1病历摘要 患者,32岁,因反复移植失败3次合并种植窗延迟,再次取卵术后1月,于2023年2月2日至四川大学华西第二医院就诊.患者12岁初潮,平素月经周期规律,周期28～32天,经期6天,经量中等,无痛经,G0P0,因原发不孕于3年前在外院行子宫输卵管碘油造影术,结果提示双侧输卵管阻塞.于外院行体外受精-胚胎移植(IVF-ET)辅助助孕,促排卵前患者于外院宫腔镜检查提示慢性子宫内膜炎,给予多西环素100 mg(每天2次,连用2周)规范治疗,采用黄体期短效长方案促排卵,共计获卵8枚,其中成熟卵7枚,获得第3天卵裂期胚胎5枚,行卵裂期新鲜胚胎移植1枚,余囊胚培养形成优质可移植囊胚3枚,行囊胚冷冻.

基因位点变异、染色体数目和/或结构异常而发生的遗传性疾病是人类面临的重大健康问题.患者可自胎儿期到出生后的任何时期发病,部分患者需要实施生命维持治疗,生命维持治疗虽可获得伦理称颂,但巨大的个人或社会公益性医疗费用支出也是家庭和社会必须正视的问题.勿需实施生命维持治疗的遗传病患者,所表现的体格发育和/或智力发育缺陷给患者、家庭和社会带来经济、生活和社交活动等多方面的负面影响.

子宫内膜癌(endometrial carcinoma,EC)是全球女性中常见的癌症,排名第6位[1],主要发生于绝经期,其中5％的患者在40岁之前发病,并且大多数还未完成生育[2].EC的标准手术治疗方式包括全子宫切除术+双侧附件切除术,患者将因此失去生育能力,由于女性生育年龄的推迟和EC的良好预后,保留生育功能治疗备受关注.保留生育功能治疗主要包括大剂量的孕激素制剂、宫内孕激素缓释系统、促性腺激素释放激素激动剂(GnRHa)及联合宫腔镜手术[3].

卵泡正常发育并排出卵子,是维持正常月经,实现生育的必备条件.下丘脑-垂体-卵巢轴的控制与反馈正常与否,是决定卵泡发育及排出是否正常的核心,该轴线疾病、影响该轴线功能的相关生理状态或疾病、药物或手术干预等将引起卵泡发育缓慢、停滞、异期或排出受阻,将导致异常子宫出血(cabnormal uterine bleeding,AUB)、闭经和不孕.在排除妊娠、哺乳、药物避孕或手术导致双侧卵巢功能丧失等状态下的卵泡发育异常或排出障碍,称之为排卵障碍.2022年 10 月,国际妇产科联盟(International Federation of Gynecology and Obstetrics,FIGO)在人类生殖《Human Reproduction》、生育与不育《Fertility and Sterility》和国际妇产科杂志《International Journal of Gynecology &Obstetrics》发表了基于德尔菲共识方法(Delphi con-sensus process)形成的排卵障碍分类系统[1].

Background To compare the efficacy and safety of follitropin delta in its individualized fixed-dose regimen with follitropin alfa in a conventional adjustable dosing regimen in Chinese women. Methods This was a subgroup analysis of the randomized, multi-center, assessor-blind, non-inferiority trial (GRAPE) including 759 Chinese women (aged 20–40 years) recruited in 16 reproductive medicine clinics in China. Women were randomized in a 1:1 ratio to be treated with either follitropin delta dose based on anti-Müllerian hormone (AMH) and body weight or conventional dosing with follitropin alfa following a gonadotropin-releasing hormone (GnRH) antagonist protocol. The primary outcome was ongoing pregnancy rate assessed 10–11 weeks after embryo transfer in the fresh cycle (non-inferiority margin -10.0%). Results 378 in the follitropin delta group and 381 in the follitropin alfa group were randomized and exposed. Non-inferiority was confirmed with respect to ongoing pregnancy with rates of 31.0% vs. 25.7% for follitropin delta compared to follitropin alfa, estimated mean difference of 5.1% (95% confidence interval (CI) -1.3% to 11.5%). The clinical pregnancy rate (35.4% vs. 31.5%, P = 0.239) and live birth rate (31.0% vs. 25.5%, P = 0.101) were comparable between the follitropin delta group and the follitropin alfa group. Overall, the individualized follitropin delta treatment resulted in fewer oocytes retrieved compared to follitropin alfa treatment (10.3 ± 6.2 vs. 12.5 ± 7.5, P < 0.001), which was mainly due to fewer oocytes (10.5 ± 6.4 vs. 13.9 ± 7.8) in women with AMH ≥ 15 pmol/L. Accordingly there was a lower incidence of early ovarian hyper-stimulation syndrome (OHSS) and/or preventive interventions (6.1% vs. 11.0%, P = 0.013). A daily follitropin delta dose of 10.2 µg (95% CI: 9.3—11.2 µg) was estimated to provide the same number of oocytes retrieved as a starting dose of 150 IU/d of follitropin alfa. Conclusion Follitropin delta in its individualized fixed-dose regimen showed similar efficacy and improved safety compared with follitropin alfa in a conventional adjustable dosing regimen in Chinese women. Clinical trial registration number NCT03296527.

