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Extracorporeal fertilization (ECO) and the transfer of the embryo (PE) in the uterus. Women's health What is Eco and PE

The invention relates to the field of medicine, namely to the field of gynecology and reproductology, and concerns the method of selection of patients with "empty" follicles syndrome (SPF) for the ECO and PE program for donor oocytes. The method is carried out by determining in the follicular fluid in patients with the SPF content of the compound of the follicularity immuling hormone (FSH), an insulin-like growth factor (IPFR-1) and human chorionic gonadotropin (CHG) and calculate the DP differential indicator according to the formula:

DP \u003d EXP (PP) / 1 + EXRP), where

PP \u003d 1,821 + 1 × FSG-0.18 × IPFR-1 + 0.136 × chgg

EXER - exponential function,

and with an indicator of dp less than 0.5, the development of the SPF is absolute and the patient is recommended to donation of officers, with DP more than 0.5, the development of SPF is sporadic and the patient recommends repeated medical cycles of ECO. The advantage of the invention is to develop a method for predicting ECO and PE. 3 table.

The invention relates to medicine, namely to gynecology and reproductology, and will find use in Eco and PE programs in order to increase the frequency of pregnancy.

High efficiency has accumulated over the past 25 years, its high efficiency has been proved by the ECO and PE method. If in the 70s - early 80s, a description was described only by the ECO successful treatment of patients, then at present it is necessary to recognize that due to its implementation in practice there was a real opportunity to effectively overcome almost all the well-known forms of female and male infertion (Ovsyannikova T.V. et al., 1998; Orlov V.I. et al., 2000). In medical science, single treatment methods are known, which so rapidly undergo evolutionary changes aimed at overcoming global problems arising at the stage of their formation. With all the irrefutableness of evidence of the success and consistency of the extracorporeal fertilization and transfer of embryos to the uterine cavity after the successful birth of the first child, Reproductologists faced serious difficulties that limit the widespread method (Anshina M.B., 1995; Kulakov V.I. et al., 2000 ; Aylamazyan E.K. et al., 2000).

Almost two decades have passed since for the first time Coulam et al., (1986) a new syndrome was described - "empty" follicles syndrome (SPF). By definition of the author, this state is characterized by the impossibility of aspiration of oocytes from the prevention follicles in the cycles of the vitro fertilization due to their absence. The emergence of this sporadic syndrome, and currently cannot be diagnosed (neither endocrinologically, nor sonographically) for some kind of ovarian reaction to the stimulation of supervision (Penarrulia J, et al., 1999; Zreik T.O. et al., 2000 ).

There are contradictory opinions regarding the etiological factor, development mechanisms, diagnosis and methods of treating this syndrome. Despite the tremendous interest from reproductologists to this "phenomenon", it remains unreasonable so far.

With a relatively low frequency of occurrence of the SPF, issues related to choosing further tactics of patients, the expediency of subsequent Eco programs and the need to use donor oocytes are practically unresolved. The development of oocytes in the growing pool of follicles is largely determined by the composition of the follicular fluid, which are adsorbed from the blood or secreted by the cells of the granolasis hormones and growth factors (Svetlakov A.V. et al., 2002; Burlev V.A. and Sovt., 1998). In addition, when studying the biochemical composition of the follicular fluid, the cyclicality of changes in the parameters of the anthral environment, depending on the stages of the follicular development (Boyarsky K.Yu., 2002, Burlev, V.A. et al., 1999; Chernuha G.E. and Sovat., 1996). Biologically active compounds contained in the antral cavity of the follicle make up the microenvironment in which the oocyte develops. Both excess and disadvantage of these compounds in the follicular fluid can have a pronounced negative effect on the development of the oocyte (Faleskov A.M., 1990; Vorobyva O.A. et al., 1998; Potin V.V. et al., 1993) . Despite the importance of the data obtained at present, namely the possibility of predicting the "empty" follicles on the hormonal composition of blood, in a particular treatment cycle, there is no confidence in its re-development in other stimulation cycles.

The lack of a clear tactics of conducting patients with SPF creates precedents of multiple unsuccessful ovarian stimulation, which adversely affects both the health and psycho-emotional state of women and the financial situation of the family. In addition, the lack of timely clear indications from doctors about the feasibility of using donor oocytes postpones the necessary program for an indefinite period and, as a rule, solved by the patient after a series of unsuccessful ECO attempts.

In cases where religious, cult and ethnic convictions are contrary to the use of donor oocytes, the patient is circumscribed on "Perennial Watching" in medical centers of various levels. All of the above was the basis for the study of this syndrome, the search and development of the differentiated tactics of patient management, which determined the purpose and objectives of our research.

In an affordable scientific-medical and patent literature, we have no techniques that allow us to carry out the argued selection of women with SPF syndrome to include ECO and PE programs in the following cycles. This served as a reason to consider the claimed invention with no prototype.

The objective of the invention: the development of objective and affordable, for widespread use, which makes the differentiated selection of patients with "absolute" and "sporadic" forms of "empty" follicles syndrome, which will enhance the patient's "Donation Oocyte" for the contingent in order to obtain a desired pregnancy.

The task is solved by the fact that the patient with the "empty" follicle syndrome produces a study of a follicular fluid, in which the level of the follicularity fluid hormone is determined, the level of insulin-like growth factor-I, the level of human chorionic gonadotropin and calculate the DP differential indicator according to the formula: DP \u003d EXP (PP ) / (1 + EXER (PP)), where:

EXR (X) - Exponential function,

PP - intermediate variable, calculated by the formula:

PP \u003d 1,821 + 1 × FSH-0.18 × IPFR-I + 0,136 + CHG, where:

FSH - Roveling of the follicularity hormone in follicular fluid, MME / ml;

IPFR-I is the level of insulin-like growth factor in follicular fluid, ng / ml;

cHG is the level of human chorionic gonadotropin in follicular fluid, me / ml,

if the obtained value of dp is less than 0.5, then this particular patient, the development of the "empty" follicle syndrome is a consequence of the disturbed processes of folliculo- and ogenesis and wears the "absolute" character, therefore it is recommended to donation of oocytes, and with a DP value of more than 0.5 development SPF is random "sporadic" character and it is possible to conduct repeated medical cycles of ECO, in order to obtain their own oocytes.

An intermediate variable is entered to simplify the record of the main diagnostic formula.

In order to carry out differential diagnostics, a comparative analysis of the content of local ingenious anthral fluid regulators is carried out using the above formula obtained using the Logit Regression method, according to the NEGAussian distribution of the source data. The use of mathematical processing allowed us to distinguish specific to the "empty" follicles syndrome reliably significant factors of internal studio regulation (FSH-follicle-sustamulating hormone, CHG - chorionic gonadotropin of human and IPFR-I - insulin-like growth factor). Our studies have been proven that there are two forms of "empty" follicles syndrome: "sporadic" and "absolute".

Thus, the data we obtained detect a clear dependence between the content of FSH, LH, estradiol, progesterone, testosterone, and in the antral liquid - FSH, CHG and IPFR-I, in the necessary adequate amount, and full folliclegenesis. The identified differences are obviously related to the provision of the most favorable conditions for the development of oocytes in the dominant follicle due to the important role of the above regulators in the folliclegenesis processes. The inclusion of these regulators in the formula also has a certain biological meaning. According to the literature (Enien W.M. et al., 1998; Roche J.F., 1996) Follicle-stimulating hormone, immunoreactive chorionic gonadotropin, as well as an insulin-like growth factor-I, are responsible for the selection of a full-fledged dominant follicle and preparation of a cumulus-oocyt complex for subsequent ovulation. The concentration of these regulators was determined by the immunofluorescent method using specific test systems. The comparative analysis of the results of immunofluorescent studies with their further mathematical treatment indicate the greater informativeness of the above-described technique in order to select patients with "empty" follicles syndrome: with its "absolute" and "sporadic" forms and, depending on the data obtained, develop further differentiated tactics of their maintenance in Programs

The coincidence of the prognostic and diagnostic criteria under the negative result of even one-time puncture of the ovaries (the absence of oocytes) is evidence of the "absolute" form of the SPF. At the values \u200b\u200bof the differential indicator, calculated on the follicular markers of less than 0.5, there is no expediency of carrying out further gonadotropic stimulations and the use of "donor" oocytes is shown. However, the lack of diagnostically significant confirmation of the "absolute" form of the SPF creates the possibility of continuing therapeutic cycles of CRP programs.

Statistical analysis of the obtained data set was carried out using a data analysis package and a set of mathematical and statistical functions (Excel 2003), as well as using standard Statistica 6.0 and Megastat application statistical analysis. The accuracy of the differentiated selection of patients with the "absolute" form of the SPF is 66.1%.

Analysis of the accuracy of the DP differential indicator is given below:

where: SP - the number of true positive cases in the sample,

IO - the number of true negative cases

LP - the number of false positive cases

Lo - the number of false negative cases.

The efficiency of the proposed method is confirmed by the following clinical examples.

Patient R-Ba, the history of illness No. 2341/222 was enrolled in the center of the person's reproduction in order to conduct it the ECO and PE program. The patient makes complaints about infertility II for 8 years. From the anamnesis it is known that the patient in 1987 moved the right-sided tubectomy and subtotal resection of the left ovary about the tube pregnancy on the right, in 1992 the resection of the right ovary about its cystic change.

