输卵管妊娠保守手术后不孕患者再手术情况分析

Analysis of reoperation for infertility women with tubal pregnancy after conservative surgery

目的 评价输卵管妊娠保守手术后的不孕患者,经腹腔镜探查联合宫腔镜下输卵管口插管通液,不孕的因素及输卵管生育功能受损情况.方法 2008年12月至2010年10月在天津医科大学第二附属医院及中国人民武装警察部队后勤学院附属医院住院治疗,有输卵管妊娠保守手术史的不孕患者37例,采用腹腔镜观察盆腔粘连程度、输卵管形态、输卵管伞端等情况;并在腹腔镜监护下行宫腔镜下输卵管口插管通液,观察输卵管管腔是否通畅.结果 97.3％ （36/37）的患者存在输卵管不孕的因素,包括输卵管形态异常或周围粘连、伞端闭锁、管腔堵塞,至少有1个或多个因素合并存在.按每例患者2条输卵管计算,输卵管管腔堵塞79.7％（59/74）,伞端闭锁54.1％（40/74）,形态异常的发生率52.7％（39/74）.盆腔粘连发生率平均89.2％,其中Ⅰ度21.6％,Ⅱ度32.4％,Ⅲ度35.1％,无Ⅳ度粘连.有妊娠史的一侧输卵管管腔堵塞75.7％、形态异常48.6％、伞端闭锁45.9％.无妊娠史的一侧输卵管,平均输卵管管腔堵塞86.5％、伞端闭锁62.2％,形态异常56.8％.患侧输卵管和对侧输卵管在输卵管形态、伞端形态、管腔堵塞方面相比较差异无统计学意义（P＞0.05）.开腹保守治疗和腹腔镜保守治疗的患者在粘连程度、患侧及对侧输卵管形态、伞端形态、管腔堵塞等方面差异均无统计学意义（均P ＞0.05）.结论 输卵管妊娠保守手术后的不孕患者,不孕的主要原因为输卵管因素,包括盆腔粘连和输卵管形态异常、管腔堵塞.保守手术时采用开腹手术或者腹腔镜手术,对继发不孕的患者,生育力损害无明显区别.

Objective To evaluate the cause of infertility and tubal abnormality in women of tubal pregnancy after conservative treatment with laparotomy or laparoscopy through a combination of laparoseopy, hysteroscopic tubal catheterization and hydrotubation. Methods Laparoscopy was performed to observe pelvic adhesions, tube shape, fimbriated extremity of fallopian and other factors related with infertility for 37 inpatients with infertility after tubal pregnancy and undergoing conservative surgery during December 2008 and October 2010. Meanwhile, hysteroseopic tubal catheterization and hydrotubation were performed with laparoscopy to examine tube patency. Results Among them, 97.3% had tube infertility caused by tube abnormality and adhesions, or tube obstruction alone or concurrently. For all tubes, tube obstruction accounted for 79.7% （59/74）, fimrial occlusion of fallopian tube 54. 1% （40/74）and tube abnormality 52.7% （39/74）. Pelvic adhesion occurred at a rate of 89. 2% and there were I degree （21.6%）, 11 degree （32.4%）, IU degree （35.1%） and 1V degree （0）. For tubes with pregnancy history, 48.6% showed tube abnormality, 45.9% fimrial occlusion of fallopian tube and 75.7% （28/37） tube obstruction. Comparatively, for the tubes without pregnancy history, 56.8% showed tube abnormality, 62, 2% fimbrial occlusion of fallopian tube and 86. 5% tube obstruction. No significant difference existed in tube shape, umbrella end and tube obstruction between the tubes with pregnancy history and those without pregnancy history. Neither statistically significant difference was found in adhesion degree, tube shape, umbrella end and tube obstruction of diseased and normal tubes between laparotomy and laparoscopy groups. Conclusion Infertility of women after tubal pregnancy and conservative surgery is mainly caused by abnormal tube including pelvic adhesion, tube morphological abnormality and tube obstruction. No marked inter-group difference exists in fertility damage after conservative surgery with laparotomy or laparoscopy.