PCOS患者未成熟卵体外成熟培养后妊娠结局分析

目的:探讨PCOS患者未成熟卵母细胞体外成熟(in vitro maturation,IVM)治疗的有效性和安全性。方法:分析比较PCOS合并不孕症自愿要求行IVM或IVF治疗的患者临床结局。结果:IVF组的平均优质胚胎数明显高于IVM组(P<0.05),两者的临床妊娠率(39.22%vs 40.32%)和着床率(24.37%vs 23.89%)无差异(P>0.05)。IVM组的妊娠丢失率为38.0%,高于IVF患者(21.1%,P<0.05),出生婴儿(单胎)的平均体质量组间无统计学差异(P>0.05)。结论:对于PCOS患者进行IVM治疗可以获得与IVF周期相类似的临床妊娠率和着床率;但是IVM治疗后流产率明显增加。     

多囊卵巢综合征与辅助生殖的热点问题讨论

一、PCOS的发病机制二、PCOS的诊断三、PCOS辅助生育治疗战略(一)PCOS的辅助治疗措施(二)PCOS患者的促排卵治疗(三)PCOS的手术治疗1、卵巢楔形切除和腹腔镜打孔术2、超声下未成熟卵泡抽吸术治疗多囊卵巢综合征不孕症的临床研究(四)辅助生殖技术在PCOS患者不孕治疗中的作用1、IVF/ICSI；2、IVM/F-ET     

体外受精联合未成熟卵母细胞体外培养技术在辅助生殖中的应用价值

近年来卵母细胞体外培养成熟(IVM)技术的应用得到迅速拓展。IVM技术可用于治疗难治 性多囊卵巢综合征(PCOS)的不孕;在常规COH中可以预防卵巢过度刺激综合征(OHSS),拯救在 控制促排卵周期中卵巢的反应不良;自然周期下联合IVM技术可以进一步提高IVF的妊娠率。人 卵母细胞IVM的培养体系的改善提高了IVM的妊娠率。IVM技术因本身价廉、避免药物副作用 以及防止发生OHSS的优点,将会在临床上得到日益广泛的应用。     

未成熟卵母细胞体外培养在体外受精中对卵巢低反应性者的补救性应用

目的:探讨未成熟卵母细胞体外培养(IVM)在体外受精(IVF)中对卵巢低反应性者的补救性治疗效果。方法:30例行IVF时表现为卵巢低反应者(实验组)在B超引导下经阴道行卵泡穿刺术,取卵后对不同期未成熟卵母细胞行IVM,再行胞浆内单精子注射(ICSI)受精;对成熟卵母细胞则进行常规受精,胚胎形成后行移植术。取同期进行ICSI周期治疗的63例作为对照组。结果:应用IVM行IVF-ET补救治疗的30个周期中有29个周期获胚胎移植,临床妊娠9例(31%),胚胎种植率18.47%,但该组未成熟卵培养成熟后的受精率、卵裂率均低于对照组;总妊娠率及胚胎种植率比常规ICSI组低。结论:IVM技术联合IVF为卵巢低反应性者提供了一种有效的补救措施,明显减少了IVF周期的取消率,提高了妊娠机会。     

非男性因素不孕体外受精失败行卵胞浆内单精子注射的结局分析

目的:探讨卵胞浆内单精子注射(ICSI)对非男性因素不孕IVF失败患者治疗结局的影响。方法:回顾性分析由于第一周期常规IVF治疗中卵子完全不受精或受精率≤25%,行补救性ICSI的10个周期(补救性ICSI组),以及因前次受精失败而在随后的治疗周期中采取ICSI方法受精的19个周期(后续性ICSI组)的ICSI治疗结局,并以因男方少弱精子症进行第1次ICSI治疗的133个周期为对照组。结果:后续性ICSI组受精率、植入率、妊娠率和分娩率均高于补救性ICSI组,但差异均无统计学意义(P>0.05)。后续性ICSI组优胚率显著高于补救性ICSI组(P<0.05);补救性ICSI组受精率(48.9%)、优质胚胎率(29.2%)、植入率(0%)、妊娠率(0%)、分娩率(0%)均显著低于对照组(分别为72.1%、46.6%、21.2%、45.1%、39.1%);后续性ICSI组受精率、植入率、妊娠率、分娩率分别为55.4%、8.8%、21.1%、15.8%,均低于对照组(P<0.05或P<0.01)。优质胚胎率后续性ICSI组(44.2%)低于对照组,但无统计学差异。结论:对于非男性因素不孕IVF失败患者,ICSI能避免受精失败,但是受精率以及妊娠结局受到卵母细胞隐匿性异常的影响。     

