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1 대한생식의학회지 : 제 37 권제 4 호 2010 관동대학교의과대학제일병원산부인과 1, 영상의학과 2 박찬우 1 차선화 1 양광문 1 한애라 1 유지희 1 송인옥 1 김혜옥 1 강인수 1 궁미경 1 이경상 2 * Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion Chan Woo Park 1, Sun Hwa Cha 1, Kwang Moon Yang 1, Ae Ra Han 1, Ji Hee Yoo 1, In Ok Song 1, Hye OK Kim 1, Inn Soo Kang 1, Mi Kyoung Koong 1, Kyung Sang Lee 2 * Departments of 1 Obstetrics & Gynecology, 2 Radiology, Cheil General Hospital and Women's Healthcare Center, Kwandong University School of Medicine, Seoul, Korea Objective: To evaluate the significance and efficacy of trans-cervical fallopian tube catheterization (TFTC) in diagnosis and optimal treatment modality for tubal blockage. Methods: The retrospective study was performed in those underwent TFTC from January 2005 to December A total of 342 fallopian tubes in 215 patients which showed tubal blockage in hysterosalpingography (HSG), were subjected to TFTC. Recanalization rate (RR) was compared according to portion of tubal blockage; proximal, isthmic and distal portion and blockage type; tapering, concave, and convex type. Results: In total, RR was 72.5% (248/342 tube). According to the portion of tubal blockage, RR was 83.8% in proximal, 45.6% in isthmic and 100% in distal portion. RR was 92.3% in tapering, 80.2% in concave and 25.5% in convex type, respectively. There were 98 pregnancies in 156 patients after successful recanalization, which shows 62.7% pregnancy rate. Conclusion: TFTC were capable of recanalizing tubal blockage in 248 of 342 tubes in 156 of 215 patients (72.5%). The RR was increased with proximal portion and tapering type tubal blockage. [Korean. J. Reprod. Med. 2010; 37(4): ] Key Words: Trans-cervical fallopian tube catheterization, Hysterosalpingography 난관원인에의한불임은여성불임의 20~30% 를차지하는것으로알려져있으며, 1,2 불임의원인진단을위한선별검사로서자궁난관조영술을많이시행하고있다. 자궁난관조영술의선별검사에서난관막힘 (tubal blockage) 의소견을보이는경우막힘부위에따라원인을달리한다. 난관원 접수일 : 2010 년 11 월 11 일, 수정일 : 2010 년 12 월 17 일게재확정일 : 2010 년 12 월 17 일주관책임자 : 이경상, 우 ) 서울특별시중구묵정동 1-19, 관동대학교의과대학제일병원영상의학과 Tel: (02) , Fax: (02) kyungsang.lee@cgh.co.kr 위부막힘 (distal tubal blockage) 은골반내유착에의한것으로추정되며, 근위부막힘 (proximal tubal blockage) 은약 10~25% 의빈도로진단되며 3,4 그원인에따라난관폐색 (obstruction) 와폐쇄 (occlusion) 등으로구분하고있지만자궁난관조영술검사상이를구분하는것은용이하지않은실정이다. Ruibn 5 은난관폐색은난관근육의경축 (spasm) 이나무정형물질에의한마개형성 (plugging by amorphous material) 으로가역적으로개통될수있는반면난관폐쇄는기질적인병변에의한막힘

