본문 바로가기
KERD
논문KCI 등재

다낭성난소증후군 환자의 불임치료

The infertility treatment related with polycystic ovary syndrome

나용진|구윤희
대한산부인과학회 (Korean Soceity of Obstetrics and Gynecology)|2010.10|Obstetrics & Gynecology Science|제53권 제10호|pp. 869-880

1

조회

0

다운로드

5

인용

0

참고문헌

키워드

다낭성난소증후군클로미펜ClomiphenePolycystic ovary syndrome불임치료Infertility treatment
주제분류산부인과학

초록

다낭성난소증후군 환자에서 불임에 대한 적절한 치료방법은 아직까지 명확히 정립되어 있지 않다. 가장 중요하게 고려할 사항은 치료를 시작하기 전 충분한 상담을 통해 다른 건강상의 문제점을 찾고, 비만한 여성은 운동 및 식이요법을 통해 체중을 감량해야 한다는 점이다. 다낭성난소증후군 환자에서 배란 유도를 위한 일차 치료제는 클로미펜이며 클로미펜에 반응이 없거나 임신에 실패한 경우 생식샘자극호르몬 투여를 고려할 수 있다. 생식샘자극호르몬을 투여할 경우 다태임신의 위험이 있으므로 난소의 반응을 초음파 검사를 통해 철저히 관찰하도록 하여야 한다. 복강경하 난소수술은 임신율 및 생존아 출생율에 있어서 생식샘자극호르몬과 비슷한 효과를 보이므로 이차적 치료로 고려할 수 있으나 수술적 위험 및 추가적인 배란유도제 사용의 필요성 때문에 배란유도의 목적만으로 시행하기에는 적절하지 않다. 체외수정은 불임 치료의 마지막 단계로 고려되며 단 한 개의 배아만 이식을 하는 방법으로 다태아 임신의 위험을 줄일 수 있다는 점에서 다낭성난소증후군 여성에서 효과적인 치료방법이 될 수 있다. Metformin과 같은 인슐린반응 개선제는 배란유도를 위한 일차 치료제 또는 클로미펜과 병합치료 시 역할에 있어 논란의 여지가 있다. 방향화효소 억제제는 배란 유도에 있어 클로미펜만큼 효과적이나 아직까지 불임치료제로서 승인이 되지 않은 상태로 향후 연구를 통해 효과 및 장기적 안정성이 입증되어야 할 것이다.

Abstract

The treatment of infertile women with polycystic ovary syndrome (PCOS) has not yet been established. Before any intervention is initiated, lifestyle modification with diet and exercise leading to weight loss should be emphasized in overweight women. The recommended first-line treatment for ovulation induction remains clomiphene citrate. If clomiphene citrate use fails to result in ovulation or pregnancy, the recommended second-line intervention is exogenous gonadotropins. The use of exogenous gonadotropins is related to an increased risk for multiple pregnancies, and, therefore, intense ovarian response monitoring is required. Laparoscopic ovarian surgery is an alternative to gonadotropin therapy because this surgery is as effective as gonadotropin in pregnancy rate or live birth rate. However, the surgery may require additional ovulation induction drug and should be performed by well-trained surgeon, its use solely to induce ovulation is unwarranted. Recommended third-line treatment is in vitro fertilization (IVF). IVF reduces the risk of multiple pregnancies by using single-embryo transfer in women with PCOS. The use of metformin alone as first-line infertility therapy or in combination with clomiphene is surrounded by controversies. Aromatase inhibitors appear to be as effective as clomiphene citrate for induction of ovulation, but the drug is currently not approved for treatment of infertility. Further studies should demonstrate the efficacy and long term safety.

