华中科技大学同济医学院附属协和医院王绍海
译文：
临床上，子宫内膜异位症与不孕相关。药物和手术治疗内异症对女性的生育机率影响不同，不管其生育是通过自然受孕还是辅助生育技术（assisted reproductive technology，ART）实现。内异症的药物治疗均有避孕效果。目前研究（尽管大多数研究没有设对照组）提示对于任何期别的内异症，手术治疗都可提高自然妊娠机率。子宫内膜异位囊肿非手术治疗的条件为：囊肿为双侧，过去手术治疗史，及卵巢储备力的改变。因为担心对手术治疗能影响卵巢功能（实际上，手术前卵巢功能就已经下降了），所以更多的人赞同ART前，不要行手术治疗这一原则，但下列情况例外：疼痛，输卵管积水以及囊肿巨大。药物治疗（3-6个月的GnRHa）能提高ART的结局。为了留出时间让患者试行自然受孕，在年龄、卵巢储备力、男方及输卵管状况等因素允许时，应考虑立即手术。其他病例，ART前不先行手术治疗，最好先用促性腺激素释放激素的激动剂（gonadotropin-releasing hormone analogue，GnRHa）。然而，这种早期手术的策略，似乎与直觉相抵触，因为存在着这样的观念，即先应用损害少的非手术治疗，最后再手术治疗（仅当初始治疗失败时）。因此在制定内异症相关的不孕的整体治疗措施时，前提条件是要衡量手术治疗、药物治疗和ART的各自优势。
我们先简述子宫内膜异位症和不孕的病理生理学，然后评价手术治疗和药物治疗的各自优势。药物治疗指的是各种能治疗内异症的制剂（所有的药物都是阻止卵巢功能，但是通过不同的机制）。目前，这些药物主要包括促性腺激素释放激素的激动剂（GnRHa），口服避孕药以及其他激素药物（如，单纯孕激素）。但并不包括各种辅助生育技术（ART），如卵巢刺激，通常用于增强生殖力，有时也用于治疗子宫内膜异位症。当手术治疗和药物治疗都无效，或者同时有输卵管疾病或存在男方问题时，有必要继续使用ART治疗。ART包括体外受精（in-vitro fertilization，IVF）和胞浆内单精子注射，这是为治疗由男性因素导致不孕的衍生技术。进而我们也将强调内异症的药物治疗和手术治疗对ART结局有何种影响。最后，有了内异症相关的不孕的整体方法这一基础，我们将简述一个实用的治疗规范，以指导临床应用。
总之，内异症女性的在位子宫内膜的变化改变了子宫内膜细胞的特性[4,14]。对手术时从盆腔收集到的子宫内膜碎片进行体外培养，发现与对照组相比，来自内异症患者的细胞种植和增生得更快[73]。因此，子宫内膜异位症本质上并不是仅仅由于经血逆流，而脱落在盆腔的子宫内膜细胞的独特性质，包括它们种植和增生的倾向性[73]，可能也起到重要作用。
图2概括了在治疗与内异症相关的不孕时需考虑的基本因素。该策略代表了结合手术和ART各自优点的整体方法的精髓，而且它与欧洲人类生殖和胚胎学会[105]以及美国生殖医学学会[106]的指南相一致。当不孕症患者在检查阶段时，如为内异症病程早期应当予以手术，因为手术的最主要的优点就是提高自然受孕的机率。根据Vercellion及同事的研究[77]，我们知道不管疾病位于哪种期别，手术都能提高自然受孕的可能性。因此当衡量手术的优势时，也应该考虑时间的可利用性、卵巢储备里及自然受孕的能力（输卵管及精子状况），而不是疾病的期别。实际上，手术后应该留出充分的时间（至少12个月），以使自然受孕的机率达到最大化。相反，如在ART即将进行前行手术治疗，基本上没有收益。
英文原文：
Endometriosis and infertility are associated clinically. Medical and surgical treatments for endometriosis havedifferent effects on a woman’s chances of conception, either spontaneously or via assisted reproductive technologies(ART). Medical treatments for endometriosis are contraceptive. Data, mostly uncontrolled, indicate that surgery atany stage of endometriosis enhances the chances of natural conception. Criteria for non-removal of endometriomasare: bilateral cysts, history of past surgery, and altered ovarian reserve. Fears that surgery can alter ovarian functionthat is already compromised sparked a rule of no surgery before ART. Exceptions to this guidance are pain,hydrosalpinges, and very large endometriomas. Medical treatment—eg, 3–6 months of gonadotropin-releasinghormone analogues—improves the outcome of ART. When age, ovarian reserve, and male and tubal status permit,surgery should be considered immediately so that time is dedicated to attempts to conceive naturally. In other cases,the preference is for administration of gonadotropin-releasing hormone analogues before ART, and no surgerybeforehand. The strategy of early surgery, however, seems counterintuitive because of beliefs that milder non-surgicaloptions should be off ered fi rst and surgery last (only if initial treatment attempts fail). Weighing up the relativeadvantages of surgery, medical treatment and ART are the foundations for a global approach to infertility associatedwith endometriosis.
