深部浸润型子宫内膜异位症合并不孕症的治疗路径选择：手术还是IVF?

doi:10.12280/gjszjk.20260287

摘要/Abstract

摘要：

深部浸润型子宫内膜异位症（deeply infiltrating endometriosis，DIE）是子宫内膜异位症的一种特殊形式，约26%的DIE患者合并不孕。现有证据表明，手术与体外受精（in vitro fertilization，IVF）均为DIE合并不孕症患者的有效治疗策略，二者具有相似的生育结局，但尚无明确的临床决策依据。通过系统比较手术与IVF的生育结局，整合影像学评估、子宫内膜异位症生育指数（endometriosis fertility index，EFI）评分及卵巢储备影响，提出决策参考。影像学检查有助于明确病灶范围、预判手术难度从而避免不必要的手术。EFI评分是预测术后自然妊娠最可靠的工具：低分者建议直接IVF，高分者可考虑术后试孕。手术可损伤DIE患者的卵巢储备功能，对卵巢储备功能减退者应优先IVF。荟萃分析显示手术与IVF整体生育结局无显著差异，但手术在EFI评分高、疼痛明显者中可能额外获益。因此，直接IVF应作为一线治疗优先考虑，手术主要适用于重度疼痛、器官梗阻风险及特定EFI评分高的患者。

关键词: 子宫内膜异位症, 不育, 女（雌）性, 妇科外科手术, 体外受精, 深部浸润型子宫内膜异位症

Abstract:

Deeply infiltrating endometriosis (DIE) is a special form of endometriosis, in which about 26% of patients are complicated by infertility. Existing evidence shows that both surgery and in vitro fertilization (IVF) are effective treatment strategies for DIE patients with infertility, and that they have similar reproductive outcomes. However, there is no clear basis for clinical decision-making. In this review, we systematically compared the reproductive outcomes of surgery and IVF, integrated imaging evaluation, endometriosis fertility index (EFI) score and ovarian reserve, and proposed the decision-making reference. Imaging examination is helpful to clarify the scope of the lesion, predict the difficulty of surgery, and avoid unnecessary surgery. EFI score is the core tool for predicting the postoperative natural pregnancy: those patients with low EFI score should be suggested direct IVF, and those with high EFI score can be considered postoperative pregnancy test. Operation may damage the ovarian reserve function of DIE patients, and IVF should be given priority to those patients with diminished ovarian reserve. Meta-analysis showed that there was no significant difference in the overall fertility outcomes between surgery and IVF, but surgery may have additional benefits in patients with high EFI scores and severe pain. Direct IVF should be considered preferentially as the first-line treatment, while surgery is mainly suitable for patients with severe pain, organ obstruction risk and specific high EFI scores.

Key words: Endometriosis, Infertility, female, Gynecologic surgical procedures, Fertilization in vitro, Deeply infiltrating endometriosis

李晓莲, 张梦宇, 陶慧敏, 樊雨邗, 李梅, 尹耀学, 侯振. 深部浸润型子宫内膜异位症合并不孕症的治疗路径选择：手术还是IVF?[J]. 国际生殖健康/计划生育杂志, 2026, 45(5): 412-417.

LI Xiao-lian, ZHANG Meng-yu, TAO Hui-min, FAN Yu-han, LI Mei, YIN Yao-xue, HOU Zhen. Treatment Pathways Selection for Deeply Infiltrating Endometriosis with Infertility: Surgery or IVF?[J]. Journal of International Reproductive Health/Family Planning, 2026, 45(5): 412-417.

