| Polycystic ovary syndrome (PCOS) is one of the endocrine disorders which is most common among women of children bearing age, and is one of the main reasons of anovulatory infertility. Its clinical manifestations are polycystic changes in ovary, high level of androgen, oligomenorrhea or amenorrhea, infertility, and so on. Though the pathogenesis is still unclear, it may be associated with primary ovary dysfunction, hypothalamus dysfunction, hyperinsulinism, primary dysfunction of adrenal glands. However, neither the effect of drugs or operation, nor the assisted reproductive technology are not good enough until now. That's why the clinical management of patients with PCOS captures more and more attention in reproductive medicine field nowadays. The author finds a good result through the method of treating PCOS with infertility by ultrasound- guided immature follicle aspiration (IMFA) assisted with intrauterine insemination (IUI).Materials1. Total of 94 patients (from June,2004 to March,2007) with PCOS were recruited from Reproductive Medical Center of Maternal and Child Health Hospital of Jiaozuo in Henan Province. PCOS patients were selected according to the criteria announced in the 2003 European Society for Human Reproduction and Embryology Rotterdam consensus.2. Induced ovulationAll patients were injected HMG 75U from the 4th day of menstrual cycle (withdrawal uterus bleeding by progesterone or artificial cycle). After 5 days the average diameter of ovarian follicle achieved 9-11mm. At that time ultrasound-guided immature follicle aspiration was done to patients, reserving only 1-2 comparatively large ovarian follicle. HMG was applied continually then. When the diameter of the dominant follicle reached above 15mm, B-ultrasound was given once a day, and meanwhile the urine LH. When at least 1 follicle diameter≥18mm, urine LH(+), HCG was intramuscularly injected. If there were 1-2 ovarian follicle≥18mm, intramuscular injection of HCG was 10000U.If there were 3 ovarian follicle≥18mm, HCG 6000U. If patients were not pregnant, the same project was repeated next cycle. 3. Intrauterine insemination (IUI) and corpus luteum supportIUI was carried out within 36 hours after injection of HCG. After semen was processed upstream, IUI was done routinely. It is the day of ovulation when follicle disappears showed by B-mode ultrasonic diagnostic. Patients were injected progesterone 40mg/qod after ovulation. Urine HCG was done 2 weeks later to ensure biochemical pregnancy. B-mode ultrasonic diagnose was done 4 weeks after ovulation in order to make clear the number of gestational sac and embryonic development.4. Monitoring index4.1 Pregnancy outcomeTwo weeks after patient's ovulation, abstract patient's venous blood to measure the HCG level of serum/the serum level of HCG. Biochemical pregnancy is identified if HCG>5miu/ml. And four weeks after ovulation, B-mode ultrasonic diagnosis will be done to determine the number of gestational sac and embryonic development. If the pregnancy ends within 28 weeks, it is called abortion.4.2 Serum sex hormoneOn the second day of menstruation in treatment cycle (before medication of Gn), (venous blood of patients was taken suction in order to) test serum LH, FSH, T, PRL, INS by chemiluminesence. Serum E2 was tested on the day of ovarian follicle maturation before the injection of HCG. If the first treatment cycle was in vain, review the serum sex hormone on the second day of next menstruation. If patients were still not pregnant after second treatment cycle, serum hormonal sex was reviewed once again on second day of the third menstruation.4.3 The number of basic and dominant ovarian follicleThe number of basic ovarian follicle:Check the number of basic ovarian follicle by B-ultrasound on the fourth day of menstruation (the day of Gn). If patients were not pregnant after first treatment cycle, the number of basic ovarian follicle was reviewed on fourth day of next menstruation. If the second treatment cycle failed again, the same procedure had to be repeated once again.The number of dominant ovarian follicle:Check the total number of ovarian follicle which average diameter>15mm on the injection day of HCG. 4.4 OHSSMedication of Gn and HCG must be stopped immediately if there are any signs of OHSS--- such as the diameter of ovary was larger than 5cm by B-ultrasound, the number of follicle with average diameter≥12mm was more than 15, the number of dominant follicle with average diameter≥15mm was more than 5, and the level of serum E2≥4000pg/ml.ResultAll these 94patients with PCOS have been implemented 173 cycles of immature follicle aspiration and 165 cycles of IUI. The results are as follows:1. Conditions of follicular development and medicationIn cycles before IMFA,9 patients have no dominant follicle after HMG. In the first and second IMFA cycles, all patients respond to HMG. In cycles before IMFA, the average dose of HMG was 1413.75U, and the average medication period was 13.24 days. In the first IMFA cycles, the average dose of HMG was 1189.5U, and the average medication period was 11.50 days. In the second IMFA cycles, the average dose of HMG was 1107U, and the average medication period was 11.52 days.2. Conditions of ovulationIn cycles before IMFA, the first and second IMFA cycles, the rate of ovulation were 79.5%,90.7%,100% respectively. There was significant difference in the three.3. Pregnancy outcomeThe pregnancy rate of the first and second IMFA cycles was 22.1% and 24.1% respectively. There was no significant difference between them.4. Level of E2In the first IMFA cycles, the level of E2 was between 350-2200pg/ml. In the second IMFA cycles, the level of E2 was between 200-900pg/ml.5. OHSSIn the first IMFA cycles,5 cases showed mild OHSS. While in the second IMFA cycles, no OHSS happened.6. Number of basic ovarian follicleThe number of basic ovarian follicles in the 94 cases before the first IMFA cycle and the 79 cases after it were 26.9±11.4 and 18.5±5.5 respectively. The number of basic ovarian follicles in the 79 cases before the second IMFA cycle and the 62 cases after it were 18.5±5.5 and 10.9±2.8 respectively. The data in the two cycles were both obviously less than before and there was significant difference between them.7. Level of serum sex hormoneThe level of LH, LH/FSH, and T all decreased apparently in the second IMFA cycle comparing with the first with significant difference. In respect of PRL and INS, no significant difference appears after treatment.ConclusionImmature follicle aspiration per vagina by B-ultrasound-guided can decrease the number and the development of basic ovarian follicles, improve the abnormal endocrinology and increase patients'responsivity to ovulation induction drugs and the rate of ovulation. IMFA assisted with IUI can improve pregnancy rate, meanwhile, reduce incidence of OHSS, multiplets and abortion. |
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