卵巢多囊样改变合并不孕症患者AMH水平对卵母细胞发育潜能的影响.pdf

医学研究杂志2 0 2 4年2 月第53卷第2 期论着卵巢多囊样改变合并不孕症患者AMH水平对卵母细胞发育潜能的影响李雪敏杨贵芳田珏郭瑞霞杨晓丽摘要目的探讨卵巢多囊样改变（polycystic ovarian morphology,PCOM）合并不孕症患者体外受精胚胎移植中抗苗勒管激素（anti-Millerian hormone,AMH)水平对卵母细胞发育潜能的影响。方法选取符合纳人与排除标准的不孕症患者48 0 例（对照组16 0 例、PCOM组10 4例、PCOS组2 16 例），比较不同组间AMH水平。PCOM及PCOS人群均按血清AMH水平（4.7ng/ml为正常值，4.7 ng/ml为高值）分为正常AMH组和高AMH组，分析PCOM及PCOS人群不同AMH水平组间的卵母细胞指标差异及其相关性。结果PCOS人群血清基础雄激素高于PCOM人群(P0.01);血清AMH水平比较：对照组 PCOM组PCOS组（P0.001）；实验室指标分析结果显示,PCOM及PCOS人群高AMH组成熟卵数、2 PN数、受精数、D3卵裂数及胚胎总数较正常AMH组增多（P0.05）,且AMH水平与成熟卵数、2 PN数、受精数、D3卵裂数、胚胎总数均呈正相关（P0.05)；PCOS人群高AMH组优势卵泡数、获卵数、优胚数及可利用胚胎数较正常AMH组增多（P0.05）,且AMH水平与优势卵泡数、获卵数、优胚数及可利用胚胎数均呈正相关（PO.05）。结论PCOM合并不孕症人群血清AMH水平较对照组升高但低于PCOS人群,高AMH水平的PCOM患者可获得质量较好的卵母细胞及更多的胚胎，增加临床中反复移植失败患者移植次数，提高临床妊娠率。关键词抗苗勒管激素体外受精胚胎移植卵巢多囊样改变多囊卵巢综合征卵母细胞发育潜能中图分类号R71Effect of Anti-Mullerian Hormone Level on the Developmental Potential of Oocytes in Patients with Polycystic Ovarian Morphology com-bined with Infertility.LI Xuemin,YANG Guifang,TIAN Jue,et al.The Ninth Clinical Medical College of Shanxi Medical University(Taiyuan Central Hospital),Shanxi 030009,ChinaAbstract Objective To investigate the effect of anti-Mullerian hormone(AMH)levels on the development potential of oocytesin patients with polycystic ovarian morphology(PCOM)complicated with infertility during in vitro fertilization-embryo transfer.MethodsA total of 480 infertile patients who met the inclusion and exclusion criteria were selected(160 cases in control group,104 cases inPCOM group and 216 cases in PCOS group),AMH levels were compared among different groups.According to the serum AMH level(4.7ng/ml as normal value,4.7ng/ml as high value),both PCOM and PCOS patients were divided into normal AMH group and highAMH group.The differences of oocyte indexes and their correlation between different AMH levels in PCOM and PCOS patients were ana-lyzed.Results The basal androgen level in PCOS group was significantly higher than that in PCOM group(P O.O1).The comparisonof serum AMH value showed that the control group PCOM groupPCOS group(P0.001).Laboratory indexes showed that the num-ber of mature oocytes,2PN,fertilization,D3 cleavage and total embryos in the high AMH group were significantly higher than those in thenormal AMH group in PCOM and PCOS patients(P0.05).The AMH levels was positively correlated with the number of mature