剖宫产瘢痕憩室相关不孕症的治疗进展

doi:10.12280/gjfckx.20221059

摘要/Abstract

摘要：

剖宫产瘢痕憩室（cesarean scar defect，CSD）是剖宫产术后常见的并发症之一，其主要的临床症状包括异常子宫出血、盆腔痛和继发性不孕等。随着生育政策的改变及剖宫产率的上升，与之相关的不孕症逐渐受到重视。目前对于有生育要求的CSD不孕患者选择何种治疗方式尚无一致意见。合并少量宫腔积液的患者可选择超长方案辅助生殖技术助孕。合并异常子宫出血或明显宫腔积液者可选择先行手术治疗。然而当前对手术方式的选择仍缺乏统一标准，通常主要由瘢痕上残留肌层厚度决定。此外，宫腔内臭氧灌注、中药调理及理疗、干细胞移植等方法也可能对CSD继发性不孕具有潜在的治疗益处。

关键词: 子宫, 瘢痕, 憩室, 剖宫产术, 不育, 女（雌）性, 生殖技术, 辅助, 外科手术

Abstract:

Cesarean scar defect (CSD) is one of the common complications after cesarean section. The clinical manifestations include abnormal uterine bleeding, pelvic pain and secondary infertility. With the evolution of fertility policy and the increase of cesarean section rate, the infertility associated with it is gradually gaining attention. There is no consensus on the treatment options of infertility secondary to CSD currently. In patients combined with small amounts of uterine cavity effusion, the prolonged GnRHa down-regulation protocol can be used to assist reproduction. While in patients with abnormal uterine bleeding or obvious endometrial cavity fluid, surgery should be considered as first-line treatment. However, there is still a lack of uniformity in the choice of surgical approach and surgical plans are usually determined based on the residual myometrial thickness on the scar. In addition, treatment options such as intrauterine ozone infusion, traditional Chinese medicine conditioning and physiotherapy, and stem cell transplantation may also have potential benefits in the treatment of secondary infertility in CSD.

Key words: Uterus, Cicatrix, Diverticulum, Cesarean section, Infertility, female, Reproductive techniques, assisted, Surgical procedures, operative

王卓敏, 胡倩瑜, 孙涛, 徐键. 剖宫产瘢痕憩室相关不孕症的治疗进展[J]. 国际妇产科学杂志, 2023, 50(3): 332-336.

WANG Zhuo-min, HU Qian-yu, SUN Tao, XU Jian. Progress in Treatment of Infertility Associated with Cesarean Scar Defect[J]. Journal of International Obstetrics and Gynecology, 2023, 50(3): 332-336.

