SART生育专家 - 消除多胎妊娠

医生。

Doctor.

凯莉：大家好，欢迎收听今天的SART生育专家播客，这是一个为想要组建家庭的人准备的节目。

Kelly Hello, and welcome to today's episode of SART Fertility Experts, the podcast for people trying to build a family.

我是医生。

I am Doctor.

凯莉·林奇，今天我的嘉宾是医生。

Kelly Lynch, and my guest today is Doctor.

埃默里大学医学院的詹姆斯·托纳。

James Toner of Emory University School of Medicine.

医生。

Doctor.

托纳医生是妇产科学教授，今天他要和我聊聊如何避免多胎妊娠。

Toner is professor of Obstetrics and Gynecology, and he is here to talk to me today about Vanquishing Multiples.

医生。

Doctor.

托纳医生，欢迎你。

Toner, welcome.

很高兴来到这里。

It's a pleasure to be here.

那你能跟我们谈谈，为什么多胎妊娠对不孕患者来说是个问题，以及为什么过去在试管婴儿治疗中多胎这么常见？

So can you talk to us a little bit about why multiple gestations are a concern for patients with infertility and why they were so common in the past with in vitro fertilization treatment?

我很乐意。

I'd be happy to.

在试管婴儿早期，十个胚胎里能有一个着床就算很幸运了。

In the early days of IVF, we were lucky if one in 10 embryos attached.

所以我们当时几乎是被迫一次移植很多胚胎，就希望能怀上一个。

So we were kind of forced into a position of putting in many embryos all at once in hopes of getting to any pregnancy at all.

但情况已经变了。

But things have changed.

随着情况的变化，我觉得我们越来越意识到，某种程度上，我们面对的不仅仅是眼前这一个病人。

And as they've changed, I think we've become much more aware that, in a way, there's more than one patient in front of us.

我们面对的不只是这对夫妻或这个病人，还有他们未来的孩子。

There's the couple or individual we're working with, but also their future offspring.

这跟“首先不伤害”的原则是一致的。我们已经认识到，对孩子来说，一次生一个对健康最好，所以这个平衡就变了。

Kind of in line with the edict to first do no harm, I think we've come to recognize that for children, it really is best for their health to be born one at a time, That sort of changed the balance.

就拿双胞胎的风险来说吧，双胞胎孩子患脑瘫的几率大约是单胎的五倍。

As an example of the risks of even twins, children born as twins have about five times as much cerebral palsy.

他们的急性问题也更多一些。

They have somewhat lower acutes.

学习障碍的问题也大得多。

They have much more problems with learning disabilities.

而且这些是终身的问题，对吧？

And these are really lifelong conditions, right?

不是说“哦，我早产了一个月”，然后出了新生儿重症监护室就能正常生活了。

They're not just, Oh, I was born a month early, and then you kind of get out of the NICU and go on with a normal life.

这些是长期的问题，但我们现在可以通过调整治疗方案，让这些问题比以前少得多。

These are long term issues that we now can adjust our treatments such that they occur much less often than before.

所以，真的，为了孩子的健康，我觉得现在在我们的社会和实践中，普遍认为胚胎最好一次只放回一个。

So really, on behalf of the children's health, I think generally, it's generally understood within our society and within our practice these days that embryos should best be put back kind of one at a time.

否则，你就没法控制多胞胎的数量了。

Otherwise, you would kind of lose the opportunity to put a lid on how many multiples are being created.

而且，多胎妊娠的情况确实会让孩子面临一些风险。

And again, the multiple pregnancy situation puts the children at some risk.

那母亲健康方面的风险呢？

What about the risks of the mother's health as well?

母亲的风险也确实会增加，但在我看来，这些风险属于另一类，因为它们是暂时的。

The mothers also are at increased risk, but they're sort of, in my mind anyway, in a somewhat different class because those are risks that are transient.

是的，糖尿病风险更高。

I mean, yes, there's more diabetes.

是的，孕期高血压风险也更高。

Yes, there's more hypertension in pregnancy.

但一旦妊娠结束，这些风险就会消失。

But once the pregnancy is behind that woman, they resolve.

而且，我觉得这跟孩子因为双胞胎或三胞胎出生而可能面临的终身问题，是不同类型的问题。

And again, so that's a different sort of an issue, I think, as opposed to the lifelong things that can happen to children that flow from being born, you know, two at a time or three at a time.

即使我们只放回一个胚胎，我们也知道有百分之一的几率会自然产生同卵双胞胎。

Even, you know, even when we put back just one, we know one in a hundred times we're gonna get identical twins anyway.

这是无法避免的。

That's unavoidable.

这……

That's...

所以即使我们做了所谓正确的事情，我们也知道偶尔还是会有双胞胎。

So even when we're doing, quote unquote the right thing, we know we're still going to have an occasional twin.

但这也意味着，如果你放回两个，有时可能会变成三个或四个。

But that also kind of means by extension that if you put in two, sometimes you get three or four.

这对孩子的健康来说风险极大。

And that's incredibly risky to the health of the children.

