-1937
[37]Martinez-Torres M, Hernandez-Caballero ME, Luis-Diaz JA,et al. Effects of luteectomy in early pregnancy on the maintenance of gestation and plasma progesterone concentrations in the viviparous temperate lizard Barisia imbricata[J]. Reprod Biol Endocrinol.2010 Feb 25;8:19.
[38]Al-Gubory KH, Solari A, Mirman B. Effects of luteectomy on the maintenance of pregnancy, circulating progesterone concentrations and lambing performance in sheep[J]. Reprod Fertil Dev.1999;11(6):317-22.
[39]Csapo AI, Pulkkinen M. Indispensability of the human corpus luteum in the maintenance of early pregnancy. Luteectomy evidence [J]. Obstet Gynecol Surv. 1978 Feb;33(2):69-81.
[40]Csapo AI, Pulkkinen MO, Wiest WG. Effects of luteectomy and progesterone replacement therapy in early pregnant patients [J]. Am J Obstet Gynecol.1973 Mar 15;115(6):759-65.
[41]丁淑珍徐旭群等,去黄体预防持续性异位妊娠的研究[J]临床医学,2007,7(27)：53-54
[42]张玉新输卵管妊娠保守性手术中黄体剥除的作用探讨[J]中国妇幼保健[J]2007,10(25)：77-79
[43]Cheong Y, Li TC.Controversies in the management of ectopic pregnancy[J]. Reprod Biomed Online.2007 Oct;15(4):396-402.
[44]Nathorst-Boos J, Rafik Hamad R. Risk factors for persistent trophoblastic activity after surgery for ectopic pregnancy [J]. Acta Obstet Gynecol Scand. 2004 May;83(5):471-5.
[45]Mol F, Strandell A,etal.The ESEP study:salpingostomy versus salpingectomy for tubal ectopic pregnancy; the impact on future fertility:a randomised controlled trial[J]. BMC Womens Health.2008 Jun 26;8:11.
[46]Silver PD,Schaper AM,Rooney B. Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy[J]. Obstet Gynecol,1993,81:710～715.
[47]Zhang J, Hao WM,etal., Outcome and relevant factors of tubal pregnancy treated with laparoscopic conservative surgery[J]. Zhonghua Fu Chan Ke Za Zhi. 2010 Feb;45(2):84-8.
[48]谢咏,王刚,林铁成,输卵管妊娠患者腹腔镜保守性手术后生育状况及其影响因素分析[J],中国实用妇科与产科杂志,2007,06(04)33：04
[49]Szabo I, Langmar Z, Fontanyi Z,et al. Selective chromopertubation via hysteroscopic tubal cannulation Orv Hetil[J].2010 Mar 14;151(11):453-6
[50]Vardhana PA, Silberzweig JE, Guarnaccia M, Hysterosalpingography with selective salpingography[J]. J Reprod Med.2009 Mar;54(3):126-32.
[51]DONNEZ J.Atlas of operative laparoscopy and hysteroscopy[M].3rd ed.Naway:Informa UK Ltd,2007:557.
[52]Al-Jaroudi D, Herba MJ, Tulandi T. Reproductive performance after selective tubal catheterization[J]. J Minim Invasive Gynecol.2005 Mar-Apr; 12(2):150-2
[53]冷金花,郎景和,腹腔镜在异位妊娠诊治中的应用[J].中国实用妇科与产科杂志2000,16(4)：
[54]Merce LT, Bau S, Bajo JM. Doppler study of arterial and venous intraovarian blood flow in stimulated cycles[J].Ultrasound Obstet Gynecol.2001 Nov;18(5): 505-10.
[55]罗丽兰.不孕不育[M].北京：人民卫生出版社,1998：166.
[56]American Fertility Society (1988) The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, secondary to tubal ligation, tubal pregnancies, Mullerian anomalies, and intrauterine adhesions[C]. Fertil Steril 49,944-949.
[57]Salvat J, Schmidt MH, Guilbert M, Vascular ligation for severe obstetrical hemorrhage:review of the literature[J]. J Gynecol Obstet Biol Reprod (Paris). 2002 Nov;31(7):629-39.
[58]Schenker JG, Evron S. New concepts in the surgical management of tubal pregnancy and the consequent postoperative results[J].Fertil Steril.1983 Dec;40(6):709-23.