参考文献 49

[1]	Betran AP, Ye J, Moller AB, et al. Trends and projections of caesarean section rates: global and regional estimates[J]. BMJ Glob Health, 2021, 6(6):e005671. doi: 10.1136/bmjgh-2021-005671. doi: 10.1136/bmjgh-2021-005671
[2]	Kremer TG, Ghiorzi IB, Dibi RP. Isthmocele: an overview of diagnosis and treatment[J]. Rev Assoc Med Bras(1992), 2019, 65(5):714-721. doi: 10.1590/1806-9282.65.5.714. doi: 10.1590/1806-9282.65.5.714
[3]	Kulshrestha V, Agarwal N, Kachhawa G. Post-caesarean Niche (Isthmocele) in Uterine Scar: An Update[J]. J Obstet Gynaecol India, 2020, 70(6):440-446. doi: 10.1007/s13224-020-01370-0. doi: 10.1007/s13224-020-01370-0
[4]	Gurbuz AS, Gode F, Ozcimen N. Non-Invasive Isthmocele Treatment: A New Therapeutic Option During Assisted Reproductive Technology Cycles?[J]. J Clin Med Res, 2020, 12(5):307-314. doi: 10.14740/jocmr4140. doi: 10.14740/jocmr4140 pmid: 32489506
[5]	Jordans IPM, de Leeuw RA, Stegwee SI, et al. Sonographic examination of uterine niche in non-pregnant women: a modified Delphi procedure[J]. Ultrasound Obstet Gynecol, 2019, 53(1):107-115. doi: 10.1002/uog.19049. doi: 10.1002/uog.19049 pmid: 29536581
[6]	Shi L, Du K. Prediction of Scar Myometrium Thickness and Previous Cesarean Scar Defect Using the Three-Dimensional Vaginal Ultrasound[J]. Contrast Media Mol Imaging, 2022, 2022:3584572. doi: 10.1155/2022/3584572. doi: 10.1155/2022/3584572
[7]	Rupa R, Kushvaha S, Venkatesh K. Uterine Isthmocele-A Frequently Overlooked Complication of Cesarean Sections[J]. Indian J Radiol Imaging, 2021, 31(3):601-604. doi: 10.1055/s-0041-1736393. doi: 10.1055/s-0041-1736393
[8]	Antila-Långsjö RM, Mäenpää JU, Huhtala HS, et al. Cesarean scar defect: a prospective study on risk factors[J]. Am J Obstet Gynecol, 2018, 219(5):458.e1-458.e8. doi: 10.1016/j.ajog.2018.09.004. doi: 10.1016/j.ajog.2018.09.004
[9]	Di Spiezio Sardo A, Saccone G, McCurdy R, et al. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials[J]. Ultrasound Obstet Gynecol, 2017, 50(5):578-583. doi: 10.1002/uog.17401. doi: 10.1002/uog.17401 pmid: 28070914
[10]	Pan H, Zeng M, Xu T, et al. The prevalence and risk predictors of cesarean scar defect at 6 weeks postpartum in Shanghai, China: A prospective cohort study[J]. Acta Obstet Gynecol Scand, 2019, 98(4):413-422. doi: 10.1111/aogs.13505. doi: 10.1111/aogs.13505
[11]	Friedenthal J, Alkon-Meadows T, Hernandez-Nieto C, et al. The association between prior cesarean delivery and subsequent in vitro fertilization outcomes in women undergoing autologous, frozen-thawed single euploid embryo transfer[J]. Am J Obstet Gynecol, 2021, 225(3):287. e1-e8. doi: 10.1016/j.ajog.2021.03.026. doi: 10.1016/j.ajog.2021.03.026
[12]	Donnez O, Donnez J, Orellana R, et al. Gynecological and obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women[J]. Fertil Steril, 2017, 107(1):289-296.e2. doi: 10.1016/j.fertnstert.2016.09.033. doi: S0015-0282(16)62853-4 pmid: 27816234
[13]	Harjee R, Khinda J, Bedaiwy MA. Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review[J]. J Minim Invasive Gynecol, 2021, 28(7):1291-1302.e2. doi: 10.1016/j.jmig.2021.03.012. doi: 10.1016/j.jmig.2021.03.012
[14]	Cai M, Pan X, Xia W, et al. Intra-cavitary fluid resulted from caesarean section but not isthmocele compromised clinical pregnancy after IVF/ICSI treatment[J]. Arch Gynecol Obstet, 2022, 306(1):229-237. doi: 10.1007/s00404-022-06436-0. doi: 10.1007/s00404-022-06436-0
[15]	Nobuta Y, Tsuji S, Kitazawa J, et al. Decreased Fertility in Women with Cesarean Scar Syndrome Is Associated with Chronic Inflammation in the Uterine Cavity[J]. Tohoku J Exp Med, 2022, 258(3):237-242. doi: 10.1620/tjem.2022.J082. doi: 10.1620/tjem.2022.J082 pmid: 36244756
[16]	Huang L, Huang S, Yuan Y, et al. Reduced pregnancy and live birth rates after in vitro fertilization in women with cesarean section scar diverticulum: A retrospective cohort study[J]. J Obstet Gynaecol Res, 2022, 48(1):146-154. doi: 10.1111/jog.15061. doi: 10.1111/jog.15061
