腹腔镜手术对IVF-ET失败病例的病因诊断和治疗价值——120例病例回顾性分析
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摘要
目的探讨IVF-ET失败的原因及行宫腹腔镜检查的意义。方法回顾分析2010年12月至2017年11月120例IVF-ET失败后行宫腹腔镜检查患者的病史资料。结果患者平均年龄35.5岁,平均不孕时间5.5年。既往IVFET失败者中,IVF-ET指征明确者55例(45.8%),不明原因者65例(54.2%);本次术后成功妊娠54例,妊娠率49.1%。IVF-ET指征明确患者中,输卵管因素34例、排卵障碍7例、男方因素9例、其他因素5例。34例因输卵管因素行IVF-ET者中,术后妊娠率为44.1%;术前子宫输卵管造影(HSG)提示55.9%(19/34例)存在单侧或双侧输卵管积水,与术中输卵管积水的诊断符合率为84.2%(16/19例);HSG提示双侧输卵管不通与术中的符合率为42.9%(6/14例)。86例既往因非输卵管因素行IVF-ET者中,经腹腔镜探查存在输卵管积水者19.8%(17/86例),术后妊娠率52.9%(9/17);不存在输卵管积水者69例,术后妊娠率39.1%(27/69),其中自然妊娠占所有妊娠者37.0%(10/27)。根据本次手术中诊断和处理输卵管积水与否将病例分组,积水组和非积水组的术后妊娠率分别为58.8%和44.2%(P=0.032)。结论应强调严格把握IVF-ET指征,腹腔镜手术对于明确助孕指征、处理输卵管积水、提高IVF-ET成功率具有重要意义;非输卵管积水的患者也能从手术中获益。合理规范的助孕前诊治流程有待于进一步研究并形成共识。
Objective:To explore the causes of IVF-ET failure and the value of hysteroscopic and laparoscopic surgery.Methods:The data of 120 patients who underwent hysteroscopic or laparoscopic surgery after the failure of IVF-ET from December 2010 to November 2017 were analyzed retrospectively.Results:The average age of the patients was 35.5 years,and the average infertility time was 5.5 years.In IVF-ET failed patients,55 patients(45.8%)were eligible for IVF-ET indications,65 patients(54.2%)were unknown cause.After the operation,54 patients were successful pregnancy,and the pregnancy rate was 49.1%.Among the patients with IVF-ET indications,34 patients had IVF-ET due to tubal factors,7 patients due to ovulatory disorder,9 patients due to male factors,and 5 patients had other factors.Among 34 patients undergoing IVF-ET due to fallopian tube factors,the postoperative pregnancy rate was 44.1%.Preoperative hysterosalpingography(HSG)indicated 55.9%(19/34)patients had unilateral or bilateral hydrosalpinx,and the diagnostic coincidence rate with intraoperative hydrosalpinx was 84.2%(16/19).The coincidence rate of bilateral fallopian tube obstruction diagnosed by HSG and by intraoperative was 42.9%(6/14).Of 86 patients with tubal factors,19.8%(17/86)of hydrosalpinx were diagnosed by laparoscopy.The postoperative pregnancy rate was 52.9%(9/17).The postoperative pregnancy rate of 69 patients without hydrosalpinx was 39.1%(27/69),and natural pregnancy accounted for 37.0%(10/27)of all pregnancies.According to the diagnosis and treatment of hydrosalpinx in the operation,the patients were divided into two groups.The postoperative pregnancy rates in the hydrosalpinx and non-hydrosalpinx groups were 58.8% and 44.2%,respectively(P=0.032).Conclusions:Emphasis should be placed on the strict grasp of IVF-ET indications.Laparoscopic surgery is of great value for clear indications of assisted pregnancy,treatment of hydrosalpinx and improvement of IVF-ET success rate.Patients with non-hydrosalpinx can also benefit from the surgery.A reasonable and standardized diagnosis and treatment process before assisted pregnancy needs further study and consensus.
