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[专业资源] 卵巢钻孔

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发表于 2019-1-2 00:01:26 | 显示全部楼层 |阅读模式
卵巢钻孔,也称为多孔或腹腔镜卵巢透热疗法,是一种使用微创腹腔镜手术用激光束或手术针刺破卵巢周围的膜的手术技术。[1]它不同于卵巢楔形切除,因为切除涉及切割组织。微创卵巢钻孔手术取代了楔形切除术。[2]卵巢钻孔优于楔形切除术,因为切入卵巢会导致粘连,这可能使术后结果复杂化。[3]卵巢钻孔和卵巢楔形切除是减少多囊卵巢综合征(PCOS)女性产生雄激素组织量的治疗选择。[4] PCOS是无排卵的主要原因,导致女性不孕。[5]单排卵周期的诱导可以恢复生育能力。[6]

腹腔镜卵巢钻孔(LOD)可以提高其他促排卵治疗的效果,并且与其他治疗方案如促性腺激素相比,可以降低多胎妊娠率[7]。口服药物克罗米芬柠檬酸盐(CC)是PCOS的一线治疗药物,然而,五分之一的女性对药物有抗药性并且不能排卵。[8]如果治疗以适当的剂量治疗失败6个月,患者被认为是耐药的。[1]卵巢钻孔是CC治疗的外科替代方案,或推荐用于WHO II组排卵障碍的女性。[6]治疗PCOS的其他非手术医疗选择包括雌激素受体调节剂,他莫昔芬,芳香酶抑制剂,胰岛素增敏药物和激素卵巢刺激。[9]外科手术的有效性类似于PC或PCOS患者诱导排卵的CC或促性腺激素治疗,但无论该技术是单侧还是双侧进行,每次持续妊娠的多胎妊娠都会减少。[10]

如果患者在卵巢钻孔治疗重建后6个月没有怀孕,可以重新引入药物治疗或考虑体外受精(IVF)。[1]

目录
1 荷尔蒙效应
2 程序
3 风险
4 优势
5 历史
6 参考

荷尔蒙效应
PCOS诊断的部分标准包括血流中雄激素水平升高或雄激素过量的其他迹象(雄激素过多症)。[1]该程序导致血清雄激素水平下降,并可能导致雌激素水平下降。[5]卵巢卵泡和基质被破坏后,这些激素水平会降低。[11]该方法导致血浆促黄体激素(LH)和脉动减少以及抑制素B水平的周期性下降[1]。最合理的理论认为,这些激素浓度的降低会导致卵泡刺激素(FSH)和性激素结合球蛋白的分泌增加,导致有效的卵泡成熟和排卵。[5] [1]血清雌二醇浓度低与芳香化酶活性降低有关[1]。由于损伤会产生炎症性生长因子,如胰岛素样生长因子-1,并通过更大的血流量和促性腺激素释放来帮助FSH的作用。[11]在PCOS女性腹腔镜卵巢钻孔术后,循环和滤泡内水平的抗苗勒管激素(AMH)可以帮助量化可招募的卵巢卵泡活动。[12]

程序
当临床医生确定卵巢钻孔是合适的并且该妇女决定进行该治疗时,获得同意。风险传达给妇女。[13]

最常用的方法是使用单极针或钩,因为设备的可用性和简单的安装。[6]其他常见的仪器包括使用双极电手术电极或CO2,氩或ND-YAG激光。[14]该仪器能够以非常集中的方法产生预期的结果。通常,首先使用100 W电烧灼器解剖器穿过卵巢皮质,然后以40 W进行电凝,但速率范围为30至400 W. [1]手术穿刺在卵巢皮质上进行,通常深4-10毫米,宽3毫米[10] [11]。穿刺次数与随后的受孕能力有关 - 已发现五到十次穿刺更有可能产生预期的受孕。[13]卵巢钻孔是通过腹腔镜进行的,可以是经脐(穹窿)或经阴道(肥大)。[1]

