经阴道注水腹腔镜联合宫腔镜及通液术在不孕妇女中的应用
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摘要
经阴道注水腹腔镜(Transvaginal hydrolaparoscopy, THL)是以阴道后穹隆为入径进入盆腔,对盆腔疾病进行诊断和治疗的妇科内镜技术。1998年Gorts等最先报道应用THL检查无明显盆腔病变的不孕妇女，THL术以生理盐水等液体为介质，利于观察盆腔脏器在生理状态下的情况，使对卵巢和输卵管的观察更为细致，清晰，术中同时应用亚甲蓝进行输卵管通液术，判断输卵管的通畅性及阻塞部位。
THL能清晰地评估不孕妇女的卵巢-输卵管结构，所提供的诊断结果准确性与腹腔镜（laparoscopy, Lap）相似。THL不需要全身麻醉，侵入性更小，花费更少。与传统的输卵管功能检查手段子宫输卵管造影术(Hysterosalpingography, HSG)相比，能精确和直观地尽可能一步到位的探查到影响不孕的所有生殖器官和盆腔环境。第一部分经阴道注水腹腔镜联合宫腔镜及通液术作为不孕妇女一线检
查方法的研究
目的:
1探讨经阴道注水腹腔镜(transvaginal hydrolaparoscopy, THL)联合宫腔镜和通液术作为不孕妇女一线检查方法的安全性。了解其探查的主要范围和观察到的主要异常情况及并发症的发生率。
2应用新设计的输卵管伞部摄卵能力评分系统，在THL镜下对不孕妇女的输卵管和伞部进行探查和评分，根据得分情况，指导不孕症妇女术后选择不同的生殖方式，通过随访术后不孕妇女的自然妊娠率、人工授精(intrauterine insemination, IUI)妊娠率及(in vitro fertilization and embryotransfer, IVF-ET)的妊娠率，验证THL和新的评分系统对临床工作指导的效率及意义。
方法:
1研究对象
2010年9月至2013年6月于白求恩国际和平医院就诊的不孕症妇女130例，行THL联合宫腔镜和通液术，检查子宫腔，盆腔及输卵管通畅情况。年龄30.92±3.54(22～47)岁，原发不孕76例，继发不孕54例，不孕年限3.39±2.67(1～18)年，体重指数23.04±2.67(15.94～33.59)。
2设备
采用德国Storz公司的注水腹腔镜操作系统(型号-26120BA)及宫腔镜系统(型号-26129BA)
3THL联合宫腔镜和通液术的操作方法
接受手术的妇女取膀胱截石位，常规消毒外阴、阴道，铺无菌巾，静脉麻醉后，常规行宫腔镜检查，完毕后宫腔放置一次性通液管（如需手术治疗，在THL后立即进行）。选择宫颈后唇下方1～1.5cm处作为穿刺点，在超声引导下，用直径2mm的Veress针刺入子宫直肠陷凹(如后位子宫，先用扩张棒将子宫位置改变成前位或平位)。快速滴注37°C生理盐水约300ml，超声观察直肠子宫陷凹有明显的均匀一致液性暗区形成。拔出Veress针，用外径5mm的Trocar在超声指引下穿入子宫直肠陷凹的液体池中，然后置入直径3.9mm，角度30°的内窥镜，从子宫后壁开始，沿盆腔侧壁，输卵管的走行至卵巢周围，用亚甲蓝(methylene blue dye)进行通液，镜下观察输卵管的通畅性，见亚甲蓝液从输卵管伞端溢出为输卵管通畅。重点观察输卵管伞部黏膜和柔韧性，与同侧卵巢的关系，是否密切或较远，两者之间有无膜状或纤维状粘连，评估伞的摄卵能力。
4输卵管伞部摄卵能力评分方法
在输卵管通液显示通畅的前提下，根据输卵管伞部形态及与卵巢的关系，分别从5个方面进行评分。①输卵管伞部黏膜形态：镜下清晰，指突色泽正常为2分，黏膜萎缩，指突粘连成团或消失为0分，介于二者之间为1分。②输卵管伞部的活动度：自然状态下伞部纤毛摆动灵活柔韧，指突间能呈伞状分开及合拢者为2分；纤毛增厚僵硬，指突间粘连不能分开或摆动，无“检拾”动作为0分，介于二者之间为1分。③输卵管伞部开口：即亚甲蓝从伞部流出的开口，在镜下，可通过调整镜头和光纤的方向清晰观察伞部的输卵管开口部位，如孔径通畅，周围指突无粘连并可散开完全无阻挡见亚甲蓝从开口部位流出，为1分；如孔径细小，周围指突粘连阻挡不能完全散开，亚甲蓝从侧旁流出，则为0分。④输卵管伞部与卵巢的关系或距离：在自然状态下，输卵管伞部通过摆动能触及同侧卵巢表面，距离较近为1分；输卵管迂曲，伞部位置固定，距同侧卵巢较远，通过摆动不能触及卵巢或伞部转向卵巢外侧方向，与卵巢呈“背靠背”关系，为0分。⑤输卵管伞部周围及与同侧卵巢间有无粘连：输卵管伞部周围无粘连，或有少量膜状粘连其范围﹤1/2且与卵巢间有自然通道，为1分；伞部周围纤维状粘连或膜状粘连但范围﹥1/2或与卵巢间有粘连阻挡，仅见亚甲蓝流出，为0分。总分在0～7分之间，认为≥4分时输卵管伞部摄卵能力优，≤3分为摄卵能力差。
5采用SPSS17.0统计软件包对数据进行检验，计量数据以均数±标准差（x±s）表示，计量资料采用方差分析，计数资料采用X2检验，p＜0.05为有统计学意义。
结果:
1THL联合宫腔镜和通液术的安全性和术中发现
1.1THL联合宫腔镜和通液术的成功率和并发症
130例不孕妇女中，127例经阴道穿刺成功进入子宫直肠窝，成功率97.7%。共出现3例并发症，包括2例直肠损伤和1例子宫后壁损伤。
总手术时间平均为36.03±9.8min（20min～60min），其中宫腔镜所用时间为12.7±6.7min（5min～30min），单纯宫腔检查术所用时间短，宫腔镜手术操作如息肉电切术，粘连分离术，中隔切除术等所用时间较长。
1.2宫腔镜发现
130例妇女全部完成宫腔镜检查。发现异常者包括子宫内膜息肉44例，检出率33.85%（44/130），术前超声提示宫内膜不均质或宫内高回声的22例，仅为50%(22/44)。宫腔粘连8例（0.063%），宫颈粘连1例，子宫粘膜下小肌瘤2例，子宫中隔2例，单角子宫1例，术前超声均未提示异常。子宫内膜不典型增生1例，宫腔镜下见内膜呈炎性改变，有多个充血点。子宫内膜息肉和子宫内膜不典型增生经病理检查确诊。
1.3THL术中发现
在穿刺成功的127例妇女中，检查盆腔无异常发现者62例，占48.82%。单纯盆腔粘连40例，合并内异症粘连11例。轻度盆腔粘连33例（合并內异症8例），中重度盆腔粘连18例（合并內异症3）。盆腔子宫内膜异位症25例，其中卵巢型内异症13例，腹膜型内异症11例，两者并存1例，均为r-AFS I～II期。2例穿刺损伤直肠者均为盆腔重度粘连合并子宫内膜异位症，子宫直肠窝消失，r-AFS评分分别为45、47分。1例子宫后壁损伤，盆腔轻度粘连，子宫后壁及骶韧带可见內异症结节，r-AFS评分7分。
1.4THL术中双侧输卵管通液及伞部摄卵能力评分结果
THL下通液示输卵管双侧通畅95例，一侧通畅22，双侧不通8例，余2不可见。卵巢-输卵管双侧不可见者2例，一侧不可见者3例。
输卵管通畅者根据输卵管伞部摄卵能力评分表进行评分，最大评分为7分，认为大于≥4分为输卵管伞部摄卵能力优，小于≤3分为摄卵能力差。至少有一侧输卵管伞部摄卵能力优的建议术后门诊指导性交自然妊娠，或人工授精；双侧输卵管伞摄卵能力差的则建议行IVF-ET。127例中，前者有81例，后者36例，伞部黏膜和柔韧度评分较高而盆腔粘连较重的患者7例，术后行腹腔镜手术分离粘连，占0.55%。
结论:
1THL联合宫腔镜和通液术操作安全，术中术后并发症少，无致命性损伤及大出血，可以做为临床上探查不孕妇女盆腔生殖器官的一线检查方法。
2THL以生理盐水为介质，可以清晰的直视盆腔生殖器官，包括子宫后壁，卵巢，输卵管，直肠前壁，盆腔侧壁等。能发现盆腔粘连，卵巢和盆腔侧壁的子宫内膜异位症等微小病变。
3THL结合宫腔镜，在门诊一次性完成对盆腔和宫腔的探查，发现宫腔的病变，尤其是超声检查不能发现的微小病变，如子宫内膜息肉，轻度的宫腔粘连，不典型的子宫小中隔等。
4THL镜下应用新设计的输卵管摄卵评分系统，对不孕妇女进行术后妊娠方式指导，使治疗有明确的选择，减少不必要等待和手术，避免过度使用辅助生殖技术。
第二部分子宫输卵管碘油造影和经阴道注水腹腔镜、腹腔镜对不孕妇女输卵管通畅性评估的对比
目的:对比分析子宫输卵管造影术（Hysterosalpingography, HSG）和经阴道注水腹腔镜(transvaginal hydrolaparoscopy, THL)、腹腔镜(laparoscopy,Lap)下输卵管通液对输卵管通畅性的评估，了解HSG评估输卵管通畅的敏感度与特异度。
方法：
1研究对象
1.1Lap研究对象的一般情况
2010年9月至2013年6月在白求恩国际和平医院妇产科行Lap的不孕妇女192例，选择术前6个月内曾行HSG检查的妇女76例为研究对象，总输卵管151条。年龄28.71±4.07(20～40)岁，不孕年限3.4±2.5(1～11)年，原发不孕38例，继发不孕38例。
1.2THL联合宫腔镜和通液术研究对象的一般情况
2010年9月至2013年6月在白求恩国际和平医院妇产科行THL联合宫腔镜和通液术的不孕妇女130例，选择术前6个月内曾行HSG检查的妇女43例为研究对象，总输卵管86条。年龄30.87±4.24(22～41)岁，不孕年限3.45±2.07(1～11)年，原发不孕23例，继发不孕20例。
2设备
采用德国Storz公司的THL操作系统(型号-26120BA)和日本Olmbs奥林巴斯Lap设备
3手术方法
3.1HSG方法
患者取膀胱截石位，窥器扩张阴道，暴露宫颈，再次消毒阴道和穹窿部，宫颈钳钳夹宫颈前唇。子宫造影通液管沿子宫方向置入宫腔，将其囊内注入76%泛影葡胺液约1～2ml，使双腔通液管固定在宫腔内。从宫腔管内徐徐注入泛影葡胺液，在X线透视下全程观察造影剂进入宫腔及输卵管直至弥散如盆腔的全过程并摄片，40分钟后再次立位摄片，观察泛影葡胺液在盆腔弥散情况。
3.2Lap手术方法
患者气管插管全麻，取膀胱截石位，先行宫腔镜检查，观察有无宫腔结构异常和子宫内膜异常，如子宫内膜息肉或宫腔粘连。撤出宫腔镜后置入子宫造影通液管备用。腹腔镜入腹腔后首先观察盆腔情况，有无粘连，探查输卵管走形和伞端情况，以及与同侧卵巢的关系。如输卵管及卵巢不能暴露，应先松解盆腔粘连，使输卵管伞部和卵巢暴露利于观察。从宫腔通液管注入亚甲蓝液，直视下观察亚甲蓝从输卵管间质部向伞部流动的过程，轻轻摆动输卵管伞部及镜头方向至清晰观察到输卵管伞部开口的亚甲蓝流出。术中所见的盆腔粘连均给予适当分离，子宫内膜异位症给予相应的剥除术和电灼术。
3.3THL手术方法如第一部分所述
结果:
1HSG和THL, Lap对输卵管通畅性的诊断对比
