Factors associated with the incidence of ectopic pregnancy in women undergoing assisted reproductive treatment / 中华医学杂志(英文版)

BACKGROUND@#Ectopic pregnancy (EP) is a common complication in women undergoing assisted reproductive treatment, but the underlying causes for this remain unclear. This study aimed to explore factors affecting the incidence of EP in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI).@*METHODS@#This was a retrospective study on the incidence of EP in IVF/ICSI cycles between January 1, 2013 and December 31, 2017. Patient age, infertility diagnosis (tubal factor or not), primary or secondary infertility, type of cycle (frozen-thawed or fresh), type of embryo(s) transferred (cleavage embryo or blastocyst), number of embryos transferred (one, two, or three), previous history of EP, and endometrial combined thickness were analyzed to explore their relationships with the incidence of EP. Based on clinical typing results, the patients were divided into an EP group or a non-EP group. Categorical variables were analyzed using Chi-squared test or Fisher exact test. Logistic regression analysis was performed to explore their associations with the incidence of EP.@*RESULTS@#The percentage of patients with primary infertility in EP group was significantly lower than that in non-EP group (31.3% vs. 46.7%, χ = 26.032, P < 0.001). The percentage of patients with tubal infertility in EP group was also significantly higher than that in non-EP group (89.2% vs. 63.6%, χ = 77.410, P < 0.001). The percentages of patients with transfer of cleavage-stage embryo or blastocyst (91.4% vs. 84.4%, χ = 10.132, P = 0.001) and different endometrial combined thickness (ECT) (χ = 18.373, P < 0.001) differed significantly between EP and non-EP groups. For patients who had a previous history of one to four EPs, the percentage of patients undergoing transfer of a cleavage-stage embryo was significantly higher in EP group than that in non-EP group (92.2% vs. 77.6%, χ = 13.737, P < 0.001). In multivariate logistic regression analysis, tubal infertility was strongly associated with EP (adjusted odds ratio: 3.995, 95% confidence interval: 2.706-5.897, P < 0.001).@*CONCLUSIONS@#In IVF/ICSI cycles, transfer of a blastocyst-stage embryo, especially for patients with a previous history of EP, reduced the rate of EP. Tubal infertility was strongly associated with EP.

NLRP3 inflammasome: a new therapeutic target for high-risk reproductive disorders? / 中华医学杂志(英文版)

The NOD-like receptor protein 3 (NLRP3) inflammasome is a key regulator of the host's immune response, and many immune and metabolic disorders are linked to its activation. This review aimed to investigate and clarify the relationship between this inflammasome and high-risk reproductive disorders. Papers cited here were retrieved from PubMed up to August 2020 using the keywords "NLRP3" or "NALP3", "caspase-1", "endometriosis", "gestational diabetes", "interleukin (IL)-18", "IL-1β", "pre-eclampsia (PE)", "preterm birth", "polycystic ovarian syndrome (PCOS)", "recurrent spontaneous abortion (RSA)", and combinations of these terms. The results show that NLRP3 inflammasome is associated with various high-risk reproductive disorders and many inflammatory factors are secreted during its activation, such as IL-1β induced during the development of endometriosis. PCOS is also associated with activation of the NLRP3 inflammasome, especially in overweight patients. It also participates in the pathogenesis of RSA and is activated in fetal membranes before preterm birth. The placentas of pregnant women with PE show higher expression of the NLRP3 inflammasome, and gestational diabetes mellitus occurs simultaneously with its activation. Current evidence suggest that the NLRP3 inflammasome plays an important role in female reproductive disorders. New treatment and management methods targeting it might help reduce the incidence of such disorders and improve neonatal outcomes.

Impact of adenomyosis on fertility and the choice of management / 中国实用妇科与产科杂志

Adenomyosis has high prevalence in infertility women,deteriorating the pregnancy results of in vitro fertilization therapy for couples with or without pelvic endometriosis.The mechanisms of effect include:anatomical distortion,uterine dysperistalsis,altered implantation environment,intrauterine free radicals excess and overactive immune system,etc.Assisted reproductive technology is an effective measure to improve the pregnancy outcome,and conservative surgery adds up some natural conception while alleviating the symptoms.Obstetric complications should be taken into account before cytoreductive surgery.Gonadotropin releasing hormone agonist is usually combined with other therapies.Robust evidence is needed for the reproductive effect and safety of high intensity focused ultrasound ablation.

