卵泡期经阴道小卵泡穿刺抽吸术治疗多囊卵巢综合征排卵障碍

目的 探讨对克罗米芬治疗无反应的多囊卵巢综合征患者在卵泡期经阴道小卵泡穿刺抽吸术后,使用促性腺激素诱发排卵时卵泡的发育及其结局。方法 选择17例对克罗米芬治疗无反应,或对促性腺激素治疗发生卵巢过度刺激或无反应,但输卵管通畅、男方精液正常的多囊卵巢综合征不孕患者,在月经(人工周期)第5天给予促性腺激素治疗,给药5d后,在B超指引下经阴道行小卵泡穿刺抽吸术,双侧卵巢仅留1—2个较大卵泡,术后继续给予促性腺激素,观察卵泡发育、排卵和妊娠情况及血中性激素水平变化。结果 17例中除2例(11．8％)对该治疗方法无反应外,15例出现优势卵泡发育和排卵,其中单卵泡发育9例(52．9％),双卵泡发育4例(23.5％),3卵泡发育2例(11．8％),发育的优势卵泡全部排卵。总共有7例妊娠,全部为单胎妊娠,单周期治疗妊娠率41．2％(7／17)。结论 卵泡期经阴道小卵泡穿刺抽吸术能使对克罗米芬治疗无反应的多囊卵巢综合征不孕患者,使用促性腺激素治疗获得良好的单卵泡发育和单胎妊娠率。     

耐枸椽酸氯米芬多囊卵巢综合症预防多卵泡发育

促性腺激素诱导排卵，经常被用于耐枸椽酸氯米芬多囊性卵巢综合症的病人。由于多囊卵巢对促性腺激素刺激的高度敏感性，多卵泡的发充则成为用促性腺激素诱导排卵的主要并发症。本文目的是对两种减少耐枸椽酸氯米芬多囊卵巢综合症病人多卵泡发育的方法进行效果比较。选择２...     

多囊卵巢综合征小剂量促卵泡激素诱导排卵

多囊卵巢综合征(PCOS)引起的无排卵性不育在处理上相当棘手。氯底酚胺(CC)治疗妊娠率低,传统的促性腺激素(Gn)治疗引起多卵泡发育,卵巢     

FSH传统方案和低剂量缓增方案治疗多囊卵巢综合征无排卵的前瞻性对比研究

多囊卵巢综合征(PCOS)患者无排卵性不孕首选治疗为氯菧酚(CC),排卵率约80％,妊娠率仅25％。CC无效者采用传统的hMG递增方案,6周期累积妊娠率82％。由于多囊卵巢对促性腺激素的高敏性,多卵泡发育,多胎妊娠和卵巢过度刺激综合征(OHSS)发生率高。纯FSH递增方案不能纠正上述缺点。近年报道FSH低剂量缓增方案可能减少这些     

雌激素及枸橼酸克罗米芬对促性腺激素刺激卵巢合成雌激素的直接增强作用

成熟卵泡合成的雌激素不但参与调节垂体促性腺激素的释放,促进副性器官的发育,而且刺激卵巢颗粒细胞增生,诱导颗粒细胞中雌激素受体的生成并增加细胞间的裂隙连结(gap junction).此外,雌激素与促卵泡成熟激素(FSH)协同作用可使卵泡腔形成,也诱导颗粒细胞生成促黄体生成激素(LH)受体.无排卵的妇女服用枸橼酸克罗米芬可增高循环中促性腺激素和雌激素的水平,导致卵泡成熟和排卵.推测克罗米芬与垂体和下丘脑的雌激素受体结合后,刺激促性腺激素的释放,但不能排除克罗米     

促黄体生成激素释放激素(LHRH)显效剂和外源性促性腺激素的联合应用成功治疗月经过少的不育妇女

在促黄体生成激素(LH)水平增高(多囊卵巢综合征)的月经过少不育妇女中,传统治疗以舒经酚刺激卵泡生长,部分病人即使孕激素水平已够仍不妊娠.应用外源性促性腺激素治疗这类病人很难诱发排卵,而且比性腺功能减退的病人妊娠率都低同时常发生卵巢肿大     