2 대한생식의학회지 으로수술적교정이필요하다고하였다. 자궁난관조영술검사상막힘소견을보이는경우선택적난관조영술 (selective hysterosalpingogram, S-HSG) 을시행하여개통을시도할수있으며, 난관폐색은가역적인막힘으로선택적난관조영술을시행하여개통될수있다. 6 한편선택적난관조영술로개통에실패한경우기질적병변으로인한난관폐쇄로추정할수있으며수술적교정이필요하지만수술적교정대신방사선투시하에난관개통술 (transcervical fallopian tube catheterization, TFTC) 을시행해볼수있다. 난관개통술은난관폐쇄가의심되는경우혈관조영기법을응용한방법으로자궁경부를통해카테터와미세철선을삽입하여폐쇄부위를개통하는시술로특히난관의근위부폐쇄시높은성공률을보고하여효과적인치료방법으로제시되고있다. 7~10 이에저자들은불임을주소로내원한환자들을대상으로자궁난관조영술을이용한난관불임선별검사에서난관막힘의소견을보인경우선택적난관조영술을우선시행후난관개통의실패시난관개통술을시행하여난관불임치료에있어난관개통술의효용성을알아보고난관폐쇄부위및형태에따른개통률을비교하고자하였다. 연구대상및방법 1. 연구대상본연구는 2005년 1월부터 2009년 12월까지불임을주소로본원아이소망센타를내원한환자들가운데불임검사에서난관원인에의한불임으로추정되는환자들을대상으로하였다. 난관불임선별검사로서자궁난관조영술을시행하였으며자궁난관조영술상난관막힘 (tubal blockage) 소견을보인환자중선택적난관조영술에실패한 215명의 342개의난관을대상으로후향적연구를진행하였다. 자궁난관조영술상특징적인 stippled or honeycombed appearance 의방사선학적소견을보인경우 결절성난관협부난관염 (salpingitis isthmica nodosa, SIN) 으로간주하였고, 11 난관개통술시난관천공, 자궁외임신의합병증이높으며수술적치료가원칙이므로대상에서제외하였다. 2. 난관막힘의분류난관막힘은위치에따라근위부 (proximal), 협부 (isthmic), 원위부 (distal) 로분류하였고자궁난관접합부 (uterotubal junction) 를기준으로근위부는자궁난관접합부가막힌경우, 협부는자궁난관접합부에서 2~3 cm, 원위부는그이후에서난관이막힌경우로정의하였다. 난관막힘형태에따라점진형 (smooth tapering), 오목하게보이는오목형 (concave), 볼록하게보이는볼록형 (convex) 로구분하였다 (Figure 1). 3. 난관개통술선택적난관조영술을시행하여개통에성공한경우난관폐색으로진단하였으며, 개통에실패한경우에는난관폐쇄로진단하고난관개통술을시행하였다. 난관개통술은선택적난관조영술시개통에실패한경우 5.5-F 카테터끝을자궁협부 (cornus) 에위치시킨후 3-F 카테터와 inch Terumo wire를조심스럽게전, 후진시켜폐쇄된부위의재개통을시행하고 guide wire가충분히유도되면 3-F 카테터를난관내부로삽입하였다 3-F 카테터를난관내부로삽입시킨후조영제를투여하여개통된것을확인한후다시 5.5-F 카테터를통해선택적난관조영술을시행하여재확인한후모든카테터를제거하고자궁난관조영술을시행하여성공여부를최종평가하였다 (Figure 2). 시술은중기난포기에실시하였고시술 3일전부터 doxycycline 100 mg을 1일 2회예방적으로투약하였으며시술전처치로 atropin을근육주사하였다

제 37 권제 4 호, 2010 박찬우 차선화 양광문 한애라 유지희외 5 인 A B C Figure 1. Classification of tubal blockage by their blockage type. (A) Smooth type, Smooth tapered obstruction is seen on Rt. proximal tube (arrow).

Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion. Korean J Reprod Med 2010. Figure 2.

