利用OMICS組學資料&AI進行卵巢老化藥物研發

https://academic.oup.com/humupd/advance-article-abstract/doi/10.1093/humupd/dmaf002/8026727?redirectedFrom=fulltext

主旨

OMICS組學資料資源最新進展包括結合創新的計算工具，為卵巢老化的分子複雜性提供了更深入的見解&加速藥物發現和開發。

從組織層級和單細胞角度擴展與卵巢老化相關的多組學數據，涵蓋基因組、轉錄組、蛋白質組、代謝組和微生物組。

利用這些新興組學資料集的分析可識別新的藥物標靶並指導減緩和逆轉卵巢老化的治療策略。

OMICS組學方法

結合基因組學、轉錄組學、表觀基因組學、DNA甲基化、RNA修飾、組蛋白修飾、蛋白質體學、代謝組學、脂質組學、微生物組、單細胞、全基因組關聯研究（GWAS）、全外顯子組定序、表觀組關聯研究（PheWAS）、孟德爾隨機化（MR）、表觀遺傳組定序、表觀組關聯研究（PheWAS）、孟德爾隨機化（MR）、表觀遺傳組定序、表觀遺傳組關聯研究（PheWAS）、孟德爾隨機化（MR）、表觀遺傳組定序、表觀遺傳學研究、研究卵巢老化的關鍵機制

OMICS多組學研究揭示了導致卵巢老化的關鍵機制，包括 DNA 損傷和修復缺陷、發炎和免疫反應、粒線體功能障礙和細胞死亡。

結果

透過OMICS多組學數據&AI深度學習研判，研究人員可以識別各個生物學層面的關鍵調控因素和機制，從而發現潛在的藥物標靶。

值得注意的例子包括 BRCA2 和 TERT 等遺傳標靶、Tet 和 FTO 等表觀遺傳標靶、sirtuins 和 CD38+ 等代謝標靶、BIN2 和 PDGF-BB 等蛋白質標靶以及 FOXP1 等轉錄因子。

結論

整合尖端OMICS組學技術，尤其是單細胞技術和空間轉錄組學的出現，為指導治療決策提供了可能機轉見解，並對減輕或逆轉卵巢老化的藥物研發提供更有效率研發進程。單細胞多組學數據與人工智慧模型的結合有可能更準確地預測候選藥物標靶。

融合OMICS組學技術為個人化醫療和精準治療提供了一個有希望的新途徑，為卵巢老化的客製化介入新的方向。

 

Harnessing omics data for drug discovery and development in ovarian aging 

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•  Recent advances in omics data resources, combined with innovative computational tools, are offering deeper insight into the molecular complexities of ovarian aging, paving the way for new opportunities in drug discovery and development.
• expanding multi-omics data, spanning genome, transcriptome, proteome, metabolome, and microbiome, related to ovarian aging, from both tissue-level and single-cell perspectives. We will specially explore how the analysis of these emerging omics datasets can be leveraged to identify novel drug targets and guide therapeutic strategies for slowing and reversing ovarian aging.

SEARCH METHODS

• genomics, transcriptomics, epigenomics, DNA methylation, RNA modification, histone modification, proteomics, metabolomics, lipidomics, microbiome, single-cell, genome-wide association studies (GWAS), whole-exome sequencing, phenome-wide association studies (PheWAS), Mendelian randomization (MR), epigenetic target, drug target, machine learning, artificial intelligence (AI), deep learning, and multi-omics. 

OUTCOMES

• Multi-omics studies have uncovered key mechanisms driving ovarian aging, including DNA damage and repair deficiencies, inflammatory and immune responses, mitochondrial dysfunction, and cell death. 
• By integrating multi-omics data, researchers can identify critical regulatory factors and mechanisms across various biological levels, leading to the discovery of potential drug targets. 
• Notable examples include genetic targets such as BRCA2 and TERT, epigenetic targets like Tet and FTO, metabolic targets such as sirtuins and CD38+, protein targets like BIN2 and PDGF-BB, and transcription factors such as FOXP1.
• 
  
• The advent of cutting-edge omics technologies, especially single-cell technologies and spatial transcriptomics, has provided valuable insights for guiding treatment decisions and has become a powerful tool in drug discovery aimed at mitigating or reversing ovarian aging. 
• As technology advances, the integration of single-cell multi-omics data with AI models holds the potential to more accurately predict candidate drug targets. 
• This convergence offers promising new avenues for personalized medicine and precision therapies, paving the way for tailored interventions in ovarian aging.