In order to obtain the cohort of oocytes, she was appointed stimulation of ovulation. Under ultrasound examination, the growth rate of the leading follicle or cohorts of follicles and the endometrium thickness was determined in accordance with the protocol. This patient was registered at the time of puncture 2 of the leading follicle in the right ovary. The endometrium thickness was 8.5 mm.

Upon reaching the maturity of follicles (on the basis of data from ultrasound and hormonal monitoring), the patient was assigned a ovulatory dose of hg ("Pregel") in the amount of 5000-10000 units. The point of purpose Xg is determined depending on the term of reaching the leading follicle of the diameter of at least 18 mm.

Aspiration of oocytes and follicular fluid produced 36 hours after the administration of the ovulatory dose of the XG separately from the right and left ovary. In order to obtain oocytes from the ovarian follicles and the follicular fluid, a transvaginal puncture was transvaginal puncture using a vaginal sensor with a frequency of 5 MHz ultrasonic apparatus ALOKA SSD-500.

In the puncture of follicles, not a single oocyte was obtained. In the anthral fluid, aspirated from the follicles, determined the level of FSH, CHG and the IPFR-I immunofluorescent method using test systems: DELFIA (Walc Oy, Turku, Finland), "CHG-Eco-test" (000 "Diatec-uh", Russia), DSL-10-2 800 (Biokhimmak Group of Companies, Russia), respectively. The obtained concentrations of these intrafollicular regulators: FSH-5.6 MME / ml; IPFR-I - 105.7 ng / ml; CHG - 38 IU / ml, in order to eliminate the randomness of the identified "empty" follicle syndrome, a mathematical processing of the obtained data was carried out using the formula for calculating PP and DP:

PP \u003d 1,821 + 1 × 5,6-0.18 × 105.7 + 0.136 × 38 \u003d (- 6,30726).

DF Differential Indicator \u003d EXP (-6,30726) / (1 + EXER (-6,30726)) \u003d 0.001819708.

According to the obtained differential indicator (0.001819708), which is less than 0.5 in this patient "absolute" form of "empty" follicles syndrome and therefore it has been proposed to obtain a desired pregnancy program "Donation Oocytes".

The patient in Va, the history of illness No. 1389/158 entered the center of reproduction of a person in order to hold it the Eco and PE program. The patient makes complaints about infertility II for 7 years. From the anamnesis, it is known that the patient in 1997 suffered a right-hand-up to-optomy about the pipe pregnancy on the right, in 1999, a left-sided tubectomy about the pipe pregnancy on the left.

At the stage of the survey, ureaplasmosis, gardnerellosis was detected before the ECO program, anti-inflammatory treatment was carried out (with effect). In order to obtain the cohort of oocytes, she was appointed stimulation of ovulation. Uz-research conducted at the time of puncture of follicles made it possible to register 9 leading follicles. Endometrial thickness is 7.1 mm.

The patient was carried out by puncture of follicles and the aspiration of their content, whose study did not reveal a single oocyte, on the basis of which it was clinically confirmed in this cycle of stimulation "empty" follicles syndrome. The levels of biologically produced active substances In the antral liquid: FSH - 2.8 MME / ml; IPFR-I - 90 ng / ml; CHG - 45 IU / ml. In the surveyed patient, mathematical processing of the data obtained was carried out using the formula for calculating PP and DP:

PP \u003d 1,821 + 1 × 2.8-0.18 × 90 + 0.136 × 45 \u003d (- 5,60152).

Differential indicator of DP \u003d EXP (-5,60152) / (1 + EXER (-5,60152)) \u003d 0.003678681.

According to the obtained differential indicator (0.003678681), which is less than 0.5 in this patient "absolute" form of "empty" follicles syndrome and therefore it has been proposed to obtain a desired pregnancy program "Donation Oocytes".

Patient C-Ba, the history of illness No. 769/56 entered the center of the person's reproduction in order to hold it the Eco and PE program. The patient presents complaints of infertility II for 5 years. From the anamnesis, it is known that the patient in 2000 moved the left-sided tubectomy about the tube pregnancy on the left, in 2001 plastic of the right tube of the uterus about the tube pregnancy on the right.

At the survey stage, the Eco-related pathology program has not been detected. In order to obtain the cohort of oocytes, she was appointed stimulation of ovulation. Uz-study conducted at the time of puncture of follicles made it possible to register 5 leading follicles in the left ovary and 2 in the right. Endometry thickness 11.2 mm.

The follicle puncture and the aspiration of their contents clinically confirmed the existence of the sick presented, in this program, SPF, since the study of the Point did not reveal a single oocyte.

In order to clarify the further tactics of this patient, the levels of biologically active substances were determined in the resulting antral liquid: FSH - 3 MME / ml; IPFR-I - 78.2 ng / ml; CHG - 70 me / ml, the examined patient carried out mathematical processing of the data obtained using the formula for calculating PP and DP:

PP \u003d 1,821 + 1 × 3-0.18 × 78.2 + 0.136 × 70 \u003d (0.20268).

Differential indicator of DP \u003d EXR (0.20268) / (1 + EXER (0.20268)) \u003d 0.550496268.

The identified differential figure of more than 0.5 indicated the existence of this patient a "sporadic" form of the "empty" follicles syndrome, so in the future it is recommended to conduct repeated medical cycles of ECO in order to obtain their own oocytes.

In this study, we examined 158 marital couples who applied to the human reproduction center in the Rostov of obstetrics and pediatrics for the period from 1996 to 2004, with the aim of conducting programs included in the list of assistive reproductive technologies (IRTI). The age of women from 158 marital couples included in the present study, in both groups ranged from 21 to 46 years. Average age Women's 1 group was 32.12 ± 4.59, 2 groups - 31.18 ± 3.69. All patients included in the survey were divided into 2 clinical groups. The first group (control) amounted to 82 women conducted according to the standard methodology in the VG programs, with a full response of the ovaries to stimulate supersuvulation. In the second (basic) group included 76 patients with diagnosed "empty" follicle "syndrome at the time of puncture of follicles and the aspiration of their content when conducting therapeutic cycles of CRP programs, using standard log protocols. Of the 76 patients with the "empty" follicles syndrome in 46 women in any of the subsequent attempts of gonadotropic stimulation aspirate the oocytes did not succeed ("Absolute" form of SPF), while 30 surveyed still managed to get oocytes in subsequent VG programs (" Sporadic "Form of SPF).

Considering the fact that the composition of the follicular fluid, to a certain extent, reflects the hormonal composition of the blood (due to the gonadotropic hormones entering the ovary with blood flow and steroid hormones produced in the ovary), the differences that we identified in the anthral environment at the surveyed control and main groups.

The results of the study of hormones in the follicular fluid of the surveyed women of the main group indicate the absence of reliable differences in the level of LG, FSH, progesterone, estradiol, testosterone compared with similar indicators in the comparison group patients (Table 1).

Despite the lack of significant differences, higher concentrations of LH, progesterone and estradiol, against the background of relatively reduced Indicators of FSH and testosterone, are recorded in patients with a full-fledged follicular apparatus. At the same time, we also followed a comparative analysis of the levels of intrafollicular regulators of folliculo- and oogenesis (epidermal growth factor, insulin-like growth factor I, inhibin A). The results of the study indicate the unequalities of their distribution in "empty" and full follicles (Table 2).

The results of studies conducted, emphasize the particular importance of determining the content of such biochemical substrates of the anthral environment, as ChG and the IPFR-I.

Table 3 shows the indicators of intrafollicular regulators in patients with negative results of puncture of follicles with all subsequent VG programs (2-C subgroups) and with effective cycles (when puncture of follicles in repeated medical cycles, IVF managed to aspirate oocytes) (2-b subgroup).

As can be seen from the data presented in Table 3, the concentration of luteinizing hormone and estradiol in the follicular fluid, aspirated in patients with a positive result of puncture, was significantly higher, and testosterone, on the contrary, is reliably lower than those surveyed in robust cycles. These differences appear to reflect the essence of the pathological condition, since it is known that the growth of follicles and the ripening of oocytes in them depend on the complex chain of the hormonal and factor regulation of the reproductive function at various stages of their translational transformation. The anthral medium in which the follicle develops, undergoes cyclic transformation, depending on the phase of the menstrual cycle and the follicle development stage.

Extracorporeal fertilization (fertilization outside the body), followed by the transfer of embryos to the uterus cavity. Eco and PE firmly entered medical practice as a recognized method of treating infertility. This method of treatment in recent years is becoming increasingly popular in connection with the development of modern ultrasound equipment, allowing to monitor the development of the follicle, to determine the time of its ripening and get eggs by virtually safe manipulation - puncture through the vagina arches.
The first child born with the help of Eco in 1978, Louise Brown, in August 1998, was 20 years old. During this period, more than 5 thousand children were born at different ends of the planet.
Many concerns the question of the usefulness of children born after Eco. The frequency of congenital deformities and chromosomal violations in children who appeared on the light after Eco does not exceed those in the overall population. Thus, the concerns of the high frequency of chromosomal violations, expressed at the dawn era Eco, were in vain.
Pregnancy after ECO, according to world statistics, occurs in 10-30% of cases.
In the basics of the legislation of the Russian Federation on the protection of citizens' health of 22.06.93 (section of the MSHR Artificial Feedback and implantation of the embryo ") It is indicated that each adult female of the childbearing age has the right to artificial fertilization and implantation of the embryo.
Artificial fertilization and implantation of the embryo is carried out in medical facilities that have licensed the specified activity, if there are written consent of the spouses (lonely woman).
The treatment of infertility by the method of extracorporeal fertilization is carried out in the presence of the following readings:
1. Zhenskoe infertility:

• absolute pipe infertility (lack of uterine pipes or non-surgical methods of their obstruction);
• infertility due to endometriosis;
• endocrine infertility (when unsuccessful hormone therapy);
• infertility of unclear etiology;
• infertility caused by a primary factor (with unsuccessful treatment by intrauterine insemination);
• absolute infertility due to the absence or inferiority of the ovaries (in these cases, ECO and PE will include the use of donor oocytes).

