RU2581027C1 - Method for prediction of clinical outcomes of ef and et programs - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to obstetrics and gynaecology, and can be used for prediction of clinical outcome of extracorporeal fertilization (EF) program and embryo transfer (ET) in infertile women of tuboperitoneal genesis. For this purpose level of anti-mullerian hormone (AMH) is determined in venous blood of women. In case if AMH level is 1.14 ng/ml and lower anxiety level is additionally determined according to Spielberg-Hann. If it is 45 and higher unfavourable outcome of IVF program for this woman is predicted.

EFFECT: invention provides more accurate prediction of clinical outcomes of EF and ET programs and efficiency of VRT program due to more accurate selection of patients at stage of pregnancy planning.

1 cl, 2 ex

Description

The invention relates to medicine, namely to obstetrics and gynecology, and can be used to predict the outcome of in vitro fertilization (IVF) and embryo transfer (PE) in female patients with tubal-peritoneal infertility.

The problem of infertility treatment is currently gaining not only medical, socio-demographic, but also economic importance (Kulakov V.I., Leonov B.V., 2004). The frequency of infertility in Russia is 10-15%, and in some regions it exceeds the 15% level defined by the WHO problem group as critical, affecting demographic indicators (V. Kulakov, 1999). The most important achievement in the treatment of infertility was the introduction of in vitro fertilization (IVF) methods into clinical practice.

Assisted reproductive technologies made it possible to realize the function of childbearing with absolute tubal infertility, hypergonadotropic forms of amenorrhea, infertility of unknown origin, as well as with various forms of male infertility that were previously considered futile (Kulakov V.I., Korneeva I.E., 2001).

If in 1987-1990. the effectiveness of the method was 10-15% per embryo transfer, then at present this indicator has increased to 25-35% of cases. Carrying out even one cycle of IVF is associated with significant economic costs and a certain risk to a woman’s health associated with ovarian stimulation (Grishenko V.I., Petrushko M.P., Pinyaev V.I., 2000).

The development of prognostic criteria for the outcome of IVF will significantly increase its effectiveness and avoid unnecessary material costs due to a more careful selection of patients at the stage of pregnancy planning. At the same time, in clinics using the IVF and PE method, the search for new approaches to increasing the effectiveness of the method continues.

A known method for predicting the outcome of an IVF and PE program by qualitatively and quantitatively assessing the contents of follicles, characterized in that the activity of peptide hydrolases is studied in a follicular fluid aspirated separately from the right and left ovaries and at a level of at least 75 mg / ml / h one of the ovaries predict a favorable outcome (RF patent No. 2193777, 11/27/2002).

This method has several disadvantages:

1. When implementing the method, the risk of complications associated with performing transvaginal puncture of the follicles, which is carried out under general anesthesia and may be complicated by bleeding, is high.

2. The method is carried out at the stage of follicle puncture, when it is impossible to adjust the patient management tactics.

3. The need to study two samples of follicular fluid (from the right and left ovaries).

A known method for predicting the results of in vitro fertilization and embryo transfer (IVF and PE) in patients with autoimmune diseases, characterized in that a woman has a history of adnexitis, determines the presence of HLA antigens B 18, Cw3, Cw4 in the phenotype and the number of platelets in the coagulogram and calculate the prognostic index F by the formula

F = 1.4 × X1-1.3 × X2-2.4 × X3-2.1 × X4 + 0.019 × X5-2.5,

where X1 is the presence (or absence) of the female phenotype of the HLA antigen B 18 (1, or 0);

X2 - the presence (or absence) of the CW3 HLA antigen in the phenotype of a woman (1, or 0);

X3 - the presence (or absence) of the CW4 HLA antigen in the phenotype of a woman (1, or 0);

X4 - the presence (or absence) in the history of adnexitis (1, or 0);

X5 - platelet count in the coagulogram (10 9 / l);

and if F is greater than 0, a successful outcome of IVF and PE is predicted, and for values of F less than 0, the inexpediency of IVF at this stage is judged (RF patent No. 2345715, 02/10/2009).