 子宮移植：2024年的現狀

https://www.eujtransplantation.com/article/view/533

• 針對先天或後天無子宮或子宮缺損ㄉ病患   為達生育目的 可採取子宮移植&代理孕母
• 第一例子宮移植發生於2000年
• 第一例子宮移植&成功生下嬰兒發生於2014年瑞典
• 活體或死體子宮捐贈者均須經過ABO 血型配對& 巨細胞病毒 (cytomegalovirus, CMV)檢測
• 巨細胞病毒感染會增加病人的罹病率及死亡率必要需施予 抗病毒藥物預防
• 子宮在切除過程必須仔細分離左右兩側上下重要血管如子宮動脈跟卵巢動脈
• 靜脈血栓形成大幅提高那個子宮子宮移植的失敗率，手術過程要全力避免靜脈血栓形成

• 捐贈者的在切除子宮的過程當中，分離子宮動脈血管必須避免輸尿管受損‧
• 手術過程當中。最重要的就是你的那個子宮切好了，子宮要很很有效率的對接。必須同時進行呢捐贈與接受體手術，
• 首先接受體手術接受體的陰道跟直腸有膀胱區分開來，把那個陰道找出來之後，把重要對接血管標示找出來‧
• 捐贈體切掉子宮過程，然後立刻拿過立刻把重要血管做對接，血管也把他找出來，然後接着子宮一拿到之後，立刻先把血管做對接的血管對接，就上下左右上面那兩條是卵巢動脈靜脈，那下面兩條是子宮圓韌帶那附近的的子宮動靜脈共8條血管。
• 縫合血管必須將子宮的血管橫切面的，跟接受體的血管側邊縫合對接，整套過程當中必須迅速有效了，整個過程當中必須全力防止血栓的形成，必須盡量在可能2小時之內把這個手術完成。可能也必須用低溫的環境器官移植，血管縫合之後再來縫合之陰道壁，
• 手術完之後，必須用超聲波來評估它的那個多普勒穿不來評估子宮血流灌注哈進去的血流跟出來血流量差異，必要的時候必須做血管攝影啊，看看他的血流的供應，另外必須評估有沒有產生一些排斥性抗體呀。
• 手術完之後一些預防抗排斥這些，像一些抗排斥的藥劑。像類固醇，azathioprine。這跟一般的那個移植手術是一樣的，另外要預防它感染一些移植常見病毒了，像CMV病毒，或是皰疹病毒是HPV EB病毒這些。這些病毒會造成加重感染排斥風險。
• 手術完之後的那個，大約半年到一年之後可以考慮開始準備懷孕。那做完子宮移植的病人是沒有辦法自然懷孕的，因爲她的輸卵管是被切除掉一部分的。如果移植子宮的過程，輸卵管沒有切掉應該可以嘗試自然懷孕，但是目前所有的做完移植子宮都是做試管懷孕，並沒有嘗試用自然懷孕。另外移植子宮後陰道與子宮連結處可能會狹窄，必須在做擴張手術。
• 整個懷孕過程仍需要持續服用抗排斥藥，抗排斥藥會不會對胎兒影響，目前好像是並不明顯。其他比較常見的是會有一些妊娠高血壓，妊娠糖尿病，子癇前症，
• 生產時間通常會比較早生，一般惠提前2-3周 約35-36周生產，生產必須採用剖腹產，因爲陰道跟子宮是用縫合的，沒有辦法進行自然生產，因為自然生產過程胎兒經過子宮陰道縫合處容易撐開從哪裏破裂，所以一定會是採用剖腹產
• 目前移植子宮並沒有很長時間追蹤，需要移植子宮的適應症對象可能會從一開始的沒有子宮的病患，慢慢擴展成爲一些比如說子宮內膜受損，或者是子宮畸形，比如一些雙子宮啊，或男生變性女生的變性人，這類的病人可能會慢慢變成一個需要子宮移植的一個對象，
• 懷孕過程當中吃的那些抗排斥藥物會不會對胎兒產生一些不良影響，目前好像最終結果並沒有很明顯。
• 另外就是移植完這個子宮，是不是要盡量保持這個子宮呢，目前有些病患確定他以後不會生產，因爲他必須維持着子宮，必須長期吃這些抗排刺激，而且有人不願意持續吃這個抗排斥制劑，就會把再次把子宮摘除掉