2. Many infertility:

• oligo-monosogenomine 1-2 degrees

3.Mixed infertility:

• the combination of the specified forms of female and male infertility.

Due to the fact that treatment of infertility by the methods of auxiliary reproductive technologies is not included in the list of guaranteed free medical services, it should be reminded that treatment is associated with significant material costs.
The cost of medical services (one attempt) is _________, in addition to drug provision goes an average of 700 y. e. (The amount is determined by the amount of drugs used in the ECO program), which, in turn, depends on the individual response of the ovaries on hormonal stimulation.
Once again it is necessary to remind you that the medical service itself is paid, and not the result of treatment. If all the stages of ECO (monitoring, puncture, embryology, embryogeneos) are performed, the medical service is provided in full. To achieve pregnancy, not one attempt may be required, as well as the treatment of infertility may be unsuccessful.

The ECO method is a complex process.
It can be schematically represented by the following steps:

FIRST STAGE - this is a preparatory stage to EcoWhen a married couple is examined and prepared for the ECO procedure. Examination The married couple can pass at the place of residence.

SECOND PHASE - monitoring the growth and ripening of follicles.
From this, almost the treatment begins. At this stage, the induction of supervision is carried out (i.e. stimulation I ripening several eggs in one menstrual cycle). For the successful implementation of ECO, it is necessary to obtain several mature eggs at once during one menstrual cycle. This possibility that provides more chances for success represents the use of hormonal drugs - decapeptile, Humegon, pregnant, or their analogues. These drugs allow you to control the course of the menstrual cycle and with the utmost accuracy, calculate the ripening time of eggs.
Women under the age of 40, as a rule, are included in the medical cycle from 17-21 days of the menstrual cycle preceding the stimulation cycle (supervision induction). From that time, the introduction of drugs (decappeptila, or its analogues), which prepare ovaries to stimulation begins. From 1-3 days of the next menstrual cycle, drugs (humegon, pregnant and their analogues) are used, which directly stimulate the growth of follicles and the ripening of egg cells, as well as the growth of endometrial-internal layer of the uterus, where the embryo will be improved. Women over 40 are included in the medical cycle from 1 day of the menstrual cycle, in which the ovarian stimulation will be carried out using the above preparations.
The growth of follicles and the ripening of eggs at this stage is estimated using ultrasonic and (according to indications) hormonal motoring. All procedures are conducted outpatient.

Third stage - puncture or aspiration of follicular fluid containing mature eggs. Puncture of follicles and fence eggs - This is an operation that can be performed in two ways.
The first method - through the front abdominal wall (transmitominally) with laparoscopy, requires hospitalization, is carried out under anesthesia and is now used very rarely.
The second method is a transvaginal, in which the ovarian puncture is carried out through the vagina using a special needle under the control of ultrasound. Because of its minimal traumaticity and pain, the transvaginal method of ovarian puncture is more convenient for patients, an outpatient care is performed with ansticity at the request of patients. On the day of puncture, both spouses come to the medical center.

Fourth stage - embryological.
The eggs obtained during the puncture are placed in special cups with a nutrient medium. The case is then placed in an incubator, where conditions are supported similar to those in the parent organism (exactly the same temperature and carbon dioxide, oxygen content). At a time when the eggs are in the incubator; Husband rents cum.
The prerequisite is preliminary abstinence from sex life within 3-5 days. For most men with 3-day abstinence, the composition of sperm and the quality of spermatozoa is the best.
Spermatogenesis largely depends on the effects of adverse factors. The quality of sperm deteriorates significantly under the influence of nicotine, alcohol, professional harm, stressful situations, with nervous and general overwork. with sharp i. chronic diseases. Planning treatment at the IVF Medical Center, it is necessary to eliminate the influence of harmful factors or to minimize it. It must be remembered that the composition of the spermatozoa is fully updated within three months. Therefore, the longer a man can observe healthy image life, the better the result.
Only spermatozoa performing translational movements are selected for Eco. The fertilization of the eggs is carried out 4-6 hours after the follicle puncture. Only one spermatozoa of tens of thousands is needed to fertilize one egg. After joining the kernel of the egg, the stage of education of zygotes occurs. As a rule, 24 hours after the fusion of the egg and spermatozoa, there is a first crushing of the zygota and the stage of 2 blastomers, or 2 cell embryo, occurs.
Steps 2-4-8 cell embryos are considered optimal for the transfer of embryos to the uterine cavity.

Fifth stage - transfer of embryos to the uterine cavity.
The transfer of embryos is carried out after 48-72 hours with special cathetteers. However, in some cases, the transfer can be carried out at later stages, up to the formation of Morula or Blastocysts. It is recommended to transfer no more than 3-4 embryos into the uteros cavity, because When transferring a larger amount of embryos, Implantation of 2 or more embryos is possible. After the transfer of embryos, the woman gets a sick leave with a diagnosis " Early pregnancy, threat of interrupts. "Hospital sheet is issued for 14 days, i.e. before the primary diagnosis of pregnancy.

Sixth stage - diagnosis of pregnancy.
Two weeks after the transfer of embryos in the uterine cavity, the diagnosis "biochemical pregnancy" can be put in terms of chorionic gonadotropin (xg) in the blood, which is produced by a fruit egg. This method is more sensitive than a qualitative method for determining the XG in the urine. After 3 weeks you can see a fruit egg in the uterine cavity at ultrasound examination.
The success of Eco depends on many factors: age of spouses, ovarian reactions to stimulation, quantity and quality of sperm, character, causes and duration of infertility. Often, the outcome of the procedure cannot be explained from the position of modern science. From patients in the treatment of infertility, the ECO method requires a great patience, discipline and strict, sturder compliance with all appointments and recommendations of the doctor.
The implementation of the ECO procedure is associated with the risk of the occurrence of certain complications associated with the induction of supervision (stimulation), the production of egg cells, as well as related to the onset of pregnancy.
Complications related to the induction of supervision:
In the ECO and PE program, as a rule, the drug stimulation of supervision is used to achieve multiple growth of follicles. Supervision stimulation schemes can be the most diverse, are determined by the attending physician, they are brought to the attention of patients. When carrying out the induction of supervision, it is possible to obtain both a weak response of the ovaries (ripening of 1-3 follicles) and an excessive ovarian response for hormonal stimulation (growth of more than 10-15 follicles). With a weak response of ovaries, the likelihood of obtaining a sufficient amount of high-quality embryos is reduced, which reduces the process of occurrence of pregnancy. With an excessive response of ovarian, the possible complication of the induction of supervision in the ECO program is the syndrome of the ovarian hyperstimulation syndrome (SGA), which is characterized by a wide range of clinical and laboratory symptoms. The frequency of moderate and severe uniforms from women who undergo treatment with the help of auxiliary reproduction methods is 3-4% and 0.1 and 0.2%, respectively.
Patients with a moderate form of KGU need serious observation (sometimes in a hospital) and timely treatment, since the clinical picture can quickly progress to severe forms, especially in the case of pregnancy. Patients with severe uniforms need immediate hospitalization and emergency treatment. Treatment of this complication is accompanied by additional material costs.

Complications related to getting eggs

The fence of the eggs is performed by puncture through the vagina versus under ultrasonic control. Sporadic cases of bleeding, as a result of injuries of blood vessels, intestinal perforations.
The procedure for obtaining oocytes can lead to infectious complications in a small pelvis.
The possibility of reactivation or relapse of infection as a result of surgical manipulations performed on the organs of the small pelvis is a generally accepted fact. Since the majority of patients undergoing Eco suffer mechanical infertility as a result of inflammatory processes, most of them have a risk of re-infection. However, the risk of infection after the transvaginal aspiration of oocytes is relatively low.

Exodus of pregnancy after eco

The early diagnosis of pregnancy is carried out on day 14 after the transfer of embryos to the oral cavity in the blood plasma. With a positive result, in two weeks, it is carried out, the presence of a fetal egg in the uterine cavity is determined. Women who have a pregnancy occurred after the use of the ECO and PE method should be under the constant observation of the doctor of the obstetrician gynecologist at the place of residence.
About 65% of all the pregnancies that have come as a result of Eco ends by the birth of living children. However, some of the pregnancies occurring after Eco may end the spontaneous abortion. The frequency of spontaneous abortions after ECO is about 26%. The following factors may be the cause of a higher frequency of spontaneous abortion after eco:
- complicated obstetric history (long experience of treating infertility with high frequency of use of operational treatment methods);
- age-related changes in the body that affect the tooling of pregnancy, because The age of women undergoing treatment with the ECO average is higher than that of women who have a pregnancy occurred naturally;
- multiple pregnancy, the frequency of which among women who have undergone treatment of Eco is significantly higher than in the population.
The higher frequency of spontaneous abortions in the group of women who have been treated by the IVF method is also explained by the fact that the fact of pregnancy is installed in almost the first weeks after the implantation of the embryo, while the frequency of spontaneous abortions in the population is calculated, as a rule, starting from 8- weekly pregnancy.
are one of the most serious complications of Eco. World statistics gives the frequency of ectopic pregnancies after Eco about 5%. This frequency of ectopic pregnancy after Eco is not a surprise, since many patients subjected to ECO have changed uterine pipes, inflammatory processes in history, which increases the risk of this complication (in the presence of uterine pipes).

