降调前后抗苗勒管激素预测控制性卵巢刺激中卵巢反应性的临床研究

目的探讨降调节前、后抗苗勒管激素(AMH)值有无变化以及何时检测对预测控制性卵巢刺激(COS)中卵巢反应性更有意义。方法选择2009年6～12月在我中心行体外授精/卵胞浆内单精子注射-胚胎移植(IVF/ICSI-ET)治疗患者159例,入选标准:年龄≤38岁,月经规律,基础卵泡刺激素(bFSH)≤10 IU/L,体重指数(BMI)在18～23,使用一致的黄体期长效促性腺激素释放激素激动剂(GnRH-a)长方案。降调节前、后月经来潮第2～5天分别抽取空腹静脉血检测AMH、性激素水平,抽血当天行阴道B超检查窦卵泡计数(AFC)。观察卵泡数、获卵数、可利用胚胎数、总促性腺激素(Gn)用量、妊娠结局。结果降调节前AMH(4.404±1.950)μg/L,降调节后AMH(3.229±0.857)μg/L,下降有统计学意义(P0.001);降调节前AFC15.31个,降调节后AFC14.52个,差异有统计学意义(P0.05);两因素相关分析结果显示降调节后AMH与卵泡数、卵子数、可利用胚胎数、使用的总Gn剂量相关系数分别为0.507、0.489、0.381、-0.343,均(P0.01),比降调节前AMH的相关系数0.397(P0.01)、0.305(P0.01)、0.200(P0.05)、-0.306(P0.01)相关性更强;降调节后AMH和降调节前AMH与其他指标比较,与获卵数相关性更强,相关系数分别0.489(P0.01)、0.305(P0.01)。降调节后AMH与获卵数直线回归方程为Y=3.522+2.936X(μg/L)。结论在卵巢储备功能良好的患者中,降调节后的AMH较降调节前有所下降、与获卵数相关性更强。降调节后AMH每增加1μg/L,预期会增加约3个获卵数,较降调节前的AMH更能预测卵巢反应性。     

降调节与卵泡发育同步化

控制性卵巢刺激(COS)中垂体降调节的主要作用是预防早发内源性黄体生成素(LH)峰.降调节方案包括有促性腺激素释放激素激动剂(GnRH-a)长、短方案,以及GnRH拮抗剂(GnRH-ant)方案等.于前一周期黄体中期开始的GnRH-a长方案在获卵数和妊娠率等方面效果最好.GnRH-a长方案在体外受精-胚胎移植(IVF-ET)治疗中效果优于GnRH-a短方案和GnRH-ant方案,其原因之一据认为是后两方案中卵泡发育缺乏同步性,致可利用卵子和胚胎数减少.COS中同步化卵泡的关键在于外源性促性腺激素(Gn)启动前使窭卵泡处于卵泡刺激素(FSH)阈值下,其处理方案有GnRH长方案、类固醇预处理和GnRH-ant预处理等.本文就各种卵泡同步化方案及其优缺点进行简单回顾.     

GnRH-a扳机对PCOS患者新鲜胚胎移植临床妊娠率的影响

目的研究促性腺激素释放激素激动剂(GnRH-a)扳机对多囊卵巢综合征(PCOS)患者新鲜周期移植临床妊娠率的影响。方法回顾性分析2016年1月1日至2018年6月30日就诊本院生殖中心行IVF/ICSI的442例PCOS患者的临床资料,根据扳机日使用的扳机方案分为两组:GnRH-a扳机组(163例),在扳机日使用GnRH-a 0.2mg扳机;HCG扳机组(279例),在扳机日使用HCG 10 000U扳机。卵巢过度刺激综合征(OHSS)低风险者(GnRH-a扳机组68例,HCG扳机组79例)取卵后5d移植1枚囊胚。GnRH-a扳机组黄体支持从取卵当天开始使用戊酸雌二醇(4mg/d)、地屈孕酮(40mg/d)和黄体酮阴道缓释凝胶(90mg/d),至孕10周停药。HCG扳机组黄体支持不使用戊酸雌二醇,其余同GnRH-a扳机组。观察获卵数、可利用胚胎数、MⅡ卵率、鲜胚移植周期临床妊娠率、持续妊娠率、早期流产率及OHSS发生率。结果两组之间的获卵数[(23.03±7.95)vs.(21.92±8.43)]、MⅡ卵率(89.60%vs.88.90%)、可利用胚胎数[(8.93±5.61)vs.(8.80±4.95)]、临床妊娠率(55.88%vs.65.82%)、持续妊娠率(48.52%vs.56.96%)及早期流产率(13.16%vs.18.42%)差异均无统计学意义(P0.05)。HCG扳机组的OHSS发生率高于GnRH-a扳机组(8.24%vs.1.23%),差异有统计学意义(P0.05)。结论本研究中GnRH-a扳机未降低PCOS患者新鲜周期移植的临床妊娠率,但显著降低OHSS的发生率。     

