输卵管切除对IVF结果影响的META分析
摘要
【目的】分析比较严重输卵管疾病及输卵管积水所致的输卵管不孕患者IVF-ET前是否输卵管切除在获得妊娠上的差异。
【方法】全面检索相关中英文数据库,系统搜索输卵管不孕严重输卵管疾病或输卵管积水患者在IVF-ET前是否行输卵管切除方面的前瞻性及回顾性研究文献,提取数据资料,应用系统评价的专用处理软件Revman5.0进行整合分析。
【结果】共有7篇文献被纳入。对于该“输卵管切除对于IVF-ET结果影响”的系统评价,目的是比较切除组(治疗组)和保留组(对照组)在获得妊娠上的差别。总共1998-2005年之间五个研究入选,切除组总共183例,保留组总共117例。结果表明图1在比较两者的临床妊娠情况OR=1.56(95%CI,1.13-2.15)>1,菱形完全位于垂直线的右侧,得出切除组更有效的结论;图2比较两者的持续妊娠情况OR=1.68(95%CI,2.20-2.36)>1,菱形完全位于垂直线的右侧,也得出切除组更有效的结论。图3把其中三个文献的异位妊娠发生情况进行比较,差异无统计学意义,菱形与垂直线相交表明差异无统计学意义,但由于这个分支的META分析病例数少,结果缺乏说服力。图4把其中三个文献的胚胎种植成功率发生情况进行比较,OR=1.5(95%CI,1.03-2.2)>1差异有统计学意义,菱形位于垂直线右侧支持差异有统计学意义,得出切除组更有效的结论。表7把国内两篇文献进行的输卵管因素不孕未合并积水患者输卵管切除组与非切除组的获卵率的比较P<0.5(表7):得出输卵管切除会引起卵巢的低反应性,减低获卵率。
【结论】输卵管不孕患者根据其输卵管病变的情况选择IVF-ET,IVF-ET前是否选择进行手术与患者的自身情况相关,该分析得出:输卵管积水的输卵管不孕患者在IVF-ET前行输卵管的手术将有利于提高IVF-ET的成功率,但输卵管切除引起的卵巢低反应性可能降低IVF-ET成功率,故应慎行切除术。轻度的可行成形术的则选择各种成形术,无法行成形术的输卵管有研究示IVF-ET前行输卵管离断术可提高IVF-ET妊娠率,但这点有待更多RCT的文章来论证。
【objective】:To compare the pregnancy rates differences of patients have salpinges ,severe tubal dieases performed salpingectomy or not before IVF-ET in salpingian infertility curing.
【method】: A systemic-through search of the literatures were performed of both prospective and retrospective studies , taking up the data for meta-analysis fowlled.
【result】: 1. 5studies were included in the meta-analysis.
2. This system evaluation is about whether infertility patients by tubal factors before IVF-ET must have salapingectomy or not, aims to compare the percent of clinical pregnancy and the ongoning pregnancy in this two groups.It takes five studies in this article,the nmbers of salpingectomy patients is 183,and the other group is 117.The result of comparation of the clinical pregnancy is (that) OR=1.56(95%CI,1.13-2.15)>1,the rhombus of the gram 1 is at the RT of the vertical line, that means the curation groups take better effectiveness. The result of comparation of the ongoing pregnancy is (that) OR=1.68(95%CI,2.20-2.36)>1,the rhombus of the gram 2 is at the RT of the vertical line,that means the curation groups take better effectiveness too.The result of comparation of the ectopic pregnancy is (that) OR=0.84(95%CI,0.4-1.75),the rhombus of the gram 3 is get across of the vertical line,that means no difference in two groups. The result of comparation of the embry transfer is (that) OR=1.5(95%CI,1.03-2.2)>1 the rhombus of gram 4 at the RT of the vertical line,that means the curation groups take better effectiveness too. From table7 we can see :Tubal factor infertility without salpingx if choice salpingectomy will influences ovarian function.Th e reason may be that operation impaired ovarian blood flow.Compare the retrieved oocytes between the salpingectomy group and the remaining group ,the p is <0.5: Salpingectomy will influences ovarian function and make the lower percent of the retrieved oocytes.