Leukocytospermia is one of the common causes of male infertility, and its effects on the clinical outcomes of assisted reproduction are controversial. There are no recommendations for the management of leukocytospermia in cases of assisted reproductive technology (ART). To investigate the impact of leukocytospermia on ART, we retrospectively compared the clinical outcomes in ART couples with or without leukocytospermia and further analysed the impact of the insemination method itself by split insemination treatment in ART couples with leukocytospermia. In this study, leukocytospermia was detected in 133 patients, namely 63 in the conventional in vitro fertilization (IVF) group, 38 in the intracytoplasmic sperm injection (ICSI) group and 32 in the split insemination group. Leukocytospermia has a negative influence on the parameters of semen samples; however, leukocytospermia did not affect the clinical outcomes of IVF or ICSI. Different insemination methods did not affect the fertilization, clinical pregnancy or live birth rates. In the split insemination study, no significant differences in clinical pregnancy and live birth rates between the IVF and ICSI groups were found; however, the numbers of two pronuclei (2PN), available embryos and good-quality embryos in the ICSI group were higher than those in the IVF group. Leukocytospermia may be a risk factor affecting semen parameters, and more attention should be given to IVF insemination. Leukocytospermia has no significant negative effect on the outcomes of ART. ICSI may obtain better embryos than IVF, but it cannot improve the clinical pregnancy and live birth rates.

集落刺激因子(colony stimulating factor,CSF)是促进髓系祖细胞增殖、分化的一组生长因子,包括巨噬细胞集落刺激因子(macrophage colony stimulating factor,M-CSF/CSF1)、粒细胞巨噬细胞集落刺激因子(granulocyte-macrophage colony stimulating factor,GM-CSF/CSF2)、粒细胞集落刺激因子(granulocyte colony stimulating factor,G-CSF/CSF3)、多重集落刺激因子(multi-CSF/IL3)等,重组上市的商品化产品则称之为相应的形成细胞刺激因子.骨髓、间质细胞、成纤维细胞、单核细胞和巨噬细胞均可产生CSF,重组的GM-CSF、G-CSF、M-CSF在血液系统疾病和防治肿瘤放化疗不良作用等领域应用已经超过30年[1].CSF 与其受体(CSF-receptor,CSF-R)结合后发挥作用.已有研究发现,除髓系祖细胞、髓系白血病细胞、成熟的中性粒细胞、血小板、单核细胞、淋巴细胞和一些T细胞和B细胞膜上表达特异性的CSF-R外,子宫内膜上皮细胞、胎盘细胞、滋养细胞和黄素化的卵巢颗粒细胞等许多非造血组织细胞亦可表达CSF-R.

1病历摘要 患者,31岁.因婚后未避孕未孕4年,体外受精(IVF)失败2次,于2019年1月5日就诊于四川大学华西第二医院生殖医学科.患者20岁时出现痛经,疼痛程度逐渐加重,8年前诊断为“子宫腺肌病”,给予去氧孕烯-炔雌醇(妈富隆)治疗,月经期间服用布洛芬.患者于2014年结婚,婚后性生活正常,未避孕一直未孕.2017年7月15日曾就诊于本院,此前在院外先后进行了生殖激素测定和丈夫精液检查(报告丢失),对所带子宫输卵管造影片进行阅片后发现,子宫腔显影良好,双侧输卵管连续显影,弥散差,提示双侧输卵管通畅,怀疑粘连.

