Role of morphologic characteristics of the uterine septum in the prediction and prevention of abnormal healing outcomes after hysteroscopic metroplasty.
Role of morphologic characteristics of the uterine septum in the prediction and prevention of abnormal healing outcomes after hysteroscopic metroplasty.
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DOI：
10.1093/humrep/deu110
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发表时间：
2014-07
期刊：
影响因子：
--
通讯作者：
Jach R
中科院分区：
文献类型：
--
作者：
Ludwin A;Ludwin I;Pityński K;Banas T;Jach R
子宫中隔的形态学测量（宽度、长度和表面积）能否预测完全宫腔镜子宫成形术（HM）后愈合相关的异常解剖结果[AR;残余中隔（RS）和其他部位的宫腔粘连（IUA-OL）]？AR的重要预测因素是间隔宽度，在较小程度上，间隔表面积。宫腔镜子宫成形术后的解剖结果有很大的差异。RS >1 cm和IUA-OL可加重生殖结局，导致需要再次手术。根据欧洲人类生殖与胚胎学学会（ESHRE）和欧洲妇科内窥镜学会（ESGE）提出了诊断子宫中隔的新标准（ESHRE-ESGE标准）。自交联透明质酸凝胶（自交联多糖）具有抗粘连作用。在2007年至2012年期间连续招募了96名女性进行了一项前瞻性观察性队列研究。在大学医院、私立医院或私立医疗中心接受评估的有子宫中隔和既往流产或不孕的妇女也包括在内。术前用三维超声宫腔造影确定间隔宽度、长度和表面积。女性患者在标准化方式下接受宫腔镜治疗，并在三维或四维经直肠超声引导下（完全切除）。患者未接受防粘连膜（49例患者）或使用防粘连膜与自交联多糖（47例患者）。通过三维宫腔超声造影和二次宫腔镜检查评估解剖结果。使用美国生殖医学会（ASRM）RS长度>1 cm（ASRM>1 cm标准）和ESHRE-ESGE标准报告了愈合依赖性AR。采用单因素和多因素Logistic回归分析确定RS、IUA-OL和AR的预测因素。在无粘连屏障的患者中，使用ASRM > 1 cm标准的49例患者中有11例（23%）诊断为AR，使用ESHRE-ESGE标准的49例患者中有20例（41%）诊断为RS [比值比（OR）ESHRE-ESGE：ASRM，2.4，P = 0.05]。在有自身交联多糖的患者中，47例患者中有2例（4%）被诊断为ARsASRM > 1 cm，47例患者中有4例（9%）被诊断为ARsESHRE-ESGE。在所有患者中，RSESHRE-ESGE的诊断率显著高于RSASRM > 1 cm的96例患者中的19例（20%）和96例患者中的5例（5%）（ORESHRE-ESGE：ASRM > 1 cm = 4.5，P < 0.01）。在无粘连屏障的患者中，ASRM > 1 cm和ESHRE-ESGE标准的logistic回归显示宽度和表面积是AR的预测因素。经患者组校正的模型证实了宽度作为ARsASRM > 1 cm的预测因子的重要性[宽度的OR为3.5（P < 0.01），OR为0.22（P < 0.01）]，宽度作为ARsESHRE-ESGE的预测因子[宽度的OR为2.2表面积作为ARsASRM > 1 cm的预测因子[表面积OR为1.5（P <0.01）];组OR为0.32（P <0.01）。在患有自交联多糖的患者中，这些预测因子并不显著。受试者工作特征曲线显示ARsASRM > 1 cm（间隔宽度，3.42 cm;间隔表面积，4.68 cm 2）和ARsESHRE-ESGE（间隔宽度，3.42 cm;间隔表面积，3.51 cm 2）的截断值。患者以时间依赖性、连续和非随机方式入组防粘连医用膜组。宽隔膜和大表面积可能是防粘连膜的适应症。使用自交联多糖可降低AR风险。ESHRE-ESGE标准可能比ASRM > 1 cm标准导致更高的RS识别频率，这可能导致使用ESHRE-ESGE标准进行更频繁的再次手术，可能对生殖性能没有任何显著影响。这项工作得到了Jagiellonian大学的支持（批准号K/ZDS/003821）。提交人没有竞争利益需要声明。
Can morphologic measurements (width, length and surface area) of the uterine septum predict healing-dependent abnormal anatomic results [ARs; residual septum (RS) and intrauterine adhesions in other locations (IUA-OLs)] after complete hysteroscopic metroplasty (HM)? Significant predictors of ARs are the septal width and, to a lesser extent, septal surface area. Anatomic results after hysteroscopic metroplasty have very large variation. A RS >1 cm and IUA-OLs can aggravate reproductive outcomes, resulting in the need for reoperation. New criteria for diagnosing a uterine septum according to the European Society of Human Reproduction and Embryology (ESHRE) and European Society for Gynaecological Endoscopy (ESGE) have been suggested (ESHRE-ESGE criteria). Autocross-linked hyaluronic acid gel (autocross-linked polysaccharide) has an antiadhesive effect. A prospective, observational cohort study was performed with 96 women consecutively enrolled between 2007 and 2012. Women who had