卵巢低反应和IVF-ET结局的预测及处理

卵巢低反应是影响体外受精-胚胎移植(IVF-ET)成功的关键因素.通过评估卵巢储备功能预测卵巢反应性,从而选择个体化的最佳的超促排卵(COH)方案,以避免卵巢低反应的发生.预测卵巢反应的常用指标有年龄、卵巢基础状态(包括卵巢体积、窦卵泡数)、内分泌激素水平(包括基础FSH、E2、Inhibin、P/E2比值及各项动力学试验)     

卵巢低反应和IVF-ET结局的预测及处理

卵巢低反应是影响体外受精-胚胎移植(IVF-ET)成功的关键因素。通过评估卵巢储备功能预测卵巢反应性,从而选择个体化的最佳的超促排卵(COH)方案,以避免卵巢低反应的发生。预测卵巢反应的常用指标有年龄、卵巢基础状态(包括卵巢体积、窦卵泡数)、内分泌激素水平(包括基础FSH、E_2、Inhibin、P/E_2比值及各项动力学试验)     

IVF-ET中卵巢低反应临床资料分析及再次治疗策略

目的:探讨在体外受精-胚胎移植(IVF-ET)周期控制性超排卵(COH)中出现临床卵巢低反应患者的临床特征及其再治疗策略。方法:回顾性分析接受IVF-ET治疗,表现为临床卵巢低反应的189例患者临床资料(以获卵≤4枚为诊断标准),并按照患者年龄分为≤30岁、>30～35岁、>35岁3组;未妊娠接受第2次IVF-ET治疗共71个周期的临床资料进行自身对照分析。结果:第1周期治疗中,≤30岁组、>30～35岁组优质胚胎率和妊娠率均高于>35岁组,周期取消率低于>35岁组;第2周期调整COH方案可以获得正常的卵巢反应;对于卵巢低反应的高龄患者,小剂量的生长激素可以增加其优质胚胎率。结论:在COH方案中,部分卵巢低反应患者存在卵巢反应的不一致性,应结合既往超排经历重新评估卵巢储备。     

卵巢低反应和IVF-ET结局的预测及处理

卵巢低反应是影响体外受精-胚胎移植(IVF-ET)成功的关键因素。通过评估卵巢储备功能预测卵巢反应性，从而选择个体化的最佳的超促排卵(COH)方案，以避免卵巢低反应的发生。预测卵巢反应的常用指标有年龄、卵巢基础状态(包括卵巢体积、窦卵泡数)、内分泌激素水平(包括基础FSH、E2、Inhibin、P／E2比值及各项动力学试验)。     

延长促性腺激素使用时间对IVF-ET中卵巢低反应者结局的影响

目的:探讨在体外受精一胚胎移植(IVF-ET)过程中延长促性腺激素(Gn)使用时间对卵巢低反应者的影响。方法:回顾性分析本中心自2005年1月～2006年12月行IVF-ET治疗的患者922例,根据卵巢低反应的预测标准选择促排卵治疗方案,经预测排除卵巢低反应者选择长方案806例,经预测可能发生卵巢低反应者选择短方案116例(C组)。在促排卵过程中,经预测排除卵巢低反应者选择长方案806例中仍有149例患者发生了无法预测的卵巢低反应(B组),未发生卵巢低反应者657例(A组),比较3组之间的年龄、基础FSH、E2、Gn使用时间、Gn使用量、胚胎种植率、临床妊娠率。结果:A组与B组之间在年龄、基础FSH、E2、胚胎种植率(20.8%vs20.1%)、临床妊娠率(34.3%vs31.9%)之间差异无显著性(P>0.01),而在Gn使用量[(35.09±8.96)支vs(52.97±15.93)支]、Gn使用时间[(11.52±1.18)天vs(15.34±3.56)天]、获卵数之间差异有显著性(P<0.01)。B组与C组相比较Gn使用量[(52.97±15.93)支vs(38.13±16.14)支]、Gn使用时间[(15.34±3.56)天vs(9.78±2.60)天]之间差异有显著性(P<0.01),两组妊娠率(31.9%vs21.6%)有差异。结论:在IVF-ET治疗过程中,对无法预测的卵巢低反应者,采用延长Gn使用时间可以增加获卵数,降低周期取消率,改善IVF结局。     

口服避孕药在体外受精周期中的应用进展

目前口服避孕药(Ocs)在体外受精(IVF)周期中广泛应用,但各位学者研究结果不一.多数文献认为,口服避孕药应用于卵巢高反应和低反应患者可以改善体外受精临床结局,而口服避孕药应用于卵巢正常反应患者,除在促性腺激素释放激素拮抗剂(GnRHA)周期可通过其对月经周期进行控制,有计划地安排工作以外,并不改变体外受精临床结局.口服避孕药停药后5 d或月经第3天给促性腺激素(Gn)优于停药后2 d给促性腺激素.选择合理的口服避孕药用药方案和临床适应症对改善体外受精临床结局起着重要作用.     

