子宫内膜异位症不孕的中医临床研究 思路与方法 Clinical study Approaches on TCM of Endometriosis-related Infertility  广州中医药大学妇科  欧阳惠卿  Ouyang Huiqing  Gynecological Department,

Presentation on theme: "子宫内膜异位症不孕的中医临床研究 思路与方法 Clinical study Approaches on TCM of Endometriosis-related Infertility  广州中医药大学妇科  欧阳惠卿  Ouyang Huiqing  Gynecological Department,"— Presentation transcript:

1 子宫内膜异位症不孕的中医临床研究 思路与方法 Clinical study Approaches on TCM of Endometriosis-related Infertility  广州中医药大学妇科  欧阳惠卿  Ouyang Huiqing  Gynecological Department,  Guangzhou University of TCM  March.22.2009  New York. USA

2 子宫内膜异位症不孕 Endometriosis-related Infertility  子宫内膜异位症（内异症）是指有生长功能 的子宫内膜组织在子宫腔以外的组织和器官 生长，并因异位内膜病灶的存在引发一系列 临床症状和体征的疾病。  Endometriosis is a disorder in which abnormal growths of tissue, histologically resembling the endometrium, are present in locations other than the uterine lining.

3 子宫内膜异位症不孕 Endometriosis-related Infertility  结婚 2 年，同居、性生活正常，未避孕而不孕 者称之为不孕症  A couple is said to be infertile if pregnancy does not result after 1 year of normal sexual activity without contraceptives.

4 子宫内膜异位症不孕 Endometriosis-related Infertility  与内异症共存的不孕症称为内异症不孕.  It has been suggested that endometriosis may more likely develop in women who fail to conceive for other reasons and thus be a secondary phenomenon; for this reason it is preferable to speak of endometriosis- related infertility in such cases.

5 子宫内膜异位症不孕  患内异症的妇女中合并不孕的约有 30 － 50 ％， 不孕症患者约有 30 － 58 ％同时患有内异症。  According to medical statistics it is estimated that 30-40% of women with endometriosis are also infertile.  30-58% of infertile women are found to have endometriosis.

6 内异症不孕发病机理 ( 一 ) Pathogenesis Ⅰ 1 、盆腔器官解剖结构改变 1.The implication of endometrial adhesions  内异症的盆腔存在程度不同的粘连 ，使输卵 管的拾卵以及在输卵管内的输送障碍 ；  内膜异位病灶，直接影响受孕 ；  If the Endometriosis related adhesions obstruct or close off the fallopian tube, they could obstruct the pathway of the egg and sperm and thus prevent conception;

7 内异症不孕发病机理 ( 一 ) Pathogenesis Ⅰ  卵巢周围粘连影响排卵；  盆腔腹膜的痛性结节造成的性交痛，可使性交频率 减少甚至拒绝性交，从而减少了受孕机会 ；  子宫后倾固定，宫颈向前变位难以接触精液池，影 响了精子的输入 ；  Adhesions around the ovary could influence ovulation;  Endometriosis also leads to dyspareunia due to some tender nodules in the posterior vaginal fornix;  Sperm motility may also be influenced by the cul- de-sac adhesions of the uterus.

8 内异症不孕发病机理 ( 二 ) Pathogenesis Ⅱ 2 、盆腔局部免疫环境的改变 2.Endometriosis causes reduced immune function in the Pelvic Cavity  盆腔内异位内膜病灶的病理生长和发展过程，使腹 腔液量增加和细胞成分的改变，激活了盆腔局部免 疫系统并引起了一系列效应是造成内异症不孕的重 要环节 。  巨噬细胞 ，细胞因子 （白细胞介素－ 1 、白细胞介 素－ 6 、肿瘤坏死因子 α 等），前列腺素（ PGS ）  Women with endometriosis appear to display immunologic defects or dysfunctions;  (Macrophage,Cytokines(IL-1,IL-6, TNF-α), Prostaglandins) 