多囊卵巢综合征( polycystic ovary syndrome,PCOS)是常见妇科内分泌疾病,对妇女健康的早期影响主要表现为月经失调、多毛、痤疮、卵泡发育障碍所致不孕,以代谢异常为核心伴发的肥胖、糖耐量受损( impaired glucose tolerance,IGT ) 、 2 型糖尿病( type 2 diabetes mellitus,T 2 DM) 、心血管疾病( cardiovascular disease,CVD) 、子宫内膜癌、阻塞性睡眠呼吸暂停综合征( obstructive sleep apnea,OSA) 、非 酒 精 性 脂 肪 肝( nonalcoholic fatty liver disease,NAFLD) 、抑郁症、暴食症或厌食症等长期并发症可出现于青春期及青春期后的各年龄段,自然妊娠或助孕成功妊娠后的并发症发生率也显著增加[1].在管理 PCOS 患者月经和生育问题的同时,必须重视长期并发症的筛查和管理.

子宫内膜癌(endometrial cancer, EC)是常见的妇科恶性肿瘤.2017年,以子宫内膜癌为主要表现的子宫体恶性肿瘤的全球新发病例超过 40 万,年发病率达到9.6/10 万[1].疾病报告体系建立完善国家新发病例的年发病率更高,达到15～27/10 万,14 ％发生于绝经前, 5 ％的患者确诊年龄低于40岁[2].美国的一项大型研究显示,子宫内膜增生年发生率为132.57/10 万,其中的子宫内膜非典型增生(endometrial atypical hyperplasia,EAH)年发生率为18.63/10 万,35岁前诊断者占2.6 ％,40 岁前患者占7.3 ％[3].80 ％的Ⅰ型 EC 与子宫内膜增生有关联,一项跨时15 年共 306 例 EAH 随访结果显示, 29.1 ％发展成为 EC[4].

目的 了解抗精子抗体(Anti-sperm antibody,ASAb)、抗子宫内膜抗体(Anti-endomertrial antibody,EMAb)、抗心磷脂抗体(Anti-cardiolioin antibody,ACAb)在不孕不育患者中的阳性率.方法 将11984例样本用酶联免疫吸附实验(enzyme-linked immunosorbent assay,ELISA)法进行检测.结果 男性ASAb阳性率11.13%,女性ASAb阳性率10.97%,EMAb阳性率6.47%,ACAb阳性率7.22%,三种抗体中的任意两种抗体阳性率4.36%,三种抗体阳性率3.49%.结论 ASAb、EMAb、ACAb在不孕不育患者中的阳性率高,可能是导致患者不孕不育的重要因素之一.

目的 探讨男性精子质量和形态对反复自然流产(RSA)的影响.方法 选择2015年1-12月就诊的568例RSA患者配偶作为试验组,选取同期进行体检的80例有过一次生育史的男性作为对照组,严格按WHO的操作指南对精液常规及形态学进行分析.结果 试验组与对照组精液的量、pH、液化时间,密度、存活率、前向运动百分率比较差异无统计学意义(P＞0.05);试验组正常形态百分率明显低于对照组,差异有统计学意义(P＜0.05).结论 RSA患者配偶精液的正常形态精子减少,畸形精子率高可能是导致RSA的原因之一.

目的:探讨淋巴主动免疫治疗原因不明复发性流产的疗效.方法:选择近三年不明原因复发性流产的患者行淋巴细胞主动免疫治疗的患者1864例,随访其转阳率、成功妊娠率、再次流产率及不良反应发生情况.结果:随访到1632名患者,经免疫治疗后HLA-DR抗体转阳率为85.11%;成功分娩1242人,分娩率76.10%;再次流产94人,再次流产率5.76%.仅22人出现了轻微的红肿反应,4人有低热,均自行好转.结论:淋巴主动免疫是治疗原因不明复发性流产有效的方法,应被广泛应用临床,积极推广.

获得生育能力称之为生育力( fecundity ),一般以观察时间段的临床妊娠率或活产率来评价,也可将获得临床妊娠时间( time to pregnancy,TTP)的长短作为评价指标。女性在25岁后,随着年龄的增加,生育力逐渐下降,自然流产率、妊娠和分娩期并发症、围生儿病率和死亡率等同步上升,35岁后这些变化更为明显,因此通常将35岁以上的妇女定义为生育高龄妇女(advanced maternal age,AMA),超过45岁以上的妇女则定位为超高龄妇女( very advanced maternal age,vAMA)[1]。据测算,我国全面实施二孩政策后符合条件的1.4亿对夫妇中,女方年龄在35岁以上的约60%[2],其中新增9000万对夫妇中,40~49岁的约占50%。全面实施二孩政策,需要解决生得起、生得出、生得好3个问题[3]。科学精准的生育力评估后,对目标人群提出合理实用的生育方法建议,使有生育能力的夫妇选择恰当的方法尽早怀孕,对已经失去自然生育能力的夫妇做出放弃生育的建议,减少夫妇实现二孩生育的经济付出和时间消耗,在此基础上对怀孕后的母胎进行科学保健以实现优生。

