参芪胶囊改善PCOS子宫内膜容受性的临床与实验研究
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摘要
背景
多囊卵巢综合征(polycystic ovarian syndrome, PCOS)是以持续性无排卵、高雄激素或胰岛素抵抗为特征的内分泌紊乱的症候群。PCOS患者因卵泡发育停滞,无成熟卵泡,因此促使卵泡发育、成熟、诱发排卵是治疗PCOS不孕症的关键环节。临床上对于PCOS无排卵性不孕的促排卵治疗首选克罗米芬(clomiphene citrate, CC),其排卵率可达80%,但妊娠率仅为30%～40%。主要是由于CC可致子宫内膜发育不良、宫颈粘液质与量的改变以及可以导致未破裂卵泡黄素化而影响妊娠率。另外(?)PCOS患者由于长期无排卵,雌、孕激素分泌不协调,使着床期子宫内膜与细胞存活相关的蛋白表达异常,导致子宫内膜容受性下降。因此,如何纠正PCOS患者内分泌紊乱及应用促排卵治疗后子宫内膜容受性的降低,是对现代医学的一大挑战。我院名老中医李丽芸教授根据前人经验结合临证经验,提出PCOS中医病因病机以肾虚为本,血瘀及痰阻为标,属虚实夹杂之证,以补肾化痰活血为法,研制出参芪胶囊,调整性腺功能,维持黄体功能,从而改善子宫内膜容受性,临床上取得较好疗效。
目的
1.探讨参芪胶囊对PCO大鼠子宫内膜整合素αvβ2、LIF、glycodelin的表达,改善子宫内膜容受性的可能作用靶点,阐明其疗效的可能分子机制,为临床治疗PCOS不孕症的基础研究提供实验依据。
2.通过阴道彩色多普勒超声监测治疗前后子宫动脉搏动指数(PI)及阻力指数(RI)、卵巢间质动脉搏动指数(PI)及阻力指数(RI)等血流动力学的改变,对参芪胶囊改善PCOS患者子宫内膜容受性的临床疗效进行客观的评价,探讨其可能的作用机制,为进一步临床应用及推广提供科学的依据。
方法
1.实验研究：通过对24日龄SD雌性大鼠皮下注射脱氢表雄酮(DHEA)+注射用油剂20天诱导PCO大鼠模型,正常对照组同期皮下注射用油剂。PCO大鼠采用随机对照法分为模型对照组、中药组、西药组及联合用药组。中药组、西药组及联合用药组于80日龄起药物干预治疗14天。治疗结束后测定血清T、FINS水平。观察各组大鼠子宫及卵巢脏器系数、子宫内膜及卵巢形态学改变；免疫组化法观察子宫内膜中整合素αvβ3、LIF、glycodelin的表达。
2.临床研究：采用临床随机对照研究方法,将广东省中医院2012年2月～2012年12月在门诊就诊符合纳入标准的患者随机分为对照组(23例)和治疗组(23例),对照组采用克罗米芬,治疗组采用克罗米芬联合参芪胶囊,采用中医证候评分表,通过监测子宫及卵巢血流动力学,结合性激素、血糖、胰岛素、血脂等指标,采用PASWStatistics17.0统计软件建立数据库并进行统计学分析。
结果
1.实验研究结果：
(1)正常对照组与模型组比较分析：模型组大鼠体质量、血清睾酮及空腹胰岛素水平均高于正常对照组,差异有统计学意义(P<0.05)。
(2)药物干预治疗后各项指标比较：
①体质量比较：药物干预治疗14天后,中药组、西药组及联合用药组大鼠体质量较模型对照组比较有下降的趋势,其中以联合用药组下降程度最明显,但差异无统计学意义(P>0.05)。
②睾酮、胰岛素水平比较：模型对照组大鼠血清T水平高于正常对照组(P<0.01)；与模型对照组相比,3组大鼠经药物干预治疗后血清T水平均有不同程度降低,差异有统计学意义(P<0.01),治疗后大鼠血清T水平以中药组最高,西药组次之,联合用药组最低,中药组与西药组组间比较,差异无统计学意义(P>0.05)。各组大鼠FINS水平,模型对照组大鼠血清FINS水平高于正常对照组(P<0.01)；中药组、西药组、联合用药组经药物干预治疗后,血清FINS水平均较模型对照组降低(P<0.01)。中药组、西药组、联合用药组三组FINS水平相近,差异无统计学意义(P>0.05)。
③子宫及卵巢脏器系数比较：模型对照组大鼠的卵巢脏器系数与正常对照组比较,差异有统计学意义(P<0.01)；治疗后,西药组及联合用药组与模型对照组相比,卵巢脏器系数下降,差异有统计学意义(P<0.05)；而中药组卵巢脏器系数与模型对照组比较,差异无统计学意义(P>0.05)；与正常对照组相比,模型对照组的子宫脏器系数降低(P＜0.05),与模型对照组比较,中药组、西药组和联合用药组子宫脏器系数比较无统计学意义(P>0.05),中药组、联合用药组子宫脏器系数较模型对照组比较有增高的趋势,西药组的子宫脏器系数低于中药组和联合用药组,差异有统计学意义(P＜0.05)。
④免疫组化结果：与正常对照组相比,模型对照组大鼠子宫内膜整合素αvβ3、LIF、glycodelin的表达强度降低(P<0.01),呈弱阳性表达。与模型对照组相比,单纯克罗米芬干预使大鼠子宫内膜整合素αvβ3、 LIF、glycodelin的表达降低,差异有统计学意义(P＜0.05),而参芪胶囊、参芪胶囊联合克罗米芬可上调其表达(P<0.01),且参芪胶囊联合克罗米芬组与正常对照组表达更接近。
2.临床研究结果：
(1)体重指数及腰臀比：治疗组(参芪胶囊联合克罗米芬)与对照组(克罗米芬)在降低PCOS患者体重指数及腰臀比均有疗效,治疗前后比较,差异有统计学意义(P<0.05)。
