自發性排卵反應隔一天即應施行人工受孕

自發性排卵反應隔一天即應施行人工受孕

隔2天施行人工受孕懷孕率會下降

Hum Reprod. 2014 Apr;29(4):697-703. doi: 10.1093/humrep/deu022. Epub 2014 Feb 18.

Should an intrauterine insemination with donor semen be performed 1 or 2 days after the spontaneous LH rise? A prospective RCT.

Blockeel C1, Knez J, Polyzos NP, De Vos M, Camus M, Tournaye H.

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Abstract

STUDY QUESTION:

What is the impact on pregnancy rates when intrauterine insemination (IUI) is performed 1 or 2 days after the spontaneous LH rise?

SUMMARY ANSWER:

IUI 1 day after the spontaneous LH rise results in significantly higher clinical pregnancy rates compared with IUI performed 2 days after the LH rise.

WHAT IS KNOWN ALREADY:

IUI is scheduled within a limited time interval during which successful conception can be expected. Data about the optimal timing of IUI are based on inseminations following ovarian stimulation. There is no available evidence regarding the correct timing of IUI in a natural menstrual cycle following the occurrence of a spontaneous LH rise.

STUDY DESIGN, SIZE, DURATION:

A prospective RCT, including patients undergoing IUI with donor sperm in a natural menstrual cycle. IUI cycles (n = 435) were randomized between October 2010 and April 2013, of which 23 were excluded owing to protocol deviation and 412 received the allocated intervention.

PARTICIPANTS/MATERIALS, SETTING, METHODS:

Serial serum LH concentrations were analysed in samples taken between 07:00 and 09:00 h to detect an LH rise from Day 11 of the cycle onwards. The subjects were randomized to receive insemination either 1 or 2 days after the observed LH rise. In the final analysis, there were 213 cycles in the group receiving IUI 1 day after the LH rise and 199 cycles in the group receiving IUI 2 days after the LH rise.

MAIN RESULTS AND THE ROLE OF CHANCE:

Significantly higher clinical pregnancy rates per IUI cycle were observed in patients undergoing IUI 1 day after the LH rise when compared with patients undergoing IUI 2 days after the LH rise [19.7 (42/213) versus 11.1% (22/199), P = 0.02]. In view of the timing of sampling for LH, the inseminations were performed at 27 h (±2 h) and 51 h (±2 h) after detection of the LH rise. The risk ratio of achieving a clinical pregnancy if IUI was scheduled 1 day after the LH rise compared with 2 days was 1.78 [95% confidence interval (CI), 1.11-2.88]. This points towards a gain of one additional clinical pregnancy for every 12 cycles performed 1 day instead of 2 days after the LH rise. When analysing the results per patient, including only women who underwent their first treatment cycle of insemination, the outcome was in line with the per cycle analysis, demonstrating an 8% difference in pregnancy rate in favour of the early group (20.5 versus 12.2%), however, this difference was not significant.

精蟲處理仍可能合併細菌感染

人工授精之精蟲處理步驟(swim-up, grading), 有可能會合併細菌感染

http://www.jhrsonline.org/article.asp?issn=0974-1208;year=2013;volume=6;issue=2;spage=152;epage=157;aulast=Abeysundara

低劑量誘導排卵可能可提高該次IVF懷孕率

較低劑量之誘導排卵可能反而可提高該次IVF懷孕率 (1450 vs 2664iu)
原計劃施行IUI改為IVF懷孕率可能反而比一般IVF較高(45 vs 34%)

http://www.ncbi.nlm.nih.gov/pubmed/23715874

AIH精液取出後30分內進行精蟲處理

人工授孕AIH，取精液最好在診所取，取出後最好30分內進行精蟲處理sperm washing
人工授孕誘導排卵最好使用hMG(取代排卵藥)
取精液後最好90分左右施行AIH

http://www.ncbi.nlm.nih.gov/pubmed/15589871

AIDS男性可預防性化療chemoprophylaxis再施行AIH

HIV男性施行人工授精最有效之預防方法為清洗精蟲sperm washing(grading, swim-up, wash)
另一方法為預防性化學藥劑治療pre-exposure chemoprophylaxis (PrEP)降低HIV titler

http://humupd.oxfordjournals.org/content/19/2/136.abstract

PCO施行IUI可將多餘卵子取出冷凍保存

多囊性卵巢PCO病患施行人工授精IUI，可考慮將多餘卵子取出冷凍保存

http://humrep.oxfordjournals.org/content/25/5/1213.full

HIV病患AIH採用多次離心法

HIV男性採用多次離心法(45–90% colloidal silica density gradient)+swim-up 清洗精蟲
分離HIV-free sperm from the infected NSC
降低精蟲感染HIV機率
統計顯示感染HIV機率低

http://humrep.oxfordjournals.org/content/25/8/1869.full

根據體重與基礎濾泡數量決定誘導排卵之劑量

人工授孕AIH, 根據體重與基礎濾泡數量決定誘導排卵之劑量
體重越重, 基礎濾泡數量越少劑量越高

http://humrep.oxfordjournals.org/content/24/10/2523.full

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Figure 1

Dosage nomogram for ovulatory IUI patients' first rFSH treatment cycle.

