【作者】 赵井苓；

【导师】 吴献群；

【作者基本信息】 湖北中医药大学 ， 中医妇科学， 2014， 博士

【摘要】 目的意义：卵巢储备功能（Ovarian Reservation，OR）是指卵巢皮质区卵泡生长、发育、形成可受精卵泡的能力。因此生殖功能的衰退表现为皮质区内的卵泡内卵母细胞储存的质量和数量下降，这也是卵巢储备功能下降（Decreasing Ovarian Reservation，DOR）的基本内涵[1]。近年来，随着社会的发展，文化观念、生活环境、工作压力等的改变，使DOR发病率有逐年上升趋势，严重影响着女性的生殖健康和生活质量，而现有国内高等院校中西医统编教材中并无DOR病症的专门论述，所涉及内容偶见于闭经、不孕症、围绝经期综合征中，相关的文献报道也甚少，更缺乏系统、全面的理论阐述和规范、具有指导意义的临床证治路径，因此，我们根据辨证论治，以中医基础理论、相关临床疗效观察为依据，用现代科学的理念和方法阐释补肾活血方干预肾虚血瘀型DOR之月经后期、过少的效应机理，探讨补肾活血法有效干预肾虚血瘀型DOR的临床证治规律，为中医药有效治疗DOR提供科学依据。研究方法：在我们既往单味黄芪对排卵障碍大鼠的干预机制研究中显示炙黄芪对女性排卵、内分泌治疗疗效明显，本研究继前优势遂组成以炙黄芪、菟丝子为君药的补肾活血方再次进行了理论及临床研究:分三部分。第一部分“DOR的文献研究”，根据翻阅古籍经典，结合近现代临床和实验研究成果，研究了卵巢储备功能的中西医研究现状及其进展。第二部分“DOR的中医证候分布研究”，根据中医辨病标准分析其中医病种归属，参照中医证候辨证标准判断其中医证候类型，分析探讨其中医证候特征。第三部分“补肾活血方干预肾虚血瘀型DOR之月经后期、过少的临床研究”，研究补肾活血方干预肾虚血瘀型DOR之月经后期、过少的有效性，观察DOR患者运用补肾活血方治疗前后症状和体征积分，基础FSH，LH，E2，FSH/LH，抑制素B，抗苗勒管激素，窦卵泡计数、卵巢体积、卵巢间质动脉血流速度峰值（PSV）、阻力指数（RI）、搏动指数（PI）等指标的改变。研究结果：（一）卵巢储备功能下降的中医证候分布调查研究结果：1.研究表明患者主诉症状出现率以不孕、月经量少、月经周期错后为主。2.中医诊断中，月经过少、月经后期、不孕症居多。在主诉症状排序中，“不孕”排序在第一位，而在中医诊断排序中，“不孕”排序在第三位。究其原因，考虑为与患者心理有关。在较多患者认为，月经量少甚至月经后期，都不影响正常生活，且无关痛痒，不对身体造成明显的不适感，故而其带来的不适不足以引起重视。由于千百年来中国人对“传嗣”的重视，导致女性对“孕育”极其敏感。部分患者认为，一旦开始备孕，就应该短时间内受孕。故而我们在临床常见备孕半年以内未受孕，而前来就诊者，说明患者对孕育的关注程度，远高于月经不调对患者造成的影响。3.证型分布以肾虚血瘀、肾虚肝郁、气滞血瘀为主。通过研究显示中医对卵巢储备功能下降的基本病因归为“肾虚、血瘀、肝郁”，本研究通过对卵巢储备功能下降患者主诉、中医诊断及辨证情况进行分析统计，月经改变是巢储备功能下降最首要的外在表现，从而可知“月经后期”、“月经过少”是卵巢储备功能下降的两个典型症状，临床常同时并存，逐渐发展，最后可致闭经。鉴于目前尚无判断卵巢储备功能下降的诊断金标准，现有的诊断标准无法明确其程度与分期，故此次研究只是小样本的临床探讨，只能说明部分卵巢储备功能下降患者的特征，不能整个囊括月经紊乱的规律，还待大样本临床探讨。（二）补肾活血方干预肾虚血瘀型卵巢储备功能下降之月经后期、过少的临床研究结果：补肾活血方对卵巢储备功能下降之月经后期、过少患者的临床症状有明显的改善作用，中药组总有效率及显效率与西药组相比无显著差异（P>0.05）。说明在治疗DOR的临床疗效上，补肾活血方与西药克龄蒙功效相当。在治疗过程中中药组有2人不孕症患者妊娠，多次体外受精-胚胎移植失败的1人成功助孕，由此可知补肾活血方（法）在治疗不孕症方面占据优势。在改善DOR患者中医证候上，中药组、西药组均取得非常好的疗效（p＜0.01）。两组间比较，补肾活血方比克龄蒙效果更佳（p＜0.01），说明在改善DOR患者证候上，中西医均有效，且中药组效果更显著。停药3个月后，中药组、西药组治疗前后有显著性差异，而空白组与上述两组治疗后比较有显著性差异，说明药物可以改善卵巢储备功能下降患者的症状，并且中药组短期综合疗效明显。中药组治疗前后各项症状积分相比，均有非常显著性差异（p＜0.01），表明了补肾活血方可以明显改善DOR患者的各项临床症状，体现了补肾活血方的补肾、养血、活血功效。西药组治疗前后各项症状积分相比，在改善月经延后、色暗有块、潮热汗出、性欲减退方面，有非常显著性差异（p＜0.01），说明克龄蒙可以改善DOR患者月经量少及雌激素下降引起的类绝经期症状；却不能改善腰骶酸痛、头晕耳鸣等症状（p＞0.05）。中药组在改善DOR患者腰骶酸软、头晕耳鸣等肾虚方面疗效更佳卓著，体现补肾活血方的补肾功效；在改善月经量少、色暗有块方面有显著性差异（p＜0.05），提示中药与西药相比在改善DOR患者经量、经质时效果明显，可能系中药组活血、养血药物调节脏腑功能之体现；在改善月经延后、潮热汗出、性欲减退方面无显著性差异（p＞0.05）。经Ridit分析（以两组合并作为标准组），中药组患者调经疗效优于西药组。补肾活血方对性激素水平有一定的调节作用，补肾活血方、克龄蒙均可明显改善DOR患者的激素水平。在LH方面有显著性差异（P<0.05），而其他方面无显著性差异，说明激素水平调节方面，中药组与西药组大致相当，仅仅在LH方面略显优势。治疗后中药组、西药组分别与3个月后空白组FSH、LH、FSH/LH、E2比较，均有非常显著性差异（P<0.01）。中西药均可以上调卵巢颗粒细胞抑制素B蛋白、抗苗勒氏管激素(AMH)的表达，改善卵巢储备功能（P<0.01）。阴式B超检查中AFC、PSV、PI、RI方面有非常显著性差异（P<0.05），补肾活血方在增加窦卵泡数、改善卵巢血供（PSV、PI、RI）上效果优于西药组。以上说明补肾活血方对卵巢储备功能下降具有良好的临床疗效，并且它的短期综合疗效明显优于西药组，短期综合疗效较稳定。结论：①通过小样本卵巢储备功能下降患者的中医证候分布研究显示卵巢储备功能下降患者的中医证型以肾虚血瘀、肾虚肝郁居多，月经改变是巢储备功能下降最首要的外在表现，“月经后期”、“月经过少”是卵巢储备功能下降的两个典型症状。另一方面，“月经后期”、“月经过少”作为中医治疗月经病的难点问题之一，如何通过中医药治疗，改善月经量、调整月经周期，是本研究的主要目的。②补肾活血方干预肾虚血瘀型DOR之月经后期、过少的效应机理可能通过干预调节生殖激素、抑制卵巢颗粒细胞凋亡、促进卵巢血管生成而实现。③肾虚血瘀型DOR的主要临床症状为月经延后，月经量少，色暗有块，小腹痛，块下痛减，腰骶酸痛、头晕耳鸣、潮热汗出、性欲减退。舌淡或紫暗边有瘀斑，脉沉细或沉涩。④补肾活血方干预肾虚血瘀型DOR之月经后期、过少的短期疗效明显优于单纯西药治疗，合理运用补肾活血方干预DOR，疗效显著，对预防、延缓POF的发生具有非常积极的意义，从而可以提高女性生活质量。⑤基础血FSH、LH、FSH/LH、E2、INHB和AMH及经阴道B超检查中的卵巢体积、AFC、PSV、PI、RI可作为临床诊断、评估DOR的可靠辅助检查指标。⑥依据中医“治未病”的理论，在卵巢功能储备功能下降的疾病发展过程中，DOR可认为是POF的“未病”阶段，POF是“已病”阶段。所以通过临床症状及实验室检查尽早发现DOR，运用“治未病”的观点指导我们在整个治疗过程中的遣方用药，积极干预，中断发展趋势。更多还原