(2)彩色多普勒超声参数：治疗组与对照组患者双侧卵巢体积治疗后较治疗前比较,差异无统计学意义(P>0.05)；治疗组治疗后子宫动脉PI、左卵巢间质动脉PI、右卵巢间质动脉PI下降,差异有统计学意义(P<0.01)。治疗组治疗后子宫动脉RI、左卵巢间质动脉RI、右卵巢间质动脉RI下降,差异有统计学意义(P<0.05)。而对照组子宫动脉及卵巢间质动脉PI、RT治疗前后均数比较,差异无统计学意义(P>0.05)。
(3)血糖及胰岛素水平：治疗组治疗后2h-PG较治疗前降低,差异有统计学意义(P<0.05)；2h-INS治疗后较治疗前降低,差异有统计学意义(P<0.01)。治疗组治疗后HOMA-IR下降,差异有统计学意义(P<0.05)。对照组治疗前后血糖、胰岛素差异无统计学意义(P>0.05)。
(4)血清性激素水平：治疗组治疗后血清LH、LH/FSH、T与治疗前均有不同程度改善,其中LH、T治疗后比治疗前降低,差异有统计学意义(P<0.01);LH/FSH(?)匕值治疗后比治疗前降低,差异有统计学意义(P<0.05)。对照组治疗后血清T水平与治疗前比较有降低的趋势,但差异无统计学意义(P>0.05),LH水平较治疗前降低,差异有统计学意义(P<0.05)。两组患者治疗前后血清FSH、E2、P和PRL比较,差异无统计学意义(P>0.05)。
(5)血脂六项：治疗组和对照组治疗前后TG、TC、HDL-C、LDL-C、ApoA1、ApoB、 ApoAl/ApoB比较,差异无统计学意义(P>0.05)。
(6)中医证候评分：治疗组和对照组中医证候评分治疗前后比较差异有统计学意义(P<0.01)。
结论
1.实验研究
(1)DHEA诱导SD幼年雌性大鼠建立的PCO动物模型,其卵巢病理形态学改变及大鼠内分泌改变与临床PCOS患者相似,是理想的PCOS动物模型。
(2)PCO大鼠CC促排卵后子宫内膜整合素αvβ3、LIF、glycodelin的低表达现象,可能与子宫内膜容受性受损有关。
(3)参芪胶囊能改善PCO大鼠子宫内膜整合素αvβ3、LIF、glycodelin的表达,改善子宫内膜容受性。
2.临床研究
(1)彩色多普勒超声检测子宫内膜的厚度及形态变化,子宫动脉及卵巢间质动脉血流参数可作为胞饮突的替代性指标,用以评价子宫内膜容受性。
(2)临床上应用CC促排卵周期中加用参芪胶囊治疗,起到协同增效作用,在改善患者子宫内膜厚度及形态变化,调节子宫动脉及卵巢间质动脉血流动力学方面均显著优于单纯克罗米芬治疗。提示参芪胶囊能调节PCOS患者内分泌功能,纠正CC对子宫内膜的负面影响,改善子宫内膜容受性。
Background
Polycystic ovarian syndrome (PCOS) is one of most common endocrine disease, the syndrome encompasses a broader spectrum of signs and symptoms, such as elevated serum hyperandrogenism and insulin resistance. PCOS patients with follicular development stagnation, and no mature follicles, so the key treatment to PCOS patients is to promoting follicles development, and inducing ovulation. For PCOS anovulatory patients, the clinical treatment of ovulation is clomiphene citrate(CC), the ovulation rate was80%, but the pregnancy rate is only30%--40%. Clomiphene can lead to endometrial dysplasia, cervical mucus quantity change and the luteinized unruptured follicle syndrome and affect the pregnancy rate. Because of chronic anovulation, estradiol and progesterone secretion is inharmonious, the implantation of endometrium and cell survival associated with abnormal expression, resulting in decrease of endometrial receptivity. Therefore, how to correct the reduced endometrial receptivity in PCOS patients with endocrine disorders and application of ovulation induction therapy, is a big challenge for modern medicine.
