에관한연구 대한생식의학회지 : 제 37 권제 4 호 2010 관동대학교의과대학제일병원산부인과 1, 영상의학과 2 구화선 1 차선화 1 양광문 1 배주연 1 안현숙 1 한애라 1 박찬우 1 강인수 1 궁미경 1 이경상 2 * Effects of Hysteroscopic Septotomy on Pregnancy in Patients with History of Infertility or Recurrent Spontaneous Abortion Hwa Seon Koo 1, Sun Hwa Cha 1, Kwang Moon Yang 1, Ju Youn Bae 1, Hyun Suk Ahn 1, Ae Ra Han 1, Chan Woo Park 1, Inn Soo Kang 1, Mi Kyoung Koong 1, Kyung Sang Lee 2 * Departments of 1 Obstetrics and Gynecology, 2 Radiology, Cheil General Hospital and Women's Healthcare Center, Kwandong University School of Medicine, Seoul, Korea Objective: The aim of this study was to evaluate the influences of uterine septum and their elimination on the reproductive outcomes in women who have history of recurrent spontaneous abortion (RSA) and/or infertility. Methods: The medical records of reproductive outcomes in patients who have had history of RSA and infertility who were diagnosed with uterine septum only by hysterosalpingogram (HSG) between January 2008 and December 2009 were retrospectively analyzed. The subjects who have had severe male factor, tubal factors, other uterine factors, endocrine abnormalities, peritoneal factors, and abnormal karyotyping among both partners were excluded. In 27 patients, confirmation of diagnosis by laparoscopy and elimination of uterine septum by trans-vaginal hysteroscopy was done. Seventeen patients were strongly suspected to uterine septum on HSG but tried to get pregnancy without any other procedure for evaluation and management of uterine anomaly. Age matched 42 patients who have history of RSA and/or infertility and diagnosed to normal HSG finding at same period were randomly selected as control. The medical records of reproductive outcomes were analyzed and compared between groups. Results: The mean time of observation after diagnosis was 21.8 months (10 to 32). 55.6% (15/27) of patients in patients who received trans-vaginal hysteroscopic uterine septotomy were success to get pregnancies and was significantly higher than that of 17 patients who did not receive proper management (23.5%, 4/17, p<0.05). In control population, 40.5% (17/42) were success to pregnancies and the differences were not statistically significant compared to both two study groups. The live birth rate which was excluded pregnancy loss by abnormal fetal karyotyping and congenital anomaly