相对于Lap，HSG的总体符合率为80.79%(122/151)，敏感性83.52%(76/91)，特异性76.67%(46/60)，阳性预测值84.44%(76/90)，阴性预测值75.41%(46/61)。两种方法相比有统计学意义(X2=69.21，P﹤0.05)。
相对于THL， HSG的总体符合率为82.6%(71/86)，敏感性86.3%(63/73)，特异性61.6%(8/13)，阳性预测值92.6%(63/68)，阴性预测值44.4%(8/18)。两种方法相比有统计学意义(X2=107.40，P﹤0.05)。
2Lap和THL的异常发现
在Lap组盆腔异常检出率为71.05%(54/76)。包括盆腔粘连23例，子宫内膜异位症15例；在THL组盆腔异常检出率为72.1%(31/43)，包括盆腔粘连23例，子宫内膜异位症10例。
结论：
1HSG与THL和Lap相比，对输卵管通畅性的诊断敏感性较高，特异性较低，其作为输卵管功能检查的一线手段不够理想。
2THL和Lap一样在直视下进行输卵管通液，效果可靠，能同时发现输卵管周围病变，探查盆腔器官，THL较Lap更经济，微创，所需人力资源少，留院时间短，适合作为不孕妇女的断输卵管通畅性首选检查手段。第三部分经阴道注水腹腔镜联合宫腔镜及通液术与子宫输卵管造影对机体的应激反应
目的:
1对比研究THL联合宫腔镜和通液术和HSG对机体的创伤和影响，探讨机体对两种手术的应激性反应。
2分析THL联合宫腔镜和通液术术后２小时不孕妇女的疼痛评分，并和HSG术后评分相比较，探讨不孕妇女对两种操作的耐受性。
方法：
1研究对象
选择同期行THL联合宫腔镜和通液术（研究组）和HSG（对照组）妇女各30例，两组年龄分别为(30.37±0.68vs.28.53±0.84)，不孕年限(2.98±0.31vs2.88±0.28)，体重指数(23.20±0.76vs,22.55±0.57)之间具有可比性(p﹥0.05)。THL组原发不孕者18例，继发12例，HSG组原发不孕21例，继发9例，两组相比无统计学意义(p﹥0.05)。
2研究方法
2.1不孕妇女对THL联合宫腔镜和通液术和HSG的机体应激反应研究方法
分别测定两组妇女术前，术后30分，术后24小时的平均动脉压(MAP)，心率(HR)，并于上述3个时间点分别采集肘静脉血3ml，迅速注入在冰水浴中冷却的含20ul EDTA的试管中，摇匀，放冰水浴中冷却后以1000转/分离心5min（在4°C离心），分离血浆，取血浆放入已预冷试管中，置-20°C冰箱保存备检。血糖(GLU)测定采用葡葡萄糖氧化酶法，其余指标促肾上腺皮质激素(ACTH)、去甲肾上腺素(NA)、血管紧张素II(AII)、胰岛素（Ins）、血糖(GLU)、C-反应蛋白（CRP）和皮质醇(Cor)均采用放射免疫测定法。
2.2不孕妇女对THL联合宫腔镜和通液术和HSG的术后2小时视觉模拟疼痛评分
利用视觉模拟疼痛评分表(Visual analogue scale,VAS)分别评估2组妇女术后2小时的VAS评分。
结果：
1THL和HSG对不孕妇女机体应激反应的指标
THL组术前术后Cor分别为187.78±19.74ng/ml和197.20±22.28ng/ml(P﹤0.05)， HSG组术前术后分别为183.00±25.77ng/ml和201.05±22.41ng/ml (P﹤0.05)。两组中的Cor手术前30min与手术后30min相比有统计学意义，术后较术前均升高，术后24小时与术前组之间无统计学意义。其余各项指标MAP，HT，GLU，ACTH，NA，INS和CRP，两组共6个时间点间相比均无统计学意义(P﹥0.05)。
2术后2小时视觉模拟疼痛评分（VAS）
THL术后2小时VAS为1.73±1.01，低于HSG组2.47±1.33，两组相比有统计学意义(P﹤0.05)。两组中均没有妇女的评分高于5分，THL组评分较低与手术中应用静脉麻醉有关，适度的麻醉降低了妇女的疼痛感，增加了手术的可耐受性。
结论：
1THL虽然有微小创伤，但和HSG一样没有增加机体的应激反应，患者的生命体征和应激指标没有较大波动，且在24小时内回复正常生理水平。
2两组患者术后VAS评分均在轻度疼痛范围以下，患者对两种术式有较好的耐受性
Transvaginal hydrolaparoscopy(THL) was first described by Gordts et alin1998as a modification of culdoscopy to evaluate the fallopian tubes andovaries of infertile women without obvious pelvic pathology. The techniqueused saline solution as distension and added the benefits of hydroflotation tothe closer, clearer, and more detailed view of the allopian tubes and ovariesachieved by culdoscopy. Combined with hysterocsopy and chromotubation, itcould assessed the tubal patency.
The ability of THL to diagnose pelvic pathology in infertile women hasbeen compared with laparoscopy, the gold standard diagnostic tool. THL has ahigh concordance rate with laparoscopy when a complete evaluation isaccomplished during THL. The appeal of THL was that it is less invasive andcan be preformed in an outpatient setting without the use of general anesthesia.THL also has been shown to have a high concordance withHysterosalpingography(HSG) for tubal patency, but THL diagnosed moreintrauterine abnormalities as well as finding adhesions and endometriosis notvisible with HSG. Thus, THL could be considered as a first-line test for theexploration of the infertile woman in place of HSG.
Part1Study of transvaginal hydrolaparoscopy with hysteroscopy andchromopertubation as a first-line test in infertility women
Objectives:
1To study the safety of the transvaginal hydrolaparoscopic (THL) withhysteroscopy and chromopertubation for the infertile woman as a first-lineexamination method, to understand the main explored range and the unusualsituation and the incidence of major complications.
2To assess and explore the ovum retrieval ability of the fallopian tubalfimbria with the THL by the new designed score system. According to the scores, we guide the infertile women to choose the different pregnancy wayafter surgery. To analysis the pregnancy rate by spontaneously coitus,intrauterine insemination (IUI) and invitro fertilization and embryo transfer(IVF-ET) after the surgery, to explore the clinical value of THL withhysteroscopy and chromopertubation in treatment of the infertile women.
Methods:
1Subjects of THL with hysteroscopy and chromopertubation
There was a total of130infertile women to be operated by THL withhysteroscopy and chromopertubation at the Bethune International PeaceHospital from2010September to2013June. The mean (±SD) age was30.92±3.54years (range22~47) and body mass index (BMI) was23.04±2.67(range15.94~33.59). Primary infertility was diagnosed in76women(58.46%) and54secondary infertility. Duration of infertility was3.39±2.67years (range1~18).
2Equipments of THL with hysteroscopy and chromopertubation
The THL and hysteroscopy equipments made by Karl Storz (Tuttlingen,Germany,26120BA,26129BA).
