752M-001C 男性不孕症:國內第一本探討男性不孕症專書

ϫᐂ ү۰ᖎ̬ .................................................................................. iii நְ‫ܜ‬Ԕ .................................................................................. ix 1 ᄂ៉շّ̙θ෧ᒚ۞࿅ΝăனдᄃϏֽ ........................ 1 œ 2 շّϠതր௚ ................................................................... 4 œ 3 շّ̙θ̝߹Җঽጯ̈́ঽЯ ............................................ 9 œ 4 ჟ୵̶‫ ژ‬.......................................................................... 16 œ 5 ჟ̄ං͌া ...................................................................... 21 œ 6 ჟ̄߿જ˧̙֖া .......................................................... 25 œ 7 ჟ̄་ԛা ...................................................................... 29 œ 8 ԩჟ̄ԩវᄃշّ̙θা .............................................. 32 œ 9 շّ‫ک‬Ԍ྽ຏߖᄃϨҕ஧ჟ̄া .................................. 35 œ 10 ൑ჟ̄া .......................................................................... 39 œ 11 ̙θাշّ۞ෲႬᄋෞҤ .............................................. 43 œ

நְ‫ܜ‬Ԕ ّΑਕᅪᘣᄃշّ̙θাߏշّጯ۞˟̂͹߹Ą޵ 1998 ѐ˾ ‫ڇ‬ᘽ˯ξĂ‫ݎ‬੓Αਕᅪᘣ۞ۢᙊᄃ‫ڼ‬ᒚд࿅Ν˩ೀѐ̚ѣ።Ϋّ ۞ซणĄТॡมӄθԫఙ۞൴‫ځ‬Ă˵ග̙θা۞‫ڼ‬ᒚ૲ֽࢭ‫ّ׻‬ ۞ซणĄ ࠎ˞ჟӉඕЪјΑĂࣧώՏѨౌᅮࢋજࣶ˯ᆆ۞Ķჟķঔጼ ఙĂᖣϤӄθԫఙΪᅮࢋಏ˘ჟ̄ӈਕјΑĂឰѣᖪᖪП፟۞շ ّ଀ͽ˘๪ࠎˠͭ۞ေຐĄ‫ݎ‬੓Αਕᅪᘣ۞˾‫ڇ‬ᘽᄃӄθԫఙĂ ֭Ⴭࠎ 20 ͵ࡔ౵ઈ̂۞˟ีᗁጯ൴‫ځ‬Ą ̙θাߏ‫ک‬Ԍࡊ‫ܝ‬෧૱֍۞યᗟ̝˘Ăࡗ 15% ۞͈‫؍‬ѣѩӧ ᙱĄĶ̙ԂѣˬĂ൑‫̂ࠎޢ‬ķ Ă઼̚ˠ็‫؟‬ତ΃۞ᑅ˧੼‫ٺ‬Ҙ͞ ۤົĂග̙θা͈‫ֽ૲؍‬ం̂۞͕நᑅ˧Ą ̙θাሕᖟ۞়ঽۢᙊă෧ᕝԫμᄃ‫ڼ‬ᒚౌ‫ܧ‬૱ኑᗔĄ˘ా Қ۞ᑭߤᄃ٩ҕᇴፂĂ‫ߏغז‬ϒ૱ᔘߏ̙ϒ૱ĉତ˭ֽިᆃᏱĉ ̂кᇴ۞ঽଈऻُౌ˘ᐝᙳͪĄഇ‫ޞ‬ᗁरд‫ܧ‬૱ѣࢨ۞࠻෧ॡม ̰ਕྋᛖ୻຾Ăԓ୕ऻُ঍Η˵ົར۩Ą ઄тਕѣ˘ώૉͪ໤۞३ᚱֻዦ᝝ĂధкႷೊٕధΞ‫҃˺ܓ‬ ྋĂΞଓĂӪมଂϏѣ̬௜շّ̙θা۞኎ି३ᚱĄ

xii

շّ̙θা Ъ੃ဦ३΍‫ ۤۍ‬൴Җ

12 ّཛྷ‫ו‬፬৵Ҳ૱ٙᄵ൴۞ّཛྷҲ૱ .............................. 50 œ 13 ੼‫֯ک‬৵ҕা .................................................................. 55 œ 14 ߖҒវள૱ᄃշّ̙θা .............................................. 61 œ 15 Y ߖҒវព຋৿εᄃշّ̙θা ................................... 64 œ 16 Аّ͇ᗕ઎Ꮾჟგ৿ε .................................................. 67 œ 17 ߟ‫ڒ‬හপͩা .................................................................. 71 œ 18 46, XX շّা࣏ཏ .......................................................... 76 œ 19 ̙θাշّ۞ᇆညጯᑭߤ .............................................. 80 œ 20 շّ̙θা۞ᘽ‫ڼۏ‬ᒚ .................................................. 85 œ 21 ჟ৶ᐖਔѡૺ̈́‫ڼ׎‬ᒚ .................................................. 89 œ 22 ᏮჟგГତ͘ఙ̈́Ꮾჟგઘ༝ӚЪ͘ఙ ...................... 93 œ 23 ઘ༝˱ᄃ༝˱ჟ̄ᕜ‫פ‬ఙ .............................................. 98 œ 24 डჟგ‫ܡ‬๫̝ঽЯ̈́‫ڼ׎‬ᒚ ........................................ 102 œ 25 ࿪፬‫פ‬ჟఙ .................................................................... 106 œ 26 ̙θাᄃّΑਕᅪᘣ .................................................... 111 œ 27 ᒖဩ੼໢‫ٽ‬ጱ࡭շّ̙θ ............................................ 114 œ 28 ᔳ༝া၆շّ̙θ̝ᇆᜩ ............................................ 117 œ

