【作者】 李洁；

【导师】 石丘玲； 曾定元； 林忠；

【作者基本信息】 重庆医科大学 ， 妇产科学（专业学位）， 2024， 博士

【摘要】 前言对于输卵管疾病引起的不孕患者,体外受精-胚胎移植（IVF-ET）仍然是目前最主要的治疗方式之一。在引起不孕的输卵管疾病中,输卵管积水是最常见的原因之一。腹腔镜下双侧输卵管近端离断+远端造口术（简称“输卵管结扎术”）是目前预处理输卵管积水的主要方法,被认为可以提高胚胎种植率。临床上,结扎输卵管的手术时机有两种,一种是在取卵前（IVF-ET前）进行输卵管结扎手术,另一种是在取卵后进行输卵管结扎手术,即先进行促排卵取卵、全胚冷冻,待输卵管结扎手术完成后再进行胚胎移植。但是,输卵管结扎术的时机选择仍存在争议,取卵前还是取卵后进行结扎对妊娠结局的影响不明,手术时机的选择缺乏基于辅助生殖助孕结局的数据支持,特别是生育能力比较低下的患者,如何选择输卵管结扎时机,亟需数据辅助医患决策。除此之外,对于已经行输卵管结扎手术的患者,术后何时进行IVF-ET助孕使患者获益最大化,目前也缺乏相关研究。本研究采用历史性和前瞻性结合的队列研究设计,建立因输卵管积水导致不孕的就医患者队列,分析结扎及助孕两个关键步骤的决策与妊娠结局的关系,并结合患者不同特征进行分层分析,从而明确治疗的最佳时机,同时整合临床和组学数据,解析结扎和助孕时机以及结扎术后影响IVF助孕结局的机制,为输卵管积水患者手术治疗及IVF-ET助孕的选择提供临床和分子依据,最终改善其妊娠结局。目的探讨输卵管积水患者结扎手术时机,挖掘输卵管积水结扎术后IVF-ET助孕最佳时间,并在临床和分子层面综合解析结扎术后不同助孕结局的机制,为临床医生提供治疗决策,使患者获益最大。方法本研究构建了历史性和前瞻性患者队列,作为回顾性队列,选取了2016年1月至2022年12月在我院接受IVF-ET助孕,且在取卵前或取卵后（且胚胎未移植前）进行腹腔镜下双侧输卵管结扎术预处理积水的患者。从医院电子病历库中导出所需患者的疾病及治疗相关数据,按结扎时机分为两组:（1）“先结扎手术组”:即先行腹腔镜下双侧输卵管结扎术处理积水,后促排卵取卵及胚胎移植;（2）“先取卵组”:即先促排卵取卵获取胚胎并全胚冷冻后,再行输卵管结扎术。分析比较先行输卵管结扎术和先行促排卵取卵的妊娠结局,来探究输卵管积水患者的结扎时机,并采用倾向性评分匹配（PSM）再次验证分析结果。并将两组患者根据年龄分成两个亚组（低龄组,<35岁组,及高龄组,≥35岁）,再根据卵巢储备功能分成两个亚组（低卵巢储备组及正常卵巢储备组）。在不同亚组人群中再次探讨输卵管积水的结扎时机。从上述回顾性队列中选取已行输卵管结扎术并且在术后1年内进行IVF或卵胞浆内单精子显微注射技术（ICSI）助孕治疗的患者。基于分段回归分析,确定出现显著妊娠结局变化的时间节点,根据妊娠结局的时间变化节点和双侧输卵管结扎术后至行IVF/ICSI助孕的时间间隔将研究对象分为3组,即结扎术后1组:患者于结扎术后3个月内行IVF/ICSI助孕;结扎术后2组:术后3-7个月内助孕;结扎术后3组:术后>7个月后助孕。比较三组输卵管结扎术后不同时机进行IVF助孕对妊娠结局的影响,并对高龄或卵巢低储备患者进行亚组分析。回顾性队列的主要结局指标包括:卵巢反应指标、胚胎实验室指标以及临床妊娠率、活产率、流产率等妊娠结局,最终指标是累积活产率。数据分析采用线性回归和Logistic回归模型,控制变量包括年龄、身体质量指数（BMI）、不孕年限等相关影响因素,采用Beta值、比值比（OR）及95%可信区间（CI）量化治疗时机与妊娠结局关系。为进一步探讨输卵管结扎术后不同助孕结局的临床和分子机制,通过构建前瞻性队列,纳入2021年10月至2023年12月行输卵管结扎术的患者,分别在术前、术后1个月、2个月、3个月以及7个月后采集患者卵巢功能和激素水平。主要评估指标包括:通过阴道超声和抽血检查,评估双侧卵巢窦卵泡计数、基础性激素及抗苗勒氏管激素水平。并将患者根据卵巢储备功能（正常卵巢储备组、低卵巢储备组）及年龄段（<35岁组、35-39岁组、≥40岁组）进行分层,采用中介效应分析,最终明确输卵管结扎术后不同时间节点助孕结局不同的临床机制。同时重新收集2024年1月至2024年7月输卵管积水患者结扎前后子宫内膜组织,结合基因转录和蛋白表达水平,进一步阐释输卵管结扎术后IVF-ET助孕时机导致助孕结局差异的潜在分子机制。结果1、结扎决策的探索:本部分共纳入1490例研究对象（先结扎组:976例;先取卵组:514例）。“先结扎组”患者的Gn启动剂量、成熟卵母细胞（MII）率均高于“先取卵组”。而“先取卵组”的获卵数、h CG注射日E₂水平、可用D3胚胎数、优质D3胚胎形成率均显著高于“先结扎组”（P<0.05）。“先结扎组”患者的血HCG阳性率、多胎妊娠率、临床妊娠率、活产率以及累积活产率却显著高于“先取卵组”,且“先结扎组”患者的流产率低于“先取卵组”（P<0.05）。Logistic回归分析显示,与“先结扎”相比,“先取卵”能降低临床妊娠率和活产率（P<0.001）,而且是早期流产率的风险因素,经过年龄和多因素校正后,仍有显著的统计学差异（P<0.05）,并且针对临床妊娠和活产的OR值进一步下降,而对早期流产的OR值则增高。上述结果也在基于年龄和不孕年限匹配分析后的样本中得到验证,即输卵管积水患者先结扎能有效提高患者的助孕结局。在亚组分析中,高龄“先结扎组”患者的可用囊胚形成率和优质囊胚形成率均优于“先取卵组”,而且,“先结扎组”的血HCG阳性率、临床妊娠率、活产率以及累积活产率也高于“先取卵组”。Logistic回归分析也发现,高龄“先结扎组”患者的临床妊娠结局优于“先取卵组”（P<0.001）。然而,在低卵巢储备亚组分析中,两组患者的妊娠结局和卵巢反应等方面并没有显著差异。此外,在“先结扎组”与“先取卵组”患者移植卵裂期D3胚胎或囊胚的妊娠结局比较中,“先结扎组”的妊娠结局也均优于“先取卵组”,且“先结扎组”的血HCG阳性率、临床妊娠率、活产率均明显高于“先取卵组”（P<0.05）。2、结扎术后IVF-ET助孕时机的探索:共纳入976例患者,本部分对输卵管结扎术后不同时间节点IVF-ET助孕结局进行了分段回归分析,发现在结扎术7个月后进行IVF-ET助孕的妊娠率显著低于7个月内,而3个月内的助孕成功率最高。通过组间比较,结扎术后3个内月行IVF助孕的累积活产率和多胎妊娠率均显著高于结扎术后3-7个月或>7个月的患者（P<0.05）。除此之外,结扎后3个内月行IVF助孕患者的生化妊娠流产率明显低于3个月后的患者（P<0.05）。在线性回归分析中,随着结扎术后IVF助孕时间间隔的推移,胚胎实验室指标中可用囊胚形成率和优质囊胚形成率均有下降的趋势（P<0.05）。Logistic回归分析也发现,结扎后3个内月行IVF助孕患者的临床妊娠率（OR:0.503,95%CI:0.320,0.789,P=0.003）和活产率（OR:0.487,95%CI:0.314,0.757,P=0.001）均显著高于>7个月行IVF助孕患者。在高龄患者亚组分析中,结扎后3个月内行IVF助孕的MII率（85.89%）高于3-7个月（81.12%）和>7个月的患者（77.19%）,而结扎后>7个月行IVF助孕的患者的胚胎移植次数显著少于7个月内的患者（P<0.05）。与此同时,结扎后3个月内行IVF的生化妊娠流产率（0%）低于3-7个月（6.78%）和>7个月行IVF的患者（6.00%）（P<0.05）,且结扎后7个月内行IVF患者的累积活产率则显著高于7个月后助孕的患者。然而,在Logistic回归分析中,我们并没有发现高龄患者结扎术后不同IVF-ET助孕时间节点能影响患者的妊娠结局。在低卵巢储备亚组分析中,卵巢储备功能低下的患者在结扎后3个月内行IVF助孕的活产率（69.23%）显著高于3-7个月（31.88%）和7个月后的患者（48.39%）（P<0.05）。线性回归分析发现,随着结扎术后IVF助孕时间间隔的推移,患者的获卵个数、可用D3胚胎数有减少的趋势,而且优质D3胚胎形成率、可用囊胚形成率和优质囊胚形成率均有降低的趋势（P<0.05）。但在Logistic回归分析中,却并没有发现不同IVF-ET助孕时间节点对妊娠结局的显著影响关系。