The aim of the stimulation was to achieve two follicles ≥18 mm and maximum one intermediate-size follicle (≥14 and <18 mm) on the day of hCG. The day of hCG was defined as the day the leading follicle reached a diameter of 18 mm. On the basis of a patient's body weight (kg) and total AFC, an individual starting dose can be identified. Reprinted from an article in Reproductive BioMedicine Online by Freiesleben et al. (2008), with permission from Reproductive Healthcare Ltd.

誘導排卵有17%提早黃體化

人工授孕誘導排卵過程有17%病患有提早黃體化現象 (LH≥10 IU/l, progesterone>1 ng/ml)

http://humrep.oxfordjournals.org/content/21/3/632.full

打完破卵針後已排卵施行人工授孕比未排卵的懷孕率較高

打完破卵針後36小時若已排卵，施行人工授孕比未排卵的懷孕率較高 (24 vs 9%)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582119/

AIH至少需500萬隻活動精蟲可供植入

人工授孕AIH至少需要500萬隻活動精蟲可供植入

<500萬隻活動精蟲，AIH懷孕率僅2%
>500萬隻活動精蟲，AIH懷孕率15%

http://www.ncbi.nlm.nih.gov/pubmed/15243004

破卵針33或39小時AIH懷孕率無明顯差異

破卵針打完後33小時 vs. 39小時施行人工授孕，懷孕率並無明顯統計差異 (21 vs.15%) http://www.ncbi.nlm.nih.gov/pubmed/15236979

人工授孕精蟲處理方式對於懷孕率並無明顯差異

人工授孕AIH精蟲處理方式(washing, grading)，對於懷孕率並無明顯差異

http://humupd.oxfordjournals.org/content/8/4/373.full.pdf+html

AIH可根據體重與基礎濾泡來決定排卵針之劑量

人工授孕AIH時，可根據體重與基礎濾泡來決定排卵針之劑量

平均基礎濾泡數量約為18

http://humrep.oxfordjournals.org/content/24/10/2523.full

人工授孕不須誘導太多卵，2顆成熟卵即已足夠

多篇論文綜合分析顯示，人工授孕AIH不須誘導太多卵，2顆成熟卵即已足夠
1顆成熟卵懷孕率約8%
2-4顆成熟卵懷孕率約13%
4顆以上成熟卵懷孕率無明顯提高，卻反而增高多胞胎懷孕之機率

http://humupd.oxfordjournals.org/content/14/6/563.full

只使用排卵藥之AIH懷孕率為5-7%

歐洲不孕症醫學會統計98 388人
人工授精AIH懷孕率為12%
單胞胎佔87%
多胞胎佔13%

只使用排卵藥不使用排卵針之AIH懷孕率為5-7%

AIH semen preparation vol=0.2-0.5ml

http://humupd.oxfordjournals.org/content/15/3/265.full

破卵後施行AIH可達較高懷孕率

破卵後施行人工授精vs破卵前施行人工授精可達較高懷孕率 (24 vs 9%)

精蟲游動速度約 1cm/min, 15-20分鐘即可從子宮游到卵巢

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582119/

施行2次人工授孕對於男性不孕症病患較有助益

施行2次人工授孕對於男性不孕症病患較有助益
對於非男性不孕病患較無明顯助益

非男性不孕病患AIH時機約為卵子剛破卵後(約hCG施打後36-40h)
男性不孕病患AIH時機約為卵子破卵前(約hCG施打後36h)+破卵後(約hCG施打後40-60h)

http://humrep.oxfordjournals.org/content/26/3/576.full

GnRHantagonist人工授孕可提高懷孕率達38%

使用腦下垂體拮抗劑GnRHantagonist+人工授孕可提高人工授孕AIH懷孕率(14%->38%)

GnRHantagonist施打於最大濾泡1.6cm, 平均施打2劑再施行AIH

成熟卵泡<2時，施行AIH沒太大成效

http://humrep.oxfordjournals.org/content/20/2/368.full

成熟卵泡數目3個以上才需要施行2次人工授孕

人工授孕AIH
成熟卵泡數目3個以上懷孕率較高(15-20%)
成熟卵泡數目2個以下懷孕率較低(5-10%)
成熟卵泡數目3個以上才有需要施行2次AIH

AIH普遍統計懷孕率約12%
其中多胞胎機率約13%

http://humrep.oxfordjournals.org/content/25/7/1684.full