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ORIGINAL ARTICLE Korean J Obstet Gynecol 2011;54(9):517-522 http://dx.doi.org/10.5468/kjog.2011.54.9.517 pissn 2233-5188 eissn 2233-5196 IN VITRO FERTILIZATION OUTCOMES IN PATIENTS WITH ADVANCED ENDOMETRIOSIS AFTER SURGICAL TREATMENT Seung Heon Yang, MD, Hye Ok Kim, MD, Na Young Sung, MD, Hyun Suk Ahn, MD, Youn Sil Choo, MD, Kwang Moon Yang, MD, In Ok Song, MD, Mi Kyoung Koong, MD, Inn Soo Kang, MD Department of Obstetrics and Gynecology, Cheil General Hospital, Kwandong University College of Medicine, Seoul, Korea Objective The aim of this study is to evaluate in vitro fertilization (IVF) outcomes in advanced endometriosis with/without surgical treatment and to compare between cyst enucleation and surgically treated peritoneal lesions without endometrioma. Methods We performed a retrospective analysis of 506 IVF cycles (345 patients) with stage III-IV endometriosis (170 cycles without surgical treatment, 336 cycles with the surgical treatment) between 1997 and 2004. Among the surgical treatment, 151 cycles were performed previously cyst enucleation with endometrioma and 185 cycles were performed only resection of peritoneal lesions without endometrioma enucleation. 313 cycles (246 patients) with the tubal factor infertility were used as controls. Results In the endometriosis group with/without surgical treatment, the number of retrieved oocytes (9.6±7.3 vs. 11.2 ± 7.5 vs. 14.8 ± 7.0, P < 0.0001) and the transferred embryos (3.5 ± 1.4 vs. 3.5 ± 1.4 vs. 3.9 ± 0.9, P = 0.001) was significantly lower than controls. But, implantation rates (17.2% vs. 15.2% vs. 15.9%), pregnancy rates (36.9% vs. 35.9% vs. 39.6%) and live birth rates (32.1% vs. 28.2% vs. 29.7%) were similar. Surgically treated peritoneal lesions group showed no difference in the number of retrieved oocytes (9.6 ± 7.9 vs. 9.8 ± 6.5), the number of transferred embryos (3.4 ± 1.4 vs. 3.7 ± 1.3), implantation rates (15.5% vs. 18.0%), pregnancy rates (34.6% vs. 39.7%) and live birth rates (29.2% vs. 35.8%) with cyst enucleation group. Conclusion IVF parameters in the patients with endometriosis are inferior to tubal factor infertility, but IVF outcomes are comparable. Surgically treated peritoneal lesions group without endometrioma enucleation shows IVF parameters as bad as cyst enucleation group. We might be considered endometriosis itself worse IVF parameters regardless previous cyst enucleation. Keywords: Endometriosis; Peritoneal; In vitro Fertilization; Cyst enucleation; Infertility 자궁내막증 (endometriosis) 은자궁내막샘 (gland) 을포함한자궁내막조직이자궁밖에위치하는질환으로, 가임기여성에서 10% 에서 30% 까지다양하게발생빈도가보고된다 [1,2]. 