A method for the diagnosis of contractile activity of uterine tubes

 

(57) Abstract:

The invention relates to medicine, gynecology, may be used for diagnostic assessment of contractile activity of uterine pipes. After salpingoophoritis (salpingostomy) under control hysteroscopy is performed catheterization proximal isthmic area of the Department of the fallopian tube, which is confirmed visually with the aid of a laparoscope. Then is fixed tube of the catheter on the ipsilateral inner thighs of the patient with adhesive tape. Similarly produce catheterization of the mouth of the contralateral fallopian tube. Creates an artificial hydropericardium with isotonic sodium chloride solution, stained with Indigo Carmine. Evaluation restore patency and contractile activity of the uterine tube is made after 24 hours. Sign normalize the function of the fallopian tube is the visualization of colored saline into the lumen of the catheter. The method allows in the early postoperative period to predict the effectiveness of laparoscopy after salpingoophoritis (salpingostomy) in the early postoperative period, when edicine, namely, gynecology, and will be used to assess the patency and functional status of the fallopian tubes in the early postoperative period to forecast subsequent conception.

Barren marriage remains one of the urgent problems of modern medicine. The frequency of infertility in Russia is 10-15% and in some regions more than 15% level, a particular problem group who as a critical influencing demographic indicators (Kulakov Century. And., 1999). Among the causes of infertility one of the first places are violations of the anatomical and functional status of the fallopian tubes, making 30-74% (Kulakov Century. And., Ovsyannikova T. C., 1996, Healy D. L. et al., 1994). The main factor in the dysfunction of the fallopian tubes are anatomical lesions, which are inflammatory changes of the pelvic organs (Westorm L. F. et al., 1992).

Lesions of the fallopian tubes are usually bilateral in nature, therefore, adversely affect reproductive function. Moreover, the pathological changes are often grab the pipe along its entire length, which may cause mechanical obstruction or distort the rhythm and ciliary muscle contractile activity. As a result of this dysfunction violated the RA for accurate diagnosis and conduct reconstructive surgery on the fallopian tubes recognized laparoscopy (Kulakov Century. And., Adamyan L. C., 2000).

Infertility caused by tubal obstruction, perform the following types of surgeries: salpingolysis, salpingostomy (salpingoneostomy), fimbrioplasty, anastomosis, implantation and combined operations.

The criterion of success of surgical treatment of patients with tubal-peritoneal infertility is the birth of full-term child. Moreover, given the average age of patients in this group average of 29 years and more (Gasparov A. S. et al., 1999), it is desirable to achieve a pregnancy as soon as possible after the operation.

Tubal patency is restored in a significant number of patients after the reconstructive plastic surgery (Danilov, A. Y. et al., 2001), but pregnancy does not occur due to the fact that it is not possible to restore normal function pipe (N. Seleznev.D.,1998).

In this regard, in addition to surgical correction of the pathology of the fallopian tubes, it is important to assess their cross-country, state of the endothelium during surgery and especially function in the early postoperative period.

Currently, with the goal of establishing assessment of the fallopian tubes during laparoscopy is Holocene false-positive results due to the passage of ink fluid through the opening in the uterus or the fallopian tube and simulation, thus, its permeability, as this paint is found in dupacova space. False negative results may be obtained due to technical malfunctions, leading to distension of the uterine cavity fluid, spasm or pathology of the mouth of the fallopian tube.

For the first time the study of the fallopian tubes through the turbulence of the gases suggested Rubin (1919). Sample ruby is the introduction into the uterus of carbon dioxide with the speed of 60-90 ml/min for 2 minutes with a pressure measurement system and its registration in kilogramme. In normal conditions, the gas is supplied into the abdominal cavity under pressure, which does not exceed 100 mm RT. Art., a pressure between 100 and 200 mm RT. Art. is pathological. The flow of carbon dioxide into the abdomen confirmed by x-ray data on the presence of gas under the diaphragm, complaints of pain under the shoulder blades, auscultatory data about the presence of a gas bubble in the abdominal cavity or a sharp decrease in the pressure, visible on kilogramme.

The disadvantages of this method are: a high percentage of false-positive and false-negative results associated with tightness of the junction of the cannula to the cervix, spasm of the pipe and once the AI in the early postoperative period in connection with the possible balance of CO2environment in which this operation.

