体外受精-胚胎移植后宫内宫外复合妊娠3例临床分析及文献复习

目的:探讨体外受精-胚胎移植术后复合妊娠的临床表现、诊断、治疗方法及妊娠结局。方法:回顾性分析北京大学第一医院自2001年1月至2013年12月接受体外受精-胚胎移植(IVF-ET)治疗后发生宫内宫外复合妊娠3例患者的临床资料。结果:第1例患者因移植后5周宫外妊娠囊破裂行急诊开腹双侧输卵管切除术,术后宫内胚胎继续妊娠至16周,无明显诱因发生流产;第2例患者移植后8周入院,入院即发现宫内胚胎停育,阴式超声发现宫外妊娠囊,行清宫术+腹腔镜双侧输卵管切除术治疗;第3例患者经阴式彩超发现复合妊娠,行腹腔镜下右输卵管切除术,术后宫内妊娠囊继续发育,现至28周。结论:复合妊娠缺乏典型临床表现,早期诊断困难,临床医生应高度警惕复合妊娠发生,并及时采取以手术为主的治疗措施,最大程度保护患者生命、生育能力及宫内胚胎存活。     

腹腔镜联合垂体后叶素治疗宫角妊娠的临床效果及预后

目的:探讨腹腔镜联合垂体后叶素治疗宫角妊娠的临床效果,并观察患者预后状况,为临床提供依据。方法:选择本院2010年1月至2013年7月收治的71例宫角妊娠患者,随机将患者分为对照组和观察组,对照组30例应用腹腔镜治疗,观察组41例应用腹腔镜时将垂体后叶素6 U注入宫角处。观察指标主要为两组术中收缩压变化、术中出血量、手术时间、排气时间和术后住院时间及治疗疗效、血β-h CG恢复时间等结果。结果:观察组用药后10 min、20 min和30 min之后收缩压变化为(5.28±0.27)mm Hg、(4.26±0.33)mm Hg和(3.17±0.22)mm Hg,均高于对照组(P0.05);观察组术中出血量(30.64±3.48)m L,低于对照组(58.76±4.11)m L(P0.05);手术时间、排气时间和术后住院时间分别为(41.06±4.27)min、(9.21±1.94)h和(3.08±0.44)d,均低于对照组(P0.05)。观察组的成功率为97.56%(40/41),高于对照组的76.67%(23/30),失败率低于对照组,差异具有显著性(P0.05)。观察组术后血β-h CG恢复时间为(3.52±0.29)周,低于对照组(5.08±0.37)周(P0.05)。结论:腹腔镜联合垂体后叶素治疗宫角妊娠临床效果较好,能够减少出血量,显著缩短患者治疗时间,预后良好,值得临床推广使用。     

男性年龄与体外受精-胚胎移植治疗结局的相关性分析

目的:探讨男性年龄对体外受精-胚胎移植(IVF-ET)治疗结局的影响。方法:按照男方年龄将接受常规IVF-ET治疗的188对夫妇分为四组:年龄31岁组53例,31~35岁组78例,36~40岁组37例,40岁组20例。分析男方年龄对IVF-ET治疗结局的影响。结果:本研究中各组间女方年龄、不孕年限、内膜厚度、基础FSH值、Gn总量、获卵总数、MII卵数、可移植胚胎率、优质胚胎率等结果比较均无显著性差异(P0.05),男方精液体积、精子密度、前向运动精子比率均无明显差异(P0.05),36~40岁组(9.3±3.0)和40岁组(9.5±2.6)的正常形态精子比率显著低于31岁组(13.5±2.8)和31~35岁组(12.6±2.7)(P0.05),而且36~40岁组的受精率(76.6%)显著低于31岁组(83.1%)和31~35岁组(81.4%)(P0.05)。另外,31岁、31~35岁、36~40岁、40岁组的着床率分别为:50.91%、41.32%、21.35%、23.4%(P0.05),妊娠率分别为64.15%、62.82%、40.54%、45.0%(P0.05),均呈一定的下降趋势。而各组间的流产率无显著差异(P0.05)。结论:随着年龄的增长,正常形态精子比率及IVF的受精率、胚胎着床率及妊娠率呈现下降的趋势,但仍需进一步的研究。     

