宫腹腔镜联合检查在原因不明不孕症诊断和治疗中的临床价值

目的探讨宫腹腔镜联合检查在原因不明不孕症诊断和治疗中的重要性。方法回顾性分析2012年5月至2015年12月因原因不明不孕症在北京协和医院行宫腹腔镜联合检查的患者519例,宫腹腔镜联合检查寻找原因不明不孕症的病因。结果在519例原因不明不孕症患者中,宫腹腔镜联合检查未发现异常者占10.2%(53/519),发现盆腔异常者占89.8%(466/519);盆腔异常患者分别为72.4%(376/519)盆腔粘连合并子宫内膜异位症、12.3%(64/519)盆腔粘连、3.7%(19/519)子宫肌瘤或卵巢囊肿以及1.3%(7/519)子宫内膜息肉。宫腹腔镜联合检查后随访12~36个月,最终纳入386例患者统计术后自然妊娠情况,术后总自然妊娠率为53.9%(208/386),年龄≥35岁患者的自然妊娠率为29.8%(31/104)。结论临床诊断为原因不明不孕症的患者,应行宫腹腔镜联合检查,在宫腹腔镜联合检查下能更直观地发现不孕症的病因,并且可进行针对性的治疗,提高妊娠率。高龄患者术后自然妊娠率明显下降,尝试自然妊娠的时间不宜过长。     

Intracytoplasmic sperm injection (ICSI) in unexplained and stage I endometriosis-associated infertility after fertilization failure with in vitro fertilization (IVF)

Purpose: To investigate possible differences between unexplained and stage I endometriosis-associated infertility in ICSI cycles conducted after low fertilization (<20%) in preceding IVF cycles with normal semen parameters. Methods: Retrospective cohort study consisting of patients with unexplained (n=48) and stage I endometriosis-associated infertility (n=43) with a minimum of one IVF cycle with <20% fertilized oocytes and normal semen quality, treated with ICSI from January 1997 to January 2006. Age matched male factor infertility patients (n=91) were used as controls. Results: Diploid fertilization rate was significantly lower in the stage I endometriosis-associated infertility group compared to the unexplained infertility group. Score of the transferred embryos, implantation rate, pregnancy rate and outcome were similar in the two groups. Conclusions: ICSI appears to be an efficient treatment option after fertilization failure with IVF in unexplained and stage I endometriosis-associated infertility.     

Assessment of endometrial receptivity during implantation window in women with unexplained infertility

Abstract

This study aimed to assess the endometrial receptivity during implantation window in women with unexplained infertility. A prospective study recruited 168 women with unexplained infertility and 169 fertile women. Ultrasonic parameters and biomarkers in the uterine fluid were detected. The endometrial vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were significantly higher in fertile women as compared with unexplained infertile women, and the integrin αvβ3, vascular endothelial growth factor (VEGF), tumor necrosis factor alpha (TNF-α), and leukemia inhibitory factor (LIF) levels in uterine fluid were significantly higher in fertile women. The biochemical pregnancy rate, clinical pregnancy rate, and ongoing pregnancy rate in fertile women were 20.12%, 18.34%, and 17.75%, respectively, which were significantly higher compared with unexplained infertile women (7.14%, 5.36%, and 4.17%, respectively). Endometrial thickness (ET), endometrial volume (EV), VI, FI, and VFI measured by ultrasound, and the integrin αvβ3, VEGF, TNF-α, and LIF levels in uterine fluid were all significantly higher in pregnant women as compared with nonpregnant women. The best parameters of ultrasonic indicators for predicting endometrial receptivity in women with unexplained infertility were FI(AUC = 0.894, sensitivity 93.8%, and specificity 83.1%). Integrin αvβ3 had the best predictive value for endometrial receptivity among biomarkers in the uterine fluid (AUC = 0.921, sensitivity 96.7%, and specificity 89.5%). Women with unexplained infertility present declined endometrial receptivity. Endometrial ultrasonic parameters detected by three-dimensional power Doppler and biomarkers in the uterine fluid may be effective indicators to predict endometrial receptivity.     

