生殖医学杂志

目的分析Ⅲ/Ⅳ期子宫内膜异位症合并不孕的患者行宫腹腔镜术后的妊娠结局,以期为患者提供更加具体的术后受孕指导。方法回顾性分析2015年2月至2018年12月于北京协和医院妇产科由同一术者针对106例Ⅲ/Ⅳ期子宫内膜异位症合并不孕的患者施行宫腹腔镜手术的病历资料,电话随访患者受孕结局,分析其可能影响因素,并就促性腺激素释放激素激动剂(GnRH-a)的辅助作用尝试总结和分析。结果 (1) 106例患者中失访3例。患者平均年龄(32.3±3.4)岁(26～41岁),平均不孕时间(3.0±2.0)年(1～10年)。修正的美国生育学会/美国生殖医学学会(rAFS/rASRM)评分中位分值48,其中16～40分34例,>40分72例;子宫内膜异位症生育指数(EFI)评分中位分值6,0～3分6例,4～5分22例,≥6分78例。(2)术后3年累计总妊娠率81.6%(84/103),其中自然妊娠41例(48.8%),IVF-ET妊娠43例(51.2%);术后半年内、一年内、两年内以及三年的累计妊娠率分别为32.0%、50.5%、73.8%和81.6%;术后同期选择IVF-ET的患者与自然妊娠的患者相比,获得妊娠的时间无统计学差异(P=0.585)。(3)Ⅲ期的患者总妊娠率显著高于Ⅳ期患者(97.0%vs.77.1%,P=0.011),但自然妊娠率和活产率无统计学差异(P>0.05)。EFI 0～3分组无自然妊娠,4～5分和≥6分组的自然妊娠率分别为21.1%和60.7%,而不同EFI分组间IVF-ET助孕后总妊娠率无统计学差异(P>0.05);有无卵巢子宫内膜异位囊肿(OMA)或深部子宫内膜异位症(DIE)组间的妊娠率无统计学差异(P>0.05),而合并子宫腺肌症(AM)组总妊娠率显著下降(P<0.05)。(4)术后是否应用GnRH-a的组间总妊娠率比较无统计学差异(81.0%vs. 86.7%,P=0.445),未应用GnRH-a组自然妊娠率似乎更高,且47.6%均在术后6个月内受孕。结论Ⅲ/Ⅳ期子宫内膜异位症术后亦有值得期待的自然妊娠率,IVF-ET并无显著的快捷优势,结合EFI评分可个体化选择妊娠方式;GnRH-a似乎对提高妊娠率无明显助益,但其通常用于病变广泛、合并DIE和/或AM的病例,这些混杂因素可能才是导致生育结局不良的重要原因。

Objective:To investigate the pregnancy outcome of infertile patients with stage Ⅲ/Ⅳ endometriosis after hystero-laparoscopic surgery, so as to provide more specific postoperative conception guidance for patients.Methods:The clinical data of 106 infertile patients with stage Ⅲ/Ⅳ endometriosis who underwent hysteron-laparoscopic surgery and received telephone follow-up of pregnancy outcome in Peking Union Medical College Hospital from February 2015 to December 2018 were retrospectively analyzed. Multiple factors related to pregnancy outcomes were analyzed, and the clinical adjuvant therapy efficacy of GnRH agonist(GnRH-a) was also investigated.Results:(1) Among the 106 patients, 3 patients were lost to follow-up. The mean age of the patients was(32.3±3.4) years(range: 26-41 years). The mean infertility time was average(3.0±2.0) years(range: 1-10 years). The median of Revised American Fertility Society/American Society of Reproductive Medicine(rAFS/rASRM)score was 48,34 patients with 16-40 and 72 patients with >40. The median of endometriosis fertility index(EFI) score was 6,six patients with 0-3,22 patients with 4-5,and 78 patients with ≥6.(2) The cumulative total pregnancy rate of 3 years after operation was 81.6%(84/103). Among them, 41 patients(48.8%) had spontaneous pregnancy and 43 patients(51.2%)got IVF-ET pregnancy. The cumulative pregnancy rate in six months, one year, two years and three years was 32.0%,50.5%,73.8% and 81.6% respectively. There was no significant difference in the time to obtain pregnancy after surgery between patients with IVF-ET and those with natural conception(P=0.585).(3) The pregnancy rate of stage Ⅲ patients was significantly higher than that of stage IV patients(97.0% vs. 77.1%,P=0.011). However, there was no significant difference in spontaneous pregnancy rate and live birth rate(P>0.05). No spontaneous pregnancy occurred in patients with EFI 0-3,and the spontaneous pregnancy rate of patients with EFI 4-5 and ≥ 6 was 21.1% and 60.7% respectively. However, there was no significant difference in the cumulative pregnancy rate after IVF-ET among the different EFI groups(P>0.05). There was no significant difference in the pregnancy rate between groups with or without ovarian endometrioma(OMA) or deep infiltrating endometriosis(DIE)(P>0.05),but the total pregnancy rate in the patients combined with adenomyosis(AM) decreased significantly(P<0.05).(4) There was no significant difference in the total pregnancy rate between the groups with or without GnRH-a(81.0% vs. 86.7%,P=0.445). The natural pregnancy rate seemed to be higher in the group without GnRH-a, and 47.6% patients were pregnant within 6 months after operation.Conclusions:The patients with stage Ⅲ/Ⅳ of endometriosis have promising spontaneous pregnancy outcome. IVF-ET compared with natural conception does not show the short-cut advantage. Combined with EFI score, obtaining pregnancy mode can be selected individually. GnRH-a seems to be useless in improving the pregnancy rate, but GnRH-a is usually used in patients with extensive lesions, combined with DIE and/or AM. These confounding factors may be the real negative factors for worse outcome.