腹腔镜保守性手术联合药物治疗中重度子宫内膜异位症的临床疗效分析
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摘要
目的探讨腹腔镜保守性手术联合药物治疗中重度子宫内膜异位症(EMs)的临床效果。方法回顾性分析2013年1月至2016年1月就诊于盛京医院妇科、行腹腔镜保守性手术治疗的中重度EMs患者420例的临床资料。根据术后用药不同分为GnRH-a组(A组,271例)和孕三烯酮组(B组,149例);其中EMs相关性不孕症患者共166例,按照术后用药分为两个亚组:A1组(使用GnRH-a,107例),B1组(使用孕三烯酮,59例)。术后随访2年,比较各组术后临床症状改善情况,及不孕症患者的妊娠结局。结果 (1)术后3个月临床疗效评估,A组治疗总有效率显著高于B组(89.2%vs.70.7%,P<0.001),但随访期间A、B两组术后复发率(13.1%vs.12.9%)及药物不良反应发生率(10.4%vs.12.1%)比较均无显著性差异(P>0.05)。(2)166例EMs相关不孕症患者中,A1组术后自然妊娠率显著高于B1组(44.9%vs.28.8%,P<0.05),但两组间总妊娠率(67.3%vs.52.5%)无显著性差异(P>0.05),两组间异位妊娠率、流产率、早产率、足月产率、剖宫产率、自然分娩率比较亦无显著性差异(均P>0.05);统计不同时间段内妊娠例数,停药后6个月内A1组妊娠率显著高于B1组(43.9%vs.27.1%,P<0.05)。(3)经Spearman秩相关分析,EMs相关不孕症患者术后妊娠率与生育指数评分(EFI)呈正相关(rs=0.714,P<0.05)。结论中重度EMs患者行腹腔镜保守性手术后联合药物治疗可改善临床治疗效果,改善自然妊娠率,且GnRH-a的临床疗效优于孕三烯酮。
Objective:To evaluate the efficacy of laparoscopic conservative surgery combined with drugs for treatment of moderate and severe endometriosis(EMs).Methods:The clinical data of 420 patients with moderate to severe EMs undergone laparoscopic conservative surgery in Shengjing Hospital of China Medical University from Jan.2013 to Jan.2016 were enrolled in this retrospective study.According to the different medications after surgery,the patients divided to two groups:271 patients in GnRH-agroup(group A)and 149 patients in gestrinone group(group B).Among them,there were 166 patients with endometriosis-associated infertility.According to the different medications after surgery,they were divided into two subgroups,as 107 in GnRH-agroup(group A1)and 59 in gestrinone group(group B1).The patients were followed for 24 months and the improvement of clinical symptoms after surgery and the pregnancy outcome of the infertile patients were compared among the groups.Results:The total clinical efficacy rate of group A was significantly higher than that of group B(89.2% vs.70.7%)(P<0.001).The recurrence rate(13.1% vs.12.9%)and drug adverse rate(10.4%vs.12.1%)were not significantly different between group A and B(P>0.05).The natural pregnant rate in group A1 was significantly higher than that in group B1(44.9% vs.28.8%,P<0.05),but there was no significant difference in total pregnant rate between group A1 and B1(67.3% vs.52.5%,P>0.05).There were no significant differences in ectopic pregnant rate,miscarriage rate,preterm rate,term rate,cesarean section rate and natural labor rate between the two groups(P>0.05)..The pregnant rate within the first 6 months after drugs cessation in group A1 was significantly higher than that in group B1(43.9%vs.27.1%,P<0.05).Spearman rank correlation analysis showed that postoperative pregnancy rate was positively correlated with endometriosis fertility index(EFI)in patients with EMs-related infertility(rs=0.714,P<0.05).Conclusions:Laparoscopic conservative surgery combined with postoperative drugs is effective and safe for endometriosis.It can bring more clinical efficacy and improve natural pregnancy rate.GnRH-a is superior to gestrinone in improving efficacy and natural pregnancy.
