The Treatment Strategies Of PCOS Patients In IVF

Polycystic Ovarian Syndrome (PCOS) is a common endocrinal disorder in women with non-ovulation infertility in childbearing age, its incidence is about5%in women of childbearing age.About80%PCOS women get pregnant through drug intervention or after laparoscopic ovarian drilling to induce normal ovulation. But there are still20%of the PCOS women require assisted reproductive technology (ART) to obtain pregnancy. In-vitro fertilization and embryo transfer (IVF-ET) is currently the most commonly-used technology, which taking the oocytes and the sperm outside the body and fertilizing them in vitro, and then culturing the zygote to early preimplantaion embryos and then transferring them back into the womb. A key step of a successful IVF-ET procedure is controlled ovarian hyperstimulation (COH), which inducing multiple follicular development and maturation in a controlled stimulation with exogenous drugs to get enough high quality oocytes, and generating multiple embryos for transfer per cycle to improve the pregnancy rate of IVF per cycle.Long gonadotropin-releasing hormone-analogues (GnRH-a) down regulation is a commonly-used COH program for PCOS patients. But, PCOS patients are often accompanied with numerous endocrinal and metabolic abnormalities, such as:the insufficient secretion of FSH, increased secretion of LH, hyperinsulinemia, and hyperandrogenism, which leads to decreased IVF pregnancy rate and increased incidence of OHSS after COH. We wish to establish a more suitable COH program with higher pregnancy rate and decreased incidence of complication after COH. According to the pathological features of PCOS, we adopted a modified ultra-long down-regulation protocol. To answer whether our protocol improves the pregnancy rate in patients with PCOS, in the first part of this thesis, we retrospectively compared IVF outcomes of modified ultra-long protocol and routinely used long protocol for PCOS patients.Good quality embryo needs to implant in the uterus, differentiation and eventually develop to a mature fetus. Implantation is another important step of a successful pregnancy. The endometrial receptivity, which refers to the endometrial ability to accept the embryo is a key aspect for a successful implantation.At present, there are several factors which affect the endometrial receptivity:the endometrial thickness, morphology, blood flow of endometrial, hormone levels, cytokines and genes which regulating uterine receptivity. All the factors interact as a network to regulate the receptivity and aid a successful implantation. In the implantation window, the endometrial thickness increases to above9mm, blood flow index of endometrial increases, pinopodes appears and the up-regulated expression of endometrial receptivity related genes such as leukocyte inhibitory factor (LIF) and HOXA10gene. Therefore, in the second part of this thesis, to explore the influence of ultra-long protocol to the endometrial receptivity, we examined emdometrial pinopodes by electron microscopy in the PCOS patients during the implantation window from both long protocol group and the modified ultra-long protocol group, we examined the expression of HOXA10, LPAR3and COX2in two groups with immunohistochemistry, realtime-PCR, Western blot. We attempts to answer whether modified ultra-long protocol generates better clinical outcomes by improving the endometrial receptivity as compared to long protocol group.Because of the low FSH level in PCOS patients which leads to accumulation of small follicles with2-8mm diameter and the narrow FSH threshold, PCOS patients are much easier to suffer from ovarian hyperstimulation syndrome (OHSS) in routine COH protocols than non-PCOS patients. The incidence of OHSS in PCOS patients is up to14%. In vitro maturation (IVM) is a novel treatment for PCOS patients, which collects immature oocytes from infertile women without or with small dose of exogenous gonadotropin stimulation, the immature oocytes are then matured in vitro and fertilized by intracytoplasmic sperm injection (ICSI). Under this circumstance, no or much less exogenous gonadotropin (Gn) is needed to generate enough oocytes for late FVF-ET, the serum estrogen level is low in IVM patient which prevent the occurrence of OHSS after injection of HCG. Meanwhile, less usage of exogenous Gn dramatically decrease the cost for a fresh ET cycle. Due to the cost and less incidence of complications, IVM is adopted by some center to be alternative procedure for PCOS patients underwent IVF treatment. Due to the success rate of conventional IVM is10-30%, much lower than routine IVF, its clinical application is restricted. In part three of the thesis, we explored the possibility of improving the efficiency of IVM program in PCOS patients, trying to establish a safe but more effective strategy.Part I. Study of modified ultra-long protocol in patients with PCOS in IVF/ICSI-ETObjective:To retrospectively and prospectively compare clinical outcomes between modified ultra-long protocol down regulation in combination with human menopausal gonadotropin (hMG) and conventional long protocol down regulation in PCOS infertile women undergoing in vitro fertilization/intracytoplasmic sperm injection and embryo transfer (IVF/ICSI-ET).Methods:(1) We retrospectively analyze the clinical data of1989PCOS patients received modified ultra-long protocol treatment and1370PCOS patients received routine down-regulation long protocol during January2008to December2012. The fertilization rate, implantation rate, pregnancy rate, lives birth rate, abortion rate and treatment cost were compared between the two groups.