卵泡穿刺抽吸在治疗多囊卵巢综合不育患者中临床意义初探

目的:探讨卵泡穿刺抽吸对多囊卵巢综合征(PCOS)不孕患者卵巢窦卵泡计数及妊娠的影响。方法:将74例行人绝经期促性腺激素(hMG)促排卵的PCOS患者随机分为二组,观察组37例,于卵泡直径达9-10mm时行卵泡穿刺抽吸;对照组37例,仅行常规促排卵,连续观察6个月,观察穿刺治疗前后性激素FSH、LH、T、E2、PRL水平的变化,比较二组患者卵巢窦卵泡计数及妊娠情况。结果:穿刺抽吸组与治疗前比较,11例患者的血清LH/FSH降低,T、E2、PRL水平无明显变化,29例患者卵巢基础窦卵泡计数降至10个/卵巢以下,无一例发生卵巢过度刺激综合征(OHSS),6个月内14例妊娠;对照组患者的血清性激素水平无明显变化,卵巢基础窦卵泡计数仍为10个/卵巢以上,发生OHSS者3例,6个月内仅3例妊娠。结论:常规治疗无效的PCOS不孕患者,行卵泡穿刺抽吸为有效治疗途径。     

多囊卵巢综合征不孕患者未成熟卵泡抽吸术的疗效分析

目的:探讨对克罗米芬抵抗的多囊卵巢综合征(PCOS)不孕患者在超声引导下行小卵泡抽吸术(IMFA)的治疗效果。方法:将42例PCOS合并克罗米芬(CC)抵抗的不孕患者,随机分为A组:19例,穿刺前用CC或来曲唑(LE)联合少量hMG促排卵;B组:23例,穿刺前用少量hMG促排卵。在阴道B超引导下进行未成熟卵泡抽吸术(IMFA),观察穿刺前及穿刺后第2周期患者的卵巢基础窦卵泡数(AFC)、抗苗勒氏管激素(AMH)、血中游离睾酮指数(FAI)、黄体生成素与卵泡刺激素的比值(LH/FSH),以及术后并发症、3个月促排卵情况和妊娠率。结果:42例患者治疗时均没有发生卵巢过度刺激综合征(OHSS)。与治疗前比较,穿刺术后A、B组AFC显著减少,AMH、FAI和LH/FSH显著降低(P<0.01)。A、B组间比较,FAI、LH/FSH、排卵率和妊娠率无统计学差异(P>0.05)。A、B组共21例妊娠,妊娠率为50%。42例患者均没有发生出血、感染、OHSS。结论:IMFA治疗克罗米芬抵抗的PCOS不孕患者有较好的疗效,本方法安全、有效。     

TGF-β_1在PCOS卵巢间质纤维化形成中的作用

目的:探讨TGF-β1在PCOS大鼠卵巢间质纤维化、包膜硬化形成中的作用。方法:利用脱氢表雄酮(DHEA)皮下注射的方法建立PCOS病理模型大鼠20只,用微粒子酶免分析法测定血清性激素E2、T、LH、FSH、LH/FSH、空腹胰岛素(FINS)水平,及光镜下观察PCOS大鼠卵巢的病理结构,透射电镜观察细胞超微结构来验证模型。采用免疫组化法检测PCOS组(n=20)卵巢细胞因子TGF-β1的表达,并与20只正常大鼠相比照。结果:TGF-β1在PCOS组各阶段卵泡卵母细胞、颗粒细胞的表达强度与对照组相比,差异无统计学意义(P>0.05)。而在窦状卵泡膜细胞和卵巢间质细胞中的表达,PCOS组显著高于对照组(P<0.01,P<0.05)。结论:多囊卵巢中TGF-β1表达异常,可能是导致多囊卵巢间质纤维化、包膜增厚的原因之一,TGF-β1也参与PCOS卵泡发育、闭锁的调控。     