【Abstract】 PURPOSE: The ovarian reserve function (Ovarian Reservation， OR)refers to the ability of ovarian cortex follicle growth anddevelopment， forming a fertilized follicles. Therefore，reproductive function recession is the quality and quantity of theoocyte cortex follicles stored down，this is the diminished ovarianreserve (Decreasing Ovarian Reservation， DOR) of the basicconnotation of. In recent years， with the development of society，culture， living environment， work pressure and other changes，the incidence of DOR increased year by year， seriously affectingwomen’s reproductive health and quality of life. But the existingdomestic universities and medical textbook are not poor ovarianreserve function disorder of the devoted， The content ofoccasionally in amenorrhea，infertility，menopause syndrome，therelevant literature is also very little，clinical treatment pathlack systematic， comprehensive theoretical explanation andsignificance，the specification. Therefore， we according tosyndrome differentiation and treatment，on the basis of the clinicalcurative effect of TCM basic theory. Using the idea and method of modern scientific explanating effect mechanism of BushenhuoxueFang treatment of kidney deficiency and blood ovarian reservedecline in the late menstruation. To investigate the clinicaltreatment of tonifying the kidney and promoting blood circulationand effective intervention of kidney deficiency and blood stasistype of diminished ovarian reserve，to provide scientific basis forthe traditional Chinese medicine is effective in the treatment ofdiminished ovarian reserve.METHODS：Research on intervention mechanism of previous singlemedicine Astragalus on anovulatory rats showed astragalus rootobviously curative effect for female ovulation, endocrine therapy.In this study, following the first advantage and compositionconsists of astragalus root and dodder Bushen Huoxue Fang once againconducted clinical and theoretical research: This text is dividedinto three parts. The first part“Study of traditional literaturediminished ovarian reserve”，According to reading books classics,combined with modern clinical and experimental research, thecurrent research situation and development of traditional Chinesemedicine and Western Medicine on ovarian reserve function. Thesecond part“Study on the distribution of TCM Syndromes of DOR”，According to the analysis of the traditional Chinese medicinedisease belong todisease differentiation criteria of traditionalChinese medicine, according toTCM differentiation standard tojudge its TCM syndrome types, analysis to explore thecharacteristics of TCM Syndromes. The third part “the ClinicalResearch of Bushenhuoxue Fang in Treating Kidney Deficiency andBlood Stasis Menopathy result from declining ovarian reserve”，study Validity of Bushenhuoxue Fang in Treating Kidney Deficiency and Blood Stasis Menopathy result from declining ovarian reserve，Observation of DOR patients by Bushenhuoxue Fang before and afterthe treatment， the symptoms and signs of integral，to study Changeof the level changes of blood basis of FSH， LH， FSH/LH and E2，INHB， AMH，AFC，the volume of ovary，PSV，RI，PI，Etc.RESULTS:The first part：The decline of ovarian reserve functionof distribution of TCM Syndromes of survey results:①Research showsthat the symptoms of patients with infertility rate, menstruation,menstrual cycle after the fault.