一般腦下垂體抑制針劑量為5mg/cc 每天施打0.1cc=0.5mg  or  0.05cc=0.25mg

針對高齡或卵巢下降患者本篇下降為

ULDL (Lupron 0.1 to 0.05 mg daily), =0.02cc qd

VLDL (Lupron 0.2 to 0.1 mg daily), =0.04cc qd

microflare (Lupron 0.05 mg twice a day), =0.01cc bid

懷孕結果無統計差異

. 2023 Aug;40(8):1881-1895.

 doi: 10.1007/s10815-023-02842-8. Epub 2023 Jun 16.

Ultra-low-dose and very-low-dose Lupron downregulation protocols for poor responders based on POSEIDON group 3 and 4 classifications

Purpose: The objective of this study was to assess if very-low-dose Lupron (VLDL) and ultra-low-dose Lupron (ULDL) protocols can have comparable cycle outcomes when compared to other "poor responder" stimulation protocols based on POSEIDON classification groups 3 (PG3) and 4 (PG4).

Methods: A retrospective cohort study at a single, large academic center was performed. Women in PG3 (age < 35, AMH < 1.2 ng/mL) or PG4 (age ≥ 35, AMH < 1.2 ng/mL) undergoing in vitro fertilization using an ULDL (Lupron 0.1 to 0.05 mg daily), VLDL (Lupron 0.2 to 0.1 mg daily), microflare (Lupron 0.05 mg twice a day), estradiol priming/antagonist, antagonist, or minimal stimulation protocols from 2012 to 2021 were included. The primary outcome was the number of mature oocytes (MII) obtained. The secondary outcome was live birth rate (LBR).

Results: The cohort included 3601 cycles. The mean age was 38.1 ± 3.8 years. In the PG3 group, ULDL and VLDL protocols produced a comparable number of MIIs (5.8 ± 4.3 and 5.9 ± 5.4, respectively) and live births (33.3% and 33.3%, respectively) when compared to other protocols. In the PG4 group, ULDL and VLDL protocols resulted in a higher percentage of MIIs when compared to microflare or minimal stimulation (Microflare/ULDL: adjusted relative risk (aRR) 0.78 (95% CI 0.65, 0.95); min stim/ULDL: aRR 0.47 (95% CI 0.38, 0.58); microflare/VLDL: aRR 0.77 (95% CI 0.63, 0.95); min stim/VLDL: aRR 0.47 (95% CI 0.38, 0.95)). There were no significant differences in LBR.

Conclusion: Dilute Lupron downregulation protocols have comparable outcomes to other poor responder protocols and are reasonable to use.

• 第1組：胚胎繼續縮小10微米或更多； 第 2 組：範圍為 -9 至 +9 µm 的胚胎； 第3組：再膨脹10μm以上。
• 第1組的臨床懷孕率為18.9%； 第2組，27%； 第 3 組為 51.2% (p = 0.007)。
• 臨床懷孕率與孵化後 2 小時測量的解凍囊胚再擴張程度有關。
• 囊胚腔 (blastocoel) 的形成和維持歸因於鈉泵 (Na+/K+−ATPase)
• 水通道蛋白穿過上皮進入囊胚的細胞外空間，形成充滿液體的囊胚腔。
• 重新擴張的能力可能意味著囊胚的功能正常程度。

• Group 1: embryos that continued to shrink by 10 µm or more; group 2: embryos that ranged from -9 to +9 µm; and group 3: re-expansion of 10 µm or more. 
• The clinical pregnancy rate for group 1 was 18.9%; group 2, 27%; and group 3, 51.2% (p = 0.007). 
• The clinical pregnancy rate correlated with the degree of thawed blastocyst re-expansion measured 2 h after incubation. 
• The formation and maintenance of the blastocyst cavity (blastocoel) are attributed to the sodium pump (Na+/K+−ATPase)
• The creation of aquaporins across the epithelium into the extracellular space of the blastocyst to form the fluid-filled blastocoel. 
• The ability to re-expand may imply the proper function of the blastocyst. 

https://www.mdpi.com/2077-0383/11/9/2673

. 2022 May 9;11(9):2673.

 doi: 10.3390/jcm11092673.