were 75% (9/12) in treated septated uterus group and 84.6% (11/13) in control group each which have no statistically significant different. In patients with septated uterus who did not receive proper management showed lower delivery rate (50%, 2/4) than that of other groups but was not statistically significant. Conclusion: According to present data, women with a uterine septum have an increased chance of successful pregnancy with improved obstetric outcome after proper management of the uterine cavity. And these results were showed in patients with no regard to their reproductive history. But, in case of failed to receive proper management, uterine septum can affect not only pregnancy ongoing but successful pregnancy too. [Korean. J. Reprod. Med. 2010; 37(4): 361-368.] Key Words: Septated uterus, Hysterosalpingogram, Reproductive outcomes 접수일 : 2010 년 11 월 11 일, 수정일 : 2010 년 12 월 6 일, 게재확정일 : 2010 년 12 월 6 일주관책임자 : 이경상, 우 ) 100-380 서울특별시중구묵정동 1-19, 제일병원영상의학과 Tel: (02) 2000-7387, Fax: (02) 2000-7389, e-mail: kyungsang.lee@cgh.co.kr - 361 -
대한생식의학회지 중격자궁은흔하게보고되는선천성자궁기형으로전체여성에서 1~4% 의빈도로발생하지만불임이나습관성유산환자들에서그빈도가증가되는것으로보고되고있다. 1~4 중격자궁은임신제1 삼분기에융합하였던두개의뮬러씨관 (Müllerian ducts) 이완전하게재흡수되지못한결과에의하여생기며중격의크기에따라자궁강내의일부분을차지하는불완전한형의자궁중격, 자궁강뿐아니라자궁경부및질내에까지중격을동반하는완전한형의자궁중격으로구분하기도한다. 5 중격자궁의존재가여성의생식수행에미치는영향에대해서는불량한산과적예후와불임의유발등이거론되고있다. 자궁내의중격이불량한산과적예후및불임을유발하는기전에대한설명으로중격상층자궁내막에서발견되는자궁내막미세구조 (ultra-structural) 의변질로인한에스트로젠 (estrogen) 에대한자궁내막반응의불량, 부적절한혈관의발달에의한혈액순환및공급장애, 그리고중격내자궁근육층의증가에의한비정상적자궁수축의증가등의학설이제기되고있다. 중격자궁에서기인한반복유산, 조산, 태아의태내선진부이상, 그리고제왕절개분만의증가등불량한산과적예후에대해서는연구자간이견이없는반면중격자궁과임신의성공여부즉, 불임의원인으로서중격자궁이미치는영향에대해서는보고자마다그결과에대한차이가극명하고다양하여자궁중격이수정, 착상등임신의성립과정에미치는영향에대해서는많은논란이존재한다. 6~11 그러므로본연구에서저자들은중격자궁이불임및임신유지의실패등생식수행에미치는영향을알아보고질식자궁경하자궁중격절제술의시행이불임의치료에효과적인수단인지알아보고자하였다. 연구대상및방법 1. 연구대상군의선정본연구는 2008년 1월부터 2009년 12월까지불임 또는습관성유산을주소로제일병원산부인과를방문하여자궁난관조영술을시행한총 2,838명의환자들중중격자궁으로진단받은환자들을대상으로하였으며그중불임및습관성유산의다른원인이존재한경우즉, 불임의원인으로난관원인, 남성원인, 자궁내막증, 복강내유착등심한복강원인및습관성유산의원인으로부부의염색체이상, 중격자궁외의자궁기형, 자가항체원인, 호르몬이상등을제외한 44명의환자를연구군으로정하여후향적으로의무기록을분석하였다. 연구군은의무기록분석결과에의해자궁중격절제술의시행여부에따라치료군과비치료군으로세분하였는데, 27명은진단적복강경및질식자궁경을시행하여중격자궁을확진하였고자궁경을이용하여자궁경하질식자궁중격절제술을시행받아치료군으로지정하였으며, 다른 17명은자궁난관조영술로중격자궁을진단받았으나복강경및자궁경등특별한치료없이임신을시도하여비치료군으로지정하였다. 대조군은습관성유산또는불임검사를위해동기간에자궁난관조영술을시행한환자들중정상소견을보인 42명을나이를고려하여무작위로선정하였다 (Figure 1). 연구및대상군들의의무기록을통해진단당시의나이, 산과력, 불임및습관성유산의기왕력여부, 평균불임기간, 그리고과거자연유산의횟수등을자궁중격절제술을받은중격자궁환자군 ( 치료군 ), 치료받지않은중격자궁환자군 ( 비치료군 ), 그리고자궁난관조형술이정상인환자군 ( 대조군 ) 간각각비교하였다. 2. 각군간생식활동수행능의비교자궁중격절제술이생식수행능에미치는영향을분석하기위해연구및대상군의의무기록분석을통해임신율 (pregnancy rate), 자궁난관조영술시행후질식초음파를이용한임신낭의확인까지소요되는기간, 임신성공시임신시도방법, 초음파를통해임신낭확인후임신 20주이전임신이자연소실된경우로정의되는자연유산율 (clinical - 362 -
