IVF-ET促排卵中卵巢过度刺激综合征高危患者的干预策略
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摘要
目的:探讨体外受精-胚胎移植(IVF-ET)促排卵中针对卵巢过度刺激综合征(OHSS)高危患者所采取的3种预防策略的有效性。方法:回顾性分析2015年1月至2016年7月在温州医科大学附属第一医院生殖医学中心行IVF促排卵5~7d后呈现卵巢高反应的OHSS高危患者178例的临床资料,根据所采用的干预策略不同分为3组。A组(低剂量HCG扳机组,n=95):继续给予促排卵用药,密切超声监测卵泡发育,直至卵泡成熟,给予较低剂量的HCG扳机;B组(小卵泡抽吸减灭组,n=23):超声引导下经阴道穿刺术减灭直径≤12mm的卵泡,之后继续促排卵用药至HCG扳机;C组(未成熟卵体外培养IVM组,n=60):停止继续促排卵用药,超声引导下经阴道穿刺术抽吸所有可见小卵泡,将卵泡液中卵丘-卵母细胞复合体分离后进行体外培养成熟。比较各组实验室结果、临床妊娠结局和OHSS发生率。结果:3组优质胚胎率、移植周期临床妊娠率以及活婴分娩率差异无统计学意义(P>0.05)。3组均无重度OHSS发生。轻、中度OHSS的发生率A组为50.53%,B组为34.78%,均显著高于C组(0%)(P<0.05),A组和B组间差异无统计学意义(P>0.05)。结论:对于IVF-ET促排卵中OHSS高危患者,采用低剂量HCG扳机、小卵泡抽吸减灭和未成熟卵体外培养均能完全避免发生重度OHSS,有效减少轻、中度OHSS的发生,同时3种干预策略都能带来较理想的妊娠结局。
Objective: To investigate the effectiveness of three strategies to prevent ovarian hyperstimulation syndrome(OHSS) in high risk patients undergoing IVF cycles. Methods: Patients in group A(n=95) received decreased dose of HCG trigger. Patients in group B(n=23) were subjected to transvaginal aspiration of small follicles. Patients in group C(n=60) were subjected to in-vitro maturation(IVM). Results: No significant differences were detected in the rate of high-quality embryos, clinical pregnancy rate per-transfer and live birth delivery rate per transfer among 3 groups(P>0.05). No severe OHSS was observed in all patients. The incidence of mild-moderate OHSS was significantly higher in group A(50.53%) and B(34.78%), while none was observed in group C(0%). Conclusion: Transformation into IVM resulted in completely absence of OHSS. Follicle aspiration and decreased HCG trigger could both avoid severe OHSS and remarkably reduce the occurrence of mildmoderate OHSS. OHSS high risk patients could have ideal pregnancy outcomes with the above-mentioned three strategies.
Objective: To investigate the effectiveness of three strategies to prevent ovarian hyperstimulation syndrome(OHSS) in high risk patients undergoing IVF cycles. Methods: Patients in group A(n=95) received decreased dose of HCG trigger. Patients in group B(n=23) were subjected to transvaginal aspiration of small follicles. Patients in group C(n=60) were subjected to in-vitro maturation(IVM). Results: No significant differences were detected in the rate of high-quality embryos, clinical pregnancy rate per-transfer and live birth delivery rate per transfer among 3 groups(P>0.05). No severe OHSS was observed in all patients. The incidence of mild-moderate OHSS was significantly higher in group A(50.53%) and B(34.78%), while none was observed in group C(0%). Conclusion: Transformation into IVM resulted in completely absence of OHSS. Follicle aspiration and decreased HCG trigger could both avoid severe OHSS and remarkably reduce the occurrence of mildmoderate OHSS. OHSS high risk patients could have ideal pregnancy outcomes with the above-mentioned three strategies.
引文
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[8]DEPA-MARTYNOW M,JEDRZEJCZAK P,PAWELCZYKL.Pronuclear scoring as a predictor of embryo quality in in vitro fertilization program[J].Folia Histochem Cytobiol,2007,45 Suppl 1:S85-S89.
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[13]VLAHOS N F,GREGORIOU O.Prevention and management of ovarian hyperstimulation syndrome[J].Ann N YAcad Sci,2006,1092(12):247-264.
[14]TSOUMPOU I,MUGLU J,GELBAYA T A,et al.Update on prediction and management of OHSS.Optimal dose of HCG for final oocyte maturation in IVF cycles:absence of evidence?[J].Reprod Biomed,2009,19(1):52-58.
