【摘要】：輸卵管能夠“撿拾”卵子,是精子與卵子受精的場(chǎng)所,也是配子和受精卵轉(zhuǎn)運(yùn)的通道,為受精卵提供了最初發(fā)育時(shí)期的適宜環(huán)境與營(yíng)養(yǎng),在妊娠中起到重要作用。受精卵滯留于輸卵管管腔內(nèi)著床,引起輸卵管妊娠。近年來(lái)輸卵管妊娠發(fā)病率增加至2%。輸卵管妊娠后生育力降低,20%遠(yuǎn)期繼發(fā)不孕、約10-27%再次輸卵管妊娠。輸卵管妊娠主要原因是輸卵管炎癥造成的輸卵管損害。輸卵管炎與輸卵管阻塞和非纖毛化有關(guān),范圍廣泛。除了肉眼形態(tài)、管腔通暢度,黏膜結(jié)構(gòu)同樣影響輸卵管功能。但輸卵管妊娠黏膜超微結(jié)構(gòu)改變少見(jiàn)報(bào)道。妊娠的輸卵管是否應(yīng)該保留?保留的輸卵管對(duì)于功能有沒(méi)有積極意義?這是本研究探討的問(wèn)題。 目的：研究輸卵管妊娠患者,妊娠輸卵管黏膜的超微結(jié)構(gòu)改變,探尋輸卵管妊娠與妊娠輸卵管功能損傷的關(guān)系。并研究輸卵管妊娠經(jīng)保守手術(shù)后繼發(fā)不孕患者,保留的輸卵管黏膜超微結(jié)構(gòu)改變,了解輸卵管妊娠后對(duì)輸卵管遠(yuǎn)期結(jié)構(gòu)和功能的影響。為有手術(shù)指征的輸卵管妊娠患者,選擇保留或切除妊娠輸卵管打下基礎(chǔ)。 方法：觀察妊娠輸卵管黏膜的超微結(jié)構(gòu)改變,實(shí)驗(yàn)組取臨床診斷為輸卵管妊娠,HCG大于5000IU/L,無(wú)內(nèi)出血,需手術(shù)治療者同意行患側(cè)輸卵管切除術(shù),腹腔鏡診斷及術(shù)后病理診斷為輸卵管壺腹部妊娠的患者。對(duì)照組取生育年齡,因卵巢良性囊腫行一側(cè)附件切除者,無(wú)生育要求,無(wú)盆腔炎病史,有陰道分娩史,病理證實(shí)輸卵管結(jié)構(gòu)正常者。輸卵管切除后立即取材固定。經(jīng)生理鹽水漂洗數(shù)次,洗去血液等,2.5%戊二醛中固定24小時(shí),PBS漂洗標(biāo)本,梯度酒精脫水,叔丁醇與100%酒精以1：1的比例混合,標(biāo)本放入純叔丁醇中一次,吸去叔丁醇,冷凍干燥,粘臺(tái),噴金,在掃描電鏡下觀察并照片。透射電鏡采用取材、前固定、后固定、梯度酒精脫水、丙酮置換、樹(shù)脂浸透、切片、染色、上鏡觀察并照片。觀察輸卵管妊娠經(jīng)保守手術(shù)后不孕患者患側(cè)輸卵管超微結(jié)構(gòu)改變,研究對(duì)象為既往經(jīng)保守手術(shù)治療,且既往為壺腹部妊娠的輸卵管妊娠后繼發(fā)不孕患者,月經(jīng)規(guī)律、有正常性生活、未避孕未孕1年以上；最后一次妊娠為輸卵管妊娠,且輸卵管妊娠次數(shù)僅一次,已治愈；子宮碘油造影提示患側(cè)輸卵管堵塞,要求行腹腔鏡探查者。腹腔鏡手術(shù)不能恢復(fù)患側(cè)管腔通暢切除患側(cè)輸卵管,取壺腹部和傘端組織作為觀察對(duì)象。采用上述掃描電鏡的方法進(jìn)行觀察。 結(jié)果：(1)輸卵管妊娠患者,妊娠部位輸卵管黏膜超微結(jié)構(gòu)改變,掃描電鏡觀察的結(jié)果與透射電鏡觀察的結(jié)果一致。(2)妊娠輸卵管壺腹部上皮由纖毛細(xì)胞和分泌細(xì)胞組成,纖毛細(xì)胞數(shù)量減少,在單個(gè)纖毛細(xì)胞上分布的纖毛數(shù)量也減少,纖毛稀疏分布,排列無(wú)規(guī)律,雜亂無(wú)章；分泌細(xì)胞數(shù)量增多,凸向管腔較正常組明顯,大小不一致,在分泌細(xì)胞頂部的微絨毛數(shù)量減少、顆粒狀、排列不規(guī)則。(3)掃描電鏡相同的倍數(shù)下,妊娠輸卵管分泌細(xì)胞數(shù)目、纖毛細(xì)胞數(shù)目分別與對(duì)照組比較差異有統(tǒng)計(jì)學(xué)意義(P0.05),纖毛長(zhǎng)度與直徑無(wú)統(tǒng)計(jì)學(xué)差異。(4)妊娠輸卵管壺腹部纖毛有9+2微管結(jié)構(gòu),線(xiàn)粒體數(shù)量減少,分泌細(xì)胞頂部凸起明顯,呈高柱狀,合成分泌的細(xì)胞器減少,固有層水腫明顯,非特異性炎細(xì)胞浸潤(rùn)明顯,基底細(xì)胞形態(tài)不規(guī)則,基底細(xì)胞胞漿內(nèi)大量擴(kuò)張的粗面內(nèi)質(zhì)網(wǎng),游離核糖體等。(5)妊娠輸卵管的非妊娠部位超微結(jié)構(gòu)改變：峽部、傘端可見(jiàn)纖毛細(xì)胞比正常相應(yīng)部位減少,纖毛變淺,纖毛數(shù)量減少。分泌細(xì)胞數(shù)量增多,大小不均,凹凸不平,微絨毛分布不均。(6)輸卵管妊娠經(jīng)保守手術(shù)后不孕患者患側(cè)輸卵管黏膜,既往妊娠部位的纖毛細(xì)胞數(shù)量明顯減少,纖毛細(xì)胞稀疏分布在分泌細(xì)胞中。分泌細(xì)胞數(shù)量明顯增加,但留存的纖毛形態(tài)完好。分泌細(xì)胞大小不均,凸向管腔的程度不一致,微絨毛大小形態(tài)不均一。妊娠輸卵管傘端上皮存在類(lèi)似的改變。 結(jié)論：妊娠的輸卵管存在嚴(yán)重超微結(jié)構(gòu)異常改變,損傷不可逆。輸卵管妊娠具有手術(shù)指征時(shí),建議切除患側(cè)輸卵管。
[Abstract]:The oviduct can "pick up" eggs. It is the place where sperm and eggs are fertilized. It is also the passage of gametes and fertilized eggs. It provides the suitable environment and nutrition for the early development of fertilized eggs and plays an important role in pregnancy. The rate increased to 2%. Fertility decreased after tubal pregnancy, 20% long-term secondary infertility, and 10-27% tubal pregnancy again. The main cause of tubal pregnancy is tubal damage caused by tubal inflammation. Tubular function. However, ultrastructural changes of the mucosa of tubal pregnancy are rarely reported. Should the tubal be retained in pregnancy? Is the retained tubal of positive significance to the function? This is the question discussed in this study.
Objective: To study the ultrastructural changes of the tubal mucosa in patients with tubal pregnancy and to explore the relationship between tubal pregnancy and tubal dysfunction during pregnancy. The effect of energy. For patients with tubal pregnancy with indications of surgery, choose to retain or resect the Pregnant Fallopian tube lay the foundation.
