【摘要】：背景 在常規(guī)體外受精-胚胎移植（IVF）治療中，子宮內(nèi)膜的超聲檢查是一種常用的非侵入性檢查方法，用來評估子宮內(nèi)膜的容受性。子宮內(nèi)膜良好的血液供應通常被認為是著床的必要條件，因此，近年來，在IVF中對子宮內(nèi)膜血流的評估受到越來越廣泛的關(guān)注。有學者認為子宮內(nèi)膜的多普勒研究并不能反映實際流向子宮內(nèi)膜的血流情況，但三維能量多普勒超聲下子宮內(nèi)膜和內(nèi)膜下血流相關(guān)參數(shù)可以更客觀和更可靠的評價子宮內(nèi)膜血流情況。然而，就其對IVF妊娠結(jié)局的預測作用，報道的結(jié)果存在爭議。究其原因可能是因為實驗設計本身的不同以及超聲數(shù)據(jù)采集日期的不同。三維能量多普勒超聲以一種新的成像方式被引入到臨床實踐中。雖然這種技術(shù)可能不會取代二維超聲，但它正在越來越廣泛的被使用，并且它是一個非常好的可重復性技術(shù)。三維能量多普勒超聲能評估特定容積內(nèi)或整個器官的血管化程度，例如子宮或卵巢，它在一個特定容積內(nèi)的血流信號比二維超聲更能反映容積內(nèi)的血管化程度。使用三維能量多普勒超聲技術(shù)，我們既可以評估動脈血流，也可以評估靜脈血流，并且計算機技術(shù)使評估結(jié)果更客觀。因此，三維能量多普勒是評估血液循環(huán)的很好的工具。 越來越多的研究證明，僅用子宮內(nèi)膜厚度和類型來評價子宮內(nèi)膜的容受性是不全面的，子宮相關(guān)血流參數(shù)才是決定IVF-ET中子宮內(nèi)膜容受性的重要因素。而對于FET周期中子宮動脈及內(nèi)膜血流的研究相對較少，故本實驗主要在FET周期中，通過不同時段監(jiān)測子宮相關(guān)血流參數(shù)來評價子宮內(nèi)膜的容受性，以期為臨床工作提供參考。 目的 通過脈沖多普勒技術(shù)（PW）及彩色多普勒超聲技術(shù)（PDI），從影像學角度監(jiān)測子宮及子宮內(nèi)膜血流動力學變化，探討其對FET周期妊娠結(jié)局的影響。 方法 選擇2013年11月-2014年2月于鄭州大學第一附屬醫(yī)院生殖醫(yī)學中心行FET患者共310例，對這些患者于內(nèi)膜轉(zhuǎn)化日及移植前一天，通過彩色多普勒超聲診斷儀（GE公司生產(chǎn)的GEVOLUSON E8），監(jiān)測子宮內(nèi)膜厚度、子宮內(nèi)膜容積（V）、子宮內(nèi)膜血管指數(shù)（VI）、血流指數(shù)（FI）、血管血流指數(shù)（VFI）、子宮動脈收縮期峰流速（PSV）、舒張末期流速（EDV）、收縮期峰值流速/舒張末期流速（S/D）、搏動指數(shù)（PI）、阻力指數(shù)（RI）等參數(shù)，分別進行分組比較，并進行統(tǒng)計學分析。 結(jié)果 1.三維能量多普勒超聲測量子宮動脈及內(nèi)膜相關(guān)指標與妊娠結(jié)局關(guān)系：轉(zhuǎn)化日妊娠組子宮動脈搏動指數(shù)（PI）顯著低于非妊娠組，兩組比較有統(tǒng)計學差異（P＜0.05）；移植前日妊娠組子宮動脈搏動指數(shù)（PI）、阻力指數(shù)（RI）顯著低于非妊娠組，且差異有統(tǒng)計學意義（P＜0.05），移植前日妊娠組子宮內(nèi)膜血管指數(shù)（VI）、血流指數(shù)（FI）、血管化血流指數(shù)（VFI）及子宮內(nèi)膜容積（V）顯著高于非妊娠組，差異有統(tǒng)計學意義（P＜0.05）。子宮內(nèi)膜容積（V）及子宮內(nèi)膜血管化血流指數(shù)（VFI）對妊娠結(jié)局有一定的預測價值，兩者的ROC曲線下面積分別為0.637、0.620。 2.轉(zhuǎn)化日與移植前日三維能量多普勒超聲測量相關(guān)指標比較：所有病例轉(zhuǎn)化日數(shù)據(jù)與移植前日數(shù)據(jù)比較發(fā)現(xiàn)，移植前日子宮動脈搏動指數(shù)（PI）雖低于轉(zhuǎn)化日，但無統(tǒng)計學差異（P＞0.05）。而移植前日子宮動脈阻力指數(shù)（RI）、子宮動脈收縮期峰值流速（PSV）、子宮動脈舒張末期流速（EDV）較轉(zhuǎn)化日降低，，且差異有統(tǒng)計學意義（P＜0.05）；移植前日子宮內(nèi)膜容積（V）、子宮內(nèi)膜血流指數(shù)（FI）較轉(zhuǎn)化日升高，且差異有統(tǒng)計學意義（P＜0.05）。 3.不同內(nèi)膜準備方式三維多普勒超聲測量參數(shù)的比較：自然周期組和激素替代周期（E-P周期）組在子宮動脈及內(nèi)膜相關(guān)血流參數(shù)方面無統(tǒng)計學差異（P＞0.05）。 4.