不孕不育癥的治療Thehigh-possibilityfertilephase

extendsfrom5daysbefore

ovulation

to

the

day

of精子出發spermatozoacansurviveinthefemalereproductive

tractfor

5–6

days

after

intercourse卵子出發21著床

4子宮——ovulation.相遇

受精輸卵管子宮頸陰道3Criteria4thed5thedVolume≥

2.0

mL≥

1.5

mLTotalsperm

number≥

40millions/ejaculate≥

39millions/ejaculateSpermconcentration≥

20millions/

mL≥

15millions/

mLTotal

motility≥

50%≥

40%Progressive

motility≥

25%≥

32%Normal

morphology≥

15%≥

4%(KrugerStrictcriteria)Vitality≥

50%≥

58%pH>7.2>7.2Liquefaction:Completewithin60

minutesatroomtemperatureAppearance:

Homogeneous,gray,andopalescentConsistency:

Leaves

pipetteasdiscretedropletsLeukocytes:

Fewerthan

1

million/mLSemenAnalysisAssisted

Reproductive

Techniques?Intra-Uterine

Insemination(IUI)–

Artificial

Insemination

with

Husband(AIH)–

Artificial

Insemination

with

Donor(AID)?Gameteintra-fallopiantransfer(GIFT)?

Zygoteintra-fallopiantransfer(ZIFT)?In

vitrofertilization(IVF)?Intracytoplasmicsperminjection

(ICSI)?Pre-implantationgeneticdiagnosis(PGD)IUI,配偶人工授孕(AIH)*（一）適應癥：男性精蟲稀少（每西西一

千萬左右），尿道下裂、陰莖畸型、陽萎

、早泄、女性陰道痙攣不能性交、配偶常出差等。*（二）方法：男性將精液取出，經液化后

,將精蟲洗滌，去除精液之雜質，在女性

排卵期將精液注入子宮腔。2014/4/24圖片來源：我省生殖醫學會網站Intra-Uterine

InseminationMale

Factor

Infertility?Bestresultswith

IUIare

achievedwhenTotal

motilespermcount(TMC)

in

theinseminationspecimenexceeds

10million

14%ormore

have

normal

morphology?Highercountsdonot

increase

success?IUI

isseldomsuccessful

iffewerthan

1

milliontotalmotilesperm

are

present.黃X

玉

陳Xj2014/4/24102年第一次醫師(二)醫學(六)Male

Factor

Infertility?

TMC<

1

million:

ICSI?

TMC>

1

and

<

10

million:IVFcanbe

performed

ifinfertility

durationis2years

or

longer?

TMC>

10

million:

IVF

is

indicated

ifthedurationis3years

or

longer.

Ifthewomanisolderthan36years,

IVF

may

beconsideredearlier.體外授精（試管嬰兒）IVF*（一）適應癥

：骨盆腔粘連、輸卵管堵塞、輸卵

管切除、嚴重度子宮內膜異位、精子稀少（五百

萬左右）、精蟲產生抗體等。*（二）方法：*(1)用排卵物誘導排卵(2)利用超音波檢查卵泡及抽血測E2(3)當卵子成熟，利用陰道超音波，將卵子取出

(4)在實驗室將精子與卵子完成受精分裂成胚胎，

再植入子宮腔2014/4/24精蟲顯微注射

:

(ICSI)應用在合并男性不孕或先前嘗試受精率低者IntraCytoplasmicSperm

InjectionMale

Factor

Infertility?

IndicationsforICSITotal

motilespermcount<

1

million<4%

normalmorphologyandTMC

<

5millionNoorpoorfertilizationin

the

first

IVF

cyclewhenTMC<

10

millionNoorpoorfertilization

intwo

IVFcycleswhenTMC>

10

millionEpididymalortesticularspermatozoa.精卵顯微授精法（microinjection）（一）適應癥：(1)嚴重精蟲稀少（在一百萬只左右）、精蟲活動

力差、IVF不能受精者。(2)精液檢查無精子，但睪丸組織有精子，請泌尿

外科大夫，將精子吸出在實驗室處理。*（二）方法：在顯微鏡下，將一只精子注射入卵子，因注射部

位不同，可分為(A)透明層下注射法(sub-zonal

injection;suzi)

(B)透明層開洞方法(partial

zonal

dissection;

PZD)(C)精子注射入卵細胞漿法(intracytoplasmicsperm

injection

ICSI)，因ICSI方法受精機率高，

2014且/4/24懷孕成功機率也高，目前廣為世界采用。B男性不孕患者，精液檢查總活動數精蟲少于

1百萬，實施人工協助生殖技術時，下列何

項處置最為有效？A.

