RU2616272C1 - In vitro fertilization method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: superovulation is stimulated, follicles are punctured, oocytesare selected from the follicular fluid and fertilized, embryo are cultured and 1-2 embryo are transferred to the uterine cavity. At that, on 6-8 day of the stimulated cycle, endometrium thickness is determined and at thickness less than 5 mm linear endometrial incisions are performed ensuring preservation of its basal layer, extending from the internal os to the boundary between the body and the uterus bottom. Incisions are arranged circularly along the uterine cavity walls at a distance of 4-8 mm apart. Linear endometrial incision is also performed, ensuring preservation of its basal layer, between the Fallopian tubes mouths. In the particular case, endometrial tissue dissection during for incision formation is made between the forceps jaws, while one jaw is immersed in the endometrium down to the basal layer, excluding penetration, and maintained at the given depth up to the completion of the incision.

EFFECT: method can improve the IVF outcome for women with a critical backlog of endometrium due to normalization of decidua formation and increased endometrial receptivity by maximizing the effect of positive pre-implantation tissue mediators and cytokines in a controlled surgical trauma prior to embryo transfer.

2 cl, 1 ex

Description

The invention relates to medicine, namely to obstetrics and gynecology, can be used during in vitro fertilization (IVF).

Infertility is one of the most important medical and social problems of modern society, affecting the demographic situation as a whole, the health and quality of life of patients, and reducing the social and psychological adaptation of women. The frequency of fruitless marriages among the population in Europe is 7-10%, in the United States 9-12%, Russia reaches 15-17% and has no tendency to decrease. This indicator is considered critical by WHO. In Russia, about 10 million people suffer from infertility (each 7 pair). Despite a large number of studies, the problem of increasing the effectiveness of IVF remains relevant to date.

Known standard IVF program, which includes the following sequentially conducted stages of treatment:

- stimulation of superovulation to obtain more mature oocytes for subsequent fertilization,

- puncture of the follicles under ultrasound control of the ovaries 35-36 hours after the introduction of the ovulatory dose of the ovulation trigger and the release of oocytes from the follicular fluid,

- fertilization of oocytes,

- cultivation of embryos for 2-3 days (to the stage of 2-4 or 6-8 blastomeres) or 5 days (to the stage of blastocyst)

- transfer of 1-2 embryos into the uterine cavity,

- support of the luteal phase with the help of progesterone preparations (“Infertile marriage, modern approaches to diagnosis and treatment”, edited by Sukhikh GT, Nazarenko TA 2010, GEOTAR-MEDICINE. pp. 179-183. https: / books .google.com / books? id = LjQ9T8mRLO4C & pg = PA179 & 1pg).

However, implantation failures during IVF are often observed due to various reasons.

A known method of IVF in patients with repeated failures of implantation, i.e. with the RIF phenomenon (Recurrent Implantation Failure), in which, to improve the implantation conditions of transferred embryos, scratching technology is used against the background of the normal thickness of the pregravid endometrium (9-12 mm on the day of the introduction of the ovulation trigger of human chorionic ganadotropin) (Li TS Evidence-based management of the couple with recurrent implantation failure // Hum Reprod. - 2012. - v. 27. - Suppl 1: Abstract Book. - O-088. - p. 35).

A "dosed" violation of the integrity of the endometrium is accompanied by massive secretion of growth factors and cytokines, which contributes to the normalization of the decidual formation and serves to increase the receptivity of the endometrium.

There are proposals to perform this procedure in the following periods:

a) in the middle of the luteal phase of the previous unstimulated cycle;

b) at the beginning of the follicular phase (on the day the gonadotropins are started) of the stimulated cycle;

c) at the end of the follicular phase (on the day of the follicle puncture) of the stimulated cycle;

d) before the start of gonadotropin stimulation (at the end of the luteal phase of the previous cycle).

