剖宫产史对继发性不孕影响的病例对照研究
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摘要
目的探讨剖宫产史对后期继发性不孕相关因素及治疗后妊娠结局的影响。方法收集2012年7月至2018年6月收治于北京协和医院妇产科,因特发性不孕接受宫腹腔镜联合手术的患者中存在剖宫产史的病例65例作为研究组,采用1:1病例对照研究方法选取同期入院的非剖宫产后特发性继发不孕患者65例为对照组。症状指标包括异常子宫出血、慢性盆腔痛及痛经情况;结局指标包括宫腹腔镜联合手术中不孕相关因素及术后妊娠结局。结果研究组中异常子宫出血、慢性盆腔痛、痛经发生率均高于对照组(分别为16.9%vs.4.6%;15.4%vs.4.6%;30.8%vs.15.4%;P均<0.05);除研究组盆腔非附件区粘连发生率高于对照组外(36.9%vs.3.1%;P<0.05),两组宫腔粘连、附件区粘连及盆腔子宫内膜异位症的发生率和输卵管通畅情况均无显著差异(P均>0.05);宫腔异常除剖宫产瘢痕缺陷外亦无显著差异(P>0.05)。研究组患者术后自然妊娠率与对照组相比无显著差异(P>0.05),70%～80%自然妊娠发生在术后半年内。结论单纯剖宫产史并不增加输卵管因素、盆腔子宫内膜异位症、宫腔粘连等常见继发不孕相关因素的发生率,亦不降低自然生育力。
Objective:To investigate the effect of cesarean section on secondary infertility related factors and the postoperative pregnancy outcomes.Methods:A case-control(1:1)observational study was conducted in Peking Union Medical College Hospital from July 2012 to June 2018.Sixty five patients with unexplained secondary infertility and history of cesarean section,who underwent hysteroscopy and laparoscopic surgery,were selected as the study group.The control group consisted of 65 unexplained secondary infertile patients without history of cesarean section,who underwent hysteroscopy and laparoscopic surgery at the same period.The symptoms including abnormal uterine bleeding,chronic pelvic pain and dysmenorrheal,and the outcome indicators including the related factors of infertility in intraoperative diagnosis and the postoperative pregnancy outcome were all concerned.Results:The incidence of abnormal uterine bleeding(16.9% vs.4.6%),chronic pelvic pain(15.4%vs.4.6%)and dysmenorrhea(30.8% vs.15.4%)in the study group was significantly higher than those in the control group(all P <0.05).The incidence of non-adnexal adhesions in the study group was significantly higher than that in the control group(36.9% vs.3.1%,P<0.05).No statistical differences were found in the incidence of intrauterine adhesion,adnexal adhesions,pelvic endometriosis and fallopian tube patency between the two groups(P>0.05).No abnormity of uterine cavity was found except previous caesarean scar defect(PCSD)between the two groups(P>0.05).Postoperative spontaneous pregnancy rate in study group was not significantly different from the control group(P>0.05).70%-80% patients were pregnant spontaneously within 6 months after surgery.Conclusions: The history of cesarean section alone does not increase the incidence of common secondary infertility-related factors such as fallopian tube patency,pelvic endometriosis and intrauterine adhesions,or reduce natural fertility.
Objective:To investigate the effect of cesarean section on secondary infertility related factors and the postoperative pregnancy outcomes.Methods:A case-control(1:1)observational study was conducted in Peking Union Medical College Hospital from July 2012 to June 2018.Sixty five patients with unexplained secondary infertility and history of cesarean section,who underwent hysteroscopy and laparoscopic surgery,were selected as the study group.The control group consisted of 65 unexplained secondary infertile patients without history of cesarean section,who underwent hysteroscopy and laparoscopic surgery at the same period.The symptoms including abnormal uterine bleeding,chronic pelvic pain and dysmenorrheal,and the outcome indicators including the related factors of infertility in intraoperative diagnosis and the postoperative pregnancy outcome were all concerned.Results:The incidence of abnormal uterine bleeding(16.9% vs.4.6%),chronic pelvic pain(15.4%vs.4.6%)and dysmenorrhea(30.8% vs.15.4%)in the study group was significantly higher than those in the control group(all P <0.05).The incidence of non-adnexal adhesions in the study group was significantly higher than that in the control group(36.9% vs.3.1%,P<0.05).No statistical differences were found in the incidence of intrauterine adhesion,adnexal adhesions,pelvic endometriosis and fallopian tube patency between the two groups(P>0.05).No abnormity of uterine cavity was found except previous caesarean scar defect(PCSD)between the two groups(P>0.05).Postoperative spontaneous pregnancy rate in study group was not significantly different from the control group(P>0.05).70%-80% patients were pregnant spontaneously within 6 months after surgery.Conclusions: The history of cesarean section alone does not increase the incidence of common secondary infertility-related factors such as fallopian tube patency,pelvic endometriosis and intrauterine adhesions,or reduce natural fertility.