透明區穿孔術（zonadrilling）B.卵質內單一精蟲注入術（intracytoplasmic

sperminjection）C.透明區下精蟲注入（subzonalsperm

injection）D.透明區磨薄術（assistedhatching）93

年第2次專技高考外科學(二)102年第二次專技醫師二醫學六C一位26歲男性，不孕3年求診，嚴格的精液分析

顯示：精液量=2.5mL，總精蟲數=1×106/mL，

4%直線前進，3%正常外觀精子，下列處理何者

較適當？A.

進行子宮腔內受精（intrauterineinsemination）B.進行體外受精（in

vitrofertilization）C.進行卵質內單一精子注入（intracytoplasmic

sperminjection）D.進行睪丸切片取精（testicularspermextraction）*一對夫妻到門診作不孕癥檢查，妻子30歲，月經

周期正常，周期第3天

FSH7.2IU/L，雙側輸卵管

通暢，先生的精蟲數目為

20萬/mL，活動力

10%，

先生的染色體為46XY，無Ychromosomemicrodeletion

。你會建議他們作何治療?A.

人工受精（intrauterineinsemination;

IUI）

B.

傳統試管嬰兒（invitrofertilization;

IVF）C.

細胞內精蟲顯微注射（intracytoplasmicsperm

injection;ICSI）D.禮物嬰兒（gamete

intrafallopiantransfer;GIFT）C2014/4/24B男性不孕患者，精液檢查總活動數精蟲少于1百萬，實施

人工協助生殖技術時，下列何項處置最為有效？

A透明區穿孔術（zonadrilling）

B卵質內單一精蟲注入術（intracytoplasmicsperminjection）C透明區下精蟲注入（subzonalsperminjection）

D透明區磨薄術（assistedhatching）A關于不孕癥的敘述，何者錯誤？A做細胞內精蟲顯微注射（intracytoplasmicsperminjection,

ICSI）的懷孕率比傳統試管嬰兒（invitrofertilization,IVF）

的懷孕率低B不孕癥是指在未避孕的情況下，一年以上沒有懷孕C所謂人工生殖技術（assistedreproductivetechnology,

ART）是指各種取卵的介入方法D女性的懷孕能力（fecundability）從30歲后開始下降2014/4/24濾泡發育與誘導排卵2014/4/24負性回饋抑制濾泡刺激素正性回饋增加黃體刺激素*一個dominant

follicle

E2>200

pg/mlfor>50

hrs

會造成positive

feedback，刺激LH大量分泌（LH

surge）并持續四十八小時>200

pg/ml

超過50小時(50-150pg/ml)大幅上升稍許上升雌激素(MetaphaseI)Meiotic

Resumption

(

M

II)just

before

ovulationMeioticArrestatMetaphaseof

Meiosis

IIGV

breakdown(GVBD)=

Meiosis

I

resumes↓

(Metaphase

II)MeioticArrestat

Diplotene,

Prophaseof

Meiosis

IGerminalVesicle

(GV)–intactYenandJaffe’sReproductiveEndocrinology6th

Ed&SperoffClinical

Gynecologic

EndocrinologyandBefore

LHsurgeLH刺激卵子成熟Oocytes25Meiotic

Resumption

(

M

II)LH Plasminogenactivator↑Plasmin

↑Collagenase

↑Ovulation28

ProstaglandinsecretionContractsmooth

muscle

OvulationOocyte(GV

intact)Pre-ovulatoryfollicle

=GraafianfollicleCumulus-OocyteComplex

Granulosa

luteinizationCumulus

cells

(specialize

dgranulosa)Mural

granulosa

cellsOocytefreedfromattachmentLH刺激卵子成熟FollicularfluidCumulusexpansionP4LHsurge1.讓卵子由「第一次減數分裂前期(prophase

I)」進展到

「第二次減數分裂間期(metaphaseII)

」

(又稱為oocytematuration，在ovulation前就已經發生)2.