促排卵治疗的母儿安全性

排卵障碍包括多囊卵巢综合征、子宫内膜异位症及盆腔炎等引发的卵泡发育障碍及卵子排出障碍,促排卵药物的应用可以有效地解决排卵障碍所致的不孕。辅助生殖技术的开展也更多地依赖于控制性超促排卵（controlled ovarian hyperstimulation,COH）以提高获卵率及妊娠率。而超生理状态下的促性腺激素（Gn）、雌激素、排卵诱导药物及孕激素可能会影响母儿近期及远期的健康,故促排卵过程中发生的副反应及远期的安全性日益受到关注。     

小剂量hCG联合HMG对低促性腺激素性腺功能减退症不育患者卵巢刺激的疗效观察

目的：探讨小剂量人绒毛膜促性腺激素（hCG）联合人绝经期促性腺激素（HMG）应用于低促性腺激素性腺功能减退症（HH）患者的卵巢刺激的可行性及其疗效。方法：对5例HH患者采用50 IU hCG联合HMG进行卵巢刺激,应用阴道超声、测量血清性激素等方法监测卵泡生长发育。结果：4例患者进行了诱发排卵6个周期,平均排卵（2.6±1.5）个,诱发排卵成功率100%,累积妊娠率100%。无患者改行多余卵泡穿刺术或体外受精-胚胎移植术,未发生中、重度卵巢过度刺激综合征,未发生高序多胎妊娠;均分娩单胎健康婴儿。1例患者进行控制性超排卵1个周期,穿刺7个卵泡,获卵5个,受精3个,分裂形成2个优质胚胎,胚胎移植后妊娠,足月分娩1个健康新生儿。结论：小剂量hCG联合HMG能够安全、有效地应用于HH患者的卵巢刺激,改善卵巢刺激的结局。     

来曲唑用于多囊卵巢综合征患者诱导排卵的系统评价

目的:系统评价来曲唑用于多囊卵巢综合征(polycystic ovary syndrome,P-COS)诱导排卵的疗效和安全性。方法:全面检索相应的中英文数据库,收集来曲唑用于PCOS患者诱导排卵的临床随机对照试验(randomized controlled trials,RCTs)。按Co-chrane系统评价方法,用系统评价专用处理软件RevMan5.0合并分析入选研究。结果:共纳入10个RCT,包括1854例患者。Meta分析显示:(1)来曲唑组周期排卵率高于克罗米芬组,HCG日子宫内膜厚度较薄,每周期成熟卵泡数少于克罗米芬组,差异有统计学意义;妊娠率、流产率两组差异无统计学意义;(2)克罗米芬抵抗的PCOS患者使用来曲唑后,周期排卵率>60%、妊娠率>30%;(3)来曲唑组周期排卵率低于促性腺激素组;妊娠率、HCG日子宫内膜厚度、流产率两组相似;来曲唑组每周期成熟卵泡数、多胎率、OHSS发生率低于促性腺激素组。结论:目前无充分证据证明,来曲唑对PCOS患者的促排卵效果优于克罗米芬,但可用来曲唑促排卵治疗对克罗米芬抵抗或促性腺激素高敏的PCOS患者,并可有效预防卵巢过度刺激综合征和多胎妊娠发生。     

PCOS患者药物促排卵中LUFS发生的相关因素

目的 探讨多囊卵巢综合征(PCOS)患者药物诱导排卵治疗中发生未破裂黄素化卵泡综合征(LUFS)的相关因素。方法 对比克罗米酚(CC)及人绝经后促性腺激素(HMG)方案用药前后PCOS患者血清PRL、FSH、LH、E_2、T水平,阴道超声检查卵巢形态,分析PCOS患者LUFS发生与基础性激素水平和卵巢形态的关系。结果 应用CC加用HCG45例,卵泡发育率66.67％,周期妊娠率为22.22％,LUFS发生率33.33％;应用CC无效者,应用HMG方案30例,卵泡发育率高(86.67％),但LUFS和过度刺激综合征(OHSS)发生率高分别为36.67％和13.33％,周期妊娠率16.67％。T水平LUFS组高于排卵组,表明LUFS的发生与血清睾酮水平有关。周边囊泡型多囊卵巢(PCP)LUFS发生率25％,普通囊泡型多囊卵巢(GCP)LUPS发生率75％。结论 普通囊泡型多囊卵巢患者易于发生卵泡黄素化不破裂综合征,可能与患者雄激素水平相对较高,卵巢包膜厚,优势卵泡不是发生在卵巢周边有关。     