Advanced Role of Hippo Signaling in Endometrial Fibrosis: Implications for Intrauterine Adhesion / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>Intrauterine adhesion (IUA) is a major health problem that causes infertility, menstrual irregularities, and recurrent pregnancy losses in women. Unfortunately, treatments for IUA are limited, and there are currently no effective strategies for preventing IUA recurrence. In this review, we introduced the role of Hippo signaling in the normal endometrium and IUA and described the mechanisms by which the Hippo pathway integrates with the Wnt and transforming growth factor-β (TGF-β) signaling pathways to form an intricate network governing the development of fibrosis.</p><p><b>DATA SOURCES</b>Original research articles in English that were published until July 2017 were collected from the PubMed database.</p><p><b>STUDY SELECTION</b>Literature search was conducted using the search terms "endometrial fibrosis OR fibrosis AND or OR intrauterine adhesion OR Asherman syndrome OR IUA," "Hippo AND or OR Hippo/TAZ," "TGF-β," and "Wnt." Related original research articles were included in the comprehensive analysis.</p><p><b>RESULTS</b>Endometrial fibrosis is recognized as a key pathological event in the development of IUA, which is characterized by epithelial/fibroblast-myofibroblast transition. Myofibroblasts play crucial roles in the pathogenesis of fibrous scarring, and myofibroblast differentiation can be triggered by multiple signaling pathways. Hippo signaling is a critical regulator of the epithelial/fibroblast-myofibroblast transition and α-smooth muscle actin, which exhibits a specific spatiotemporal expression in the endometrium.</p><p><b>CONCLUSIONS</b>Hippo signaling plays a critical role in fibrous diseases and participates in cross talks with Wnt and TGF-β signaling. Our findings not only contributed to knowledge on the pathogenesis of endometrial fibrosis, but can also serve as a useful resource for developing specific molecular inhibitors for IUA treatment and prevention.</p>

Ovarian Fibrosis: A Phenomenon of Concern / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>Ovarian fibrosis is characterized by excessive proliferation of ovarian fibroblasts and deposition of extracellular matrix (ECM) and it is one of the principal reasons for ovarian dysfunction. This review aimed to investigate the pathogenetic mechanism of ovarian fibrosis and to clarify the relationship between ovarian diseases and fibrosis.</p><p><b>DATA SOURCES</b>We searched PubMed for English language articles published up to November 2016. The search terms included ovarian fibrosis OR fibrosis, ovarian chocolate cyst OR ovarian endometrioma, polycystic ovarian syndrome (PCOS), premature ovarian failure, ECM, matrix metalloproteinases (MMPs), tissue inhibitors of matrix metalloproteinases (TIMPs), transforming growth factor-beta 1 (TGF-β1), connective tissue growth factor (CTGF), peroxisome proliferator-activated receptor gamma (PPAR-γ), vascular endothelial growth factor (VEGF), endothelin-1 (ET-1), and combinations of these terms.</p><p><b>STUDY SELECTION</b>Articles were obtained and reviewed to analyze the pathogenic mechanism of ovarian fibrosis and related ovarian diseases.</p><p><b>RESULTS</b>Many cytokines, such as MMPs, TIMPs, TGF-β1, CTGF, PPAR-γ, VEGF, and ET-1, are involved in ovarian fibrogenesis. Ovarian fibrogenesis is associated with various ovarian diseases, including ovarian chocolate cyst, PCOS, and premature ovarian failure. One finding of particular interest is that fibrogenesis in peripheral tissues around an ovarian chocolate cyst commonly causes ovarian function diminution, and therefore, this medical problem should arouse widespread concern in clinicians worldwide.</p><p><b>CONCLUSIONS</b>Patients with ovarian fibrosis are susceptible to infertility and tend to have decreased responses to assisted fertility treatment. Thus, protection of ovarian function should be a priority for women who wish to reproduce when making therapeutic decisions about ovarian fibrosis-related diseases.</p>

Expression and distribution of calcium-binding protein S100P in human placenta during pregnancy