Examination and preparation for Eco

Before starting treatment, it is necessary to undergo primary consultation in the center, during which experts will determine the scope of the survey, will choose the method of treatment and you can discuss all your questions with your doctor.
Please note that the survey is carried out by us in your interests. There are studies on which it is impossible to refuse, as they are aimed at identifying hidden pathology and allow you to prevent very serious complications for your health. Without them, we cannot carry out treatment.

Regardless of the results of previous analyzes, it will be necessary to repeat in our center!

• Both spouses:
• blood group and reserves
• blood tests on RW, AIDS
  
• blood tests on the Australian Antigen
  (for Eco is valid for 1 month, for artificial insemination - 6 months)
• documents on previously conducted examination and treatment
• Husband:
• spermogram
• morphology and sampling
• blood test on a / t to hepatitis virus with
  (for Eco is valid for 1 month, for artificial insemination - 6 months)
• coagulogram (valid 1 month)
• clinical blood test
  (for Eco is valid for 1 month, for artificial insemination - 6 months)
• smears on the flora and the degree of purity (valid 1 month)
• sowing in chlamydia, mycoplasma, ureaplasma
  (In the absence of infection, 6 months are valid.)
• atypius smear with cervix
• pictures of uterus and uterine pipes (GHG)
• help from the Health Statue Therapist and Pregnancy

\u003d\u003e If you are aware of the dispensary accounting - it is necessary to obtain a certificate from the relevant specialist about the health status and the absence of contraindications to the ECO procedure and tooling pregnancy.
A number of studies allow you to clarify the diagnosis, to develop therapeutic tactics, taking into account the characteristics of your health, reasons for infertility and ultimately increase the likelihood of pregnancy. The volume of these studies is determined by the doctor individually and our proposals in their respect are advisory in nature:

• WEN:
• blood tests on FSH, LH, E2 (for 2-5 days cycle)
• blood tests in the PRG (for 20-23 days of the cycle)
• blood tests T3, T4, TSH, PRL, Testosterone
• examination for antispermal antibodies
• blood test for antiphospholipid antibodies
• endometrium biopsy
• Husband:
• Morphology and sampling
• Examination for antispermal antibodies

If there is a complete examination and the absence of contraindications to the ECO procedure, it is necessary to come to the doctor no later than 19-20 days of the menstrual cycle for the start of treatment.

Treatment of infertility by Eco or artificial insemination method is carried out outpatient.

Material provided medical Center Avicenna

The invention relates to medicine, namely to gynecology. The essence of the method of predicting the outcomes of the ECO and PE program outputs: In the follicular fluid, the contents of the FPN and -FRF are determined. Calculate the prognostic index (PI) by the formula: pi \u003d 0.0027 · x + y · (+ 8,9626 · 10 -7 · y-3,0827 · 10 -6 · x) -0.1448, where x - quantity FNO-, Y - the number of the FRF. Obtaining a result is less than 0.3038 indicates a favorable forecast for in-vitro fertilization. If it is equal to or greater than 0.3038, the adverse outcome of the in-vitro fertilization is predicted. The method allows to improve the accuracy and informativeness of the ECO and PE program forecast.

(56) (continued):

Class \u003d "B560m" Fasouliotis SJ et al. Maternal Serum Levels of Interferon-Gamma and Interleukin-2 Solule Receptor-Alpha Predict The Outcome of Early Ivf Pregnancies. Hum Reprod. 2004, 19 (6), p. 1357-63, Ref.

DRIANCORT MA ET AL. Control of Oocyte Growth and Maturation by Follicular Cells and Molecules Present in Follicular Fluid. A Review. REPROD NUTR DEV. 1998, 38 (4), p. 345-62, Ref.

McNatty KP et al. Control of Early Ovarian Follicular Development. J Reprod fertil Suppl. 1999, 54, p. 3-16, Ref.

The invention relates to medicine, namely to gynecology, and will find use to predict in-vitro fertilization in order to improve the efficiency of the method of extracorporeal fertilization and transfer of embryos (ECOIPE).

The problem of treating infertility is currently becoming not only medical, socio-demographic, but also economic importance (Kulakov V.I., Leonov B.V., 2004). The infertility frequency in Russia is 10-15%, and in some regions exceeds a 15% level determined by the WHO problematic group as a critical affecting demographic indicators (Kulakov VI, 1999). Today, the method of treating infertility is becoming increasingly distributed in our country and all over the world by extracorporeal fertilization and transfer of crushing embryos to the patient's uterus cavity. If in 1987-1990 the efficiency of the method was 10-15% per embryo transfer, then this indicator has increased to 25-35% of cases. At the same time, the clinics applying the ECO and PE method continues to search for new approaches to improve the efficiency of the method.

The ECO and PE program is complex due to the fact that it is a multi-step, but not all stages can be objectively monitored. To a certain extent, part of the unsuccessful outcomes of ECO is laid in the very nature of the reproductive process of a person, which is about 20% for the marital couple at the age of 20 (Nikitin A.I., 1995). In this regard, there was an idea of \u200b\u200bstimulation of supervision in order to obtain a larger number of eggs due to the use of gonadotropins. However, an increase in the number of eggs entails another negative factor - some of them may be defective, with impaired ogenesis or chromosomal pathology, while others can become the path of reverse development in the process of foliculargenesis. In order to improve the quality of oocytes and prevent their premature maturation due to the ejection of the endogenous luteinizing hormone into the supervision stimulation scheme, the hormone gonadotropin agonists are included (Fleming R. et al., 1990).

A very important factor for ECO outcome is the state of men's genital cells. At the same time, significant progress associated with the introduction into the practice of the intracitoplastomatic injection of the spermatozoa, makes it possible to have offspring to men with severe forms of diseases, previously doomed to absolute infertility (Leonov et al., 1999).

The readiness of the endometrium is the most important condition for successful implantation transferred to the Embrycot Makeup (Tabibzadeh S. et al., 1995). In case of suspected the presence of violations of cyclic transformation of the endometrium, a number of authors are recommended to conduct preliminary drug therapy containing progesterone and estradiol (FFrindler S. et al., 1992).

A very important factor affecting the success of implantation of the embryo is the process of transferring to the uterus (Tomar et al., 2002). But currently exist different types catheters that ensure this procedure atraumatic (Mansour R.T. et al., 2002). In addition, the conduct of hystercopia prior to the implementation of the ECO program makes it possible to estimate the condition of the walls of the cervical canal, endometrial and in cases of the presence of pathology to produce appropriate operational interventions.

A significant moment that influence the success of the implantation of the embryo is the age of a woman. However, given the use of donor oocytes, the frequency of successful results of the ECO and PE program does not differ in the patients of early and late reproductive age (Craft J., 1990).

Particular attention should be paid to the infectious morbidity, affecting the sexual system, which can lead to a violation of in-vitro fertilization and the occurrence of pregnancy, prevent the birth of a healthy offspring (Steyaert S.R., et al., 2000). Therefore, a significant moment in the implementation of the ECO and PE program is the timely identification and treatment of infections in the marital pair of infections, closely related to the reproductive system included in the so-called Torch complex (Toxaplasaplasmosis, rubella, cytomegalovirus and herpetic infections, chlamydia, syphilis, hepatitis A and in , Gonococcal infection, lesteriosis) (Kuzmichyev L.N., 1998).

Defining factor positive result ECO and PE programs are an embryo state that determines the success of implantation P (Lenz J.V. et al., 1996). At the same time, in order to obtain good quality embryos, it is necessary that the development of the prevention oocyte is not impaired in the conditions of in-vitro fertilization.

Research of recent years confirm the hypothesis that many immunoactive cytokines participate in implantation and placental development processes. The change in the mother's T-helper (TH) of the cell response required for the onset of normal pregnancy sharply changes from the THI-type reaction. On the contrary, the persistence of the TH1 type response is characteristic of violating the course of pregnancy of early terms (Hill J.A. et al., 1995). This opinion is supported by many clinical studies (Marzi M. et al., 1996; Raghupathy R. et al., 2000; Makhseed M. et al., 2001), in which it is convincing that the increase in production of peripheral lymphocytes TH1 cytokines is observed in women With the adverse results of the ECO and PE program, in contrast to the th2 domination of the reaction characteristic of normally flowing pregnancy.

At the same time, data indicating that cytokines, especially the growth factors contained in the follicular fluid, are important modulators of internal processes regulating the development of the oocyte (Kane Mt Morgan PM Coonan C. Peptide Growth Factors and Preimplantation Development // Hum . REPROD. UPD.- 1997-Vol.3 - 137-157).

The reduced content of the insulin-like growth factor (IFR) in the follicular fluid was revealed in a group of fruitless patients having endometriosis, ovarian dysfunction and low results of the ECO and PE program (Cunha-Filho JSL, Lemos Na, Freitas FM, Kiefer K, Faller M., Passos EP // Insulin-Like Growth Factor (IGF) -l and IGF Binding Protein-1 and -3 in the Follicular Fluid of Infertile Patients with Endometriosis Hum. Reprod.- 2003-18-423-428).

