Uterine cavity assessment prior to IVF

Approximately 15% of couples are affected with subfertility, of which up to 20% remain unexplained. Uterine cavity abnormalities can be a contributing cause of subfertility and recurrent implantation failure. Uterine cavity assessment has been suggested as a routine investigation in the evaluation of subfertile women. Traditionally, hysterosalpingography has been the most commonly used technique in the evaluation of infertility. Transvaginal ultrasound scan allows visualization of the endometrial lining and cavity, and has been used as a screening test for the assessment of uterine cavity. Abnormal uterine findings on a baseline scan can be further evaluated with saline hysterosonography, which is highly sensitive and specific in identifying intrauterine abnormalities. Hysteroscopy is considered as the definitive diagnostic tool to evaluate any abnormality suspected on hysterosalpingography, transvaginal ultrasound scan or saline hysterosonography during routine investigation of infertile patients. Minimally invasive hysteroscopes have minimized the pain experienced by patients during the procedure and made it feasible to use hysteroscopy as a routine outpatient examination. Following recurrent IVF failure there is some evidence of benefit from hysteroscopy in increasing the chance of pregnancy in the subsequent IVF cycle, both in those with abnormal and normal hysteroscopic findings. Various possible mechanisms have been proposed for this beneficial effect, but more randomized controlled trials are needed before its routine use in the general subfertile population can be recommended.     

Value of hysteroscopy in management of unexplained infertility

ObjectiveTo assess the value of hysteroscopy in unexplained infertility.Methods200 infertile women in whom standard infertility investigations revealed no abnormalities were included in the study between January 2009 and December 2013. All women underwent hysteroscopy for diagnosis and treatment of any uterine lesion which was previously undetected by hysterosalpingography (HSG). Treated women were followed up for one year during which pregnancy rate was determined. As all other causes that contribute to infertility (other than the subtle uterine lesions) were excluded. No other infertility treatment was performed during this period.ResultsOf the 200 women studied, hysteroscopy revealed abnormalities in 65 (33%) women. Most uterine abnormalities were mild adhesions, small submucous myomas and polyps and their incidence was greater in women aged ≥ 30 years and women with secondary infertility. The overall pregnancy rate in the treated women within one year of follow up was 46%.ConclusionAs a cause of unexplained infertility, subtle uterine abnormalities are diagnosed only during hysteroscopy and they are relatively common in infertility women. Although the presence of these abnormalities is not detected by the basic investigations for infertility, their correction seems to be necessary when infertility is desired and other infertility causes are excluded.     

宫腔镜检查在辅助生育技术中的应用价值

目的:探讨宫腔镜检查在辅助生育技术中的临床应用价值。方法:回顾分析2008年1月～2009年1月96例辅助生育技术失败后(研究组)及53例辅助生育技术助孕前(对照组)行宫腔镜检查的病例资料。结果:辅助生育技术失败后(研究组)宫腔镜检查发现异常的阳性检出率达66.67%(64/96),其中原发性不孕宫腔异常发生率为64.91%,继发性不孕宫腔异常发生率为69.23%,两种情况在子宫内膜炎、子宫内膜息肉、宫颈管赘生物、先天性子宫发育异常等方面差异无统计学意义,但在宫腔粘连方面差异有统计学意义。53例辅助生育技术助孕前(对照组)宫腔镜检查发现异常的阳性检出率达66.04%(35/53),原发性不孕宫腔异常发生率为68.75%,继发性不孕宫腔异常发生率为61.90%,两种情况在子宫内膜炎、子宫内膜息肉、宫颈管赘生物、宫腔粘连等方面差异无统计学意义。结论:宫腔镜检查创伤小、恢复快,具有可接受性和准确性,应作为辅助生育技术前的常规检查。     

Efficiency of saline contrast hysterosonography for evaluating the uterine cavity