3Procedure of THL with hysteroscopy and chromopertubation
The THL with hysteroscopy and chromopertubation could be performedwithin3-7days after cessation of menstruation. The operation was done underthe intravenous anesthetic of propofol in the dorsal lithotomic position. Adiagnostic hysteroscopy was carried out with a2.9mm hysteroscopy (KarlStorz, Tuttlingen, Germany). Normal saline solution was used to distend theuterine cavity at a filling pressure of120mmH2O. After completion of thehysteroscopy, a size10Foley catheter was introduced into the uterine cavityand the inflated balloon with3ml normal saline solution, then the methyleneblue dye was drop.
Next, THL was performed. The posterior lip of the cervix was elevatedwith a tenaculum, and a4-mm stab incision was made1.5cm posterior to thecervix. The system made by Karl Storz Endoscopy includes a spring-loadedneedle, dilator, and sheath. The needle was placed through the dilator, which was placed through the sheath. The needle was used to enter the pouch ofDouglas through the vaginal wall fast and easily. It wasn’t withdrawn until theouter sheath was intraperitoneal when the dilator was advanced. The dilatorwas removed, a rigid endoscopy less than3mm in diameter with a30-dregreeoptical angle was placed through the sheath. Once the endoscopy wassuccessfully introduced into the pouch of Douglas,200to300mL of warmedsaline solution was drop to float the bowel out of the pelvis.
Firstly, we evaluated the posterior aspect of the uterus, and the scope wasmoved laterally to identify the tubo-ovarian structures. The ovarian surfacewas inspected from the ovarian fossa to around ovaries for determiningwhether ovulation and endometriotic leision were existed. The fimbrial part ofthe fallopian tubes was inspected carefully. The methylene dye could beinjected transcervically to assess tubal patency. The pelvic sidewalls and theanterior of rectum were inspected similarly, the pelvic adhesions andendometriosis could be seen easily with the transvaginal optic scope, and laxadhesions could be removed. The vaginal incision was left to closespontaneously.
4Methods of the scores for tubal fimbrial ovum retrieval
According to the tubal fimbrial mucosa morphology and relationship withovarian, the scores were graded from5aspects respectively.①the fallopiantubal mucosa morphology: Tubal fimbrial interdigitating had a clear imageand normal color which was2points, the atrophic mucosa and interdigitatingadhesion into mass or vanished were0point, it was1point between in twoconditions;②the flexibility of tubal fimbria: fimbrial ciliums swung pliableand flexible under natural states and interdigitating could separated and foldedlikely umbrella shape, it was2points. Ciliums was thickened andinterdigitating couldn’t swing or be separated, and had not actions as “retrievaloocyte” for0point, it was1point between in two conditions;③the openingof tubal fimbria: the methylene blue flew from the fallopian tube. It could beobserved clearly under the THL through the adjusted direction of lens. If itwas unobstructed, the around interdigitating was not adhesive and could spread, the methylene blue could be seen flowing from the opening position. Ifits diameter was small, the around interdigitating was adhesive and couldn’tspread totally, the methylene blue flew from the side. These conditions were1and0piont respectively.④the relationship or distance between tubal fimbriaand ovary: It was1point that tubal fimbria could be touched the homolateralovary through swinging in the natural state, and which was0point that itcouldn’t be touched because the fallopian tube was fixed and anfractuous orfar, even a "back to back" relationship with ovary.⑤the surroundings of tubalfimbria and ovary: There were natural channel and without adhesion betweenthe tubal fimbria and ovary, or slight adhesion scope less than1/2, it was1point. When the fibrous adhesion or film adhesion scope was1/2, and therewas adhesive barrier between tubal fimbria and ovary, it was0point. Totalscore was from0to7. When the score was more than4, it was deemed thatthe retrieval oocyte ability was good. When it was less than3, it was poor.
5Statistical analysis
Statistical analysis of the data was performed by Student's t-test andchi-square test using SSPS17.0, and when p was less than0.05, it wasconsidered to be statistically significant.
Results:
1Safety and findings in the operation of THL with hysteroscopy andchromopertubation
1.1Success rate and complications of THL with hysteroscopy andchromopertubation
In130patients,127patients were probed successfully, the success ratewas97.7%(127/130).Among the127patients, There were2cases of rectalperforation and1case of uterine injury. The average total operation time was35.6±10.03min (range18min～60min), the hysteroscopic time was12.7±6.7min (5min~30min). The hysteroscopy took shorter time but hysteroscopicsurgical operations such as polyp’s electricity cutting, the intrauterine adhesionseparation and the uterine septum resection took longer time.
1.2Findings by the hysteroscopy
A total of130infertile women were operated by the hysteroscopy.Fifty-eight patients were detected uterine disease findings the detection rate44.6%. There were22diagnosed from the uterine polypus,8the intrauterineadhesion,1the cervical adhesions,2the submucous myoma,2the septateuterus and1the unicornous uterus, but they weren’t detected before operation.There was one case suffering from the endometrial atypical hyperplasia.Endometrial inflammation changes and Congestion points could be foundunder the hysteroscope.
1.3Findings in the operation of THL
In127women, there were62(48.82%) cases having a normal pelvic,51cases having pelvic adhesions,11cases having endometriosis co-existing withadhesion. The Mild and moderate-serious pelvic adhesions were33and18cases respectively. In25cases, the superficial endometriotic lesions weredetected on the ovarian surface (10) and the peritoneum of the lateral pelvicwall (15). Most the endometriotic lesions were very small. All of them wereclassified as stage I or II endometriosis according to the revised AFSclassification (American Fertility Society,1985).
1.4The scores of the tubal fimbria in the THL
The rate of completely evaluated tubo-ovarian structures was122(96.1%).In122(96.1%) patients, bilateral tubal patency, unilateral tubalpatency and bilateral tubal obstruction and invisibility were95,22,8and2cases respectively. There were2cases whose bilateral tubo-ovarian structurescouldn’t be visualized, and3whose unilateral tubo-ovarian structures couldn’tbe visualized due to the extensive adhesions.
There were81women scored more than4and36cases less than3. Thewomen with at least one side tube patency had good capability scores for tubalfimbrial retrieval oocyte, and they were advised to be pregnant by spontaneouscoitus or intrauterine insemination (IUI), the others by vitro fertilization andembryo transfer (IVF-ET).
Conclusions:
1THL with hysteroscopy and chromopertubation is a feasible and safe method and may be considered as a first-line test for the infertile woman.
2Pelvic genital organs can be invisible clearly in saline medium, whichincludes of the posterior aspect of the uterus, the pelvic sidewalls, the ovaries,fallopian tubal fimbria and so on. The pelvic adhesion and tiny lesions such asovary and pelvic endometriosis could be found under THL.
3In the outpatient, pelvic and uterine can be probed completely at onceby THL combined with hysteroscopy. Some abnormal uterine cavity can befound, especially some microlesions such as endometrial polyps, mildintrauterine adhesions, the submucous myoma, the septate uterus, theunicornous uterus and so on, which can’t be found by ultrasonic inspection.
4The infertile woman could choice a suitable treatment after THL underthe guide of the new scoring system and avoids unnecessary waiting, surgeryand excessary ART.
Part2Effectiveness of the Hysterosalpingography and laparoscopy,transvaginal hydrolaparoscopy on the tubal patency
Objective:
To compare and analysis the influence to the tubal patency between theHysterosalpingography(HSG) and laparoscopy(Lap), transvaginalhydrolaparoscopy with chromopertubation (THL), To understand thecoincidence rate of two methods and assess the sensitivity and specificity ofthe tubal patency.
Methods:
1Subjects
There were43and76infertile women to be operated respectively byTHL and Lap who had HSG prior to the process at the Bethune InternationalPeace Hospital from2010September to2013June.
The mean (±SD) age in Lap group was28.71±4.24years (range20~40),and duration of infertility was3.4±2.5years (range1~11). Primary infertilitywas diagnosed in38women (50%) and38secondary infertility.
The mean (±SD) age in THL group was30.87±4.24years (range22~41)and duration of infertility was3.45±2.07years (range1~11). Primary infertility was diagnosed in23women (53.5%) and20secondary infertility.
2Equipments of THL and Lap
The THL and hysteroscopy equipments made by Karl Storz (Tuttlingen,Germany,26120BA,26129BA) and Lap equipments made by Olympus.
3Procedures of HSG, Lap and THL
The HSG could be performed within3-7days after cessation ofmenstruation. The procedure was done in the dorsal lithotomic position. A size12uterus radiography catheter for drainage was introduced into the uterinecavity and the inflated balloon with1～2ml76%meglumine diatrizoatesolution, then the meglumine diatrizoate solution was drop. Then the wholeprocess of throughout the uterine and fallopian tubes into the pelvis diffusionwas observed in the X-ray, the orthostatic radiography was done after40minutes again to assess the pelvic dispersion.
The Lap was done under the tracheal intubation anesthesia in the dorsallithotomic position. A diagnostic hysteroscopy was carried out with a2.9mmhysteroscopy (Karl Storz, Tuttlingen, Germany), a size10Foley catheter wasintroduced into the uterine cavity, and then the Lap was performed. The scopewas moved in pelvic cavity to identify the tubes and ovarian structures, and toexplore whether adhesions and endometriosis around the pelvic genital organs.The methylene dye could be injected transcervically to assess tubal patency.The pelvic adhesions were given adhesiolysis, and endometriosis could bedone cystectomy and ablation corresponding.
THL procedure was same as part1.
Results:
1Fallopian tube patency between HSG and Lap, THL.