9 内异症不孕发病机理 ( 三 ) Pathogenesis Ⅲ 3 、卵泡功能异常 3.Endometriosis results in the dysfunction of the Ovum  可能与腹腔液中前列腺素的含量增高有关；  Prostaglandins are released into the abdomen instead of the uterus;  促卵泡成熟素 (FSH) 含量偏低，泌乳素（ PRL ）含量偏高也 是影响卵巢排卵功能的因素之一 ；  low level of FSH and high level of PRL;  常有黄体功能不足 ；  Occasional luteal insufficiency;  黄素化未破裂卵泡综合症（ LUFS ）。  Luteinized unruptured follicle syndrome;

10 内异症不孕发病机理 ( 四 ) Pathogenesis Ⅳ 4 、 子宫内膜功能的改变 4.Dysfunction of Endometrium  子宫内膜自身抗体及炎症改变 ；  Endometrial antibody;Inflammatory responses ;  白细胞介素－ 2(IL-2) ，可以促进淋巴细胞增 生影响有效封闭抗体形成，使母体对胚胎产 生免疫攻击，抑制胚胎的发育 ；  IL-2;

11 内异症不孕发病机理 ( 四 ) Pathogenesis Ⅳ  一氧化氮合酶 ，持续过高的分泌可能降低精子活动度，过量 或不足会破坏胚胎早期发育而影响妊娠率 ；  Nitric Oxide Synthase ；  整合素；  Integrin ；  芳香化酶 ，局部过高水平的芳香化酶所导致的 E2 水平升高 可增加子宫肌收缩性和引起子宫内膜的微环境变化而影响胚 胎的种植促成不孕 ；  Aromatase;  基质金属蛋白酶（ MMPS ）及其抑制物（ TIMPS ）。  MMPS/TIMPS 。

12 内异症的病理类型 ( 一 ) Pathology Ⅰ  内异症在组织学上是良性表现，但由于在疾 病发展中可引起局部浸润、播散，造成盆腔 器官或组织的广泛损害，因而导致内异症的 病理形态表现为多形性和不一致性。  Endometriosis is a benign lesion, but can be invasive; widely implanted and recurrent ， causing multi-formations ．  按异位病灶发生的部位 可分为：  Manifestations of the pathology differ according to locations:

13 内异症的病理类型 ( 二 ) Pathology Ⅱ 1 、腹膜内异症 1. Peritoneal Endometriosis  镜下病变  Lesions under the microscope  早期临床病变或活动性病变，又称红色病变  red lesions  典型病变或进展活动性、晚期病变，又称黑色病变  black typical lesions  愈合病变或非活动性病变，又称白色病变  white lesions

14 内异症的病理类型 ( 三 ) Pathology Ⅲ 2 、卵巢内异症 ( 又稱卵巢朱古力囊腫 ) 2. Ovarian Endometrial Cysts or Endometrioma - "chocolate cysts" due to the large amount of blood and debris they contain; 3 、结节性或阴道直肠子宫内膜异位症 3.Deep Nodular Endometriosis - ectopic tissue infiltrates into the rectovaginal septum or fibromuscular pelvic structures (e.g. uterosacral and utero-ovarian ligaments).

15 内异症不孕的临床诊断 ( 一 ) Diagnosis Ⅰ 1 、症状 1.Symptoms  不孕；  Infertility  痛经为内异症患者的常见症状，多为继发性和渐进性；  Dysmenorrhea;  或痛经发作时伴有腰骶部疼痛、肛门下坠感；  Lower back pain and Dyschezia ;  部分患者表现为持续性下腹部疼痛、性交痛等；  Dyspareunia (painful intercourse);  部份患者表现为月经量增多或经期延长。  Heavy or long menstrual periods.

