不孕不育症的治疗_第1页
不孕不育症的治疗_第2页
不孕不育症的治疗_第3页
不孕不育症的治疗_第4页
不孕不育症的治疗_第5页
已阅读5页,还剩114页未读 继续免费阅读

下载本文档

版权说明:本文档由用户提供并上传,收益归属内容提供方,若内容存在侵权,请进行举报或认领

文档简介

不孕不育症的治疗Thehigh-possibilityfertilephase

extendsfrom5daysbefore

ovulation

to

the

day

of精子出发spermatozoacansurviveinthefemalereproductive

tractfor

5–6

days

after

intercourse卵子出发21着床

4子宫——ovulation.相遇

受精输卵管子宫颈阴道3Criteria4thed5thedVolume≥

2.0

mL≥

1.5

mLTotalsperm

number≥

40millions/ejaculate≥

39millions/ejaculateSpermconcentration≥

20millions/

mL≥

15millions/

mLTotal

motility≥

50%≥

40%Progressive

motility≥

25%≥

32%Normal

morphology≥

15%≥

4%(KrugerStrictcriteria)Vitality≥

50%≥

58%pH>7.2>7.2Liquefaction:Completewithin60

minutesatroomtemperatureAppearance:

Homogeneous,gray,andopalescentConsistency:

Leaves

pipetteasdiscretedropletsLeukocytes:

Fewerthan

1

million/mLSemenAnalysisAssisted

Reproductive

Techniques•Intra-Uterine

Insemination(IUI)–

Artificial

Insemination

with

Husband(AIH)–

Artificial

Insemination

with

Donor(AID)•Gameteintra-fallopiantransfer(GIFT)•

Zygoteintra-fallopiantransfer(ZIFT)•In

vitrofertilization(IVF)•Intracytoplasmicsperminjection

(ICSI)•Pre-implantationgeneticdiagnosis(PGD)IUI,配偶人工授孕(AIH)*(一)适应症:男性精虫稀少(每西西一

千万左右),尿道下裂、阴茎畸型、阳萎

、早泄、女性阴道痉挛不能性交、配偶常出差等。*(二)方法:男性将精液取出,经液化后

,将精虫洗涤,去除精液之杂质,在女性

排卵期将精液注入子宫腔。2014/4/24图片来源:我省生殖医学会网站Intra-Uterine

InseminationMale

Factor

Infertility•Bestresultswith

IUIare

achievedwhenTotal

motilespermcount(TMC)

in

theinseminationspecimenexceeds

10million

14%ormore

have

normal

morphology•Highercountsdonot

increase

success•IUI

isseldomsuccessful

iffewerthan

1

milliontotalmotilesperm

are

present.黄X

陈Xj2014/4/24102年第一次医师(二)医学(六)Male

Factor

Infertility•

TMC<

1

million:

ICSI•

TMC>

1

and

<

10

million:IVFcanbe

performed

ifinfertility

durationis2years

or

longer•

TMC>

10

million:

IVF

is

indicated

ifthedurationis3years

or

longer.

Ifthewomanisolderthan36years,

IVF

may

beconsideredearlier.体外授精(试管婴儿)IVF*(一)适应症

:骨盆腔粘连、输卵管堵塞、输卵

管切除、严重度子宫内膜异位、精子稀少(五百

万左右)、精虫产生抗体等。*(二)方法:*(1)用排卵物诱导排卵(2)利用超音波检查卵泡及抽血测E2(3)当卵子成熟,利用阴道超音波,将卵子取出

(4)在实验室将精子与卵子完成受精分裂成胚胎,

再植入子宫腔2014/4/24精虫显微注射

:

(ICSI)应用在合并男性不孕或先前尝试受精率低者IntraCytoplasmicSperm

InjectionMale

Factor

Infertility•

IndicationsforICSITotal

motilespermcount<

1

million<4%

normalmorphologyandTMC

<

5millionNoorpoorfertilizationin

the

first

IVF

cyclewhenTMC<

10

millionNoorpoorfertilization

intwo

IVFcycleswhenTMC>

10

millionEpididymalortesticularspermatozoa.精卵显微授精法(microinjection)(一)适应症:(1)严重精虫稀少(在一百万只左右)、精虫活动

力差、IVF不能受精者。(2)精液检查无精子,但睪丸组织有精子,请泌尿

外科大夫,将精子吸出在实验室处理。*(二)方法:在显微镜下,将一只精子注射入卵子,因注射部

位不同,可分为(A)透明层下注射法(sub-zonal

injection;suzi)

(B)透明层开洞方法(partial

zonal

dissection;

PZD)(C)精子注射入卵细胞浆法(intracytoplasmicsperm

injection

ICSI),因ICSI方法受精机率高,

2014且/4/24怀孕成功机率也高,目前广为世界采用。B男性不孕患者,精液检查总活动数精虫少于

1百万,实施人工协助生殖技术时,下列何

项处置最为有效?A.

