| [Background and Objective]Infertility refers to the biological inability of a person to contribute to conception especially when the person has normal sexual life and does not take contraception measures after marriage during two years of cohabitation. The case in which the woman is never pregnant is called primary infertility, while it is secondary infertility if the woman was once pregnant and then could not produce offspring、For a normal couple who are willing to have babies,85%of them have a successful conception within one year after marriage、Therefore, the situation in which one has normal sexual life for one year without contraception measures and cannot yet have successful pregnancy is diagnosed as infertility. According to statistics, among Chinese women of child-bearing age, about10%-15%have infertility、Based on the survey, woman’s factors take up40-55%, man’s factors account for25-30%, both man and woman’s factors occupy20-30%, and there are not clear causes in10%of infertility. Woman’s factors conclude to four major categories:oviduct factor, uterus factor, endocrine factor, vulvar and vaginal factors. Oviduct disease is the most common cause for women’s infertility, accounting for25%-35%. It plays an important role in the treatment of infertility that oviducts have no obstruction and sound function. Oviduct obstruction occupies a large proportion in the tubal infertility. What’s more, the incidence of oviduct obstruction tends to rise due to changes of people’s lifestyle and the environment. In a word, precise diagnosis of tubal patency is significant for infertile patients.The methods for diagnosis of oviduct infertility include:1) Tubal insufflation and hydrotubation. Both techniques belong to blind operations and have poor accuracy. Moreover, these tests aim at tubal patency and do not have obvious diagnostic significance for uterine cavity lesions, simply serving as early screening approach for tubal patency、2) Hysterosalpingography (HSG、Although HSG is simple and rapid with low cost and the diagnosis is explicit, leading to a clear understanding of tubal blocking location and internal condition, the false-positive rate is quite high mainly because of fallopian tube convulsion and inequality of bilateral uterine pressure、3) Laparoscopic infusion of methylene blue solution、 This operation is accurate and straightforward, possessing high specificity and sensitivity for diagnosis of oviduct infertility、Currently it belongs to the gold standard, but it has not been widespread in basic-level hospitals since it is an invasive procedure with high charges and equipment requirements、Uterine factor accounts for10%in infertile women、Cervical status and cervical mucus morphology directly influence sperms moving into the uterus、The uterus has such functions as storing and transporting sperms, receiving fertilized eggs and nourishing fetus, so the cervix and uterus have important reproductive functions、If patients suffer from endometrial polyps or submucous fibroid tumors which would affect implantation of zygotes, abortion may occur、The diagnoses of uterine cavity diseases mainly rely on abdominal or vaginal ultrasonography、Uterine acoustic imaging (sonohysterography, SHG) is a specialized procedure by which contrast medium is delivered into the uterine cavity to enhance the acoustic impedance among tissues and dilate the uterine cavity, so that ultrasonic imaging is achieved and diagnosis is made、Uterine acoustic imaging can not only examine tubal patency accurately, but also observe intrauterine space-occupying lesions conveniently in the expanded uterus、At the same time adhesion may be separated and inflammation can be treated、The quality of acoustic contrast agents and ultrasonic imaging technology are two crucial factors affecting the accuracy of SHG and determining SHG effects、With the rapid development of acoustic equipments, ultrasonography has gained new applications in the field of uterine acoustic imaging, evolving from abdominal type B ultrasonography to vaginal type B ultrasonography, from black-white to color Doppler There are two kinds of ultrasonic contrast agents in clinic One is negative contrast agent which does not show image under type B ultrasound, including normal saline and5%glucose%They are cheap and have no side-effects, neither do they interfere with imaging effect of intrauterine pathology、The other is positive contrast agent with strong echoes, for example, hydrogen peroxide, carbon dioxide foaming agent, carbamide peroxide, hand-shake microbubbles, acoustic shock microbubbles, Echovist, Levovist and so on、The positive contrast agent used in acoustics has undergone three generations、The first generation product is represented by Levovist; the second generation contains macromolecular inert gas, represented by SonoVue; and the third generation contrast agent is under development、The present study chose the mixed liquid of physiological saline, lidocaine, gentamycin, and dexamethasone as contrast agent、With regard to ultrasonic imaging technique, transvaginal type B ultrasonography was combined with CDFI (color Doppler flow imaging) to inject mixed solution into the uterine cavity、The hemodynamic state was simulated through extracorporal pressure、When the contrast agent was flowing along the uterine cavity, fallopian tubes into the abdomen, a color signal was shown to move towards one direction on color Doppler ultrasonogram, which was used to judge the tubal patency%The present study considered laparoscopic circulation of methylene blue solution as gold standard, discussing accuracy, sensitivity, and specificity of TSSG in tubal patency test and assessing diagnostic values of TSSG in tubal infertility、[Methods] 1Clinical data:data of cases:From October2010to September2011, a total of142infertile patients (280fallopian tubes) underwent color Doppler sonohysterography to test tubal patency, four patients of whom were excised unilateral oviduct due to ectopic pregnancy. There were70cases (49.2%) of primary infertility and72cases (50.7%) with secondary infertility. Patients with secondary infertility had medical history of artificial abortion or drug-induced abortion or ectopic pregnancy, the age of whom was (28.86±4.51) years old. Their