对于D5/D6囊胚移植的患者,结扎后3个月内行IVF-ET助孕患者的早期流产率（3.77%vs.12.39%vs.21.05%）低于3个月后的患者（P<0.05）。而在卵裂期D3胚胎和囊胚移植中,患者的生化妊娠流产率会随着结扎术后IVF时间间隔的延长而增加。3、输卵管结扎术后卵巢功能和激素改变对IVF助孕结局影响:回顾性的数据发现,卵巢功能和激素水平随着结扎术后取卵时间的延长,有着显著差异。前瞻性队列数据发现,与结扎术前情况相比,结扎术后1个月、2个月基础FSH水平（9.15±3.20 miu/ml、8.48±2.51 miu/ml）明显高于术前水平（7.61±2.56 miu/ml）,但术后1个月、2个月AFC平均个数（13.98±8.30个、15.84±8.77个）则低于术前（20.78±10.29个）。此外,结扎术后1个月AMH值为2.26±1.64 ng/ml,显著低于术前2.87±2.04 ng/ml（P<0.05）。与术前比较,结扎术3个月后FSH、LH、E₂水平、AMH值以及AFC均无差异。这些指标在高龄和低卵巢储备功能患者结扎术后的变化趋势是一致的。中介效应分析验证了输卵管结扎术后至IVF助孕时间间隔与助孕结局有直接关联,但卵巢功能和激素水平对这一关联并没有中介效应。4、输卵管结扎术后子宫内膜免疫微环境对IVF助孕妊娠结局改善的机制:为进一步挖掘输卵管结扎术后子宫内膜微环境变化对IVF-ET影响的机制,我们对输卵管结扎术前后患者的子宫内膜组织进行了RNAseq和蛋白层面的分析,并发现输卵管结扎术后子宫内膜的CXCL14、CLIC6、FCGBP等基因高表达,而免疫炎症相关信号通路则被抑制。CIBERSORTx免疫细胞成分分析和免疫组化则发现输卵管结扎术后子宫内膜中大量的M2型巨噬细胞浸润。子宫内膜单细胞测序则发现子宫内膜上皮细胞中CXCL14基因高表达,可能与巨噬细胞CXCR4受体存在交互作用,从而维持子宫内膜免疫微环境的稳定,使得输卵管积水结扎术后患者获得更好的IVF-ET助孕结局。结论1、针对输卵管积水的不孕患者,优先在取卵前进行输卵管结扎,对患者的妊娠结局意义更大,尤其对临床上生育能力低下的高龄患者疗效显著。2、输卵管结扎术后7个月内行IVF-ET助孕将有益于患者的妊娠结局,尤其在结扎术3个月内的助孕成功率最高。但这一时机的选择对高龄和卵巢功能减退的人群不适用。3、虽然患者实施输卵管结扎术后卵巢功能会存在一过性的损伤,但在术后3个月基本恢复至术前水平。4、输卵管结扎术后IVF-ET助孕时间节点不同所导致妊娠结局差异的主要原因是由于子宫内膜免疫微环境的变化,而非患者的卵巢功能或者激素水平改变导致。更多还原

【Abstract】 BackgroundFor patients with infertility due to tubal disease,in vitro fertilization-embryo transfer（IVF-ET）remains the primary treatment option.Among the tubal diseases that cause infertility,hydrosalpinx is one of the most common causes.Laparoscopic bilateral proximal tubal occlusion and distal salpingostomy（referred to as"Tubal Ligation"）is the main method to improve the rate of embryo implantation and pretreat hydrosalpinx.Clinically,there were two surgical programs for tubal ligation:one was tubal ligation before oocyte retrieval（before IVF-ET）,and the other was tubal ligation after oocyte retrieval,that is,ovulation induction and oocyte retrieval,all embryo frozen,and embryo transfer after the completion of tubal ligation.However,the time of tubal ligation was controversial.The effect of ligation before or after oocyte retrieval on pregnancy outcome was unknown.There is a lack of data support for the outcome of assisted reproductive technology in the selection of surgical timing,especially for patients with poor fertility.How to choose the timing of tubal ligation needs data to assist the decision-making of doctors and patients.In addition,there is a lack of research on when to maximize the benefits of IVF-ET treatment for patients who have already undergone tubal ligation.In this study,a combination of historical and prospective cohort study design was used to establish a cohort of medical patients with infertility due to hydrosalpinx.The relationship between the decision selection of the two key steps of ligation and pregnancy assistance and the pregnancy outcome was analyzed,and the stratified analysis was carried out according to different characteristics of patients,so as to determine the best time for treatment.At the same time,clinical and omics data were integrated to analyze the timing of ligation and assisted pregnancy as well as the mechanism affecting the outcome of IVF treatment after ligation,to provide clinical and molecular basis for the surgical treatment of hydrosalpinx patients and the selection of IVF-ET treatment,and finally improve the pregnancy outcome.PurposeTo explore the timing of ligation surgery for patients with hydrosalpinx,explore the best time for IVF-ET to assist pregnancy after hydrosalpinx ligation,and comprehensively analyze the mechanism of different assisted pregnancy outcomes after