子宫内膜异位症生育指数对子宫内膜异位症合并内膜息肉宫腹腔镜术后自然妊娠结局的评估价值
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摘要
目的研究子宫内膜异位症(EMS)与内膜息肉(EPs)的关系,并探讨EMS生育指数(EFI)评分对EMS合并EPs患者生育力的评估价值。方法回顾性分析接受宫、腹腔联合手术治疗的248例EMS相关不孕患者的临床资料,按是否合并EPs分为息肉组(105例)和非息肉组(143例),随访并比较其妊娠情况和妊娠结局。结果 EMS患者EPs的发生率为42.3%,中重度EMS患者(Ⅲ～Ⅳ期) EPs的发生率(50.8%)略高于轻度患者(Ⅰ～Ⅱ期)(39.6%),但差异无统计学意义(P>0.05)。EFI评分越高,在同一EFI分值中,合并EPs的患者所占比例越低,差异有统计学意义(P=0.000)。息肉组术后的自然妊娠率(37.1%)、活产率(27.6%)均低于非息肉组(57.3%,P=0.002;48.3%,P=0.001)。同一EFI分值,息肉组的妊娠率低于非息肉组,但差异无统计学意义(P>0.05)。息肉组与非息肉组组内比较,EFI分值越高,妊娠率越高,差异有统计学意义(P=0.000)。96.7%患者多在术后2年内成功妊娠,息肉组术后1年内妊娠35例,占其妊娠总人数的89.7%,高于非息肉组的73.1%,差异有统计学意义(P=0.038)。结论 EPs在EMS合并不孕患者中的发生率明显升高。宫、腹腔镜联合手术治疗能明显提高EMS合并EPs患者的生育力,术后2年内是妊娠的最佳时期;EFI评分对合并EPs的EMS患者术后生育力的评估价值有待商榷。
Objective To investigate the relationship of endometrial polyps(EPs) and endometriosis(EMS), and evaluate the predictive value of EMS fertility index(EFI) for women's fertility with EMS combined with EPs. Methods A total of 248 infertile patients with EMS and EPs who underwent laparoscopic and hysteroscopic surgery were analyzed. The patients were divided into EPs group and nonEPs group. Then the pregnancy outcome was compared between the two groups. Results The incidence of EPs was 42.3%. The incidence of EPs in patients with moderate to severe EMS(stages Ⅲ-Ⅳ) was slightly higher than that in mild patients(stages Ⅰ-Ⅱ), but there was no significant difference between the two groups(P>0.05). The higher the EFI score, the lower the proportion of patients with EPs in the same EFI score, the difference was statistically significant(P=0.000). The natural pregnancy rate(37.1%) and the live birth rate(27.6%) were lower in the EPs group than in the non-EPs group(57.3%, P=0.002; 48.3%, P=0.001). At the same EFI score, the pregnancy rate of the EPs group was lower than that of the non-EPs group, but there was no statistical difference(P>0.05). Within the EPs group and non-EPs group, the spontaneous pregnancy rate increased with increasing EFI score, the difference was statistically significant(P=0.00). Most of the patients got pregnant within 2 years after operation(96.7%). The EPs group had 35 pregnancies within 1 year, accounting for 89.7% of the total number of pregnancies, which was higher than that in the non-EPs group of 73.1%, the difference was statistically significant(P=0.038). Conclusion There was a higher incidence of EPs among infertile patients with EMS. Hysteroscopy combined with laparoscopic surgery can significantly improve fertility for patients with EMS and EPs. The best time for pregnancy was within 2 years after surgery. The value of EFI score for predicting pregnancy rate for women with EMS and EPs remains to be discussed.
Objective To investigate the relationship of endometrial polyps(EPs) and endometriosis(EMS), and evaluate the predictive value of EMS fertility index(EFI) for women's fertility with EMS combined with EPs. Methods A total of 248 infertile patients with EMS and EPs who underwent laparoscopic and hysteroscopic surgery were analyzed. The patients were divided into EPs group and nonEPs group. Then the pregnancy outcome was compared between the two groups. Results The incidence of EPs was 42.3%. The incidence of EPs in patients with moderate to severe EMS(stages Ⅲ-Ⅳ) was slightly higher than that in mild patients(stages Ⅰ-Ⅱ), but there was no significant difference between the two groups(P>0.05). The higher the EFI score, the lower the proportion of patients with EPs in the same EFI score, the difference was statistically significant(P=0.000). The natural pregnancy rate(37.1%) and the live birth rate(27.6%) were lower in the EPs group than in the non-EPs group(57.3%, P=0.002; 48.3%, P=0.001). At the same EFI score, the pregnancy rate of the EPs group was lower than that of the non-EPs group, but there was no statistical difference(P>0.05). Within the EPs group and non-EPs group, the spontaneous pregnancy rate increased with increasing EFI score, the difference was statistically significant(P=0.00). Most of the patients got pregnant within 2 years after operation(96.7%). The EPs group had 35 pregnancies within 1 year, accounting for 89.7% of the total number of pregnancies, which was higher than that in the non-EPs group of 73.1%, the difference was statistically significant(P=0.038). Conclusion There was a higher incidence of EPs among infertile patients with EMS. Hysteroscopy combined with laparoscopic surgery can significantly improve fertility for patients with EMS and EPs. The best time for pregnancy was within 2 years after surgery. The value of EFI score for predicting pregnancy rate for women with EMS and EPs remains to be discussed.