妊娠期糖尿病对体外受精-胚胎移植妊娠结局影响分析

目的探讨妊娠期糖尿病对体外受精-胚胎移植妊娠结局的影响研究。方法选取2015年1月至2017年1月宝鸡市中心医院行体外受精-胚胎移植分娩的妊娠期糖尿病患者58例作为研究对象(观察组)。另选取2015年1月至2017年1月宝鸡市中心医院行体外受精-胚胎移植分娩的糖代谢正常产妇50例作为对照组。比较两组治疗周期临床特征、妊娠情况和种植情况、孕产妇并发症情况及新生儿并发症情况。结果两组促卵泡激素天数、促卵泡激素量、优胎率、移植胚胎数比较差异无统计学意义(P0.05);两组妊娠率和种植率比较差异无统计学意义(P0.05);观察组剖宫产、产后出血、胎儿窘迫、缺铁性贫血发生率均低于对照组,差异具有统计学意义(P0.05);而两组胎膜早破比较无统计学差异(P0.05);观察组新生儿窒息多于对照组,但差异无统计学意义(P0.05);观察组巨大儿多于对照组,且差异具有统计学意义(P0.05)。结论妊娠期糖尿病增加了体外受精-胚胎移植妊娠结局不良风险。     

子宫内膜形态与体外受精-胚胎移植妊娠的相关性分析

目的:分析阴道B超下子宫内膜形态与体外受精-胚胎移植(In vitro fertilization and embryo transfer,IVF-ET)妊娠成功之间的相关性,寻找影响试管婴儿妊娠率的相关因素,为提高助孕成功率提供指导。方法:选择2014年3月至2015年2月在我院接受IVF-ET治疗的不孕患者87例作为研究对象,所有孕妇均采用长方案促排,卵泡符合IVF-ET条件后行体外受精-胚胎移植术。在排卵日记录患者阴道B超检查结果,收集每位患者的子宫内膜形态相关参数并整理,按照患者行IVF-ET术后是否成功妊娠将其分为两组,妊娠组(61例)和未妊娠组(26例)。促排后,B超监测排卵情况,符合取卵条件时对患者采用阴道B超监测患者子宫内膜厚度、子宫形态,并根据后续是否妊娠分组整理上述数据并比较。采用Pearson程序分析子宫内膜形态与妊娠间的相关性。结果:妊娠组和未妊娠组患者的年龄、不孕原因、不孕类型、不孕病程、激素水平比较差异均无统计学意义(P0.05);经IVF-ET治疗后,妊娠组患者子宫内膜厚度(12.03±1.23)mm,子宫形态分类(有中线型18例,无中线型8例),未妊娠组患者子宫内膜厚度(11.95±1.29)mm,子宫形态分类(有中线型12例,无中线型49例),子宫内膜厚度两组比较差异无统计学意义(P0.05),子宫形态比较两组差异有统计学意义(P0.05);子宫内膜厚度与妊娠的Pearson相关性系数为0.5790.750,子宫内膜形态与妊娠的相关系数为0.754,说明子宫内膜形态与妊娠有相关性。结论:阴道B超下子宫内膜的形态与妊娠有一定的相关性,临床可作为妊娠判断的参考,但还应结合组织免疫学、患者激素水平等指标进行综合判断。     

不同氧浓度对体外受精-胚胎移植妊娠结局的影响

目的:探讨体外培养时不同氧浓度对体外受精-胚胎移植(in vitro fertilization-embryo transfer,IVF-ET)中胚胎发育潜能及妊娠结局的影响。方法:将471例于2013年在本生殖中心行IVF-ET的患者,根据其体外培养的氧浓度将其随机分为5%低氧浓度组(n=247)和20%高氧浓度组(n=224)。比较两组间卵子成熟率、受精率、卵裂率、正常受精率、多PN率、D3优质胚胎率、囊胚形成率、可利用胚胎率、临床妊娠率、着床率及活产率。结果:两组间患者的卵子成熟率、受精率、卵裂率、正常受精率、多PN率、D3优质胚胎率、囊胚形成率、可利用胚胎率、临床妊娠率、着床率均无统计学差异(P0.05)。但低氧浓度组的活产率显著高于高氧浓度组(48.2%vs.38.4%,P0.05)。结论:低氧浓度胚胎培养能够改善IVF的妊娠结局。     