In Lap group, the coincidence rate was80.79%(122/151), the sensitivity,specificity, positive and negative predictive values of HSG was83.52%(76/91),76.67%(46/60),84.44%(76/90)，75.41%(46/61) respectively. There was astatistically significant in the diagnosis of the tubal patency between HSG andLap in the same patients(X2=69.21，P﹤0.05)
In THL group, the coincidence rate was82.6%(71/86), the sensitivity, specificity, positive and negative predictive values of HSG was86.3%,61.5%,92.6%,44.4%respectively. There was a statistically significant in thediagnosis of the tubal patency between HSG and THL in the samepatients(X2=107.40，P﹤0.05).
2Abnormal findings in Lap and THL
In the Lap group, the abnormality rate in pelvic cavity was71.05%(54/76). Including pelvic adhesion in23cases and15cases of endometriosis;in the THL group, the abnormality rate in pelvic cavity was72.1%(31/43),including pelvic adhesions in23cases and10cases of endometriosis.
Conclusions:
1There were higher sensitivity and lower specificity in evaluationfallopian tube patency by HSG compared with Lap and THL. That showedHSG was not the perfect method to evaluate the fallopian tube patency.
2THL provided more accurate tubal patency surroundings, also couldgive additional information about the pelvic cavity as Lap that could not beobtained through HSG, and may be considered as a first-line test for theexploration of fallopian tube patency.
Part3Body stress response to the THL with hysteroscopy andchromopertubation and HSG.
Objectives:
1To compare body stress response, trauma and influence to the bodyafter the operation of the THL with hysteroscopy and chromopertubation andHSG.
2To evaluate the pain by the visual analogue scale (VAS) at2hours afterthe performed operation between the THL with hysteroscopy andchromopertubation and the HSG, to explore the tolerability of two kinds ofoperation on infertile women.
Methods:
1Subjects
Thirty women were chosen to be performed THL with hysteroscopy andhydrotubation as the study group, and30women to be performed HSG as the control group correspondly at the same period. The mean (±SD) age in studygroup was30.37±0.68and28.53±0.84in control group, Duration of infertility2.98±0.31vs2.88±0.28, body mass index (BMI)23.20±0.76vs,22.55±0.57.Primary infertility was18women and12secondary infertility in study group,while21and9in control group.
2Method and indicator of the body stress response to THL withhysteroscopy and hydrotubation and HSG
Both groups’ average artery pressure (MAP), heart rate (HR), plasmaadrenocor ticotropic hormone (ACTH), noradrenaline (NA), angiotensin (AII),cortisol (Cor), insulin(INS), C reactive protein(CRP) and glucose (GLU) weremeasured respectively. The blood sample was obtained by a consecutive seriesof30patients of each group. We collected elbow vein blood3ml at three timesand rapidly put into the precooling vitro containing20ul EDTA, aftercentrifugal separated for5minutes at4°C, then the plasma was preserved in-20°C refrigerator to be measured. GLU was measured by glucose oxidasemethod and the other markers were used radioimmunoassay. Equipment wasmade by Siemens IMMULITE2000and reagent kit was provided by SiemensCompany.
3Method of VAS after the THL with hysteroscopy and hydrotubation andHSG
To evaluate the Tolerance of THL and HSG,60consecutive patients wereasked to score their most intense pain experience during THL and HSG on a10cm visual analog pain scale2hours after the operation. The VAS scoreswere from0(no pain, perfectly acceptable) to10(unbearable pain, completelyunacceptable).
Results:
1Comparison of the body stress response to THL with hysteroscopy andhydrotubation and HSG
In a consecutive series of30patients, plasma Cor in THL and HSG athalf hour before and after the surgery were187.78±19.74ng/ml and183.00±25.77ng/ml versus197.20±22.28ng/ml and201.05±22.41ng/ml respectively, which significantly increased after the both operations(p＜0.05),the others were no statistically significant (p＞0.05).
2The VAS scores
The VAS scores had statistically significant between two groups but wereboth lower (p＜0.05). The average pain score was1.73(SD±1.01) in THL andno women marked a score above5and2.47(SD±1.33) in HSG. Theappropriate anesthesia would reduce the pain and increase the tolerationduring the operation.
Conclusions:
1Our study has demonstrated that there was microtrauma to body byTHL with hysteroscopy and chromopertubation as same as HSG, it couldrecovered in24hours.
2The two groups VAS score were below the mild pain, and it wasaccepted better and tolerated both procedure.
THL能清晰地评估不孕妇女的卵巢-输卵管结构，所提供的诊断结果准确性与腹腔镜（laparoscopy, Lap）相似。THL不需要全身麻醉，侵入性更小，花费更少。与传统的输卵管功能检查手段子宫输卵管造影术(Hysterosalpingography, HSG)相比，能精确和直观地尽可能一步到位的探查到影响不孕的所有生殖器官和盆腔环境。第一部分经阴道注水腹腔镜联合宫腔镜及通液术作为不孕妇女一线检
查方法的研究
目的:
1探讨经阴道注水腹腔镜(transvaginal hydrolaparoscopy, THL)联合宫腔镜和通液术作为不孕妇女一线检查方法的安全性。了解其探查的主要范围和观察到的主要异常情况及并发症的发生率。
2应用新设计的输卵管伞部摄卵能力评分系统，在THL镜下对不孕妇女的输卵管和伞部进行探查和评分，根据得分情况，指导不孕症妇女术后选择不同的生殖方式，通过随访术后不孕妇女的自然妊娠率、人工授精(intrauterine insemination, IUI)妊娠率及(in vitro fertilization and embryotransfer, IVF-ET)的妊娠率，验证THL和新的评分系统对临床工作指导的效率及意义。
方法:
1研究对象
2010年9月至2013年6月于白求恩国际和平医院就诊的不孕症妇女130例，行THL联合宫腔镜和通液术，检查子宫腔，盆腔及输卵管通畅情况。年龄30.92±3.54(22～47)岁，原发不孕76例，继发不孕54例，不孕年限3.39±2.67(1～18)年，体重指数23.04±2.67(15.94～33.59)。
2设备
采用德国Storz公司的注水腹腔镜操作系统(型号-26120BA)及宫腔镜系统(型号-26129BA)
3THL联合宫腔镜和通液术的操作方法