Effect of urinary versus recombinant FSH on clinical outcomes after frozen–thawed embryo transfers: a systematic review

Recent randomized trials, systematic reviews and cost-effectiveness analyses have demonstrated the relative efficacy, and in some cases superiority, of urinary gonadotrophins (uFSH, human menopausal gonadotrophin) compared with recombinant FSH (rFSH). However, the effectiveness of frozen-embryo transfers (FET) following ovarian stimulation with uFSH versus rFSH in the fresh cycle has not been well investigated. The objective of this study was to determine whether there are differences in clinical outcomes in women undergoing FET according to the type of gonadotrophin used during ovarian stimulation. Following a meticulous search, all published comparative studies of FET using ovarian stimulation were reviewed. Data on clinical outcomes were extracted and systematically presented. Using the agonist long protocol for down-regulation, five trials provided extractable data for live-birth and ongoing pregnancy rates following FET, as well as the cumulative live-birth, ongoing pregnancy and clinical pregnancy rates following fresh-embryo transfer and FET from the same cycle. There was no evidence of significant effect difference between the uses of uFSH versus rFSH regarding any of the outcomes. In conclusion there is insufficient evidence to determine whether the use of a certain type of gonadotrophin during ovarian stimulation affects the clinical outcomes in subsequent FET.Clinical efficiency in IVF procedures has been debated for years. Defining a unified goal, or endpoint, for IVF treatments has shown marked discrepancies among clinicians, regulatory bodies and organizations; with some regarding a clinical pregnancy, an ongoing pregnancy, a live-birth, or even a take-home baby as the primary outcome of IVF treatments. The objective of this systematic review was to determine the effectiveness of the use of urinary versus recombinant FSH on the results of frozen embryo transfers and the effect that this would have on the cumulative clinical results of IVF. This systematic review has shown that there is insufficient evidence to determine whether the use of a certain type of gonadotrophin during ovarian stimulation affects the clinical outcomes in subsequent frozen embryo transfers, such as live-birth rate, ongoing pregnancy rate, clinical pregnancy rate. With respect to cumulative rates, it is noted that no significant differences in live birth rate, ongoing pregnancy rate, and clinical pregnancy rate following fresh and frozen transfer cycles. It is concluded that well-designed and powered studies are needed to determine possible effects of the use of a certain type of gonadotrophin during ovarian stimulation on the clinical outcomes in subsequent frozen thawed embryo transfers.     

Hormonal treatments and epithelial ovarian cancer risk

Exogenous sex hormones are widely used by women either for pregnancy prevention, as part of infertility treatment, or for treatment of menopausal symptoms. The role of these hormones in the development of ovarian cancer has been vastly explored. The protective effect of combined oral contraceptive pill is confirmed in multiple studies, but it is not clear whether this protection also covers women with a genetic predisposition to ovarian cancer. There is no conclusive evidence of infertility treatments increasing ovarian cancer risk, but infertility as such is a risk factor. Currently available data suggest that long-term users of hormone replacement therapy may have a slightly increased risk for ovarian cancer compared to women who have never used estrogen. The risk might particularly involve the endometrioid type of ovarian cancer. Most data on ovarian cancer and estrogen comes from epidemiological studies, since the normally high concentrations of estrogens in ovarian tissue and follicular fluid make direct biologic studies on the effects of exogenous estrogens on the ovarian cell difficult. This review discusses the risk of ovarian cancer associated with the use of sex steroid hormones, with special emphasis on the possible risk associated with estrogens.     