促性腺激素释放激素激动剂联合小剂量HCG双扳机在IVF-ET中的临床应用

目的探讨促性腺激素释放激素激动剂(GnRH-a)联合小剂量HCG扳机在IVF-ET温和刺激方案中的临床应用。方法选取2014年1月至2018年6月在我院就诊行IVF-ET温和刺激方案的165例患者,随机分为3组,采用不同的扳机方案:GnRH-a扳机组(60个周期)给予GnRH-a 0.2 mg皮下注射;双扳机组(42个周期)给予GnRH-a 0.2 mg皮下注射和小剂量HCG 2 000 U肌肉注射;HCG扳机组(63个周期)给予HCG 10 000 U肌肉注射。比较3组患者的临床参数,包括Gn天数、Gn用量、扳机日E₂和P水平以及14 mm以上的卵泡数和平均获卵数;比较3组患者的实验室参数,包括患者的MⅡ卵率、受精率、卵裂率和优胚率;比较鲜胚和冻胚移植的临床妊娠结局,包括平均移植胚胎数目、胚胎着床率、临床妊娠率、自然流产率以及卵巢过度刺激综合征(OHSS)发生率。结果在温和刺激方案中,无论单用GnRH-a扳机、双扳机还是HCG扳机,3组患者新鲜周期的Gn天数、Gn用量、扳机日E₂和P水平、14 mm以上的卵泡数、平均获卵数、受精率和卵裂率均...     

微刺激全胚胎冷冻方案在高龄患者中的应用

目的探讨微刺激全胚胎冷冻方案在高龄患者中的应用价值。方法对542例年龄≥38岁、应用微刺激方案行IVF/ICSI-FET的1 020个周期进行回顾性分析,根据患者年龄分为3组:A组(38~40岁);B组(40~43岁);C组(≥43岁),比较3组间月经第3天FSH、Gn总量、Gn天数、平均获卵数、成熟卵母细胞总数、胚胎形成数、胚胎冷冻数以及妊娠结局。结果 1 020个刺激周期中119个周期因卵巢反应不良放弃周期,周期取消率11.67%;1 001个取卵周期中69个周期获卵失败,平均获卵率93.11%。932个周期获得卵母细胞,平均获卵数(1.98±1.40)个,共565个周期有胚胎冷冻,胚胎冷冻率60.62%。3组比较HCG日卵泡数、获卵数无显著性差异(P0.05),月经第3天FSH水平、Gn天数、成熟卵母细胞数、胚胎形成数、胚胎冷冻数组间有显著性差异(P0.05),其中B组的Gn天数、Gn总量、成熟卵母细胞数、胚胎冷冻数显著高于C组(P0.05),C组的成熟卵母细胞数、胚胎冷冻数显著低于其他两组(P0.05)。342人共行585个移植周期,移植周期的妊娠率为20.00%,移植周期的累积妊娠率为34.21%,起始周期的累积妊娠率为21.59%。3组中随着年龄的增加,妊娠率逐渐下降(P0.05)。结论高龄患者使用微刺激全胚冷冻方案可以获得相对满意的妊娠结局,不失为临床上的一个选择。但针对高龄患者如何根据年龄、卵巢储备功能和前次促排卵治疗结果制定适宜的治疗方案,有待于进一步的随机对照试验探讨。     