Objective:To explore the causes of IVF-ET failure and the value of hysteroscopic and laparoscopic surgery.Methods:The data of 120 patients who underwent hysteroscopic or laparoscopic surgery after the failure of IVF-ET from December 2010 to November 2017 were analyzed retrospectively.Results:The average age of the patients was 35.5 years,and the average infertility time was 5.5 years.In IVF-ET failed patients,55 patients(45.8%)were eligible for IVF-ET indications,65 patients(54.2%)were unknown cause.After the operation,54 patients were successful pregnancy,and the pregnancy rate was 49.1%.Among the patients with IVF-ET indications,34 patients had IVF-ET due to tubal factors,7 patients due to ovulatory disorder,9 patients due to male factors,and 5 patients had other factors.Among 34 patients undergoing IVF-ET due to fallopian tube factors,the postoperative pregnancy rate was 44.1%.Preoperative hysterosalpingography(HSG)indicated 55.9%(19/34)patients had unilateral or bilateral hydrosalpinx,and the diagnostic coincidence rate with intraoperative hydrosalpinx was 84.2%(16/19).The coincidence rate of bilateral fallopian tube obstruction diagnosed by HSG and by intraoperative was 42.9%(6/14).Of 86 patients with tubal factors,19.8%(17/86)of hydrosalpinx were diagnosed by laparoscopy.The postoperative pregnancy rate was 52.9%(9/17).The postoperative pregnancy rate of 69 patients without hydrosalpinx was 39.1%(27/69),and natural pregnancy accounted for 37.0%(10/27)of all pregnancies.According to the diagnosis and treatment of hydrosalpinx in the operation,the patients were divided into two groups.The postoperative pregnancy rates in the hydrosalpinx and non-hydrosalpinx groups were 58.8% and 44.2%,respectively(P=0.032).Conclusions:Emphasis should be placed on the strict grasp of IVF-ET indications.Laparoscopic surgery is of great value for clear indications of assisted pregnancy,treatment of hydrosalpinx and improvement of IVF-ET success rate.Patients with non-hydrosalpinx can also benefit from the surgery.A reasonable and standardized diagnosis and treatment process before assisted pregnancy needs further study and consensus.
引文
[1] Steptoe PC,Edwards RG.Birth after the reimplantation of a human embryo[J].Lancet.1978,2(8085):366.
[2] Ledger WL,Anumba D,Marlow N,et al.The costs to the NHS of multiple births after IVF treatment in the UK[J].BJOG,2006,113:21-25.
[3] Balasch J.Investigation of the infertile couple:investigation of the infertile couple in the era of assisted reproductive technology:a time for reappraisal[J].Hum Reprod,2000,15:2251-2257.
[4] Broughton DE,Moley KH.Obesity and female infertility:potential mediators of obesity’s impact[J].Fertil Steril,2017,107:840-847.
[5] Luttjeboer FY,Verhoeve HR,van Dessel HJ,et al.The value of medical history taking as risk indicator for tuboperitoneal pathology:a systematic review[J].BJOG,2009,116:612-625.
[6] Camus E,Poncelet C,Goffinet F,et al.Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and withouthydrosalpinx:ameta-analysisofpublished comparative studies[J].Hum Reprod,1999,14:1243-1249.
[7] Strandell A,Lindhard A.Why does hydrosalpinx reduce fertility?The importance of hydrosalpinx fluid[J].Hum Reprod,2002,17:1141-1145.
[8] Mijatovic V,Veersema S,Emanuel MH,et al.Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization-embryo transfer in patients with a contraindication for laparoscopy[J].Fertil Steril,2010,93:1338-1342.
[9] Tsiami A,Chaimani A,Mavridis D,et al.Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer:a network meta-analysis[J].Ultrasound Obstet Gynecol,2016,48:434-445.
[10] Matorras R,Rabanal A,Prieto B,et al.Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated[J].Eur J Obstet Gynecol Reprod Biol,2013,169:54-59.
[11] Lorente GJ,Rios CJ,Pomares TE,et al.Essure a novel option for the treatment of hydrosalpinx:a case series and literature review[J].Gynecol Endocrinol,2016,32:166-170.
[12] Swart P,Mol BW,van der Veen F,et al.The accuracy of hysterosalpingography in the diagnosis of tubal pathology:a meta-analysis[J].Fertil Steril,1995,64:486-491.
[13]王巍,陈蓉,田秦杰,等.子宫输卵管造影诊断输卵管因素不孕的价值分析[J].生殖医学杂志,2013,22:297-300.
[14] Boujenah J,Santulli P,Mathieu-D’Argent E,et al.First line managementwithoutIVFofinfertilityrelatedto endometriosis:Result of medical therapy?Results of ovarian superovulation? Resultsofintrauterineinsemination?CNGOF-HAS Endometriosis Guidelines[J].Gynecol Obstet Fertil Senol,2018,46:331-337.
