输卵管性不孕微创手术的过去、现在与未来

Minimally Invasive Surgery for Tubal Infertility:the Past, Present and Future

手术是治疗输卵管阻塞的主要方法,宫腹腔镜技术使治疗女性不孕症的输卵管手术进入了微创时代。准确评价输卵管功能有助于分析不孕症的病因,为临床治疗提供重要依据。腹腔镜检查、超声检查和子宫输卵管造影是术前评估输卵管状态的常用方法。二维、三维、四维子宫输卵管超声造影技术的发展,通过观察输卵管动态变化,对输卵管病变的评估更趋准确。输卵管远端阻塞的治疗有输卵管造口术、输卵管切除术、输卵管近端阻断、宫腔镜下输卵管栓塞术、输卵管伞端成形术、输卵管近端结扎远端造口术、超声引导下输卵管积水抽吸硬化疗法等术式,各有其适应证。输卵管插管疏通术是治疗输卵管近端阻塞的有效方法,可在腹腔镜、宫腔镜、超声引导下或放射线介入下进行。其中以宫腹腔镜联合疏通输卵管最为常用,并可同时诊治盆腔粘连和子宫内膜异位症。体外受精和输卵管手术是输卵管性不孕的互补治疗。将输卵管镜、机器人和三维腹腔镜以及COOK导丝用于输卵管重建手术中,有望提高妊娠率。

Surgery is the main effective method for the treatment of fallopian tube occlusion. Hysteroscopy and laparoscopy lead the treatment of tubal infertility into the era of minimally invasive surgery. The accurate evaluation of tubal function helps to analyze the causes of infertility, which provides important clinical evidence for treatment. Laparoscopic, ultrasonographic examination and hysterosalpingography are useful methods to evaluate the status of fallopian tube. The development of 2D hysterosalpingo-contrast-sonography （2D-HyCoSy）, 3D-HyCoSy and 4D-HyCoSy technologies make the evaluation of tubal lesion more accurate by observing the dynamic change of fallopian tube. The treatment of distal tube obstruction includes salpingostomy, salpingectomy, proximal tubal block, tubal embolization under hysteroscope, fimbrioplasty, proximal tubal block and salpingostomy for distal tube, under the guidance of ultrasound hydrosalpinx suction sclerosis therapy, and so on, all of which have their own indications. Tubal cannulation technique is an effective method for the treatment of proximal tubal obstruction, which is operated by means of laparoscopy, hysteroscopy, ultrasonography or radiation guidance. The combination of laparoscopy with hysteroscopy in the tubal cannulation is the most common method, which makes it to be possible to diagnose and treat simultaneously pelvic adhesions and endometriosis. In vitro fertilization is a complementary treatment of tubal surgery for infertile women with tubal occlusion. Falloscopy, robotic and 3D laparoscopy as well as COOK guide-wire are increasingly used in tubal reconstructive surgery, which are expected to increase the pregnancy rate.