16 内异症不孕的临床诊断 ( 二 ) Diagnosis Ⅱ 2 、体征 2.Signs  典型的内异症多表现为子宫后倾固定；  Fixed and retroverted uterus;  子宫直肠陷窝、宫骶韧带或子宫后壁下段等部位可扪及大小 不等的触痛性结节；  Tender nodules in the posterior vaginal fornix and pain on gynaecological examination;  宫颈或阴道壁可见点状或结节状紫蓝色病灶；  Indigo nodules;  可在一侧或双侧附件区扪及与子宫有粘连的囊性包块；  Adnexal masses;  重度者可触及 “ 冰冻骨盆 ” 。  internal organs may fuse together, causing a condition known as a "frozen pelvis” (advanced stages);

17 内异症不孕的临床诊断 ( 三 ) Diagnosis Ⅲ 3 、影像学检查 3.Imaging tests  阴道 B 超对卵巢内膜异位囊肿的诊断准确率较高。  肠道浸润的深部内异症，经直肠超声是一种较准确 的诊断方法。  核磁共振（ MRI) 对卵巢囊肿、宫骶韧带独立结节和 阴道直肠膈结节的敏感性又高于阴道 B 超。  但對盆腔广泛性病变的诊断性不高。  Ultrasound  Magnetic resonance imaging

18 内异症不孕的临床诊断 ( 四 ) Diagnosis Ⅳ 4 、腹腔镜检查 —— 腹腔镜检查及术中活组织检查是诊断内异 症的 “ 金标准 ” 4. Laparoscopy & Biopsy - the "the golden standard” to definitively diagnose endometriosis according to its pathological manifestation;  能直接观察到腹膜表面各病理类型的病灶和卵巢朱古力囊肿；  卵巢和输卵管的形态和解剖关系，输卵管注入美蓝液尚可觀 察到输卵管的通畅度，以评估其对生育能力的影响；  但对阴道直肠膈深部浸润的内异症（病灶向腹膜下浸润达到 5mm 以上的内异症）则容易漏诊。

19 内异症不孕的临床诊断 ( 五 ) Diagnosis Ⅴ 5 、生化检测 5.Marker----CA125  血清 CA 125 对诊断深部内异症和卵巢内异症参考价 值较高，作为内异症诊断以及治疗后复发的参考依 据。  may predict the response to medical and surgical treatment;  may also be helpful in differentiating endometriomas from non-endometriotic benign cysts.

20 TCM VIEW 祖国医学对内异症不孕研究思路的启示  中医古籍无内异症的病名记载，西医关于内异症的 病理机制研究 —— 经血倒流内膜种植学说，恰好是 王清任提出的离经之血即是瘀血的现代临床研究。  There were no records of endometriosis in the ancient books of Chinese Medicine;  The theory of Wang Qingren, a famous Chinese physician of ancient times, views extravasated blood as stasis is in accord with Western theories of retrograde menstruation and transplantation;

21 TCM VIEW  中医认为，不循正常通道 —— 即阴道排出而逆流入 盆腔的经血为 “ 离经之血 ” ，即是瘀血，瘀血聚结胞 中，导致冲任二脉失调，或瘀血占住胞宫均可致不 能摄精成孕，因此认定内异症以瘀血为基本病机。  根据内异症以血瘀为本的研究思路，临床上的治疗 研究以活血化瘀为基本方法 。  According to current TCM views, Endometriosis is considered as blood stasis in the Chong and Ren channels that subsequently leads to infertility;  Therefore the TCM treatment principle is to remove the stasis by promoting circulation;

22 内异症不孕的中医治疗 TCM Therapy  治療原則：活血祛瘀  選藥原則：活血化瘀不動血，散結消癥不 破血， 調經止血不歛濇，通調經脈以助孕，補血慎用益精 藥，益氣少用壅補劑。  Treatment principle:  remove the blood stasis and promote the circulation;  Selecting the right herbs:  Avoid herbs which strongly move blood  Avoid astringent herbs  Do not use too many tonifying herbs

