宫、腹腔镜联合探查对原因不明性不孕诊断及临床疗效
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摘要
目的:探讨宫、腹腔镜联合探查术在原因不明性不孕患者中的诊断治疗价值及术后妊娠结局。方法:回顾性收集2014年1月—2017年12月本院生殖中心门诊诊断原因不明性不孕患者,根据是否接受宫、腹腔镜联合探查分为手术组和非手术组,比较两组临床资料及妊娠结局。结果:手术组(67例)、非手术组(103例)年龄、体质量指数、不孕类型及不孕年限等比较无差异(P>0.05)。手术组中发现了98.5%患者影响妊娠可能原因,术后尝试体内受精试孕的患者HCG阳性率、临床妊娠率和持续妊娠率均高于非手术组(52.2%比22.3%,52.2%比20.4%, 47.8%比16.5%,均P<0.05)。体内受精试孕者于术后(4.0±2.6)个月妊娠,临床妊娠率术后6个月内较术后6～12个月提高(37.3%比18.5%,P<0.05)。尝试体内受精未孕者于术后(6.5±1.7)个月接受IVF-ET助孕,其中手术组和非手术组间的HCG阳性率、临床妊娠率和持续妊娠率均无差异(76.9%比72.4%,61.5%比69.0%,53.9%比48.3%,均P>0.05)。logistic回归分析提示宫、腹腔镜联合探查术是原因不明性不孕患者妊娠相关的独立影响因素。结论:宫、腹腔镜联合探查术能够对不明性不孕患者明确病因同时行相应治疗,显著增加术后妊娠率。术后应争取在6个月内尽快妊娠,仍未孕者可考虑及时行辅助生殖助孕。
Objective: To explore the value of hysteroscopy combined with laparoscopy for diagnosing and treating unexplained infertility women. Methods: A retrospective study was conducted on the unexplained infertility women from January 2014 to December 2017. The unexplained infertility women were divided into the study group and the control group according to whether the women treated by hysteroscopy combined with laparoscopy. Results: 67 women in the study group were given hysteroscopy combined with laparoscopy surgical, and 103 women in the control group hadn't experienced surgical. There were no significant differences in age, BMI, type and duration of infertility between the two groups. 98.1% of women in the study group had been found one or more causes that might be related to their infertility. The rates of positive HCG, clinical pregnancy, and continued pregnancy of the women who underwent in vivo fertilization in the study group were significant higher than those of women in the control group(52.2% VS. 22.3%, 52.2% VS. 20.4%, 47.8% VS. 16.0%, P<0.05). The average time of women who underwent in vivo fertilization(IVF-ET) became pregnant women after operation was(4.0±2.6) months. The clinical pregnancy rate was 37.3% within half a year after surgery, which was significant higher than that(18.5%) in 6-12 months after surgery(P<0.05). Among the women without pregnancy who had received IVF-ET after 6.5±1.7 months, there were no significant difference in the rates of positive HCG, clinical pregnancy, and continuous pregnancy between the two groups(76.9% VS. 72.4%, 61.5% VS. 69.0%, 53.9% VS. 48.3%, P>0.05). Logistic regression analysis suggested that hysteroscopy combined with laparoscopy was the independent effect factor for pregnancy of women with unexplained infertility.Conclusion:The hysteroscopy combined with laparoscopy should be used in women with unexplained infertility,which can significantly increase the rate of pregnancy.The women with unexplained infertility should be try to get pregnancy within 6 months after hysteroscopy combined with laparoscopy surgical,and as for those women without pregnancy,IVF-ET should be used.
Objective: To explore the value of hysteroscopy combined with laparoscopy for diagnosing and treating unexplained infertility women. Methods: A retrospective study was conducted on the unexplained infertility women from January 2014 to December 2017. The unexplained infertility women were divided into the study group and the control group according to whether the women treated by hysteroscopy combined with laparoscopy. Results: 67 women in the study group were given hysteroscopy combined with laparoscopy surgical, and 103 women in the control group hadn't experienced surgical. There were no significant differences in age, BMI, type and duration of infertility between the two groups. 98.1% of women in the study group had been found one or more causes that might be related to their infertility. The rates of positive HCG, clinical pregnancy, and continued pregnancy of the women who underwent in vivo fertilization in the study group were significant higher than those of women in the control group(52.2% VS. 22.3%, 52.2% VS. 20.4%, 47.8% VS. 16.0%, P<0.05). The average time of women who underwent in vivo fertilization(IVF-ET) became pregnant women after operation was(4.0±2.6) months. The clinical pregnancy rate was 37.3% within half a year after surgery, which was significant higher than that(18.5%) in 6-12 months after surgery(P<0.05). Among the women without pregnancy who had received IVF-ET after 6.5±1.7 months, there were no significant difference in the rates of positive HCG, clinical pregnancy, and continuous pregnancy between the two groups(76.9% VS. 72.4%, 61.5% VS. 69.0%, 53.9% VS. 48.3%, P>0.05). Logistic regression analysis suggested that hysteroscopy combined with laparoscopy was the independent effect factor for pregnancy of women with unexplained infertility.Conclusion:The hysteroscopy combined with laparoscopy should be used in women with unexplained infertility,which can significantly increase the rate of pregnancy.The women with unexplained infertility should be try to get pregnancy within 6 months after hysteroscopy combined with laparoscopy surgical,and as for those women without pregnancy,IVF-ET should be used.