透明区穿孔术(zonadrilling)B.卵质内单一精虫注入术(intracytoplasmic

sperminjection)C.透明区下精虫注入(subzonalsperm

injection)D.透明区磨薄术(assistedhatching)93

年第2次专技高考外科学(二)102年第二次专技医师二医学六C一位26岁男性,不孕3年求诊,严格的精液分析

显示:精液量=2.5mL,总精虫数=1×106/mL,

4%直线前进,3%正常外观精子,下列处理何者

较适当?A.

进行子宫腔内受精(intrauterineinsemination)B.进行体外受精(in

vitrofertilization)C.进行卵质内单一精子注入(intracytoplasmic

sperminjection)D.进行睪丸切片取精(testicularspermextraction)*一对夫妻到门诊作不孕症检查,妻子30岁,月经

周期正常,周期第3天

FSH7.2IU/L,双侧输卵管

通畅,先生的精虫数目为

20万/mL,活动力

10%,

先生的染色体为46XY,无Ychromosomemicrodeletion

。你会建议他们作何治疗?A.

人工受精(intrauterineinsemination;

IUI)

B.

传统试管婴儿(invitrofertilization;

IVF)C.

细胞内精虫显微注射(intracytoplasmicsperm

injection;ICSI)D.礼物婴儿(gamete

intrafallopiantransfer;GIFT)C2014/4/24B男性不孕患者,精液检查总活动数精虫少于1百万,实施

人工协助生殖技术时,下列何项处置最为有效?

A透明区穿孔术(zonadrilling)

B卵质内单一精虫注入术(intracytoplasmicsperminjection)C透明区下精虫注入(subzonalsperminjection)

D透明区磨薄术(assistedhatching)A关于不孕症的叙述,何者错误?A做细胞内精虫显微注射(intracytoplasmicsperminjection,

ICSI)的怀孕率比传统试管婴儿(invitrofertilization,IVF)

的怀孕率低B不孕症是指在未避孕的情况下,一年以上没有怀孕C所谓人工生殖技术(assistedreproductivetechnology,

ART)是指各种取卵的介入方法D女性的怀孕能力(fecundability)从30岁后开始下降2014/4/24滤泡发育与诱导排卵2014/4/24负性回馈抑制滤泡刺激素正性回馈增加黄体刺激素*一个dominant

follicle

E2>200

pg/mlfor>50

hrs

会造成positive

feedback,刺激LH大量分泌(LH

surge)并持续四十八小时>200

pg/ml

超过50小时(50-150pg/ml)大幅上升稍许上升雌激素(MetaphaseI)Meiotic

Resumption

(

M

II)just

before

ovulationMeioticArrestatMetaphaseof

Meiosis

IIGV

breakdown(GVBD)=

Meiosis

I

resumes↓

(Metaphase

II)MeioticArrestat

Diplotene,

Prophaseof

Meiosis

IGerminalVesicle

(GV)–intactYenandJaffe’sReproductiveEndocrinology6th

Ed&SperoffClinical

Gynecologic

EndocrinologyandBefore

LHsurgeLH刺激卵子成熟Oocytes25Meiotic

Resumption

(

M

II)LH Plasminogenactivator↑Plasmin

↑Collagenase

↑Ovulation28

ProstaglandinsecretionContractsmooth

muscle

OvulationOocyte(GV

intact)Pre-ovulatoryfollicle

=GraafianfollicleCumulus-OocyteComplex

Granulosa

luteinizationCumulus

cells

(specialize

dgranulosa)Mural

granulosa

cellsOocytefreedfromattachmentLH刺激卵子成熟FollicularfluidCumulusexpansionP4LHsurge1.让卵子由「第一次减数分裂前期(prophase

I)」进展到

「第二次减数分裂间期(metaphaseII)

(又称为oocytematuration,在ovulation前就已经发生)2.