多囊卵巢综合征(PCOS)患者在IVF-ET中发生严重卵巢过度刺激综合征(OHSS)的特点分析

目的:通过总结IVF-ET中多囊卵巢综合征(PCOS)患者应用控制性超促排卵(COH)后发生卵巢过度刺激综合征(OHSS)的特点,提出防止中、重度OHSS发生的有效措施。方法:将IVF/ICSI治疗时出现中、重度OHSS的患者根据有无PCOS史分成PCOS组和对照组。比较分析PCOS组和非PCOS组在COH中的雌激素水平、卵泡数、取卵数及发生中、重度OHSS的时间等临床资料;分析妊娠对OHSS的影响。结果:PCOS组的Gn用药总量及hCG注射日的血清E2水平比对照组低,其总卵泡数、中小卵泡数明显高于对照组,发生中、重度OHSS的时间早,妊娠可能加重OHSS病情发展。结论:卵泡总数、中小卵泡数可作为PCOS患者预测中、重度OHSS独立的重要指标,建议即使取卵前E2水平不高、获卵数不多也考虑行全胚冷冻,以阻止严重的OHSS发生。     

不同剂量HCG对体外受精-胚胎移植的影响

目的 :比较使用不同剂量人绒毛膜促性腺激素 (HCG)对体外受精 /胞浆内单精子注射 (IVF/ICSI)的结局及对卵巢过度刺激综合征 (OHSS)发病率的影响。方法 :对在本所接受IVF/ICSI辅助生育的 2 6 2例采用GnRH a长方案促排卵的患者进行回顾性分析 ,按HCG用量分为A组 (HCG 5 0 0 0～ 6 0 0 0U)、B组 (HCG 80 0 0～ 10 0 0 0U)。结果 :两组临床妊娠率分别为 35 .94 %和 38.0 5 % (P >0 .0 5 ) ,OHSS发生率分别为 2 .34%和 4 .4 8% (P >0 .0 5 )。结论 :减少HCG用量后对IVF/ICSI的临床妊娠率无明显影响 ,且可以减少OHSS的发生。     

多囊卵巢综合征患者体外受精-胚胎移植后的妊娠结局

目的 分析多囊卵巢综合征(PCOS)患者体外受精-胚胎移植(IVF-ET)后的妊娠结局,及不同表型PCOS患者妊娠结局的差异.方法 选取2005年1月至2010年2月在山东大学附属省立医院生殖医学中心行IVF-ET治疗的PCOS患者631例(PCOS组),按照年龄与孕前体质指数( BMI)配对选择输卵管性不孕患者1423例作为对照组.对两组患者的临床资料进行回顾性分析,比较两组患者IVF-ET治疗后的流产率和单胎妊娠结局.结果 PCOS组和对照组患者IVF-ET后流产率分别为22.7％(143/631)和18.69％(266/1423),两组比较,差异有统计学意义(P＜0.05).PCOS组和对照组孕单胎例数分别为339例和794例,两组单胎妊娠结局为:PCOS组和对照组早产率分别为11.2％(38/339)和6.4％( 51/794),两组比较,差异有统计学意义(P＜0.05);妊娠期糖尿病发生率分别为1.5％(5/339)和0.6％ (5/794)、妊娠期高血压疾病发生率分别为4.7％( 16/339)和3.0％( 24/794)、妊娠天数分别为(272±13)d和(273±10)d、新生儿畸形率分别为0.6％(2/339)和0.8％ (6/794)、足月新生儿出生体质量均为(3.5±0.5) kg,以上各项两组比较,差异均无统计学意义(P＞0.05).PCOS组中规律排卵患者流产率及单胎早产率分别为18.6％(19/102)和8.2％(4/49),与对照组分别比较,差异均无统计学意义(P均＞0.05);稀发排卵患者流产率及单胎早产率分别为23.4％( 124/529)和11.7％ (34/290),与对照组比较,差异有统计学意义(P＜0.05).结论 PCOS患者行IVF-ET治疗后流产率、早产率增加,但PCOS患者中规律排卵型患者各种并发症发生率未升高.     