②The Chinese medicine diagnosis,menstruation, menstruation, infertility. The symptoms sort,"infertility" ranking in the first place, and in the diagnosis ofTCM sort,"infertility" ranking in third. Investigate its reason,considered as related to mental patients. Think in more patients,menstruation or menstrual period, do not affect normal life, andbe of no importance, not cause obvious discomfort, so its discomfortis not sufficient attention. Since thousands of years Chinese on"people" attention, resulting in women is extremely sensitive tothe "birth". Some patients think, once begin to prepare forpregnancy; it should be a short time insemination. Therefore wecommon pregnant within six months of non pregnancy in clinical, andcame to visit, the patient attention to inoculation, far higher thanthe irregular menstruation effect on patients caused by.③Syndromedistribution to kidney deficiency and blood stasis, kidneydeficiency and liver qi stagnation, Qi and blood stasis. Throughthe research shows the basic cause Chinese descent on ovarianreserve function as "kidney deficiency, blood stasis, stagnationof liver qi", menstrual change is the nest functional reserveexternal performance the most important, is directly reflect the decline in female fertility, through the study on the ovarianreserve function decline, the patient complained of TCM diagnosisand syndrome differentiation were analyzed statistically, thus the"late period","menstruation" is the decline of ovarian reservefunction of two typical symptoms, clinical often coexist at the sametime, develop gradually, and finally can cause amenorrhea. In viewof the fact that there is no judgment the diagnostic gold standarddiminished ovarian reserve, the existing diagnostic criteria cannot clear the extent and staging, this study is the small sampleclinical study, can only explain part of the diminished ovarianreserve patient characteristics, not the whole encompassingmenstrual disorder rules, also be big sample clinical study.Thesecond part：Results of the clinical research of bushenhuoxue fangin treating kidney deficiency and blood stasis menopathy resultfrom declining ovarian reserve：①The clinical symptoms of "BushenHuoxue Fang on menstrual ovarian function decline, too late"patients have obvious improvement, traditional Chinese medicinegroup total effective rate and significant efficiency and thewestern medicine group showed no significant difference (P>0.05).The clinical efficacy in the treatment of DOR, effect of BushenHuoxue Decoction and Western medicine Climen effect is equivalentto. In the course of treatment of traditional Chinese medicine group,pregnancy2infertility patients,1person times of in vitrofertilization and embryo transfer failure success helps is pregnant,so the Bushen Huoxue Fang (Law) occupy the advantage in thetreatment of infertility.