卵巢子宫内膜异位囊肿相关性不孕研究进展

doi:10.12280/gjfckx.20200461

摘要/Abstract

摘要：

卵巢子宫内膜异位囊肿（varian endometrial cyst,OEC）是最常见的子宫内膜异位症（endometriosis,EMs）,可引起疼痛和不孕。由于其具有增生、侵润等破坏卵巢功能及治疗后复发等恶性肿瘤样特征,OEC合并不孕的治疗越来越受到临床医师的重视。目前主要的治疗方法包括手术治疗、药物治疗及辅助生殖治疗,有时需相互补充。然而,迄今为止,关于OEC合并不孕患者选择何种治疗方式能有效提高妊娠率却存在争议。现结合文献就OEC引起不孕的机制、腹腔镜下囊肿剥除术存在的问题及术中卵巢功能的保护,硬化治疗的进展、辅助生殖治疗、体外受精（in vitro fertilization,IVF）治疗前促性腺激素释放激素（gonadotrophin releasing hormone,GnRH）使用及手术处理等问题作一综述,以期为OEC合并不孕的临床治疗提供参考。

关键词: 子宫内膜异位症, 卵巢囊肿, 妇科外科手术, 腹腔镜, 硬化疗法, 生殖技术,辅助

Abstract:

Ovarian endometriotic cyst (OEC) is the most common form of endometriosis, which can cause pain and infertility. Because of its malignant tumor characteristics such as hyperplasia, invasion, destruction of ovarian function and recurrence after treatment, clinicians pay more and more attention to the treatment of OEC complicated with infertility. At present, the main treatment methods include surgical treatment, drug therapy and assisted reproductive therapy, which sometimes need to complement each other. However, so far, there is controversy about how to effectively improve the pregnancy rate of infertile patients with OEC. This article reviews the mechanism of infertility caused by OEC, the problems existing in laparoscopic cystectomy, the protection of ovarian function during operation,the progress of sclerotherapy, assisted reproductive therapy, the use of GnRH before IVF treatment and the surgical treatment of OEC, in order to provide reference for the clinical treatment of OEC complicated with infertility.

Key words: Endometriosis, Ovarian cysts, Gynecologic surgical procedures, Laparoscopes, Sclerotherapy, Reproductive techniques,assisted

付利梅, 平毅. 卵巢子宫内膜异位囊肿相关性不孕研究进展[J]. 国际妇产科学杂志, 2021, 48(1): 21-25.

FU Li-mei, PING Yi. Research Progress of Infertility Related to Ovarian Endometriosis Cyst[J]. Journal of International Obstetrics and Gynecology, 2021, 48(1): 21-25.