Some researchers associate reduced concentrations of the vascular endothelial growth factor (SEFR) in follicular fluid to obtain oocytes and higher quality embryo, increasing the frequency of pregnancy (Friedman Ci, Seifer DB, Kennard EA, et al .. Elevated Level of Follicular Fluid Vascular Endothelial Growth Factor IS A Marker of Diminished Pregnancy Potential // FERTIL. Steril. - 1998-70-836-839; Barroso G., Barrionuevo M., Rao P. et al Vascular Endothelial Growth Factor, Nitric Oxide, and Leptin Follicular Fluid Levels Correlate Negatively with Embryo Quality in IVF Patients // FERTIL. Steril.-1999-V.72-p.1024-1026).

It is known that higher concentrations of the transforming growth factor (TFR-B1) in the follicular fluid are reliably related to successful pre-embryonic development, elevated levels of implantation of embryos and the occurrence of pregnancy (Van Rooij Iaj, M.Broekmans FJ, TE Velde Er Serum Anti-Mullerian Hormone Levels : A Novel Measure of Ovarian Reserve // \u200b\u200bHum. Reprod.- 2002-17-3065-3071).

Hammadeh M. E. et al. (2002) did not find significant changes in the concentration of a colony-posulisting growth factor in a follicular fluid during comparative study of patients with various infertility factors (pipe, endometriosis, infertility of unclear genes and male factor) (Hammaden Me, Ertan AK, Zeppezauer M. et al.immunoglobulins and CYTOKINES LEVEL IN FOLLICULAR FLUID IN RELATION TO ETIIOLOGY OF INFERTILITY AND THEIR.//AJRI 2002-47-82-90).

However, the overall disadvantages of the above works are: carrying out definitions of growth factors in the follicular fluid in groups of patients with different etiological factors of female and male infertility, in other words, there are no criteria for incorporation and exception in the study group on the etiological principle. Works also lack information on the testimony to conduct the ECO and PE program. Also, the significant disadvantage of the above work should recognize the absence of information on the content of growth factors in the follicular fluid in cases of stopping the fertilization of oocytes or embryos.

Thus, today certain information has been accumulated, indicating the possible prediction of the results of the ECO and PE program on the basis of determining the content of growth factors in the follicular fluid.

At the same time, it is known that in the group of patients with pipe infertility when conducting an ECO program, the lack of fertilization of in-vitro egg cells is observed in 9% of cases, and stopping the development of embryo in 8.4% of cases (Witkin, SS et al., 1996 ). It should be emphasized that in Russia for the absolute majority of patients the main indication for the ECO and PE program is the pipe infertility.

In this connection, the further development of methods can be predicting in-vitro fertilization, and primarily for this category of patients, which is particularly relevant in cases of expensive methods of treating infertility to which the ECO and PE belongs to.

The prototype of the invention is a method for evaluating the development of oocytes by studying markers in the follicular fluid obtained during the puncture of follicles and the aspiration of their content when conducting the ECO and PE program to determine the outcomes of the program. The essence of this study is that the follicular fluid is determined higher levels of insulin-like growth factor (IFR) and low interleukin-1, which indicate a favorable forecast for the occurrence of pregnancy. (Mendoza S., Ruiz-Requena E., Ortega E., Cremades N., Martinez F., Bemabeu R., Greco, E., Tesarik, J.Follicular Fluid Markers Butoocyte Developmental Potential.// Hum. Reprod.- 2002-17-1017-1022).

The disadvantages of the prototype are: First, the lack of clear criteria, under what values \u200b\u200bof the examined markers should be thought of an adverse outcome of the ECO program, which reduces the accuracy and information content of this method; Secondly, this study was carried out in the group of patients without pathology from the reproductive system, the indication for the ECO program was a male infertility factor in connection with which the in-vitro fertilization was carried out using the intracitoplasmic injection of the spermatozoa, while the main testimony to conduct Extracorporeal fertilization programs are pipe infertility; Thirdly, there are no information about patients who have not been carried out in connection with the impaired in-vitro fertilization.

These disadvantages are eliminated in the proposed invention. The objective of the invention is to increase the accuracy of the method and its informativeness.

The task is solved in the fact that after conducting the puncture of follicles, the aspiration of their contents and the allocation of oocytes is determined by the average concentrations of the FPN and -FRF. The prognostic index (PI) is obtained by calculating the formula: pi \u003d 0.0027 · x + y · (+ 8,9626 · 10 -7 · Y-3,0827 · 10 -6 · x) 0.1448, where H-FLN -, Y--FRF. The pi value is equal or more than 0.3038 indicates that in-vitro fertilization will be broken. The accuracy of the obtained formula - P-VALUE: 2,299E-8

The technical result obtained as a result of predicting the outcomes of the ECO and PE program outputs in this method is that:

1) the accuracy and informativeness of the projection of the outcomes of the ECO and PE program outcomes in the early stages of its implementation are significantly increasing;

2) it is possible to study the material obtained during puncture (follicular fluid and cells contained in it) for the purpose of timely examination of the patient;

3) the effectiveness of the following ECO programs is increasing by carrying out the patient's etiotropic therapy, taking into account the survey results;

4) one can take a timely decision on the intracitoplasmic spermatozooid injection in order to improve the results of in-vitro fertilization;

5) The psychological burden on the patient decreases, which awaits information on the results of in-vitro fertilization and the end of embryo transfer due to early warning on the possible adverse outcome of fertilization.

6) the medicinal burden on the patient is reduced by excluding it from the ECO and PE program.

The success criterion for one of the most important stages of the ECO program is to obtain good quality embryos. At the same time, the development of the IN-VITRO embryo is directly related to the state of the oocyte and the intrinsic processes that ensure its development that occur as noted above, with the direct participation of growth factors, which determination of the content in the follicular fluid can contribute to forecasting the outcomes of the ECO and PE program In the early stages of its holding.

In order to develop a method for predicting the results of the ECO and PE program, we conducted a study of the growth in the follicular fluid growth factors - FPN and -FRF in 637 follicles in 75 patients with a tube factor of infertility, who applied to the Rostov Research Institute of Obstetrics and Pediatrics. Of the 36 patients (1 group), the in-vitro fertilization was violated at the stage of the development of egg cells in 61.2% (22) cases, and at the stage of development of embryos of 38.8% (14). The transfer of embryos in this group was not carried out. In the second group of research, 39 patients were included, in which in-vitro fertilization proceeded normally and ended with the transfer of embryos. The prognostic formula (PI) was obtained on the basis of a comparative analysis of the average concentrations of the FPN and -FRF in groups of patients with the in-vitro fertilization occurred and with the absence of in-vitro fertilization. Mathematical analysis was carried out using the Polyanalist 3.5 software (Megaputer Intelligence).

Analysis of scientific and medical and patent literature allowed us to establish that only single studies undertaken to determine the adverse effect of fluid contained inside the hydraulpinx, on the development and implantation of the embryo in the experiment (Arrighi CV et al, 2001, Carrasco I, are devoted to the study of violations of in-vitro .ET Al., 2001, Ajonuma LC et al., 2003). In other works, the violation of fertilization during cultivation of oocytes is associated with cellular or genetic disorders, which are called "Oocyte Factor", and, as the authors themselves emphasize, these findings require further refinement (Levran D. et al., 2002).

At the same time, most patients suffering from tubular infertility have a chronic inflammatory process that causes them to be adhesive diseases of the small pelvis. Spikes of the small pelvis organs may be the consequence of reconstructive plastic surgery or tubectomy. The purpose of gonadotropins during the controlled stimulation of superstulation can be one of the factors contributing to the exacerbation of the chronic inflammatory process of uterus's appendages, which leads to the appearance of cellular and plasma mediators of the inflammatory process - cytokines, which include the growth factors of the FPN and -FRF.

The FNO and -FRF contained in the follicular fluid can be secreted by granolas and leukocytes: in lymphocytes, monocytes, natural killers, the number of which is increased with inflammatory diseases of the small pelvic organs. Theoretically, they can also fall into follicles from peritoneal fluid due to diffusion through the ovarian capsule in cases of inflammatory process of the small pelvic organs, but these data are currently absent in the literature. At the same time, the study of Cheong Y.c. et al. (2002) indicates high concentrations of the FNO-in peritoneal fluid in the adhesive disease of the small pelvis organs, which may also have a negative impact on coherent processes. Growth factors can have an effect on follicle cells in various ways: autocrine, paracryn, intracrine and endocrine (Mandrup-poolsen T. et al., 1995; Vinatier D. et al., 1995). FNO- can cause a decrease in the ovarian function against the background of the inflammatory process due to the inhibition of the inhibition of the stimulated by gonadotropin steroidogenesis in undifferentiated ovarian cells due to a decrease in adenyl cyclase secretion and C-ATP (Terranova P.F., Rice V.M., 1997). In addition, the elevated concentrations of the FNO-in follicular fluid lead to apoptosis (Matsubara H. et al, 2000).

