找黃貞瑜醫師聊療不孕、助孕規劃與荷爾蒙

  

 

　　傳統的破卵針（成分為「人類絨毛膜激素」hCG）誘發卵子成熟、脫離濾泡壁，並且幫助後續的黃體維持，有利於撐持初期懷孕。但由於hCG的本質，在體內會作用太強太久，往往造成穩健的黃體維持背後，潛藏著卵巢過度刺激(OHSS)的風險！近幾十年來，醫界發展出替代hCG的新型破卵針（成分為GnRH agonist, 以下簡稱GnRHa），可讓OHSS幾成絕響，但是有一好沒兩好，由於對於黃體撐持的能力比自然生理狀況弱，因此使成功的著床往往因此流產，功虧一簣。換言之，若因顧慮OHSS的風險而使用新型破卵針，則懷孕成功的關鍵，就在於黃體功能的提升。

　　過去的學者相繼發展出各種提升黃體功能的方式，主要有三種：

1. 採用極高密度與強度的黃體素補充法(每天肌肉注射挨針是基本元件！)
2. 新型破卵針合併低劑量的hCG共同破卵。
3. 在給予單純新型破卵針之後35小時，給予低劑量hCG以助黃體維持。

 

然而，至今仍沒有一個真正能夠兼顧成功率和屏除OHSS危險的確切方式。

許多不孕症中心依方法1.如法炮製，雖然確保「零OHSS」但成功率總差強人意；而方法2.和方法3.使用在OHSS的高危險群，還是會有些OHSS發生，因為畢竟：hCG的存在，雖能增加成功率，卻也同時增加OHSS的風險。hCG就如同雙面刃，運用是需要小心拿捏的。

 

台北榮總不孕症科，汲取前人的智慧，集各家之大成，做了細節的關鍵調整，現在已能達到比之前更有信心的成功率和零OHSS率! 我們採用的是「分期付款」的概念，以更低劑量的hCG協助新型破卵針，併後續以嚴密的監控和客製化的超低量第二劑hCG補強黃體期。

（續下篇：-2011美國生殖醫學年會口頭發表: 兼顧成功率並降低卵巢過度風險的新療程（下））

參考資料:

• Humaidan P, Quartarolo J, Papanikolaou EG. Preventing ovarian hyperstimulation syndrome: guidance for the clinician. Fertil Steril. 2010 Jul;94(2):389-400. 
• Damewood MD, Shen W, Zacur HA, Schlaff WD, Rock JA, Wallach EE. Disappearance of exogenously administered human chorionic gonadotropin. Fertil Steril. 1989 Sep;52(3):398-400.
• Itskovitz-Eldor J, Kol S, Mannaerts B. Use of a single bolus of GnRH agonist triptorelin to trigger ovulation after GnRH antagonist ganirelix treatment in women undergoing ovarian stimulation for assisted reproduction, with special reference to the prevention of ovarian hyperstimulation syndrome: preliminary report: short communication. Hum Reprod. 2000 Sep;15(9):1965-8.
• Humaidan P, Ejdrup Bredkjær H, Bungum L, Bungum M, Grøndahl ML, Westergaard LG, et al. GnRH agonist (Buserelin) or hCG for ovulation induction in GnRH antagonist IVF/ICSI cycles: a prospective randomised study. Hum Reprod 2005;20:1213–20.
• Griesinger G, Diedrich K, Devroey P, Kolibianakis EM. GnRH agonist for triggering final oocyte maturation in the GnRH antagonist ovarian hyperstimulation protocol: a systemic review and meta-analysis. Hum Reprod Update 2006; 12:159–168.
• Youssef MA, Van der Veen F, Al-Inany HG, Griesinger G, Mochtar MH, Aboulfoutouh I, Khattab SM, van Wely M. Gonadotropin-releasing hormone agonist versus HCG for oocyte triggering in antagonist assisted reproductive technology cycles.Cochrane Database Syst Rev. 2011 Jan 19;(1):CD008046.
• Fauser BC, de Jong D, Olivennes F, Wramsby H, Tay C, Itskovitz-Eldor J and van Hooren HG (2002) Endocrine profiles after triggering of final oocyte maturation with GnRH agonist after cotreatment with the GnRH antagonist ganirelix during ovarian hyperstimulation for in vitro fertilization. J Clin Endocrinol Metab 87,709–715.
• Nevo O, Eldar-Geva T, Kol S and Itskovitz-Eldor J (2003) Lower levels of inhibin A and pro-alphaC during the luteal phase after triggering oocyte maturation with a gonadotropin-releasing hormone agonist versus human chorionic gonadotropin. Fertil Steril 79,1123–1128.
• Engmann L, DiLuigi A, Schmidt D, Nulsen J, Maier D, Benadiva C. The use of gonadotropin-releasing hormone (GnRH) agonist to induce oocyte maturation after cotreatment with GnRH antagonist in high-risk patients undergoing in vitro fertilization prevents the risk of ovarian hyperstimulation syndrome: a prospective randomized controlled study. Fertil Steril. 2008 Jan;89(1):84-91.
• Shapiro BS, Daneshmand ST, Garner FC, Aguirre M, Thomas S. Gonadotropin-releasing hormone agonist combined with a reduced dose of human chorionic gonadotropin for final oocyte maturation in fresh autologous cycles of in vitro fertilization. Fertil Steril. 2008 Jul;90(1):231-3.
• Humaidan P, Ejdrup Bredkjaer H, Westergaard LG, Yding Andersen C. 1,500 IU human chorionic gonadotropin administered at oocyte retrieval rescues the luteal phase when gonadotropin-releasing hormone agonist is used for ovulation induction: a prospective, randomized, controlled study. Fertil Steril. 2010 Feb;93(3):847-54. 

     與提出方法1.的學者Engmann合影