The famous professor Li Liyun of Guangdong Province Hospital Of Traditional Chinese Medical, created Shen-Qi capsule. She basis the previous experience with clinical experience, put forward the traditional chinese medical etiology and pathogenesis of kidney deficiency, blood stasis and phlegm as a standard, with kidney and phlegm and activating blood method, adjustment of gonadal function, maintenance of luteal function, thus improving improve the receptivity of endometrium, to achieve better clinical efficacy.
Objective
1. To investigate the expression of Shen-Qi capsule on PCO in rat's endometrium integrin αvβ3, LIF, glycodelin, improve the expression of endometrial receptivity, to clarify the possible molecular mechanism of its efficacy, to provide the experimental basis for the clinical treatment of PCOS based on infertility.
2. By transvaginal color Doppler flow imaging before and after the treatment of uterine artery pulsatility index (PI) and resistance index (RI), ovarian stromal artery pulsatility index (PI) and resistance index (RI) hemodynamic changes, to evaluate the clinical effect of Shen-Qi capsule improvement PCOS in patients with endometrial receptivity, and explore its possible mechanisms of action, and provide a scientific basis for further clinical application and promotion.
Methods
1. Experimental study:PCO rat model was experimentally induced by the24-day-old female rats by subcutaneous injection of oilsolution of dehydroepiandrosterone (DHEA) for continuous20days. The rats with PCO were randomly divided into control group, model group, Shen-Qi treating group, clomiphene treating group, Shen-Qi and clomiphene treating group. The treatments were given for14days since80days after birth. The serum testosterone and fasting insulin levels were obtained after treatment. We observed the change of uterine and ovarian organ coefficient, endometrium and ovarian morphology. The expressions of integrin αvβ3, LIF and glycodelin, to explore the possible mechanism of Shen-Qi capsule.
2. Clinical research:by means of randomized controlled clinical research methods, Guangdong Province Hospital Of Traditional Chinese Medical, from2012.2-2012.12, They are divided divided into two groups by1:1randomly, the control group including23cases, and treatment group including23cases, clomiphene is given to the control group, and at the same time clomiphene and Shen-Qi capsule are given to treatment group. Two groups are inspected by using Chinese medicine syndromes graded tables, the hemodynamic monitoring of uterus and ovary, and other observe variable index, such as sex hormones, blood glucose, insulin, blood lipid, using PASW Statistics17.0statistical software to establish a database and statistical analysis.
Results
1. Results of experimental study:
(1) The comparison of control group and the successed animal model group: the latter surpass the former in these mean observe index, such as weight, serum testosterone and fasting insulin levels, the differences were statistically significant (P<0.05).
(2) The difference of each group after treatment of drug intervention:
①) Weight:The treatments were given for14days, Shen-Qi treating group, clomiphene treating group and Shen-Qi and clomiphene treating group rats' weight compared with model group tended to decrease, which is in the Shen-Qi and clomiphene treating group decreased more obviously, but the differences were not statistically significant (P>0.05).
②Comparison of testosterone, fasting insulin levels:model group serum T got higher level than control group(P<0.01); compared with model group, the three treating groups serum T levels were decreased to some extent, the differences were statistically significant (P<0.01), But from the comparison of the mean, the first is Shen-Qi treating group, the second is clomiphene treating group, the lowest is Shen-Qi and clomiphene treating group. There is no distinct statistcal differences between Shen-Qi treating group and clomiphene treating group(P>0.05). The FINS level of each group:compared with control group, model group got higher the serum T level (P<0.01); Shen-Qi treating group, clomiphene treating group, Shen-Qi and clomiphene treating group after therapy, the serum FINS level were compared with model group decreased(P<0.01). The serum FINS levels were similar between these three groups, the differences were not statistically significant (P>0.05).