[59]Brzezinski A, Schenker JG. Current status of endoscopic surgical management of tubal pregnancy[J].Eur J Obstet Gynecol Reprod Biol.1994 Mar 31;54(1):43-53.
[60]Stock RJ, Hansen KA, Reed ME. The value of peritoneal hCG and vasopressin in ectopic pregnancy[J].J Am Assoc Gynecol Laparosc.1996 Aug;3(4):S48.
[61]MUGUR M, YESILYURT H, SOYSAL S, et al. Prophylactic vasopressin during laparoscopic salpingotomy for ectopic pregnancy[J].J Am Assoc Gynecol Laparosc,1996,3(3):365-368
[62]乐杰,主编.妇产科学[M].第6版.北京：人民卫生出版社,2005：9.
[63]陈淑琴,姚书忠,张成美,两点注射垂体后叶素在腹腔镜下输卵管切开术中的临床价值[J].中国内镜杂志.2008,7(14)：777-779
[64]Ben-Arie A, Goldchmit R, Dgani R, Trophoblastic peritoneal implants after laparoscopic treatment of ectopic pregnancy [J]. Eur J Obstet Gynecol Reprod Biol.2001 May;96(1):113-5.
[65]Pal L, Parkash V, Rutherford TJ. Omental trophoblastic implants and hemoperitoneum after laparoscopic salpingostomy for ectopic pregnancy[J]. A case report. J Reprod Med.2003 Jan;48(1):57-9.
[66]Qureshi NS. Treatment options for threatened miscarriage[J]. Maturitas.2009 Dec;65 Suppl 1:S35-41. Epub 2009 Nov 27.
[67]Martinez-Torres M, Hernandez-Caballero ME, Luis-Diaz JA,etc. Effects of luteectomy in early pregnancy on the maintenance of gestation and plasma progesterone concentrations in the viviparous temperate lizard Barisia imbricata imbricata[J]. Reprod Biol Endocrinol.2010 Feb 25;8:19.
[68]Daya S. Luteal support:progestogens for pregnancy protection[J]. Maturitas. 2009 Dec;65 Suppl 1:S29-34. Epub 2009 Nov 12.
[69]El-Zibdeh MY, Yousef LT. Dydrogesterone support in threatened miscarriage[J]. Maturitas.2009 Dec;65 Suppl 1:S43-6. Epub 2009 Dec 14.
[70]Liu HC, Pyrgiotis E, Davis O, Active corpus luteum function at pre-, peri-and postimplantation is essential for a viable pregnancy [J]. Early Pregnancy.1995 Dec;1(4):281-7.
[71]Ramirez NC, Lawrence WD, Ginsburg KA, Ectopic pregnancy. A recent five-year study and review of the last 50 yearsr'literature[J]. J Reprod Med.1996 Oct;41(10):733-40
[72]McComb P, Delbeke L. Decreasing the number of ovulations in the rabbit with surgical division of the blood vessels between the fallopian tube and ovary [J]. J Reprod Med,1984,29(11):827-9.
[73]Otubu JA, Winston RM. Ovarian function after salpingostomy following mechanically produced hydrosalpinx in rabbits[J]. Afr J Med Med Sci.1986 Mar-Jun;15(1-2):19-24.
[74]Kelekci S, Yilmaz B, Yakut Y, Hormonal and ovarian stromal blood supply changes after laparoscopic tubal sterilization:a prospective controlled study[J]. Contraception.2006 Mar;73(3):279-83. Epub 2005 Sep 26.
[75]CCW Chan,EHY Ng,CF Li,et al.Impaired ovarian blood flow and reduced antral follicle count following laparoscopic salpingectomy for ectopic pregnancy [J]. Hum Reprod,2003,18(11):2175
[76]Mardesic T, Muller P, Huttelova R.etc. Effect of salpingectomy on the results of FVF in women with tubal sterility--prospective study[J]. Ceska Gynekol.2001 Jul;66(4):259-64.
[77]Johnson N, van Voorst S, Sowter MC,etc. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation[J]. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD002125
[78]Ahmad G, Watson A, Vandekerckhove P. etc.Techniques for pelvic surgery in subfertility[J]. Cochrane Database Syst Rev.2006 Apr 19;(2):CD000221.