参考文献 31

[1]	As-Sanie S, Mackenzie SC, Morrison L, et al. Endometriosis: A Review[J]. JAMA, 2025, 334(1):64-78. doi: 10.1001/jama.2025.2975. pmid: 40323608
[2]	Ou Y, Wang H, Zhou C, et al. Endometriosis-associated infertility: Multi-omics insights into pathogenesis and precision therapeutics[J]. Front Endocrinol (Lausanne), 2025, 16:1613334. doi: 10.3389/fendo.2025.1613334.
[3]	Liang Y, Liu M, Zhang J, et al. First-line surgery versus first-line assisted reproductive technology for women with deep infiltrating endometriosis: a systematic review and meta-analysis[J]. Front Endocrinol (Lausanne), 2024, 15:1352770. doi: 10.3389/fendo.2024.1352770.
[4]	Asgari Z, Boostan A, Hosseini R, et al. Diagnostic performance of the #Enzian classification via ultrasound compared to laparoscopic findings in endometriosis: a retrospective cohort study[J]. J Turk Ger Gynecol Assoc, 2025, 26(4):276-283. doi: 10.4274/jtgga.galenos.2025.2025-7-2.
[5]	Noventa M, Scioscia M, Schincariol M, et al. Imaging Modalities for Diagnosis of Deep Pelvic Endometriosis: Comparison between Trans-Vaginal Sonography, Rectal Endoscopy Sonography and Magnetic Resonance Imaging. A Head-to-Head Meta-Analysis[J]. Diagnostics (Basel), 2019, 9(4):225. doi: 10.3390/diagnostics9040225.
[6]	Mohamed Y, Kol SQ, Stoker J, et al. Deep endometriosis: evaluation of ENZIAN and #ENZIAN classification systems by MRI compared with surgery-a meta-analysis[J]. Eur Radiol, 2026, 36(6):4489-4502. doi: 10.1007/s00330-025-12154-3.
[7]	Thomassin-Naggara I, Dolciami M, Chamie LP, et al. ESUR consensus MRI for endometriosis: indications, reporting, and classifications[J]. Eur Radiol, 2025, 35(11):7260-7268. doi: 10.1007/s00330-025-11579-0.
[8]	Gupta N, Joseph T, Karuppusami R, et al. Predictive factors for spontaneous conception in women with moderate and severe endometriosis following operative laparoscopy: A cohort study[J]. Eur J Obstet Gynecol Reprod Biol, 2025, 309:192-199. doi: 10.1016/j.ejogrb.2025.03.052. pmid: 40168751
[9]	Zhang N, Sun S, Zheng Y, et al. Reproductive and postsurgical outcomes of infertile women with deep infiltrating endometriosis[J]. BMC Womens Health, 2022, 22(1):83. doi: 10.1186/s12905-022-01666-5. pmid: 35313876
[10]	中国妇幼保健协会生育力保存专业委员会, 中国医疗保健国际交流促进会生殖医学分会. 子宫内膜异位症相关不孕诊治专家共识(2025年)[J]. 中华生殖与避孕杂志, 2025, 45(12):1221-1231. doi: 10.3760/cma.j.cn101441-20250729-00320.
[11]	Becker CM, Bokor A, Heikinheimo O, et al. ESHRE guideline: endometriosis[J]. Hum Reprod Open, 2022, 2022(2):hoac009. doi: 10.1093/hropen/hoac009.
[12]	Alborzi S, Askary E, Poordast T, et al. Relation of Endometrioma and Deep Infiltrating Endometriosis Surgery on Ovarian Reserve: A Large Single-Centre, Cross-Sectional Study[J]. Int J Fertil Steril, 2025, 19(4):360-365. doi: 10.22074/ijfs.2025.2034762.1723. pmid: 41090419
[13]	Grigoriadis G, Daniilidis A, Pitsillidi A, et al. Evidence on Serum Anti-Müllerian Hormone Levels and Endometriosis Surgery[J]. J Clin Med, 2025, 14(11):3772. doi: 10.3390/jcm14113772.
[14]	Dunselman GA, Vermeulen N, Becker C, et al. ESHRE guideline: management of women with endometriosis[J]. Hum Reprod, 2014, 29(3):400-412. doi: 10.1093/humrep/det457.
[15]	Daraï E, Marpeau O, Thomassin I, et al. Fertility after laparoscopic colorectal resection for endometriosis: preliminary results[J]. Fertil Steril, 2005, 84(4):945-950. doi: 10.1016/j.fertnstert.2005.04.037. pmid: 16213848
[16]	Meuleman C, D'Hoore A, Van Cleynenbreugel B, et al. Outcome after multidisciplinary CO₂ laser laparoscopic excision of deep infiltrating colorectal endometriosis[J]. Reprod Biomed Online, 2009, 18(2):282-289. doi: 10.1016/s1472-6483(10)60267-2.