复发性卵巢子宫内膜异位症的管理

子宫内膜异位症（内异症）是慢性复发性疾病,年复发率约10%。复发性卵巢子宫内膜异位症一般指卵巢子宫内膜异位囊肿复发,是内异症最常见的复发类型,也是导致再次手术的主要原因。治疗原则基本遵循初始治疗,但应个体化。治疗包括药物治疗和手术治疗。常用药物有孕激素类、促性腺激素释放激素激动剂（GnRH-a）、复方口服避孕药物及中医中药等。有些药物比如地诺孕素可以使复发的卵巢子宫内膜异位囊肿明显变小甚至消失,从而免去了患者承受再次手术的风险,近年来广泛推荐使用。再次手术对卵巢储备功能影响更大,术后仍易复发,部分患者也可选择超声引导穿刺治疗。对合并不孕者首先推荐辅助生殖技术。药物维持治疗及长期管理是减少卵巢子宫内膜异位囊肿复发的关键。业已证明,长期使用孕激素类、GnRH-a和复方口服避孕药等均可预防卵巢子宫内膜异位囊肿复发。     

Simultaneous intrauterine and ovarian pregnancy following treatment with clomiphene citrate

Heterotopic pregnancy is increasingly being diagnosed since the advent of assisted reproductive technology involving the use of superovulatory drugs and/or in-vitro fertilization and the availability of high-resolution ultrasound scans. There are reports of Heterotopic tubal pregnancies following clomiphene use. Heterotopic ovarian pregnancies are however rare. Clomiphene citrate, which is widely used in the primary care setting to treat anovulatory infertility, is felt safe. We present a case of heterotopic ovarian pregnancy following treatment with clomiphene citrate. The diagnosis and management of heterotopic ovarian pregnancy are also discussed.     

The role of LHRH agonists and antagonists

Administration of GnRH analogues (agonists as well as antagonists) produces suppression of the pituitary---gonadal axis, thus inhibiting the secretion of LH, FSH and sexual steroids. For this reason, analogs are indicated in all those clinical situations where suppression of gonadotrophins (precocious puberty, contraception) or of sexual steroids (endometriosis, prostate hyperplasia, cancer, uterine fibroids) is desired. For several years GnRH agonists have been used in combination with gonadotrophins for ovarian stimulation for assisted reproduction in order to control premature LH surges and to reduce cancellation rate with improvement of the pregnancy rate per cycle. This effect is obtained after 2 weeks of agonist administration. The immediate suppression of the pituitary achieved by GnRH antagonists without an initial stimulatory effect is the main advantage of these compounds over the agonists. The prevention of a premature LH surge by GnRH antagonists can be obtained by multiple dose or by a single administration. Both protocols offer the following advantages over the agonists: they require fewer ampoules of gonadotrophins, shorter duration of stimulation, there is a preserved pituitary response to GnRH, less risk of ovarian hyperstimulation syndrome and the luteal phase seems to be more preserved. The main disadvantages of the antagonists are that they are expensive and that pregnancy rate appears to be slightly lower than with the agonists. GnRH antagonists will probably replace agonists in ovarian stimulation treatment for assisted reproduction techniques.     

Ovulation induction by human menopausal gonadotropin with ultrasonic monitoring of the ovarian follicles

One hundred sixteen cycles of human menopausal gonadotropin (hMG) treatment for ovulation induction were studied. The ovarian response to hMG treatment was monitored by the daily determination of serum estradiol (E2) or by daily serum E2 and repeated ultrasonic examination of the ovaries. There were more follicles 18 mm in diameter or larger at the time of human chorionic gonadotropin (hCG) administration in the pregnancy than in the non-pregnancy cycles, and in the hyperstimulated than in the nonhyperstimulated cycles. The ovulatory rate and the pregnancy rate per cycle did not improve with the use of ultrasound. The number of treatment cycles required to achieve pregnancy was less in patients who had ultrasonic examination of the ovarian follicles. These results suggest that ultrasonic examination of the ovarian follicle helps to reduce the number of hMG cycles required to achieve pregnancy. The development of multiple follicles results in more pregnancies. However, the use of ultrasound does not improve the pregnancy rate.     