[15] Ploteau S,Merlot B,Roman H,et al.Minimal and mild endometriosis:Impact of the laparoscopic surgery on pelvic pain and fertility.CNGOF-HAS Endometriosis Guidelines[J].Gynecol Obstet Fertil Senol,2018,46:273-277.
[17] Hunter T,Hart R.Endoscopic surgery for female infertility:a review of current management[J].Aust N Z J Obstet Gynaecol,2009,49:588-593.
[18] Muhlstein J,Monceau E,Lamy C,et al.[Contribution of robot-assisted surgery in the management of female infertility][J].J Gynecol Obstet Biol Reprod(Paris),2012,41:409-417.
[2] Ledger WL,Anumba D,Marlow N,et al.The costs to the NHS of multiple births after IVF treatment in the UK[J].BJOG,2006,113:21-25.
[3] Balasch J.Investigation of the infertile couple:investigation of the infertile couple in the era of assisted reproductive technology:a time for reappraisal[J].Hum Reprod,2000,15:2251-2257.
[4] Broughton DE,Moley KH.Obesity and female infertility:potential mediators of obesity’s impact[J].Fertil Steril,2017,107:840-847.
[5] Luttjeboer FY,Verhoeve HR,van Dessel HJ,et al.The value of medical history taking as risk indicator for tuboperitoneal pathology:a systematic review[J].BJOG,2009,116:612-625.
[6] Camus E,Poncelet C,Goffinet F,et al.Pregnancy rates after in-vitro fertilization in cases of tubal infertility with and withouthydrosalpinx:ameta-analysisofpublished comparative studies[J].Hum Reprod,1999,14:1243-1249.
[7] Strandell A,Lindhard A.Why does hydrosalpinx reduce fertility?The importance of hydrosalpinx fluid[J].Hum Reprod,2002,17:1141-1145.
[8] Mijatovic V,Veersema S,Emanuel MH,et al.Essure hysteroscopic tubal occlusion device for the treatment of hydrosalpinx prior to in vitro fertilization-embryo transfer in patients with a contraindication for laparoscopy[J].Fertil Steril,2010,93:1338-1342.
[9] Tsiami A,Chaimani A,Mavridis D,et al.Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer:a network meta-analysis[J].Ultrasound Obstet Gynecol,2016,48:434-445.
[10] Matorras R,Rabanal A,Prieto B,et al.Hysteroscopic hydrosalpinx occlusion with Essure device in IVF patients when salpingectomy or laparoscopy is contraindicated[J].Eur J Obstet Gynecol Reprod Biol,2013,169:54-59.
[11] Lorente GJ,Rios CJ,Pomares TE,et al.Essure a novel option for the treatment of hydrosalpinx:a case series and literature review[J].Gynecol Endocrinol,2016,32:166-170.
[12] Swart P,Mol BW,van der Veen F,et al.The accuracy of hysterosalpingography in the diagnosis of tubal pathology:a meta-analysis[J].Fertil Steril,1995,64:486-491.
[13]王巍,陈蓉,田秦杰,等.子宫输卵管造影诊断输卵管因素不孕的价值分析[J].生殖医学杂志,2013,22:297-300.
[14] Boujenah J,Santulli P,Mathieu-D’Argent E,et al.First line managementwithoutIVFofinfertilityrelatedto endometriosis:Result of medical therapy?Results of ovarian superovulation? Resultsofintrauterineinsemination?CNGOF-HAS Endometriosis Guidelines[J].Gynecol Obstet Fertil Senol,2018,46:331-337.
[15] Ploteau S,Merlot B,Roman H,et al.Minimal and mild endometriosis:Impact of the laparoscopic surgery on pelvic pain and fertility.CNGOF-HAS Endometriosis Guidelines[J].Gynecol Obstet Fertil Senol,2018,46:273-277.
[17] Hunter T,Hart R.Endoscopic surgery for female infertility:a review of current management[J].Aust N Z J Obstet Gynaecol,2009,49:588-593.
[18] Muhlstein J,Monceau E,Lamy C,et al.[Contribution of robot-assisted surgery in the management of female infertility][J].J Gynecol Obstet Biol Reprod(Paris),2012,41:409-417.