【作者】 李晓；

【导师】 陈子江； 颜磊；

【作者基本信息】 山东大学 ， 妇产科学（专业学位）， 2019， 硕士

【摘要】 研究背景:宫腔粘连,又称Asherman’s综合征,是子宫内膜创伤导致子宫腔或宫颈管部分或全部闭塞,表现为月经异常、不孕症和反复流产。宫腔镜下粘连分离术(transeervicalresection of adhesions,TCRA)是治疗IUA的标准术式。通过宫腔镜直视下,对病变部位、病变性质、累及范围做出准确诊断的同时,可为病情评估、预后提供参考依据,宫腔镜手术分离粘连,可避免操作的盲目性,降低出血、子宫穿孔等手术风险。目前临床上主要采用宫腔镜电切和剪刀机械性分离两种手术方式。宫腔镜电切手术对致密粘连进行快速分离的同时有效止血,维持手术视野清晰,降低手术风险,但是其电热效应可能会破坏病变周围残存的子宫内膜,进一步降低残留正常内膜的面积,不利于术后内膜修复,此外,炎症因子的渗出增加会促进再粘连的形成。应用剪刀可避免热效应,从而最小化对病变周边内膜的损伤;缺点是分离致密和周边型粘连操作困难且难以止血。残留内膜面积是内膜修复的重要基础,再粘连的形成是影响子宫内膜的修复的重要的因素。治疗的目的尽可能恢复宫腔的正常解剖形态,预防再粘连,促进内膜功能恢复,最终改善患者的生殖结局。目前两种手术治疗方式的效果优劣尚无定论,需进一步研究为临床手术方式的选择、进一步改善患者生殖结局提供依据。研究目的:回顾性分析IUA患者的临床特征,评价不同宫腔镜手术术后的内膜恢复、妊娠结局及影响因素,从而为临床实践中手术方式的选择提供参考,以期改善IUA患者的辅助生殖结局。研究方法:本研究收集2014年1月-2017年12月于山东大学附属生殖医院住院行宫腔镜下粘连分离术且行IVF/ICSI助孕的20-45岁不孕妇女456例,其中电切组378例,剪刀组78例。术后均给雌激素治疗2个周期,术后1个月复查宫腔镜。收集患者的临床基线资料,包括年龄、体重指数、手术前后AFS评分、促排卵数据、妊娠结局,比较两组的内膜厚度及妊娠结局,并通过多因素Logistic回归模型分析妊娠结局的影响因素。研究结果:456例IUA患者中298例(65.4%)有妊娠相关的诱发因素,其中有265例(58.1%)有妊娠相关的宫腔操作病史。不同程度IUA组的宫腔操作次数差异有统计学意义,其中中度IUA患者的宫腔操作次数明显高于轻度IUA患者(p<0.01)。电切组与剪刀组的术后AFS评分均较术前显著下降(P<0.01),两组术后AFS评分无差异。电切组的平均内膜厚度及薄型子宫内膜率分别为0.90±0.20cm、11.1%,而剪刀组的平均内膜厚度及薄型子宫内膜率分别为0.87±0.18cm、14.1%,两组差异无显著性。电切组与剪刀组的年龄、BMI、基础内分泌水平、促排卵基线资料未见明显差异,剪刀组IUA程度略高于电切组,考虑了IUA程度混杂影响后两组的生化妊娠率、临床妊娠率、持续妊娠率、活产率、生化妊娠流产率、临床妊娠流产率均无统计学差异(p>0.05)。通过Logistic回归分析临床妊娠的独立影响因素为HCG注射日内膜厚度(OR 5.614,95%CI 1.746-18.048)、年龄(OR 0.570,95%CI 0.369-0.881)、AMH(OR 1.192,95%CI 1.092-1.301),活产的独立影响因素为宫腔操作次数(OR 0.726,95%CI 0.598-0.881)、HCG 日注射日内膜厚度(OR 5.655,95%CI 1.653-19.343)、BMI(OR 0.431,95%CI 0.266-0.699)、AMH(OR 1.181,95%CI 1.091-1.279)。研究结论:1、妊娠因素是宫腔粘连形成的主要诱因,宫腔操作次数增加,宫腔粘连的程度会增加。2、宫腔镜下粘连分离术能有效改善宫腔粘连状况,宫腔镜下电切及剪刀宫腔粘连分离术的临床疗效无显著性差异,需要更大样本量的前瞻性研究为临床工作提供更具有指导性的建议。3、HCG注射日内膜厚度、年龄、AMH为宫腔粘连术后患者IVF/ICSI助孕治疗临床妊娠结局的独立影响因素,宫腔操作次数、HCG日内膜厚度、AMH、BMI为宫腔粘连术后患者IVF/ICSI助孕治疗活产结局的独立影响因素。更多还原

