CHUYEN B i ; HiNH THAI HQC VA CflNG N0H6 TH6NG TIN
N G H I £ N CI)U HlNH THAI PHOI SAU SINH THIET DE C H £ N DOAN Dl TRUYEN TRUAC CHUYEN P H D I
T 6 M TAT
DM vSn tfe: c6 nhdu phudng phip dlSu tri cho cac b$nh nhSn hiem mu^n trong dd phUflng phap thu tinh trong ong nghidm dong m?t vai trt) quan trpng trong Unh vi/c ho trO sinh sSn vk ngay cang dUdc phit trien r6ng khSp trSn the gidi. Tuy nhien ty le thJnh cong trong ho trd sinh san mdi chi dat khoang 30-40%. Hien nay, hau nhu viec lua chpn phoi deu dUa tren nhifng tieu chuan ve hinh thai ciia phoi. Tuy nhiSn, viec danh gia ve hinh thai chua phan anh day du chat luttng thUc cua phoi, neu chi dUa vao cac thong so ve hinh thai thi ket qua dieu tri thu tinh ong nghiem bi han che. De nang cao chat iUdng trong dieu dong thdi sang Ipc mpt so benh di truyen, viec chan doan di truyen trUcfc chuyen phoi (Preimpiantation Genetic Diagnosis /PGD) la mpt trong nhuTig yeu cau quan trpng, cap thiet va thuc tien. Tren cti sd dp chiing tpi tien hanh nghien cUu vdi ten de tai la "Nghien ciiU hinh thai phei sau sinh thiet de chan doan di truyen trudc chuyen phoi" nham danh gia sU thay doi hinh thai phoi sau sinh thiet ng^y 3 va tim hieu mpt sp yeu te anh hUdng tdi kha nang phoi song sot va tao phoi tui sau sinh thiet. Odl tu'dng va phu'dng phip nghien cihi: 102 phoi c6n dU khi thu tinh trong ong nghiem, sinh thiet ngay 3.Chat lupng phoi dUdc danh gia theo du^ theo tac gia Andres Salumets, 2001:[10]vao 3 tieu chuan chinh la; sd lupng cua cac phoi bao trong mpt phoi, su dong deu giiJa cac phoi bao va ti ie(%) giifa manh vS bap tUdng va the tich cua phoi. Ket qua: Sau sinh thiet 24 gid ty le phoi song sot, tiep tuc phat trien chung cua ca 3
Nguyen Ng^c Di?p*, Nguyin Thanh T4ng*, Nguyin Dinh Tao*, Quan Hoiing Lam*
nhdm i i 93 phoi trong tong so 102 ph6i, dat 91,17% vh sau 48 gid ty IS hinh thanh ph6l till la 83 ph6i, dat 81,37% trong do so ph6i tui tiep tuc sSng sdt va phit trien (lo?i AA vi AB) 1^ 67 phoi chlJm 55,68%. Ty 1$ manh v3 bao tuBng, d6 diy mang trong suot, dudng kinh phdi glQ^
cac nhdm thay dSi khdng co y nghla thSng ke.
Ket lu$n: Sinh thiet bSng tia laser khong lam thay doi hinh thai phoi, kha nang song sdt va tao thanh phoi bjl. Tuoi m?, thdi gian vo sinh, nong dp FSH cang cao thi ty le phoi song sdt va tao thanh phoi bji cang glim. Phudng phap thu Unh IVF hoSc ICSI khong inh hudng tdi thi ty le phoi song sot, tiep tuc phat trien v i tao thinh phoi tui sau sinh thiet.
SUMMARY
STUDY ON EMBRYO MORPHOLOGICAL CHANGES AFTER EIMBRYO BIOPSY FOR
GENETIC DIAGNOSIS PRIOR EMBRYO TRANSFER
Bacliground: There are many methods for treating Infertility patients, IVF plays an important rale in the field of assisted reproduction and development are increasingly vtfidespread in the vtforid. However, the success rate in assisted reproduction only reached 30- 40%. Currently, most are choosing embryos based on morphological criteria of the embiyo.