Objective:To evaluate the efficacy of laparoscopic conservative surgery combined with drugs for treatment of moderate and severe endometriosis(EMs).Methods:The clinical data of 420 patients with moderate to severe EMs undergone laparoscopic conservative surgery in Shengjing Hospital of China Medical University from Jan.2013 to Jan.2016 were enrolled in this retrospective study.According to the different medications after surgery,the patients divided to two groups:271 patients in GnRH-agroup(group A)and 149 patients in gestrinone group(group B).Among them,there were 166 patients with endometriosis-associated infertility.According to the different medications after surgery,they were divided into two subgroups,as 107 in GnRH-agroup(group A1)and 59 in gestrinone group(group B1).The patients were followed for 24 months and the improvement of clinical symptoms after surgery and the pregnancy outcome of the infertile patients were compared among the groups.Results:The total clinical efficacy rate of group A was significantly higher than that of group B(89.2% vs.70.7%)(P<0.001).The recurrence rate(13.1% vs.12.9%)and drug adverse rate(10.4%vs.12.1%)were not significantly different between group A and B(P>0.05).The natural pregnant rate in group A1 was significantly higher than that in group B1(44.9% vs.28.8%,P<0.05),but there was no significant difference in total pregnant rate between group A1 and B1(67.3% vs.52.5%,P>0.05).There were no significant differences in ectopic pregnant rate,miscarriage rate,preterm rate,term rate,cesarean section rate and natural labor rate between the two groups(P>0.05)..The pregnant rate within the first 6 months after drugs cessation in group A1 was significantly higher than that in group B1(43.9%vs.27.1%,P<0.05).Spearman rank correlation analysis showed that postoperative pregnancy rate was positively correlated with endometriosis fertility index(EFI)in patients with EMs-related infertility(rs=0.714,P<0.05).Conclusions:Laparoscopic conservative surgery combined with postoperative drugs is effective and safe for endometriosis.It can bring more clinical efficacy and improve natural pregnancy rate.GnRH-a is superior to gestrinone in improving efficacy and natural pregnancy.
引文
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[8]郑婧,王燕,王晓黎.腹腔镜术后孕三烯酮GnRH-a序贯用药治疗中、重度子宫内膜异位症合并不孕的临床疗效[J].中国计划生育学杂志,2018,26:299-302.
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[11]钟亚娟,张蔚,张文婷,等.促性腺激素释放激素激动剂联合腹腔镜手术治疗中、重度内异症的疗效观察[J].中华妇产科杂志,2013,48:180-182.
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[14]崔建营,赵梅,梁明,等.子宫内膜异位症不孕患者血清CA125水平与术后妊娠结局的关系[J].现代妇产科进展,2013,22:139-141.
[15]李薇薇,郭艺红.子宫内膜异位症患者生育力保护[J].生殖医学杂志,2018,27:595-600.
[16]Cranney R,Condous G,Reid S.An update on the diagnosis,surgical management,and fertility outcomes for women with endometrioma[J].Acta Obstet Gynecol Scand,2017,96:633-643.
[17]Santulli P,Collinet P,Fritel X,et al.Management of assisted reproductive technology(ART)in case of endometriosis related infertility:CNGOF-HAS Endometriosis Guidelines[J].Gynecol Obstet Fertil Senol,2018,46:373-375.
[18]徐楗荧,罗英,曲仕浩,等.子宫内膜异位症不孕患者腹腔镜术后IVF-ET妊娠结局影响因素分析[J].生殖医学杂志,2018,27:540-544.
[19]Nirgianakis K,Bersinger NA,McKinnon B,et al.Regression of the inflammatory microenvironment of the peritoneal cavity in women with endometriosis by GnRHa treatment[J].Eur JObstet Gynecol Reprod Biol,2013,170:550-554.
[20]甄宗慧.腹腔镜手术联合孕三烯酮治疗子宫内膜异位症合并不孕对基质金属蛋白酶及炎性因子的影响[J].中国妇幼保健,2018,33:2373-2376.
[21]叶晶晶,李留霞,胡珍华,等.生育指数评分对子宫内膜异位症不孕患者术后妊娠方式选择预测价值[J].国际生殖健康/计划生育杂志,2018,37:187-191.
[22]Maheux-Lacroix S,Nesbitt-Hawes E,Deans R,et al.Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis[J].Hum Reprod,2017,32:2243-2249.
[23]DiVasta AD,Feldman HA,Sadler Gallagher J,et al.Hormonal add-back therapy for females treated with gonadotropin-releasing hormone agonist for endometriosis:Arandomized controlled trial[J].Obstet Gynecol,2015,126:617-627.
[24]宋菁华,鲁桦,张军,等.腹腔镜手术联合促性腺激素释放激素激动剂治疗内异症的临床研究[J].中华妇产科杂志,2013,48:584-588.
[2]Zhou Z,Zheng D,Wu H,et al.Epidemiology of infertility in China:a population based study[J].BJOG,2018,125:432-441.
[3]Koninckx PR,Zupi E,Martin DC.Endometriosis and pregnancy outcome[J].Fertil Steril,2018,110:406-407.