23 内异症不孕的中医治疗 TCM Therapy 1 、活血化瘀消癥法  Method -1: Herbs to move blood and remove stasis  司徒仪报道，用丹参、赤芍、当归、郁金、水蛭活血化瘀， 三棱、莪术、鸡内金、浙贝、鳖甲化癥散结，枳壳理气，治 疗内异症不孕 15 例，受孕 8 例（妊娠率 53.3% ）。本方用水 蛭配伍三棱、莪术会加强活血消癥之力。  Salvia, Red Peony Root, Angelica Sinensis, Curcuma Longa, Leech - to activate blood circulation.  Rhizoma Sparganii, Zedoary Turmeric, Galli Corium Stomachium, Fritillary Bulb, Trio Nyx Sinensis - to disperse mass.  Citrus aurtantium – to regulate blood condition.  Source: study by Situ Yi - Pregnancy rate achieved: 53.3%

24 内异症不孕的中医治疗 TCM Therapy 2 、化瘀通腑法  Method – 2: Disperse blood stasis by Purging  王祖倩报道以醋制大黄、醋制炙鳖甲、琥珀按 2 ∶ 2 ∶ 1 比例制成丸剂，治疗内异症不孕患者 25 例，受孕 8 例（妊娠率 32 ％）。本方用大黄化瘀通腑逐邪为特 点。  Pills composed of Da huang (Rhubarb processed with vinigar), Trio Nyx Sinensis (processed with vinigar), Amber - to cure the patients with endometriosis related infertility;  Pregnant rate was 32%.  Reported by Wang Zuqian.

25 内异症不孕的中医治疗 TCM Therapy 3 、化瘀祛痰消癥法 Method – 3: Remove blood stasis, phlegm and mass  周元荣报道用大黄、血竭、三七、穿山甲、鳖甲、怀牛膝、 地鳖虫化瘀消癥，海藻、薏苡仁、川贝母利湿祛痰。治疗内 异症不孕 17 例，受孕 4 例（妊娠率 23.55% ）。本方痰瘀分消， 据报道纳入治疗 60 例，其中巧克力囊肿患者占 26 例。从组方 分析，本资料比较有针对性的治疗卵巢巧克力囊肿。  Rhubarb, Daemonorops draco, Panax Notoginseng, Pangolin, Trio Nyx Sinensis, Achyranthes Bidentata Bl., Eupolyphaga - to remove blood stasis and mass;  Varec, Semen Coicls, Bulbus Fritillariae Cirrhosae - to promote diuresis to eliminate damp and phlegm;  Pregnant rate was 23.55%  Reported by Zhou Yuanrong.

26 内异症不孕的中医治疗 TCM Therapy 4 、温阳化瘀法  Method– 4:Warm the yang and remove blood stasis  朱兰等报道用良方温经汤加味，以当归、川芎、白 芍、牛膝、莪术、丹皮活血化瘀，桂心温补元阳， 人参温补中焦，治疗内异症不孕 15 例，治疗后妊娠 12 例， ( 妊娠率 80 ％ ) 。  Angelica, Rhizoma Ligustici Chuanxiong, Radix Paeoniae Alba, Achyranthes Bidentata, Cortex Moutan - to remove blood stasis;  Cinnamon and Panax - to warm the yang.  Pregnant rate was 80 ％ (Reported by Zhu Lan)

27 Method4  张予宛报道用少腹逐瘀汤加味以当归、川芎、蒲黄、五灵脂、 赤芍、没药、元胡索活血理气化瘀，肉桂、干姜、小茴香温 阳，治疗内异症不孕 94 例，受孕 57 例， ( 妊娠率 60.63 ％ ) 。 以上两报道均以肉桂温阳通脉散瘀配伍辛温之归芎，非寒实 证不可轻用。  Angelica, Rhizoma Ligustici Chuanxiong, Radix Paeoniae Rubra, Typha orientalis, Faeces Trogopterori, Rhizoma Corydalis, Myrrh - to promote blood circulation and regulate qi to remove blood stasis;  Cinnamon, Dried Ginger, fennel can warm yang.  Pregnant rate was 60.63 ％.(Reported by Zhang yuwan)