ligation at the clinical and molecular levels,so as to provide clinicians with treatment decisions and maximize the benefits for patients.MethodsIn this study,a historical and prospective patient cohort was constructed.As a retrospective cohort,we selected patients who received IVF-ET treatment in our hospital from January 2016 to December 2022 and underwent laparoscopic bilateral fallopian tube ligation pre-treatment with hydrops before or after oocyte retrieval（and before embryo transfer）.The disease and treatment related data of required patients were extracted from the hospital electronic medical record database and divided into two groups according to the time of ligation:（1）"Proximal Tubal Occlusion First Group":firstly,laparoscopic bilateral proximal fallopian tube dissection and distal ostomy were performed to treat hydrops.And then ovulation induction and embryo transfer were performed.（2）"Oocyte Retrieval First Group":the oocytes were obtained by ovulation induction first and the whole embryo was frozen.Then the proximal fallopian tube was severed and the distal ostomy was performed.The pregnancy outcomes after tubal ligation first and oocyte retrieval first were analyzed and compared to explore the ligation time of hydrosalpinx patients,and the analysis results were verified again using Propensity score matching（PSM）.The above two groups of patients were divided into two subgroups according to different ages:the advanced age group and the young group（Young group,Age<35years,Advanced age group,Age≥35 years）.They were then divided into two subgroups according to ovarian reserve function（Diminished ovarian reserve group and Normal ovarian reserve group）.The ligation time of hydrosalpinx was discussed again in different subgroups.Patients who had undergone tubal ligation and underwent IVF-ET or Intracytoplasmic sperm injection（ICSI）within 1 year after ligation were selected from this retrospective cohort.Based on segmented regression analysis,the time nodes for significant changes in pregnancy outcomes were determined,and all subjects were divided into 3 groups according to the changes in pregnancy rate nodes and the interval between bilateral tubal ligation and IVF treatment.Group 1:Patients underwent IVF/ICSI treatment within 3 months after ligation.Group 2:Patients underwent IVF/ICSI treatment within 3-7 months after ligation.Group 3:Patients underwent IVF/ICSI treatment>7 months after ligation.Subgroup analysis was conducted for advanced patients or patients with diminished ovarian reserve function,to compare the effect of IVF on pregnancy outcomes after tubal ligation in three groups.The main outcome measures in the retrospective cohort included:ovarian response indicators,laboratory indicators,and clinical pregnancy outcomes,such as clinical pregnancy rate,live birth rate and abortion rate,ect.,and the final outcome was cumulative live birth rate.Linear regression and Logistic regression analysis was performed after adjusting some indicators,such as age,body mass index,infertility duration,ect.,and the Beta,odds ratios（OR）and 95%confidence interval（CI）were used as quantitative indexes.To further explore the clinical and molecular mechanisms of different assisted pregnancy outcomes after tubal ligation,we reconstructed a prospective cohort to include patients who underwent tubal ligation between October 2021 and December 2023,and collected ovarian function and hormone levels before ligation,1 month,2 months,3 months,and 7months after