RU2472425C2 - Method of estimating uterine tube patency - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to diagnostics. In order to estimate uterine tube patency chromosalpingoscopy during laparoscopy and visual assessment of uterine tube state and patency are performed. During chromosalpingoscopy determined are: rate of liquid dye passage along uterine tube, type of outflowing liquid dye and degree of uterine tube patency. Uterine tube patency is determined by point system: 5 points - liquid enters pelvis minor by tube 1-3 seconds after introduction by free wide flow through free fimbriae; 4 points - liquid enters pelvis minor after 2-5 seconds in form of stream; 3 points - liquid enters pelvis minor with 5-10 second delay, and uterine tube considerably expands and liquid is released in fast large drops; 2 points - liquid is released in slow drops after considerable delay or dye reintroduction; 1 point - liquid soaks through fimbrial part of tube; 0 points - liquid does not enter pelvis minor at all, fimbrial part of tube is not formed, expressed adhesive process is observed.

EFFECT: method increases accuracy of diagnostics due to quantitative estimation of degree of uterine tube patency.

4 ex

Description

The present invention relates to medicine, namely to diagnosis, and can be used in gynecology to quantify the degree of patency of the fallopian tube.

The ability to assess the patency of the fallopian tubes is an important problem for the doctor in the process of examining a patient with infertility. A number of pathological processes in the genital area (inflammation, adhesions, infantilism, tumors) can disrupt the permeability of the fallopian tube and create an obstacle to conception or to advance an already fertilized egg through the tube into the uterine cavity. In the latter case, there is a possibility of tubal pregnancy, which also applies to serious disorders of reproductive function.

Currently, the following methods are used to assess patency of the fallopian tubes.

Hysterosalpingography (GHA) is an X-ray examination in which a radiopaque substance is injected through the cervix into the uterine cavity, allowing you to visualize the internal shape of the uterus and fallopian tubes. During hysterosalpingography, a radiopaque fluid fills the uterus and moves further into the tubes. Of the undoubted advantages of the method, it is necessary to note the possibility of documenting - taking pictures. (Duda V.I., Duda I.V. Gynecology, 2nd ed., Stereotype. - M .: ACT, Mn .: Harvest, 2005 - p. 28)

GHA allows you to diagnose obstruction of the fallopian tubes with accurate localization and to determine indirect signs of an adhesive process in the small pelvis. Pathological changes in the tube, such as the hydrosalpinx (irreversibly modified, enlarged, fluid-filled fallopian tube), can also be detected during GHA. If the fallopian tubes are freely passable, the contrast fluid during hysterosalpingography goes into the abdominal cavity.

However, this fact does not guarantee that the ciliary epithelium of the tubes functions normally. GHA only allows you to assess whether the fallopian tubes are passable or not, without an accurate assessment of the degree of patency. GHA is associated with the need to irradiate the gonads, and can cause spasmodic pain in the patient. In addition, this method has up to 20% false results due to a possible spasm of the tube, which may be mistaken for its obstruction and affect further tactics and prognosis. The known method requires medical preparation with antispasmodics, sedatives. If the obstruction of the tubes is clearly visible on the radiographs, and pregnancy, despite treatment, does not occur, the repetition of the images is completely meaningless.

There is a method of assessing the patency of the fallopian tubes using ultrasound (ultrasound) - sonohysterosalpingoscopy (SSSS).

This procedure is similar to GHA, but it is more gentle, since there is no irradiation of the pelvic organs, in particular, the ovaries. Instead of a radiopaque substance, a sterile inert solution is injected into the uterine cavity, which enters the fallopian tubes and, in the presence of their patency, enters the abdominal cavity, which is visualized during the U3 study. (Ryazantsev A.A. Echographic and laparoscopic assessment of patency of the fallopian tubes // Abstracts of the III Congress of the Russian Association of Specialists in Ultrasound Diagnostics in Medicine. - M., 1999. - P.19.)

However, the known method is less reliable compared to GHA, since the resolution of the ultrasound apparatus is much lower than the resolution of the x-ray apparatus. The assessment is carried out in real time, therefore it is quite subjective and can only indicate the fact of fluid entering through the tubes into the pelvic cavity, but it does not allow us to characterize the anatomical features of the tube itself and the dynamics of fluid movement through it. In addition, there are problems with the documentation of this diagnostic procedure, you have to focus only on the protocol and subjective assessment of the doctor who conducted the study.