③Comparison of uterine and ovarian organ coefficient:there is distinct statistical differences between control group and model group ovarian organ coefficient (P<0.01); after treatment, compared with model group, clomiphene treating group and Shen-Qi and clomiphene treating group decreased ovarian organ coefficient, the differences were statistically significant(P<0.05) there is no distinct statistical differences between Shen-Qi treating group and model group(P>0.05); compared with control group, there is lower uterine organ coefficient model group(P<0.05);compared with model group, there is no significant uterine organ coefficient statistical among Shen-Qi treating group、clomiphene treating group and Shen-Qi and clomiphene treating group(P >0.05). compared with model group, Shen-Qi treating group, Shen-Qi and clomiphene treating group uterine organ coefficient increased, uterine organ coefficient in clomiphene treating group is lower than that of Shen-Qi treating group and Shen-Qi and clomiphene treating group, the difference was statistically significant (P<0.05).
④The results of immunohistochemistry:compared with the control group, model group endometrial the expression of integrin αvβ3, LIF, glycodelin decreased(P<0.01). Compared with model group, clomiphene treating group endometrium integrin avP3, LIF, glycodelin decreased significantly, the differences were statistically significant (P<0.05), while Shen-Qi treating group, Shen-Qi and clomiphene treating group can upregulate the expression (P<0.01), and Shen-Qi and clomiphene treating group was closer to the expression of control group.
2. Results of Clinical study:
(1) Body mass index and waist-hip ratio:the treatment group (Shen-Qi and clomiphene treating group) and control group (clomiphene treating group) with body weight, BMI and waist-hip ratio levels than before treatment was significantly decreased, the differences were statistically significant (P <0.05).
(2) Color Doppler flow imaging:the treatment group and the control group of patients with ovarian volume after treatment than before treatment, there is no statistical difference (P>0.05); After treatment, the treatment group of uterine artery PI, left ovarian stromal artery PI and right ovarian stromal artery PI than before treatment was signicantly decreased, the differences were statistically significance(P<0.01). After treatment, the treatment group of uterine artery RI, the left ovarian stromal artery RI and right ovarian stromal artery RI than before treatment was signicantly decreased, the differences were statistically significance (P<0.05). While the control group of uterine artery and ovarian stromal artery PI、RI after treatment than before treatment, there is no statistical difference(P>0.05).
(3)Blood glucose and insulin levels:after treatment, the treatment group of2h-PG decreased, the differences were statistically significant (P<0.05);2h-INS than before treatment decreased, the differences were statistically significant(P<0.01). After treatment, HOMA-IR decreased, the differences were statistically significant (P<0.05). The control group of patients with blood glucose, insulin after treatment than before treatment, there was no statistical difference(P>0.05).
(4) Serum sex hormones levels:after treatment, the treatment group of patients with LH, LH/FSH and T before treatment were improved in varying degrees, LH and T levels reduced than before treatment, the differences were statistically significant (P<0.01); LH/FSH reduced than before treatment, the differences were statistically signif icant(P<0.05). After treatment, the control group compared with before treatment T level has a tendency to decreased, but there was no statistically significant difference (P>0.05), serum LH level was lower (P<0.05). after treatment, serum FSH, E2^P and PRL before treatment, there was no statistically significant difference (P>0.05).
(5) Blood lipids:the treatment group and the control group with TG, TC, HDL-C, LDL-C, ApoAl, ApoB, ApoAl/ApoB after treatment than before treatment, there is no statistical difference (P>0.05).
(6) TCM syndrome:the treatment group and the control group both can improve the quantitative scores of TCM symptoms of PCOS patients (P<0.01).
Conelusion
1. Experimental study:
(1) The PCO animal model of SD juvenile female rats established induced by DHEA, the morphology changes and endocrine alterations are similar to clinical PCOS patients, is an ideal animal model of PCOS.
(2) The phenomenon of low expression of PCO rats use clomiphene ovulation and endometrial integrin avβ3、LIF、glycodelin, may be related to endometrial receptivity damage.
(3) Shen-Qi capsule can improve the PCO rat endometrial the expression of integrin αvβ3、LIF、glycodelin, improve the endometrial receptivity.
2. Clinical research:
(1) Endometrial thickness and morphology of color Doppler flow imaging, uterine and ovarian stromal artery blood flow can serve as an indicator of pinopode, for evaluation of endometrial receptivity.
(2) The clinical application of clomiphene in ovulation induction cycle plus Shen-Qi capsule, play a synergistic effect, in the improvement in patients with Endometrial thickness and morphology, adjust the uterine artery and ovarian stromal artery blood flow were significantly better than clomiphene therapy. Prompt Shen-Qi capsule can regulate the endocrine function of patients with PCOS, correct clomiphene negative effects on the endometrium, improve endometrial receptivity.