3 제 37 권제 4 호, 2010 박찬우 차선화 양광문 한애라 유지희외 5 인 A B C Figure 1. Classification of tubal blockage by their blockage type. (A) Smooth type, Smooth tapered obstruction is seen on Rt. proximal tube (arrow). (B) Convex type: Blunt obstruction is seen on mid portion of Rt. tube (arrow). (C) Concave type: Concave-appeared obstruction is seen on Rt. proximal tube (arrow). Chan Woo Park. Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion. Korean J Reprod Med Figure 2. Selective Hysterosalpingogram (S-HSG) and Transcervical Fallopian Tube Catheterization (TFTC). (A) On routine HSG, non-visualized both tubes suggest both tubal obstruction, proximal. (B & E) On selective HSG using 5F catheter, non-visualized Lt. (B), Rt. (E) tubes suggest true both tubal obstruction. (C, F) Catherization was done using 0.018F terumo guide-wire. (D, G) successfully recanalized Lt. (D), Rt. (G) tube with peritoneal spillages was demonstrated. (H) After catheterization, well visualized both tubes with peritoneal spillages showed. Chan Woo Park. Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion. Korean J Reprod Med 난관개통판정난관개통은시술시 3-F 카테터를통해난관의전체가확인되고복강내조영제유출을확인한후선택적난관조영술과자궁난관조영술을시행하여조영제가난관의내강을따라서원위부의팽대부 (ampulla) 를거쳐서복강내로유출된경우를개통된것으로판정하였다. 5. 통계분석통계적인분석은 SPSS ver (windows, Microsoft, WA, USA) 프로그램을이용하였으며, p<0.05인경우통계학적유의성이있는것으로간주하였다

4 대한생식의학회지 결 과 불임검사를위해시행한자궁난관조영술검사상난관막힘소견을보인환자가운데난관개통술을시행받은환자들의평균나이는 29세였다 (Table 1). 난관막힘의위치에따른분포는근위부 235예, 협부 103예, 원위부막힘이 4예로근위부막힘이 68.7% 로가장많았다. 막힘형태에따라분 Table 1. Clinical characteristics of study population No. of patients 215 Mean age (yr) 29 (23~47) Infertility duration (month) 27 (7~48) No. of tubal blockage 342 Portion of blockage Proximal portion 235 Isthmic portion 103 Distal portion 4 Type of blockage Blunt type 172 Concave 86 Convex 86 Tapering 170 Chan Woo Park. Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion. Korean J Reprod Med 류하면점진형은 170예, 오목형은 86예, 볼록형은 86예로점진형이 49.7% 를차지하였다 (Table 2). 난관개통술을시행하여 342개의난관가운데 248개의난관이개통되어 72.5% 의난관개통률을보였다. 막힘부위에따른난관개통률은근위부 83.8% (197/235예), 협부 45.6% (47/103예), 원위부 100% (4/4예) 를보여자궁-난관접합부에가까운막힘일수록높은개통률을보였다. 막힘형태에따른개통률은점진형은 92.3% (157/170예), 오목형은 80.2% (69/86예), 볼록형은 25.5% (22/86예) 의 난관개통률을보였다. 