Diagnostic hysteroscopy is the standard investigation performed in the case of abnormal vaginal blood loss. More recently there has been increasing interest for minimal invasive saline contrast hysterosonography (SCHS) as this technique is less painful and less expensive. SCHS is indicated in case of abnormal uterine bleeding (premenopausal and postmenopausal), bleeding while using tamoxifen, suspicion of a congenital uterine abnormality and Asherman's syndrome. As well as intracavity abnormalities (polyps and myomas) SCHS can also be used to evaluate the intramural extension of myomas, which is necessary to assess whether hysteroscopic resection is possible. The sensitivity and specificity of SCHS for demonstrating intracavity abnormalities (with a prevalence of 54%) are 94% (95%-CI; 91-97) and 89% (95%-CI: 85-94) respectively. The positive and negative predictive values are 91% (95%-CI: 87-95) and 92% (95%-CI: 89-97) respectively. SCHS has a short learning curve and can be performed in an outpatient setting. SCHS fails more frequently in postmenopausal women than premenopausal women (12.5% vs. 4.7%; p = 0.03). The chance of a non-conclusive SCHS is 7.6% and is higher if the uterine volume is greater than 600 cm3 (relative risk: 2.63; 95%-CI: 1.05-6.60) and if two or more myomas are present: (RR 2.65; 95%-CI: 1.16-6.10). SCHS is 2 to 9 times cheaper than diagnostic hysteroscopy. It can replace 84% of the diagnostic hysteroscopies. SCHS, in combination with endometrial sampling, whenever indicated, might be able to replace diagnostic hysteroscopy as gold standard in the evaluation of the uterine cavity.     

宫腔病变与不孕症的关系及诊治进展

不孕症中10%～15%为宫腔因素所致,最为常见的原因是子宫内膜息肉、子宫黏膜下肌瘤、子宫纵隔和宫腔粘连,其他如慢性子宫内膜炎、子宫内膜结核、宫腔妊娠物残留等,可引起宫腔形态失常、收缩异常、异常血管形成、炎症反应、内膜容受性下降等,影响受孕和导致流产发生。适时而恰当地给予子宫性不孕、不明原因不孕症患者宫腔镜检查和治疗,可以显著改善这部分人群的妊娠率和妊娠结局。     

男性不育患者精子染色体畸变的检测及其对ICSI影响的研究

目的:探讨男性不育患者精子染色体畸变率及其对ICSI结果的影响。方法:随机选取外周血细胞染色体正常、行ICSI治疗的男性不育患者32例,其中少精症8例、严重少精症9例、阻塞性无精症经皮附睾穿刺吸精子11例、精液正常但常规IVF不受精患者4例以及5例对照组。应用荧光原位杂交技术检测了各类男性不育患者精子性染色体、13、18、21号染色体非整倍体的发生率和二倍体的发生率,统计分析这些染色体畸变的发生率与ICSI后的受精率、卵裂率、优质胚胎率、妊娠率、胚胎种植率以及流产率之间的关系。结果:少精症组精子性染色体非整倍体发生率明显升高(0.58%、0.25%,P<0.001),常见的形式为精子XY二体、XX二体以及YY二体;在严重少精症组,精子性染色体二体率(0.94%、0.25%)、13号染色体二体率(0.40%、0.09%)、21号染色体二体率(0.48%、0.10%)、二倍体率(0.43%、0.09%)明显高于对照组,有显著性差异(P<0.001);在阻塞性无精症组,性染色体二体率(1.43%、0.25%)、二倍体率(0.32%、0.09%)明显高于对照组,有显著性差异(P<0.001)。在IVF不受精组,各项检测指标与对照组相比无明显差异。严重少精症组ICSI后的优质胚胎率、妊娠率以及胚胎种植率明显下降,流产率升高。结论:在行ICSI治疗前,用FISH方法进行精子染色体畸变的检测是有效的,也是必要的;对检测阳性的患者,在行ICSI后对早期胚胎进行遗传学检测可减少或避免遗传缺陷的发生。     