Currently, data are obtained that testify to inhibit the products of Estrogen FNO- (Pottratz S.T. et al., 1994). Moreover, it was found that FNF inhibits products of progesterone with a yellow body and causes the follicle atresia (Buscher U. et al., 1999, Nash Maet Al., 1999; Yeh J. and Adashi Ey, 1999; Doraiswamy V. et al, 2000). The increase in the concentration of the FLNO-in follicular fluid can adversely affect ovulation and in in-vitro fertilization (CIANCI A. et al., 1996) and have an embryotoxic effect (SUNG L. et al., 1997). On the other hand, it is known that the ovary is an organic organ with an extremely high level of angiogenesis (Redmer, D.A. and Reynolds, L.P., 1996) and the growth of the vascular part of the follicle tissue is adjustable -FRF (Schams D. et al., 1996). There is also a hypothesis that low levels of serum estrogen are insufficient for cell proliferation depend on various growth factors, including from-FRF (Hermenegildo S., Sapo A., 2000). There is also information about the important meaning of the FRF for the pre-limiting development of the embryo (Chai N. et al., 1998).

The studies have made it possible to establish the relationship between the concentrations of the FPN and -FRF in the follicular fluid and in-vitro fertilization. Determining the content of these growth factors allows you to predict the result of in-vitro fertilization in the early stages of the ECO and PE program.

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

To implement the method, the following equipment is used: a standard set of equipment and equipment for Eco and PE laboratories, a photometer (Victor, 1420 Multilabel Counter, Wallac, Finland). The level of concentrations in the follicular liquid of cytokines was determined using commercial TNF-(CYTELISA) and -FRF (Cytimmune, Science Inc., USA).

Supervision stimulation is carried out according to the "short protocol" using the gonadoliberine analog (DIFERELIN, Bofour IPSEN) in a daily dose of 0.1 mg, which is assigned on the first day of the menstrual cycle after ultrasound. The next day, the stimulation of follicularogenesis is beginning to introduce drugs of recombinant follicular-suite hormone (Pureregon, organone) in a daily dose of 150-250 me. Stimulation is carried out until the day reaching the leading follicles of the diameter of 18 mm, determined during transvaginal echography, after which the injection of the "ovulatory dose" of the chorionic gonadotropin (pregnive, organon) is prescribed.

35-36 hours after injection of chorionic gonadotropin, there is a transvaginal puncture of follicles and aspiration of preventive oocytes. Transvaginal puncture is performed in a gynecological chair using the Aloka Sal500 ultrasound (Japan). Crotch and vagina disinfect. Patient is covered with sheets, leaving an open crotch. With the help of a vaginal sensor with a special nozzle for a puncture needle, an ultrasound study of the small pelvis organs is carried out to select the optimal position of the location of the puncture path. After determining the correct direction of the puncture trajectory through the clearance of the nozzles of the vaginal ultrasonic sensor, it is punctured by the contents of follicles using the needle. Aspiration of the contents of follicles is performed using vacuum suction, under a pressure of 80 mm Hg, providing an admission of aspirate into sterile test tubes. The resulting follicular fluid transmits an embryologist to identify and allocate oocytes from it. Sperm preparation is carried out using the Swim-Up technique in Mtdium B1 (CCD, France) medium. Aspirated oocytes are inside and cultivated in an inra medium (CCD, France). Samples of follicular fluid are centrifuged at a speed of 400 g for 10 minutes and the net fraction is used to determine the FNO and -FRF in it. The method of determining the FPN and -FRF is described in the manufacturer's manual of a commercial set.

The obtained values \u200b\u200bof the FPN and -FRF are substituted into the calculation formula pi \u003d 0.0027 · x + y · (+ 8,9626 · 10 -7 · y-3,0827 · 10 -6 · x) -0.1448, where x - TNF-, Y - -FRF, and if a pic value is equal or more than 0.3038, then predict the adverse outcome of the ECO and PE, which is an indication for the exclusion of a woman from the program and the direction of its additional examination.

We present clinical examples confirming the performance of the method.

Patient P-VA L.V., 35 years old, medical history №582 / 60, Date of puncture of follicles 14.06.01.

Diagnosis: chronic double-sided salpingitis. Condition after Salpingosorolysis, Salpingostomy. Fitz Hugh Curtis syndrome. Secondary infertility.

The average concentrations were FNF- \u003d 20.5 pg / ml, -phrf \u003d 167.5 ng / ml.

After substitution of the data obtained, the PI \u003d -0.0501 was obtained in the formula, which indicated a favorable ECO outcome. As a result of the cultivation of In-Vitro oocytes, embryos were obtained and their transfer was carried out.

Patient Ch-Va N.V. 28 years old, illness history №4094 / 441, Date of puncture of follicles 19.06.02g.

The average concentrations were FNF- \u003d 315.1 pg / ml, -phrf \u003d 1210.0 ng / ml.

After substitution of the data obtained in the formula, the PI \u003d 1.1933 was obtained, which indicated the adverse outcome of the ECO. As a result of the cultivation of oocytes, the in-vitro fertilization did not occur, the embryos were not obtained.

Patient Sh-K I.V., 33 years old, medical history №2529 / 286, Date of puncture of follicles 13.04.02

Diagnosis: status after a 2-sided tubectomy. Flashing diseases of the small pelvis. Secondary infertility.

The average concentrations were FNF- \u003d 87.0 PG / ml, -FRF \u003d 482.3 ng / ml.

After the substitution of the data obtained, the PI \u003d 0.3038 was obtained in the formula, which indicated the unfavorable outcome of the ECO and PE. As a result of the cultivation of oocytes, the in-vitro fertilization did not occur, the embryos were not obtained.

According to the materials of the proposed method for predicting the ECO and PE program, we examined 152 patients who applied for extracorporeal fertilization about pipe infertility into the Rostov Research Institute of Obstetrics and Pediatrics. The age of the surveyed patients ranged from 24 to 36 years, on average, amounting to 29.4 ± 2.2 years. Of these, 59% were diagnosed with primary infertility, 41% is a second. The duration of infertility varied from 6 to 14 years, constituting an average of 7.4 ± 2.1 years. In 11 patients, Pi values \u200b\u200bamounted to more than 0.3038, in-vitro fertilization in these cases did not occur, which served as the grounds for their further survey. In the remaining patients, Pi values \u200b\u200bwere less than 0.3038, in-vitro fertilization in these cases occurred and embryos were carried out.

The inventive method is based on the use of standard laboratory equipment, does not require technical modification. The use of this technique allows the doctor in the first day of the cultivation of oocytes to predict the result of fertilization in order to develop further patient tactics and conducting additional laboratory studies in order to clarify the causes of the violation of fertilization. The claimed method can be used in gynecological hospitals using the ECO and PE program.

CLAIM

The method of predicting the outcome of the ECO and PE program by studying the follicular fluid, characterized in that the follicular fluid is carried out a quantitative determination of the TNP and -FRF content, the prognostic index (PI) is calculated by the formula

Pi \u003d 0.0027 · x + y · (+ 8,9626 · 10 -7 · y-3,0827 · 10 -6 · x) -0,1448,

where X is the amount of FPN, Y - the amount of the FRF, and with the value of Pi, less than 0.3038, predict the favorable outcome of the in-vitro fertilization, and with a value equal to or greater than 0.3038, the unfavorable outcome of fertilization predicts in-vitro.

(information for patients planning treatment for infertility with the use of auxiliary reproductive technologies)

