子宫内膜异位囊肿对卵巢储备功能的影响

Impact of ovarian endometrioma on the ovarian reserve

目的探讨未经手术治疗的子宫内膜异位囊肿对卵巢储备功能及患者临床妊娠结局的影响。方法收集2011年1月—2017年10月期间于中山大学孙逸仙纪念医院生殖中心行体外受精/胞质内单精子注射(IVF/ICSI)新鲜胚胎移植的助孕患者,其中子宫内膜异位囊肿未经手术治疗的患者176例为内膜异位囊肿组,同期匹配年龄的男方因素不孕患者176例为对照组。子宫内膜异位囊肿组又分为单侧内膜异位囊肿亚组(n=146)和双侧内膜异位囊肿亚组(n=30)。根据囊肿直径大小将内膜异位囊肿组分为<3cm亚组和≥3cm亚组。比较各组患者的窦卵泡计数(AFC)、血清抗苗勒管激素(AMH),以及超促排卵后的获卵数和妊娠结局。在单侧内膜异位囊肿患者中,比较有囊肿侧卵巢(患侧)与无囊肿侧卵巢(健侧)的AFC及获卵数。结果内膜异位囊肿组患者的AFC[(5.7±3.8)个]、AMH[(3.32±2.71)μg/L]显著低于对照组[(8.1±4.3)个,P<0.001;(4.60±3.18)μg/L,P=0.006];超促排卵后,内膜异位囊肿组的获卵数[(9.1±6.2)个]少于对照组[(11.8±6.3)个,P<0.001],优质胚胎率、胚胎种植率及临床妊娠率组间差异均无统计学意义(P>0.05)。双侧内膜异位囊肿亚组AFC[(4.8±3.2)个]显著低于单侧内膜异位囊肿亚组[(5.9±3.4)个,P=0.05],但两组间AMH、获卵数和优质胚胎率差异均无统计学意义(P>0.05),单侧内膜异位囊肿亚组的胚胎种植率(33.54%)及临床妊娠率(57.63%)均高于双侧内膜异位囊肿亚组(22.22%、26.36%),但差异均无统计学意义(P>0.05);单侧内膜异位囊肿患者中,患侧卵巢AFC[(5.0±3.6)个]和获卵数[(4.2±3.3)个]均显著少于健侧卵巢[(6.5±4.0)个,P<0.001;(4.8±3.7)个,P=0.030]。不同内膜异位囊肿直径大小的患者中,直径<3cm亚组的优质胚胎率(33.82%)显著高于直径≥3cm亚组的优质胚胎率(26.85%,P=0.031)。结论未经手术治疗的内膜异位囊肿本身会降低卵巢储备功能,降低卵巢对超促排卵的反应性,但对内膜异位囊肿患者的妊娠结局并无影响。

Objective To evaluate the impact of ovarian endometrioma without surgery on patients’ ovarian reserve and clinical pregnancy outcomes after control ovarian hypersimulation. Methods A total of 352 patients were included, who were performed the first cycle of in vitro fertilization or intracytoplasmic sperm injection (IVF/ICSI) followed by fresh embryo transfer in Sun Yat-Sen Memorial Hospital Sun Yat-Sen University Reproductive Medicine Center between January 2011 and October 2017. The 176 patients with ovarian endometrioma without surgery treatment were classified into ovarian endometrioma group;meanwhile the other 176 cases with male factor infertility matched with age were classified into control group. The ovarian endometrioma group was further divided into unilateral endometrioma subgroup (n=146) and bilateral endometrioma subgroup (n=30). According to the average diameter of the endometrioma, the ovarian endometrioma group was divided into two subgroups:<3 cm group and≥3 cm group. The serum antral follicle count (AFC), anti-Müllerian hormone (AMH), and the number of oocytes retrieved and pregnancy outcomes after assisted reproductive technology (ART) were compared between the groups. The AFC and number of oocytes retrieved from the endometrioma-containing ovary and the opposite ovary were also compared in patients with unilateral ovarian endometrioma. Results The AFC and AMH were significantly lower in ovarian endometrioma group [5.7±3.8,(3.32±2.71)μg/L] than in control group [8.1±4.3, P<0.001;(4.60±3.18)μg/L, P=0.006], and the number of oocytes retrieved in ovarian endometrioma group (9.1±6.2) was lower than that in control group (11.8±6.3, P<0.001), but there were no significant differences in high-quality embryo rate, embryo implantation rate, and clinical pregnancy rate between the two groups (P>0.05). The AFC was significantly lower in patients with bilateral endometrioma (4.8±3.2) than that in patients with unilateral endometrioma (5.9±3.4, P=0.05), but no differences have been found in terms of AMH, the number of oocytes retrieved, and high-quality embryo rate (P>0.05). Embryo implantation rate and clinical pregnancy rate in unilateral group (34.54%, 57.63%) were higher than those in bilateral group (22.22%, 26.36%), but without statistical significances (P>0.05). In the patients with unilateral ovarian endometrioma, the AFC and AMH were both lower in the endometrioma-containing ovary (5.0±3.6, 4.2±3.3) than in the opposite ovary (6.5±4.0, P<0.001;4.8±3.7, P=0.030). In the patients with different diameter of ovarian endometrioma, the high-quality embryo rate of the group with a diameter≥3 cm (33.82%) was significantly lower than that of the group with a diameter <3 cm (26.85%, P=0.031). Conclusion The ovarian endometrioma without surgery treatment itself could damage the ovarian reserve and reduce the ovarian response to controlled hyperstimulation, but has no impact on the pregnancy outcomes of patients with ovarian endometrioma.