血清及卵泡液中抑制素B动态变化及其与促排卵结局的相关研究

发布时间：2018-05-02 18:49

本文选题：抑制素B + 体外受精-胚胎移植术　；参考：《河北医科大学》2017年硕士论文

【摘要】：目的:抑制素B(inhibin B,INHB)是由α及β(B型)亚单位构成的异源二聚体糖蛋白激素,属于转化生长因子β(transforming growth factor-β,TGF-β)超家族的多功能细胞生长因子。在卵巢组织,INHB主要由中、小窦卵泡颗粒细胞分泌,颗粒细胞分泌的INHB可通过内分泌机制特异性作用于脑垂体反馈性抑制促性腺激素(follicular stimulation hormone,FSH)分泌,同时还可通过自/旁分泌作用增加雌激素(estrogen,E2)底物产生进而调节E2的生成,INHB的这种经典的内分泌及自/旁分泌作用,在卵泡发生、发育、选择和成熟等过程中均起到重要作用。本实验通过对不同控制性超促排卵(controlled ovarian hyperstimu-lation,COH)方案中不同时间节点的血清及取卵日不同大小卵泡中抑制素B(inhibin B,INHB)水平进行检测并与COH结局进行相关分析,进而探讨不同COH方案中血清及卵泡液(follicular fluid,FF)中INHB动态变化过程及其与COH结局的相关性。方法:1研究对象2015.7~2015.12月主因输卵管因素和/或男方因素在石家庄白求恩国际和平医院生殖中心首次接受IVF/ICSI-ET助孕的76例患者,将其随机分为长方案组(38例)及非降调方案组(38例)。纳入标准:年龄35岁;双侧卵巢AFC共10-20个;体重指数18-25kg/m2;月经周期26-35天;基础激素水平正常;双侧卵巢无手术史;无其他内分泌疾病,近6个月内未应用过激素类药物。排除标准:高泌乳素血症;PCOS;子宫内膜异位症。所有受试者均经医院伦理委员会批准,签署知情同意书。2 COH方案2.1短效长方案治疗前一周期的黄体中期皮下注射促性腺激素释放激素激动剂(gonadotropin-releasing hormone agonist,Gn RH-a)达菲林(注射用醋酸曲普瑞林,0.1mg/支,法国益普生)0.1mg/d至月经第3天起检测血清雌二醇(estrogen,E2)、孕酮(progesterone,P)、黄体生成素(luteinzing hormone,LH)、促卵泡生成素(follicular stimulation hormone,FSH)并超声监测降调情况,达降调标准后(E250pg/ml,P2ng/ml,LH5m IU/ml,FSH5m IU/ml;B超显示无直径大于10mm的卵泡,子宫内膜5mm,无功能性囊肿)改皮下注射达菲林0.05mg/d,同时给予促性腺激素(gonadotropins,Gn)75-300IU/d直至扳机日。当B超示双侧卵巢≥18mm的卵泡个数/≥14mm卵泡个数≥60%,≥14mm卵泡血清E2平均水平值为200-300pg/ml时,当晚皮下注射重组人绒毛膜促性腺激素(Recombinant human chorionic gonadotropin,rh CG,250ugug/支,默克雪兰诺有限公司)250ug,35-36小时后经阴道超声引导下穿刺取卵。取卵(ovum pick up,OPU)后3d,当子宫内膜≥8mm,P1.5ng/ml,且无卵巢过度刺激综合征(OHSS)风险时,行胚胎移植。OPU当日起每日肌注射黄体酮(20mg/支,浙江仙琚制药)60mg,自移植日起添加黄体酮软胶囊(100mg/胶囊,法国卡普苏格尔有限公司)200mg/支阴道给予,行黄体支持。移植14d后检测血清h CG水平确定是否妊娠,4周后B超检查观察到妊娠囊确定临床妊娠。2.2非降调方案月经第3天起口服来曲唑(LE,2.5mg/片,江苏恒瑞)2.5mg/d,同时注射用尿促性素(h MG,75IU/支,中国丽珠医药集团股份有限公司)150-300IU肌注,1次/d,连用5天后停来曲唑改口服枸橼酸氯米酚(CC,50mg/片,塞浦路斯高特药厂),严密超声监测卵泡直径,并检测血E2、P、FSH、LH。达扳机标准后,当晚50-100mg/d皮下注射达菲林0.2mg,吲哚美辛栓(50mg/片,东信药业有限公司)50mg,直肠给药1次/8h。余治疗同短效长方案组。3血清及FF收集收集月经第3天、降调月经第3天、Gn启动日、Gn第5天、h CG日、h CG次日、OPU第3天清晨空腹外周静脉血,并于12小时内2000*rpm离心10min,取上清1ml于1.5ml EP管置于-80℃冰箱,待检。同时,收集OPU日清亮FF并根据卵泡大小将其分为大中小三类(大卵泡:直径≥18mm、中卵泡:14mm≤直径18mm、小卵泡:10mm≤直径14mm),3000*rpm离心10min,取上液约3ml于5ml EP管置于-80℃冰箱,待检。4 INHB及血清E2、P、LH、FSH的测定应用酶联免疫吸附实验(enzyme-linked immunosorbent assay,ELISA)试剂盒(美国Anshlabs公司)检测血清和FF中INHB水平。应用化学发光免疫测定试剂盒(ELECSYS,罗氏,德国)检测血清E2、P、LH、FSH水平。5数据统计分析采用SPSS21.0软件,计量资料采用均数±标准差表示,组间数据比较用两独立样本t检验或t’检验。组内数据比较采用配对样本t检验或Wilcoxon秩和检验。相关性分析采用Pearson相关系数进行分析。P0.05表示差异有统计学意义。结果:1患者一般情况纳入76例IVF助孕患者,根据促排卵方案的不同分为短效长方案组及非降调组,每组各38例,共76个COH周期。两组患者年龄、月经周期、不孕年限、基础内分泌情况及AFC差异无统计学意义(P0.05),两组资料具有可比性。2 COH相关参数比较长方案组Gn用量为1998.68±154.76IU较非降调组的2110.20±150.00IU明显降低(P=0.002);长方案组Emh CG日厚度及E2h CG日分别为10.83±1.51mm和4160.40±1073.67pg/ml较非降调组的9.12±0.98mm及3737.51±643.28pg/ml明显升高(P=0.000;P=0.041)。与非降调组比,长方案组获卵数稍高,而Gn天数、MⅡ卵数、2PN受精数、优质胚数及可利用胚数稍低(P0.05)。3 COH中血清及FF中INHB水平变化降调过程中,降调月经第3天和降调18天即Gn启动日血清INHB水平分别为:50.63±23.80pg/ml、28.99±8.83pg/ml,两者较基础的89.07±26.07pg/ml明显下降,差异有显著统计学意义(P=0.000)。Gn启动日长方案组血清INHB水平为28.99±8.83pg/ml,明显低于非降调组的79.08±21.98pg/ml,有显著统计学差异(P=0.000)。Gn启动后两组血清INHB水平呈上升趋势至h CG日达高峰后下降,OPU第3天显著下降。