经皮穴位电刺激对IVF中卵巢储备下降患者卵巢功能的影响

发布时间：2018-07-08 19:18

本文选题：经皮穴位电刺激 + 体外受精-胚胎移植　；参考：《山东大学》2016年博士论文

【摘要】：目的卵巢储备功能通常包括卵巢内储存的窦卵泡数量和卵子的质量两个方面,临床上往往将卵巢储备功能作为反映女性生育能力的一项重要指标。随着体外受精-胚胎移植(in vitro fertilization and embryo transfer,IVF-ET)及其衍生技术的不断发展,许多不孕症夫妇需要通过辅助生殖技术妊娠,但目前辅助生殖技术仍面临着一系列的挑战,其中提高卵巢储备功能下降患者的临床疗效及妊娠率仍缺乏安全、有效的方法,是困扰临床医生的一个难题。近年来有研究发现采用经皮穴位电刺激(transcutaneous electrical acupoint stimulation,TEAS)对体外受精-胚胎移植的患者进行治疗,可以改善卵子质量,提高妊娠率。经皮穴位电刺激是一种新的穴位刺激方法,与传统手捻针灸不同,治疗时以电刺激信号代替机械刺激,避免了针刺带来的疼痛和局部皮肤组织损伤,更易于被患者接受,并且治疗的刺激时间和强度是可以定量控制的,目前已在临床治疗和科学研究中广泛应用。本研究主要观察经皮穴位电刺激治疗对接受体外受精-胚胎移植助孕治疗的卵巢储备下降的患者卵巢功能的影响,希望为这类患者寻求一种安全、有效的治疗方法。方法1、研究对象本研究选择接受体外受精-胚胎移植治疗的符合卵巢储备下降标准的患者,年龄为26-47岁,平均36.69±4.95岁,不孕年限1-15年,平均4.89±2.89年,不孕原因均为输卵管因素导致的配子运输障碍。治疗组患者180例,顺序编号,随机分为3组,人工周期治疗组(A组)60例、安慰型经皮穴位电刺激组(B组)60例和经皮穴位电刺激治疗组(C组)60例。同时选取同期不愿接受人工周期或经皮穴位电刺激治疗的患者60例作为空白对照组(D组)。试验设计经医院伦理委员会讨论批准,入组患者均知情同意并签署试验知情同意书。2、入组标准及排除标准2.1入组标准目前卵巢储备功能下降尚无统一的标准,我们根据文献报道,采用以下卵巢储备下降的预测方法,同时具备以下(1)、(2)项和(3)、(4)项其中之一者,考虑其卵巢储备下降,纳入我们的研究范围：(1)至少两次基础FSH水平≥10IU/L者,或FSH/LH≥3.6者;(2)双侧卵巢窦卵泡数目≤5个者；(3)有盆腔手术史者(曾经进行卵巢囊肿手术或卵巢部分切除手术)；(4)年龄≥35岁者。(5)选择不孕原因为输卵管因素导致的配子运输障碍,超促排卵方案采用常规短方案的患者,以避免不同不孕原因及超促排卵方案对临床妊娠率的影响。2.2排除标准由于观察指标中有获卵数、受精率、卵裂率、优胚率、临床妊娠率及早期流产率的比较,为避免其他因素对这些指标的影响,入组的患者需排除子宫内膜异位症和进行卵胞浆内单精子注射(intracytoplasmic sperm injection,ICSI)的患者。(1)子宫内膜异位症的诊断标准1)临床症状和体征：继发性痛经进行性加重；月经改变；其他异位病灶的改变；妇科检查典型的体征是宫骶韧带痛性结节以及附件粘连包块。2)影像学检查：超声、CT、MRI检查发现卵巢子宫内膜异位囊肿或深部病变。3)腹腔镜检查：腹腔镜中病理诊断为子宫内膜异位症。4)伴或不伴血清CA125水平的升高。(2)进行卵胞浆内单精子注射(ICSI)的患者：由于男性因素导致无法自然受精,需要进行卵胞浆内单精子注射辅助受精的患者。3、治疗方法3.1人工周期治疗方案人工周期治疗组患者从月经周期的第5天开始每日口服戊酸雌二醇片(补佳乐,1mg/片,拜耳医药公司)2mg/d,连用21天,最后10天加用地屈孕酮片(达芙通,10mg/片,Abbott Healthcare products B. V.),20 mg/d,连用3个周期。3.2经皮穴位电刺激治疗方案经皮穴位电刺激治疗组患者给予经皮穴位电刺激治疗的时间是在月经干净后,采用北京大学神经研究所的韩氏穴位神经刺激仪(HANS),选择治疗强度20-25mA,频率为2Hz,每日一次,每次30分钟,直到下次月经来潮前结束,这样就完成一个疗程的治疗。在进入超促排卵周期前共治疗3个疗程,在超促排卵的当个周期,经皮穴位电刺激治疗于月经干净后继续进行,方法与前述相同,直至取卵日。3.3安慰型经皮穴位电刺激治疗方案采用安慰型韩氏穴位神经刺激仪(假HANS),这是一种科研用仪器,仪器外观与韩氏穴位神经刺激仪(真HANS)完全相同,但无论仪器显示的电流强度是多少,通电时间为接通3秒,停顿7秒,实际输出电流强度均为5mA,可以引起穴位酥麻的感觉,但没有治疗作用,仅起到安慰剂的作用,仪器的安慰剂作用已在研究中得到证实。治疗时间、疗程及操作方法均和经皮穴位电刺激治疗方案相同。4、主要检测指标4.1超声检查指标于治疗前患者月经第二天测定窦卵泡数、卵巢动脉血流搏动指数(ovarian artery pulsatility index, PI)、卵巢动脉血流阻力指数(ovarian artery resistance index,RI)、收缩期/舒张期血流速度比值(systolic/diastolic flow velocity ratio,S/D),治疗3个周期后重复测定以上各参数。4.2内分泌激素的检测于治疗前患者月经第二天测定基础雌二醇(estradiol, E2)值、基础卵泡刺激素(follicle-stimulating hormone, FSH)值、基础黄体生成素(luteinizing hormone, LH)值、抗苗勒氏管激素(Anti-Mtillerian hormone, AMH)值、基础卵泡刺激素／黄体生成素(FSH/LH)比值,治疗3个周期后重复测定以上各参数。4.3临床指标的收集超促排卵过程中统计促性腺激素用量、促性腺激素使用天数。取卵后统计四组患者的获卵数、卵泡颗粒细胞卵泡刺激素受体(follicle stimulating hormone receptor,FSHR)、受精率、卵裂率、优胚数、临床妊娠率及早期流产率。结果1、各组患者基础情况的比较治疗过程中人工周期治疗组有6例患者由于终断服药或间断服药脱落,经皮穴位电刺激治疗组及安慰型经皮穴位电刺激组均有4例患者中断治疗脱落。排除脱落患者后人工周期治疗组(A组)54例,安慰型经皮穴位电刺激组(B组)56例,经皮穴位电刺激治疗组(C组)56例。四组患者的一般情况如患者年龄、身高、体重、体重指数差异无统计学意义(P0.05)。四组患者按不孕的病因及不同类型卵巢手术病史统计,差异无统计学意义(P0.05)。四组患者治疗前超声检测指标如窦卵泡数、卵巢血流RI、PI、S/D比较差异无统计学意义(P0.05)。四组患者治疗前基础内分泌激素如E2、FSH、LH、T、AMH比较差异无统计学意义(P0.05)。因此,四组患者的一般情况和基础指标比较均无明显差异(P0.05),具有可比性。2、治疗组各组患者治疗效果的比较2.1 三组治疗组患者治疗前后超声检测指标的比较经皮穴位电刺激治疗组患者治疗后较治疗前窦卵泡数明显增多,差异有显著意义(P0.05)。经皮穴位电刺激治疗组与安慰型经皮穴位电刺激治疗组相比治疗后窦卵泡个数及治疗前后差值明显增多,差异有显著意义(P0.05)。人工周期治疗组患者治疗后较治疗前窦卵泡数明显增多,差异有显著意义(P0.05)。安慰型经皮穴位电刺激治疗组患者治疗前后窦卵泡数无明显变化(P0.05)三组患者治疗前后卵巢动脉血流阻力指数(RI)、卵巢动脉血流搏动指数(PI)以及收缩期／舒张期血流速度比值(S/D)差异无显著性意义(P0.05)。