子宫内膜异位症155例术后妊娠率及其影响因素分析

发布时间：2018-04-25 11:48

本文选题：腹腔镜 + 子宫内膜异位症　；参考：《河北医科大学》2014年硕士论文

【摘要】：目的：不孕症（infertility）指有生育要求的夫妇，规律性生活，未避孕一年未孕[1]。WHO预测，不孕将成为仅次于肿瘤和心脑血管疾病的第三大疾病[2]。正常妊娠的维持经历了卵巢排卵、精卵结合、受精卵输送与胚胎着床及胚胎发育等多个步骤，任何一环节异常都可能导致整个妊娠过程失败。子宫内膜异位症可以影响任一环节导致不孕发生。子宫内膜异位症虽然是一种良性疾病，但其表现为恶性生物学行为：细胞增生、浸润和复发。子宫内膜异位症的临床表现有很多种，临床上主要表现为痛经、性交痛、慢性盆腔痛、月经不调和不孕。在不孕患者中，大约80%合并子宫内膜异位症[3]。子宫内膜异位症所引起的痛经及慢性盆腔疼痛等严重影响了妇女的身体健康和生活质量，不孕更是影响家庭的稳定和正常生活。子宫内膜异位症最主要的病变是粘连，包括盆腔粘连，输卵管梗阻或周围粘连。粘连的发生是个长期、慢性的过程。子宫内膜异位种植后随月经变化发生周期性出血，在卵巢局部形成内含巧克力样陈旧血的囊肿。囊肿逐渐增大，其内压力也逐渐增大，当囊壁出现裂隙时囊内巧克力样液体便会自裂隙渗出，继而引起卵巢周围组织炎性反应和纤维化，正常基质缺损，受累卵泡颗粒细胞功能异常、激素水平异常等，而致卵巢排卵异常。中、重度内异症可破坏盆腔解剖结构，如子宫与直肠粘连，输卵管伞端粘连。子宫内膜异位症还能降低宫腔内正常子宫内膜对受精卵的容受性，造成宫内种植障碍[4]。当前广泛使用的内异症分期标准为1985年美国生育学会AFS提出的“修正子宫内膜异位症分期法”[5]。此分期法将子宫内膜异位症分为四期：I期（微型）1-5分；II期（轻度）6-15分；III期（中度）16-40分；IV期（重度）＞40分。卵巢是最容易受到异位子宫内膜侵犯的的器官，约80%的内异症患者一侧卵巢受累，约50%的患者双侧卵巢同时受累[6]。关于卵巢病变侧别与术后妊娠率关系，有报道左侧卵巢病变治疗后易复发，妊娠率较右侧低[7]，这可能与左侧盆腔有乙状结肠、容易发生组织粘连有关。亦推测可能与右侧卵巢血供来自腹主动脉(左侧可来自左肾动脉)，血运丰富，卵巢功能恢复快有关。年龄是影响卵巢储备功能的重要因素之一。目前，年龄超过40岁是公认的卵巢低反应性的高危因素。随着年龄增长，卵巢卵泡数量迅速减少，卵母细胞质量降低，卵母细胞核异常显著增多，颗粒细胞凋亡率上升，卵泡闭锁加速从而导致女性生育能力下降。子宫内膜异位症临床类型，期别及子宫内膜异位囊肿侧别、直径，患者年龄等均可能影响内异症不孕患者术后妊娠率。本文旨在研究子宫内膜异位症腹腔镜术后的妊娠情况及子宫内膜异位症的临床类型，期别及子宫内膜异位囊肿侧别、直径，患者年龄对术后妊娠率的影响。方法：回顾性分析2008-1至2013-1主因不孕并且有生育要求而就诊于河北医科大学第二医院的女性患者病例。以确诊为子宫内膜异位症的155例患者为研究对象，这些患者均行腹腔镜探查术，，术后病理确诊为子宫内膜异位症。统计分析其临床及手术情况，包括年龄分布，术中病灶分布、粘连及子宫内膜异位囊肿直径，发生侧别，术后分期，通过术后门诊复查及电话随访术后妊娠情况，分析以上五个影响因素对术后妊娠率的影响。结果：治疗后155例患者中45例成功受孕，妊娠率29.03%(45/155)。妊娠率Ⅰ、Ⅱ、Ⅲ、Ⅳ期分别57.89%(11/19)、52.17%(12/23)、26.09%(18/69)、09.09%(4/44)，差别有统计学意义(X2=22.44，P＜0.05)，单纯子宫内膜异位囊肿术后妊娠率为44.23%(23/52)，子宫内膜异位囊肿同时合并其他部位和仅其他部位内膜异位症术后妊娠率分别为16.13%(10/62)和29.27%(12/41)，差异有统计学意义(X2=10.84，P＜0.05)。右侧子宫内膜异位囊肿术后妊娠率为53.85%(21/39)，高于左侧23.26%(10/43)和双侧5.71%(2/35)(X2=21.93，P＜0.05)。子宫内膜异位囊肿直径＜3cm术后妊娠率为55.00%(11/20)，3-5cm者为41.56%(32/77)，＞5cm者为20.69%(12/58)，差异有统计学意义（X2=10.11，P＜0.05）。年龄20-25岁妊娠率为53.85%(19/42)，26-30岁妊娠率为29.85%(20/67)，＞30岁妊娠率为13.04%(6/46)，差异有统计学意义（X2=11.08，P＜0.05）。结论：子宫内膜异位症影响女性的生育能力是肯定的，子宫内膜异位症的临床期别、内异症病灶部位、子宫内膜异位囊肿发生侧别及子宫内膜异位囊肿直径，患者年龄等对治疗后妊娠率都有影响。及时的手术治疗有利于妊娠率提高。
[Abstract]:Objective : infertility ( infertility ) refers to couples with reproductive health requirements , regular life , and no conception of contraception for one year . The WHO estimates that infertility will be the third major disease that is next to tumors and cardiovascular and cerebrovascular diseases . The maintenance of normal pregnancy has experienced many steps such as ovarian ovulation , fertilization , fertilization and embryo implantation and embryo development . Any abnormality in any link may lead to failure of the whole process of pregnancy . The endometriosis may affect any link to cause infertility .