引文
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[3]Shen L,Wang Q,Huang W,et al.High prevalence of endometrial polyps in endometriosis associated infertility[J].Fertil Steril,2011,95(8):2722-2724.DOI:10.1016/j.fertnstert.2011.04.067.
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[8]魏代敏,郁琦,孙爱军,等.子宫内膜异位症生育指数与相关不孕患者腹腔镜术后妊娠的相关性[J].中华妇产科杂志,2011,46(11):806-808.DOI:10.3760/cma.j.issn.0529-567x.2011.11.003.
[9]王冬梅,曲绪琴,王惠,等.子宫内膜异位症生育指数对子宫内膜异位症合并不孕患者术后生育能力的评估[J].现代妇产科进展,2014,23(3):208-210.DOI:10.13283/j.cnki.xdfckjz.2014.03.013.
[10]Vercellini P,Fedele L,Aimi G,et al.Reproductive performance,pain recurrence and disease relapse after conservative surgical treatment for endometriosis:the predictive value of the current classification system[J].Hum Reprod,2006,21(10):2679-2685.DOI:10.1093/humrep/del230.
[11]Adamson GD,Pasta DJ.Endometriosis fertility index:the new,validated endometriosis staging system[J].Fertil Steril,2010,94(5):1609-1615.DOI:10.1016/j.fertnstert.2009.09.035.
[12]Bulun SE,Yang S,Fang Z,et al.Role of aromatase in endometrial disease[J].Steroid Biochem Mol Biol,2001,79(1):19-25.DOI:10.1016/S0960-0760(01)00134-0.
[13]Tian Y,Kong B,Zhu W,et al.Expression of steroidogenic factor1(SF-1)and steroidogenic acute regulatory protein(StAR)in endometriosis is associated with endometriosis severity[J].Inter Med Res,2009,37(5):1389-1395.DOI:10.1177/147323000903700513.
[14]李斌,王君,范颖.子宫内膜异位症患者雌、孕激素受体和Bcl-2、Bax表达的研究[J].中国微创外科杂志,2011,11(1):86-90.
[15]Park JS,Lee JH,Kim M,et al.Endometrium from women with endometriosis shows increased proliferation activity[J].Fertil Steril,2009,92(4):1246-1249.DOI:10.1016/j.fertnstert.2009.04.025.
[16]王洋,马彩虹,乔杰,等.子宫内膜异位症合并内膜息肉宫、腹腔镜联合手术后的自然妊娠结局[J].中国微创外科杂志,2014,14(3):207-211.
[17]李宇彬,欧建平,麦庆云,等.不孕症患者临床情况与EPs的关系研究[J].实用妇产科杂志,2011,27(11):852-855.DOI:10.3969/j.issn.1003-6946.2011.11.022.
[18]林金芳,孙翠翔.应用腹腔镜诊断和治疗子宫内膜异位症及不孕症的疗效[J].中华妇产科杂志,2005,40(1):9-12.DOI:10.3760/j.issn:0529-567X.2005.01.004.
[19]张向卉,冯雪,黄薇,等.子宫内膜异位症生育指数(EFI)对EMs相关不孕妇女腹腔镜术后自然妊娠的预测价值[J].现代妇产科进展,2014,23(12):968-970.DOI:10.13283/j.cnki.xdfckjz.2014.12.014.
[20]Hughes E,Brown J,Collins JJ,et al.Ovulation suppression for endometriosis[CD].Cochrane Database Syst Rev,2007,18:CD000155.DOI:10.1002/14651858.CD000155.pub2.
[21]付改玲,黄鹏翀,周晓亮.卵巢子宫内膜异位囊肿合并不孕患者术后治疗探讨[J].生殖与避孕,2014,34(6):515-518.DOI:10.7669/j.issn.0253-357X.2014.06.0515.
[22]陈建欢,马彩玲.GnRH-a治疗腹腔镜术后子宫内膜异位症合并不孕症的作用机制与疗效[J].生殖与避孕,2013,33(5):333-337.DOI:10.7669/j.issn.0253-357X.2013.05.0333.
[2]Shokeir T,Shalan HM,El-Shafei MM.Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women[J].Obstet Gynaecol Res,2004,30(2):84-89.DOI:10.1111/j.1447-0756.2003.00163.
[3]Shen L,Wang Q,Huang W,et al.High prevalence of endometrial polyps in endometriosis associated infertility[J].Fertil Steril,2011,95(8):2722-2724.DOI:10.1016/j.fertnstert.2011.04.067.