2.2三组治疗组患者治疗前后及组间基础内分泌激素的比较经皮穴位电刺激治疗组患者治疗后较治疗前AMH值明显提高,差异有显著性意义(P0.05)。经皮穴位电刺激治疗组与安慰型经皮穴位电刺激治疗组相比治疗后AMH值明显增多,差异有显著意义(P0.05)。人工周期治疗组患者治疗后较治疗前AMH值明显提高,差异有显著性意义(P0.05)。安慰型经皮穴位电刺激治疗组患者治疗前后AMH值无明显变化(P0.05)。经皮穴位电刺激治疗组患者治疗后较治疗前基础E2值、基础FSH/LH值、基础FSH值降低,差异均有显著性意义(P0.05)。经皮穴位电刺激治疗组与安慰型经皮穴位电刺激治疗组相比治疗后上述激素水平明显降低,前后差值明显增高,差异均有显著意义(P0.05)。人工周期治疗组患者治疗后较治疗前上述激素均有降低,差异有显著性意义(P0.05)。安慰型经皮穴位电刺激治疗组患者治疗前后上述激素无明显变化(P0.05)。2.3 四组患者各项临床指标的比较经皮穴位电刺激治疗组患者与安慰型经皮穴位电刺激治疗组及对照组相比Gn用量、Gn天数明显降低,差异有显著性意义(P0.05)。人工周期治疗组与对照组相比Gn用量、Gn天数明显降低,差异有显著性意义(P0.05)。经皮穴位电刺激治疗组患者与人工周期治疗组相比Gn用量、Gn天数降低,差异有显著性意义(P0.05)。经皮穴位电刺激治疗组患者获卵数、优质胚胎数与安慰型经皮穴位电刺激治疗组及对照组相比明显增加,差异有显著性意义(P0.05)。人工周期治疗组获卵数、优质胚胎数与对照组相比明显增加,差异有显著性意义(P0.05)。经皮穴位电刺激治疗组患者获卵数、优质胚胎数多于于人工周期治疗组,差异有显著性意义(P0.05)。四组患者受精率、卵裂率无明显差异(P0.05)。经皮穴位电刺激治疗组患者临床妊娠率与人工周期组、安慰型经皮穴位电刺激治疗组及对照组相比均明显增加,差异有显著性意义(P0.05)。人工周期治疗组临床妊娠率与安慰型经皮穴位电刺激治疗组及对照组相比明显增加,差异有显著性意义(P0.05)。四组患者早期流产率率无明显差异(P0.05)。3.四组患者卵泡颗粒细胞FSHR蛋白表达的比较经皮穴位电刺激治疗组患者与安慰型经皮穴位电刺激治疗组及对照组患者相比卵泡颗粒细胞FSHR蛋白表达量高,差异有显著性意义(P0.05)。人工周期治疗组患者与安慰型经皮穴位电刺激治疗组及对照组患者相比卵泡颗粒细胞FSHR蛋白表达量高,差异有显著性意义(P0.05)。经皮穴位电刺激治疗组患者与人工周期治疗组患者相比卵泡颗粒细胞FSHR蛋白表达量高,差异有显著性意义(P0.05)。结论1、经皮穴位电刺激治疗可以增加卵巢储备功能下降患者的窦卵泡数,提高患者AMH水平,降低患者基础E2水平、基础FSH水平及基础FSH/LH比值,从而改善卵巢储备下降患者的卵巢功能。2、经皮穴位电刺激治疗可以减少IVF过程中促性腺激素的使用剂量和使用时间,增加患者的获卵数及优质胚胎数,从而减少了患者的经济负担,改善了IVF的治疗效果。3、经皮穴位电刺激治疗的作用可能与经皮穴位电刺激治疗可以上调FSHR表达,使卵泡对于外源性FSH的刺激更为敏感有关。4、经皮穴位电刺激与传统的针刺相比,避免了皮肤损伤、感染、晕针等不良反应,且刺激持续、定量,易操作,无痛苦,易于被患者接受。作为一种无明显不良反应的治疗方法,经皮穴位电刺激可以提高卵巢储备功能,改善IVF治疗效果,在IVF卵巢储备下降患者中有很好的应用价值。
[Abstract]:Objective ovarian reserve functions usually include the number of ovum vesicles stored in the ovary and the quality of the egg. In clinical practice, ovarian reserve function is often used as an important indicator to reflect the fertility of women. With the continuous fertilization and embryo transfer (in vitro fertilization and embryo transfer, IVF-ET) and its derivative technology Development, many infertility couples need assisted reproductive technology, but at present, assisted reproductive technology is still facing a series of challenges, of which the clinical efficacy and pregnancy rate of patients with decreasing ovarian reserve function are still lack of safety. Effective methods are a difficult problem for clinicians. Acupoint electrical stimulation (transcutaneous electrical acupoint stimulation, TEAS) can improve the quality of ovum and improve the pregnancy rate. The percutaneous point electrical stimulation is a new method of acupoint stimulation, which is different from the traditional hand twisting acupuncture and moxibustion, and the electrical stimulation signal is replaced by the electrical stimulation signal in place of the mechanical stimulation. The pain and local skin tissue injury caused by acupuncture are easier to be accepted by the patient, and the time and intensity of the treatment can be controlled quantitatively. It is now widely used in clinical and scientific research. This study mainly observed the ovarian reserve of the percutaneous acupoint electrical stimulation therapy for the treatment of in vitro fertilization and embryo transfer. The effect of ovarian function in the decreased patients was expected to seek a safe and effective treatment for these patients. Method 1, the study selected patients who were treated with in vitro fertilization and embryo transfer for the standard of ovarian reserve reduction. The age was 26-47 years old, the average age of 36.69 + 4.95 years, the infertile years 1-15 years, the average of 4.89 + 2.89 years, infertility. All the causes were tubal factors caused by gamete transport disorder. 