非降调促排卵方案在多囊卵巢综合征患者行体外授精-胚胎移植治疗中的疗效比较

Effects of ovarian stimulations without pituitary down regulations in induction of ovulation in infertile women with polycystic ovary syndrome (PCOS) undergoing IVF-ET

目的：比较单纯促性腺激素（gonadotropin,Gn）与来曲唑（letrozole LE）联合Gn及克罗米芬（clomiphene citrate CC）联合Gn对多囊卵巢综合征（polycystic ovarian syndrome,PCOS）不孕患者行体外授精-胚胎移植（IVF）的治疗疗效。方法：对2014年3月到2015年8月在温州医科大学附属第一医院生殖中心进行体外受精-胚胎移植（in vitrofertilization-embryo transfer,IVF-ET）治疗的90例PCOS不孕症患者进行前瞻性研究,随机分为Gn组、LE组和CC组各30例。Gn组在月经周期第3~5天开始用低剂量Gn促排卵;LE组在月经周期第3~5天开始口服来曲唑片2.5 mg bid,之后根据B超监测及血内分泌情况决定何时予以人绝经期促性腺激素（human menopausal gonaotropin,HMG）以及是否口服来曲唑直至诱发排卵日,CC组在月经周期第3~5天开始口服来克罗米芬片100 mg qd,如果当优势卵泡达到14 mm而内膜厚度〈7 mm时,加芬吗通白片（雌二醇）1mg pv qn,并且继续克罗米芬50 mg直至诱发排卵日,比较三组的实验室指标及临床结局。结果：（1）实验室指标：Gn组获卵393个,LE组获卵281个,CC组获卵383个,三组之间的卵母细胞成熟率分别为86.01%（338/393）、81.85%（230/281）、82.25%（315/383）,受精率分别为72.19%（244/338）、72.17%（166/230）、70.48%（222/315）,优胚率分别为53.97%（129/239）、57.32%（90/157）、52.80%（113/214）,差异均无统计学意义（P〉0.05）,CC组的种植率为31.25%（15/48）,稍低于Gn组37.31%（25/67）及LE组33.87%（21/62）,但差异无统计学意义（P〉0.05）。（2）临床结局：HCG日内膜厚度,CC组明显低于Gn组和LE组,分别为（7.40±2.70）mm、（10.13±2.27）mm、（9.10±2.09）mm,差异均具有统计学意义（P〈0.05）,临床妊娠率三组分别为45.83%、60.00%、57.14%,Gn明显高于其他两组,但差异无统计学意义（P〉0.05）。三组的流产率分别为5.56%（1/18）、18.75%（3/16）、18.18%（2/11）,差异均无统计学意义（P〉0.05）。卵巢过度刺激综合征（OHSS）发生率LE组（46.67%）明显低于其他两组,且差异具有统计学意义（P〈0.05）。结论：PCOS不孕患者使用Gn、LE、CC三种非降调促排卵方法均可获得较满意的实验室和临床结局。CC组的HCG日内膜虽然较Gn及LE两组薄,但联合芬吗通白片使用后其临床结局与其他两组并无统计学差异,故就经济效应及临床结局双重而言,仍是PCOS患者的一线选择。

AIM： To compare the effectiveness of Gonadotropin（ Gn） and letrozole（ LE） combined with Gn and clomiphene citrate（ CC） combined with Gn in infertile women with PCOS undergoing in vitro fertilization-embryo transfer（ IVF-ET）. METHODS： 90 infertile patients with PCOS undergoing IVF-ET in reproductive medicine center of the first affiliated hospital of Wenzhou Medical Colleage from March 2014 to August 2015 were enrolled and wererandomly divided into three groups： Gn group（ 30cycles）,gonadotropin only; CC group（ 30 cycles）,which was treated with clomiphene citrate（ CC）combined with gonadotropin,added estradiol when endometrium was thin; LE group（ 30 cycles）,which was treated with letrozole（ LE） combined with gonadotropin. Laboratory and clinical parameters were compared among the three groups. RESULTS： MII rate,fertilization rate,cleavage rate,high-quality embryos rate among the three groups showed no statistical difference（ P 〉 0. 05）. Implantation rate of CC group（ 31. 25%） was lower than the Gn group（ 37. 31%） and LE group（ 33. 87%） butit did not have statistical difference（ P 〉 0. 05）. Endometrial thickness on the HCG trigger day in CC group（ 7. 40± 2. 70） mm was thinner than Gn group（ 10. 13 ±2. 27） mm and LE group（ 9. 10 ± 2. 09） mm,the difference was significant（ P 〈 0. 05）. The clinical pregnancy rate of Gn group（ 60. 00%） was much higher than LE group and CC group,but showed no statistical difference（ P 〉 0. 05）. The abortion rate of the three group showed no statistical difference. The rate of ovarian hyper stimulation syndrome（ OHSS）in LE group was lowest among the three groups（ P 〈0. 05）. CONCLUSION： Infertile patients with PCOS undergoing the three patterns of ovarian stimulation without pituitary down regulation can get satisfactory laboratory and clinical outcomes. Though the use of CC may present thinner endometrial,estradiol can improve the clinical effects,so it’s still the recommended therapy for PCOS considering the economic effect when compared with Gn and LE.