改良短方案与高孕激素状态下促排卵在卵巢储备功能低下的高龄患者中的应用比较

目的探讨新改良短方案与高孕激素状态下促排卵（PPOS）在高龄（年龄≥35岁）且卵巢储备功能低下（基础窦卵泡≤8个）患者中行体外受精-胚胎移植/卵胞浆内单精子显微注射技术（IVF/ICSI-ET）助孕的治疗效果。 方法回顾性分析2016年1月至2017年9月于湘潭市中心医院生殖中心就诊的高龄且卵巢储备功能低下患者340个IVF/ICSI-ET周期，按促排卵方案分为改良短方案组（175个取卵周期）和PPOS方案组（165个取卵周期），统计2组患者促排卵结局和临床结局，采用t检验比较2组患者促性腺激素（Gn）用量、Gn使用时间、可移植胚胎数、药物费用等的差异，应用χ²检验比较2组患者双原核卵裂率、优胚率、种植率、临床妊娠率、活产率、胚胎流失率、异位妊娠率、流产率的差异。 结果PPOS方案组的Gn用量显著下降［（2204.6±1539.4）U vs （2736.0±633.6）U，t=4.516，P<0.001］，Gn使用时间缩短［（9.45±1.75）d vs （10.34±2.00）d，t=5.125，P<0.001］，促排卵费用减少［（650.22±450.52）元vs（843.73±273.43）元，t=6.755，P<0.001］；改良短方案组的获卵数［（4.88±2.21）个vs（4.01±2.39）个，t=4.507，P=0.001］、可移植胚胎数［（3.35±1.81）个vs （2.90±1.92）个，t=3.302，P=0.005］高于PPOS方案组；改良短方案种植率高于PPOS方案组［23.69%（95/401）vs 14.01%（36/257）］，差异具有统计学意义（χ²=9.210，P=0.002），累积临床妊娠率［37.62%（79/210）vs 27.62%（29/105），χ²=3.107，P=0.078］、活产率［22.38%（47/210）vs 17.14%（18/105），χ²=1.173，P=0.279］较PPOS方案组有改善趋势，流产率［3.33%（7/210） vs 1.90%（2/105），χ²=0.475，P=0.723］、异位妊娠率［1.90%（4/210） vs 0.95%（1/105），χ²=0.443，P=0.668］比较，差异均无统计学意义（P>0.05）。 结论改良短方案与PPOS方案相比，可获得理想的获卵数、可移植胚胎数、胚胎种植率及临床妊娠率，因此，对于高龄且卵巢储备功能低下的患者，改良短方案不失为高龄患者新的选择。

Application of improved short protocol with gonadotropin-releasing hormone agonist and progestin primed ovarian stimulation in elderly patients with low ovarian reserve function

ObjectiveTo compare the clinical outcome of improved short protocol with gonadotropin-releasing hormone agonist (GnRH-a) and progestin primed ovarian stimulation (PPOS) in aged patients (age≥ 35 years) with diminished ovarian reserve (the number of antral follicles<8). MethodsA retrospective analysis was performed on 340 cycles of aged patients with diminished ovarian reserve who received in vitro fertilization (IVF)/intracytoplasmic sperm injection and embryo transfer (ICSI-ET) from January 2016 to September 2017 at the Reproductive Center of Xiangtan Central Hospital. According to the program of controlled ovulation, the patients were divided into either an improved short protocol group (175 cycles) or a PPOS group (165 cycles). The outcome of controlled ovulation induction and clinical outcomes of the two groups were analyzed. Gonadotropin (Gn) dosage, Gn days, number of transplantable embryos, and drug cost in the two groups were compared by the t-test. The rate of 2PN fertilization, rate of good embryo implantation, clinical pregnancy rate, live birth rate, embryo loss rate, ectopic pregnancy rate, and abortion rate between the two groups were compared by the χ² test. ResultsGn dosage in the PPOS group was significantly lower than that in the short protocol group (2736.0±633.6) U vs (2204.6±1539.4) U, t=4.516, P<0.001]. The duration of Gn use was significantly shorter in the PPOS group than in the improved short protocol group (10.34±2.00) days vs (9.45±1.75) days, t=5.125, P<0.001], and the cost of ovulation induction was lower in the PPOS group than in the improved short protocol group (843.73±273.43) yuan vs (650.22±450.52) yuan, t=6.755, P<0.001]. The number of oocytes retrieved (4.88±2.21) vs (4.01±2.39), t=4.507, P=0.001] and the number of transplantable embryos (3.35±1.81) vs (2.90±1.92), t=3.302, P=0.005] in the improved short protocol group were significantly higher than those in the PPOS group. For clinical outcomes, the implantation rate of the improved short protocol group 23.69% (95/401) vs 14.01%(36/257), χ²=9.210, P=0.002] was significantly higher than that in the PPOS group, and the improved short protocol group tended to have a higher cumulative pregnancy rate 37.62% (79/210) vs 27.62% (29/105), χ²=3.107, P=0.078] and live birth rate 22.38% (47/210) vs 17.14% (18/105), χ²=1.173, P=0.179], although the difference was not significant (P>0.05). The differences in abortion rate 3.33% (7/210) vs 1.90% (2/105), χ²=0.475, P=0.723] and ectopic pregnancy rate 1.90% (4/210) vs 0.95% (1/105), χ²=0.443, P=0.668] did not differ significantly between the two groups. ConclusionCompared with PPOS, the improved short protocol with GnRH-a can achieve satisfactory oocyte retrieval, transplantable embryo, implantation rate, and clinical pregnancy rate. Therefore, the improved short protocol with GnRH-a is a new choice for elderly patients with diminished ovarian reserve.