臨床婦人科産科60巻2号

2006年02月発行

今月の臨床 子宮内膜症の新しい治療戦略

不妊症の治療

内膜症のART

著者： 藤井俊策¹ 木村秀崇¹

所属機関： ¹弘前大学医学部産科婦人科学教室

ページ範囲：P.195 - P.199

文献概要

内膜症はARTの治療成績を低下させるか？

　内膜症で起り得る骨盤内の器質的異常，すなわち卵のpick upや胚・配偶子の輸送を妨げる癒着などはARTで克服できる．現に多くの内膜症性不妊女性がARTにより児を得ている．しかし，ARTを繰り返し行っても妊娠が成立しない内膜症性不妊もしばしば経験する．その多くが重症例で，卵巣刺激を行っても採卵数が少なく，不良胚しか得られない．

　Barnhartら_1）は，内膜症性不妊と卵管性不妊とでARTの転帰を比較した報告のうち，妊娠率が記載された22文献についてmeta─analysisを行い，内膜症性不妊では妊娠率のみならず採卵数，受精率，着床率のすべてが低下すると結論した．また，重症例では軽症例と比較してこれら評価項目すべてが低かった．重症男性不妊のためICSIを施行した症例を対象とした検討_2）でも，内膜症では採卵数が少なかったと報告されている．海外におけるdonor卵を用いたARTの成績は，内膜症性不妊の問題点を明瞭にする．Recipientの内膜症は妊娠率に影響しない_3～5）が，卵のdonorに内膜症があるとrecipientの妊娠率と着床率が低下する_6）．さらに，内膜症女性の卵を用いたARTでは，donorとrecipientのいずれにおいても妊娠率が低下する_7）．さらに，先のメタ分析には含まれなかった報告でも，内膜症性不妊での治療成績の低下が示されている_{8, 9）}．したがって，内膜症性不妊では卵の質・量とも低下し，ARTでも克服できない不利な問題を抱えていると考えざるを得ない．

参考文献

1）Barnhart K, Dunsmoor─Su R, Coutifaris C : Effect of endometriosis on in vitro fertilization. Fertil Steril 77 : 1148─1155, 2002

2）Minguez Y, Rubio C, Bernal A, et al : The impact of endometriosis in couples undergoing intracytoplasmic sperm injection because of male infertility. Hum Reprod 12 : 2282─2285, 1997

3）D?az I, Navarro J, Blasco L, et al : Impact of stage III─IV endometriosis on recipients of sibling oocytes : matched case─control study. Fertil Steril 74 : 31─34, 2000

4）Zenke U, Chetkowski RJ : Transfer and uterine factors are the major recipient─related determinants of success with donor eggs. Fertil Steril 82 : 850─856, 2004

5）Sung L, Mukherjee T, Takeshige T, et al : Endometriosis is not detrimental to embryo implantation in oocyte recipients. J Assist Reprod Genet 14 : 152─156, 1997

6）Simon C, Gutierrez A, Vidal A, et al : Outcome of patients with endometriosis in assisted reproduction : results from in─vitro fertilization and oocyte donation. Hum Reprod 9 : 725─729, 1994

7）Shulman A, Frenkel Y, Dor J, et al : The best donor. Hum Reprod 14 : 2493─2496, 1999

8）Al─Azemi M, Bernal AL, Steele J, et al : Ovarian response to repeated controlled stimulation in in─vitro fertilization cycles in patients with ovarian endometriosis. Hum Reprod 15 : 72─75, 2000

9）Azem F, Lessing JB, Geva E, et al : Patients with stages III and IV endometriosis have a poorer outcome of in vitro fertilization─embryo transfer than patients with tubal infertility. Fertil Steril 72 : 1107─1109, 1999

10）Wunder DM, Mueller MD, Birkhauser MH, et al : Steroids and protein markers in the follicular fluid as indicators of oocyte quality in patients with and without endometriosis. J Assist Reprod Genet 22 : 257─264, 2005

