| Background and objectivesInfertility is defined as failure to achieve pregnancy during one year of frequent unprotected intercourse. In our country, infertility is defined as failure to achieve pregnancy during more than two years. Infertility is not only a common clinical problem, but a public problem. The prevalence varies widely, in the late 1980s, the World Healthy Organization made a report about the infertility of the 33 centers during the 25 countries in the world said that infertility affected 5% to 8% in the developed countries, but more than 30% in the developing countries,and about 6% to 15% in China. It's said that being less in developed countries and more in developing countries where limited resources for investigation and treatment are available. Female factors have complained for about 60% in the infertility, female infertility accounts for about 10% of women in childbearing age. There are many factors leading to female infertility, such as ovarian dysfunction, bubal disease, uterine factor, cervical factor, vulva vaginal factors, endometriosis, the most accepted factors for female infertility is the tubal disease and the ovarian dysfunction. The aim to the diagnosis of infertility is to find the factors that cause infertility. Since the 1980 years, laparoscopic techniques have been carrying out widely, because of small incision wounds, suffering light, little adhesion formation post surgical, quick recovery, short hospital stay and so on. The technique has been used in the field of gynecology more widely, especially in the treatment of female infertility it has been made irreplaceable role. At the same time, as another branch of minimally invasive surgery, the development of hysteroscopy also changed the diagnosis and treatment of gynecological diseases patterns. Hysteroscopy can be clearly observed intrauterine situation to see whether intrauterine factors cause the infertility, such as cervical intrauterine adhesions, endometrial polyps, uterine septum, uterine muscle sub mucosal carcinoma, endometrial hyperplasia and other abnormal situation, and at the same time can do operation. In the past, gynecological endoscope is used separately to cure the infertility, and it delays the treatment of the infertility. Along with the development of gynecologic endoscopies, laparoscopy combined with hysteroscopy to diagnose and treat the female infertility is widely used in clinical, and they have become the golden standard to the diagnosis of pelvic and uterine disease. The pelvic and/or uterine diseases which lead to infertility can be fined and resolved during the laparoscopy simultaneously with the hysteroscopy under once anesthesia, especial for the further cure of the fallopian tube obstruction. Because of the technology with an intuitive, minimally invasive, safe, integration features of diagnosis and treatment, it has become an important means of diagnosis and treatment of female infertility. Because CO2 gas has more features such as colorless, odorless, non-flammable, non-combustion, high solubility in the blood, not easy to form air embolism, it is mostly used for laparoscopic surgery to expand intra-abdominal field. Abdominal pressure is maintained at 12～15mmHg with CO2 gas. The effect of positive pressure pneumoperitoneum can greatly reduce blood loss and descend the incidence of postoperative infection, shorten the time of surgery and postoperative recovery. But pneumoperitoneum pressure not only reduces lung ventilation function, but also makes a CO2 pressure difference between the abdominal cavity and blood vessels. Due to a high solubility property, CO2 can quickly be absorbed by peritoneal, and the maximum absorption rate is up to 90 mL/min which can lead to high CO2 acidosis and carbon dioxide poisoning. CO2 pneumoperitoneum during the surgery can cause blood high sugar, elevate insulin, reduce insulin sensitivity and result the insulin resistance (IR), and the degree of IR is related to CO2 pneumoperitoneum. In the diagnose and therapeutic hysteroscopy, the organ cavity is filled with a distention fluid in order to improve overall visibility during the intervention. At the same time, uterine distension can create sufficient pressure to inhibit intracavitary bleeding. However, excess absorption of the distention fluid is the most serious complications in resectoscopy and is called fluid overload syndrome (FOS). Distention fluid is pressed not only through iatrogenically opened vessels in to the patient's vascular system(a process called intravasation), but also is pressed in to the abdominal cavity through the fallopian tubes and then be absorbed slowly by the pneumoperitoneum into the patient's vascular system. Moreover, the intravasation in hysteroscopic surgery is inevitable. Patients suffering from FOS are at risk for pulmonary or cerebral edema, and cardiovascular collapse. It's more effective in reducing hysteroscopic complications when doing operation under the monitor of the laparoscopy. Simultaneous combined laparoscopy and hysteroscopy, you can use electro coagulation or suturing to stop bleeding under the laparoscopy when hysteroscopy perforation and injury occurs during the hysteroscopy. And you can suck out the fluid that is pressed into the abdominal cavity through the unblocked bubal during the hysteroscopy to reduce the fluid into the patient's vascular system.Materials and Method In this study, we collected 41 female infertilities who were performed hysteroscopic combined with laparoscopic surgery under general anesthesia from Jan. 2009 to May 2009 in our hospital, including 21 primary infertilities