卵子卵丘復合體(cumulus-oocytecomplex,簡稱COC)脫

離濾泡壁(NSAID無法抑制)(此約發生于LH或hCGonset

后34-36小時

，所以是試管嬰兒療程之

取卵時機)3.

Ovulation(足量的NSAID可抑制)4.Ovulation后,濾泡壁上剩下的細胞(granulosacell&thecacell)受到LH(或人工生殖中取代以hCG)作用而luteinization形成「黃體」

--負責供應E&P,使子宮內膜

得以完整地decidualization，開啟implantationwindow

俾利胚胎著床LH(或人工生殖中取代LH的hCG)

之四大功能Cumulus-OocyteComplexMeiotic

Resumption(

M

II)Oocyte卵子LHsurge2020/4/8誘導排卵(Controlledovarianstimulation)人工授精

：1~3個濾泡發育試管嬰兒

：8-15個濾泡發育follicles

development(養濾泡)

trigger

final

oocyte

for

7-9

days

or

more

maturation

(破卵)(controlledovarianstimulation

by

rFSH)34-

36

hours(TextbookofART,2nd

Ed.,

2004)取卵黃體期補充人工授精

或自行同房一

次誘發多個濾泡，會加速卵量衰竭？而提早停經嗎？DrugsforART

「排卵藥」

:提升FSH+/-?

口服:Clomiphenecitrate

or

Letrozole

(

)?皮下注射:

Follicle-stimulating

hormone

(FSH)

Puregon(保妊康)/Gonal-F(果那芬)

/long-actingFSH(Elonva)?皮下注射:

Human

menopausal

gonadotropins(HMG)Menopur(美諾孕)

、rFSH+rLH

Pergoveris(倍孕力)

長大的濾泡吃這個LH?Gonadotropin

releasing

hormoneanalogues

(GnRH

agonist)

Leuplin(柳菩林)/Decapeptyl(弟凱得)?

Gonadotropin

releasing

hormone

an

a一g:o預n防isLtH提早上升

(GnRH

antagonist)Orgalutron(柔妊孕)/Cetrotide(欣得泰)------------------------------------------------------取-代/引發LH?

Human

chorionic

gonadotropin

(hCG)

&卵子最后之

Ovidrel

(克諾得)/Pregnyl(保健寧)

(「破卵針」Leuplin(柳菩林)/Decapeptyl(弟凱得)?GnRH

agonist熟成)誘導排卵(Controlledovarianstimulation)人工授精

：1~3個濾泡發育試管嬰兒

：8-15個濾泡發育*E2>200pg/ml

for>

50

hrs會造成positive

feedback

，刺激LH大量分泌（LH

surge）eachfollicle沒有做好做滿serumE2就可達帶動LH上升「目的」同:讓follicle做好做滿GnRHagonistvs.GnRH

antagonist:

「用法」異Pulsatile

GnRH

(t

?

:2-4

min)(frequency)

FSHand

LH

in

pituitarygland

Ovary:folliculargrowth,ovulationandcorpus

luteumformation

Estrogenand

ProgesteroneaffectstheendometriumHypothalamus:GnRH?GnRH(GonadotropinReleasing

Hormone)–

半衰期短:2~4min–producedinthearcuate

nucleusofthe

hypothalamus,

inapulsatilefashion–ControlFSH/LH

by

differentfrequency–排卵前強:度短小而密–排卵后強:度高而間隔長(3~4h)–

DecapeptideGnRHandGnRH-R

binding328aminoacidsDeca-peptideGnRH

receptorGnRH610王鵬惠Anim

Reprod

Sci

2005;88:5-28Modifications?

Position6:↓

enzymaticdegradation?

Position

10:↑

potency?