②In improving the TCM syndrome inpatients with DOR syndrome, traditional Chinese medicine group,western medicine group has very good curative effect (P<0.01). The comparison between two groups, better than the effect of BushenHuoxue Climen (P<0.01), in the patients with DOR syndrome,traditional Chinese medicine and Western medicine are effective,and the traditional Chinese medicine group has more remarkableeffect.3months after drug withdrawal, there was significantdifference before and after the Chinese medicine group, westernmedicine treatment group and blank group, and the two groups aftertreatment were significant difference, the medicine can improve thesymptoms of patients with diminished ovarian reserve, and thetherapeutic effect of traditional Chinese medicine group was short.③Compared with the Chinese medicine group before and aftertreatment the symptom integral, there was significant difference(P<0.01), show that the effect of Bushen Huoxue Decoction cansignificantly improve the clinical symptoms of the patients withDOR, the effect of Bushen Huoxue Decoction of invigorating thekidney, nourishing the blood, promoting blood circulation effect.Compared with the western medicine group before and after treatmentthe symptom integral, in the improvement of delayed menstruation,color block, hectic fever and sweating, hyposexuality, there wasa significant difference (P<0.01), explain Climen can improvepatients with DOR menstruation and menopause syndrome caused bydecreased estrogen class like; but does not improve the lumbosacralpain, dizziness tinnitus symptoms (P>0.05). Traditional Chinesemedicine group in improving DOR in patients with lumbosacral achingand limp, dizziness and tinnitus, kidney deficiency on bettercurative effect, embodies the Bushen Huoxue Fang kidney; inimproving menstrual quantity is little, there is a dark color withsignificant difference (P<0.05), suggesting that traditional Chinese medicine and Western medicine in patients with DOR comparedto the volume, the matter, obviously, traditional Chinese medicinegroup and activating blood, nourishing the blood may reflect theinternal organs function of drug regulation; there was nosignificant difference in the improvement of delayed menstruation,hectic fever and sweating, hyposexuality aspects (P>0.05).④By theanalysis of Ridit (the two together as the standard group), Chinesemedicine group is better than western medicine group menstruation.⑤Effect of Bushen Huoxue decoction has certain effect onregulating the levels of sex hormones, Bushen Huoxue Fang, Climencould significantly improve the hormone levels in patients with DOR.There were significant differences in LH (P<0.05), but nosignificant difference in other aspects, the hormone levelregulation, traditional Chinese medicine group and Westernmedicine group is roughly equal, only slightly in the LH advantage.After the treatment of traditional Chinese medicine group andWestern medicine group, respectively, and3months after the blankgroup FSH, LH, FSH/LH, E2, there was significant difference(P<0.01).