ϫᐂ Ъ੃ဦ३΍‫ ۤۍ‬൴Җ

xiii

29 ٩ඵᄃշّ̙θা ........................................................ 120 œ 30 ฼੧ᄃշّ̙θা ........................................................ 122 œ 31 ᒉዳᄃշّ̙θা ........................................................ 124 œ 32 ۲ࡡᄃշّ̙θা ........................................................ 126 œ 33 ྻજᄃշّ̙θা ........................................................ 128 œ 34 ඊ࿪‫͘׶‬፟۞̙༊ֹϡᄃշّ̙θা ........................ 131 œ 35 ͕நᑅ˧ᄃշّ̙θা ................................................ 134 œ 36 Ѯߖᄃշّ̙θা ........................................................ 137 œ 37 ๬̼጗ᄃշّ̙θা .................................................... 139 œ 38 ˠ̍Ϡതԫఙдշّ̙θা۞ᑕϡ ............................ 149 œ 39 ჟ̄ᅙҖᄃᄂ៉ჟ̄ॕᙑ۞ன‫ ڶ‬................................ 153 œ 40 շّ̙θ۞Ꮩથ ............................................................ 160 œ ‫ܢ‬ᐂ ᄂ៉շّጯᗁጯົ̝շّ̙θ‫ڼ‬ᒚ޽͔ .................... 164

1

ᄂ៉շّ̙θ෧ᒚ۞ ࿅ΝăனдᄃϏֽ ү۰Ęѯ႔ᓏ ᗁर

ଂ࿅Ν‫ז‬னдĂᄂ៉շّ̙θ෧ᒚ۞α֧࣎඀༫Ξͽྏᑢт ˭ٙЕĈ

็௚ٕགྷរᒚ‫۞ڱ‬ॡ΃

1960 ѐͽ݈

၁ᙋ෧ᒚฟؕ۞ѐ΃

1960-1980

շّ̙θјࠎշࡊ۞૞ຽ

1980-1993

ྏგϠതࡊԫ‫ ׶‬ICSI

1993 ͽ‫ޢ‬

д็௚ᒚ‫ڱ‬ॡ΃Ƃᄂ៉շّ̙θ෧ᒚ۞পᕇߏĈ 1. ՟ѣ૞ຽ ۞ۢᙊ‫׶‬ᗁᒚĂϔிֶᏥ۞ߏˠ̠Ϻ̠۞ઐ͞Ăᗁर۞఍͞˵к ᛳ‫ٺ‬གྷរᒚ‫ڱ‬Ą 2. ̃ˠࠎ͹۞̙θ෧ᒚĄࡇѣ͌ᇴ۞‫ک‬ԌࡊᗁϠ ણᄃշّᗁጯ۞෧ᒚĂΒ߁˘̈ొ̶ᗁϠ၆շّ̙θѣᎸ኷Ă΁ ࣇ˵ઇۤົ˯۞‫ିّ׌‬ֈĂឰϔி၆‫ّ۞ّ׌‬ϠநăϠതѣྵૄ ώ۞ໄ‫ه‬Ą

2

շّϠതր௚ ү۰Ę‫ڒ‬ϖ‫ ځ‬ᗁर

շّϠതր௚Β߁˞༝˱ (testis)ăઘ༝˱ (epididymis)ăᏮჟ გ (vas deferens)ăडჟგ (ejaculatory duct)ăᐼჟᝃ (seminal vesicle)ăᛷ᜕ཛྷ (prostate)ăԌ྽஧ཛྷ (bulbourethral gland) ඈĞтဦ 2-1ğĄ‫̚׎‬༝˱۞ΑਕΒ߁˞ᄦౄჟ̄ᄃயϠ༝‫( ⟮׽‬testosterone)Ąдࡣࡩ൴ֈ۞࿅඀̚Ă༝˱۞൴ֈՙ‫ߏٺؠ‬ӎѣ Y ߖҒ វ̈́ Y ߖҒវ˯ߏӎѣ SRY ૄЯĄ ༝˱జ˘࣎‫ݓ‬၁۞ඕ቙௡ᖐٙΒᖬĂჍࠎϨቯĄଂϨቯ‫ؼ‬ҩ ΍۞ඕ቙௡ᖐ૟༝˱ထ̶ј̂ࡗ 250 ࣎̈ཧĂՏ࣎̈ཧ̰ѣ 1 Ҍ 4 ୧௟ჟ̈გ (seminiferous tubule)ĂՏ˘୧௟ჟ̈გ‫ ࡗܜ‬50 ̶̳Ă ᜇᖒд̈ཧ̰Ăჟ̄۞ᄦౄಶд௟ჟ̈გ̰ԆјĞтဦ 2-2ğ Ą ჟ̄۞ᄦౄд௟ჟ̈გ̝˯ϩ௟ࡪ (epithelium) ԆјĄ˯ϩ ௟ࡪ۞௡јΒ߁Ϡത௟ࡪ (germ cell) ᄃΫћӀ௟ࡪ (Sertoli cell) Ğтဦ 2-3ğ ĄΫћӀ௟ࡪࠎ˘͚޺ّ௟ࡪĂ͚޺˞௟ჟ̈გ۞ၹ ౄĂιТॡ˵ߏ௟ჟ̈გ۞ᒉዳ௟ࡪĂ̙ᕝ۞೩ֻዳ̶ගϠത௟ ࡪĂֹܳϠത௟ࡪ൴ֈјჟ̄Ą