【conclusion】: The infertility patients by tubal factors make the choice to IVF-ET,before IVF-ET taking some operation or not must detimine by the Patients’condition.In this meta-analysis we can find: The presence of hydrosalpinges in women considering IVF treatment is an indication for surgical treatment,it must be careful to do salpingectomy for that may cause lower response to stimulus of the ovarian.If the tubal have chance to choice salpingplasty then do that.If the disease is serious ,choice the surgery to cut the tubal but keep the blood vessel may be good ,but that need more RCT articles to proof.
【方法】全面检索相关中英文数据库,系统搜索输卵管不孕严重输卵管疾病或输卵管积水患者在IVF-ET前是否行输卵管切除方面的前瞻性及回顾性研究文献,提取数据资料,应用系统评价的专用处理软件Revman5.0进行整合分析。
【结果】共有7篇文献被纳入。对于该“输卵管切除对于IVF-ET结果影响”的系统评价,目的是比较切除组(治疗组)和保留组(对照组)在获得妊娠上的差别。总共1998-2005年之间五个研究入选,切除组总共183例,保留组总共117例。结果表明图1在比较两者的临床妊娠情况OR=1.56(95%CI,1.13-2.15)>1,菱形完全位于垂直线的右侧,得出切除组更有效的结论;图2比较两者的持续妊娠情况OR=1.68(95%CI,2.20-2.36)>1,菱形完全位于垂直线的右侧,也得出切除组更有效的结论。图3把其中三个文献的异位妊娠发生情况进行比较,差异无统计学意义,菱形与垂直线相交表明差异无统计学意义,但由于这个分支的META分析病例数少,结果缺乏说服力。图4把其中三个文献的胚胎种植成功率发生情况进行比较,OR=1.5(95%CI,1.03-2.2)>1差异有统计学意义,菱形位于垂直线右侧支持差异有统计学意义,得出切除组更有效的结论。表7把国内两篇文献进行的输卵管因素不孕未合并积水患者输卵管切除组与非切除组的获卵率的比较P<0.5(表7):得出输卵管切除会引起卵巢的低反应性,减低获卵率。
【结论】输卵管不孕患者根据其输卵管病变的情况选择IVF-ET,IVF-ET前是否选择进行手术与患者的自身情况相关,该分析得出:输卵管积水的输卵管不孕患者在IVF-ET前行输卵管的手术将有利于提高IVF-ET的成功率,但输卵管切除引起的卵巢低反应性可能降低IVF-ET成功率,故应慎行切除术。轻度的可行成形术的则选择各种成形术,无法行成形术的输卵管有研究示IVF-ET前行输卵管离断术可提高IVF-ET妊娠率,但这点有待更多RCT的文章来论证。
【objective】:To compare the pregnancy rates differences of patients have salpinges ,severe tubal dieases performed salpingectomy or not before IVF-ET in salpingian infertility curing.
【method】: A systemic-through search of the literatures were performed of both prospective and retrospective studies , taking up the data for meta-analysis fowlled.
【result】: 1. 5studies were included in the meta-analysis.
2. This system evaluation is about whether infertility patients by tubal factors before IVF-ET must have salapingectomy or not, aims to compare the percent of clinical pregnancy and the ongoning pregnancy in this two groups.It takes five studies in this article,the nmbers of salpingectomy patients is 183,and the other group is 117.The result of comparation of the clinical pregnancy is (that) OR=1.56(95%CI,1.13-2.15)>1,the rhombus of the gram 1 is at the RT of the vertical line, that means the curation groups take better effectiveness. The result of comparation of the ongoing pregnancy is (that) OR=1.68(95%CI,2.20-2.36)>1,the rhombus of the gram 2 is at the RT of the vertical line,that means the curation groups take better effectiveness too.The result of comparation of the ectopic pregnancy is (that) OR=0.84(95%CI,0.4-1.75),the rhombus of the gram 3 is get across of the vertical line,that means no difference in two groups. The result of comparation of the embry transfer is (that) OR=1.5(95%CI,1.03-2.2)>1 the rhombus of gram 4 at the RT of the vertical line,that means the curation groups take better effectiveness too. From table7 we can see :Tubal factor infertility without salpingx if choice salpingectomy will influences ovarian function.Th e reason may be that operation impaired ovarian blood flow.Compare the retrieved oocytes between the salpingectomy group and the remaining group ,the p is <0.5: Salpingectomy will influences ovarian function and make the lower percent of the retrieved oocytes.