ligation.The main assessment measures included:bilateral ovarian sinus follicle counts were assessed by vaginal ultrasound and blood draw,basic sex hormones and anti-Mullerian hormone levels.The patients were evaluated according to ovarian reserve function（normal ovarian reserve group,diminished ovarian reserve group）and age（<35 years old group,35-39 years old group,≥40 years old group）stratification with using mediation effects analysis,and finally identify the different clinical mechanisms of assisted pregnancy outcomes at different time points after tubal ligation.At the same time,the endometrial tissues of patients with hydrosalpinx before and after ligation from January 2024 to July 2024 were collected again,and the gene transcription and protein expression levels were combined to further elucidate the potential molecular mechanism of the difference in assisted pregnancy outcome caused by the timing of IVF-ET treatment after tubal ligation.Results1.Exploration of ligation decision:A total of 1490 subjects were included in this part（Proximal Tubal Occlusion First Group:976,Oocyte Retrieval First Group:514）.The Gn initiation dose and Mature Oocyte（MII）rate in the"ligation first group"were higher than those in the"oocyte retrieval first group".The number of oocytes obtained,E₂ level on h CG injection day,number of available D3 embryos,and high-quality D3embryo formation rate of patients in the"oocyte retrieval first group"were higher than those in the"ligation first group"（P<0.05）.The positive blood HCG rate,multiple pregnancy rate,clinical pregnancy rate,live birth rate and cumulative live birth rate of patients in the"ligation first group"were higher than those in the"oocyte retrieval first group"（P<0.05）,and the abortion rate in the"ligation first group"was lower than that in the"oocyte retrieval first group"（P<0.05）.Logistic regression analysis showed that"oocyte retrieval first"could decrease the clinical pregnancy rate and live birth rate compared with"ligation first"（P<0.001）,and was a risk factor for early miscarriage,with significant differences after adjusting for age and multiple factors（P<0.05）,and the OR values for clinical pregnancy and live birth further decreased,while the OR values for early abortion increased.These results were confirmed in the samples after a propensity score matching analysis based on age and infertile duration,indicating that ligation first in hydrosalpinx patients could effectively improve the outcome of assisted pregnancy.In addition,in subgroup analysis,the available blastocyst formation rate and high-quality blastocyst formation rate of advanced age patients in the"ligation first group"were better than those in the"oocyte retrieval first group",and the positive blood HCG rate,clinical pregnancy rate,live birth rate and cumulative live birth rate of advanced age patients in the"ligation first group"were higher than those in the"oocyte retrieval first group".In Logistic regression analysis,the clinical pregnancy outcome of the advanced age"ligation first group"was better than that of the advanced age"oocyte retrieval first group"（P<0.001）.In the analysis of the diminished ovarian reserve subgroup,there was no significant difference in pregnancy outcomes and ovarian response between the"ligation first group"and the"oocyte retrieval first group".In the comparison of pregnancy outcomes between the"ligation first group"and the"oocyte retrieval first group"patients who transplanted D3embryos or blastocysts,the