孕三烯酮预处理对子宫内膜异位症患者体外受精-胚胎移植结局的影响

目的探讨孕三烯酮预处理对子宫内膜异位症患者体外受精-胚胎移植(IVF-ET)结局的影响。方法选择珠海市妇幼保健院生殖中心2015年1~12月接受IVF-ET治疗的子宫内膜异位症患者208个新鲜周期进行回顾性分析。按降调节方案分为3组:孕三烯酮预处理后长方案降调节为A组,共60个周期;超长方案降调节为B组,共56个周期;常规长方案降调节C组,92个周期。分析和比较A组与B组、C组在年龄、不育年限、Gn天数、Gn剂量、血清基础卵泡刺激素(FSH)、黄体生成素(LH)、雌激素(E2)水平、HCG日子宫内膜厚度、获卵数、可移植胚胎数、优质胚胎率、种植率、临床妊娠率、流产率等差异。结果 A组与B组、C组比较,年龄、不育年限、Gn剂量、血清基础FSH、LH、E2水平、HCG日子宫内膜厚度、获卵数、可移植胚胎数、种植率、临床妊娠率、流产率等均无统计学差异(P0.05);A组的Gn天数[(11.4±2.0)d]和优质胚胎率(48.9%)均显著高于B组[分别为(10.6±1.8)d,37.6%]和C组[分别为(10.7±1.6)d,39.5%](P0.05)。结论孕三烯酮预处理可以提高子宫内膜异位症患者助孕的优质胚胎率,但未明显改善临床结局。     

高纯尿源性卵泡刺激素在高龄妇女控制性超排卵中的临床应用

世界上第一例试管婴儿采用自然周期方案,随后随着控制性超排卵(COH)的应用大大提高了试管婴儿获卵数及妊娠率.近年来生殖专家不再一味追求获卵数,而更关注卵母细胞及胚胎的质量[1],特别是对于高龄不孕患者.现在多个研究发现体外受精(IVF)的COH过程中卵巢反应不良的发生率在高龄妇女显著增高[2,3].中国高龄不孕患者逐年升高,这些患者卵巢储备低下,对COH药物的反应下降,临床结局不理想.要解决这些患者的不孕问题对临床医师来说是个很大的挑战.现在临床上有多种COH药物,包括克罗米酚、人绝经期促性腺激素(HMG)、重组卵泡刺激素(rFSH)、尿源性卵泡刺激素(uFSH)及用于垂体降调的促性腺激素释放激素激动剂(GnRH-a)[4-8].到底哪一种药物更适合于高龄卵巢低反应的不孕患者,现在还没有定论.     

控制性卵巢刺激中卵巢慢反应的发生原因及处理方法

对促性腺功能正常的妇女采用促性腺激素释放激素激动剂(GnRH-a)长方案进行控制性卵巢刺激(COS)仍是目前的“主流”方案.然而,GnRH-a降调节作用可能导致部分妇女内源性黄体生成素(LH)抑制过深,仅使用卵泡刺激素(FSH)促排卵可能出现卵巢慢反应甚至低反应,导致不良临床结局.GnRH-a降调节垂体抑制过深是发生卵巢慢反应的主要原因.临床上及时补充LH能有效改善卵巢慢反应,减少周期取消率,提高体外受精-胚胎移植(IVF-ET)成功率.     

降调节COS方案中的卵泡发育不同步

1988年Palermo等[1]第一次在12例反复控制性卵巢刺激(COS)失败的妇女采用黄体期短效促性腺激素释放激素激动剂(GnRH-a)长方案(500～600 ug/d喷鼻)联合促性腺激素(Gn)治疗获得多卵泡发育,获卵数由(3.2±0.1)个增加到(8.0±0.3)个.由此提出GnRH-a给药早期的垂体激发作用有利于血清黄体生成素(LH)和卵泡刺激素(FSH)水平升高、增加卵泡募集,促进卵泡发育的同步化.     