28 内异症不孕的中医治疗 TCM Therapy 5 、化瘀补肾法 Method-5:Nourish Kidneys and Remove Blood Stasis  王宁以当归、桃仁、石打穿、蒲黄、五灵脂、皂角刺活血化瘀散结，肉 桂、淫羊藿、地黄、制首乌补肾益精治疗内异症不孕 15 例，受孕 9 例 （妊娠率 60 ％）。另外，不孕症并自然流产者 15 例，用該方治疗后已分 娩 11 人，孕期大于 4 个月 4 人（妊娠率 88.2 ％）。本研究主要探讨活血化 瘀佐以补肾方药对内异症不孕与内异症自然流产的免疫调节作用。本組 病例中， 29 例血清子宫内膜抗体阳性患者治疗 2 个月复查子宫内膜抗体， 结果 28 例呈阴性反应，阴转率达 96.5% 。  Angelica, Peach Kernel, Faeces Trogopterori, Rhizoma Corydalis, Zaojaoci, Shidachuan - to remove blood stasis and mass;  Cinnamon, Barrenwort, Rehmanniae, Polygonum - to invigorate the kidney.  Pregnant rate was 60 ％. (Reported by Wang Ning)

29 Method 5  张丽君以丹参、川芎、三棱、莪术、血竭末、茺蔚 子活血化瘀，续断、枸杞子、菟丝子补肾益精，治 疗内异症不孕 30 例，经 1 ～ 3 疗程治疗后，受孕 5 例， ( 妊娠率 17 ％ ) 。本法以化瘀消癥为主，补肾药性平 和，不偏温通滋而不膩。  Salvia, Rhizoma Ligustici Chuanxiong, Rhizoma Ligustici Chuanxiong, Rhizoma Sparganii, Zedoary Turmeric, Daemonorops draco, Motherwort Seed - to remove blood stasis and promote the circulation.  Teasel,Wolfberry, Cuscuta Chinensis - to invigorate the kidney.  Pregnant rate was17 ％.(Reported by Zhang Lijun)

30 Method 5  李祥云以三棱、莪术、水蛭、地鳖虫、穿山甲活血 化瘀，菟丝子、仙灵脾补肾气治疗内异症不孕 109 例， 68 例受孕，治愈率为 63.39% 。本法消癥通络力 稍强，经量多或经期长者，要注意服药时间、配伍 及剂量调节。  Rhizoma Sparganii, Zedoary Turmeric, Leech, Eupolyphaga Sinensis, Pangolin - to remove blood stasis and promote the circulation;  Cuscuta Chinensis, Xianlingpi - to supplement the kidney;  Pregnant rate was 63.39%.(Reported by Li Xiangyun)

31 内异症不孕的中医治疗 TCM Therapy 6 、益气化瘀法 Method-6: Tonify Qi and Remove Blood Stasis  陈晓平等报道以补阳还五汤原方运用，以当归尾、川芎、赤 芍、桃仁、红花活血化瘀，地龙通络，黄芪补气，治疗内异 症不孕 16 例，受孕 12 例（妊娠率 75 ％）。  Angelica, Peach Kernel, Rhizoma Ligustici Chuanxiong, Safflower, Radix Paeoniae Alba - to remove the stasis.  Di long (Earthworm) – to unblock the channels;  Huang qi (Astragalus) – to supplement Qi.  Pregnant rate was 75%.(Reported by Chen Xiaoping).

32 Method 6  傅友丰等以失笑散、生贯众、鬼见羽、益母草、制香附、元 胡索活血理气化瘀，皂角刺祛痰散结，黄芪、人参补气治疗 内异症不孕 22 例，受孕 9 例（ 40.9% ）。本法黄芪重用，意 在补气以行血、补为通用。  Typha orientalis, Faeces Trogopterori, Cyrtomium Fortunei, Motherwort, Aconite, Rhizoma Corydalis - to regulate Qi and promote the circulation;  Zaojiaoci - to disseminate mass and Huang qi (Astragalus) and ren shen (Panax) - to supplement Qi.  Pregnant rate was 40.9%.(Reported by Fu Youfeng)