oo-cytes,2PN,fertilization,D3 cleavage and total embryos(P0.05).In the PCOS group,the number of dominant follicles,oocytes,high-quality embryos and available embryos in the high AMH group were significantly higher than those in the normal AMH group(P0.05),and the AMH levels was positively correlated with the number of dominant follicles,oocytes,high-quality embryos and availableembryos(P0.05).Conclusion The serum AMH level of PCOM patients with infertility is higher than that of the control group,but lower thanthat of PCOS patients.PCOM patients with high AMH level can obtain better quality oocytes and more embryos,and increase the number基金项目：山西省医学重点科研计划项目重大科技攻关专项（2 0 2 0 XM09）；山西省省筹资金资助回国留学人员科研项目（2 0 2 117 5）；山西省研究生教育创新项目（2 0 2 1Y400）作者单位：0 30 0 0 9太原，山西医科大学第九临床医学院（太原市中心医院）（李雪敏、杨贵芳、郭瑞霞、杨晓丽）；7 50 0 0 4银川，宁夏医科大学病理生理学系（田）通信作者：杨晓丽，电子信箱：文献标识码马AD0110.11969/j.issn.1673-548X.2024.02.01681J Med Res,February 2024,Vol.53 No.2论着of transplantation in patients with repeated transplantation failure,thereby improving the clinical pregnancy rate.Key words Anti-Mullerian hormone;In vitro fertilization-embryo transfer;Polycystic ovarian morphology;Polycystic ovary syn-drome;Oocyte developmental potential卵巢多囊样改变（polycystic ovarian morphology，PCOM)指超声监测下单侧卵巢内直径2 9mm的卵泡12 个或卵巢体积 10 ml,可引起女性肥胖、月经紊乱甚至激素分泌失调，约33%的育龄女性超声显示PCOML1.2。既往研究表明，PCOM是处于正常卵巢和多囊卵巢综合征（polycystic ovarysyndrome，P-COS)间的独特实体,其超声表现、颗粒细胞异常程度及部分临床指标均与PCOS有所差异,且部分患者属于PCOM合并不孕症需辅助生殖技术（assisted repro-ductive technology，A RT）助孕，故有必要将PCOM独立分组研究3 6 。ART中卵母细胞的良好发育是获得良好妊娠结局的基础，抗苗勒管激素（anti-Millerian hormone，A M H)是评估卵巢储备功能及卵子质量的良好生物学标志物,其与PCOS的关系报道颇多7 1。但不同AMH水平对PCOM患者卵母细胞发育的影响鲜见报道，且PCOM及PCOS人群中不同AMH水平与卵母细胞发育指标的关系是否相同也鲜见报道。本研究拟通过测定 PCOM 及 PCOS 患者血清AMH水平,分析两人群中血清AMH水平与卵母细胞指标关系有无差异,探讨 AMH水平对 PCOM 患者卵母细胞发育潜能影响,旨在预测临床不同AMH水平的PCOM患者卵母细胞发育情况，制定更具针对性的诊疗计划,减少体外受精-胚胎移植（in vitro fertiliza-tion-embryo transfer，I V FET）失败次数，提高临床妊娠率,对AMH进一步应用于ART领域具备一定价值。1.研究对象：选取2 0 17 年8 月2 0 2 2 年12 月在山西医科大学第九临床医学院生殖医学中心行IVF-ET的48 0 例不孕症患者作为研究对象。2.纳人与排除标准：纳人标准：(1)PCOM患者纳人标准:因输卵管因素行IVF-ET助孕;超声监测下单侧卵巢内直径2 9 mm 的卵泡12 个或卵巢体积 10 mll;基础性激素正常；排卵正常。(2)PCOS患者纳人符合鹿特丹标准12 。（3)年龄2035岁。（4)阴超证实双侧卵巢完整且无形态学异常。（5)病历信息完整。排除标准：（1)盆腔恶性肿瘤病史者。（2)有放化疗及药物服用史等损害卵巢功能者。（3）患有其他影响促性腺激素分泌疾病82者。（4)合并有严重全身性疾病患者。3.分组：对照组（因输卵管因素行IVFET 助孕)16 0 例;PCOM组（因PCOM合并输卵管因素行IVF-ET助孕）10 4例；PCOS组（因PCOS因素行IVF-ET助孕）2 16 例。一项Meta分析结果表明，AMH截止值为4.7 ng/ml时诊断有症状PCOS的特异性和敏感度为7 9.4%和8 2.8%13。