初步探讨针刺治疗对卵巢过度刺激综合征(OHSS)的影响

目的:探讨针刺治疗在体外受精/卵胞质内单精子显微注射-胚胎移植(IVF/ICSI-ET)治疗过程中对卵巢过度刺激综合征(OHSS)的发生所产生的影响。方法:将进行IVF/ICSI-ET治疗的304例不孕症患者随机分为针刺治疗组(研究组)和对照组。采用黄体期促性腺激素释放激素激动剂(GnRH-a)长方案进行控制性超促排卵,研究组患者从控制性超促排卵第1日开始接受针刺治疗,直至胚胎移植日(取卵日不进行针刺治疗),对照组不作针刺治疗,其余同研究组。观察比较研究组和对照组促性腺激素(Gn)用量、血清雌二醇(E2)水平、OHSS发生率、获卵数、临床妊娠率和流产率等。结果:①研究组OHSS的发生率低于对照组(2.03%vs 7.33%,P<0.05);②研究组胚胎移植日血清E2水平低于对照组(P<0.05);③研究组临床妊娠率和流产率与对照组相比均无统计学差异(52.90%vs 50.74%,P>0.05;10.96%vs 10.14%,P>0.05).结论:针刺辅助治疗对降低IVF-ET治疗过程中OHSS的发生起到一定的作用。     

未成熟卵体外培养成熟技术治疗后妊娠情况及结局分析

目的通过比较接受人类未成熟卵体外培养成熟（IVM）技术、常规体外受精技术（IVF）及单精子卵胞浆内注射技术（ICSI）治疗后妊娠的病例，分析妊娠和产科结局，从而评估IVM技术的安全性。方法回顾性分析安徽医科大学第一附属医院生殖医学中心2004年1月～2007年12月接受IVM35例、IVF369例和ICSI298例治疗后妊娠的702例患者的临床资料。结果3组的多胎妊娠发生率、流产率、异位妊娠率比较，差异无显著性（P〉0.05）。除外流产和继续妊娠外，IVM、IVF和ICSI治疗后出生婴儿数分别为34、321和243例，比较3组单胎妊娠和双胎妊娠的妊娠结局，差异无显著性（P〉0．05）。结论与常规IVF、ICSI比较。IVM并不增加妊娠风险、产科并发症和新生儿异常的比例。     

In-vitro maturation of immature oocytes for infertile women with PCOS

Immature oocyte retrieval followed by in-vitro maturation (IVM) is a promising potential treatment option, especially for women who are infertile through polycystic ovarian syndrome (PCOS). Although the pregnancy and implantation rates of IVM treatment are not as high as conventional IVF treatment, IVM treatment has many advantages for infertile women with PCOS, because this group of patients is extremely sensitive to stimulation with exogenous gonadotrophins and is at increased risk of developing ovarian hyperstimulation syndrome (OHSS). Different protocols have been used before immature oocyte retrieval, indicating that there are beneficial effects with FSH or LH priming on oocyte maturation. To date, the clinical pregnancy and implantation rates obtained from IVM treatment in infertile women with PCOS are approximately 30-35% and 10-15% respectively. Therefore, as an option, IVM treatment can be offered to women with PCOS instead of conventional IVF treatment with ovarian stimulation.     