子宫输卵管碘油造影检查诊断不孕症222例分析

目的探讨子宫输卵管碘油造影(HSG)对女性不孕病因的诊断价值。方法回顾性分析222例行子宫输卵管碘油造影(HSG)不孕患者资料,并与宫/腹腔镜检查结果进行比较。结果222例中宫腔形态异常者36例,占16.22%;宫腔粘连7例,占3.15%;输卵管异常179支,占80.63%;宫腔和输卵管均异常8例,占3.60%。在诊断输卵管通畅度中,HSG与宫、腹腔镜检查的诊断率无显著差异(p>0.05),但在诊断盆腔粘连时有显著差异(p<0.05);在诊断宫腔形态异常中,HSG与宫腔镜检查的诊断率无显著差异(p>0.05)。结论HSG对子宫腔及输卵管性不孕具有较好的诊断价值。     

Uterine artery blood flow in the periimplantation period in embryo transfer cycles

ObjectiveTo assess the role of the uterine artery blood flow in the prediction of implantation in women undergoing embryo transfer during the periimplantation period.MethodsA total of 233 couples were included in this prospective study. All patients had embryo transfer, 125 were performed in in-vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) and 108 in cryo cycles. Ultrasound measurements were performed immediately before transfer. The pulsatility index (PI), Resistance index (RI) and the peak systolic velocity (PSV) were measured in both uterine arteries using endovaginal ultrasound.ResultsIn IVF/ICSI cycles the doppler parameters PI (2.48 vs. 2.15), RI (0.78 vs. 1.30) and PSV (60 vs. 63) did not differ significantly between the pregnant and non-pregnant group. The pregnancy rate per transfer was similar in women showing an unilateral (24%), bilateral (33%) or no (27%) notch in the uterine blood flow. In cryo cycles the uterine artery blood flow parameters PI (3.2 vs. 3.0), RI (0.9 vs. 0.9) and PSV (53.2 vs. 51.2) did not differ either between pregnant and not pregnant patients.ConclusionsPrevious studies were aiming at the measurement of arterial doppler parameters during the follicular phase which may not be adequate for the prediction of implantation. However, our results show that doppler studies during the early luteal phase of assisted reproductive technology cycles are not indicative for the likelihood of pregnancy, too.     

不孕患者子宫内膜息肉的宫腔镜诊治的临床探析

目的:探讨不孕患者子宫内膜息肉的宫腔镜诊治效果。方法:选取2018年12月~2019年12月本院接治的64例不孕患者,随机分为两组,所有患者均接受B超检查和宫腔镜检查,对照组在宫腔镜下行刮宫术治疗,研究组行宫腔镜子宫内息肉切除术。对比两组患者手术治疗情况及治疗前后月经量变化情况。结果:与病理诊断对照发现,研究组诊断符合率高于对照组(P<0.05);治疗前,两组月经量情况无明显差异(P>0.05),治疗后研究组月经量改善情况好于对照组(P<0.05)。结论:不孕患者子宫内息肉临床诊断和治疗过程中,应用宫腔镜进行诊治,在有效改善患者月经量同时,其诊断符合率也极高,在临床中意义及作用巨大。     

高频微波子宫内膜去除术后宫腔影像随访观察

目的:随访微波子宫内膜去除术(MEA)后宫腔影像改变情况;评价MEA宫腔镜检查的意义。方法:在2000～2008年349例行MEA手术患者中术后随机抽取53例进行宫腔镜检查,观察患者MEA术后宫腔内膜的破坏、宫腔粘连的形成及组织愈合的情况;同时随访患者术后月经改变情况,探讨术后宫腔形态的变化与患者术后月经情况的联系。随访时间为术后1个月至术后8年。结果:共53例MEA术后患者行宫腔镜检查。术后3个月内宫腔内主要为坏死脱落的内膜组织及退变的平滑肌,患者月经改变为不规则点滴出血;术后半年,宫腔内可见肉芽组织形成及纤维化改变,患者表现为规律的少量月经或闭经;术后1年以上,宫腔内主要为瘢痕组织覆盖,而患者月经改变主要为闭经;术后2年以上,宫腔镜检查可见不同形态的宫腔粘连。共28例(52.8%)发生术后宫腔粘连,其中1例表现为宫颈管粘连,12例(22.6%)发生宫底部位灶性粘连,11例(20.7%)形成管状宫腔,双侧宫角均封闭,4例(7.5%)宫腔完全粘连、闭锁。此28例患者中,22例月经表现为闭经,4例表现为不规则的点滴出血,2例出现月经减少。结论:微波子宫内膜去除术后宫腔形态改变差异十分显著,患者术后月经改变与术后宫腔形态改变密切相关。术后行宫腔镜检查有助于对MEA术后各种阴道出血进行鉴别。     