자궁내막증은골반내에서난소또는복막에주로발생하고, 월경주기에따른호르몬영향으로주기적출혈과염증을일으켜, 월경통, 성교통, 부정기출혈, 불임등의다양한임상증상을나타낸다 [1]. 자궁내막증이불임을일으키는기전은골반유착으로인한골반구조의변화, 복막액 (peritoneal fluid) 내의기능변화등으로난자의배출과나팔관안으로난자획득 (pick up) 장애, 착상장애등이다 [3-8]. 중증자궁내막증 (advanced endometriosis) 은나팔관과골반내에심한유착 Received: 2011. 3. 2. Revised: 2011. 5.27. Accepted: 2011. 7. 4. Corresponding author: Hye Ok Kim, MD Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Cheil General Hospital & Women s Healthcare Center, Kwandong University College of Medicine, 1-19 Mukjeong-dong, Jung-gu, Seoul 100-380, Korea Tel: +82-2-2000-4738 Fax: +82-2-2000-7790 E-mail: ok58163@hanmail.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2011. Korean Society of Obstetrics and Gynecology WWW.KJOG.ORG 517

KJOG Vol. 54, No. 9, 2011 이동반되어해부학적인변화 (anatomical distortion) 를가져오기때문에임신을위해체외수정시술 (in vitro ffertilization [IVF]-embryo transfer) 을시행하게된다. 그러나이러한환자들의착상률과임신율은난관인자로인한불임여성보다낮게보고되었는데, 이는난소기능의저하로양질의난자를획득하기어렵고, 복막액내의 cytokines, growth factor, activated macrophage 등이증가되어난자에해로운영향을미칠수있기때문이라고설명되었다 [8-16]. 하지만, 중증자궁내막증은체외수정을통해임신율의향상을가져올수있는데, 저자들은중증자궁내막증을가진불임환자에서체외수정을통하여난관요인을가진불임환자와유사한임신율을보고하였고, 과거의수술적치료를받은환자군에서통계적으로유의하게획득된난자의수가감소됨을보고하였다 [17]. 체외수정시술전에자궁내막증에대해수술적치료를받은경우체외수정시술결과에미치는영향에대한보고가많은데 [17-22], Matalliotakis 등 [9] 은체외수정시술시중증자궁내막증으로수술적치료를받은환자군이수술적치료를받지않았던여성들보다난소반응이감소하였음을보고하였고, Esinler 등 [10] 도난소자궁내막증의수술적치료를받은경우체외수정에서난소반응의저하를보였다고보고하였다. 그러나, 이러한중증자궁내막증에는난소자궁내막증과복막자궁내막증만이존재하는경우가혼재되어있고, 수술적치료그룹내에서난소자궁내막증과복만에만자궁내막증이있는환자를구분하여수술후체외수정에대한결과를보고한논문은없다. 이에저자들은중증자궁내막증환자에서수술적치료후체외수정시술결과를평가하고, 특히난소자궁내막증과복막자궁내막증환자의수술적치료후체외수정시술의척도와결과들을비교해보고자하였다. 1997년부터 2004년까지 OO에서체외수정시술을받은총 591명 (819 주기 ) 를대상으로후향적으로연구하였다. 이중중증자궁내막증으로진단받았던환자는모두 506주기 (345명) 였으며, 이중수술적치료를받지않은군은 170주기 (116명), 수술적치료를받은경우는 336 주기 (229명) 였다. 수술적치료를받은 336주기에서난소자궁내막증 ( 자궁내막종 ) 은 151주기 (108명), 자궁내막종이없는복막자궁내막증은 185주기 (121명) 였다. 그리고, 체외수정시술중난소자궁내막증이보였던경우는 84주기였는데이중수술적치료를받지않은경우는 21주기, 수술적치료를받은경우는 63주기였다. 대조군은동일기간내에난관요인으로체외수정시술을받은 313주기 (246명) 를대상으로하였다. 제외기준으로는여성의나이가 36세이상, basal follicle stimulating hormone (FSH) level이 20 miu/ml 이상, 다낭성난소증후군, 심각한남성요인이동반된경우는제외하였다. 수술적치료를받지않은환자들은불임을주소로클리닉에내원하여불임검사로서진단적복강경을시행받았던환자로서, 불임기간과환 자의나이등이고려되어바로체외수정시술을받은경우에해당하였다. 자궁내막증은모두진단적복강경검사또는수술적복강경을통해병변의유무가확인되었고 revised American society for reproductive medicine classification에의해 scoring을하여병기를결정하였고, stage III-IV를중증의자궁내막증으로분류하였다. 체외수정의척도 (IVF parameter) 는 human chorionic gonadotropin (hcg) 투여일의 estradiol (E 2 ) 농도, 획득된난자의수, 수정률, 총배아수, 양질의배아수, 이식된배아수로평가하였고, 체외수정의결과 (IVF outcomes) 는착상률, 임신율, 태아생존율로비교하였다. 