子宫内膜异位症不育患者的助孕治疗

子宫内膜异位症 (内异症 )发生在 10 %～ 15 %的育龄妇女 ,是妇科常见病。其发病机理尚不明确 ,很多学者从免疫角度进行研究 ,发现内异症局部变化的特点与不育的原因有关。内膜异位局部ＣＤ+3Ｔ淋巴细胞、ＣＤ+8杀伤 /抑制Ｔ细胞及ＣＤ+8/ＣＤ+4 辅助Ｔ细胞比值 ,以及ＣＤ+6 8巨噬细胞 ,均较在位内膜及正常子宫内膜为高[1] ;趋化因子ＲＡＮＴＥＳ (ｒｅｇｕｌａｔｅｄｕｐｏｎａｃｔｉｖａｔｉｏｎ ,ｎｏｒｍａｌＴｃｅｌｌｅｘｐｒｅｓｓｅｄａｎｄｓｅｃｒｅｔｅｄ)在内异症患者腹水中增多 ,可招募大量巨噬细胞和Ｔ淋巴细胞至腹腔中 ,与肿…     

Autoimmune phenomena in infertile patients with endometriosis

To assess the presence of autoimmune factors in patients with endometriosis, endometrial homogenates, peritoneal fluid, and serum were evaluated in 23 patients with endometriosis and 22 control subjects. The methods used were Ouchterlony immunodiffusion, immunoelectrophoresis, polyacrylamide gel electrophoresis, and radial immunodiffusion. The study demonstrated precipitation lines between endometrial homogenates and serum from some endometriosis patients but not from the control subjects. Immunoelectrophoresis demonstrated precipitation lines at beta-globulin position when endometrial homogenates were used against serum of patients with endometriosis and with goat antihuman serum. It is suggested that an antigen, possibly a glycoprotein, is present in the endometrial homogenates. Radial immunodiffusion studies for immunoglobulins (Ig) G, A, and M and complement components C3c and C4 showed significantly higher concentrations of C3c and C4 in serum and peritoneal fluid of patients with endometriosis than the control subjects (P less than .05). There was no significant difference in concentration of IgG, A, M, factor B, and properdin.     

Results of treating endometriosis with infertility using operative laparoscopy]

In the work, the efficiency of treating endometriosis by hormonal as well as combined methods, and employing the operative laparoscopy was evaluated. The study involved 89 infertile women with endometriosis being of various grade of advancement. Sixty women underwent combined treatment according to Samm, the remaining 29 were given hormonal therapy with Danazol and Orgametril preparations. After combined treatment full recovery was obtained in 26.7% of cases, improvement in 40%, but after the use of preparations Orgametril, Organon or Danazol, Winthrop, complete cure was reached in 12.8% of cases, improvement in 31%. Only 8 women became pregnant after combined therapy. Complete recovery concerned mainly less advanced endometriosis, particularly following the combined treatment according to Semm. Early laparoscopic diagnosis increases the chance of curing endometriosis and fertility associated with it.     

Local peritoneal factors: their role in infertility associated with endometriosis

In order to detect peritoneal abnormalities that could account for infertility associated with endometriosis, 122 infertile individuals were studied at the time of laparoscopy for diagnostic purposes or for in vitro fertilization. Four groups were defined: group 1, laparoscopy without endometriosis; group 2, laparoscopy with endometriosis; group 3, in vitro fertilization without endometriosis; and group 4, in vitro fertilization with endometriosis. Mean peritoneal fluid volume was greater, although not significantly so, in group 4 (29.0 +/- 6.6 ml, mean +/- SEM) than in group 3 (18.2 +/- 2 ml). The concentration and total number of pelvic macrophages were similar for groups 1 and 2. The total number of pelvic macrophages was increased in group 4 (16.9 +/- 4.2 x 10(6)) versus group 3 (10.0 +/- 1.8 x 10(6)) (p = 0.08). The mean sperm phagocytosis in vitro did not differ among the four groups studied. Interleukin 1 activity within the peritoneal fluid and the in vitro interleukin 1 production rate did not differ between individuals with and without endometriosis. Peritoneal fluid and macrophage supernatants from individuals with endometriosis were not embryotoxic when studied in an in vitro mouse embryo system.     

