腹腔镜卵巢子宫内膜异位囊肿剥除联合CO_2激光消融术对卵巢储备功能的影响

Effects of Laparoscopic Ovarian Endometrioma Removal Combined with CO_2 Laser Ablation on Ovarian Reserve Functions

目的：探讨腹腔镜卵巢子宫内膜异位囊肿剥除术中应用CO2激光消融术与双极电凝2种方法破坏病灶和止血对卵巢储备功能的影响。方法选择2013年4月～2014年3月上海市嘉定区妇幼保健院住院治疗的双侧卵巢子宫内膜异位囊肿56例，术前1个月经周期第3天晨起抽取静脉血查FSH、E2，超声测量双侧卵巢基础窦卵泡数（ antral follicle count ， AFC）和卵巢体积。56例随机分为2组，行常规腹腔镜双侧卵巢子宫内膜异位囊肿剥除术，术中在卵巢囊肿大部分剥除后，剩余卵巢门部位的囊肿壁分别采用CO2激光消融术（激光组）或双极电凝（电凝组）进行病灶破坏和止血。术后药物治疗后第1、2、6个月经周期第3天复查FSH、E2、双侧AFC和卵巢体积，比较2种技术对卵巢储备功能的影响。结果术后药物治疗后第1、2、6个月，电凝组FSH 均明显高于激光组[（8．60±0．62） IU／L vs．（8．18±0．52） IU／L， t ＝－2．746，P＝0．008；（8．49±0．37）IU／L vs．（7．84±0．51）IU／L，t＝－5．459，P＝0．000；（8．24±0．56）IU／L vs．（6．26±1．37）IU／L，t＝－7．079，P＝0．000]。术后药物治疗后1、2、6个月，电凝组E2均显著低于激光组[（35．57±11．96）μg／L vs．（47.39±16．03）μg／L， t＝3.127，P＝0.003；（38．50±17．25）μg／L vs．（50．29±16．79）μg／L，t＝2．592，P＝0．012；（40．57±18．46）μg／L vs．（51．96±18.62）μg／L，t＝2．299，P＝0．025]。术后药物治疗后第1个月2组患者AFC无显著性差异[（3．6±1．3）个 vs．（3．3±1．4）个，t＝0．831，P＝0．410]，但第2、6个月激光组AFC显著高于电凝组[（6．0±1.1）个vs．（3．3±1．2）个，t＝8．776，P＝0．000；（8．2±1．9）个vs．（4．0±1．8）个，t＝8．491，P＝0．001]。术后药物治疗后第1、2、6个月，电凝组卵巢体积均显著低于激光组[（5．15±0.99）cm3vs．（5．62±0．73）cm3，t＝2．022，P＝0．048；（5．72±0．98）cm3vs．（7．39±0．69）cm3，t＝3．373，P＝0．000）；（5．82±1.29）cm3vs．（7．86±0．88）cm3，t＝6．913，P＝0．000]。结论腹腔镜卵巢子宫内膜异位囊肿剥除术中采用CO2消融术对于卵巢储备功能的影响低于双极电凝，是一种对卵巢储备能力影响较小的方法。

Objective To study the effects of two techniques frequently used in laparoscopic ovarian endometrioma removal -CO2 laser ablation and bipolar electric coagulation , which were used both to destroy the endometriotic lesion and to stop the bleeding on ovarian reserve functions . Methods The study was prospectively designed and carried out .The subjects included 56 cases of bilateral ovarian endometrioma （ OEM） , who underwent laparoscopic OEM removal from April 2013 to March 2014.Blood levels of FSH and E2 were measured, and the antral follicle count （AFC） and ovarian volume were ultrasonically reviewed on the third day of the very menstrual cycle merely prior to the operation .The 56 cases were randomly divided into 2 groups , both of which received laparoscopic OEM removal .After the most endometriotic lesions were removed during the operation , one group （ Laser group, 28 cases） was treated with CO2 laser ablation and another group （Coagulation group,28 cases） with bipolar electric coagulation to destroy the remained lesions especially near hilum of ovary and to help to stop bleeding .After the medication following the operation was finished, FSH, E2 , AFC, and ovarian volume were detected on the third day respectively of the following first , second, and sixth menstrual cycles , which were compared to observe the difference of the ovarian reserve functions between the two groups . Results At postoperative 1, 2, and 6 months after drug treatment , the FSH levels in Coagulation group were significantly higher than those in Laser group [（8.60 ±0.62） IU/L vs.（8.18 ±0.52） IU/L, t=-2.746, P=0.008;（8.49 ±0.37） IU/L vs.（7.84 ±0.51） IU/L, t=-5.459, P=0.000;（8.24 ±0.56） IU/L vs.（6.26 ±1.37） IU/L, t=-7.079, P=0.000].At postoperative 1, 2, and 6 months after drug treatment , the E2 levels in Coagulation group were significantly lower than those in Laser group [（35.57 ±11.96）μg/L vs.（47.39 ±16.03） μg/L, t=3.127, P=0.003; （38.50 ±17.25） μg/L vs.（50.29 ±16.79） μg/L, t=2.592,P=0.012;（40.57 ±18.46） μg/L vs.（51.96 ±18.62） μg/L, t=2.299, P=0.025].There was no significant difference in AFC between the two groups in the first menstrual cycle after postoperative medication [（3.6 ±1.3） vs.（3.3 ±1.4）, t=0.831,P=0.410].But at 2 and 6 months after drug treatment, postoperative AFC was significantly higher in Laser group than that in Coagulation group [（6.0 ±1.1） vs.（3.3 ±1.2）, t =8.776, P=0.000; （8.2 ±1.9） vs.（4.0 ±1.8）, t =8.491, P =0.001].At postoperative 1, 2, and 6 months after drug treatment , the ovarian volume was significantly lower in Coagulation group than in Laser group [（5.15 ±0.99） vs.（5.62 ±0.73） cm3, t=2.022, P=0.048;（5.72 ±0.98） vs.（7.39 ±0.69） cm3, t=3.373, P=0.000;（5.82 ±1.29） vs.（7.86 ±0.88） cm3, t=6.913, P=0.000]. Conclusions In laparoscopic OEM removal operations, use of CO2 laser ablation may produce less impairment to ovarian reserve functions than the use of bipolar electric coagulation .CO2 laser ablation is a safe technique which provides better protection of ovarian functions .