շّ̙θ̝ ߹Җঽጯ̈́ঽЯ

3

ү۰ĘૺԈѯ ᗁर

շّ̙θ̝߹Җঽጯ௚ࢍྤफ़ ֶፂᄂ៉շّጯᗁጯົĂ̙θ̈௡д 2011 ѐ੫၆ᄂ៉гડշ ّ̙θাᓜԖপᇈ̶‫۞ژ‬ಡӘĄᇹώᄓะଂϔ઼˝˩˛ѐ˘͡Ҍ ˩˟͡ࠎഇ˘ѐĂϤέ̂ăέΔၷᓁăΔᗁăາЍ̈́ј̂ᗁੰ̝ շّᗁጯົ̙θ̈௡јࣶВТԆјĂВᄓะ 308 ЩᇹώซҖ௚ࢍ ̶‫ژ‬Ą Ր෧۞̙θշّĂঽΫѣ 1 ‫ ז‬2 ѐĂΚ 56% ࠎ౵кĂ 3 ѐΚ 12.7% Ă 4 ѐΚ 6.0% Ă 5 ѐΚ 7.3% Ą ܑ 3-1

Ꭾଈ̙θঽΫ̝ॡม̶Ҷ‫ڶې‬ ঽΫѐᇴ

ˠᇴ

Ѻ̶ͧ

<1 1-2 2-3 3-4 4-5 5-6 >6

2 42 42 19 9 11 26

1.3 28.0 28.0 12.7 6.0 7.3 17.4

4

ჟ୵̶‫ژ‬ ү۰Ę‫ ޜ؟ڒ‬ᗁर

ٙᏜჟ୵̶‫( ژ‬semen analysis)Ăಶߏ૟շّಏѨड΍۞ჟ ୵Ăਖ਼Ҍ၁រ‫̼ވ‬រ̶̈́‫ژ‬Ąѩ˘ՎូĂੵ˞Ξͽ˞ྋྍҜշّ ჟ୵̚ჟ̄۞хдଐԛ̈́ჟ̄۞‫ݡ‬ኳĂ˵ΞͽᑒӄԧࣇᎡᑭ‫׎‬Ϡ ത྽Ξਕхд۞યᗟ়ٕঽĄЯѩĂჟ୵̶‫ߏژ‬ෞҤշّϠതਕ ˧˘࣎ࢦࢋ۞̍‫׍‬Ă͍‫׎‬дշّ̙θাଈ۰۞෧ᕝ˯ĂՀԷႊ࠹ ༊ࢦࢋ۞֎ҒĄ

ჟ୵۞ଳะ ჟ୵̶‫˘ژ‬ฟؕ౵ࢦࢋ۞ՎូĂಶߏ‫ྏצ଀פ‬۰۞ჟ୵ĂЯ ̶‫۞ژ‬ඕ‫ڍ‬ट‫זצٽ‬ଳะ͞ё۞ᇆᜩĂ߇ϒቁ۞ଳะ͞ёĂΞͽ ᑒӄԧࣇ଀‫ז‬Հ໤ቁ۞ᇴፂĄͽ˭‫ܮ‬Е΍ଳะჟ୵ٙυื‫ڦ‬ຍ۞ ೀีࢦᕇĈ 1. ଳะჟ୵݈༰ᇒ 2~7 ͇Ą ༰ᇒ۞ॡม͉ൺĂჟ୵ณ̈́ჟ̄ᇴณົഴ͌ć҃༰ᇒ۞ॡม͉ ‫ܜ‬Ă‫݋‬ჟ̄߿જ˧Ξਕົ˭ࢫĄ