infertility lasted for (2.34±1.80) years. The frequency of gestation was (0.88±1.18) times and that of giving birth was (0.25±0.46) time. All of the patients received hydrotubation under the monitoring of transvaginal type B color Doppler ultrasonography, among whom25cases (49fallopian tubes, including1patient who had unilateral oviduct owing to ectopic pregnancy) had laparoscopic infusion of methylene blue solution.2. Surgical method2.1After conventional disinfection, the uterine cervix was disinfected and hydrotubation pipe was inserted into the cervix. The liquid of2-3ml was injected into the balloon and overflow of contrast agent was avoided. A mixed solution had been made consisting of50-150ml physiological saline,5ml lidocaine,80000U gentamycin, and then it was injected into the hydrotubation pipe in a velocity of1.5-2.0ml per second. The resistance was felt and it was observed whether the flow of contrast agent was smooth in the oviduct through the vaginal type B ultrasonography, whether color Doppler had signals, whether the same amount of liquid appeared in the pelvic cavity, and whether there were intrauterine lesions in the dilated uterus.3.Method of laparoscopic infusion of methylene blue solution2.1Pelvic detection. If there were pelvic adhesion, ovarian cyst, uterine fibroids, endometriosis or other pelvic lesions, they should be dealt with by separating adhesion, removing cysts or leiomyomas (Note that fibroids must be removed after hysteroscopy check in case of perforation of the uterus), and electrocoagulating endometriosis foci、If the adhesion or hydrops occurred around fallopian tubes and fimbriae, proper operations should be performed to restore the normal position of oviducts and anatomical relationship with peripheral tissues, thus normal fimbriae structure being fully exposed、2.2Methylene blue solution (20ml) was injected smoothly without obstruction、 If it was observed that the solution flew out from the tube fimbria, the fallopian tube was patent (+)、If there was certain resistance when methylene blue solution was injected, the pressure was increased and20-50ml solution was injected、As a result, the fallopian tube was slightly swollen, dyed blue, and a little methylene blue solution flew from the tube fimbria slowly、This indicated that the tube was partly patent (±)、If there was great resistance and reflux, no liquid flowing out of the tube fimbria, and the proximal end of obstructing site was dilated, dyed blue or pale, it was tubal obstruction (-)、4Postoperative management、Usually patients were given antibiotics for three days after TSSG to prevent infection、Sexual behavior and vaginal irrigation were banned for14days、[Results]1. A total of142patients were successfully carried out sonohysterography. Altogether there were280fallopian tubes (four patients were excised unilateral oviduct due to ectopic pregnancy).Among these cases, there were137patent fallopian tubes, accounting for48.92%;65fallopian tubes (23.21%) were blocked (5tubes with obvious hydrops,1.78%);78fallopian tubes were partly blocked, accounting for27.85%、2. Twenty-five patients had no complications after laparoscopic detection、A total of25patients had49fallopian tubes (One patient was once excised a oviduct because of ectopic pregnancy)、By TSSG diagnosis20fallopian tubes were partly obstructed, while through laparoscopic hydrotubation of methylene blue solution17tubes were suggested to be partly obstructed and3tubes were patent; By TSSG diagnosis15fallopian tubes were blocked, whereas through laparoscopic hydrotubation of methylene blue solution two tube was partly blocked, one tube was patent, the remaining tubes were all blocked; besides, by TSSG diagnosis14fallopian tubes were patent, and laparoscopic hydrotubation of methylene blue solution showed same results、Supposing laparoscopic hydrotubation of methylene blue solution was gold standard, the sensitivity of TSSG diagnosis for tubal patency, Sensitivity, specificity, positive predicted value, negative predicted value were77.8%,100%,100%,88.9%, respectively、In addition,4cases of uterine polyps and3cases of intrauterine adhesions were found and proved by hysteroscopy and pathological examination、3. By means of statistical test (chi-square test), Kappa=0.709, P<0.05there was no significant difference between TSSG and laparoscopic hydrotubation of methylene blue solution、[Discussion]The birth of TSSG and its continuous improvement in technology has provided a new approach for clinical diagnosis of infertility、The present study adopted mixed liquid of physiological saline, lidocaine, gentamycin and dexamethasone that was capable of curing slight adhesions of fallopian tube、Combined with CDFI, the signal could be observed directly that indicated the mixed liquid passing through the fallopian tube、This study was a retrospective test, in which25infertile patients underwent TSSG and laparoscopic hydrotubation of methylene blue solution respectively、If laparoscopic hydrotubation of methylene blue solution was regarded as gold standard, results showed that the sensitivity of TSSG diagnosis for tubal patency,, sensensitive, specificity, positive predicted value and negative predicted value were77.8%,100%,100%,88.9%, respectively、The results of this clinical trial were consistent with those of domestic and foreign studies, confirming the high application values of TSSG diagnosis for tubal patency、Through laparoscopic hydrotubation of methylene blue solution, the uterine cavity can be observed under direct view with advantages of being accurate and straightforward, so it is recognized as one of gold standards for clinical diagnosis of tubal patency、By comparison between results of TSSG and results of laparoscopy, it proved that there was no statistically significant difference between transvaginal TSSG diagnosis and laparoscopy、Moreover, there are such advantages as simple materials, safe operation, easy handling, and low cost, which make TSSG technology possess high value of application and popularization、 Therefore, TSSG can be a first-choice examination for diagnosing tubal patency since it may exclude space-occupying lesion factor for infertility, which laparoscopy is not able to do、... |
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