引文
[1] 杨一华,覃爱平,全松,等.不明原因不孕症的诊断与治疗的中国专家共识(初稿)[C].《中华医学会生殖医学规范指南》中国行学术巡讲会议,2018-04,广州.
[2] 谢幸,苟文丽,林仲秋,等.妇产科学[M].第8版.北京:人民卫生出版社,2013:369.
[3] 黄荷凤,周馥贞,金帆等.现代辅助生育技术[M].北京:人民军医出版社,2003:64.
[4] Practice Committee of the American Society for Reproductive Medicine.Effectiveness and treatment for unexplained infertility[J].Fertil steril,2006,86(5 Suppl 1):111-114,156-160.
[5] Guideline NC.Fertility:assessment and treatment for people with fertility problems[J].National Institute for Health and Clinical Excellence:Guidance 2013.
[6] Van den Eede B.Investigation and treatment of infertile couples:ESHRE guidelines for good clinical and laboratory practice.European Society of Human Reproduction and Embryology[J].Hum Reprod.1995,10(5):1246-71.
[7] 陈进,何小红,韩立薇,等.宫腹腔镜联合探查对诊治不明原因不孕症的临床价值[J].中国计划生育学杂志,2014,09(22):632-633.
[8] 邓锁,卢美松,李萌,等.宫腔镜诊断慢性子宫内膜炎与不明原因不孕关系的探讨[C].中华医学会第六次全国妇科内镜及微创技术学术会议论文集,2013-04,洛阳.
[9] Meuleman C,Tomassetti C,Wolthuis A,et al.Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis:a prospective cohort study[J].Ann Surg,2014,259(3):522-31.
[10] Mishra VV,Gaddagi RA,Aggarwal R,et al.Prevalence;Characteristics and Management of Endometriosis Amongst Infertile Women:A One Year Retrospective Study[J].J Clin Diagn Res,2015,9(6):QC01-3.
[11] Elisabetta MC,Rizzello F,Cammilli F,et al.Endometriosis and infertility:surgery and ART:an integrated approach for successful management[J].Eur J Obstet Gynecol Reprod Biol,2008,138(1):54-59.
[12] Vaid K,Mehra S,Verma M,et al.Pan endoscopic approach "hysterolaparoscopy" as an initial procedure in selected infertile women[J].J Clin Diagn Res.2014,8(2):95-98.
[13] Kasius JC,Fatemi HM,Bourgain C,et al.The impact of chronic endometritis on reproductive outcome [J].Fertil steril,2011,96(6):1451-1456.
[14] 乌云塔娜,刘玲玲,赵勇,等.宫腹腔镜联合诊治女性不孕症461例临床疗效分析[J].中国计划生育学杂志,2016,24(4):256-260.
[15] Litman E,Giudice L,Lathi R,et al.Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles[J].Fertil Steril,2005,84(6):1574-1578.
[16] Mahran A,Abdelraheim AR,Eissa A,et al.Does laparoscopy still has a role in modern fertility practice[J]?Int J Reprod Biomed (Yazd),2017,15(12):787-794.
[17] Bouet PE,EI Hachem,Monceau E,et al.Choronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure:prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis[J].Fertil Steril,2016,105(1):106-110.
[18] 宋冬梅,黄晓武.慢性子宫内膜炎的宫腔镜诊断[J].国际生殖健康/计划生育杂志,2017,36(3):234-237.
[19] 王丽琼.不明原因不孕不育患者治疗中采用宫腔镜下子宫内膜搔刮术联合宫腔使用几丁糖的临床疗效并分析其安全性[J].临床医学,2018(3):27-29.
[20] Cicinelli E,Matteo M,Tinelli R,et al.Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment[J].Reprod Sci,2014,21(5):640-647.
[21] Randolph F,Jr John.Unexplained infertility.Clin Obstet Gynecol,2000,43(4):897-901.