自然週期vs誘導排卵      誘導排卵並不明顯提高胚胎染色體異常率 

自然週期vs誘導排卵      胚胎異常率均隨女性年齡而增加， 

自然週期vs誘導排卵      整倍體囊胚的植入率相同。

誘導排卵對胚胎非整倍體風險或胚胎生殖潛力沒有明顯副作用。

• Embryonic aneuploidy rates are equivalent in natural cycles and gonadotropin-stimulated cycles
• Aneuploidy rates were equivalent in unstimulated and stimulated IVF cycles. 
• The prevalence of aneuploidy in natural cycles increased with the age of the female partner in a manner identical to that seen in stimulated IVF cycles. 
• Implantation rates of euploid blastocysts were equivalent in natural and stimulated IVF cycles.
• No measurable toxic effect of gonadotropin administration on aneuploidy risk or embryonic reproductive potential. 

• The overall sustained implantation rate (SIR) did not differ for patients in the natural cycle group (60.0%) as compared to superovulatory controls (63.8%)
• Patients less than 35 years of age had an SIR of 61.7% in the natural cycle group versus 66.5% in the control group (P=.45). 
• There were no differences in SIR between patients that were 35 to 37 years of age in natural cycle (53.3%) versus gonadotropin control cycle patients (62.9%, P=.52). 
• Patients between the ages of 38 and 40 had SIR of 69.2% and 60.2%, in study and control groups, respectively (P=.65). 
• The SIR similarly did not vary for patients ages 41–42 in the natural cycle group and the superovulatory control group (33.3% vs. 61.4%, P=.33), or greater than 42 years of age (50.0% vs. 50.0%, P>.99). 

在所有年齡層  囊胚持續著床率比較

第5天優質囊胚>第 5 天中等囊胚>5 天差等囊胚>第 6 天胚胎 

第 5 天囊胚著床率與年齡>36歲有輕微負相關

第 6 天囊胚著床率與年齡>36歲有較明顯負相關

質量最佳的整倍體第 5 天胚胎在所有年齡的著床率高達 80%。

質量一般/較差的第 5 天胚胎和第 6 天胚胎的著床率約 50% 

 https://www.sciencedirect.com/science/article/pii/S1472648321002923

There was a clinically significant higher sustained implantation rate at all ages for euploid day 5 good quality embryos compared with day 5 fair, day 5 poor and day 6 embryos.

• For all ages the sustained implantation rates for day 5 good quality blastocysts were higher than for day 5 fair, day 5 poor and day 6 blastocysts. 
• At a maternal age of 36 years the best-fit sustained implantation rates were 86% for day 5 good quality blastocysts, 64% for day 5 fair, 63% for day 5 poor, and 51% for all day 6 blastocysts analysed as one group. 
• The best-fit sustained implantation rates for age 33 compared to age 39 years were 86% versus 80% for day 5 good, 71% versus 62% for day 5 fair, 59% versus 55% for day 5 poor, and 81% versus 46% for all day 6.
• The best quality euploid day 5 embryos had a SIR of 80–90% at all ages. 
• Even fair/poor quality day 5 embryos and day 6 embryos had a SIR of approximately 50% or greater. 
• euploid blastocyst transfers a reasonable performance goal is an overall SIR of 60–65% per embryo and a LBR of 50–60% per embryo. 

 誘導排卵成效與下列有關

• dehydroepiandrosterone DHEA (n = 1,336); 
• testosterone (n = 418); 
• high- vs. low-dose gonadotropin (n = 957); 
• delayed-start protocol with gonadotropin hormone-releasing hormone antagonist (n = 398); 

 誘導排卵成效與下列無關

• letrozole (n = 612); 
• clomiphene citrate (1,113); 
• growth hormone (311); l
• uteal phase stimulation (n = 57); 
• dual triggering (n = 139); dual stimulation (168); 
• luteinizing hormone (979); 
• oestradiol pretreatment (n = 552); 
• corifollitropin alfa (n = 561).