Position6and

10:↑

receptor

affinity受體結合區D-型氨基酸替代點

增強受體的結合

Disulphidebridge:C14-C200;C114-C196內生性酶切除點–臨床藥物GnRH

agonist--ex.AA

6

modification

Longacting,desensitizeGnRH

receptorsafterdaysofstimulation臨?床藥物GnRH

antagonist--AA1,2,3,6,8,10

modification2014/4/24GnRH類似物?Ovulationinduction/Controlledovarian

hyperstimulation1.

Oral2.

Injectionsc「排卵藥」:提升FSH+/-LH

E2>200

pg/ml

for

>50

hrsHypothalamic

level:

ER

depletion

會造成positive

feedbackDay

2~6

GnRH:

↑frequency↑amplitude

LH

surgeMC

start

↑FSH

↑LH

給完藥后5-12天(通常7天)會LH

surge

5days

(建議此時QOD同房)

50~150

mg

HSFolliclegrowth,

E2

rise慢性不排卵（月經不準時，愛愛日好難算！）第一線口服排卵藥:

喜妊(Clomiphene)

(健保給付)--可能面臨問題:

1.子宮內膜太薄而不利于著床;2.子宮頸黏液較不利于精子進入(自然同房者)

;3.至多六

周期;4.

BMI高;5.胰島素阻抗高效果差102年第二次專技醫師二醫學六關于口服排卵藥物clomiphenecitrate，下列

敘述何者最正確？A.

需使用于hypothalamus-pituitaryaxis功能

失調的女性B.

具強效的雌激素作用C.會減少GnRH分泌D.會使子宮內膜變薄D2014/4/24103年第一次專技高考醫師(一)醫學(二)下列有關

clomiphene的藥理學作用描述，何者錯

誤？A.

為一種雌激素受體部分作用劑（partialestrogen

agonist），可以刺激促性腺激素(

gonadotropins）的分泌作用B.

對于排卵功能障礙的婦女具有刺激排卵的作用C.使用時會降低血漿中黃體化激素（LH）

和濾泡

促進素（FSH）的濃度D.容易誘發熱潮紅（hotflushes）的產生C第二線口服排卵藥物：復乳納Letrozole(自費)?

沒有Clomiphene的副作用，而且成功率和Clomiphene并駕

齊驅。?

罹患乳癌卻仍想生育的婦女?

可能有些潛在的副作用尚未被發現。但以目前的研究證據看來，Letrozole并沒有造成比Clomiphene多的胚胎異常。(Clin.Gynecol.

Endocrinol.Infertil.,6th

Ed.)

(TextbookofART,2nd

Ed.,2004)Two

Cell-TwoGonadotropin

Theory雄性素AromataseInhibitor(AI)女性素2014/4/24人工授精

篩選精蟲試管嬰兒($$

>,<)輸卵管有通,可先嘗試自然同房/人工受精自然同房亦要考慮年齡因素(卵子質量的關鍵所在)輸卵管不通/嚴重精蟲問題/前述方式失敗精卵相遇的途徑

?排卵針幫助排卵的藥物↓(Clin.Gynecol.

Endocrinol.Infertil.,6th

Ed.)

(TextbookofART,2nd

Ed.,2004)Two

Cell-TwoGonadotropin

Theory女性素雄性素濾泡萎縮早期黃體化卵子質量受損濾泡正常發育卵子成熟雄性素前軀物不足導致雌激素低下濾泡后期發育不良卵子無法完全成熟在不使用GnRH-a

或GnRH-ant時，FSH誘導排卵約有

20%會發生LH早期

上升下視丘/腦下垂體疾病

或使用GnRH-adepot

,

可能導致LH不足黃體刺激素（LH）在誘導排卵的角色LH

適

當

濃度LH上限~10

mIU/mlLH閾值~1

mIU/mlLH

濃度High

LH

Levels

are

Unfavorable

toReproductiveOutcome?Highendogenous

LH:

increasedincidence

ofinfertilityand

miscarriages?LH

inhibitsgranulosacell

proliferationathighconcentrations,andinduce

atresia

of

follicles?LH

hasa

negativeeffect

on

the

endometriumTo

preventLH

prematuresurge預防LH提早上升(PREMATURE

LUTEINIZATION)各種protocol之介紹Ovulationinduction提升FSH+/-

LH養卵泡誘導排卵(Controlledovarianstimulation)人工授精

：1-3個濾泡發育試管嬰兒

：8-15個濾泡發育*E2>200pg/ml

for>

50

hrs會造成positive

feedback

，刺激LH大量分泌（LH

surge）濾泡還不夠熟就發生了!!GnRHagonistvs.GnRH

antagonist:「目的」同:預防LH提早上升「用法」異長療程（

Long

protocol）(Eur.J.Obstet.Gynecol.,2004;Hum.