However, the morphological assessment not fufly reflect the true quality of the embryos, if only based pn mprphological parameters, the results nf in vitro fertilizatipn treatment is limited. To improve the quality and refinement of some Trung lam Cong Nghe Phdi - Hoc vien Qudny
Y HQC VigT NAM T H A N G 10 • s 6 OAC BlgT/2013
genetic diseases, Preimpiantation Genetic Diagnosis (PGD) is one of the critical requirements, urgent and practical. On that basis, we conducted a study with project is
"Study on embryo morphological changes after embryo biopsy for genetic diagnosis prior embryo transfer" to evaluate embryo morphological changes and assess some factors affecting the ability of embryo survival and create blastocyst after biopsy. Subjects a n d Methods: 102 surplus embryos, biopsy on day 3. Quality be
^ l u a t e d based on the author Andres Salumets, 2001: [10] on three main criteria: number of blastomeres in an embryo, cytoplasm fragments and the embryo volume. Results: After 24 hours biopsy sun/ival rate of embryos, further development of the 3 groups of 93 embryos in total 102 embryos, reached 91.17 % and after 48 hours blastocyst formation is 83, reaching 81.37
%. Number of embryos that survived continued development (AA and AB) account for 65.68 % of 67 embryos. Debris cytoplasm fragment ratio, ZP thidmess, embryo diameter between the groups did not change significantly. Conclusion: laser biopsy does not alter embryo morphology, viability and bag forming blastocyst. The more higher l^aternal age, duration of infertillity, FSH concentrations the less survival rats of embryos and less fomiing blastocyst. IVF or ICSI did not affed the survival rate of embryos, further development of blastocyst after embryo biopsy.
IOATVXNOE
Vo sinh \k vdn de dang dugc quan tam ngay cang nhiSu tren thk gioi noi chung va Vi§t Nam n6i rieng, theo t6 chuc Y te ThS gioi, ty 1? vo sinh chiSm khoang 10% cac cSp vo ch6ng. Tai Viet Nam theo Nguyin Viet Ti§a va cpng sir (2013) [3], ty la v6 sinh trong cgng d6ng chi^m 7,5%. Ngay nay co
"Weu phuong phap dieu tri cho cac benh
nhan hi^m mugn trong do phucmg phap thu tinh trong 6ng nghi?m dong mpt vai tr6 quan trpng trong ITnh w c h5 trpr sinh sdn vk ngky c4ng dug-c phdt t r i k r6ng khfip trSn the gidi.
Tuy nhiSn t^ 1§ thanh cong trong h6 trpf sinh sdn m6i chi dgt khodng 30-40%, trong ITnh vyc ndy c6n nhieu vkn dk cdn dugc tiSp tyc nghidn cuu. Hi§n nay, hdu nhu vi^c lua chpn phoi deu dya tr6n nh&ng tieu chuin ve hinh thdi cua phoi. Tuy nhien, vi$c ddnh gid ve hinh thdi chua phdn dnh ddy du chat lugng thyc cua phoi, n^u chi dya vdo cdc thong so ve hinh thai thi ket qua dilu trj thu tinh 6ng nghipm bi han che. De ndng cao chdt lugng trong dieu trj cGng nhu dam bdo cho ra ddi mpt the h? khoe manh vk thk lyc, sdng su6t ve tinh than, dong th6i sdng lpc mpt s6 benh di truyen, vi$c chan dodn di truydn truoc chuyen phoi (Preimpiantation Genetic Diagnosis /PGD) Id mpt trong nhihig yeu cdu quan trpng, cap thiet va thyc tien. Nguyen tic ky thuat cua PGD dua tren viSc thyc hi$n thy tinh trong ong nghiem (TTTON) de tao phoi, sau do sinh thiet phoi va phdn t'ch nhilm sdc thi ho^c DNA bdng ky thudt FISH, CGH ho?c PCR [1]. Nhin chung ky thu^t PGD g6m 2 buoc chinh: Sinh thiet phoi va chdn dodn di truyin. Kit qud nghien cuu cua nhieu tdc gid [1] cho thdy khong co su khde biet v l ty 1?
thdnh cong cung nhu kha ndng phdt triln tinh thdn va tam sinh ly khi so sdnh tre sau PGD voi tre sau khi ICSI vd nhom tre sinh ra tir thy thai ty nhifin.
K$? thu^t sinh thiit phoi la ky thudt xdm lan, d6i hoi nhilu thao tdc ti mi, chinh xdc.
Vi vdy trong qud trinh thyc hien co the dnh hudng den chdt lugng cua ph6i. Song song voi c6ng vipc hoan thien quy trinh sinh thiet phoi, chung toi tien hanh ddnh gia hinh thai phoi, vd khao sdt mpt so yeu to co the anh huong tai sy phdt triln cua phoi ph6i sau
CHUYSN D I I HINH THAI HPC VA ceNS ncHe TH6N6 TIM
sinh thiSt. Tren co s6 d6 chiing toi tiSn hanh nghien cilu v6i ten da t« \i "Nghien cihi hinh thai phoi sau sinh thiet dc chan doin di truyen trir*c chuyen ph8i" nhSm c4c myc tieu cau:
/. Bdnh gid s{e thay ddi hinh Ihdi phoi sau sinh thiit ngay 3.
2. rim hiiu mQl s6 yiu Id dnh huong t6i kha nang phdi sdng sdt vd tgo phoi lui sau sinh thiet.