(Kumbak B., Sahin L., Ozkan ZS et al. Value of office hysteroscopy and stimulations endometrial sampling performed on day 21 preceding IVF cycle in patients given GnRH agonist long protocol. // Hum Reprod. - 2012 .-- v. 27. - Suppl 1: Abstract Book. -O-036. - pp. 15-16; Dadras N., Parsanezhad ME, Zolghadri J., Younesi M. Effect of local endometrial injury on pregnancy rate in couples with unexplained infertility. // Hum Reprod. - 2012. - v. 27. - Suppl 1: Abstract Book. - P-330. - p. 244; Potdar N., Mason-Birks S., Elson CJ et al. Endometrial injury for recurrent implantation failure: how robust is the evidence? // Hum Reprod. - 2012 .-- v. 27. - Suppl 1: Abstract Book. - P-229).

However, in the literature there is no information about the use of scratching technology in patients with severe (critical) lag in the development of the endometrium.

Among women with the RIF phenomenon, a large number of patients with an endometrial thickness of less than 7 mm are noteworthy. The probability of clinical pregnancy for infertile women with endometrial thickness ≤7 mm is significantly lower compared to programs in which the endometrium was> 7 mm (23.3% and 48.1%, respectively).

A known method of IVF in patients with thin endometrium, including hormone therapy with estrogen and gonadotropin releasing hormone agonists, vasoactive measures such as aspirin, vitamin E, pentoxifylline, the use of granulocyte colony stimulating factor (G-CSG), regenerative medicine (http://www.tandfonline.com/doi/abs/10.3109/09513590.2014.906571?journalCod e = igye20), which we have chosen as a prototype.

However, the use of the prototype method leads only to minor changes in the thickness of the endometrium, and the onset of pregnancy during IVF practically does not increase.

The task was to develop an affordable effective way of conducting IVF in patients with a “thin” endometrium.

The technical result achieved by the implementation of the invention is to improve the outcome of IVF in women with a critical lag in the development of the endometrium due to the normalization of the decidual formation and increased receptivity of the endometrium by maximizing the positive preimplantation effects of tissue mediators and cytokines in a controlled surgical trauma prior to embryo transfer.

For the first time, an original technology of endometrial scratching for thin endometrium was proposed and the optimal period for its implementation during IVF in patients with the RIF phenomenon was selected.

Thus, the distinctive features of the proposed technology of stretching is:

- its appointment to a contingent of patients for whom such technology had not previously been used at all, i.e. patients with a critical lag of endometrial maturation in stimulated IVF cycles;

- performing scratching in terms in which it was not previously performed, i.e. on the fifth-seventh day of the use of gonadotropins (on the sixth-eighth day of the stimulated cycle);

- as well as the very method of applying notches to the endometrium, involving the dissection of the endometrium in certain areas with the preservation of its basal layer.

The proposed method of scratching provides the creation of more favorable conditions for implantation of embryos in patients with critical retardation of endometrial maturation, which is characterized by a very low (about 10%) pregnancy rate during embryo transfer. The chosen time period for notching the endometrium was favorable for maximizing the positive proimplantation effects of tissue mediators and cytokines released during controlled surgical trauma prior to embryo transfer.

In other words, the selected period for the formation of endometrial incisions allows it to be carried out at the maximum thickness of the endometrium, which is important for patients with a “thin” endometrium. This circumstance, as well as the nature of the effect on the endometrium (exposure zones), allows to maximize the positive proimplantation effects of tissue mediators and cytokines.

In addition, the proposed time for dosed surgical trauma of the endometrium and its nature ensure the timely healing of the endometrium until the implantation of the embryos.

The invention consists in the following.

The proposed method of IVF involves stimulation of superovulation, follicular puncture, isolation of oocytes from follicular fluid, fertilization of oocytes, embryo culture, transfer of 1-2 embryos into the uterine cavity. At the same time, on the 6-8th day of the stimulated cycle, the thickness of the endometrium is determined and, with its thickness less than 5 mm, linear endometrial incisions are performed, ensuring the preservation of its basal layer with a length from the internal pharynx to the border between the body and the bottom of the uterus. The incisions are arranged circularly on the walls of the uterine cavity at a distance of 4-8 mm from each other. A linear incision of the endometrium is also performed, ensuring the preservation of its basal layer, between the mouths of the fallopian tubes.

