本文關(guān)鍵詞： 子宮內(nèi)膜異位癥 體外受精-胚胎移植 臨床結(jié)局 子宮內(nèi)膜異位癥 氧化應(yīng)激 不孕 維生素E 體外受精-胚胎移植　出處：《廣州醫(yī)科大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

【摘要】：研究背景 子宮內(nèi)膜異位癥，簡(jiǎn)稱為內(nèi)異癥，是指子宮內(nèi)膜組織（腺體和間質(zhì)）出現(xiàn)在子宮體以外的部位。內(nèi)異癥是一種激素依賴性疾病，可人為地應(yīng)用藥物和手術(shù)來(lái)減緩和暫停其發(fā)展。其在組織學(xué)上是良性的，但是在臨床行為學(xué)上具有種植、侵襲及遠(yuǎn)處轉(zhuǎn)移等類似惡性腫瘤的特點(diǎn)。主要臨床表現(xiàn)是持續(xù)性加重的盆腔粘連、疼痛以及不孕。在育齡期婦女中患病率約為25%，其中21%~44%合并有不孕。子宮內(nèi)膜異位癥及其不孕癥的相關(guān)發(fā)病機(jī)制尚未完全闡明，導(dǎo)致了對(duì)其治療效果的不理想。一直以來(lái)，子宮內(nèi)膜異位癥及其所導(dǎo)致的不孕患者都是以手術(shù)及藥物治療為主，，隨著輔助技術(shù)的發(fā)展與成熟，為該類患者帶來(lái)了新的希望。但是在臨床工作中發(fā)現(xiàn)，子宮內(nèi)膜異位癥不孕患者行輔助生殖技術(shù)的成功率仍不理想，這可能與子宮內(nèi)膜異位癥對(duì)盆腔結(jié)構(gòu)、卵巢功能、排卵功能、卵子質(zhì)量、精卵結(jié)合能力、胚胎質(zhì)量以及子宮內(nèi)膜和相關(guān)環(huán)境的影響均具有一定的關(guān)系。為了進(jìn)一步闡明子宮內(nèi)膜異位癥不孕患者的發(fā)病機(jī)制，了解該類患者行輔助生殖技術(shù)的成功率偏低的原因，氧化應(yīng)激在子宮內(nèi)膜異位癥中的作用受到了越來(lái)越多的關(guān)注。氧化應(yīng)激與多種機(jī)體疾病的發(fā)生發(fā)展密不可分，其在不孕患者行輔助生殖中所起的作用與子宮內(nèi)膜異位癥在不孕患者所起作用有相似之處。近年來(lái)，對(duì)于氧化應(yīng)激在內(nèi)異癥患者中所起的作用也得到了多方面研究的證實(shí)。維生素E作為一種眾所周知的抗氧化物質(zhì)，被廣泛應(yīng)用到農(nóng)業(yè)與生活中，但是其在輔助生殖技術(shù)領(lǐng)域的應(yīng)用仍未得到廣泛認(rèn)可。對(duì)于維生素E的劑量及用藥時(shí)間仍然存在爭(zhēng)議。 本課題將探討子宮內(nèi)膜異位癥的嚴(yán)重程度對(duì)IVF-ET的影響，了解內(nèi)異癥可能從哪些方面影響不孕患者行IVF-ET的成功率；另外，利用維生素E的抗氧化作用降低內(nèi)異癥不孕患者體內(nèi)的氧化應(yīng)激水平，探討其在臨床應(yīng)用的前景。 研究?jī)?nèi)容 第一部分子宮內(nèi)膜異位癥不孕患者行IVF-ET結(jié)局分析 研究目的 探討子宮內(nèi)膜異位癥對(duì)IVF-ET的影響，初步分析內(nèi)異癥的嚴(yán)重程度從哪些方面影響該類患者行IVF-ET結(jié)局。 研究方法 收集2012年1月至2013年12月期間在廣東省婦幼保健院生殖健康與不孕癥科接受IVF-ET治療的子宮內(nèi)膜異位癥不孕患者92例。IVF治療前均進(jìn)行腹腔鏡或開(kāi)腹手術(shù)確定子宮內(nèi)膜異位癥的分期。按內(nèi)異癥的不同分期把研究對(duì)象分為兩組，A組（65例）為子宮內(nèi)膜異位癥Ⅰ、Ⅱ期患者，B組（27例）為Ⅲ、Ⅳ期患者。研究對(duì)象均為首次接受IVF-ET治療，術(shù)前B超未提示內(nèi)異癥復(fù)發(fā)并排除多囊卵巢綜合征等其他全身內(nèi)分泌疾病。C組（154例）為隨機(jī)選取的同時(shí)期因雙側(cè)輸卵管阻塞行IVF-ET的患者，排除多囊卵巢綜合征等其他全身內(nèi)分泌疾病。所有研究對(duì)象均進(jìn)行IVF-ET的控制性超排卵長(zhǎng)方案治療，比較各組間的基本背景、超促排卵情況和臨床結(jié)局指標(biāo)。研究結(jié)果應(yīng)用SPSS19.0統(tǒng)計(jì)學(xué)軟件包進(jìn)行統(tǒng)計(jì)學(xué)分析。各組均數(shù)之間采用t檢驗(yàn)，各組率的比較采用卡方檢驗(yàn)。P值0.05為差異有統(tǒng)計(jì)學(xué)意義。 研究結(jié)果 1.各組不孕患者的年齡、不孕年限、基礎(chǔ)FSH、LH和E2水平均無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 2.各組在超促排卵過(guò)程中，HCG日E2水平及移植日內(nèi)膜厚度均無(wú)明顯差異；而隨著內(nèi)異癥病情的加重，Gn用量和Gn時(shí)間呈現(xiàn)增加趨勢(shì)、獲卵數(shù)則逐漸減少，其中B組的Gn用量及獲卵數(shù)較C組有明顯改變，有統(tǒng)計(jì)學(xué)意義（P0.05）。 3.A組及B組分別與對(duì)照組比較，兩組患者行IVF-ET的受精率、優(yōu)質(zhì)胚胎率、種植率及臨床妊娠率都有減少，但是差異無(wú)統(tǒng)計(jì)學(xué)差異（P0.05）。 研究結(jié)論 1.子宮內(nèi)膜異位癥患者不孕的原因可能主要是異位病灶影響了患者的機(jī)體內(nèi)環(huán)境； 2.IVF-ET是有效的提高該類患者的妊娠機(jī)會(huì)的技術(shù)，但其行IVF-ET的成功率較輸卵管因素的偏低。 第二部分維生素E對(duì)內(nèi)異癥不孕患者行IVF-ET的效果探討 研究目的 探討維生素E對(duì)子宮內(nèi)膜異位癥不孕患者行IVF-ET的治療效果，為其臨床應(yīng)用提供理論依據(jù)。 研究方法 選取于2013年8月至2014年2月在廣東省婦幼保健院生殖健康與不孕癥科行IVF-ET的子宮內(nèi)膜異位癥患者作為研究對(duì)象進(jìn)行前瞻性病例對(duì)照研究。研究對(duì)象均為經(jīng)開(kāi)腹手術(shù)或者腹腔鏡手術(shù)證實(shí)為Ⅰ、Ⅱ期子宮內(nèi)膜異位癥患者，IVF-ET術(shù)前檢查未發(fā)現(xiàn)內(nèi)異癥復(fù)發(fā)及排除子宮腺肌癥患者。