多囊卵巢综合征(polycystic ovarian syndrome, PCOS)是以持续性无排卵、高雄激素或胰岛素抵抗为特征的内分泌紊乱的症候群。PCOS患者因卵泡发育停滞,无成熟卵泡,因此促使卵泡发育、成熟、诱发排卵是治疗PCOS不孕症的关键环节。临床上对于PCOS无排卵性不孕的促排卵治疗首选克罗米芬(clomiphene citrate, CC),其排卵率可达80%,但妊娠率仅为30%～40%。主要是由于CC可致子宫内膜发育不良、宫颈粘液质与量的改变以及可以导致未破裂卵泡黄素化而影响妊娠率。另外(?)PCOS患者由于长期无排卵,雌、孕激素分泌不协调,使着床期子宫内膜与细胞存活相关的蛋白表达异常,导致子宫内膜容受性下降。因此,如何纠正PCOS患者内分泌紊乱及应用促排卵治疗后子宫内膜容受性的降低,是对现代医学的一大挑战。我院名老中医李丽芸教授根据前人经验结合临证经验,提出PCOS中医病因病机以肾虚为本,血瘀及痰阻为标,属虚实夹杂之证,以补肾化痰活血为法,研制出参芪胶囊,调整性腺功能,维持黄体功能,从而改善子宫内膜容受性,临床上取得较好疗效。
目的
1.探讨参芪胶囊对PCO大鼠子宫内膜整合素αvβ2、LIF、glycodelin的表达,改善子宫内膜容受性的可能作用靶点,阐明其疗效的可能分子机制,为临床治疗PCOS不孕症的基础研究提供实验依据。
2.通过阴道彩色多普勒超声监测治疗前后子宫动脉搏动指数(PI)及阻力指数(RI)、卵巢间质动脉搏动指数(PI)及阻力指数(RI)等血流动力学的改变,对参芪胶囊改善PCOS患者子宫内膜容受性的临床疗效进行客观的评价,探讨其可能的作用机制,为进一步临床应用及推广提供科学的依据。
方法
1.实验研究：通过对24日龄SD雌性大鼠皮下注射脱氢表雄酮(DHEA)+注射用油剂20天诱导PCO大鼠模型,正常对照组同期皮下注射用油剂。PCO大鼠采用随机对照法分为模型对照组、中药组、西药组及联合用药组。中药组、西药组及联合用药组于80日龄起药物干预治疗14天。治疗结束后测定血清T、FINS水平。观察各组大鼠子宫及卵巢脏器系数、子宫内膜及卵巢形态学改变；免疫组化法观察子宫内膜中整合素αvβ3、LIF、glycodelin的表达。
2.临床研究：采用临床随机对照研究方法,将广东省中医院2012年2月～2012年12月在门诊就诊符合纳入标准的患者随机分为对照组(23例)和治疗组(23例),对照组采用克罗米芬,治疗组采用克罗米芬联合参芪胶囊,采用中医证候评分表,通过监测子宫及卵巢血流动力学,结合性激素、血糖、胰岛素、血脂等指标,采用PASWStatistics17.0统计软件建立数据库并进行统计学分析。
结果
1.实验研究结果：
(1)正常对照组与模型组比较分析：模型组大鼠体质量、血清睾酮及空腹胰岛素水平均高于正常对照组,差异有统计学意义(P<0.05)。
(2)药物干预治疗后各项指标比较：
①体质量比较：药物干预治疗14天后,中药组、西药组及联合用药组大鼠体质量较模型对照组比较有下降的趋势,其中以联合用药组下降程度最明显,但差异无统计学意义(P>0.05)。
②睾酮、胰岛素水平比较：模型对照组大鼠血清T水平高于正常对照组(P<0.01)；与模型对照组相比,3组大鼠经药物干预治疗后血清T水平均有不同程度降低,差异有统计学意义(P<0.01),治疗后大鼠血清T水平以中药组最高,西药组次之,联合用药组最低,中药组与西药组组间比较,差异无统计学意义(P>0.05)。各组大鼠FINS水平,模型对照组大鼠血清FINS水平高于正常对照组(P<0.01)；中药组、西药组、联合用药组经药物干预治疗后,血清FINS水平均较模型对照组降低(P<0.01)。中药组、西药组、联合用药组三组FINS水平相近,差异无统计学意义(P>0.05)。
③子宫及卵巢脏器系数比较：模型对照组大鼠的卵巢脏器系数与正常对照组比较,差异有统计学意义(P<0.01)；治疗后,西药组及联合用药组与模型对照组相比,卵巢脏器系数下降,差异有统计学意义(P<0.05)；而中药组卵巢脏器系数与模型对照组比较,差异无统计学意义(P>0.05)；与正常对照组相比,模型对照组的子宫脏器系数降低(P＜0.05),与模型对照组比较,中药组、西药组和联合用药组子宫脏器系数比较无统计学意义(P>0.05),中药组、联合用药组子宫脏器系数较模型对照组比较有增高的趋势,西药组的子宫脏器系数低于中药组和联合用药组,差异有统计学意义(P＜0.05)。
④免疫组化结果：与正常对照组相比,模型对照组大鼠子宫内膜整合素αvβ3、LIF、glycodelin的表达强度降低(P<0.01),呈弱阳性表达。与模型对照组相比,单纯克罗米芬干预使大鼠子宫内膜整合素αvβ3、 LIF、glycodelin的表达降低,差异有统计学意义(P＜0.05),而参芪胶囊、参芪胶囊联合克罗米芬可上调其表达(P<0.01),且参芪胶囊联合克罗米芬组与正常对照组表达更接近。
2.临床研究结果：
(1)体重指数及腰臀比：治疗组(参芪胶囊联合克罗米芬)与对照组(克罗米芬)在降低PCOS患者体重指数及腰臀比均有疗效,治疗前后比较,差异有统计学意义(P<0.05)。