180 patients in the treatment group were numbered, randomly divided into 3 groups, 60 cases of artificial periodic treatment group (group A), 60 cases of consolation percutaneous acupoint electrical stimulation group (group B) and 60 cases (group C) with percutaneous acupoint electrical stimulation (Group). At the same time, they were not willing to accept manual or percutaneous point electrical stimulation at the same time. 60 patients were treated as the blank control group (group D). The experimental design was approved by the hospital ethics committee. The patients were all informed consent and signed informed consent.2. There was no uniform standard for the decline of ovarian reserve function at the standard of entry group and the standard of exclusion standard 2.1. We reported using the following ovarian reserve according to the literature. The descent prediction method, with one of the following (1), (2) and (3), (4) items, considered the decline in the ovarian reserve, and included the scope of our study: (1) at least two basal FSH levels or more than 10IU/L, or FSH/LH > 3.6; (2) the number of bilateral ovarian follicles was less than 5; (3) patients with pelvic surgery (once ovarian cysts were performed) Or ovarian partial resection); (4) (4) the age of 35 years old. (5) the choice of infertility due to the tubal factors caused by the gamete transport disorder, the superovulation scheme using conventional short program patients, to avoid different infertility causes and superovulation schemes for the clinical pregnancy rate of the effect of exclusion criteria due to the number of eggs in the observation index, fertilization, fertilization. Rate, cleavage rate, optimal embryo rate, clinical pregnancy rate and early abortion rate, in order to avoid the influence of other factors on these indicators, patients in the group need to exclude endometriosis and patients with intracytoplasmic sperm injection, ICSI. (1) diagnostic criteria for endometriosis 1) clinical symptoms and Signs: secondary dysmenorrhea progressively aggravated; menstrual changes; other ectopic lesions; the typical signs of gynecologic examination were uterosacral ligamentous nodules and adnexal mass.2) imaging examination: ultrasound, CT, MRI examination found ovarian endometriosis cysts or deep lesions.3) laparoscopy: pathological diagnosis in celiac mirror Patients with endometriosis.4) with or without elevated serum CA125 levels. (2) patients with intracytoplasmic sperm injection (ICSI): a patient with intracytoplasmic sperm injection assisted fertilization (.3) due to male factors resulting in insemination, and the treatment of artificial cycle treatment group 3.1 The fifth day of the menstrual cycle began to take Estradiol Valerate Tablets (bout, 1mg/, Bayer pharmaceutical company) 2mg/d daily for 21 days, and the last 10 days were added to Dydrogesterone Tablets (Duff, 10mg/, Abbott Healthcare products B. V.), 20 mg/d, with 3 cycles of the percutaneous acupoint electrical stimulation