난관막힘부위와형태를 Table 2. Successful canalization rate according to occlusion portion and type Successful canalization Portion of blockage Proximal portion 197/235 (83.8) Isthmic portion 47/103 (45.6) Distal portion 4/4 (100) Type of blockage Blunt type Concave 69/86 (80.2) Convex 22/86 (25.5) Tapering 157/170 (92.3) Values are presented as number (%). Chan Woo Park. Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion. Korean J Reprod Med Table 3. Successful canalization rate according to combination of occlusion portion and type Tapering type Blunt type Concave Convex Total Proximal 91.6 (143/156) 82.6 (38/46) 48.5 (16/33) 83.8 (197/235) Isthmic 100 (10/10) 77.5 (31/40) 11.3 (6/53) 45.6 (47/103) Distal portion 100 (4/4) 0 (0/0) 0 (0/0) 100 (4/4) Total 92.3 (157/170) 80.2 (69/86) 25.5 (22/86) 72.5 (248/342) Values are presented as number (%). Chan Woo Park. Efficacy of Transcervical Fallopian Tube Catheterization in Infertility Patients with Fallopian Tube Occlusion. Korean J Reprod Med

5 제 37 권제 4 호, 2010 박찬우 차선화 양광문 한애라 유지희외 5 인 종합하여볼때난관근위부점진형막힘의경우 91.6% (143/156예) 의높은개통률을보인반면난관협부볼록형막힘의경우에는개통률이 11.3% (6/53예) 에불과하였다 (Table 3). 난관개통에성공한 156명가운데 98명에서임신에성공하여 62.7% 의임신율을보였다. 난관개통술을시행한가운데 13.2% (45/342예) 에서난관천공의합병증을동반하였으며, 6예에서난관이다시막혔고, 자궁외임신이 3명에서발생하였다. 고찰불임환자에있어난관원인에의한불임은 25~35% 를차지하는것으로알려져있으며, 불임의난관원인을알아보는검사로난관-초음파검사 (salpingo-sonography), 자궁난관조영술, 진단복강경등의방법이알려져있으나자궁난관조영술이자궁내막과난관질환유무를알아보는선별검사로널리사용되고있으며, 민감도와특이도가 58% 와 77% 이고높은 25% 의위양성률과 40% 의위음성률을보고하고있다. 12 자궁난관조영술을시행한후임신율이 13~ 55% 에이른다는보고들이있으며, 13 이는난관의점액괴 (mucus plug) 제거에의한것으로추정해볼때난관이기질화되지않거나병변을동반하지않은경우에는물리적방법에의해개통될수있다. 본원에서는자궁난관조영술검사상난관막힘의소견을보이는경우일차적으로선택적난관조영술을시행하여개통을시도한후개통에성공한경우에는난관폐색으로진단하고, 개통에실패한경우에는난관폐쇄로진단하여난관개통술을시행하고있다. 한편, 본원에서선택적난관조영술의효용성을알아보기위해조사해본결과 2010년한해동안전체의난관막힘환자 1,000명중 89명의환자에서성공적으로난관이개통되어선택적난관조영술에의한난관개통률은약 8.9% 를보였다 (not published). 난관폐쇄시난관개통술을비롯하여수술적개복에의한자궁난관문합술, 시험관아기시술에이르기까지다양한치료방법이제시되고있다. 수술적치료는 metrosalpingo-anastomosis의자궁난관이식술 (macrosurgical uterotubal implantation) 이 Watkins 에의해시술된이래여러저자들에의해시도되어 1970년대에는시술후 34% 의출생률을보고한바있으며, 이후미세자궁난관문합술 (microsurgical tubocornual anastomosis) 이도입되어시술후 37~ 56% 에이르는출생률을보고한바있다. 14 선택적난관조영술의방사선적시도는 1977년부터있었으며, 이후자궁경부를통한카테터시술이나풍선난관성형술 (transcervical ballon tuboplassty) 등이 fluoroscopy, hysteroscopy, falloscopy 및 sonography 하에시도되었다. 