四维子宫输卵管超声造影输卵管通畅度及术后妊娠结局相关影响因素分析

Analysis of factors related to tubal patency and postoperative pregnancy outcome by four-dimensional hysterosalpingo contrast sonography

目的探讨影响四维子宫输卵管超声造影(4D-HyCoSy)输卵管通畅度及妊娠结局的相关因素。方法前瞻性收集2019年3—5月于我院行经阴道4D-HyCoSy的575例患者的临床资料,记录超声造影术中推注造影剂的剂量、时间等相关指标及4D-HyCoSy评估输卵管通畅情况。随访患者术后24个月内的妊娠情况。将术后积极试孕的524例患者根据输卵管梗阻状况分为3组进行统计学分析:双侧输卵管通畅(A组,n=370)、一侧输卵管梗阻(B组,n=119)、双侧输卵管梗阻(C组,n=35)。采用Kaplan-Meier生存曲线描述术后累积妊娠率,采用单因素分析及Cox比例风险模型进行多因素回归分析校正混杂因素。结果524例患者术后积极试孕,自然妊娠164例、人工授精妊娠50例,妊娠率40.8%(214/524),中位妊娠时间3(1.0,8.3)个月;术后3、6、12、18、24个月内累积妊娠率分别22.1%、27.5%、36.3%、40.3%和40.8%,其中67.3%发生在术后6个月内。C组患者年龄显著高于A组而卵巢高储备比例显著低于A组(P<0.05),C组原发不孕的比例显著低于其他两组(P<0.05)。有输卵管检查史的患者比例在A、B、C组中依次升高,组间比较均有统计学差异(P<0.05)。A组造影剂推注时间显著短于其他两组,而速度显著大于其他两组(P<0.05)。C组仅3例自然妊娠。A组达成妊娠时间显著早于B组[3(1,7)个月vs.7(3.0,11.5)个月,P<0.05]。A组术后3、6个月内累积妊娠率均显著高于B组(分别为26.8%vs.13.4%和32.4%vs.19.3%,P<0.05)。A组术后3个月内妊娠率显著高于4~6个月时段(P<0.05),而B组术后3个月内妊娠率高于其后各个时间段,但无统计学差异(P>0.05)。多因素Cox分析显示年龄、不孕病因及输卵管通畅度分型是影响妊娠结局的因素(P<0.05)。结论反复宫腔操作史可能影响输卵管通畅度;建议患者HyCoSy术后积极试孕,尤其是术后3个月内;双侧输卵管通畅患者如术后3月未妊娠,建议结合患者年龄及不孕病因,必要时可进一步积极行腹腔镜检查或IVF助孕;对于一侧输卵管梗阻患者如果条件允许可期待至术后15个月;双侧输卵管梗阻的患者由于术后自然妊娠率极低,建议积极IVF助孕。

Objective:To investigate the factors related to tubal patency and postoperative pregnancy outcome by four-dimensional hysterosalpingo contrast sonography(4D-HyCoSy).Methods:The clinical data of 575 patients who underwent transvaginal 4D-HyCoSy in our hospital from March to May 2019 were collected prospectively.The relative indicators such as the doses and time of the contrast medium injection during HyCoSy were recorded for assessing the patency of the fallopian tube.The pregnancy outcomes of patients within 24 months after operation were followed-up.According to the status of tubal obstruction,they were divided into three groups for statistical analysis:bilateral tubal patency(group A,n=370),unilateral tubal obstruction(group B,n=119)and bilateral tubal obstruction(Group C,n=35).The Kaplan-Meier survival curve was used to describe the cumulative pregnancy rate after operation.Univariate analysis and Cox proportional hazard model were used to perform multivariate regression analysis for correcting confounding factors.Results:A total of 524 patients actively attempted spontaneous pregnancy after HyCoSy,164 patients of spontaneous pregnancy and 50 patients of artificial insemination pregnancy,the pregnancy rate was 40.8%(214/524),the median pregnancy time was 3(1,8.3)months.The cumulative pregnancy rates within 3,6,12,18 and 24 months after operation were 22.1%,27.5%,36.3%,40.3%and 40.8%,respectively,of which 67.3%occurred within 6 months after operation.The patients in group C were significantly older than that in group A,and the proportion of high ovarian reserve was significantly lower than that in group A(P<0.05).The proportion of primary infertility in group C was significantly lower than that of the other two groups(P<0.05).The proportion of patients with a history of fallopian tube examination increased in groups A,B,and C sequentially,and there was significant difference among the groups(P<0.05).The injection time of contrast medium in group A was significant shorter than that in the other two groups,and the speed was significantly higher than that in the other two groups(P<0.05).There were only 3 spontaneous pregnancies in group C.The time to reach pregnancy in group A was significantly earlier than that in group B[3(1,7)months vs.7(3,11.5)months,P<0.05].The cumulative pregnancy rate within 3 and 6 months after operation in group A were significantly higher than those in group B(26.8%vs.13.4%and 32.4%vs.19.3%,respectively,P<0.05).The pregnancy rate within 3 months was significantly higher than that within 4-6 months in group A(P<0.05),while the pregnancy rate within 3 months was higher than that in subsequent periods in group B,but the difference was not significant(P>0.05).Multivariate Cox analysis showed that age,cause of infertility and classification of tubal patency were the factors affecting pregnancy outcome(P<0.05).Conclusions:History of repeated intrauterine operations may affect tubal patency.Patients are advised to actively try to conceive after HyCoSy,especially within 3 months.If the patients with bilateral tubal patency do not get pregnant within 3 months after operation,it is suggested that laparoscopy or IVF should be actively performed in combination with the patient’s age and infertility causes.For patients with one fallopian tube obstruction,it can be expected to conceive 15 months after operation if conditions permit.In patients with bilateral tubal obstruction,IVF is recommended because of spontaneous conception extremely low.