种植窗口期宫腔镜检查对原因不明不孕症患者子宫内膜容受性及妊娠结局的预测价值

目的 探讨种植窗口期官腔镜检查用于预测原因不明不孕症患者子宫内膜容受性及妊娠结局的价值.方法 选择2007年10月-2009年3月在广东省计划生育专科医院就诊的原因不明不孕症患者93例,在排卵后7～9 d(即种植窗口期)行宫腔镜检查,将其中未发现官腔病变的79例患者根据宫腔镜下子宫内膜腺体开口和血管的形态分为佳型内膜组19例、差型内膜组60例.比较两组患者子宫内膜的形态、厚度、分泌情况、胞饮突形态及数量、血管分布等,以及两组患者的血性激素水平、宫腔冲洗液中白血病抑制因子(LlF)及妊娠相关子宫内膜蛋白glycodelin水平、妊娠结局等.结果 (1)佳型内膜组患者种植窗口期血雌二醇、孕酮水平分别为(518±176)pmol/L、(40±20)nmol/L,分别与差型内膜组[分别为(513±244)pmoL/L、(37±19)nmol/L]比较,差异均无统计学意义(P>0.05).B超检查显示,佳型内膜组排卵日、种植窗口期子宫内膜厚度分别为(1.06±0.10)cm和(1.16±0.08)cm,分别与差型内膜组[分别为(0.93±0.12)cm和(1.02±0.10)cm]比较,差异均无统计学意义(P>0.05);佳型内膜组患者排卵日内膜形态为A、B、C型者分别占63%(12/19)、37%(7/19)和0(0/19),差型内膜组分别占23%(14/60)、77%(46/60)和0(0/60),两组A、B型内膜百分率分别比较,差异均有统计学意义(P<0.05);两组患者种植窗口期内膜形态均为B型.(2)佳型内膜组患者中89%(17/19)子宫内膜分泌正常,差型内膜组患者中仅7%(4/60)子宫内膜分泌正常,两组比较,差异有统计学意义(P<0.01).(3)佳型内膜组患者中,胞饮突形态为成熟期者占84%(16/19),胞饮突数量丰富者占89%(17/19),均明显高于差型内膜组[分别为42%(25/60)和57%(34/60),P<0.05].(4)佳型内膜组内膜中CD_(34)表达水平及微血管密度(MVD)分别为(40.1±1.2)阳性单位(PU)和(21.7±4.0)条/高倍视野(HP),均明显高于差型内膜组[分别为(18.1±1.3)PU和(8.5±1.3)条/HP,P均<0.01].(5)佳型内膜组宫腔冲洗液中LIF、glycodelin水平分别为(72±54)ng/L和(196±20)μg/L,均明显高于差型内膜组[分别为(15±16)ng/L和(116±26)μg/L,P均<0.05].(6)佳型内膜组患者临床妊娠率、自然流产率、足月分娩率分别为74%(14/19)、0(0/14)和100%(14/14),差型内膜组分别为23%(14/60)、14%(2/14)和86%(12/14),佳型内膜组的临床妊娠率及足月分娩率均明显高于差型内膜组(P<0.01).结论 种植窗口期宫腔镜检查能反映子宫内膜血管及腺体的发育水平,是一种较好的评估子宫内膜容受性的方法,对预测妊娠结局有一定的价值.

Predictive value of endometrial receptivity and pregnancy outcome by hysteroscopy examination at the phase of implantation window in unexplained infertile women

Objective To explore predictive value of endometrial receptivity and pregnancy outcome by hysteroscopy examination at the phase of implantation window in unexplained infertile women.Methods From Oct.2007 to Mar.2009,93 unexplained infertile women underwent hysteroscopy examination at 7-9 days after a spontaneous ovulation in Family Planning Research Institute of Guangdong Province.According to the endometrial glandular openings and vascular shape,79 cases without pathological endometrial changes were divided into 60 cases in good endometrium group and 19 cases in poor endometrium group.The following clinical parameters were analyzed and compared between two groups,including endometrial configuration,thickness,secretion,the development and number of pinopodes,vascular distribution,and the level of sex hormone,leukemia inhibitory factor (LIF) and glycodelin in the uterine flushing,and pregnancy outcome.Results (1)There was no statistical difference in the level of serum estrogen and progesterone at the phase of implantation window,which were (518 ± 176)pmol/L,(40 ±20)nmol/L in good group and (513 ±244) ptnol/L,(37 ± 19) nmol/L in poor group (P<0.05).The endometrium thickness at periovulatroy and implantation window days (1.06 ±0.10)cm/(1.16 ± 0.08)cm in good group did not show significant difference with (0.93 ±0.12) cm /(1.02 ±0.10) cm in poor group (P>0.05).The proportion of type A,B and C endometrium at periovulatory days were 63% (12/19),37% (7/19) and 0 (0/19) in good group and 23% (14/60),77% (46/60) and 0 (0/60) in poor group.When compared with those of type A or B between two groups respectively,it all showed statistical difference (P<0.05).However,at phase of implantation window,endometrium configurations were all type B at both groups.(2)90% (17/19)of women in good group and 7% (4/60)of women in poor group showed normal endometrial secretion function,which showed significant differences (P< 0.01).(3)The percentage of fully developed pinopodes and abundant pinopodes [84% (16/19) and 90% (17/19)] in good group were significantly higher than 42% (25/60)and 57% (34/60) in poor group (P<0.05).(4) The level of CD_(34) expression and microvessel density[MVD; (40.1 ± 1.2) positive unit(PU) and(21.7 ±4.0)/high power field (HP)] in good group were significantly higher than(18.1 ± 1.3) PU and (8.5 ± 1.3)/HP in poor group (P< 0.01).(5)The level of LIF and glycodelin in uterine flushing [(72 ± 54)ng/L and (196 ±20)μg/L] in good group were significantly higher than (15±16) ng/L and (116 ±26) μg/L in poor group (P<0.05).(6) The rate of clinical pregnancy,spontaneous abortion and term delivery were 74% (14/19),0 (0/14) and 100% (14/14) in good group and 23% (14/60),14% (2/14) and 86% (12/14) in poor group,the rate of clinical pregnancy and term delivery in good group were significantly increased when compared with those in poor group (P<0.01).Conclusions Hysteroscopy examination at the phase of implantation window could reflect the development of glandular openings and vasculature.It is a preferable method to evaluate the endometrial receptivity and predict pregnancy outcome.