Prospective randomized study for hydrotubation with or without lidocaine before intrauterine insemination in unexplained infertility

ObjectiveTo investigate the therapeutic yield of hydrotubation using low-dose lidocaine conducted one-day before intrauterine insemination (IUI) in stimulated cycles for couples with unexplained infertility.DesignProspective randomized controlled trial.Patients and methodsTwo hundred and nineteen women with unexplained infertility were scheduled randomly for hydrotubation either with saline (109 patients) or low dose Lidocaine in saline (110 patients). Hydrotubation was carried on one-day before intrauterine insemination in clomiphene citrate stimulated cycle. Outcome measures were rates of pregnancy, first trimester abortion, ectopic pregnancy, multiple pregnancy, and ovarian hyperstimulation syndrome, and procedure related pain.ResultsLidocaine group had higher clinical pregnancy rates when compared with saline group with no significant difference (17.43% vs 11.2%, respectively; p = 0.193). There were no statistical significant differences as regards the rates of multiple pregnancy, first trimester abortion, and ectopic pregnancy between both groups. No ovarian hyperstimulation syndrome occurred in either group. Using the visual analog score, patients in both groups felt mild to moderate pains without significant differences in frequencies of pain intensity in both groups.ConclusionHydrotubation with low dose Lidocaine in saline one day before IUI allowed a nonsignificant higher pregnancy rate when compared to saline alone in couples with unexplained infertility.     

Disordered zona pellucida-induced acrosome reaction and failure of in vitro fertilization in patients with unexplained infertility

OBJECTIVE: To determine the relationship between the zona pellucida (ZP)-induced acrosome reaction (AR) and fertilization rate and pregnancy rate in standard IVF and the frequency of disordered ZP-induced AR (DZPIAR) in patients with unexplained infertility. DESIGN: Prospective study. SETTING: Academic research and teaching tertiary hospital. PATIENTS: Patients with unexplained infertility with normal semen analysis. INTERVENTION: None. MAIN OUTCOME MEASURE: Semen analysis, the ZP-induced AR, and measurements of fertilization rate and pregnancy rate with in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). RESULT(S): A statistically significant correlation was found for the ZP-induced AR and fertilization rate with standard IVF (n = 65). Patients with DZPIAR (ZP-induced AR of 16%, who had an average fertilization rate of 61%. The sensitivity and specificity of DZPIAR for prediction of IVF rates <30% and >or=30% were 80% and 86%, respectively. Of 260 patients screened, the frequency of DZPIAR was 29%. Ten patients with DZPIAR had an average fertilization rate of 15% and no pregnancy with initial IVF cycles, and a fertilization rate of 61% (with three live-birth pregnancies) with subsequent ICSI cycles. Another 33 patients with DZPIAR were treated with ICSI alone, with an average fertilization rate of 71% and a live-birth pregnancy rate of 17% per embryo transfer. Sixteen of the patients had live-birth pregnancies (including one set of twins) after undergoing an average of 3.2 embryo transfers. CONCLUSION(S): Patients with DZPIAR have a low or zero fertilization rate with standard IVF but high fertilization and pregnancy rates with ICSI. Up to 29% of patients with unexplained infertility with normal semen analysis may have this condition, which should be diagnosed and treated with ICSI rather then standard IVF.     

Nitric oxide donors increase the pregnancy rate in patients with unexplained infertility undergoing clomiphene citrate stimulation and intrauterine insemination: a randomized controlled pilot study

This study evaluated the effects of nitric oxide donor’s treatment on the pregnancy rate and uterine blood flow in patients with unexplained infertility undergoing clomiphene citrate stimulation and intrauterine insemination. A total of 120 patients were randomly allocated to a control group who received 100?mg clomiphene citrate daily from day 5 to 9 of cycle plus placebo vaginal tablets, and a study group received clomiphene citrate plus isosorbide mononitrate 10?mg vaginal tablets. Vaginal ultrasound was done before treatment and every other day starting from day 12 of cycle to count mature follicles and ovulation was triggered by IM injection of 10 000?IU hCG when one follicle measured 18?≥?mm followed by intrauterine insemination after 36?h. The endometrial thickness, uterine arteries resistance and pulsation indices, and endometrial vascular flow and vascular flow indices were measured before treatment and at day of hCG injection. Results were analyzed after one cycle treatment using the Mean?±?SD, the Student t test and the Fisher Exact test. Significant result was considered at p values?<0.05. The study group had significant higher pregnancy rate/cycle, higher endometrial and lower uterine artery blood flow indices (p?相似文献   

