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Менеджмент эндометриом
Дубровина С.О., Берлим Ю.Д., Гимбут В.С. и др. Менеджмент эндометриом. Гинекология. 2017; 19 (4): 30–35. DOI: 10.26442/2079-5696_19.4.30-35
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Dubrovina S.O., Berlim Yu.D., Gimbut V.S. et al. Management of endometriomas. Gynecology. 2017; 19 (4): 30–35. DOI: 10.26442/2079-5696_19.4.30-35
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Аннотация
Яичниковые эндометриомы могут поражать до 44% всех женщин с эндометриозом, часто ассоциированы с тазовой болью и бесплодием. Выбор лечения включает выжидательную тактику, медикаментозное или хирургическое лечение, а также экстракорпоральное оплодотворение. Предпочтение в методе лечения зависит большей частью от ассоциированных симптомов. В большинстве случаев хирургическое вмешательство является основным выбором, поскольку эндометриомы не отвечают на медикаментозное лечение, способное только облегчить боль. В случае бесплодия экстракорпоральное оплодотворение может быть подходящей альтернативной хирургическому вмешательству, особенно при отсутствии боли. Согласно научным заключениям, лапароскопическое удаление эндометриом может быть рассмотрено как процедура выбора. Однако хирургическое лечение может повредить овариальный резерв. В то же время недавние исследования подтверждают, что частично повреждения могут быть обусловлены самой эндометриомой. При выборе хирургического лечения должны быть взвешены возможные риски повреждения овариального резерва во время операции и преимущества хирургического вмешательства для облегчения болевого синдрома, а также возможность получения тканей для исключения редких случаев малигнизации. В статье представлены таблица подсчета рисков и обоснований, необходимых для клиницистов в принятии решения о необходимости выполнении хирургического лечения, и шкала подсчета индекса фертильности во время оперативного вмешательства при эндометриозе.
Ключевые слова: Лонгидаза, эндометриоз, эндометриома, терапия.
Ключевые слова: Лонгидаза, эндометриоз, эндометриома, терапия.
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Ovarian endometriomas could affect up to 44% of women with endometriosis, and are often associated with pelvic pain and infertility. Treatment options include expectant management, medical and/or surgical treatment, and in vitro fertilization. The choice of treatment depends mostly on the associated symptoms. In most cases, surgery is the preferred choice, since endometriomas do not respond to medical treatment, which may only treat associated pain. In case of infertility, in vitro fertilization and embryo transfer may be a suitable alternative to surgery, particularly when there is no associated pain. According to the best available scientific evidence, laparoscopic excision of the endometrioma wall should be considered the procedure of choice. The surgical excision may damage the ovarian reserve. At the same time, recent evidences demonstrate that part of the damage may be due to the presence of the endometrioma itself. Indication to surgical treatment should balance the possible risks of damaging the ovarian reserve with the advantages of surgery in terms of satisfactory pain relief rates and pregnancy rates, and of obtaining tissue specimen for ruling out the rare cases of unexpected ovarian malignancy. A score system to guide the clinician in the decision to perform or withhold surgery and endometriosis fertility index are presented.
Key words: Longidaza, endometriosis, endometrioma, therapy.
Полный текст
Список литературы
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2. Practice Committee of the American Society for Reproductive Medicine Endometriosis and infertility: a committee opinion. Fertil Steril 2012; 98 (3): 591–8.
3. Practice Committee of the American Society for Reproductive Medicine. Treatment of pelvic pain associated with endometriosis: a committee opinion. Fertil Steril 2014; 101 (4): 927–35. DOI: 10.1016/j.fertnstert.2014.02.012
4. Muzii L, Tucci CD, Feliciantonio MD et al. Management of Endometriomas. Semin Reprod Med 2017; 35 (1): 25–30. DOI: 10.1055/s-0036-1597126
5. Dunselman GA, Vermeulen N, Becker C et al. ESHRE guideline: management of women with endometriosis. Hum Reprod 2014; 29 (3): 400–12. DOI: 10.1093/humrep/det457
6. Guzick DS, Silliman NP, Adamson GD et al. Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis. Fertil Steril 1997; 67 (5): 822–9.
