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[摘要]目的探讨术前使用促性腺激素释放激素激动剂(GnRH-a)亮丙瑞林对行腹腔镜卵巢子宫内膜异位症(EMs)囊肿剔除术病人卵巢功能的作用。方法选择行腹腔镜卵巢EMs囊肿剔除术的病人180例,随机分为2组,各90例。研究组术前应用亮丙瑞林2个周期后行腹腔镜卵巢EMs囊肿剔除术,对照组直接施术,术后均未再给予亮丙瑞林治疗。检测两组病人术前血清卵泡刺激素(FSH)、雌二醇(E2)、FSH/黄体生成素(LH)、抗苗勒管激素(AMH)水平,记录术中情况及标本囊壁残留卵泡情况,用免疫组化法检测囊壁残留卵巢组织AMH表达水平。随访6个月,比较两组病人卵巢储备功能变化。结果两组病人术前血清FSH、E2、FSH/LH及AMH水平差异均无统计学意义(P>0.05)。研究组手术时间、术中出血量均低于对照组,差异有统计学意义(t=4.598、8.124,P<0.05)。研究组标本囊壁卵泡残留比例、AMH表达阳性率均低于对照组,差异有统计学意义(χ2=10.56、11.25,P<0.05)。术后6个月研究组血清AMH水平高于对照组(t=4.523,P<0.05)。结论术前使用亮丙瑞林2个周期对行腹腔镜卵巢EMs囊肿剔除术病人的卵巢储备功能有一定的保护作用。
[关键词]亮丙瑞林;腹腔镜检查;卵巢囊腫;子宫内膜异位症;卵巢储备功能
[中图分类号]R711.71[文献标志码]A[文章编号] 2096-5532(2018)06-0656-05
EFFECT OF GONADOTROPIN-RELEASING HORMONE AGONIST ON OVARIAN FUNCTION IN PATIENTS UNDERGOING LA-PAROSCOPIC OVARIAN ENDOMETRIOSIS CYST REMOVAL ZHANG Fang, WU Min, WANG Jianhui, TANG Mi(Department of Gynecology Section 1, Hu′nan Provincial Maternal and Child Health Care Hospital, Changsha 410053, China)
[ABSTRACT]ObjectiveTo investigate the effect of preoperative application of gonadotropin-releasing hormone agonist (GnRH-a), leuprorelin, on ovarian function in patients undergoing laparoscopic ovarian endometriosis cyst removal. MethodsA total of 180 patients who underwent laparoscopic ovarian endometriosis cyst removal were enrolled and randomly divided into study group and control group, with 90 patients in each group. The patients in the study group were given two cycles of leuprorelin before removal, and those in the control group underwent surgery alone; no leuprorelin treatment was given after surgery. Serum levels of follicle-stimulating hormone (FSH), estradiol (E2), FSH/luteinizing hormone (LH), and anti-mullerian hormone (AMH) were measured before surgery, intraoperative conditions and residual follicles on the cyst wall were recorded, and immunohistochemistry was used to measure the expression of AMH in the residual ovarian tissue on the cyst wall. The patients were followed up for 6 months, and the change in ovarian reserve function was compared between the two groups. ResultsThere were no significant differences in the serum levels