제 37 권제 4 호, 2010 구화선 차선화 양광문 배주연 안현숙외 5 인 Figure 1. Diagram of included study populations in this study. The septated uterus was allocated to two groups by receiving of further management or not after diagnosis of uterine anomaly at HSG. Hwa Seon Koo. Effects of Hysteroscopic Septotomy on Pregnancy in Patients with History of Infertility or Recurrent Spontaneous Abortion. Korean J Reprod Med 2010. abortion rate) 과임신이 26주이상진행된생존분만율 (live birth rate) 등을비교분석하였으며자연유산의원인이태아의염색체이상에기인한경우는자연유산율의분석시대상에서제외하였다. 3. 자궁경을통한질식자궁중격절제술의방법자궁중격절제술은환자의생리주기중난포기에시행되었으며수술약 10~12시간전자궁경부개대를위해 misoprostol (Cytotec, Pfizer, Panama) 200 μg을질내삽입하도록하였다. 수술은정맥내마취하에진행되었으며우선진단적복강경을실시하여자궁체부의외관을관찰후쌍각자궁, 이중자궁등의환자들을배제하였고중격자궁으로진단이확실시되는환자들을대상으로 Hegar's 자궁경부확장기를 6번크기까지삽입하여자궁경부를개대후직경 6 mm의수술적자궁내시경기구 (operative hysteroscopy, Wolf, Germany) 를삽입하였다. 시야확보및세척을위해자궁강확장을위한물질로생리식염수액이사용되었고자궁내중격은수술적자궁내시경기구내측에위치한터널을따라조직생검격자 (punch biopsy forcep, Wolf, Germany) 를삽입후조직생검격자끝에위치한커터를이용하여제거하였다. 자궁중격의제거시자궁내강의모양이가능한역삼각형형태가될때 까지시행하였으며중격제거과정중출혈양의과도한증가등의소견이보이는경우는수술을중단하였다 (Figure 2). 수술후모든환자들은자궁유착의발생을방지하기위해수술직후자궁내확장장치 ( 소아용 8 Fr foley) 를 1주일간장치하였으며 1주일후외래진찰시자궁내확장장치를제거하였다. 또한 estradiol valerate 6 mg (Proginova, German Remedies, Germany) 과 Medroxy progesterone acetate (Provera, Pharmacia and Upjohn, Kalamazoo, MI, USA) 5 mg의병합투여를통한고용량호르몬요법을 2주기시행하였으며호르몬투여요법종료후배란기자궁내막을질식초음파로관찰하여자궁내중격이제거된소견을보이며자궁내유착의증거가없는경우에한해서임신을시도하였다. 4. 통계적분석연구결과는 SPSS ver. 12.0 (windows, Microsoft, WA, USA) 통계프로그램을사용하여분석하였다. 대상군과대조군간의평균값의비교를위해 student's t-test를이용하였고빈도값의비교는 chi-square를이용하여분석하였으며 p값이 0.05 미만인경우통계적으로의미있다고판단하였다. - 363 -
대한생식의학회지 평균연령은각각 35.1±0.9세, 35.1±1.3세, 그리고 34.6±0.7세로통계학적으로유의한차이를보이지않았고, 각군간임신및출산력또한통계학적으로유의한차이를보이지않았다. 또한불임의기왕력을가진환자의빈도및불임의기간그리고반복유산의기왕력을가진환자의비율역시각군간통계학적으로유의한차이를보이지않았다. 한편본연구의추적관찰기간은자궁난관조영술을시행후평균 21.8개월 (10~32개월) 이었다 (Table 1). Figure 2. V-shaped uterus with central filling defect is seen with patent both tubes and good peritoneal spillages in hysterosalpingography (A). The diagnosis of septated uterus was confirmed by diagnostic laparoscopy (B). Hwa Seon Koo. Effects of Hysteroscopic Septotomy on Pregnancy in Patients with History of Infertility or Recurrent Spontaneous Abortion. Korean J Reprod Med 2010. 