5

ჟ̄ං͌া ү۰Ęች‫۾‬Ϡ ᗁर

݈֏ ෧ᕝշّ̙θাॡĂ౵ࢦࢋ۞˘ีᑭរಶߏჟ୵̶‫ژ‬Ąдჟ ୵̶‫̚ژ‬Ăົѣͽ˭Чણᇴ۞ീณඕ‫ڍ‬Ğҭ่̙ࢨ‫ٺ‬дѩٙЕ ۞ğĈჟ୵ณ (semen volume)ăᓁჟ̄ᇴ (total sperm number)ă ჟ̄፧‫( ޘ‬sperm concentration)ăᓁ߿જ˧ (total motility)ăѣड़߿ જ˧ (progressive motility)ăх߿‫( ޘ‬vitality)ăჟ̄ԛၗ (sperm morphology)Ăͽ̈́ᅕែ‫( ޘ‬pH value)Ą ఺ֱણᇴ۞ϒ૱ࣃߏགྷϤ̶‫̂ژ‬ఢሀ۞ࡁտඕ‫ڍ‬ٙ଀΍Ğ͵ ࠧ኎Ϡ௡ᖐ 2010 ѐğ Ă‫׎‬ϒ૱ࣃ۞˯ă˭ࢨЧߏ΃ܑ 95 Ѻ̶Ҝᇴ (percentile) ̈́ 5 Ѻ̶ҜᇴĄࢋ‫ڦ‬ຍ۞ߏЯࠎ࣎ˠჟ୵‫ݡ‬ኳົᐌॡ มԼតĂ߇ჟ୵̶‫̙ژ‬ਕΪઇ˘ѨĂ҃ߏᅮҌ͌ેҖ˟ƂˬѨĂ ྵਕ‫࣎଀פ‬ˠჟ୵‫ݡ‬ኳ۞ૄ໤ࣃ (baseline data)Ą

6

ჟ̄߿જ˧ ̙֖া ү۰Ęች‫۾‬Ϡ ᗁर

݈֏ дჟ୵‫ݡ‬ኳ̶‫۞ژ‬ણᇴ̚Ăᄃҋ൒ᘃθѣᙯ۞‫࣎׌‬ણᇴಶߏ ჟ̄߿જ˧ĞΒ߁ᓁ߿જ˧ (total motility) ᄃѣड़߿જ˧ (progressive motility)ğ Ą఺ᕇд‫ܕ‬ഇٙ൴ܑ۞͛ᚥ̚ĞBuck Louis ඈጯ۰ 2013 ѐ̈́ Bjorndahl ି଱ 2010 ѐ۞ኢ͛ğ ĂΞͽԱ‫ז‬ᙋፂĄ͍‫ߏ׎‬ ྻϡˠ̍Ϡത۞јΑத˵ᄃჟ̄߿જ˧ि​ि࠹ᙯĂՀព΍ჟ̄߿ જ˧дߙֱ඀‫ܑ΃˯ޘ‬඾ჟ̄۞‫צ‬θ˧Ą

‫ؠ‬ཌྷ дീณჟ̄߿જ˧ॡĂॲፂ౵າ۞͵ࠧ኎Ϡ௡ᖐ 2010 ѐ۞ᇾ ໤Ăߏ૟ჟ̄ѣ‫ځ‬ពഫજĞྮशࠎۡቢٕ̂๪ԛğ۞ჟ̄ᇴϫҫ Бొჟ̄۞ᇴϫּͧ‫ؠ‬ཌྷࠎѣड़߿જ˧ (progressive motility)ć҃ Бొົજ۞ჟ̄ᇴϫҫБొჟ̄۞ᇴϫּͧಶߏᓁ߿જ˧ (total motility)Ą҃ѣड़߿જ˧ᇾ໤۞˭ࢨĞ5 Ѻ̶Ҝᇴğࠎ 32% Ăᓁ߿ જ˧ᇾ໤۞˭ࢨࠎ 40% Ą˲ߏҲ‫ٺ‬ѩ˟ણᇴᇾ໤۞˭ࢨĂಶჍ̝ ࠎჟ̄߿જ˧̙֖া (asthenozoospermia)Ą

7

ჟ̄་ԛা ү۰Ę‫ڒ‬ϖ‫ ځ‬ᗁर

̦ᆃߏჟ̄་ԛা ჟ̄་ԛা (teratozoospermia) ᖎಏ۞ᓾಶߏჟ̄۞‫ݭ‬ၗ̙ϒ ૱Ąॲፂ͵ࠧ኎Ϡ௡ᖐ‫ ٺ‬2010 ѐ̳ٙҶ̝ௐ̣‫ۍ‬ჟ୵̶‫ژ‬ણ҂ᇾ ໤ࣃ (reference value)âҜշّ̝ჟ̄ࡶֶ໰ Kruger/Tygerberg ጯ۰ٙ೩΍۞ᚑॾᇾ໤ֽᑭߤĂჟ̄۞‫ݭ‬ၗ௑Ъྍᇾ໤۞ࠎϒ૱ ჟ̄Ăٙᑭߤ۞ჟ̄̚ĂΪࢋඈ‫ ٺٕ̂ٺ‬4% ̝ჟ̄γ‫ݭ‬ϒ૱Ă ӈࠎϒ૱Ą࠹ͅ۞Ăٙᑭߤ۞ჟ̄̚Ă̈‫ ٺ‬4% ۞ჟ̄‫ݭ‬ၗϒ ૱Ăಶߏჟ̄་ԛাĄ

