-
随着环境及生活方式的变化,不孕症病人数量逐年增加。女性不孕症因素中,输卵管因素占25%~35%[1]。目前检查输卵管的一线方法是子宫输卵管造影(hysterosalpingography,HSG),但HSG诊断输卵管近端梗阻假阳性达42.4%[2],宫腹腔镜检查输卵管是金标准,但输卵管的微小病变导致功能改变却难以诊断,宫腹腔镜术后妊娠率差异大。对于输卵管性不孕,是选择生殖外科手术让病人有充分自然试孕的机会,还是选择体外受精(in vitro fertilization,IVF)让病人免受手术创伤,是生殖科医生面对的难题。本研究选择226例不同类型输卵管病变的病人,经宫腹腔镜手术治疗后,分析其妊娠结局,探讨输卵管性不孕病人更好的治疗方式。
-
226例病人术后1年内临床妊娠56例(24.8%),其中流产5例(2.2%),异位妊娠2例(0.9%),分娩49例(21.7%)。
-
单侧近端梗阻、双侧近端梗阻、单侧远端梗阻、双侧远端梗阻、不全梗阻的病人术后妊娠率差异均无统计学意义(P>0.05)(见表 1)。
输卵管病变 n 临床妊娠 未妊娠 χ2 P 单侧近端梗阻 19 4(21.1) 15(78.9) 2.81 >0.05 双侧近端梗阻 11 2(18.2) 9(81.8) 单侧远端梗阻 55 11(20.0) 44(80.0) 双侧远端梗阻 108 33(30.6) 75(69.4) 不全梗阻 24 6(25.0) 18(75.0) 表 1 不同类型输卵管病变经不同方式宫腹腔镜手术治疗后妊娠情况[n;百分率(%)]
-
226例病人术中发现盆腔粘连192例,轻度盆腔粘连术后临床妊娠率46.7%,重度盆腔粘连术后临床妊娠率16.3%,差异有统计学意义(P < 0.01)(见表 2)。本研究输卵管远端梗阻的病例中,重度盆腔粘连有119例,占81.0%(119/147)。
盆腔粘连 n 临床妊娠 未妊娠 χ2 P 轻度 45 21(46.7) 24(53.3) 17.67 < 0.01 重度 147 24(16.3) 123(83.7) 合计 192 45(23.4) 147(76.6) 表 2 不同盆腔粘连程度术后妊娠情况[n;百分率(%)]
-
226例病人中, < 35岁病人术后临床妊娠率27.5%,≥35岁病人术后临床妊娠率3.8%,差异有统计学意义(P < 0.01)(见表 3)。
年龄/岁 n 临床妊娠 未妊娠 χ2 P < 35 200 55(27.5) 145(72.5) 6.91 < 0.01 ≥35 26 1(3.8) 25(96.2) 合计 226 56(24.8) 170(75.2) 表 3 不同年龄段手术后妊娠情况[n;百分率(%)]
-
226例病人中,不孕年限 < 2年的病人术后临床妊娠率37.5%,2~5年的病人术后临床妊娠率21.8%,>5年的病人术后临床妊娠率14.3%,差异有统计学意义(P < 0.05)(见表 4)。
不孕年限/年 n 临床妊娠 未妊娠 χ2 P < 2 56 21(37.5) 35(62.5) 7.18 < 0.05 2~5 142 31(21.8) 111(78.2) >5 28 4(14.3) 24(85.7) 表 4 不孕年限各阶段病人手术后妊娠情况[n;百分率(%)]
输卵管性不孕病人行宫腹腔镜手术后自然妊娠结局分析
Analysis of spontaneous pregnancy outcome in patients with fallopian tube infertility after hysteroscopy and laparoscopy
-
摘要:
目的分析不同类型输卵管性不孕病人经宫腹腔镜手术后的自然妊娠结局。 方法回顾性分析因输卵管因素不孕行宫腹腔镜手术的病例226例。按照输卵管梗阻部位和侧别分为单侧输卵管近端梗阻、双侧近端梗阻、一侧近端一侧远端梗阻、单侧远端梗阻、双侧远端梗阻、不全梗阻,采用近端插管、伞端造口、伞端成型及盆腔粘连松解术等手术方式,术后至少有一侧输卵管通畅。比较不同类型输卵管性不孕病人手术治疗后1年内的自然妊娠情况。 结果单侧近端梗阻、双侧近端梗阻、单侧远端梗阻、双侧远端梗阻、不全梗阻的病人术后妊娠率差异均无统计学意义(P>0.05)。226例病人术中发现盆腔粘连192例,轻度盆腔粘连术后临床妊娠率46.7%,重度盆腔粘连术后临床妊娠率16.3%,差异有统计学意义(P < 0.01)。 < 35岁病人术后临床妊娠率27.5%,≥35岁病人术后临床妊娠率3.8%,差异有统计学意义(P < 0.01)。不孕年限 < 2年的病人术后临床妊娠率37.5%,2~5年的病人术后临床妊娠率21.8%,>5年的病人术后临床妊娠率14.3%,差异有统计学意义(P < 0.05)。 结论不同类型输卵管性不孕病人行相应的手术治疗是可行的,术后妊娠率无显著差异。重度盆腔粘连的病人术后妊娠率低,不适合期待试孕。年龄和不孕时限可能是影响术后妊娠的独立因素。 Abstract:ObjectiveTo analyze the spontaneous pregnancy outcomes in patients with different types of fallopian tube infertility after hysteroscopy and laparoscopy. MethodsA total of 226 cases with fallopian tube infertility were analyzed retrospectively.According to the location and side of tubal obstruction, it was divided into unilateral proximal tubal obstruction, bilateral proximal tubal obstruction, unilateral proximal and unilateral distal tubal obstruction, unilateral distal tubal obstruction, bilateral distal tubal obstruction and incomplete tubal obstruction.Proximal intubation, umbrella end colostomy, umbrella end molding and pelvic adhesiolysis were used, and at least one fallopian tube was unobstructed after operation.The spontaneous pregnancy outcomes in patients with different types of tubal infertility within one year after operation were compared. ResultsThere was no significant difference in pregnancy rate among patients with unilateral proximal obstruction, bilateral proximal obstruction, unilateral distal obstruction, bilateral distal obstruction and incomplete obstruction(P>0.05).Among 226 patients, 192 cases with pelvic adhesions were found.The clinical pregnancy