결 본연구에서불임또는습관성유산의기왕력이있는환자중중격자궁의발생빈도는전체 2,838명중 44명이진단되어약 1.6% 의빈도로조사되었다. 과 1. 연구대상군및대조군의임상적특징 연구대상 44명중자궁중격절제술받은 27명및치료를받지않은 17명그리고대조군 42명의 A B 2. 연구대상군및대조군에서의생식수행의비교각군에서추적관찰기간중의임신율을비교해보면자궁중격절제술을시행한 27명에서 55.6% (15/27), 특별한치료를받지않은 17명에서 23.5% (4/17) 로자궁중격절제술을시행받은환자에서통계학적으로유의하게임신율이높았다 (p<0.05). 반면, 대조군 42명의임신율은 40.5% (17/42) 였으며이는자궁중격절제술을받은 27명과치료받지않은 17명과비교하였을때통계학적으로유의한차이를보이지는않았다. 임신에성공한환자들을자궁난관조영술을시행한시점을기준으로임상적으로임신이확인되기까지의기간을분석하여본결과자궁중격절제술을받은그룹에서평균 6.5개월, 치료를받지않은그룹에서평균 6.8개월이었고대조군에서는평균 6.7개월로나타났으며이는통계학적으로유의한차이를보이지는않았다. 또한성공적인임신을가능하도록한임신시도방법들 ( 자연임신, 임신주기법, 자궁강내정액주입술또는체외수정 ) 을분석해본결과각군사이의임신시도방법에있어통계학적인차이를보이지않았다. 자궁중격절제술을시행받은후임신에성공한 15명중 3명, 정상자궁을진단받은대조군에서임신에성공한 17명중 4명에서태아의비정상적인핵형이원인이되어자연유산된것으로조사되었으며이를제외한각각의그룹에서의자연유산율을살펴보면자궁중격절제술을받은후임신에성공한 12명중 3명 (25.0%), 치료를받지않은그룹 - 364 -
제 37 권제 4 호, 2010 구화선 차선화 양광문 배주연 안현숙외 5 인 Table 1. Clinical characteristics of study and control groups Control (n=42) Treated group * (n=27) Septated uterus Untreated group (n=17) Age (yr) 34.6±0.7 35.1±0.9 35.1±1.3 NS p-value Gravidity 0.8±0.2 1.7±0.2 1.2±0.3 NS Parity 0.1±0.1 0.4±0.1 0.4±0.2 NS Infertility 22/42 (52.4) 15/27 (55.6) 11/17 (64.7) NS Duration of infertility (month) 23.7±3.9 36.1±7.6 36.8±12.1 NS Recurrent spontaneous abortion 5/42 (11.9) 2/27 (7.4) 3/17 (17.6) NS Infertility and recurrent spontaneous abortion 15/42 (35.7) 10/27 (37.0) 3/17 (17.6) NS Duration of follow up (month) 22.7±1.1 21.2±1.2 20.3±1.5 NS Values were mean±standard error (SE) or number (%). NS, statistically not significant. * In case of patients who was diagnosed to septated uterus in HSG and have received hysteroscopic uterine septotomy. In case of patients who was diagnosed to septated uterus in HSG but did not have received further management about their uterine anomaly. Hwa Seon Koo. Effects of Hysteroscopic Septotomy on Pregnancy in Patients with History of Infertility or Recurrent Spontaneous Abortion. Korean J Reprod Med 2010. 에서임신에성공한 4명중 2명 (50%), 대조군에서 13명중 2명 (15.4%) 으로분석되었으며자연유산율에있어서각군간의통계학적으로유의한차이는없었으나치료를받지않은군에서자연유산율이증가하는경향을보였다. 재태연령 26주이상을기준으로한생존아출산율 (live birth rate) 은자궁중격절제술을받은그룹에서 75% (9/12), 치료를받지않은그룹에서 50% (2/4), 대조군에서 84.6% (11/13) 을보여치료를받지않은군에서높은경향을보였으나통계학적으로유의한차이는없었고출생아들의출생당시체중역시통계학적으로유의한차이를보이지않았다 (Table 2). 