참고문헌 (52)

  1. Stein IF, "Amenorrhoea associated with bilateral polycystic ovaries", Am J Obstet Gynecol, 29, pp.181~191 (1935)
  2. The Rotterdam ESHRE, "ASRM sponsored PCOS consensus workshop group", Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome, 2004, pp.81, 19~25
  3. Practice Committee of the American Society for Reproductive Medicine, "Use of insulin-sensitizing agents in the treatment of polycystic ovary syndrome", Fertil Steril, 90(5), pp.69~73 (2008)
  4. The Thessalonoki ESHRE, "ASRM sponsored PCOS consensus workshop group", Consensus on infertility treatment related to polycystic ovary syndrome, 2008, pp.89, 505~522
  5. Moran LJ, "Dietary composition in restoring reproductive and metabolic physiology in overweight women with polycystic ovary syndrome", J Clin Endocrinol Metab, 88, pp.812~819 (2003)
  6. Kiddy DS, "Improvement in endocrine and ovarian function during dietary treatment of obese women with polycystic ovary syndrome", Clin Endocrinol (Oxf), 36, pp.105~111 (1992)
  7. Tsagareli V, "Effect of a very-low-calorie diet on in vitro fertilization outcomes", Fertil Steril, 86, pp.227~229 (2006)
  8. Stamets K, "A randomized trial of the effects of two types of short-term hypocaloric diets on weight loss in women with polycystic ovary syndrome", Fertil Steril, 81, pp.630~637 (2004)
  9. Reaven GM, "The insulin resistance syndrome: definition and dietary approaches to treatment", Annu Rev Nutr, 25, pp.391~406 (2005)
  10. Wright CE, "Dietary intake, physical activity, and obesity in women with polycystic ovary syndrome", Int J Obes Relat Metab Disord, 28, pp.1026~1032 (2004)
  11. Jayagopal V, "Orlistat is as beneficial as metformin in the treatment of polycystic ovarian syndrome", J Clin Endocrinol Metab, 90, pp.729~733 (2005)
  12. Sabuncu T, "Sibutramine has a positive effect on clinical and metabolic parameters in obese patients with polycystic ovary syndrome", Fertil Steril, 80, pp.1199~1204 (2003)
  13. Imani B, "A nomogram to predict the probability of live birth after clomiphene citrate induction of ovulation in normogonadotropic oligoamenorrheic infertility", Fertil Steril, 77, pp.91~97 (2002)
  14. Eijkemans MJ, "High singleton live birth rate following classical ovulation induction in normogonadotrophic anovulatory infertility (WHO 2)", Hum Reprod, 18, pp.2357~2362 (2003)
  15. Legro RS, "Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome", N Engl J Med, 356, pp.551~566 (2007)
  16. Kosmas IP, "Human chorionic gonadotropin administration vs. luteinizing monitoring for intrauterine insemination timing, after administration of clomiphene citrate: a meta-analysis", Fertil Steril, 87, pp.607~612 (2007)
  17. Messinis IE, "Ovulation induction: a mini review", Hum Reprod, 20, pp.2688~2697 (2005)
  18. Kousta E, "Modern use of clomiphene citrate in induction of ovulation", Hum Reprod Update, 3, pp.359~365 (1997)
  19. Kolibianakis EM, "Endometrial thickness cannot predict ongoing pregnancy achievement in cycles stimulated with clomiphene citrate for intrauterine insemination", Reprod Biomed Online, 8, pp.115~118 (2004)
  20. Palomba S, "Management strategies for ovulation induction in women with polycystic ovary syndrome and known clomifene citrate resistance", Curr Opin Obstet Gynecol, 21, pp.465~473 (2009)
  21. Daly DC, "A randomized study of dexamethasone in ovulation induction with clomiphene citrate", Fertil Steril, 41, pp.844~848 (1984)
  22. Mitwally MF, "Use of an aromatase inhibitor for induction of ovulation in patients with an inadequate response to clomiphene citrate", Fertil Steril, 75, pp.305~309 (2001)
  23. Biljan MM, "he outcome of 150 babies following the treatment with letrozole or letrozole and gonadotropins", Fertil Steril, 84(1), pp.95~ (2005)
  24. Elizur SE, "Drugs in infertility and fetal safety", Fertil Steril, 89, pp.1595~1602 (2008)
  25. Tulandi T, "Congenital malformations among 911 newborns conceived after infertility treatment with letrozole or clomiphene citrate", Fertil Steril, 85, pp.1761~1765 (2006)
  26. Tang T, "Combined lifestyle modification and metformin in obese patients with polycystic ovary syndrome. A randomized, placebo-controlled, double- blind multicentre study", Hum Reprod, 21, pp.80~89 (2006)
  27. Harborne L, "Descriptive review of the evidence for the use of metformin in polycystic ovary syndrome", Lancet, 361, pp.1894~1901 (2003)