接受手术的妇女取膀胱截石位，常规消毒外阴、阴道，铺无菌巾，静脉麻醉后，常规行宫腔镜检查，完毕后宫腔放置一次性通液管（如需手术治疗，在THL后立即进行）。选择宫颈后唇下方1～1.5cm处作为穿刺点，在超声引导下，用直径2mm的Veress针刺入子宫直肠陷凹(如后位子宫，先用扩张棒将子宫位置改变成前位或平位)。快速滴注37°C生理盐水约300ml，超声观察直肠子宫陷凹有明显的均匀一致液性暗区形成。拔出Veress针，用外径5mm的Trocar在超声指引下穿入子宫直肠陷凹的液体池中，然后置入直径3.9mm，角度30°的内窥镜，从子宫后壁开始，沿盆腔侧壁，输卵管的走行至卵巢周围，用亚甲蓝(methylene blue dye)进行通液，镜下观察输卵管的通畅性，见亚甲蓝液从输卵管伞端溢出为输卵管通畅。重点观察输卵管伞部黏膜和柔韧性，与同侧卵巢的关系，是否密切或较远，两者之间有无膜状或纤维状粘连，评估伞的摄卵能力。
4输卵管伞部摄卵能力评分方法
在输卵管通液显示通畅的前提下，根据输卵管伞部形态及与卵巢的关系，分别从5个方面进行评分。①输卵管伞部黏膜形态：镜下清晰，指突色泽正常为2分，黏膜萎缩，指突粘连成团或消失为0分，介于二者之间为1分。②输卵管伞部的活动度：自然状态下伞部纤毛摆动灵活柔韧，指突间能呈伞状分开及合拢者为2分；纤毛增厚僵硬，指突间粘连不能分开或摆动，无“检拾”动作为0分，介于二者之间为1分。③输卵管伞部开口：即亚甲蓝从伞部流出的开口，在镜下，可通过调整镜头和光纤的方向清晰观察伞部的输卵管开口部位，如孔径通畅，周围指突无粘连并可散开完全无阻挡见亚甲蓝从开口部位流出，为1分；如孔径细小，周围指突粘连阻挡不能完全散开，亚甲蓝从侧旁流出，则为0分。④输卵管伞部与卵巢的关系或距离：在自然状态下，输卵管伞部通过摆动能触及同侧卵巢表面，距离较近为1分；输卵管迂曲，伞部位置固定，距同侧卵巢较远，通过摆动不能触及卵巢或伞部转向卵巢外侧方向，与卵巢呈“背靠背”关系，为0分。⑤输卵管伞部周围及与同侧卵巢间有无粘连：输卵管伞部周围无粘连，或有少量膜状粘连其范围﹤1/2且与卵巢间有自然通道，为1分；伞部周围纤维状粘连或膜状粘连但范围﹥1/2或与卵巢间有粘连阻挡，仅见亚甲蓝流出，为0分。总分在0～7分之间，认为≥4分时输卵管伞部摄卵能力优，≤3分为摄卵能力差。
5采用SPSS17.0统计软件包对数据进行检验，计量数据以均数±标准差（x±s）表示，计量资料采用方差分析，计数资料采用X2检验，p＜0.05为有统计学意义。
结果:
1THL联合宫腔镜和通液术的安全性和术中发现
1.1THL联合宫腔镜和通液术的成功率和并发症
130例不孕妇女中，127例经阴道穿刺成功进入子宫直肠窝，成功率97.7%。共出现3例并发症，包括2例直肠损伤和1例子宫后壁损伤。
总手术时间平均为36.03±9.8min（20min～60min），其中宫腔镜所用时间为12.7±6.7min（5min～30min），单纯宫腔检查术所用时间短，宫腔镜手术操作如息肉电切术，粘连分离术，中隔切除术等所用时间较长。
1.2宫腔镜发现
130例妇女全部完成宫腔镜检查。发现异常者包括子宫内膜息肉44例，检出率33.85%（44/130），术前超声提示宫内膜不均质或宫内高回声的22例，仅为50%(22/44)。宫腔粘连8例（0.063%），宫颈粘连1例，子宫粘膜下小肌瘤2例，子宫中隔2例，单角子宫1例，术前超声均未提示异常。子宫内膜不典型增生1例，宫腔镜下见内膜呈炎性改变，有多个充血点。子宫内膜息肉和子宫内膜不典型增生经病理检查确诊。
1.3THL术中发现
在穿刺成功的127例妇女中，检查盆腔无异常发现者62例，占48.82%。单纯盆腔粘连40例，合并内异症粘连11例。轻度盆腔粘连33例（合并內异症8例），中重度盆腔粘连18例（合并內异症3）。盆腔子宫内膜异位症25例，其中卵巢型内异症13例，腹膜型内异症11例，两者并存1例，均为r-AFS I～II期。2例穿刺损伤直肠者均为盆腔重度粘连合并子宫内膜异位症，子宫直肠窝消失，r-AFS评分分别为45、47分。1例子宫后壁损伤，盆腔轻度粘连，子宫后壁及骶韧带可见內异症结节，r-AFS评分7分。
1.4THL术中双侧输卵管通液及伞部摄卵能力评分结果
THL下通液示输卵管双侧通畅95例，一侧通畅22，双侧不通8例，余2不可见。卵巢-输卵管双侧不可见者2例，一侧不可见者3例。
输卵管通畅者根据输卵管伞部摄卵能力评分表进行评分，最大评分为7分，认为大于≥4分为输卵管伞部摄卵能力优，小于≤3分为摄卵能力差。至少有一侧输卵管伞部摄卵能力优的建议术后门诊指导性交自然妊娠，或人工授精；双侧输卵管伞摄卵能力差的则建议行IVF-ET。127例中，前者有81例，后者36例，伞部黏膜和柔韧度评分较高而盆腔粘连较重的患者7例，术后行腹腔镜手术分离粘连，占0.55%。
结论:
1THL联合宫腔镜和通液术操作安全，术中术后并发症少，无致命性损伤及大出血，可以做为临床上探查不孕妇女盆腔生殖器官的一线检查方法。
2THL以生理盐水为介质，可以清晰的直视盆腔生殖器官，包括子宫后壁，卵巢，输卵管，直肠前壁，盆腔侧壁等。能发现盆腔粘连，卵巢和盆腔侧壁的子宫内膜异位症等微小病变。
3THL结合宫腔镜，在门诊一次性完成对盆腔和宫腔的探查，发现宫腔的病变，尤其是超声检查不能发现的微小病变，如子宫内膜息肉，轻度的宫腔粘连，不典型的子宫小中隔等。
4THL镜下应用新设计的输卵管摄卵评分系统，对不孕妇女进行术后妊娠方式指导，使治疗有明确的选择，减少不必要等待和手术，避免过度使用辅助生殖技术。
第二部分子宫输卵管碘油造影和经阴道注水腹腔镜、腹腔镜对不孕妇女输卵管通畅性评估的对比
目的:对比分析子宫输卵管造影术（Hysterosalpingography, HSG）和经阴道注水腹腔镜(transvaginal hydrolaparoscopy, THL)、腹腔镜(laparoscopy,Lap)下输卵管通液对输卵管通畅性的评估，了解HSG评估输卵管通畅的敏感度与特异度。
方法：
1研究对象
1.1Lap研究对象的一般情况
2010年9月至2013年6月在白求恩国际和平医院妇产科行Lap的不孕妇女192例，选择术前6个月内曾行HSG检查的妇女76例为研究对象，总输卵管151条。年龄28.71±4.07(20～40)岁，不孕年限3.4±2.5(1～11)年，原发不孕38例，继发不孕38例。
1.2THL联合宫腔镜和通液术研究对象的一般情况
2010年9月至2013年6月在白求恩国际和平医院妇产科行THL联合宫腔镜和通液术的不孕妇女130例，选择术前6个月内曾行HSG检查的妇女43例为研究对象，总输卵管86条。年龄30.87±4.24(22～41)岁，不孕年限3.45±2.07(1～11)年，原发不孕23例，继发不孕20例。
2设备
采用德国Storz公司的THL操作系统(型号-26120BA)和日本Olmbs奥林巴斯Lap设备
3手术方法
3.1HSG方法
患者取膀胱截石位，窥器扩张阴道，暴露宫颈，再次消毒阴道和穹窿部，宫颈钳钳夹宫颈前唇。子宫造影通液管沿子宫方向置入宫腔，将其囊内注入76%泛影葡胺液约1～2ml，使双腔通液管固定在宫腔内。从宫腔管内徐徐注入泛影葡胺液，在X线透视下全程观察造影剂进入宫腔及输卵管直至弥散如盆腔的全过程并摄片，40分钟后再次立位摄片，观察泛影葡胺液在盆腔弥散情况。
3.2Lap手术方法
患者气管插管全麻，取膀胱截石位，先行宫腔镜检查，观察有无宫腔结构异常和子宫内膜异常，如子宫内膜息肉或宫腔粘连。撤出宫腔镜后置入子宫造影通液管备用。腹腔镜入腹腔后首先观察盆腔情况，有无粘连，探查输卵管走形和伞端情况，以及与同侧卵巢的关系。如输卵管及卵巢不能暴露，应先松解盆腔粘连，使输卵管伞部和卵巢暴露利于观察。从宫腔通液管注入亚甲蓝液，直视下观察亚甲蓝从输卵管间质部向伞部流动的过程，轻轻摆动输卵管伞部及镜头方向至清晰观察到输卵管伞部开口的亚甲蓝流出。术中所见的盆腔粘连均给予适当分离，子宫内膜异位症给予相应的剥除术和电灼术。
3.3THL手术方法如第一部分所述
结果:
1HSG和THL, Lap对输卵管通畅性的诊断对比
相对于Lap，HSG的总体符合率为80.79%(122/151)，敏感性83.52%(76/91)，特异性76.67%(46/60)，阳性预测值84.44%(76/90)，阴性预测值75.41%(46/61)。两种方法相比有统计学意义(X2=69.21，P﹤0.05)。
相对于THL， HSG的总体符合率为82.6%(71/86)，敏感性86.3%(63/73)，特异性61.6%(8/13)，阳性预测值92.6%(63/68)，阴性预测值44.4%(8/18)。两种方法相比有统计学意义(X2=107.40，P﹤0.05)。
2Lap和THL的异常发现
在Lap组盆腔异常检出率为71.05%(54/76)。包括盆腔粘连23例，子宫内膜异位症15例；在THL组盆腔异常检出率为72.1%(31/43)，包括盆腔粘连23例，子宫内膜异位症10例。
结论：
1HSG与THL和Lap相比，对输卵管通畅性的诊断敏感性较高，特异性较低，其作为输卵管功能检查的一线手段不够理想。
2THL和Lap一样在直视下进行输卵管通液，效果可靠，能同时发现输卵管周围病变，探查盆腔器官，THL较Lap更经济，微创，所需人力资源少，留院时间短，适合作为不孕妇女的断输卵管通畅性首选检查手段。第三部分经阴道注水腹腔镜联合宫腔镜及通液术与子宫输卵管造影对机体的应激反应
目的:
1对比研究THL联合宫腔镜和通液术和HSG对机体的创伤和影响，探讨机体对两种手术的应激性反应。
2分析THL联合宫腔镜和通液术术后２小时不孕妇女的疼痛评分，并和HSG术后评分相比较，探讨不孕妇女对两种操作的耐受性。
方法：
1研究对象
选择同期行THL联合宫腔镜和通液术（研究组）和HSG（对照组）妇女各30例，两组年龄分别为(30.37±0.68vs.28.53±0.84)，不孕年限(2.98±0.31vs2.88±0.28)，体重指数(23.20±0.76vs,22.55±0.57)之间具有可比性(p﹥0.05)。THL组原发不孕者18例，继发12例，HSG组原发不孕21例，继发9例，两组相比无统计学意义(p﹥0.05)。
2研究方法
2.1不孕妇女对THL联合宫腔镜和通液术和HSG的机体应激反应研究方法
分别测定两组妇女术前，术后30分，术后24小时的平均动脉压(MAP)，心率(HR)，并于上述3个时间点分别采集肘静脉血3ml，迅速注入在冰水浴中冷却的含20ul EDTA的试管中，摇匀，放冰水浴中冷却后以1000转/分离心5min（在4°C离心），分离血浆，取血浆放入已预冷试管中，置-20°C冰箱保存备检。血糖(GLU)测定采用葡葡萄糖氧化酶法，其余指标促肾上腺皮质激素(ACTH)、去甲肾上腺素(NA)、血管紧张素II(AII)、胰岛素（Ins）、血糖(GLU)、C-反应蛋白（CRP）和皮质醇(Cor)均采用放射免疫测定法。
2.2不孕妇女对THL联合宫腔镜和通液术和HSG的术后2小时视觉模拟疼痛评分
利用视觉模拟疼痛评分表(Visual analogue scale,VAS)分别评估2组妇女术后2小时的VAS评分。
结果：
1THL和HSG对不孕妇女机体应激反应的指标
THL组术前术后Cor分别为187.78±19.74ng/ml和197.20±22.28ng/ml(P﹤0.05)， HSG组术前术后分别为183.00±25.77ng/ml和201.05±22.41ng/ml (P﹤0.05)。两组中的Cor手术前30min与手术后30min相比有统计学意义，术后较术前均升高，术后24小时与术前组之间无统计学意义。其余各项指标MAP，HT，GLU，ACTH，NA，INS和CRP，两组共6个时间点间相比均无统计学意义(P﹥0.05)。
2术后2小时视觉模拟疼痛评分（VAS）
THL术后2小时VAS为1.73±1.01，低于HSG组2.47±1.33，两组相比有统计学意义(P﹤0.05)。两组中均没有妇女的评分高于5分，THL组评分较低与手术中应用静脉麻醉有关，适度的麻醉降低了妇女的疼痛感，增加了手术的可耐受性。
结论：
1THL虽然有微小创伤，但和HSG一样没有增加机体的应激反应，患者的生命体征和应激指标没有较大波动，且在24小时内回复正常生理水平。
2两组患者术后VAS评分均在轻度疼痛范围以下，患者对两种术式有较好的耐受性
Transvaginal hydrolaparoscopy(THL) was first described by Gordts et alin1998as a modification of culdoscopy to evaluate the fallopian tubes andovaries of infertile women without obvious pelvic pathology. The techniqueused saline solution as distension and added the benefits of hydroflotation tothe closer, clearer, and more detailed view of the allopian tubes and ovariesachieved by culdoscopy. Combined with hysterocsopy and chromotubation, itcould assessed the tubal patency.
