经阴道注水腹腔镜诊治输卵管性不孕50例分析

Application of transvaginal hydrolaparoscopy to tubal infertility:clinical analysis of 50 cases

目的使用经阴道注水腹腔镜(THL)评价子宫输卵管造影(HSG)中输卵管通畅性的准确性,并探讨THL的治疗价值。方法于2008年1月～2009年2月应用THL对50例术前已行子宫输卵管造影(HSG)的不孕症患者进行输卵管通畅性准确性的评价,并对盆腔病变进行治疗。术中同时施行宫腔镜检查及宫腔镜下输卵管口插管通液术。结果①输卵管通畅性评价:HSG诊断输卵管阻塞的准确性仅为64.7%。HSG的敏感性和特异性分别为80.5%和69.5%。②手术治疗:在THL显示阻塞的41条输卵管中,7条伞端闭锁。其余34条输卵管中的18条经宫腔镜下输卵管口插管通液后被疏通,疏通率52.9%。术中发现轻度盆腔粘连15例、中度粘连2例、重度粘连2例。所有轻度和中度粘连患者的薄膜粘连绝大部分被松解;有1个卵巢与盆壁间存在致密粘连,未能松解;对2例重度粘连患者未行粘连松解。另外,对6例患者的子宫内膜异位病灶,均予以电凝治疗。对2例氯米芬抵抗的PCOS患者行卵巢打孔治疗。③无术中术后并发症发生。④术后随访6～19个月,3例失访,除外2例重度粘连病例,其余45例患者妊娠18例,妊娠率40%。结论HSG诊断输卵管阻塞时的结果不太可靠;THL可以对一些简单的盆腔病变进行手术治疗,联合宫腔镜效果更好。

[Objective] To confirm tubal patency in hysterosalpingography （HSG） by transvaginal hydrolaparoscopy （THL） and to evaluate THL in treating pelvic lesions. [Methods] One to four days after HSG, the tubal pateney of fifty infertile women was verified by dye-test during THL and the pelvic lesions were treated at the same time from Jan. 2008 to Feb. 2009. After THL, hysteroseopy and dye-test using catheterization of the tubal ostium by hysteroscopy were performed immediately. [Results] ①Value of tubal pateney： The accuracy of HSG was only 64.7% when the examination revealed blocked tubes. The sensitivity and specificity of HSG were respectively 80.5% and 69.5%. ②Therapy for pelvic lesions： of 41 blocked tubes in THL, 7 were hydrosalpinx due to distal obstruction. Of the remained 34 tubes, 18 （52.8%） were patent after the dyetest using catheterization of the tubal ostium by hysteroscopy. Mild pelvic adhesion was found in 15 eases, moderate adhesion in 2 and severe adhesion in 2. Of 15 eases with mild adhesion and 2 eases with moderate adhesion, adhesiolysis was finished successfully for filmy pelvic adhesion using 5Fr bipolar electrocoagulating needle and 7Fr hook scissors, but the cohesive adhesion that occurred at 1 ovary entirely failed to be lyzed. For the two eases with severe adhesion, the adhesiolysis was not performed. In addition, endometriosis spots of 6 cases were treated by bipolar electrocoagulating needle. Two PCOS cases with clomiphene citrateresistance successfully underwent ovarian drilling. ③No perioperative complications occurred. ④Three women were out of follow-up, and excluding 2 cases with severe adhesion 18 out of 45 cases （40%） became pregnant during a follow-up of 6-19 months. [Conclusions] HSG is not very reliable in diagnosis of blocked tubes. Some simple operations could be performed easily under THL and THL could achieve better effect while it is combined with hysteroscopy.