Evaluation of serum prolactin levels in patients with endometriosis and infertility.

The aim of this study was to clarify the significance of serum prolactin concentrations in patients with infertility and endometriosis. Forty patients with infertility and laparoscopically proven endometriosis were recruited into the study. Basal serum prolactin levels and prolactin levels after TRH administration were measured. The mean basal serum prolactin concentrations were 12.5, 16.5, 19.5, and 26.5 ng/ml and those after thyrotropin-releasing hormone (TRH) administration were 88.3, 114.2, 125.3 and 138.8 ng/ml in patients with stages I, II, III and IV endometriosis, respectively. A statistically significant relationship was found between the basal serum prolactin levels as well as those after TRH injection and the stage of the endometriosis. The patients were divided in two groups. Group I consisted of 20 patients who did not receive any treatment, while group II consisted of 20 patients who were initially treated with GnRH analogues for 24 week and subsequently with several therapeutic schemes in order to improve their fecundity. The pregnancy rate was not different between the two groups. The patients, however, who did not become pregnant had higher serum prolactin concentrations after TRH administration as compared to those who conceived. We conclude that occult hyperprolactinemia may be a cause of infertility in patients with endometriosis.     

Relation between macrophages in peritoneal fluid of endometriosis and infertility]

Peritoneal fluid was collected from 18 endometriosis-associated infertile patients and 14 unexplained infertile women. The cells were counted in a hemacytometer and subjected to morphologic analysis. The phagocytic activity on Candida Albicans and on Sperms was evaluated and the activity of acid phosphatase in the pelvic fluid and within the macrophages were measured. The results showed that the endometriosis samples have macrophages of large size as compared with the macrophages found in unexplained infertile or fertile women, the concentration of pelvic macrophages in endometriosis is higher, the phagocytic and bactericidal activity is also higher and the macrophages in endometriosis engulf sperms as well. The accentuated activity of pelvic macrophages may be associated with the infertility in patients with endometriosis.     

Laparotomy in infertility patients with endometriosis. Use of the CO2 laser

Sixty-eight women underwent laparotomy for endometriosis associated with infertility. They were not candidates for laser laparoscopy by our criteria, or they had failed to conceive after previous therapy. The cumulative pregnancy rate was 70% at 48 months. Patients who failed to conceive after previous laparotomy and those who failed to conceive after previous medical therapy experienced 44% and 28% term pregnancy rates, respectively, after laparotomy using the CO2 laser. Thus, for women who have failed to conceive after major surgical procedures, repeat surgery may offer a greater chance of conception than do multiple cycles of in vitro fertilization/embryo transfer.     

Laser laparoscopy versus laparotomy in the treatment of infertility patients with severe endometriosis

The best pregnancy rates reported in the literature for infertility patients with severe pelvic endometriosis (stage IV) have been attributed to surgical management. In the last few years, improved endoscopic instruments have allowed gynecologists to treat difficult conditions with the CO 2 laser via laparoscopy, with good results. To assess the usefulness of the CO 2 laser via laparoscopy in treating severe pelvic endometriosis, two groups of patients were studied. Thirteen patients were treated by laparotomy (group I) and 11 patients by laparoscopy (group II). Seven achieved pregnancy in group I (53.8%), and pregnancy occurred in 6 patients in group II (54.5%). This study suggests that the management of severe pelvic endometriosis in infertility patients via laparoscopy seems to yield similar pregnancy rates to those treated with laparotomy, with the advantages of faster recovery and fewer hospitalization days for those undergoing laparoscopic surgery.     

