t the GP will see as normal for your general health). For donor eggcycles, studies have suggested that if the lining is too old(lining starts to grow shortly after the beginning of your periodon a natural cycle or, on from the start of estrogen (or stimms)medication on a down regulated cycle), then implantation ratesfall.
A significant fall in pregnancy rateshas been observed if estrogen medication was started more than 7weeks before embryo transfer 。
首先,治療好可能導(dǎo)致內(nèi)膜薄的內(nèi)膜炎癥,
其次,嘗試用藥提高內(nèi)膜厚度,如:
1) 萬(wàn)艾可:每天4次每次25mg陰道給藥;
2) 雌二醇:國(guó)內(nèi)是補(bǔ)佳樂(lè)或芬嗎通,準(zhǔn)醫(yī)囑;
3)特布他林:另外一種血管擴(kuò)張藥物,每日5mg每天三次口服同時(shí)新鮮周期促排后或人工解凍周期如補(bǔ)佳樂(lè)日開(kāi)始每天25mg每日四次陰道給藥,夜針日停
【新鮮周期】或移植前3天停【人工解凍周期】)、
4) G-CSF宮腔灌注;
5) 己酮可可堿:400mg每天2次,與ve同服,并可幫助內(nèi)異患者免疫調(diào)節(jié));
6) Ve 精氨酸:ve(每天600mg)聯(lián)合服用精氨酸(每天6g);
7) 足夠的蛋白質(zhì)和硒的攝入:蛋白粉、硒片、高蛋白飲食;
8) 中藥調(diào)理 泡腳;
再次,檢查甲狀腺激素,確保沒(méi)有甲亢或甲減。即使是別人給你供卵,你的內(nèi)膜長(zhǎng)得慢一樣影響受孕率。有研究表明,移植前運(yùn)用雌激素藥物超過(guò)7周將會(huì)大大降低妊娠率。
2) 卵巢反應(yīng)不好
poor response i.e., less than 4 eggs recovered - 3 months DHEApretreatment (see supplements), estrogen priming protocols, higherstarting doses (often with a step down in dose after a few days),short protocol with natural cycle start rather than from the pill,long protocol if you have not already tried that,agonist/antagonist conversion protocols - diminished ovarianreserve can also be exacerbated by being subclinically hypothyroid- its definitely worth checking your TSH and FT4 with your GP - seeThyroid. Also, consider treatment with dexamethasone 0.5mg (orequivalent dose of prednisolone) possibly for up to 3 months priorto IVF, in case autoimmune activity (e.g., antiovarian antibodies)are compromising ovarian response. For some ladies with poorresponse/high AMH there is no advantage in using stimulated IVF andthey might actually have a slightly better chance with a naturalcycle IVF.
少于4個(gè)泡要提前吃3個(gè)月dhea。Ivf前吃3個(gè)月地米每天0.5mg(或同等劑量強(qiáng)的松)預(yù)防免疫亢奮影響卵巢反應(yīng)。最好自然周期取卵。
3) 卵泡質(zhì)量不好
poor egg quality - resveratrol and/or pycnogenol and/or lycopenepretreatment (also antioxidant diets e.g., those with lots ofred/orange/green veg, wheatgrass, spirulina, beetroot powder etc),melatonin, inositol or alpha lipoic acid (mainly for PCOSsufferers), 3 months DHEA pretreatment (but not if there is a highLH:FSH ratio, low SHBG, high testosterone, high antral folliclecounts or PCOS), assisted hatching, high protein/low GI diet,limiting LH (by using only/mainly pure FSH until day 4 of stims,and then using a limited dose of LH per day - e.g., using mainlygonal-F, puregon or follistim with either menopur or luveris to addLH) and by using long protocol or a short protocol with a half doseof antagonist which starts on day 1 of stims. Poor egg qualitywhere eggs show thickened zona and none of the eggs recovered areimmature can indicate that the stimulation was continued for toolong and the eggs are over-mature/atresic (a good indicator of thequality of a batch of eggs is to have 10-40% immature eggs in thebatch) - better quality eggs may result from doing a shortstimulation and not sacrificing the dominant (and probably bestquality) follicles in order to allow the rest of the batch to catchup. Anti-inflammatory diet/supplements if elevated TNFa appears tobe involved. Natural cycle IVF or very low dose stimulationprotocols are worth considering to maximise egg quality, althoughthis will be at the expense of egg numbers, so you may need to seethis as more of a course of, say, 3 natural cycle IVFs before youcan decide whether the approach is working for you.
