四维子宫输卵管超声造影结果与非体外受精治疗妊娠率的关系

Relationship between four-dimensional hysterosalpingo-contrast sonography types and in vitro fertilization treatment-independent pregnancy rate

目的探讨不孕症患者四维子宫输卵管超声造影(4D-HyCoSy)检查分型与非体外受精(IVF)治疗妊娠率的关系。方法回顾性分析2018年1月1日至2018年6月30日于北京大学第三医院生殖医学中心行4D-HyCoSy检查的不孕症患者791例,4D-HyCoSy检查结果有6型,据此分为6组:Ⅰ型组:双侧输卵管通畅458例;Ⅱ型组:一侧输卵管通畅一侧输卵管通而不畅118例;Ⅲ型组:一侧输卵管通畅一侧输卵管阻塞40例;Ⅳ型组:双侧输卵管通而不畅86例;Ⅴ型组:一侧输卵管通而不畅一侧输卵管阻塞44例:Ⅵ型组:双侧输卵管阻塞45例。通过Kaplan-Meier法估算患者4D-HyCoSy检查后累积非IVF治疗宫内妊娠率。结果Ⅱ型组、Ⅲ型组患者4DHyCoSy检查后12个月累积非IVF治疗宫内妊娠率与Ⅰ型组患者比较差异无统计学意义(Ⅱ型组vs.Ⅰ型组:35.89%vs. 36.80%,P>0.05;Ⅲ型组vs.Ⅰ型组:41.31%vs. 36.80%,P>0.05),调整年龄、不孕年限、血清抗米勒管激素(AMH)水平及窦卵泡数(AFC)后,差异仍无统计学意义(Ⅱ型组:HR=1.030,95%CI 0.699~1.518;Ⅲ型组:HR=1.328,95%CI 0.754~2.338);Ⅳ型组患者4D-HyCoSy检查后3个月累积非IVF治疗宫内妊娠率与Ⅰ型组患者比较差异无统计学意义(10.84%vs. 17.67%,P>0.05),检查后6个月、12个月累积非IVF治疗宫内妊娠率显著低于Ⅰ型组患者(6个月:14.72%vs. 26.00%,P<0.05;12个月:25.44%vs. 36.80%,P<0.05),但调整年龄、不孕年限、血清AMH水平及AFC后,检查后12个月累积非IVF治疗宫内妊娠率两组间差异无统计学意义(HR=0.809,95%CI 0.492~1.329);Ⅴ型组、Ⅵ型组患者4D-HyCoSy检查后12个月累积非IVF治疗宫内妊娠率显著低于Ⅰ型组患者(Ⅴ型组vs.Ⅰ型组:7.28%vs. 36.80%,P<0.05;Ⅵ型组vs.Ⅰ型组:5.67%vs. 36.80%,P<0.05),调整年龄、不孕年限、血清AMH水平及AFC后,差异仍有统计学意义(Ⅴ型组:HR=0.174,95%CI 0.043~0.706;Ⅵ型组:HR=0.224,95%CI 0.055~0.910)。Ⅰ型组、Ⅱ型组、Ⅲ型组患者在4D-HyCoSy检查后3个月、6个月、12个月总体累积非IVF治疗宫内妊娠率分别为17.26%、25.95%、36.89%,且6个月与3个月比较、12个月与6个月比较累积妊娠率显著性升高(P<0.001)。结论 4D-HyCoSy诊断单侧输卵管通畅的患者具有与双侧输卵管通畅的患者相似的非IVF治疗妊娠率,可尝试自然妊娠或人工授精(IUI)至4D-HyCoSy后12个月;4D-HyCoSy诊断双侧输卵管通而不畅的患者可尝试自然妊娠或IUI,但年龄偏大、卵巢功能较差、不孕年限较长的患者不建议尝试超过3个月;4DHyCoSy诊断一侧输卵管通而不畅一侧输卵管阻塞的患者建议尽快IVF或输卵管手术治疗。

