宫腔粘连767例临床分析

Clinical Analysis of 767 Cases of Intrauterine Adhesions

目的:探讨宫腔粘连的病因、诊断及宫腔镜粘连分离术的疗效。方法:分析因体外受精-胚胎移植(IVF-ET)失败行宫腔镜检查发现宫腔粘连并行分离术的767例患者的病因,并随访术后月经及宫腔形态恢复情况,探讨其术后疗效及再次行胚胎移植后妊娠情况。结果:767例宫腔粘连患者中57.6%(442/767)有流产手术史,0.7%(5/767)有诊断性刮宫史,41.7%(320/767)患者无宫腔手术史。仅有14例宫腔镜检查前超声检查提示宫腔内膜线中断或HSG检查提示宫腔粘连可能。767例患者中,周围型粘连占98.2%(753/767例),混合型粘连占1.8%(14/767);轻度粘连占13.8%(106/767),中度粘连占65.7%(504/767),重度粘连占20.5%(157/767)。粘连分离术后患者有效率达94.9%(728/767);手术的有效性与宫腔粘连的程度有关,粘连越重,效果越差(χ2=-9.45,P=0.000)。术后已行胚胎移植的421例患者中,临床妊娠率为52.0%(219/421)。结论:子宫内膜的机械损伤是宫腔粘连的主要因素,但并非唯一因素。大部分宫腔粘连为周围型粘连,超声和HSG诊断敏感性差。宫腔粘连的范围(程度)影响宫腔粘连手术的效果。

Objective：To evaluate the causes and the diagnosis for intrauterine adhesions and the effects of hysteroscopic adhesiolysis on pregnancy outcome. Methods：767 patients underwent hysteroscopic adhesiolysis and the etiologic factors and the menstrual flow were recorded. A second time hysteroscopy was performed to re-evaluate the cavity of uterus. Then all patients underwent IVF-ET,and the pregnancy outcomes were analyzed. Results：57.6% of patients（442/767）used to receive curettage for induced or spontaneous abortion,and 1% of patients（5/767）used to receive diagnostic curettage. 41.7% of patients （320/767）had no history of operation in the cavity of uterus. Ultrasound scan or HSG examination showed intrauterine adhe- sions for endometriat line interruption before hysteroscopy only in 14 cases. 98.2% of patients （753/767） were marginal adhesions and 1.8% of patients（14/767）were blend adhesions,and no one was simply cen- tral adhesions. 13.8% （106/767） of patients had mild adhesions, 65.7% （504/767） had moderate, and 20.5% （157/767）had severe adhesions according to the Feng Criteria. Improvement in menstrual flow and shape of cavity of uterus occurred in 94.9% （728/767）patients. Effectiveness of surgery is negatively related with the degree of intrauterine adhesions （X^2 = -9.45, P = 0.000）. 52.0%（219/421）of embryo transfer patients after surgery achieved pregnancy or living birth. Conclusions：The major cause of intrauterine adhesions is damage to the basilar layer of the endometrium due to curettage. But the trauma of the endometrium is not the only factor contributed to the development of intrauterine adhesions. HSG and ultrasound have limit- ed value in diagnosis of intrauterine adhesions because majority patients are marginal adhesions. Most pa- tients can achieve normal menstrual flow after treatment, and more severe adhesions are associated with more poor pregnant outcome.