Therapeutic management in women with a diminished ovarian reserve: a systematic review and meta-analysis of randomized controlled trials

https://www.fertstert.org/article/S0015-0282(24)02256-8/fulltext

PGS應用是否能提高累積懷孕率與年齡有關

對於>35歲以上較能提高懷孕率，主因在於囊胚染色體異常率較高

年輕<35歲病患因為囊胚染色體異常率較低 ，PGS對於提高累積懷孕率較無明顯影響

Success rates with preimplantation genetic testing for aneuploidy in good prognosis patients are dependent on age

https://www.fertstert.org/article/S0015-0282(24)02261-1/abstract

To evaluate cumulative live birth after preimplantation genetic testing for aneuploidy (PGT-A) with next generation sequencing (NGS) compared with morphology alone among patients aged 21–40 years undergoing single blastocyst transfer.

• A total of 56,469 retrieval cycles were included in the analysis. Retrieval cycles were stratified based on age (<35, 35–37, and 38–40 years) and exposure to PGT-A with NGS. 
• the use of PGT-A was associated with a slightly lower cumulative live birth in individuals aged <35 years (risk ratio [RR]: 0.96; 95% CI: 0.93–0.99) compared with no PGT, 
• but higher cumulative live birth in ages 35–37 years (RR: 1.04; 95% CI: 1.00–1.08), 
• and 38–40 years (RR: 1.14; 95% CI: 1.07–1.20). 
• PGT-A was associated with higher cumulative live birth in individuals aged ≥35 years 
• was similar to no PGT in individuals aged <35 years. 
• Miscarriage was significantly less likely in individuals aged ≥35 years using PGT-A compared with no PGT-A.

精蟲頭部型態跟下列因素有關

1. acrosome formation頂體形成 
2. proacrosomal vesicles  前頂體囊泡 (PAV) 
3. manchette 
4. perinuclear theca 核週膜 (PT)
5. chromatin condensation染色質凝聚 
6. linker of nucleoskeleton 核骨架連接子
7. cytoskeleton complex細胞骨架 (LINC) 複合物 
8. ‘histone-to-protamine (HTP) transition‘組蛋白到魚精蛋白 (HTP) 轉變

精蟲頭部型態正常與否與ICSI結果有關

卵子冷凍相關知識

• 多數研究表明胚胎的品質不會受到冷凍保存時間的影響。人類胚胎長期冷凍保存不會影響懷孕結果。
• 未成熟GV與成熟M-II期玻璃化冷凍存活率無明顯差異。
• 解凍後卵母細胞的受精率也與新鮮自體卵胞漿內精子注射週期相當（70% 對 72%）。
• 玻璃化冷凍卵母細胞的每個胚胎的植入率(43% vs. 35%) 和每次移植的臨床懷孕率(57% vs. 44%) 明顯較高於與新鮮卵母形成胚胎植入。但活產/持續懷孕率並沒有統計上顯著差異（39% vs. 35%）。
• 每顆凍卵解凍受孕植入之活產嬰兒機率約6.4%。
• 使用自體卵母細胞玻璃化冷凍加熱的治療效果與使用新鮮卵母細胞的週期一樣好。
• MI階段卵子解凍後僅有44%可成熟至MII 階段， GV階段卵子解凍後僅有4% 能成熟至MII階段。

 https://www.fertstert.org/article/S0015-0282(15)02037-3/fulltext

l         Most studies dicate that the quality of embryos is not influenced by the duration during cryo-storage. 

l          Long-term cryo-storage of human embryos did not affect the pregnancy outcome. 

l          There is no significant difference in the survival rate between oocytes vitrified at the  immature GV stage and those vitrified at the mature M-II stage. 

l          Postthaw oocyte fertilization rates were also comparable to fresh autologous intracytoplasmic sperm injection cycles (70% vs. 72%). 

l          Implantation rates per embryo transferred (43% vs. 35%) and clinical pregnancy rates per transfer (57% vs. 44%) were significantly higher with vitrified–warmed compared with fresh oocytes. 

l          However, there was no statistically significant difference in live birth/ongoing pregnancy (39% vs. 35%). 

l          The overall vitrified–warmed oocyte to live born child efficiency was 6.4%.

l          Treatment outcomes using autologous oocyte vitrification and warming are as good as cycles using fresh oocytes. 

l          only 44% of the oocytes vitrified at the MI stage subsequently matured to the MII stage in vitro after warming, and only 4% of the oocytes vitrified at the GV stage did so.