II. 061TU0NG VA PHUONG PHAP NGHIEN COfU 2.1, Boi tirffng
- G6m 102 phoi nguoi con du Ichi th\i tinh trong 6ng nghi$m.
Cac d6i tugng nghien cuu dupe chia thanh 3 nhom:
- Nhom 1:33 phoi ciia benh nhSn < 30 tuoi - Nhom II; 39 phoi cua benh nhan > 30 tudi - Nhom II: 30 phoi cua b?nh nhan > 35 tuoi
* Tieu chu^ I\ra chon phoi de sinh thiet:
- Phoi duac nuoi cay dSn ngay thu 3 trong moi truong nuoi cay cua TTTON. Cac phoi CO ti bao d6ng deu, ty Ie manh vo bao tuong (fragment) ducri 20% {Phoi dp ni, dp IV)
* Tieu chuan lo^i trir:
- Cac ph6i giai doan som dp I, dp II: cac ti bao khong ddng deu, ty Ie manh va bao tuong tir 20% tro Ien.
2.2. Phuong phdp
2.2.1. Ddnh gid thu tinh vd qud trinh nuoi cdy phdi
Khoang 16-18 gio sau khi tiem tinh triing vao tning, tning duoc dupe danh gia xem CO th\i tinh hay khong. Neu da thy tinh tao thanh phoi se xuat hien 2 tien nhan va 2' the cue. Sau do phoi dupe danh gia ghi 6iim 6 timg thoi di8m 40 gio, 68 giof va 112 gid sau khi thu tinh va danh gia hinh thai phoi sau sinh thiet 24h, 48h. So lupng va hinh th^
phoi bao va the loai manh v5, dp day mang
trong sudt, duong kinh phoi dupe thu thap dS ddnh gia chat lupng cua phoi [5].
2.2,2. C&c tieu chuan ddnh gii chat lugng phoi
Danh gia ch^t lupng phoi nuoi ciy ngiy thil 3 theo T. Ebner., 2003 vi dang dupe ap dvng tai Trung tam cong ngh? phoi.
Theo each cho diim nay vi$c danh gia chit lupng phoi nuoi ciy ngay thii 3 d\ra vio 3 tieu chuin chinh Ii: s6 lupng cua cic phoi bao trong mpt phoi, su dong diu giifa cac phoi bio vi ti le (%) giira minh vS bio tuong vi thi tich ciia phfii. [7]
- S6 phoi bio (dupe ky hieu li mpt con s6)
- So sinh sv dong deu giira cdc phoi bao (dupe ky hieu la mpt chO cii viSt hoa):
A- Cic phoi bao ddng dJu B- Cic phdi bao khdng ddng diu - Ti 1$ manh v8 bio tuong (dupe ky hieu li mdt con sd, chinh la ti 1? % manh va bao tuong so voi the tich cua phdi)
1: Khdng co manh vd bao tuong.
2: Ti I? manh va bao tuong <20%.
3: Ti Ie minh v8 bio tuong tit 20% dSn 50%.
4: Ti it minh va bao tuong >50%.
- can cir phan do phdi theo 4 d^ dupe ip dyng dd dinh gii chat lupng phdi tai Tiung tam cdng nghe phdi, Hpc vien quan y theo tic gii Andres Salumets, 2001 :[10]
- Dp IV: Cac phdi cd sd phdi bao ddng deu, va khdng co hoac cd rat it (khdng dang ke) cic manh va bao tuong.
- Dp III: Cic phdi co sd phdi bao khdng ddng deu vaAiogc cd ti Ie minh vd bio tuong
<20 % the tich cua phdi.
- Dp II: Cic phdi cd ti Ie minh v5 bao tuong tir 20 % ddn <50% thd tich ciia phdi.
- Dp I: Cac phdi cd ti Ie minh vd bao tuong > 50% the tich cua phdi.
Y HQC VigT NAM T H A N G 10 - S 6 D A C B I $ T / 2 0 1 3
III. KIT QUA NGHIEN CQU
3.1. Mot so d^c diem cua doi tir^'ng nghien cthi
Nghien cuu thyc hlpn tren 102 b?nh nhSn, m6i benh nhan 1 phoi dugc dua vdo d^i tugng nghien ciiu, doi tugng nghien ciiu dugc chia thdnh 3 nhom nhu sau:
3.1.1. So lugng b^nh nhan vo sinh cua cdc nhdm nghien cuu
Trong ting so 102 bfnh nhan, chiing toi chia lam 3 nhom, nh6m I gom 33 BN c6 dg tuli duoi 30 chiim 32,35%, nhom II gom 39 BN CO dp tu6i tir 30-35 chiim 38,24% va nh6m III gim 30 BN c6 dp tuoi tr^n 35 chiem 29,41%, voi s6 lugng tren ddm bdo cho cac chi tieu nghien cuu.