Objective To study the relationship between four-dimensional hysterosalpingo-contrast sonography(4D-Hy Co Sy)types and in vitro fertilization(IVF)treatment-independent pregnancy rate.Methods The data from 791 infertile patients who underwent 4 D-Hy Co Sy at Peking University Third Hospital from January 2018 to June 2018 were retrospectively collected and analyzed. The patients were classified into six groups according to the 6 types of Hy CoSy findings:typeⅠgroup with both fallopian tubes patent,458 patients;type Ⅱgroup with one tube patent while the other less patent,118 patients;type Ⅲ group with one tubepatent while the other occluded,40 patients;type Ⅳ group with both tubes less patent,86 patients;type Ⅴ group with one tube less patent while the other occluded,44 patients;and type Ⅵ group with both tubes occluded,45 patients. Kaplan-Meier curves were constructed to estimate the cumulative IVF treatment-independent intrauterine pregnancy rate.ResultsNo significant difference was identified in the cumulative IVF treatment-independent intrauterine pregnancy rate at 12 months after 4 D-HyCoSy either between type Ⅱ and Ⅰ group,or between type Ⅲ and Ⅰ group(type Ⅱ group vs. type Ⅰ group:35.89% vs.36.80%,P>0.05;type Ⅲ group vs. typeⅠgroup:41.31% vs. 36.80%,P>0.05);there was no significant difference after adjustments for age,infertility duration,serum anti-mullerian hormone(AMH)level and antral follicle count(AFC)(type Ⅱ group,HR=1.030,95% CI 0.699~1.518;type Ⅲ group,HR=1.328,95% CI 0.754~2.338). There was no significant difference in the cumulative IVF treatment-independent intrauterine pregnancy rate between type Ⅳ group and typeⅠgroup at 3 months(10.84% vs. 17.67%,P>0.05);the cumulative IVF treatment-independent intrauterine pregnancy rate of type Ⅳ group was significantly lower than that of typeⅠgroup at 6 months and 12 months after HyCoSy (6 months:14.72% vs. 26.00%,P<0.05;12 months:25.44% vs. 36.80%,P<0.05);however,the difference was not statistically significant at 12 months after 4 D-HyCoSy after adjustments for age,infertility duration,AMH level and AFC (HR=0.809,95%CI 0.492~1.329). The cumulative IVF treatment-independent intrauterine pregnancy rates of typeⅤ and Ⅵ groups were markedly lower than that of typeⅠgroup(type Ⅴgroup vs. typeⅠgroup:7.28% vs. 36.80%,P<0.05;type Ⅵ group vs. type Ⅰ group:5.67% vs. 36.80%,P<0.05);the difference was still statistically significant after adjustments for age,infertility duration,AMH level and AFC(group Ⅴ,HR=0.174,95%CI 0.043~0.706;type Ⅵ group,HR=0.224,95%CI 0.055~0.910). The total cumulative IVF treatment-independent intrauterine pregnancy rate of type Ⅰ,Ⅱ and Ⅲ groups at 3,6 and 12 months after 4 D-HyCoSy were 17.26%,25.95% and 36.89%,respectively. There was a significant increase in cumulative pregnancy rate when comparing between 3 months and 6 months,and between 6 and 12 months after 4 D-HyCoSy.ConclusionPatients with a unilateral patent tube detected on 4 D-HyCoSy may have a similar IVF treatment-independent pregnancy rate to those with bilateral patent tubes,and can attempt spontaneous conception or intrauterine insemination(IUI)up to 12 months after 4 D-HyCoSy. Patients with bilateral less-patent tubes detected on 4 D-HyCoSy can attempt spontaneous conception or IUI;however,for those with advanced age,poor ovarian reserve or long infertility duration it is not recommended to attempt for more than 3 months. Patients with one less-patent tube and one occluded tube detected on 4 D-HyCoSy should be referred for IVF or tubal surgery as soon as possible.