Gonadotropin induction of ovulation

Gonadotropins have been widely used worldwide for many years to induce ovulation. Three main exogenous gonadotropins are used for ovulation induction—follicle stimulating hormone (FSH), luteinising hormone (LH) and human chorionic gonadotropin (hCG). Currently, these gonadotropins are available in the urinary (with the exception of LH) and recombinant forms. FSH (± LH) is used to stimulate follicular development and hCG is used to trigger ovulation of the mature follicle(s). Indications for gonadotropin ovulation induction include hypogonadotrophic hypogonadism and clomifene-resistant normogonadotrophic anovulation. Gonadotropins are also used for controlled ovarian hyperstimulation in conjunction with intrauterine insemination in ovulatory women treated for unexplained or mild male factor infertility. Two main regimens of gonadotropin ovarian stimulation are used, namely step-up and the step-down protocols. The choice of gonadotropin preparation and treatment regimen depends on the underlying ovarian dysfunction. Strict monitoring of gonadotropin treatment with implementation of strict cancellation criteria are recommended to minimise the risks of ovarian hyperstimulation and multiple pregnancy.     

Clomiphene citrate challenge test predicts outcome of intrauterine insemination in women aged under 37 years

The clomiphene citrate challenge test is a tool to predict ovarian reserve and fertility. It has mainly been used as a predictor of success of IVF/intracytoplasmic sperm injection (ICSI) cycles. Infertile young women with diminished ovarian reserve have a worse prognosis than women with adequate ovarian reserve attempting IVF/ICSI cycles. Nothing is known regarding the outcome of young women with diminished ovarian reserve undergoing low-complexity assisted reproductive treatment such as ovulation induction plus intrauterine insemination (IUI). This study included all women under 37 years who consulted in the authors' centre between May 2004 and August 2005 who underwent ovulation induction and IUI. Ninety-six women younger than 37 years with adequate ovarian reserve, and 50 women with diminished ovarian reserve were found. The pregnancy rate and pregnancy rate per cycle in the adequate ovarian reserve group were significantly higher than those of the diminished ovarian reserve group (46.7% versus 25%, P < 0.02 ; 15.9% versus 7.6%, P < 0.02 respectively). It is concluded that the clomiphene citrate challenge test is a good predictor of low-complexity infertility intervention outcome, and represents an effective tool to establish a prognosis. Therefore, it is very useful in planning therapy, and advising the infertile couple.     

Pretreatment for ovarian endometrial cyst before in vitro fertilization

Assisted reproductive technology is a widely accepted treatment for infertile women with endometriosis. The presence of an ovarian endometrial cyst reduces the quality of oocytes, while surgical resection of endometrioma may reduce the ovarian reserve for ovarian stimulation by exogenous gonadotropins. To determine what pretreatment should be performed for ovarian endometrial cyst before IVF-ET, we analyzed IVF outcomes with or without pretreatment in patients with endometrioma. Infertile women with endometrioma who underwent IVF-ET were divided into 3 groups, including patients who had received laparotomy or laparoscopy, patients for whom the endometrioma content had been aspirated and treated with or without alcohol fixation, and patients who did not undergo pretreatment. The number of retrieved oocytes, rate of mature oocytes, and fertilization rate were compared among groups. The results showed that pretreatment for endometrioma reduces the number of retrieved oocytes. Although oocyte quality as a rate of mature oocytes was not affected by the presence of an ovarian endometrial cyst, the fertilization rate was improved by cyst aspiration. We propose that surgical pretreatment is not necessary for ovarian endometrial cyst before IVF-ET, but cyst aspiration may be beneficial after several failed attempts of IVF.     

子宫内膜异位症与不孕症

子宫内膜异位症（EMs）在育龄妇女中发病率较高,较易引起患者生育能力下降乃至不孕。目前这类不孕症的治疗方式主要包括手术治疗和多种辅助生殖技术（ART）,包括体外受精（IVF）、促排卵治疗、宫内受精等。传统的药物加外科治疗方式对不孕症的治疗效果相当有限,因此越来越多的证据显示ART应该作为EMs相关不孕症患者的首选治疗,其中IVF因其相对较高的成功率备受关注。但是诸如IVF前的卵巢调控方式、妊娠后如何防治疾病本身带来的妊娠期并发症等诸多悬而未决的问题需要大型的研究来提供新的理论支持。