无症状子宫黏膜下子宫囊性腺肌病一例诊治体会

子宫囊性腺肌病是子宫腺肌病的一种少见类型。报告1例通过宫腔镜诊断并治疗的位于子宫黏膜下且无明显症状的子宫囊性腺肌病患者情况。该病例病灶凸向宫腔,且无明显的临床症状,术前B超多次提示子宫壁或宫腔有异常表现,行宫腔镜检查时降低膨宫压力才发现位于黏膜下的2处病灶。在治疗过程中保留囊肿底部囊壁,使其成为子宫内膜的一部分,术后行3个月雌孕激素序贯治疗,最终通过体外受精-胚胎移植技术获得妊娠。通过对此特殊病例进行回顾性分析,加深对特殊位置的子宫囊性腺肌病的认识及诊断,当B超多次提示子宫壁或宫腔有异常表现,而宫腔镜检查却无明显异常时,应考虑黏膜下子宫囊性腺肌病的可能,建议降低宫内压后再观察宫腔内病灶。在治疗过程中也可采取“开窗术”,术后再给予雌孕激素序贯治疗从而改变妊娠结局。     

体外受精-胚胎移植术移植日子宫内膜容受性的超声学研究

目的:探讨体外受精-胚胎移植(IVF-ET)/卵泡浆内单精子显微注射(ICSI)周期胚胎移植日胚胎种植率的影响因素。方法:将实施IVF/ICSI的112个周期根据助孕结局分为妊娠组和非妊娠组,比较两组的E2、P、E2/P及子宫内膜厚度/形态、宫腔深度,并与自然周期模拟移植日子宫内膜厚度/形态、宫腔深度进行自身对照研究。结果:两组超排卵周期胚胎移植日宫腔深度、内膜厚度均显著高于自然周期模拟移植日(P0.001);两组胚胎移植日C型内膜的比率均高于模拟移植日(P0.05),而妊娠组与非妊娠组之间宫腔深度、内膜厚度、C型内膜比率无统计学意义;妊娠组E2、E2/P显著低于非妊娠组(P0.05)。结论:超排卵治疗改变了子宫容积和内膜形态,通过生殖激素的变化而影响IVF/ICSI的妊娠结局。     

1H NMR based metabolic profiling of day 2 spent embryo media correlates with implantation potential

Abstract

Morphological assessment is currently the primary technique for selection of viable embryos for uterine transfer during assisted reproductive techniques, however this method has limited predictive power. The objective of this study was to employ NMR based metabolic profiling analysis of spent embryo culture media to identify novel biomarkers of embryo viability and provide insight into the metabolism of a viable embryo. A total of 37 patients undergoing IVF/ICSI treatment were recruited and 58 media samples were collected from embryos that were transferred back to the uterus. ¹H NMR spectra were acquired and analyzed resulting in the quantification of 12 metabolites in the media samples. Analysis of metabolite ratios revealed significant differences between those patients with positive (n?=?27) and negative (n?=?31) urinary βhCG results. Some of the most biologically relevant differences include a 17% increase in the formate to glycine ratio and a 22% decrease in the citrate to alanine ratio in the spent embryo media from the positive pregnancy group. Overall, the results indicate that metabolic profiling may provide a means of identifying biomarkers that aid selection of viable embryos.     