고찰중격자궁은적게는여성의약 1~2%, 많게는 3~ 4% 의비율로이환되는것으로보고되며, 3,12 자궁기형중가장흔한형태로서여러형태를나타나는전체자궁기형의약 35% 를차지하는것으로알려 져있다. 8,12,13 저자들의본연구에서는불임또는습관성유산의기왕력을가진환자들을대상으로중격자궁의진단빈도는 1.6% (44/2,838) 의유병률을보였으며이는본연구의대상군이생식수행의장애가있을것으로고려되는불임또는습관성유산환자들을대상으로한연구임을감안할때그발생빈도가기존의다른연구결과보다는다소낮은결과를보였다. 하지만국내여성들을대상으로한자궁기형의빈도에관한정확한보고가아직없어본연구자들의불임또는습관성유산환자에서의중격자궁의유병률에대한결과는학술적인가치가있을것으로생각된다. 여성비뇨생식기계는태생 6주경에형성되는 Müller 씨관이정중앙 (midline) 및미측 (caudal) 으로자라나와태생 10주경융합하여자궁의협부및경부를구성한후태생 13주에융합된 Müller 씨관사이에서세포의급격한분화에의해자궁중격을형성한후 20주까지중격의흡수가일어난다. 이러한중격의흡수는미측 (caudal) 및두측 - 365 -
대한생식의학회지 Table 2. Comparison of reproductive outcomes between study and control groups Control (n=42) Treated group (n=27) Septated uterus Untreated group (n=17) p-value Pregnancy rates during follow up period 17/42 (40.5) 15/27 (55.6) * 4/17 (23.5) * * p=0.037 Time to pregnancy success from diagnosis (month) 6.7±1.2 6.5±1.3 6.8±1.6 NS The method for pregnancy achieve Naturally conceived 6/17 (35.3) 7/15 (46.7) 2/4 (50.0) NS Timed intercourse 3/17 (17.6) 1/15 (6.7) 1/4 (25) NS Intrauterine insemination (IUI) 2/17 (11.8) 1/15 (6.7) 0 NS In vitro fertilization and embryo transfer (IVF-ET) 6/17 (35.3) 5/15 (33.3) 1/4 (25) NS Clinical abortion rate 2/13 (15.4) 3/12 (25.0) 2/4 (50.0) NS Live birth rate 11/13 (84.6) 9/12 (75.0) 2/4 (50.0) NS Body weight of delivered baby (g) 3192±168.6 3412±213.2 3025±515.0 NS Values were mean±standard error (SE) or number (%). NS, statistically not significant. * Statistically significant different between groups. These values were counted after exclusive of pregnancy lose cases due to abnormal fetal karyotype. Indicated that pregnancies sustained up to 26 gestational weeks. Hwa Seon Koo. Effects of Hysteroscopic Septotomy on Pregnancy in Patients with History of Infertility or Recurrent Spontaneous Abortion. Korean J Reprod Med 2010. (cephal) 의양방향으로진행되며미측 (caudal) 의자궁경부및질의중격이소실되고두측 (cephal) 으로진행시자궁체부의중격이소실되게되지만이런중격의흡수가결여된경우완전혹은부분중격자궁으로표현되는자궁기형이생성된다. 14,15 중격자궁이여성의생식수행에미치는악영향에대해서는많은연구가있었지만크게두분류의문제즉, 1) 산과적합병증의유발, 2) 불임의유발등으로정리되고있다. 8 이중산과적인합병증즉, 자연유산율의증가, 조산의증가, 태아의태내선진부이상, 그리고제왕절개분만의증가등이유의하게증가한다는연구결과에대해서는보고자간일치된결과를보인다. 저자들의본연구결과도비록통계학적의미있는차이를보이지않았지만적절한치료를받지않은중격자궁환자에서정상자궁을가진환자군과비교하여자연유산의 증가및생존분만율의감소경향을보이는기존의결과에상응한다. 반면, 중격자궁과불임의유발과와관련된연구는기존의연구결과들에서보고자간의결과가상이하여중격자궁의존재가임신력 (fecundity) 에미치는영향에대해서는여전히논란이있다. 하지만저자들의본연구에서관찰되는것과같이치료받지않은중격자궁환자에서일정기간관찰시적절한치료를받은중격자궁환자군에비해임신율이유의하게감소한결과는중격자궁의존재는임신력의저하및불임의원인이될것으로생각되어심각한임신율의저하및치료후증가된임신율을보고한기존의연구결과에상응하였다. 6,10 중격자궁이진단되면자궁내중격절제술이치료적방법으로고려되며본연구에서는자궁경을이용한질식자궁중격절제술을시행하였다. 과거 - 366 -