生长激素辅助促排卵改善卵巢低反应患者不孕治疗的结局

目的:观察联合使用生长激素和促性腺激素对卵巢反应低下者促排卵后指导同房的治疗效果。方法:实验组患者在促性腺激素促排卵过程中联合使用生长激素,对照组患者单纯使用促性腺激素启动促排卵。比较两组促排卵前后的相关指标及临床结局。结果:实验组促性腺激素时间短,所需剂量少,HCG日子宫内膜厚度、E2水平均显著高于对照组,且妊娠率较高。结论:生长激素可提高卵巢反应性,促进子宫内膜生长,能改善卵巢低反应患者的促排卵治疗效果。     

口服避孕药在体外受精周期中的应用进展

目前口服避孕药(OCs)在体外受精(IVF)周期中广泛应用,但各位学者研究结果不一。多数文献认为,口服避孕药应用于卵巢高反应和低反应患者可以改善体外受精临床结局,而口服避孕药应用于卵巢正常反应患者,除在促性腺激素释放激素拮抗剂(GnRHA)周期可通过其对月经周期进行控制,有计划地安排工作以外,并不改变体外受精临床结局。口服避孕药停药后5d或月经第3天给促性腺激素(Gn)优于停药后2d给促性腺激素。选择合理的口服避孕药用药方案和临床适应症对改善体外受精临床结局起着重要作用。     

脱氢表雄酮对卵巢储备功能降低患者IVF-ET结果的影响

目的:探讨脱氢表雄酮(DHEA)对卵巢储备功能降低(DOR)患者行体外受精-胚胎移植(IVF-ET)治疗结局的影响。方法:对接受体外受精/卵胞浆内单精子注射(IVF/ICSI)助孕治疗的47例DOR患者DHEA辅助治疗前后周期进行自身对照研究,分析卵巢储备功能指标(基础激素水平、窦卵泡计数等)及周期治疗参数(卵泡数、获卵数、受精率、卵裂率、胚胎种植率、临床妊娠率、周期取消率、流产率等)的变化。结果:前后周期超促排卵方案无显著性差异,DHEA辅助治疗后基础窦卵泡计数、卵泡数、获卵数显著增加(P<0.05),卵裂率、胚胎种植率、临床妊娠率显著提高(P<0.05),周期取消率呈降低趋势(P>0.05),而受精率、流产率无差异(P>0.05)。结论:DHEA辅助治疗可以改善DOR患者卵巢储备功能,提高卵巢反应性,改善IVF治疗结局。     

复方口服避孕药治疗多囊卵巢综合征

多囊卵巢综合征是生育年龄妇女常见的内分泌及糖代谢异常所导致的病理状态。以高雄激素血症及慢性不排卵性不孕为其临床特征。目前，复方口服避孕药逐渐用于多囊卵巢综合征妇女的治疗并取得了良好的效果，成为多囊卵巢综合征患者首选的治疗方案。     

复方口服避孕药治疗经前期综合征的临床疗效和安全性评价

目的:研究复方口服避孕药物治疗经前期综合征的疗效和安全性。方法:经前期综合征患者86例,随机分为治疗组(45例)和对照组(41例),治疗组给予复方口服避孕药,对照组给予维生素B6。分别用经期不适问卷(MDQ)和证候评分评估服药前和服药1、3、6个周期后经期不适的程度。结果:试验结束后,治疗组的MDQ评分、证候评分较对照组有显著性差异(P<0.05);治疗组和对照组的临床疗效总有效率分别81.1%和48.7%,有明显显著性差异(P<0.01);结论:复方口服避孕药对经前期综合征有较好的疗效和安全性。     

Once-a-month contraceptive pills in China: a review of available evidence

OBJECTIVE: A review of evidence was conducted to assess the safety, effectiveness and continuation of once-a-month contraceptive pills. METHODS: Papers were identified by electronic searches in Chinese and international databases and manual searches of Chinese journals and index of family planning literature. Data on pharmacokinetics, clinical performance and laboratory examinations were extracted from 17 papers of mixed quality on pills containing quinestrol 3 mg and norgestrel 12 mg (Quin-Ng) or levonorgestrel 6 mg (Quin-Lng) used by women in China. RESULTS: Quin-Lng pills gave steady-state serum levels of ethinylestradiol between 0.20-0.25 and 0.15 ng/mL. The 1-year perfect use pregnancy rate was 1.1 per 100 women-years. Nausea and increased leukorrhea were common; bleeding control was good. Hypertension developed in 5.8% of Quin-Ng pill users during the first year of use. For Quin-Ng and Quin-Lng once-a-month pills, 1 year continuation rates were 73.6 and 82.1 per 100, respectively. CONCLUSIONS: Lack of good quality data prevents confident assessment of the safety and efficacy of once-a-month pills. Short-term safety information indicates a high incidence of bothersome side effects and hypertension. The high monthly estrogen and progestogen doses raise questions about the safety of the once-a-month pills.     