S100P is a member of the S100 family of calcium-binding proteins, and it participates in pathophysiological events, such as tumor growth and invasion. Based on the striking similarities between trophoblast cells and tumor cells with regard to proliferative and invasive properties, we raised the question of whether and how S100P expresses in trophoblast cells during development. This study aimed to investigate the expression pattern of S100P in the human placenta during pregnancy development. In this experimental study, we collected 16 first-trimester placental tissues, 10 second-trimester placental tissues, and 12 term placentas. The mRNA expression levels of S100P were detected by reverse-transcription-polymerase chain reaction [RT-PCR] and quantitative real-time PCR, the protein expression levels were detected by western blot, and the localization of S100P was measured by immunohistochemical staining. The values obtained from PCR and western blot analysis were expressed as the mean +/- SD. Levene's test was used to test equal variances, and one-way analysis of variance [ANOVA] was used to evaluate differences between groups. Protein and mRNA expression of S100P could be detected in placenta during pregnancy, with minor higher levels in first-trimester [p>0.05]. Immunohistochemical staining revealed that S100P protein was strongly expressed in syncytiotrophoblasts, and moderate expression was detected in villous cytotrophoblasts and cytotrophoblast columns. The S100P protein was localized to both cytoplasm and nuclei in syncytiotrophoblasts, while it only existed in the cytoplasm of cytotrophoblasts. S100P was strongly detected in human placenta during pregnancy. The specific expression and distribution of S100P in human placenta throughout gestation suggested that S100P function might vary with its location in the placenta

Intracytoplasmic Sperm Injection Fertilization Rate Does Not Depend on the Proportion of Round-headed Sperm, Small-acrosomal Sperm, or Morphologically Normal Sperm in Patients with Partial Globozoospermia / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Generally, intracytoplasmic sperm injection (ICSI) may be the preferable method to treat partial globozoospermia, but whether there exist some correlations between ICSI fertilization rate and the proportion of round-headed sperm or morphologically normal sperm remains open. This study was to explore the correlation between ICSI fertilization rate and the sperm morphology in patients with partial globozoospermia.</p><p><b>METHODS</b>Thirty-four patients diagnosed with partial globozoospermia accepted the following assisted fertilization treatments - 2 cases accepted in-vitro fertilization (IVF) alone, 26 cases accepted ICSI alone, and 6 accepted split IVF/ICSI. Detailed morphological characteristics were described using Diff-Quik rapid staining. Sixty cases accepting IVF or ICSI treatment in our reproductive center were considered as the control group after being matched by relevant criteria. Fertilization rate, embryo quality, embryo implantation rate and clinical pregnancy rate were calculated.</p><p><b>RESULTS</b>Besides very high proportion of round-headed sperm, partial globozoospermia also showed very high proportion of small-acrosomal sperm and very low proportion of morphologically normal sperm. Fertilization rate of IVF (IVF alone plus split IVF) was very low in partial globozoospermia (25.4% ± 17.4%), but ICSI (ICSI alone plus split ICSI) achieved satisfying fertilization rate compared with the control group (66.2% ± 22.5% vs. 68.8% ± 29.4%, P > 0.05). In patients with partial globozoospermia, there were no correlations between ICSI fertilization rate and the proportion of round-headed sperm, small-acrosomal sperm, or morphologically normal sperm.</p><p><b>CONCLUSIONS</b>There was high proportion of small-acrosomal sperm in partial globozoospermia. For patients with partial globozoospermia, ICSI is more preferable than IVF. ICSI fertilization rate does not depend on the proportion of round-headed sperm, small-acrosomal sperm, or morphologically normal sperm.</p>