For the prototype of the invention, a well-known method for assessing the patency of the fallopian tubes was selected, including performing chromosalpingoscopy during laparoscopy and a visual assessment of the condition of the fallopian tubes (see L.V.Dubnitskaya D.N. Bakanova T.A. Nazarenko // Reproduction Problems, No. 1, 2006, pp. 11-14. Diagnostic value of transvaginal hydrolaparoscopy in the examination of patients with infertility.).

Chromosalpingoscopy (CSU) is a method for determining the patency of the fallopian tubes during laparoscopic surgery. A known method is to visually control the flow of inert dye through the fallopian tubes into the pelvic cavity. The advantages of the method include the ability to inspect and determine the anatomical features of the tube, the presence of an adhesion process and a number of other changes that may not be found in other studies (endometriosis, developmental abnormalities, etc.).

However, the generally accepted CSU allows us to establish the fact that the tube is passable for a liquid dye, since the fluid is poured into the pelvic cavity. This does not take into account the fact that even if the pipe is passable for a liquid medium, it is far from always possible to freely move a fertilized egg through it.

It is very important to be able not only to qualitatively assess the patency of the fallopian tube for a liquid dye used for diagnostic purposes, but also to quantify the patency of the fallopian tube, which allows the doctor to give a prognosis of the restoration of fertility in this patient and adequate recommendations for further treatment.

The task of the invention is to increase the accuracy of diagnosis by providing a quantitative assessment of the degree of patency of the fallopian tubes, determining treatment tactics, and providing the ability to predict the restoration of fertility.

The problem is solved in that in the known method for evaluating the patency of the fallopian tube, including performing chromosalpingoscopy during laparoscopy and a visual assessment of the condition and patency of the fallopian tube, when performing chromosalpingoscopy, the rate of passage of the liquid dye through the fallopian tube, and the nature of the resulting liquid dye and the degree of patency of the fallopian pipes are evaluated by a point system, where:

5 points - the fluid enters the small pelvis through the pipe 1-3 seconds after injection in a free wide flow through the free fimbriae;

4 points - the liquid enters after 2-5 seconds with a stream;

3 points - the liquid arrives with a delay of 5-10 seconds, while the pipe is significantly inflated and the liquid is released by large rapid drops;

2 points - the liquid is released in slow drops after a significant delay or re-introduction of the liquid dye;

1 point - the fluid flows through the fimbrial section of the pipe;

0 points - the fluid does not enter the pelvic cavity at all, the fimbrial part of the tube is not formed, a marked adhesion process is noted.

The present invention meets the criteria of “novelty” and “inventive step”, since when conducting patent information research, sources of scientific, technical and patent literature that would discredit the novelty of the invention, as well as technical solutions with essential features of the proposed method, were not identified

The present invention provides when using the following technical effect.

The method provides a quantitative assessment of the patency of the fallopian tubes, that is, it allows you to assess the degree of patency of the fallopian tubes, which in turn will differentiate the choice of tactics for the treatment of infertility. The method allows to judge the feasibility of preserving each of the fallopian tubes during the operation and the prospects for restoring the reproductive function of the patient, as well as timely determining indications for assisted reproductive technologies (IVF and PE). This is especially true in patients with a long history of infertility, as well as with the presence of aggravating factors (age, concomitant pathology, previously inadequate treatment, repeated surgical interventions on the pelvic organs, etc.).

The proposed method is tested on the basis of the regional clinical hospital. N.A.Semashko, Nizhny Novgorod. A total of 300 patients were examined, of which 10% of patients had a score of 4-5 points, 40% received 3-4 points, 50% received a score of 0-2 points. Of the total number of patients who received 4-5 points (10%), pregnancy occurred in 40%, and in patients who received 3-4 points, pregnancy occurred in 15% of patients.

The research results showed that when assessing the degree of patency of the fallopian tubes by: 4-5 points, the patient has a good prognosis in terms of the implementation of the reproductive function;

when assessing the degree of patency by 2-3 points, a plastic tube according to Bruis, salpingolysis is required, in general, the forecast is favorable;

when assessing the degree of patency of 1-2 points, neosalpingostomy, plastic surgery, a dubious prognosis are required;

when assessed at 0 points, the pipe is functionally inferior, the changes are deep, the interventions on the pipes are unpromising. Indications for pipe removal to prepare for IVF and PE.

