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如何解決不孕癥病因診斷的困難？

出處：網(wǎng)絡(luò)收集 日期：2024-07-08 12:38:43 編輯：秩名

盡管根據(jù)不孕癥的定義很容易判斷某個(gè)婦女患有不孕癥，但要進(jìn)一步查明具體引起不孕癥的病因環(huán)節(jié)，為臨床治療對癥下藥，藥到病除提供依據(jù)，還是不孕癥診斷中的難點(diǎn)問題。有時(shí)查到其中一個(gè)原因?qū)ΠY治療，但仍未能達(dá)到受孕的效果，進(jìn)一步檢查才發(fā)現(xiàn)更隱匿的原因還存在；有的不孕夫婦各項(xiàng)檢查均正常，但終難受孕，直到放棄治療，領(lǐng)養(yǎng)了義子，不知不覺中又喜懷身孕，原來是精神緊張而引起了精神性不孕。因此，查明原因，明確診斷是對癥治療不孕癥的關(guān)鍵問題，也是難點(diǎn)問題。臨床診斷中，除了在四診的基礎(chǔ)上，結(jié)合婦女的生理病理特點(diǎn)，進(jìn)行八綱辨證和臟腑辨證外，還需從多層次、多側(cè)面、多因素尋找并評價(jià)各種致病原因，為治療提供有效的依據(jù)。
 
預(yù)測排卵的方法很多，但都有一定的局限性，多種方法聯(lián)合應(yīng)用，優(yōu)勢互補(bǔ)，方能更加準(zhǔn)確地預(yù)測排卵。其中基礎(chǔ)體溫測定及黃體中期孕酮測定是回顧性的，即排卵后基礎(chǔ)體溫才上升，孕酮才升高。尿黃體生成素峰值測定及超聲波卵泡監(jiān)測，可在排卵前預(yù)計(jì)排卵發(fā)生的時(shí)間，因而在治療上更為有用。一般在黃體生成素峰值后24個(gè)小時(shí)可出現(xiàn)排卵。超聲波監(jiān)測排卵，除了能直觀地了解卵泡發(fā)育并診斷排卵外，特別對黃素化未破裂卵泡綜合征能直接觀察，但B超往往不能了解卵泡的內(nèi)分泌功能。宮頸評分，只能反映雌激素水平，但對是否真正排卵尚不能確診。在排卵障礙的診治中最值得一提的是，婦科腹腔鏡的應(yīng)用。腹腔鏡檢查最為可靠。排卵發(fā)生后4天行腹腔鏡檢查，可見典型的排卵三聯(lián)征表現(xiàn)：卵巢排卵斑：多位于新鮮血體中央的卵巢表面，排卵不久的排卵斑形狀如火山狀或魚口狀，中央凹陷，外周隆起，可見血液從洞口溢出；排卵后稍久，排卵口表面覆蓋1層半透明狀薄膜，洞口縮小而外周變平坦，如同高爾夫球洞口狀。血體形成：血體多在卵巢表面，直徑1.0～1.5厘米大小，排卵斑多位于血體中央。血性腹腔液：有排卵斑及血體者，其子宮直腸窩及膀胱側(cè)窩多能見到血性腹腔液，其血性程度隨排卵長短而異，剛排卵不久均呈血性，稍久成膿血水樣，時(shí)間再長些則呈淡血水樣。排卵的典型三聯(lián)征是檢查是否排卵的金指標(biāo)，婦科腹腔鏡檢查可為不孕癥診斷獲得更多信息，許多醫(yī)院把腹腔鏡列為常規(guī)檢查項(xiàng)目，并可于排卵后不久進(jìn)行。排卵后，尚可吸取腹腔液作性激素檢查，并與血清中性激素含量作對比，以輔助診斷排卵之有無。正常排卵后，含高濃度性激素的卵泡液進(jìn)入腹膜腔，使性激素含量升高，尤其是雌激素含量，腹腔中雌激素濃度越高，說明其卵泡質(zhì)量越好，妊娠率越高。
 
子宮輸卵管造影和腹腔鏡檢查均為不孕癥的主要檢查方法，文獻(xiàn)報(bào)道，有兩種方法對輸卵管檢查的符合率為46%～89%。在子宮輸卵管造影中誤診為輸卵管癥側(cè)端阻塞，與多子宮角部的痙攣性收縮有關(guān)，多因輸卵管造影劑的黏稠度美藍(lán)為高所致。用子宮輸卵管造影來檢查宮腔情況的準(zhǔn)確性較高，故可用于篩選子宮異常的患者，而腹腔鏡檢查，不僅可確診輸卵管是否通暢，還可發(fā)現(xiàn)影響生育的其他病理情況，如子宮內(nèi)膜異位癥和粘連等。
 
通過腹腔鏡檢查，可以發(fā)現(xiàn)其他檢查所不能發(fā)現(xiàn)的宮腔內(nèi)病變，如子宮黏膜下肌瘤、子宮內(nèi)膜息肉、子宮內(nèi)膜結(jié)核、宮腔粘連、子宮內(nèi)膜缺陷和殘余的宮內(nèi)節(jié)育器等，同時(shí)可于腹腔鏡下對其進(jìn)行治療，不僅有診斷價(jià)值，而且還有治療意義。
 
在腹腔鏡廣泛應(yīng)用之前，對輕、中度子宮內(nèi)膜異位癥的診斷，只有經(jīng)過剖腹探查才能明確診斷。近年來，由于腹腔鏡的廣泛應(yīng)用，在鏡檢下可以直接看到內(nèi)異癥的病灶，并可對內(nèi)異癥病灶進(jìn)行組織活檢。同時(shí)，腹腔鏡的應(yīng)用，可以更直觀地檢測到黃素化未破裂卵泡綜合征。使以前診斷為不明原因不孕者，有20%～40%可能與子宮內(nèi)膜異位癥和黃素化未破裂卵泡綜合征相聯(lián)系。隨著免疫學(xué)新技術(shù)的發(fā)展，抗內(nèi)膜抗體、抗卵磷脂抗體與抗精子抗體等抗體的發(fā)現(xiàn)，使部分既往認(rèn)為不明原因的不孕，找到了免疫學(xué)方面的原因。
 

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