[15]NARGUND G,HUTCHISON L,SCARAMUZZI R,et al.Low-dose HCG is useful in preventing OHSS in high-risk women without adversely affecting the outcome of IVF cycles[J].Reprod Biomed Online,2007,14(6):682-685.
[16]KAHNBERG A,ENSKOG A,BRANNSTROM M,et al.Prediction of ovarian hyperstimulation syndrome in women undergoing in vitro fertilization[J].Acta Obstet Gynecol Scand,2009,88(12):1373-1381.
[17]SCHR?DER A K,SCH?PPER B,ALHASANI S,et al.Unilateral follicular aspiration and in-vitro maturation before contralateral oocyte retrieval:a method to prevent ovarian hyperstimulation syndrome[J].Eur J Obstet Gynecol Reprod Biol,2003,110(2):186-189.
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[19]COLACURCI N,ZULLO F,DE F P,et al.In vitro fertilization following laparoscopic ovarian diathermy in patients with polycystic ovarian syndrome[J].Acta Obstet Gynecol Scand,1997,76(6):555-558.
[20]OYAWOYE O A,CHANDER B,HUNTER J,et al.Prevention of ovarian hyperstimulation syndrome by early aspiration of small follicles in hyper-responsive patients with polycystic ovaries during assisted reproductive treatment cycles[J].Med Gen Med,2005,7(3):60.
[21]池海虹,黄朝霞,程静,等.小卵泡穿刺术在控制性促排卵中应用的效果观察[J].温州医科大学学报,2014,44(9):657-659.
[22]CHIAN R C,BUCKETT W M,TULANDI T,et al.Prospective randomized study of human chorionic gonadotrophin priming before immature oocyte retrieval from unstimulated women with polycystic ovarian syndrome[J].Hum Reprod,2000,15(1):165-170.
[23]BUCKETT W,CHIAN R C,TAN S L.Can we eliminate severe ovarian hyperstimulation syndrome?Not completely[J].Hum Reprod,2005,20(8):2367-2368.
[24]王佩玉,赵军招,金聪聪,等.IVM技术在PCOS与非PCOS患者促排卵与未刺激周期中的临床应用比较[J].中华妇产科杂志,2014,49(12):903-908.
[25]MIKKELSEN A L,SMITH S,LINDENBERG S.Possible factors affecting the development of oocytes in in-vitro maturation[J].Hum Reprod,2000,15 Suppl 5:11-17.
[26]BUCKETT W M,CHIAN R C,HOLZER H,et al.Obstetric outcomes and congenital abnormalities after in vitro maturation,in vitro fertilization,and intracytoplasmic sperm injection[J].Obstet Gynecol,2007,110(4):885-891.
[27]HATIRNAZ S,ATA B,SAYNUR HATIRNAZ E,et al.Oocyte in vitro maturation:A sytematic review[J].Turk J Obstet Gynecol,2018,15(2):112-125.
[28]WALLS M L,HART R J.In vitro maturation[J].Best Pract Res Clin Obstet Gynaecol,2018,7(s):1521-1534.
[2]DELVIGNE A.Symposium:update on prediction and management of OHSS:epidemiology of OHSS[J].Reprod Biomed Online,2009,19(1):8-13.
[3]NAMAVAR J B,PARSANEZHAD M E,SHOMALI Z,et al.Ovarian hyperstimulation syndrome:A narrative review of its pathophysiology,risk factors,prevention,classification,and management[J].Iran J Med Sci,2018,43(3):248-260.
[4]CHAN W S,DIXON M E.The"ART"of thromboembolism:a review of assisted reproductive technology and thromboembolic complications[J].Thromb Res,2008,121(6):713-726.
[5]SZKODZIAK P R,CZUCZWAR P,WRONA W,et al.Ascites Index-a novel technique to evaluate ascites in ovarian hyperstimulation syndrome:a concept-proof study[J].Ginekologia Polska,2018,89(4):182-188.
[6]MACKLON N S,FAUSER B C.Gonadotropin therapy for the treatment of anovulation and for ovarian hyperstimulation for IVF[J].Mol Cell Endocrinol,2002,186(2):159-161.
[7]余蓉,林佳,赵军招,等.未成熟卵母细胞体外成熟与常规体外受精-胚胎移植技术治疗多囊卵巢综合征不孕的疗效比较[J].中华妇产科杂志,2012,47(4):250-254.
[8]DEPA-MARTYNOW M,JEDRZEJCZAK P,PAWELCZYKL.Pronuclear scoring as a predictor of embryo quality in in vitro fertilization program[J].Folia Histochem Cytobiol,2007,45 Suppl 1:S85-S89.