Fertility-preserving treatment and pregnancy outcomes in the early stage of endometrial carcinoma / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>This study aimed to review the available literature on fertility-preserving treatment and pregnancy outcomes in patients with early-stage endometrial carcinoma who desired to preserve their fertility.</p><p><b>DATA SOURCES</b>The PubMed database (1992-2012) was searched for the words "conservative "OR" fertility sparing "OR" fertility preserving" AND "endometrial neoplasms" (MeSH). All relevant articles in English and the relevant references were collected.</p><p><b>STUDY SELECTION</b>Data from published articles about fertility-preserving treatment of endometrial cancer, including the response and recurrence rate of conservative treatment, strategies of infertility treatment, pregnancy, and obstetric outcomes, were selected. Data were mainly extracted from 41 studies, which are listed in the reference section of this review.</p><p><b>RESULTS</b>Hormone therapy was the most common method used for early-stage endometrial carcinoma in patients who wished to preserve fertility. Sixty percent of the patients became pregnant after remission of the carcinoma. The percentage of patients who conceived in the assisted reproductive technology group was higher than that of the natural pregnancy group (80.0% vs. 43.2%, P < 0.01). A higher rate of preterm labor and multiple pregnancies was observed in the assisted reproductive technology group than that in the natural pregnancy group. The majority of pregnancies (71.4%) in the assisted reproductive technology group were achieved by in vitro fertilization-embryo transfer. The clinical pregnancy rate of transfer cycles in patients with endometrial carcinoma was 34.1%.</p><p><b>CONCLUSIONS</b>Assisted reproductive technology is a good option in well-selected patients with early-stage endometrial carcinoma who have completed conservative treatment. In vitro fertilization-embryo transfer offers an opportunity to achieve an immediate pregnancy.</p>

Three-dimensional cultures of human endometrial cells on Matrigel mimic in vivo morphology / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The regulation of endometrial physiology and morphogenesis by the paracrine effectors has been well established using in vivo studies. A more complete understanding of the endometrial function has been delayed due, in part, to a lack of appropriate culture models. In this study, we aimed to simulate the in vivo three-dimensional (3-D) growth pattern of endometrial cells using a 3-D in vitro culture system.</p><p><b>METHODS</b>Isolated endometrial epithelial cells, stromal cells and RL95-2 cells were seeded into culture chambers coated with the extracellular matrix Matrigel and observed using light microscopy. Fluorescence staining and immunohistochemistry were used to assess the morphology.</p><p><b>RESULTS</b>Depending on the culture conditions, epithelial cells and RL95-2 cells formed multicellular structures on Matrigel; stromal cells remained individually distinguishable or grew together to form 3-D lattice-like structures.</p><p><b>CONCLUSIONS</b>Matrigel provided a good microenvironment for culturing endometrial cells. The cells cultured in the Matrigel-coated chambers closely resembled those seen in vivo.</p>

Outcome of conservative treatment and subsequent assisted reproductive technology for patients with early-stage endometrial adenocarcinoma and poor fertility potential / 中华医学杂志(英文版)

Conservative treatment with high doses of progestin is an alternative to standard hysterectomy for young patients with early-stage endometrial adenocarcinoma who desire to preserve their fertility. Here we report a patient with well-differentiated early-stage endometrial adenocarcinoma and poor fertility potential who failed to become pregnant in two in vitro fertilization-embryo transfer cycles and suffered a relapse after conservative treatment. This case illustrates that assessment of fertility potential is critical at the time of initial evaluation and conservative treatment planning for patients with endometrial adenocarcinoma.

Outcome of in vitro fertilization in endometriosis-associated infertility: a 5-year database cohort study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Endometriosis affects natural fertility through various approaches, and in vitro fertilization (IVF) is a good treatment. But the IVF result of endometriosis patients is still under debate. We investigated the effect of endometriosis on IVF by analyzing the data from a single reproductive center.</p><p><b>METHODS</b>A retrospective, database-searched cohort study was performed. Relevant information was collected from the electronic records of women who underwent IVF/intracytoplasmic sperm injection between January 2006 and December 2010 in the Assisted Reproductive Unit of Sir Run Run Shaw Hospital. Patients with endometriosis were enrolled the study group. The rest of the women formed the control group. The main outcome was the clinical pregnancy rate. Secondary outcomes were oocytes retrieved number, fertilization rate, high-quality embryo rate, number of high-quality embryo for embryo transplantation, and implantation embryo/high-quality embryo ratio (IE/HQE ratio). Comparisons were performed by the c(2)-test and independent t-test.</p><p><b>RESULTS</b>The endometriosis group (n = 177) had a markedly lower oocytes retrieved number, fertilization rate, implantation rate, and clinical pregnancy rate (7.6 ± 5.1, 63.6%, 27.7%, and 45.2%, respectively) compared with the non-endometriosis group (n = 4267; 11.8 ± 7.3, 68.4%, 36.2%, and 55.2%, respectively). Stratified analysis showed that this difference was found in the subgroup younger than 35-years old, while only fertilization rate and implantation rate were different in the elder subgroup. The ratio of high-quality embryos transferred is lower in endometriosis group (53.7% vs. 71.8%, P < 0.05), but there is no difference in IE/HQE ratio between two groups. There is no significant difference in fertilization rate, implantation rate, and clinical pregnancy rate between mild and severe endometriosis patients.</p><p><b>CONCLUSIONS</b>Endometriosis patients suffer a decreasing IVF pregnancy rates mainly caused by reducing oocytes number and fertilization rate, regardless of the severity of the disease. Appropriate intracytoplasmic sperm injection manipulation might improve the outcomes of IVF.</p>

