不同时期高孕激素下促排卵在高龄卵巢低反应患者助孕中的应用

目的探讨卵泡期外源性高孕激素下促排卵(progestin-primed ovarian stimulation,PPOS)方案、黄体期内源性高孕激素下促排卵(luteal-phase ovarian stimulation,LPOS)方案和拮抗剂方案在高龄卵巢低反应(poor ovarian response,POR)患者体外受精/卵母细胞质内单精子注射-胚胎移植(in vitro fertilization/intracytoplasmic sperm injection-embryo transfer,IVF/ICSI-ET)助孕中的临床应用。方法回顾性分析2015年1月至2019年6月于济宁市第一人民医院生殖医学科行IVF/ICSI-ET助孕的高龄POR患者224个控制性超促排卵(controlled ovarian hyperstimulation,COH)周期的临床资料,根据促排方案不同分为3组,分别为A组(拮抗剂方案,88个周期)、B组(PPOS方案,61个周期)、C组(LPOS方案,75个周期),观察3组患者的助孕效果。结果①A、B、C组患者年龄(39.65±2.73)岁、(40.16±2.75)岁、(39.89±3.30)岁]、不孕年限(3.40±2.18)年、(3.92±2.08)年、3.33±2.23)年]比较,差异无统计学意义(P>0.05)。②3组患者周期临床资料比较:A、B、C组患者外源性促性腺激素(gonadotropin,Gn)使用总量(2124.16±590.44)U、(2075.57±592.18)U、(1993.67±556.60)U]、Gn使用时间(8.99±2.69)d、(8.77±2.47)d、8.17±2.23)d]比较差异无统计学意义(P>0.05);A组人绒毛膜促性腺激素(human chorionic gonadotropin,h CG)日雌二醇(estradiol,E2)水平(3404.38±1276.94)pmol/L]、h CG日优势卵泡数(3.09±1.23)个]、卵泡输出率(follicular output rate,FORT)(66.34%)均小于B组(4085.66±1033.77)pmol/L、(3.70±1.42)个、81.88%]和C组(3954.49±1150.74)pmol/L、(3.64±1.54)个、81.01%],差异有统计学意义(P<0.05);A组早发黄体生成素(luteinizing hormone,LH)峰率(6.82%)大于B、C组(1.64%、0),差异有统计学意义(P<0.05);上述临床资料B组与C组比较,差异无统计学意义(P>0.05)。③3组患者实验室指标比较:A组获卵数(88个)多于B、C组(61个、75个)(P<0.05);3组患者成熟卵率(85.27%、86.18%、85.56%)、ICSI率(15.89%、17.05%、16.30%)、2PN受精率(72.09%、74.19%、75.19%)比较差异均无统计学意义(P>0.05);A组卵裂数(2.31±1.02)个]、可利用胚胎数(1.63±0.86)个]、优质胚胎数(1.16±0.78)个]均少于B组(2.79±1.25)个、(2.07±0.98)个、(1.57±0.74)个]和C组(2.85±1.29)个、(2.11±0.99)个、(1.53±0.79)个)],周期取消率(21.59%)大于B、C组(8.20%、9.33%),差异均有统计学意义(P<0.05),上述实验室指标B组与C组比较,差异无统计学意义(P>0.05)。结论在高龄POR患者COH周期中,PPOS方案与LPOS方案有相近的促排疗效;与拮抗剂方案相比,PPOS及LPOS方案均能提高高龄POR患者FORT、有效预防早发LH峰、降低周期取消率,获得更多的优质胚胎,提示PPOS及LPOS方案是高龄POR患者理想的COH方案。

Application of ovulation promotion with high progestin in different periods in assisting pregnancy in elderly patients with low ovarian response