of FSH, E2, FSH/LH, and AMH between the two groups before surgery (P>0.05). The study group had a significantly shorter time of operation and a significantly lower intraoperative blood loss than the control group (t=4.598 and 8.124,P<0.05). Compared with the control group, the study group had significantly lower rate of residual follicles on the cyst wall and positive rate of AMH in samples (χ2=10.56 and 11.25,P<0.05). At 6 months after surgery, the study group had a significantly higher serum level of AMH than the control group (t=4.523,P<0.05). ConclusionPreoperative application of leuprorelin for 2 cycles has a certain protective effect on ovarian reserve function in patients undergoing laparoscopic ovarian endometriosis cyst removal. [KEY WORDS]leuprolide; laparoscopy; ovarian cysts; endometriosis; ovarian reserve
子宮内膜异位症(EMs)是指具有活性的子宫内膜组织(腺体和间质)出现在子宫内膜以外的部位,其中卵巢EMs囊肿是最常见的类型,占盆腔EMs的17%~44%,好发于育龄期女性[1]。目前,腹腔镜下卵巢EMs囊肿剔除术已成为临床首选治疗方案。有研究结果表明,EMs本身可致卵巢储备功能降低,手术又进一步影响卵巢功能,甚至导致卵巢功能早衰,对女性生育功能造成极大影响[2-3]。术中如何最大程度地减少对卵巢组织的损伤,保护卵巢储备功能,已成为目前临床研究的热点。本研究旨在探讨术前使用2个周期促性腺激素释放激素激动剂(GnRH-a)亮丙瑞林预处理后行腹腔镜卵巢EMs囊肿剔除术对卵巢储备功能的保护作用。
1资料与方法
1.1对象及分组
选取2017年1—6月本院收治的有手术指征的卵巢EMs囊肿病人180例,年龄为20~42岁,平均为(30.15±6.24)岁。纳入标准:①既往无卵巢手术史,超声检查显示单侧附件区囊性包块的直径>5 cm,提示卵巢EMs囊肿;②月经周期正常(25~35 d);③无多囊卵巢综合征及其他内分泌疾病,半年内无激素类药物服用史;④无手术禁忌证;⑤由于经济原因,术后均未再使用亮丙瑞林治疗。按随机数字表法将病人分为研究组和对照组各90例。
1.2治疗方法
1.2.1术前处理研究组病人于术前月经来潮第1~3天皮下注射3.75 mg亮丙瑞林(北京博恩特药业有限公司),每28 d注射1次,共注射2次后实施手术。对照组直接手术。
1.2.2手术方法腹腔镜手术均在全麻下进行,术中先分离卵巢与周围组织粘连,恢复其正常解剖后剥除囊肿,最大程度保留正常卵巢组织,出血处以双极电凝(功率30 W)止血,用3-0可吸收线“8”字缝合卵巢皮质予以成形。手术及术后随访均由同一组医师完成。
1.3观察指标
1.3.1术中情况记录两组病人手术时间和术中出血量。
1.3.2病理学检查剥除的卵巢囊壁标本送病理学检查,苏木精-伊红染色后在显微镜下观察囊壁组织卵泡残留比例。采用免疫组化法检测囊壁残留卵巢组织抗苗勒管激素(AMH)表达水平,操作严格按说明书进行。以PBS代替一抗作阴性对照,用已知阳性片作阳性对照。以细胞核出现棕黄色或黄褐色颗粒为阳性表达。由两位有经验病理医师采用双盲法进行评估,根据阳性细胞染色深浅和阳性细胞占颗粒细胞总数的百分数进行评分[4]。①按细胞有无显色和显色深浅计分:无显色计0分,浅黄色计1分,棕黄色计2分,黄褐色计3分;②按显色细胞的比例计分:显色细胞<1%计0分,1%~10%计1分,11%~50%计2分,51%~100%计3分。两项计分乘积0分为阴性(-),1~4分为弱阳性(+),6分为中度阳性(),9分为强阳性()。
1.3.3术前及术后6个月激素水平分别于亮丙瑞林治疗前月经第2天及术后6个月,在德国罗氏601型化学发光仪上,用电化学免疫发光法测定病人血清卵泡刺激素(FSH)、雌二醇(E2)、黄体生成素(LH)水平;采用酶联免疫吸附试验法测定血清AMH水平,操作严格按照试剂盒(由上海晶抗公司提供)说明书进行。
1.4统计学处理
