多发性子宫肌瘤腹腔镜剔除术后影响患者生育力的多因素分析

A Multivariate Analysis of Reproductive Outcome after Laparoscopic Multiple Uterine Myomectomy

目的观察腹腔镜多发性子宫肌瘤剔除术后生育状况并探讨其影响因素。方法 2005年1月～2011年12月,对169例多发性子宫肌瘤行腹腔镜子宫肌瘤剔除术,观察其术后宫内妊娠率、妊娠结局、流产率、复发情况,采用Logistic回归分析盆腔粘连、子宫的切口数、年龄等对术后生育结局的影响。结果随访1～6年,腹腔镜多发性子宫肌瘤剔除术后自然宫内妊娠率60.9%(103/169),流产率5.9%(10/169),足月分娩率53.3%(90/169),异位妊娠率5.3%(9/169)。所有妊娠患者无妊娠子宫破裂及产科合并症。单因素分析结果显示,影响腹腔镜下多发性子宫肌瘤剔除术后宫内妊娠率的自变量是年龄、术前宫腔形态、子宫切口数、肌瘤数目、盆腔粘连(P<0.05),而肌瘤是否穿透内膜、肌瘤大小无统计学意义(P>0.05)。多因素分析显示,术后宫内妊娠率的影响因素是年龄(OR=0.110,95%CI:0.050～0.240),盆腔粘连(OR=0.018,95%CI:0.003～0.117),术前宫腔形态(OR=0.057,95%CI:0.014～0.232),子宫切口数(OR=0.398,95%CI:0.226～0.702)(P<0.05)。结论腹腔镜多发性子宫肌瘤剔除术具有微创、安全、术后自然宫内妊娠率满意的优点,患者的年龄、术中盆腔粘连状况、术前宫腔形态、子宫切口数是影响术后宫内妊娠率的相对独立因素,对于年龄>35岁、重度盆腔粘连、子宫切口数>4个的患者,若1年无自然受孕,建议辅助受孕。

Objective To observe patients＇ reproductive outcome after laparoscopie multiple uterine myomectomy and analyze its influential factors. Methods A retrospective study was carried out on 169 patients with multiple uterine myoma undergoing laparoscopic uterine myomectomy from January 2005 to December 2011. We investigated the rate of post-operative pregnancy, delivery outcome, abortion and disease recurrence. Logistic regression analysis was used to analyze the impact of pelvic adhesion, number of uterine incisions, age etc. on the patients＇ reproductive outcome following the surgery. Results The 1 - 6 years follow-up showed that the rate of post-operative pregnancy, abortion, term birth and ectopic pregnancy was 60.9% （103/169） , 5.9% （ 10/169 ） , 53.3% （90/169） and 5.3% （9/169） respectively. No gravid uterus rupture and obstetric complications occurred. Univariate analysis showed that the independent variables of post-operative pregnancy rate ＇were age, preoperative uterine cavity shape, number of uterine incision, fibroid,and pelvic adhesion （ P 〈 0.05）. Other factors such as size of fibroid and penetration into uterine lining had no statistical significance（P 〉 0.05）. In multivariate analysis, the factors of post-operative pregnancy rate were age （OR = 0. 110, 95% CI ： 0. 050 - 0. 240）, pelvic adhesion （ OR = 0.018, 95% CI ： 0. 003 - 0. 117 ）, preoperative uterine cavity shape （ OR = 0. 057, 95%CI： 0.014 -0.232）, and number of uterine incisions （OR =0.398, 95% CI： 0.226 -0.702） （P 〈0.05）. Conclusions Laparoseopic multiple uterine myomectomy has the advantage of being minimally invasive, safe and having satisfactory rate of natural postoperative intrauterine pregnancy. Patients＇ age, intraoperative pelvic adhesion situation, preoperative uterine cavity shape and number of uterine incisions were independent factors affecting postoperative pregnancy rate. To female patients who are over 35 years old, have severe pelvic adhesion and more than 4 uterine incisions, assisted reproductive technology is recommended if they fail to conceive after 12 months of unprotected intercourse.