  28. Moll E, "Effect of clomifene citrate plus metformin and clomifene citrate plus placebo on induction of ovulation in women with newly diagnosed polycystic ovary syndrome: randomised double blind clinical trial", BMJ, 332, pp.1485~ (2006)
  29. Nestler JE, "Metformin in the treatment of infertility in polycystic ovarian syndrome: an alternative perspective", Fertil Steril, 90, pp.14~16 (2008)
  30. Tang T, "Insulin-sensitising drugs (metformin, rosiglitazone, pioglitazone, D-chiro-inositol) for women with polycystic ovary syndrome, oligo amenorrhoea and subfertility", Cochrane Database Syst Rev (2010)
  31. Christin-Maitre S, "A comparative randomized multicentric study comparing the step-up versus step-down protocol in polycystic ovary syndrome", Hum Reprod, 18, pp.1626~1631 (2003)
  32. Balen AH, "Hypersecretion of luteinising hormone: a significant cause of infertility and miscarriage", Br J Obstet Gynaecol, 100, pp.1082~1089 (1993)
  33. Calaf Alsina J, "Ovulation induction with a starting dose of 50 IU of recombinant follicle stimulating hormone in WHO group II anovulatory women: the IO-50 study, a prospective, observational, multicentre, opentrial", BJOG, 110, pp.1072~1077 (2003)
  34. Homburg R, "Low-dose FSH therapy for anovulatory infertility associated with polycystic ovary syndrome: rationale, results, reflections and refinements", Hum Reprod Update, 5, pp.493~499 (1999)
  35. Hugues JN, "The use of a decremental dose regimen in patients treated with a chronic low-dose step-up protocol for WHO Group II anovulation: a prospective randomized multicentre study", Hum Reprod, 21, pp.2817~2822 (2006)
  36. Practice Committee of the American Society for Reproductive Medicine, "Ovarian hyperstimulation syndrome", Fertil Steril, 86(5), pp.178~183 (2006)
  37. Balasch J, "The safety and effectiveness of stepwise and low-dose administration of follicle stimulating hormone in WHO group II anovulatory infertile women: evidence from a large multicenter study in Spain", J Assist Reprod Genet, 13, pp.551~556 (1996)
  38. Hamilton-Fairley D, "Common problems in induction of ovulation", Baillieres Clin ObstetGynaecol, 4, pp.609~625 (1990)
  39. Hendriks ML, "Why does ovarian surgery in PCOS help? Insight into the endocrine implications of ovarian surgery for ovulation induction in polycystic ovary syndrome", Hum Reprod Update, 13, pp.249~264 (2007)
  40. Amer SA, "A prospective dosefinding study of the amount of thermal energy required for laparoscopic ovarian diathermy", Hum Reprod, 18, pp.1693~1698 (2003)
  41. Malkawi HY, "Medical vs. surgical treatment for clomiphene citrate-resistant women with polycystic ovary syndrome", J Obstet Gynaecol, 23, pp.289~293 (2003)
  42. Farquhar C, "Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome", Cochrane Database Syst Rev (2007)
  43. Gurgan T, "The effect of short-interval laparoscopic lysis of adhesions on pregnancy rates following Nd-YAG laser photocoagulation of polycystic ovaries", Obstet Gynecol, 80, pp.45~47 (1992)
  44. Greenblatt EM, "Adhesion formation after laparoscopic ovarian cautery for polycystic ovarian syndrome: lack of correlation with pregnancy rate", Fertil Steril, 60, pp.766~770 (1993)
  45. Amer SA, "Long-term follow-up of patients with polycystic ovary syndrome after laparoscopic ovarian drilling: endocrine and ultrasonographic outcomes", Hum Reprod, 17, pp.2851~2857 (2002)
  46. Eijkemans MJ, "Individualized cost-effective conventional ovulation induction treatment in normogonadotrophic anovulatory infertility (WHO group 2)", Hum Reprod, 20, pp.2830~2837 (2005)
  47. Al-Inany HG, "Gonadotrophin-releasing hormone antagonists for assisted conception", Cochrane Database Syst Rev, 3 (2006)
  48. Tso LO, "Metformin treatment before and during IVF or ICSI in women with polycystic ovary syndrome", Cochrane Database Syst Rev (2009)
  49. Heijnen EM, "A meta-analysis of outcomes of conventional IVF in women with polycystic ovary syndrome", Hum Reprod Update, 12, pp.13~21 (2006)
  50. van Rumste MM, "The influence of the number of follicles on pregnancy rates in intrauterine insemination with ovarian stimulation: a meta-analysis", Hum Reprod Update, 14, pp.563~570 (2008)
  51. Albano C, "Avoidance of multiple pregnancies after ovulation induction by supernumerary preovulatory follicular reduction", Fertil Steril, 76, pp.820~822 (2001)
  52. Haydardedeoglu B, "The impact of rescue in vitro fertilization converted from high-response gonadotropin intrauterine insemination cycles in terms of implantation and pregnancy rates as compared with matched controls", Fertil Steril, 92, pp.137~142 (2009)