本研究将PCOS人群按血清AMH水平（4.7 ng/ml为正常值，4.7ng/ml为高值）分为正常AMH组（n=72）和高AMH组（n=144）,PC O M 人群也就此标准分为正常AMH组（n=72）和高AMH组（n=32）。本研究符合赫尔辛基宣言原则，患者均已签署知情同意书，本研究获得了山西医科大学第九临床医学院医学伦理学委员会批准（伦理学审批号：2 0 2 10 0 2）。4.IVF-ET方案：48 0 例患者采取不同促排方案，激素用量据卵泡生长情况确定，经阴道超声下有2个以上卵泡直径2 0 mm当日夜间给予人绒毛膜促性腺激素10 0 0 0 U或8 0 0 0 U促进排卵。次日经阴道超声引导下取卵，术后据患者经阴道超声及激素情况决定是否进行鲜胚移植术,鲜胚移植患者术后给予黄体酮支持治疗。5.AMH检测及基础性激素检测：使用Access2贝克曼全自动免疫分析仪（美国Beckman-Coulter公司，规格型号：8 16 0 0 N)检测AMH水平及血清性激素指标。6.观察指标：观察并比较患者的基本资料，包括年龄、不孕年限、空腹血糖浓度（fastingblood sugar，资料与方法FBS）、体重指数（badymass index，BM I）、基础促卵泡生成素（follicle stimulating hormone,FSH）、基础黄体生成素（luteinizing hormone,LH）、基础睾酮（testoster-one,T）、不孕类型、促排方案。观察并比较患者的实验室指标,包括优势卵泡数、获卵数、成熟卵数、2 PN卵数、受精数、D3卵裂数、优胚数、胚胎总数、可利用胚胎数;计算获卵率、成熟卵率、2 PN率、受精率、D3卵裂率、优胚率。指标计算方法：获卵率（%）=获卵数/优势卵泡数10 0%；成熟卵率（%）=成熟卵数/获卵数10 0%;2 PN率（%）=2 PN数/获卵数10 0%；受精率（%）=受精数/获卵数10 0%；D3卵裂率（%）=D 3卵裂数/受精数10 0%；优胚率（%）=优胚数/2 PN 数10 0%。医学研究杂志2 0 2 4年2 月第53卷第2 期论7.统计学方法：应用SPSS26.0统计学软件对数据进行统计分析。符合正态分布的计量资料以均数标准差（xs)表示,组间比较采用t检验；不符合正态分布的计量资料以中位数（四分位数间距）M（Q 1，Q 3）表示,组间比较采用非参数检验。计数资料以例数（构成比）n（%）】表示,组间比较采用x检验。符合正态分布的计量资料采用Pearson相关性分析,不符合正态分布的计量资料采用Spearman相关性分析,以P0.05为差异有统计学意义。1.PCOM组与PCOS组一般资料比较：PCOM组与PCOS组在基础T方面比较,差异有统计学意义（P0.05,表 1)。表1PCOM组和 PCOS 组一般资料比较n(%）,x s 项目(n=104)年龄（岁）30.08 4.522不孕年限（年）3.14 2.20FBS(mmol/L)5.04 0.41BMI(kg/m2)24.23 4.14 25.41 3.90基础 FSH(mIU/ml)5.60 1.57基础 LH(mIU/ml)4.17 2.74基础 T(ng/ml)0.32 0.14不孕类型原发继发促排方案拮抗剂长方案超长方案项目年龄（岁）不孕年限（年）FBS(mmol/L)BMI(kg/m)不孕类型原发继发促排方案拮抗剂长方案超长方案2.对照组、PCOM组与PCOS组血清AMH的比较：对照组、PCOM组、PCOS组血清AMH水平两两比较,差异有统计学意义(P0.01,图1)。207*#15一(ru/eu)HNV10结果50对照组PCOM组PCOS组图1对照组、PCOM组及PCOS组血清AMH水平比较与对照组比较，*P0.01；与PCOM组比较，#P0.05,表2)。4.PCOM与PCOS人群血清正常AMH组与高AMH组实验室指标比较：PCOM人群中正常AMH组与高AMH组在成熟卵数、2 PN数、受精数、D3 卵裂数、胚胎总数方面比较,差异均有统计学意义（P0.05）;PCO S人群中正常AMH组与高AMH组在优势卵泡数、获卵数、成熟卵数、2 PN数、受精数、D3 卵裂数、优胚数、胚胎总数、可利用胚胎数方面比较，差异均有统计学意义（P0.05,表3）。正常AMH组P(n=72)0.75828.94 4.120.2404.42 2.310.3835.09 0.620.09825.76 4.450.67348(64.3)24(35.7)0.27136(50.0)20(27.8)16(22.2)PCOS高AMH组X(n=144)29.94 3.883.88 2.765.11 0.5625.43 3.7788(54.5)56(45.5)36(25.0)84(58.3)24(16.7)P0.8750.3860.7150.478-0.0930.9260.2810.7800.1590.7714.7770.08683J Med Res,February 2024,Vol.53 No.2论着表3PCOM与PCOS人群血清正常AMH组与高AMH组实验室指标比较xs,M(Q1，Q 3)项目正常AMH组(n=72)优势卵泡数（枚）15.39 4.77获卵数（枚）14.50 5.61成熟卵数（枚）11.44 4.912PN数(枚）9.44 5.02受精数(枚）10.39 4.97D3 卵裂数(枚)9.78 4.70优胚数（枚）1.00(0.00,2.50)胚胎总数(枚)9.67 4.84可利用胚胎数（枚）7.94 4.30获卵率(%)96.08 29.79成熟卵率(%）79.76 18.112PN率(%)69.15 25.95受精率(%）75.16 22.97D3 卵裂率(%)93.06 9.97优胚率（%）11.12(0.00,33.44)7.94(0.00,28.75)5.PCOM及PCOS人群血清AMH水平与卵母细胞指标的相关性分析：PCOM人群血清AMH水平与成熟卵数、2 PN数、受精数、D3卵裂数、胚胎总数均呈正相关(P0.05）;PC O S人群血清AMH水平与优势卵泡数、获卵数、成熟卵数、2 PN数、受精数、D3 卵裂数、优胚数、胚胎总数、可利用胚胎数均呈正相关(P0.05,表 4)。