[79]张金玉李文玲郭新宇等,卵巢及输卵管术后患者超排卵治疗卵巢反应性的观察[J].中华妇产科杂志2003.7(38)：433-434
[80]Bangsgaard N,Lund CO,Ottesen B,etal.Improved fertility following conservative surgical treatment of ectopic pregnancy[J].BJOG,2003,110(8): 765-770。
[81]Goynumer G, Kayabasoglu F, Aydogdu S.etc. The effect of tubal sterilization through electrocoagulation on the ovarian reserve[J]. Contraception.2009 Jul;80(1):90-4. Epub 2009 Mar 6.
[82]Baloglu A, Uysal D, Karci L, Effects of laparoscopic tubal ligation on ovarian blood flow and steroidogenesis[J]. Clin Exp Obstet Gynecol.2005;32(4):230-2.
[83]Duffy JM, Johnson N, Ahmad G.etc. Postoperative procedures for improving fertility following pelvic reproductive surgery [J]. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD001897.
[84]Hwa Sook Moon MD, PhD, Young Joo Choi MD, Yang Hee Park MD. New simple endoscopic operations for interstitial pregnancies [J] American Journal of Obstetrics and Gynecology.2000,1(182):114-121
[85]Nash S. Moawad MD. Sangeeta T.et al. Current diagnosis and treatment of interstitial pregnancy [J].American Journal of Obstetrics and Gynecology.2010, 202(1):15-29
[86]Tulandi T, Al-Jaroudi D. Interstitial pregnancy:results generated from the Society of Reproductive Surgeons Registry [J]. Obstet Gynecol.2004 103(1):47-50.
[87]Timmerman E, Roovers JP, Ankum WM, Interstitial pregnancy:a rare type of ectopic pregnancy[J]. Ned Tijdschr Geneeskd.2008 Apr 5;152(14):787-91.
[88]Choi YS, Eun DS, Choi J,etc. Laparoscopic cornuotomy using a temporary tourniquet suture and diluted vasopressin injection in interstitial pregnancy[J]. Fertil Steril.2009 91(5):1933-7. Epub 2008 Apr 18.
[89]Fujishita A, Khan KN, Kitajima M, Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy [J]. Eur J Obstet Gynecol Reprod Biol.2008 Apr; 137(2):210-6.
[90]van Mello NM, Mol F, Adriaanse AH, The METEX study:methotrexate versus expectant management in women with ectopic pregnancy:a randomised controlled trial[J]. BMC Womens Health.2008 Jun 19;8:10.
[91]Krag Moeller LB, Moeller C, etal. Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies:a randomized trial[J]. Acta Obstet Gynecol Scand.2009;88(12): 1331-7.
[92]Mol F, Mol BW, Ankum WM, etal. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy:a systematic review and meta-analysis[J]. Hum Reprod Update. 2008 Jul-Aug;14(4):309-19.
[93]Hajenius PJ, Mol F, Mol BW,etal.Interventions for tubal ectopic pregnancy[J]. Cochrane Database Syst Rev.2007 Jan 24;(1):CD000324.
[2]Varma R, Gupta J. Tubal ectopic pregnancy.Clin Evid (Online).2009 Apr 20 pii: 1406.
[3]Fambrini M, Cioni R, Marchionni M,et al.Macroscopic evidence of ectopic pregnancy associated with mechanical tubal obstruction[J].Obstet Gynaecol. 2010 Jan;32(1):9.
[4]Obed S A, Wilson JB,Elkins TE.Diagnosing unruptured ectopic pregnancy [J]. Gynecol Obstet,1994,45:21.
[5]Yao M, Tulandi T.Current status of surgical and nonsurgical management of ectopic pregnancy[J]. Fertil Steril1997,67 (3):421
[6]Ehrenberg-Buchner S, Sandadi S,etc. Ectopic pregnancy:role of laparoscopic treatment[J]. Clin Obstet Gynecol.2009 Sep;52(3):372-9.
[7]Oelsner G. Ectopic pregnancy in the sole remaining tube and the management of the patient with multip le ectopic pregnancies[J]. Clin Obstet Gynecol,1987,30 (1):225-229.
[8]Diamond MP,Decherney AH, Surgical techniques in the management of ectopic pregnancy[J]. Clin Obstet Gynecol.1987.30(1):200～209.
