史精华;冷金花;李孟慧;贾双征;郎景和;
SHI Jing-hua,LENG Jin-hua,LI Meng-hui,JIA Shuang-zheng,LANG Jing-he Department of Obstetrics and Gynecology,Peking Union Medical College Hospital,Chinese Academy of MedicalSciences & Peking Union Medical College,Beijing 100730,China

• 1:中国医学科学院北京协和医学院北京协和医院妇产科

摘要(Abstract)：

目的探讨腹腔镜卵巢子宫内膜异位囊肿剔除手术对卵巢储备功能及生育的影响。方法 采用前瞻性对照研究,对照组为40例单侧卵巢成熟性囊性畸胎瘤及10例双侧卵巢成熟性囊性畸胎瘤行腹腔镜囊肿剔除术患者;试验组为126例卵巢子宫内膜异位囊肿腹腔镜囊肿(巧囊)剔除术患者,分为单侧巧囊<35岁(40例),单侧巧囊≥35岁(26例),双侧巧囊<35岁(41例)和双侧巧囊≥35岁(19例)4组。比较各组手术前、手术后24小时内以及手术后6个月血清卵泡刺激素(follicle stimulating hormone,FSH)和雌二醇(estradiol,E2)水平,术后6个月卵巢最大平面平均直径,并随访术后18个月妊娠结局。结果 双侧巧囊<35岁及≥35岁患者卵巢子宫内膜异位囊肿剔除术后24小时内FSH较术前明显增高(P<0.05),而E2明显减低(P<0.05)。而畸胎瘤对照患者及单侧巧囊<35岁及≥35岁患者手术前后各激素水平比较差异均无统计学意义(P(0.05)。双侧巧囊<35岁患者,术后6个月基础FSH恢复至正常范围者占77.8%,而双侧巧囊≥35岁患者中基础FSH恢复至正常范围者仅占53.3%,两组比较差异具有统计学意义(P<0.05)。术后6个月手术侧与未手术侧卵巢缩小率比较差异具有统计学意义(P<0.05)。术后18个月妊娠率非巧囊组(92.9%)明显高于巧囊组(45.2%)(P<0.05);单侧巧囊<35岁、单侧巧囊≥35岁、双侧巧囊<35岁及双侧巧囊≥35岁患者的妊娠率分别为60%、37.5%、46.2%和16.7%,各组比较差异具有显著意义(P<0.05),其中以双侧巧囊≥35岁患者的妊娠率最低。结论腹腔镜双侧卵巢子宫内膜异位囊肿剔除术对卵巢功能有一定程度的影响,但大部分年轻患者可以在术后6个月内恢复。对有生育要求的患者应注意围手术期卵巢功能的评估和卵巢的保护。
Objective To investigate the influence of laparoscopic ovarian cystectomy on ovarian reserve function and pregnantic outcome in women with ovarian endometriotic cyst.Methods A total of 176 women with ovarian cyst undergoing laparoscopic cystectomy were divided into six groups:40 patients with uni-lateral teratoma(con1),10 patients with bilateral teratoma(con2),40 patients with unilateral ovarian endometriotic cyst less than 35y(A),26 patients with unilateral ovarian endometriotic cyst no less than 35y(B),41 patients with bilateral ovarian endometriotic cyst less than 35y(C),and 19 patients with bilateral ovarian endometriotic cyst no less than 35y(D).Blood samples were obtained from patients before operation,24 hours after operation and on the second and third day of the menstrual cycle 6 months after operation.Mean ovarian diameter were evaluated by ultrasound 6 months after operation and pregnancy outcome was recorded in the following 18 months after the operation.Results In the bilateral groups(C and D),the serum level of follicle stimulating hormone(FSH)increased significantly after the operation(P<0.05),while estradiol decreased significantly(P<0.05).No significant difference between pre-and post-operational hormone levels were observed in the unilateral groups(A and B)and control group Serum basal FSH recovered to normal 6 months after the operation in 77.8% of patients in group C and 53.3% in group D(P<0.05).The reduction of mean ovarian diameter six months after operation was significantly different between the affected and contralateral ovaries(P<0.05).During the follow-up,the pregnancy rate was 92.9% in controlled group,compared to 45.2% in the endometriosis group(P<0.05)and 60%,37.5%,46.2%,and 16.7%,respectively,for group A,B,C,and D.Conclusion The ovarian reserve function decreases after laparoscopic ovarian cystectomy in women with ovarian endometriotic cyst.However,most young patients recover after 6 months.Peri-operative ovarian function assessment and ovarian protection should be carefully designed and performed for women who intend to get pregnant.