1) 과배란유도체외수정을위한과배란유도 (controlled ovarian hyperstimulation) 는단기 (short protocol) 또는장기 (long protocol) 요법을이용하였다. 난관요인군은단기요법이 184주기, 장기요법이 129주기였으며, 수술적치료를받지않은자궁내막증군에서는단기요법이 101주기, 장기요법이 69주기, 수술적치료를받은자궁내막증군은단기요법이 243주기, 장기요법이 93주기에해당하였다. 단기요법은 gonadotropin releasing hormone agonist (Bucerelin acetate, Suprefact R, Hoechst, Frankfurt, Germany) 를생리주기 2-3일부터, 장기요법은전생리주기에서배란을확인하고, human recombinant FSH (Puregon R, Organon, Oss, the Netherlands; Gonal-F R, Serono, Geneva, Switzerland) 또는 highly purified-fsh (Pergonal R, Serono, Switzerland) 를이용하여 ovarian stimulation을하였다. 성숙난포가 17-18 mm에도달하였을때, hcg (Pregnyl R, Organon) 10,000 IU를투여하고, 34-36시간이후난자채취를시도하였다. 체외수정은고식적체외수정시술 (conventional IVF) 또는세포질내정자주입술 (intracytoplasmic sperm insemination, ICSI) 의방법을이용하였고, 정액주입이나 ICSI 후 16-20시간후에 2개의극체와전핵 (pronucleus) 이관찰되면수정으로확인하였다. 배아이식은난자채취후 2-5일후에양질의배아를선택하여자궁강내에이식하였다. 배아의상태는할구 (blastomere) 의균등성과세포질파편 (cytoplasmic fragment), 세포질공포 (bleb) 등으로등급을나누었고, good embryos 는 grade I, grade I-a, grade II까지의배아로정의하였으며, 여분의배아는동결보존하였다. 황체기보강을위해 progesterone in oil (Progest, Samil, Co., Seoul, Korea) 을 2주간근주하였다. 2) 임신결과의판정임신의확인은난자채취후 12일째에혈중 ß-hCG가 5 miu/ml 이상이고, 추적검사에서상승을보이며임신 5-6주사이에태낭 (gestational sac) 이확인되면임상적인임신으로판정하였고, 착상률 (implantation rate) 은이식된배아수에대해확인된태낭수의비율로, 태아생존율 (live birth rate) 은배아이식주기당분만시생존했던태아의비율로정의하였다. 518 WWW.KJOG.ORG

Seung Heon Yang, et al. IVF outcomes in patients with advanced endometriosis after surgical treatment Table 1. Demographic characteristics of patients with tubal factor and advanced endometriosis associated infertility Endometriosis Total Tubal factor 819 cycles (313 cycles) Without surgery With surgery (170 cycles) (336 cycles) Age (yr) 31.0 ± 2.4 31.3 ± 1.9 30.9 ± 2.3 Duration of infertility (month) 40.3 ± 26.6 51.8 ± 21.4 a 42.0 ± 23.7 Primary infertility (%) 32.5 76.4 b 73.1 b Prior IVF cycles 2.0 ± 1.6 2.2 ± 1.9 2.0 ± 1.4 Basal FSH (miu/ml) 6.6 ± 2.0 7.4 ± 2.4 c,d 8.1 ± 3.2 e Previous cyst enucleation 0 NA 151 (45.3) Cyst on IVF NA 21 (12.4) 63 (18.8) Values are mean ± standard deviation or number (%). NA, not applicable; FSH, follicle stimulating hormone; IVF, in vitro fertilization. a P < 0.0001, compared to tubal factor and treated endometriosis infertility. b P < 0.0001, c P = 0.006, e P < 0.0001 compared to tubal factor infertility. d P = 0.04, compared to surgically treated endometriosis. 통계학적분석은 SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA) 을이용하였다. 각그룹내의데이터는평균값과표준편차 (mean ± standard deviation) 로나타내었고, 세그룹간의평균값의비교는 one-way analysis of variance를사용하였고, 사후분석은 Bonferroni method를이용하였다. 