Reprod.,2007)MonitoringofPituitarydown-regulation:a)

Menstrualbleedingb)

E2

<

80

pg/mlc)P4

<

1.5

ng/mld)

Endometrialthickness<8

mm抑制劑療程（Antagonist

protocol）S5Betterstartfrom

MCday2-3

(earlyfollicularphase≤

5th

day,

nodominantfollicular

yet.Theearlier,themorefollicles)93年第一次專技高考基礎二有關gonadotropin-releasinghormone

(GnRH)之敘述中，下列何者正確？A.

其由腦下垂體產生B.

為一種多勝

(poly-peptide)組成C.長期大量給與GnRH類似物，會產生生殖

腺官能不足D.持續大量給與GnRH類似物，會使GnRH

接受器之敏感性加強BCC關于目前用于刺激排卵的GnRH-agonist，下列敘述何者正確？A長療程（longprotocol）乃利用其up-regulation特性B和內生性GnRH比較，只有1個氨基酸不同C半衰期比內生性GnRH長D可口服使用誘導排卵MC

↑MC

↑(TextbookofART,2nd

Ed.,2004;Semin.

Reprod.

Med.,2002

)with

GnRH

antagonistwithGnRH

agonist頭三天FSH&

LH

↑,S5MC

↑SOAPControlledovarianhyperstimulation:用藥Orgalutron(柔妊孕)/monitoringControlledovarianhyperstimulation:--Receptive

to

blastocyst

implantation

~6

daysafter

ovulation

and

remains

receptive

for4

days.ImplantationWindowProgesterone

effectovulationP>1.5

↓Decidualizationo

A.

Natural

conception:#

LH

surge

→

ovulation

→

oocyte

exposed

to

spermatozoa

→

embryomic

window

of

implantation

(WOI,

blastulation)

#

meaningful

P

shortly

after

LH

surge

↑

→

secretory

transformation

→endometrial

window

of

implantation

(WOI)o

B.

IVF

(lost

of

natural

coordination

=

embryonic-endometrial

dyssynchrony):口

1.

P

↑faster

(16~24

hr)口2.

bastulation

may

be

delayed

(older,

low

responders)natural

conception

invitrofertilization(IVF)Recombinant

Hormoneα-Subunits1Corifollitropinalfa92

aaβ-Subunits2110

aahCG

t?

=40

h92

aa29

aa2t?

corifollitropinalfa=

69

h4aa=amino

acids;t?

=

half

life.1.Adaptedwith

permissionfromStraussJetal.YenandJaffe's

ReproductiveEndocrinology:Physiology,Pathophysiology,andClinicalManagement.

5thedition.Saunders;2004;2.

Fares

FAetal.ProcNatl

AcadSciU

SA.

1992;89:4304–4308;3.

PUREGON?

(rFSH)

summaryofproduct

characteristics,2010.;4.

ELONVA?(corifollitropinalfa)summaryofproductcharacteristics,2010.Corifollitropinalfa(Elonva?

)

Is

at?

rFSH

=40

h3t?

rFSH

=40

hTmax

=

10–12

h3StimulationdaysrFSH=recombinantFSH;t1/2=

half-life;Tmax

=timeto

maximum

concentration.1.Adaptedwith

permissionfrom

FauserBCetal.HumReprodUpdate.2009;15:309–321;2.

ELONVA?(corifollitropinalfa)

summary

of

product

characteristics,2010;3.

PUREGON?