After touching on the pathophysiological backgroundof endometriosis and infertility, we will assess therespective values of surgery and medical treatments. Bymedical treatments we mean the various agents proposedfor treatment of endometriosis (all block ovarian functionbut by diff erent means). Today, drugs mainly amount toagonists of gonadotropin-releasing hormone, oralcontraceptives, and other hormone treatments(ie, progestins only). These, however, do not encompassthe various assisted reproductive technologies (ART),such as ovarian stimulation, which is used foraugmentation of fertility and is sometimes undertakenfor endometriosis. When surgery and medical treatmentsfail, or natural conception is impossible because ofcoexisting tubal disease or altered male characteristics,reversion to ART is necessary. Such techniques includein-vitro fertilisation (IVF) and its variant for male factorinfertility, intracytoplasmic sperm injection. Hence, wewill also highlight how medical and surgical treatmentsof endometriosis affect the outcome of ART. Finally,having laid the foundation for a global approach toinfertility associated with endometriosis, we will sketch apractical algorithm for guidance of clinical management.
In summary, changes recorded in the eutopicendometrium in women with endometriosis alter thecharacteristics of endometrial cells.4,14 Endometrial debriscollected in the pelvic cavity at the time of surgeryimplants and proliferates in vitro quicker when itoriginates from patients with endometriosis comparedwith unaffected women.73 Endometriosis, therefore, doesnot result solely from retrograde bleeding per se. Rather,the very properties of endometrial cells that are shed inthe pelvic cavity, including their tendency to implant andproliferate,73 probably have a pivotal role as well. Thisnovel idea refutes the longlasting objection to Sampson’stheory, that although most women have retrogrademenstruation, only a few develop endometriosis.
Figure 2 outlines primary variables to be taken intoaccount during treatment of infertility associated withendometriosis. The proposed strategy represents theessence of a global approach that combines respectiveadvantages of surgery and ART, and it accords withguidelines of the European Society of HumanReproduction and Embryology105 and American Societyfor Reproductive Medicine.106 Surgery should be off eredearly in the course of endometriosis, when infertility isat the workup stage, because the primary benefi t ofsurgery is to enhance the chances of natural conception.From work of Vercellini and colleagues,77 we know thatsurgery augments the probability of natural conceptionirrespective of disease stage. Therefore, when weighingup the advantages of surgery, considerations shouldinclude availability of time, ovarian reserve, and capacityto conceive naturally (tubal and sperm status) ratherthan disease stage. Indeed, sufficient time (at least12 months) needs to be allocated after surgery tomaximise the chances of a natural pregnancy.Conversely, surgery undertaken just before ART offers,in principle, little benefit.
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