宫腔镜在辅助生殖技术前的应用价值

随着辅助生殖技术的开展,移植前宫腔镜检查评估宫腔越来越受到重视,尤其对于体外受精-胚胎移植(IVF-ET)反复着床失败的患者,宫腔镜检查和治疗有助于改善IVF-ET的妊娠结局。在不孕女性中,子宫内异常病变发生率为10%~15%,这些异常包括子宫内膜息肉、子宫黏膜下肌瘤、子宫纵隔、宫腔粘连、子宫内膜炎。经阴道二维超声(TVS)、子宫输卵管造影(HSG)、宫腔注水超声(SIS)可用于评估宫腔情况,而宫腔镜检查仍是诊断宫内病变的金标准,但对于子宫内膜炎组织病理学才是诊断的金标准。宫腔镜手术是治疗宫内病变的有效方法,宫腔镜下子宫内膜息肉电切术、子宫肌瘤电切术、子宫隔膜切除术及宫腔粘连分离术,术后妊娠率均有显著提高,宫腔镜手术后进行辅助生殖的时机因手术方式不同而不同,通常术后1~3个月不等。值得肯定的是宫腔镜检查在不孕症诊治中发挥了重要作用,但是否对于所有拟进行IVF-ET的患者常规进行宫腔镜检查尚有争议。     

不同体外受精方式对胚胎玻璃化冷冻复苏的影响

目的:观察常规体外受精和卵胞浆内单精子注射两种不同体外受精方式对胚胎玻璃化冷冻复苏的影响。方法:将移植冷冻复苏胚胎的患者(均为玻璃化法)分为两组。IVF组:新鲜周期采取常规体外受精方式而获得的胚胎;ICSI组:新鲜周期采取卵胞浆内单精子注射方式受精而得到的胚胎;比较两组的不孕类型、不孕原因以及冷冻复苏周期的复苏率、着床率、临床妊娠率和流产率等。结果:IVF组和ICSI组的复苏率、着床率、临床妊娠率差异无统计学意义(P>0.05),ICSI组的流产率明显高于IVF组但差异无统计学意义(P>0.05),IVF组和ICSI组原发不孕所占比例、继发不孕所占比例差异有统计学意义(P<0.05),IVF组和ICSI组男方因素不孕所占比例、输卵管因素不孕所占比例差异有统计学意义(P<0.05)。结论:ICSI不影响胚胎玻璃化冷冻周期的复苏率、着床率及临床妊娠率,ICSI后胚胎玻璃化冷冻复苏流产率有升高的趋势,ICSI体外受精方式主要用于原发不孕患者以及男方因素导致的不孕患者。     

子宫纵隔不孕症患者行宫腔镜子宫纵隔切除术后IVF/ICSI结局分析

目的：探讨宫腔镜子宫纵隔切除术（transcervical resection of septum,TCRS）对子宫纵隔不孕症患者行体外受精（in vitro fertilization,IVF）/卵细胞质内单精子注射（intracytoplasmic sperm injection,ICSI）结局的影响。方法：回顾性分析并比较2013年1月—2020年7月在南京大学医学院附属鼓楼医院生殖医学中心进行IVF/ICSI的183例子宫纵隔不孕症患者的治疗结局。其中156例行TCRS后IVF/ICSI(TCRS组),而27例患者拒绝TCRS直接行IVF/ICSI（未行TCRS组）。结果：共有247个移植周期,其中新鲜胚胎移植周期100个,临床妊娠率64.0%,活产率49.0%;冻融胚胎移植周期147个,临床妊娠率51.0%,活产率40.1%。新鲜胚胎移植周期和冻融胚胎移植周期中TCRS组与未行TCRS组的胚胎种植率、临床妊娠率、流产率、早产率、活产率及单胎妊娠新生儿出生体质量比较,差异均无统计学意义（均P>0.05）。新鲜胚胎移植周期中,与TCRS组比较,未行TCRS组的双胎妊娠率高（...     