(rFSH)summaryofproductcharacteristics,2010.Comparative

Pharmacokineticst?

corifollitropinalfa=

69

h

Tmax

=36–48

h2Corifollitropinalfa

rFSHFSHactivity1Long

protocol(GnRHagonistdown-regulationprotocol)Flare

upFSH&

LH

↑亦即內生性LHsurge(幅度夠，但duration略遜)+FSHsurge(hCGtrigger所缺)Dualsuppresion:2-3weeksof(monophasic)Oral

pills5

daysGnRHantagonistprotocola)

Menstrualbleedingb)E2

<

80

pg/mlc)

P4

<

1.5

ng/mld)

Endometrialthickness<8

mmTrigger:

hCG

orGnRH

agonistMonitoringofPituitarydown-regulation:Trigger:

hCGAntagonist

protocol搭配Dualtrigger:GnRHagonist(Decapeptyl

?

0.2mg)

+

low-dosehCG

(Pregnyl?

)[怕OHSS者hCG只給0~1500IU]Antagonist

protocol搭配Dualtrigger亦可用于不怕OHSS者:6500

IU

hCG(Ovidrel?一支)

+GnRHagonist(Decapeptyl

?0.2mg)

[取其FSHsurge的好處]?

The

LHsurgeiscaused

by

the

increase

in

plasma

E2attheendofthefollicular

phase?

Studiesoncontraceptionhaveshownthatprogesteroneisableto

blockthis

LHsurgeandthereforeovulation?

Experimentsonmonkeyshave

shownthat–

Theadministrationofa

progestin(levonorgestrel)atthebeginning

ofthe

cyclepreventsthe

LHsurgedespitethe

increase

in

E2,foras

longas

it

is

continued–

Theinhibitionofthe

LHsurge

by

progesterone

isa

hypothalamicaction(Massin

N,

Hum.

Reprod.Update,2017)Useofprogestogento

block

LHsurgeantagonistPrevent

LHprematuresurgeGonadotropinfor

follicledevelopmentOVARIAN

STIMULATION

FOR

IVF/ICSIExogenous

PDifferentIVF

ProtocolsFollicularPhaseLuteal

Phase…26

27

28

0102030405

………

10

11

12

1314151617

18

19

20

21

22

……Short

ProtocolG

nRH

Agonist

rFSH

GnRHAntagonistrFSH

or

HMG±GnRH

AntagonistHMG/FSHProvera/Utrogestan/DuphastonTrigger(HCG/Agonist)TransvaginalOocyte

RetrievalPPOSProgestinPrimeOvarianLutealStimulationLong

ProtocolAntagonist

ProtocolrFSH

+

LHLutealGnRH

AgonistrFSH

±

LH83黃體愈旺(luteotrophic

activity↑↑)=著床愈穩但OHSS可能愈嚴重黃體身負重任，持續分泌P&

E(decidualization之所需)預防卵巢過度刺激的關鍵在于減少hC的G使用，Why?(Humaidan.

PreventionstrategiesforOHSS.FertilSteril*(hCG:比LH更強的luteotropic

activity)Granulosa-

luteal

cellsTriggerviahCGvs

GnRHa?hCG

trigger

longer

and

stronger

luteotropicactivity?GnRH

agonist

(GnRHa)

trigger

more

rapidluteolysisP.

Humaidan.

Human

Reproduction

Update2011,

17

(4)

:510–524不孕癥治療常見之并發癥?

卵巢過度刺激癥候群OHSSI/O

、腹圍、體重鉀可預測誰會發生卵巢過度刺激癥候群嗎??

Higher

androgen

levels

(Elder-G-epv

o2b0

y

not

—broad

range–

otherssuggestinggreatergonadotropindose

requirement

(Homburg

1996)?