关键词(KeyWords)： 子宫内膜异位症;腹腔镜卵巢囊肿剔除术;卵巢储备功能;妊娠结局
endometriosis;laparoscopic cystectomy;ovarian reserve function;pregnantic outcome

Abstract:

Keywords:

基金项目(Foundation): 国家自然科学基金(NSFC30950020)

作者(Author): 史精华;冷金花;李孟慧;贾双征;郎景和;
SHI Jing-hua,LENG Jin-hua,LI Meng-hui,JIA Shuang-zheng,LANG Jing-he Department of Obstetrics and Gynecology,Peking Union Medical College Hospital,Chinese Academy of MedicalSciences & Peking Union Medical College,Beijing 100730,China

Email:

DOI:

参考文献(References)：

• [1]冷金花,郎景和.腹腔镜手术治疗子宫内膜异位症[J].中国实用妇科与产科杂志,2003,19:660.
• [2]Busacca M,Vignali M.Ovarian endometriosis:from patho-genesis to surgical treatment[J].Curr Opin Obstet Gyne-col,2003,15:321-326.
• [3]Whiteside JL,Keup HL.Laparoscopic managementof the o-varian mass:a practical approach[J].Clin Obstet Gyne-col,2009,52:327-334.
• [4]李晓燕,冷金花,郎景和,等.卵巢子宫内膜异位囊肿黏连程度与临床表现、手术效果和术后复发关系的研究[J].中华妇产科杂志,2009,44:328-332.
• [5]王艳艳,冷金花.卵巢子宫内膜异位囊肿剔除手术对卵巢储备功能的影响[J].中国实用妇科与产科杂志,2007,23:806-808.
• [6]王艳艳,冷金花,郎景和,等.腹腔镜双侧卵巢子宫内膜异位囊肿剔除术后卵巢功能早衰—病例报道并文献复习[J].中华妇产科杂志,2007,42:774-776.
• [7]Hart RJ,Hickey M,Maouris P,et al.Excisional surgery versus ablative surgery for ovarian Endometriomata:a Co-chrane Review.[J].Hum Reprod,2005,20:3000-3007.
• [8]Miro F,Parker SW,Aspinall LJ,et al.Sequential classifi-cation of endocrine stages during reproductive aging in women:the FREEDOM study[J].Menopause,2005,12:281-290.
• [9]孙瑜,朱依敏.促性腺激素释放激素拮抗剂方案在有卵巢低反应风险患者中的应用价值[J].浙江大学学报,2009,38:305-310.
• [10]Frattarelli JL,Levi AJ,Miller BT.A prospective novel method of determining ovarian size during in vitro fertilization cycles[J].J Assist Reprod Genet,2002,19:39-41.
• [11]张惜阴.实用妇产科学[M].北京:人民卫生出版社,2003:745-749.
• [12]The Practice Committee of the American Society for Repro-ductive Medicine.Endometriosis and infertility[J].Fertil Steril,2004,82(Suppl1):40-45.
• [13]陈燕.子宫内膜异位症相关不孕病因病理与临床治疗文献综述[J].中国实用医药,2010,5:244-245.
• [14]Shebl O,Ebner T,Sommergruber M,et al.Antimuellerian hormone serum levels in women with endometriosis:a case-control study[J].Gynecol Endocrinol,2009,25:713-716.
• [15]李晓燕,冷金花,郎景和,等.不同类型卵巢子宫内膜异位囊肿临床特点及疗效分析[J].中国实用妇科与产科杂志,2009,25:124-127.
• [16]Muzii L,Bianchi A,Bellati F,et al.Histologic analysis of endometriomas:whatthe surgeon needs to know[J].Fertil Steril,2007,87:362-366.
• [17]Garcia-Velasco JA,Mahutte NG,Corona J,etal.Removal of endometriomas before in vitro fertilization does not improve fertility outcomes:a matched,case-control study[J].Fertil Steril,2004,81:1194-1197.
• [18]Kahyaoglu S,Ertas E,Kahyaoglu I,etal.Does laparoscop-ic cystectomy and cauterization of endometriomas greater than3cm diminish ovarian response to controlled ovarian hyperstimulation during IVF-ET Acase-control study[J].J Obstet Gynaecol Res,2008,34:1010-1013.
• [19]Horikawa T,Nakagawa K,Ohgi S,et al.The frequency of ovulation from the affected ovary decreases following laparo-scopic cystectomy in infertile women with unilateral endom-etrioma during a natural cycle[J].J Assist Reprod Genet,2008,25:239-244.