摘要
目的：主要探讨不同中医治疗方案对IVF-ET短方案治疗卵巢低反应的干预效应：从基础内分泌、卵巢的血流指数、基础体温、临床症状等方面探讨不同方案对低反应患者卵巢储备功能的影响；从进周后取卵数、胚胎移植数,受精率、优质胚胎率等反面探讨不同方案对卵巢低反应患者再次进周反应性的影响：从胚胎移植后生化妊娠率、临床妊娠率与流产率等方面探讨不同方案对卵巢低反应患者再次进周后妊娠结局的影响,从而为中医药参与辅助生殖技术提供有效的依据。
方法：根据卵巢低反应的诊断标准与纳入标准,将纳入病例随机分为护卵安胎方案、暖巢安胎方案、促排安胎方案及安胎方案等4组。护卵安胎方案于失败后进周前服用护卵汤与暖巢煲,连续服用3个月经周期；进周后于促排当天开始服用促排汤,连续服用6天；于胚胎移植当天开始服用安胎汤,连续服用12付。暖巢安胎方案于失败后进周前连续服用暖巢煲3个月经周期,余过程服药方法同护卵安胎方案。促排安胎方案进周前不服药,于促排当天开始服用促排汤,连续服用12付,胚胎移植当天开始服用安胎汤,连续服用6付。安胎方案仅于胚胎移植当天开始服用安胎汤,连续服用12付。进周前收集护卵安胎方案组与暖巢安胎方案组的治疗前后基础内分泌、卵巢基础血流指数、基础窦卵泡数(AFC)、基础体温(BBT)、临床症状等资料,采用自身前后对照与组间对照进行统计分析,以了解不同方案对低反应患者卵巢储备功能的影响；进周后收集不同方案组的取卵数、受精率、优质胚胎率及胚胎移植数,采用自身前后对照与组间对照进行统计分析,以观察不同方案对低反应患者再次进周后卵巢反应性的影响;胚胎移植后收集不同方案的生化妊娠率、临床妊娠率与流产率,采用组间对照进行统计分析,以观察不同方案对低反应患者再次进周后妊娠结局的影响。
结果：
1在改善卵巢储备功能方面：护卵安胎方案与暖巢安胎方案均能降低升高的b-FSH,台疗前后差异显著,有统计学意义(p<0.05);但护卵汤方案疗效更明显,差异有统计学意义(p<0.01)。护卵安胎方案与暖巢安胎方案对过高与过低的b-E：都有双向调节作用,但护卵安胎方案的疗效较暖巢安胎方案更明显,差异有统计学意义(p<0.05)。护卵安胎方案与暖巢安胎方案对升高的b-LH没有明显的降低作用,但均能升高过低的b-LH,差异有统计学意义(p<0.05),护卵安胎方案临床疗效优于后者,差异有统计学意义(p<0.05)。护卵安胎方案组能明显降低过高的FSH/LH,台疗前后差异显著(p<0.01)；暖巢安胎方案治疗前后差异不明显(p>0.05),无统计学意义。护卵安胎方案在改善低反应患者PI、RI、PSV方面差异性显著(p<0.05),有统计学意义。暖巢安胎方案治疗前后差异不显著(p>0.05),无统计学意义。护卵安胎方案与暖巢安胎方案均可以增加低反应患者AFC数目,治疗前后差异性显著(p<0.05),有统计学意义；但护卵安胎方案明显优于暖巢安胎方案,差异性显著(p<0.05),有统计学意义。在改善低反应患者卵巢体积方面,2种方案疗效均不明显,治疗前后差异性显著(p>0.5)。护卵安胎方案能明显改善低反应患者过薄的子宫内膜,治疗前后差异性显著(p<0.05)。在改善BBT方面,护卵安胎方案疗效显著,治疗前后差异性明显(p<0.01),有统计学意义。暖巢安胎方案治疗前后差异不显著(p>0.05),无统计学意义。
2在改善临床症状方面：护卵安胎方案在改善月经颜色黯黑、腰骶酸困、疲倦乏力、性欲减退等方面较暖巢安胎方案明显,但经统计学处理差异不显著(p>0.05),可能与样本量小有关,需要在今后的研究中增加样本量。尤其值得指出的是护卵安胎方案中有2例患者自然怀孕,占护卵汤组的5%,但由于样本量小,两种方案经统计学处理自然妊娠率差异性不显著(p>0.05),无统计学意义。临床证候积分经过统计学处理后两种方案在改善低反应患者肾虚证候均有良好疗效,治疗前后差异显著(p<0.01);临床证候疗效差异显著(p<0.05),护卵安胎方案疗效明显优于暖巢安胎方案。
3进周后在获卵数、受精率、优质胚胎率及移植数方面：护卵安胎方案、暖巢安胎方案、促排安胎方案相比取卵数差异性显著(p<0.01),移植数差异性不显著。护卵安胎方案明显优于其他两种方案,差异性显著(p<0.04),暖巢安胎方案与促排安胎方案差异不明显(p>0.05),无统计学意义。三种方案的受精率本周期差异性显著(p<0.01),有统计学意义。护卵安胎方案受精率明显高于其他两种方案,差异显著(p<0.01),暖巢安胎方案与促排安胎方案差异性不显著(p>0.05),无统计学意义。优质胚胎率三种方案差异不显著(p>0.05),无统计学意义
4胚胎移植后,在妊娠结局方面：护卵安胎方案、暖巢安胎方案、促排安胎方案及安胎方案生化妊娠率与临床妊娠率差异性显著(p<0.05),有统计学意义。护卵安胎方案在生化妊娠率与暖巢安胎方案差异不显著(p>0.05),无统计学意义,但较另两种方案差异显著(p<0.05)。临床妊娠率方面护卵安胎方案与暖巢安胎方案及促排安胎方案差异不显著(p>0.05),有统计学意义;但与安胎方案差异显著(p<0.05),无统计学意义。四种方案流产率差异不显著(P>0.05)。
结论：
1护卵安胎方案能有效提高IVF-ET短方案治疗卵巢低反应的生化妊娠率与临床妊娠率。暖巢煲养胎方案次之。促排安胎方案及养胎方案疗效较差。
2中医药参与IVF-ET治疗卵巢低反应的最佳时机应该从进周前开始,通过对低反应患者卵巢储备功能及子宫内膜容受性的改善,为其再次进周打下良好基础。进周后或胚胎移植后采用中药的效果不如进周前开始调理。
3暖巢煲作为中药食疗也可以在一定程度上改善低反应患者的卵巢储备功能与子宫内膜容受性。
4补肾健脾疗法可以通过补后天而达到调先天的目的,改善低反应患者的卵巢储备功能,增加其在促排卵过程中的获卵率,并提高卵子质量,从而达到提高其优质胚胎率、生化妊娠率与临床妊娠率。
5“安胎前移”思想的提出与西医的黄体支持疗法异曲同工,通过健脾而达到加强子宫内膜摄胎、载胎、纳胎的功能,增强子宫内膜的容受性,有效提高低反应患者的妊娠率,降低其流产率
Objective:The objective of this thesis is to observe the effects of different TCM treatments interve the short program of IVF-ET treatment POR:to probe into the impact of different TCM treatments over POR's ovary reserve function from basis endocrine, the exponent of ovary, BBT and clinical symptoms and so on;to probe into the effect of the program on POR's responses when they enter a new cycle again from the numbers of taking eggs,the rate of fertility,the numbers of fertilized eggs, superior embryo rate, etc; to probe into the effect of different TCM treatments over POR's the final progency results when they enter the new cycle from the biochemical pregnancy ratio,clinical pregnancy ratio;abortion ratio and so forth.