腹腔镜下卵巢打孔术治疗多囊卵巢综合征合并不孕68例临床观察

目的:探讨腹腔镜下卵巢打孔术对多囊卵巢综合征(PCOS)合并不孕的治疗价值。方法:回顾性分析在我院行腹腔镜下双侧卵巢打孔术的68例PCOS合并不孕患者的临床资料和治疗效果。检测手术前后血清促卵泡生成素(FSH)、黄体生成素(LH)、睾酮(T)、雌二醇(E2)水平并进行对比分析,观察术后排卵情况及妊娠率。结果:术后1个月血清LH、LH/FSH、T显著下降(P<0.05)。术后自然排卵率82.4%(56/68),术后妊娠率77.9%(53/68)。结论:腹腔镜下卵巢打孔术是PCOS合并不孕有效的治疗方法,创伤小、出血少、术后恢复快、并发症少。     

腹腔镜电凝打孔术治疗耐氯米芬多囊卵巢综合征不孕43例疗效分析

目的:探讨腹腔镜下卵巢表面电凝打孔术对耐氯米芬(CC)多囊卵巢综合征(PCOS)所致不孕症患者的疗效。方法:对耐氯米芬的PCOS不孕患者43例,行腹腔镜下卵巢表面电凝打孔术。术后随访3~12个月。观察手术前后血清黄体生成素(LH)、卵泡刺激素(FSH)、睾酮(T)、雌二醇(E2)、泌乳素(PRL)水平变化,卵巢体积及窦卵泡数的变化,术后月经和排卵情况、妊娠率及流产率。结果:术后LH、T、LH/FSH、PRL水平、卵巢体积、窦卵泡数均较术前明显降低(P<0.01),而FSH、E2术前、术后差异无显著性(P>0.05),月经情况明显改善,术后排卵率为93.0%(40/43),妊娠率为58.1%(25/43),流产率为16.0%(4/25)。结论:腹腔镜下卵巢表面电凝打孔术对于耐CC的PCOS不孕患者具有高排卵率和妊娠率以及低流产率的疗效。同时,具有创伤小、恢复快、并发症少的优点,是治疗耐CC的PCOS不孕患者的有效手段。     

多囊卵巢综合征患者促排卵中发生卵泡未破裂黄素化综合征的临床分析

目的:探讨多囊卵巢综合征(PCOS)促排卵治疗中出现的卵泡未破裂黄素化综合征(LUFS)的原因和治疗措施。方法:PCOS不孕患者给予促排卵治疗,对治疗中发生LUFS的51例患者分别给予卵泡穿刺(29例)和针灸(22例)治疗,比较治疗后的妊娠率。结果:29例卵泡穿刺组患者,10例妊娠,妊娠率34.48%。22例针灸患者,2例妊娠,妊娠率9.09%。结论:PCOS患者促排卵治疗中发生LUFS给予卵泡穿刺术治疗效果肯定,是一种有效的治疗方法。     

腹腔镜治疗难治性多囊卵巢综合征不孕患者38例临床分析

目的:探讨腹腔镜对难治性多囊卵巢综合征(PCOS)不孕的治疗效果。方法:2001年3月至2005年5月对我院诊治的38例难治性PCOS不孕症患者,行腹腔镜下卵巢多点打孔术及盆腔粘连松解、输卵管整形术。手术前后分别测血清黄体生成素(LH)、卵泡刺激素(FSH)、雄激素(T)及雌二醇(E2)水平;术后监测排卵情况、妊娠率及妊娠结果。结果:术后血LH和T水平较术前有显著性下降(P<0.01)。术后排卵率81.6%(31/38),1年内累计妊娠18例,妊娠率为47.3%(18/38),早期流产率为16.7%(3/18)。有4例术后3个月内予氯米芬(CC)1~2个疗程后恢复月经外,其余月经情况(经量及持续时间)较术前均有明显改善。结论:腹腔镜卵巢多点打孔术能明显改善难治性PCOS患者的排卵和受孕机会,相对于单纯促排卵药物治疗具有术后排卵率高、妊娠率高、流产率低的优点,尤其对难治性PCOS不孕患者不失为一个有效治疗手段。     