(2) PCOS patients who underwent IVF/ICSI-ET treatment from September2011to April2012in our hospital were divided into two groups:ultra-long protocol group (n=75) and long protocol group(n=72). The average number of retrieved oocytes, fertilization rate, implantation rate, pregnancy rate, abortion rate, thickness, morphology and pulsed Doppler study of uterine artery of endometrial on the day of hCG administration and the day of ET were detected and assessed by Doppler ultrasound and compared. Otherwise, the related indexes of two groups such as serum progestogen, estradiol and luteinizing hormone level and P/E2on hCG day were compared.Results:(1) In the retrospective study, there were no significant differences in average age, body mass index, average infertility duration, basal FSH and LH level, average oocyte number, good-quality-embryo formation rate, average transferred embryos, cancellation rate, severe OHSS incidence between ultra-long protocol and long protocol. But the clinical pregnancy rate, implantation rate and take-home-baby rate in ultra-long protocol (74.56%,52.51%and60.43%, respectively) are much higher than in long protocol (56.02%,37.83%and42.88%, respectively). In ultra-long protocol, the serum P level on the day of hCG injection is lower than in long protocol (0.62±0.29ng/ml vs.0.81±0.39ng/ml, P<0.05), and the endometrial thickness is higher than in long protocol (12.26±2.42mm vs.11.36±2.43mm, P<0.001). The early abortion rate in ultra-long protocol is reduced than in long protocol (6.02%和8.59%, P<0.05). In addition, the average overall cost for ultra-long protocol is significantly reduced than for long protocol (989.58±418.59and5831.73±2313.13, P<0.001).(2) Totally147patients were included in the prospective study,75patients were in ultra-long protocol and72patients were in long protocol. The average Gn usage, duration for Gn, serum E2and LH level on day of hCG injection, average oocyte, fertilization rate, good quality embryo rate, cancellation rate, average transferred embryos, severe OHSS incidence, abortion rate showed no significant difference. But in ultra-long protocol, the clinical pregnancy rate per transfer cycle and the implantation rate were significantly higher than in long protocol (77.9%and59.6%vs.61.3%and44.1%,P<0.05). Compared to patients in long protocol, the patients in ultra-long protocol had lower serum P level on the day of hCG injection, and had better endometrial thickness, improved morphorlogy and blood flow.Conclusion:Modified ultra-long protocol combined with hMG could improve the implantation rate and the clinical pregnancy rate for PCOS patients underwent IVF-ET treatment through increasing the endometrial thickness, promoting endometrial morphology transition and blood flow. Part II Effect of modified ultra-long protocol on endometrium receptivity of PCOS patientsObjective:Comparatively study the morphology of endometrium pinopodes, the expression of HOXA10, LPAR3and COX2in PCOS patients in modified ultra-long protocol and long protocol.Methods:Separately collect day6endometrium after oocyte retrieval from PCOS patients who underwent IVF/ICSI-ET treatment in either ultra-long protocol or long protocol, and quit the fresh embryo transfer due to OHSS risk. The expression of HOXA10, LPAR3and COX2in two groups was determined by immunohistochemistry, Real time-PCR, Western blot, and pinopodes were observed and analyzed by electron microscopy.Results:We detected more uniform distribution of a fully developed pinopodes in the endometrium of patients in modified ultra-long protocol than in long protocol, which exhibited a large number mushroom like structure with smooth surface, clear boundary and membrane protrusions. And in the group of long protocol, the pinopodes distribute focally, the surface is not smooth, much of them covered with microvilli. The expression of implantation related factors LPAR3, COX2and HOXA10were higher in the endometrium from modified ultra-long protocol group than in the endometrium from long protocol group in either mRNA level and protein level during the period of implantation widow.Conclusion:Modified ultra-long protocol may improve the endometrium receptivity through increasing pinopodes generation and LPAR3, COX2and HOXA10expression. Part Ⅲ Study on different in vitro maturation treatments for PCOS patientsObjetive:To compare the clinical outcomes among IVM, low dose gonadotrophin stimulate IVM and long protocol in women with PCOS and find a safer and more effective treatment protocol for these patientsMethods:PCOS patients in our hospital from Jan.2010to.Dec.2012.were divided into three groups prospectively. Group A (n=140), routine IVM; Group B (n=152), low dose gonadotrophin stimulate IVM and Group C (n=505), long protocol group. The clinical outcomes of these three groups were compared.Results:(1) The clinical pregnancy rates of group B and group C showed no significant differences (52.59%and58.35%, respectively, P>0.05) and were significantly higher than that in group A (32.23%, P<0.05).(2) The thickness of endometrial on the day of hCG injection in group A, B and C were5.99±1.96mm,7.87±2.14mm and11.81±2.20mm, showed significantly differences, P<0.05. At the same time, there were statistical significant for high-quality embryo rate in groupA、B and C(47.23±29.17vs.59.95±30.43vs.65.66±23.35, P<0.05).(3) There were significantly differences in the usage of Gn, no usage in group A, and the dosage of Gn in group B were600.08±291.21IU and the cost were1868.11±1208.67yuan. The dosage of Gn in group C were1776.36±693.76IU and the cost were5508.23±2193.17yuan (P<0.05)(4) There were no OHSS in group A^B, the severe OHSS rate in group C were2.18%.Conclusion:IVM can avoid occurance of OHSS. The low dosage stimulation of Gn after down regulation then in vitro maturation can obtain similar clinical pregnancy rate compared to long protocol FVF due to improved endometrium. IVM is a safer and effective strategy for PCOS patients.