5.1.2. Tuoi vd thori gian vo sinh cua cdc nhdtn benh nhdn nghien ciru
Tuoi trung binh cua tat ca cat. benh nhan nghien cuu Id 29,3 ± 3,6 (tir 20 d i n 42 tu6i), Tuoi tning binh cua bfinh nhdn thupc nhom I la 21,5 ± 3,2 (tu6i thdp nhdt Id 20, tu6i cao nhat la 29). Benh nhdn thugc nhom II cd tuoi tnmg binh la 32,5 ± 2,2 (tu6i thdp nhdt Id 30, tuoi cao nhat la 35). Benh nhdn thupc nhom ni CO tu6i trung binh Id 38,4 ± 3,0 (tu6i thdp nhdt la 36, tuli cao nhdt Id 42).
Thcfi gian vo sinh trung binh cua cac benh nhan thupc nhom I Id 3,3 ± 2,3 nam, thfid gian ngan nhat Id 1 ndm vd nhieu nhat la 5 nam. Cac benh nhdn thugc nhom II co thoi gian vo sinh trung binh la 4,1 ± 2,6 nam, thoi gian ngan nhdt Id 1 nam va dai nhdt la 7 ndm.
Ck benh nhan thupc nhom IH co thai gian v5 sinh trung binh Id 4,8 ± 3,4 ndm thai gian ngan nhdt la 1 nam vd dai nhdt la 12 ndm.
Qua so lieu ta thdy thai gian vo sinh cua nh6m I la ngdn nhdt va thai gian vo sinh ciia nhom Illid ddi nhdt.
3.2. Sir thay doi hinh thai cua phoi sau sinh thiet.
3.2.]. Hinh thdi phdi d Ihdi diSm 3 ngdy ludi trudc sinh thiit
Truoc khi tiln hdnh sinh thiit chung toi tien hdnh do cdc chi tieu de lam ca so so sdnh, ddnh gid su thay dii ddc diim hinh thai ciia cdc phoi truac vd sau khi sinh thiit. Cdc chi tieu ddnh gia ldn lugt la: S6 lugng phoi bdo, ti le manh v5 bdo tuong, chilu ddy mang trong suot va ducmg kinh phoi. S6 lugng phoi bdo trung binh ciia nhom tuli I, II, III ldn lugt la 7,8 ± 1,21; 7,9 ± 3,13; 8,2 ± 2,25, do ddy mang trong suot lan nhat la 24,4nm thugc nhom III, mong nhdt la 7,2 |im thupc nhom II. Ti 1? mdnh va bdo tuong trung binh tucmg iing timg nhom la 6,21 ± 1,23; 5,63 ± 1,31; 6,82 ± 1,27. Chilu day mang trong suot dugc do ngdu nhien cr 3 vi tri khac nhau, do day mang trong suot trung binh cua 3 nhom I, II, III ldn lugt la 15,70 ± 3,14; 16,20 ± 2,22; 16,60 ± 2,42. Duong kinh phoi trung binh tuong iing 3 nhom la 150,20 ± 7 , 8 5 ; 150,20 ± 7 , 8 5 ; 149,50 ±8,15.
Ti Ie mdnh vd bao tuang cao nhat la 15%
phdn bo nhieu nhdt 6 nhom tuoi tren 35 vd it nhdt 6 nhom tuli duoi 30. Tuy vdy, sy khac bi?t v l s6 lugng phoi bdo, ti le manh va bao tucmg, dp day mdng trong suot, duang kinh phoi giiia 3 nhom tuoi khong co y nghTa thong ke.
Phoi sau khi sinh thiit tilp tuc dugc nuoi trong tu nuoi cdy Cook, sau sinh thiit ldn lugt 24h, 36h vd 48h chung toi lai tiln hanh do cdc chi tieu: duang kinh phoi, dp day mang trong suit, ti le phoi ket dinh vd ti 1|
hinh thanh blastocyst 6 moi nhom tuli de danh gia sy phdt trien cua phoi sau sinh thiet.