Acrosin activity as a potential marker for sperm membrane characteristics in unexplained male infertility

OBJECTIVE: To evaluate sperm membrane system integrity in unexplained infertile male subjects with three consecutive conception failures on IUI even though semen clinical parameters were normal. DESIGN: Prospective study. SETTING: Medical biotechnology laboratory, School of Medical Science and Technology IIT Kharagpur, India. PATIENT(S): Twenty-nine patients with unexplained infertility, 17 normal proven-fertile healthy donors, and 21 infertile males with low motility but with other semen parameters remaining normal. INTERVENTION(S): Semen samples were collected from unexplained infertile patients as well as from healthy fertile donors after abstinence of 3-5 days and were analyzed according to World Health Organization guidelines. MAIN OUTCOME MEASURE(S): Release of 5'-nucleotidase (plasma membrane marker), lactate dehydrogenase (mitochondrial marker) and free acrosin, proacrosin, and total acrosin (acrosomal membrane marker). RESULT(S): Plasma membrane integrity and respiratory activity of sperm cells were comparable in all three groups. The proacrosin-acrosin system was adversely affected in unexplained infertile subjects despite high sperm motility. CONCLUSION(S): Total acrosin activity may be considered as a sensitive biochemical marker for clinical evaluation of unexplained infertility in males.     

The role of hyaluronic acid binding assay in choosing the fertilization method for patients undergoing IVF for unexplained infertility

Purpose  

Patients with unexplained infertility may have fertilization problems. Split fertilization (ICSI and conventional IVF on sibling oocytes) is often used to avoid poor fertilization. Our aim was to assess the ability of hyaluronic acid binding (HA-binding) assay to predict spontaneous fertilization during IVF.     

Vitamin E effect on controlled ovarian stimulation of unexplained infertile women

Purpose  

To determine Vit E effect on the treatment outcomes of women with unexplained infertility undergoing controlled ovarian stimulation and intrauterine insemination (IUI).     

Advantages of recombinant follicle-stimulating hormone over human menopausal gonadotropin for ovarian stimulation in intrauterine insemination: a randomized clinical trial in unexplained infertility

Objective

To compare two different gonadotropin preparations, human menopausal gonadotropin (hMG) and recombinant follicle-stimulating hormone (rFSH), combined with clomiphene citrate (CC) in women with unexplained infertility undergoing intrauterine insemination (IUI).

Study design

In this prospective clinical trial, couples prepared for IUI cycles were randomly allocated to two groups either to receive CC and hMG (group A, n = 127) or CC and rFSH (group B, n = 132) for ovarian stimulation. Outcomes including rates of clinical pregnancy, miscarriage, OHSS, multiple pregnancy, cancelation, and live birth were compared between groups.

Results

Duration of gonadotropin therapy was significantly shorter in group B (5.1 ± 0.84 vs. 4.7 ± 0.8 days, CI = 95%, P < 0.001). The total dose of administered gonadotropin was also significantly lower in group B (386.9 ± 68.2 vs. 348.2 ± 56.3 IU, CI = 95%, P < 0.001). Dominant follicle number (>17 mm), mean follicular diameter, and endometrial thickness on the day of hCG injection were similar. Clinical pregnancy, multiple pregnancies, abortion, live birth, ovarian hyperstimulation syndrome (OHSS), and cancelation rates were not statistically different between the groups.

Conclusion

IUI cycles in which rFSH had been administered may require shorter duration and a lower total gonadotropin dose.     

The management of unexplained infertility: an evidence-based guideline from the Canadian Fertility and Andrology Society

Unexplained infertility is a common diagnosis affecting as many as 50% of couples seeking infertility care. As a diagnosis of exclusion, its treatment remains largely empirical. Historically, a step-wise progression in treatment has been initiated with the least invasive, least expensive option followed by a gradual progression to therapies using assisted reproductive technology. In recent years there have been advocates for more rapid-progression IVF. This guideline from the Canadian Fertility and Andrology Society (CFAS) provides comprehensive, evidence-based recommendations for the treatment of unexplained infertility, including expectant management, laparoscopy, intrauterine insemination (IUI) alone, ovarian stimulation with oral agents or gonadotropins alone, ovarian stimulation + IUI, and IVF. The quality of supporting evidence for each recommendation is evaluated using the framework outlined by the Canadian Task Force on Preventive Health Care. This guideline recognizes that the therapeutic approach should be individualized taking into account patient age and duration of infertility, and emphasizes those strategies that are most likely to result in a healthy live birth.     