The proposed method is as follows.

The patient undergoes a standard examination and preparation before laparoscopy for infertility, informed consent is given to the intervention. After adequate anesthesia with transcervical access, a system is installed for introducing an inert liquid dye through the uterine cavity into the fallopian tubes during the operation. Laparoscopic intervention is performed under anesthesia in the position of the patient according to Trendelenburg. After a visual audit of the abdominal cavity and pelvic organs, a liquid dye is injected through the installed system into the uterine cavity, calculated on its entry through the fallopian tubes into the abdominal cavity (CSU). At this time, the surgeon, using a laparoscope, assesses the structural features of the fallopian tubes, establishes the fact of the presence of fluid in the tubes, and then through the tubes into the pelvic cavity. The degree of patency of the fallopian tubes is assessed in points, fixing the rate of advancement of the liquid dye through the tubes from the moment of its introduction and the nature of the outflowing fluid. Patency of the fallopian tube is estimated at 5 points if the liquid dye enters the small pelvis through the tube 1-3 seconds after the introduction of a free wide stream through the free fimbriae. When fluid enters the small pelvis after 2-5 seconds, the patency of the fallopian tube is estimated at 4 points. If the fluid arrives with a delay of 5-10 seconds after its introduction, while the tube is significantly swollen and the fluid is released by large rapid drops, the patency of the fallopian tube is estimated at 3 points. When liquid is released in slow drops after a significant delay or the repeated introduction of a liquid dye, patency of the fallopian tube is estimated at 2 points. If the liquid dye only flows through the fimbrial section of the tube, its permeability is estimated at 1 point. 0 points - the fluid does not enter the pelvic cavity at all, the fimbrial part of the tube is not formed, a marked adhesion process is noted.

Examples of specific performance are given in the form of extracts from the medical history. Example 1

Patient P., 29 years old, was inpatient treatment at the gynecological clinic of the NKB them. Semashko from 11/19 to 11/26/2010 with DZ: Chronic bilateral adnexitis. Adhesive process of the pelvis. Infertility 1 of mixed genesis. External genital endometriosis.

Upon receipt of a complaint of periodic aching pains in the lower abdomen, pain during sexual intercourse, absence of pregnancy for 10 years. A history of repeated anti-inflammatory therapy, ureaplasma infection, surgery for a cyst of the right ovary. Menses from 11 years, 3-4 days, regular, after 28 days.

With an objective examination, the appendages are rigid, their area is heavy.

Operation protocol. Laparoscopy with CSU, dissection of adhesions, neosalpingostomy on the right, removal of the tube on the left.

Laparocentesis through the navel. Pneumoperitoneum 3000 ml CO ₂ . 3 additional trocars into the abdominal cavity. Liver, intestinal loops, stomach - without features, omentum soldered to the anterior abdominal wall. In the pelvis 10 ml of serous-hemorrhagic fluid.

The uterus is 48 * 42 * 32 mm, pear-shaped, pink in color. On the peritoneum of the sacro-uterine ligaments - small foci of endometriosis. The right ovary is represented by a fragment of 1 * 1.5 cm, there is a hemorrhagic cyst in its lower pole, size. 1 * 0.8 cm. The right fallopian tube about 10 cm long, crimped, there are adhesions with the ovary, the fimbrial region is not expressed, it is sealed.

The left ovary contains the corpus luteum, is in adhesions with the tube. The left fallopian tube is sharply thickened, twisted, scarred, contains constrictions along the surface, fimbriae are soldered.

Conclusion: chronic bilateral salpingitis with the presence of hydrosalpinx on the left. External genital endometriosis. Hemorrhagic cyst on the right. Cicatricial adhesion process of the abdominal cavity.

Interventions: dissection of adhesions, coagulation of foci of endometriosis, CSU - the right fallopian tube is passable by 2 points (the fluid is released by slow drops after a significant delay), the left tube is impassable, the fluid does not enter the small pelvis (0 points). Neosalpingostomy on the right - with CSU, the fluid enters after 2-5 seconds with a stream (patency of the fallopian tube 4 points). On the left, an attempt was made for a neosalpingostomy - unsuccessful, the left fallopian tube removed.