CHUYEN Pg; HiWH THAI HOC VA C6NG NSH6 T H 6 N B TIM
3.2.2. Ty If phdi song sol, liip lvc phdi triin vd ty If phdi IQO Blastocyst sau sinh thiit.
Sau sinh thi& 24 gid ty I? phdi song sdt, ti^p tyc phit trien chung cua ci 3 nhdm li 93 phdi trong tong so 102 phdi dat 91,17% vi ciia timg nhdm I, II vi III li 93,93%;
92,31%; 86,66% vi den ngiy thir 5 ty I? hinh thinh blastocyst chung ciia ci 3 nhdm 14 83 phdi trong tdng s6l02 d^it 81,37 vi cua timg nhdm li 84,84%; 82,05%; 76,66%. Sv khic biet gitta cic nhdm I va nhdm II khdng cd y nghia thdng ke vdi P >0,05, tuy nhien sy khic bi?t gitta cic nhdm I so vdi III vi II so vdi III cd y nghTa thong ke vdi P <0,05. K&
qua phan loai theo Gardner (2001) cho thiy sd phdi 4AA chiem ty I? 9,63%, phdi 4AB chiSm 8,43%, phdi 4BB chiSm 3,61%, phdi 4BC chiem 3,61%, phdi 3AA chiem ty Ie 9,65%, phdi 3AB chiSm ty le 8,43%, phdi 3BB chidm ty le 1,20%, 3BC chidm ty Ie 2,41%, phdi 2AA chidm 9,63%, phdi 2AB chidm 10,84%, phdi 2BB chidm 4,82%>, phdi 2BC chiSm 3,61%, phdi 1 AA chiSm 14,45%, phdi lAB chijm 9,63%. Nhu vay sau sinh thiet 48 gid sd phdi tui tidp tuc sdng sdt va phit triSn (loai AA va AB) li 67 phdi trong tdng 102 sd phdi nghien cim chidm 65,68%.
3.3. Mot s6 yen t6 anh hirdng tdi kha nang song sot ciia phoi va t^o Blastocyst.
3.3.1. Tuoi cua benh nhan dnh huang tai kha ndng sdng sdt ciia phoi vd Igo Blastocyst.
Trong tdng sd 102 benh nhan, chung tdi chia lam 3 nhdm, nhdm 1 gdm 33 BN cd dp tudi dudi 30 chidm 32,35%, nhom II gdm 39 BN cd dp tudi tu 30 - 35 chidm 38,24% vi nhdm 111 gdm 30 BN cd dp tuoi tren 35 chiSm 29,41%. Sau sinh thidt 24 gid ty Ie phdi sdng sdt, tidp tuc phit tridn timg nhdm I, II vi III la 93,93%; 92,31%; 86,66% vi ddn ngiy thir 5 ty 1$ hinh thanh blastocyst li 84,84%; 82,05%; 76,66%. Sv khic biet gitta
cic nhdm I vi nhdm II khdng cd ^ nglila thdng ke vdi P >0,05, tuy nhien sv khic bi?t gitta cic nhdm I so vdi III va II so vdi III c6
^ nghla thong ke vai P <0,05.
3.3.2. Thdi gian vd sinh cua benh nhdn dnh huang tdi khd ndng sdng sdt cua phoi va tgo Blastocyst.
Trong tong sd 102 phdi dupe nghife ciiu cd 58 b?nh nhan vd sinh tir 1-5 nim, 29 bjnh nhan vd sinh tir 5-10 nim vi 15 benh nhan vd sinh tren 10 nim. Trong dd ty I? phdi sdng sdt, tiep tyc phit trien tuong tirng li 91,13;
93,10; 86,66 va ty Ie phdi tao Blastocyst tuong ling Ii 84,48; 82,76; 66,66. Sy khde biet gitta cic nhdm I va nhdm II khdng cd J nghia thdng ke voi P >0,05, tuy nhien sir khic biet gitta cac nhdm I so vdi III vi II so vdi in cd y nghla thdng ke vdi P <0,05.
3.3.3 Ndi tiit FSH (dan vi do lU/l) ngay 2 chu ky kinh cua bfnh nhdn dnh huang lai khd nang sdng sdt cua phoi vd tgo Blastocyst
Trong tdng sd 102 phdi dupe nghien ciiu cd 23 benh nhan cd chi sd npi tiet FSH ngay 2 chu ky kinh <5 IU/1, 72 bfnh nhan FSH tir 5-10 lU/I vi 7 benh nhan FSH tren 10 IU/1.
Trong dd ty I? phdi sdng sdt, tiep tyc phat tridn tucmg tiing la 91,30; 91,67; 85,71 vitj Id phdi tao Blastocyst tuong irng la 84,53;
83,33; 71,42. Sy khic biet giiia cac nhdm I va nhdm II khdng cd y nghia thdng ke vdi P
>0,05, tuy nhien su khac biet giua cic nhom 1 so vdi III vi II so vdi III cd y nghla tiidng ke vdi P <0,05.
3.3.4 Phuang phdp sir dung thudc hormon kich thich dnh huang tai khd nang song sdt cua phdi vd tgo Blastocyst.
Trong tdng sd 102 phdi dupe nghien ciiu cd 53 benh nhan su dung phae dd ngin, 21 benh nhan sir dung phac d6 dii vi 28 benh nhan sir dung phic dd antagonist. Trong do ty Id phdi sdng sdt, tidp tuc phat tridn tuong
Y H P C VI$T NAM T H A N G 10 - S O P A C BIJTO013
timg 14 92,45; 95,23; 85,71 va ty 1$ phdi tjo Blastocyst tuong ttng Ii 84,90; 80,95; 75,00. Su Ichic bi$t gitta cac nhdm I vi nhdm II khdng cd J ngbiathdng ke vdi P >0,05, tuy nhien su khic bi?t giiia cic nhdm I so vdi III v4 11 so vdi III CO <i nghia thdng ke vdi P <0,05.