⑥Chinese and Western medicine could increase ovariangranulosa cell inhibin B protein, anti Mullerian hormone (AMH)expression, improve the ovarian reserve function (P<0.01).⑦Therewas a significant difference between female B ultrasoundexamination in AFC, PSV, PI, RI (P<0.05), Bushen Huoxue Fang on theincreasing number of antral follicles, improve the ovarian bloodsupply (PSV, PI, RI) is better than western medicine group. Theeffect of Bushen Huoxue decoction has good curative effect onovarian reserve function decline, and short-term therapeuticeffect of it is better than medicine group, short-term curative effect is stable.CONCLUSION：①Through a small sample of diminished ovarian reservedistribution of TCM Syndromes of patients showed a decline inovarian reserve function of TCM syndromes in patients with kidneydeficiency and blood stasis, kidney deficiency and liver stagnationin multiple, menstrual change is the nest functional reserveexternal performance the most important,"late period","menstruation" is the decline of ovarian reserve function twotypical symptoms. On the other hand,"late period","menstruation"as the Chinese medicine treatment of menstrual disease one of themost difficult issues, how to improve the treatment of traditionalChinese medicine, menstrual quantity, adjust the menstrual cycle,is the main purpose of this study.②Effects and mechanism of BushenHuoxue Fang intervention menstrual blood stasis DOR, too late mayinterfere with the regulation of reproductive hormones, inhibit theapoptosis of ovarian granulosa cells of ovary, promote angiogenesisand implementation.③The main clinical symptoms of kidneydeficiency and blood stasis type DOR for delayed menstruation,menstrual quantity is little, there is a dark color, small abdominalpain, block alleviation of pain, lumbosacral pain, dizziness andtinnitus, hectic fever and sweating, sexual hypoesthesia. Paletongue or dark purple edge petechiae, pulse small or astringent.④Short term effect of Bushen Huoxue Fang intervention menstrualblood stasis DOR, too late is better than pure western medicinetreatment, rational use of Bushen Huoxue Fang intervention DOR,obvious curative effect, to prevent the occurrence of POF, delayis a very positive meaning, which can improve the quality of lifeof women.⑤Based on FSH, LH, FSH/LH, blood E2, INHB and AMH and transvaginal B ultrasound examination of the ovarian volume, AFC,PSV, PI, RI can be used as a reliable auxiliary examination indexof clinical diagnosis, assessment of DOR.⑥According totraditional Chinese medicine "preventive treatment of disease"theory, course of the disease decline in ovarian reserve function,DOR can be considered to be POF "no disease" stage, POF is "disease"stage. So based on the clinical symptoms and laboratory examinationto find DOR, the use of "preventive treatment of disease" point ofview to guide us in the whole course of treatment of the prescription,active intervention, interrupt the development trend.更多还原