Methods:The medical records chosen are divides into4groups:the group of Huluanantai,the group of Nuanchaoantai the group of Cupaiantai and the group of Antai according to the standards of diagnose and choosing. The patients in the group of Huluanantai continue taking the Huluantang and nuanchaobao3menstrual cycles after IVF-ET fail befor enter another IVF-ET's cycle. They continue taking Cupaitang6fu from the day of entering IVF-ET's cycles;and continue taking Antaitang12days from the day of embryo transfer.The patients in the group of Nuanchaoantai continue taking Nuanchaobao3menstrual cycles after IVF-ET fail befor enter another IVF-ET's cycle. Other taking medicine methods are the same as the methods of the group of Huluanantai. The patients in group of Cupaiantai needn't take medince before entering IVF-ET's cycle, and begin to take Cupaitang on the day of ovulation and continue taking6fu; begin take Antaitang on the embryo transfer and continue taking12days. The patients in group of Antai begin to take Antaitang and continue taking12days. In order to learn the impact of the two programs over ovary reserve function, we collected the datas of groups of Huluanantai and Nuanchaoantai, such as basis endocrine,ovary basis bloodstream exponent,basis hole follicle number(AFC),the basis temperature(BBT),clinical symptoms and so on before they entered into IVF-ET's cycle. In order to observe the different program's ovary effect entering cycle once again to POR, we collected every group data of the number of taking the ovum, fertilization rate high grade embryo rates and the number of embryo transfer after they entered into IVF-ET's cycle. In order to observe the different program's pregnancy outcomes, we collected the biochemistry pregnancy rate, clinical pregnancy rate and abortion rate of every forms
Results:
1In the field of improvement ovary reserve function. Huluanantai scheme and Nuanchaoantai scheme all can reduce b-FSH rising, the difference curing the front and back notable,had statistics meaning (p<0.05),but Huluanantai scheme curative effect was more obvious, the difference had statistics meaning (p<0.01). The schemes of Huluanantai and Nuanchaoantai all have two-way to b-E2rising such or descending such adjusts an effect, but the Huluanantai scheme curative effect was more obvious, and the difference had statistics meaning (p<0.05) Huluanantai scheme and Nuanchaoantai scheme regimen in not significantly decrease elevated b-LH, but both can increase the too low b-LH, The difference was statistically significant (p<0.05).Clinical dfficacy of Huluanantai scheme was better than the latter, the difference was statistically significant (p<0.05). Huluanantai scheme ccould reduce too high FSH/LH obviously, the difference curing befor and after treatment was notable (p<0.01); the difference of Nuanchaoantai scheme was not obvious curing before and after (p>0.05),there was no statistics intention. Huluanantai scheme can improvement POR's PI、RI、PSV obviously,the differernce had statistics meaning. And Nuanchaoantai scheme was contrary. The schemes of Huluanantai and Nuanchaoantai both ccould increase the number of POR's AFC,the difference curing befor and after treatment was notable,had statistics meaning (p<0.05);and the scheme was obvious better than that Nuanchaoantai scheme, the difference was obviously, it had statistics meaning (p<0.05).In the field of POR's ovary volume, the two schemes were not obviously,the difference curing before and after treatment was not notable (p>0.5). Huluanantai scheme could improve the thickness of POR's endometria obviously, the difference curing before and after treatment was notable (p<0.05). In the field of improving BBT, the curative effect of Huluananti scheme was distinct, the difference curing before and after treatment was notable (p<0.01). And the Nuanchaoantai scheme's curative effect not notable.