且两组基础及Gn启动后的血清INHB水平无统计学差异(P0.05)。两组FF中INHB水平随卵泡直径增大而升高。大卵泡INHB水平差异无统计学意义(p0.05);但长方案组中小卵泡INHB水平明显高于非降调组,差异有显著统计学意义(P=0.000)。4 INHB与COH结局的相关性分析两方案中与COH结局相关性由强到弱的血清INHB检测时间分别是:Gn第5天、h CG日、h CG次日、基础月经第3天及OPU第3天。且长方案降调月经第3天及Gn启动日INHB水平与COH结局也有较好的相关性,其中Gn启动日血清INHB水平与Gn用量显著负相关(r=-0.716,P0.01)与E2h CG日显著正相关(r=0.600,P0.01)。两方案中,大卵泡INHB水平与COH结局相关性最强;中卵泡INHB水平与COH结局也存在较好的相关性;而小卵泡INHB水平与COH结局相关性不明确。结论:1长方案降调过程中血清INHB水平显著下降,且降调后的血清INHB水平预示着降调节对卵泡同步化作用较好。2 COH过程中的血清及大中卵泡INHB水平能够很好的预测卵巢反应性及COH结局。
[Abstract]:Objective: inhibin B (inhibin B, INHB) is a heterogenous two polymer glycoprotein composed of alpha and beta (B) subunits. It belongs to the multifunction cell growth factor of the superfamily of transforming growth factor beta (transforming growth factor- beta, TGF- beta). In ovarian tissue, INHB is mainly secreted by small sinus granulosa cells, and INHB can be secreted by granular cells in ovarian tissue. The endocrine mechanism specifically acts on follicular stimulation hormone (FSH) secreted by the feedback inhibition of the pituitary gland, and can also increase the production of E2 by increasing the substrate of the estrogen (estrogen, E2) through the self / paracrine effect. This classic endocrine and paracrine role of INHB in the follicle and the development of the follicle. In the process of selection and maturation, this experiment was carried out by detecting and analyzing the levels of inhibin B (inhibin B, INHB) in different sizes of serum and ovum follicles in different controls of controlled ovarian hyperstimu-lation (COH). The dynamic changes of INHB in the serum and follicular fluid (FF) in the same COH scheme and their correlation with the COH outcome. Methods: 1 the 1 subjects were randomly divided into 76 patients who were first received IVF/ICSI-ET assisted pregnancy for the main factors of the fallopian tube factors and / or male factors at the Bethune International Heping Hospital reproductive center in Shijiazhuang. For the long square case group (38 cases) and the non downfall program group (38 cases), the age 35 years old; bilateral ovarian AFC 10-20; body mass index (BMI) 18-25kg/m2; menstrual cycle 26-35 days; normal basal hormone level; bilateral ovarian no surgery history; no other endocrine diseases, no hormone drugs in the last 6 months. Exclusion criteria: hyperprolactinemia; PCOS Endometriosis. All subjects were approved by the hospital ethics committee to sign the.2 COH scheme 2.1 short effect long prescription for the prior period of the treatment of the.2 COH agonist, Gn RH-a (Gn RH-a) Dafilin (Triptorelin acetate for injection, 0.1mg/ branch). From 0.1mg/d to third days of menstruation, serum estradiol (estrogen, E2), progesterone (progesterone, P), luteinizing hormone (Luteinzing hormone, LH), follicle stimulating hormone (follicular stimulation hormone, FSH) and ultrasonic monitoring were monitored. The follicles with a diameter larger than 10mm, endometrium 5mm, non functional cyst) were subcutaneously injected