超声下未成熟卵泡抽吸术治疗多囊卵巢综合征不孕的临床研究

目的　探讨超声下未成熟卵泡抽吸术(IMFA)对多囊卵巢综合征(PCOS)不孕患者卵巢窦卵泡计数及其内分泌功能的影响;观察IMFA后,应用人绝经期促性腺激素(hMG)促排卵治疗的效果、妊娠及并发症情况。方法　将71例PCOS不孕患者随机分为两组。组Ⅰ: 37例,穿刺前用少量hMG促排卵; 组Ⅱ: 34例,不用任何促排卵药物。在阴道超声引导下进行IMFA,检查穿刺后第2个周期患者的内分泌功能和卵巢基础窦卵泡计数,可连续2~3个周期进行穿刺。随后2组均用hMG常规促排卵治疗,随访其排卵及妊娠情况。结果　组Ⅰ进行了88个周期的穿刺治疗,经过2~3次穿刺后,睾酮水平、黄体生成素(LH )与卵泡刺激素(FSH)的比值均明显降低,与治疗前比较,差异有统计学意义(P<0. 01), 33例(89%, 33 /38)患者基础窦卵泡计数降至10个/卵巢以下。组Ⅱ进行了87个周期治疗,所有患者睾酮水平均显著降低,与治疗前比较,差异有统计学意义(P<0 01 ); 30例LH/FSH<2, 28例(82%, 28 /34)患者基础窦卵泡计数降到10个/卵巢以下。在IMFA之后, 诱发排卵时hMG用量组Ⅰ为(21±6)支,组Ⅱ(23±10)支,两组比较,差异无统计学意义(P>0 .05),在注射人绒毛膜促性腺激素(hCG)后均出现排卵, 组Ⅱ有2例发生轻度卵巢过度刺激综合征(OHSS)。连续促排卵治疗1 ~3个月后, 共36例(51% )     

两种促排卵方案治疗对常规疗法不敏感的多囊卵巢综合征不孕的疗效比较

目的 :观察两种促排卵方案 :中药助孕方加克罗米酚 (CC)和三苯氧胺 (TMX)加CC治疗常规CC疗法不敏感的多囊卵巢综合征 (PCOS)不孕患者的疗效。方法 :对 58例常规CC疗法不敏感的PCOS不孕患者随机分成两组 ,Ⅰ组为助孕方加CC治疗 30例 ,Ⅱ组为TMX加CC治疗 2 8例。结果 :Ⅰ组的妊娠率明显高于Ⅱ组 (P <0 .0 5) ,两组的排卵率、自然流产率比较差异无显著性 (P >0 .0 5) ,Ⅰ组的黄体功能不足 (LPD)发生率、未破裂卵泡黄素化 (LUF)发生率明显低于Ⅱ组 (P <0 .0 1 ,P <0 .0 5) ,两组均未发生卵巢过度刺激综合征 (OHSS)。结论 :采用中药助孕方联合CC的促排卵方案治疗常规CC疗法不敏感的PCOS不孕患者优于TMX联合CC的促排卵方案的治疗     

PCOS患者卵泡液内IGF-Ⅰ的水平对卵母细胞成熟的影响

目的:探讨PCOS患者卵泡液内胰岛素样生长因子-Ⅰ(IGF-Ⅰ)的水平与卵母细胞发育成熟的关系。方法:选取因PCOS接受IVF治疗的患者41例为PCOS组、同期因输卵管因素接受治疗的患者37例为对照组。在取卵日根据卵泡直径进行分组,分为≤14mm组和>14mm组,每例患者留取不同直径3～4个卵泡的卵泡液。分别检测PCOS组和对照组患者卵泡液内IGF-Ⅰ的水平,并分析其与卵母细胞成熟和受精的关系。结果:PCOS组IGF-Ⅰ、雌二醇(E2)、睾酮(T)的水平显著高于对照组(P<0.05),与卵泡直径不相关。在卵泡直径≤14mm组,PCOS患者卵母细胞成熟率和受精率明显高于对照组(P<0.05)。在卵泡直径>14mm组,PCOS组与对照组间卵母细胞成熟率和受精率无差异性。PCOS组卵泡液内IGF-Ⅰ水平和E2、T呈正相关(P<0.05)。结论:PCOS患者促排卵过程中卵泡液内IGF-Ⅰ水平的升高与卵泡直径无相关性,而卵泡液内高IGF-Ⅰ水平可影响PCOS患者小于14mm卵泡的卵母细胞成熟和受精。     

