腹腔镜手术对IVF-ET失败病例的病因诊断和治疗价值——120例病例回顾性分析

Diagnostic and therapeutic value of hysteroscopic and laparoscopic surgery in patients failed in IVF-ET:a retrospective analysis of 120 cases

目的探讨IVF-ET失败的原因及行宫腹腔镜检查的意义。方法回顾分析2010年12月至2017年11月120例IVF-ET失败后行宫腹腔镜检查患者的病史资料。结果患者平均年龄35.5岁,平均不孕时间5.5年。既往IVFET失败者中,IVF-ET指征明确者55例(45.8%),不明原因者65例(54.2%);本次术后成功妊娠54例,妊娠率49.1%。IVF-ET指征明确患者中,输卵管因素34例、排卵障碍7例、男方因素9例、其他因素5例。34例因输卵管因素行IVF-ET者中,术后妊娠率为44.1%;术前子宫输卵管造影(HSG)提示55.9%(19/34例)存在单侧或双侧输卵管积水,与术中输卵管积水的诊断符合率为84.2%(16/19例);HSG提示双侧输卵管不通与术中的符合率为42.9%(6/14例)。86例既往因非输卵管因素行IVF-ET者中,经腹腔镜探查存在输卵管积水者19.8%(17/86例),术后妊娠率52.9%(9/17);不存在输卵管积水者69例,术后妊娠率39.1%(27/69),其中自然妊娠占所有妊娠者37.0%(10/27)。根据本次手术中诊断和处理输卵管积水与否将病例分组,积水组和非积水组的术后妊娠率分别为58.8%和44.2%(P=0.032)。结论应强调严格把握IVF-ET指征,腹腔镜手术对于明确助孕指征、处理输卵管积水、提高IVF-ET成功率具有重要意义;非输卵管积水的患者也能从手术中获益。合理规范的助孕前诊治流程有待于进一步研究并形成共识。

Objective:To explore the causes of IVF-ET failure and the value of hysteroscopic and laparoscopic surgery.Methods:The data of 120 patients who underwent hysteroscopic or laparoscopic surgery after the failure of IVF-ET from December 2010 to November 2017 were analyzed retrospectively.Results:The average age of the patients was 35.5 years,and the average infertility time was 5.5 years.In IVF-ET failed patients,55 patients(45.8%)were eligible for IVF-ET indications,65 patients(54.2%)were unknown cause.After the operation,54 patients were successful pregnancy,and the pregnancy rate was 49.1%.Among the patients with IVF-ET indications,34 patients had IVF-ET due to tubal factors,7 patients due to ovulatory disorder,9 patients due to male factors,and 5 patients had other factors.Among 34 patients undergoing IVF-ET due to fallopian tube factors,the postoperative pregnancy rate was 44.1%.Preoperative hysterosalpingography(HSG)indicated 55.9%(19/34)patients had unilateral or bilateral hydrosalpinx,and the diagnostic coincidence rate with intraoperative hydrosalpinx was 84.2%(16/19).The coincidence rate of bilateral fallopian tube obstruction diagnosed by HSG and by intraoperative was 42.9%(6/14).Of 86 patients with tubal factors,19.8%(17/86)of hydrosalpinx were diagnosed by laparoscopy.The postoperative pregnancy rate was 52.9%(9/17).The postoperative pregnancy rate of 69 patients without hydrosalpinx was 39.1%(27/69),and natural pregnancy accounted for 37.0%(10/27)of all pregnancies.According to the diagnosis and treatment of hydrosalpinx in the operation,the patients were divided into two groups.The postoperative pregnancy rates in the hydrosalpinx and non-hydrosalpinx groups were 58.8%and 44.2%,respectively(P=0.032).Conclusions:Emphasis should be placed on the strict grasp of IVF-ET indications.Laparoscopic surgery is of great value for clear indications of assisted pregnancy,treatment of hydrosalpinx and improvement of IVF-ET success rate.Patients with non-hydrosalpinx can also benefit from the surgery.A reasonable and standardized diagnosis and treatment process before assisted pregnancy needs further study and consensus.