引文
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[18]钱睿亚,陈政弘,张为远,等.剖宫产女性产后月经改变及异常妊娠状况调查[J].医学研究杂志,2017,46:123-126.
[19]Adesiyun AG,Ojabo A.Subfertility following caesarean section at last delivery:aetiology[J].Fertil Steril,2009,92:S93-S94.
[2]Li HT,Luo S,Trasande L,et al.Geographic variations and temporal trends in cesarean delivery rates in China,2008-2014[J].JAMA,2017,317:69-76.
[3]Gurol-Urganci I,Bou-Antoun S,Lim CP,et al.Impact of Caesarean section on subsequent fertility:a systematic review and meta-analysis[J].Hum Reprod,2013,28:1943-1952.
[4]Zegers-Hochschild F,Adamson GD,de Mouzon J,et al.The International Committee for Monitoring Assisted Reproductive Technology(ICMART)and the World Health Organization(WHO)revised glossary on ART terminology,2009[J].Hum Reprod,2009,24:2683-2687.
[5]田秦杰,葛秦生.实用女性生殖内分泌学(第二版)[M].北京:人民卫生出版社,2018:331.
[6]Tower AM,Frishman GN.Cesarean scar defects:an underrecognized cause of abnormal uterine bleeding and other gynecologic complications[J].J Minim Invasive Gynecol,2013,20:562-572.
[7]Seyam E,Ibrahim EM,Youseff AM,et al.Laparoscopic Management of Adhesions Developed after Peritoneal Nonclosure in Primary Cesarean Section Delivery.[J].Obstet Gynecol Int,2018,2018:1-7.
[8]中华医学会妇产科学分会.宫腔粘连临床诊疗中国专家共识[J].中华妇产科杂志,2015,50:881-887.
[9]张宁宁,王光伟,杨清.剖宫产子宫瘢痕憩室52例的临床诊治分析[J].生殖医学杂志,2017,26:331-335.
[10]Mollison J,Porter M,Campbell D,et al.Primary mode of delivery and subsequent pregnancy[J].BJOG,2005,112:1061-1065.
[11]Evers EC,Mcdermott KC,Blomquist JL,et al.Mode of delivery and subsequent fertility[J].Hum Reprod,2014,29:2569-2574.
[12]Saraswat L,Porter M,Bhattacharya S,et al.Caesarean section and tubal infertility:is there an association?[J].Reprod Biomed Online,2008,17:259-264.
[13]Morris H.Surgical pathology of the lower uterine segment caesarean section scar:is the scar a source of clinical symptoms?[J].Int J Gynecol Pathol,1995,14:16-20.
[14]Allornuvor GF,Xue M,Zhu X,et al.The definition,aetiology,presentation,diagnosis and management of previous caesarean scar defects[J].J Obstet Gynaecol,2013,33:759-763.
[15]Tulandi T,Cohen A.Emerging Manifestations of Cesarean Scar Defect in Reproductive-aged Women[J].J Minim Invasive Gynecol,2016,23:893-902.
[16]Api M,Boza A,Gorgen H,et al.Should cesarean scar defect be treated laparoscopically?A case report and review of literature[J].J Minim Invasive Gynecol,2015,22:1145-1152.
[17]钱俏红,张剑峰,朱芝玲,等.阴式手术治疗剖宫产术切口憩室15例临床分析[J].生殖医学杂志,2014,23:958-961.
[18]钱睿亚,陈政弘,张为远,等.剖宫产女性产后月经改变及异常妊娠状况调查[J].医学研究杂志,2017,46:123-126.
[19]Adesiyun AG,Ojabo A.Subfertility following caesarean section at last delivery:aetiology[J].Fertil Steril,2009,92:S93-S94.