Comparison of the metabolic effects of oral contraceptive and nonhormonal contraceptive use in women over 40 years old

The aim of this study was to compare metabolic changes during use of low-dose combined oral contraceptives (COCs) and those of nonhormonal contraceptives in perimenopausal women. Thirty-nine healthy women over 40 years old who attended the Family Planning Clinic of the King Chulalongkorn Memorial Hospital, Bangkok, Thailand, were recruited, 20 in the COC group received COC preparations containing 30 microg of ethinyl estradiol and 150 microg of levonorgestrel and 19 in the nonhormonal group were intrauterine device users. Blood samples were taken upon admission and 6 months later. Minor biochemical changes associated with low-dose COC use included an increase in glucose tolerance, triglycerides, serum albumin, serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) levels but a decrease in fasting plasma glucose, total cholesterol, high-density lipoprotein cholesterol, total bilirubin and alkaline phosphatase levels. There was no clinical significance for the metabolic changes. Low-dose COCs can be a satisfactory contraceptive choice for healthy perimenopausal women.     

Randomized trial of the effect of tailored versus standard use of the combined oral contraceptive pill on continuation rates at 1 year

Background

There is growing interest from women and clinicians in extended or tailored use of the combined oral contraceptive (COC) pill. Potential advantages include less bleeding, greater contraceptive efficacy and user satisfaction. We examined the effect of a tailored pill regimen, compared with the standard regimen, on continuation and satisfaction rates at 1 year and associated bleeding patterns.

Study Design

This was a randomized controlled trial with 503 women aged 18–45 years. Women were randomized to either the standard regimen (21 daily pills followed by a 7-day pill-free interval) or tailored regimen (daily pills until three consecutive days bleeding triggers a 3-day pill-free interval) of Microgynon 30® (ethinyl oestradiol 30 mcg, levonorgestrel 150 mcg). Primary outcome was COC continuation at 12 months; secondary outcomes included satisfaction with pill regimen regarding contraception and bleeding pattern. Daily electronic diaries were used to record women's pill use, switching to other contraceptive methods, menstrual bleeding patterns and satisfaction levels.

Results

Eighty-three percent of women were already taking the COC at recruitment, 13% were restarting the COC and 4% were first time COC users. Seventy-one percent of all women were followed up at 12 months. Continuation rates at 1 year were 82% in the tailored arm versus 80% in the standard arm [odds ratio (OR)=1.13; 95% confidence interval (CI)=0.67–1.91]. Satisfaction with contraceptive regimen was 86% (tailored) versus 94% (standard) (OR=0.37; 95% CI=0.17–0.79), and satisfaction with bleeding pattern was 79% versus 87%, respectively (OR=0.53; 95% CI=0.30–0.93). Median number of bleeding days per month was 2.4 (tailored) and 4.9 (standard). Incidence, duration and intensity of bleeding episodes were significantly lower in the tailored arm.

Conclusions

In women familiar with standard use of the COC, switching to tailored COC use or continuing with standard use were both associated with high COC continuation rates and high satisfaction with contraceptive regimen and bleeding pattern. While significant differences tended to favor the standard group, tailored COC use was associated with significantly less bleeding, suited some women very well and can provide a suitable alternative to standard use.     

Randomized controlled study of the influence of two low estrogen dose oral contraceptives containing gestodene or desogestrel on carbohydrate metabolism

This study compared the impact on carbohydrate metabolism of two combinedoral contraceptives (COCs). This open-label, single-center trial enrolled participants for a total of 15 cycles. Thirty-six women were randomized to receive either 20 μg ethinyl estradiol (EE) and 75 μg gestodene (GSD) or 20 μg ethinyl estradiol and 150 μg desogestrel (DSG) daily for 21 days out of 28. A glucose tolerance test was performed at baseline and cycles 6 and 13. The area under the curve (AUC) for glucose increased in both study groups. The change was statistically significant (p = 0.036) for the 20 EE/75 GSD group at cycle 6 versus baseline. Fasting blood glucose at cycle 13 was significantly (p < 0.01) higher for both treatment groups compared to baseline. No changes were found for fasting insulin and fasting C-peptide levels or for the AUCs of insulin or C-peptide. Both regimens were well tolerated. Gestodene and desogestrel in combination with 20-μg ethinyl estradiol induce similar changes in carbohydrate metabolism which are smaller than those described earlier for COCs containing higher estrogen doses or more androgenic progestins such as levonorgestrel.     

