输卵管妊娠患侧输卵管切除术患者的助孕策略

Fertility strategies for patients with salpingectomy on the affected side of tubal pregnancy

目的探讨输卵管妊娠(tubal pregnancy,TP)患侧输卵管切除患者助孕策略。方法回顾性队列研究分析2019年1月1日至2020年12月31日期间因TP切除患侧输卵管于北京大学第三医院妇产科生殖医学中心行子宫输卵管超声造影(hysterosalpingo contrast sonography,HyCoSy)的患者临床资料。根据患者接受HyCoSy时的试孕时间及是否有不孕症/史分为3组,A组:既往无不孕症病史,TP后试孕<1年(n=33),B组:既往有不孕症病史,TP后试孕<1年(n=22),C组:TP后试孕≥1年(n=64),分析输卵管通畅度检查及临床结局的影响因素。结果A、B、C三组间患者年龄、孕次、重复TP史、窦卵泡计数、体外受精(in vitro fertilization,IVF)妊娠率、IVF及自然妊娠再次TP发生率、HyCoSy后至妊娠的时间(time to pregency,TTP)比较差异均无统计学意义(均P>0.05)。C组输卵管切除术至HyCoSy的时间(time to HyCoSy,TTH)[30.0(20.0,42.0)个月]显著大于A、B组[13.0(7.5,16.5)个月、8.0(7.0,10.0)个月,P<0.001]。A组通畅型输卵管比例[72.7%(24/33]及自然妊娠率[42.4%(14/33)]显著高于C组[43.8%(28/64),P=0.025;12.5%(8/64),P=0.004]。A组IVF治疗比例[30.3%(10/33)]显著小于B、C组[86.4%(19/22)、71.9%(46/64),P<0.001]。B组通畅型输卵管比例及自然妊娠率高于C组,差异无统计学意义(P>0.05)。自然妊娠所需时间A组小于B、C组,差异均无统计学意义(均P>0.05)。logistic回归分析显示不孕(史/症)是输卵管通畅度和妊娠结局的相关影响因素(OR=0.366,95%CI:0.148~0.904,P=0.029;OR=8.504,95%CI:2.294~31.519,P=0.014)。结论一侧输卵管切除术后,无不孕史患者可积极试孕6个月,如未孕可积极行输卵管通畅度评估后决定助孕策略;而已有不孕(史/症)患者建议积极IVF助孕,无需进行输卵管通畅性评估。

Objective To explore the strategy of pregnancy in patients with tubal pregnancy(TP)undergoing salpingectomy.Methods A retrospective cohort study was conducted to analyze the clinical data of patients who underwent hysterosalpingo contrast sonography(HyCoSy)at Reproductive Medicine Center of Peking University Third Hospital from January 1,2019 to December 31,2020 due to salpingectomy for TP.Patients were divided into 3 groups according to the time of pregnancy test and infertility history at the time to HyCoSy(TTH),group A:patients with no history of infertility,attempted pregnancy<1 year after TP(n=33);group B:patients with history of infertility,attempted pregnancy<1 year after TP(n=22);group C:patients attempted pregnancy≥1 year after TP(n=64).The remaining tubal patency and clinical outcome were analyzed.Results There were no significant differences in age,number of pregnancies,history of repeated TP(RTP),number of antral follicles,pregnancy rate treated with in vitro fertilization(IVF),incidence of RTP in IVF and spontaneous pregnancy,and the time to pregnancy(TTP)from HyCoSy among groups A,B and C(all P>0.05).TTH from salpingectomy in group C[30.0(20.0,42.0)months]was significantly longer than that in groups A and B[13.0(7.5,16.5)months,8.0(7.0,10.0)months,P<0.001].The proportion of unobstructed fallopian tubes and the spontaneous pregnancy rate in group A were significantly higher than those in group C[72.7%(24/33)vs.43.8%(28/64),P=0.025;42.4%(14/33)vs.12.5%(8/64),P=0.004],and the IVF treatment rate in group A[30.3%(10/33)]was significantly lower than that in groups B and C[86.4%(19/22),71.9%(46/64),P<0.001].The proportion of unobstructed fallopian tubes and the spontaneous pregnancy rate in group B were higher than those in group C,and the differences were not statistically significant(all P>0.05).The time required for spontaneous pregnancy in group A was less than that in groups B and C,but the difference was not statistically significant(P>0.05).Logistic regression analysis showed that infertility(history/symptom)was a related factor of tubal patency and pregnancy outcome(OR=0.366,95%CI:0.148-0.904,P=0.029;OR=8.504,95%CI:2.294-31.519,P=0.014).Conclusion After salpingectomy on one side,patients without infertility(history/symptoms)can actively try to conceive for 6 months,if they are not pregnant,tubal patency test can be actively performed and decide on fertility strategy;for patients with infertility(history/symptom),IVF was recommended actively without tubal patency evaluation.