The ability of THL to diagnose pelvic pathology in infertile women hasbeen compared with laparoscopy, the gold standard diagnostic tool. THL has ahigh concordance rate with laparoscopy when a complete evaluation isaccomplished during THL. The appeal of THL was that it is less invasive andcan be preformed in an outpatient setting without the use of general anesthesia.THL also has been shown to have a high concordance withHysterosalpingography(HSG) for tubal patency, but THL diagnosed moreintrauterine abnormalities as well as finding adhesions and endometriosis notvisible with HSG. Thus, THL could be considered as a first-line test for theexploration of the infertile woman in place of HSG.
Part1Study of transvaginal hydrolaparoscopy with hysteroscopy andchromopertubation as a first-line test in infertility women
Objectives:
1To study the safety of the transvaginal hydrolaparoscopic (THL) withhysteroscopy and chromopertubation for the infertile woman as a first-lineexamination method, to understand the main explored range and the unusualsituation and the incidence of major complications.
2To assess and explore the ovum retrieval ability of the fallopian tubalfimbria with the THL by the new designed score system. According to the scores, we guide the infertile women to choose the different pregnancy wayafter surgery. To analysis the pregnancy rate by spontaneously coitus,intrauterine insemination (IUI) and invitro fertilization and embryo transfer(IVF-ET) after the surgery, to explore the clinical value of THL withhysteroscopy and chromopertubation in treatment of the infertile women.
Methods:
1Subjects of THL with hysteroscopy and chromopertubation
There was a total of130infertile women to be operated by THL withhysteroscopy and chromopertubation at the Bethune International PeaceHospital from2010September to2013June. The mean (±SD) age was30.92±3.54years (range22~47) and body mass index (BMI) was23.04±2.67(range15.94~33.59). Primary infertility was diagnosed in76women(58.46%) and54secondary infertility. Duration of infertility was3.39±2.67years (range1~18).
2Equipments of THL with hysteroscopy and chromopertubation
The THL and hysteroscopy equipments made by Karl Storz (Tuttlingen,Germany,26120BA,26129BA).
3Procedure of THL with hysteroscopy and chromopertubation
The THL with hysteroscopy and chromopertubation could be performedwithin3-7days after cessation of menstruation. The operation was done underthe intravenous anesthetic of propofol in the dorsal lithotomic position. Adiagnostic hysteroscopy was carried out with a2.9mm hysteroscopy (KarlStorz, Tuttlingen, Germany). Normal saline solution was used to distend theuterine cavity at a filling pressure of120mmH2O. After completion of thehysteroscopy, a size10Foley catheter was introduced into the uterine cavityand the inflated balloon with3ml normal saline solution, then the methyleneblue dye was drop.
Next, THL was performed. The posterior lip of the cervix was elevatedwith a tenaculum, and a4-mm stab incision was made1.5cm posterior to thecervix. The system made by Karl Storz Endoscopy includes a spring-loadedneedle, dilator, and sheath. The needle was placed through the dilator, which was placed through the sheath. The needle was used to enter the pouch ofDouglas through the vaginal wall fast and easily. It wasn’t withdrawn until theouter sheath was intraperitoneal when the dilator was advanced. The dilatorwas removed, a rigid endoscopy less than3mm in diameter with a30-dregreeoptical angle was placed through the sheath. Once the endoscopy wassuccessfully introduced into the pouch of Douglas,200to300mL of warmedsaline solution was drop to float the bowel out of the pelvis.
Firstly, we evaluated the posterior aspect of the uterus, and the scope wasmoved laterally to identify the tubo-ovarian structures. The ovarian surfacewas inspected from the ovarian fossa to around ovaries for determiningwhether ovulation and endometriotic leision were existed. The fimbrial part ofthe fallopian tubes was inspected carefully. The methylene dye could beinjected transcervically to assess tubal patency. The pelvic sidewalls and theanterior of rectum were inspected similarly, the pelvic adhesions andendometriosis could be seen easily with the transvaginal optic scope, and laxadhesions could be removed. The vaginal incision was left to closespontaneously.
4Methods of the scores for tubal fimbrial ovum retrieval
According to the tubal fimbrial mucosa morphology and relationship withovarian, the scores were graded from5aspects respectively.①the fallopiantubal mucosa morphology: Tubal fimbrial interdigitating had a clear imageand normal color which was2points, the atrophic mucosa and interdigitatingadhesion into mass or vanished were0point, it was1point between in twoconditions;②the flexibility of tubal fimbria: fimbrial ciliums swung pliableand flexible under natural states and interdigitating could separated and foldedlikely umbrella shape, it was2points. Ciliums was thickened andinterdigitating couldn’t swing or be separated, and had not actions as “retrievaloocyte” for0point, it was1point between in two conditions;③the openingof tubal fimbria: the methylene blue flew from the fallopian tube. It could beobserved clearly under the THL through the adjusted direction of lens. If itwas unobstructed, the around interdigitating was not adhesive and could spread, the methylene blue could be seen flowing from the opening position. Ifits diameter was small, the around interdigitating was adhesive and couldn’tspread totally, the methylene blue flew from the side. These conditions were1and0piont respectively.④the relationship or distance between tubal fimbriaand ovary: It was1point that tubal fimbria could be touched the homolateralovary through swinging in the natural state, and which was0point that itcouldn’t be touched because the fallopian tube was fixed and anfractuous orfar, even a "back to back" relationship with ovary.⑤the surroundings of tubalfimbria and ovary: There were natural channel and without adhesion betweenthe tubal fimbria and ovary, or slight adhesion scope less than1/2, it was1point. When the fibrous adhesion or film adhesion scope was1/2, and therewas adhesive barrier between tubal fimbria and ovary, it was0point. Totalscore was from0to7. When the score was more than4, it was deemed thatthe retrieval oocyte ability was good. When it was less than3, it was poor.
5Statistical analysis
Statistical analysis of the data was performed by Student's t-test andchi-square test using SSPS17.0, and when p was less than0.05, it wasconsidered to be statistically significant.
Results:
1Safety and findings in the operation of THL with hysteroscopy andchromopertubation
1.1Success rate and complications of THL with hysteroscopy andchromopertubation
In130patients,127patients were probed successfully, the success ratewas97.7%(127/130).Among the127patients, There were2cases of rectalperforation and1case of uterine injury. The average total operation time was35.6±10.03min (range18min～60min), the hysteroscopic time was12.7±6.7min (5min~30min). The hysteroscopy took shorter time but hysteroscopicsurgical operations such as polyp’s electricity cutting, the intrauterine adhesionseparation and the uterine septum resection took longer time.
1.2Findings by the hysteroscopy
A total of130infertile women were operated by the hysteroscopy.Fifty-eight patients were detected uterine disease findings the detection rate44.6%. There were22diagnosed from the uterine polypus,8the intrauterineadhesion,1the cervical adhesions,2the submucous myoma,2the septateuterus and1the unicornous uterus, but they weren’t detected before operation.There was one case suffering from the endometrial atypical hyperplasia.Endometrial inflammation changes and Congestion points could be foundunder the hysteroscope.
1.3Findings in the operation of THL
In127women, there were62(48.82%) cases having a normal pelvic,51cases having pelvic adhesions,11cases having endometriosis co-existing withadhesion. The Mild and moderate-serious pelvic adhesions were33and18cases respectively. In25cases, the superficial endometriotic lesions weredetected on the ovarian surface (10) and the peritoneum of the lateral pelvicwall (15). Most the endometriotic lesions were very small. All of them wereclassified as stage I or II endometriosis according to the revised AFSclassification (American Fertility Society,1985).
1.4The scores of the tubal fimbria in the THL
The rate of completely evaluated tubo-ovarian structures was122(96.1%).In122(96.1%) patients, bilateral tubal patency, unilateral tubalpatency and bilateral tubal obstruction and invisibility were95,22,8and2cases respectively. There were2cases whose bilateral tubo-ovarian structurescouldn’t be visualized, and3whose unilateral tubo-ovarian structures couldn’tbe visualized due to the extensive adhesions.
There were81women scored more than4and36cases less than3. Thewomen with at least one side tube patency had good capability scores for tubalfimbrial retrieval oocyte, and they were advised to be pregnant by spontaneouscoitus or intrauterine insemination (IUI), the others by vitro fertilization andembryo transfer (IVF-ET).
Conclusions:
1THL with hysteroscopy and chromopertubation is a feasible and safe method and may be considered as a first-line test for the infertile woman.