33 西医药物治疗 Western Medication  醋酸炔诺酮 5mg/D*6 个月  Ethyl nortestosterone 5mg/D,6months  甲羟孕酮 20~50mg/D*6 个月  Medroxyprogesterone 20~50mg/D ， 6 months  达那唑 0.2 Bid~Tid*6 个月  Danazol 0.2 Bid~Tid ， 6 months  孕三烯酮 2.5mg/ 次 每周 2 次 *3-6 个月  Gestrinone 2.5mg/each time and two times per week, 3-6 months  亮丙瑞林 3.75mg 皮下注射 每 28 天一次  Leuprorelin(GnRH-α) 3.75mg Subcutaneous injection, every 28 days.  戈舍瑞林 3.6mg 皮下注射 每 28 天一次  Goserelin Acetate Leuprorelin(GnRH-α) 3.6mg Subcutaneous injection, every 28 days.

34 手术治疗 Surgical Treatment  卵巢异位内膜囊肿剔除术  盆腔粘连松解术  盆腔腹膜病灶去除术  盆腔深部结节去除术  Excision (endometrioma,deeper lesions )  Pelvic adhesion lysis  Electrosurgical Ablation

35 治疗选择的建议 ( 一 ) Treatment Suggestions Ⅰ 1 、首先了解盆腔病变情况对生育功能的影响，根据患者的证 候、病理类型的不同，制定个体化的治疗方案。  盆腔器官无解剖变异因素存在，中药治疗可作为首选。  若卵巢被粘连包裹、输卵管阻塞，則药物治疗难以奏效，不 宜作为内异症不孕的中药治疗研究对象。  1.According to clinical manifestation individual therapeutic strategies are established, depending on how the disease may influence the reproductive function:  Chinese medication may be the first choice if no anatomical structures change in pelvic cavity;  Chinese medication is used only in support of WM if the patient suffers from severe adhesions that obstructs the fallopian tubes; 

36 治疗选择的建议 ( 二 ) Suggestions of treatment Ⅱ 2 、中、重度内异症不孕，但输卵管通畅，手术 松解盆腔粘连或剔除较大的卵巢巧克力囊肿 后，施以中药治疗，临床观察表明，可缩短 疗程提高疗效。 2. Clinical studies show that Chinese medicine can shorten the healing process and increase the chances of fertility in women with severe adhesions, but patent fallopian tubes.

37 治疗选择的建议 ( 三 ) Suggestions of treatment Ⅲ 3 、年龄大于 35 岁，双侧输卵管阻塞者，宜施行人工 受精或试管婴儿。辅助生育手术前，中药治疗 3 － 6 个月，改善盆腔微环境，可提高妊娠率。  3.Infertile women with endometriosis who are older(>35), or who have fallopian tube obstructions, can undergo assisted reproduction (in vitro fertilization, gamete intra-fallopian transfer,etc).  Chinese medicine will be used to assist conception and improve successful pregnancy rate.

38 治疗选择的建议 ( 四 ) Suggestions of treatment Ⅳ 4 、伴有月经量多，经期延长或月经先期者，非 经时用药宜选用祛瘀不动血药，经时用药宜 祛瘀止血药如失笑散、三七、大黄、血竭、 没药、茜草、大蓟、小蓟等；  4. Infertile women with endometriosis who suffer from menorrhagia, or menostaxis, or prolonged menstrual cycle may choose different herbs in different phases of their cycle.

39 治疗选择的建议 ( 四 ) Suggestions of treatment Ⅳ  气虚证者宜益气摄血如白术、黄芪、人参等；  阳虚肾虚者宜温补肾阳如艾叶、续断、鹿角霜等。  Treat Qi deficiency with herbs that can tonify vital energy and nourish blood, such as Atractylodes, Huang qi (Astragalus), ren shen (Panax),etc.  Treat deficiency of kidney-yang with herbs that can warm kidney-yang, such as mugworf leaf, Teasel etc.