[17]	Donnez J, Squifflet J. Complications, pregnancy and recurrence in a prospective series of 500 patients operated on by the shaving technique for deep rectovaginal endometriotic nodules[J]. Hum Reprod, 2010, 25(8):1949-1958. doi: 10.1093/humrep/deq135.
[18]	Kavallaris A, Chalvatzas N, Hornemann A, et al. 94 months follow-up after laparoscopic assisted vaginal resection of septum rectovaginale and rectosigmoid in women with deep infiltrating endometriosis[J]. Arch Gynecol Obstet, 2011, 283(5):1059-1064. doi: 10.1007/s00404-010-1499-9. pmid: 20458487
[19]	Douay-Hauser N, Yazbeck C, Walker F, et al. Infertile women with deep and intraperitoneal endometriosis: comparison of fertility outcome according to the extent of surgery[J]. J Minim Invasive Gynecol, 2011, 18(5):622-628. doi: 10.1016/j.jmig.2011.06.004.
[20]	Ouafdi H, Dabi Y, Touboul C, et al. Major Postoperative Complications After Endometriosis Surgery: Incidence and Outcomes From a Multicenter French Cohort[J]. J Minim Invasive Gynecol, 2026 Apr 3:S1553-4650(26)00230-X. doi: 10.1016/j.jmig.2026.03.040. Epub ahead of print.
[21]	Colombi I, Ginetti A, Cannoni A, et al. Combine Surgery and In Vitro Fertilization (IVF) in Endometriosis-Related Infertility: When and Why[J]. J Clin Med, 2024, 13(23):7349. doi: 10.3390/jcm13237349.
[22]	Riemma G, García-Velasco JA, Abrão MS, et al. IVF/ICSI or surgery as first approach for the treatment of infertility associated with ovarian and deep infiltrating endometriosis? A systematic review and meta-analysis[J]. Reprod Biomed Online, 2026, 52(2):105178. doi: 10.1016/j.rbmo.2025.105178.
[23]	Maignien C, Santulli P, Bourdon M, et al. Deep Infiltrating Endometriosis: a Previous History of Surgery for Endometriosis May Negatively Affect Assisted Reproductive Technology Outcomes[J]. Reprod Sci, 2020, 27(2):545-554. doi: 10.1007/s43032-019-00052-1. pmid: 32046438
[24]	Benaglia L, Reschini M, Ottolina J, et al. O-249 Surgery versus IVF for the treatment of infertility associated to ovarian and deep endometriosis (SVIDOE). Preliminary results from a multicenter randomized controlled trial[J]. Hum Reprod, 2025, 40(Suppl 1):deaf097.249. doi:10.1093/humrep/deaf097.249.
[25]	Ballester M, Roman H, Mathieu E, et al. Prior colorectal surgery for endometriosis-associated infertility improves ICSI-IVF outcomes: results from two expert centres[J]. Eur J Obstet Gynecol Reprod Biol, 2017, 209:95-99. doi: 10.1016/j.ejogrb.2016.02.020. pmid: 26965272
[26]	Bianchi PH, Pereira RM, Zanatta A, et al. Extensive excision of deep infiltrative endometriosis before in vitro fertilization significantly improves pregnancy rates[J]. J Minim Invasive Gynecol, 2009, 16(2):174-180. doi: 10.1016/j.jmig.2008.12.009.
[27]	Centini G, Afors K, Murtada R, et al. Impact of Laparoscopic Surgical Management of Deep Endometriosis on Pregnancy Rate[J]. J Minim Invasive Gynecol, 2016, 23(1):113-119. doi: 10.1016/j.jmig.2015.09.015.
[28]	Capelle A, Lepage J, Langlois C, et al. Surgery for deep infiltrating endometriosis before in vitro fertilization: no benefit for fertility?[J]. Gynecol Obstet Fertil, 2015, 43(2):109-116. doi: 10.1016/j.gyobfe.2014.12.003. pmid: 25595945
[29]	Supramaniam PR, Mittal M, Becker C, et al. The Effect of Surgery on Endometriomas on Fertility (2025 Second Edition): Scientific Impact Paper No 55[J]. BJOG, 2025, 132(11):e175-e184. doi: 10.1111/1471-0528.18221.
[30]	Bafort C, Beebeejaun Y, Tomassetti C, et al. Laparoscopic surgery for endometriosis[J]. Cochrane Database Syst Rev, 2020, 10:CD011031. doi: 10.1002/14651858.CD011031.pub3.
[31]	Khan S, Lee CL. Treating Deep Endometriosis in Infertile Patients before Assisted Reproductive Technology[J]. Gynecol Minim Invasive Ther, 2021, 10(4):197-202. doi: 10.4103/GMIT.GMIT_154_20. pmid: 34909375