The disadvantages of the method are:

1. The method can be used only in patients with autoimmune diseases.

2. For the analysis of HLA antigens, the method of serological histotyping is used, which is based on the reaction of cell lysis with subsequent microscopy, the accuracy of which depends on the subjective assessment of the researcher.

3. The method involves the determination of a large number of variable indicators: HLA antigens B18, Cw3, Cw4, platelet count in a coagulogram.

4. The complexity of the mathematical calculation of the prognostic index.

A known method for predicting the risk of early fetal loss during induced pregnancy in IVF programs by examining the biological fluid by the enzyme immunoassay, characterized in that in women in the event of induced pregnancy in the follicular fluid, the content of specific immune complexes alpha 2-macroglobulin - immunoglobulin G (MT-IgG ) and lactoferrin immunoglobulin G (LF-IgG) and when the MT-IgG value is less than 0.6 μg / ml, and LF-IgG less than 0.8 μg / ml predict a high probability of an early miscarriage (patent F №2394495, 20.07.2010).

This method has several disadvantages:

1. The method is an invasive diagnostic method.

2. The method involves the determination of specific immune complexes of alpha 2-macroglobulin by ELISA, which increases the material load on patients.

A known method for predicting the outcome of an IVF and PE program by examining a follicular fluid, characterized in that in the follicular fluid, quantitatively determine the content of TNF-α and -FRF, calculate the prognostic index (PI) by the formula

PI = 0.0027 · X + Y · (+ 8.9626 · 10-7 · Y-3.0827 · 10-6 · X) -0.1448,

where X is the amount of TNF-, Y is the amount of FRF,

and with a PI value less than 0.3038, a favorable in-vitro fertilization outcome is predicted, and with a value equal to or greater than 0.3038, an unfavorable in-vitro fertilization outcome is predicted (RF patent No. 2273031, 03/27/2006) .

This method has several disadvantages:

1. The method involves the study of follicular fluid, which is obtained using invasive technology.

2. The complexity of the mathematical calculation of the prognostic index.

There is a method for predicting the effectiveness of the treatment of infertility by in vitro fertilization, including transvaginal puncture of the follicles under ultrasound control followed by examination of the obtained follicular fluid, characterized in that the follicular fluid is subjected to chemiluminescent analysis by a standard method, the free radical activity of the samples is determined and the total antioxidant activity is determined by the rate of activity, and the antioxidant is predicted the onset of pregnancy: with indicators of total antioxidant active activity of 0.05 and above give an unfavorable prognosis, with indicators of total antioxidant activity below 0.05 give a favorable prognosis - the probability of pregnancy is more than 50%.

This method has several disadvantages:

1. The complexity of conducting research methods using invasive technologies.

A known method for predicting pregnancy in a program of in vitro fertilization and embryo transfer in the standard long protocol of stimulation of superovulation. The essence of the method lies in the fact that before the IVF and PE program in the standard long protocol of stimulation of superovulation in a patient, a hormonal status study is performed - the content of progesterone receptors in the mononuclear fraction of peripheral blood cells is determined. At the same time, the content of progesterone receptors in the mononuclear fraction of peripheral blood cells is determined in the middle of the luteal phase of the patient’s menstrual cycle, before the appointment of a gonadotropin-releasing hormone agonist during treatment according to the standard long superovulation stimulation protocol. With a value of more than 700 progesterone receptors per cell, pregnancy is predicted as a result of the IVF and PE program in the standard long protocol for stimulating superovulation% (RF patent No. 2430379, September 27, 2011).

This method has several disadvantages:

1. The method has several stages of research.

2. The method can be used only when using the standard long protocol of stimulation of superovulation.

This method is accepted by us as a prototype.

There is a method for predicting the outcome of the program of in vitro fertilization and embryo transfer in women with infertility by examining the histocompatibility complex antigens in peripheral venous blood prior to stimulation of superovulation, characterized in that class II HLA gene polymorphism is determined in leukocytes and when DQA1 * 0101-DQB haplotype carriers are detected * 0501 or DQA1 * 0102-DQB1 * 0502 predict an unfavorable outcome, and in the absence of carriage of haplotypes.