비율과빈도의분석은 chi-square test를이용하였고, P 값이 0.05 미만인경우통계학적으로유의한차이가있는것으로판정하였다. 평균불임기간은수술적치료를받지않은군은 51.8 ± 21.4개월로수술적치료를받은군 (42.0 ± 23.7개월 ) 과난관인자 (40.3 ± 26.6개월 ) 불임군보다통계적으로유의하게높았고 (P < 0.0001), 일차성불임의빈도는자궁내막증으로수술적치료를받지않은군 (76.4%) 과받은군 (73.1%) 의불임여성에서난관인자 (32.5%) 를가진여성보다높았다 (P < 0.0001). 기저난포자극호르몬 (basal FSH) 은수술적치료를받은군 (8.1 ± 3.2 miu/ml) 이수술적치료를받지않은군 (7.4 ± 2.4 miu/ml) 보다통계적으로유의하게높았고 (P = 0.04), 난관인자 (6.6 ± 2.0 miu/ml) 는수술적치료를받지않은군보다유의하게낮았다 (P = 0.006) (Table 1). hcg 투여일에측정한혈청 E 2 농도는수술적치료를받지않은군 (2089.7 ± 1348.3 pg/ml) 에서수술적치료를받은군 (1652.7 ± 1195.6 pg/ml) 보다유의하게높았지만 (P = 0.001) 대조군 (2463.7 ± 1302.5 pg/ml) 보다유의하게낮았다 (P = 0.008). 획득된난자수도각각 11.2 ± 7.5개, 9.6 ± 7.3개, 14.8 ± 7.0개로중증의자궁내막증에서난 관인자보다유의하게적었다 (P < 0.0001). 수정률 (%) 은수술적치료를받지않은군 (65.2 ± 24.2) 에서수술받은군 (71.9 ± 21.8) 보다통계적으로유의하게낮았다. 총배아수는수술적치료를받지않은군에서 6.7 ± 4.5개, 받은군에서 6.5 ± 5.0개로난관인자 10.1 ± 5.3개보다적었다 (P < 0.0001). 하지만양질의배아 (good quality embryo) 는치료를받지않은군에서 2.5 ± 1.6개로난관인자 2.8 ± 1.6개와비슷한결과를보여주었고, 치료를받은군에서는 2.4 ± 1.7개로난관인자에비해적은개수를보여주었다 (P = 0.001). 한주기에서이식된배아수는수술적치료를받지않은군 3.5 ± 1.4개, 받은군 3.5 ± 1.4개로난관인자 3.9 ± 0.9개보다적었다 (P = 0.001, P < 0.0001). 배아이식주기당초음파에서태낭을확인할수있었던임상적임신율은수술적처치를받지않은군에서 35.9%, 수술적처치를받은군에서 36.9% 로, 난관인자 39.6% 보다적었으나통계적인차이는없었다 (Table 2). 수술적처치를받은중증자궁내막증환자에서난소자궁내막증과복막자궁내막증환자의평균연령은 30.6 ± 2.3세, 31.1 ± 2.2세로차이가없었으나, 과거 IVF 치료주기는난소자궁내막증환자가 1.87 ± 1.1주기로, 복막자궁내막증환자 2.16 ± 1.6주기보다통계적으로유의하게낮았다 (P = 0.006). 그리고 hcg 투여일에측정한혈청 E 2 농도는난소자궁내막증 (1625.7 ± 987.1 pg/ml) 치료군에서복막자궁내막증 (1693.2 ± 1352.2 pg/ml) 보다통계적으로유의하게낮았다 (P = 0.011). 이식된배아수도난소자궁내막증 3.67 ± 1.3개, 복막자궁내막증 3.39 ± 1.4개로비슷한결과를보여주었고, 임신율은각각 39.7%, 34.6% 로통계적인차이가없었으며, 착상률은 18.0 ± 26.8%, 15.5 ± 26.4% 로난소자궁내막증에서보다높았으나유의한차이가없었다. 배아이식주기당생존아출생률은난소자궁내막증환자에서 WWW.KJOG.ORG 519

KJOG Vol. 54, No. 9, 2011 Table 2. IVF parameters and outcomes in tubal factor and advanced endometriosis associated infertility with/without surgical treatment Total 819 cycle Tubal factor (313 cycles) Without surgery (170 cycles) Endometriosis With surgery (336 cycles) Serum E 2 (pg/ml) on hcg day 2463.7 ± 1302.5 2089.7 ± 1348.3 a,b 1652.7 ± 1195.6 c No. of retrieved oocytes 14.8 ± 7.0 11.2 ± 7.5 d 9.6 ± 7.3 e Fertilization method ICSI 117 (37.4) 76 (44.7) 177 (52.7) Fertilization rates (%) 68.8 65.2 f 71.9 No. of total embryos 10.1 ± 5.3 6.7 ± 4.5 g 6.5 ± 5.0 h No. of good embryos 2.8 ± 1.6 2.5 ± 1.6 2.4 ± 1.7 i No. of transferred embryos 3.9 ± 0.9 3.5 ± 1.4 j 3.5 ± 1.4 k Implantation rates (%) 15.9 15.2 17.2 Pregnancy rates 124 (39.6) 61 (35.9) 124 (36.9) Live birth rates 93 (29.7) 48 (28.2) 108 (32.1) Values are mean ± standard deviation or number (%). IVF, in vitro fertilization; E 2, estradiol; hcg, human chorionic gonadotropin; No, number; ICSI, intracytoplasmic sperm injection. a P = 0.008, c,d,e,g,h,k P < 0.0001, i,j P = 0.001 compared to tubal factor infertility. b P = 0.001, f P = 0.002 compared to surgically treated endometriosis. Table 3. IVF parameters and outcomes in patients with endometriosis between cyst enucleation and peritoneal lesions only without endometrioma after surgical treatment Total 506 cycles Surgical treatment of endometriosis Cyst enucleation (n=151) Peritoneal lesions only without endomerioma (n=185) P-value Age (yr) 30.6 ± 2.3 31.1 ± 2.2 NS Duration of infertility (month) 38.8 ± 22.7 44.8 ± 24.4 NS Prior IVF cycles 1.9 ± 1.1 2.2 ± 1.6 0.006 Serum E 2 (pg/ml) on hcg day 1625.7 ± 987.1 1693.2 ± 1352.2 0.011 No. of retrieved oocytes 9.8 ± 6.5 9.6 ± 7.9 NS Fertilization rates (%) 73.3 70.9 NS No. of total embryos 6.9 ± 5.0 6.2 ± 5.0 NS No. of good embryos 2.6 ± 1.7 2.2 ± 1.6 NS No. of transferred embryos 3.7 ± 1.3 3.4 ± 1.4 NS Implantation rates (%) 18.0 15.5 NS Pregnancy rates 60 (39.7) 64 (34.6) NS Live birth rates 54 (35.8) 54 (29.2) NS Values are mean ± standard deviation or number (%). IVF, in vitro fertilization; E 2, estradiol; hcg, human chorionic gonadotropin; NS, not signifi cant; No, number. 35.8%, 복막자궁내막증환자에서 29.2% 로통계적인차이를보이지않았다 (Table 3). 자궁내막증은골반구조의해부학적변화를일으켜난자의배출과나팔관으로의획득장애를가져오고, 복막액내의 macrophage, prostaglandin, interleukin-1, protease의증가와자궁내막의면역학적 520 WWW.KJOG.ORG

Seung Heon Yang, et al. IVF outcomes in patients with advanced endometriosis after surgical treatment 인자의변화로인한착상장애등을유발하여불임과의관련성이높다 [2,18]. 기존의연구들은자궁내막증에대한수술적치료를받은환자에서체외수정시술시과배란유도에대한난소반응이저하되었지만, 임신율에서는난관인자와비교하여좋지않음을보고하거나 [17], 크게차이가없음을보고하였다 [9,10,16]. 본연구에서는난관인자와비교시자궁내막증의수술적치료유무에관련없이 hcg 투여일에측정한혈청 E 2 농도, 획득된난자수, 수정률, 총배아수등체외수정의척도는낮으나임신율, 착상률, 태아생존율등에서는차이를보이지않았다. 중증의복막자궁내막증만있는경우난소에외과적처치를하지않았음에도불구하고획득된난자수가감소하고, 체외수정의시술척도가감소하게되는것일까? 이유로는첫째, 중증복막자궁내막증만있는환자의경우골반내유착으로인한골반의해부학적변화가있게되고치료후에도재발이잘되기때문에난자채취가어려워적은수의난자가획득될가능성이있다 [22]. 둘째, 복강내 (peritoneal cavity) 에 macrophage, prostaglandin, interleukin-1, protease의증가와면역학적변화로인해자궁내막증자체가체외수정시술척도에나쁜영향을미칠수있다 [2,8]. 셋째, 중증의복막자궁내막증의수술적치료시난소표면에있는자궁내막증에대한전기소작술 (electric coagulation) 또는병변의광범위한완전절제 (complete resection) 로골반내혈류장애로인한난소예비력 (ovarian reserve) 이저하될수있겠다 [21]. 본연구의제한점은첫째, 체외수정시수술적치료이후자궁내막증의재발여부를확인할수없었고, 둘째, 난소의자궁내막증은자궁내막종 (endometrioma) 이있어수술한경우에해당되어, 실제난소표면에만자궁내막증이있는경우는복막자궁내막증으로분류되었다는점, 셋째, 수술적치료가병변의완전절제 (complete resection) 인지부분절제 (partial resection) 인지확인하지못했고, 넷째, 난포자극호르몬이 20 miu/ml 이상인그룹을제외시켜수술후발생할수있는심각한체외수정저반응군을제외시켰다는제한점을가지고있다. 