他莫昔芬在不同原因薄型子宫内膜患者冻融胚胎移植周期中的作用

发布时间：2018-06-04 13:05

本文选题：他莫昔芬 + 薄型子宫内膜　；参考：《山东大学》2017年硕士论文

【摘要】：研究背景良好的子宫内膜容受性是胚胎着床的必要条件,其主要评价指标包括内膜厚度,内膜形态和内膜(或内膜下)血流。薄型子宫内膜往往预示着不良妊娠结局,是目前人工辅助生殖临床中最棘手的问题之一。然而,目前仍然没有公认有效的措施来提高内膜厚度,进而改善妊娠结局。同时,由于导致薄型子宫内膜的病因多样,如机械性损伤、感染因素、内分泌因素等,需要寻找一个高效简便的子宫内膜改善方法以适合不同病因的患者。冻融胚胎移植为人工辅助生殖技术中的重要手段之一,它能够减少促排卵过程中对内膜容受性带来的不良影响,提供时机准备子宫内膜,以便在子宫内膜容受性良好的条件下行胚胎种植,从而获得满意的妊娠结局。目的探讨冻融胚胎移植(Frozen-thawed Embryo Transfer,FET)周期中,他莫昔芬用于子宫内膜准备方案,对不同原因薄型子宫内膜患者内膜容受性和妊娠结局的改善作用。方法回顾性分析2012年1月至2015年8月山东大学附属生殖医院FET中使用自然周期、直接替代周期或促排卵周期准备子宫内膜时反复出现内膜薄(2次或2次以上内膜厚度7.5mm),后改用他莫昔芬方案进行内膜准备的267名患者(共1099个FET周期)。比较既往方案和他莫昔芬方案中子宫内膜厚度、形态和血流。进一步根据内膜薄的病因分为四个亚组:宫腔粘连组(n=34)、清宫≥2次组(n=104)、双侧输卵管梗阻(n=78)、多囊卵巢综合征(Polycystic Ovarian Syndrome,PCOS)组(n=51),比较四个亚组的患者在接受他莫昔芬周期后子宫内膜厚度的改善情况以及妊娠结局。结果和既往周期相比,他莫昔芬可以将内膜厚度由自然周期的6.04±0.83mm提高至7.81±1.49mm,由激素替代周期的6.22±1.06提高至8.12±1.63mm,由促排卵周期的6.31±0.97mm提高至7.96±1.46mm,其差异均具有统计学意义(P均0.001);但对内膜形态没有明显改善(P值分别为0.298,0.500,0.494)。同时,对63个患者的内膜血流分析显示,他莫昔芬对血流没有显著影响(P=0.254)。进一步分析,宫腔粘连、清宫史≥2次、双侧输卵管梗阻以及PCOS四个亚组在他莫昔芬周期平均内膜厚度分别为7.13±1.16mm,8.13±1.49mm,7.83±1.30mm,9.24±1.65mm,差异均具有统计学意义(P0.001),PCOS组的子宫内膜厚度明显高于其他3个亚组。同时,PCOS组可以获得最低的周期取消率和最良好的妊娠结局:四组移植取消率依次为45.24%(19/42)、28.24%(37/131)、39.81%(41/103)、14.04%(8/57),差异有统计学意义(P=0.001);生化妊娠率依次为43.48%(10/23),48.94%(46/94),44.07%(26/59),71.43%(35/49),差异具有统计学意义(P=0.019);临床妊娠率依次为43.48%(10/23),32.98%(38/94),38.98%(23/59),63.27%(31/49),差异有统计学意义(P=0.041);活产率依次为 30.43%(7/23),32.98%(31/94),18.64%(11/59),53.06%(26/49),差异有统计学意义(P=0.002)。二元logistic回归显示,内膜厚度、年龄,移植胚胎数和活产结局相关。结论1、冻融胚胎移植周期中他莫昔芬可以显著增加薄型子宫内膜患者的内膜厚度;2、他莫昔芬对内膜形态和内膜血流没有明显作用;3、年龄、内膜厚度、胚胎移植数与冻融胚胎移植周期中是否活产相关;4、他莫昔芬对多种病因导致的薄型内膜均有不同程度的改善,其中PCOS患者的效果最为显著,并获得较理想的妊娠结局。
[Abstract]:Well studied endometrium receptivity is a necessary condition for the implantation of the embryo. The main evaluation indexes include the thickness of the endometrium, the morphology of the endometrium and the blood flow of the intima (or intima). The thin endometrium often indicates the bad pregnancy outcome. It is one of the most difficult problems in the artificial assisted reproductive clinic. However, it is still not recognized at present. It is effective to improve the thickness of the endometrium and improve the pregnancy outcome. At the same time, due to the various causes of the endometrium, such as mechanical damage, infection factors, endocrine factors, and so on, a efficient and simple method of endometrial improvement is needed to fit for patients with different causes. One of the most important measures in the process is that it can reduce the adverse effects on the endometrial receptivity during ovulation, and provide the opportunity to prepare the endometrium so that the embryo can be planted under the condition of the endometrium with good tolerance, so as to obtain a satisfactory pregnancy outcome. The purpose of this study is to explore the period of Frozen-thawed Embryo Transfer (FET). In addition, tamoxifen is used for endometrial preparation, the improvement of endometrial receptivity and pregnancy outcome in patients with different causes of thin endometrium. Methods a retrospective analysis of the use of the natural cycle in FET, a