高雅 常豐華 王智霆 王媛媛 李穎穎 封全靈
【摘要】 目的:統(tǒng)計(jì)并分析行腹腔鏡下不同術(shù)式的輸卵管積水患者術(shù)后接受輔助生殖的妊娠結(jié)局和遠(yuǎn)期卵巢儲(chǔ)備功能。方法:回顧性分析2019年3月-2021年9月于鄭州大學(xué)第三附屬醫(yī)院就診的因輸卵管積水所致不孕的患者103例,根據(jù)其手術(shù)術(shù)式分為兩組,A組(n=64)采用雙側(cè)輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù),B組(n=39)采用雙側(cè)輸卵管切除。術(shù)后隨訪12個(gè)月,比較兩組手術(shù)指標(biāo)、術(shù)后發(fā)熱率、并發(fā)癥情況、妊娠結(jié)局和遠(yuǎn)期卵巢儲(chǔ)備功能。結(jié)果:兩組手術(shù)時(shí)間、胃腸功能恢復(fù)時(shí)間、住院天數(shù)比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05);A組術(shù)中出血量和輸卵管評(píng)分均低于B組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。兩組術(shù)后發(fā)熱率、并發(fā)癥情況比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。隨訪期間A組妊娠35例,B組妊娠20例。兩組妊娠率、流產(chǎn)率、異位妊娠率比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05)。兩組術(shù)前及術(shù)后6個(gè)月月經(jīng)量、卵泡刺激素(FSH)、黃體生成素(LH)、雌二醇(E2)、內(nèi)膜厚度比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05);術(shù)后6個(gè)月,A組的FSH水平低于B組,B組內(nèi)膜厚度低于A組(P<0.05)。結(jié)論:采用雙側(cè)輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù)和雙側(cè)輸卵管切除術(shù)均可改善因輸卵管積水導(dǎo)致不孕的患者的妊娠結(jié)局,雙側(cè)輸卵管切除術(shù)可能對(duì)遠(yuǎn)期卵巢儲(chǔ)備功能產(chǎn)生影響。
【關(guān)鍵詞】 輸卵管積水 輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù) 輸卵管切除術(shù) 妊娠結(jié)局 卵巢儲(chǔ)備功能
[Abstract] Objective: To statistically and analyze the pregnancy outcomes and long-term ovarian reserve function of patients undergoing assisted reproductive surgery for hydrosalpinx undergoing different laparoscopic procedures. Method: A retrospective analysis was performed on 103 cases of infertility due to hydrosalpinx treated in the Third Affiliated Hospital of Zhengzhou University from March 2019 to September 2021. The patients were divided into two groups according to their surgical procedures, the group A (n=64) received bilateral proximal tubal ligation + distal ostomy, the group B (n=39) received bilateral salpingectomy. Postoperative follow-up was conducted for 12 months, and the surgical indexes, postoperative fever rate, complications, pregnancy outcome and long-term ovarian reserve function were compared between the two groups. Result: There were no significant differences in operation time, gastrointestinal function recovery time and hospital stay between the two groups (P>0.05). The intraoperative blood loss and tubal score in group A were lower than those in group B, the differences were statistically significant (P<0.05). There were no significant differences in postoperative fever rate and complications between the two groups (P>0.05). During the follow-up period, there were 35 pregnancies in group A and 20 pregnancies in group B.?There were no significant differences in pregnancy rate, abortion rate and ectopic pregnancy rate between the two groups (P>0.05). There were no significant differences in menstrual volume, follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2) and endometrial thickness between the two groups before and 6 months after surgery (P>0.05). Six months after operation, the FSH level of group A was lower than that of group B, and the intima thickness of group B was lower than that of group A (P<0.05). Conclusion: Both proximal tubal ligation + distal ostomy and bilateral salpingectomy can improve the pregnancy outcome of patients with infertility due to hydrosalping, the bilateral salpingectomy may have an impact on long-term ovarian reserve function.