therapy for the 3 cycles of the percutaneous acupoint electrical stimulation treatment group The time for the treatment of the percutaneous acupoint electrical stimulation is to use the Han's acupoint nerve stimulator (HANS) of the Peking University neuroresearch Institute to select the treatment intensity of 20-25mA, the frequency of 2Hz, once a day, 30 minutes each time, until the next period of menstruation, so as to complete a course of treatment. A total of 3 courses of treatment, in the period of superovulation, the treatment of meridian acupoint electric stimulation continued after menstruation. The method is the same as the foregoing, until the egg day.3.3 consolation meridian acupoint electrical stimulation therapy is adopted by the comfort type Han's acupoint nerve stimulator (false HANS). This is a kind of scientific research instrument, the appearance of the instrument and Han's point The position nerve stimulator (true HANS) is exactly the same, but no matter how much the current intensity is shown by the instrument, the time is 3 seconds and a pause is 7 seconds. The actual output current is 5mA, which can cause the feeling of acupoint numb, but there is no therapeutic effect. The placebo effect of the instrument has been confirmed in the study. Time, course of treatment and operation methods were the same as that of the percutaneous acupoint electrical stimulation therapy (.4). The main index of the test was to determine the number of sinus follicles, the ovarian artery pulsatility index (PI), the blood flow resistance index (ovarian artery resistance index, ovarian artery), and the ovarian artery blood flow pulsation index (artery pulsatility index, PI) before the treatment. RI), the ratio of systolic / diastolic blood flow velocity (systolic/diastolic flow velocity ratio, S/D). After treatment for 3 cycles, the measurements of the above parameters,.4.2 endocrine hormone, were measured for the basal estradiol (estradiol, E2) and basal follicle stimulating hormone (follicle-stimulating hormone, FSH) values for second days before the treatment of the patients. The value of luteinizing hormone (luteinizing hormone, LH), anti lerlerian tube hormone (Anti-Mtillerian hormone, AMH), basal follicle stimulating hormone / luteinizing hormone (FSH/LH) ratio, treatment of 3 cycles and repeated measurements of the above parameters.4.3 clinical indicators for the collection of gonadotropin dosages and gonadotropin use in the process of ovulation. Count the number of acquired eggs, follicle stimulating hormone receptor (follicle stimulating hormone receptor, FSHR), fertilization rate, cleavage rate, optimal embryo number, clinical pregnancy rate and early abortion rate in four groups of patients. 6 patients in the artificial cycle treatment group of each group had a final break uniform during the comparative treatment process of each group. There were 4 cases of interruption treatment in the treatment group and the consolation percutaneous acupoint electric stimulation group, 54 cases in the artificial period treatment group (group A), the consolation percutaneous point electric stimulation group (group B) 56 cases, and the 56 cases of the percutaneous acupoint electric stimulation treatment group (group C). The