[9]Farquhar CM. Ectopic pregnancy[J]. Lancet 2005;366:583-91.
[10]Kaser O, IKLe FA, Hirsch HA,妇科手术图解[M].第2版.广州：广东科技出版社,1996.211-212.
[11]Weekes LR,Ectopic pregnancy:current clinical trends, a fifteen year study. J Natl Med Assoc[J].1981 Sep;73(9):823-33
[12]夏恩兰主编.妇科内镜学[M].北京[J]人民卫生出版社,2001.347
[13]Keckstein J, Hepp S, Schneider V,et al. The contact Nd:YAG laser:a new technique for conservation of the fallopian tube in unruptured ectopic pregnancy[J]. Br J Obstet Gynaecol.1990 Apr;97(4):352-6.
[14]Bornstein, et al. Treatment of ectopic pregnancy with laparoscopicresection in a communnity hospital[J]. J Reprod Med,1987,32:59.
[15]Bruhat MA, Manhes H.Treatment of ectopic pregnancy by means of laparoscopy[J]. Fertil Steril,1980,33,411-414.
[16]Mettler L, Semm K. Management of ectopic pregnancy:a Shift from laparotomy to pelviscopy[J]. Inter J Fertil,1998,33(6):389～392.
[17]F. Mol, B.W. Mol, Ankum WM, et al.Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy:a systematic review and meta-analysis[J]. Hum Reprod Update. 2008 Jul-Aug;14(4):309-19.
[18]Templeman C, Davis C, Janik G,et al. Laparoscopic microsurgical anastomosis of the blocked, solitary post-ectopic Fallopian tube:Case report[J].Hum Reprod. 2006Jun;17(6):1630-2
[19]Ding DC, Chu TY, Kao SP, et al. Laparoscopic management of tubal ectopic pregnancy[J]. JSLS.2008 Jul-Sep;12(3):273-6.
[20]Seeber BE, Barnhart KT. Suspected ectopic pregnancy[J]. Obstet Gynecol.2006 Feb;107(2 Pt 1):399-413.
[21]Condous G. Ectopic pregnancy:challenging accepted management strategies [J]. Aust NZJ Obstet Gynaecol.2009 Aug;49(4):346-51.
[22]陈全娘,张晓薇,胡淑君等,输卵管妊娠保留输卵管的腹腔镜手术方法研究[J]中国实用妇科与产科杂志1998,1(14)：37-39.
[23]徐丽珍腹腔镜下异位妊娠保守性手术的临床应用[J].广西医学2006,4(21)： 23-24
[24]Fujishita A, Masuzaki H, Khan KN,.Laparoscopic salpingotomy for tubal pregnancy:comparison of linear salpingotomy with and without suturing[J]. Hum Reprod 2004 May; 19(5):1195-200.
[25]Nutun Jain.State of the Art Atlas of Endoscopic Surgery in Infertility and Gynecology[M]2006.3.114
[26]Bonatz G, Lehmann-Willenbrock E, Kunstmann P, et al, Management of patients with persistent beta-hCG values following laparoscopic surgical and local drug treatment for ectopic pregnancy[J]. Int J Gynaecol Obstet.1994 Oct;47(1):33-8
[27]Giuliani A,Hoenigl W.Reproductive outcome after laparoscopic instillation of hyperosmolar glucose into unruptured tubal pregnancies[J].Fertil Steril,2001,76 (2):366.
[28]Arikan GM,J eline KB, Tamussino K,et al.Local injection of hyperosmolar glucose solution versus salpingotomy for tube-preserving therapy in women with unrruptured tubal pregnancy and a serum HCG level of 2500IU/L[J]. Ferti 1 S teri l,2001,75 (4):826.
[29]Ocal P, Erkan S,etal. Transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose for treatment of unruptured tubal heterotopic pregnancy[J]. Arch Gynecol Obstet.2007 Sep;276(3):281-3.
[30]李光仪,异位妊娠腹腔镜保守手术[J].中国实用妇科与产科杂志2006,4(22)：198-200
[31]Agdi M, Tulandi T. Surgical treatment of ectopic pregnancy [J]. Best Pract Res.Clin Obstet Gynaecol.2009 Aug;23(4):519-27.