and 20 secondary infertilities. We pay close attention to clinical symptoms and signs changed intraoperative and postoperative. And also we record these parameters, such as time of anesthesia, time of CO2 pneumoperitoneum, time of uterine distention (hysteroscopic surgery time), the total volume of uterine distention fluid, the volume of fluid out-flowing through the uterus cervix, total volume of distention medium into the abdominal cavity through the fallopian tube, and the blood biochemical parameters before and after surgery at moment. Last we calculate the fluid into the vascular system, and explore the relate factors.Results1. None of the 41 female infertilities who received laparoscopic and hysteroscopic surgery simultaneously under general anesthesia suffer from hypercarbia, CO2 poisoning, FOS and delusional hyponatremia. Compared with pre-operation, blood sugar,potassium and serum chloride wasrespectively increased (0.6±0.8) mmol/L, (0.1±0.4) mmol/L and (1.4±6.8) mmol/L. There is significantly different in the change of blood sugar and serum chloride (t=-4.32, P= 0.000; t=1.34, P=0.001). Meanwhile we find that compared with the preoperative hemoglobin, serum sodium, and carbon dioxide combining power was respectively reduced (9.8±9.4) g/L, (4.3±3.5) mmol/L and (0.7±2.9) mmol/L after operation. There is significant different in the hemoglobin, serum sodium decreased (t =6.64, P=0.000; t=7.95, P=0.000). And there is no significant different in the change of potassium and carbon dioxide combining power (t=-2.96, P=0.057; t= 1.54, P=0.131). There is a significant negative correlation between the sodium change with the time of hysteroscopy and the amount intravascular of uterine distention medium (r=-0.346, P=0.028; r=-0.318, P=0.042). However, all of the above values after the surgery were still within the range of clinical normal values.2. Maintaining a continuous pressure at 150mmHg to distend uterine, we find that there is a significant positive correlation between the amount of uterine distention fluid intravasation and the duration of anesthesia, the time of CO2 pneumoperitoneum or the length of hysteroscopic surgery respectively (rp=0.469, P=0.002; rp=0.332, P=0.034; rp=0.759, P=0.000). At the same time, the type of hysteroscopic surgery have influence on the amount of fluid intravasation in our study (Welch=8.604, P=0.005). The average rate of fluid intravasation is (26.2±17.7) ml/min in patients with bilateral patency fallopian tubes and (20.1±14.9) ml/min in patients with unilateral tube patency (including unilateral tube absented). To the patients with bilateral fallopian tubes occluded, the average rate is (28.7±19.7) ml/min.3. Transtubal intraabdominal spillage with peritoneal absorption is a mechanism of absorption in operative hysteroscopy. There is a significant positive correlation between the average volume of the fluid into the abdominal cavity and the duration of the hysteroscopy (rp=0.510, P=0.001). But the type of the hysteroscopic surgery hasn't significant influence on the average volume of the abdominal fluid in our research ((F=1.827, P=0.175)). The mean rate of transtubal intraabdominal spillage is (8.2±6.4) ml/min in patients with bilateral patency fallopian tubes, (8.5±7.0) ml /min in patients with unilateral patency tube (including unilateral fallopian tube absented), and (4.7±5.7) ml/min in patients with bilateral fallopian tubes occluded.ConclusionsUsing computer software for statistical data analysis, our results of 41 infertile cases simultaneous laparoscopy and hysteroscopy suggest:1. It's relatively safe that simultaneous laparoscopy and hysteroscopy under general anesthesia to treat the infertility. The blood biochemical parameters change after operation. However, all of them are not beyond the range of clinical normal values. There is a significant correlation between the decline of serum sodium and the duration of the hysteroscopy or the amount of uterine irrigation fluid absorption into the system vascular. 2. Using the 3L surgery paste towel, we can measure the out-flowing amount of the distend medium through the uterus cervix, and then calculate the medium the amount intravasation. Monitoring blood biochemical parameters before and after surgery is efficient to avoid the occasions of FOS and dilution hyponatremia which is comparable to the TURP syndrome. During simultaneous laparoscopy and hysteroscopy to treat the infertility under general anesthesia at 150mmHg uterine distend pressure, the type of hysteroscopic surgery have influence on the volume of the distend medium into the vascular system. There is a significant positive correlation between the amount of the fluid intravasation and the duration of anesthesia, the time of CO2 pneumoperitoneum or the length of hysteroscopic surgery respectively. However the fallopian tubes patency or not has no influence on the amount of distend medium into the vascular system.3. In fact, under high pressure, the fallopian tubes would react as a safety valve and let the irrigation fluid reach the peritoneal cavity where it is slowly absorbed. There is a positive significant correlation between the volume of the fluid into the peritoneal cavity and the duration of the hysteroscopy intervention. However, the type of the hysteroscopic surgery does not have significant influence on the average volume of the abdominal fluid.In brief, in our preliminary research of the safety of simultaneous laparoscopy and hysteroscopy, the results suggest that the infertile surgery under general anesthesia is relatively safe. |
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