输卵管栓塞术对体外受精-胚胎移植结局的影响

目的:探讨输卵管栓塞术治疗输卵管积水的治疗效果及对体外受精-胚胎移植(IVF-ET)结局的影响。方法:选择25例输卵管阻塞但无积水(A组)和22例输卵管积水(B组),其中B组先行输卵管栓塞术,再行IVF-ET,A组直接行IVF-ET,同时选择同期输卵管积水未处理直接行IVF-ET对照组。比较三组患者IVF-ET情况。结果:B组行输卵管栓塞术总成功率为100%。对照组临床妊娠率低于A组和B组,异位妊娠率和流产率高于A组和B组,差异均具有统计学意义(P0.05),而A组和B组之间临床妊娠率、异位妊娠率和流产率无明显差别(P0.05)。结论:输卵管栓塞术治疗输卵管积水有效,IVF-ET前行介入栓塞术可提高临床妊娠率,降低异位妊娠率和流产率,值得在IVF-ET前输卵管积水的治疗中推广。     

精子DNA损伤对体外受精-胚胎移植妊娠结局的影响研究

目的 分析精子DNA损伤与体外受精-胚胎移植(IVF-ET)受精率、胚胎发育及妊娠结局等的关系。方法 选取2020年1月至2021年8月甘肃省妇幼保健院诊治的286例不孕不育患者作为研究对象,经双方病因筛查,确定需进行IVF-ET。对其进行常规精液分析及形态评估,采用精子染色质结构分析法(SCSA)计算精子DNA碎片指数(DFI),根据精子DFI将其分为A组(DFI≤15%,n=72)、B组(15%30%,n=76)。统计分析三组体外受精(IVF)率、卵裂率、优质胚胎率、种植率和妊娠结局。结果 三组间正常受精率及总受精率比较,A组高于B组及C组,差异具有统计学意义(P<0.05);B组与C组比较,差异无统计学意义(P>0.05)。三组间卵裂率比较,差异无统计学意义(P>0.05)。三组间优质胚胎率比较,A组高于B组及C组,差异具有统计学意义(P<0.05);B组与C组比较,差异无统计学意义(P>0.05)。三组间种植率比较,C组低于B组,差异具有统计学意义(P<0.05);C组与A组比较,差异...     

短效长方案中GnRH-a使用时长对体外受精-胚胎移植结局的影响

目的探讨在短效长方案超促排卵(controlled ovarian hyperstimulation,COH)周期中,促性腺激素释放激素激动剂(gonadrotropinreleasing hormone agonist,GnRH-a)使用时长对体外受精-胚胎移植(in vitrofertilization and embryo transfer, IVF-ET)助孕结局的影响。方法选取2015年1月至2018年1月山东中医药大学附属医院中西医结合生殖与遗传中心采用短效长方案行IVF/ICSI-ET助孕的776例患者作为研究对象。回顾性分析776例患者接受短效长方案降调节后超促排卵患者的临床资料,根据GnRH-a的使用时长为分组依据,分为三组:A组:GnRH-a的使用天数为14d;B组:GnRH-a的使用天数为15d～17d;C组:GnRH-a的使用天数≥18d。比较各组之间临床资料、治疗情况及临床结局。结果三组患者平均年龄、体质量指数(BMI)、基础内分泌、原发性不孕比例、助孕方式、促性腺激素(Gonadotropin, Gn)使用总量、Gn使用时间、添加尿促性素(HMG,珠海丽珠制药)总量组间比较差异无统计学意义(P0.05);三组患者降调节天数、Gn启动日及HCG日内分泌、HMG使用时间、降调节费用、总费用、获卵数、优质胚胎数组间比较差异有统计学意义(P0.05);三组患者2PN受精率、新鲜胚胎移植率、移植胚胎数、胚胎种植率、临床妊娠率、流产率、卵巢过度刺激综合征(ovarian hyperstimulation syndrome, OHSS)发生率比较差异均无统计学意义。结论短效长方案降调节中,在达到降调节标准的前提下,GnRH-a使用14天,即可获得满意的IVF-ET妊娠结局,GnRH-a使用时间过长反而会影响获卵数及胚胎质量,增加医疗费用。     