pregnancy outcomes of the"ligation first group"were also better than those of the"oocyte retrieval first group",and the positive rate of blood HCG,clinical pregnancy rate and live birth rate of patients in the"ligation first group"were significantly higher than those in the"oocyte retrieval first group"（P<0.05）.2.Exploration on the timing of IVF-ET treatment after ligation:A total of 976 patients were included.We conducted a stepwise regression analysis of IVF-ET assisted pregnancy outcomes at different time points after tubal ligation,and found that the pregnancy rate of patients undergoing IVF-ET treatment>7 months after ligation was significantly lower than that of patients within 7 months,and the success rate of assisted pregnancy within 3 months after ligation was the highest.The cumulative live birth rate and multiple pregnancy rate of IVF treatment within 3 months after ligation were significantly higher than those of IVF within 3-7 months or>7 months after ligation（P<0.05）.In addition,the rate of biochemical pregnancy loss was significantly lower in patients within 3 months after ligation than in patients after 3 months（P<0.05）.In linear regression analysis,with the passage of time interval of IVF treatment after ligation,both the available blastocyst formation rate and the high-quality blastocyst formation rate showed a decreasing trend（P<0.05）.In Logistic regression analysis,the clinical pregnancy rate（OR:0.503,95%CI:0.320,0.789,P=0.003）and the live birth rate（OR:0.487,95%CI:0.314,0.757,P=0.001）of IVF treatment within 3 months after ligation was significantly higher than that of>7 months.In the subgroup analysis of advanced age patients,the MII rate of IVF treatment within 3 months after ligation（85.89%）was higher than that of within 3-7 months（81.12%）and>7 months（77.19%）.The number of embryo transfers in IVF treatment after 7 months was significantly lower than that within 7 months（P<0.05）.At the same time,the rate of biochemical pregnancy loss（0%）in patients undergoing IVF treatment within 3 months after ligation was lower than that at 3-7 months（6.78%）and>7 months（6.00%）（P<0.05）.The cumulative live birth rate was also significantly higher in patients who underwent IVF treatment within 7months after ligation than>7 months after ligation.However,in Logistic regression analysis,we did not find that different IVF-ET treatment time nodes after ligation significantly affected the pregnancy outcomes of patients for advanced age patients.In the analysis of diminished ovarian reserve subgroups,the live birth rates were significantly higher within 3 months after ligation（69.23%）than in patients with 3-7 months（31.88%）and>7 months after ligation（48.39%）（P<0.05）.In linear regression analysis,with the passage of IVF treatment time interval after ligation,the number of oocytes obtained and the number of available D3 embryos decreased,and the rate of high-quality D3 embryo formation,blastocyst formation and high-quality blastocyst formation decreased（P<0.05）.However,in Logistic regression analysis,there was no significant relationship between different IVF-ET treatment time nodes and pregnancy outcomes for DOR.In the analysis of D5/D6 blastocyst transplantation,the rate of early miscarriage（3.77%vs.12.39%vs.21.05%）in patients with IVF-ET treatment within 3 months after ligation was lower than that in patients after 3 months（P<0.05）.In the analysis of D3 embryo and blastocyst transfer,it was found that the biochemical pregnancy loss rate of