[17]	Huang J, Li Q, Yuan X, et al. Intrauterine infusion of clinically graded human umbilical cord-derived mesenchymal stem cells for the treatment of poor healing after uterine injury: a phase I clinical trial[J]. Stem Cell Res Ther, 2022, 13(1):85. doi: 10.1186/s13287-022-02756-9. doi: 10.1186/s13287-022-02756-9 pmid: 35241151
[18]	Mashiach R, Burke YZ. Optimal Isthmocele Management: Hysteroscopic, Laparoscopic, or Combination[J]. J Minim Invasive Gynecol, 2021, 28(3):565-574. doi: 10.1016/j.jmig.2020.10.026. doi: 10.1016/j.jmig.2020.10.026
[19]	Al Mutairi BH, Alrumaih I. Hysteroscopy in the Treatment of Myometrial Scar Defect (Diverticulum) Following Cesarean Section Delivery: A Systematic Review and Meta-Analysis[J]. Cureus, 2020, 12(11):e11317. doi: 10.7759/cureus.11317. doi: 10.7759/cureus.11317
[20]	Tanimura S, Funamoto H, Hosono T, et al. New diagnostic criteria and operative strategy for cesarean scar syndrome: Endoscopic repair for secondary infertility caused by cesarean scar defect[J]. J Obstet Gynaecol Res, 2015, 41(9):1363-1369. doi: 10.1111/jog.12738. doi: 10.1111/jog.12738
[21]	Zeller A, Villette C, Fernandez H, et al. Is Hysteroscopy a Good Option to Manage Severe Cesarean Scar Defect?[J]. J Minim Invasive Gynecol, 2021, 28(7):1397-1402. doi: 10.1016/j.jmig.2020.11.005. doi: 10.1016/j.jmig.2020.11.005
[22]	Tsuji S, Kimura F, Yamanaka A, et al. Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome[J]. J Obstet Gynaecol Res, 2018, 44(1):43-48. doi: 10.1111/jog.13464. doi: 10.1111/jog.13464
[23]	Vitale SG, Ludwin A, Vilos GA, et al. From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis[J]. Arch Gynecol Obstet, 2020, 301(1):33-52. doi: 10.1007/s00404-020-05438-0. doi: 10.1007/s00404-020-05438-0 pmid: 31989288
[24]	He Y, Zhong J, Zhou W, et al. Four Surgical Strategies for the Treatment of Cesarean Scar Defect: A Systematic Review and Network Meta-analysis[J]. J Minim Invasive Gynecol, 2020, 27(3):593-602. doi: 10.1016/j.jmig.2019.03.027. doi: 10.1016/j.jmig.2019.03.027
[25]	Zhang Y. A Comparative Study of Transvaginal Repair and Laparoscopic Repair in the Management of Patients With Previous Cesarean Scar Defect[J]. J Minim Invasive Gynecol, 2016, 23(4):535-541. doi: 10.1016/j.jmig.2016.01.007. doi: 10.1016/j.jmig.2016.01.007
[26]	Karampelas S, Salem Wehbe G, de Landsheere L, et al. Laparoscopic Isthmocele Repair: Efficacy and Benefits before and after Subsequent Cesarean Section[J]. J Clin Med, 2021, 10(24):5785. doi: 10.3390/jcm10245785. doi: 10.3390/jcm10245785
[27]	Liu SJ, Lv W, Li W. Laparoscopic repair with hysteroscopy of cesarean scar diverticulum[J]. J Obstet Gynaecol Res, 2016, 42(12):1719-1723. doi: 10.1111/jog.13146. doi: 10.1111/jog.13146
[28]	Zhang NN, Wang GW, Zuo N, et al. Novel laparoscopic surgery for the repair of cesarean scar defect without processing scar resection[J]. BMC Pregnancy Childbirth, 2021, 21(1):815. doi: 10.1186/s12884-021-04281-8. doi: 10.1186/s12884-021-04281-8
[29]	韩玉英, 王庆一, 林树莹. 宫腹腔镜下叠瓦式缝合+圆韧带缩短术修复子宫憩室的疗效观察[J]. 中国现代医生, 2019, 57(33):67-70.
[30]	Candiani M, Ferrari SM, Marotta E, et al. Mini-invasive transvaginal repair of isthmocele: a video case report[J]. Fertil Steril, 2019, 111(4):828-830. doi: 10.1016/j.fertnstert.2018.12.010. doi: S0015-0282(18)32296-9 pmid: 30853089
[31]	Zhou X, Yang X, Chen H, et al. Obstetrical outcomes after vaginal repair of caesarean scar diverticula in reproductive-aged women[J]. BMC Pregnancy Childbirth, 2018, 18(1):407. doi: 10.1186/s12884-018-2015-7. doi: 10.1186/s12884-018-2015-7
[32]	Deng K, Liu W, Chen Y, et al. Obstetric and Gynecologic Outcomes after the Transvaginal Repair of Cesarean Scar Defect in a Series of 183 Women[J]. J Minim Invasive Gynecol, 2021, 28(5):1051-1059. doi: 10.1016/j.jmig.2020.12.009. doi: 10.1016/j.jmig.2020.12.009
[33]	Zhang D, Liang S, Zhu L. Comparison of transvaginal repair versus laparoscopic repair of lower-segment cesarean scar defects[J]. Int J Gynaecol Obstet, 2019, 145(2):199-204. doi: 10.1002/ijgo.12797. doi: 10.1002/ijgo.12797 pmid: 30801700