제 37 권제 4 호, 2010 구화선 차선화 양광문 배주연 안현숙외 5 인 많이시행되었던중격자궁절제술의방법인개복을통한자궁중격절제술은수술후유착으로인해불임을야기할수있고임신시자궁의파열위험이높아지며결과적으로제왕절개술에의한분만의비율이증가하는단점이있다고보고한반면, 16 개복에의한중격절제술과자궁경에의한중격절제술간에시술후임신의결과에있어서는차이가없다는결과가보고되기도하였다. 17 이러한연구결과와는별도로최근수술후통증및회복기간의감소그리고창상등수술후합병증을피하기위한방법인자궁경을이용한질식자궁내중격절제술은중격자궁치료의근간을이루고있다. 기존연구자에의하면자궁중격절제술시행후임신율은 60%, 생존분만율 (live birth rate) 는 45% 이며, 8 불완전자궁중격환자 40명을대상으로자궁중격절제술전후의임신성공률과생존분만율을비교한결과각각 73%, 86% 로자궁내중격절제술후임신성공률과생존분만율이의미있게증가하였다고보고하였다. 18 저자들의본연구에서도자궁내중격절제술을시행받은환자군과치료를받지않은환자군에서일정기간관찰후임신성공률을비교한결과각각 55.6% (15/27), 23.5% (4/17) 로치료를받은환자군에서통계학적으로유의하게임신성공율이높았다. 반면, 자연유산율과생존분만율의비율은치료를받지않은군에서치료한군과자궁내기형이없는환자군에비해낮은경향을보이나통계학적인의미있는차이를보이지는않았으며이는연구대상군의숫자가작음에그원인이있는것으로그대상군의확대된연구를통해확인이필요할것으로생각된다. 본연구에서저자들은중격자궁이생식수행에미치는영향을알아보고자하였으며결과에의해중격자궁이생식수행에미치는영향은자연유산등산과적합병증뿐아니라오히려임신력의저하에더큰악영항을미칠수있으며자연유산, 조산등산과적합병증의기왕력이없는불임환자에서자궁중격의존재시적극적인치료가임신성공율의향상에도움이될것을제시하였다. 본연구의한 계로연구대상군의관찰기간이길지않고중격자궁의심한정도에대한분석이없으며그대상군이많지않아조산등산과적예후에대한분석이결여된점등이있으며결론을명확하게도출하기위해서보다규모가크고관찰기간이긴대단위연구가필요할것으로생각된다. 참고문헌 1. Acien P, Acien M. Evidence-based management of recurrent miscarriage. Surgical management. Int Congr Series 2004; 1266: 335-42. 2. Ashton D, Amin HK, Richart RM, Neuwirth RS. The incidence of asymptomatic uterine anomalies in women undergoing transcervical tubal sterilization. Obstet Gynecol 1988; 72: 28-30. 3. Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update 2001; 7: 161-74. 4. Harger JH, Archer DF, Marchese SG, Muracca-Clemens M, Garver KL. Etiology of recurrent pregnancy losses and outcome of subsequent pregnancies. Obstet Gynecol 1983; 62: 574-81. 5. Nouri K, Ott J, Huber JC, Fischer EM, Stogbauer L, Tempfer CB. Reproductive outcome after hysteroscopic septoplasty in patients with septate uterus--a retrospective cohort study and systematic review of the literature. Reprod Biol Endocrinol 2010; 8: 52. 6. Hollett-Caines J, Vilos GA, Abu-Rafea B, Ahmad R. Fertility and pregnancy outcomes following hysteroscopic septum division. J Obstet Gynaecol Can 2006; 28: 156-9. 7. Mollo A, De Franciscis P, Colacurci N, Cobellis L, Perino A, Venezia R, et al. Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial. Fertil Steril 2009; 91: 2628-31. 8. Raga F, Bauset C, Remohi J, Bonilla-Musoles F, Simon C, Pellicer A. Reproductive impact of congenital Mullerian anomalies. Hum Reprod 1997; 12: 2277-81. 9. Simon C, Martinez L, Pardo F, Tortajada M, Pellicer A. Mullerian defects in women with normal reproductive outcome. - 367 -
