【作者】 潘晓明；

【导师】 黄荷凤； 陆秀娥；

【作者基本信息】 浙江大学 ， 妇产科学， 2010， 硕士

【摘要】 研究背景不明原因不孕(unexplained infertility, UI)是一种排除性诊断,通常是指,通过常规的不孕症检查,包括：精液检查、排卵及黄体功能检查、输卵管检查等均未发现异常而不孕者,目前仍无统一的诊断标准。其发病率随诊断技术的提高而逐步下降,据统计,约15%一30%的不孕夫妇属于此类。其治疗包括：期待治疗、诱导排卵后指导同房、诱导排卵加宫腔内人工授精,如果经过上述治疗仍不能成功妊娠,则选择不孕治疗的最后一步——体外受精和胚胎移植(IVF-ET).部分不明原因不孕患者不孕的原因可能是存在受精障碍。目前多数中心认为单精子卵浆内注射(ICSI)可以提高受精率,但也有研究发现对于不明原因不孕患者行ICSI的受精率、着床率、妊娠率与常规IVF无显著性差异。本研究通过对2002—2009年在浙江大学医学院附属妇产科医院行体外受精助孕技术的不明原因不孕患者不同受精方式(常规IVF、ICSI、一半IVF一半ICSI)对受精率和优质胚胎率的影响的研究,希望得出的结论能为将来行体外受精助孕技术的不明原因不孕患者在受精方式的选择上提供参考意见。目的探讨不同临床状况的不明原因不孕患者行体外受精助孕时,选择何种受精方式更有利。方法系统回顾2002—2009年在我院生殖中心行体外受精助孕的不明原因不孕患者共198例。不明原因不孕的诊断标准为：(1)有规律的月经周期,月经第3天测基础内分泌值正常,超声监测有排卵,或子宫内膜活检有分泌期改变；(2)输卵管碘油造影示输卵管通畅；(3)男方精液检查提示正常；(4)腹腔镜检查排除盆腔炎性疾病后遗症、子宫内膜异位症等疾病(腹腔镜为诊断不明原因不孕的金标准,但由于部分患者不愿意行腹腔镜检查,临床实践上存在一定困难,故临床上把上述前三项检查未发现异常,既往无盆腔炎、子宫内膜异位症病史,妇科检查无异常发现的患者也归于不明原因不孕)。其中116例行常规IVF,62例行ICSI,20例行一半IVF一半ICSI。分析不明原因不孕患者不同临床因素与行不同受精方式时受精率和优质胚胎率的关系。结果1.不明原因不孕患者行体外受精时,行ICSI受精率显著高于行IVF者。不同患者行ICSI的受精率(73.1%)显著高于行IVF者(51.9%)(P<0.01),但两者的受精完全失败率无显著性差异(P>0.05)。行ICSI的优质胚胎率(65.6%)显著高于行IVF者(49.7%)(P<0.01)。同一患者行一半IVF一半ICSI受精时,ICSI的平均受精率(79.1%)显著高于IVF(58.6%)(P<0.05),但受精完全失败率、优质胚胎率无显著差异(P>0.05)。2.不明原因不孕患者行体外受精时,随着年龄的增大,行IVF者的受精率、优质胚胎率有下降的趋势,但无显著性差异；行ICSI者的受精率无明显下降,优质胚胎率有下降的趋势,但无显著性差异。3.不明原因不孕患者行体外受精时,随着不孕年限的延长,行IVF的受精率下降,行ICSI的受精率无明显下降。同一患者行一半IVF一半ICSI受精,当不孕年限≥5年时,IVF的受精率(52.8%)显著低于ICSI(86.0%) (P＜0.01), IVF的优质胚胎率(48.6%)显著低于ICSI(65.5%) (P＜0.05)。4.不明原因不孕患者行体外受精时,原发不孕患者行ICSI的受精率显著高于行IVF者,且优质胚胎率无明显下降。对于不同的患者,无论原发不孕还是继发不孕,行ICSI的受精率均显著高于行IVF者(P<0.01)；继发不孕的患者行ICSI的优质胚胎率(66.1%)显著高于行IVF者(46.1%)(P<0.05)。同一患者行一半IVF一半ICSI受精时,原发不孕者ICSI的受精率(80.3%)显著高于IVF(61.2%)(P<0.05)。继发不孕者IVF与ICSI的受精率、优质胚胎率无显著性差异(P>0.05)。5.不明原因不孕患者行体外受精时,当AIH≥2次者行ICSI的受精率高于行IVF者(P<0.05),但其优质胚胎率无显著性差异(P>0.05)。AIH 2次时不同患者行ICSI的受精率为73.9%,IVF的受精率为46.0%；AIH 3次时不同患者行ICSI的受精率为72.0%,IVF的受精率为49.2%；AIH≥4次时不同患者行ICSI的受精率为80.8%,IVF的受精率为57.8%。6.不明原因不孕患者行体外受精时,如前次IVF受精率>1／3,则第二次行IVF的受精率无明显下降(P>0.05),如前次IVF受精率<1／3,则第二次行ICSI的受精率明显提高(10.6%VS 80.7%)(P<0.01)。结论不明原因不孕患者,如果为原发不孕、年龄≥40岁、不孕年限≥5年、AIH≥2次,可考虑行ICSI方式受精。如果获卵数>10个,为了避免受精完全失败,可行一半IVF、一半ICSI.更多还原