No

good

way

except

prior

history?就算沒有危險因子仍可能潛在過度刺激的風險?每個多囊患者接受排卵針都有風險?只要有多囊型態的卵巢，無論是否符合多囊性卵

巢癥候群的診斷標準，風險一樣高！

(Kim

YJ2010;

SwantonA2010)C通常需要以剖腹探查來治療D臨床癥狀通常在人類絨毛膜促性腺激素（hCG）注射后3－7天

開始出現A.一位28歲不孕癥婦女在6天前接受取卵手術，共取出20顆卵子，

2天后植入3個胚胎。今天來到急診，主訴呼吸困難、腹脹以及惡心。超音波發現兩側卵巢腫大約6公分、有大量腹水。下

列那一項處置較不適合？A抽血驗CA125,CEA,CA199B抽血驗CBC,electrolytes,GPT(ALT),

BUN,creatinineC抽腹水D給予大量normalsaline2014/4/24C有關卵巢過度刺激癥候群（OHSS）

的敘述，下列何者錯誤？A卵巢會腫大B嚴重時會有腹水Oocyteretrieval(Egg

pick

up)取卵TimingofOocyte

Retrieval?Scheduled

at

about

34-36

h

after

hCG

injection:the

oocytes

are

expected

to

ovulate

at

37

h

post-hCG.?AfterhCG

injection,the

intercellularconnections

betweenthegranulosacellsandthe

oocytes

are

interrupted?

Meiosis

is

resumedandtheoocyte

progressesfrom

prophase

I

to

metaphase

II.103年第一次專技高考

醫師二醫學六

*取卵的時機一般是在絨毛性腺激素（humanchorionicgonadotropin）注射后幾

小時？A.20～24

hrB.

34～36hrC.

40～44hrD.

48～52hrB2014/4/241.

Placethetesttubes,handlingmedium,andthermometerin

a

warmblockonthe

staging

stage2.

Flushtheaspiration

needleand

itstubingwith

medium.3.Singlelumen

v.s.

double

lumen

needle(Thedeadspaceofthe

needle

andtubingis

about

1

ml)PreparationofMaterialsforOocyte

Retrieval(TextbookofART,2nd

Ed.,2004)手術全程保持無菌狀態,并在超音波導引下進行取卵經陰道以超音波輔助取卵(TextbookofART,2nd

Ed.,2004)經陰道以超音波輔助取卵不成熟卵子

成熟卵子取得卵子顯微鏡下結構卵丘卵子復合體精蟲之準備卵子體外受精(in

vitro

fertilization)精蟲顯微注射

:

(ICSI)應用在合并男性不孕或先前嘗試受精率低者體外受精及胚胎早期發育D3植入

或繼續培養↓四細胞受精卵八細胞兩細胞胚胎培養至囊胚期雷射輔助孵化

D5植入桑葚胚囊胚黃體期補充人工生殖中為何要黃體期補充?Abnormal

Luteal

FunctionAfterOvarianStimulationfor

IVF:

Mechanisms?

Continueddown-regulationbyGnRHa

LH

↓?Induction

of

multiple

follicles

perse?Removaloflargequantitiesofgranulosa

cellsatoocyte

retrieval?

SupraphysiologicalE2/P4

in

early

luteal

phase

negativefeedback

LH↓--Receptive

to

blastocyst

implantation

~6

daysafter

ovulation

and

remains

receptive

for4

days.ImplantationWindowProgesterone

effectDecidualizationElements

of

Luteal

Phase

Support?HCG:

1500-2000

IU

i.m.q3dfor4doses

fromoocyte

retrieval?P4:fromoocyteretrievalto

7-10weeks1)progesteronein

oil

25-100

mg

i.m.

qd2)utrogestan200

mg

p.o.orvag.tid-qid3)Crinonegel

90

mgvag.

qd?E2:fromoocyteretrievalto

7-10weeks

E2valerate2

mg

p.o.

bid術后用藥+Lutealsupport(藥物+monitor)取卵34~36小時

之后破卵Micronized

progesteronecapsuleIntramuscularprogesteroneHCGCrinonevs.Vaginal

P4vs.OralP4ART誘導排卵后黃體期之E與P取卵GnRHatriggerGnRHatrigger取卵破卵破卵?

取卵數:25?

植入囊胚期

胚胎OocyteSpermIntraCytoplasmicSperm

Injection2pronuclei4cell2cell8cellGrade2embryosLessthan

10%fragmentationorUnequal-sizedblastomeresGrade3

embryos10%to50%fragmentation

with/withoutUnequal-sizedblastomeresGrade4embryosMorethan50%fragmentation

with/withoutUnequal-sizedblastomeresMorulaand

Blastocysttheembryo,NO

overallsize

increase.with

slight