대한생식의학회지 Fertil Steril 1991; 56: 1192-3. 10. Valle RF. Hysteroscopic treatment of partial and complete uterine septum. Int J Fertil Menopausal Stud 1996; 41: 310-5. 11. Wang JH, Xu KH, Lin J, Chen XZ. Hysteroscopic septum resection of complete septate uterus with cervical duplication, sparing the double cervix in patients with recurrent spontaneous abortions or infertility. Fertil Steril 2009; 91: 2643-9. 12. Parsanezhad ME, Alborzi S, Zarei A, Dehbashi S, Shirazi LG, Rajaeefard A, et al. Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum. Fertil Steril 2006; 85: 1473-7. 13. Saygili-Yilmaz ES, Erman-Akar M, Yilmaz Z. A retrospective study on the reproductive outcome of the septate uterus corrected by hysteroscopic metroplasty. Int J Gynaecol Obstet 2002; 78: 59-60. 14. Acien P. Embryological observations on the female genital tract. Hum Reprod 1992; 7: 437-45. 15. Muller P, Musset R, Netter A, Solal R, Vinourd JC, Gillet JY. State of the upper urinary tract in patients with uterine malformations. Study of 133 cases. Presse Med 1967; 75: 1331-6. 16. Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril 2000; 73: 1-14. 17. Fayez JA. Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol 1986; 68: 399-403. 18. Marabini A, Gubbini G, Stagnozzi R, Stefanetti M, Filoni M, Bovicelli A. Hysteroscopic metroplasty. Ann N Y Acad Sci 1994; 734: 488-92. = 국문초록 = 목적 : 중격자궁은흔하게보고되는선천성자궁기형중하나이며여성의생식능력에미치는영향에대해아직이견이많고, 따라서치료의필요성에대해서도아직정립되지않았다. 본연구에서는중격자궁의존재및치료여부가생식수행에미치는영향에대해알아보고자하였다. 연구방법 : 2008년 1월부터 2009년 12월까지불임또는습관성유산을주소로제일병원산부인과를방문하여자궁난관조영술을시행한총 2,838명의환자들중중격자궁이진단된 44명의환자들을대상으로하였으며, 이중 27명은자궁경하자궁중격절제술을시행받았으며, 17명은진단후추가적인치료를받지않았다. 대조군은동일기간내에자궁기형이진단되지않은환자 42명을나이를고려후무작위선정하였다. 연구대상군의임신율, 자연유산율, 그리고생존분만율등에대한의무기록을후향적으로분석하였으며, 대상군들의평균추적관찰기간은진단후 21.8개월이었다. 결과 : 추적관찰기간중자궁경하질식자궁중격절제술을시행받은환자 (n=27) 의 55.6% (15/27) 가임신에성공한반면치료를받지않은환자 (n=17) 의약 23.5% (4/17) 만이임신에성공하여치료받은군에서통계적으로의미있는높은수치를보였다 (p<0.05). 한편생존분만율은치료를받은환자군및자궁기형이진단되지않은불임또는습관성유산환자 ( 대조군, n=42) 에서각각 75% 와 84.6% 를보인반면치료받지않은군에서는 50% (2/4) 를보여치료받지않은중격자궁환자에서낮은경향을보이지만통계학적의미는없었다. 결론 : 중격자궁이생식수행에미치는영향은자연유산등산과적합병증뿐아니라오히려임신력의저하에더큰악영항을미칠수있으며불임환자에서중격자궁의존재시적극적인치료가임신성공률의향상에도움이될것으로생각되지만보다명확한결론을위해규모가크고관찰기간이긴대단위연구가필요할것으로생각된다. 중심단어 : 중격자궁, 자궁난관조영술, 생식수행 - 368 -