(2)彩色多普勒超声参数：治疗组与对照组患者双侧卵巢体积治疗后较治疗前比较,差异无统计学意义(P>0.05)；治疗组治疗后子宫动脉PI、左卵巢间质动脉PI、右卵巢间质动脉PI下降,差异有统计学意义(P<0.01)。治疗组治疗后子宫动脉RI、左卵巢间质动脉RI、右卵巢间质动脉RI下降,差异有统计学意义(P<0.05)。而对照组子宫动脉及卵巢间质动脉PI、RT治疗前后均数比较,差异无统计学意义(P>0.05)。
(3)血糖及胰岛素水平：治疗组治疗后2h-PG较治疗前降低,差异有统计学意义(P<0.05)；2h-INS治疗后较治疗前降低,差异有统计学意义(P<0.01)。治疗组治疗后HOMA-IR下降,差异有统计学意义(P<0.05)。对照组治疗前后血糖、胰岛素差异无统计学意义(P>0.05)。
(4)血清性激素水平：治疗组治疗后血清LH、LH/FSH、T与治疗前均有不同程度改善,其中LH、T治疗后比治疗前降低,差异有统计学意义(P<0.01);LH/FSH(?)匕值治疗后比治疗前降低,差异有统计学意义(P<0.05)。对照组治疗后血清T水平与治疗前比较有降低的趋势,但差异无统计学意义(P>0.05),LH水平较治疗前降低,差异有统计学意义(P<0.05)。两组患者治疗前后血清FSH、E2、P和PRL比较,差异无统计学意义(P>0.05)。
(5)血脂六项：治疗组和对照组治疗前后TG、TC、HDL-C、LDL-C、ApoA1、ApoB、 ApoAl/ApoB比较,差异无统计学意义(P>0.05)。
(6)中医证候评分：治疗组和对照组中医证候评分治疗前后比较差异有统计学意义(P<0.01)。
结论
1.实验研究
(1)DHEA诱导SD幼年雌性大鼠建立的PCO动物模型,其卵巢病理形态学改变及大鼠内分泌改变与临床PCOS患者相似,是理想的PCOS动物模型。
(2)PCO大鼠CC促排卵后子宫内膜整合素αvβ3、LIF、glycodelin的低表达现象,可能与子宫内膜容受性受损有关。
(3)参芪胶囊能改善PCO大鼠子宫内膜整合素αvβ3、LIF、glycodelin的表达,改善子宫内膜容受性。
2.临床研究
(1)彩色多普勒超声检测子宫内膜的厚度及形态变化,子宫动脉及卵巢间质动脉血流参数可作为胞饮突的替代性指标,用以评价子宫内膜容受性。
(2)临床上应用CC促排卵周期中加用参芪胶囊治疗,起到协同增效作用,在改善患者子宫内膜厚度及形态变化,调节子宫动脉及卵巢间质动脉血流动力学方面均显著优于单纯克罗米芬治疗。提示参芪胶囊能调节PCOS患者内分泌功能,纠正CC对子宫内膜的负面影响,改善子宫内膜容受性。
Background
Polycystic ovarian syndrome (PCOS) is one of most common endocrine disease, the syndrome encompasses a broader spectrum of signs and symptoms, such as elevated serum hyperandrogenism and insulin resistance. PCOS patients with follicular development stagnation, and no mature follicles, so the key treatment to PCOS patients is to promoting follicles development, and inducing ovulation. For PCOS anovulatory patients, the clinical treatment of ovulation is clomiphene citrate(CC), the ovulation rate was80%, but the pregnancy rate is only30%--40%. Clomiphene can lead to endometrial dysplasia, cervical mucus quantity change and the luteinized unruptured follicle syndrome and affect the pregnancy rate. Because of chronic anovulation, estradiol and progesterone secretion is inharmonious, the implantation of endometrium and cell survival associated with abnormal expression, resulting in decrease of endometrial receptivity. Therefore, how to correct the reduced endometrial receptivity in PCOS patients with endocrine disorders and application of ovulation induction therapy, is a big challenge for modern medicine.