7. Vercellini P, Somigliana E, Viganò P et al. Surgery for endometriosis-associated infertility: a pragmatic approach. Hum Reprod 2009; 24 (2): 254–69. DOI: 10.1093/humrep/den379
8. Leyland N, Casper R, Laberge P et al. Endometriosis: diagnosis and management. J Obstet Gynaecol Can 2010; 32 (7 Suppl. 2): S1–32.
9. Alcá́zar JL, Royo P, Jurado M et al. Triage for surgical management of ovarian tumors in asymptomatic women: assessment of an ultrasoundbased scoring system. Ultrasound Obstet Gynecol 2008; 32 (2): 220–5.
10. Valentin L, Ameye L, Franchi D et al. Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol 2013; 41 (1): 80–9. DOI: 10.1002/uog.12308
11. Gonçalves FC, Andres MP, Passman LJ et al. A systematic review of ultrasonography-guided transvaginal aspiration of recurrent ovarian endometrioma. Int J Gynaecol Obstet 2016; 134 (1): 3–7. DOI: 10.1016/j.ijgo.2015.10.021
12. Padilla SL. Ovarian abscess following puncture of an endometrioma during ultrasound-guided oocyte retrieval. Hum Reprod 1993; 8 (8): 1282–3.
13. Muzii L, Marana R, Caruana P et al. Laparoscopic findings after transvaginal ultrasoundguided aspiration of ovarian endometriomas. Hum Reprod 1995; 10 (11): 2902–3.
14. Chapron C, Vercellini P, Barakat H et al. Management of ovarian endometriomas. Hum Reprod Update 2002; 8 (6): 591–7.
15. Alborzi S, Momtahan M, Parsanezhad ME et al. A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril 2004; 82 (6): 1633–7.
16. Carmona F, Martínez Zamora MA et al. Ovarian cystectomy versus laser vaporization in the treatment of ovarian endometriomas: a randomized clinical trial with a fiveyear followup. Fertil Steril 2011; 96 (1): 251–4.
17. Hart RJ, Hickey M, Maouris P et al. Excisional surgery versus ablative surgery for ovarian endometriomata. Cochrane Database Syst Rev 2008; 2: CD004992. DOI: 10.1002/14651858.CD004992.pub3
18. Tsolakidis D, Pados G, Vavilis D et al. The impact on ovarian reserve after laparoscopic ovarian cystectomy versus three-stage management in patients with endometriomas: a prospective randomized study. Fertil Steril 2010; 94 (1): 71–7. DOI: 10.1016/j.fertnstert.2009.01.138
19. Kondo W, Bourdel N, Zomer MT et al. Laparoscopic cystectomy for ovarian endometrioma – a simple stripping technique should not be used. J Endometr 2011; 3 (3): 125–34.
20. Дубровина С.О., Берлим Ю.Д., Гимбут В.С. и др. Современные представления об эндометриоидных кистах яичников. Проблемы репродукции. 2015; 21 (3): 98–105. / Dubrovina S.O., Berlim Yu.D., Gimbut V.S. i dr. Sovremennye predstavleniia ob endometrioidnykh kistakh iaichnikov. Problemy reproduktsii. 2015; 21 (3): 98–105. [in Russian]
21. Bourdel N, Roman H, Mage G, Canis M. Surgery for the management of ovarian endometriomas: fr om the physiopathology to the pre-, peri- and postoperative treatment. Gynecol Obstet Fertil 2011; 39 (12): 709–21. DOI: 10.1016/j.gyobfe.2011.07.051
22. Coric M, Barisic D, Pavicic D et al. Electrocoagulation versus suture after laparoscopic stripping of ovarian endometriomas assessed by antral follicle count: preliminary results of randomized clinical trial. Arch Gynecol Obstet 2011; 283 (2): 373–8. DOI: 10.1007/s00404-010-1676-x
23. Guo SW. Recurrence of endometriosis and its control. Hum Reprod Update 2009; 15 (4): 441–61. DOI: 10.1093/humupd/dmp007
24. Busacca M, Marana R, Caruana P et al. Recurrence of ovarian endometrioma after laparoscopic excision. Am J Obstet Gynecol 1999; 180 (3 Pt. 1): 519–23.