风险
卵巢钻孔虽然比在卵巢上形成切口更可取,但确实存在一些风险。这些是:盆腔粘连形成,出血,气体栓塞,气,卵巢早衰,长期卵巢功能,发展过度刺激综合征,粘连形成,不孕和多胎。[2] [13] [6] [15]经阴道水力腹腔镜(THL)卵巢钻孔可以最大限度地降低医源性粘连形成和卵巢储备(DOR)的风险,这可能会影响生育能力。[16] LOD不会导致卵巢储备减少的风险。[12]垄断电流存在电气事故风险。[1] LOD罕见的并发症是主要的血管损伤,主要是在手术开始时插入Veress针和套管针时,前腹壁的小血管。[15]

好处
卵巢钻孔术具有较低的卵巢过度刺激综合征和多胎妊娠率[17] [7]。该方法的优点还包括其单一治疗,而不是几项排卵诱导试验。[2]该技术的其他好处包括成本效益,并且可以作为门诊手术进行。[6]

历史
卵巢钻孔术于1984年首次用于治疗PCOS,并已发展成为一种安全有效的手术。[11] 在1984年对CC耐药患者进行腹腔镜电外科卵巢钻孔后,Gjönnaess发现这种技术将排卵率提高到45%,妊娠率提高到42%。[18] 1988年,腹腔镜多次穿刺切除下丘脑 - 垂体轴上的卵巢,略微改变了Gjönnaess的手术,导致PCOS治疗中LH搏动和垂体反应性降低[19]。 1989年,用氩气,二氧化碳(CO2)或磷酸钾 - 钾(KTP)激光蒸发进行卵巢钻孔,导致71%的患者自发排卵。[14] 该方法已在CC耐药患者的治疗中得到修改和推广[11]。

参考
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Portuondo, J. A.; Melchor, J. C.; Neyro, J. L.; Alegre, A. (1984-07-01). "Periovarian adhesions following ovarian wedge resection or laparoscopic biopsy". Endoscopy. 16 (4): 143–145. doi:10.1055/s-2007-1018560. ISSN 0013-726X. PMID 6236073.
Ndefo, Uche Anadu; Eaton, Angie; Green, Monica Robinson (2013-06-01). "Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches". P & T: A Peer-Reviewed Journal for Formulary Management. 38 (6): 336–355. ISSN 1052-1372. PMC 3737989. PMID 23946629.
Hueb, Cristina Kallás; Dias Júnior, João Antônio; Abrão, Maurício Simões; Filho, Elias Kallás (2015-11-01). "Drilling: medical indications and surgical technique". Revista Da Associacao Medica Brasileira (1992). 61 (6): 530–535. doi:10.1590/1806-9282.61.06.530. ISSN 1806-9282. PMID 26841163.
Lebbi, Issam; Ben Temime, Riadh; Fadhlaoui, Anis; Feki, Anis (2015-01-01). "Ovarian Drilling in PCOS: Is it Really Useful?". Frontiers in Surgery. 2: 30. doi:10.3389/fsurg.2015.00030. PMC 4505069. PMID 26236709.
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Moazami Goudarzi, Zahra; Fallahzadeh, Hossein; Aflatoonian, Abbas; Mirzaei, Masoud (2014-08-01). "Laparoscopic ovarian electrocautery versus gonadotropin therapy in infertile women with clomiphene citrate-resistant polycystic ovary syndrome: A systematic review and meta-analysis". Iranian Journal of Reproductive Medicine. 12 (8): 531–538. ISSN 1680-6433. PMC 4233311. PMID 25408702.
Wang, Rui; Kim, Bobae V.; Wely, Madelon van; Johnson, Neil P.; Costello, Michael F.; Zhang, Hanwang; Ng, Ernest Hung Yu; Legro, Richard S.; Bhattacharya, Siladitya (2017-01-31). "Treatment strategies for women with WHO group II anovulation: systematic review and network meta-analysis". BMJ. 356: j138. doi:10.1136/bmj.j138. ISSN 0959-8138. PMC 5421445. PMID 28143834.
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