超声引导下经阴道卵巢内激光治疗多囊卵巢综合征的剂量研究

Ultrasound-guided transvaginal ovarian interstitial laser treatment in patients with polycystic ovary syndrome： a laser dose-finding study

目的评价不同激光剂量对超声引导下经阴道卵巢内激光治疗多囊卵巢综合征（PCOS）排卵障碍患者的临床及内分泌效果的影响。方法选择2005年1月至2007年7月就诊于深圳市妇幼保健院的对枸橼酸氯米芬治疗无反应的PCOS不孕患者56例，随机分为A、B、C、D共4组，行超声引导下经阴道卵巢内激光治疗，激光治疗的剂量以卵巢内凝固点数表示，每个凝固点采用功率为3～5W的激光持续作用1～3min，直径约为10mm。其中A组为1个点，B组为2个点，C组为3个点，D组为4～5个点。比较治疗后6个月内各组患者自发排卵率、妊娠率及月经周期情况，并比较治疗前后各组患者血清性激素水平的变化。结果（1）C组和D组治疗后自发排卵率分别为71％（10／14）和79％（11／14），均高于A组（0）和B组（21％，3／14），差异均有统计学意义（P〈0．05）。C组和D组治疗后6个月累积临床妊娠率分别为43％（6／14）和36％（5／14），均高于A组（0），差异均有统计学意义（P〈0．01、P〈0．05）；与B组（14％，2／14）比较，差异无统计学意义（P〉0．05）。C组与D组的自发排卵率及累积临床妊娠率分别比较，差异均无统计学意义（P〉0．05）。（2）治疗前的各项性激素水平，各组患者之间分别比较，差异均无统计学意义（P〉0．05）；治疗后的黄体生成素（LH）、睾酮水平及LH／卵泡刺激素（FSH）比值，A组[分别为（11．9±3．1）U／L、（3．9±1．6）nmol／L和2．1±0．5]、B组[分别为（10．4±3．9）U／L、（3．3±1．1）nmol/L和2．0±0．6]分别与C组[分别为（6．3±2．6）U／L、（2．2±0．7）nmol／L和1．1±0．3]、D组[分别为（5．8±2．5）U／L、（2．1±0．4）nmol／L和1．0±0．4]比较，差异均有统计学意义（P〈0．05）；C组与D组分别比较，差异均无统计学意义（P〉0．05）。C、D组治疗后的平均LH、睾酮水平及LH／FSH比值分别较治疗前下降了42％、39％、42％和53％、40％、58％，均高于A组（分别下降了4％、9％和16％）和B组（分别下降了11％、6％和5％），差异均有统计学意义（P〈0．05）；C组与D组之间比较，差异均无统计学意义（P〉0．05）。结论每侧卵巢内选择1～2个激光凝固点的临床效果较差，3个激光凝固点是卵巢内激光治疗PCOS排卵障碍的有效剂量，在此基础上增加凝固点数不能提高治疗效果。

Objective To evaluate the clinical and endocrine effectiveness of different laser doses for ultrasound-guided transvaginal ovarian interstitial laser treatment in patients with polyeystie ovary syndrome （PCOS）. Methods Between January 2005 and July 2007, 56 women with elomifene citrate- resistant PCOS selected from the patients who were referred to Shenzhen Maternity and Child Healtheare Hospital with a request for fertility underwent ultrasound-guided transvaginal ovarian interstitial laser treatment. All subjects were randomly divided into four groups of A, B, C and D. In group A, one coagulation point per ovary was done and group B, two points; group C, three points; group D, four to five points. The size of each point was about 10 mm in diameter （ the electrical laser was projected persistently for 1 -3 min with a power of 3 -5 W） . The serum sexual hormone level, ovulation rate and pregnancy rate within six postoperative months were compared among the four groups. Results （ 1 ） The spontaneous ovulation rates of groups A （0） and B （21% ） within six postoperative months were significantly lower than groups C （71% ,P 〈0. 05） and D （79%, P 〈0. 01 ）. The accumulative pregnancy rates of group C（43% ） and D （36%） for six postoperative months were significantly higher than group A（0; P 〈 0. 01,P 〈 0. 05 ）. Although they were also higher than that of group B, no statistical significance was found （ P 〉 0.05 ）. （ 2 ） No statistically significant differences were found among four groups when various preoperative hormone values were compared （ P 〉 0.05 ）. The mean serum luteinizing hormone （ LH）, testosterone level and LH/ follicle stimulating hormone （FSH） ratio was significantly lower postoperatively in groups C [ （ 6. 3 ± 2. 6 ） U/L, （2. 2 ±0.7 ） nmol/L, 1.1 ± 0. 3 ] and D [ （5.8 ± 2. 5 ） U/L, （2. 1 ± 0.4） nmol/L, 1.0 ± 0.4 ] than in groups A [（11.9 ±3.1）U/L,（3.9 ± 1.6）nmol/L,2. 1±0.5] and B [ （10.4 ± 3.9）U/L, （3.3 ± 1.1） nmol/L, 2.0± 0. 6], respectively（P 〈 0. 05 ）. The mean LH, testosterone level and LH/FSH ratio reduced more obviously in groups C （42% ,39% and 42% ） and D（ 53%, 40% and 58% ） than in groups A （4%, 9% and 16% ）and B（ 11%, 6% and 5% ; P 〈0.05）. All above-mentioned parameters between groups C and D had no statistical significant difference （ P 〉 0. 05 ）. Conclusions One and two intraovarian laser coagulation points per ovary are associated with poor results. Three points per ovary seem to represent the plateau of effective dose for the ovarian interstitial laser treatment. Increasing the dose above it does not improve the outcome.