Ultrasonographical predictive factors of ovarian response to stimulation prior to in vitro fertilization

OBJECTIVE: Evaluate whether ovarian antral follicles number, ovarian volume and ovarian area are predictive of ovarian response. PATIENTS AND METHODS: Prospective cohort analysis of 41 women with normal basal serum FSH concentration, who were undergoing their IVF cycle. The ovarian antral follicle number, the ovarian volume and area were determined by transvaginal ultrasonography on the third menstrual day for 20 women, and after pituitary suppression for 21 women. The main outcome measures are the number of follicles the day of HCG with a diameter >or=14 mm, the number of oocytes retrieved and the number of embryos. RESULTS: The antral follicle count was significantly correlated to the number of follicles (R=0.7; P<0.001), to the number of oocytes retrieved (R=0.46; P=0.008) and to the number of embryos (R=0.44; P=0.01). The ovarian volume and area was significantly correlated to the number of follicles. DISCUSSION AND CONCLUSION: The total antral follicle number on day 3 has a predictive value for favourable IVF outcome. Because this sonographic count is easy, safe and inexpensive it should be performed prior every IVF cycle.     

Drug-free in-vitro activation of follicles for infertility treatment in poor ovarian response patients with decreased ovarian reserve

Research questionThe recently developed in-vitro activation (IVA) approach provides a promising infertility treatment for patients with premature ovarian insufficiency. The IVA method promotes growth of residual ovarian follicles following ovarian tissue fragmentation leading to Hippo signalling disruption, together with in-vitro incubation with Akt stimulators. As poor ovarian response (POR) patients with decreased ovarian reserve (DOR) have multiple secondary follicles, this study tested whether Hippo signalling disruption alone using in-vitro ovarian cortical fragmentation, followed by autologous grafting, was sufficient to promote follicle growth.DesignA case series study.ResultsIn 9 out of 11 POR patients with DOR treated with a simplified IVA procedure, increases in antral follicle numbers in multiple growth waves were detected following FSH treatment. Subsequent injection with human chorionic gonadotrophin allowed retrieval of more mature oocytes for IVF (median antral follicle counts before and after IVA per ovarian stimulation: 1.0 versus 2.6) with 68.7% fertilization rates and 56.9% showing high-quality embryonic development. One natural conception and 16 embryo transfers in five patients resulted in one live birth, two ongoing pregnancies and one miscarriage. Three additional patients and the miscarriage patient have cryopreserved embryos for future transfer.ConclusionsThe present drug-free IVA approach may be suitable for POR patients with DOR, as it increased the number of antral follicles. The procedure also eliminated the need for 2-day incubation with drugs and required only one surgery. This approach could allow the retrieval of more oocytes in middle-aged women to achieve higher pregnancy rates and deserves proper evaluation in future randomized controlled trials.     

Prediction of pregnancy in IVF cycles on the fourth day of ovarian stimulation

Purpose Prediction of IVF outcome on the first days of ovarian stimulation has focused clinical research for many years. The aim of this work is to predict the probability of pregnancy on the fourth day of ovarian stimulation for IVF cycle, using parameters usually determined in this stage—estradiol, antral follicle count—together with parameters determined previously: FSH on the third day of cycle and women age. Materials and methods One hundred and ten patients with primary infertility due to a tubal factor were recruited to participate in a prospective study. FSH was determined on the third day of spontaneous cycle. Antral follicles and estradiol were measured on the fourth day of ovarian stimulation. After oocyte pick-up, quality and quantity of oocytes and embryos and pregnancy rates were assessed. Results In stepwise multiple logistic regression the variables with better predictiveness over pregnancy are: antral follicles count, estradiol and woman age. The logistic regression analyses demonstrate that the capacity of the model that uses these variables to predict pregnancy is 75%, with a positive predictive value of 69% and a negative predictive value of 80%. Conclusions On the fourth day of ovarian stimulation of IVF cycles, the variables with highest predictiveness are: antral follicle count, estradiol and women age. When these variables are included in a model of prediction, the capacity to predict pregnancy is 75%. On the fourth day of ovarian stimulation for IVF cycles, antral follicles count, estradiol and woman age predict IVF outcome as reflected by quantity and quality of oocytes, embryos obtained and pregnancy rates.     