25. Morgante G, Ditto A, La Marca A et al. Low-dose danazol after combined surgical and medical therapy reduces the incidence of pelvic pain in women with moderate and severe endometriosis. Hum Reprod 1999; 14 (9): 2371–4.
26. Yap C, Furness S, Farquhar C et al. Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev 2004; 3: CD003678.
27. Seracchioli R, Mabrouk M, Manuzzi L et al. Post-operative use of oral contraceptive pills for prevention of anatomical relapse or symptom-recurrence after conservative surgery for endometriosis. Hum Reprod 2009; 24 (11): 2729–35. DOI: 10.1093/humrep/dep259
28. Vercellini P, DE Matteis S, Somigliana E et al. Long-term adjuvant therapy for the prevention of postoperative endometrioma recurrence: a systematic review and meta-analysis. Acta Obstet Gynecol Scand 2013; 92 (1): 8–16. DOI: 10.1111/j.1600-0412.2012.01470.x
29. Seracchioli R, Mabrouk M, Frascà C et al. Long-term cyclic and continuous oral contraceptive therapy and endometrioma recurrence: a randomized controlled trial. Fertil Steril 2010; 93 (1): 52–6. DOI: 10.1016/j.fertnstert.2008.09.052
30. Seracchioli R, Mabrouk M, Frascà C et al. Long-term oral contraceptive pills and postoperative pain management after laparoscopic excision of ovarian endometrioma: a randomized controlled trial. Fertil Steril 2010; 94 (2): 464–71. DOI: 10.1016/j.fertnstert.2009.03.083
31. Muzii L, Maneschi F, Marana R et al. Oral estroprogestins after laparoscopic surgery to excise endometriomas: continuous or cyclic administration? Results of a multicenter randomized study. J Minim Invasive Gynecol 2011; 18 (2): 173–8. DOI: 10.1016/j.jmig.2010.11.004
32. Muzii L, Di Tucci C, Achilli C et al. Continuous versus cyclic oral contraceptives after laparoscopic excision of ovarian endometriomas: a systematic review and metaanalysis. Am J Obstet Gynecol 2016; 214 (2): 203–11. DOI: 10.1016/j.ajog.2015.08.074
33. Vercellini P, Chapron C, De Giorgi O et al. Coagulation or excision of ovarian endometriomas? Am J Obstet Gynecol 2003; 188 (3): 606–10.
34. Llarena N, Flyckt R. Strategies to preserve and optimize fertility for patients with endometriosis. J Endometr Pelvic Pain Disord 2017; 9 (2): 98–104.
35. Busacca M, Riparini J, Somigliana E et al. Postsurgical ovarian failure after laparoscopic excision of bilateral endometriomas. Am J Obstet Gynecol 2006; 195 (2): 421–5.
