不妊治療の光と影

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Remarkable progress in reproductive medicine has been taken place in the latter half of the 20th century. These progress is compared to "Light" bringing glad tidings to in fertile couples. Now we can use several regimen of ovulation induction for anovulatory patients. Clomiphene citrate and hMG have a higt pregnancy rate for hypothalamic anovulation. Laparoscopic surgery is a useful method for patients with polycystic ovary syndrome (PCOS). Hyperprolactinemia has been revealed to be responsible for anovulation. Bromocriptin lowers serum PRL level and restores ovulation in hyperprolactinemic patients. Assited reproductive technologies (ART) including IVF-ET and ICSI have been developed for patients having tubal factor or severe male factor, and these techniques are effective for infertile couples. On the other hand, we are confronted with "Shadow" of reproductive medicine : outbreak of side effects of multiple pregnancy and ovarian hyperstimulation syndrome (OHSS). Rate of multiple pregnancy has been elevating in accordance with wide use of reproductive medicine. Multiple pregnancy and OHSS have become an object of public concern. Especially with the wide uses of ART and induction of ovulation, side effects have increased. We have developed possible methods for reducing these side effect. Low dose-FSH therapy and FSH-pulsatile GnRH therapy are effective methods to reduce the side effects in induction of ovulation. These methods have high ovulation rates and pregnancy rates equal to conventional hMG therapy, and yet have lower rates of multiple pregnancy and OHSS. Both methods are also useful for higt risk patients such as PCOS. In ART, to limit the number of transferred embryo is effective for reducing multiple pregnancy. Blastcyst stage transfer has a higt pregnancy rate even if the number of embryo is limited to two. OHSS in ART is considerably preventable by reducing hCG administration in stimulated cycle. Cryopreservation of all embryos is useful in hCG cutback and lowers incidence of OHSS. Preserved embryos are transferred in non-stimulated, cycles and pregnancy rate of these cycle is as high as subsequent ET in the same cycle. Progesterone suppository as luteal support is also a useful method to prevent OHSS. Ethical problems in reproductive medicine have been attracted public attention recently. Our research revealed that number of reduction of multiple pregnant embryos has been increasing year by year in Japan. Perinatel outcome of patients who received reduction was better than that of patients who went on with supertwin pregnancies. However, we must always keep it in mind that the embryo reduction includes many unsolved problems. We have to study further to reduce the occarrence of multiple pregnancy itself. Oocyte donation also includes many unsettled problems. Prior to the approval of oocyte donation, we must seek a thorough practice of informed consent by counselor, establishment of legal metterrs of babies and recruitment of voluntary donors. The advance of medicine has enabled us to develop a new technology on reproductive treatment. However we must not introduce it immediately without consideration or discussion among people of all walks of life, even if some patients desire it and we can do it. I would like to send a message to gynecologists who are going to play an important role in the reproductive medicine of the 21th century ; We have acquired light in latter half of the 20th century, but it has brought shadow to be solved. We should not pursue light alone, but bring the shadow to light solving the problems among physicians, patient and public.
2000-08-01

不妊治療の光と影

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