Implantation failures in women with infertility associated endometriosis

Abstract

Endometriosis is currently considered as one of the most common diseases associated with infertility. A controversial issue is whether endometriosis per se exerts a detrimental effect on IVF outcomes. Failure of implantation due to endometriosis-associated infertility is a contradictory and widely discussed burden nowadays. The purpose of the study is to assess the quality of embryos and implantation rate in women with infertility associated with endometriosis. The study included infertile reproductive aged women, between 26 and 40 years who underwent IVF and ICSI procedures. The patients were divided into two groups: group I (n?=?70) involved 70 patients with recurrent unilateral endometriomas, II control group (n?=?50) with tubal factor infertility. The quality of the retrieved embryos was assessed according to the generally accepted classification of Gardner, indicating the rate of implantation in each group. Embryo transfer was performed in case of high quality embryos. Assessing the ovarian reserve indicators, in the group I patients with recurrent unilateral endometriomas the serum level of AMH was significantly lower (2.1?±?1.75 vs. 3.2?±?1.4, p?<?.005), as well as the number of retrieved oocytes (8.1?±?3.9 and 10.1?±?6.8, p?<?.005). The analysis of the results demonstrated that the duration of stimulation in the group patients with recurrent unilateral endometriomas was significantly higher in comparison with the group II (12.2?±?1.8 and 10.2?±?1.6 days, p?<?.001). Nevertheless, the number of good quality embryos retrieved was comparable in both groups (2.2?±?1.5 and 2.8?±?1.8). In the group I patients with recurrent unilateral endometriomas, there was a statistically significant decrease of implantation rate (17.1% vs. 24% p?<?.005). The results of the study revealed no statistical difference in embryo quality in the study cohort. However, it is important to note that a statistically significant difference in implantation rate in the group of endometriosis-associated infertility compared was obtained 1.5 times lower than in the control group (15.8% vs. 24.0% p?<?.005). The achieved results demonstrated an adverse IVF outcome in infertile women with recurrent endometrioma compared to the control group.     

Oocyte quality in women with infertility associated endometriosis

Abstract

The mechanisms of endometriosis-related infertility remain still unknown. Endometriosis and clinical markers of oocyte quality are a very important problem of reproduction. The purpose of the study is to assess the quality of oocytes in women with infertility associated with endometriosis. The study included infertile reproductive aged women, between 29 and 40 years who underwent IVF and ICSI procedures. The patients were divided into three groups: group I involved 50 (n?=?50) patients with recurrent unilateral endometriomas, group II included 50 patients (n?=?50) unilateral endometriomas after surgical treatment and control group with 30 (n?=?30) patients with tubal factor infertility. Clinical and morphological assessment of oocyte quality was performed in all IVF/ICSI cycles. The results of the study demonstrate a statistically significant increase in the number of immature oocytes of metaphase MI and immature oocytes at the GV germinal vesicle stage in patients with infertility associated with endometriosis, compared with the control group (p<.005). There is deterioration in the quality of the obtained oocytes in patients with the presence of endometrioma more than 3?cm in diameter. The results of this study allow to conclude that endometriomas negatively affect quality of oocyte and ovarian reserve, whereas endometriomas after cystectomy, have a deleterious and sustained effect on ovarian reserve.     