난관의폐쇄를병리학적인면에서살펴보면재개통이가능한경우는 Sulak 등 4 이언급했었던 cast 를형성할수있는 'amorphous material' 등이난관을일시적으로폐쇄시키는경우라고할수있고, Rubin 5 이나 DeCherney 6 이지칭한폐색 (obstruction) 에해당한다고볼수있다. Rubin과 DeCherney는협부폐색과폐쇄의차이점에대해언급하여폐쇄 (occlusion) 는결절성협부난관염 (salpingitis isthmica nodosa) 이나난관내의섬유증 (intraluminal fibrosis) 의경우와같이진성으로해부학적막힘 (blockage) 이있음을일컫는것이고, 반면폐색은기능적막힘으로 Sulak 등 4 은 ' 무정형물질 (amorphous material)' 등이난관을일시적으로차단한상태를나타낸다고하였다. Roh 등 15 은난관폐쇄부위에따른개통률을보고하여근위부폐쇄의경우 71.2%, 원위부의경우 42.5% 의난관개통률을보여자궁근위부일수록개통률이증가함을보고하였다. 본연구에서는적은수의원위부막힘을제외하고근위부막힘시 83.8% 의개통률을보여협부막힘 45.6% 의개통률보다높은개통률을보였다. 난관막힘의형태에따른개통률은점진형막힘에서오목형이나볼록형막힘보다높은개통률을

6 대한생식의학회지 보였다. 난관막힘부위와형태를종합하여볼때난관근위부점진형막힘시가장높은개통률을보고한반면난관협부볼록형막힘시낮은개통률을보여근위부점진형난관막힘시우선적으로난관개통술을시행해볼수있다하겠다. 본연구에서는난관막힘형태를병리학적소견과연관지어고찰하지못하였지만점진형과오목형은 DeCherney 6 이기술했던폐색에해당하는예가많을것이라추정되며선택적난관조영술을우선적으로시도해볼수있고, 볼록형은기질적인병변을동반하는폐쇄의경우가많을것으로추정되며선택적난관조영술및난관개통술을시행해볼수있다. 난관개통술시개통이안된경우에는수술적치료나체외수정시술이치료법이될수있으리라생각된다. 앞으로병리학적고찰과연관된연구를통하여이러한내용을확인해나가는것이필요하겠다. 선택적난관조영술및난관개통술시난관천공의합병증은 3~11% 에이르는것으로알려져있으며 16,17 저자들도본연구에서도난관개통술시 13.2% 에서난관천공을동반하여유사한결과를보였으며별다른합병증없이치유되었다. 난관개통술이성공한 156명의환자가운데평균 2.5년의추적관찰을통하여 98명에서임신에성공하여 62.7% 의임신율을보고하여난관막힘에의한불임환자에서효과적인치료법이라하겠다. 아울러자궁경부를통한시술로수술적방법이나체외수정시술의난자채취에비해덜침습적인방법으로입원치료가필요없이시행할수있는시술로비교적적은비용으로불임의원인을극복할수있는장점이있어난관원인에의한불임환자에서우선적으로시행해볼수있는효과적인치료방법이라할수있다. 또한난관막힘부위가근위부이며막힘형태가점진형이거나오목형인경우에는선태적난관조영술및난관재개통술을일차적으로시행하여보는것이바람직할것으로생각된다. 참고문헌 1. Musich JR, Behrman SJ. Surgical management of tubal obstruction at the uterotubal junction. Fertil Steril 1983; 40: Serafini P, Batzofin J. Diagnosis of female infertility. A comprehensive approach. J Reprod Med 1989; 34: Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J. Diagnosis of cornual obstruction by transcervical fallopian tube cannulation. Fertil Steril 1988; 50: Sulak PJ, Letterie GS, Coddington CC, Hayslip CC, Woodward JE, Klein TA. Histology of proximal tubal occlusion. Fertil Steril 1987; 48: Rubin IC. Uterotubal insufflation; value in the treatment of tubal obstruction to ovular migration. Fertil Steril 1954; 5: DeCherney AH. Anything you can do I can do better... or differently! Fertil Steril 1987; 48: Confino E, Friberg J, Gleicher N. Transcervical balloon tuboplasty. Fertil Steril 1986; 46: Confino E, Friberg J, Gleicher N. Preliminary experience with transcervical balloon tuboplasty. Am J Obstet Gynecol 1988; 159: Jansen RP, Anderson JC. Catheterisation of the fallopian tubes from the vagina. Lancet 1987; 2: Platia MP, Krudy AG. Transvaginal fluoroscopic recanalization of a proximally occluded oviduct. Fertil Steril 1985; 44: Creasy