剖宫产术后瘢痕子宫患者行单胚胎移植的临床结局分析

Clinical outcome analysis of single embryo transfer in patients with scarred uterus after cesarean

目的探讨瘢痕子宫以及瘢痕憩室对行单胚胎移植(single embryo transfer,SET)的再生育妇女妊娠结局的影响。方法回顾性队列研究分析2016年1月至2018年4月期间在南京医科大学第一附属医院生殖医学科行SET的再生育妇女的临床数据,根据既往分娩方式分为剖宫产分娩(cesarean delivery,CD)组及经阴道分娩(vaginal delivery,VD)组,根据移植胚胎的时期分成两个亚组,分别比较移植卵裂期胚胎CD1组(928例)和VD1组(928例),移植囊胚期胚胎CD2组(570例)和VD2组(480例)的妊娠结局。将CD组进一步分为憩室组和无憩室组,观察子宫瘢痕憩室对妊娠结局的影响。结果无论移植卵裂期胚胎或囊胚期胚胎,CD组同VD组两组之间的活产率、妊娠率、种植率、流产率、早产率等指标差异均无统计学意义(P均>0.05)。同VD组相比,CD组妊娠期并发症如前置胎盘、产后出血、妊娠期糖尿病、妊娠期高血压等疾病的发生率差异均无统计学意义(P均>0.05)。同剖宫产术后无憩室患者相比,合并憩室的患者,移植囊胚期胚胎活产率下降[30.00%(12/40)比51.32%(272/530),P=0.013],移植卵裂期胚胎的妊娠率[18.97%(11/58)比32.30%(281/870),P=0.034]和种植率[18.97%(11/58)比31.26%(272/870),P=0.049]均下降。结论采用SET策略,具有剖宫产史的患者同阴道分娩史患者获得相似的妊娠结局,并且没有增加围产期并发症的风险。但是瘢痕憩室影响体外受精-胚胎移植的妊娠结局。推荐对瘢痕子宫患者行单囊胚移植。

Objective To explore the effect of scarred uterus and cesarean scar defect(CSD)on the reproductive outcomes of patients with previous cesarean delivery undergoing single embryo transfer(SET).Methods A retrospective cohort study was conducted to analyze the data of patients with a history of cesarean delivery(CD)who accepted SET between January 2016 and April 2018 in Reproductive Medicine Center of the First Affiliated Hospital,Nanjing Medical University.According to the previous mode of delivery,patients were divided into CD group and vaginal delivery(VD)group.The pregnancy outcomes were analyzed in each embryo stage respectively.Furthermore,according to embryonic development stage,patients were divided into cleavage-stage embryo group(CD1 group,n=928 and VD1 group,n=928)and blastocyst-stage embryo group(CD2 group,n=570 and VD2 group,n=480).The CD population were further divided into two groups according to the presence of CSD to investigate the effect of CSD on pregnancy outcomes.Results Regardless of women undergoing transfer of a cleavage-stage embryo or a blastocyst-stage embryo,there were no statistical differences in live birth rate,pregnancy rate,implantation rate,abortion rate and premature birth rate between CD group and VD group(all P>0.05).Compared with VD group,the risk of gestational complications such as placenta previa,postpartum hemorrhage,gestational diabetes,and gestational hypertension were not significantly increased in CD group(all P>0.05).The live birth rate was lower in CSD group than in non-CSD group in women undergoing the transfer of blastocyst-stage embryo[30.00%(12/40)vs.51.32%(272/530),P=0.013].The pregnancy rate and the implantation rate were lower in CSD group than in non-CSD group in women undergoing the transfer of the cleavage-stage embryo[18.97%(11/58)vs.32.30%(281/870),P=0.034;18.97%(11/58)vs.31.26%(272/870),P=0.049].Conclusion With SET strategy,patients with a history of cesarean section have similar pregnancy outcomes to those with VD,and there is no increased risk of perinatal complications.However,the pregnancy outcomes of in vitro fertilization-embryo transfer are hampered in women with CSD.Single blastocyst-stage embryo transfer strategy is recommended for patients with scarred uterus.