One of the important content of assisted reproductive technology(ART) is ovarian stimulation,the application which can improve the clinical pregnancy rate, but increase multiple pregnancy, ovarian hyperstimulation syndrome(OHSS), and some other complication rates. The common used drugs for ovulation induced include clomiphene citrate(CC), aromatase inhibitors, gonadotropin(Gn), gonadotrophin-releasing hormone analog(Gn RHa) such as Gn RH-agonist(Gn RH-a) and Gn RH-antagonist(Gn RH-A). Drugs have different indications,contraindication and protocls. There are other ovulation stimulants including oral contraceptive(OC), metformin,dopmine receptor agonists, etc. The commonly used therapeutic evaluation index and calculation method are also introduced. Combining the study progress and clinical application of related fields domestic and abroad in recent years, some experts of Chinese Medical Association Reproductive Medicine Group reached a consensus on the application of ovarian stimulation in ART, in order to guide the standardization of its clinical use.

目的 比较各细胞因子和趋化因子在多囊卵巢综合征(PCOS)患者和正常妇女卵巢黄素化颗粒细胞的表达及血清、卵泡液中的水平,初步探讨PCOS慢性炎症的可能机制.方法 2014年1月-8月选择体外受精-胚胎移植中PCOS患者及非PCOS患者各40例,收集其颗粒细胞、卵泡液和血清,分别用实时荧光定量-聚合酶链式反应、酶联免疫吸附法进行检测,观察肿瘤坏死因子-α(TNF-α)、白细胞介素(IL)-6、IL-8及生长调节致癌基因-α(GRO-α)表达的差异,并按是否肥胖(体质量指数＞25 kg/m2)分层进行组间比较.结果 在肥胖者中,TNF-α、IL-6、IL-8、GRO-α在PCOS组的表达高于对照组,差异有统计学意义(P＜0.05);在非肥胖者中,TNF-α、IL-8、GRO-α在PCOS组的表达高于对照组,差异有统计学意义(P＞0.05),两组IL-6表达差异无统计学意义(P＞0.05).结论 炎性因子IL-8、TNF-α、IL-6和趋化因子GRO-α在PCOS的发生发展中可能起了重要的作用.PCOS可能是一种慢性炎性疾病.

促排卵治疗是辅助生殖技术(ART)的重要内容之一,但其改善临床妊娠率的同时,亦使卵巢过度刺激综合征(OHSS)、多胎妊娠、多部位妊娠等并发症发生几率增高.本文从ART并发症的诊断、治疗及预防等方面进行阐述,结合近年来国内、外相关领域研究进展及临床应用,中华医学会生殖医学分会部分专家对ART并发症的诊断和处理达成共识,以指导规范的临床应用.

胎儿电子监护是迄今为止最为简便且较为准确地探测胎儿宫内是否存在乏氧状态的方法,32周以上以及产程发作后应该常规进行。正确的监护操作、图形识别、结果判断、及时正确处理异常结果,方可获得满意的围产儿结局。

Objective To investigate the clinical characteristics,diagnosis,treatment and maternal-fetal prognosis of acute fatty liver of pregnancy(AFLP).Methods A retrospective analysis was performed in 17 cases with AFLP from January 2003 to December 2012 at the department of gynecology and obstetrics in our hospital.Results In 17 cases with AFLP,there were two cases of maternal deaths(11.2%) and two cases of fetal death(11.2%).The clinical manifestations of the most patients were gastrointestinal symptoms.Laboratory examinations showed abnormal liver function and disturbances of blood coagulation.Treatments included timely termination of pregnancy,comprehensive treatment and intensive care.Conclusions AFLP is a dangerous disease with high rate of mother-fetal death.The understanding of the diseases,timely diagnosis and comprehensive treatment may improve the clinical outcome.

<正>患者,26岁,月经规律,周期30天左右。10天前因孕39+2周,规律腹痛,外阴静脉曲张在外院行剖宫产术,术中发生产后出血,输入红细胞悬液800 ml,冰冻血浆100 ml,冷沉淀1个单位。术后恢复正常,第9天出院。出院后次日出现无任何诱因的发热,自测体温38℃以上,同时阴道较多流血,进而出现头晕、乏力。再次急诊入前次医院,急查显示,大量阴道流