Renal transplantation in gigantism: A case report

BACKGROUNDGigantism, characterized by excessive growth and height is due to increased secretion of growth hormone, most commonly from a pituitary adenoma. In addition to the surgical and anesthetic complexity, the extreme stature of these patients presents a unique challenge for kidney transplantation in deciding whether to proceed with a single or dual kidney transplantation. The lack of relevant literature further adds to the dilemma. CASE SUMMARYA 45-year-old patient with untreated gigantism and end stage renal failure on renal replacement therapy was waitlisted for a deceased donor dual kidney transplantation due to the extreme physical stature (Height-247 cm and weight-200 kg). He was offered 2 kidneys from a 1-0-1 HLA mismatched 24-year-old DCD donor (Height-179 cm and weight-75 kg), and was planned for a bilateral retroperitoneal implantation into the recipient external iliac vessels. The immunosuppression consisted of alemtuzumab induction (50 mg) and steroid-free maintenance with tacrolimus. The donor’s right kidney was uneventfully implanted extra-peritoneally into the right external iliac vessels. On contralateral exposure, the left common and external iliac arteries were ectatic and frail. A complex vascular reconstruction was not preferred in order to preserve the arterial supply to the left lower limb, to minimise the cold ischemia time and prevent additional warm ischemic insult to the second kidney. Hence, it was decided not to proceed with dual transplantation. Amidst concerns of nephron mass insufficiency, the graft function was remarkable with a serum creatinine of 120 µmol/L within a month from transplantation and 94 µmol/L at 1-year post transplantation, and without proteinuria. CONCLUSIONTo our knowledge, this is the first case report on kidney transplantation in gigantism. Although it is believed that dual kidney transplantation is ideal, a single kidney transplantation from an appropriately selected donor can provide sufficient functioning nephron mass in patients with gigantism.     

Intra-abdominal desmoid tumor after liver transplantation: A case report

We are reporting the first documented case of an abdominal desmoid tumor presenting primarily after liver transplantation. This tumor, well described in the literature as occurring both in conjunction with familial adenomatous polyposis as well as in the post-surgical patient, has never been noted after solid organ transplantation and was therefore not included in our differential upon presentation. Definitive diagnosis required the patient to undergo surgical excision and immunochemical staining of the mass for confirmation. A review of the literature showed no primary tumors after transplantation. In a population of patients who received a small bowel transplant after they developed short gut post radical resection of aggressive fibromatosis, only rare recurrences were seen. No connection of tumor development with immunosuppression or need to decrease immunosuppressant treatment has been demonstrated in these patients. Our case and the literature show the risk of this tumor presenting in the post-transplantation patient and the need for a high index of suspicion in patients who present with a complex mass after transplantation to prevent progression of the disease beyond a resectable lesion. Results of a thorough search of the literature are detailed and the medical and surgical management of both resectable and unresectable lesions is reviewed.     

Giant condyloma acuminatum in pregnancy: A case report

The giant condyloma acuminatum (GCA), also known as Buschke–Löwenstein tumor (BLT), is a type of human papilloma virus‐associated sexually transmitted infection. Treatment options for condyloma acuminatum remain controversial, but surgery seems to be the best option. The management of GCA during pregnancy is more complicated since one has to evaluate the condition of both the mother and the fetus. In this report, we presented a GCA case in a pregnant woman with giant masses that covered the perineal and perianal region. Considering the gestational age and the fetal neurological risk from the anticipated lengthy procedure of mass removal surgery for tumor of this size, we decided to resect the tumor 2 weeks after the infant was delivered via C‐section.     

输卵管妊娠手术后持续性异位妊娠的临床分析

目的：探讨输卵管妊娠术后并发症——持续性异位妊娠（persistent ectopic pregnancy,PEP）的高危因素、监测及诊治方法。方法：对我院2011年1月至2013年12月412例输卵管妊娠腹腔镜手术后出现的持续性输卵管妊娠共19例患者的资料进行分析,在输卵管妊娠术前预测PEP的高危因素,术后血β-绒毛膜促性腺激素（β-human chorionic gonadotropin,β-HCG）监测,治疗以甲氨蝶呤（MTX）1mg/kg单次肌肉注射为主,必要时给予米非司酮50mg,1次/d,5d或行再次手术。结果：发生PEP患者中保留输卵管手术比根治性的输卵管切除术发生PEP者高,输卵管伞部妊娠行妊娠产物挤出术又较其他术式高（P〈0.05）;术前高血β-HCG值、妊娠包块周边血流半环-环状、输卵管手术史、盆腔炎史者均明显高于未发生PEP患者（P〈0.05）。结论：手术前、中、后对发生PEP风险的评估、早期诊断、及时治疗是PEP防治的关键。     