【Abstract】 ObjectiveTo research which way is better for unexplained infertility with different clinical factors, in vitro fertilization or intracytoplasmic sperm injection.Methods198 patients who were diagnosed unexplained infertility were analyed retrospectively,which were done from January 2002 to December 2009 in our reproductive center.116 paitents applied IVF,62 paitents applied ICSI,20 paitents applied half IVF and half ICSI.Infertility is customarily defined as the inability to conceive after 1 year of regular unprotected intercourse.Diagnosis of Unexplained Infertility:The basic infertility evaluation is normal, including:a semen analysis, assessment of ovulation (tests for ovarian reserve), a hysterosalpingogram,and, if possible, laparoscopy.The fertilization rate, the rate of top quality embryos were observed and analyzed according to different way of fertilization (IVF or ICSI), female age, duration of infertility,primary infertility or secondary infertility,times of AIH, times of in vitro fertilization. Results1.Applying of ICSI remarkably increased the the fertilization rate compared to applying of IVF. In different patients, the fertilization rate of ICSI was remarkably high compared to IVF(73.1% VS 51.9%) (P<0.01), but there was no difference between the two groups in the total fertilization failure rate, the top quality embryos rate of ICSI was also remarkably high compared to IVF(65.6% VS 49.7%) (P＜0.01).In patients who applied half IVF and half ICSI, the fertilization rate of ICSI was remarkably high compared to IVF(79.1% VS 58.6%) (P＜0.05), but there was no difference in the total fertilization failure rate and the top quality embryos rate.2. The fertilization rate and the top quality embryos rate of IVF gradually decreased with the age growed, the fertilization rate of ICSI didn’t change much,but the top quality embryos rate of ICSI gradually decreased with the age growed.3.The fertilization rate of IVF gradually decreased with the duration of infertility prolonged. In patients who applied half IVF and half ICSI, when the duration of infertility≥5 years, the fertilization rate of IVF is remarkably low compared to ICSI (52.8% VS 86.0%) (P＜0.01),the top quality embryos rate of IVF is also remarkably low compared to ICSI(48.6% VS 65.5%) (P＜0.05)4. In patients who were primary infertility, the fertilization rate of ICSI was remarkably high compared to IVF. In different patients, whether primary infertility or secondary infertility, the fertilization rate of ICSI was remarkably high compared to IVF. the top quality embryos rate of ICSI was remarkably high compared to IVF in patients who were secondary infertility (66.1% VS 46.1%) (P＜0.05). In patients who applied half IVF and half ICSI, the fertilization rate of ICSI was remarkably high compared to IVF In patients who were primary infertility (80.3% VS 61.2%) (P＜0.05),while in patients who were secondary infertility, there was no difference.5.When the times of AIH> 2, the fertilization rate of ICSI was remarkably high compared to IVF,but there was no difference in the top quality embryos rate. The fertilization rate of ICSI was 73.9%, while IVF was 46.0% in patients who had 2 times of AIH; The fertilization rate of ICSI was 72.0%, while IVF was 49.2% in patients who had 3 times of AIH; The fertilization rate of ICSI was 80.8%, while IVF was 57.8% in patients who had≥4 times of AIH;6. If the former fertilization rate of IVF>1/3, the fertilization rate of the later IVF didn’t decrease much (P>0.05), if not, applying ICSI would remarkably increase the fertilization rate (P＜0.01).ConclusionsAs to patients who were diagnosed unexplained infertility,if there were fators such as primary infertility, the age≥40 ys, the duration of infertility≥5 ys, the times of AIH≥2, we should consider ICSI as the way of fertilization. For patients who get more than 10 oocytes we can apply half IVF and half ICSI.更多还原