[4]McBean JH,Gibson M,Brumsted JR.The association of intrauterine filling defects on hysterosalpingogram with endometriosis[J].Fertil Steril,1996,66(4):522-526.DOI:10.1016/S0015-0282(16)58562-8.
[5]Bosteels J,Kasius J,Weyers S,et al.Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities[CD].Cochrane Database Syst Rev,2015,2:CD9461.DOI:10.1002/14651858.CD009461.pub3.
[6]Perez-Medina T,Bajo-Arenas J,Salazar F,et al.Endometrial polyps and their implication in the pregnancy rates of patients undergoing intrauterine insemination:a prospective,randomized study[J].Hum Reprod,2005,20(6):1632-1635.DOI:10.1093/humrep/deh822.
[7]Tomassetti C,Geysenbergh B,Meuleman C,et al.External validation of the endometriosis fertility index(EFI)staging system for predicting non-ART pregnancy after endometriosis surgery[J].Hum Reprod,2013,28(5):1280-1288.DOI:10.1055/s-0032-1333475.
[8]魏代敏,郁琦,孙爱军,等.子宫内膜异位症生育指数与相关不孕患者腹腔镜术后妊娠的相关性[J].中华妇产科杂志,2011,46(11):806-808.DOI:10.3760/cma.j.issn.0529-567x.2011.11.003.
[9]王冬梅,曲绪琴,王惠,等.子宫内膜异位症生育指数对子宫内膜异位症合并不孕患者术后生育能力的评估[J].现代妇产科进展,2014,23(3):208-210.DOI:10.13283/j.cnki.xdfckjz.2014.03.013.
[10]Vercellini P,Fedele L,Aimi G,et al.Reproductive performance,pain recurrence and disease relapse after conservative surgical treatment for endometriosis:the predictive value of the current classification system[J].Hum Reprod,2006,21(10):2679-2685.DOI:10.1093/humrep/del230.
[11]Adamson GD,Pasta DJ.Endometriosis fertility index:the new,validated endometriosis staging system[J].Fertil Steril,2010,94(5):1609-1615.DOI:10.1016/j.fertnstert.2009.09.035.
[12]Bulun SE,Yang S,Fang Z,et al.Role of aromatase in endometrial disease[J].Steroid Biochem Mol Biol,2001,79(1):19-25.DOI:10.1016/S0960-0760(01)00134-0.
[13]Tian Y,Kong B,Zhu W,et al.Expression of steroidogenic factor1(SF-1)and steroidogenic acute regulatory protein(StAR)in endometriosis is associated with endometriosis severity[J].Inter Med Res,2009,37(5):1389-1395.DOI:10.1177/147323000903700513.
[14]李斌,王君,范颖.子宫内膜异位症患者雌、孕激素受体和Bcl-2、Bax表达的研究[J].中国微创外科杂志,2011,11(1):86-90.
[15]Park JS,Lee JH,Kim M,et al.Endometrium from women with endometriosis shows increased proliferation activity[J].Fertil Steril,2009,92(4):1246-1249.DOI:10.1016/j.fertnstert.2009.04.025.
[16]王洋,马彩虹,乔杰,等.子宫内膜异位症合并内膜息肉宫、腹腔镜联合手术后的自然妊娠结局[J].中国微创外科杂志,2014,14(3):207-211.
[17]李宇彬,欧建平,麦庆云,等.不孕症患者临床情况与EPs的关系研究[J].实用妇产科杂志,2011,27(11):852-855.DOI:10.3969/j.issn.1003-6946.2011.11.022.
[18]林金芳,孙翠翔.应用腹腔镜诊断和治疗子宫内膜异位症及不孕症的疗效[J].中华妇产科杂志,2005,40(1):9-12.DOI:10.3760/j.issn:0529-567X.2005.01.004.
[19]张向卉,冯雪,黄薇,等.子宫内膜异位症生育指数(EFI)对EMs相关不孕妇女腹腔镜术后自然妊娠的预测价值[J].现代妇产科进展,2014,23(12):968-970.DOI:10.13283/j.cnki.xdfckjz.2014.12.014.
[20]Hughes E,Brown J,Collins JJ,et al.Ovulation suppression for endometriosis[CD].Cochrane Database Syst Rev,2007,18:CD000155.DOI:10.1002/14651858.CD000155.pub2.
[21]付改玲,黄鹏翀,周晓亮.卵巢子宫内膜异位囊肿合并不孕患者术后治疗探讨[J].生殖与避孕,2014,34(6):515-518.DOI:10.7669/j.issn.0253-357X.2014.06.0515.
[22]陈建欢,马彩玲.GnRH-a治疗腹腔镜术后子宫内膜异位症合并不孕症的作用机制与疗效[J].生殖与避孕,2013,33(5):333-337.DOI:10.7669/j.issn.0253-357X.2013.05.0333.