In-vitro maturation versus IVF with GnRH antagonist for women with polycystic ovary syndrome: treatment outcome and rates of ovarian hyperstimulation syndrome

In-vitro maturation (IVM) treatment has gained popularity for decreasing the incidence of ovarian hyperstimulation syndrome (OHSS) by eliminating or minimizing the use of gonadotrophins in women with polycystic ovary syndrome (PCOS). Studies have shown that IVF with GnRH-antagonist protocol is associated with a lower incidence of OHSS. Data comparing the relative success of these two treatments is, however, lacking. Treatment outcome and rates of OHSS were compared in patients with PCOS who underwent assisted conception with either IVM or IVF with GnRH-antagonist protocol between 2006 and 2011. The number of oocytes retrieved was higher in the IVM group, whereas the number of mature oocytes, fertilization rate and number of embryos cleaved were comparable. The implantation rate was higher in the IVF group. The clinical pregnancy rates per embryo transfer were not statistically different (IVF: 45.8% versus IVM: 32.4%). The live-birth rate was higher in the IVF group (IVF: 40.7% versus IVM: 23.5%; P = 0.04). Five women developed moderate or severe OHSS in the IVF group, whereas none did in the IVM group. Both IVM and IVF with GnRH-antagonist protocol seem to be effective treatment regimens in women with PCOS, although IVM is associated with a lower risk of OHSS.     

Follicular aspiration during the selection phase prevents severe ovarian hyperstimulation in patients with polycystic ovary syndrome who are undergoing in vitro fertilization

OBJECTIVE: The objective was to assess the effectiveness of follicular aspiration in the selection phase of infertile women with polycystic ovary syndrome (PCOS) under controlled ovarian hyperstimulation (COH). STUDY DESIGN: In group A, 13 infertile patients with PCOS failed at previous IVF or intracytoplasmic sperm injection (ICSI) treatment due to ovarian hyperstimulation syndrome (OHSS; a total of 13 cycles). In group B, new IVF cycles with ultrasound-guided transvaginal follicular aspirations during the selection phase (a total of 13 cycles) were conducted using the same patients. No more than ten follicles remained in bilateral ovaries. Parameters monitored included ovarian size, number of dominant follicles, estradiol (E2) level on the day of human chorionic gonadotrophin (HCG) injection, maturation of oocytes, fertilization rate, cleavage rate, embryo implantation rate, pregnancy rate, and level of serum hormone. RESULTS: In group B, the average number of follicles>or=12 mm and average serum E2 level were 15.5+/-4.0 and 9899+/-1430 pmol/l, respectively, which were significantly lower than 29.1+/-8.4 (P<0.001) and 15,544+/-1766 pmol/l (P<0.001) in group A. No cycles with moderate or severe OHSS occurred in group B, while nine out of 13 (69.2%) cycles did have this problem in group A. Oocyte maturation rate, fertilization rate and cleavage rate in group B were 80.7%, 76.9%, and 80.3%, respectively; and all of them are significantly higher than 56.4% (P<0.01), 58.7% (P<0.01), and 70.2% (P<0.02) respectively in group A. CONCLUSION: Follicular aspiration during the selection phase can prevent severe OHSS and reduce OHSS prevalence in patients with PCOS undergoing COH.     

Oocyte quality in patients with severe ovarian hyperstimulation syndrome: a self-controlled clinical study

OBJECTIVE: To investigate the oocyte quality in patients with severe ovarian hyperstimulation syndrome (OHSS). DESIGN: Self-controlled clinical study. SETTING: University teaching hospital. PATIENT(S): Twenty-two patients from our assisted reproductive technology (ART) program who developed severe OHSS during their first controlled ovarian hyperstimulation for IVF or intracytoplasmic sperm injection (ICSI) (OHSS cycles) during a period of 10 years and had a second ART attempt performed in our center in which OHSS did not develop (control cycles). INTERVENTION(S): IVF and ICSI. MAIN OUTCOME MEASURE(S): Oocyte yield and quality, fertilization rate, embryo yield and quality, implantation rate, and pregnancy rate. RESULT(S): The total number of oocytes retrieved and the mean number of metaphase II oocytes were significantly higher in patients with OHSS than in control cycles. Fertilization rates were similar in both groups of ART cycles, and thus the number of viable embryos were significantly higher in OHSS cycles. Implantation and pregnancy rates were similar in OHSS and control cycles. Oocyte and embryo yield and quality were similar in early and late OHSS. Oocyte yield and quality, embryological outcome, and implantation and pregnancy rates were similar in patients with and without polycystic ovarian syndrome (PCOS) both in cycles developing OHSS and control cycles. CONCLUSION(S): Oocyte quality is not compromised in severe OHSS cycles irrespective of whether patients had or did not have PCOS.     