[34]	Vissers J, Hehenkamp W, Lambalk CB, et al. Post-Caesarean section niche-related impaired fertility: hypothetical mechanisms[J]. Hum Reprod, 2020, 35(7):1484-1494. doi: 10.1093/humrep/deaa094. doi: 10.1093/humrep/deaa094
[35]	Lawrenz B, Melado L, Garrido N, et al. Isthmocele and ovarian stimulation for IVF: considerations for a reproductive medicine specialist[J]. Hum Reprod, 2020, 35(1):89-99. doi: 10.1093/humrep/dez241. doi: 10.1093/humrep/dez241
[36]	王雅琴, 高玥, 徐望明, 等. 剖宫产手术史对体外受精-胚胎移植患者临床结局的影响[J]. 中华生殖与避孕杂志, 2017, 37(7):556-560. doi: 10.3760/cma.j.issn.2096-2916.2017.07.007. doi: 10.3760/cma.j.issn.2096-2916.2017.07.007
[37]	Tian J, Kang N, Wang J, et al. Transcriptome analysis of eutopic endometrium in adenomyosis after GnRH agonist treatment[J]. Reprod Biol Endocrinol, 2022, 20(1):13. doi: 10.1186/s12958-021-00881-3. doi: 10.1186/s12958-021-00881-3
[38]	张帆. 两种GnRHa降调节方案在多囊卵巢综合征患者冻融胚胎移植中的对比分析[J]. 中国现代医药杂志, 2019, 21(6):45-47. doi: 10.3969/j.issn.1672-9463.2019.06.012. doi: 10.3969/j.issn.1672-9463.2019.06.012
[39]	温灿鑫, 潘萍, 刘庆洲, 等. GnRH激动剂延长降调节方案改善有症状的子宫瘢痕憩室患者体外受精助孕结局[J]. 生殖医学杂志, 2020, 29(5):586-592. doi: 10.3969/j.issn.1004-3845.2020.05.005. doi: 10.3969/j.issn.1004-3845.2020.05.005
[40]	Pan D, Yang J, Zhang N, et al. Gonadotropin-releasing hormone agonist downregulation combined with hormone replacement therapy improves the reproductive outcome in frozen-thawed embryo transfer cycles for patients of advanced reproductive age with idiopathic recurrent implantation failure[J]. Reprod Biol Endocrinol, 2022, 20(1):26. doi: 10.1186/s12958-022-00897-3. doi: 10.1186/s12958-022-00897-3
[41]	Shebley M, Polepally AR, Nader A, et al. Clinical Pharmacology of Elagolix: An Oral Gonadotropin-Releasing Hormone Receptor Antagonist for Endometriosis[J]. Clin Pharmacokinet, 2020, 59(3):297-309. doi: 10.1007/s40262-019-00840-7. doi: 10.1007/s40262-019-00840-7 pmid: 31749075
[42]	Davar R, Dashti S, Omidi M. Endometrial preparation using gonadotropin-releasing hormone agonist prior to frozen-thawed embryo transfer in women with repeated implantation failure: An RCT[J]. Int J Reprod Biomed, 2020, 18(5):319-326. doi: 10.18502/ijrm.v13i5.7150. doi: 10.18502/ijrm.v13i5.7150 pmid: 32637860
[43]	Ergani SY, Dilbaz B, Ergani HM, et al. Effect of intrauterine ozone therapy on Asherman syndrome, an experimental rat model[J]. Eur J Obstet Gynecol Reprod Biol, 2022, 277:90-96. doi: 10.1016/j.ejogrb.2022.08.014. doi: 10.1016/j.ejogrb.2022.08.014 pmid: 36055047
[44]	王凤, 龙惠东, 肖海威, 等. 手术及保守治疗对子宫瘢痕憩室合并宫腔积液患者行体外受精-胚胎移植妊娠结局的影响[J]. 中国性科学, 2022, 31(7):99-103. doi: 10.3969/j.issn.1672-1993.2022.07.026. doi: 10.3969/j.issn.1672-1993.2022.07.026
[45]	Cen J, Zhang Y, Bai Y, et al. Research progress of stem cell therapy for endometrial injury[J]. Mater Today Bio, 2022, 16:100389. doi: 10.1016/j.mtbio.2022.100389. doi: 10.1016/j.mtbio.2022.100389
[46]	Kim JH, Park M, Paek JY, et al. Intrauterine Infusion of Human Platelet-Rich Plasma Improves Endometrial Regeneration and Pregnancy Outcomes in a Murine Model of Asherman's Syndrome[J]. Front Physiol, 2020, 11:105. doi: 10.3389/fphys.2020.00105. doi: 10.3389/fphys.2020.00105 pmid: 32116803
[47]	Fan Y, Sun J, Zhang Q, et al. Transplantation of human amniotic epithelial cells promotes morphological and functional regeneration in a rat uterine scar model[J]. Stem Cell Res Ther, 2021, 12(1):207. doi: 10.1186/s13287-021-02260-6. doi: 10.1186/s13287-021-02260-6 pmid: 33762002
[48]	Hsu I, Hsu L, Dorjee S, et al. Bacterial colonization at caesarean section defects in women of secondary infertility: an observational study[J]. BMC Pregnancy Childbirth, 2022, 22(1):135. doi: 10.1186/s12884-022-04471-y. doi: 10.1186/s12884-022-04471-y
[49]	Yang X, Pan X, Li M, et al. Interaction between Cervical Microbiota and Host Gene Regulation in Caesarean Section Scar Diverticulum[J]. Microbiol Spectr, 2022, 10(4):e0167622. doi: 10.1128/spectrum.01676-22. doi: 10.1128/spectrum.01676-22