2Pelvic genital organs can be invisible clearly in saline medium, whichincludes of the posterior aspect of the uterus, the pelvic sidewalls, the ovaries,fallopian tubal fimbria and so on. The pelvic adhesion and tiny lesions such asovary and pelvic endometriosis could be found under THL.
3In the outpatient, pelvic and uterine can be probed completely at onceby THL combined with hysteroscopy. Some abnormal uterine cavity can befound, especially some microlesions such as endometrial polyps, mildintrauterine adhesions, the submucous myoma, the septate uterus, theunicornous uterus and so on, which can’t be found by ultrasonic inspection.
4The infertile woman could choice a suitable treatment after THL underthe guide of the new scoring system and avoids unnecessary waiting, surgeryand excessary ART.
Part2Effectiveness of the Hysterosalpingography and laparoscopy,transvaginal hydrolaparoscopy on the tubal patency
Objective:
To compare and analysis the influence to the tubal patency between theHysterosalpingography(HSG) and laparoscopy(Lap), transvaginalhydrolaparoscopy with chromopertubation (THL), To understand thecoincidence rate of two methods and assess the sensitivity and specificity ofthe tubal patency.
Methods:
1Subjects
There were43and76infertile women to be operated respectively byTHL and Lap who had HSG prior to the process at the Bethune InternationalPeace Hospital from2010September to2013June.
The mean (±SD) age in Lap group was28.71±4.24years (range20~40),and duration of infertility was3.4±2.5years (range1~11). Primary infertilitywas diagnosed in38women (50%) and38secondary infertility.
The mean (±SD) age in THL group was30.87±4.24years (range22~41)and duration of infertility was3.45±2.07years (range1~11). Primary infertility was diagnosed in23women (53.5%) and20secondary infertility.
2Equipments of THL and Lap
The THL and hysteroscopy equipments made by Karl Storz (Tuttlingen,Germany,26120BA,26129BA) and Lap equipments made by Olympus.
3Procedures of HSG, Lap and THL
The HSG could be performed within3-7days after cessation ofmenstruation. The procedure was done in the dorsal lithotomic position. A size12uterus radiography catheter for drainage was introduced into the uterinecavity and the inflated balloon with1～2ml76%meglumine diatrizoatesolution, then the meglumine diatrizoate solution was drop. Then the wholeprocess of throughout the uterine and fallopian tubes into the pelvis diffusionwas observed in the X-ray, the orthostatic radiography was done after40minutes again to assess the pelvic dispersion.
The Lap was done under the tracheal intubation anesthesia in the dorsallithotomic position. A diagnostic hysteroscopy was carried out with a2.9mmhysteroscopy (Karl Storz, Tuttlingen, Germany), a size10Foley catheter wasintroduced into the uterine cavity, and then the Lap was performed. The scopewas moved in pelvic cavity to identify the tubes and ovarian structures, and toexplore whether adhesions and endometriosis around the pelvic genital organs.The methylene dye could be injected transcervically to assess tubal patency.The pelvic adhesions were given adhesiolysis, and endometriosis could bedone cystectomy and ablation corresponding.
THL procedure was same as part1.
Results:
1Fallopian tube patency between HSG and Lap, THL.
In Lap group, the coincidence rate was80.79%(122/151), the sensitivity,specificity, positive and negative predictive values of HSG was83.52%(76/91),76.67%(46/60),84.44%(76/90)，75.41%(46/61) respectively. There was astatistically significant in the diagnosis of the tubal patency between HSG andLap in the same patients(X2=69.21，P﹤0.05)
In THL group, the coincidence rate was82.6%(71/86), the sensitivity, specificity, positive and negative predictive values of HSG was86.3%,61.5%,92.6%,44.4%respectively. There was a statistically significant in thediagnosis of the tubal patency between HSG and THL in the samepatients(X2=107.40，P﹤0.05).
2Abnormal findings in Lap and THL
In the Lap group, the abnormality rate in pelvic cavity was71.05%(54/76). Including pelvic adhesion in23cases and15cases of endometriosis;in the THL group, the abnormality rate in pelvic cavity was72.1%(31/43),including pelvic adhesions in23cases and10cases of endometriosis.
Conclusions:
1There were higher sensitivity and lower specificity in evaluationfallopian tube patency by HSG compared with Lap and THL. That showedHSG was not the perfect method to evaluate the fallopian tube patency.
2THL provided more accurate tubal patency surroundings, also couldgive additional information about the pelvic cavity as Lap that could not beobtained through HSG, and may be considered as a first-line test for theexploration of fallopian tube patency.
Part3Body stress response to the THL with hysteroscopy andchromopertubation and HSG.
Objectives:
1To compare body stress response, trauma and influence to the bodyafter the operation of the THL with hysteroscopy and chromopertubation andHSG.
2To evaluate the pain by the visual analogue scale (VAS) at2hours afterthe performed operation between the THL with hysteroscopy andchromopertubation and the HSG, to explore the tolerability of two kinds ofoperation on infertile women.
Methods:
1Subjects
Thirty women were chosen to be performed THL with hysteroscopy andhydrotubation as the study group, and30women to be performed HSG as the control group correspondly at the same period. The mean (±SD) age in studygroup was30.37±0.68and28.53±0.84in control group, Duration of infertility2.98±0.31vs2.88±0.28, body mass index (BMI)23.20±0.76vs,22.55±0.57.Primary infertility was18women and12secondary infertility in study group,while21and9in control group.
2Method and indicator of the body stress response to THL withhysteroscopy and hydrotubation and HSG
Both groups’ average artery pressure (MAP), heart rate (HR), plasmaadrenocor ticotropic hormone (ACTH), noradrenaline (NA), angiotensin (AII),cortisol (Cor), insulin(INS), C reactive protein(CRP) and glucose (GLU) weremeasured respectively. The blood sample was obtained by a consecutive seriesof30patients of each group. We collected elbow vein blood3ml at three timesand rapidly put into the precooling vitro containing20ul EDTA, aftercentrifugal separated for5minutes at4°C, then the plasma was preserved in-20°C refrigerator to be measured. GLU was measured by glucose oxidasemethod and the other markers were used radioimmunoassay. Equipment wasmade by Siemens IMMULITE2000and reagent kit was provided by SiemensCompany.
3Method of VAS after the THL with hysteroscopy and hydrotubation andHSG
To evaluate the Tolerance of THL and HSG,60consecutive patients wereasked to score their most intense pain experience during THL and HSG on a10cm visual analog pain scale2hours after the operation. The VAS scoreswere from0(no pain, perfectly acceptable) to10(unbearable pain, completelyunacceptable).
Results:
1Comparison of the body stress response to THL with hysteroscopy andhydrotubation and HSG
In a consecutive series of30patients, plasma Cor in THL and HSG athalf hour before and after the surgery were187.78±19.74ng/ml and183.00±25.77ng/ml versus197.20±22.28ng/ml and201.05±22.41ng/ml respectively, which significantly increased after the both operations(p＜0.05),the others were no statistically significant (p＞0.05).
2The VAS scores
The VAS scores had statistically significant between two groups but wereboth lower (p＜0.05). The average pain score was1.73(SD±1.01) in THL andno women marked a score above5and2.47(SD±1.33) in HSG. Theappropriate anesthesia would reduce the pain and increase the tolerationduring the operation.
Conclusions:
1Our study has demonstrated that there was microtrauma to body byTHL with hysteroscopy and chromopertubation as same as HSG, it couldrecovered in24hours.
2The two groups VAS score were below the mild pain, and it wasaccepted better and tolerated both procedure.
引文
1Gordts S, Campo R, Rombauts L, et al. Transvaginal hydrolaparoscopy asan outpatient procedure for infertility investigation. Hum Reprod.1998Jan,13(1):99～103
2Gordts S, Watrelot A, Campo R, et al. Risk and outcome of bowel injuryduring transvaginal pelvic endoscopy.2001,76:1238～1241
3Darai E, Dessolle L, Lecuru F, et al. Transvaginal hydrolaparoscopycompared with laparoscopy for the evaluation of infertile women: aprospective comparative blind study. Hum Report.2000,15(11):2379～82.
4Fujiwara H, Shibahara H, Hirano Y, et al. Usefulness and prognostic valueof transvaginal hydrolaparoscopy in infertile women. Fertil Steril.2003Jan,79(1):186～9.
5Connez J, Casanas-Roux F. Prognostic factors of fimbrial micorsurgery.Fertil Steril,1986,46(1):200～204
6Mage G, Pouly JL, Bouquet de Joliniere J, et al. A preoperative classifica-rion to predict the intrauterine and cetopic pregnancy rates after distaltubal micorsurgery. Fertil Steril,1986,46(2):807～810
7乔杰.生殖医学临床诊疗常规.人民军医出版社.2013,6:57
8Shibahara H, Shimada K, Kikuchi K, et al. Major complications andoutcome of diagnostic and operative transvaginal hydrolaparoscopy. JObstet Gynecol Res.2007,33:705～709
9Stefanescu A, Marinescu B. Diagnostic hysteroscopy--a retrospectivestudy of1545cases. Maedica (Buchar).2012,7(4):309～14
10Dechaud H, Ali Ahmed S-A, Aligier N, et al. Does transvaginalhydrolaparoscopy render standard diagnostic laparoscopy obsolete forunexplained infertility investigation? Eur J Obstet Gynecol Reprod Biol，2001,94:97～102
11Nakagawa K, Ohgi S, Horikawa T, et al. Laparoscopy should be stronglyconsidered for examining women with unexplained infertility. J ObstetGynecol Res2007,33:665～70
12Fujiwara H, Shibahara H, Hirano Y, et al. Usefulness and prognostic valueof transvaginal hydrolaparoscopy in infertile women. Fertil Steril.2003,79(1):186～9
13van Tetering EA, Bongers MY, Wiegerinck MA, et al. Prognostic capacityof transvaginal hydrolaparoscopy to predict spontaneous pregnancy. HumReprod.2007,22(4):1091～4
1Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvicinflammatory disease and infertility. Obstet Gynecol,2012,120(1):37～43
2Zimmer M, Milnerowicz-Nabzdyk E, Rosner-Tenerowicz A, et al.Transvaginal hydrolaparoscopy for diagnosis of tubal infertility. NeuroEndocrinol Lett.2011,2(9),32～5
3Gocmen A, Atak T. Diagnostic laparoscopy findings in unexplainedinfertility cases. Clin Exp Obstet Gynecol.2012,39(4):452～3
4丰有吉,沈铿.妇产科学.人民卫生出版社.第2版.2010,7:451
5The American Fertility Society classification of adnexal adhesions, distaltube occlusion, tubal occlusion secondary to tubal ligation, tubalpregnancies, mullerian anomalies and intrauterine adhesion. Fertil Steril.1988,49(6):944～955
6孙爱军,黄坚,周远征等.子宫输卵管碘油造影和腹腔镜检查对盆腔粘连不孕诊治价值的探讨.中国实用妇科与产科杂志,2008.24(5):369～370.