36. Coccia ME, Rizzello F, Mariani G et al. Ovarian surgery for bilateral endometriomas influences age at menopause. Hum Reprod 2011; 26 (11): 3000–7. DOI: 10.1093/humrep/der286
37. Goodman LR, Goldberg JM, Flyckt RL et al. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol 2016; 215 (5): 589.e1–589.e6. DOI: 10.1016/j.ajog.2016.05.029
38. Chen Y, Pei H, Chang Y et al. The impact of endometrioma and laparoscopic cystectomy on ovarian reserve and the exploration of related factors assessed by serum anti-Mullerian hormone: a prospective cohort study. J Ovarian Res 2014; 7: 108. DOI: 10.1186/s13048-014-0108-0
39. Benaglia L, Bermejo A, Somigliana E et al. In vitro fertilization outcome in women with unoperated bilateral endometriomas. Fertil Steril 2013; 99 (6): 1714–9. DOI: 10.1016/j.fertnstert.2013.01.110
40. Sanchez AM, Viganò P, Somigliana E. The distinguishing cellular and molecular features of the endometriotic ovarian cyst: from pathophysiology to the potential endometrioma-mediated damage to the ovary. Hum Reprod Update 2014; 20 (2): 217–30. DOI: 10.1093/humupd/dmt053
41. Ding Y, Yuan Y, Ding J et al. Comprehensive Assessment of the Impact of Laparoscopic Ovarian Cystectomy on Ovarian Reserve. J Minim Invasive Gynecol 2015; 22 (7): 1252–9. DOI: 10.1016/j.jmig.2015.07.011
42. Celik HG, Dogan E, Okyay E et al. Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels. Fertil Steril 2012; 97 (6): 1472–8. DOI: 10.1016/j.fertnstert.2012.03.027
43. Ercan CM, Sakinci M, Duru NK et al. Antimullerian hormone levels after laparoscopic endometrioma stripping surgery. Gynecol Endocrinol 2010; 26 (6): 468–72. DOI: 10.3109/09513591003632134
44. Hirokawa W, Iwase A, Goto M et al. The post-operative decline in serum anti-Mullerian hormone correlates with the bilaterality and severity of endometriosis. Hum Reprod 2011; 26 (4): 904–10. DOI: 10.1093/humrep/der006
45. Hamdan M, Dunselman G, Li TC et al. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis. Hum Reprod Update 2015; 21 (6): 809–25. DOI: 10.1093/humupd/dmv035
46. Tsoumpou I, Kyrgiou M, Gelbaya TA et al. The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis. Fertil Steril. 2009; 92 (1): 75–87. DOI: 10.1016/j.fertnstert.2008.05.049
47. Benschop L, Farquhar C, van der Poel N et al. Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev 2010; 11: CD008571. DOI: 10.1002/14651858.CD008571.pub2
48. Almog B, Sheizaf B, Shalom-Paz E et al. Effects of excision of ovarian endometrioma on the antral follicle count and collected oocytes for in vitro fertilization. Fertil Steril 2010; 94 (6): 2340–2. DOI: 10.1016/j.fertnstert.2010.01.055
49. Somigliana E, Ragni G, Benede F et al. Does laparoscopic excision of endometriotic ovarian cysts significantly affect ovarian reserve? Insights from IVF cycles. Hum Reprod 2003; 18 (11): 2450–3.
50. Esinler I, Bozdag G, Aybar F et al. Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas. Fertil Steril 2006; 85 (6): 1730–5.
51. Ho HY, Lee RK, Hwu YM et al. Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation. J Assist Reprod Genet 2002; 19 (11): 507–11.
52. Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod 2009; 24 (3): 496–501. DOI: 10.1093/humrep/den398
53. Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010; 94 (5): 1609–15. DOI: 10.1016/j.fertnstert.2009.09.035
54. Luciano DE, Roy G, Luciano AA. Adhesion reformation after laparoscopic adhesiolysis: wh ere, what type, and in whom they are most likely to recur. J Minim Invasive Gynecol 2008; 15 (1): 44–8. DOI: 10.1016/j.jmig.2007.09.012