【Abstract】 Background:Intrauterine adhesions,also known as Asherman’s syndrome,is a consequence of trauma to the endometrium,producing partial or complete obliteration of the uterine cavity and/or the cervical canal,manisfested as menstrual abnormalities,infertility,and recurrent pregncancy loss.Transerervical resection of adhesions(TCRA)is currently the most important surgical procedure for the treatment of intrauterine adhesions(IUA).Hysteroscopy can accurately confirm the presence,nature,extent of adhesions providing references for the assessment and prognosis of the disease because uterine cavity can be directly inspected.Hysteroscopic surgery is the main choice of treatment for IUA beacause it can be performed under direct vision,reducing the risk of uterine perforation.Adhesiolysis may be performed with the help of the hysteroscopic scissors or eclectrode needle or loop currently.Electrosurgery system can provide effective and precise cutting as well as good hemostasis maintaing a clear operative field and reducing the risk,but there is a theoretical possibility of further endometrial damage.The damage of residual endometrium aside adhesions will affect the endometrial healing.In addition,increased inflammatory factors promote the reformation of adhesions.Hysteroscopic adhesiolysis using scissors has the advantage that it permitts dissection and avoids complications related to energy sources,and it possibly minimizes the destruction endometrium.But the disadvantage is that it is more difficult to seperate dense,marginal adhesions with a scissor and without good hemostasis.This will carry a increased risk of perforation.The area of residual endometrium is fundamental basis for endometrial repair,and reformation of adhesion is also an important factor affecting wound healing.Treatment of IUA aims at restoring the normal size and shape of the uterine cavity,preventing recurrence of the adhesion,promoting the repair and regeneration of the destroyed endometrium,and ultimately improving the patient’s reprodctive outcome.Whether hysteroscopic adhesiolysis using scissors or a electrosurgery system is better for IUA is unkown.Further research is needed to provide evidence for the selection of surgical methods and improvement of reprductive outcome.Objective:To analyze retrospectively clinical features of patients with intrauterine adhesions,and to evaluate the efficacy,pregnancy outcomes after different methods of hysteroscopic adhesiolysis and influencing factors of pregnacncy outcome,thus provide evidence for the selection of surgical methods.Method:A total of 456 infertile women aged from 20 to 45 years old who diagnosed with intrauterine adhesion underwent hysteroscopic adhesiolysis followed by IVF/ICSI-ET in the affiliated reproductive hospital of Shandong University from January 2014 to July 2018.There were 378 cases in electrode knife group and 78 cases in scissor group.Estrogen treatment was administered postoperatively for 2 months in both groups.A second-look hysteroscopy was carried out 1 month after the surgery.The clinical baseline data including age,body mass index,AFS score before and after surgery,ovarian stimulation procedure and reproductive outcome were collected.Endometrial thickness and reproductive outcome were compared.And factors influecing pregnancy outcomes were analyzed by univariate and multivariate Logistic regression model.Results:65.4%(298/456)of IUA cases had pregnancy-related predisposing factors and 58.1%(265/456)had a history of pregnancy-related intrauterine operations.There were significant differences in the number of intrauterine operations between different degrees of intrauterine adhesion.The number of intrauterine operations in patients with moderate IUA was significantly higher than that in patients with mild IUA(p<0.01).The postoperative AFS scores of the electrode knife group and the scissor group were significantly lower than those before surgery(P<0.01)and there was no significant difference in postoperative AFS sore between both groups.There was no significant differences in age,BMI,basal endocrine level and ovulation-induced baseline data between electrode knife group and scissor group.The mean endometrial thickness and thin endometrial rate of electrode kinfe group were 0.90±0.20cm and 11.1%,wheras 0.87±0.18cm and 14.1%in scissor group and no statistical significance was found between two groups(p>0.05).Baseline data of both groups were similar,except IUA are more severe in knife group than that in scissor group.There was no significant difference in biochemical pregnancy rate,clinical pregnancy rate,ongoing pregnancy rate,live birth rate,biochemical pregnancy abortion rate,clinical pregnancy abortion rate between electrode knife and scissor group considering the mixed effects of severity of IUA(p>0.05).Logistic regression analysis showed that the independent influencing factors of clinical pregnancy were endometrial thickness on HCG trigger day(OR 5.6 14,95%CI 1.746-18.048),age(OR 0.570,95%CI 0.369-0.881),AMH(OR 1.192,95%CI 1.092-1.301)are the independent factors that affect the clinial pregnancy rate.And the number of intrauterine operations(OR 0.726,95%CI 0.598-0.881),endometrial thickness on HCG trigger day(OR 5.655,95%CI 1.653-19.343),BMI(OR 0.431,95%CI 0.266-0.699),AMH(OR 1.181,95%CI 1.091-1.279)are the independent influencing factors of live birth rate.Conclusion:1.Pregnancy is the dominating predisposing factor of the formation of intrauterine adhesions.As the number of intrauterine operation increases,the degree of intrauterine adhsion will increase.2.Hysteroscopic adhesiolysis is an effective and safe operation for the treatment of IUA.Different methods of operation do not influence the efficacy and reproductive outcome of IUA patient who received IVF/ICSI-ET after hysteroscopic adhesiolysis.Prospective studies with more samples are needed to provide guidance for clinical practice.3.Endometrial thickness on HCG trigger day,age,AMH are independent factors of clinial pregnancy in patients with intrauterine adhesions who received IVF/ICSI-ET postoperatively.Number of intrauterine operations,Endometrial thickness on HCG trigger day,BMI,AMH are independent factors of live birth in patients with intrauterine adhesions who received IVF/ICSI-ET postoperatively.更多还原