또한, 난소의예비력에대한평가또한기존의난포자극호르몬의수치만을보여주었기때문에저반응군에대한평가가적절히이루어지지못하였다. 이는향후항뮬러관호르몬 (anti-mullerian hormone) 을가지고난소예비력의차이를비교해볼수있겠다. 결론적으로중증자궁내막증으로수술적치료없이바로체외수정을시행받은경우와수술적치료를받은후자연임신이되지않아체외수정시술을시행받은경우모두에서과배란유도시난소반응저하를관찰할수있었으나임신율에는차이가없어, 자궁내막증이체외수정결과에영향을주지않음을확인하였다. 그리고, 복막자궁내막증과난소자궁내막증으로치료를받은경우모두에서난소반응의저하로적은수의난자가획득됨을알수있었고, 체외수정시술의결과에는차이가없음을확인하였다. References 1. Smith S, Pfeifer SM, Collins JA. Diagnosis and management of female infertility. JAMA 2003;290:1767-70. 2. Practice Committee of the American Society for Reproductive Medicine. Endometriosis and infertility. Fertil Steril 2004;81:1441-6. 3. Koninckx PR. Is mild endometriosis a condition occurring intermittently in all women? Hum Reprod 1994;9:2202-5. 4. Moen MH. Why do women develop endometriosis and why is it diagnosed? Hum Reprod 1995;10:8-11. 5. Gleicher N, Barad D. Unexplained infertility: does it really exist? Hum Reprod 2006;21:1951-5. 6. Brosens I. Endometriosis and the outcome of in vitro fertilization. Fertil Steril 2004;81:1198-200. 7. Olivennes F. Results of IVF in women with endometriosis. J Gynecol Obstet Biol Reprod (Paris) 2003;32:S45-7. 8. Barnhart K, Dunsmoor-Su R, Coutifaris C. Effect of endometriosis on in vitro fertilization. Fertil Steril 2002;77:1148-55. 9. Matalliotakis IM, Cakmak H, Mahutte N, Fragouli Y, Arici A, Sakkas D. Women with advanced-stage endometriosis and previous surgery respond less well to gonadotropin stimulation, but have similar IVF implantation and delivery rates compared with women with tubal factor infertility. Fertil Steril 2007;88:1568-72. 10. Esinler I, Bozdag G, Aybar F, Bayar U, Yarali H. Outcome of in vitro fertilization/intracytoplasmic sperm injection after laparoscopic cystectomy for endometriomas. Fertil Steril 2006;85:1730-5. 11. Tsoumpou I, Kyrgiou M, Gelbaya TA, Nardo LG. The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: a systematic review and meta-analysis. Fertil Steril 2009;92:75-87. 12. Azem F, Lessing JB, Geva E, Shahar A, Lerner-Geva L, Yovel I, 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 1999;72:1107-9. 13. Garcia-Velasco JA, Mahutte NG, Corona J, Zúñiga V, Gilés J, Arici A, et al. Removal of endometriomas before in vitro fertilization does not improve fertility outcomes: a matched, casecontrol study. Fertil Steril 2004;81:1194-7. 14. Somigliana E, Vercellini P, Viganó P, Ragni G, Crosignani PG. Should endometriomas be treated before IVF-ICSI cycles? Hum Reprod Update 2006;12:57-64. 15. Olivennes F, Feldberg D, Liu HC, Cohen J, Moy F, Rosenwaks Z. Endometriosis: a stage by stage analysis--the role of in vitro fertilization. Fertil Steril 1995;64:392-8. 16. Bergendal A, Naffah S, Nagy C, Bergqvist A, Sjöblom P, Hil- WWW.KJOG.ORG 521