patients also increased with the extension of IVF treatment interval after ligation.3.A preliminary analysis of the mechanism of ovarian function and hormone changes after tubal ligation on IVF assisted pregnancy outcome:Retrospective data showed that there were significant differences in ovarian function and hormone levels with the extension of the time interval from ligation to IVF treatment.A prospective cohort study found that,compared to pre-ligation conditions,the basal FSH level（9.15±3.20 miu/ml,8.48±2.51 miu/ml）at 1st and second months after ligation was significantly higher than that before ligation（7.61±2.56 miu/ml）.However,the average number of AFC at 1st and second months after ligation（13.98±8.30,15.84±8.77）was significantly lower than that before ligation（20.78±10.29）.In addition,the AMH value 1st month after ligation was 2.26±1.64 ng/ml,which was significantly lower than that before ligation（2.87±2.04 ng/ml）（P<0.05）.There were no differences in FSH,LH,E₂,AMH and AFC after3rd months of ligation.The change trend of these indexes was consistent in the advanced age and diminished ovarian reserve patients after ligation.The mediation effect analysis verified that the time interval between tubal ligation and IVF treatment was directly associated with assisted pregnancy outcomes,but ovarian function and hormone levels had no mediating effect on this association.4.The mechanism of endometrial immune microenvironment after tubal ligation to improve the pregnancy outcome of IVF treatment:In order to further explore the mechanism of the influence of endometrial microenvironment changes after tubal ligation on IVF-ET,RNAseq and protein levels were analyzed in endometrial tissues of patients before and after tubal ligation,and it was found that CXCL14,CLIC6,FCGBP and other genes were highly expressed in endometrial tissues after tubal ligation,and immunoinflammatory signaling pathways were inhibited.CIBERSORTx immunocytoanalysis and immunohistochemistry revealed a large number of M2-type macrophages infiltrated the endometrium after tubal ligation.Combined with endometrial single cell sequencing,This study found that the high expression of CXCL14 gene in endometrial epithelial cells may interact with CXCR4 receptors in macrophages,thereby maintaining the stability of the endometrial immune microenvironment and achieving better IVF-ET assisted pregnancy outcomes for patients after hydrosalpinx ligation.Conclusions1.For infertile patients with hydrosalpinx,tubal ligation should be given before priority oocytes retrieval,which had greater significance for the pregnancy outcome of patients,especially for the advanced age patients with low fertility in clinic.2.IVF-ET treatment and oocytes retrieval in hydrosalpinx patients within 7 months after ligation will benefit the pregnancy outcome of the patients,especially within 3 months after ligation,the success rate of assisted pregnancy is the highest.However,this timing is not suitable for the advanced age patients and the population with diminished ovarian function.3.Although the ovarian function of the patient after tubal ligation might be temporarily impaired,it was basically restored to the preoperative level 3 months after the ligation.4.The main reason for the difference in pregnancy outcomes caused by different time points of IVF-ET treatment after tubal ligation is the change of endometrial immune microenvironment,rather than the change of ovarian function or hormone level of the patients.更多还原