我们现在有了一个工具，我们可以谈谈我们是怎么走到这一步的，这个工具可以用来保护试管婴儿的健康。

We now have a tool, and we can talk about how we got here, a tool for doing what can be done to protect the health of IVF children.

那你觉得试管婴儿项目有哪些方法能提高怀孕成功率，同时降低多胎妊娠的风险呢？

So what do you think are the ways that IVF programs have been able to help improve pregnancy rates while reducing the risk of multiple gestations?

是的，我们现在能做的治疗和以前不一样了。

Yeah, the treatments that we now can do are different than before.

其中有好几项让我们既能保持高成功率，又能降低多胎妊娠率。

Several of them have led to our ability to have high success rates and low multiple pregnancy rates all at the same time.

我觉得最重要的可能是让胚胎在实验室里培养的时间比早期试管婴儿长得多。

I think probably the most significant one is the ability to allow embryos to develop in the lab for much longer than in the early days of IVF.

在试管婴儿早期，你把精子和卵子放在培养皿里，一天后，只要看起来受精了，就放回去，然后祈祷一切顺利。

In the early days of IVF, you would put sperm and egg together in a dish, and initially, one day later, you'd put back anything that looked like it had fertilized and hope for the best.

后来，胚胎可以在实验室里培养三天，但现在可以培养五天了。

Then it became possible to culture embryos for three days in the lab, but now it's possible to culture embryos five days.

通过延长培养，胚胎能够以一种以前不可能的方式自我筛选，区分出五天后还在继续生长的和那些发育落后或完全停止生长的。

With extended culture, the embryos are able to sort themselves in a way that wasn't possible before into those that are still growing well after five days and those that have fallen behind or stopped growing altogether.

所以现在能活到第五天的胚胎，比早期无法在实验室里延长培养时，更可能是健康和有活力的。

So embryos that now get to day five are much more likely to be healthy and competent than in the early days when we couldn't achieve extended culture in the lab.

所以这是一个巨大的变化。

So that's a huge change.

另一个让我们能够减少多胎妊娠的因素是胚胎的安全冷冻，效率很高，大约百分之九十五的冷冻胚胎在解冻后看起来和表现都跟从未冷冻过一样。

The other thing that has allowed us to reduce multiples is safe freezing of embryos, high efficiency, probably ninety five percent of embryos that are frozen thaw and look and behave just like they would have had they never been frozen.

此外，你还可以检测胚胎的遗传状况。

And also, you can test the genetic status of embryos.

这对于那些提供卵子的女性年龄可能超过38岁的情况尤其有帮助，因为即使是来自40岁女性的看起来健康的胚胎，其着床率也不如来自30岁女性的看起来健康的胚胎。

And that's especially helpful for the cases where the women who are providing the eggs are perhaps above age 38, Because even a healthy looking embryo from a 40 year old doesn't attach as often as a healthy looking embryo from a 30 year old.

这是因为即使它们看起来很好，其中更高比例的胚胎染色体数目异常，最终只会导致流产。

And that's because much higher proportion of them, even though they look good, have the wrong number of chromosomes, and they would have just been a miscarriage.

所以如果你能进行基因筛查，即使是对于40岁或42岁的女性，你也能找到那些可能成功的胚胎。

So if you can do the genetic screening, even for women who are 40 or 42, you can find the ones that are likely to work.

这样你就可以坚持一次只移植一个胚胎的政策，即使是对于年龄在

And that allows you to stick with this one embryo at a time policy, even for women in their

40多岁的女性。

40s.

对，所以你说的是，延长培养让我们能更精准地选择移植哪个胚胎，这样我们就能更清楚地知道哪个胚胎最有可能着床，从而更有信心地只移植一个胚胎。

Right, so extended culture, what you're saying is it allows us to be more selective about which embryo to transfer, so we have a better idea of which embryo is most likely to implant, so we can put back one embryo with greater confidence.

是的，现在如果你有一个形态良好的胚胎，发育满五天，达到囊胚阶段，着床率能达到一半，尤其是在38岁以下。如果知道基因正常，染色体数目正确，是应有的46条，那么40岁的女性着床率也有一半。

Yeah, and these days, if you have a good looking embryo that's developed for five full days and achieves this stage of development called blastocyst, they attach half the time, especially under 38, and they'll still attach half the time in women 40 if you know that they're also normal genetically, that they have the right number, the 46 chromosomes that they should.

对，所以基因检测能让年龄较大的患者知道他们移植的是正常胚胎，这也能让他们有信心只移植一个胚胎。

Right, so genetic testing can allow those patients who are older to know that they're transferring a normal embryo, which can also allow them to transfer a single embryo with confidence.

没错，因为以前随着女性年龄增长，需要移植越来越多的胚胎，因为那些胚胎可能存在问题，而这些问题光靠肉眼是看不出来的。

Right, because it used to be that there was this need to transfer more and more embryos as women got older because those embryos were likely to have trouble that you couldn't see by just looking at them.

但现在能够检测基因，这带来了巨大的改变。

But now the ability to test their genetics makes a huge difference.

托纳医生，

Dr.

当你看到一对夫妇说，我们只负担得起一个周期的试管婴儿，

Toner, what do you say when you see a couple that says, We can only afford to do one cycle of IVF.