JL, Clark RL, Cuttino JT, Groff TR. Salpingitis isthmica nodosa: radiologic and clinical correlates. Radiology 1985; 154: Johannes LH, Jolande A. Diagnosing the tubal factorslaparoscopy vs. traditional techniques. In: Filicori M, Falmigni C, editors. Treatment of infrtility: the new frontiers. New Jersey: Communications Media for Education; p DeCherney AH, Kort H, Barney JB, DeVore GR. Increased pregnancy rate with oil-soluble hysterosalpingography dye. Fertil Steril 1980; 33: Gomel V. Tubal reanastomosis by microsurgery. Fertil Steril 1977; 28: Roh SI, Kang SO, Kwon HC, Cho JH, Lee SJ, Park JM, et al. Transcervical fallopian tube catheterization for proximal tubal

7 제 37 권제 4 호, 2010 박찬우 차선화 양광문 한애라 유지희외 5 인 obstruction. Korean J Obstet Gynecol 1992; 35: Kumpe DA, Zwerdlinger SC, Rothbarth LJ, Durham JD, Albrecht BH. Proximal fallopian tube occlusion: diagnosis and treatment with transcervical fallopian tube catheterization. Radiology 1990; 177: LaBerge JM, Ponec DJ, Gordon RL. Fallopian tube catheterization: modified fluoroscopic technique. Radiology 1990; 176: = 국문초록 = 목적 : 불임을주소로내원한환자들을대상으로자궁난관조영술을이용한난관불임선별검사에서난관막힘의소견을보인경우선택적난관조영술을시행후실패시난관개통술을시행하여난관불임치료에있어난관개통술의효용성을알아보고난관막힘부위및형태에따른난관개통률을비교하고자하였다. 연구방법 : 난관불임선별검사로서자궁난관조영술을시행하였으며자궁난관조영술상난관막힘소견을보인 215명의 342개의난관을대상으로후향적연구를진행하였다. 결과 : 난관개통술을시행하여 342개의난관가운데 248개의난관이개통되어 72.5% 의난관개통률을보였다. 막힘부위에따른난관개통률은근위부 83.8% (197/235예), 협부 45.6% (47/103예), 원위부 100% (4/4예) 를보여자궁- 난관접합부에가까운막힘일수록높은개통률을보였다. 막힘형태에따른개통률은점진형은 92.3% (157/170예), 오목형은 80.2% (69/86예), 볼록형은 25.5% (22/86예) 의난관개통률을보였다. 난관막힘부위와형태를종합하여볼때난관근위부점진형막힘의경우 91.6% (143/156예) 의높은개통률을보인반면난관협부볼록형막힘의경우에는개통률이 11.3% (6/53예 ) 에불과하였다. 난관개통에성공한 156명가운데 98명에서임신에성공하여 62.7% 의임신율을보였다. 결론 : 난관개통술은자궁경부를통한시술로수술적방법이나체외수정시술의난자채취에비해덜침습적인방법으로입원치료가필요하지않으며비교적적은비용으로불임의원인을극복할수있는장점이있어난관원인에의한불임환자에서우선적으로시행해볼수있는효과적인치료방법이라할수있다. 중심단어 : 난관개통술, 자궁난관조영술

대한방사선의학회지 1993 ; 29 (3) : 492"-'496 Journal of Korean Radiological Society. May 선택적난관조영술을이용한자궁외임신의치료 -Abstract - 고려대학교의과대학방사선과학교실 조성범 김철중 김명규 이영

대한방사선의학회지 1993 ; 29 (3) : 492-'496 Journal of Korean Radiological Society. May 선택적난관조영술을이용한자궁외임신의치료 -Abstract - 고려대학교의과대학방사선과학교실 조성범 김철중 김명규 이영 대한방사선의학회지 13 ; 2 (3) : 42"-'46 Journal of Korean Radiological Society. May. 13 선택적난관조영술을이용한자궁외임신의치료 -Abstract - 고려대학교의과대학방사선과학교실 조성범 김철중 김명규 이영란 차인호 이남준 정규병 Transcervical Interruption of Ectopic Pregnancy