周醫師不孕症病例討論
Rubin test:
check fallopian intact with gas
HSG;
Hysterosalpingogram
Outpatient 5
mins
Do it in
proliferative phase
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Ovidrel
(hCG), can retrieve oocytes >10mm
Estrade
Urogestin
Clomid day
2-5 initiation, anti estrogen, oocyte maturation for about 11 days
Gonal-F
Penfill 450Iu/0.75ml
學名Follitropin Alfa
藥價 5625
衛生署許可證適應症(1)婦女經CLOMIPHENE CITRATE治療，仍無法排卵者(含多囊性卵巢症，PCOD)
。(2)對於實施人工生殖協助技術(ART)，如體外受精(IVF)，配子輸卵管植入(GIFT)，合子輸卵管植入(ZIFT)的病人，可刺激其多濾泡發育。(3)與黃體刺激素(LH)併用，使用於嚴重缺乏黃體刺激激素與濾泡刺激激素患者的濾泡刺激成長。男性患者治療男性對於患有先天或後天性腺刺激素不足之性腺功能低下症，併用人類絨毛膜性腺刺激素(hCG)，刺激精子生成。台大藥典
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Sperm
survival: 2-5 days
------------
2p
2pronucleus 雙側
Two cell
Four cell
Morula
Blastocyst
對稱性
Fragmentattion
------------
Day 3
找細胞多的
7c2
8c2
後面stage
A immature
B
C mature
Day 3-5
implantation, no more than 6 days
HCG doubling
in 2 days
多的養到第五天, 好的存起來
預產期 266 days
GA從LMP開始算
比受精多兩周
九個月又七天
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Salpingectomy,
tubal ligation, ballooning
HOXA10,
Hydrosalpix
雙側尋求ART
單側可以自然懷孕
------------
Day 2, check
FSH, LH, Estrogen, progesterone, TSH
排除不正常出血，假性月經
TSH<2.5
排除hyperthyroidism
------------
Dysmenorrhea
排除endometriosis
------------
Embryo
transfer
age<35
2顆
Age
35-38 2-3顆
Age>38
4顆
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MESA;
Microendoscopic sperm aspiration
------------
Flagyl. Metronidazole
Paramol
------------
Cogwheel sign
Fallopian
tube inflammation
------------
CAVD;
Congenital absence of vas deferens
Risk factor
Cystic
fibrosis, chromosome 7
Unilateral
renal agenesis
------------
TESA; testicular sperm aspiration
PESA; percutaneous epididymal sperm aspiration
------------
Recheck SA
semen analysis
------------
冷凍費沒繳錢其實沒有銷毀
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陳教授OHSS
OHSS
唯一ART要住院
Taiwan 79 IVF
center
PCOS
月經週期>35天
>10 2-5mm
follicle
------------
Multiparity
Med not
related to cancer, but gene related to cancer
ICSI
Greek 100%
Other
>30%, most 70%
- Y Microdeletion: SRY, ambiguous genitalis
- Cytogenetics analysis
Mortality
------------
Fetal anomaly
1-3%
Imprinting
disorder
------------
OHSS; Ovarian Hyperstimulation Syndrome 發生率1.2%
Pathophysiology: VEGF↑
Ascites, abdominal pressure↑,
poor bowel movement, anuria
Hydrothorax
- Early onset is preventive，check hCG within 10 days
- Late onset is not,取卵數量不多，多胞胎相關，減少胎數可以降低發生率
Risk factor
- PCOS, narrow threshold of gonadotropin
- High estrogen>4000
- Young, age<30
- Low body weight
- History of OHSS
- Long protocol
- Pregnancy
------------
PRC
Clomiphene
多子丸
2005 只有35 IVF center
------------
Golan
classification Grade 1-5
Mild 33%
1 abdominal
distension
2 nausea,
vomiting, diarrhea, ovarian enlargement<12cm
Moderate 3,
severe 4-5, 3-8%
Grade 3 mild+
ascites
4
moderate+hydrothorax
5
hemoconcentration , hypercoagulation, electrolyte disorder, renal,
ovarian>12
May
deteriorate very soon!