[Key words] Hydrosalpinx Proximal tubal ligation + distal ostomy Salpingectomy Pregnancy outcome Ovarian reserve function
First-author's address: The Third Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
doi:10.3969/j.issn.1674-4985.2023.13.012
根據(jù)我國最新全國生殖健康流行病學(xué)調(diào)查結(jié)果顯示,我國的不孕率高達(dá)18%,輸卵管因素約占不孕癥的25%[1]。在輸卵管疾病中最嚴(yán)重的就是輸卵管積水,占輸卵管疾病的10%~30%[2]。輸卵管積水可使傘部撿卵功能難以正常發(fā)揮,影響受精卵的形成、發(fā)育和輸送[3]。盆腔感染、不潔性生活、鄰近器官感染等原因?qū)е屡枨粌?nèi)組織粘連、輸卵管堵塞,使黏液滲出物無法通暢排出,輸卵管積液在管腔內(nèi)聚集形成[4]。在臨床工作中,對(duì)不同程度積水可采用不同的方式診治,首選腹腔鏡手術(shù),但對(duì)于輸卵管積水的處理迄今為止仍無統(tǒng)一的原則。本研究討論兩種術(shù)式對(duì)患者的妊娠結(jié)局和遠(yuǎn)期卵巢儲(chǔ)備功能是否產(chǎn)生影響,為臨床術(shù)式選擇做參考,現(xiàn)報(bào)道如下。
1 資料與方法
1.1 一般資料 選擇2019年3月-2021年9月就診于鄭州大學(xué)第三附屬醫(yī)院的輸卵管積水性不孕并行腹腔鏡手術(shù)的患者103例作為研究對(duì)象。納入標(biāo)準(zhǔn):經(jīng)子宮輸卵管造影或者其他影像學(xué)方法顯示為雙側(cè)輸卵管積水;雙側(cè)輸卵管及卵巢于腹腔鏡術(shù)前未有手術(shù)史;處于育齡期并有生育愿望;月經(jīng)周期規(guī)律;術(shù)后能配合回訪。排除標(biāo)準(zhǔn):合并有其他系統(tǒng)嚴(yán)重疾病;平素月經(jīng)周期紊亂;盆腔合并嚴(yán)重感染;其他因素所導(dǎo)致不孕;男方因素所致不孕。根據(jù)其手術(shù)術(shù)式分為A組(n=64)與B組(n=39)。本研究獲本院醫(yī)學(xué)倫理委員會(huì)批準(zhǔn)。
1.2 方法 取頭低臀高截石位,麻醉均采用全麻,在電視腹腔鏡系統(tǒng)下,于患者肚臍,左側(cè)腹及左下腹各切開1個(gè)穿刺孔,植入相應(yīng)器械,對(duì)宮腔進(jìn)行全面探查,將盆腔粘連分離,充分暴露輸卵管。(1)A組采用輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù):經(jīng)陰道放置子宮腔雙腔管,術(shù)中行輸卵管亞甲藍(lán)通液。在輸卵管近端行結(jié)扎術(shù),使用單極電凝于遠(yuǎn)端盲端處行“十”字切開,輸卵管傘端黏膜在輸卵管抓鉗作用下向外側(cè)翻開,將傘瓣固定于漿膜層上,注射稀釋的亞甲藍(lán)通液,通液經(jīng)子宮腔雙腔管流入輸卵管,輸卵管復(fù)通成功表現(xiàn)為術(shù)中可見輸卵管遠(yuǎn)端有亞甲藍(lán)液流出;(2)B組采用雙側(cè)輸卵管切除:在輸卵管系膜及近兩側(cè)宮角處使用單極或雙極電凝進(jìn)行切除,將離斷的患側(cè)輸卵管取出后對(duì)切口進(jìn)行檢查,縫合切口。輸卵管抽芯切除:將0.9%氯化鈉注射液分別多處注入輸卵管中的漿膜層下,充分將輸卵管管芯與輸卵管的漿膜層分離,沿輸卵管走行,充分暴露輸卵管組織,并使輸卵管組織在鈍性分離操作下游離出來,在峽部處斷開,對(duì)輸卵管近端電凝,遠(yuǎn)端切除,系膜出血處電凝或者縫合。
1.3 觀察指標(biāo)及判定標(biāo)準(zhǔn) (1)手術(shù)指標(biāo):記錄手術(shù)中的各項(xiàng)指標(biāo)包括手術(shù)時(shí)間、術(shù)中出血量、胃腸功能恢復(fù)時(shí)間、住院天數(shù)和輸卵管評(píng)分,其中輸卵管評(píng)分要求2位及以上副主任醫(yī)師同時(shí)依據(jù)輸卵管遠(yuǎn)端病變分期標(biāo)準(zhǔn)對(duì)術(shù)中輸卵管情況進(jìn)行評(píng)分[5]。評(píng)分標(biāo)準(zhǔn):輸卵管部分阻塞2分,完全阻塞5分;輸卵管黏膜正常0分,減少5分,缺失10分;輸卵管壁正常0分,薄壁5分,厚壁/僵硬10分。Ⅰ期2~5分;Ⅱ期7~10分;Ⅲ期12~15分;Ⅳ期>15分。(2)術(shù)后指標(biāo):術(shù)后發(fā)熱率及并發(fā)癥發(fā)生情況。