DQA1 * 0101-DQB1 * 0501 and DQA1 * 0102-DQB1 * 0502 - a favorable outcome of the IVF and PE program (RF patent No. 2474822.10.02.2013).

This method has several disadvantages:

1. The method involves the determination of a large number of antigens of the histocompatibility complex.

2. The complexity of the mathematical calculation of the prognostic index.

Thus, to date, certain information has been accumulated that indicates the possible forecasting of the results of the IVF and PE program.

In this connection, further development of methods is needed that allows for the prediction of in-vitro fertilization, especially for this category of patients, which is especially relevant in cases of using expensive methods of infertility treatment, which include IVF and PE.

The task of the invention is to improve the accuracy of prediction of the result of in vitro fertilization and embryo transfer (IVF and PE) in patients with tubal-peritoneal infertility.

The problem is solved by examining the patient’s venous blood serum: prior to the start of the IVF and PE protocol, a woman is determined in the venous blood the level of antimüller hormone (AMH), and if it is 1.14 or lower ng / ml, the level of anxiety according to Spielberg-Hann and if it is 45 points or more, an unfavorable outcome of the IVF program for this woman is predicted.

The technical result is aimed at improving the accuracy of predicting the outcomes of the IVF and PE program in women with tubal-peritoneal infertility, based on the study of the level of antimuller hormone in the patient’s venous blood serum and determining the level of anxiety on the Spilberger-Hanin scale, which will significantly increase the effectiveness of the ART program due to a more accurate selection of patients at the stage of pregnancy planning.

The obvious advantage of the method is its economic efficiency due to the possibility of its application before the start of the IVF and PE protocol.

Causal relationship

According to several authors (Kulakova E.V., 2007; Eugster A., Vingerhoets A.J.J.M., 1999; Matthiesen S.M.S. et al., 2010), the influence of the patient’s mental state and psychological characteristics have a negative effect on the outcome of ART programs. In this connection, the study of the problem of psychoemotional reactions in women undergoing treatment for infertility, including using ART methods, is becoming increasingly important. It was found that in the body during stress there is a decrease in the levels of steroid hormones of both the adrenal axis and the ovarian axis, which include the antimuller hormone.

The role of AMH as a peripheral signal in a pool of growing follicles can be of great clinical importance. Patients treated for infertility with a low ovarian reserve are expected to have a “poor” response of the ovaries to exogenous administration of gonadotropic drugs during stimulation of superovulation under the IVF and PE program, as well as a low pregnancy rate (Visser JA, de Jong FH, Laven JSE, Themmen APN, 2006).

Some studies have also shown that AMH is a reliable marker of ovarian response to hormonal stimulation. In their observations, they noted that in women with a “poor” ovarian response, AMH levels were lower than in patients with a normal ovarian response, while the ovarian response was assessed by the number of aspirated oocytes, as well as inadequate growth of follicles or their complete absence (Seifer DB et al., 2002; van Rooij LA. Et al., 2002).

However, the drawback of these studies is the lack of accurate intervals in the level of AMH, at which there is a decrease in the effectiveness of the IVF and PE program.

A group of researchers concluded that women with chronic stress have a low chance of a favorable outcome of the IVF and PE program, possibly due to psychobiological mechanisms that influence, among other things, the number of oocytes received as part of the ART program (Ebbesen SMS et al., 2009).

Thus, patients with reduced reproductive potential and a high level of anxiety, chronic stress and various types of psychological and mental conditions belong to the group of patients with increased requirements for resolving infertility problems due to the reduced period of childbearing. The search for additional ways to optimize the IVF and PE program in this group of patients is especially relevant in increasing the effectiveness of ART methods, which will increase the woman's chances in fulfilling her biological role.

After conducting a correlation analysis, using multivariate analysis (Decision Trees), it was found that if patients with tubal-peritoneal infertility have an AMH level of 1.14 ng / ml or lower, the anxiety level is 45 points or higher (high anxiety), then the outcome of the IVF and PE program is extremely unfavorable.