5.5.5. Phuang phdp thti linh (IVF hogc ICSI) dnh hudng ldi khd nang song sdt cua phoi vd tgo Blastocyst.
Trong tdng s6 102 phdi dupe nghien ciiu CO 26 b?nh nhan 4p dyng phuang phip IVF, 76 bSnh nhan ICSI. Trong dd ty 1? phdi sdng sot, tiSp tyc phit tridn tuong timg 14 88,46;
92,11 v4 ty le phdi tao Blastocyst tucmg ling la 80,76; 81,57. Su khac bidt gitta cic nhdm kh6ng cd y nghla thdng ke.
IV. BAN LUAN
4.1. Sv can thiet cua chan doan di truyen tnrdc chuyen phoi
Chin doan di truydn trudc chuydn phdi (PGD = Preimpiantation Genetic Diagnosis) da duoc ap dung tren nhidu nudc tien tien tren the gicri tir nhttng tiiap ky tnrdc. Nguyen tie ky fhuat ciia PGD dua tren viec thuc hien thy tinh trong dng nghidm (TTTON) de tao phdi, sau do sinh thidt phdi va phan tich nhiem sac the hoac DNA bang ky thu^t FISH, CGH hojc ]PCR (polymerase chain reaction). Nhin chung iky Ihuat PGD gom 2 budc chinh; Sinh thidt iPhoi va chin doan di truydn. Kdt qui nghien
|Cuu ciia nhidu tie gii [1] cho thiy khdng cd sir khac biet vi ty Id thinh cdng cOng nhu kha nang phat tridn tinh thin vi tam sinh ly khi so sinh tre sau PGD vdi tre sau khi ICSI va nhom he sinh ra ttt thy thai tu nhien.
Trong sinh thiit phdi dupe tien hinh qua ba buoc: chuin bi, md cua sd ming trong su6t vi Iiy ti bio. Cd 3 phucmg phap chinh dugc diing de md cira sd ming trong sudt;
phuong phip co hpc, hda hpc hay diing tia
laser. Hien nay, diing tia laser de md ciia sd ming zona dupe xem 14 phucmg ph4p don gi4n, an to4n v4 de su dyng nhat. Sy phat trien cila phdi sau sinh thiet phu thupc vio rat nhieu yeu td, sau diy 14 mdt sd yeu td lien quan cd the inh hudng tdi hinh thii phdi sau sinh thiet.
Nim 1995, sir dung phuong phip lai huynh quang tai cho, Munne nhin thay ring ty le phdi bj Idnh bpi vi sd lupng minh vd ting din theo tudi cua ngudi m?: 16% tren phy ntt 20 din 34 tydi; 37% tren phu ntt tu 35 ddn 39 tudi va cao nhit 53% d phy ntt tren 40 tuoi. Tac gii niy nam 2002 nghien ciiu dua trdn 1 TB (94 phdi) va tren 2 TB (304 phdi) thiy ring ty le LBT, minh vd tang theo tudi me, tu 12,2% d lua tudi dudi 35, ddn 31 % d lua tudi tren 40 [4].
Nghien cttu so sinh gitta phuang phip thy tinh trong dng nghidm thdng thudng (IVF) vi phuong phap tiem tinh trimg vao bio tuong noan (ICSI) thiy ring hinh thii phdi tao ra ttt 2 phuong phip tren la nhu nhau. Tuy nhien Walker. M. C, Murphy KE, Pan S (2004) cho thiy ty le NST bit tiiudng cao hom cd y nghia thdng ke d nhdm bdnh nhan diing phuang phap phuang phap tiem tinh trung vio bio tuong noan, khi nhttng benh nhan niy 14 ngudi mang rdi loan vd nhidm sac the, cd tinh trimg it, ydu v4 di dang. Trong nhttng trudng hpp niy, chin doin trudc khi lim td nen dupe tiin h4nh khi xet nghiem miu vi tinh dich do thiy ring nhttng benh nhan niy cd xu hudng truydn cac benh vd rdi loan nhiem sac the.
