GnRH-a降调节激素替代方案在IVF移植失败患者中应用的探讨

Application of GnRH-aDown-regulated Hormone Replacement Protocol in IVF Transfer Failure Cases

目的:探讨促性腺激素释放激素激动剂(GnRH-a)降调节激素替代方案在体外受精(IVF)移植失败患者中的适用指征,规范临床方案的选择。方法:选择2015年1月至2018年10月于江西省妇幼保健院行冻融胚胎移植周期的5467例患者,按照IVF移植失败0次、1次、2次及2次以上将患者分为4个层次,分别比较降调节激素替代方案组(GnRH-a组)与非降调节激素替代方案组(HRT组)的临床结局。最后通过多元Logistic回归控制混杂因素。结果:移植失败0、1次时GnRH-a组女方年龄显著高于HRT组(P<0.05),失败2次患者HRT组继发不孕占比高于GnRH-a组(65.4%vs 57.4%),差异有统计学意义(P<0.05)。临床结局比较中,GnRH-a组内膜厚度显著高于HRT组(P<0.05),差异均有统计学意义(P<0.01),失败0次患者GnRH-a组活产率显著低于HRT组(35.14%vs 47.62%,P<0.05),差异有统计学意义。多元Logistic回归分析显示,对于移植失败>2次患者,调整女性年龄、移植胚胎数目、移植胚胎分期等混杂因素后,GnRH-a降调节方案较HRT方案活产率更高(调整OR=0.46,P=0.028)。结论:GnRH-a降调节方案可有效增加内膜厚度;对于移植失败0、1次患者,GnRH-a方案不增加活产率;对于移植失败2次患者,GnRH-a降调节方案有升高活产率的趋势,但尚需大样本研究验证;对于移植失败>2次患者,GnRH-a降调节方案对增加活产率有利。

Objective:To explore the indications of Gonadotropin-releasing hormone agonist(GnRH-a)down-regulated hormone replacement protocol in patients with in vitro fertilization(IVF)transfer failure,and to standardize the selection of clinical protocols.Methods:A total of 5467 patients who underwent freeze-thaw embryo transfer in Jiangxi maternal and child health hospital from January 2015 to October 2018 were analyzed.The patients were divided into four levels according to IVF transfer failures of 0,1,2 and more than 2 times.The clinical outcomes of down-regulated(GnRH-a group)and non-down-regulated hormone replacement(HRT group)protocol were compared respectively.The confounding factors were controlled by multiple logistic regression.Results:The age of the GnRH-a group was significantly higher than that of the HRT groupin patients with 0 or 1 times IVF transfer failure.For patients with 2 IVF transfer failure,the proportion of secondary infertility in the HRT group was significantly higher(65.4%vs.57.4%)than that in the GnRH-a group.In comparison of clinical outcomes,the endometrium in GnRH-a group was significantly thicker than that in HRT group(P<0.01).For patients with no IVF transfer failure,the live birth rate of GnRH-a group was significantly lower(35.14%vs.47.62%)than that of HRT group.Multivariate logistic regression analysis showed that for patients with>2 times transfer failures,down-regulation with GnRH-a could increase live birth rate compared with HRT protocol after controlling for confounding factors such as female age,number of embryos transferred and phase of embryo transferred(adjustOR=0.46,P=0.028).Conclusions:GnRH-a downregulation protocol could improve endometrium thickness.GnRH-a down-regulation does not increase the live birth rate for patients with 0 or 1 times transfer failure.GnRH-a down-regulation has a tendency to increase the live birth rate for patients with 2 times transfer failure,which still needs large sample research to verify.GnRH-a down-regulation is beneficial to increase live birth rate in patients with>2 times transfer failure.