Adamson G D, Pasta D J
Department of Gynecology and Obstetrics, Stanford University School of Medicine, Palo Alto, CA.
Am J Obstet Gynecol. 1994 Dec;171(6):1488-504; discussion 1504-5. doi: 10.1016/0002-9378(94)90392-1.
Our purpose was to evaluate the role of surgery in the treatment of endometriosis associated with infertility.
We used a prospective cohort analysis of pregnancy rates and variables affecting pregnancy rates for surgical, medical, and no treatment. Our studies were combined with those reported by Hughes et al. (Fertil Steril 1993; 59:963-70), and the meta-analysis was expanded to include additional comparisons. Treatment was performed by a single surgeon in a referral reproductive endocrinology and surgery private practice. Results from 579 women with endometriosis and infertility in our study and the meta-analysis of 25 studies by Hughes et al. were examined. Interventions consisted of no treatment, medical treatment, or surgical treatment by laparoscopy or laparotomy. The main outcome measure was pregnancy rates.
For minimal and mild disease, no treatment, laparoscopy, and laparotomy had equivalent 3-year estimated cumulative life-table pregnancy rates (67% +/- 12%, 68% +/- 4%, and 74% +/- 8%, respectively) that were higher than medical treatment pregnancy rates (Breslow p = 0.003). For moderate and severe disease, all but 11 patients were treated surgically. The 3-year estimated cumulative life-table pregnancy rates were 62% + 6% [corrected] for 120 laparoscopy cases and 44% + 6% [corrected] for 102 laparotomy cases (Breslow p = 0.054). For endometriomas, 48 laparoscopy patients had a 3-year estimated cumulative life-table pregnancy rate of 52% +/- 9% and 52 laparotomy patients had a 3-year estimated cumulative life-table pregnancy rate of 46% +/- 9% (Breslow p = 0.48). For 28 patients with complete cul-de-sac obliteration, the 3-year estimated cumulative life-table pregnancy rates were 30% +/- 14% after laparoscopy and 24% +/- 12% after laparotomy (Breslow p = 0.084). Comparison of our results with the expanded meta-analysis revealed deficiencies in the design of meta-analysis studies and the impact of our using life-table pregnancy rates controlled for factors influencing outcome (survival analysis with fixed covariates) rather than the simple pregnancy rates used in the meta-analysis. Benefits of sophisticated statistical techniques, including propensity scores, to adjust for noncomparability of groups in prospective cohort studies were identified.
Both our study and the meta-analysis show that either no treatment or surgery is superior to medical treatment for minimal and mild endometriosis associated with infertility. For moderate and severe disease, surgery is usually used. In these patients experienced surgeons utilizing good clinical judgment can achieve results at operative laparoscopy at least equivalent to those at laparotomy, even in cases involving endometriomas and complete cul-de-sac obliteration. Prospective randomized trials should be performed to confirm these findings.
我们的目的是评估手术在治疗与不孕症相关的子宫内膜异位症中的作用。
我们对手术治疗、药物治疗和未治疗的妊娠率及影响妊娠率的变量进行了前瞻性队列分析。我们的研究与休斯等人（《生育与不育》1993年；59：963 - 70）报告的研究相结合，并扩大了荟萃分析以纳入更多比较。治疗由一位在转诊生殖内分泌与外科私人诊所的外科医生进行。对我们研究中的579例患有子宫内膜异位症和不孕症的女性的结果以及休斯等人对25项研究的荟萃分析结果进行了检查。干预措施包括不治疗、药物治疗或通过腹腔镜或剖腹手术进行手术治疗。主要结局指标是妊娠率。
对于轻度和中度疾病，不治疗、腹腔镜手术和剖腹手术的3年估计累积生命表妊娠率相当（分别为67%±12%、68%±4%和74%±8%），高于药物治疗的妊娠率（Breslow p = 0.003）。对于重度疾病，除11例患者外均接受了手术治疗。120例腹腔镜手术病例的3年估计累积生命表妊娠率为62% + 6%[校正后]，102例剖腹手术病例的为44% + 6%[校正后]（Breslow p = 0.054）。对于子宫内膜瘤，48例腹腔镜手术患者的3年估计累积生命表妊娠率为52%±9%，52例剖腹手术患者的为46%±9%（Breslow p = 0.48）。对于28例完全性直肠子宫陷凹闭塞患者，腹腔镜手术后的3年估计累积生命表妊娠率为30%±14%，剖腹手术后为24%±12%（Breslow p = 0.084）。将我们的结果与扩大后的荟萃分析进行比较，发现荟萃分析研究设计存在缺陷，以及我们使用控制影响结局因素的生命表妊娠率（固定协变量的生存分析）而非荟萃分析中使用的简单妊娠率的影响。确定了包括倾向评分在内的复杂统计技术在调整前瞻性队列研究中组间不可比性方面的益处。
我们的研究和荟萃分析均表明，对于与不孕症相关的轻度和中度子宫内膜异位症，不治疗或手术均优于药物治疗。对于重度疾病，通常采用手术治疗。在这些患者中，经验丰富的外科医生运用良好的临床判断力，即使在涉及子宫内膜瘤和完全性直肠子宫陷凹闭塞的病例中，通过腹腔镜手术也能取得至少与剖腹手术相当的结果。应进行前瞻性随机试验以证实这些发现。