Standardization of Post-Vitrification Human Blastocyst Expansion as a Tool for Implantation Prediction

The increased use of vitrified blastocysts has encouraged the development of various criteria for selecting the embryo most likely to implant. Post-thaw assessment methods and timetables vary among investigators. We investigated the predictive value of well-defined measurements of human blastocyst re-expansion, following a fixed incubation period. Post-thaw measurements were taken exactly at 0 and 120 ± 15 min. Minimum and maximum cross-sectional axes were measured. Three groups were defined: Group 1: embryos that continued to shrink by 10 µm or more; group 2: embryos that ranged from -9 to +9 µm; and group 3: re-expansion of 10 µm or more. Patient and morphokinetic data were collected and integrated into the analysis. A total of 115 cases were included. The clinical pregnancy rate for group 1 was 18.9%; group 2, 27%; and group 3, 51.2% (p = 0.007). Pre-thaw morphologic grading and morphokinetic scores of the study groups did not reveal differences. p-values were 0.17 for the pre-thaw morphologic score, 0.54 for KID3, and 0.37 for KID5. The patients' demographic and clinical data were similar. The clinical pregnancy rate correlated with the degree of thawed blastocyst re-expansion measured 2 h after incubation. This standardized measure is suggested as a tool to predict the potential of treatment success before embryo transfer.

• 與非 PCOS 卵丘細胞(CC 相比，PCOS CC 中表達顯著差異的基因。
• PCOS CC 中的一些基因失調，包括前列腺素內過氧化物合成酶2 (PTGS2)、腫瘤壞死因子-α 誘導蛋白6 (TNFαIP6)、 TGF-β2 、caveolin 1 (CAV1)、抑制素、β B (INHβB)、EGFR 和 DNA 結合抑制劑 3 (ID3)。
• 當雙股 DNA 斷裂時，人類未成熟卵母細胞中的 DNA 修復途徑更加活躍，這可能會推遲減數分裂的恢復
• 負責 PCOS CCS 增殖的基因在 GV 階段上調，導致更多的未成熟卵泡。
• 經ART 治療後，這些基因的表達恢復到正常水平。
• 與對照CC 相比，參與細胞增殖、激素受體信號傳導、間隙通訊、卵泡發生和氧化壓力等重要過程的基因在GV 階段均在PCOS CC 中異常表達，但在GV 階段均恢復至正常水平。資訊產業部階段。
• ART不僅可以誘導PCOS患者排卵，還可以在轉錄組層級修復卵母細胞品質差，提高受精卵裂率和胚胎品質。

• Genes with significantly differential expression in PCOS cumulus cells(CCs)  comparing with non-PCOS CC. 
• Among many genes that are involved in cell proliferation, several genes were deregulated in PCOS CCs compared with non-PCOS CCs, including prostaglandin-endoperoxide synthase 2 (PTGS2), tumor necrosis factor-alpha-induced protein 6 (TNFαIP6), TGF-β2, caveolin 1 (CAV1), inhibin, beta B (INHβB), EGFR, and inhibitor of DNA binding 3 (ID3) (Fig. 6A). 
• DNA repair pathways are more active in human immature oocytes when double-strand DNA breaks, which may defer meiotic resumption
•  genes responsible for the proliferation of PCOS CCS were upregulated at the GV stage, which resulted in more immature follicular than normal. 
• But after ARTs, the expression of those genes was restored to its normal level. 
• Genes that participate in vital processes such as cell proliferation, hormone receptors signaling, gap communication, folliculogenesis, and oxidative stress were all abnormally expressed in PCOS CCs compared with control CCs at the GV stage, but all of them were recovered to normal levels at the MII stage.