with Da field 0.05mg/d, and were given gonadotropin (gonadotropins, Gn) 75-300IU/d until the trigger day. When B ultrasound showed that the number of follicles in the follicle of the bilateral ovaries more than 18mm was more than 60%, and the average level of the serum E2 average of more than 14mm follicular serum was 200-300pg/ml, the evening skin. The recombinant human chorionic gonadotropin (Recombinant human chorionic gonadotropin, Rh CG, 250ugug/ branch, Merck snow lano Limited) 250ug, after 35-36 hours of transvaginal ultrasound guided puncture, was taken from the eggs. The ovum (ovum pick up, OPU) was taken after the endometrium was above the endometrium, and there was no ovarian hyperstimulation syndrome. On the day of embryo transfer,.OPU was injected daily with progesterone (20mg/ branch, Zhejiang immortal pharmaceuticals) 60mg. From the day of transplantation, Progesterone Soft Capsules (100mg/ capsule, French Karp sugel Co., Ltd.) was given 200mg/ vagina, and luteal support was given. The serum h CG level was detected after 14d transplantation, and pregnancy was determined by the serum h CG level. After 4 weeks, B ultrasound examination observed the pregnancy sac. To determine the.2.2 non - descending scheme of clinical pregnancy, third days after menstruation, oral letrozole (LE, 2.5mg/ tablet, Jiangsu Heng Rui) 2.5mg/d, and Menotropins for Injection (H MG, 75IU/ branch, Chinese Li Zhu Pharmaceutical Group Limited by Share Ltd) 150-300IU muscle injection, 1 /d, and 5 days later, to stop letrozole to oral chloramol citrate (CC, 50mg/ tablet, Cyprus high special medicine). After strict ultrasonic monitoring of follicle diameter and detecting blood E2, P, FSH and LH., 50-100mg/d subcutaneous injection of Da phifo 0.2mg, Indomethacin Suppositories (50mg/ tablet, Dongxin Pharmaceutical Co., Ltd.) 50mg, rectal administration 1 times /8h. residual therapy and.3 sera and FF collection for third days, third days of menstruation and Gn start day. N fifth days, H CG day, H CG on the next day, OPU third days early morning venous blood, and 2000*rpm centrifuge 10min within 12 hours, take the supernatant 1ml at 1.5ml EP tube in -80 C fridge, to be examined. < < diameter 14mm), 3000*rpm centrifuge 10min, take the upper liquid about 3ml to 5ml EP tube at -80 centigrade refrigerator, wait for.4 INHB and serum E2, P, LH. CSYS, Roche, Germany) detected the serum E2, P, LH, FSH level of.5 data statistical analysis using SPSS21.0 software, the measurement data were expressed with mean standard deviation, and the inter group data were compared with two independent samples t test or T 'test. The intra group data were compared with the paired sample t test or Wilcoxon rank sum test. Correlation analysis adopted Pearson correlation coefficient. .P0.05 showed that the difference was statistically significant. Results: 1 patients were generally included in 76 cases of IVF pregnancy. According to the difference of ovulation promotion, there were 38 