参考文献 39

[1]	Rehmer JM, Flyckt RL, Goodman LR, et al. Management of Endometriomas[J]. Obstet Gynecol Surv, 2019,74(4):232-240. doi: 10.1097/OGX.0000000000000660. doi: 10.1097/OGX.0000000000000660 pmid: 31344251
[2]	Somigliana E, Vigano P, Benaglia L, et al. Management of Endometriosis in the Infertile Patient[J]. Semin Reprod Med, 2017,35(1):31-37. doi: 10.1055/s-0036-1597125. doi: 10.1055/s-0036-1597125 pmid: 27926972
[3]	Vassilopoulou L, Matalliotakis M, Zervou MI, et al. Endometriosis and in vitro fertilisation[J]. Exp Ther Med, 2018,16(2):1043-1051. doi: 10.3892/etm.2018.6307. doi: 10.3892/etm.2018.6307 pmid: 30116357
[4]	Eisenberg VH, Weil C, Chodick G, et al. Epidemiology of endometriosis: a large population-based database study from a healthcare provider with 2 million members[J]. BJOG, 2018,125(1):55-62. doi: 10.1111/1471-0528.14711. doi: 10.1111/1471-0528.14711 pmid: 28444957
[5]	Khan Z. Fertility-related considerations in endometriosis[J]. Abdom Radiol(NY), 2020,45(6):1754-1761. doi: 10.1007/s00261-019-02307-6.
[6]	The Effect of Surgery for Endometriomas on Fertility: Scientific Impact Paper No. 55[J]. BJOG, 2018 , 125(6):e19-e28. doi: 10.1111/1471-0528.14834. doi: 10.1111/1471-0528.14834 pmid: 28944556
[7]	张丽, 刘效群. 子宫内膜异位症相关不孕症的治疗策略[J]. 生殖医学杂志, 2018,27(8):804-808. doi: 10.3969/j.issn.1004-3845.2018.08.023.
[8]	Máté G, Bernstein LR, Török AL. Endometriosis Is a Cause of Infertility. Does Reactive Oxygen Damage to Gametes and Embryos Play a Key Role in the Pathogenesis of Infertility Caused by Endometriosis?[J]. Front Endocrinol(Lausanne), 2018,9:725. doi: 10.3389/fendo.2018.00725.
[9]	陈峥峥, 凌斌. 催乳素在子宫内膜异位症发病机制中作用的研究进展[J]. 国外医学·计划生育/生殖健康分册, 2006,25(5):273-276. doi: 10.3969/j.issn.1674-1889.2006.05.011.
[10]	Hobo R, Nakagawa K, Usui C, et al. The Endometriosis Fertility Index Is Useful for Predicting the Ability to Conceive without Assisted Reproductive Technology Treatment after Laparoscopic Surgery, Regardless of Endometriosis[J]. Gynecol Obstet Invest, 2018,83(5):493-498. doi: 10.1159/000480454. doi: 10.1159/000480454 pmid: 28873380
[11]	Pantou A, Simopoulou M, Sfakianoudis K, et al. The Role of Laparoscopic Investigation in Enabling Natural Conception and Avoiding in vitro Fertilization Overuse for Infertile Patients of Unidentified Aetiology and Recurrent Implantation Failure Following in vitro Fertilization[J]. J Clin Med, 2019,8(4):548. doi: 10.3390/jcm8040548. doi: 10.3390/jcm8040548
[12]	姚书忠, 梁炎春. 重视子宫内膜异位症手术治疗的恰当性和彻底性[J]. 中国实用妇科与产科杂志, 2020,36(1):45-49. doi: 10.19538/j.fk2020010111.
[13]	齐琳婧, 马彩虹, 杨艳, 等. 子宫内膜异位症生育力指数对腹腔镜术后自然妊娠预测价值的研究[J]. 中国妇产科临床杂志, 2017,18(6):503-506.
[14]	张丽华. 开腹与腹腔镜治疗子宫内膜异位症合并不孕症的影响评价[J]. 当代医学, 2020,26(12):52-54. doi: 10.3969/j.issn.1009-4393.2020.12.021.
[15]	Coccia ME, Rizzello F, Capezzuoli T, et al. Bilateral Endometrioma Excision: Surgery-Related Damage to Ovarian Reserve[J]. Reprod Sci, 2019,26(4):543-550. doi: 10.1177/1933719118777640. doi: 10.1177/1933719118777640 pmid: 29848225
[16]	元万芹. 抗苗勒管激素评估卵巢储备功能的应用进展[J]. 药品评价, 2019,16(14):10-12. doi: 10.3969/j.issn.1672-2809.2019.14.004.
[17]	Cohen J, Chabbert-Buffet N, Darai E. Diminished ovarian reserve, premature ovarian failure, poor ovarian responder--a plea for universal definitions[J]. J Assist Reprod Genet, 2015,32(12):1709-1712. doi: 10.1007/s10815-015-0595-y. doi: 10.1007/s10815-015-0595-y pmid: 26463876
[18]	张琬琳, 王晓红. 子宫内膜异位症相关不孕诊治指南解读[J]. 实用妇产科杂志, 2018,34(5):341-343.
[19]	Saridogan E, Becker CM, Feki A, et al. Recommendations for the surgical treatment of endometriosis-part 1: ovarian endometrioma[J]. Gynecol Surg, 2017,14(1):27. doi: 10.1186/s10397-017-1029-x. doi: 10.1186/s10397-017-1029-x pmid: 29285022
[20]	Muzii L, Di Tucci C, Di Feliciantonio M, et al. Ovarian Reserve Reduction With Surgery Is Not Correlated With the Amount of Ovarian Tissue Inadvertently Excised at Laparoscopic Surgery for Endometriomas[J]. Reprod Sci, 2019,26(11):1493-1498. doi: 10.1177/1933719119828055. doi: 10.1177/1933719119828055 pmid: 30764716
[21]	Ghafarnejad M, Akrami M, Davari-Tanha F, et al. Vasopressin Effect on Operation Time and Frequency of Electrocauterization during Laparoscopic Stripping of Ovarian Endometriomas: A Randomized Controlled Clinical Trial[J]. J Reprod Infertil, 2014,15(4):199-204. pmid: 25473628