[22] Donnez J,Chantraine F,Nisolle M.The efficacy of medical and surgical treatment of endometriosis-associated infertility:arguments in favour of a medico-surgical aproach[J].Hum Reprod Update.2002,8(1):89-94.
[23] 戴凯玲,李瑞岐,郑灵燕,等.不孕症患者焦虑抑郁情绪的影响因素及其对体外受精妊娠结局的影响[J].中华生殖与避孕杂志,2018,38(7):573-577.
[2] 谢幸,苟文丽,林仲秋,等.妇产科学[M].第8版.北京:人民卫生出版社,2013:369.
[3] 黄荷凤,周馥贞,金帆等.现代辅助生育技术[M].北京:人民军医出版社,2003:64.
[4] Practice Committee of the American Society for Reproductive Medicine.Effectiveness and treatment for unexplained infertility[J].Fertil steril,2006,86(5 Suppl 1):111-114,156-160.
[5] Guideline NC.Fertility:assessment and treatment for people with fertility problems[J].National Institute for Health and Clinical Excellence:Guidance 2013.
[6] Van den Eede B.Investigation and treatment of infertile couples:ESHRE guidelines for good clinical and laboratory practice.European Society of Human Reproduction and Embryology[J].Hum Reprod.1995,10(5):1246-71.
[7] 陈进,何小红,韩立薇,等.宫腹腔镜联合探查对诊治不明原因不孕症的临床价值[J].中国计划生育学杂志,2014,09(22):632-633.
[8] 邓锁,卢美松,李萌,等.宫腔镜诊断慢性子宫内膜炎与不明原因不孕关系的探讨[C].中华医学会第六次全国妇科内镜及微创技术学术会议论文集,2013-04,洛阳.
[9] Meuleman C,Tomassetti C,Wolthuis A,et al.Clinical outcome after radical excision of moderate-severe endometriosis with or without bowel resection and reanastomosis:a prospective cohort study[J].Ann Surg,2014,259(3):522-31.
[10] Mishra VV,Gaddagi RA,Aggarwal R,et al.Prevalence;Characteristics and Management of Endometriosis Amongst Infertile Women:A One Year Retrospective Study[J].J Clin Diagn Res,2015,9(6):QC01-3.
[11] Elisabetta MC,Rizzello F,Cammilli F,et al.Endometriosis and infertility:surgery and ART:an integrated approach for successful management[J].Eur J Obstet Gynecol Reprod Biol,2008,138(1):54-59.
[12] Vaid K,Mehra S,Verma M,et al.Pan endoscopic approach "hysterolaparoscopy" as an initial procedure in selected infertile women[J].J Clin Diagn Res.2014,8(2):95-98.
[13] Kasius JC,Fatemi HM,Bourgain C,et al.The impact of chronic endometritis on reproductive outcome [J].Fertil steril,2011,96(6):1451-1456.
[14] 乌云塔娜,刘玲玲,赵勇,等.宫腹腔镜联合诊治女性不孕症461例临床疗效分析[J].中国计划生育学杂志,2016,24(4):256-260.
[15] Litman E,Giudice L,Lathi R,et al.Role of laparoscopic treatment of endometriosis in patients with failed in vitro fertilization cycles[J].Fertil Steril,2005,84(6):1574-1578.
[16] Mahran A,Abdelraheim AR,Eissa A,et al.Does laparoscopy still has a role in modern fertility practice[J]?Int J Reprod Biomed (Yazd),2017,15(12):787-794.
[17] Bouet PE,EI Hachem,Monceau E,et al.Choronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure:prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis[J].Fertil Steril,2016,105(1):106-110.
[18] 宋冬梅,黄晓武.慢性子宫内膜炎的宫腔镜诊断[J].国际生殖健康/计划生育杂志,2017,36(3):234-237.
[19] 王丽琼.不明原因不孕不育患者治疗中采用宫腔镜下子宫内膜搔刮术联合宫腔使用几丁糖的临床疗效并分析其安全性[J].临床医学,2018(3):27-29.
[20] Cicinelli E,Matteo M,Tinelli R,et al.Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment[J].Reprod Sci,2014,21(5):640-647.
[21] Randolph F,Jr John.Unexplained infertility.Clin Obstet Gynecol,2000,43(4):897-901.
[22] Donnez J,Chantraine F,Nisolle M.The efficacy of medical and surgical treatment of endometriosis-associated infertility:arguments in favour of a medico-surgical aproach[J].Hum Reprod Update.2002,8(1):89-94.
[23] 戴凯玲,李瑞岐,郑灵燕,等.不孕症患者焦虑抑郁情绪的影响因素及其对体外受精妊娠结局的影响[J].中华生殖与避孕杂志,2018,38(7):573-577.