卵子卵丘复合体(cumulus-oocytecomplex,简称COC)脱

离滤泡壁(NSAID无法抑制)(此约发生于LH或hCGonset

后34-36小时

,所以是试管婴儿疗程之

取卵时机)3.

Ovulation(足量的NSAID可抑制)4.Ovulation后,滤泡壁上剩下的细胞(granulosacell&thecacell)受到LH(或人工生殖中取代以hCG)作用而luteinization形成「黄体」

--负责供应E&P,使子宫内膜

得以完整地decidualization,开启implantationwindow

俾利胚胎着床LH(或人工生殖中取代LH的hCG)

之四大功能Cumulus-OocyteComplexMeiotic

Resumption(

M

II)Oocyte卵子LHsurge2020/4/8诱导排卵(Controlledovarianstimulation)人工授精

:1~3个滤泡发育試管嬰兒

:8-15个滤泡发育follicles

development(养滤泡)

trigger

final

oocyte

for

7-9

days

or

more

maturation

(破卵)(controlledovarianstimulation

by

rFSH)34-

36

hours(TextbookofART,2nd

Ed.,

2004)取卵黄体期补充人工授精

或自行同房一

次诱发多个滤泡,会加速卵量衰竭?而提早停经吗?DrugsforART

「排卵药」

:提升FSH+/-•

口服:Clomiphenecitrate

or

Letrozole

(

)•皮下注射:

Follicle-stimulating

hormone

(FSH)

Puregon(保妊康)/Gonal-F(果那芬)

/long-actingFSH(Elonva)•皮下注射:

Human

menopausal

gonadotropins(HMG)Menopur(美诺孕)

、rFSH+rLH

Pergoveris(倍孕力)

长大的滤泡吃这个LH•Gonadotropin

releasing

hormoneanalogues

(GnRH

agonist)

Leuplin(柳菩林)/Decapeptyl(弟凯得)•

Gonadotropin

releasing

hormone

an

a一g:o预n防isLtH提早上升

(GnRH

antagonist)Orgalutron(柔妊孕)/Cetrotide(欣得泰)------------------------------------------------------取-代/引发LH•

Human

chorionic

gonadotropin

(hCG)

&卵子最后之

Ovidrel

(克诺得)/Pregnyl(保健宁)

(「破卵针」Leuplin(柳菩林)/Decapeptyl(弟凯得)•GnRH

agonist熟成)诱导排卵(Controlledovarianstimulation)人工授精

:1~3个滤泡发育試管嬰兒

:8-15个滤泡发育*E2>200pg/ml

for>

50

hrs会造成positive

feedback

,刺激LH大量分泌(LH

surge)eachfollicle没有做好做满serumE2就可达带动LH上升「目的」同:让follicle做好做满GnRHagonistvs.GnRH

antagonist:

「用法」异Pulsatile

GnRH

(t

½

:2-4

min)(frequency)

FSHand

LH

in

pituitarygland

Ovary:folliculargrowth,ovulationandcorpus

luteumformation

Estrogenand

ProgesteroneaffectstheendometriumHypothalamus:GnRH•GnRH(GonadotropinReleasing

Hormone)–

半衰期短:2~4min–producedinthearcuate

nucleusofthe

hypothalamus,

inapulsatilefashion–ControlFSH/LH

by

differentfrequency–排卵前强:度短小而密–排卵后强:度高而间隔长(3~4h)–

DecapeptideGnRHandGnRH-R

binding328aminoacidsDeca-peptideGnRH

receptorGnRH610王鹏惠Anim

Reprod

Sci

2005;88:5-28Modifications•

Position6:↓

enzymaticdegradation•

Position

10:↑

potency•

Position6and

10:↑

receptor

affinity受体结合区D-型氨基酸替代点

增强受体的结合

Disulphidebridge:C14-C200;C114-C196内生性酶切除点–临床药物GnRH

agonist--ex.AA

6

modification

Longacting,desensitizeGnRH

receptorsafterdaysofstimulation临•床药物GnRH

antagonist--AA1,2,3,6,8,10

modification2014/4/24GnRH类似物•Ovulationinduction/Controlledovarian

hyperstimulation1.