[32]Gajewska M,Kaminski.P,etal.Laparoscopicmanagement of ectopic pregnancy[J]. Neuro Endocrinol Lett.2008 Apr;29(2):267-71
[33]Akhan SE, Baysal B. Laparotomy or laparoscopic surgery? Factors affecting the surgeons choice for the treatment of ectopic pregnancy [J]. Arch Gynecol Obstet. 2002Apr;266(2):79-82.
[34]古伟文,张秀俊输卵管系膜血管结扎术在输卵管妊娠治疗中的应用[J]中国实用妇科与产科杂志1993,6(9)：53-54
[35]王雁,吴翘楚结扎输卵管系膜血管在输卵管妊娠保守性手术中的应用(附90例报告)广东药学院学报[J]1998,14(4)：354～355
[36]Young-Sam Choi M.D. Dae-Sook Eun M.D. Jin Choi M.D.et al.Laparoscopic cornuotomy using a temporary tourniquet suture and diluted vasopressin injection in interstitial pregnancy[J].Fertility and Sterility 2009,91(5): 1933-1937
[37]Martinez-Torres M, Hernandez-Caballero ME, Luis-Diaz JA,et al. Effects of luteectomy in early pregnancy on the maintenance of gestation and plasma progesterone concentrations in the viviparous temperate lizard Barisia imbricata[J]. Reprod Biol Endocrinol.2010 Feb 25;8:19.
[38]Al-Gubory KH, Solari A, Mirman B. Effects of luteectomy on the maintenance of pregnancy, circulating progesterone concentrations and lambing performance in sheep[J]. Reprod Fertil Dev.1999;11(6):317-22.
[39]Csapo AI, Pulkkinen M. Indispensability of the human corpus luteum in the maintenance of early pregnancy. Luteectomy evidence [J]. Obstet Gynecol Surv. 1978 Feb;33(2):69-81.
[40]Csapo AI, Pulkkinen MO, Wiest WG. Effects of luteectomy and progesterone replacement therapy in early pregnant patients [J]. Am J Obstet Gynecol.1973 Mar 15;115(6):759-65.
[41]丁淑珍徐旭群等,去黄体预防持续性异位妊娠的研究[J]临床医学,2007,7(27)：53-54
[42]张玉新输卵管妊娠保守性手术中黄体剥除的作用探讨[J]中国妇幼保健[J]2007,10(25)：77-79
[43]Cheong Y, Li TC.Controversies in the management of ectopic pregnancy[J]. Reprod Biomed Online.2007 Oct;15(4):396-402.
[44]Nathorst-Boos J, Rafik Hamad R. Risk factors for persistent trophoblastic activity after surgery for ectopic pregnancy [J]. Acta Obstet Gynecol Scand. 2004 May;83(5):471-5.
[45]Mol F, Strandell A,etal.The ESEP study:salpingostomy versus salpingectomy for tubal ectopic pregnancy; the impact on future fertility:a randomised controlled trial[J]. BMC Womens Health.2008 Jun 26;8:11.
[46]Silver PD,Schaper AM,Rooney B. Reproductive outcome after 143 laparoscopic procedures for ectopic pregnancy[J]. Obstet Gynecol,1993,81:710～715.
[47]Zhang J, Hao WM,etal., Outcome and relevant factors of tubal pregnancy treated with laparoscopic conservative surgery[J]. Zhonghua Fu Chan Ke Za Zhi. 2010 Feb;45(2):84-8.
[48]谢咏,王刚,林铁成,输卵管妊娠患者腹腔镜保守性手术后生育状况及其影响因素分析[J],中国实用妇科与产科杂志,2007,06(04)33：04
[49]Szabo I, Langmar Z, Fontanyi Z,et al. Selective chromopertubation via hysteroscopic tubal cannulation Orv Hetil[J].2010 Mar 14;151(11):453-6
[50]Vardhana PA, Silberzweig JE, Guarnaccia M, Hysterosalpingography with selective salpingography[J]. J Reprod Med.2009 Mar;54(3):126-32.
[51]DONNEZ J.Atlas of operative laparoscopy and hysteroscopy[M].3rd ed.Naway:Informa UK Ltd,2007:557.