4J. Hinh thai phdi tnrdc va sau sinh thiet Ddi vdi phdi sinh thidt ng4y 3; Trong nghien ciiu, cic phdi trudc va sau sinh thiet ddu dupe chia thinh 4 dp dua vio hinh thai ciu triic cua phdi theo tidu chuin dinh gii phdi cua Salumets A. (2001) [10]. Mac dii
CHUVeM pg: HINH THAI HpC VA CdNG NGHJ THdNG TIN
bing nhttng nhin xet chu quan nhung lupng gii dupe so lupng te bio ciia phdi, ciu true vi ty I? sdng sdt ciia phdi, die bi$t Ii quan sit nhttng minh vd bio tuong, chiing tdi cd the dinh gii dupe d$ phdi trudc vi sau sinh thiit, nhung sy lupng gii cy thi li cin thidt dd phan dp phdi. Cho den nay, dinh gii chat lupng phdi chii dya vio cac chi tieu sau: s6 lupng ti bio, ty Id cic minh vd bio tuang vi sy ddng deu gitta cic phdi bio. Nhidu nghien ciiu tren thd gidi chi ra ring nhttng phdi cd chit lupng tdt, cd so phdi b4o ddng ddu, cd it minh vd bio tucmg thi it hoic khdng bi thay ddi hinh thii sau khi sinh thiit, nhiing phdi cd ty le cic manh vd bio tuong cing cao thi ty le sdng sau sinh thidt cing giim [8]. Ket qui nghien ciiu cho thiy nhttng phdi dp 4 sau sinh thidt cdn nguyen ven 100%, phdi dp 3 sau sinh thiit chi cdn nguyen ven li 72,2%. Kdt qui niy phii hop vdi nghien cim cua Herhberger PE. vi cs., (2012) cho thiy ty Id phdi phat tridn khdng tang khi ty le cic minh vo bio tucmg tren 20% [7], [8].
4.3. Mpt s6 yiu td dnh hud'ng tori kha ning phoi sdng sol vd tao blastocyst.
Cic tie gia cho thiy ring tuoi me cing cao thi ty Id thanh cdng trong IVF cing thip.
Mac dil khi chit lupng phdi di d£it dupe dp III vi dp IV, nhung khi nghien cilu trdn khi ning phdi tidp tyc phit tridn, tfio blastocyst ciia cac phdi sau sinh thidt thi thiy su khic biet cua gitta cic nhdm van cd su khic bidt cd y nghia thong kd. Ddi vdi thdi gian vd sinh, phdi cd tidp tyc phat tridn hay khdng li phan ldn phu thupc vio chit lupng cua phdi ban diu. Hmh fliai cua phdi sau sinh tiiidt khdng phu fliudc vio ngudn gde ciia phdi ta ngudi m? cd tiidi gian vd smh bao nhieu nam mi phy tiiypc vio chit lupng cua phdi tmdc
sinh thiet, tuy nhien trong nghien ciru niy thdi gian vd sinh ciing inh hudng tdi khi ning sdng sdt vi tgo blastocyst cua phdi, ket qui niy phu hpp vdi nghien ciiu ciia Munne. S[9].
FSH CO bin khdng inh hudng nhidu tdi hinh thii phdi sau sinh thiet, kdt qui niy phi hpp vdi nghidn ciiu cua Murme vi CS da so sinh moi lidn quan giiia hinh thii phdi vi nong dp FSH de ttt dd dinh gi^mdi lidn quan gitta ndng dp FSH ca bin vdi nhiing biin dii hinh thii phdi trong qua trinh phit hidn ciia phdi sau sinh thidt. Ddi vdi phy ntt dudi 40 tydi ndng dp FSH cao, cd ty Id rdi loan nhilm sic thd, phdi dp 3 dp 4 ting ding ke (p<0,02), nhung khdng phu thupc vio ndng dp FSH. Ty Id bit thudng nhiem sic the, phdi dp 3 dp 4 6 phy ntt duoi 40 tuoi cd ndng do FSH trdn 10 mlU/ml tuong duang vdi ty I?
rdi loan NST d phy ntt tren 40 tudi cd ciing ndng dp FSH. Nhu viy tang ty Id rdi loan nhiem sic thd, hinh thii phdi 6 phy ntt trdn 40 tydi khdng phy thupc vio ndng dp FSH, ma ting nong dp FSH lidn quan ddn giim khi nang du trO budng tning vi phii hpp vdi ty Id cd thai thip d nhdm benh nhan niy [9].
Tuy nhien ddi vdi phu nu dudi tren 35 tudi ndng dp FSH cao, mac dii hinh thai phdi it phy thudc vio ndng dp FSH, nhung tang ndng dd FSH lien quan ddn giim khi nang du trO budng tning vi phu hpp vdi t^ 16 cd thai thip d nhdm bdnh nhan niy [2]. Kit qua gitta cic phac dd diing thudc cho thiy sau khi sinh thiet cic phdi tiip tyc phat tridn vi tjio Blastocyst khdng phy thudc nhidu vio phdi cd ngudn gde tu BN diing thudc theo phic dd nio, tuy nhien ddi vdi nhOng benh nhan tiiii cao, thdi gian vd sinh keo dai cung inh hudng tcri khi nang tao blastocyst, phi hgp vdi ket qui nghien ciru cila Munne vi CS [9J.