口服避孕药预处理对卵巢反应正常者体外受精-胚胎移植结局的影响

目的:探讨超排卵前口服短效避孕药预处理对卵巢反应正常者体外受精-胚胎移植(IVFET)结局的影响。方法:回顾分析本中心采用长方案的358个IVF-ET周期,分为黄体中期降调组(A组)188例,口服避孕药预处理组(B组)170例。比较两组的GnRHa、Gn用量、超排卵启动时间、用药持续时间、HCG日血清E2和LH水平及内膜厚度、获卵率、受精率、卵裂率、着床率、妊娠率等。结果:两组一般情况无差异。B组促性腺激素释放激素激动剂(GnRHa)用量少于A组,而促性腺激素(Gn)用量多于A组,Gn用药时间明显长于A组(P0.05),Gn启动时间早于A组(P0.05),HCG注射日血清LH水平明显低于A组(P0.05),内膜薄于A组(P0.05)。A组着床率和妊娠率明显高于B组(P0.05)。两组的HCG日血清E2水平、获卵数、受精率、卵裂率、优质胚胎率均无显著性差异(P0.05)。结论:GnRHa垂体降调前口服短效避孕药预处理可以减少GnRHa的用量,却延长了Gn用药时间及超排卵中Gn用量,能有效抑制血清LH的水平,不会影响卵泡和胚胎的质量,但是妊娠率和着床率下降,或许GnRHa和口服避孕药联合使用只对卵巢低反应和高反应者存在优势,对于卵巢反应正常者并不是最佳治疗方案。     

A finger-saving operation in squamous cell carcinoma of the right thumb. A case report

A 68-year-old man with squamous cell carcinoma of the right thumb underwent a finger-saving operation. The lesion (2 X 2.3 cm) was located near the IP joint. There were no distant metastases. A wide local excision including the MP joint was performed, and the axillary lymph nodes were dissected. To avoid any loss of length the bone defect was treated with a 2.5-cm-long bone graft from the third rib. The skin defect was closed with a local flap. In the histological examination tumor cells reached the subcutaneous layer; the deeper layers and the bone were not involved. Two years after the operation neither local recurrence nor distant metastases were found and the function of the right hand was good. The good outcome of this case does not allow any general conclusion on the best treatment for such cases; but it does emphasize the difficulties of deciding on the treatment (amputation or excision) to be applied in this area.     

Orthotopic liver transplantation for giant liver haemangioma: A case report

In liver haemangiomas, the risk of complication rises with increasing size, and treatment can be obligatory. Here we present a case of a 46-year-old female who suffered from a giant haemangioma causing severe portal hypertension and vena cava compression, leading to therapy refractory ascites, hyponatremia and venostasis-associated thrombosis with pulmonary embolism. The patients did not experience tumour rupture or consumptive coagulopathy. Surgical resection was impossible because of steatosis of the non-affected liver. Orthotopic liver transplantation was identified as the only treatment option. The patient's renal function remained stable even though progressive morbidity and organ allocation were improbable according to the patient's lab model for end-stage liver disease(lab MELD) score. Therefore, non-standard exception status was approved by the European organ allocation network "Eurotransplant". The patient underwent successful orthotopic liver transplantation 16 mo after admission to our centre. Our case report indicates the underrepresentation of morbidity associated with refractory ascites in the lab MELD-based transplant allocation system, and it indicates the necessity of promptly applying for non-standard exception status to enable transplantation in patients with a severe clinical condition but low lab MELD score. Our case highlights the fact that liver transplantation should be considered early in patients with non-resectable, symptomatic benign liver tumours.     

Use of frozen sperm for in vitro fertilization. A case report

A case of a man with a malignant testicular tumor is reported; during the time between orchiectomy and retroperitoneal lymphadenectomy his semen was preserved and stored in liquid nitrogen (-196 degrees C). Due to postoperative ejaculation disturbance resulting in infertility of the husband, artificial insemination with cryopreserved semen was performed over a period of 9 months without leading to conception. During a laparoscopy and perturbation, which were combined with an attempt for in vitro fertilization (IVF), three oocytes were collected and fertilized in vitro by cryopreserved spermatozoa of the husband. Two days later two embryos were transferred, unfortunately resulting in a bilateral tubal pregnancy. The case report demonstrates that less than 10,000 progressively motile spermatozoa are sufficient to perform successful IVF and embryo transfer.