植入幾個胚胎較好(TSRM0315)_摘要
Transcript of 植入幾個胚胎較好(TSRM0315)_摘要
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植入幾個胚胎較好 ?如何看待「只植入一兩個胚胎」
的世界趨勢 林口長庚醫院生殖醫學中心
陳俊凱
倫理道德議題
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• ASRM Practice Committee: Guidelines on number of embryos transferred
• Fertil Steril 2004; 81:1207
• JAMA 1999; 282:1832
• AJOG 2002; 187:1163
• Fertil Steril 2008
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學習目的•了解試管嬰兒發生多胞胎的機率•多胞胎與減胎•減少植入胚胎的數目 , 世界的趨勢•植入幾個胚胎較好•如何看待「只植入一兩個胚胎」的世界趨勢,我們該如何準備
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多胞胎的併發症• 胎兒• 母親• 家庭影響• 社會成本
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ASRM/SART Registry: 2000
• 單胞胎 64.6%• 雙胞胎 31.0%• 三胞胎 4.1%• 251 stillborn infants (10 per 1000 neonat
es)– 95 stillborn 發生在單胞胎– 170 stillborn 發生在雙胞胎– 64 stillborn 發生在三胞胎以上
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ASRM/SART Registry: 2000
• 平均值入胚胎數 3.11
• < 35 歲 2.88
• 35-37 歲 3.16
• 38-40 歲 3.44
• > 40 歲 3.61
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學習目的•了解試管嬰兒發生多胞胎的機率•多胞胎與減胎•減少植入胚胎的數目 , 世界的趨勢•植入幾個胚胎較好•如何看待「只植入一兩個胚胎」的世界趨勢,我們該如何準備
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減胎 (Fetal reduction)
• Loss rate 5.4%• Loss rate 最高發生在六胞胎以上的減胎, 三、四、五胞胎減胎的 loss rate 差不多
•減胎後, 雙胞胎或三胞胎的生產週數與沒減胎的雙胞胎或三胞胎差不多
•減成單胞胎在此統計中, loss rate 最低, preterm rate 最低
AJOG 2002;187:1163
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減胎 (Fetal reduction)
• 平均 Loss rate 4.7%
• 雙胞胎減成單胞胎的 loss rate 最低 (2.1%)
• 減成單胞胎的生產體重最高, 早產機率最小
AJOG 2008; 199:406
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減胎 (Fetal reduction)
• 從腹部減胎比從陰道減胎好• 特別是三胞胎要減胎,或是要減成單胞胎• 此篇報告建議在 12-13 週減胎, 減胎前可以先評估胎兒的構造
AJOG 2004; 191:2085
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學習目的•了解試管嬰兒發生多胞胎的機率•多胞胎與減胎•減少植入胚胎的數目 , 世界的趨勢•植入幾個胚胎較好•如何看待「只植入一兩個胚胎」的世界趨勢,我們該如何準備
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ESHRE 2002 共識 (荷蘭 )
• 試管嬰兒的基本目標是健康的單胞胎• 雙胞胎應視為併發症• 建議 36 或小於 36 歲而且有好的胚胎,建議選擇性單一胚胎植入 ( elective single embryo transfer ; eSET )
• 應將單胞胎活產率是為主要的評估標準
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• 歐洲國家保險制度全部或部分給付試管嬰兒• 比利時,瑞典立法要求實施單一胚胎植 入 (singl
e embryo transfer; SET)• 因為以上原因, SET 在歐洲迅速被推廣• 2006 ASRM/SART guideline 建議預後最好的病人只植入一個胚胎
• CDC/SART 年報從 2003 年開始也將 eSET 列入臨床統計
世界趨勢
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學習目的•了解試管嬰兒發生多胞胎的機率•多胞胎與減胎•減少植入胚胎的數目 , 世界的趨勢•植入幾個胚胎較好•如何看待「只植入一兩個胚胎」的世界趨勢,我們該如何準備
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ASRM guidelines on number of embryos transferred
• 不考慮年齡,下列情況認為是較好的癒後因素– 第一次作試管嬰兒– 根據型態的標準有好的胚胎– 有多餘的好品質的胚胎可以冰凍– 先前試管嬰兒成功
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• 如果兩次或兩次以上試管嬰兒失敗或有特殊狀況,在充分諮詢後可以植入較多胚胎
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4?
3?
2?
1?
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• 相較於兩個囊胚期植入 (double-blastocyst transfer; DBT) ,在預後好的病人, eSET 可以大幅降低雙胞胎率 (1% vs.44%) ,同時有相同的懷孕率 (65% vs. 63%)
• 如果沒有經濟的壓力,病人會較願意選擇 eSET
Fertil Steril 2008
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• 年齡• 胚胎狀況• 冷凍保存的可能性• 囊胚期培養• 新技術臨床經驗的累積 ( 如 PGD 等 )
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PGD 可減少多胞胎的發生 (Reduction in multiple conceptions)
Controls PGD
Cycles 108 108
Av. Age 40 40
Av. # emb replaced 3.6 1.5
Implantation rate
p<0.001
11% 22%
Pregnancy rate 33% 30% N.S.
Triplets 2 0
PGD with 1-2 embryos replaced
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Comparison of blastocyst transfer with or without PGD in couples with advanced maternal age
Control PGD-AS
Cycles (n) 141 148
No. of embryo transfers (ETs) 121 81 p<0.001
Total number of embryos transferred 338 164
Mean embryos transferred 2.8+ 1.2 2.0+ 0.9 p<0.001
No. of implantations with fetal heartbeat (%)
39 (11.5) 28(17.1)
Outcome
Preclinical Abortions 9 7
Ongoing > 12 weeks 29 22
No. of ongoing implantations (%) 35 (10.4) 27 (16.5) p=0.06
PGD-AS 可減少植入胚胎的數目 , 但著床率不變 .Staessen et al. 2004
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學習目的•了解試管嬰兒發生多胞胎的機率•多胞胎與減胎•減少植入胚胎的數目 , 世界的趨勢•植入幾個胚胎較好•如何看待「只植入一兩個胚胎」的世界趨勢,我們該如何準備
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• 改善胚胎培養技術狀況• 囊胚期培養• 改善胚胎等級的評估系統• 改善冷凍保存技術的可能性• 新技術臨床經驗的累積 ( 如 PGD 等 )
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個案討論
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Thank you for your attention!