其中給予維生素E的子宮內(nèi)膜異位癥患者作為研究組，沒(méi)有給予維生素E的子宮內(nèi)膜異位癥患者作為對(duì)照組。所有研究對(duì)象均采用黃體中期降調(diào)節(jié)長(zhǎng)方案，于取卵日收集兩組患者外周靜脈血及卵泡液，采用比色法、黃嘌呤氧化酶法(羥胺法)及化學(xué)熒光法分別測(cè)定兩組患者血清及卵泡液中的維生素E（VE）、超氧化物歧化酶（SOD）及活性氧簇（ROS）的水平。比較兩組間的臨床結(jié)局以及上述氧化應(yīng)激指標(biāo)與臨床結(jié)局的相關(guān)性。研究結(jié)果應(yīng)用SPSS19.0統(tǒng)計(jì)學(xué)軟件包對(duì)實(shí)驗(yàn)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)學(xué)分析。計(jì)數(shù)資料采用卡方檢驗(yàn)，計(jì)量資料采用獨(dú)立樣本t檢驗(yàn)，實(shí)驗(yàn)數(shù)據(jù)與臨床評(píng)價(jià)指標(biāo)間行相關(guān)性分析，用Spearman相關(guān)系數(shù)表示。P0.05為差異有統(tǒng)計(jì)學(xué)意義。 結(jié)果 1.研究組血清及卵泡液中的VE含量較對(duì)照組血清及卵泡液中的VE含量顯著增高，有統(tǒng)計(jì)學(xué)意義（P0.05），研究組中SOD以及ROS水平較對(duì)照組水平無(wú)明顯改變，無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 2.研究組與對(duì)照組中，VE的水平在血清中較卵泡液中明顯增高，SOD的水平在卵泡液中較血清中明顯增高，有統(tǒng)計(jì)學(xué)差異（P0.05）。 3.研究組與對(duì)照組之間的平均獲卵數(shù)以及臨床妊娠率均無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。對(duì)照組的受精率及優(yōu)質(zhì)胚胎率較研究組高，研究組的種植率較對(duì)照組高，但是均無(wú)統(tǒng)計(jì)學(xué)意義（P0.05）。 4.對(duì)照組中將血清和卵泡液中的VE、SOD和ROS水平與IVF-ET結(jié)局評(píng)價(jià)指標(biāo)進(jìn)行相關(guān)性分析發(fā)現(xiàn)血清和卵泡液中ROS水平與IVF-ET結(jié)局評(píng)價(jià)指標(biāo)呈負(fù)相關(guān)趨勢(shì)，其中在卵泡液中ROS的水平與種植率呈負(fù)相關(guān)，有統(tǒng)計(jì)學(xué)意義（P0.05）。但是發(fā)現(xiàn)SOD與結(jié)局評(píng)價(jià)指標(biāo)呈負(fù)相關(guān)趨勢(shì)。研究組中，ROS在血清中與IVF-ET結(jié)局評(píng)價(jià)指標(biāo)基本上呈現(xiàn)負(fù)相關(guān)趨勢(shì)，但均無(wú)統(tǒng)計(jì)學(xué)差異（P0.05）�？傮w來(lái)說(shuō)，對(duì)照組與研究組VE、SOD及ROS與IVF-ET結(jié)局評(píng)價(jià)指標(biāo)的相關(guān)性不大。 結(jié)論 子宮內(nèi)膜異位癥不孕患者體內(nèi)存在氧化應(yīng)激，通過(guò)損害全身或者卵泡局部環(huán)境，繼而影響行IVF-ET的結(jié)局；添加維生素E對(duì)于子宮內(nèi)膜異位癥不孕患者行IVF-ET的療效不明確，可能與維生素E的原氧化性質(zhì)有關(guān)，添加維生素E的劑量與用藥時(shí)間仍需進(jìn)一步完善。
[Abstract]:Research background
Endometriosis, referred to as endometriosis, refers to endometrial tissue (glands and stroma) in uterine tissue outside. Endometriosis is a hormone dependent disease, can be used for medicine and surgery to slow down and suspend its development. It is benign in histology, but in the clinical behavior of planting, similar to the characteristics of malignant invasion and distant metastasis of tumor. The main clinical manifestations of pelvic adhesions is durative accentuation, pain and infertility. The prevalence rate is about 25% in women of childbearing age, including 21%~44% infertility. The pathogenesis of endometriosis and infertility have not been fully elucidated and the cause of its treatment effect is not ideal. All the time, endometriosis and infertility are caused by surgery and drug therapy, with the development of assistive technology and mature, for this kind of patients Bring new hope. But in clinical work, is still not ideal of infertile patients with endometriosis for assisted reproductive technology success rate, which may be related to endometriosis of pelvic structure, ovarian function, ovulation, egg quality, sperm egg binding capacity, effect of embryo quality and endometrial and related