[4]Vassilopoulou L,Matalliotakis M,Zervou MI,et al.Endometriosis and in vitro fertilization[J].Exp Ther Med,2018,16:1043-1051.
[5]Collinet P,Fritel X,Revel-Delhom C,et al.Management of endometriosis:CNGOF/HAS clinical practice guidelinesShort version[J].J Gynecol Obstet Hum Reprod,2018,47:265-274.
[6]Koga K,Takamura M,Fujii T,et al.Prevention of the recurrence of symptom and lesions after conservative surgery for endometriosis[J].Fertil Steril,2015,104:793-801.
[7]Adamson GD.Endometriosis Fertility Index:is it better than the present staging systems?[J].Curr Opin Obstet Gynecol,2013,25:186-192.
[8]郑婧,王燕,王晓黎.腹腔镜术后孕三烯酮GnRH-a序贯用药治疗中、重度子宫内膜异位症合并不孕的临床疗效[J].中国计划生育学杂志,2018,26:299-302.
[9]S7ritsa D,Saare M,Laisk-Podar T,et al.Pregnancy rate in endometriosis patients according to the severity of the disease after using a combined approach of laparoscopy,GnRHagonist treatment and in vitro fertilization[J].Gynecol Obstet Invest,2015,79:34-39.
[10]彭靖,张萌,利桂玲.子宫内膜异位症相关不孕的治疗进展[J].国际生殖健康/计划生育杂志,2017,36:82-86.
[11]钟亚娟,张蔚,张文婷,等.促性腺激素释放激素激动剂联合腹腔镜手术治疗中、重度内异症的疗效观察[J].中华妇产科杂志,2013,48:180-182.
[12]Alkatout I,Mettler L,Beteta C,et al.Combined surgical and hormone therapy for endometriosis is the most effective treatment:prospective,randomized,controlled trial[J].JMinim Invasive Gynecol,2013,20:473-481.
[13]Sesti F,Capozzolo T,Pietropolli A,et al.Recurrence rate of endometrioma after laparoscopic cystectomy:a comparative randomized trial between post-operative hormonal suppression treatment or dietary vs.placebo[J].Eur J Obstet Gynecol Rprod Biol,2009,147:72-77.
[14]崔建营,赵梅,梁明,等.子宫内膜异位症不孕患者血清CA125水平与术后妊娠结局的关系[J].现代妇产科进展,2013,22:139-141.
[15]李薇薇,郭艺红.子宫内膜异位症患者生育力保护[J].生殖医学杂志,2018,27:595-600.
[16]Cranney R,Condous G,Reid S.An update on the diagnosis,surgical management,and fertility outcomes for women with endometrioma[J].Acta Obstet Gynecol Scand,2017,96:633-643.
[17]Santulli P,Collinet P,Fritel X,et al.Management of assisted reproductive technology(ART)in case of endometriosis related infertility:CNGOF-HAS Endometriosis Guidelines[J].Gynecol Obstet Fertil Senol,2018,46:373-375.
[18]徐楗荧,罗英,曲仕浩,等.子宫内膜异位症不孕患者腹腔镜术后IVF-ET妊娠结局影响因素分析[J].生殖医学杂志,2018,27:540-544.
[19]Nirgianakis K,Bersinger NA,McKinnon B,et al.Regression of the inflammatory microenvironment of the peritoneal cavity in women with endometriosis by GnRHa treatment[J].Eur JObstet Gynecol Reprod Biol,2013,170:550-554.
[20]甄宗慧.腹腔镜手术联合孕三烯酮治疗子宫内膜异位症合并不孕对基质金属蛋白酶及炎性因子的影响[J].中国妇幼保健,2018,33:2373-2376.
[21]叶晶晶,李留霞,胡珍华,等.生育指数评分对子宫内膜异位症不孕患者术后妊娠方式选择预测价值[J].国际生殖健康/计划生育杂志,2018,37:187-191.
[22]Maheux-Lacroix S,Nesbitt-Hawes E,Deans R,et al.Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis[J].Hum Reprod,2017,32:2243-2249.
[23]DiVasta AD,Feldman HA,Sadler Gallagher J,et al.Hormonal add-back therapy for females treated with gonadotropin-releasing hormone agonist for endometriosis:Arandomized controlled trial[J].Obstet Gynecol,2015,126:617-627.
[24]宋菁华,鲁桦,张军,等.腹腔镜手术联合促性腺激素释放激素激动剂治疗内异症的临床研究[J].中华妇产科杂志,2013,48:584-588.