大剂量孕激素治疗早期子宫内膜癌及子宫内膜重度不典型增生患者的妊娠结局及相关因素分析

Pregnant rate and pregnancy.relating factors of patients with early endometrial carcinoma and severe atypical hyperplasia of endometrium after fertility-preserving treatment by progestin

目的 了解大剂量孕激素保守治疗早期子宫内膜癌及子宫内膜重度不典型增生的妊娠结局及相关因素.方法 1996年6月至2010年1月北京协和医院收治的年轻早期子宫内膜癌（38例）及子宫内膜重度不典型增生患者（13例）共51例,采用连续口服大剂量孕激素治疗,每3个月诊刮了解子宫内膜变化情况,病理检查证实完全缓解后给予个体化的后续治疗.回顾性分析其妊娠结局及相关因素.结果 51例患者的中位年龄为29岁.有45例（88％,45/51）患者获得完全缓解,迫切要求生育且随诊满3个月者有34例.共有16例患者成功妊娠22次,妊娠率为47％（16/34）；12例获得活产儿,生育率为35％（12/34）.年龄＞35岁和≤35岁者妊娠率分别为0/2和50％（16/32）,治疗前有和无不孕症病史者妊娠率分别为40％ （8/20）和8/14,子宫内膜癌和重度不典型增生患者妊娠率分别为40％（10/25）和6/9；分别比较,差异均无统计学意义（P＞0.05）.采用体外受精-胚胎移植助孕、口服促排卵药物及未助孕治疗期待自然妊娠者妊娠率分别为7/7、6/16和3/11,3者比较,差异有统计学意义（P＜0.01）.结论 大剂量连续口服孕激素保守治疗早期子宫内膜癌及子宫内膜重度不典型增生可获得较高的完全缓解率；辅助生殖技术可显著提高治疗后的妊娠率.

Objective To summarize the pregnant rate of patients with early endometrial carcinoma and severe atypical hyperplasia after fertility-preserving treatment and analyze their pregnancy-relating factors.Methods Endometrial curettage was used to evaluate the therapy response of endometrium after every 3 months of administration of high-dose progestin as fertility-sparing treatment for 51 patients with stage Ⅰ endometrial carcinoma or severe endometrial atypical hyperplasia from Jun.1996 to Jan.2010.Individualized maintained treatment was given to patients after achieving complete remission of the endometrium.Pregnant results and pregnancy-relating factors were analyzed retrospectively.Results The median age of all the 51 patients was 29 years old.Forty-five （88%,45/51） achieved complete response.Of the 34 cases who desired to conceive after complete response,16 of them had 22 pregnancies,the pregnant rate was 47% （16/34） ; and 12 women obtained healthy live birth baby,the fertility rate was 35% （12/34）.The pregnant rate of patients at age 〉35 or ≤35 was 0/2 and 50% （16/32） respectively （P 〉0.05）.The pregnant rate of patients with or without infertility was 40% （8/20） and 8/14,with endometrial cancer or severe atypical hyperplasia was 40% （10/25） and 6/9,respectively （all P 〉 0.05）.The pregnant rate of patients who received in vitro fertilization-embryo transfer,ovulation promotion,or no treatment was 7/7,6/16 and 3/11 respectively （P 〈 0.01）.Conclusions Fertility-preserving treatment for early endometrial cancer and severe atypical hyperplasia with high-dose progestin could achieve higher response rate.Assisted reproductive technologies could significantly increase the chance of conception.