For pertubative proposed various devices. The greatest distribution was received by the apparatus A. E. Mandelstam, the apparatus of the factory “red guard” and their modifications. When conducting kymographic pertubative by the apparatus of the factory “red guard” I. S. Rozovsky and p. P. Nikulin (1960) recommended to take into account such factors as the maximum pressure, the nature kymographic curve, the minimum pressure in the system after the termination of gas injection. Analysis of the results allowed the authors to distinguish 6 types kamagraviagra curves characterizing permeability and motility of the fallopian tubes.

For this method peculiar to the same disadvantages as for samples of ruby. Along with this method does not give a clear picture, if one tube is permeable, and the other does not.

There is a method of determining the patency of the fallopian tubes in the early postoperative period using the diagnostic and treatment hydrotube (Grant And, 1971).

The disadvantages of this method are additional pain to the patient and the possibility of development of inflammation in the early postoperative period, the inability to evaluate restorative is edenia this procedure and the risk of development of hydrosalpinx (N. Seleznev.D., 1988).

J. Stangel (1986) proposed to determine tubal patency and occlusion using a cannula (J. Sklar Manufacturing Company) of different lengths, designed for retrograde perfusion.

The disadvantage of this method is the possibility to use only during laparotomy and impossibility, as if chromopertubation, evaluating the function of the fallopian tubes.

The Pallady, A. et al. (1989) proposed a method of diagnosis of the fallopian tubes using ecohydraulic based on filling the uterine cavity gas-liquid environment with parallel conducting ULTRASONIC scanning. In the future, this technique has been improved through the creation of a special contrast agents, such as Infuson” and others, and the method is called hysterosalpingography sonography (Boudghene F. P. et al., 2001). However, these methods are inherent disadvantages to hydrotubation and chromopertubation.

Recently to assess patency and internal anatomy of the fallopian tube method falloposcopy (Kerin J. et al., 1990, Bauer O. et al., 1992). Falloposcope is a transcervical endoscopic examination of the fallopian tubes, allowing to precisely estimate the with the degree of patency of the tubes, abnormal epithelial changes, abnormal vascular pattern, the degree of formation of growths, abnormal intraluminal contents, as follows: 1 (normal), 2 (disease moderate) and 3 (severe). So vote for all 4 sections of the left and right fallopian tubes. The total score of not more than 20 for each of the fallopian tube, it is considered the norm, the sum of 20-30 means the disease is moderate, and over 30 is a severe disease.

The disadvantage of this method is the impossibility of evaluating the function of the fallopian tube.

The known method and apparatus for analysis of the functioning of the smooth muscle wall of the proposed C. D. Wilhelmson Adrianus (Holland, 1995). This method is based on the definition of the function body contains muscle tissue, and provides a measure of the contractile activity of the element of the muscular wall of the bladder, blood vessels, fallopian tubes, intestines, uterus, etc. For this purpose it is necessary to attach the marker to the specified element of the muscular wall with the subsequent registration of cuts through a magnetic field or electromagnetic radiation in the high frequency range. The disadvantages of this method with the traditional it applications, the inability to determine the patency of the fallopian tubes.

A known method of selective transcervical catheterization of the proximal fallopian tubes (Adamyan L. C. et al., 2000) to assess their patency. To conduct catheterization of fallopian tubes used modified angiographic technique, which is performed in the operating conditions, equipped with x-ray surgical equipment.

The disadvantages of this method is its complexity and the lack of opportunity to assess the function of the fallopian tubes.

The prototype of the invention selected method intraperitoneal administration of a radioactive drug and investigated downward isoperistaltic current peritoneal fluid in fallopian tubes using radioisotope studies (Volobuev, A. I., 1986).

The essence of the method lies in the fact that during the puncture of the posterior vaginal fornix into the abdominal cavity is injected with 0.9 MBq colloidal solution of radioactive gold in 5 ml of physiological solution. The vagina swab is introduced, which changes every 24 hours, the last tampon is removed through 96 hours after the puncture. Then the swabs are placed in the counter, and counts the number of pulses. About proniknovenie the data pulses in a tampon, which indicates normal function of the fallopian tubes.

The disadvantages of the method are: first, the lack of clear criteria, which of the fallopian tubes retained function and is passable; secondly, the technical complexity results (requires special equipment to interpret the data); and thirdly, the radiation load on the medical staff and the patient.