采用SPSS 19.0统计学软件进行统计分析,计量资料数据以±s表示,组间比较采用t检验,计数资料组间比较采用χ2检验,检验水准α=0.05。
2结果
2.1两组病人一般情况比较
两组病人年龄、体质量指数(BMI)、囊肿直径比较,差异均无统计学意义(P>0.05)。见表1。
2.2两组病人术中情况比较
研究组病人手术时间和术中出血量均明显低于对照组(t=4.598、8.124,P<0.05)。见表2。
2.3两组病人术前及术后6个月激素水平比较
本文两组病人术前血清FSH、E2、FSH/LH及AMH水平比较差异均无统计学意义(P>0.05)。术后随访6个月,两组病人手术前后FSH、FSH/LH、E2水平比较差异无统计学意义(P>0.05);两组病人术后AMH水平均较术前降低,且研究组术后血清AMH水平高于对照组,差异有统计学意义(t=4.523,P<0.05)。见表3。
2.4两组病人囊壁组织卵泡残留比例和AMH表达水平比较
研究组和对照组病人囊壁组织卵泡残留比例分别为67.78%(61/90)和94.44%(85/90),研究组囊壁卵泡残留比例显著低于对照组(χ2=10.56,P<0.05)。研究组囊壁卵巢组织中AMH表达阳性率
658青岛大学学报(医学版)54卷
为52.22%(47/90),染色强度集中在+~;对照组囊壁卵巢组织中AMH表达阳性率为65.56%(59/90),染色强度集中在+~,两组AMH阳性表达率比较差异有显著性(χ2=11.25,P<0.05)。见图1。
3讨论
卵巢储备是指卵巢产生卵子数量和质量的潜能,可以间接反映卵巢功能,是女性生育能力的重要标志之一[5]。卵巢内卵泡数量减少,产生卵子能力减弱,卵母细胞质量下降而致生育能力降低,称为卵巢储备功能受损。目前,临床上常用的反映卵巢储备功能的指标有FSH、FSH/LH、E2、AMH、卵巢体积、窦卵泡计数(AFC)等。其中AMH主要由窦前、小窦卵泡的颗粒细胞分泌,相较其他指标,目前被认为是最准确的预测指标[6-8]。近期多项研究显示,卵巢EMs囊肿病人实施腹腔镜下囊肿剔除术后,卵巢储备功能明显下降[9-10]。2014年,ALBORZI等[2]对193例行卵巢EMs囊肿剔除术的育龄女性进行研究,随访6个月后发现,卵巢体积、AFC及AMH水平均较术前明显降低。提示卵巢囊肿剥除术可损伤部分正常卵巢组织,导致病人术后卵巢储备功能降低。本文研究结果显示,两组病人术后6个月血清AMH水平明显低于术前,而手术前后FSH、FSH/LH、E2水平比较差异均无统计学意义。提示手术可致卵巢储备功能降低,且AMH较其他预测指标灵敏性、特异性更高。腹腔镜下卵巢囊肿剔除术后卵巢功能损伤主要原因可能为:①手术操作使部分卵巢组织丢失;②术中使用电凝止血,造成卵巢组织损伤;③术中卵巢成形时缝线过密过紧,影响卵巢血运,致卵巢功能下降[11-12]。本研究中术后病理检查显示,两组标本囊壁组织均有卵巢组织残留,这从病理学角度证实了手术可致部分正常卵巢组织丢失,造成卵巢功能受损。EMs病灶呈侵入性生长,使囊壁分层不清,手术时囊壁撕脱困难,不可避免带走部分正常卵巢组织。 GnRH-a为人工合成的十肽类化合物,其作用与体内GnRH相同,但其亲和力较天然GnRH高百倍,竞争性地与垂体表面的GnRH受体结合,当GnRH受体被全部占滿或耗尽,FSH和LH水平大幅下降,导致卵巢分泌的性激素明显降低至绝经期水平。临床上GnRH-a多用于卵巢EMs术后,萎缩残留的微小病灶,降低EMs复发率[13-14]。国外有研究表明,无论在位内膜还是异位内膜组织均表达GnRH受体,当GnRH-a与受体结合时可抑制细胞增殖,促进细胞凋亡;同时GnRH-a具有下调血管内皮生长因子表达,抑制小血管生成及异位内膜组织炎症反应的作用[15-16]。本文研究组手术时间和术中出血量均低于对照组,差异有统计学意义。分析原因可能为:术前使用亮丙瑞林,可抑制小血管增生使术中出血量减少,同时可抑制病灶与周边组织的炎性反应,减轻粘连,使囊壁分层清楚、更易撕脱,在减少术中出血的同时缩短了手术时间。
AMH主要由卵巢组织中窦前、小窦卵泡的颗粒细胞分泌[17-18],而这两类卵泡恰是卵泡储备池的主要组成部分。对于手术可导致卵巢损伤国内外已有大量文献报道,但关于手术损失的是卵巢储备池中哪一类卵泡却少有报道。本文研究组卵泡残留比例明显低于对照组,差异有统计学意义。免疫组化结果显示,研究组AMH表达阳性率为52.22%,染色强度集中在+~,对照组AMH表达阳性率为65.56%,染色强度集中在+~,两组比较差异有统计学意义。提示研究组的卵泡损失率低于对照组,尤其是窦前、窦卵泡的损失率较对照组低。说明术前使用亮丙瑞林预处理,可有效减少在撕脱囊壁时正常卵巢组织的丢失,特别是能减少窦前、窦卵泡的损失,对卵巢功能起到一定的保护作用。对于术前使用GnRH-a,是否会因病灶过度萎缩而致病灶残留,目前尚有争论。多数研究认为,病灶萎缩程度与GnRH-a使用时间呈正相关,使用时间越长,病灶萎缩越显著,甚至达到肉眼不可见的程度,这也是临床上术后使用GnRH-a降低EMs复发的理论基础[19]。本研究术前使用GnRH-a两个周期,术后随访6个月尚未见复发病例。GnRH-a使用多长时间能最大程度萎缩病灶,使术中既能减少卵巢损伤又能避免遗漏病灶,且不增加其复发率,还需进一步大样本量研究。