ࣃ଀˘೩۞ߏĂ Kruger/Tygerberg ጯ۰ٙ೩΍۞ෞҤ͞‫ྵڱ‬ ࠎኑᗔĂυᅮ‫ פ‬5-10 ຋̿۞ჟ୵ཉ‫˯ͯࠟٺٸ‬ĂͽߦͩߖҒ (Papanicolaou stain)Ăдព຋ᙡ‫ڵ‬ᙡ˭‫ ̂ٸ‬1000 ࢺĂ៍၅֭੃ᐂ Ҍ͌ 200 ੸ჟ̄۞‫ݭ‬ၗĄࡶ‫ܧ‬૞‫ܝ‬ଂְϠതԫఙ۞ᗁᒚੰٙâ ਠ۞ᗁੰᑭរ‫ٕވ‬ϔมᑭរಏҜĂ‫ޝ‬ᙱซҖ఺ᇹ۞ᑭߤĄ

8

ԩჟ̄ԩវᄃ շّ̙θা ү۰ĘዑྈϠ ᗁर

͈‫۞؍‬Їң˘͞૟ჟ̄༊ઇγֽ‫ۏ‬Ă‫ו‬፬Һࠪ௟ࡪயϠ၆ԩ ჟ̄۞ԩវĂপჍࠎԩჟ̄ԩវ (antisperm antibody)Ąॲፂ Cline ᗁरд 2009 ѐٙ൴ܑ۞ಡӘ̚޽΍Ă̂ࡗѣ 10-15% ۞շّ̙θ া‫ ࡗ׶‬15-20% ّ̙̃θাߏЯԩჟ̄ԩវ͔੓Ą̂ొ̶ϒ૱۞ ّ̙֭̃ົ၆Ω˘Η۞ჟ̄யϠԩჟ̄ԩវĂྎ௟ࣧЯϫ݈̪̙ ୻຾ĂΪਕᄲ˯‫ޓ‬౹ౄّ̃ତ‫צ‬շّĂග˞఺࣎ҺࠪপధĂˠᙷ ̖଀ͽᓄࢉϠϠ̙िĄࠎ̦ᆃົயϠԩჟ̄ԩវѣ‫ޝ‬кଯኢĂΒ ߁അགྷϠതր௚ຏߖঽΫĞт٣җෂğٕ۰ߏѣ༝˱͘ఙٕຫ๋ ঽΫĂٕഅགྷତ‫צ‬Ꮾჟგඕ௛͘ఙඈඈĂҭߏ̂ొ̶ࣧЯ̪̙‫ځ‬Ą շّ̃Ϲडჟ̝‫ޢ‬Ă˼༱ჟ̄̂࢕ᐌӈֽ‫̄ז‬झᐚ఺ௐ˘྽ ᙯΙĂ఺ॡт‫ڍ‬ѣԩჟ̄ԩវĂົ෭‫ܢ‬дჟܑ̄ࢬĂጱ࡭ჟ̄ົ జ̄झᐚᕆ୵᚜ၟጿд̄झට̝γĂჟ̄ಶ̙ਕ‫ז‬྿ᏮӉგᄃӉ ̄ඕЪĄԩჟ̄ԩវт‫ڍ‬ඕЪ‫ٺ‬ჟ̄۞ԍొ‫ࢫົ݋‬Ҳჟ̄۞߿જ ˧Ăಶზჟ̄စࣁ఼࿅̄झᐚ‫ז‬྿ᏮӉგĂ઄тჟ̄ᐝొܑࢬᕆ ѣԩჟ̄ԩវĂჟ̄˵̙‫ࡍٽ‬࿅Ӊ̄γಛ۞౅‫( ૲ځ‬zona pellucida) ᄃӉ̄‫צ‬ჟĂซ҃ౄј̙θĄΩγĂ͌ᇴԩჟ̄ԩវົ‫ו‬፬ ๝ّ̚Ϩҕ஧̈́λጥ௟ࡪ͔൴Һࠪͅᑕֽ৔ᗼჟ̄ϠјĂౄјჟ