You have to treat infertility with the use of auxiliary reproductive technologies. Auxiliary reproductive technologies include a group of methods to overcome infertility through the creation of optimal conditions for fertilization and conception within a female body (controlled ovarian stimulation (CPCs) - applied with an isolated anoint infertility (absence of ripening and exit of eggs from the ovary); insemination of sperm husband (IOSM ) - with an isolated immunological infertility (negative postcoital test) or lightweight degrees of fertility (ability to fertilization) in the husband) and with the "prosthetics" function of fertilization (carrying out fertilization outside the body, "in a test tube"): Eco and PE method ( Embryoral fertilization and transfer of the embryo to the uterine cavity) - It is used for pipe and hormonal infertility in women and with a moderate violation of fertility in men (with the method, specially prepared spermatozoa fertilize the egg cell "in the tube", but the fertilization mechanism itself does not differ from estimated; The ECO Ixi method (extracorporeal fertilization by microsurgical cellular technology - spermatozoa in the egg) - applied with pronounced disorders of fertility in men. In the absence of sperm in the seminal fluid, methods of surgical sperm sperm sperm (TESA, PESA) may be proposed or use to fertilize the cryopreserved donor sperm, including the IOSD - artificial insemination of the donor sperm.
Currently, there are no data proving a negative impact on the offspring of the ECO method. Any negative impact on sex cells at the step of fertilization and early crushing has its consequences for the embryo (embryo) the law "All or nothing": the embryo either dies or develops without any consequences. No "increasing" influences on the body at this stage of the development of the human embryo are impossible. From this it does not follow that, as a result of the ECO program, children will not be born with defects, health problems - naturally can, but the likelihood of the birth of such children does not exceed those in the population and is determined not by the technology of fertilization, and the heredity (your husband and your husband), The health of the parents of the child's parents, the conditions of their life and professional activity, the peculiarities of the course of pregnancy and childbirth. The situation is somewhat differently with ICSI technology, because In the manufacture of ICSI, the fertilizing spermatozoa is selected not by natural selection, by virtue of which the resulting embryo has a greater risk of genetic anomalies, which is confirmed in practice by a higher frequency of miscarriage of pregnancies obtained as a result of ICSI. In addition, the studies carried out by the present time make it possible to assume with a fairly high share that the boys born as a result of ICS technology will subsequently in a certain percentage of cases will need an ADC to implement their reproductive function.
The effectiveness of CBS and IOSM procedures does not exceed 18-20%. The effectiveness of the ECO procedure in the classic version is currently 30-35% and the last 10 years does not change in principle. Under efficiency, the percentage of clinical (i.e.-approved ultrasound) of pregnancy in patients who have the ECO program has been fully completed, that is, it became the transfer of the embryo to the uterine cavity. In terms of obtaining (birth), the ECO effectiveness is currently 18-20%. This is due to the fact that approximately 25-30% of the pregnancies obtained as a result of the ECO, for various reasons end with miscarriages. In addition, in some cases, an electronic pregnancy may occur as a result of ECO (the probability of ectopic pregnancy in patients is about 4 times higher than in the overall population, moreover, in these patients, ectopic pregnancy may occur even in the absence of uterine pipes). It is extremely rare in Eco and other abnormal forms of conception, such as trophoblastic disease (bubbling and chorionepitheloma). However, despite the low efficiency, the ECO method is the most effective method of overcoming infertility today, and its effectiveness is determined not by the imperfection of technology, but the natural patterns of human reproduction: the fact is that the probability of conception in a human pair in the natural menstrual cycle does not exceed 25 -30%, and is determined by these laws of genetics and non-natural selection mechanisms. In the process of dividing and fertilization in the genetic apparatus of genital cells, breakdowns can occur - mutations, which leads to the formation of a genetically defective embryo. According to the literature of such embryos, a healthy pair can be up to 70%. The existing mechanism of natural selection ceases the development of such embryos or at the implantation stage (pregnancy does not occur), or in the early period of pregnancy (in this case, pregnancy can either regress, or to end the miscarriage (up to 90% of the miscarriage in the first trimester of pregnancy have genetic causes). Breakage In the mechanisms of natural selection, leads to the birth of children with developmental anomalies, chromosomal and genetic diseases
(Bhd Down, etc.), however, fortunately, this is very rare (in thousandths of interest percent). It is the "genetic quality" of the embryo and determines the efficiency or inefficiency of the ECO program: when receiving a "genetically high-quality" embryo, a pregnancy in the Eco program will almost certainly arise (the probability of such a situation is 30-35%). When receiving a "genetically poor-quality" embryo, pregnancy will not come under any methods of optimizing the program (the likelihood of such a situation is 65-70%). It is not necessary to remember that it is impossible to evaluate the "genetic quality" of the embryo today. Embryologists leading the ECO program assess the quality of the embryo (there are even different scales of such an assessment), however, the basis of such an assessment is not the "genetic quality" of the embryo, but the speed of its crushing and the presence or absence of crushing anomalies (the presence or absence of fragmentation of blastomer - cells, Of which the embryo consists). Unfortunately, there are situations where the embryo with serious chromosomal or genetic "breakdowns" in the early stage of development (which is observed by embryologists in the ECO program) looks and develops completely normal, but after transferring such embryos, pregnancy is impossible.

1. Extracorporal fertilization (ECO).
2. Transferring Games, embryos to fallopian tubes (Gift, Zyft).
3. Micromanipulating on gates in the treatment of male infertility:
partial dissection zone of a shiny shell;
subseal fertilization;
Intracitoplasmic spermatozoa injection (ITSI).
4. Auxiliary methods of reproduction using donor oocytes and embryos.
5. Surrogate motherhood (a donor woman shears the genetic child of the customer's family).
6. Cryoconservation of spermatozoa, eggs and embryos.
7. Artificial insemination of sperm of her husband or donor (ISM, ISD).

Justification

The frequency of fruitless marriages in Russia exceeds 15%, which, according to WHO, is considered a critical level. There are more than 5 million barren marital couples in the country, of which more than half need to use HRD methods. According to expert evaluation, the indicator of only female infertility has increased by 14% over the past 5 years.

The basis for the development of a number of approaches that are currently united by the general thermal IRT, has become the classic ECO and PE method into the uterus cavity. In this case, oocytes after cultivation in a special nutrient medium fertilize with the sperm, which is pre-centrifuged and treated in a nutrient medium.

Types of HRD:

• introduction of the embryo to the woman by the woman ("Surrogate" motherhood) for the subsequent transfer of the child (children) genetic parents;
• oocyte and embryos donation;
• Ixi;
• cryoconservation of oocytes and embryos;
• preimplantation diagnostics of hereditary diseases;
• reduction of embryos with multiple pregnancy;
• actually eco and PE.

ECOin the world practice of infertility therapy since 1978 in Russia, this method was first successfully implemented in the Scientific Center of Obstetrics, Gynecology and Perinatology, RAMS, where in 1986, thanks to the works of Professor B.V. Leonov was born the first child "from the test tube". The development of the ECO method brought the problem of treating pipe infertility from a dead end and made it possible to achieve the onset of pregnancy in a huge number of women previously doomed to childlessness.

In relation to patients, the ECO program is needed that it is about infertility with a married couple as a whole. This fundamentally changes the approach to the selection of patients and their preparation for the program - makes a mandatory preliminary assessment of the state of the reproductive system of both women and men.

Approximately 40% of infertility among married couples is due to male infertility. The ICSI method allows you to have the offspring of men with heavy forms of infertility (oligo, astheno, the teratozooms of heavy degrees), sometimes only in the presence of single spermatozoa in the point obtained during the egg biopsy. Eco using the donor oocytes is used to overcome infertility in cases where a woman cannot obtain their own oocytes or receive poor-quality oocytes that are not able to fertilize and develop a full pregnancy.

The program "surrogate" motherhood is the only method of obtaining a genetically of his child for women with a missing uterus or expressed extragenital pathology, when pregnancy is impossible or contraindicated.

Preimplantation diagnostics are also based on the ECO method. Its goal is to obtain an embryo in the early stages of preimplantation development, examination of it on genetic pathology and PE to the uterine cavity. The reduction operation is performed with more than three embryos. This is a forced procedure, but necessary for the successful course of multiple pregnancy. The rational and scientifically informed application of reduction, as well as the improvement of the technique of its implementation in multiple pregnancy makes it possible to optimize the clinical course of such pregnancy, predict the birth of a healthy offspring and reduce the frequency of perinatal losses.

* Insemination of sperm husband (ISM)

Insemination of the sperm of the husband (ISM) is the transfer a) in the van-bolt and the neck of the uterine of a small amount of fresh sperm or b) directly into the uterine cavity of sperm prepared in the laboratory conditions by the method of pop-up or filtering through the perclace gradient. The ISM is made in cases where the woman is completely healthy and pipes are passable.

Indications for use ISM:

♦ the impossibility of vaginal ejaculation (psychogenic or organic impotence, heavy hypospadia, retrograde ejaculation, vaginal dysfunction);
♦ Male infertility factor - a shortage of quantity (olive-state-permanent), mobility (asthenospermia) or a violation of the structure (teratrommia) sperm;
♦ An unfavorable cervical factor that is not-possible to overcome with traditional treatment;
♦ The use of cryopreserved sperms for induction of pregnancy (cum is obtained before the treatment of cancer or vasectomy).

The effectiveness of the procedure when - 20 %.

Insemination of the sperm of the donor (ISD)

Used frostated cryopreser donor sperm. ISD is carried out with the ineffectiveness of the sperm of the husband or if it fails to overcome the incompatibility barrier. Technique ISM and ISD is the same.

Efficiency ISD - 50% (the maximum number of cycles in which attempts to take - 4) is advisable.

Gift - Transfer of eggs together with spermatozoa in the fallopian tubes. The woman take one or more egg cells, her husband - cum, mix and introduce them to the uterine tube.

Зит. - Transfer of embryo (zygotes) to uterine pipes.
When ziphet, the likelihood of the occurrence of pregnancy is significantly higher than with hyptea. Gift and zipte can be made both during laparoscopy and under ultrasound control.

In the first case, the gameta or zygotes are introduced into the tube from the abdominal cavity, in the second - through the cervix. Gift and zip are combined with diagnostic laparoscopy and spend once. Efficiency up to 30%.

In vitro fertilization (OIV) - The process of mixing oocyte and sperm in laboratory conditions. The ovarian stimulation is controlled by measuring the level of estradiol in the blood plasma and ultrasound measurement of the growth of follicles. Pencil of follicles and aspiration of their contents. The resulting oocytes are incubated with cumulated sperms of the husband, then the resulting embryos are transferred to the uterine cavity between 2 and 6 by day after the follicle puncture, as it occurs in the case of natural fertilization.

Indications for HIV:
♦ irreversible damage to the uterine pipes as a result of the inflammatory process or in surgical intervention;
♦ Male infertility;
♦ immunological infertility;
♦ infertility in endometriosis;
♦ infertility of unclear genesis.

ECO method using donor embryos

It is used in women with non-functioning ovaries (with "early climax" or after their removal). The essence of the method: the patient is transferred to the embryo, resulting from the fertilization of the donor egg with a sperm of her husband. Sometimes for this purpose, donor embryos use donor embryos instead of eggs. Subsequently, the UGT is carried out, imitating the state of a woman in conventional physiological pregnancy.

Surrogacy

This type of Eco is carried out in patients without uterus. The essence of the method: the sperm of her husband in the woman received from a woman, and then transfer the resulting embryo in the uterus of another woman - "surrogate" mother, agreed to enter the child and after childbirth to give it to the "hostess" of egg cells, i.e. Genetic mother.