environment have certain relationship. In order to further elucidate the pathogenesis of endometriosis infertility patients, the patients understand the reasons for the low success rate of assisted reproductive technology, role of oxidative stress in endometriosis has attracted more and more attention. Oxidative stress and various body disease development are inseparable, the in the patients with infertility for assisted reproduction and the role of endometriosis in the patients with infertility effects are similar. In recent years, the oxidative stress, The different patients function also obtained the various research confirmed. Vitamin E as an antioxidant as everyone knows, is widely used in agriculture and life, but its application in the field of assisted reproductive technology has not been widely recognized. Controversy still exists for the dosage and medication time of vitamin E.
This paper will discuss the influence of the severity of endometriosis on IVF-ET, endometriosis may understand from what influence the success rate of IVF-ET for patients with infertility; in addition, reduce the level of oxidative stress in patients with infertility of endometriosis using vitamin E antioxidant effect and explore its clinical application in the future.
research contents
Analysis of IVF-ET outcome in the first part of endometriosis infertile patients
research objective
To investigate the effect of endometriosis on IVF-ET, and to analyze the effect of the severity of endometriosis on the IVF-ET outcome in this type of patients.
research method
During the period from January 2012 to December 2013 in IVF-ET treated in Guangdong Provincial Maternity and Child Care Center of reproductive health and infertility of endometriosis and 92 cases of.IVF patients before treatment were performed laparotomy or laparoscopic staging of endometriosis endometriosis. According to the different stages of the study subjects were divided into two groups, A group (65 cases) for endometrial endometriosis I and II patients, B group (27 cases) for III and IV patients. The subjects were first treated with IVF-ET, preoperative ultrasonography showed no recurrence of endometriosis and exclusion of polycystic ovary syndrome and other body endocrine disorders in.C group (154 cases) were randomly selected at the same period due to bilateral fallopian tube obstruction in IVF-ET patients, exclusion of polycystic ovary syndrome and other endocrine diseases. All subjects were controlled IVF-ET superovulation long treatment, basic back between groups were compared The ovulation and clinical outcome were investigated. The results of the study were statistically analyzed by SPSS19.0 statistical software package. The t test was used to calculate the mean between the 0.05 groups. The chi square test and the.P value of each group were compared with each other. The difference was statistically significant.