不同內(nèi)膜厚度三維多普勒超聲測量參數(shù)的比較：內(nèi)膜厚度≥15mm組及8-14mm組子宮動脈PI、RI與≤7mm組相比較顯著降低，且差異均有明顯統(tǒng)計學意義（P＜0.05），≤7mm組子宮內(nèi)膜容積（V）與8-14mm、≥15mm組比較顯著較低，且差異有統(tǒng)計學意義（P＜0.05）。 5.不同指標與子宮內(nèi)膜厚度的相關(guān)性：子宮動脈RI、PI及子宮內(nèi)膜容積與子宮內(nèi)膜厚度的相關(guān)系數(shù)分別為-0.431、-0.775及0.796（P＜0.01）。 6.不同子宮動脈阻力指數(shù)（RI）妊娠率比較：子宮動脈阻力指數(shù)（RI）為0.70-0.85和0.86-0.95時，兩組妊娠率分別為53.18%、40.00%，且有統(tǒng)計學差異（P＜0.05）。 結(jié)論 1.子宮動脈阻力指數(shù)（RI）較低者較易獲得妊娠。子宮動脈阻力指數(shù)（RI）、子宮內(nèi)膜容積（V）及子宮內(nèi)膜血管化血流指數(shù)（VFI）是預測凍融胚胎解凍移植周期（FET）結(jié)局較好的指標，借助超聲監(jiān)測具有簡單、準確、快速的優(yōu)點。 2.子宮內(nèi)膜較厚者子宮動脈搏動指數(shù)（PI）、子宮動脈阻力指數(shù)（RI）較低。 3.不同內(nèi)膜準備方式子宮動脈及內(nèi)膜相關(guān)血流參數(shù)無明顯差異。
[Abstract]:background
In conventional in vitro fertilization-embryo transfer (IVF) treatment, endometrial ultrasonography is a commonly used noninvasive method for evaluating endometrial receptivity. Good blood supply to the endometrium is often considered a necessary condition for implantation. Therefore, the evaluation of endometrial blood flow in IVF has been increasing in recent years. Some scholars believe that the endometrial Doppler study does not reflect the actual flow of blood to the endometrium, but the parameters related to endometrial and subendometrial blood flow under three-dimensional power Doppler ultrasound can more objectively and reliably evaluate the endometrial blood flow. However, their predictions of IVF pregnancy outcome Three-dimensional power Doppler ultrasound has been introduced into clinical practice as a new imaging method. Although this technique may not replace two-dimensional ultrasound, it is being used more and more widely. And it's a very reproducible technique. Three-dimensional power Doppler ultrasound can assess the degree of vascularization in a particular volume or in an entire organ, such as the uterus or ovary. Its blood flow signals in a specific volume can better reflect the degree of vascularization in a specific volume than two-dimensional ultrasound. Using three-dimensional power Doppler ultrasound, we Both arterial and venous blood flow can be assessed, and computer technology makes the assessment more objective. Therefore, three-dimensional power Doppler is a good tool for assessing blood circulation.