Freeze spermatozoa and embryos

Benefits of the method:
♦ the ability to use cum at any time and anywhere;
♦ The implementation of donor controls in relation to the in-feast of their sperm with the AIDS virus, which eliminates the danger of infection both women and the fetus;
♦ The possibility of using embryos in cycles, followed by an unsuccessful attempt to eco, if eggs and embryos were obtained more than necessary for transfer (usually more than 3-4).

Purpose of VRP

Obtaining a healthy offspring in fruitless couples.

VRP readings

• absolute tube infertility in the absence of uterine pipes or their obstruction;
• infertility of unclear origin;
• infertility, not amenable to therapy, or infertility, the probability of overcoming which with the help of Eco is higher than when using other methods;
• immunological forms of infertility (the presence of antispermal at Mar test ≥50%);
• various forms of male infertility (oligo, astheno or teratozoospermia) requiring the use of the ICSI method;
• SPKA;
• endometriosis.

Contraindications of VRT.

• congenital malformations or acquired deformations of the uterine cavity, in which embryo implantation is impossible or tooling;
• benign tumors of uterus, requiring operational treatment;
• malignant neoplasms of any localization (including history);
• ovarian tumors;
• acute inflammatory diseases of any localization;
• somatic and mental illnesses that are contraindicated for tooling pregnancy and childbirth.

Preparation for conducting

The volume of the survey of the married couple before conducting the ECO is regulated by the Order of the Ministry of Health of the Russian Federation of February 26, 2003 No. 67 "On the application of the IPT in the therapy of female and male infertility".

For women are required:

• conclusion Therapist on the state of health and the possibility of hacking pregnancy;
• research on the microflora from the urethra and cervical canal and the degree of purity of the vagina;
• clinical blood test, including determining blood coagulation time (valid 1 months);
• general and special gynecological examination;
• definition of blood group and resfactor;
• Ultrasound of small pelvis organs.

According to the testimony, additionally holds:

• bacteriological examination of material from the urethra and cervical canal;
• endometrial biopsy;
• infectious examination (chlamydia, ureaplasm, mycoplasma, HPV, CMV, toxoplasm, rubella virus);
• study of the state of the uterus and uterine pipes (GSG or hysterosalpingoscopy and laparoscopy);
• examination for the presence of antispermal and antiphospollipid (
• determination of the blood plasma concentrations of FSH, LH, estradiol, prolactin, testosterone, cortisol, progesterone, thyroid hormones, TG, STG;
• cytological examination of cervical smears.

If necessary, we assign consultations from other specialists.

For men are required:

• blood test on syphilis, HIV, hepatitis B and C (valid 3 months);
• sperrogram. According to the testimony, they are carried out:
• infectious examination (chlamydia, ureaplasm, mycoplasma, HSV, CMV);
• Fish diagnostics of spermatozoa (method of fluorescent hybridization in situ);
• definition of blood group and respector.

Also appoint advice from Andrologist. For a married couple over 35 years old, prescription is needed.

Methodology VRT.

The ECO procedure consists of the following steps:

• selection, examination and detection of deviations - preliminary preparation of patients;
• supervision stimulation (controlled ovarian stimulation), including monitoring follicleogenesis and endometrial development;
• puncture of follicles of ovarian in order to obtain preventive oocytes;
• insemination of oocytes and cultivation of the in vitro embryos developed by fertilization;
• PE to the uterine cavity;
• support for the PE period;
• diagnosis of pregnancy in early time.

Efficiency of VRP

According to the European Association of Reproductologists in Europe today, more than 290,000 WPT cycles per year are carried out, of which 25.5% end in childbirth; In the United States - more than 110,000 cycles per year with a frequency of pregnancy on average 32.5%.

In the clinics of Russia, the ART is held 10,000 cycles per year, while the frequency of pregnancy is about 26%.

Factors affecting the effectiveness of the ART

The development of the pharmacological industry led to the creation of new drugs to stimulate follicularogenesis, new disposable puncture needles for obtaining oocytes, as well as modern atraumatic catheters for PE to the uterine cavity. This made it possible to extract more oocytes of good quality, reduce the risk of possible complications during TVP and, accordingly, improve the efficiency of the ECO program to 36-39% at the rate of one PE into the uterine cavity.

The ECO and PE program is the most effective scheme of stimulation of supervision by the preparations of recombinant gonadotropins against the background of the desensitization of the reproductive system of GNVG. From our point of view, the application of supervium stimulation schemes using recombinant gonadotropin and GNWG antagonists are less efficient, however, it allows to reduce the frequency of development of the NGU almost 2 times.

Application of the ICSI method from married couples with two and more unsuccessful attempts of Eco and PE in history with normal spermatogenesis and disturbed indicators reproductive feature A woman allows you to achieve pregnancy in 52% of cases.

Egg biopsy and / or an appendage of eggs followed by histological examination in combination with hormonal and genetic screening in patients with azoospermia makes it possible to determine the diagnosis and to determine the further tactics of the treatment of infertility with a matrimonial pair. A group of patients with an unstructive shape of azoospermia is prognostically unfavorable in terms of obtaining sperm and pregnancy in Eco / Ixxi. The frequency of the occurrence of pregnancy in this group of patients is 14.3%.

The cryopreservation in the VIR today is applied for almost any species of biological materials. This method allows for a long time to store cum, test tissue, oocytes and embryos. After thawing, 95% spermatozoa, 80% of embryos are viable. With the abolition of the PE procedure in the stimulated cycle of the high risk of the development of the NGU and at the cryopreservation of all the "good" embryos, the frequency of pregnancy in patients is 37.1% of the calculation to the stimulation cycle. The effectiveness of the blastocyst cultivated after cryopreservation in Went programs in women with an unsuccessful attempt was 29.5%.

Prenatal diagnosis in ECO and PE programs reduced the frequency of spontaneous abortions to 13% of family parwhere one of the parents is a carrier of chromosomal aberration, compared with the frequency of spontaneous abortions in patients with similar problems that did not use the services of prenatal diagnostics. The detection of chromosomal pathology in embryos and transfer only genetically normal embryos increases the percentage of implantation, reduces the risk of spontaneous abortion and warns the birth of a child with genetic pathology in patients in Eco's programs. With the help of prenatal diagnostics, chromosomal diseases linked with the fetal floor (hemophilia A and B, Duceda Miopathy, Martin-Bella Miopathy, etc.), trisomy of 21th chromosome (Down syndrome), 13th chromosome (Patau syndrome), 18th chromosome ( Edwards Syndrome), Monosomy (Sherosevsky-Turner), etc.

Prenatal diagnosis is shown in the case of children with hereditary and congenital pathology in history, presence in the karyotype of balanced chromosomal aberrations, two and more unsuccessful attempts of eco in history, bubble drift in history, an increased percentage of spermatozoa with aneuploidia of different chromosomes (by x, y chromosomes\u003e 0.25%) in the ejaculate of the spouse, at the age of women older than 35 years, to determine the floor of the fetus. The accuracy of determining the floor of the embryo this method is 95-97%. The frequency of the occurrence of pregnancy after applying the prenatal diagnosis in the FSU "NC Agip Rosmedtekhnologii" in the BRD department in 2006 amounted to 32%.

The operation of the reduction of embryos allows to reduce the frequency of complications of multiple pregnancy, since the risk of unbearably and the birth of deeply premature babies when having toed triple reaches 70%. For the first time, the reduction of multiple pregnancy in the I trimester was carried out using transcervical access and removal of the underlying fruit egg. The method was extremely traumatic and accompanied by a large number of complications, so I did not find use in practice. Currently use transabdominal or transvaginal access.

With transvaginal access, intrauterine intervention is carried out by a specially labeled needle through the rear or front vaginal arch. For visual control over the promotion of the needle, special biopsy adapters use, which allow you to visualize the movement of the needle in the uterine cavity.

To reduce embryos through transabdominal access, a sensor used for a transabdominal scan is used, equipped with a biopsy adapter, and a length of 15 cm long, with an echogenic surface in 1 cm at the distal end, equipped with self-locking mandren.

When reducing the reduction with both methods, the electronic marking of the sensor is directed to the chest embryo and the needle to a quick movement into the cavity of the fetal egg, controlling the accuracy of the video image manipulation on the monitor screen of ultrasonic diagnostics. The penetration depth of the needle is controlled visually. After penetrating the cavity of the fetal egg, the needle tip is fed to the chest of a reduced embryo and mechanically destroy the organs of the chest up to stop cardiac activity. In the case of the preservation of heartbeats, the reduction of the embryo is carried out by re-reduction in 2-4 days.

Complications of the VRP

• allergic reactions to drugs for ovulation stimulation;
• inflammatory processes;
• bleeding;
• multiple pregnancy;
• SGI, which occurs, as a rule, after PE, is a non-herogenous state characterized by an increase in the size of the ovaries and the formation of a cyst. This condition is accompanied by an increase in vascular permeability, hypovolemia, hemoconcentration, hypercoagulation, ascite, hydrotorax and hydropericard, an electrolyte imbalance, an increase in the concentration of estradiol and oncomarcker CA125 in a blood plasma (more in the section "Officon hyperstimulation syndrome");
• extopic ectopic pregnancy. The frequency of occurrence of ectopic pregnancy when using HRT ranges from 3% to 5%.