A frozen-thawed embryo transfer program improves the embryo utilization rate / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Frozen-thawed embryo transfer (FET) is the most common way to prevent serious late ovarian hyperstimulation syndrome and increase the cumulative pregnancy rate. We evaluated the effectiveness of an FET program for improving the embryo implantation and clinical pregnancy rates, and ultimate embryo utilization rate in infertility treatment.</p><p><b>METHODS</b>Patients undergoing in vitro fertilisation (IVF) cycles from January 2006 to June 2008 were enrolled, including 179 patients who had undergone the first FET cycle after controlled ovarian hyperstimulation (COH) in which all embryos were frozen (group C1) and 1306 patients who had COH with fresh embryo transfer (ET) (group T1). Logistic regression was used to model the embryo implantation and clinical pregnancy rates based on the mother's age, numbers of oocytes retrieved, embryos transferred and high-quality embryos transferred. The embryo implantation and clinical pregnancy rates were also compared between two groups after adjusting for age, the numbers of oocytes retrieved and the numbers of embryos transferred.</p><p><b>RESULTS</b>Logistic regression analysis confirmed that embryo implantation and clinical pregnancy rates in group C1 were both significantly higher than those in group T1 after adjusting for confounding factors (43.6% vs 29.0%, 63.1% vs 47.0%, respectively; P < 0.01). The embryo implantation and clinical pregnancy rates were consistently higher in group C1 by comparing the age groups >or= 35 or < 35 years. The clinical pregnancy rates for the numbers of oocytes retrieved per cycle being >or= 15 or < 15 were higher in group C1, as was the embryo implantation rate. These differences were statistically significant for oocyte numbers >or= 15 (P < 0.05). The embryo implantation and clinical pregnancy rates in group C1 were both significantly higher than in group T1 when two or three embryos were transferred (P < 0.05).</p><p><b>CONCLUSION</b>A program of freezing all embryos and performing FET improved the rates of embryo implantation and clinical pregnancy, and ultimately enhanced the embryo utilization rate.</p>

Sperm morphology does not influence fertilization rate in vitro / 中华男科学杂志

<p><b>OBJECTIVE</b>To determine the correlation of the rate of morphologically normal sperm, sperm head defect, teratozoosperm index (TZI) and sperm deformity index (SDI) with the fertilization outcome of IVF and intracytoplasmic sperm injection (ICSI).</p><p><b>METHODS</b>We detected normal sperm morphology, sperm head defect, TZI and SDI by Krüger's strict criteria and compared them with the rate of fertilization.</p><p><b>RESULTS</b>In either IVF or ICSI, the fertilization rate did not show any correlation with the normal sperm morphology rate, the head defect rate, TZI and SDI, nor any statistic differences were found in the rates of fertilization, clinical pregnancy and quality embryos either between the SDI > 1.6 and the SDI < 1.6 groups (P > 0.05) or between the normal sperm morphology rate > 15% and < 15% groups (P > 0.05).</p><p><b>CONCLUSION</b>Sperm morphology has no predictive value for the rate of fertilization in vitro.</p>