Methods: The ultrastructural changes of tubal mucosa in pregnancy were observed. The patients in the experimental group were diagnosed as tubal pregnancy with HCG greater than 5000IU/L and no internal bleeding. The patients in the experimental group were consented to salpingectomy, laparoscopic diagnosis and postoperative pathological diagnosis as tubal ampulla pregnancy. No fertility requirement, no history of pelvic inflammation, vaginal delivery, and pathologically confirmed normal tubal structure were found in the cyst patients who underwent unilateral adnexal excision. The specimens were mixed in proportion and put into pure tert-butanol once. The specimens were sucked out tert-butanol, freeze-dried, plated and sprayed with gold. The samples were observed and photographed under scanning electron microscope. Patients with tubal ultrastructural changes in the affected side, the object of study for conservative surgical treatment, and previous ampullary pregnancy after tubal pregnancy secondary infertility patients, menstrual regularity, normal sexual life, no contraception not more than one year; the last pregnancy for tubal pregnancy, and tubal pregnancy only once, has been cured uterus; Laparoscopic operation can not restore the lumen of the affected side to resect the fallopian tube unobstructed. The tissue of ampulla and umbrella end was taken as the object of observation. The method of scanning electron microscope was used for observation.
Results: (1) The ultrastructural changes of oviduct mucosa were observed by scanning electron microscopy and transmission electron microscopy in tubal pregnancy. (2) The epithelium of ampulla of tubal pregnancy consisted of ciliated cells and secretory cells, the number of ciliated cells decreased, and the number of ciliated cells distributed on single ciliated cells decreased. The number of secretory cells increased and the number of ciliary cells increased. The number of microvilli on the top of secretory cells decreased, granular and arranged irregularly. (3) Under the same multiple of scanning electron microscope, the number of secretory cells and the number of ciliary cells in pregnancy fallopian tubes were compared with the control group, respectively. There was no significant difference in cilia length and diameter between the two groups (P 0.05). (4) There were 9+2 microtubules in the ampulla of tubal ampulla during pregnancy. The number of mitochondria was reduced, the top of secretory cells was prominently raised, the number of organelles synthesized and secreted was reduced, the lamina propria edema was obvious, the infiltration of non-specific inflammatory cells was obvious, and the morphology of basal cells was obvious. (5) Ultrastructural changes of the non-pregnant parts of the fallopian tube during pregnancy: the isthmus and fimbria showed that the cilia were less than the normal corresponding parts, the cilia became shallow, the cilia decreased. The secretory cells increased, the size of uneven, uneven, and the distribution of microvilli was not uniform. (6) The number of ciliated cells in the fallopian tube mucosa of the infertile patients after conservative surgery decreased significantly, and the secretory cells were sparsely distributed in the secretory cells. There was a similar change in the epithelium of the fallopian tube.
Conclusion: There are serious ultrastructural abnormalities in the fallopian tube of pregnancy, and the injury is irreversible.
【學(xué)位授予單位】：天津醫(yī)科大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2014
【分類(lèi)號(hào)】：R714.22

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