综上所述,腹腔镜下EMs囊肿剔除术可导致卵巢功能受损,术前使用GnRH-a两个周期预处理可有效减少手术导致的卵泡丢失,特别是窦前、窦卵泡的丢失,从而有效降低手术对卵巢储备功能的影响。该法对于病灶较大、双侧EMs囊肿、复发性EMs囊肿以及未生育的病人尤其适用。
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[关键词]亮丙瑞林;腹腔镜检查;卵巢囊腫;子宫内膜异位症;卵巢储备功能
[中图分类号]R711.71[文献标志码]A[文章编号] 2096-5532(2018)06-0656-05
EFFECT OF GONADOTROPIN-RELEASING HORMONE AGONIST ON OVARIAN FUNCTION IN PATIENTS UNDERGOING LA-PAROSCOPIC OVARIAN ENDOMETRIOSIS CYST REMOVAL ZHANG Fang, WU Min, WANG Jianhui, TANG Mi(Department of Gynecology Section 1, Hu′nan Provincial Maternal and Child Health Care Hospital, Changsha 410053, China)
[ABSTRACT]ObjectiveTo investigate the effect of preoperative application of gonadotropin-releasing hormone agonist (GnRH-a), leuprorelin, on ovarian function in patients undergoing laparoscopic ovarian endometriosis cyst removal. MethodsA total of 180 patients who underwent laparoscopic ovarian endometriosis cyst removal were enrolled and randomly divided into study group and control group, with 90 patients in each group. The patients in the study group were given two cycles of leuprorelin before removal, and those in the control group underwent surgery alone; no leuprorelin treatment was given after surgery. Serum levels of follicle-stimulating hormone (FSH), estradiol (E2), FSH/luteinizing hormone (LH), and anti-mullerian hormone (AMH) were measured before surgery, intraoperative conditions and residual follicles on the cyst wall were recorded, and immunohistochemistry was used to measure the expression of AMH in the residual ovarian tissue on the cyst wall. The patients were followed up for 6 months, and the change in ovarian reserve function was compared between the two groups. ResultsThere were no significant differences in the serum levels of FSH, E2, FSH/LH, and AMH between the two groups before surgery (P>0.05). The study group had a significantly shorter time of operation and a significantly lower intraoperative blood loss than the control group (t=4.598 and 8.124,P<0.05). Compared with the control group, the study