Oral2.

Injectionsc「排卵药」:提升FSH+/-LH

E2>200

pg/ml

for

>50

hrsHypothalamic

level:

ER

depletion

会造成positive

feedbackDay

2~6

GnRH:

↑frequency↑amplitude

LH

surgeMC

start

↑FSH

↑LH

给完药后5-12天(通常7天)会LH

surge

5days

(建议此时QOD同房)

50~150

mg

HSFolliclegrowth,

E2

rise慢性不排卵(月经不准时,爱爱日好难算!)第一线口服排卵药:

喜妊(Clomiphene)

(健保给付)--可能面临问题:

1.子宫内膜太薄而不利于着床;2.子宫颈黏液较不利于精子进入(自然同房者)

;3.至多六

周期;4.

BMI高;5.胰岛素阻抗高效果差102年第二次专技医师二医学六关于口服排卵药物clomiphenecitrate,下列

叙述何者最正确?A.

需使用于hypothalamus-pituitaryaxis功能

失调的女性B.

具强效的雌激素作用C.会减少GnRH分泌D.会使子宫内膜变薄D2014/4/24103年第一次专技高考医师(一)医学(二)下列有关

clomiphene的药理学作用描述,何者错

误?A.

为一种雌激素受体部分作用剂(partialestrogen

agonist),可以刺激促性腺激素(

gonadotropins)的分泌作用B.

对于排卵功能障碍的妇女具有刺激排卵的作用C.使用时会降低血浆中黄体化激素(LH)

和滤泡

促进素(FSH)的浓度D.容易诱发热潮红(hotflushes)的产生C第二线口服排卵药物:复乳纳Letrozole(自费)•

没有Clomiphene的副作用,而且成功率和Clomiphene并驾

齐驱。•

罹患乳癌却仍想生育的妇女•

可能有些潜在的副作用尚未被发现。但以目前的研究证据看来,Letrozole并没有造成比Clomiphene多的胚胎异常。(Clin.Gynecol.

Endocrinol.Infertil.,6th

Ed.)

(TextbookofART,2nd

Ed.,2004)Two

Cell-TwoGonadotropin

Theory雄性素AromataseInhibitor(AI)女性素2014/4/24人工授精

筛选精虫试管婴儿($$

>,<)输卵管有通,可先尝试自然同房/人工受精自然同房亦要考虑年龄因素(卵子质量的关键所在)输卵管不通/严重精虫问题/前述方式失败精卵相遇的途径

•排卵针帮助排卵的药物↓(Clin.Gynecol.

Endocrinol.Infertil.,6th

Ed.)

(TextbookofART,2nd

Ed.,2004)Two

Cell-TwoGonadotropin

Theory女性素雄性素滤泡萎缩早期黄体化卵子质量受损滤泡正常发育卵子成熟雄性素前躯物不足导致雌激素低下滤泡后期发育不良卵子无法完全成熟在不使用GnRH-a

或GnRH-ant时,FSH诱导排卵约有

20%会发生LH早期

上升下视丘/脑下垂体疾病

或使用GnRH-adepot

,

可能导致LH不足黄体刺激素(LH)在诱导排卵的角色LH

浓度LH上限~10

mIU/mlLH阈值~1

mIU/mlLH

浓度High

LH

Levels

are

Unfavorable

toReproductiveOutcome•Highendogenous

LH:

increasedincidence

ofinfertilityand

miscarriages•LH

inhibitsgranulosacell

proliferationathighconcentrations,andinduce

atresia

of

follicles•LH

hasa

negativeeffect

on

the

endometriumTo

preventLH

prematuresurge预防LH提早上升(PREMATURE

LUTEINIZATION)各种protocol之介绍Ovulationinduction提升FSH+/-

LH养卵泡诱导排卵(Controlledovarianstimulation)人工授精

:1-3个滤泡发育試管嬰兒

:8-15个滤泡发育*E2>200pg/ml

for>

50

hrs会造成positive

feedback

,刺激LH大量分泌(LH

surge)滤泡还不够熟就发生了!!GnRHagonistvs.GnRH

antagonist:「目的」同:预防LH提早上升「用法」异长疗程(

Long

protocol)(Eur.J.Obstet.Gynecol.,2004;Hum.