The Antral Follicle Count Predicts the Outcome of Pregnancy in a Controlled Ovarian Hyperstimulation/Intrauterine Insemination Program

Purpose: Our purpose was to test whether age-related changes in antral follicle counts can predict the pregnancy outcome in the early follicular phase of a controlled ovarian hyperstimulation/intrauterine insemination (COH/IUI) program. Methods: A selected group of 107 women (36 healthy women requesting child sex preselection, 52 women with unexplained infertility, and 19 with minimal endometriosis) who underwent controlled ovarian hyperstimulation with clomiphene citrate (CC) plus human menopausal gonadotrophin (hMG) and subsequent intrauterine insemination were enrolled in the study. Transvaginal ultrasonography (7.0 MHz) was used to determine the total number of antral follicles (2–8 mm) in the right and left ovaries. The association among the antral follicle count, age, dominant follicle, and estradiol (E ₂ ) level on the day of human chorionic gonadotropin (hCG) was analyzed. The association of the pregnancy rate and OHSS with the antral follicle count, dominant follicle count, and age was also examined. Results: The total antral follicle number decreased with age (P<0.0001). Dominant follicle number increased with total antral follicle number in women who received CCplus hMG/ IUI (P<0.0001). The pregnant group had a higher number of antral follicle and dominant follicles in comparison with the nonpregnant group (P<0.01 and P<0.02, respectively). The E ₂ level on the day of hCG injection increased positively with the total number of antral follicles (P<0.0001) and the total number of dominant follicles (P<0.0001). In women aged younger than 35 years, the pregnancy rate and dominant follicle number rose as the number of antral follicles increased (P<0.03 and P<0.0001, respectively). The pregnancy rate was low (2/39) in women aged older than 35 years regardless of the number of antral follicles (P<0.05) and the extent of hMG administration (P<0.02). Women aged older than 35 also produced fewer dominant follicles (P<0.001). No pregnancy was achieved in a patient with an antral follicle number of less than five (17 cases). Conclusions: Age-related changes in antral follicle count significantly predicted the dominant follicle count and the pregnancy outcome. In women with antral follicle counts of less than five or who are older than 35 years, the application of COH/IUI may not be indicated.     

The influence of anti-Mullerian hormone on folliculogenesis

The main biological role of the anti-Mullerian hormone (AMH) is to induce the involution of the Muller ducts in embryos during differentiation of masculine gender. In case of women, AMH is produced in granular cells of primary, preantral and antral follicles. The expression of AMH initiates at the moment of the follicle recruitment and it lasts until the stage of an antral follicle. The level of this hormone decreases with age and in postmenopausal period is undetectable in blood. Therefore, AMH could be a useful marker of ovarian reserve. Multiple investigations have revealed higher AMH levels in the blood of PCOS patients. It is believed to be the consequence of the increased amount of small antral follicles. AMH is considered to have an essential role in folliculogenesis. It inhibits the process of recruitment of primordial follicles and modifies the growth of preantral and antral follicles by diminishing the sensitivity of follicles for FSH stimulation. The paper is a review of the present knowledge of the structure and activity of AMH. AR gene and protein. Participation of AMH in folliculogenesis and changes of AMH levels depending on structure and age of the ovary have also been discussed. Recent findings concerning the possibility of using AMH to assess ovarian reserve and efficiency of the stimulation of ovulation in infertile women have been presented. It is believed that increased knowledge concerning AMH might improve the diagnosis and treatment of infertility caused by lack of ovulation.     

