| ObjectivesProspective analysis the effects of high-intensity focused ultrasound(HIFU)and uterine artery embolization(UAE)pretreatment to cesarean scar pregnancy(CSP)on ovarian function and endometrial receptivity,and retrospective analysis the re-pregnancy outcomes of two pretreatment methods in the treatment of CSP to explore the effect on female fertility.Methods1.Patients admitted to the gynecology department of affiliated hospital of north sichuan medical college from October 2018 to December 2019 and diagnosed with CSP by gynecological ultrasound and/or pelvic MRI were collected.Identify research subjects based on established inclusion and exclusion criteria.The subjects selected the pretreatment method after being fully informed and understood,and were divided into HIFU group and UAE group.1-3 days after HIFU or UAE pretreatment,pregnancy tissue removal is performed,and the hemoglobin decrease value,HCG decrease rate,postoperative hospitalization day,hospitalization cost,postoperative vaginal bleeding time,menstrual recovery time,and menstrual volume are recorded,fewer patients underwent hysteroscopy to assess the condition of the uterine cavity.Preoperative blood tests for all patients to assess basic ovarian function,and returned to hospital for review of AMH in the luteal phase one month and three months after surgery,meanwhile,the endometrial thickness,uterine artery blood flow parameters(RI,PI,S/D)and endometrial blood perfusion parameters(VI,FI,VFI)were measured by gynecological ultrasound to evaluate endometrial receptivity.2.A total of 303 patients diagnosed with CSP and pretreated with HIFU or UAE in the affiliated hospital of north sichuan medical college from January 2015 to September 2018 were followed up,and their repregnancy status was recorded.And analyze the effects of the two pretreatments on repregnancy and its outcome.Results1.Fifty-seven patients were treated successfully and followed up completely,30 in the HIFU group and 27 in the UAE group,without secondary surgery or hysterectomy.The decrease of hemoglobin in HIFU group was more significant than that in UAE group,and the difference was statistically significant(t=2.529,P=0.014).There were no statistically significant differences in HCG decline rate,postoperative hospital stay,hospital expenses,postoperative vaginal bleeding time and menstrual recovery time between the two groups(P>0.05).According to the two-factor repeated measures analysis of variance,AMH value of CSP patients in the two groups showed no statistically significant difference(Fgroup=0.308,P=0.581),and no statistically significant difference at different time points(Ftime=0.622,P=0.533),and AMH value of CSP patients in the two groups showed a similar trend over time(Fgroup*time=0.279,P=0.749).The results showed that the average endometrial thickness in HIFU group at 1 month and 3 months after surgery was thicker than that in UAE group,but the difference was not statistically significant(P>0.05),the thickness of the endometrium at 3 months after surgery in both groups increased compared with 1 month after surgery,but the difference was not significant(P>0.05);There were no significant differences in uterine artery blood flow parameters RI,PI,and S/D between groups,time points,and interactions between groups and time points(P>0.05);The comparison of endometrial perfusion parameters between the two groups showed that the VFI of the HIFU group was higher than that of the UAE group at 1 month and 3 months after surgery(Fgroup=6.961,P=0.011),and the inter-group t-test showed no significant difference at 1 month after surgery(t=1.404,P=0.167),while the difference was significant at 3 months after surgery(t=3.382,P=0.001).There was no significant difference in VFI between the two groups over time(Ftime=0.066,P=0.799)and no significant difference in variation trend(Fgroup*time=1.988,P=0.164),while there was no statistically significant difference in VI and FI between groups,time point,and interactions between groups and time points(P>0.05).Follow-up changes in the menstrual volume of the two groups of patients.Further hysteroscopy was performed in those with reduced menstrual flow,no cases of intrauterine adhesions were found in the HIFU group,but six of the 7 patients with reduced menstrual flow in the UAE group were diagnosed with intrauterine adhesions,the difference was statistically significant(P=0.033).2.303 patients were followed up,of which 60 patients were pretreated with HIFU,12 patients were lost to follow-up,243 patients were pretreated with UAE,and 54 were lost to follow-up.In the HIFU group,12 cases had intentionto conceive,9 cases of successful pregnancy with a success rate of 75.00%,including 4 cases of full-term labor,3 cases of ongoing pregnancy(2 cases over 28 weeks),1 case of recurrent CSP(RCSP),and 1 case of spontaneous abortion.Among the 36 patients who had no intentionto conceive,6 had unplanned pregnancy,all of which were intrauterine pregnancy and were terminated in early pregnancy.UAE group had 60 cases of pregnancy intention,43 cases of successful pregnancywith a success rate of 71.67%,Among them,there were 3 cases of full term cesarean section and 1 pregnancy after delivery,namely 46 pregnancies in total,including 18 cases of full term delivery(9 cases of abnormal placenta),4 cases of premature delivery(3 cases of abnormal placenta),8 cases of ongoing pregnancy(2 cases of over 28 weeks and 1 case of abnormal placenta),10 cases of RCSP,3 cases of spontaneous abortion and 3 cases of tubal pregnancy.Twelve of the 129 patients who did not intend to conceive were pregnant unexpectedly,including 9 intrauterine pregnancy and 3 RCSP,all of which were terminated during the early pregnancy.There were no statistically significant differences in pregnancy rate and pregnancy outcomes(term birth,preterm birth,induced abortion,spontaneous abortion,RCSP,tubal pregnancy and mid-pregnancy)between the two groups(P>0.05).The placentas of all patients with full-term labor,preterm labor and gestational week>28 weeks in the two groups were recorded.All 13 cases of placental abnormalities occurred in UAE group,with statistically significant differences compared with HIFU group(P=0.024).Three of the four premature births resulted from premature termination due to placental abnormalities.Uterine rupture did not occur in all cases which childbirth was completed.Conclusion1.Both HIFU and UAE can be used as preoperative pretreatment for CSP to reduce the risk of intraoperative hemorrhage,but UAE hemostasis is more accurate.2.HIFU and UAE treatments have no significant effect on ovarian reserve function in the short term.3.HIFU and UAE pretreatments can achieve satisfactory natural pregnancy rates,but UAE may increase the risk of RCSP.4.UAE reduces endometrial receptivity,increases the risk of intrauterine adhesion,and is more prone to placenta previa,placenta implantation and other placental abnormalities during repregnancy,increasing the rate of preterm birth,For women with fertility requirements,HIFU treatment is preferred if the condition permits. |
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