affiliated reproductive Hospital of Shandong University from January 2012 to August 2015, was used to replace the weeks or the period of ovulation preparation for endometrium. Endometrial thin (2 or more than 2 times intima thickness 7.5mm) and 267 patients (a total of 1099 FET cycles) prepared by tamoxifen scheme. The endometrium thickness, morphology and blood flow in the tamoxifen scheme were compared in four subgroups: the intrauterine adhesion group (n=34) and the uterine cavity more than 2 times (or more than 2 times). N=104), bilateral fallopian tube obstruction (n=78), polycystic ovary syndrome (Polycystic Ovarian Syndrome, PCOS) group (n=51). Compared with the four subgroups, the endometrial thickness improvement and pregnancy outcome after the tamoxifen cycle were compared with the previous cycle. Tamoxifen could make the thickness of the endometrium from 6.04 + 0.83M to the natural cycle. M increased to 7.81 + 1.49mm, increased from 6.22 + 1.06 of the hormone replacement cycle to 8.12 + 1.63mm, increased from 6.31 + 0.97mm to 7.96 + 1.46mm, and the difference was statistically significant (P 0.001), but the morphology of the endometrium was not significantly improved (P value was 0.298,0.500,0.494). At the same time, the analysis of the intima flow of 63 patients showed that Tamoxifen had no significant influence on blood flow (P=0.254). Further analysis, intrauterine adhesions, uterine cavity history more than 2 times, bilateral fallopian tube obstruction and PCOS four subgroups in the tamoxifen cycle average intimal thickness was 7.13 + 1.16mm, 8.13 + 1.49mm, 7.83 + 1.30mm, 9.24 + 1.65mm, the difference was statistically significant (P0.001), PCOS group endometrium The thickness of the PCOS group was significantly higher than that of the other 3 subgroups. At the same time, the lowest cycle cancellation rate and the best pregnancy outcome were obtained: the four groups were 45.24% (19/42), 28.24% (37/131), 39.81% (41/103), 14.04% (8/57), and the difference was statistically significant (P=0.001); the rate of biochemical pregnancy was 43.48% (10/23), 48.94% (46/94), 44.07% (26/59). 71.43% (35/49), the difference was statistically significant (P=0.019); the clinical pregnancy rate was 43.48% (10/23), 32.98% (38/94), 38.98% (23/59), 63.27% (31/49), and the difference was statistically significant (P=0.041); the survival rate was 30.43% (7/23), 32.98% (31/94), 18.64% (11/59), 53.06% (26/49). The difference was statistically significant (P=0.002). Two yuan regression showed significant regression. Conclusion 1, tamoxifen could significantly increase the intimal thickness of endometrium in patients with thin endometrium during the period of freeze-thaw embryo transfer; 2, tamoxifen had no significant effect on intimal morphology and intimal flow; 3, age, intima thickness, embryo transfer number and frozen thawing embryo transfer cycle 4, tamoxifen improved the thin endometrium caused by a variety of causes, of which PCOS patients had the most significant effect and achieved an ideal pregnancy outcome.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R714.8

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