The famous professor Li Liyun of Guangdong Province Hospital Of Traditional Chinese Medical, created Shen-Qi capsule. She basis the previous experience with clinical experience, put forward the traditional chinese medical etiology and pathogenesis of kidney deficiency, blood stasis and phlegm as a standard, with kidney and phlegm and activating blood method, adjustment of gonadal function, maintenance of luteal function, thus improving improve the receptivity of endometrium, to achieve better clinical efficacy.
Objective
1. To investigate the expression of Shen-Qi capsule on PCO in rat's endometrium integrin αvβ3, LIF, glycodelin, improve the expression of endometrial receptivity, to clarify the possible molecular mechanism of its efficacy, to provide the experimental basis for the clinical treatment of PCOS based on infertility.
2. By transvaginal color Doppler flow imaging before and after the treatment of uterine artery pulsatility index (PI) and resistance index (RI), ovarian stromal artery pulsatility index (PI) and resistance index (RI) hemodynamic changes, to evaluate the clinical effect of Shen-Qi capsule improvement PCOS in patients with endometrial receptivity, and explore its possible mechanisms of action, and provide a scientific basis for further clinical application and promotion.
Methods
1. Experimental study:PCO rat model was experimentally induced by the24-day-old female rats by subcutaneous injection of oilsolution of dehydroepiandrosterone (DHEA) for continuous20days. The rats with PCO were randomly divided into control group, model group, Shen-Qi treating group, clomiphene treating group, Shen-Qi and clomiphene treating group. The treatments were given for14days since80days after birth. The serum testosterone and fasting insulin levels were obtained after treatment. We observed the change of uterine and ovarian organ coefficient, endometrium and ovarian morphology. The expressions of integrin αvβ3, LIF and glycodelin, to explore the possible mechanism of Shen-Qi capsule.
2. Clinical research:by means of randomized controlled clinical research methods, Guangdong Province Hospital Of Traditional Chinese Medical, from2012.2-2012.12, They are divided divided into two groups by1:1randomly, the control group including23cases, and treatment group including23cases, clomiphene is given to the control group, and at the same time clomiphene and Shen-Qi capsule are given to treatment group. Two groups are inspected by using Chinese medicine syndromes graded tables, the hemodynamic monitoring of uterus and ovary, and other observe variable index, such as sex hormones, blood glucose, insulin, blood lipid, using PASW Statistics17.0statistical software to establish a database and statistical analysis.
Results
1. Results of experimental study:
(1) The comparison of control group and the successed animal model group: the latter surpass the former in these mean observe index, such as weight, serum testosterone and fasting insulin levels, the differences were statistically significant (P<0.05).
(2) The difference of each group after treatment of drug intervention:
①) Weight:The treatments were given for14days, Shen-Qi treating group, clomiphene treating group and Shen-Qi and clomiphene treating group rats' weight compared with model group tended to decrease, which is in the Shen-Qi and clomiphene treating group decreased more obviously, but the differences were not statistically significant (P>0.05).
②Comparison of testosterone, fasting insulin levels:model group serum T got higher level than control group(P<0.01); compared with model group, the three treating groups serum T levels were decreased to some extent, the differences were statistically significant (P<0.01), But from the comparison of the mean, the first is Shen-Qi treating group, the second is clomiphene treating group, the lowest is Shen-Qi and clomiphene treating group. There is no distinct statistcal differences between Shen-Qi treating group and clomiphene treating group(P>0.05). The FINS level of each group:compared with control group, model group got higher the serum T level (P<0.01); Shen-Qi treating group, clomiphene treating group, Shen-Qi and clomiphene treating group after therapy, the serum FINS level were compared with model group decreased(P<0.01). The serum FINS levels were similar between these three groups, the differences were not statistically significant (P>0.05).