rate of mild and severe pelvic adhesion was 46.7% and 16.3%, respectively, the difference of which was statistically significant(P < 0.01).The clinical pregnancy rate was 27.5% in patients under 35 years old and 3.8% in patients over or equal to 35 years old, the difference of which was statistically significant(P < 0.01).The clinical pregnancy rate was 37.5% in patients with less than 2 years of infertility, 21.8% in patients with 2-5 years of infertility, and 14.3% in patients with more than 5 years of infertility, the difference of which was statistically significant(P < 0.05). ConclusionsIt is feasible for patients with different types of fallopian tube infertility to receive corresponding surgical treatment, and there is no significant difference in postoperative pregnancy.Patients with severe pelvic adhesion have a low postoperative pregnancy rate and are not suitable for expectant pregnancy.Age and infertility duration may be independent factors affecting postoperative pregnancy. -
Key words:
- infertility /
- fallopian tube /
- laparoscopy /
- pregnancy
-
表 1 不同类型输卵管病变经不同方式宫腹腔镜手术治疗后妊娠情况[n;百分率(%)]
输卵管病变 n 临床妊娠 未妊娠 χ2 P 单侧近端梗阻 19 4(21.1) 15(78.9) 2.81 >0.05 双侧近端梗阻 11 2(18.2) 9(81.8) 单侧远端梗阻 55 11(20.0) 44(80.0) 双侧远端梗阻 108 33(30.6) 75(69.4) 不全梗阻 24 6(25.0) 18(75.0) 表 2 不同盆腔粘连程度术后妊娠情况[n;百分率(%)]
盆腔粘连 n 临床妊娠 未妊娠 χ2 P 轻度 45 21(46.7) 24(53.3) 17.67 < 0.01 重度 147 24(16.3) 123(83.7) 合计 192 45(23.4) 147(76.6) 表 3 不同年龄段手术后妊娠情况[n;百分率(%)]
年龄/岁 n 临床妊娠 未妊娠 χ2 P < 35 200 55(27.5) 145(72.5) 6.91 < 0.01 ≥35 26 1(3.8) 25(96.2) 合计 226 56(24.8) 170(75.2) 表 4 不孕年限各阶段病人手术后妊娠情况[n;百分率(%)]
不孕年限/年 n 临床妊娠 未妊娠 χ2 P < 2 56 21(37.5) 35(62.5) 7.18 < 0.05 2~5 142 31(21.8) 111(78.2) >5 28 4(14.3) 24(85.7) -
[1] PAPAIOANNOU S. A hypothesis for the pathogenesis and natural history of proximal tubal blockage[J]. Hum Reprod, 2004, 19(3): 481. doi: 10.1093/humrep/deh111 [2] 郑兴邦, 关菁, 于晓明, 等. 子宫输卵管造影显示输卵管近端阻塞行宫腹腔镜联合手术118例结果分析[J]. 实用妇产科杂志, 2015, 31(3): 213. [3] BAN FH, KOROSEC S, POZLEP B, et al. Spontaneous pregnancy rates after reproductive surgery[J]. Reprod Biomed Online, 2017: 35165. [4] 田秦杰, 邓姗. 北京协和医院妇科内分泌疾病病例精解[M]. 北京: 科学技术文献出版社, 2018: 8. [5] Practice Committee of the American Society for Reproductive Medicine. Role of tubal surgery in the era of assisted reproductive technology: a committee opinion[J]. Fertil Steril, 2015, 103(6): e37. doi: 10.1016/j.fertnstert.2015.03.032 [6] DE SILVA PM, CHU JJ, GALLOS ID, et al. Fallopian tube catheterization in the treatment of proximal tubal obstruction: a systematic review and meta-analysis[J]. Hum Reprod, 2017, 32(4): 836. [7] 关菁. 辅助生殖年代生殖外科与输卵管修复性手术[J/CD]. 中华临床医师杂志(电子版), 2015, 9(1): 1. [8] YU X, CAI H, ZHENG X, et al. Tubal restorative surgery for hydrosalpinges in women due to in vitro fertilization[J]. Arch Gynecol Obstet, 2018, 297(5): 1169. doi: 10.1007/s00404-018-4695-7 [9] TULANDI T, AKKOUR K. Role of reproductive surgery in the era of assisted reproductive technology[J]. Best Pract Res Clin Obstet Gynaecol, 2012, 26(6): 747. doi: 10.1016/j.bpobgyn.2012.04.003 [10] FOSTER L, ROBSON SJ, YAZDANI A, et al. Changes in the incidence and uptake of reproductive surgery versus in vitro fertilisation in Australia between 2001 and 2015: a population-based study[J]. Aust N Z J Obstet Gynaecol, 2019, 59(2): 272. doi: 10.1111/ajo.12926