子宫内膜异位症不孕患者腹腔镜术后提高妊娠率方法及助孕时机选择

目的探讨子宫内膜异位症不孕患者腹腔镜术后提高妊娠率的有效方法及助孕时机的选择。方法选择浙江大学附属妇产科医院2006年1月至2008年1月331例子宫内膜异位症不孕患者为研究对象,根据其腹腔镜术后不同治疗方案分组:A组(82例)腹腔镜术后未用药物直接试孕者;B组(81例)腹腔镜术后试孕1年及以上未孕接受辅助生育技术(ART)者;C组(90例)腹腔镜术后应用促性腺激素释放激素激动剂(GnRH-a)辅助治疗3个月后直接试孕者;D组(78例)腹腔镜术后应用GnRH-a辅助治疗3个月后接受ART者。分析患者的临床病理资料,并追踪随访24个月。结果Ⅲ、Ⅳ期子宫内膜异位症不孕患者在术后2年内,妊娠率A组32.7%(17/52),B组58.0%(29/50),C组45.2%(28/62),D组59.6%(31/52),A组显著低于B和D组(P<0.01);A组与C组妊娠率比较,C组与B、D组的妊娠率比较,B组与D组的妊娠率比较,差异均无统计学意义(P>0.05)。结论Ⅲ、Ⅳ期子宫内膜异位症不孕患者腹腔镜术后采用ART治疗可以有效提高妊娠率;术后是否需要药物预治疗以及ART选择时机应根据患者年龄、不孕年限、病情程度等差异而制...     

Etiopathogenesis of endometriosis related infertility

In the last years the entire scientific community has devoted remarkable resources to the understanding of endometriosis. In spite of this, endometriosis remains one of the most complex gynecological diseases, in nearly all of its physiopathological aspects and implications. In particular, the association between endometriosis and infertility has proven to be complex and it has been widely discussed. It is generally accepted that moderate/severe endometriosis related sterility is due to mechanical factors, namely to the distortion/subversion of the regular pelvic anatomy. On the contrary, the factors behind infertility/subfertility related to minimal/mild endometriosis are less clear. None of the hypothesized mechanisms exhaustively explained the infertility related to endometriosis, while it is possible that such disease is caused by multiple factors altogether. The aim of this thorough review of the international literature is to analyze the main etiological factors (i.e. alterations in oocyte maturation and/or growth, defects of fertilization, impairments of implantation or aberrant immunological mechanisms) that are potentially involved, as well as the role that each of the above mentioned factors has in determining the endometriosis related infertility/subinfertility.     

Treatment of endometriosis associated infertility

During the last 13 years, 2,080 infertile patients were subjected to diagnostic laparoscopy. The mean age was 32.3 and their mean infertility period was 6.0 years. Of these, 1,263(60.7%) patients were diagnosed to have endometriosis: 587(46.5%) were stage I (R-AFS), 348(27.6%) were stage II, 184(14.6%) were stage III and 144(11.4%) were stage IV. The age and the infertility period were almost the same among the stage of the disease. The overall pregnancy rate was 34.6%, after minimum 2 month follow up. The presence of endometriosis did not affect the prognosis of infertility: 34.2% pregnancy rate for patients with endometriosis, and 35.3% for those without endometriosis. There was an inverse relationship between the stage of the disease and the subsequent pregnancy rate: 37.8% for stage I, 34.8% for stage II, 32.1% for stage III and 20.8% for stage IV. But statistical significant difference was observed only between stage I and II, and stage IV. To elucidate the mechanism of endometriosis associated infertility, peritoneal fluid volume, intratubal sperm transport (peritoneal sperm recovery test), and phagocytosis of sperm in the tube and in the peritoneal fluid were examined in more than 1,000 cases. However, no positive relationship was found between the disease and these parameters. Fimbrial microbiopsy also revealed that endometriosis did not affect the ciliation index of the fimbria, nor changed the fine surface structure. Patients with minimal-mild disease were first managed expectantly for one year after laparoscopy: The pregnancy rate was 36.1% for stage I, and 29.7% for stage II. Ninety-eight patients who failed to conceive by expectant management were put on danazol therapy (600 mg/day, for 6 months). However, the results were very disappointing. Of 44 patients with stage I disease, only 3(6.8%) achieved a pregnancy, and none of 54 stage II patients conceived so far. Moreover, second-look laparoscopy revealed that danazol had no effect on the eradication of minimal-mild endometriosis. The patients with stage I-II disease were then treated exclusively by electrocautery at the time of initial laparoscopy: The pregnancy rate was 30.8% (57/185) for stage I, and 23.8% (25/105) for stage II. At second-look laparoscopy, 45.5% (10/22) of stage I and 73.7% (14/19) of stage II were disease free or improved, although the pregnancy rate was not so good as expected.(ABSTRACT TRUNCATED AT 400 WORDS)     

Conservative surgery of ovarian endometriosis in infertility

53 patients attending the infertility clinic were operated for ovarian endometriosis. The overall pregnancy rate was 53%. The major benefit of the surgery was that 79% of the pregnancies occurred within the year following the operation.     