[9]GOLAN A,WEISSMAN A.Symposium:Update on prediction and management of OHSS.A modern classification of OHSS[J].Reprod Biomed Online,2009,19(1):28-32.
[10]WORMER K C,JANGDA A A,EISAYED F A,et al.Is thromboprophylaxis cost effective in ovarian hyperstimulation syndrome:A systematic review and cost analysis[J].Eur J Obstet Gynecol Reprod Biol,2018,224(5):117-124.
[11]CORBETT S,SHMORGUN D,CLAMAN P.The prevention of ovarian hyperstimulation syndrome[J].J Obstet Gynaecol Can,2014,36(11):1024-1033.
[12]AJONUMA L C.Is vascular endothelilagrowthfactor(VEGF)the main mediatorion ovarian hyperstimulation syndrome(OHSS)?[J].Med Hypotheses,2008,70(60):1174-1178.
[13]VLAHOS N F,GREGORIOU O.Prevention and management of ovarian hyperstimulation syndrome[J].Ann N YAcad Sci,2006,1092(12):247-264.
[14]TSOUMPOU I,MUGLU J,GELBAYA T A,et al.Update on prediction and management of OHSS.Optimal dose of HCG for final oocyte maturation in IVF cycles:absence of evidence?[J].Reprod Biomed,2009,19(1):52-58.
[15]NARGUND G,HUTCHISON L,SCARAMUZZI R,et al.Low-dose HCG is useful in preventing OHSS in high-risk women without adversely affecting the outcome of IVF cycles[J].Reprod Biomed Online,2007,14(6):682-685.
[16]KAHNBERG A,ENSKOG A,BRANNSTROM M,et al.Prediction of ovarian hyperstimulation syndrome in women undergoing in vitro fertilization[J].Acta Obstet Gynecol Scand,2009,88(12):1373-1381.
[17]SCHR?DER A K,SCH?PPER B,ALHASANI S,et al.Unilateral follicular aspiration and in-vitro maturation before contralateral oocyte retrieval:a method to prevent ovarian hyperstimulation syndrome[J].Eur J Obstet Gynecol Reprod Biol,2003,110(2):186-189.
[18]EGBASE P E,SHARHAN M A,GRUDZINSKAS J G.Early unilateral follicular aspiration compared with coasting for the prevention of severe ovarian hyperstimulation syndrome:a prospective randomized study[J].Hum Reprod,1999,14(6):1421-1425.
[19]COLACURCI N,ZULLO F,DE F P,et al.In vitro fertilization following laparoscopic ovarian diathermy in patients with polycystic ovarian syndrome[J].Acta Obstet Gynecol Scand,1997,76(6):555-558.
[20]OYAWOYE O A,CHANDER B,HUNTER J,et al.Prevention of ovarian hyperstimulation syndrome by early aspiration of small follicles in hyper-responsive patients with polycystic ovaries during assisted reproductive treatment cycles[J].Med Gen Med,2005,7(3):60.
[21]池海虹,黄朝霞,程静,等.小卵泡穿刺术在控制性促排卵中应用的效果观察[J].温州医科大学学报,2014,44(9):657-659.
[22]CHIAN R C,BUCKETT W M,TULANDI T,et al.Prospective randomized study of human chorionic gonadotrophin priming before immature oocyte retrieval from unstimulated women with polycystic ovarian syndrome[J].Hum Reprod,2000,15(1):165-170.
[23]BUCKETT W,CHIAN R C,TAN S L.Can we eliminate severe ovarian hyperstimulation syndrome?Not completely[J].Hum Reprod,2005,20(8):2367-2368.
[24]王佩玉,赵军招,金聪聪,等.IVM技术在PCOS与非PCOS患者促排卵与未刺激周期中的临床应用比较[J].中华妇产科杂志,2014,49(12):903-908.
[25]MIKKELSEN A L,SMITH S,LINDENBERG S.Possible factors affecting the development of oocytes in in-vitro maturation[J].Hum Reprod,2000,15 Suppl 5:11-17.
[26]BUCKETT W M,CHIAN R C,HOLZER H,et al.Obstetric outcomes and congenital abnormalities after in vitro maturation,in vitro fertilization,and intracytoplasmic sperm injection[J].Obstet Gynecol,2007,110(4):885-891.
[27]HATIRNAZ S,ATA B,SAYNUR HATIRNAZ E,et al.Oocyte in vitro maturation:A sytematic review[J].Turk J Obstet Gynecol,2018,15(2):112-125.
[28]WALLS M L,HART R J.In vitro maturation[J].Best Pract Res Clin Obstet Gynaecol,2018,7(s):1521-1534.