group had significantly lower rate of residual follicles on the cyst wall and positive rate of AMH in samples (χ2=10.56 and 11.25,P<0.05). At 6 months after surgery, the study group had a significantly higher serum level of AMH than the control group (t=4.523,P<0.05). ConclusionPreoperative application of leuprorelin for 2 cycles has a certain protective effect on ovarian reserve function in patients undergoing laparoscopic ovarian endometriosis cyst removal. [KEY WORDS]leuprolide; laparoscopy; ovarian cysts; endometriosis; ovarian reserve
子宮内膜异位症(EMs)是指具有活性的子宫内膜组织(腺体和间质)出现在子宫内膜以外的部位,其中卵巢EMs囊肿是最常见的类型,占盆腔EMs的17%~44%,好发于育龄期女性[1]。目前,腹腔镜下卵巢EMs囊肿剔除术已成为临床首选治疗方案。有研究结果表明,EMs本身可致卵巢储备功能降低,手术又进一步影响卵巢功能,甚至导致卵巢功能早衰,对女性生育功能造成极大影响[2-3]。术中如何最大程度地减少对卵巢组织的损伤,保护卵巢储备功能,已成为目前临床研究的热点。本研究旨在探讨术前使用2个周期促性腺激素释放激素激动剂(GnRH-a)亮丙瑞林预处理后行腹腔镜卵巢EMs囊肿剔除术对卵巢储备功能的保护作用。
1资料与方法
1.1对象及分组
选取2017年1—6月本院收治的有手术指征的卵巢EMs囊肿病人180例,年龄为20~42岁,平均为(30.15±6.24)岁。纳入标准:①既往无卵巢手术史,超声检查显示单侧附件区囊性包块的直径>5 cm,提示卵巢EMs囊肿;②月经周期正常(25~35 d);③无多囊卵巢综合征及其他内分泌疾病,半年内无激素类药物服用史;④无手术禁忌证;⑤由于经济原因,术后均未再使用亮丙瑞林治疗。按随机数字表法将病人分为研究组和对照组各90例。
1.2治疗方法
1.2.1术前处理研究组病人于术前月经来潮第1~3天皮下注射3.75 mg亮丙瑞林(北京博恩特药业有限公司),每28 d注射1次,共注射2次后实施手术。对照组直接手术。
1.2.2手术方法腹腔镜手术均在全麻下进行,术中先分离卵巢与周围组织粘连,恢复其正常解剖后剥除囊肿,最大程度保留正常卵巢组织,出血处以双极电凝(功率30 W)止血,用3-0可吸收线“8”字缝合卵巢皮质予以成形。手术及术后随访均由同一组医师完成。
1.3观察指标
1.3.1术中情况记录两组病人手术时间和术中出血量。
1.3.2病理学检查剥除的卵巢囊壁标本送病理学检查,苏木精-伊红染色后在显微镜下观察囊壁组织卵泡残留比例。采用免疫组化法检测囊壁残留卵巢组织抗苗勒管激素(AMH)表达水平,操作严格按说明书进行。以PBS代替一抗作阴性对照,用已知阳性片作阳性对照。以细胞核出现棕黄色或黄褐色颗粒为阳性表达。由两位有经验病理医师采用双盲法进行评估,根据阳性细胞染色深浅和阳性细胞占颗粒细胞总数的百分数进行评分[4]。①按细胞有无显色和显色深浅计分:无显色计0分,浅黄色计1分,棕黄色计2分,黄褐色计3分;②按显色细胞的比例计分:显色细胞<1%计0分,1%~10%计1分,11%~50%计2分,51%~100%计3分。两项计分乘积0分为阴性(-),1~4分为弱阳性(+),6分为中度阳性(),9分为强阳性()。
1.3.3术前及术后6个月激素水平分别于亮丙瑞林治疗前月经第2天及术后6个月,在德国罗氏601型化学发光仪上,用电化学免疫发光法测定病人血清卵泡刺激素(FSH)、雌二醇(E2)、黄体生成素(LH)水平;采用酶联免疫吸附试验法测定血清AMH水平,操作严格按照试剂盒(由上海晶抗公司提供)说明书进行。
1.4统计学处理
采用SPSS 19.0统计学软件进行统计分析,计量资料数据以±s表示,组间比较采用t检验,计数资料组间比较采用χ2检验,检验水准α=0.05。
2结果
2.1两组病人一般情况比较
两组病人年龄、体质量指数(BMI)、囊肿直径比较,差异均无统计学意义(P>0.05)。见表1。
2.2两组病人术中情况比较
研究组病人手术时间和术中出血量均明显低于对照组(t=4.598、8.124,P<0.05)。见表2。
2.3两组病人术前及术后6个月激素水平比较