Reprod.,2007)MonitoringofPituitarydown-regulation:a)

Menstrualbleedingb)

E2

<

80

pg/mlc)P4

<

1.5

ng/mld)

Endometrialthickness<8

mm抑制剂疗程(Antagonist

protocol)S5Betterstartfrom

MCday2-3

(earlyfollicularphase≤

5th

day,

nodominantfollicular

yet.Theearlier,themorefollicles)93年第一次专技高考基础二有关gonadotropin-releasinghormone

(GnRH)之叙述中,下列何者正确?A.

其由脑下垂体产生B.

为一种多胜

(poly-peptide)组成C.长期大量给与GnRH类似物,会产生生殖

腺官能不足D.持续大量给与GnRH类似物,会使GnRH

接受器之敏感性加强BCC关于目前用于刺激排卵的GnRH-agonist,下列叙述何者正确?A长疗程(longprotocol)乃利用其up-regulation特性B和内生性GnRH比较,只有1个氨基酸不同C半衰期比内生性GnRH长D可口服使用诱导排卵MC

↑MC

↑(TextbookofART,2nd

Ed.,2004;Semin.

Reprod.

Med.,2002

)with

GnRH

antagonistwithGnRH

agonist头三天FSH&

LH

↑,S5MC

↑SOAPControlledovarianhyperstimulation:用药Orgalutron(柔妊孕)/monitoringControlledovarianhyperstimulation:--Receptive

to

blastocyst

implantation

~6

daysafter

ovulation

and

remains

receptive

for4

days.ImplantationWindowProgesterone

effectovulationP>1.5

↓Decidualizationo

A.

Natural

conception:#

LH

surge

ovulation

oocyte

exposed

to

spermatozoa

embryomic

window

of

implantation

(WOI,

blastulation)

#

meaningful

P

shortly

after

LH

surge

secretory

transformation

→endometrial

window

of

implantation

(WOI)o

B.

IVF

(lost

of

natural

coordination

=

embryonic-endometrial

dyssynchrony):口

1.

P

↑faster

(16~24

hr)口2.

bastulation

may

be

delayed

(older,

low

responders)natural

conception

invitrofertilization(IVF)Recombinant

Hormoneα-Subunits1Corifollitropinalfa92

aaβ-Subunits2110

aahCG

=40

h92

aa29

aa2t½

corifollitropinalfa=

69

h4aa=amino

acids;t½

=

half

life.1.Adaptedwith

permissionfromStraussJetal.YenandJaffe's

ReproductiveEndocrinology:Physiology,Pathophysiology,andClinicalManagement.

5thedition.Saunders;2004;2.

Fares

FAetal.ProcNatl

AcadSciU

SA.

1992;89:4304–4308;3.

PUREGON®

(rFSH)

summaryofproduct

characteristics,2010.;4.

ELONVA®(corifollitropinalfa)summaryofproductcharacteristics,2010.Corifollitropinalfa(Elonva®

)

Is

at½

rFSH

=40

h3t½

rFSH

=40

hTmax

=

10–12

h3StimulationdaysrFSH=recombinantFSH;t1/2=

half-life;Tmax

=timeto

maximum

concentration.1.Adaptedwith

permissionfrom

FauserBCetal.HumReprodUpdate.2009;15:309–321;2.

ELONVA®(corifollitropinalfa)

summary

of

product

characteristics,2010;3.

PUREGON®

(rFSH)summaryofproductcharacteristics,2010.Comparative

Pharmacokineticst½

corifollitropinalfa=

69

h

Tmax

=36–48

h2Corifollitropinalfa

rFSHFSHactivity1Long

protocol(GnRHagonistdown-regulationprotocol)Flare

upFSH&

LH

↑亦即内生性LHsurge(幅度够,但duration略逊)+FSHsurge(hCGtrigger所缺)Dualsuppresion:2-3weeksof(monophasic)Oral

pills5

daysGnRHantagonistprotocola)

Menstrualbleedingb)E2

<

80

pg/mlc)

P4

<

1.5

ng/mld)

Endometrialthickness<8

mmTrigger:

hCG

orGnRH

agonistMonitoringofPituitarydown-regulation:Trigger:

hCGAntagonist

protocol搭配Dualtrigger:GnRHagonist(Decapeptyl

®

0.2mg)

