长效GnRHa“flare-up”效应通过AMPK通路抑制子宫腺肌症患者卵泡发育的机制

Adenomyosis is a common disease in obstetrics and gynecology clinic which is difficult to be treated. The clinical pregnancy rate of IVF-ET cycle of infertile women with adenomyosis was significantly lower, while the risk of early miscarriage increased. The pretreatment of long-acting GnRH agonist may improve the clinical outcome, but increases drug dose and reduces the number of eggs obtained. Previous researches mainly focused on the effects of long-acting GnRH agonist on endometrial receptivity, rarely discussed the inhibition mechanism of signaling pathways in the follicular development under the long down-regulation status. Our former results showed that AMPK is located at the upstream of multiple follicle development signaling pathways. And it is reported that FSH can promote ovarian follicle development via AMPK inhibition, too. Therefore, we hypothesized that the flare-up effect of long-acting GnRH agonist can stimulate to secrete a big amount of FSH in a short term, then the growing follicles were over activated and exhausted by AMPK signaling, and the remaining primordial follicles fail to respond to FSH. Thus, this project intends to study the ovarian tissue from adenomyosis mouse model or human infertile adenomyosis patients, then to testify the inhibition mechanism of follicular development in ovarian tissue with long-acting GnRH agonist for Adenomyosis based on a signaling mechanism involving AMPK.

子宫腺肌症是与不孕症高度关联的妇科常见疑难病。子宫腺肌症不孕妇女IVF-ET治疗周期的临床妊娠率明显降低且早期流产风险增加，是辅助生殖技术中的难点和重点。长效GnRha预处理可改善临床结局，但增加促排药物量、减少获卵数。以往研究主要集中在长效GnRHa注射后的长降调对子宫内膜容受性的改善，尚无其抑制卵泡发育的机制探讨。我们已有的研究结果显示AMPK位于多条卵泡发育信号通路的上游，调节哺乳动物卵巢卵泡和血管发育，其他文献亦证实FSH可抑制AMPK磷酸化并促进卵泡发育。由此我们推测长效GnRHa的“点火效应”可促使垂体在短期内大量释放FSH，经AMPK信号通路使生长卵泡被过度激活而耗尽，剩余原始卵泡对FSH不反应致卵巢反应性降低。因此本项目拟通过研究长效GnRHa处理的子宫腺肌症模型小鼠及人卵巢组织，明确其基于AMPK信号通路的卵泡发育抑制机制，为该类患者选择更合适的治疗策略寻找理论支持依据。

子宫腺肌症是与不孕症高度关联的妇科常见疑难病。子宫腺肌症不孕妇女IVF-ET治疗周期的临床妊娠率明显降低且早期流产风险增加，是辅助生殖技术中的难点和重点。长效GnRha预处理可改善临床结局，但增加促排药物量、减少获卵数。.为选择合理的治疗方案并寻找理论依据，本研究回顾性分析2004年5月至2013年4月选用长降调促排方案进行IVF-ET治疗并新鲜胚胎移植的子宫腺肌症不孕妇女的临床数据，及2017年1月至2020年1月期间选用“先促排全胚冻存、后长降调冻胚移植”治疗方案进行IVF-ET治疗的子宫腺肌症不孕患者的临床结局，结果显示子宫腺肌症超长方案新鲜移植的患者促排天数最长、用药支数最多、受精率最低、可用胚胎数最少，而全胚冻存的子宫腺肌症不孕患者经长降调冻胚移植组的临床妊娠率最高，双胎率最低，低出生体重新生儿仅一例，无出生缺陷。证明“先促排全胚冻存、后长降调冻胚移植”的治疗策略最合理，最终的临床结局是最佳的。小鼠卵巢的体外培养实验证实，FSH可经AMPK-mTOR信号通路中HIF-1α、VEGF和AMPK-YAP通路中CTGF对卵巢组织卵泡发育产生影响。成功建立子宫腺肌症小鼠模型后，后续的降调/不降调、促排/不促排实验证实，对子宫腺肌症模型小鼠促排卵前进行长降调，会抑制其卵泡发育，使卵巢排卵数显著减少。分子实验显示，未降调而进行超促排卵的模型小鼠的卵巢组织其HIf1α表达量最低，而降调后进行超促排卵的模型小鼠的卵巢组织HIf1α表达量最高，也证实了GnRHa长降调通过抑制HIf1α等表达影响卵泡发育。.综上所述，本研究通过动物模型，验证长效GnRHa经AMPK信号通路抑制子宫腺肌症不孕患者卵泡发育的调控机制，为此类疑难患者选择“先促排全胚冻存、后长降调冻胚移植”的治疗策略寻找理论支持依据，达到合理治疗、减少患者就医成本、节约社会医疗资源的目的。