After surgery, ceftriaxone 1.0 V / V twice, ketonal 2 ml V / m.

Discharged on the 3rd day after the operation, removal of sutures on the 7-8th day, pregnancy planning is recommended.

Example 2

Patient G., 35 years old, was inpatient treatment at the gynecological clinic of the NKB them. Semashko from 11/17 to 11/23/2010 with DZ: Chronic bilateral adnexitis with the formation of a right-sided hydrosalpinx. Adhesive process of the pelvis. Infertility 2.

Upon receipt of a complaint about the absence of pregnancy for 10 years.

History - suffers from chronic adnexitis from 16 years, exacerbation 1 time per year. In 2000 - drugs with CSU, neosalpingostomy, salpingo-ovariolysis for hydrosalpinx. In 2007 - drugs with CSU, right-sided fimbriolysis (according to the protocol of operation, the pipes were passable). Menses from 13 years, 4 days, regular, after 32 days. One medical abortion for honey. indications.

With an objective examination of the uterus in retroflexio, the appendages on the right are enlarged, sensitive, arches are heavy.

Operation protocol. Laparoscopy with CSU, dissection of adhesions, bilateral tubectomy.

Laparocentesis through the navel. Pneumoperitoneum 3000 ml CO ₂ . 3 additional trocars into the abdominal cavity. Liver, intestinal loops, stomach, omentum - without features.

The uterus is 46 * 42 * 35 mm, rounded, pink in retroflexio. The right ovary is 25 * 20 * 17 mm, without marked folding, in adhesions with a tube. The right fallopian tube up to 7-8 cm long, sharply crimped, with constrictions, scarred, with signs of chronic inflammation, fimbriae stick together.

Left ovary 20 * 18 * 15 mm, without pronounced folding, sealed. The left fallopian tube is up to 7-8 cm long, crimped, with constrictions, with signs of chronic inflammation.

Conclusion: chronic bilateral salpingitis. Cicatricial-adhesive process of the small pelvis.

Interventions: dissection of scars and adhesions - ovarioadhesiolysis. CSU - the right tube is impassable, the liquid does not enter the small pelvis at all (0 points), the left one is poorly passable - the liquid arrives with a delay of 5-10 seconds, while the tube is significantly inflated and the liquid is secreted by fast large drops (3 points). An attempt to plastic the left fallopian tube is without success. Bilateral tubectomy.

After surgery, ceftriaxone 1.0 V / V twice, ketonal 2 ml V / m.

Discharged on the 4th day after the operation, removal of sutures on the 7-8th day, preparation for IVF is recommended.

Example 3

Patient I., 25 years old, was on station. treatment in the gynecological clinic Semashko from December 3 to December 9, 2010 with DZ: Infertility of 1 tubal-peritoneal genesis.

Chronic bilateral salpingitis. Adhesive process of the pelvis. Uterine fibroids.

Upon receipt of a complaint about the absence of pregnancy for 3 years.

A history of anti-inflammatory therapy, GHA - from September 2010 - according to the protocol of the study of the pipe on both sides are passable, there are signs of an adhesion process. Menses from 13 years, 3-5 days, regular, after 30 days.

With an objective examination of the uterus without features, the area of the appendages is heavy on palpation.

Operation protocol. Laparoscopy with CSU, dissection of adhesions and scars, bruis fimbrioplasty.

Laparocentesis through the navel. Pneumoperitoneum 3000 ml CO ₂ . 2 additional trocars into the abdominal cavity. Liver, intestinal loops, stomach, omentum - without features. In the small pelvis, about 15 ml of serous-hemorrhagic fluid.

The uterus is 46 * 42 * 30 mm, pear-shaped, pink in color, in the region of the base of the ovary's own ligament there is a formation, size. with a pea - a myomatous node? The right ovary is 35 * 25 * 18 mm, contains a cystic cavity up to 4 mm, with hemorrhagic contents. The right fallopian tube up to 10 cm long, with signs of chronic inflammation, fimbriae are expressed, however, the openings of the scar are narrowed.

Left ovary 30 * 20 * 18 mm, ordinary shape and structure. The left fallopian tube up to 10 cm long, with signs of chronic inflammation, there is a hydatide, size. 5 mm, fimbriae are expressed, however, the holes of the scar are narrowed.