Although endometriosis is a benign disease , it is characterized by malignant biological behavior : cell proliferation , infiltration and recurrence . The clinical manifestations of endometriosis are various , mainly in dysmenorrhea , sexual intercourse , chronic pelvic pain , irregular menstruation and infertility . Approximately 80 % of infertility patients combine endometriosis . dysmenorrhea and chronic pelvic pain caused by endometriosis have a serious impact on the physical health and quality of life of women , and the infertility affects the stability and normal life of the family .

The most important pathological changes in endometriosis are adhesions , including pelvic adhesion , obstruction of the fallopian tube or peripheral adhesion . The occurrence of adhesions is a chronic , chronic process . In 1985 , the clinical staging standard of endometriosis was divided into four stages : phase I ( micro ) 1 - 5 ;
Phase II ( mild ) 6 - 15 min ;
Phase III ( moderate ) 16 - 40 minutes ;
Phase IV ( severe ) > 40 points .

The ovaries are the most susceptible to ectopic endometrium invasion , about 80 % of the patients with endometriosis have ovarian involvement , and about 50 % of the patients have bilateral ovaries and are affected at the same time . The relationship between the side of the ovarian lesion and the pregnancy rate was reported . It was reported that the left ovary lesion was easy to recur after the treatment , and the pregnancy rate was lower than that of the right side . This could be related to the presence of sigmoid colon in the left pelvic cavity and easy tissue adhesion . It is also speculated that the right ovary blood may be related to the rapid recovery of ovarian function from the abdominal aorta ( left renal artery from the left side ) , abundant blood transport and recovery of ovarian function .

Age is one of the most important factors affecting ovarian reserve function . At present , the number of ovarian follicles is rapidly decreased , the quality of oocytes decreased , the number of oocytes was decreased , the apoptosis rate of granulose cells increased , and follicular atresia accelerated , resulting in a decline in female fertility .

The purpose of this study was to study the clinical types of endometriosis , the clinical types , the diameter of endometriosis , the influence of age on pregnancy rate after operation .

Methods : The clinical and operative conditions of 155 patients with endometriosis diagnosed as endometriosis were analyzed retrospectively , including age distribution , distribution of lesions in operation , adhesions and ectopic cyst diameter , incidence side , post - operative staging , post - operative outpatient review and post - operative pregnancy , and analyzed the effect of the above five factors on pregnancy rate after operation .

Results : The pregnancy rate was 53.85 % ( 11 / 19 ) , 52.17 % ( 12 / 23 ) , 26.09 % ( 18 / 69 ) , 09 . 09 % ( 12 / 23 ) , 26.09 % ( 18 / 69 ) , 09 . 09 % ( 12 / 23 ) , 26.09 % ( 18 / 69 ) , 09 . 09 % ( 4 / 44 ) respectively .

Conclusion : The effect of endometriosis on the fertility of women is positive , the clinical stage of endometriosis , the location of endometriosis , the incidence of endometriosis cyst , the diameter of ectopic cyst , the age of the patient and so on have an influence on the rate of pregnancy after treatment . The timely surgical treatment is beneficial to the improvement of pregnancy rate .

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R711.71

【引证文献】