general condition of the four groups was as follows. There was no significant difference between patients' age, height, weight and body mass index (P0.05). There was no statistically significant difference between the four groups according to the etiology of infertility and the history of different types of ovarian surgery (P0.05). There was no significant difference between the four groups before treatment, such as the number of sinus follicles, the ovarian blood flow RI, PI, and S/D (P0.05). The four groups of patients were not statistically significant. There was no significant difference between the basal endocrine hormones such as E2, FSH, LH, T, and AMH before treatment (P0.05). Therefore, there was no significant difference between the general and basic indexes of the four groups (P0.05), comparable to.2, and compared with the treatment group in the treatment group 2.1 and three groups of patients before and after treatment. The number of follicles in the anterior sinus was significantly increased after treatment in the acupoint electric stimulation treatment group, and the difference was significant (P0.05). The number of follicles in the post treatment group and the difference before and after treatment were significantly increased in the treatment group of the percutaneous acupoint electric stimulation treatment and the consolation percutaneous acupoint electric stimulation treatment group. The difference was significant (P0.05). The number of follicles in the anterior sinus was significantly increased after treatment, and the difference was significant (P0.05). There was no significant change in the number of follicular follicles in the consolation percutaneous acupoint electric stimulation group (P0.05) before and after treatment (RI), the pulsation index (PI) of the ovarian artery and the systolic / diastolic blood flow velocity before and after treatment. The difference of the ratio (S/D) was not significant (P0.05). The comparison of the basal endocrine hormone between the treatment group and the group of the three groups of the three groups was significantly higher than the pre treatment AMH value in the patients after the treatment of the percutaneous acupoint electric stimulation treatment group. The difference was significant (P0.05). The treatment group of the percutaneous acupoint electrical stimulation and the consolation percutaneous acupoint electric stimulation treatment group Compared with the treatment, the AMH value increased significantly (P0.05). The AMH value of the patients in the artificial cycle treatment group was significantly higher than that before the treatment (P0.05). The AMH value of the patients in the consolation percutaneous acupoint electric stimulation treatment group was not significantly changed (P0.05). The treatment group of the percutaneous acupoint electric stimulation group was treated after treatment. The base E2 value, base FSH/LH value, basic FSH value decreased, and the difference was significant (P0.05). The level of the above hormone levels decreased significantly after the treatment group compared with the consolation percutaneous acupoint electric stimulation treatment group, and the difference was significantly higher (P0.05). After the treatment of the