55. Fayez JA, Vogel MF. Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynecol 1991; 78 (4): 660–5.
56. Ahmad G, O'Flynn H, Hindocha A et al. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015; 4: CD000475. DOI: 10.1002/14651858.CD000475.pub3
57. Tulandi T, Closon F, Czuzoj-Shulman N et al. Adhesion Barrier Use After Myomectomy and Hysterectomy: Rates and Immediate Postoperative Complications. Obstet Gynecol 2016; 127 (1): 23–8. DOI: 10.1097/AOG.0000000000001186
58. Петрович Е.А., Манухин И.Б. Инновационный подход к лечению трубно-перитонеального бесплодия. Вопр. гинекологии, акушерства и перинатологии. 2010; 9 (6): 5–10. / Petrovich E.A., Manukhin I.B. Innovatsionnyi podkhod k lecheniiu trubno-peritoneal'nogo besplodiia. Vopr. ginekologii, akusherstva i perinatologii. 2010; 9 (6): 5–10. [in Russian]
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60. Стрижаков А.Н., Пирогова М.Н., Шахламова М.Н. и др. Профилактика и лечение спаечного процесса после оперативного лечения апоплексии яичника. Рос. вестн. акушера-гинеколога. 2015; 2: 36–42. / Strizhakov A.N., Pirogova M.N., Shakhlamova M.N. i dr. Profilaktika i lechenie spaechnogo protsessa posle operativnogo lecheniia apopleksii iaichnika. Ros. vestn. akushera-ginekologa. 2015; 2: 36–42. [in Russian]
61. Манухин И.Б., Колесов А.А., Бекмурзаева Л.К., Петрович Е.А. Профилактика спаечного процесса после оперативных вмешательств на яичниках и маточных трубах. Вопр. гинекологии, акушерства и перинатологии. 2007; 6 (1). / Manukhin I.B., Kolesov A.A., Bekmurzaeva L.K., Petrovich E.A. Profilaktika spaechnogo protsessa posle operativnykh vmeshatel'stv na iaichnikakh i matochnykh trubakh. Vopr. ginekologii, akusherstva i perinatologii. 2007; 6 (1). [in Russian]
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36. Coccia ME, Rizzello F, Mariani G et al. Ovarian surgery for bilateral endometriomas influences age at menopause. Hum Reprod 2011; 26 (11): 3000–7. DOI: 10.1093/humrep/der286
37. Goodman LR, Goldberg JM, Flyckt RL et al. Effect of surgery on ovarian reserve in women with endometriomas, endometriosis and controls. Am J Obstet Gynecol 2016; 215 (5): 589.e1–589.e6. DOI: 10.1016/j.ajog.2016.05.029
38. Chen Y, Pei H, Chang Y et al. The impact of endometrioma and laparoscopic cystectomy on ovarian reserve and the exploration of related factors assessed by serum anti-Mullerian hormone: a prospective cohort study. J Ovarian Res 2014; 7: 108. DOI: 10.1186/s13048-014-0108-0
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40. Sanchez AM, Viganò P, Somigliana E. The distinguishing cellular and molecular features of the endometriotic ovarian cyst: from pathophysiology to the potential endometrioma-mediated damage to the ovary. Hum Reprod Update 2014; 20 (2): 217–30. DOI: 10.1093/humupd/dmt053
41. Ding Y, Yuan Y, Ding J et al. Comprehensive Assessment of the Impact of Laparoscopic Ovarian Cystectomy on Ovarian Reserve. J Minim Invasive Gynecol 2015; 22 (7): 1252–9. DOI: 10.1016/j.jmig.2015.07.011
42. Celik HG, Dogan E, Okyay E et al. Effect of laparoscopic excision of endometriomas on ovarian reserve: serial changes in the serum antimüllerian hormone levels. Fertil Steril 2012; 97 (6): 1472–8. DOI: 10.1016/j.fertnstert.2012.03.027
43. Ercan CM, Sakinci M, Duru NK et al. Antimullerian hormone levels after laparoscopic endometrioma stripping surgery. Gynecol Endocrinol 2010; 26 (6): 468–72. DOI: 10.3109/09513591003632134
44. Hirokawa W, Iwase A, Goto M et al. The post-operative decline in serum anti-Mullerian hormone correlates with the bilaterality and severity of endometriosis. Hum Reprod 2011; 26 (4): 904–10. DOI: 10.1093/humrep/der006
45. Hamdan M, Dunselman G, Li TC et al. The impact of endometrioma on IVF/ICSI outcomes: a systematic review and meta-analysis. Hum Reprod Update 2015; 21 (6): 809–25. DOI: 10.1093/humupd/dmv035
46. Tsoumpou I, Kyrgiou M, Gelbaya TA et al. The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis. Fertil Steril. 2009; 92 (1): 75–87. DOI: 10.1016/j.fertnstert.2008.05.049
47. Benschop L, Farquhar C, van der Poel N et al. Interventions for women with endometrioma prior to assisted reproductive technology. Cochrane Database Syst Rev 2010; 11: CD008571. DOI: 10.1002/14651858.CD008571.pub2
48. Almog B, Sheizaf B, Shalom-Paz E et al. Effects of excision of ovarian endometrioma on the antral follicle count and collected oocytes for in vitro fertilization. Fertil Steril 2010; 94 (6): 2340–2. DOI: 10.1016/j.fertnstert.2010.01.055
49. Somigliana E, Ragni G, Benede F et al. Does laparoscopic excision of endometriotic ovarian cysts significantly affect ovarian reserve? Insights from IVF cycles. Hum Reprod 2003; 18 (11): 2450–3.