These drawbacks are eliminated in the present invention. The task of the invention is to improve the accuracy of the method and its information content.

The problem is solved by the fact that after the execution of salpingoophoritis (salpingostomy) during laparoscopy is transcervical catheterization interstitial departments right and left fallopian tubes, and solution dyed Indigo Carmine, is entered using acupuntura into the abdominal cavity. The function of the fallopian tube is not disturbed in case of visualization of the colored solution in the lumen of the tubular catheter after 24 hours. Using this method it is possible to judge, which of the fallopian tubes regained its function.

Analysis of the medical-scientific and patent literature has allowed to establish that the study of the fallopian tubes in rannametsa of hydrotube and having a specific method of the above disadvantages.

It should be emphasized that in normal fallopian tube shows constant complex spontaneous activity, a complete state of peace does not happen. Even during pregnancy, when the contractility of the uterus falls, fallopian tubes remain spontaneous activity, albeit reduced (Coutincho E. M. et al., 1975).

Revealed two peaks of contractile activity of the uterine tube: one during menstruation at most a low level of estrogen; the second during ovulation, when higher estrogen content of (Coutincho E. M. et al., 1975).

Therefore, for the most objective assessment of the recovery of the function of the fallopian tubes surgery should be carried out in the middle of the menstrual cycle, during one of their periods of higher activity. In addition, the ovulation period is characterized by the predominance of anabolic processes in the female body that is the most favourable background for carrying out reconstructive surgery (Garsia C.-R., 1980.).

Our studies allowed us to establish a direct relationship between the restoration of normal function of the fallopian tube in the early postoperative period and frequency of pregnancy within 1 year.

Evaluation of restoration options erational period can significantly improve the prognostic accuracy of conception, to conduct the selection of patients for holding ovulation induction or IVF program and PE.

Detailed description of the method and examples of its application-specific

To implement the method using the following equipment: a standard set of laparoscopic equipment and instruments for conducting gynecological operations hysterscopy, the system catheters RIMBACH company KARL STORZ (Germany), 0.9% sodium chloride solution (200 ml, dyed with Indigo Carmine.

The patient is in position for lithotomy. By disinfection of the anterior abdominal wall, perineum and vagina bactericidal solutions. The patient cover sheets, leaving open the lower abdomen and perineum. After the study of vaginal installed intrauterine cannula having a channel for holding hydrotubation. Through the navel entered the Veress needle and after the sample, confirming the presence of her in the abdominal cavity that connects automatic CO2-insufflator to create pneumoperitoneum. Upon reaching a pressure of 15 mm RT.article pull the needle and replaced it with an 11-mm trocar, through which the laparoscope is introduced, connected to the video system. To perform surgeons who Ara 6-8 cm above the symphysis at the outer edges of recti. At the beginning of laparoscopy inspect the cavity of the pelvis, its anatomical features and evaluated the incidence of adhesions. Using intrauterine cannula into the uterine cavity is entered unpainted isotonic solution for the diagnosis of tubal patency. Then spend salpingostomy (fibrolysis) and or salpingoophoritis.

After reconstructive stage surgery of the fallopian tubes intrauterine cannula is removed. Is serial dilatation of the cervical canal dilator of Hagara, starting with No. 3 and bringing up to No. 8. In the uterine cavity is entered hard 8-millimetrovy hysteroscope and starts the supply of isotonic sodium chloride solution.

After visualization of the mouth of the fallopian tube is the summing up of the uterine cannula to the last. For uterine cannula is inserted tubular catheter, and gradually moving up to fibrillose Department under the control of the laparoscope, located in the abdominal cavity. In the case constrained advancement of the catheter through the fallopian tubes is equidistance in-line binding with a syringe with isotonic sodium chloride solution, connected to the hole injection. After exclusion begins by visually with the aid of a laparoscope. Then is fixed tube of the catheter on the ipsilateral inner thighs of the patient with adhesive tape. Similarly produce catheterization of the mouth of the contralateral fallopian tube.

At the end of operative intervention peritoneal cavity washed with isotonic, carefully removed the clots and fragments of adhesions. Creates an artificial hydropericardium with isotonic sodium chloride solution, stained with Indigo Carmine, using irrigation systems included laparoscopic equipment.