7Muzii L, Sereni MI, Battista C, et al. Tubo-peritoneal factor of infertility:diagnosis and treatment. Clin Ter,2010,161(1):77～85.
8Robabeh M, Roozbeh T. Comparison of hysterosalpingography andlaparoscopy in infertile Iranian women with tubal factor. Ginekol Pol.2012,83(11):841～3.
9Mallarini G, Saba L, Role and applicati on of hysterosalpingography andFallopian tube recanalization. Minerva Ginecol,2010,62(6):541～549
10刘丹丹,马彩虹,乔杰.宫、腹腔镜联合诊治女性不孕症145例临床分析.中国微创外科杂志.2009,9(8):724～727
11Jonsdottir K, Lundorff P. Transvaginal hydrolaparoscopy: a new diagnostictool in infertility. Acta Obstet Gynecol Scand.2002,81(9):882～885
12Gocmen A, Atak T. Diagnostic laparoscopy findings in unexplainedinfertility cases. Clin Exp Obstet Gynecol.2012,39(4):452～3
13Schippert C, Soergel P, Staboulidou I. et al. The risk of ectopic pregnancyfollowing tubal reconstructive miCorsurgery and assisted reproductivetechnology procedures. Arch Gynecol Obstet.2012,285(3):863～71
14Fujiwara H, Shibahara H, Hirano Y, et al. Usefulness and prognostic valueof transvaginal hydrolaparoscopy in infertile women. Fertil Steril.2003.79(1):186～9.
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2Veenhof AA, Vlug MS, van der Pas MH, et al. Surgical stress responseand postoperative immune function after laparoscopy or open surgery withfast track or standard perioperative care: a randomized trial. Ann Surg.2012,255(2):216～21
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2Gordts S, Watrelot A, Campo R, et al. Risk and outcome of bowel injuryduring transvaginal pelvic endoscopy.2001,76:1238～1241
3Darai E, Dessolle L, Lecuru F, et al. Transvaginal hydrolaparoscopycompared with laparoscopy for the evaluation of infertile women: aprospective comparative blind study. Hum Report.2000,15(11):2379～82.
4Fujiwara H, Shibahara H, Hirano Y, et al. Usefulness and prognostic valueof transvaginal hydrolaparoscopy in infertile women. Fertil Steril.2003Jan,79(1):186～9.
5Connez J, Casanas-Roux F. Prognostic factors of fimbrial micorsurgery.Fertil Steril,1986,46(1):200～204
6Mage G, Pouly JL, Bouquet de Joliniere J, et al. A preoperative classifica-rion to predict the intrauterine and cetopic pregnancy rates after distaltubal micorsurgery. Fertil Steril,1986,46(2):807～810
7乔杰.生殖医学临床诊疗常规.人民军医出版社.2013,6:57
8Shibahara H, Shimada K, Kikuchi K, et al. Major complications andoutcome of diagnostic and operative transvaginal hydrolaparoscopy. JObstet Gynecol Res.2007,33:705～709
9Stefanescu A, Marinescu B. Diagnostic hysteroscopy--a retrospectivestudy of1545cases. Maedica (Buchar).2012,7(4):309～14
10Dechaud H, Ali Ahmed S-A, Aligier N, et al. Does transvaginalhydrolaparoscopy render standard diagnostic laparoscopy obsolete forunexplained infertility investigation? Eur J Obstet Gynecol Reprod Biol，2001,94:97～102
11Nakagawa K, Ohgi S, Horikawa T, et al. Laparoscopy should be stronglyconsidered for examining women with unexplained infertility. J ObstetGynecol Res2007,33:665～70
12Fujiwara H, Shibahara H, Hirano Y, et al. Usefulness and prognostic valueof transvaginal hydrolaparoscopy in infertile women. Fertil Steril.2003,79(1):186～9
13van Tetering EA, Bongers MY, Wiegerinck MA, et al. Prognostic capacityof transvaginal hydrolaparoscopy to predict spontaneous pregnancy. HumReprod.2007,22(4):1091～4
1Wiesenfeld HC, Hillier SL, Meyn LA, et al. Subclinical pelvicinflammatory disease and infertility. Obstet Gynecol,2012,120(1):37～43
2Zimmer M, Milnerowicz-Nabzdyk E, Rosner-Tenerowicz A, et al.Transvaginal hydrolaparoscopy for diagnosis of tubal infertility. NeuroEndocrinol Lett.2011,2(9),32～5
3Gocmen A, Atak T. Diagnostic laparoscopy findings in unexplainedinfertility cases. Clin Exp Obstet Gynecol.2012,39(4):452～3
4丰有吉,沈铿.妇产科学.人民卫生出版社.第2版.2010,7:451
5The American Fertility Society classification of adnexal adhesions, distaltube occlusion, tubal occlusion secondary to tubal ligation, tubalpregnancies, mullerian anomalies and intrauterine adhesion. Fertil Steril.1988,49(6):944～955
6孙爱军,黄坚,周远征等.子宫输卵管碘油造影和腹腔镜检查对盆腔粘连不孕诊治价值的探讨.中国实用妇科与产科杂志,2008.24(5):369～370.
7Muzii L, Sereni MI, Battista C, et al. Tubo-peritoneal factor of infertility:diagnosis and treatment. Clin Ter,2010,161(1):77～85.
8Robabeh M, Roozbeh T. Comparison of hysterosalpingography andlaparoscopy in infertile Iranian women with tubal factor. Ginekol Pol.2012,83(11):841～3.
9Mallarini G, Saba L, Role and applicati on of hysterosalpingography andFallopian tube recanalization. Minerva Ginecol,2010,62(6):541～549
10刘丹丹,马彩虹,乔杰.宫、腹腔镜联合诊治女性不孕症145例临床分析.中国微创外科杂志.2009,9(8):724～727
11Jonsdottir K, Lundorff P. Transvaginal hydrolaparoscopy: a new diagnostictool in infertility. Acta Obstet Gynecol Scand.2002,81(9):882～885
12Gocmen A, Atak T. Diagnostic laparoscopy findings in unexplainedinfertility cases. Clin Exp Obstet Gynecol.2012,39(4):452～3
13Schippert C, Soergel P, Staboulidou I. et al. The risk of ectopic pregnancyfollowing tubal reconstructive miCorsurgery and assisted reproductivetechnology procedures. Arch Gynecol Obstet.2012,285(3):863～71
14Fujiwara H, Shibahara H, Hirano Y, et al. Usefulness and prognostic valueof transvaginal hydrolaparoscopy in infertile women. Fertil Steril.2003.79(1):186～9.
1Azemati S, Savai M, Khosravi MB, et al. Combination of remifentanilwith isoflurane or propofol: effect on the surgical stress response. ActaAnaesthesiol Belg.2013,64(1):25～31
2Veenhof AA, Vlug MS, van der Pas MH, et al. Surgical stress responseand postoperative immune function after laparoscopy or open surgery withfast track or standard perioperative care: a randomized trial. Ann Surg.2012,255(2):216～21
3Hvizd' R, Krska Z, Kvasnicka J. Comparison of the overall stress duringlarge bowel operations in senior patients (laparoscopy versus opensurgery). Cas Lek Cesk.2012,151(4):201～7
4Marana E, Scambia G, Maussier ML, et al. Neuroendocrine stress responsein patients undergoing benign ovarian cyst surgery by laparoscopy,minilaparotomy, and laparotomy. J Am Assoc Gynecol Laparosc.2003,10(2):159～65
5Lattermann R, Schricker T, Wachter U, et al. Laparoscopic-assistedvaginal hysterectomy and the hyoerglycemic response to surgery. Anobservational study. Can J Anaesth.2001,48(9):871～875
6Bozkurt P, Kaya G, Altintas F, et al.Systemic stress response duringoperations for acute abdominal pain performed via laparoscopy orlaparotomy in children. Anaesthesia.2000,55(1):5～9
7Froghi F, Sodergren MH, Wright VJ, et al. Single-center experience insystemic stress and short-term morbidity of single-incisioncholecystectomy. Surg Innov.2012,19(2):117～22
8Cicinelli E, Matteo M, Causio F, et al. Tolerability of themini-pan-endoscopic approach (transvaginal hydrolaparoscopy andminihysteroscopy) versus hysterosalpingography in an outpatientinfertility investigation. Fertil Steril.2001,76(5):1048～1051
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