50. Esinler I, Bozdag G, Aybar F et al. Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas. Fertil Steril 2006; 85 (6): 1730–5.
51. Ho HY, Lee RK, Hwu YM et al. Poor response of ovaries with endometrioma previously treated with cystectomy to controlled ovarian hyperstimulation. J Assist Reprod Genet 2002; 19 (11): 507–11.
52. Garcia-Velasco JA, Somigliana E. Management of endometriomas in women requiring IVF: to touch or not to touch. Hum Reprod 2009; 24 (3): 496–501. DOI: 10.1093/humrep/den398
53. Adamson GD, Pasta DJ. Endometriosis fertility index: the new, validated endometriosis staging system. Fertil Steril 2010; 94 (5): 1609–15. DOI: 10.1016/j.fertnstert.2009.09.035
54. Luciano DE, Roy G, Luciano AA. Adhesion reformation after laparoscopic adhesiolysis: wh ere, what type, and in whom they are most likely to recur. J Minim Invasive Gynecol 2008; 15 (1): 44–8. DOI: 10.1016/j.jmig.2007.09.012
55. Fayez JA, Vogel MF. Comparison of different treatment methods of endometriomas by laparoscopy. Obstet Gynecol 1991; 78 (4): 660–5.
56. Ahmad G, O'Flynn H, Hindocha A et al. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015; 4: CD000475. DOI: 10.1002/14651858.CD000475.pub3
57. Tulandi T, Closon F, Czuzoj-Shulman N et al. Adhesion Barrier Use After Myomectomy and Hysterectomy: Rates and Immediate Postoperative Complications. Obstet Gynecol 2016; 127 (1): 23–8. DOI: 10.1097/AOG.0000000000001186
58. Petrovich E.A., Manukhin I.B. Innovatsionnyi podkhod k lecheniiu trubno-peritoneal'nogo besplodiia. Vopr. ginekologii, akusherstva i perinatologii. 2010; 9 (6): 5–10. [in Russian]
59. Smirnova L.E., Umakhanova M.M., Torchinov A.M. Sovremennye vzgliady na spaechnyi protsess v briushnoi polosti pri trubno-peritoneal'nom besplodii. Akusherstvo i ginekologiia. 2016; 11. 148–52. [in Russian]
60. Strizhakov A.N., Pirogova M.N., Shakhlamova M.N. i dr. Profilaktika i lechenie spaechnogo protsessa posle operativnogo lecheniia apopleksii iaichnika. Ros. vestn. akushera-ginekologa. 2015; 2: 36–42. [in Russian]
61. Manukhin I.B., Kolesov A.A., Bekmurzaeva L.K., Petrovich E.A. Profilaktika spaechnogo protsessa posle operativnykh vmeshatel'stv na iaichnikakh i matochnykh trubakh. Vopr. ginekologii, akusherstva i perinatologii. 2007; 6 (1). [in Russian]
Авторы
С.О.Дубровина*, Ю.Д.Берлим, В.С.Гимбут, Л.В.Красильникова, К.А.Арешян
ФГБОУ ВО «Ростовский государственный медицинский университет» Минздрава России. 344022, Россия, Ростов-на-Дону, Нахичеванский пер., д. 29
*s.dubrovina@gmail.com
ФГБОУ ВО «Ростовский государственный медицинский университет» Минздрава России. 344022, Россия, Ростов-на-Дону, Нахичеванский пер., д. 29
*s.dubrovina@gmail.com
________________________________________________
S.O.Dubrovina*, Yu.D.Berlim, V.S.Gimbut, L.V.Krasilnikova, K.A.Areshyan
Rostov State Medical University. 344022, Russian Federation, Rostov-on-Don, Nakhichevanskii per., d. 29
*s.dubrovina@gmail.com
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