微刺激方案对卵巢低反应患者体外受精-胚胎移植周期治疗结局的分析

目的探讨来曲唑/尿卵泡刺激素微刺激方案对卵巢低反应患者的治疗结局。方法研究对象为2007年7月至2009年4月在我院生殖中心接受体外受精/卵胞浆内单精子注射(IVF/ICSI)助孕的卵巢低反应患者111例,随机分为两组,60例使用微刺激方案(实验组),51例使用微量长方案(对照组)。对两组的周期取消率、获卵数、可移植胚胎数、临床妊娠率、胚胎种植率等进行比较。结果对照组与实验组的平均获卵数分别为(4.0±1.3)和(3.0±2.0)个,差异有显著性(P0.05);两组周期取消率、可移植胚胎数、临床妊娠率、胚胎种植率差异无显著性(P0.05)。结论来曲唑/尿卵泡刺激素微刺激方案对卵巢低反应的患者是一种有效的治疗方案,并且费用低廉。     

Perioperative recombinant human erythropoietin

The risks of transfusion-associated infectious disease have made increased efforts to avoid homologous transfusion imperative. Little attention has been focused on efforts to accelerate erythropoiesis as a method of reducing homologous blood use. Recombinant human erythropoietin (rHuEPO) has been shown to enhance erythropoiesis. The purpose of this study was to evaluate the effects of perioperative rHuEPO administration on postoperative erythropoiesis. Fifteen baboons were divided into three groups of five each. Group I received no rHuEPO. Group II received five daily preoperative doses of rHuEPO (1000 U/kg). Group III received five daily preoperative doses and 14 daily postoperative doses of rHuEPO (1000 U/kg). All animals underwent a laparotomy followed by an exchange transfusion to a final hematocrit of 15%. The time in days required to recover to hematocrits of 20% was significantly shorter in both groups that received preoperative doses of rHuEPO when compared with that of controls (3.3 vs 5.7 days, p less than 0.01). The recovery times to hematocrits of 25%, 30%, and baseline levels were all significantly shorter in the group that received both preoperative and postoperative doses of rHuEPO. The data show that perioperative dosage of rHuEPO significantly accelerates postoperative erythropoiesis. Perioperative administration of rHuEPO may reduce the requirements for homologous transfusion.     

重组人骨保护素与重组核因子κb活化因子受体蛋白对破骨前体细胞分化的影响

目的:对比重组人骨保护素(rhOPG-Fc)与重组核因子κb活化因子受体蛋白(rhRANK)对破骨前体细胞分化的影响.方法:采用成骨细胞与破骨前体细胞RAW264.7混合培养,在地塞米松、1,25 (OH) 2VitD3诱导下生成破骨细胞的方法.研究分3组:rhRANK组:10-5 g/L;rhOPG-Fc组:10-5 g/L;空白对照组.作用9d后观察破骨细胞数目和形态,抗酒石酸酸性磷酸酶(TRAP)染色阳性细胞个数,骨磨片吸收陷窝计数.结果:在空白对照组,小鼠成骨细胞与破骨前体细胞RAW264.7混合培养6d后,开始出现多核细胞,9d时可见大量成熟多核细胞,经TRAP染色证实为成熟破骨细胞,而rhRANK组及rhOPG-Fc组TRAP染色阳性多核细胞数较对照组均减少,特别是rhRANK组减少更明显.骨片吸收陷窝计数显示rhRANK组及rhOPG-Fc组较对照组也明显减少,而相对来说,rhRANK组较rhOPG-Fc组更少.结论:rhOPG-Fc与rhRANK均可以有效抑制破骨前体细胞分化成为成熟破骨细胞,且rhRANK较rhOPG-Fc抑制效果更明显.     

A totally recombinant human fibrin sealant

Background

Applications of plasma-derived human fibrin sealants (pdhFS) have been limited because of cost, limited supply of pathogen-screened plasma, the need for bioengineering improvements, and regulatory issues associated with federal approval. We describe a totally recombinant human fibrin sealant (rhFS), which may engender an abundant, safe, and cost-effective supply of efficacious fibrin sealant.