Assessment of recovery of contractile activity of the uterine tube is made after 24 hours. Sign normalize the function of the fallopian tube is the visualization of colored saline into the lumen of the catheter.

Here are clinical examples, confirming the efficiency of the method.

Example 1.

Case history No. 3873/379 date operations 14.06.01,

Patient N. Kaya, I. N. 35

Diagnosis: Chronic bilateral salpingitis. Adhesive disease of the pelvic organs 2 degrees. Syndrome Fitz-Hjo-Curtis. Primary infertility.

Produced: Laparoscopy. Salpingopharyngeal.

Estimated recovery of contractile activity of the uterine tube of the inventive method after 24 hours. Painted saline into the lumen of the catheter is not observed.

The effectiveness of surgical treatment were assessed after 1 year - the pregnancy does not come.

Example 2.

Case history No. 4445/428 date operations 04.07.01,

The patient And society So M 29

Diagnosis: Chronic right-sided salpingitis, hydrosalpinx. Adhesive disease of the pelvic organs 3 degrees. The state after the left-hand tubectomy (1997). Produced: Laparoscopy. Visceralis. Salpingoophoritis, salpingostomy right. Hydrotubation. Hysteroscopy. Catheterization of the fallopian tube. Artificial hydropericardium.

Estimated recovery of contractile activity of the uterine tube by the present method. After 24 hours in the lumen of the catheter is visualized dyed saline solution.

The effectiveness of surgical treatment were assessed after 1 year - the pregnancy occurred.

According to the materials of the proposed method of assessing the patency and functional status of the fallopian tubes in the early postoperative period, 86 patients, OII inclusion in the study group were as follows: presence adnexal adhesions moderate or severe normospermic her spouse, positive postcoital test, the duration of infertility for over 2 years, no endometriosis and endocrine diseases.

The age of examined patients ranged from 24 to 36 years, on average accounting for 29,42,2 year. Of these, 59% diagnosed with primary infertility, 41% secondary. Duration of infertility ranged from 3 to 15 years, averaging 7,92,1 year.

During laparoscopy, all patients made salpingoophoritis and/or salpingostomy, fibrolysis using tools and equipment of the firm “STORZ”. The incidence of adhesions was evaluated according to the classification adnexal adhesions of the American society of fertility. After carrying out stage laparoscopic surgery patients produced catheterization of the fallopian tubes under the control of hysteroscopy and artificial hydropericardium with isotonic sodium chloride solution, stained with Indigo Carmine.

67 (77,9%) patients within 24 hours of occurrence painted saline into the lumen of the catheter, which was regarded by us as a sign, indicating the recovery of contractile activity of the uterine tube. 19 (here are the fallopian tubes, which was identified during laparoscopy when performing catheterization of the fallopian tubes and hydrotubation.

To confirm the high reliability of the research restore the function of the fallopian tubes in the early postoperative period we have conducted a comparative analysis of pregnancy rate at one year in patients of these two groups. Of the 67 patients with a positive test result uterine pregnancy occurred in 83.6% of cases, from 19 patients with negative test - 10.5%, and in one case, the pregnancy was a tubal. The sensitivity of our proposed method is 86.6% and a specificity of 89.5% of

The developed method allows to avoid holding hydrotube in the early postoperative period, which, according to some authors, lead to unnecessary injury of tubular epithelium and may contribute to the infection of the fallopian tubes after surgery. In addition, the use to conduct catheterization of fallopian tubes hysteroscopy allows you to diagnose and resolve intrauterine pathology in this group of patients.

The method is based on the use of standard laparoscopies and hysteroscopic oborudovaniya period to predict the effectiveness of laparoscopy after salpingoophoritis and/or salpingostomy in the early postoperative period, to reduce the time interval between surgery and the onset of pregnancy, carrying out the selection of patients with negative test results for the IVF program and PE.

The claimed method can be used in gynecologic hospitals, use of endoscopic techniques for the surgical treatment of tubal-peritoneal infertility.

A method for the diagnosis of contractile activity of uterine tubes by introducing diagnostic solution into the abdominal cavity, characterized in that in the early postoperative period after reconstructive stage surgery of the fallopian tubes produce catheterization isthmic departments last and create artificial hydropericardium with isotonic sodium chloride solution, stained with Indigo Carmine, whose appearance in the lumen of the catheter after 24 h regarded as the restoration of the patency and function of the fallopian tube.

 

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