40 病案分析 Case  黄某， 36 岁  因 “ 痛经 10 年余，不孕 3 年 ” 于 2006 年 12 月 28 日初诊。  Ms Huang, Aged 36.  She first came to clinic for her 10-year dysmenorrhea and 3-year infertility on Dec.28th,2006.

41  患者因 “ 痛经、不孕 ”2002 年 3 月经腹腔镜检查诊断为盆 腔子宫内膜异位症，并行病灶剔除术。术后痛经减轻， 月经正常，经量中等。 2004 年 1 月右输卵管妊娠行右输 卵管切除术。此后未避孕未再孕。末次月经月 2006 年 12 月 12 日， 7 天干净，经色暗红挟血块。经前乳房胀痛， 经行小腹痛甚，伴四肢冷，恶心欲吐。卧床 2 日，服止 痛药 3 天。舌质紫黯有瘀斑，苔黄，脉弦。  She was diagnosed ‘endometriosis’ by Laparoscopy and lesions was ablated at the same time in March, 2002. Dysmenorrhea was improved with normal period. Salpingectomy (right side) was done due to tubal pregnency in Jan.,2004. LMP Dec. 12th,2006. Period bleeding was dark with gore. Breast felt pain before period and low abdomen felt pain during period with cold extremities and nausea.  Dark purple tongue with ecchymosis and yellow coating.  Wiry pulse.

42  证属气滞血瘀，拟祛瘀消癥，行气止痛。  Qi stagnation and blood stasis,  Remove blood stasis and mass and promote qi to relieve pain.

43  方药：鸡内金 9 克，蒲黄（包） 12 克，五灵脂 9 克， 延胡索 15 克，乌药 15 克，三七 9 克，大黄 9 克，土鳖 虫 12 克，益母草 15 克，莪术 9 克，三棱 9 克，丹皮 12 克，醋鳖甲 20 克，猫爪草 15 克，赤芍 12 克。  Precription:  Jineijin 9g, Puhuang 12g, Wanglingzhi 9g, Yanhusuo 15g, Wuyao 15g, Sanqi 9g, Dahuang 9g, Tubiechong 12g, Yimucao 15g, Ezhu 9g, Sanleng 9g, Danpi 12g, Biejia 20g, Maozhuacao 20g, Chishao 12g.

44  治疗 2 月，痛经明显减轻，继以补肾活血法调治， 上方加菟丝子 15 克，续断 15 克，熟地 15 克，治疗近 4 个月怀孕，但妊娠 6 周因工作操劳至流产。  本例先拟化瘀理气治疗，痛经减轻，生活质素得以 改善后，在活血化瘀为主佐以补肾治疗而获妊娠。 但患者于妊娠后未注意调摄，伤损胎气以至流产。 Dysmenorrhea relieved obviously after 2-month treatment. Then nourishing kidney was added. Tusizi(15g), Xuduan(15g), Shudi(15g) was used. The patient was expecting after 4-month treatment. Miscarriage was happened after 6 weeks pregnancy because of swink.

45  内异症术后妊娠率可达 53 － 73 ％左右。随着距离手 术时间愈长，临床观察到部分患者妊娠率有逐渐下 降的趋势。本例活血化瘀中药止痛调经疗效较显著。 目前研究的结果表明，主要是调低前列腺的活性作 用，对前列腺素的细胞介素、肿瘤坏死因子以及对 卵巢子宫内膜免疫损伤的调节被认为是促进内异症 不孕的可能因素。  The pregnancy rate after surgical treatment may reach to 53-73% of the endometriosis, but it may decrease with the passage of time.  The studies showed that the herbs that can move blood and remove stasis may relieve pain and regulate menstruation because the activities of prostaglandins were decreased.

46  在既往很多的报道中，补肾中药具有性激素 作用，故必须在活血化瘀消癥的治疗基础上 使用。  The herbs that nourish kidney may show the role of sexual hormone on the basis of removing blood stasis and mass.

47 Thank you!