不同程度宫腔粘连宫腔镜术后的转归分析

Analysis of the Outcomes of Patients with Different Degrees of Intrauterine Adhesion after Hysteroscopy

目的评价不同程度宫腔粘连患者行宫腔镜下粘连分解术,术后放置元宫环并联合雌、孕激素人工周期治疗后的宫腔形态改变、复粘率、月经恢复情况及妊娠率。方法对同济大学附属第一妇婴保健院2013年6月至2015年6月宫腔粘连的患者进行回顾性分析,共67例患者行宫腔镜下宫腔粘连分解术,术后予以炔雌醇及醋酸甲地孕酮序贯治疗,3个疗程后再次行宫腔镜检查了解宫腔形态。术前术后均采用美国生殖协会（AFS）标准对宫腔粘连程度进行评分,随访月经量改变,复粘率及妊娠率。结果术后随访5-16个月,67例中随访成功且有生育意愿者63例。63例患者依宫腔粘连程度分为：轻度粘连29例,中度粘连20例,重度粘连14例。通过宫腔镜二次探查发现轻度宫腔粘连者的复粘率为13.8%,中度宫腔粘连复粘率为40.0%,重度宫腔粘连复粘率为57.1%。86.2%轻度粘连者、90.0%中度粘连者、100.0%重度粘连者经量增多（包括恢复至正常）。术后随访妊娠18例,总妊娠率为28.6%（18/63）,其中轻度粘连者术后妊娠率为37.9%（11/29）,中重度粘连者妊娠率为20.5%（7/34）。妊娠患者中5例（27.8%）足月妊娠,3例（16.7%）稽留流产,9例（50.0%）继续妊娠中,1例（5.6%）异位妊娠。结论宫腔镜下宫腔粘连分解术后放置宫内节育器可有效避免宫腔再次粘连,术后使用雌、孕激素人工周期治疗修复内膜,可增加子宫内膜容受性,从而增加妊娠的机会。

Objective To evaluate the changes of the uterine morphology,readhesion rate,menstruation,pregnancy rate of patients with intrauterine adhesion who experienced hysteroscopic adhesiolysis,the placement of intrauterine device（IUD）and the estrogen and progestin artificial cycles treatment.Methods Clinical data of 67 women with intrauterine adhesion who underwent hysteroscopic adhesiolysis in our hospital between June 2013 and June 2015 were retrospectively analyzed.The uterine morphology was evaluated by hysteroscopy after three courses estrogen and progestin artificial cycles treatment.The degree of intrauterine adhecion was scored according to AFS criteria.The uterine adhesion,menstrual flow,re-adhesion rate and pregnancy rate were followed up.Results Among the 67 patients,63 with childbearing requirement were followed up for 5to 16 months.There were 29 cases of mild adhesion,20 cases of moderate adhesion and 14 cases of severe adhesion.Hysteroscopy showed that the re-adhesion rates were 13.8%in mild adhesion group,40%in moderate adhesion group,and 57.1%in server adhesion group.The menstrual flow was increased in 86.2% mild adhesion patients,90.0% moderate adhesion patients and100.0% severe adhesion patients.The total pregnant rate was 28.6%（18/63）.The pregnancy rates were 37.9%in mild adhesion group（11/29）and 20.5%in moderate and severe adhesion group（7/34）.In the pregnant patients,five had term pregnancy（27.8%）,three had inevitable abortion（16.7%）,nine were still in the pregnancy（50.0%）and one had ectopic pregnancy（5.6%）.Conclusion Hysteroscopic adhesiolysis with use of an IUD can effectively prevent the intrauterine re-adhesion in patients with intrauterine adhesion.Estrogen and progestin artificial cycles treatment can restore the endometria,increase the endometrial receptivity and improve the pregnant rate.