国际妇产科学杂志

国际妇产科学杂志 ›› 2012, Vol. 39 ›› Issue (5): 426-432.

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子宫内膜异位症合并不孕症的治疗策略

冒韵东   

  1. 210036 南京医科大学第一附属医院/江苏省人民医院/江苏省妇幼保健院临床生殖医学科
  • 收稿日期:1900-01-01 修回日期:1900-01-01 出版日期:2012-10-15 发布日期:2012-10-15

Treatment Strategy of Endometriosis with Infertility

MAO Yun-dong   

  1. Clinical Center of Reproduction Medicine，the First Affiliated Hospital of Nanjing Medical University；Jiangsu Province Hospital；Jiangsu Province Maternal and Children's Hospital，Nanjing 210036，China
  • Received:1900-01-01 Revised:1900-01-01 Published:2012-10-15 Online:2012-10-15

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摘要： 子宫内膜异位症（EMs）是妇科的常见病。单纯激素治疗并不能改善EMs合并不孕患者的生育结局。腹腔镜切除/剥除Ⅰ、Ⅱ期EMs病灶可增加不孕妇女的活产率。对于Ⅲ～Ⅳ期EMs合并不孕的首选治疗多数认为应采用手术+促性腺激素释放激素激动剂（GnRHa），但也有一些异议。目前还没有证据表明哪一种腹腔镜下的手术技术可以获得更好的效果。荟萃分析发现EMs合并不孕患者与输卵管因素患者比较，助孕的总妊娠率下降约37%。有研究提示体外受精-胚胎移植（IVF-ET）前延长应用GnRHa可能会提高IVF的持续妊娠率和种植率。部分研究者认为，手术剥除卵巢内异囊肿会明显降低卵巢功能，而另一些作者则认为只要积累经验，注意保护卵巢组织，则手术对卵巢功能的影响不大。Ⅰ～Ⅱ期EMs术后可给予一定时间试孕，而Ⅲ～Ⅳ期EMs术后则应积极考虑助孕。对于助孕前是否应先行腹腔镜手术处理卵巢内异囊肿，目前存在争论。EMs复发，用药后助孕，特别是2次或以上的IVF，妊娠率明显优于再次手术。鉴于EMs对妊娠许多环节都有不利影响，助孕前先用药抑制EMs的活动无疑有利于助孕结果。

关键词: 子宫内膜异位症, 不育, 女（雌）性, 治疗, 受精, 体外

Abstract: Hormonal treatment does not improve the fecundity of infertile women with endometriosis. In stage Ⅰ/Ⅱ endometriosis，laparoscopic ablation of endometrial implants has been associated with a significant improvement in live birth rates. While in women with stage Ⅲ-Ⅳ endometriosis conservative surgical treatment with laparoscopy and possible laparotomy plus GnRH agonist may increase fertility，but there is some objection. There is no evidence that the outcome is affected by the method of ablation，either electrosurgery or laser delivery systems in laparoscopy. Patients with endometriosis-associated infertility undergoing assisted reproduction respond with significantly decreased 37% pregnancy rate comparing that of women with tubal factor infertility for IVF. Prolonged use of GnRH agonist before IVF-ET in patients with endometriosis resulted in significantly higher ongoing pregnancy and implantation rates than standard controlled ovarian hyperstimulation regimens. There are some evidence supporting the idea that surgery may negatively affect ovarian reserve and other investigator consider that negatively affect will decrease to minimal by practices accumulating and protecting ovarian tissue. Patients in stage Ⅰ-Ⅱ endometriosis with infertility should be expect to nature fecundity months after laparoscopy，and who in stage Ⅲ-Ⅳ will be suggested to get assisted reproduction. There are heated argument in laparoscopy before IVF-ET/ICSI. When recurrent of endometriosis are present，more than one time IVF after GnRH agonist treatment of severe month have better pregnancy rates than laparoscopy again. Treatment with a GnRH agonist for 3-6 months before IVF in women with endometriosis increases the rate of clinical pregnancy as negative effect of fertility in many mechanisms by endometriosis. There are some introduction in Endometriosis Fertility Index（EFI），some guideline and committee opinion from European Society of Human Reproductive and Embryology（ESHRE），American Society of Reproductive Medicine （ASRM） and Chinese Medicine Association. The treatment strategy in endometriosis and infertility of author′s ART center is introduction.

Key words: Endometriosis, Infertility, female, Therapy, Fertilization in vitro