9

շّ‫ک‬Ԍ྽ຏߖ ᄃϨҕ஧ჟ̄া ү۰Ęౘ࣒ཐ ᗁर

‫ک‬Ԍ྽ຏߖߏ‫ک‬Ԍࡊ‫ܝ‬෧˩̶૱֍۞়ঽ̝˘Ăͽշّ҃ ֏Ăд˘ਠ‫ک‬Ԍࡊ‫ܝ‬෧̚ĂΞਕ่Ѩ‫ٺ‬ඕϮᄃᛷ᜕ཛྷ۲̂âਠ ៍‫֏҃˯ه‬ĂϤ‫ٺ‬շ̃Ϡநၹౄ̙ТĂЯѩĂ‫ک‬Ԍ྽ຏߖкͽ̃ ّࠎ͹Ă҃ͷ͹ࢋߏͽާّ჻਋‫ܑۆ‬னĄͽշّ҃֏Ă‫ک‬Ԍ྽ຏ ߖт‫ֶڍ‬൴Ϡ۞ଐԛ̶ֽᙷĂ̂࡭˯Ξ̶ࠎާّ̈́ၙّ‫ᙷ̂׌‬Ă ҃ࡶͽ൴Ϡ۞ҜཉֽᄲĂ૱֍۞Ξ̶ࠎ჻਋‫ۆ‬ăᛷ᜕ཛྷ‫̈́ۆ‬༝˱ ̈́ઘ༝˱‫ۆ‬ඈೀ჌Ą‫׎‬૱֍া‫݋ې‬Β߁ѣᐛԌăྋԌূ൭ăྋԌ ӧᙱă൴፵ăࠦರăԌ୵஄፩ٕೋਙඈা‫ې‬Ăт‫ྵͧڍ‬ᚑࢦ۞ଈ ۰ࠤҌΞਕ΍னҕԌăᓘԌҌࠤҌЯԌྮր௚ຏߖ͔੓۞ୀҕা ඈĂӮѣΞਕ൴ϠĄΩγĂдা‫̶ొ࣎఺ې‬ĂυืপҾᄲ‫ߏ۞ځ‬ т‫ڍ‬ѣާّᛷ᜕ཛྷ൴‫ۆ‬Ă૱ົҡᐌѣ྆ާ‫۞ࢦޢ‬া‫ې‬΍னĂੵѩ ̝γĂࡶᛷ᜕ཛྷ൴‫ۆ‬ซणјࠎၙّᛷ᜕ཛྷ൴‫ۆ‬Ăଈ۰૱ົЯЧ჌ ଵԌা‫҃ې‬Ҍ‫ܝ‬෧ಶ෧ĂΒ߁ѣᐛԌăྋԌӧᙱăົౚొূ൭ٕ ණ൭ă˭ཛొূ൭ඈা‫ې‬΍னĂЯѩĂд੫၆ѩᙷଈ۰‫ڼ‬ᒚ˯Ă ᗁर‫ܮ‬ᅮՀྎ௟г˞ྋଈ۰۞࿅ΝঽΫĂͧྵਕૉઇ΍ϒቁ۞෧ ᕝĄ༊൒Ăѣ͌ᇴշّଈ۰ߏЯࠎඪ۟ඪ‫ۆ‬ĞܸჍඪ᝙൴‫ۆ‬ğ҃ Ҍ‫ܝ‬෧Ր෧Ă҃Ϥ‫఼ٺ‬૱ѩᙷଈ۰૱Ъ‫׀‬ѣԌྮր௚‫ܡ‬๫Ğтඕ

10

൑ჟ̄া ү۰Ę‫ڒ‬ϖ‫ ځ‬ᗁर

1992 ѐĂ༊̙θা۞‫ڼ‬ᒚซˢಏ˘ჟ̄ព຋‫ڦ‬ड (intracytoplasmic sperm injection, ICSI) ̝‫ޢ‬Ăྋՙ˞ధкշّჟ̄ං͌া ۞યᗟĄЯࠎΪࢋጴᖣ඾˘੸ჟ̄Ăಶѣ፟ົͽ ICSI ˠ̍Ϡതࡊ ԫૻ࢝‫צ‬ჟĂ҃྿‫ז‬ᘃθ۞ϫ۞Ą‫ܕ‬ѐֽ̏ѣధк۞ ICSI ᚗᚗౙ ᜈኚϠĄҭߏдշّ̙θা۞ଈ۰̚Ă̪ѣ 15-20% ߏᛳ‫ٺ‬൑ჟ ̄া (azoospermia)ĄϺӈĂдଈ۰ٙड΍۞ჟ୵̚Ա̙‫ז‬Їңჟ ̄Ą‫ޝ‬ព൒۞Ă΁ࣇ൑‫ۡڱ‬ତӀϡ ICSI ԫఙ྿‫צז‬θ۞ϫ۞Ą

൑ჟ̄া۞෧ᕝᄃࣧЯ ൑ჟ̄া۞෧ᕝυᅮѣҌ͌‫׌‬Ѩჟ୵̶‫۞ژ‬ᑭវĂགྷ࿅ᗓ͕ ‫ޢ‬Ă‫˭פ‬ᆸᗓ͕Օ፥‫ۏ‬ᑭរߏ൑ჟ̄۞ᑭរඕ‫ڍ‬Ą ౄј൑ჟ̄া۞ࣧЯҌ̫̪ϏԆБ‫ځ‬ᒢĂֶঽЯΞ̶ј༝˱ ݈ă༝˱ᄃ༝˱‫ޢ‬Ą૱֍۞ࣧЯΒ߁ߖҒវள૱ăჟ྽൴‫ۆ‬ă̙ ༊۞͘ఙγ๋ă੼໢ăА͇ྋ࣠ၹౄள૱ăјˠམཛྷ‫ۆ‬ă‫ߋܦ‬ഇ ൴ֈ̙։ăᔳ༝াă༝˱ԮᖼăෲႬᄋள૱ăᏬड໰डăૄЯள ૱ඈĄᓜԖ˯Ă̪ѣధкଈ۰ᛳ‫ࣧٺ‬Я̙‫ځ‬Ą