The relationship between antisperm antibodies prevalence and genital Chlamydia trachomatis infection in women with unexplained infertility

BackgroundChlamydia trachomatis infection is one of the most common sexually transmitted diseases. Sperm-associated antibody could impair fertility through various mechanisms; both factors could be correlated to affect the fertility status of women.DesignA retrospective case-control study was performed enrolling ninety (n = 90) patients with primary or secondary infertility as the case group, in addition to another eighty (n = 80) healthy women attending the family planning clinic to investigate the correlation between C. trachomatis past and current infections and antisperm antibodies (ASA) in women with unexplained infertility.ResultsThe PCR prevalence of C. trachomatis did not differ significantly among both groups (2.4% versus 1.6%, p value = 0.66). In contrast, significantly higher prevalence of anti-C. trachomatis specific IgG (39% versus 19%, p value = 0.87) antibodies was found among infertile women. ASA prevalence was significantly higher in infertile group (20% versus 5%, p = 0.04). The final study results have failed to find a positive correlation between current or past C. trachomatis infection and the level of antisperm antibodies level in women suffering of un-explained infertility.ConclusionAntisperm antibodies were significantly higher in infertile women, but without a significant difference between the incidences of ASA in infertile women with past or current C. trachomatis current infection.     

SIRTI and cortisol in unexplained infertile females; a cross sectional study,in Karachi Pakistan

ObjectiveTo explore a disparity in anti-oxidants (SIRT1) and pro-oxidants (cortisol) levels as a plausible cause of unexplained infertility in females.MethodologyIt was a cross sectional study in which 342 females with unexplained infertility were recruited from ACIMC outpatient clinic: 135 infertile cases and 207 fertile controls. Biochemical estimation of serum cortisol and SIRT1 was performed using Enzyme Linked Immuno Sorbent Assay. Statistical comparisons were performed using Student-t test and Mann-Whitney U test. Associations between circulating hormone levels and infertility were determined using Spearman's rank correlation. Associations were considered significant where value of p was less than 0.05.ResultsThe stress hormones profile of case and control demonstrated that the antioxidant SIRT1 was significantly lower in infertile females when compared with the fertile (p =< 0.001) while (the oxidant) Cortisol showed a contrast of results with higher values of in infertile females when compared with fertile counterparts (p =< 0.01). There was a strong negative association observed between SIRT1 and cortisol serum level (r = 0.244, p < 0.001).ConclusionChronic stress causes oxidative stress that is depicted by a decrease in antioxidant levels in infertile females.     

Endometriosis diagnosed by laparoscopy in adolescent girls

105 adolescent girls with mean age of 17.3 (11 – 19) years had laparoscopy/pelviscopy between 1996 and 1997. In 37 cases, endometriosis was diagnosed (35.2%). The majority of the girls (32.4%) presented with endoscopic endometriosis classification (EEC) stage I. 2.8% of the girls had stage EEC II. The lesions involved one site or pelvic organ (64.8%) with a mean age of 18.7 (14 – 19) years. In 35.2% of cases, the lesions were at multiple sites with a mean age of 16.9 (11 – 19) years. Indications for laparoscopy included chronic or acute pelvic pain and right-sided lower abdominal pain. Endometriotic lesions were found in the pouch of Douglas (64.8%), uterosacral ligaments (37.8%), and ovarian fossa (24.3%). 42.8% of directed biopsies were positive. Endocoagulation of the endometriotic lesions was performed in 91.9% of cases. Accepted: 30 September 1997     

Pregnancy rates after laparoscopy for infertility

To obtain prognostic data on the likelihood of pregnancy in infertile women with no observable abnormalities at diagnostic laparoscopy, the occurrence of pregnancy was studied in a series of 229 patients. The cumulative conception rate during a follow-up period of at most 5 yr was 50%. The probability of pregnancy proved to decline with age and duration of infertility. The cumulative conception rate during the first year after laparoscopy was approx. 30%, and there was no significant difference between the patients that were treated with respect to other sub-optimal fertility factors (subfertile group) and the patients in whom no rational treatment could be instituted (unexplained infertility group). Implications of these findings with respect to the treatment of long-term infertility are discussed. Knowledge of pregnancy rates after infertility laparoscopy seems important for the evaluation of results of therapy in unexplained infertility.     