artificial cycle treatment group, the patients were treated with the treatment group. The above hormones were reduced before treatment, and the difference was significant (P0.05). There was no significant change in the above hormone in the consolation percutaneous acupoint electric stimulation treatment group (P0.05) the clinical indexes of the.2.3 four groups were compared with the patients in the percutaneous acupoint electric stimulation treatment group and the comfortable percutaneous acupoint electric stimulation treatment group and the control group. Compared with the dosage of Gn, the number of Gn days decreased significantly (P0.05). Compared with the control group, the number of Gn days decreased significantly compared with the control group, the difference was significant (P0.05). The number of Gn used in the percutaneous acupoint electric stimulation treatment group was lower than that of the artificial cycle treatment group, the number of Gn days decreased, the difference was significant (P0.05). Percutaneous point (P0.05). The difference was significant (P0.05). The number of acquired eggs in the treatment group was significantly higher than that in the control group and the control group (P0.05). The number of eggs obtained in the artificial period treatment group was significantly increased compared with the control group, the difference was significant (P0.05). There were significant differences in the number of high quality embryos in the artificial cycle treatment group (P0.05). The fertilization rate and cleavage rate of the four groups were not significantly different (P0.05). The clinical pregnancy rate of the patients with the percutaneous acupoint electric stimulation treatment group was significantly increased compared with the artificial cycle group, the consolation percutaneous acupoint electric stimulation treatment group and the control group. Significant significance (P0.05). The clinical pregnancy rate in the artificial period treatment group was significantly increased compared with the consolation percutaneous acupoint electric stimulation treatment group and the control group. The difference was significant (P0.05). There was no significant difference in the rate of early abortion rate between the four groups (P0.05) the comparison of the expression of FSHR protein in the follicle granulocyte in the.3. four groups was treated by percutaneous acupoint electrical stimulation There was a significant difference in the expression of FSHR protein in the follicle granulosa cells of the patients in the treatment group and the consolation percutaneous acupoint electric stimulation treatment group and the control group (P0.05). Compared with the placebo percutaneous acupoint electric stimulation treatment group and the control group, the expression of FSHR protein in the granulosa cells was significantly higher in the artificial cycle treatment group than in the control group. The difference was significant. Significance (P0.05). The expression of FSHR protein in follicular granulosa cells was higher in patients treated with transcutaneous electrical acupoint stimulation compared with those in artificial cycle therapy group.
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R714.8

【参考文献】