11

̙θাշّ۞ ෲႬᄋෞҤ ү۰ĘเԠኰ ᗁर

݈֏ շّ۞ϠതΑਕΞ̶ࠎჟ̄۞ᄦౄᄃჟ̄۞ྻਖ਼‫̶ొ̂׌‬Ą ჟ̄ᄦౄ۞Ҝཉߏ༝˱Ąჟ̄ᄦౄԆј‫ޢ‬ĂజᏮਖ਼‫ז‬ઘ༝ĂГ‫ڻ‬ Ꮾჟგਖ਼‫ז‬डჟგ‫׶‬Ԍ྽̚ĄᖣϤౚఀ‫ݎ‬੓ᄃडჟ۞જүĂ૟ჟ ̄ଵ΍វγĂ҃አଠჟ̄ᄦౄ۞Я̄Ă‫˘ߏ݋‬इ࠹̢ᇆᜩ۞ෲႬ ᄋր௚Ą఺࣎ր௚ଂ౵˯ഫ۞˭ෛ͸Ğhypothalamus ĂҜ‫ٺ‬มཝ ˭͞ğ Ă‫̚ז‬ഫ۞ཝ˭ཛྷ (pituitary gland)ĂГ‫˭ז‬ഫ۞༝˱มኳ (testicular interstitium)Ăԛј˘࣎ˬ࣎ᆸ৺۞ෲႬᄋአଠր௚Ăଠ ‫ט‬඾ჟ̄۞ϠјĞ֍ဦ 11-1ğ Ą

˭ෛ͸۞ෲႬᄋ ˭ෛ͸ΞᄲߏϠതෲႬᄋ۞༼‫ޠ‬ᕇĂд˭ෛ͸྆ࢬ۞ৠགྷ̮ ົ༼‫ّޠ‬гăฉഇّг̶‫ک‬Ķّཛྷ‫ו‬፬৵ᛖ‫ٸ‬৵ķ ĂᖎჍĶّᛖ ৵ķ Ğgonadotropin releasing hormone Ăᒺᆷ GnRHğ ĂѩෲႬᄋົ ‫ו‬፬ཝ˭ཛྷ݈ཧ (anterior pituitary) ۞௟ࡪĂֹ‫ّک̶׎‬ཛྷ‫ו‬፬৵ (gonadotropins)ĂГΝ‫ו‬፬Հ˭ഫ۞༝˱Ą

12

ّཛྷ‫ו‬፬৵Ҳ૱ ٙᄵ൴۞ّཛྷҲ૱ ү۰ĘเԠኰ ᗁर

݈֏ ّཛྷ‫ו‬፬৵̶‫ک‬ณ࿅ҲĂТॡ༝⟮̶‫ک‬ณ˵ໂҲ۞ଐԛĂΨ ઇĶّཛྷ‫ו‬፬৵Ҳ૱ٙᄵ൴۞ّཛྷҲ૱ķ(hypogonadotropic hypogonadism)Ą఺჌ଐԛયᗟ΍дཝ˭ཛྷ۞ّཛྷ‫ו‬፬৵̶‫̙ک‬ ֖Ą‫ࣧ׎‬ЯΞͽߏࣧ൴ّĞidiopathic Ăٕ primary Ă˫ჍࠎА͇ ّĂࡻ͛ߏ congenitalğ ĂٕߏѨ൴ّĞsecondary Ă˫Ⴭ‫ّ͇ޢ‬Ă ࡻ͛ߏ acquiredğ Ąͽ˭ಶ‫׎‬ᓜԖܑனᄃ‫׌‬჌̶ᙷ۞ͧྵү˘ᄲ ‫ځ‬ĂТॡ၆‫ڼ׎‬ᒚ͞‫ڱ‬ᄃ‫ڼ‬ᒚΞਕ۞࿰ഇඕ‫ڍ‬ઇ˘ፋநĄ

ّཛྷ‫ו‬፬৵Ҳ૱ٙᄵ൴۞ّཛྷҲ૱۞ᓜԖ ܑன ᓜԖܑனͽّཛྷҲ૱۞া‫ࠎې‬͹ĄΒ߁ّᇒҲăّΑਕε አăБ֗൑˧ăវͨංழඈĄ‫΁׎‬া‫ې‬ᅮॲፂঽଈߏࣧ൴ّٕѨ ൴ّ۞়ঽ҃‫ؠ‬Ą

13

੼‫֯ک‬৵ҕা ү۰ĘเԠኰ ᗁर

݈֏ ੼‫֯ک‬৵ҕা (hyperprolactinemia) ߏ޽ҕ̚‫֯ک‬৵ (prolactin) ፧‫ޘ‬࿅੼۞˘჌ঽၗĄঽଈ૱‫׀‬൴ѣّཛྷΑਕҲ૱ (hypogonadism) ۞ଐԛĂጱ࡭ّΑਕᅪᘣ (erectile dysfunction) ᄃ̙θা ۞யϠĄώౢ૞‫ܝ‬੫၆‫֯ک‬৵۞Αਕᄃ‫ک̶׎‬አଠĂᄃ‫֯ک‬৵ᄃ ϠതΑਕ۞ᙯܼઇ͹คĂГჸ൏д੼‫֯ک‬৵ҕাтң͔੓ّཛྷΑ ਕҲ૱۞፟ᖼĂͽ̈́ϫ݈၆੼‫֯ک‬৵ҕা۞࠹ᙯ‫ڼ‬ᒚซणĂᄃт ңԼචঽଈ۞ϠതΑਕઇ˘࣎எˢ୺΍۞ᄲ‫ځ‬Ą