------------
Hemoconcentration
Hematocrit
Man 45%
Woman 40%
20%↑ hemoconcentration: Woman>48%
Hyponatremia,
hypoalbuminemia
Hyperkalemia
------------
OHSS Hospitalization
- Oliguria <0.5 per kg per min
- Hematocrit >48%
- Tense ascites
- Sodium<135 mEq/l
- Leukocytosis
- ARDS
- Thromboembolic phenomenon
- Frank renal failure
------------
Tx
1000 ml NS
crystalloids , NO Ringer with potassium
25% 50 cc Albumin colloid drip 30 mins *4
Dopamine drip
Paracentesis
Furosemide
注意時序，先補水再打利尿
Therapeutic
abortion
------------
比較Liver cirrhosis
Spontaneous
bacterial peritonitis
不能抽完
抽三瓶補一瓶albumin
------------
OHSS可以Total paracentesis，撐兩三天
可能會Labia Majora大陰唇水腫
胸水 負壓 只能放一瓶
------------
OHSS體質
做SET
Single ET
Single
blastocyst transfer, vitrify surplus
------------
GnRH
antagonist course
GnRH agonist
triggering
------------
Complications
Torsion
Control 0.99%
OHSS 2.9%
------------
Ectopic
Heterotopic
Pregnancy
------------
童教授
Premenstrual
syndrome:月經來就好了
經痛:經血最多時候痛
------------
Type1~5
Endometrial
------------
跟膀胱的homogeneous尿比較
------------
Functional cyst
4-8 weeks
disappear
------------
Hemorrhagic
cyst
2-3 days
follow up
------------
Endometrial
tumor
Sand like
Blood is
outside the tumor
------------
Dermoid cyst
Ovarian
crescents
15% torsion
5cm torsion
many
10% bilateral
------------
Malignant
- Septum
- Solid
- Flow
------------
Serous
cystadenomas
Thin walls
------------
Mucinous
cystadenomas
很難區分endometrial
cyst
------------
CT 是用來staging
不是用來rule out
------------
CA125
吸引病人下次來才開的，做為base line沒有太大意義
------------
Surgical
indication
- Malignancy
- Symptoms: torsion, rupture
- Infertility, adhesion
------------
TX
- NSAID
- GnRH agonist
- Oral pills E+P,. Only P may bleeding
------------
Oral pills
inhibit new onset functional cysts
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連教授ART
台大一年五百個ART活產
全台五千個
------------
最近三個月到六個月都是28～30天叫做規律月經
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Cetrotide
GnRH抑制劑
Day6開始打
Pregnyl(hCG破卵針) →
progesterone
Identical
twins 5%
Heterozygous
twins 95%
------------
Ovulation
粘液白色增加
Progesterone 造成體溫上昇
Fern pattern
子宮頸透明粘液增加快要排卵
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IVF
complication
Spontaneous
abortion
General
population 1%
Age>40 15%
IVF 15-20%
Multiple
pregnancy 30%
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Lithopedion
石化
北榮 case 1950
------------
Ectopic
pregnancy 1%->5%
Most in
ampulla
Heterotopic
pregnancy 1/30000->1/100
Risk Factor
- Age>35
- History
- PID
- Surgery
- Induced Abortion
- Tubal ligation, 再度接通後仍然提高風險
- IUD
- Progesterone oral pills
- IVF
Symptoms
Intra
bleeding, peritoneal sign
Post
menstrual bleeding
Fallopian
tube length 12cm
Rupture when
>3cm
Week 6 1%
Week 7 Most
hCG
Day 14 50
miu/ml
Doubling time
2 days
GA Week 6
6400, IUGS; intraluterine gestation sac
看不到胚囊, 三天後再看一次
Treatment
Surgery
MTX
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