表4PCOM及PCOS人群血清AMH水平与卵母细胞指标的相关性分析PCOM-AMH指标P优势卵泡数1获卵数一成熟卵数0.4342PN数0.484受精数0.506D3卵裂数0.513优胚数一胚胎总数0.500可利用胚胎数一讨 论既往研究认为,PCOM是卵巢形态的正常变异，而近年发现PCOM不孕症患者已出现卵泡期延长、小卵泡排卵、卵泡未破裂黄素化等症状,亦有部分患者属PCOM合并不孕症14。诸多研究将PCOM单独分组,Emanuel等3 研究表明,PCOM颗粒细胞存在异常,Uk等15 研究认为PCOM 是不同于PCOS 的独特表型。现ART愈发应用于PCOM及PCOS不孕症患84PCOM高AMH组(n=32)20.00 7.6019.75 7.9416.88 8.4916.16 8.5816.75 8.6515.63 7.501.50(0.00,3.00)16.63 8.4711.75 6.41101.84 29.1083.08 10.9282.73 12.3286.00 10.8495.08 8.99PCOS-AMHP一0.588一0.4560.0270.5330.0120.4080.0080.4410.0070.4540.2830.0090.456一0.467PCOS正常AMH组高AMH组t/zP-1.8910.0711.9370.0652.0690.049-2.5080.019-2.3870.025-2.4310.0230.2880.7742.6740.013-1.7880.086-0.4580.6510.4790.636-1.3990.175-1.6390.114-0.4910.6280.0860.932者,ART中精确评估卵巢功能与卵母细胞发育情况成为获得满意妊娠结局的关键，因此探究PCOM卵母细胞的发育情况尤为重要，可在早期对ART助孕结局发挥预测作用。AMH在月经周期中波动最小,可以更好地评估PCOM患者的临床特征,但AMH对于PCOM患者卵母细胞的影响未见报道16.17 。本研究全面纳入卵母细胞发育相关指标，探讨了PCOM与PCOS人群中正常AMH水平与高AMH水平对卵母细胞发育的影响。一般资料比较发现,PCOS组血清基础雄激素较PCOM组显著升高,这与Ozay等18 的研究发现相同，0.001原因是PCOS 组存在高雄激素血症。AMH值比较发0.001现,对照组 PCOM组 PCOS组,PCOS组AMH水平0.001高于PCOM组表明窦卵泡数量增加不是血清AMH0.0020.0010.0010.0400.0010.001t/z(n=72)(n=144)16.06 6.6121.19 6.9613.94 6.2920.00 9.649.78 4.6117.36 8.678.39 5.1414.92 8.859.61 6.0616.56 9.388.67 6.1116.08 8.831.00(0.00,1.25)2.00(1.00,3.75)8.72 6.4016.06 9.156.22 5.0011.94 6.4888.33 25.3896.88 38.5574.02 24.5486.51 10.2765.53 23.7073.33 18.6071.06 25.8882.64 16.7190.11 16.4197.51 52.548.34(0.00,28.78)11.66(0.93,33.33)唯一决定因素,AMH还与其他因素如排卵障碍、高雄激素血症等相关19,2 0 。PCOM和PCOS人群不同AMH水平分组一般资料比较，差异无统计学意义。实验室指标显示，PCOM及PCOS人群中高AMH组较正常AMH组有更多成熟卵数、2 PN数、受精数、D3 卵裂数及胚胎总数,且血清AMH水平与成熟卵数、2 PN数、受精数、D3卵裂数、胚胎总数均呈正相关，这与Nikbakht等2 1的研究结论不同。本研究提示，AMH水平与PCOM 患者卵母细胞质量及胚胎数量密切相关,较高的AMH水平提示较好的卵巢储备功能,PCOM及P-COS人群AMH水平越高，成熟卵数及可利用卵数越多,正常受精的卵母细胞越多,胚胎数目就越多2 1。P-2.6000.0122.4150.0194.1950.0002.8870.006-2.8510.006-3.1960.002-2.1990.028-3.0430.0043.2820.002-0.8510.3992.0710.051-1.3240.191-1.7270.097-1.8650.078-1.0260.305医学研究杂志2 0 2 4年2 月第53卷第2 期对于临床中高AMH水平的PCOM患者可减少反复移植失败后再次取卵次数,增加移植机会，节约治疗成本的同时有利于患者获得更好的生殖结局。本研究显示,PCOS人群卵母细胞指标中优势卵泡数、获卵数、优胚数及可利用胚胎数与AMH呈正相关，但PCOM人群中未发现此现象，提示AMH对于PCOM患者卵母细胞数量及优质胚胎无明显影响。