探讨四维输卵管超声造影（4D-HyCoSy）中输卵管显影形态在不孕症患者输卵管通畅性评估中的应用价值。

选取2016年1月至2019年7月于杭州市中医院行4D-HyCoSy检查的不孕症患者52例，所有患者造影后3个月内行腹腔镜下亚甲蓝通液检查，根据亚甲蓝通液检查结果分为阻塞组（18例）和非阻塞组（34例）。选择其中87条输卵管分析显影形态（腹腔镜下亚甲蓝通液检查显示为通畅39条、通而不畅28条、远端阻塞20条）。形态正常包括输卵管走行自然、管径粗细均匀；形态异常包括输卵管迂曲、僵硬、纤细（内径突然变细，内径＜0.5倍邻近内径）或扩张（内径突然扩张，内径＞2倍邻近内径）。患者一般资料特征及输卵管不同显影形态组间比较采用Mann-Whitney U检验、Pearson χ²检验或Fisher确切概率检验。采用Logistics回归中的多项逻辑回归分析，以迂曲、僵硬、纤细及扩张为影响因素，寻找腹腔镜下不同输卵管通畅度在显影形态方面的危险因素，评估各显影形态对输卵管通畅性的诊断价值。

非阻塞组与阻塞组患者年龄、不孕时间、不孕类型和子宫肌瘤、内膜息肉、宫腔粘连、盆腔内膜异位的患病率比较，差异均无统计学意义（P均＞0.05）。纳入分析的87条输卵管中显影形态表现为迂曲35条（40.2%，35/87），扩张35条（40.2%，35/87），纤细40条（46.0%，40/87）；僵硬10条（11.5%，10/87）。在单因素分析中，输卵管通畅组、通而不畅组和远端阻塞组迂曲、扩张、纤细这3种形态比较［2（5.1%）vs 16（57.1%）vs 17（85.0%）；5（12.8%）vs 12（42.9%）vs 18（90.0%）；7（17.9%）vs 20（71.4%）vs 13（65.0%）］，差异均有统计学意义（χ²=18.17、10.76、13.67，P＜0.001、=0.005、=0.001）。不同通畅度组僵硬形态比较，差异无统计学意义（P＞0.05）。在多因素分析中，迂曲、纤细为通而不畅的独立危险因素（OR=19.884、9.721；P=0.001、0.001）；迂曲、扩张、纤细为远端阻塞的独立危险因素（OR=41.275、12.377、6.071；P=0.001、0.015、0.040）。

4D-HyCoSy显示的输卵管迂曲、扩张、纤细是重要的输卵管异常形态改变，为输卵管通畅度评价提供了更准确的诊断信息。

To assess the value of abnormal morphologies of the fallopian tubes revealed by four-dimensional hysterosalpingo contrast sonography (4D-HyCoSy) in the diagnosis of fallopian tube patency.

In this retrospective observational study, 52 infertile female patients undergoing 4D-HyCoSy from January 2016 to July 2019 were included. All the patients were followed by laparoscopic and dye hydrotubation (Lap and Dye) within 3 months, and according to the results of Lap and Dye, they were divided into an obstruction group (n=18) and a non-obstruction group (n=34). Eighty-seven patent, partially patent, or distally obstructed fallopian tubes, as revealed by Lap and Dye, were included in the analysis. Abnormal morphologies of the tubes, as revealed by 4D-HyCoSy, were recorded and analyzed. Normal morphologies of the tubes were defined as smooth shape and uniform inner diameter. Abnormal morphologies of the tubes were defined as distortion, stiffness, slenderness (sudden narrow, inner diameter ＜ 0.5×inner diameter nearby), and dilation (sudden dilation, inner diameter ＞ 2×inner diameter nearby). The general data of the patients were compared between different groups using Mann-Whitney U test, Pearson Chi-square test, or Fisher exact test. The correlation between the abnormal morphologies of the tubes and fallopian tube patency degree was analyzed by multinomial logistics regression (including single factor analysis and multi-factor analysis). Each examination was performed by two experienced physicians who had worked for more than 5 years.

There was no significant difference in age, duration of infertility, primary infertility, 2D-ultrasound observations (myomas, endometrial polyps, intrauterine adhesions, and pelvic endometriosis) between the obstruction group and non-obstruction group (P＞0.05). Of the 87 tubes included, 35 were distorted (40.2%), 35 were dilated (40.2%), 40 were slender (46.0%), and 10 were stiff (11.5%). The Chi-square test showed a statistically signi?cant association between fallopian tube patency and distortion, dilation, and slenderness [2 (5.1%) vs 16 (57.1%) vs 17 (85.0%), χ²=18.17, P＜0.001; 5 (12.8%) vs 12 (42.9%) vs 18 (90.0%), χ²=10.76, P=0.005; 7 (17.9%) vs 20 (71.4%) vs 13 (65.0%), χ²=13.67, P=0.001, but no significant association with stiffness (P＞0.05). The influencing factors of distortion and slenderness were independent factors for partial patency (OR=19.884 and 9.721; P=0.001 and 0.001, respectively), while distortion, dilation, and slenderness were independent factors for distal obstruction (OR=41.275, 12.377, and 6.071; P=0.001, 0.015, and 0.040, respectively).

Distortion, dilation, and slenderness are important abnormal morphologies of the fallopian tubes evaluated by 4D-HyCoSy, suggesting that it could provide more accurate diagnostic information for evaluation of fallopian tube patency. Our findings need verification by a large, retrospective observational study.