KJOG Vol. 54, No. 9, 2011 lensjö T. Outcome of IVF in patients with endometriosis in comparison with tubal-factor infertility. J Assist Reprod Genet 1998;15:530-4. 17. Kim HO, Kang IS. Comparison of IVF outcomes in patients with endometriosis according to severity. Korean J Fertil Steril 2006;33:219-27. 18. Garrido N, Navarro J, Remohí J, Simón C, Pellicer A. Follicular hormonal environment and embryo quality in women with endometriosis. Hum Reprod Update 2000;6:67-74. 19. Omland AK, Åbyholm T, Fedorcsák P, Ertzeid G, Oldereid NB, Bjercke S, et al. Pregnancy outcome after IVF and ICSI in unexplained, endometriosis-associated and tubal factor infertility. Hum Reprod 2005;20:722-7. 20. Calhaz-Jorge C, Chaveiro E, Nunes J, Costa AP. Implications of the diagnosis of endometriosis on the success of infertility treatment. Clin Exp Obstet Gynecol 2004;31:25-30. 21. Maneschi F, Marasá L, Incandela S, Mazzarese M, Zupi E. Ovarian cortex surrounding benign neoplasms: a histologic study. Am J Obstet Gynecol 1993;169:388-93. 22. Papaleo E, Ottolina J, Viganó P, Brigante C, Marsiglio E, F DEM, et al. Deep pelvic endometriosis negatively affects ovarian reserve and the number of oocytes retrieved for in vitro fertilization. Acta Obstet Gynecol Scand 2011;90:878-84. 중증자궁내막증의수술적치료후체외수정의결과 관동대학교제일병원산부인과불임및생식내분비분과양승헌, 김혜옥, 성나영, 안현숙, 추연실, 양광문, 송인옥, 궁미경, 강인수 목적중증자궁내막증환자에서수술적처치가체외수정결과에미치는영향을평가하고, 특히난소자궁내막증과복막자궁내막증환자의수술적처치후체외수정시술의척도들을비교해보고자한다. 연구방법 1997년에서 2004년까지, 복강경검사로중증자궁내막증을진단받고체외수정을시행한 506주기를대상으로후향적연구를하였다. 170주기는수술받지않았고, 336주기는수술적치료 (151주기는난소자궁내막증, 185 주기는복막자궁내막증 ) 후체외수정시술을받았다. 대조군은동일기간내에난관요인에의해체외수정시술을받은 313주기를대상으로하였다. 결과자궁내막증의수술적처치를한그룹과수술을받지않은그룹에서, 채취된난자수 (9.6 ± 7.3 vs. 11.2 ± 7.5 vs. 14.8 ± 7.0, P < 0.0001) 와이식된배아수 (3.5 ± 1.4 vs. 3.5 ± 1.4 vs. 3.9±0.9, P = 0.001) 가유의하게대조군보다낮았다. 하지만, 착상률 (17.2% vs. 15.2% vs. 15.9%) 과임신율 (36.9% vs. 35.9% vs. 39.6%), 태아생존율 (32.1% vs. 28.2% vs. 29.7%) 은유사하였다. 수술받은복막자궁내막증그룹의체외수정에서는채취된난자수 (9.6 ± 7.9 vs. 9.8 ± 6.5), 이식된배아수 (3.4 ± 1.4 vs. 3.7 ± 1.3), 착상률 (15.5% vs. 18.0%), 임신율 (34.6% vs. 39.7%), 태아생존율 (29.2% vs. 35.8%) 이수술받은난소자궁내막증그룹과유의한차이를보이지않았다. 결론자궁내막증환자는과거의수술적치료유무와상관없이체외수정시술척도가낮았으나, 임신율에는차이가없었다. 수술적치료를받은복막자궁내막증그룹은난소자궁내막증과유사하게낮은체외수정시술척도를보였다. 따라서, 난소자궁내막증수술여부와관계없이자궁내막증자체만으로체외수정시술척도에안좋은영향을미치는것으로생각된다. 중심단어 : 자궁내막증, 복막, 체외수정, 자궁내막종, 불임 522 WWW.KJOG.ORG