A detailed description of the method and examples of its specific implementation.

The method is as follows.

Before the IVF and PE protocol begins, on the 2-3 day of the menstrual cycle, blood is drawn from a vein in an amount of 5 ml into a test tube and the AMH level in the serum of venous blood of a patient with tube-peritoneal infertility is measured (by enzyme-linked immunosorbent assay to quantify the concentration of antimuller hormone in serum blood using the reagent kit "uE3 kit", Delphia, Finland).

If the AMG level is below 1.14 ng / ml, the level of anxiety is additionally determined on the Spilberger-Khanin scale (I. Dermanova, 2002). This scale consists of forty questions, including twenty questions characterizing reactive anxiety (questionnaire A), and another twenty questions characterizing personal anxiety (questionnaire B). The patient is invited to answer the questions of how she feels at the moment (reactive anxiety) and how she usually feels (personal anxiety). The indicator of personal anxiety gives an idea of the high probability of the occurrence of a state of anxiety in a subject in situations that he perceives as threatening. The indicator of reactive anxiety indicates a pronounced psycho-emotional stress.

If the AMG level is below 1.14 ng / ml, the anxiety level is more than 45 points, then the outcome of the IVF and PE program is extremely unfavorable.

The efficiency of this technique is confirmed by the following clinical examples.

Example 1

Patient T, 36 years old, individual 256/12 card, contacted the Department of Reproductive Health and ART for an IVF and PE program. The patient complains of primary infertility for 9 years. From the anamnesis it is known that the patient underwent laparoscopy 2 times for tubal-peritoneal infertility factor, however, it was not possible to restore the patency of the fallopian tubes due to the pronounced inflammatory process that led to endosalpingitis and adhesions in the interstitial section. A history of 3 attempts of the IVF and PE program (without a positive result). Before the next IVF program during hormonal research, an AMH level of 0.9 ng / ml was detected. We determined the level of anxiety using the Spielberger-Khanin questionnaire, and revealed high anxiety (48 points). These data indicate, according to our methodology, a high probability of an unfavorable outcome of IVF. After hormonal stimulation of superovulation, 4 oocytes were obtained from both ovaries, 2 class B embryos were obtained. After transfer of the embryos to the uterus, biochemical and clinical pregnancy did not occur.

Example 2

A 32-year-old patient of R-na, an individual card 224/1, applied to the Department of Reproductive Health and ART for an IVF and PE program. The patient complains of secondary infertility for 4 years. From the anamnesis it is known that the patient had 2 pregnancies, which ended in medical abortion in the period up to 12 weeks (without complications). History - 1 attempt of the IVF and PE program (without a positive result). Before the next IVF program during hormonal research, an AMH level of 1.0 ng / ml was detected. The level of anxiety was determined using the Spielberger-Hanin questionnaire. High anxiety was revealed (52 points). After hormonal stimulation of superovulation, 6 oocytes, 1 class A embryo, 3 class B embryos were obtained. After the embryos were transferred to the uterus, biochemical and clinical pregnancy did not occur.

Method sensitivity: 76.9%

Method specificity: 92.9%

Method accuracy: 81.1%

The advantages of the proposed method:

1. The method can be used to predict the outcome of an IVF and PE program in women with tubal-peritoneal infertility.

2. High accuracy - 81.1%, specificity - 92.9% and sensitivity - 76.9% of the method.

3. The method provides simplicity of the study, reducing its cost, increasing the reliability of forecasting by taking into account an objective indicator that indirectly characterizes the hormonal status of patients.

Claims (1)

A method for predicting the outcomes of an IVF and PE program by examining a patient’s blood, characterized in that patients with tubal-peritoneal infertility before the start of the IVF and PE protocol are pre-determined in the venous blood level of the anti-Muller hormone (AMH), and if it is 1.14 ng / ml and below, additionally determine the level of anxiety according to Spielberg-Hann, and if it is 45 or more points, an unfavorable outcome of the IVF program for this patient is predicted.