【conclusion】: The infertility patients by tubal factors make the choice to IVF-ET,before IVF-ET taking some operation or not must detimine by the Patients’condition.In this meta-analysis we can find: The presence of hydrosalpinges in women considering IVF treatment is an indication for surgical treatment,it must be careful to do salpingectomy for that may cause lower response to stimulus of the ovarian.If the tubal have chance to choice salpingplasty then do that.If the disease is serious ,choice the surgery to cut the tubal but keep the blood vessel may be good ,but that need more RCT articles to proof.
引文
【1】曹泽毅,中华妇产科学[M]第2版北京:人民卫生出版社, 2008: 07195。
【2】Richard O.Burney,Daniel.J.Schust,郎景和译,Novak妇科学[M]第14版,人民卫生出版社,2007,745。
【3】夏恩兰.宫腔镜与腹腔镜检查.[J]中国实用妇科与产科杂志,1999;15(6):338。
【4】张耀,何玮,孙敏,李俊林.腹腔镜手术与经腹手术治疗输卵管性不孕的效果分析.[J]中国计划生育学杂志,2010年第1期总第172期,147。
【5】Cordula Schippert[J] JOURNAL OF RECONSTRUCTIVE MICROSURGERYVOLUME 26, NUMBER 5 2010.
【6】Steptoe PC. Pregnancies following implantation of human embryos grown in culture[J] The Scientific Meeting of the Royal College of Obstetricians and Gynaecologists, Program Supplement; 1979.
【7】Vandromme J, Chasse E, Lejeune B, et al .Hydrosalpinges in in-vitro fertilization: an unfavourable prognostic feature. [J]Hum Reprod1995;10:576-579.
【8】Knutzen V, Soto-Albors CE, Fuller D, et al.Mock embryo transfer(MET) in early luteal phase, the cycle prior to in vitro fertilization and embryo transfer[J] The American Fertility Society; 1989,152,13-16.
【9】Verhulst G, Vandersteen N, Van Steirtegham AC,et al .Bilateral salpingectomydoes not compromise ovarian stimulation in an in-vitro fertilization/embryo transferprogramme[J] Hum Reprod 1994;9:624-628
【10】Shelton KE, Butler L, Toner JP, et al.Salpingectomy improves the pregnancy rate in in-vitro fertilization patients with hydrosalpinx. [J]Hum Reprod1996;11:523-525.
【11】Benadiva CA, Kligman I, Davis O, et al. In vitro fertilization verus tubal surgery: is pelvic reconstructive surgery obsolete? [J] Fertil Steril 1995;64:1051-1061.
【12】A Strantell,A Landhard et al Hydrosalpinx and IVF-ET outcome :a prospective and randomized multicentre trial in Scandinavia on salpingectomy prior to IVF-ET? [J]Human Reproduction ,1999,14 (11),2762-2769.
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【30】Bildirici I, Bukulmez O, Ensari A, et al. A prospective evaluation of the effect of salpingectomy on endometrial receptivity in cases of women with communicating hydrosalpinges. [J]Hum Reprod 2001(16)2422–2426.
【31】Luca Sabatini ,Colin Davis, et al. The management of hydrosalpinges: tubal surgery or salpingectomy? [J]Current Opinion in Obstetrics and Gynecology 2005 (17)323–328.
【32】Vandromme,j,et al, Hydrosalpinges in vitro fertilization an unfavorable prognostic feature.[J]Hum Reprod,1995(10)576-579.
【33】Puttemans PJ, Brosens I Aet al. Salpingectomy improves ui-vitrofertilization outcome m patients with a hydrosalpinx blind victimization of the fallopian tube[J]Hum Reprod ,2005(11),2079-2081.
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【35】冯玉蓉,黄绘等,输卵管切除对体外受精一胚胎移植中卵巢反应性及临床妊娠率的影响[J]中国妇幼保健2008年第23卷3427-3428.
【36】李柳铭吴洪波等,输卵管手术对体外受精一胚胎移植患者卵巢血流及反应性的影响[J]生殖与避孕第28卷第1期17-20.
【37】Raoul Orvieto, Bozhena Saar,et alDoes salpingectomy affect the ipsilateral ovarian response to gonadotropin during in vitro fertilization–embryo transfer cycles[J]Fertility and Sterility,2011, Vol. 95, No. 5, April,1842-1846.