Conclusion: chronic bilateral salpingitis. Adhesive process of the pelvis 1 tbsp. Uterine fibroids.

Interventions: dissection of scars and adhesions. CSU - pipes on both sides are passable by 2 points - the liquid is released in slow drops after a significant delay or re-introduction of the dye. Bruis fimbrioplasty on both sides. With repeated CSF - the right tube is passed by 4 points - the liquid enters after 2-5 seconds by the stream, the left tube is passed by 5 points - the liquid enters through the pipe into the small pelvis 1-3 seconds after the introduction of free wide flow through the free fimbria.

After the operation - ceftriaxone 1.0 V / V twice, Bacimex 100 ml I / O., Ketonal 2 ml I / m.

Discharged on the 4th day after the operation, it is recommended to remove the sutures on the 7-8th day, the course of longidase V / m, physiotherapy (alternating magnetic field on the lower abdomen), ultrasound control, pregnancy planning.

Example 4

Patient S., 27 years old, was on station. treatment in the gynecological clinic Semashko from 11/26 to 12/02/2010 with DZ: Chronic bilateral salpingitis with the formation of a hydrosalpinx on the left. Adhesive process of the pelvis. Infertility of 1 tubo-peritoneal genesis.

Upon receipt of a complaint of drawing pains in the lower abdomen, lack of pregnancy.

In the anamnesis - considers herself a patient from 13 years old, since then - periodic exacerbations of adnexitis. In 2007 - removal of the right tube about the pyosalpinx. According to an ultrasound scan from September 2010, the left-sided hydrosalpinx, adhesive process of the small pelvis. Menses from 13 years, 3-4 days, regular, after 28-32 days, heavy.

With an objective examination, the appendages on the left are enlarged, sensitive, arches heavy.

Operation protocol. Laparoscopy with CSF, dissection of adhesions, neosalpingostomy, fimbrioplasty according to Bruis.

The duration of the operation is 09-50 - 10-20.

Laparocentesis through the navel. Pneumoperitoneum 3000 ml CO ₂ . 2 additional trocars into the abdominal cavity. Liver, intestinal loops, stomach, omentum - without features.

The uterus is 42 * 38 * 35 mm, pear-shaped, pink in color, in the area of the sacro-uterine ligaments - adhesions with the intestines. The right ovary is 30 * 25 * 18 mm, of usual shape and structure, there are adhesions along the posterior surface. The right fallopian tube is absent (removed promptly earlier).

Left ovary 27 * 22 * 15 mm, of usual shape and structure, in adhesions in a pipe. The left fallopian tube expanded to 1 cm, twisted, the fimbrial region is sealed, scarred.

Conclusion: chronic salpingitis with the formation of hydrosalpinx on the left. Adhesive process of the pelvis.

Interventions: dissection of adhesions. CSU - the left tube is filled with liquid, which is released by slow drops after a significant delay - patency of 2 points. Neosalpingostomy. Fimbrioplasty according to Bruis. With repeated CSF - the liquid enters after 2-5 seconds by stream - the right pipe is well passable by 4 points.

After surgery, ceftriaxone 1.0 V / V twice, ketonal 2 ml V / m.

Discharged on the 4th day after the operation, it is recommended to remove the sutures on the 7-8th day, the course of longidase V / m, physiotherapy (alternating magnetic field on the lower abdomen), pregnancy planning.

Claims (1)

A method for assessing the patency of the fallopian tube, including performing chromosalpingoscopy during laparoscopy and a visual assessment of the condition and patency of the fallopian tubes, characterized in that when performing chromosalpingoscopy, the rate of passage of the liquid dye through the fallopian tube is determined, and the nature of the resulting liquid dye and the degree of patency of the fallopian tube are evaluated by a point system, where: 5 points - the fluid enters the small pelvis through the pipe 1-3 seconds after the introduction of a free wide stream through the free phi Bree; 4 points - liquid enters through 2-5 with a stream; 3 points - the fluid arrives with a delay of 5-10 s, while the pipe is significantly inflated and the fluid is released by rapid large drops; 2 points - the liquid is released in slow drops after a significant delay or re-introduction of the dye; 1 point - the fluid flows through the fimbrial section of the pipe; 0 points - the fluid does not enter the pelvic cavity at all, the fimbrial part of the tube is not formed, a marked adhesion process is noted.