[22]	王瑞, 李望舒, 刘雪兰, 等. 腹腔镜下卵巢囊肿剥除术中垂体后叶素-水囊分离法对卵巢功能的保护作用[J]. 宁夏医学杂志, 2017,39(5):385-388. doi: 10.13621/j.1001-5949.2017.05.0385.
[23]	Garcia-Tejedor A, Martinez-Garcia JM, Candas B, et al. Ethanol Sclerotherapy versus Laparoscopic Surgery for Endometrioma Treatment: A Prospective, Multicenter, Cohort Pilot Study[J]. J Minim Invasive Gynecol, 2020,27(5):1133-1140. doi: 10.1016/j.jmig.2019.08.036. doi: 10.1016/j.jmig.2019.08.036 pmid: 32272240
[24]	Leone Roberti Maggiore U, Gupta JK, Ferrero S. Treatment of endometrioma for improving fertility[J]. Eur J Obstet Gynecol Reprod Biol, 2017,209:81-85. doi: 10.1016/j.ejogrb.2016.02.035. doi: 10.1016/j.ejogrb.2016.02.035 pmid: 26968428
[25]	中国医师协会妇产科医师分会子宫内膜异位症专业委员会, 中华医学会妇产科学分会子宫内膜异位症协作组. 子宫内膜异位症长期管理中国专家共识[J]. 中华妇产科杂志, 2018,53(12):836-841. doi: 10.3760/cma.j.issn.0529-567x.2018.12.007.
[26]	Zhu W, Tan Z, Fu Z, et al. Repeat transvaginal ultrasound-guided aspiration of ovarian endometrioma in infertile women with endometriosis[J]. Am J Obstet Gynecol, 2011, 204(1): 61.e1-e6. doi: 10.1016/j.ajog.2010.08.040. doi: 10.1016/j.ajog.2010.08.040
[27]	郭红梅, 陈建文, 梁元豪, 等. 经阴道彩超介入硬化治疗卵巢子宫内膜异位囊肿的效果评价[J]. 中国妇幼保健, 2018,33(15):3551-3553. doi: 10.7620/zgfybj.j.issn.1001-4411.2018.15.61.
[28]	García-Tejedor A, Castellarnau M, Ponce J, et al. Ethanol sclerotherapy of ovarian endometrioma: a safe and effective minimal invasive procedure. Preliminary results[J]. Eur J Obstet Gynecol Reprod Biol, 2015,187:25-29. doi: 10.1016/j.ejogrb.2015.02.004. doi: 10.1016/j.ejogrb.2015.02.004 pmid: 25739052
[29]	Cohen A, Almog B, Tulandi T . Sclerotherapy in the management of ovarian endometrioma: systematic review and meta-analysis[J]. Fertil Steril, 2017, 108(1):117-124.e5. doi: 10.1016/j.fertnstert.2017.05.015. doi: 10.1016/j.fertnstert.2017.05.015 pmid: 28579409
[30]	Han K, Seo SK, Kim MD, et al. Catheter-directed Sclerotherapy for Ovarian Endometrioma: Short-term Outcomes[J]. Radiology, 2018,289(3):854-859. doi: 10.1148/radiol.2018180606. doi: 10.1148/radiol.2018180606 pmid: 30152743
[31]	陈欣, 刘海元, 郎景和, 等. 手术前GnRH-a治疗对卵巢子宫内膜异位囊肿患者手术后自然妊娠的影响[J]. 中华妇产科杂志, 2018,53(10):683-688. doi: 10.3760/cma.j.issn.0529-567x.2018.10.006.
[32]	南朝香. 腹腔镜联合亮丙瑞林对卵巢子宫内膜异位症的术后复发和自然妊娠的影响[D]. 延吉:延边大学, 2018.
[33]	Sallam HN, Garcia-Velasco JA, Dias S, et al. Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis[J]. Cochrane Database Syst Rev, 2006(1):CD004635. doi: 10.1002/14651858.CD004635.pub2. doi: 10.1002/14651858.CD004288.pub3 pmid: 26799160
[34]	Georgiou EX, Melo P, Baker PE, et al. Long-term GnRH agonist therapy before in vitro fertilisation (IVF) for improving fertility outcomes in women with endometriosis[J]. Cochrane Database Syst Rev, 2019, 2019(11):CD013240. doi: 10.1002/14651858.CD013240.pub2. pmid: 31743430
[35]	Lessey BA, Gordts S, Donnez O, et al. Ovarian endometriosis and infertility:in vitro fertilization (IVF) or surgery as the first approach?[J]. Fertil Steril, 2018,110(7):1218-1226. doi: 10.1016/j.fertnstert.2018.10.003. doi: 10.1016/j.fertnstert.2018.10.003 pmid: 30503109
[36]	Nickkho-Amiry M, Savant R, Majumder K, et al. The effect of surgical management of endometrioma on the IVF/ICSI outcomes when compared with no treatment? A systematic review and meta-analysis[J]. Arch Gynecol Obstet, 2018,297(4):1043-1057. doi: 10.1007/s00404-017-4640-1. doi: 10.1007/s00404-017-4640-1 pmid: 29344847
[37]	Wu CQ, Albert A, Alfaraj S, et al. Live Birth Rate after Surgical and Expectant Management of Endometriomas after In Vitro Fertilization: A Systematic Review, Meta-Analysis, and Critical Appraisal of Current Guidelines and Previous Meta-Analyses[J]. J Minim Invasive Gynecol, 2019, 26(2):299-311.e3. doi: 10.1016/j.jmig.2018.08.029. doi: 10.1016/j.jmig.2018.08.029 pmid: 30717864
[38]	ETIC Endometriosis Treatment Italian Club. When more is not better: 10 ′don′ts′ in endometriosis management. An ETIC* position statement[J]. Hum Reprod Open, 2019, 2019(3):hoz009. doi: 10.1093/hropen/hoz009. doi: 10.1093/hropen/hoz008 pmid: 31206036
[39]	Lee D, Kim SK, Lee JR, et al. Corrigendum to "Management of endometriosis-related infertility: Considerations and treatment options"[J]. Clin Exp Reprod Med, 2020,47(2):153. doi: 10.5653/cerm.2020.47.1.1.e1. doi: 10.5653/cerm.2020.47.1.1.e1 pmid: 32259915