白藜蘆醇和/或碧蘿芷和/或番茄紅素(或抗氧化劑飲食如紅色、橙色、綠色蔬菜,螺旋藻等),褪黑素,肌醇或α新硫酸(尤其多囊患者),3個(gè)月dhea(高lh:fsh者,低SHBG,睪酮水平高,高竇卵泡計(jì)數(shù)或多囊卵巢綜合征者不能吃),輔助孵化,高蛋白/低GI飲食,限制LH(前四天促排只用純FSH藥物,然后每天用限量的LH-例如Gonal-F),等等。如果tnf高,要同時(shí)抗炎飲食或治療;最好自然周期ivf或者低劑量促排。
GI(GlycemicIndex)是指食物的血糖生成指數(shù),是反映食物引起人體血糖升高程度的指標(biāo),是人體進(jìn)食后機(jī)體血糖生成的應(yīng)答狀況。GI值高的食物進(jìn)入腸道后容易吸收,葡萄糖能夠很快的進(jìn)入血液,導(dǎo)致血糖升高的速度較快,容易出現(xiàn)高血壓、高血糖的現(xiàn)象.而GI值低的食物進(jìn)入腸道后釋放緩慢,吸收的速度也較慢,所以不容易引起血糖的變化。多余的胰島素還有利于幫助糖原、脂肪和蛋白質(zhì)的分解,燃燒體內(nèi)脂肪,起到瘦身的作用。低gi食物:
1. 谷類:極少加工的粗糧。如煮過(guò)的整粒小麥、大麥及黑麥;硬質(zhì)的小麥粉面條、通心面;玉米面粥、強(qiáng)化蛋白質(zhì)的苗條等;
2. 干豆類及其制品:豆類的GI值普遍較低,如綠豆、蠶豆、扁豆及其制品等;
3. 乳類及其制品:乳類產(chǎn)品大多都是低GI產(chǎn)品,如牛奶、全脂&脫脂牛奶、奶粉、酸奶等;
4. 薯類:生的薯類以及經(jīng)過(guò)冷處理的舒蕾制品,如芋頭、藕粉、馬鈴薯粉條等;
5. 水果類:含果酸較多的水果,如蘋果、桃、李子、櫻桃等;
6. 即食食品:全麥或高纖維產(chǎn)品,如大麥面包、閑趣餅干、蕎麥方便面等;
7. 混合膳食:主要看食物的種類和比例,如包子、餃子、餛飩、豬肉燉粉條等;
8. 其他:含果糖、乳糖的農(nóng)作物及其制品。如花生。
4)
多囊PCO - asfor poor egg quality, but also pill pre-treatment to try to calmthe ovaries, low
GI(Glycemic Index) diet/healthy BMI, short protocolor agonist/antagonist conversion protocol, assisted hatching,metformin pre-treatment, alpha lipoic acid pretreatment, inositolpretreatment.
參考卵泡質(zhì)量不好解決辦法,進(jìn)周后服用避孕藥(如達(dá)英)讓卵巢休息。低GI飲食、控制體重、短的促排方案或激動(dòng)劑/拮抗劑方案、輔助孵化,提前2-3個(gè)月服用二甲雙胍、肌醇&膽堿、α-硫辛酸。
5)內(nèi)異/腺肌癥
endometriosis/adenomyosis - pycnogenol/resveratrol pre-treatment,prolonged pre-treatment down regulation, natural cycle FET, immunetreatment for NKa, anti-inflammatory supplements/diet,letrozole/femara in-cycle treatment.
提前吃碧蘿芷或白藜蘆醇,自然周期移植,針對(duì)NKa的免疫治療,抗炎飲食或治療,周期中服用來(lái)曲唑。
6) 胚胎分裂不好:參考卵泡質(zhì)量不好的解決辦法
slow cleavage embryos - same as poor egg quality
7) 受精率低:
poor fertilisation rates with IVF - ICSI, possibly assistedhatching, 3 months of antioxidants for the male partner, possiblyantibiotics if the male partner is carrying an infection
輔助孵化,同時(shí)男方提前三個(gè)月的抗氧化劑治療(詳見(jiàn)十全大補(bǔ) 精子調(diào)理方案)
8) 卵巢過(guò)度刺激OHSS - lower dose of stims, short protocol, alternate daysdose of stims (e.g., alternating between 150 iu and 75 iu), 3months of birth control pill before starting, metformin, low GIdiet/healthy BMI, prolonged coasting (i.e., giving fairly low dosestimms e.g., 150 iu and stopping it as soon at least 2 follicleshave attained a mean diameter of 18-22mm (on ultrasound) and 50% ofthe remaining follicles have reached 14-16mm, and waiting (up to 5days) until the blood estrodial level falls below 2,500pg/ml beforegiving the HCG trigger shot), cabergoline tablets (a drug which hasbeen shown to reduce the severity of OHSS without damaging eggquality/pregnancy rates), freezing all embryos and having a FET thefollowing month.