【38】覃桂荣,蔡小勇等,不孕症实施腹腔镜下输卵管、卵巢电凝电切手术对卵巢功能的近期影响[J]中国计划生育学杂志2011年1月第19卷第1期,26-30。
【39】Sefa,k,BluentY,etal.Ovarian reserve and ovarian stromal blood supply after tubal ligation by the POmetry technique comparison with controls.
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【42】Cordula Schippert, Christina Bassler, Philipp Soergel,,et al. Reconstructive, organ-preserving microsurgery in tubal infertility: still an alternative to in vitro fertilization[J]Fertil Steril_ 2010(93)1359–1361
【1】曹泽毅.中华妇产科学[M]第1版.北京:人民卫生出版社, 1999:2312-2313.
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【11】Practice Committee of the American Society for Reproductive medicine.Salpingectomy for hydrosalpinx prior to in vitro fertilization. [J]Fetil Steril 2004;82 (1): 117–S119. PMID19007249.
【12】De Vantery Arrighi C, Lucas H, El-Mowafi D, et al. Effects of human hydrosalpinx fluid on in-vitro murine fertilization. [J]Hum Reprod 2001, 16(4):676–682. PMID11278217.
【13】Bildirici I, Bukulmez O, Ensari A, et al. A prospective evaluation of the effect of salpingectomy on endometrial receptivity in cases of women with communicating hydrosalpinges. [J]Hum Reprod 2001,16(11):2422–2426.PMID11679532.
【14】Sabatini L, Davis C, et al. The management of hydrosalpinges: tubal surgery or salpingectomy? [J]Current Opinion in Obstetrics and Gynecology 2005, 17(4):323–328.PMID15976534.
【15】BenjiaminC.Primary therapy for tubal disease :surgery vesus IVF-ET? [J]Fertil, 1995,291-302.
【16】Schippert C, Bassler C, Soergel P, et al. Reconstructive, organ-preserving microsurgery in tubal infertility: still an alternative to in vitro fertilization. [J] Fertil Steril, 2010,93(4):1359–1361.PMID 19782355.
【17】严英,陆丽明,周伟生,et al。中医药治疗输卵管阻塞性不孕随机对照试验文献的质量评价。[J]广州中医药大学学报。2010,27(2):181-183。
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【19】Hull MG, Fleming C,et al.Tubal surgery versus assisted reproduction :asseing their role in infertility therapy。[J] Current opinion in obstetrics and gynecology,1995,7(3):160-167.PMID 7647266.
【20】Nackley AC, Muasher SJ. The significance of hydrosalpinx in in vitro fertilization [J]FERTILITY AND STERILITY,1998, 70(4):787-788.PMID9531862.
【2】Richard O.Burney,Daniel.J.Schust,郎景和译,Novak妇科学[M]第14版,人民卫生出版社,2007,745。
【3】夏恩兰.宫腔镜与腹腔镜检查.[J]中国实用妇科与产科杂志,1999;15(6):338。
【4】张耀,何玮,孙敏,李俊林.腹腔镜手术与经腹手术治疗输卵管性不孕的效果分析.[J]中国计划生育学杂志,2010年第1期总第172期,147。
【5】Cordula Schippert[J] JOURNAL OF RECONSTRUCTIVE MICROSURGERYVOLUME 26, NUMBER 5 2010.
【6】Steptoe PC. Pregnancies following implantation of human embryos grown in culture[J] The Scientific Meeting of the Royal College of Obstetricians and Gynaecologists, Program Supplement; 1979.
【7】Vandromme J, Chasse E, Lejeune B, et al .Hydrosalpinges in in-vitro fertilization: an unfavourable prognostic feature. [J]Hum Reprod1995;10:576-579.
【8】Knutzen V, Soto-Albors CE, Fuller D, et al.Mock embryo transfer(MET) in early luteal phase, the cycle prior to in vitro fertilization and embryo transfer[J] The American Fertility Society; 1989,152,13-16.
【9】Verhulst G, Vandersteen N, Van Steirtegham AC,et al .Bilateral salpingectomydoes not compromise ovarian stimulation in an in-vitro fertilization/embryo transferprogramme[J] Hum Reprod 1994;9:624-628
【10】Shelton KE, Butler L, Toner JP, et al.Salpingectomy improves the pregnancy rate in in-vitro fertilization patients with hydrosalpinx. [J]Hum Reprod1996;11:523-525.
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