输卵管手术对体外受精-胚胎移植患者卵巢血流及反应性的影响

目的:探讨在体外受精-胚胎移植(IVF-ET)中输卵管手术对控制性超排卵(COH)患者卵巢的血流及卵巢储备功能的影响。方法:选择因异位妊娠或输卵管阻塞粘连行一侧输卵管切除或修复整形(单侧手术组)、双侧输卵管切除或双侧输卵管修复整形(双侧手术组)以及双侧输卵管均未行手术(对照组)的输卵管性不孕患者共70例,观察其在IVF-ET控制性超排卵中卵巢的血流变化及卵巢对COH的反应。结果:①3组患者的年龄、不育年限、用药天数及用药量均无统计学差异(P>0.05),单侧手术组术侧卵巢月经d3卵巢基质血流的搏动指数(PI)、收缩期峰流速(PSV)及hCG注射日(dhCG)PI与健侧卵巢差异无统计学意义(P>0.05)。但术侧卵巢d3血流阻力指数(RI)、RI(dhCG)明显大于健侧卵巢,PSV(dhCG)则明显小于健侧卵巢(P<0.05)。术侧卵巢的基础窦卵泡数(AFC)、dhCG≥14mm卵泡数以及获卵数明显少于健侧卵巢(P<0.05);②3组患者在d3的PI、RI、PSV,PI(dhCG)、RI(dhCG)差异无统计学意义(P>0.05)。但双侧手术组PSV(dhCG)明显低于对照组(P<0.05),其基础AFC、hCG注射日≥14mm卵泡数及获卵数也明显少于对照组(P<0.05)。结论:输卵管手术会影响卵巢的血运,降低卵巢的储备功能。     

Three-dimensional ultrasonographic ovarian measurements and in vitro fertilization outcome are related to age

OBJECTIVE: To evaluate whether the number of ovarian antral follicles, ovarian volume, and ovarian stromal blood flow change with age and to prospectively analyze whether three-dimensional ultrasonographic measurements predict ovarian response and IVF outcome. DESIGN: Prospective analysis. SETTING: Assisted reproductive unit. PATIENT(S): Fifty-six consecutive women 22 to 43 years of age with normal basal serum FSH concentrations who were undergoing their first IVF cycle. MAIN OUTCOME MEASURE(S): Number of ovarian antral follicles, ovarian volume, and ovarian stromal flow index were determined by three-dimensional and power Doppler ultrasonography. Pretreatment measurements were compared with number of recovered oocytes, fertilization rates, and pregnancy rates. RESULT(S): As patient age increased, significant trends in ovarian volume, number of follicles, and stromal vascularity decreased. Three-dimensional ovarian measurements and fertilization rates differed significantly among age groups. For each age group, a higher number of antral follicles, greater ovarian volume, and favorable ovarian stromal vascularity was associated with higher number of retrieved oocytes and increased pregnancy rates. CONCLUSION(S): Increasing patient age is associated with poor ovarian response, as represented by smaller ovarian volume, lower antral follicle count, and poor stromal vascularity. Three-dimensional power Doppler ultrasonography can help to individualize IVF in patients regardless of age.     

多囊卵巢综合征患者显著升高的抗苗勒管激素水平对超促排卵的影响

目的 探讨多囊卵巢综合征(PCOS)患者血清抗苗勒管激素(AMH)水平升高的原因和对体外受精(IVF)促排卵反应的影响。方法 回顾性分析第1次行长方案助孕的PCOS患者(n=158)和排卵正常的卵巢多囊样改变(PCOM)患者(n=256)的临床资料,将患者按“获卵数”分组,获卵数≤5个,为低反应组,获卵数6~14个为正常反应组,获卵数≥15个为高反应组,比较各组间治疗后各项指标的差异。结果 PCOM组和PCOS组的血清AMH值、窦卵泡数(AFC)、血清AMH/AFC比值(AMH×100/AFC总数)组间有统计学差异(P0.05)。促性腺激素(Gn)使用总量和Gn使用时间组间均有统计学差异(P0.05)。PCOM组中,随着AMH水平、AFC总数及AMH/AFC比值的增加,卵巢低反应者也增加。PCOS组中,卵巢反应低下组较正常反应及卵巢高反应组具有更高的AMH水平、AFC总数及AMH/AFC比值。结论 PCOS患者高血清AMH水平可能并不仅仅是因为窦卵泡数量增多的累加效应,同时可能是单个窦卵泡异常过多分泌所致。AMH异常升高可能影响卵巢对Gn的敏感性,但其作用机制仍需更深入研究。