Methyltestosterone treatment of infertility associated with pelvic endometriosis.

Sixty-four patients who had infertility associated only with endometriosis were treated with methyltestosterone, 5 mg/day, continuously for a period of 6 months. The patients continued to ovulate while receiving medication and 12 patients became pregnant, on an average, 6 months after the initiation of therapy. A computer analysis indicated that approximately 30% of the patients could expect pregnancy within 2 years after the testosterone treatment was begun. The side effects of the low-dose methyltestosterone therapy were acne in 6% of the patients, mild hirsutism in 3%, and an occasional delay in ovulation.     

Videolaseroscopy for the treatment of endometriosis associated with infertility

Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results of 243 patients with infertility associated with endometriosis ranging in severity from mild to extensive who were treated by the same surgeon using CO2 laser laparoscopically with videocamera augmentation and control. Of the 243 infertility patients, 168 (69.1%) achieved pregnancy. The pregnancy rates were 71.8% in 39 patients with stage I disease, 69.8% in 86 patients with stage II disease, 67.2% of 67 patients with stage III disease, and 68.6% in 51 patients with stage IV disease. The life table and two-parameter exponential model were used to calculate monthly fecundity, "cure," and "probability of pregnancy" rates. The results indicate that videolaseroscopic treatment of endometriosis associated with infertility, in surgically experienced hands, is at least as efficacious as other forms of therapy for mild and moderate cases of disease, but appears to be more successful than laparotomy for the more severe and extensive stages of disease.     

Medical management of endometriosis and infertility

Objective: To review the literature on the use of medical management of endometriosis and infertility.

Design: Literature review.

Result(s): Endometriosis is a common finding in women with infertility, but the mechanism by which it renders a woman infertile remains unclear. Despite many years of controversy and debate, there remains a strong bias against medical treatment for endometriosis-associated infertility. A review of the current literature suggests that medical management of endometriosis may be effective in selected patients and in certain settings, including patients undergoing IVF.

Conclusion(s): A closer look at the question of medical management of endometriosis reveals that much remains to be learned before a final decision can be made about the use of medical therapies, such as GnRH agonists, for endometriosis and associated infertility.     

子宫内膜异位症合并不孕患者经体外受精/卵胞质内单精子注射-胚胎移植治疗后妊娠结局及相关因素的分析

目的探讨子宫内膜异位症(EMS)对不孕患者经体外受精/卵胞质内单精子注射-胚胎移植(IVF/ICSI-ET)治疗后妊娠结局的影响及其与妊娠结局相关的因素。方法选择行IVF/ICSI-ET治疗的46例EMS合并不孕患者的55个取卵周期作为EMS组;选择同期行IVF/ICSI-ET治疗的126例非EMS患者的156个周期作为对照组。回顾性分析患者的临床资料,并进一步分析与妊娠结局相关的因素。结果 EMS组CA-125水平、周期取消率显著高于对照组(P0.05);基础窦卵泡数(AFC)、hCG注射日成熟卵泡数、获卵数、MII卵数、双原核(2PN)数、卵裂数、优质胚胎数、优质胚胎率显著低于对照组(P0.05);hCG注射日成熟卵泡数与EMS患者未妊娠的相关回归系数0。结论 EMS合并不孕患者卵巢储备功能下降,卵子和胚胎质量下降,更易取消周期。但其卵子成熟率、正常受精率及临床结局与非EMS对照组不孕患者相比无统计学差异;hCG注射日成熟卵泡数是EMS患者妊娠的保护因素。