In a particular case, endometrial tissue is dissected when a notch is formed between the jaw branches, while one of the branches is immersed in the endometrium to the basal layer, excluding penetration into it, and it is kept at this depth until the notch is completed.

The method is as follows.

Superovulation is stimulated to produce more mature oocytes for subsequent fertilization. Superovulation is stimulated using various types of ovulation stimulants (the drug and dose are selected individually according to the standards and depends on the patient's age and ovarian reserve).

Various options for stimulation protocols can be used (“Clinical Aspects of the Treatment of Infertility in Marriage”, ed. K. Krasnopolskaya, T. Nazarenko 2013. GEOTAR-MEDIA, pp. 162-180).

At this stage, on day 6-8 of the stimulated cycle, U3 monitoring of follicular growth (ovarian response to stimulants) is carried out and, accordingly, an assessment of the thickness of the endometrium is performed. When the thickness of the endometrium is less than 5 mm, endometrial scratching is performed - notching the endometrium according to the proposed method.

Office hysteroscopy is performed using a KARL STORZ firm Hopkins II hysteroscope with an outer diameter of the distal part of 2.0 mm and an operating tube to form a permanent irrigation system with a diameter of 4.2 mm. For the installation of liquids with the aim of regulating the fluid flow rate and pressure, an electric pump HAMOU ENDOMAT, Karl Storz, is used. Constant pressure in the uterine cavity is maintained at a level of 100-150 mm Hg, fluid flow rate from 200 to 350 ml / min, the aspiration pressure was 0.2 bar.

As the expansion medium, physiological saline is used, which is an isotonic solution that does not irritate tissues.

As a light source, a Karl Storz xenon light source is used.

When conducting Bettocchi office hysteroscopy, the patient is on the operating table in a lithotomy position. Without preliminary introduction of vaginal mirrors and the application of bullet forceps on the cervix, the hysteroscope is inserted into the vagina when a tension medium (physiological solution) is applied. When the stretching medium leaks from the vagina, the labia majora is reduced by the thumb and forefinger of the left hand. After filling the vagina with physiological saline, a vaginoscopy is performed, the cervix is found. The main guideline of the cervix in this case is a smooth flat epithelium in contrast to the folded epithelium of the vagina.

Then find the external pharynx of the cervical canal. As you move along the cervical canal and when reaching the internal pharynx, the hysteroscope should be rotated so that its longitudinal axis coincides with the transverse axis of the uterine pharynx (in order to reduce pain).

Further, after passing the internal pharynx, the walls of the uterine cavity are examined, the mouths of the fallopian tubes are visualized, and the thickness of the endometrium is estimated. Through the operating channel of the hysteroscope, a semi-rigid instrument with a diameter of 5 Fr. is inserted into the uterine cavity. Spoon-shaped biopsy forceps with two movable branches can be used.

In the open state, the tongs of the forceps are immersed in the endometrium to the basal layer (to the level of the basal layer, without penetrating into the last) in the region of the internal pharynx and the instrument is distal with the part immersed in the endometrium from the internal pharynx to the bottom of the uterus along its posterior wall (to the border between the body and the bottom of the uterus), then the instrument is transferred laterally or medially to the width of the jaw and the manipulation is repeated (linear incisions are formed at a distance of 4-8 mm from each other).

By moving the manipulator in a circle, incisions are made that correspond to the thickness of the endometrium (the entire thickness of the endometrium except the basal layer), along all walls of the uterine cavity, excluding the bottom of the uterus.

Next, a similar manipulation (the formation of a linear notch on the endometrium) is performed by conducting an open jaw of forceps from the mouth of one fallopian tube to the opposite.

At the end of the procedure, an endometrial biopsy is performed with a biopsy instrument and the hysteroscope, together with the manipulator, is pulled out.