11）Nakahara K, Saito H, Saito T, et al : Ovarian fecundity in patients with endometriosis can be estimated by the incidence of apoptotic bodies. Fertil Steril 69 : 931─935, 1998

12）Seino T, Saito H, Kaneko T, et al : Eight─hydroxy─2’─deoxyguanosine in granulosa cells is correlated with the quality of oocytes and embryos in an in vitro fertilization─embryo transfer program. Fertil Steril 77 : 1184─90, 2002

13）Kennedy S, Bergqvist A, Chapron C, et al : ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 20 : 2698─2704, 2005

14）Kissler S, Hamscho N, Zangos S, et al : Diminished pregnancy rates in endometriosis due to impaired uterotubal transport assessed by hysterosalpingoscintigraphy. BJOG 112 : 1391─1396, 2005

15）Suzuki T, Izumi S, Matsubayashi H, et al : Impact of ovarian endometrioma on oocytes and pregnancy outcome in in vitro fertilization. Fertil Steril 83 : 908─913, 2005

16）Younis JS, Ezra Y, Laufer N, et al : Late manifestation of pelvic abscess following oocyte retrieval, for in vitro fertilization, in patients with severe endometriosis and ovarian endometriomata. J Assist Reprod Genet 14 : 343─346, 1997

17）Pabuccu R, Onalan G, Goktolga U, et al : Aspiration of ovarian endometriomas before intracytoplasmic sperm injection. Fertil Steril 82 : 705─711, 2004

18）Fisch JD, Sher G : Sclerotherapy with 5％tetracycline is a simple alternative to potentially complex surgical treatment of ovarian endometriomas before in vitro fertilization. Fertil Steril 82 : 437─441, 2004

19）Okagaki R, Osuga Y, Momoeda M, et al : Laparoscopic findings after ultrasound─guided transvaginal ethanol sclerotherapy for ovarian endometrial cyst. 1999 Hum Reprod（letter）

20）Noma J, Yoshida N : Efficacy of ethanol sclerotherapy for ovarian endometriomas. Int J Gynaecol Obstet 72 : 35─39, 2001

21）Jones KD, Sutton CJ : Pregnancy rates following ablative laparoscopic surgery for endometriomas. Hum Reprod 17 : 782─785, 2002

22）Muzii L, Bianchi A, Croce C, et al : Laparoscopic excision of ovarian cysts : is the stripping technique a tissue─sparing procedure？Fertil Steril 77 : 609─614, 2002

23）Hachisuga T, Kawarabayashi T : Histopathological analysis of laparoscopically treated ovarian endometriotic cysts with special reference to loss of follicles. Hum Reprod 17 : 432─435, 2002

24）Canis M, Pouly JL, Tamburro S, et al : Ovarian response during IVF─embryo transfer cycles after laparoscopic ovarian cystectomy for endometriotic cysts of＞3 cm in diameter. Hum Reprod 16 : 2583─2586, 2001

25）Loh FH, Tan AT, Kumar J, et al : Ovarian response after laparoscopic ovarian cystectomy for endometriotic cysts in 132 monitored cycles. Fertil Steril 72 : 316─321, 1999

26）Rickes D, Nickel I, Kropf S, et al : Increased pregnancy rates after ultralong postoperative therapy with gonadotropin─releasing hormone analogs in patients with endometriosis. Fertil Steril 78 : 757─762, 2002

27）Surrey ES, Silverberg KM, Surrey MW, et al : Effect of prolonged gonadotropin─releasing hormone agonist therapy on the outcome of in vitro fertilization─embryo transfer in patients with endometriosis. Fertil Steril 78 : 699─704, 2002

28）Garrido N, Navarro J, Garcia─Velasco J, et al : The endometrium versus embryonic quality in endometriosis─related infertility. Hum Reprod Update 8 : 95─103, 2002