Ultrasonographic markers of endometrial receptivity of letrozole and clomiphene citrate in unexplained infertile women

ObjectiveTo compare endometrial receptivity of letrozole and clomiphene citrate.Study designA prospective comparative study.Subjects120 women with unexplained infertility undergoing superovulation.InterventionSixty patients underwent ovulation induction using 5 mg letrozole compared with another 60 patients using 100 mg clomiphene citrate.Main outcomeThe endometrial thickness, the endometrial volume, uterine artery and spiral artery Doppler indices at 7 days after HCG administration.ResultsThe mean age, parity and duration of infertility in both groups of patients were similar. There was a significant difference in the endometrial thickness, endometrial volume, and spiral artery Doppler indices between the two groups one week after HCG administration. No difference was found in the uterine artery Doppler indices in both groups. The pregnancy rate was higher in the letrozole group but it was statistically insignificant.ConclusionLetrozole (5 mg) showed a significantly better endometrial response than 100 mg of clomid.     

Elevated early follicular gonadotropin levels in women with unexplained infertility do not provide evidence for disordered gonadotropin-releasing hormone secretion as assessed by luteinizing hormone pulse characteristics

OBJECTIVE: To determine whether women with rigorously defined unexplained infertility demonstrated altered GnRH secretion, as reflected by serum LH secretion patterns. DESIGN: Prospective observational study. SETTING: National Center for Infertility Research at Michigan. PATIENT(S): Nine women with rigorously defined unexplained infertility and 11 healthy, parous age-matched control women.Gonadotropin-releasing hormone (25 ng/kg) as a bolus injection. MAIN OUTCOME MEASURE(S): Daytime pulse patterns of LH secretion measured every 10 minutes; mean serum concentrations of LH, FSH, E(2), P, PRL, and cortisol; and response to a physiologic dose of GnRH in the early follicular, late follicular, mid-luteal, and late luteal phases of the same menstrual cycle. RESULT(S): Serum LH pulse frequency and pulse amplitude and LH secretion in response to a physiologic bolus of GnRH were not significantly different in unexplained infertility patients at any phase of the cycle. Luteinizing hormone pulse frequency and amplitude, as well as response to GnRH, varied significantly across the cycle. Mean early follicular serum LH and FSH concentrations were significantly higher in unexplained infertility patients than in fertile control subjects (LH: 5.31 +/-.51 vs. 4.03 +/-.33 [mIU/mL +/- SEM]; FSH: 5.81 +/-.63 vs. 3.80 +/-.45) but were not different at any other phase of the cycle. CONCLUSION(S): These data do not support the hypothesis that unexplained infertility is caused by an abnormality in pulsatile GnRH secretion or abnormal pituitary sensitivity to GnRH. However, the results are consistent with a difference in negative feedback from the ovary to the pituitary in unexplained infertility patients that is suggestive of diminished ovarian reserve.     

Oocyte quality in women with infertility associated endometriosis

Abstract

The mechanisms of endometriosis-related infertility remain still unknown. Endometriosis and clinical markers of oocyte quality are a very important problem of reproduction. The purpose of the study is to assess the quality of oocytes in women with infertility associated with endometriosis. The study included infertile reproductive aged women, between 29 and 40 years who underwent IVF and ICSI procedures. The patients were divided into three groups: group I involved 50 (n?=?50) patients with recurrent unilateral endometriomas, group II included 50 patients (n?=?50) unilateral endometriomas after surgical treatment and control group with 30 (n?=?30) patients with tubal factor infertility. Clinical and morphological assessment of oocyte quality was performed in all IVF/ICSI cycles. The results of the study demonstrate a statistically significant increase in the number of immature oocytes of metaphase MI and immature oocytes at the GV germinal vesicle stage in patients with infertility associated with endometriosis, compared with the control group (p<.005). There is deterioration in the quality of the obtained oocytes in patients with the presence of endometrioma more than 3?cm in diameter. The results of this study allow to conclude that endometriomas negatively affect quality of oocyte and ovarian reserve, whereas endometriomas after cystectomy, have a deleterious and sustained effect on ovarian reserve.