관련 논문AI추천

다낭성난소증후군 환자에서 체질량지수가 체외수정시술에 미치는 영향강병문, 김성훈, 김소라, 김유진, 김정훈, 전균호, 채희동대한산부인과학회 · Obstetrics & Gynecology Science2009 · 제52권 제01호다낭성 난소 증후군 환자에서 메트포민 치료의효과와 인슐린 저항성구승엽, 김석현, 김정구, 문신용, 배광범, 백광현, 서창석, 손영수, 전혜원, 지병철, 최두석, 최영민, 황규리대한산부인과학회 · Obstetrics & Gynecology Science2004 · 제47권 제10호체외수정시술을 받는 다낭성난소증후군 환자들에서GnRH Antagonist를 이용한 과배란유도의 효용성강병문, 김성훈, 김정훈, 나희영, 손영수, 이영진, 이향아, 채희동, 최정원, 홍석호대한산부인과학회 · Obstetrics & Gynecology Science2005 · 제48권 제3호다낭성난소증후군과 인슐린 저항성이병석, 황주연대한산부인과학회 · Obstetrics & Gynecology Science2006 · 제49권 제6호다낭성난소증후군 치료의 최신지견김정훈대한산부인과학회 · Obstetrics & Gynecology Science2005 · 제48권 제8호다낭성 난소 증후군을 이환하는 난임 환자에서 통합 의학 치료의 효과 : 체계적 문헌 고찰 및 메타분석박경덕, 배주은, 윤영진대한한방부인과학회 · 대한한방부인과학회지2017 · 제30권 제4호

이 간행물의 다른 논문 (3건)

자궁경부종양 환자에서 polymerase chain reaction 방법에 의한 인유두종바이러스 16형과 18형 검출에 관한 연구박충학, 김재경pp. 894-904자궁근종 환자에서 측정한 혈중 bisphenol-A 농도변재천, 한명석pp. 915-920임신 13주 제왕절개 반흔임신의 성공적 자궁동맥색전치료 1예: 증례보고백민정, 석준민, 이유미, 장성운, 문명진, 장지현pp. 934-939
원문 보기