Comparison of ethinylestradiol pharmacokinetics in three hormonal contraceptive formulations: the vaginal ring, the transdermal patch and an oral contraceptive

This open-label, randomized study compared the pharmacokinetics of ethinylestradiol (EE) from the contraceptive vaginal ring NuvaRing (15 microg EE/day), the transdermal patch (20 microg EE/day) and a combined oral contraceptive (COC) containing 30 microg EE. After 2-8 weeks of synchronization by COC treatment, subjects were randomized to 21 days of treatment with NuvaRing, patch or COC. Analysis of area under the EE concentration-versus-time curve (AUC) during 21 days of treatment showed that exposure to EE in the NuvaRing group was 3.4 times lower than in the patch group (p < .05) and 2.1 times lower than in the pill group (p < .05). Serum EE levels of subjects showed much lower variation with NuvaRing than with the patch or the COC. Thus, exposure to EE was significantly lower with NuvaRing than with the patch and pill methods, demonstrating that NuvaRing is a low-estrogen-dose contraceptive method that also results in low estrogen exposure.     

体外受精-胚胎移植中卵巢反应不良患者妊娠成功率的相关因素分析

目的探讨体外受精-胚胎移植中卵巢反应不良患者妊娠成功率的影响因素。方法回顾性分析IVF-ET/IVF-ICSI治疗的1 376个临床卵巢反应不良周期的妊娠情况进行分析,采用回顾性病例对照研究的方法,对妊娠组与非妊娠组的相关因素进行分析。结果两组年龄、不孕年限、不孕原因、是否有手术史,周期数、基础性激素水平、促排卵方案、Gn种类、hCG日激素水平、获卵数、成熟卵子数、hCG日内膜厚度及形态、受精率、可移植胚胎数、优质胚胎数等因素比较,差异有统计学意义。用药方案、女方年龄、可利用胚胎、优质胚胎进入多重线性回归模型。结论影响卵巢反应不良妊娠结局最重要的因素是年龄,对于年龄小于35岁的反应不良患者,可获取卵子数目的减少并不等同于卵子质量的下降,在获得可供移植的胚胎后仍可获得不错的妊娠率。各种超排卵方案中,长方案仍然是妊娠率较高的一种方法,对于具备一定程度卵巢储备的患者,仍然不要放弃传统长方案(包括长效长方案和短效长方案)的使用。     

Effects on serum hormone levels of low-dose estrogen in place of placebo during the hormone-free interval of an oral contraceptive

BACKGROUND: The study was conducted to evaluate the effects of low-dose estrogen compared to placebo on ovarian activity during the traditional 7-day hormone-free interval (HFI) of an oral contraceptive (OC). STUDY DESIGN: Women were randomized to placebo or low-dose estrogen for 7 days during the HFI. Serum levels of estradiol, follicle-stimulating hormone (FSH), luteinizing hormone and inhibin B were obtained before, during and after treatment. RESULTS: Mean hormone levels remained constant or only increased slightly for the low-dose estrogen group compared to greater more sustained increases observed for the placebo group. Estradiol, FSH and inhibin B levels were substantially higher for those on placebo. Differences were most noticeable by the end of the HFI and persisted into the subsequent cycle. CONCLUSION: Subjects receiving low-dose estrogen for 7 days during the HFI demonstrated more pronounced ovarian suppression compared to placebo as evidenced by attenuation of increases in serum inhibin B, FSH and estradiol levels.     

Comparative study on intermittent versus continuous use of a contraceptive pill administered by vaginal route

A multicenter, international, randomized, comparative trial was conducted to assess the acceptability, efficacy and safety of two different schedules of a contraceptive pill, containing 250 μg levonorgestrel and 50 μg ethinyl estradiol, administered by the vaginal route. One schedule of daily administration for 21 days with a seven-day interruption to allow withdrawal bleeding was compared to daily administration without interruption for bleeding. A total of 900 women were recruited in three countries, Brazil, Egypt and China; 7,090 women-months of vaginal pill use were recorded (3,364 using the pills intermittently and 3,726 continuously). Four undesired pregnancies occurred, one in Egypt and three in China, all four in women using the pills intermittently. There was a statistically significant difference (p = 0.486) in pregnancy rate between the two groups. There were no other significant differences in discontinuation rates despite marked differences in bleeding patterns, amenorrhea predominating in the continuous use group. Hemoglobin levels increased significantly in the two groups but hematocrit was significantly higher in the continuous use group.