人未成熟卵母细胞体外培养成熟、受精及胚胎移植

目的 应用卵母细胞体外成熟(IVM)技术帮助卵泡成熟障碍的不孕症患者获得妊娠及分娩。方法 接受未成熟卵IVM技术治疗者30例35个周期,其中多囊卵巢综合征14例,有卵巢过度刺激综合征病史6例,体外受精和胚胎移植(IVF-ET)周期中卵巢反应不良患者10例。设计卵巢刺激方案,采用含人成熟卵泡液的IVM培养液,建立未成熟卵母细胞的体外培养方法。结果 35个周期共取得未成熟卵母细胞203个,平均每个周期5．8个。培养后有156个卵母细胞排出第一极体,IVM率76．8％(156／203);在卵胞浆单精子显微注射(ICSI)12～18h后观察原核,正常受精率为76．9％(120／156);共有移植周期33个,获8例临床妊娠,妊娠率24％(8／33);有5例共7个婴儿出生。结论 IVM对一些卵泡发育和成熟障碍,特别是顽固性多囊卵巢综合征患者,是一种有效的辅助生育措施。人成熟卵泡液含有理想的自然促卵母细胞成熟的成分。     

来曲唑联合促卵泡素在PCOS患者IVF-ET中的应用及效价分析

目的:探讨来曲唑(LE)联合FSH在多囊卵巢综合征(PCOS)患者IVF-ET或ICSI中的应用及效价分析。方法:回顾性分析接受IVF-ET/ICSI治疗的170名PCOS不孕患者,分为LE组(LE-FSH组,n=59)与对照组(GnRHa-FSH组,n=111)。比较组间促排卵、妊娠结局、每周期治疗费用及药物效价比。结果:LE组和对照组FSH用药天数分别为6.3±1.9 d vs 13.0±2.3、用药量为615.6±284.6 IU vs l 504.9±424.9 IU,组间比较有显著性差异(P<0.01);hCG注射日E2值分别为1 965.3±1119.7 pmol/L vs 12 660.2±7 254.2 pmol/L,获卵数分别为6.5±3.3 vs16.6±7.9,组间比较均有显著性差异(P<0.01);受精率、胚胎种植率分别为66.1%vs71.6%,25.58%vs 23.63%,临床妊娠率为49.12%vs 34.48%,组间比较无显著性差异(P>0.05);中-重度OHSS发生率分别为O%和6.89%,组间比较差异有显著性(P<0.01)。LE组每刺激周期药费(2 877±1 240元)及每妊娠周期药费(3 014±1581元)显著低于对照组(6 561±1 852元、8774±1970元)(P<0.01),治疗效价比分别为5 959元vs 30 067元。结论:LE联合促卵泡素可有效运用于PCOS患者的IVF-ET中,较传统的GnRHa-FSH促排卵相比,无OHSS的发生、费用低、效价比高,且不影响妊娠率和种植率。     

来曲唑联合促性腺激素超促排卵用于PCOS患者行IVF-ET的临床研究

目的:研究来曲唑(LE)在多囊卵巢综合征(PCOS)患者超促排卵行IVF-ET中的应用。方法:90例PCOS患者随机分成LE组(n=49)和GnRHa长方案组(对照组,n=41),比较组间的促排卵天数、促性腺激素(Gn)使用剂量、获卵数、受精率、卵裂率、优质胚胎率、种植率和临床妊娠率以及卵巢过度刺激综合征(OHSS)发生率。结果:LE组与对照组的Gn剂量分别为18.0±6.6支和29.3±9.5支,促排卵天数分别为7.8±1.3 d和10.0±1.2 d,获卵数分别为7.9±4.1个和19.8±7.2个,MⅡ卵率分别为74.5%和82.9%,启动周期中-重度OHSS发生率4.1%(2/49)vs 29.3%(12/41),差异均具有统计学意义(P<0.05),而组间的种植率和临床妊娠率(33.3%vs27.5%和51.1%vs 48.5%)差异无统计学意义(P>0.05)。结论:LE用于PCOS超促排卵行IVF-ET与传统的GnRHa长方案相比,在不影响临床妊娠率的前提下,可以有效减少促排卵时间和Gn使用剂量,降低OHSS发生风险,具有极大的临床应用前景。