2In the field of improving clinical symptom:Huluanantai scheme was more obvious than Nuanchaoantai scheme curative effect in the field of improvement the coulor of menstrual, acid bottom of the lumbar pain,the feel of tired, undersexed etc. But the difference was not notable after statistics treatment (p>0.05).May be connected with sample book amounts for limited. So to need the amounts increasing a sample book in research the days to come. Being worth pointing out especially, there were2natural regular patient gestation in A scheme, account for5%of group Huluanantai, however being sample book was limited, the difference of natural2schemes pregnancy rate was not notable afer statistics (p>0.05), there was no statistics significance. In the improvment POR's deficiency of the kidney syndrome the2schemes have the fine curative effect equally after statistics handles the clinical syndrome integrates, the difference curing before and after treatment was notable (p<0.01);clinical syndrome curative effect difference was notable (p<0.05),the Huluanantai scheme curative effect was obvious better than Nuanchaoantai scheme.
3In the field of the number of obtain the ovum,fertilization rate, high grade embryo rates and the number of transplant after entering cycle. Huluanantai schemes、Nuanchaoantai scheme and Cupaiantai scheme were compared with each other fetching an ovum difference being notable (p<0.01),the difference was not notable in the number of transplanting. Huluanantai scheme was obvious better than the other2schemes, the difference was notable (p<0.04),Nuanchaoantai scheme and Cupaiantai scheme difference were not notable (p>0.05, there was no statistics significance.3schemes fertilization rate difference was notable in the period (p<0.01), there was statistics significance. The schemes fertilization rate overtops Huluanantai schemes obviously2grows a scheme other. The difference was notable (p<0.01),Nuanchaoantai scheme and Cupaiantai scheme difference weree not notable (p>0.05), there was no statistics significance. The differernce of quality embryo rate of the3schemes was not notable (p>0.05), there was no statistics significance. In the field of pregnancy outcome after embryo transfer:4.1The difference of the three schemes is notable in the field of biochemistry pregnancy rate and clinical pregnancy rate (p<0.05),there was statistics significance. In the biochemistry pregnancy rate, Huluanantai scheme and Nuanchaoantai scheme difference aren't notable (p<0.05),there wasn't statistics significance. But Huluanantai scheme and another two kinds scheme comparison difference were all notable (p<0.05) In the field of clinical pregnancy rate, Huluanantai scheme and Nuanchaoantai schemes and Cupaiantai scheme difference were not notable (p>0.05), there wasn't statistics significance. But it and Antai scheme difference is notable(p<0.05),there was statistics sifnificance.4.2The4schemes abortion rate difference was not notable (p>0.05)
Conclusion:
1Huluanantai scheme cures POR biochemistry pregnancy rate and clinical pregnancy rate than C scheme can have an effect to improve the scheme more. Cupaiantai scheme and Yangtai scheme curative are relatively poor.2TCM participation IVF-ET cures optimum POR opportunity ought to begin from entering cycle. This can improve the POR's ovarian reserve function and endometrial receptivity, so to make a good foundation for the POR entering cycle again. After entering the cycle or (and) embryo transfer rear beginning to adopt TCM to assist the cffect treating to take second place.
3Nuanchaobao diet can improve the POR's ovarian reserve function and endometrial reccptivity.
4Bushenjianpi therapy can be nursed XIANTIAN to health by nourishing HOUTIAN, improve POR's ovarian reserve function, increase their tate of oocytes in ovulation induction, improve their biochemical pregnancy rate and clinical pregnancy rate.
5"Antaiqianyi"thought and luteal support therapy of Western Midicine Different approaches but equally satisfactory results, they are to strengthen the function of endometrial's SHETAI and ZAITAI and NATAI and enhancement of endometrial receptivity, so can effectively improve the POR's pregnancy rate, reduce the rate of abortion.
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