uterine septum and previous miscarriage or infertility presented for evaluation at a university hospital, private hospital or private medical center were included. Preoperative septal width, length and surface area were determined with three-dimensional sonohysterography. Women were treated by hysteroscopy in a standardized manner with three- or four-dimensional transrectal ultrasound guidance (complete resection). Patients received either no adhesion barrier (49 patients) or adhesion barrier with autocross-linked polysaccharide (47 patients). Anatomic results were assessed with three-dimensional sonohysterography and second-look hysteroscopy. Healing-dependent ARs were reported using both American Society of Reproductive Medicine (ASRM) criterion of RS length >1 cm (ASRM>1 cm criterion) and ESHRE-ESGE criteria. Univariate and multivariate logistic regression were used to identify predictors of RS, IUA-OLs and ARs. In patients who had no adhesion barrier, ARs were diagnosed in 11 of 49 patients (23%) using the ASRM > 1 cm criterion and in 20 of 49 patients (41%) using the ESHRE-ESGE criteria for RS [odds ratio (OR)ESHRE-ESGE:ASRM, 2.4, P = 0.05]. In the patients who had autocross-linked polysaccharide, ARsASRM > 1 cm were diagnosed in 2 of 47 patients (4%) and ARsESHRE-ESGE in 4 of 47 patients (9%). RSESHRE-ESGE was diagnosed significantly more often than RSASRM > 1 cm 19 of 96 (20%) versus 5 of 96 (5%) in all patients (ORESHRE-ESGE:ASRM > 1 cm = 4.5, P < 0.01). In patients who had no adhesion barrier, logistic regression with ASRM > 1 cm and ESHRE-ESGE criteria showed that the width and surface area were predictors of ARs. Models adjusted by patient group confirmed the significance of width as a predictor of ARsASRM > 1 cm [OR for width, 3.5 (P < 0.01); OR for group, 0.22 (P < 0.01)], width as a predictor of ARsESHRE-ESGE [OR for width, 2.2 (P < 0.01); OR for group, 0.26 (P < 0.01)] and surface area as a predictor of ARsASRM > 1 cm [OR for surface area, 1.5 (P < 0.01)]; OR for group, 0.32 (P < 0.01). In patients who had autocross-linked polysaccharide, these predictors were not significant. Receiver-operating characteristic curves showed cutoff values for ARsASRM > 1 cm (septal width, 3.42 cm; septal surface area, 4.68cm2) and ARsESHRE-ESGE (septal width, 3.42 cm; septal surface area, 3.51cm2). Patients were enrolled in the adhesion barrier group in a time-dependent, consecutive and non-randomized manner. A wide septum and large surface area may be indications for adhesion barrier. The use of autocross-linked polysaccharide reduces the risk of ARs. The ESHRE-ESGE criteria may cause greater frequency of recognition of RS than the ASRM > 1 cm criterion, which could result in more frequent reoperations with use of the ESHRE-ESGE criteria, possibly without any significant effect on reproductive performance. This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interest to declare.
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