本文两组病人术前血清FSH、E2、FSH/LH及AMH水平比较差异均无统计学意义(P>0.05)。术后随访6个月,两组病人手术前后FSH、FSH/LH、E2水平比较差异无统计学意义(P>0.05);两组病人术后AMH水平均较术前降低,且研究组术后血清AMH水平高于对照组,差异有统计学意义(t=4.523,P<0.05)。见表3。
2.4两组病人囊壁组织卵泡残留比例和AMH表达水平比较
研究组和对照组病人囊壁组织卵泡残留比例分别为67.78%(61/90)和94.44%(85/90),研究组囊壁卵泡残留比例显著低于对照组(χ2=10.56,P<0.05)。研究组囊壁卵巢组织中AMH表达阳性率
658青岛大学学报(医学版)54卷
为52.22%(47/90),染色强度集中在+~;对照组囊壁卵巢组织中AMH表达阳性率为65.56%(59/90),染色强度集中在+~,两组AMH阳性表达率比较差异有显著性(χ2=11.25,P<0.05)。见图1。
3讨论
卵巢储备是指卵巢产生卵子数量和质量的潜能,可以间接反映卵巢功能,是女性生育能力的重要标志之一[5]。卵巢内卵泡数量减少,产生卵子能力减弱,卵母细胞质量下降而致生育能力降低,称为卵巢储备功能受损。目前,临床上常用的反映卵巢储备功能的指标有FSH、FSH/LH、E2、AMH、卵巢体积、窦卵泡计数(AFC)等。其中AMH主要由窦前、小窦卵泡的颗粒细胞分泌,相较其他指标,目前被认为是最准确的预测指标[6-8]。近期多项研究显示,卵巢EMs囊肿病人实施腹腔镜下囊肿剔除术后,卵巢储备功能明显下降[9-10]。2014年,ALBORZI等[2]对193例行卵巢EMs囊肿剔除术的育龄女性进行研究,随访6个月后发现,卵巢体积、AFC及AMH水平均较术前明显降低。提示卵巢囊肿剥除术可损伤部分正常卵巢组织,导致病人术后卵巢储备功能降低。本文研究结果显示,两组病人术后6个月血清AMH水平明显低于术前,而手术前后FSH、FSH/LH、E2水平比较差异均无统计学意义。提示手术可致卵巢储备功能降低,且AMH较其他预测指标灵敏性、特异性更高。腹腔镜下卵巢囊肿剔除术后卵巢功能损伤主要原因可能为:①手术操作使部分卵巢组织丢失;②术中使用电凝止血,造成卵巢组织损伤;③术中卵巢成形时缝线过密过紧,影响卵巢血运,致卵巢功能下降[11-12]。本研究中术后病理检查显示,两组标本囊壁组织均有卵巢组织残留,这从病理学角度证实了手术可致部分正常卵巢组织丢失,造成卵巢功能受损。EMs病灶呈侵入性生长,使囊壁分层不清,手术时囊壁撕脱困难,不可避免带走部分正常卵巢组织。 GnRH-a为人工合成的十肽类化合物,其作用与体内GnRH相同,但其亲和力较天然GnRH高百倍,竞争性地与垂体表面的GnRH受体结合,当GnRH受体被全部占滿或耗尽,FSH和LH水平大幅下降,导致卵巢分泌的性激素明显降低至绝经期水平。临床上GnRH-a多用于卵巢EMs术后,萎缩残留的微小病灶,降低EMs复发率[13-14]。国外有研究表明,无论在位内膜还是异位内膜组织均表达GnRH受体,当GnRH-a与受体结合时可抑制细胞增殖,促进细胞凋亡;同时GnRH-a具有下调血管内皮生长因子表达,抑制小血管生成及异位内膜组织炎症反应的作用[15-16]。本文研究组手术时间和术中出血量均低于对照组,差异有统计学意义。分析原因可能为:术前使用亮丙瑞林,可抑制小血管增生使术中出血量减少,同时可抑制病灶与周边组织的炎性反应,减轻粘连,使囊壁分层清楚、更易撕脱,在减少术中出血的同时缩短了手术时间。
AMH主要由卵巢组织中窦前、小窦卵泡的颗粒细胞分泌[17-18],而这两类卵泡恰是卵泡储备池的主要组成部分。对于手术可导致卵巢损伤国内外已有大量文献报道,但关于手术损失的是卵巢储备池中哪一类卵泡却少有报道。本文研究组卵泡残留比例明显低于对照组,差异有统计学意义。免疫组化结果显示,研究组AMH表达阳性率为52.22%,染色强度集中在+~,对照组AMH表达阳性率为65.56%,染色强度集中在+~,两组比较差异有统计学意义。提示研究组的卵泡损失率低于对照组,尤其是窦前、窦卵泡的损失率较对照组低。说明术前使用亮丙瑞林预处理,可有效减少在撕脱囊壁时正常卵巢组织的丢失,特别是能减少窦前、窦卵泡的损失,对卵巢功能起到一定的保护作用。对于术前使用GnRH-a,是否会因病灶过度萎缩而致病灶残留,目前尚有争论。多数研究认为,病灶萎缩程度与GnRH-a使用时间呈正相关,使用时间越长,病灶萎缩越显著,甚至达到肉眼不可见的程度,这也是临床上术后使用GnRH-a降低EMs复发的理论基础[19]。本研究术前使用GnRH-a两个周期,术后随访6个月尚未见复发病例。GnRH-a使用多长时间能最大程度萎缩病灶,使术中既能减少卵巢损伤又能避免遗漏病灶,且不增加其复发率,还需进一步大样本量研究。
综上所述,腹腔镜下EMs囊肿剔除术可导致卵巢功能受损,术前使用GnRH-a两个周期预处理可有效减少手术导致的卵泡丢失,特别是窦前、窦卵泡的丢失,从而有效降低手术对卵巢储备功能的影响。该法对于病灶较大、双侧EMs囊肿、复发性EMs囊肿以及未生育的病人尤其适用。
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