[52]Al-Jaroudi D, Herba MJ, Tulandi T. Reproductive performance after selective tubal catheterization[J]. J Minim Invasive Gynecol.2005 Mar-Apr; 12(2):150-2
[53]冷金花,郎景和,腹腔镜在异位妊娠诊治中的应用[J].中国实用妇科与产科杂志2000,16(4)：
[54]Merce LT, Bau S, Bajo JM. Doppler study of arterial and venous intraovarian blood flow in stimulated cycles[J].Ultrasound Obstet Gynecol.2001 Nov;18(5): 505-10.
[55]罗丽兰.不孕不育[M].北京：人民卫生出版社,1998：166.
[56]American Fertility Society (1988) The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, secondary to tubal ligation, tubal pregnancies, Mullerian anomalies, and intrauterine adhesions[C]. Fertil Steril 49,944-949.
[57]Salvat J, Schmidt MH, Guilbert M, Vascular ligation for severe obstetrical hemorrhage:review of the literature[J]. J Gynecol Obstet Biol Reprod (Paris). 2002 Nov;31(7):629-39.
[58]Schenker JG, Evron S. New concepts in the surgical management of tubal pregnancy and the consequent postoperative results[J].Fertil Steril.1983 Dec;40(6):709-23.
[59]Brzezinski A, Schenker JG. Current status of endoscopic surgical management of tubal pregnancy[J].Eur J Obstet Gynecol Reprod Biol.1994 Mar 31;54(1):43-53.
[60]Stock RJ, Hansen KA, Reed ME. The value of peritoneal hCG and vasopressin in ectopic pregnancy[J].J Am Assoc Gynecol Laparosc.1996 Aug;3(4):S48.
[61]MUGUR M, YESILYURT H, SOYSAL S, et al. Prophylactic vasopressin during laparoscopic salpingotomy for ectopic pregnancy[J].J Am Assoc Gynecol Laparosc,1996,3(3):365-368
[62]乐杰,主编.妇产科学[M].第6版.北京：人民卫生出版社,2005：9.
[63]陈淑琴,姚书忠,张成美,两点注射垂体后叶素在腹腔镜下输卵管切开术中的临床价值[J].中国内镜杂志.2008,7(14)：777-779
[64]Ben-Arie A, Goldchmit R, Dgani R, Trophoblastic peritoneal implants after laparoscopic treatment of ectopic pregnancy [J]. Eur J Obstet Gynecol Reprod Biol.2001 May;96(1):113-5.
[65]Pal L, Parkash V, Rutherford TJ. Omental trophoblastic implants and hemoperitoneum after laparoscopic salpingostomy for ectopic pregnancy[J]. A case report. J Reprod Med.2003 Jan;48(1):57-9.
[66]Qureshi NS. Treatment options for threatened miscarriage[J]. Maturitas.2009 Dec;65 Suppl 1:S35-41. Epub 2009 Nov 27.
[67]Martinez-Torres M, Hernandez-Caballero ME, Luis-Diaz JA,etc. Effects of luteectomy in early pregnancy on the maintenance of gestation and plasma progesterone concentrations in the viviparous temperate lizard Barisia imbricata imbricata[J]. Reprod Biol Endocrinol.2010 Feb 25;8:19.
[68]Daya S. Luteal support:progestogens for pregnancy protection[J]. Maturitas. 2009 Dec;65 Suppl 1:S29-34. Epub 2009 Nov 12.
[69]El-Zibdeh MY, Yousef LT. Dydrogesterone support in threatened miscarriage[J]. Maturitas.2009 Dec;65 Suppl 1:S43-6. Epub 2009 Dec 14.
[70]Liu HC, Pyrgiotis E, Davis O, Active corpus luteum function at pre-, peri-and postimplantation is essential for a viable pregnancy [J]. Early Pregnancy.1995 Dec;1(4):281-7.
[71]Ramirez NC, Lawrence WD, Ginsburg KA, Ectopic pregnancy. A recent five-year study and review of the last 50 yearsr'literature[J]. J Reprod Med.1996 Oct;41(10):733-40
[72]McComb P, Delbeke L. Decreasing the number of ovulations in the rabbit with surgical division of the blood vessels between the fallopian tube and ovary [J]. J Reprod Med,1984,29(11):827-9.