尽管PCOM人群高AMH组中优势卵泡数与获卵数较正常AMH组呈增高趋势，但差异无统计学意义，因此临床中因获卵数过多而发生卵巢过度刺激综合征的概率可能较PCOS低，这符合PCOM超声表现中卵巢体积略逊于PCOS 的报道,可能与PCOS患者更为复杂的生殖内分泌紊乱及代谢异常相关2 2 5。另外本研究样本量相对较小且为单中心调查，也可能是产生差异的原因,未来有望在多中心的大样本量研究中予以进一步证实。综上所述,PCOM患者血清AMH水平对卵母细胞质量及胚胎数量有指示作用，AMH水平较高的PCOM人群在ART过程中可能拥有质量更佳的卵母细胞,形成数量较多的胚胎。利益冲突声明：所有作者均声明不存在利益冲突。参考文献1 Dietz de Loos A,Hund M,Buck K,et al.Antimullerian hormone todetermine polycystic ovarian morphology J.Fertil Steril,2021,116(4):1149-11572Nikbakht R,Mohammadjafari R,Rajabalipour M,et al.Evaluationof oocyte quality in polycystic ovary syndrome patients undergoing ARTcyclesJ.Fertil Res Pract,2021,7(1):23Emanuel RHK,Roberts J,Docherty PD,et al.A review of the hor-mones involved in the endocrine dysfunctions of polycystic ovary syn-drome and their interactions J.Front Endocrinol:Lausanne,2022,13:10174684 Emekgi Ozay O,Ozay AC,Gun I.Comparison of stromal thicknessand doppler findings in polycystic ovary syndrome and healthy womenwith ultrasonographic evidence of polycystic ovaries?A cross-section-al studyJ.J Obstet Gynaecol,2022,42(6):2367-23725Siristatidis C,Sergentanis TN,Vogiatzi P,et al.In vitro maturationin women with vs.without polycystic ovarian syndrome:a systematicreview and Meta-analysisJ.PLoS One,2015,10(8):e01346966聂明月，洪黎明，杨晓葵卵巢多囊样改变对体外受精一胚胎移植结局的影响J中国计划生育和妇产科，2 0 16，8（5）：16 187Hashemian Z,Afsharian P,Farzaneh P,et al.Establishment andcharacterization of a PCOS and a normal human granulosa cell lineJ.Cytotechnology,2020,72(6):833-8458Dai X,Wang Y,Yang H,et al.AMH has no role in predicting oo-cyte quality in women with advanced age undergoing IVF/ICSI cyclesJ.Sci Rep,2020,10(1):197509Muharam R,Prasetyo YD,Prabowo KA,et al.IVF outcome with ahigh level of AMH:a focus on PCOS versus non-PCOS J.BMCWomens Health,2022,22(1):172论着10o Chen Y,Ye B,Yang X,et al.Predicting the outcome of differentprotocols of in vitro fertilization with anti-Muullerian hormone levelsin patients with polycystic ovary syndrome J.J Int Med Res,2017,45(3):1138-114711Liu S,Hong L,Mo M,et al.Association of antimullerian hormonewith polycystic ovarian syndrome phenotypes and pregnancy outcomesof in vitro fertilization cycles with fresh embryo transfer J.BMCPregnancy Childbirth,2022,22(1):17112Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus WorkshopGroup.Revised 2003 consensus on diagnostic criteria and long-termhealth risks related to polycystic ovary syndrome J.Fertil Steril,2004,81(1):19-2513Iliodromiti S,Kelsey TW,Anderson RA,et al.Can anti-Mullerianhormone predict the diagnosis of polycystic ovary syndrome?A system-atic review and Meta-analysis of extracted dataJ.J Clin Endocri-nol Metab,2013,98(8):3332-334014胡仲梅，王露娟，何雪瑞，等。