• ARTs not only can induce ovulation in PCOS patients but also repair the poor quality of oocytes at the transcriptome level and increase the ratio of fertilization and cleavage and the quality of embryos.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177934/

Figure 5

Differentially expressed genes in PCOS oocyte studied through single-cell RNA sequencing.

The threshold of Padj was set at < 0.05 to find significantly expressed genes. (A) Boxplot showing differentially expressed genes involved in meiosis process. (B) Boxplot showing differentially expressed genes included in gap junction pathway. (C) Boxplot showing differentially expressed genes related to hormone receptor signaling. (D) Boxplot showing differentially expressed genes involved in DNA repairing. (E) Boxplot showing significantly expressed genes are related to secreted factors. *Padj < 0.05. The y axis indicates the log2 (FPKM + 1) expression levels.

•  近 6,000 個基因在 GV 和 MII 階段之間存在差異表達。
• 大約 450 個基因在單一階段中獨特表達。
• ANXA5 在年輕族群中表現增加，它編碼一種與蛋白激酶 C 相互作用的蛋白質，而蛋白激酶 C 是受精事件的關鍵調節因子。
• 精子 ZP 膜的融合將觸發使用鈣作為第二信使的分子變化，導致減數分裂 II 恢復和原核融合。
• 在不同成熟階段的98個卵母細胞中ZP基因（ZP1-4）的mRNA表現顯示，從GV到MII階段，ZP 1、2和4顯著下降，而ZP3表現則不顯著下降。
• 老年女性卵子中發現 PRRG1（一種鈣離子結合蛋白基因）的表達增加，這可能會損害受精事件。
• 從成熟卵母細胞胞質轉移到未成熟卵母細胞後誘導的基因表現改變可能導致鈣損傷，導致受精失敗。
• ECAT1 等基因受損會導致裂解率降低（異常分裂）。
• ECAT1 破壞不僅與成熟受損有關，而且與胚胎發育失敗有關。
• 成熟的卵母細胞被具有不同基因表現譜的卵丘細胞包圍
• 從成熟卵母細胞到細胞質發生改變的卵母細胞的細胞質轉移（CT）無法有效恢復受體 GV 卵母細胞的細胞質成熟度。
• 與未成熟卵母細胞相比，粒線體相關基因（如 COX6B1、COX8A、COX4l1 和 NDUFB9）在健康 MII 期卵母細胞中高度表達。

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10504133/

• Almost 6,000 genes differentially expressed between GV and MII stages [21].
• Around 450 genes uniquely expressed in single stages. 
• Increased in expression for the younger groups, ANXA5 codes for a protein which interacts with protein kinase C, a key regulator of fertilisation events. 
• Fusion of ZPmembranes of sperm  will trigger molecular changes using calcium as a second messenger, resulting in meiosis II resumption and fusion of pronuclei. 
• mRNA expression of ZP genes (ZP1-4) in 98 oocytes at different maturation stages, showed a significant decrease in ZP 1, 2 and 4 together with a non-significant decrease in ZP3 expression from GV to MII-stages [.
• Increased expression of PRRG1, a calcium ion binding protein gene, was found in older women which could impair fertilisation events. 
• Gene expression alterations induced after cytoplasmic transfer from a mature to an immature oocyte could lead to calcium impairment, which could lead to fertilisation failures. 
• Impairment of genes such ECAT1 result in reduced cleavage rates (abnormal divisions). 
• Hence ECAT1 disruption was not only associated with compromised maturation but also with embryos which fail to develop.
• Mature oocytes have been found to be surrounded by cumulus cells with distinct gene expression profiles [14]. 
• Mature oocytes have been found to be surrounded by cumulus cells with distinct gene expression profiles 
• Cytoplasmic transfer (CT), from a mature oocyte to an oocyte with cytoplasmic alterations, was not effective to restore cytoplasmic maturity of recipient GV oocytes [10].
• Mitochondria-related genes such as COX6B1, COX8A, COX4l1, and NDUFB9 have been shown to be highly expressed in healthy MII-stage oocytes compared to immature oocytes.