+

low-dosehCG

(Pregnyl®

)[怕OHSS者hCG只给0~1500IU]Antagonist

protocol搭配Dualtrigger亦可用于不怕OHSS者:6500

IU

hCG(Ovidrel®一支)

+GnRHagonist(Decapeptyl

®0.2mg)

[取其FSHsurge的好处]•

The

LHsurgeiscaused

by

the

increase

in

plasma

E2attheendofthefollicular

phase•

Studiesoncontraceptionhaveshownthatprogesteroneisableto

blockthis

LHsurgeandthereforeovulation•

Experimentsonmonkeyshave

shownthat–

Theadministrationofa

progestin(levonorgestrel)atthebeginning

ofthe

cyclepreventsthe

LHsurgedespitethe

increase

in

E2,foras

longas

it

is

continued–

Theinhibitionofthe

LHsurge

by

progesterone

isa

hypothalamicaction(Massin

N,

Hum.

Reprod.Update,2017)Useofprogestogento

block

LHsurgeantagonistPrevent

LHprematuresurgeGonadotropinfor

follicledevelopmentOVARIAN

STIMULATION

FOR

IVF/ICSIExogenous

PDifferentIVF

ProtocolsFollicularPhaseLuteal

Phase…26

27

28

0102030405

………

10

11

12

1314151617

18

19

20

21

22

……Short

ProtocolG

nRH

Agonist

rFSH

GnRHAntagonistrFSH

or

HMG±GnRH

AntagonistHMG/FSHProvera/Utrogestan/DuphastonTrigger(HCG/Agonist)TransvaginalOocyte

RetrievalPPOSProgestinPrimeOvarianLutealStimulationLong

ProtocolAntagonist

ProtocolrFSH

+

LHLutealGnRH

AgonistrFSH

±

LH83黄体愈旺(luteotrophic

activity↑↑)=着床愈稳但OHSS可能愈严重黄体身负重任,持续分泌P&

E(decidualization之所需)预防卵巢过度刺激的关键在于减少hC的G使用,Why?(Humaidan.

PreventionstrategiesforOHSS.FertilSteril*(hCG:比LH更强的luteotropic

activity)Granulosa-

luteal

cellsTriggerviahCGvs

GnRHa•hCG

trigger

longer

and

stronger

luteotropicactivity•GnRH

agonist

(GnRHa)

trigger

more

rapidluteolysisP.

Humaidan.

Human

Reproduction

Update2011,

17

(4)

:510–524不孕症治疗常见之并发症•

卵巢过度刺激症候群OHSSI/O

、腹围、体重钾可预测谁会发生卵巢过度刺激症候群吗?•

Higher

androgen

levels

(Elder-G-epv

o2b0

y

not

—broad

range–

otherssuggestinggreatergonadotropindose

requirement

(Homburg

1996)•

No

good

way

except

prior

history•就算没有危险因子仍可能潜在过度刺激的风险•每个多囊患者接受排卵针都有风险•只要有多囊型态的卵巢,无论是否符合多囊性卵

巢症候群的诊断标准,风险一样高!

(Kim

YJ2010;

SwantonA2010)C通常需要以剖腹探查来治疗D临床症状通常在人类绒毛膜促性腺激素(hCG)注射后3-7天

开始出现A.一位28岁不孕症妇女在6天前接受取卵手术,共取出20颗卵子,

2天后植入3个胚胎。今天来到急诊,主诉呼吸困难、腹胀以及恶心。超音波发现两侧卵巢肿大约6公分、有大量腹水。下

列那一项处置较不适合?A抽血验CA125,CEA,CA199B抽血验CBC,electrolytes,GPT(ALT),

BUN,creatinineC抽腹水D给予大量normalsaline2014/4/24C有关卵巢过度刺激症候群(OHSS)

的叙述,下列何者错误?A卵巢会肿大B严重时会有腹水Oocyteretrieval(Egg

pick

up)取卵TimingofOocyte

Retrieval•Scheduled

at

about

34-36

h

after

hCG

injection:the

oocytes

are

expected

to

ovulate

at

37

h

post-hCG.•AfterhCG

injection,the

intercellularconnections

betweenthegranulosacellsandthe

oocytes

are

interrupted•

Meiosis

is

resumedandtheoocyte

progressesfrom

prophase

I

to

metaphase

II.103年第一次专技高考

医师二医学六

*取卵的时机一般是在绒毛性腺激素(humanchorionicgonadotropin)注射后几

小时?A.20~24

hrB.