Objective To explore the progestin-primed ovarian stimulation(PPOS) scheme in the follicular phase,the luteal-phase ovarian stimulation( LPOS) scheme and the antagonist scheme in the advanced age clinical application of in vitro fertilization/intracytoplasmic sperm injection-embryo transfer( IVF/ICSI-ET) to assist pregnancy in patients with poor ovarian response( POR).Methods Retrospective analysis of 224 controlled ovarian hyperstimulation( COH) cycles in elderly POR patients who underwent IVF/ICSI-ET assisted pregnancy in the Department of Reproductive Medicine of Jining First People’s Hospital from January 2015 to June2019. The clinical data was divided into 3 groups according to different types of promotion schedules: group A( antagonist program,88 cycles),group B( PPOS program,61 cycles),and group C( LPOS program,75 cycles). Observe the effect of assisting pregnancy in3 groups of patients. Results(1) The age of patients in groups A,B,and C was ( 39. 65 ± 2. 73) years,( 40. 16 ± 2. 75) years,( 39. 89 ± 3. 30) years],infertility years ( 3. 40 ± 2. 18) years,( 3. 92 ± 2. 08) years,( 3. 33 ± 2. 23) years],the differences were not statistically significant( P > 0. 05).(2) Comparison of clinical data of three groups of patients: The total amount of gonadotropin( Gn) used by patients in groups A,B,and C ( 2 124. 16 ± 590. 44) U,( 2 075. 57 ± 592. 18) U,( 1 993. 67 ±556. 60) U],Gn use time ( 8. 99 ± 2. 69) d,( 8. 77 ± 2. 47) d,( 8. 17 ± 2. 23) d] were compared,there were no statistically significant differences( P > 0. 05);Estradiol( E2) level of human chorionic gonadotropin( h CG) day( 3 404. 38 ± 1 276. 94)pmol/L],number of dominant follicles of h CG day ( 3. 09 ± 1. 23) ],follicular output rate( FORT)( 66. 34 %) in group A were less than group B ( 4 085. 66 ± 1 033. 77) pmol/L,( 3. 70 ± 1. 42),81. 88 %]and group C ( 3 954. 49 ± 1 150. 74) pmol/L,( 3. 64 ± 1. 54),81. 01 % ],the differences were statistically significant( P < 0. 05);the peak rate of early luteinizing hormone( LH) in group A( 6. 82 %) was greater than that in groups B and C( 1. 64 %,0) the difference was statistically significant( P <0. 05);there was no significant difference between group B and group C in the above clinical data( P > 0. 05).(3) Comparison of laboratory indexes of the three groups of patients: The number of eggs obtained in group A( 88) was less than that in groups B and C( 61,75)( P < 0. 05);the mature egg rate of the three groups of patients( 85. 27 %,86. 18 %,85. 56 %),ICSI rate( 15. 89 %,17. 05 %,16. 30 %),2 PN fertilization rates( 72. 09 %,74. 19 %,75. 19 %) were not statistically significant( P > 0. 05);the number of cleavages in group A( 2. 31 ± 1. 02),available embryos( 1. 63 ± 0. 86),high-quality embryos( 1. 16 ± 0. 78) were less than group B ( 2. 79 ± 1. 25),( 2. 07 ± 0. 98),( 1. 57 ± 0. 74) ]and group C ( 2. 85 ± 1. 29),( 2. 11 ± 0. 99),( 1. 53± 0. 79) ],the cycle cancellation rate( 21. 59 %) was greater than that of group B and C( 8. 20 %,9. 33 %),the differences were statistically significant( P < 0. 05). There was no statistically significant difference between the above laboratory indicators in group B and group C( P > 0. 05). Conclusion In the COH cycle of elderly POR patients,PPOS and LPOS have similar effects in promoting elimination;compared with antagonists program,both PPOS and LPOS can improve the FORT of elderly POR patients and effectively prevent early onset. LH peak,lower cycle cancellation rate,and obtain more high-quality embryos,suggesting that PPOS and LPOS schemes are ideal COH schemes for elderly POR patients.