根據(jù)文獻(xiàn)[6],術(shù)后發(fā)熱率通常是指手術(shù)后次日起至出院前,每天至少測(cè)2次體溫,有2次及以上體溫≥38 ℃;記錄術(shù)后12個(gè)月內(nèi)并發(fā)癥(盆腔積液,月經(jīng)不調(diào),下腹墜痛等)。(3)妊娠情況:術(shù)后隨訪12個(gè)月,觀察兩組的總?cè)焉飻?shù),患者在行體外受精-胚胎移植,14 d后檢測(cè)人絨毛膜促性腺激素水平,移植30 d對(duì)胎囊進(jìn)行超聲檢查,證實(shí)有胎囊及胎心搏動(dòng)后診斷為妊娠,隨之進(jìn)行隨訪;流產(chǎn)數(shù)(妊娠前12周內(nèi)發(fā)生流產(chǎn));異位妊娠數(shù)。(4)卵巢儲(chǔ)備功能:術(shù)前及術(shù)后6個(gè)月,于月經(jīng)2~5 d采集外周靜脈血5 mL,分離取血清,采用放射免疫法檢測(cè)卵泡刺激素(FSH)、黃體生成素(LH)、雌二醇(E2)水平;月經(jīng)量評(píng)價(jià)是依據(jù)Higham評(píng)價(jià)標(biāo)準(zhǔn),將經(jīng)期所需衛(wèi)生巾10~20片(月經(jīng)量30~80 mL)定義為月經(jīng)正常;經(jīng)期所需衛(wèi)生巾少于10片(月經(jīng)量<30 mL)定義為月經(jīng)過少;經(jīng)期所需衛(wèi)生巾多于20片(月經(jīng)量>80 mL)定義為月經(jīng)過多[7];子宮內(nèi)膜厚度在患者月經(jīng)干凈3 d后用B超檢測(cè)子宮內(nèi)膜厚度。
1.4 統(tǒng)計(jì)學(xué)處理 使用SPSS 23.0統(tǒng)計(jì)軟件對(duì)數(shù)據(jù)進(jìn)行處理,手術(shù)指標(biāo)、術(shù)前與術(shù)后6個(gè)月卵泡期性激素用(x±s)表示,符合正態(tài)分布后采用t檢驗(yàn),不滿足正態(tài)分布的計(jì)量資料以M(P25,P75)表示;妊娠率以率(%)表示,組間比較采用字2檢驗(yàn)。以P<0.05為差異有統(tǒng)計(jì)學(xué)意義。
2 結(jié)果
2.1 兩組一般資料比較 兩組年齡、體重、孕次、產(chǎn)次、不孕年限比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性,見表1。
2.2 兩組手術(shù)指標(biāo)比較 兩組手術(shù)時(shí)間、胃腸功能恢復(fù)時(shí)間、住院天數(shù)比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05);A組術(shù)中出血量和輸卵管評(píng)分均低于B組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表2。
2.3 兩組術(shù)后發(fā)熱率和并發(fā)癥情況比較 兩組術(shù)后發(fā)熱率、并發(fā)癥情況比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),見表3。
2.4 兩組妊娠結(jié)局比較 經(jīng)腹腔鏡治療后的103例輸卵管積水患者術(shù)后行IVF-ET,隨訪期間觀察妊娠數(shù)為55例:A組妊娠數(shù)為35例,B組妊娠數(shù)為20例。兩組妊娠率、流產(chǎn)率、異位妊娠率比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05),見表4。
2.5 兩組術(shù)前與術(shù)后6個(gè)月卵泡期性激素比較 兩組術(shù)前及術(shù)后6個(gè)月月經(jīng)量、FSH、LH、E2、內(nèi)膜厚度比較,差異均無統(tǒng)計(jì)學(xué)意義(P>0.05);術(shù)后6個(gè)月A組的FSH水平低于B組,B組內(nèi)膜厚度低于A組,差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。見表5。
3 討論