低劑量促排,短方案,混合使用促排擠,提前三個(gè)月避孕藥,二甲,低GI飲食,控制體重指數(shù),滑行方案(低劑量促排,如150iu,暫停,當(dāng)最少2個(gè)卵泡達(dá)到18-22mm和50%的卵泡在14-16mm的時(shí)候停5天,等到血雌二醇低于2500pg/ml時(shí)打hcg),卡麥角林片方案(一種藥物已被證明可以降低OHSS的嚴(yán)重程度而不破壞卵子的質(zhì)量/妊娠率),冷凍胚胎次月移植。
9)移植后抽筋 cramping after embryo transfer - see Tocolytics
10) 移植問(wèn)題implantation problems - clotting (see thrombophilia),infection (see chlamydia, mycoplasma and ureaplasma), naturalkiller cells (see NK cells), elevated cytokines (see cytokines),lack of blocking antibodies (see LAD), short implantation window(consider starting progesterone at a lower dose then stepping upthe dose after a week, and/or switching to a day 3 transfer insteadof a blast transfer) - treatments to consider are empiricaltreatment with clexane and steroids (see Treating empirically),going down the immune testing route and having treatment withsteroids/humira/LIT/IVIG/intralipids/clexane and/or newertreatments like PBMC (see PBMC) and neupogen (see G-CSF) or ifendometriosis/adenomyosis is suspected 3 months pre-treatment withdown reg or in-cycle treatment with femara/letrozole.
Also consider hysteroscopy to rule out hard-to-detectscarring in the uterus, to do a mild D&Cand maybe a scratch biopsy or fundus cut - and/or a saline wash 2days before ET.
凝血(血栓危險(xiǎn))、感染(衣原體、支原體、尿素),nk細(xì)胞,高細(xì)胞活性,封閉抗體缺乏,窗口期短(考慮低劑量孕酮支持,后一周逐步加量,和/或移植前3天孕酮支持)。
治療支持:類固醇/阿達(dá)木/LIT/IVIG/脂肪乳/肝素和/或新療法G-CSF或提前3個(gè)月來(lái)曲唑(內(nèi)異和腺肌癥患者)。同時(shí)考慮宮腔鏡檢查排除子宮瘢痕,做溫和的D&C宮腔鏡檢查或組織活檢,或移植前2天生理鹽水沖洗宮腔。
11)、空泡:
不是說(shuō)卵泡里沒(méi)有卵子或提前排了,而是說(shuō)醫(yī)生取卵的時(shí)候沒(méi)有吸到卵子,那么,卵子在哪里?為什么拿不出來(lái)?如果你看卵子周期發(fā)展的掛圖,你就知道,當(dāng)時(shí)卵子是和卵泡壁粘在一起的,到后面才進(jìn)入卵泡中間,浮里液體當(dāng)中。所以空泡發(fā)生的時(shí)候多數(shù)情況就是卵泡還粘在上面沒(méi)下來(lái)。成因不明,可能是:1、卵子本身沒(méi)有長(zhǎng)熟,2、病人受體對(duì)HCG不敏感導(dǎo)致卵子與卵泡壁沒(méi)有分離。
排除醫(yī)生對(duì)取卵時(shí)間把握不準(zhǔn)這一選項(xiàng),這里有幾種辦法來(lái)解決這個(gè)問(wèn)題:
1、打兩次HCG針。在兩次針之間查血值看HCG的吸收情況。
2、換一批HCG藥,看看是否人體接受會(huì)好些。
3、使用不同的促排卵藥(比如LUPRON)來(lái)進(jìn)行TRIGGER。
4、使用加拮抗劑(antagonist)的試管方案。讓每一卵子長(zhǎng)得更平均些成熟些。
5、用HCG 稀釋LUPRON雙“擊”(Double trigger)的方式來(lái)促排卵。
6、如果是LUPRONTRIGGER的,加大LUPRON用量。比如原來(lái)醫(yī)生囑咐15IU,改為30IU。(60IU以下都是安全TRIGGER劑量。)
結(jié)論:空泡是有卵子但取不出來(lái)??赡芨炎淤|(zhì)量和醫(yī)生取卵時(shí)間把握有關(guān),也可能跟病人對(duì)排卵針不敏感不關(guān)。目前有效的的方式是用第五–DOUBLETRIGGER的方式。