经阴道超声在不孕症患者宫腔疾病中的应用价值

目的对照分析不孕症患者经阴道超声检查与宫腔镜病理检查结果,以探讨经阴道超声在不孕症患者宫腔疾病中的诊断及应用价值。方法回顾分析因不孕症在我院行经阴道超声检查的患者185例并与宫腔镜检查及病理结果进行对照分析。结果 185例不孕症患者的宫腔镜检查结果中,发现宫内病变共87例(47.03%),经阴道超声检查发现宫内病变共80例,超声诊断符合率为:子宫内膜息肉76.92%,粘膜下肌瘤94.74%;子宫纵隔88.89%,宫腔粘连50%;子宫内膜增生60%,子宫内膜炎40%。结论对于不孕症患者宫腔情况的筛查,经阴道超声是一种简便而有效的检查方法,可为进一步行宫腔镜检查提供依据。     

Comparative study on risk for birth defects among infants after in vitro fertilization and intracytoplasmic sperm injection

This large retrospective study was conducted to compare the risk for birth defects among infants conceived by in vitro fertilization (IVF) with that among infants conceived by intracytoplasmic sperm injection (ICSI) and to explore the effect of frozen embryo transfer (FET) on the risk for birth defects among infants born by IVF and ICSI. All patients who received assisted reproductive technology (ART) treatment and who underwent childbirth during the period January 2005–August 2017 were included in this study. There were 18,221 births after ART included in the analysis; of these births, 12,649 were conceived by IVF, and 5,572 were conceived by ICSI. In the study, the prevalence of any birth defect in singleton infants was 1.15% with the use of IVF and 1.38% with the use of ICSI, and that in twin infants increased to 2.74% by IVF and 2.58% by ICSI. However, no significant difference between IVF and ICSI was found among all infants, singleton births or twin births. Additionally, in assessing ART infants born after FET, we did not detect a difference in the risk for birth defects between infants born by IVF and those born by ICSI. These results indicate that among the entire cohort of children conceived from ART and among the children conceived from FET, the risk for birth defects after ICSI is similar to that after IVF.Abbreviations: IVF: in vitro fertilization; ICSI: intracytoplasmic sperm injection; FET: frozen embryo transfer; ART: assisted reproductive technology; ET: embryo transfer; BMI: body mass index; OHSS: ovarian hyperstimulation syndrome; CMOH: Chinese Ministry of Health; ICD-10: International Classification of Diseases, 10^th edition; PTB: preterm birth; OR: odds ratio; aOR: adjusted odds ratio; CI: confidence interval     

复发性流产和异常子宫出血患者宫腔镜检查结果分析

目的:评价宫腔镜在复发性流产和异常子宫出血中的应用价值。方法:对198例复发性流产患者(A组)以及257例异常子宫出血者(B组)行宫腔镜检查,了解其宫腔情况,对宫腔异常者,在宫腔镜下进行矫治,追踪随访其妊娠结局。结果:A组198例复发性流产患者宫腔镜检查正常宫腔80例(40.40%),异常宫腔118例(59.60%),其中主要病变类型包括子宫纵隔48例,宫腔粘连32例等;B组257例异常子宫出血患者宫腔镜检查正常宫腔62例(24.12%),异常宫腔195例(75.88%),其中主要病变类型包括子宫内膜肥厚49例,子宫内膜炎46例,子宫内膜息肉45例,子宫粘膜下肌瘤22例。两组患者宫腔镜下的宫腔病变类型有显著性差异(P<0.05)。A组病人共随访到104例,其中正常宫腔17例,足月分娩4例(23.53%);异常宫腔87例,行矫正手术后,足月妊娠分娩45例(51.72%),足月分娩率明显提高。结论:宫腔镜是安全、有效、可行的诊断宫腔病变的检查方法,有助于明确复发性流产和异常子宫出血的病因。对宫腔异常的复发性流产患者,在宫腔镜下进行矫治后,可以明显提高足月分娩率。     

宫腔镜在42例宫腔粘连诊治中的应用分析

目的分析宫腔镜在诊治宫腔粘连中的作用;术毕放置节育环,术后人工周期3个月,防止再粘连的疗效。方法回顾性分析42例宫腔粘连患者宫腔镜联合人工周期的临床诊治资料。结果 42例均手术顺利,随访观察,35例(83%)宫腔形态基本恢复正常;6例(14%)基本恢复宫腔形态,治疗有效患者41例,占97.6%。结论宫腔镜是诊治宫腔粘连有效及安全的方法,联合节育环及人工周期,可有效防止再粘连。