Walker. M. C, Murphy KE, Pan S (2004) nghidn ciiu so sinh gitta phuong phip tiiy
Y HQC Vl|T NAM THANG 10 - s6 DAC BlgT/2013 tinh trong ong nghiem thong thucmg (IVF) v^
phucmg phap tiem tinh triing vao bao tirong noan (ICSI) thay rang hinh thai phoi tao ra tir 2 phuong phdp tren la nhu nhau. Tuy nhien ty 1? NST bit thudng cao ban co y nghia thong ke cr nhom b | n h nhan diing phuong phap phuong phap tiem tinh triing vao bao tuong noan vi nhttng b$nh nhan nay la ngucri mang r6i loan ve nhiem sic the, co tinh trung it, yku vk di dang. Song khi phoi da d^t a tieu chuin phoi do III va phoi dp IV thi khong 4nh huong t6i hinh thai phoi trong qua trinh phat trien sau sinh thiet [6].
V. KET LUAN
Qua nghien cijru hinh thai 102 phoi sau sinh thiet de chan doan di truyen truac chuy6n phoi toi xin rut ra hai ket luan sau:
1. Sinh thiet b^ng tia laser khong lam thay dSi hinh thai phoi, kha nang song sot va tao thanh phoi tui.
1.1. Sau sinh thi6t 24 gia ty le phoi song s6t, tiep tuc phat trien chung cua ca 3 nhom la 93 phoi trong tong so 102 phoi, dat 91,17% va sau 48 gio ty le hinh thanh phoi tiii la 83 phoi, dat 81,37% trong do s6 phoi tiii tiep tuc song sot va phat trien (loai AA va AB) la 67 phoi chidm 65,68%.
1.2. Ty le manh va bao tuong, dp day mang trong suot, ducmg kinh phoi giiia cac nhom thay doi khong c6 y nghTa thong ke.
2. Mot so yiu to anh hirdng toi kha nang phSi song sot va tao phoi tiii sau sinh thiet.
2.1. Tuoi me, thai gian vo sinh, nong dp FSH cang cao thi ty le phoi song sot va tao t h ^ phoi tiii cang giam.
2.2. Phuang phap thu tinh IVF ho^c ICSI khong anh hucmg tai thi ty Ie phoi song sot, tiep tuc phat triln va tao thanh phoi tui sau sinh thiit.
TAI UEU THAM K H A O
1. Trirong Dinh Kift, Ho Manh TiroTig (2011) "Thiet Igp quy trinh ky thudt trong chdn dodn di truyen tien lam Id (PGD) cdc phoi thu linh trong dng nghidm" Bao cao de taicapth^nhph64/2011.
2. Nguyin Thi Ngpc Phirong (2013) "Npi tiet sinh san" Nha xuat ban y hpc.
3. Nguyen Viet Tien, (2012), "Dfch ti hoc vd sinh vd cdc phirang ahaps dieu tri", Nha xuat ban Y hpc.
4. Alfarawati. S, Fragouli E, Colls. P, Stevens. J, Gutierrez. C, Schoolcraft.
(2011) "The relationship between blastocyst morphology, chromosomal abnormality, and embryo gender". Fertility and Sterility, 95;
520-524
5. Alikani, M., Cohen, J., et al. (1999). Human embryo fragmentation in vitro and its implications for pregnancy and implantation.
Ferlil. Steril.,l\,%^6~%A2.
6. Ebner T, Moser M, Sommet^ruber M, et al (2003). "Selection based on morphological assessment of oocytes and embryos at different stages of preimpiantation developmenf. Hum Reprod Update 2003; 9:251-262.
7. Gardner. D. K, Schoolcraft W.B, Wagley.
L (1998). "A prospective randomized trial of blatocyst culture and transfer in in vitro fertilization". Human Reproduction. 13:
3434-3440.
8. Hershberger PE, Gallo AM, Kavanaugh K, (2012) "The decision-making process of genetically at-risk couples considering preimpiantation genetic diagnosis: initial findings from a grounded theory study". Soc Sci Med. 2012 May;74( 10): 1536-43.
9. Munne. S, Chen S, Colls P, Garrisi J, Zheng X, Cekleniak N (2007), "Maternal age, morphology, development and chromosome abnormalities in over 6000 cleavage-stage embryos". Reproductive Biomedicine Online, 14; 628-634.
10. Salumets A, Hyden-Granskog C, Suikkari AM, Tiitinen A. (2001) 'The predictive value of pronuclear morphology of zygotes in the assessment of human embryo quality".
Hum Reprod. 2001 Oct;16(tO):2177-81.
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