Research results
1. the age, infertile years, basic FSH, LH and E2 levels were not statistically significant (P0.05) in all groups of infertile patients.
In the 2. groups during COH, there were no significant difference between the HCG and E2 levels on endometrial thickness and transplantation; with the aggravation of endometriosis disease, dosage of Gn and Gn increased, the number of oocytes is gradually reduced, the amount of Gn in the B group and the number of oocytes than in the C group have obvious change there was statistical significance (P0.05).
3.A group and B group were compared with the control group, the two groups of patients IVF-ET fertilization rate, quality embryo rate, implantation rate and clinical pregnancy rate all decreased, but the difference was not statistically significant (P0.05).
research conclusion
1. the causes of infertility in patients with endometriosis may be mainly due to the effect of ectopic focus on the patient's internal environment.
2.IVF-ET is an effective technique to improve the chances of pregnancy in this type of patient, but the success rate of IVF-ET is lower than that of the fallopian tube factor.
The effect of the second part of vitamin E on IVF-ET in infertile patients with endometriosis
research objective
To investigate the effect of vitamin E on the treatment of endometriosis infertile patients with IVF-ET, and provide a theoretical basis for its clinical application.
research method
From August 2013 to February 2014 in Guangdong Provincial Maternity and Child Care Center Department of reproductive health and infertility in IVF-ET patients with endometriosis as the research object for prospective case-control study. The subjects were underwent open surgery or laparoscopic surgery confirmed I, II patients with endometriosis, IVF-ET preoperative examination showed no recurrence of endometriosis and uterus exclusion the patients with adenomyosis. The vitamin E given endometriosis patients as the study group, not given vitamin E in endometriosis patients as the control group. All subjects were using the mid luteal phase falling day long program, the two groups were collected peripheral venous blood and follicular fluid on the day of oocyte retrieval by colorimetric by the method of xanthine oxidase (hydroxylamine) two groups of serum and follicular fluid of patients with vitamin E in the determination of fluorescence and chemical method respectively (VE), superoxide dismutase Enzyme (SOD) and reactive oxygen species (ROS) level. The clinical outcomes were compared between the two groups and the correlation between oxidative stress indexes and clinical outcomes. Results using SPSS19.0 statistical software package was used for statistical analysis of experimental data. Count data using chi square test, measurement data using independent samples t test, correlation analysis of the experimental data and clinical evaluation index, using Spearman correlation coefficient.P0.05 difference was statistically significant.
Result
1. the content of VE in serum and follicular fluid of the study group was significantly higher than that of the control group in serum and follicular fluid VE (P0.05). The level of SOD and ROS in the study group did not change significantly compared with that in the control group, with no statistical significance (P0.05).
2. in the study group and the control group, the level of VE increased significantly in serum than follicular fluid, and the level of SOD in follicular fluid was significantly higher than that in serum (P0.05).
3., the average number of eggs and clinical pregnancy rate between the study group and the control group were not statistically significant (P0.05). The fertilization rate and quality embryo rate in the control group were higher than those in the study group, and the implantation rate in the study group was higher than that in the control group, but there was no statistical significance (P0.05).
4. in the control group, serum and follicular fluid in VE, SOD and ROS levels and IVF-ET outcome evaluation index correlation analysis found that ROS levels and outcome of IVF-ET in serum and follicular fluid index was negatively correlated with the level of trend, planted in the follicular fluid of ROS was negatively correlated, with statistical significance (P0.05). But SOD and outcome evaluation index was negatively correlated. In the study group, the serum ROS in IVF-ET evaluation and outcome basically shows a negative trend, but there were no significant differences (P0.05). In general, the control group and study group VE, SOD and ROS have little relevance to the outcome of IVF-ET and the evaluation index.
conclusion
Oxidative stress of infertile patients with endometriosis in vivo, by systemic or local environmental damage follicle IVF-ET, thereby affecting the outcome; effect of adding vitamin E for endometriosis infertility patients with IVF-ET is not clear, may be related to the original oxidation properties and vitamin E, dosage and medication time of adding vitamin E still need further perfect.

【學(xué)位授予單位】：廣州醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R711.71

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8 朱志潔;徐榮春;陳麗春;;子宮內(nèi)膜異位癥治療60例臨床分析[J];中國(guó)現(xiàn)代藥物應(yīng)用;2013年18期

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