‫֯ک‬৵۞Αਕᄃአଠ፟‫ט‬ ‫֯ک‬৵ߏཝ˭ཛྷ݈ཧ̶ٙ‫࣎˘۞ک‬ᷴ H ᙷෲႬᄋĂ‫׎‬үϡΞ ͽֹܳ֯ཛྷ۞൴ֈᄃ‫۞֯ک‬જүĂТॡ˵ણᄃϠതΑਕ۞຋አ ༼Ąд౦ᙷĂ‫֯ک‬৵ಶߏԷႊϠ‫ܜ‬፬৵۞Αਕćдࣲ֯ᙷĂ‫׎‬ඕ ၹ˵ᄃϠ‫ܜ‬፬৵࠹Ҭćд᜿ጎᙷજ‫ۏ‬Ăࡶ૟າϠ۞ρဂ̷ੵ‫׎‬ཝ ˭ཛྷ݈ཧĂТॡྃ·‫֯ک‬৵̝γ۞ٙѣ݈ཧෲႬᄋĂົ൴னρဂ

14

ߖҒវள૱ᄃ շّ̙θা ү۰Ę‫ڒ‬ϖ‫ ځ‬ᗁर

շّ̙θাΞਕᄃߖҒវள૱ѣᙯ ॲፂለ߷‫ک‬Ԍࡊᗁጯົ۞௚ࢍĂдշّ̙θা۞ଈ۰̚Ăࡗ ѣ 40%~50% ߏᛳ‫ࣧٺ‬Я̙‫̝ځ‬շّ̙θাĄᗁጯ૞छࣇ࠹‫ܫ‬Ă ఺ֱࣧЯ̙‫۞ځ‬ౄჟᅪᘣ఼૱ᄃߖҒវள૱ٕૄЯள૱ѣᙯĄ ॲፂଯҤĂѣᇴ˼࣎ૄЯᄃˠᙷ̝ϠതѣᙯĂҭߏϫ݈дᓜ Ԗ˯Ă੫၆շّ̙θাଈ۰Ăਕᑭീ۞࠹ᙯีϫΪΒ߁˞Ĉ 1. ߖ Ғវள૱Ą 2. ᝃཚញჯাૄЯ (cystic fibrosis transmembrane conductance regulator, CFTR) ࡎតĄ 3. Y ߖҒវព຋৿ε (Y chromosome microdeletion)Ą‫̚׎‬੫၆Аّ͇Ꮾჟგ৿εଈ۰ٙซҖ۞ CFTR ૄЯࡎតᑭീĂᄃ੫၆ჟ̄ං͌াଈ۰ٙซҖ۞ Y ߖҒវ ព຋৿εᑭീĂ‫ٺ‬ώ३̚‫΁׎‬ౢ༼ѣซ˘Վ۞ᄲ‫ځ‬Ą ˠᙷѣ 23 ၆ߖҒវĂΒ߁ 22 ၆វߖҒវᄃ 1 ၆ّߖҒវĞӈ X ߖҒវᄃ Y ߖҒវğ Ąϒ૱շّߖҒវ௡јࠎ 46, XY ẵّࠎ 46, XX ĄߖҒវள૱Ξͽᖎಏડ̶ࠎߖҒវᇴϫ˯۞ள૱Ăּт к˘ٕ࣎͌˘࣎ߖҒវć̈́ߖҒវඕၹ˯۞ள૱ĂּтߖҒវ۞

15

Y ߖҒវព຋৿ εᄃշّ̙θা ү۰Ę‫ڒ‬ϖ‫ ځ‬ᗁर

Y ߖҒវព຋৿εߏշّ̙θা૱֍۞ࣧЯ ̝˘ дˠᙷ Y ߖҒវ‫ܜ‬ᓖ˯ѣధкଠ‫ט‬༝˱ౄჟΑਕ۞ૄЯĂ‫ܕ‬ 20 ѐ۞ࡁտ൴னĂొЊշّ̙θাଈ۰۞ Y ߖҒវѣព຋৿ε (microdeletion) ۞ଐԛĄЯࠎ఺ֱૄЯ۞৿εĂጱ࡭ჟ̄Ϡј۞ ᅪᘣĄ఺˘ડม۞ߖҒវజ‫׻‬Щࠎ AZFĞazoospermia factor Ă൑ ჟ̄াЯ̄ğ Ąѣ Y ߖҒវព຋৿ε۞շّੵ˞ౄჟΑਕᅪᘣͽ γĂ̙ົѣ‫ܑ΁׎‬ன‫۞ݭ‬ள૱Ą Y ߖҒវព຋৿εϫ݈̏జᄮࠎ ߏ่Ѩ‫ڒߟٺ‬හপͩা (Klinefelter’s syndrome, 47, XXY)Ă౵૱֍ ౄјշّ̙θা۞᏷็Я̄Ą

Y ߖҒវព຋৿ε̝ᑭീ Y ߖҒវព຋৿εЯࠎ৿ε۞ડાྵ̈Ă൑‫˘ͽڱ‬ਠߖҒវ ᑭߤ͞‫ڱ‬ᑭរ΍ֽĂυื٩‫פ‬ҕ୵̚۞Ϩҕ஧ DNA ĂֹϡჸЪ 㤲ాᗆͅᑕ (polymerase chain reaction, PCR) ֽᑭീĄϫ݈Ă̙֭