拮抗剂方案中晚卵泡期高孕酮暴露时间对临床妊娠率的影响

Correlation of the exposure time of progesterone elevation with pregnancy outcome of gonadotropin-releasing hormone antagonist cysles in women undergoing in vitro fertilization

目的分析探讨拮抗剂方案中晚卵泡期早发孕酮升高(PPR)暴露时间与临床妊娠率的关系。方法回顾性分析2015—2017年间本中心卵巢储备功能正常患者行拮抗剂方案促排卵,比较停药日孕酮(P)≤1.5μg/L与P>1.5μg/L组的妊娠率;根据促排卵晚卵泡期P达到1.5μg/L至停药日暴露时间,将促排卵停药日P<1.5μg/L患者定为高P暴露0 d,纳入A组,促排卵停药日P=1.5μg/L定为高P暴露1 d,纳入B组,促排卵晚卵泡期P达到1.5μg/L至停药日暴露2 d、3 d、≥4 d分别纳入C组、D组、E组,分析5组患者的基线资料、促排卵药物使用及实验室数据及临床妊娠率。结果 hCG注射日P≤1.5μg/L与P>1.5μg/L组临床妊娠率差异无统计学意义(P>0.05);A组、B组、C组临床妊娠率差异无统计学意义,E组妊娠率(35.29%)显著低于A^C组(57.69%、58.92%、57.57%,P=0.007);停药日P水平在A^E组间差异均有统计学意义[(1.34±0.14)μg/L、(1.76±0.23)μg/L、(2.01±0.25)μg/L、(2.47±0.71)μg/L、(2.56±0.77)μg/L,P=0.005];停药日E2水平A^E组间比较差异均有统计学意义[(3 472.42±1 686.26)μg/L、(4 160.82±2 197.45)μg/L、(5 250.63±2 292.16)μg/L、(5 291.71±2 084.86)μg/L、(5 139.90±2 756.57)μg/L],其中A组显著低于C组、D组、E组(P=0.000)。促排卵Gn使用总量E组[(2 094.40±759.75)IU]显著高于B组、C组、D组[(1 701.45±639.15)IU、(1 527.65±424.98)IU、(1 622.34±416.30)IU,P=0.000];5组间获卵数差异有统计学意义(10.9±6.7、14.9±8.2、19.0±9.2、18.9±9.2、15.8±9.4,P=0.000),5组间MII卵数差异有统计学意义(9.3±6.8、12.6±8.0、16.6±8.7、16.1±7.6、11.8±7.8,P=0.000)。结论 PPR常伴发h CG注射日高雌激素水平和获卵数增高,卵巢储备正常的年轻患者,拮抗剂方案促排卵过程中晚卵泡期P升高可能与多卵泡发育累计效应有关。晚卵泡期血清P达到1.5 ng/mL暴露0~2 d的临床妊娠率差异无统计学意义,暴露超过4 d的临床妊娠率显著下降,建议取消移植。患者子宫内膜容受性不仅需参考h CG注射当日的P水平,而且充分考虑到高P暴露时间长短对子宫内膜容受性的影响。

Objective To evaluate the clinical pregnancy rate of the exposure time of progesterone （P） elevation≥1.5 ng/mL from 0 d to 4 d in gonadotropin-releasing hormone antagonist （GnRH-A） cysles. Methods In this retrospective study, the data of 364 IVF GnRH-A cycles performed in our hospital from 2015 to 2017 were analyzed. According to the day of the exposure time of P elevation ≥1.5 μg/L, the patients were divided into five groups （groups A-E） of the exposure time 0-4 d, the clinical outcomes were compared among the groups. Results The clinical pregnancy rate was not significantly different between the P levels ≤ 1.5μg/L on hCG injection day group and 〉1.5μg/L on hCG injection day group; the clinical pregnancy rates in groups A-C were not significantly different, it was significantly lower in group E （35.29%） than in groups A-C （57.69%, 58.92%, 57.57%）; the dosage of Gn used, No. of oocytes retrieved and M11 oocytes were significantly different among five groups （P〈0.05）. Serum E2 and P levels of the trigger day were significantly different among five groups （P〈0.05）. Conclusion Premature P rise was related to the total FSH dosage and number of the oocytes, not only the absolute P level on the day of hCG injection as an indicator of endometrial recepitivity, but also the time of the exposure time of P elevation should be considered, the clinical pregnancy rate was significantly lower with the exposure time of 4 d of P elevation 1.5 μg/L and should be cancellated the cycle at all.