【作者】 黄贵松；

【导师】 罗颂平；

【作者基本信息】 广州中医药大学 ， 中医妇科学， 2010， 博士

【摘要】 研究目的不孕症是妇科常见病,它不是一种独立的疾病,而是由许多疾病或多种因素造成的生殖障碍。近年来不孕症发病率有逐年上升的趋势,与高龄、多次流产、心理压力过大和环境污染等因素有关。不孕症已成为影响人类发展与健康的一个全球性医学和社会问题。本研究是临床研究,主要是探讨不孕的子宫因素,观察药物干预后对不孕妇女增殖期子宫内膜的影响。方法60位受试者就诊于台北市联合医院中医科。分为2组：对照组30人,用纯中药加味归芍地黄汤进行干预；实验组30人,用加味归芍地黄汤加西医促排卵药克罗米芬干预。两组皆观察受试者服药前后的变化、做自我比较,然后再观察两组之异同。评估的时间是在排卵前1～2天,方法是利用经阴道多普勒超声,测量子宫内膜厚度及内膜三线征(Triple line),测量子宫动脉、螺旋动脉之多普勒Pulse Index(PI), Resistance Index(RI)和S/D ratio,还测量其卵泡的大小与数量。同时观察子宫颈黏液之多寡。计算治疗后的妊娠率。结果受试者平均年龄为35.7±3.5,大部份为高龄患者。体重平均为55.0±5.4,BMI(kg/m2)为21.4±2.0。两组受试者来就诊时皆有不孕多年、高龄、经血量少、怀孕压力大、眠不安宁、倦怠乏力、无性欲等症状。研究发现,纯中药组(加味归芍地黄汤)受试者,治疗后优势卵泡达1.92±0.3cm,子宫内膜增厚,达0.92±0.21cm,80%的患者子宫内膜出现“三线”(Triple line)征。怀孕率占67%。加味归芍地黄汤加克罗米芬组治疗后,排卵数目1～3颗,卵泡达1.80±0.39cm。子宫内膜增厚,达0.89±0.23cm,76.7%有出现“三线”(Triple line)征。妊娠率33%。关于多普勒效应,中药组服药前后有非常显著的改变,服药后子宫动脉和螺旋动脉多普勒RI、PI、S/D皆有下降的现象(P<0.001)。实验组服药后子宫动脉和螺旋动脉多普勒RI、PI、S/D亦有下降的现象(P<0.01),但是对照组下降数值较高、效果较好。可见,加味归芍地黄汤对子宫内膜的血液微循环阻力有下降之作用,能促进子宫血液正常灌注,使子宫内膜对胚胎的接受度而提高怀孕率。结论1.加味归芍地黄汤能促进子宫内膜发育至正常的厚度,出现三线征,并降低子宫动脉和螺旋动脉的血流阻力(RI)；改善子宫内膜的血液灌注。为胚胎着床提供条件。2.加味归芍地黄汤有助于卵泡正常发育,也增加宫颈分泌清稀透明的黏液以利精子的活动,从而提高妊娠的机会。3.对于排卵障碍的患者,使用西药克罗米芬虽然可以促排卵,但可能引起子宫内膜发育不良,宫颈黏液变稠,反而不利于怀孕。本研究发现,应用加味归芍地黄汤可以克服克罗米芬的副作用,从而提高妊娠率。更多还原

【Abstract】 PurposeInfertility is a common gynaecological problem of reproductive disturbance that involved by many diseases and multiple factors. It relates to high aging, multiple abortions, psychological stress and environmental air pollutants. Rising infertility rates around the world have had a profound impact on human development and female reproductive health, nowadays it is considered as a worldwide public problem. This is a prospective clinical observation research, our aim is to study the effects of endometrium during proliferative phase after medication in women with infertility.Methods60 participants from the Taipei United Hospital, department of Chinese medicine were recruited, they were divided into two groups:30 of them were in controlled group, they received Chinese herbal medicine Jia Wey Guei Shuoh Dih Hwang Tang alone, and the other 30 participants in experimental group, they received Jia Wey Guei Shuoh Dih Hwang Tang with Clomiphene Citrate together, we observed the changes of endometrium before and after medication, making self compared firstly, and then compared the difference between these two groups. Our investigation time was one or two days before ovulation. Transvaginal ultrasound-color flow Doppler was the investigative tool. We measured the thickness of endometrium, observing endometrial triple line, and measured the Doppler flow indices (resistance index (RI),pulsatility index (PI) and systolic/diastolic (S/D) ratio) of uterine and spiral arteries. The number and size of follicles were measued and we also observed the amount of cervical mucus. The fertility rate was counted after medication.ResultsThe average age of participants was 35.7±3.5, most of them are high age. The average weight was 55.0±5.4, BMI (kg/m2) was 21.4±2.0. They came for treatment due to unable to conceive for many years, high age, hypomenorrhea, high stress of infertility, no sexual desire etc.The findings of the controlled group, that received only the Chinese herbal medicine Jia Wey Guei Shuoh Dih Hwang Tang, only one mature follicle was found before and after medication, but the size of follicle is bigger after medication. The average size was 1.92±0.3cm. The endometrium became thicker, the average thickness was 0.92±0.21cm. Triple line was found in 80% of endometrium. The fertility rate of this group is 67%. In the experimental group, they received Jia Wey Guei Shuoh Dih Hwang Tang and Clomiphene Citrate together.1-3 mature follicles were found, The average size was 1.80±0.39cm. The endometrium also became thicker, the average thickness was 0.89±0.23cm. Triple line was found in76.7% of endometrium. The fertility rate of this group is 33%.Concerning the Doppler effect, the controlled group had a significance change before and after medication, the RI, PI, S/D ratio of uterine and spiral arteries were lower (P＜0.001). The RI, PI, S/D of uterine and spiral arteries in the experimental group were also became lower (P＜0.01).Both of these two groups have good effects in the endometrium, but the controlled group is better. Jia Wey Guei Shuoh Dih Hwang Tang can decrease the Doppler flow indices, improve blood perfusion of uterus, regulate uterine receptivity and implantation and increase the outcome of pregnancy.Conclusions1. Jia Wey Guei Shuoh Dih Hwang Tang can improve the growth of endometrial thickness and triple line, it can decrease the RI of uterine and spiral arteries, improve blood perfusion of uterus,regulate uterine receptivity and implantation of embryo.2. Jia Wey Guei Shuoh Dih Hwang Tang can improve the growth of follicle, increase ovulatary cervical mucus that benefits the motility of sperms, this condition will increase the chance of pregnancy.3. For the patients who are disturbed by anovulation, inducing ovulation by using clomiphene citrate is effective but it may adversely affect the endometrium and impair formation of cervical mucus and so reduce the chance of conception. In this study, we found out that using Jia Wey Guei Shuoh Dih Hwang Tang and clomiphene citrate together could decrease the side effects of clomiphene citrate and raise the outcome of pregnancy.更多还原