[73]Otubu JA, Winston RM. Ovarian function after salpingostomy following mechanically produced hydrosalpinx in rabbits[J]. Afr J Med Med Sci.1986 Mar-Jun;15(1-2):19-24.
[74]Kelekci S, Yilmaz B, Yakut Y, Hormonal and ovarian stromal blood supply changes after laparoscopic tubal sterilization:a prospective controlled study[J]. Contraception.2006 Mar;73(3):279-83. Epub 2005 Sep 26.
[75]CCW Chan,EHY Ng,CF Li,et al.Impaired ovarian blood flow and reduced antral follicle count following laparoscopic salpingectomy for ectopic pregnancy [J]. Hum Reprod,2003,18(11):2175
[76]Mardesic T, Muller P, Huttelova R.etc. Effect of salpingectomy on the results of FVF in women with tubal sterility--prospective study[J]. Ceska Gynekol.2001 Jul;66(4):259-64.
[77]Johnson N, van Voorst S, Sowter MC,etc. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation[J]. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD002125
[78]Ahmad G, Watson A, Vandekerckhove P. etc.Techniques for pelvic surgery in subfertility[J]. Cochrane Database Syst Rev.2006 Apr 19;(2):CD000221.
[79]张金玉李文玲郭新宇等,卵巢及输卵管术后患者超排卵治疗卵巢反应性的观察[J].中华妇产科杂志2003.7(38)：433-434
[80]Bangsgaard N,Lund CO,Ottesen B,etal.Improved fertility following conservative surgical treatment of ectopic pregnancy[J].BJOG,2003,110(8): 765-770。
[81]Goynumer G, Kayabasoglu F, Aydogdu S.etc. The effect of tubal sterilization through electrocoagulation on the ovarian reserve[J]. Contraception.2009 Jul;80(1):90-4. Epub 2009 Mar 6.
[82]Baloglu A, Uysal D, Karci L, Effects of laparoscopic tubal ligation on ovarian blood flow and steroidogenesis[J]. Clin Exp Obstet Gynecol.2005;32(4):230-2.
[83]Duffy JM, Johnson N, Ahmad G.etc. Postoperative procedures for improving fertility following pelvic reproductive surgery [J]. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD001897.
[84]Hwa Sook Moon MD, PhD, Young Joo Choi MD, Yang Hee Park MD. New simple endoscopic operations for interstitial pregnancies [J] American Journal of Obstetrics and Gynecology.2000,1(182):114-121
[85]Nash S. Moawad MD. Sangeeta T.et al. Current diagnosis and treatment of interstitial pregnancy [J].American Journal of Obstetrics and Gynecology.2010, 202(1):15-29
[86]Tulandi T, Al-Jaroudi D. Interstitial pregnancy:results generated from the Society of Reproductive Surgeons Registry [J]. Obstet Gynecol.2004 103(1):47-50.
[87]Timmerman E, Roovers JP, Ankum WM, Interstitial pregnancy:a rare type of ectopic pregnancy[J]. Ned Tijdschr Geneeskd.2008 Apr 5;152(14):787-91.
[88]Choi YS, Eun DS, Choi J,etc. Laparoscopic cornuotomy using a temporary tourniquet suture and diluted vasopressin injection in interstitial pregnancy[J]. Fertil Steril.2009 91(5):1933-7. Epub 2008 Apr 18.
[89]Fujishita A, Khan KN, Kitajima M, Re-evaluation of the indication for and limitation of laparoscopic salpingotomy for tubal pregnancy [J]. Eur J Obstet Gynecol Reprod Biol.2008 Apr; 137(2):210-6.
[90]van Mello NM, Mol F, Adriaanse AH, The METEX study:methotrexate versus expectant management in women with ectopic pregnancy:a randomised controlled trial[J]. BMC Womens Health.2008 Jun 19;8:10.
[91]Krag Moeller LB, Moeller C, etal. Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies:a randomized trial[J]. Acta Obstet Gynecol Scand.2009;88(12): 1331-7.
[92]Mol F, Mol BW, Ankum WM, etal. Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy:a systematic review and meta-analysis[J]. Hum Reprod Update. 2008 Jul-Aug;14(4):309-19.
[93]Hajenius PJ, Mol F, Mol BW,etal.Interventions for tubal ectopic pregnancy[J]. Cochrane Database Syst Rev.2007 Jan 24;(1):CD000324.