34~36hrC.

40~44hrD.

48~52hrB2014/4/241.

Placethetesttubes,handlingmedium,andthermometerin

a

warmblockonthe

staging

stage2.

Flushtheaspiration

needleand

itstubingwith

medium.3.Singlelumen

v.s.

double

lumen

needle(Thedeadspaceofthe

needle

andtubingis

about

1

ml)PreparationofMaterialsforOocyte

Retrieval(TextbookofART,2nd

Ed.,2004)手术全程保持无菌状态,并在超音波导引下进行取卵经阴道以超音波辅助取卵(TextbookofART,2nd

Ed.,2004)经阴道以超音波辅助取卵不成熟卵子

成熟卵子取得卵子显微镜下结构卵丘卵子复合体精虫之准备卵子体外受精(in

vitro

fertilization)精虫显微注射

:

(ICSI)应用在合并男性不孕或先前尝试受精率低者体外受精及胚胎早期发育D3植入

或继续培养↓四细胞受精卵八细胞两细胞胚胎培养至囊胚期雷射辅助孵化

D5植入桑葚胚囊胚黄体期补充人工生殖中为何要黄体期补充?Abnormal

Luteal

FunctionAfterOvarianStimulationfor

IVF:

Mechanisms•

Continueddown-regulationbyGnRHa

LH

↓•Induction

of

multiple

follicles

perse•Removaloflargequantitiesofgranulosa

cellsatoocyte

retrieval•

SupraphysiologicalE2/P4

in

early

luteal

phase

negativefeedback

LH↓--Receptive

to

blastocyst

implantation

~6

daysafter

ovulation

and

remains

receptive

for4

days.ImplantationWindowProgesterone

effectDecidualizationElements

of

Luteal

Phase

Support•HCG:

1500-2000

IU

i.m.q3dfor4doses

fromoocyte

retrieval•P4:fromoocyteretrievalto

7-10weeks1)progesteronein

oil

25-100

mg

i.m.

qd2)utrogestan200

mg

p.o.orvag.tid-qid3)Crinonegel

90

mgvag.

qd•E2:fromoocyteretrievalto

7-10weeks

E2valerate2

mg

p.o.

bid术后用药+Lutealsupport(药物+monitor)取卵34~36小时

之后破卵Micronized

progesteronecapsuleIntramuscularprogesteroneHCGCrinonevs.Vaginal

P4vs.OralP4ART诱导排卵后黄体期之E与P取卵GnRHatriggerGnRHatrigger取卵破卵破卵•

取卵数:25•

植入囊胚期

胚胎OocyteSpermIntraCytoplasmicSperm

Injection2pronuclei4cell2cell8cellGrade2embryosLessthan

10%fragmentationorUnequal-sizedblastomeresGrade3

embryos10%to50%fragmentation

with/withoutUnequal-sizedblastomeresGrade4embryosMorethan50%fragmentation

with/withoutUnequal-sizedblastomeresMorulaand

Blastocysttheembryo,NO

overallsize

increase.with

slight

温馨提示

  • 1. 本站所有资源如无特殊说明,都需要本地电脑安装OFFICE2007和PDF阅读器。图纸软件为CAD,CAXA,PROE,UG,SolidWorks等.压缩文件请下载最新的WinRAR软件解压。
  • 2. 本站的文档不包含任何第三方提供的附件图纸等,如果需要附件,请联系上传者。文件的所有权益归上传用户所有。
  • 3. 本站RAR压缩包中若带图纸,网页内容里面会有图纸预览,若没有图纸预览就没有图纸。
  • 4. 未经权益所有人同意不得将文件中的内容挪作商业或盈利用途。
  • 5. 人人文库网仅提供信息存储空间,仅对用户上传内容的表现方式做保护处理,对用户上传分享的文档内容本身不做任何修改或编辑,并不能对任何下载内容负责。
  • 6. 下载文件中如有侵权或不适当内容,请与我们联系,我们立即纠正。
  • 7. 本站不保证下载资源的准确性、安全性和完整性, 同时也不承担用户因使用这些下载资源对自己和他人造成任何形式的伤害或损失。

评论

0/150

提交评论