卵巢多囊样改变不孕患者的临床特征分析J现代医药卫生，2 0 19，35（10）：1493-1496，149915Uk A,Decanter C,Grysole C,et al.Polycystic ovary syndrome phe-notype does not have impact on oocyte morphology J.Reprod BiolEndocrinol,2022,20(1):716Bedenk J,Vrtacnik-Bokal E,Virant-Klun I.The role of anti-Mullerian hormone（A M H)i n o v a r i a n d i s e a s e a n d i n f e r t i l i t y JJ.JAssist Reprod Genet,2020,37(1):89-10017Howard JA,Hart KN,Thompson TB.Molecular mechanisms of AMHsignalingJ.Front Endocrinol:Lausanne,2022,13:92782418Ozay AC,Emekc Ozay O,Gulekli B.Comparison of anti-mullerianhormone(AMH)and hormonal assays for phenotypic classification ofpolycystic ovary syndrome J.Ginekol Pol,2020,91(11):661-66719Dewailly D,Barbotin AL,Dumont A,et al.Role of anti-mullerianhormone in the pathogenesis of polycystic ovary syndrome J.FrontEndocrinol:Lausanne,2020,1l:64120Rudnicka E,Kunicki M,Calik-Ksepka A,et al.Anti-MullerianHormone in pathogenesis,diagnostic and treatment of PCOS J.Int JMol Sci,2021,22(22):1250721de Kat AC,Broekmans FJM,Lambalk CB.Role of AMH in predic-tion of menopause J.Front Endocrinol:Lausanne,2021,12:73373122Ozdemir O,Sari ME,Kalkan D,et al.Comprasion of ovarian stromalblood flow measured by color Doppler ultrasonography in polycystic o-vary syndrome patients and healthy women with ultrasonographic evi-dence of polycysticJ.Gynecol Endocrinol,2015,31(4):322-32623Sun B,Ma Y,Li L,et al.Factors associated with ovarian hyperstim-ulation syndrome（O H Ss)s e v e r i t y i n w o me n w i t h p o l y c y s t i c o v a r ysyndrome undergoing IVF/ICSI J.Front Endocrinol:Lausanne,2021,11:61595724Liao B,Qiao J,Pang Y.Central regulation of PCOS:abnormal neu-ronal-reproductive-metabolic circuits in PCOS pathophysiology J.Front Endocrinol:Lausanne,2021,12:66742225Jie HY,Zhou X,Zhao MP,et al.Pregnancy outcomes in patientswith polycystic ovary syndrome who conceived after single thawed blas-tocyst transfer:a propensity score-matched studyJ.BMC Preg-nancy Childbirth,2022,22(1):718（收稿日期：2 0 2 3-0 2-16)（修回日期：2 0 2 3-0 3-0 6）85