 

 

 

冷凍卵子相關實證結果與常見問題

 

隨著科技的進步，卵子冷凍技術已十分成熟並也是現今試管嬰兒療程標準步驟之一。

相關常見問體列舉如下:

 

接受卵子冷凍的女性的預期活產率是多少？

自體冷凍保存卵子和新鮮卵子每次移植的持續懷孕率相同（分別為 38.6% 和 36%，P>.05）。

若你30歲冷凍卵子  等你40歲才解凍植入,該週期懷孕率大致與你30歲植入相同‧

 

凍卵取卵時的年齡如何影響結果？

卵母細胞效率隨著年齡的增加而降低（每顆卵子解凍後懷孕率依年齡成反比）

<30 歲女性每顆卵子解凍後懷孕率為7.4%，

30-34 歲女性每顆卵子解凍後懷孕率為7.0%，

35-37 歲女性每顆卵子解凍後懷孕率為6.5%，

38-40 歲女性每顆卵子解凍後懷孕率為5.2%。

41-42 歲女性的有效率為 2.4 %，

 

Age (y)	Cycles	Oocytes	Children (fresh ET)	Vitrified blastocysts	Children (cryo ET)a	Total children	Children per oocyte (%)
<30	2,085	34,017	1,339	4,484	1,611	2,950	8.67
30–34	5,715	83,597	3,257	10,409	3,601	6,858	8.20
35–37	4,189	53,794	2,097	5,404	1,844	3,941	7.33
38–40	4,148	46,582	1,573	2,928	509	2,082	4.47
41–42	1,831	18,584	379	544	85	464	2.49
43–44	778	7,318	67	81	11	78	1.06

Fertil Steril .2016 Feb;105(2):459-66.

 

 

卵子經歷冷凍解凍過程是否會對其品質及其後續受精所得之胚胎發育造成影響？

卵子受孕率而言: 新鮮卵子受孕率高於冷凍卵子(85% vs 80%)

第三天高品質胚胎比率: 新鮮卵子形成率高於冷凍卵子(38% vs 30%)

囊胚比率: 新鮮卵子形成率高於冷凍卵子(41% vs 36%)

 

新鮮胚胎植入 vs. 冷凍胚胎植入 vs. 解凍卵子所得胚胎植入，何者為優？

懷孕率最好的是使用冷凍胚胎的解凍植入，次佳的是使用解凍卵子所得胚胎植入，最差的是新鮮胚胎的植入。

主因為新鮮植入週期中使用大量誘導排卵的藥物，造成子宮內膜提早成熟 (黃體化)，子宮內膜基因表現改變等現象，進而影響胚胎著床。

而在解凍植入週期中，因為前段並無使用大量藥物劑量，進而子宮內膜所受之影響也較少。使用解凍卵子所得的胚胎和新鮮胚胎相比，縱使品質上較差，但在植入後仍有較佳的懷孕率和著床率。

(Fertil Steril 2016;106:615–22. 2016)

 

新生兒併發症是否有差異?

新鮮卵子或冷凍卵子在懷孕期和新生兒健康結果沒有顯著差異。

 

應該冷凍多少卵子才能達到合理的活產機會？

卵子細胞效率會隨著年齡的增長而降低，目前沒有足夠的證據來可達到合理的活產機率

部分研究估計，要實現70% 的活產機會，30-34 歲的女性需要冷凍保存14 個成熟卵母細胞，35-37 歲的女性需要冷凍保存15 個成熟卵母細胞，38-40 歲的女性需冷凍保存26 個成熟卵母細胞。

部分研究估計，<35 歲女性每個加熱的卵母細胞產生活產的機率為 2.6%，而 >35 歲女性的活產機率為 1.3%。他們計算出，35 歲以下的女性需要 38.8 個卵母細胞才能達到活產，而 35 歲以上的女性則需要 77 個卵母細胞。

 

冷凍自體卵子 vs 捐贈卵子

通常捐贈卵子多較為年輕 懷孕續自然比冷凍字體卵子為高‧若年齡卵巢功能相若ㄉ狀況下  懷孕率應無差異‧

但冷凍技術日新月異，10年前得冷凍技術應該降目前的冷凍技術略低，懷孕率應該也較低

 

結論，

隨著高齡與晚婚  冷凍卵子逐漸成為女性必須考慮之治療，建議應趁早施行相關保存，若已婚卻選擇晚點懷孕可優先考慮取卵後受孕形成胚胎再冷凍，若未婚女性或男方無法於取卵時提供精子的狀況下再選擇卵子冷凍。建議至少取卵2次以上，累積25-30顆以上卵子為妥‧