More and more studies have proved that it is incomplete to evaluate endometrial receptivity only by endometrial thickness and type, and the parameters of uterine related blood flow are the important factors determining the endometrial receptivity of IVF-ET. To evaluate endometrial receptivity by monitoring uterine blood flow parameters at different time intervals, so as to provide reference for clinical work.
objective
The changes of uterine and endometrial hemodynamics were monitored by pulse Doppler (PW) and color Doppler ultrasound (PDI) in order to explore the effects of PW and PDI on the outcome of FET cycle pregnancy.
Method
A total of 310 FET patients were selected from the Reproductive Medical Center of the First Affiliated Hospital of Zhengzhou University from November 2013 to February 2014. The endometrial thickness, endometrial volume (V) and endometrial vascular index (VI) were monitored by color Doppler ultrasonography (GEVOLUSON E8) on the day of endometrial transformation and the day before transplantation. Blood flow index (FI), vascular flow index (VFI), uterine artery peak systolic velocity (PSV), end-diastolic velocity (EDV), peak systolic velocity/end-diastolic velocity (S/D), pulsatile index (PI), resistance index (RI) and other parameters were compared and statistically analyzed.
Result
1. The relationship between uterine artery and endometrial related parameters and pregnancy outcome measured by three-dimensional power Doppler ultrasound: The uterine artery pulsatility index (PI) of pregnancy group on the day of transformation was significantly lower than that of non-pregnancy group, the difference between the two groups was statistically significant (P < 0.05); the uterine artery pulsatility index (PI) and resistance index (RI) of pregnancy group on the day before transplantation were significantly lower than that of non-pregnancy group. The endometrial vascularization index (VI), blood flow index (FI), vascularized blood flow index (VFI) and endometrial volume (V) were significantly higher in the pregnant group than in the non-pregnant group on the day before transplantation (P < 0.05). The predicted area of the ROC curve is 0.637,0.620.
2. Comparing the data of conversion day and pre-transplantation day by three-dimensional power Doppler ultrasound, it was found that the PI of uterine artery on the day before transplantation was lower than that on the day before transplantation, but there was no significant difference (P > 0.05). Peak flow velocity (PSV) and end-diastolic flow velocity (EDV) of uterine artery were significantly lower than those on the day of transformation (P < 0.05), and endometrial volume (V) and endometrial blood flow index (FI) were significantly higher on the day before transplantation (P < 0.05).
3. Comparison of three-dimensional Doppler ultrasound parameters in different endometrial preparation methods: There was no significant difference in uterine artery and endometrial related blood flow parameters between natural cycle group and hormone replacement cycle group (E-P cycle) (P > 0.05).
4. Comparison of three-dimensional Doppler ultrasonographic parameters of different endometrial thickness: PI and RI of uterine artery in group (> 15mm) and group (> 7mm) were significantly lower than those in group (> 7mm) (P < 0.05). Endometrial volume (V) in group (> 7mm) was significantly lower than that in group (> 15mm), and the difference was statistically significant (P < 0.05). .05).
5. Correlation between different parameters and endometrial thickness: the correlation coefficients of RI, PI and endometrial volume with endometrial thickness were - 0.431, - 0.775 and 0.796 respectively (P < 0.01).
6. Comparing the pregnancy rates of different uterine artery resistance index (RI): when the RI was 0.70-0.85 and 0.86-0.95, the pregnancy rates of the two groups were 53.18% and 40.00% respectively, and there was significant difference (P < 0.05).
conclusion
1. Pregnancy is more likely to occur if the uterine artery resistance index (RI) is low. The uterine artery resistance index (RI), endometrial volume (V) and endometrial vascularization blood flow index (VFI) are good indicators for predicting the outcome of frozen-thawed embryo transfer cycle (FET).
2. the uterine artery pulsatility index (PI) and uterine artery resistance index (RI) were thicker in the endometrium.
3. there was no significant difference in blood flow parameters between endometrium and endometrium.
【學位授予單位】：鄭州大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R714.8

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