③Comparison of uterine and ovarian organ coefficient:there is distinct statistical differences between control group and model group ovarian organ coefficient (P<0.01); after treatment, compared with model group, clomiphene treating group and Shen-Qi and clomiphene treating group decreased ovarian organ coefficient, the differences were statistically significant(P<0.05) there is no distinct statistical differences between Shen-Qi treating group and model group(P>0.05); compared with control group, there is lower uterine organ coefficient model group(P<0.05);compared with model group, there is no significant uterine organ coefficient statistical among Shen-Qi treating group、clomiphene treating group and Shen-Qi and clomiphene treating group(P >0.05). compared with model group, Shen-Qi treating group, Shen-Qi and clomiphene treating group uterine organ coefficient increased, uterine organ coefficient in clomiphene treating group is lower than that of Shen-Qi treating group and Shen-Qi and clomiphene treating group, the difference was statistically significant (P<0.05).
④The results of immunohistochemistry:compared with the control group, model group endometrial the expression of integrin αvβ3, LIF, glycodelin decreased(P<0.01). Compared with model group, clomiphene treating group endometrium integrin avP3, LIF, glycodelin decreased significantly, the differences were statistically significant (P<0.05), while Shen-Qi treating group, Shen-Qi and clomiphene treating group can upregulate the expression (P<0.01), and Shen-Qi and clomiphene treating group was closer to the expression of control group.
2. Results of Clinical study:
(1) Body mass index and waist-hip ratio:the treatment group (Shen-Qi and clomiphene treating group) and control group (clomiphene treating group) with body weight, BMI and waist-hip ratio levels than before treatment was significantly decreased, the differences were statistically significant (P <0.05).
(2) Color Doppler flow imaging:the treatment group and the control group of patients with ovarian volume after treatment than before treatment, there is no statistical difference (P>0.05); After treatment, the treatment group of uterine artery PI, left ovarian stromal artery PI and right ovarian stromal artery PI than before treatment was signicantly decreased, the differences were statistically significance(P<0.01). After treatment, the treatment group of uterine artery RI, the left ovarian stromal artery RI and right ovarian stromal artery RI than before treatment was signicantly decreased, the differences were statistically significance (P<0.05). While the control group of uterine artery and ovarian stromal artery PI、RI after treatment than before treatment, there is no statistical difference(P>0.05).
(3)Blood glucose and insulin levels:after treatment, the treatment group of2h-PG decreased, the differences were statistically significant (P<0.05);2h-INS than before treatment decreased, the differences were statistically significant(P<0.01). After treatment, HOMA-IR decreased, the differences were statistically significant (P<0.05). The control group of patients with blood glucose, insulin after treatment than before treatment, there was no statistical difference(P>0.05).
(4) Serum sex hormones levels:after treatment, the treatment group of patients with LH, LH/FSH and T before treatment were improved in varying degrees, LH and T levels reduced than before treatment, the differences were statistically significant (P<0.01); LH/FSH reduced than before treatment, the differences were statistically signif icant(P<0.05). After treatment, the control group compared with before treatment T level has a tendency to decreased, but there was no statistically significant difference (P>0.05), serum LH level was lower (P<0.05). after treatment, serum FSH, E2^P and PRL before treatment, there was no statistically significant difference (P>0.05).
(5) Blood lipids:the treatment group and the control group with TG, TC, HDL-C, LDL-C, ApoAl, ApoB, ApoAl/ApoB after treatment than before treatment, there is no statistical difference (P>0.05).
(6) TCM syndrome:the treatment group and the control group both can improve the quantitative scores of TCM symptoms of PCOS patients (P<0.01).
Conelusion
1. Experimental study:
(1) The PCO animal model of SD juvenile female rats established induced by DHEA, the morphology changes and endocrine alterations are similar to clinical PCOS patients, is an ideal animal model of PCOS.
(2) The phenomenon of low expression of PCO rats use clomiphene ovulation and endometrial integrin avβ3、LIF、glycodelin, may be related to endometrial receptivity damage.
(3) Shen-Qi capsule can improve the PCO rat endometrial the expression of integrin αvβ3、LIF、glycodelin, improve the endometrial receptivity.
2. Clinical research:
(1) Endometrial thickness and morphology of color Doppler flow imaging, uterine and ovarian stromal artery blood flow can serve as an indicator of pinopode, for evaluation of endometrial receptivity.
(2) The clinical application of clomiphene in ovulation induction cycle plus Shen-Qi capsule, play a synergistic effect, in the improvement in patients with Endometrial thickness and morphology, adjust the uterine artery and ovarian stromal artery blood flow were significantly better than clomiphene therapy. Prompt Shen-Qi capsule can regulate the endocrine function of patients with PCOS, correct clomiphene negative effects on the endometrium, improve endometrial receptivity.
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