Under ultrasound control of the ovaries, 35-36 hours after the administration of the ovulatory dose of the ovulation trigger, follicles are punctured and oocytes are extracted from the follicular fluid. All follicles with a diameter of ≥15 mm are punctured.

After fertilization of the oocytes, embryos are cultured for 2-3 days (to the stage of 2-4 or 6-8 blastomeres) or 5 days (to the stage of blastocyst).

Embryo transfer implies morphological selection of the best embryos on the day of transfer. Carry out the transfer of 1-2 embryos using a catheter into the uterine cavity.

The luteal phase is then maintained with progesterone preparations.

The stages of puncture, fertilization of oocytes, cultivation and transfer of embryos, as well as support for the luteal phase with progesterone preparations are known from the literature ("Stimulation of ovarian function" edited by T. A. Nazarenko. 2008 MEDpress-inform).

To prove the possibility of realizing the claimed purpose and achieving the specified technical result, we provide the following data.

Clinical example.

Patient B., 32 years old. From the anamnesis of 4 failed IVF programs. The programs noted a marked lag in the development of the endometrium. In 2015, the fifth IVF program was conducted. The thickness of the endometrium on the 6th day of the stimulated cycle of 4.6 mm, on the same day the endometrium was scratched by the proposed method. 2 embryos were transferred into the uterine cavity on the 5th day of cultivation. A singleton pregnancy has come.

Patient K., 37 years old. From the anamnesis 2 failed IVF programs and 1 ECO-CRIO program. The programs noted a marked lag in the development of the endometrium. In 2015, the third IVF program was carried out. The thickness of the endometrium on the 8th day of the stimulated cycle is 5 mm; on the same day, endometrial scratching was performed according to the proposed method. 2 embryos were transferred into the uterine cavity on the 5th day of cultivation. A singleton pregnancy has come.

The proposed method was used in 16 patients with the RIF phenomenon and a critical lag of endometrial ripening (endometrial thickness equal to or less than 5 mm) on the 6-8th day of the stimulated cycle.

The results of treatment according to the proposed method (in terms of the CNB (pregnancy rate) on PE (embryo transfer) were compared with the data of 31 patients with the RIF phenomenon and a similar lag in endometrial maturation, observed over the past 3 years in the MONIIAG reproduction department, with which the IVF procedure was not supplemented with scratching endometrium according to the proposed method.

A comparative study showed a statistically significant greater therapeutic efficacy of the proposed method for IVF in this group of patients. So, when applying endometrial scratching in accordance with the proposed method, the CNB on PE was 50% (8 of 16), and without its use, the CNB on PE did not exceed 12.9% (4 of 31).

The use of the proposed method by increasing the rate of CNB _PE in individuals with the RIF phenomenon associated with a pronounced lag of endometrial maturation in the stimulated cycle reduces the need for repeated IVF attempts.

Sketching using the described technology involves the use of tools used for routine office hysteroscopy, i.e. It is not accompanied by any noticeable appreciation of the ongoing IVF program.

Claims (2)

1. The method of in vitro fertilization, including stimulation of superovulation, follicular puncture, isolation of oocytes from the follicular fluid, fertilization of oocytes, embryo culture, transfer of 1-2 embryos into the uterine cavity, characterized in that the thickness of the endometrium is determined on the 6-8 day of the stimulated cycle and with its thickness less than 5 mm, linear endometrial incisions are performed, ensuring the preservation of its basal layer, extending from the internal pharynx to the border between the body and the bottom of the uterus, placing them circularly along the walls of the uterine cavity at a distance of 4-8 mm from each other, as well as a linear notch of the endometrium, ensuring the preservation of its basal layer, between the mouths of the fallopian tubes. 2. The method according to p. 1, characterized in that the dissection of the endometrial tissue during the formation of the notch is performed between the jaws of the forceps, while one of the branches is immersed in the endometrium to the basal layer, excluding penetration into it, and stored at this depth until the notch is completed.