輸卵管是輸送受精卵的通路,任何原因?qū)е螺斅压茏枞梢l(fā)不孕。14項(xiàng)觀察性研究的Meta分析顯示,輸卵管積水的女性相對(duì)于未患有輸卵管積水的女性流產(chǎn)風(fēng)險(xiǎn)增加74%,也印證了輸卵管積水對(duì)妊娠產(chǎn)生負(fù)面影響[8-9]。造成影響的原因:卵泡的發(fā)育依賴于卵巢血液的供應(yīng),當(dāng)積水在輸卵管中聚集時(shí)會(huì)使卵巢血管受到擠壓,這種作用在影響卵巢血供的同時(shí)不利于卵泡的營養(yǎng)與發(fā)育;積液產(chǎn)生的壓力在反流入宮腔時(shí)會(huì)降低胚胎著床率,影響妊娠;積液使子宮內(nèi)膜組織中炎癥細(xì)胞因子TNF-α和IL-2 mRNA的表達(dá)水平增高,不僅降低子宮內(nèi)膜的接受度,而且積液的毒性會(huì)殺滅胚胎活性[10]。對(duì)于輸卵管積液的患者,進(jìn)行輸卵管積液預(yù)處理是對(duì)患者成功妊娠的重要保障[11-12]。D'Arpe等[13]也認(rèn)為應(yīng)對(duì)進(jìn)行試管嬰兒的輸卵管積水的女性,考慮使用腹腔鏡手術(shù)治療,并且應(yīng)對(duì)術(shù)后女性進(jìn)行卵巢儲(chǔ)備功能的監(jiān)測(cè)。
近年來,由于輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù)和切除術(shù)的普遍應(yīng)用,輸卵管積水患者可在行輔助生殖前進(jìn)行有效的預(yù)處理。本研究顯示,輸卵管兩種術(shù)式的患者手術(shù)時(shí)間、腸道功能恢復(fù)時(shí)間、住院天數(shù)等手術(shù)指標(biāo)與妊娠率差異均無統(tǒng)計(jì)學(xué)意義,即腹腔鏡下輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù)和雙側(cè)輸卵管切除術(shù)對(duì)輸卵管積水不孕患者的治療都是有效的。根據(jù)文獻(xiàn)[14]發(fā)現(xiàn)不同的術(shù)式對(duì)提升胚胎種植率、妊娠率和活產(chǎn)率并無明顯差別,而與是否處理輸卵管積水密切相關(guān)。沈亞等[15]認(rèn)為由于輸卵管積水持續(xù)存在,輸卵管內(nèi)壓力不斷增加,影響卵巢血供;輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù)可以解放輸卵管內(nèi)的壓力,降低血流阻力,使卵巢血供增加,有利于卵泡發(fā)育。子宮容受性在輸卵管炎癥的影響下可產(chǎn)生不良反應(yīng),將輸卵管切除會(huì)在徹底阻斷炎癥作用的同時(shí)預(yù)防卵巢癌發(fā)生的可能[16]。Palagiano等[17]認(rèn)為輸卵管積水可以影響HOXA10基因的表達(dá),在指導(dǎo)胚胎植入和發(fā)育過程中該基因是關(guān)鍵和必須的。HOXA10基因在子宮內(nèi)膜中的表達(dá)可以經(jīng)雙側(cè)輸卵管切除術(shù)的治療后得到改善,在提高患者妊娠率的方面發(fā)揮重要作用。
在本研究中發(fā)現(xiàn),腹腔鏡下雙側(cè)輸卵管切除術(shù)對(duì)遠(yuǎn)期卵泡刺激素和子宮內(nèi)膜的影響大于近端結(jié)扎+遠(yuǎn)端造口術(shù),其原因可能是在輸卵管切除術(shù)過程中易損傷輸卵管系膜內(nèi)吻合支,影響卵巢血供,破壞卵泡的正常發(fā)育;造口術(shù)有利于對(duì)輸卵管系膜內(nèi)血管的保護(hù),減少對(duì)卵巢血供的作用[18]。文獻(xiàn)[19]認(rèn)為由于卵巢上存在子宮動(dòng)脈上行支供應(yīng),術(shù)后卵巢功能不會(huì)受到切除術(shù)的影響;Sabatini等[20]認(rèn)為輸卵管切除術(shù)是一種確定性手術(shù),因此應(yīng)在輸卵管積水無法修復(fù)或體外受精失敗的情況下進(jìn)行。在輕度至中度輸卵管疾病中,應(yīng)優(yōu)先考慮輸卵管結(jié)扎造口術(shù)而不是切除術(shù)。從遠(yuǎn)期發(fā)展來考量,輸卵管結(jié)扎造口術(shù)術(shù)后依然存在不孕的可能和復(fù)發(fā)的風(fēng)險(xiǎn),另外輸卵管妊娠的風(fēng)險(xiǎn)也會(huì)有所增加[21]。
綜上所述,輸卵管近端結(jié)扎+遠(yuǎn)端造口術(shù)和雙側(cè)輸卵管切除術(shù)均可以有效治療輸卵管積水所致不孕,提升患者IVF-ET妊娠率,但不同術(shù)式的側(cè)重和優(yōu)劣不同,應(yīng)該擴(kuò)大樣本量深入研究。在臨床工作中,醫(yī)者應(yīng)綜合不同術(shù)式的特點(diǎn)和適用范圍,尊重患者的想法、根據(jù)患者的病情特點(diǎn)和個(gè)體差異為患者選擇合適的手術(shù)方式,提高妊娠率的同時(shí)減少對(duì)卵巢功能的傷害。
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(收稿日期:2022-11-03) (本文編輯:田婧)