cases in each group and 76 COH cycles. The age of the two groups, the period of menstruation, the limit of infertile years, and the difference of basal endocrine and AFC were not statistically significant. P0.05), the data of the two groups were comparable to the.2 COH related parameters. The dosage of Gn was 1998.68 + 154.76IU compared with 2110.20 + 150.00IU in the non lowering group (P=0.002). The Emh CG day thickness and E2h CG were 10.83 + 1.51mm and 4160.40 + 4160.40 +, respectively, 9.12 + and 3737.51 +. Higher (P=0.000; P=0.041). Compared with the non lowering group, the number of ovum was slightly higher in the long Fang case group, while the number of Gn days, the number of M II eggs, the number of 2PN fertilization, the number of high quality embryos and the decrease of INHB levels in the serum and FF in P0.05.3 COH, the third days of the menstruation and the 18 days of the Gn startup day were 50.63 +, 28., respectively. 99 + 8.83pg/ml, compared with the base 89.07 + 26.07pg/ml, the difference was significantly decreased. The difference was significant (P=0.000), the serum INHB level was 28.99 + 8.83pg/ml in the.Gn start day long program group, obviously lower than the 79.08 + 21.98pg/ml in the non descending group. There were significant statistical differences (P=0.000) after.Gn startup, the level of serum INHB increased to h CG day. There was a significant decrease in the OPU third days after the peak, and there was no significant difference in the level of serum INHB between the two groups and the Gn. The level of INHB in the two groups increased with the increase of follicle diameter. The difference in INHB level between the large follicles was not statistically significant (P0.05), but the level of INHB in the medium and small groups was significantly higher than that in the non lowering group, and the difference was significant. The correlation analysis between the P=0.000.4 INHB and the COH outcome in the two scheme, the correlation between the strong to weak serum INHB detection time and the COH outcome was: Gn fifth days, H CG days, H CG, third days of basal menstruation and third days of OPU. There was a significant negative correlation between the serum INHB level of N on the start day and the dosage of Gn (r=-0.716, P0.01) and E2h CG day (r=0.600, P0.01). In the two scheme, the correlation between the INHB level of the large follicle and the COH outcome was the strongest; the median follicle INHB level had a good correlation with the outcome, but the correlation between the level of the follicle and the outcome was not clear. Conclusion: the conclusion: 1 long prescription The serum level of INHB decreased significantly during the downfall of the case, and the serum INHB level after the downfall indicates that the serum and the large and medium follicle INHB levels in the.2 COH process can predict the ovarian responsiveness and the outcome of COH well.

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.8

【参考文献】