Effects of gonadotropin-releasing hormone antagonists on the expression of vascular endothelial growth factor and its receptors in a rat model of ovarian hyperstimulation syndrome / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Ovarian hyperstimulation syndrome (OHSS) is one of the most life-threatening complications of assisted reproduction treatments. Gonadotropin-releasing hormone antagonists (GnRHanta) are thought to be effective in preventing this complication, and some clinical trials have found lower incidences of OHSS in patients treated with GnRHanta. Our aim was to investigate the effects of GnRHanta on vascular permeability and the expression of vascular endothelial growth factor (VEGF) and its receptors in a rat model of OHSS.</p><p><b>METHODS</b>An immature early OHSS rat model was established. Three ovarian stimulation protocols were used: pregnant mare serum gonadotropin/human chorionic gonadotropin (hCG) alone, with a GnRHanta, or with a gonadotropin-releasing hormone agonists (GnRHa). Blood and tissue samples were collected at 48 hours after hCG administration. Vascular permeability was evaluated by measuring the Evans-Blue content of extravasated peritoneal fluids. The expression of VEGF and its receptors, including flt-1 and KDR, were detected by reverse transcriptase-polymerase chain reaction and Western blotting.</p><p><b>RESULTS</b>Treatment with both a GnRHanta and a GnRHa resulted in significant reductions in serum estradiol and peritoneal vascular permeability, as well as decreased ovarian expression of VEGF and its two receptors. However, GnRHanta treatment caused a greater reduction in serum estradiol concentrations, and in VEGF receptor mRNA expression than GnRHa. There were no significant reductions in the expression of VEGF or its receptors in extra-ovarian tissues, including the liver, lungs and peritoneum.</p><p><b>CONCLUSION</b>Our results reveal that GnRHanta are more potent than GnRHa in preventing early OHSS through down-regulation of the expression of VEGF and its receptors in hyperstimulated ovaries.</p>

Enucleation of benign ovarian cysts by laparoscopy / 浙江大学学报·医学版

<p><b>OBJECTIVE</b>To evaluate the efficacy of improved laparoscopic enucleation of benign ovarian cysts.</p><p><b>METHODS</b>A total of 234 cases of ovarian cysts with 271 cysts were analyzed retrospectively. 152 patients with 177 ovarian cysts (Group A) underwent the improved laparoscopic enucleation and 82 patients with 94 ovarian cysts (Group B) underwent the classic laparoscopic enucleation. The data of operative process and postoperative follow-up were compared between two groups.</p><p><b>RESULTS</b>The rate of spillage of the Group A and Group B was 1.7% and 18.1% (P<0.01), respectively. The operating time was (40 +/-14)min and (47 +/- 16)min (P<0.01), respectively. The blood loss was (25 +/-17)ml and (27 +/- 19)ml (P>0.05), respectively. The bowel deflation recovery time was (18 +/- 8)h and (19 +/- 8)h (P>0.05), respectively. The length of hospital stay was (2.0 +/- 0.5)d and (2.2 +/- 0.8)d (P>0.05), respectively.</p><p><b>CONCLUSION</b>Compared with classic laparoscopic procedure, the improved laparoscopic ovarian enucleation seems to be safer and more effective with shorter operating time.</p>

Effect of pelvic inflammatory disease grades on in vitro fertilization-embryo transfer outcome / 中华妇产科杂志

Objective To evaluate the effect of different grades of pelvic inflammatory disease (PID)and of salpingectomy on outcomes of in vitro fertilization-embryo transfer(IVF-ET).Methods Two hundred and twenty three cycles of IVF-ET were divided into three groups,including mild group,moderate group and severe group,according to different grades of sequelae of PID finding in exploratory operations before IVF.Patients in each group were divided into two subgroups according to receiving salpingectomy or not.The data of total dose of gonadotrophin(Gn),oocyte number,low response rate,fertilization rate,good embryo number and pregnancy rate were analysed between three groups and the two subgroups of each group, respectively.Results All parameters were related to PID grades except fertilization rate.The total dose of Gn,oocyte number,good embryo number,low response rate and pregnancy rate were(2057?503)IU/L, (16?6),(6.0?4.3),4.2%,63.9% in mild group;(2204?603)IU/L,(12?6),(4.5?3.5), 13.9%,46.8% in moderate group;and(2372?1018)IU/L,(9?6),(3.1?2.9),33.8%,41.2% in severe group.The total dose of Gn and low response rate increased with the aggravation of the grades of PID (P