Materials and methods

A first-generation rhFS made from recombinant human fibrinogen (rhFI; produced in the milk of transgenic cows), activated recombinant human factor XIII (rhFXIIIa; produced in yeast), and recombinant human thrombin (rhFIIa; purchased, made in animal cell culture) was formulated using thromboelastography (TEG). The hemostatic efficacy of rhFS versus commercial pdhFS was compared in a nonlethal porcine hepatic wedge excision model.

Results

The maximal clot strength of rhFS measured in vitro by TEG was not statistically different than that of pdhFS. TEG analysis also showed that the rhFS gained strength more quickly as reflected by a steeper α angle; however, the rhFS achieved this clot strength with a 5-fold lower factor I content than the pdhFS. When these fibrin sealants were studied in a porcine hepatic wedge excision model, the hemostatic scores of the rhFS were equivalent or better than that of the pdhFS.

Conclusions

The bioengineered rhFS had equivalent or better hemostatic efficacy than the pdhFS in a nonlethal hemorrhage model, despite the factor I concentration in the rhFS being about one-fifth that in the pdhFS. Because the rhFS is amenable to large-scale production, the rhFS has the potential to be more economical and abundant than the pdhFS, while having a decreased risk of blood-borne pathogen transmission.     

Metabolic effects of recombinant human insulin-like growth factor-I in humans: comparison with recombinant human growth hormone

Many of the metabolic actions of growth hormone (GH( are mediated through insulin-like growth factors or somatomedins. Recombinant human insulin-like growth factor-I (rhIGF-I) has a dichotomous insulin-like and GH-like action when used in different clinical situations in humans. Its effets on carbohydrate metabolism show a prominent increase in total insulin sensitivity, causing hypoglycemia in higher doses and maintaining normal glucose homeostasis in lower doses. This polypeptide selectively stimulates whole body protein synthesis with no effect on proteolysis when given in doses of 100 g/kg subcutaneously twice daily for at least 5–7 days, effects which are indistinguishable from those of GH. This contrasts with the marked suppression of proteolysis observed when higher doses are given, similar to the effects observed with insulin. When used in combination with rhGH, rhIGF-I has a synergistic effect, improving total nitrogen retention in calorically deprived subjects, yet it does not cause any greater enhancement of whole body protein anabolism in normally fed volunteers than giving rhGH and rhIGF-I individually. This suggests a common pathway for IGF-I and GH enhancing protein anabolism in the normally fed state. rhIGF-I also stimulates linear growth in children with defects in the GH receptor. Recent data show that this potent growth factor has a potential advantage over GH in the treatment of severe protein catabolic states, particularly the glucocorticosteroid-dependent model, as it ameliorates the marked increase in protein catabolism caused by the steroids, but without a diabetogenic effect. Here, a brief overview is provided of available human data on the actions of this peptide on carbohydrate, lipid, and protein metabolism, linear growth, and its anabolic effects. rhIGF-I offers promise in the treatment of selective growth disorders and in protein catabolic and insulin-resistant states.     

Successful human islet isolation utilizing recombinant collagenase

The enzymatic dissociation of acinar tissue by collagenase is a substantial step in the isolation of pancreatic islets. Although essential collagenase components have been purified, the variability in the activity of different batches limits long-term reproducibility of isolation success. The utilization of purified recombinant proteases would solve this problem. In the present study, pancreases from multiorgan donors were dissociated by means of digestion-filtration using either Liberase HI (n = 51) or a recombinant collagenase blend (n = 25). No significant differences were found regarding islet yield before and after purification, the percent of exocrine-attached islets, and final purity. However, the ratio between islet equivalents and islet numbers indicated a lesser fragmentation in islets isolated with recombinant collagenase (P < 0.01). In contrast, viability was slightly higher in islets isolated with Liberase (92.3 +/- 0.8 vs. 85.6 +/- 2.9%; P < 0.05). Insulin release during static glucose incubation was not different between experimental groups. Islet transplantation into diabetic nude mice resulted in sustained normoglycemia in either group until the graft was removed. These results demonstrated that viable human islets can be isolated using recombinant collagenase. Final optimization of this enzyme blend would offer continuous reproducibility of isolation success.