我们想移植两个胚胎，你会怎么说？

We wanna put back two embryos.

我们想要双胞胎。

We want twins.

您怎么给他们建议？

How do you counsel them?

我们确实会给他们建议，他们的担忧也是合理的。

Well, we do counsel them and those concerns are legitimate.

所以我不会轻易忽视这些担忧。

So I don't brush them off lightly.

我想我通常会解释，取卵这个最初的步骤才是非常昂贵的部分，而使用冷冻胚胎则是便宜得多的步骤。

I guess what I tend to describe the fact that it's the initial effort to get eggs that's the very expensive part, whereas the use of any frozen embryos is a much less expensive step.

我也会试着鼓励他们，除了考虑经济因素——这确实是合理的顾虑——还要考虑未来孩子的健康。

And I try to, again, encourage them to think perhaps, in addition to the finances, which are a valid concern, about the health of their future children.

通过强调双胞胎出生时确实存在风险，而这些风险基本上可以通过稍后再使用第二个胚胎来避免。

And by, I think, focusing, drawing attention to the fact that there are real risks to children born as twins that are essentially avoidable by just using that second embryo a little later.

大多数夫妇或个人最终会选择一次只移植一个胚胎的方式。

Most couples end up deciding, or individuals end up deciding, to go with the one embryo at a time approach.

而且记住，胚胎一旦冷冻，就不会变老。

And remember that once an embryo is frozen, it never gets older.

所以如果你做了一次试管婴儿，得到了两个胚胎，先把第一个放进去，第二个在35岁时冷冻，比如，然后三四年后再回来用第二个胚胎，那个胚胎还是35岁的状态。

So if you went through an IVF cycle, had two embryos produced, you put the first one in, freeze the second one when you were 35, for instance, and then you come back three or four years later for another tribe with the second, that embryo's gonna act 35.

它不会变成38岁或39岁。

It's not gonna act 38, 39.

所以把两个胚胎一起放回去，并没有医学上的优势，也没有紧迫性，因为时间在流逝。

So there isn't any medical advantage to putting them back together, or urgency, because time is going by.

卵子和胚胎不会变老，子宫在女性接近50岁之前也不会真正老化。

The eggs, the embryos, will not get a day older, and the uterus doesn't really age either until women are in their late 40s.

所以40岁的子宫和35岁的子宫一样能承载胚胎。

So a 40 year old uterus can carry an embryo just as well as a 35 year old.

所以通过移植单个胚胎，你给了你的后代最好的机会，也把多胞胎相关的并发症风险降到最低。

So you're giving your offspring the best possible chance and lowest risk of complications associated with multiples by transferring singletons.

我觉得这个领域，现在有了这些新方法，应该追求让宝宝尽可能健康的目标。

I think the field is, again, now that these new approaches are available to us, to embrace the goal of having the healthiest children possible.

多胎妊娠的风险会危及孩子，而现在大部分这种风险都是可以避免的。

Risk of multiples puts the children at risk, and most of that risk is now avoidable.

所以，作为这个领域，似乎已经达成了共识：为了孩子的健康，也符合我们“首先不伤害”的誓言，大多数诊所现在都实行单胚胎移植的政策。

So as a field, there seems to be a consensus that on behalf of the health of the children, and in line with sort of our oath to first do no harm, it really has become a policy of single embryo transfer in most clinics.

这是个好政策。

And it's a good one.

我也这么认为。

I think it is.

我觉得这确实对孩子的健康有好处。

I think it really does benefit the health of the children.

举个例子，大约十五年前，这些新方法开始流行之前，超过一半的试管婴儿是在至少双胞胎、甚至三胞胎或四胞胎的妊娠中出生的。

Just as kind of maybe a reference point, until about fifteen years ago when these new approaches started to become more popular, more than half of the IVF children were born in pregnancies that were at least twin, if not triplet, then quadruplet.

而且，那百分之五六十的出生孩子都面临某种风险，因为他们是以多胎妊娠的形式出生的。

And again, that fifty, sixty percent of the born children were all of them at some risk because they had come in the form of a multiple pregnancy.

在最近有结果数据的年份，这个比例已经降到了不超过百分之五。

In the most recent year, where we have information about outcomes, it's now not higher than five percent.

所以，我们把原本至少百分之五十的多胎妊娠风险，降到了百分之五。

So we've taken a risk that was at least fifty percent of a multiple pregnancy and driven it down to five percent.

而自然怀孕的多胎率是百分之一。

And the natural rate is one percent.

所以我们现在的方法，几乎不会比没有生育问题的人产生更多的多胞胎。

So we're getting close to an approach that hardly produces any more multiples than would occur in people with no fertility challenges.

这真是巨大的进步。

It's a dramatic improvement.

你觉得保险覆盖在减少多胞胎方面起到了什么作用？

What do you think about the role of insurance coverage in helping to reduce multiples?

我觉得这正好回应了你之前提到的，那些没有保险、担心费用高的患者，他们可能会选择一次移植多个胚胎，而不是分次移植。我理解这种想法。

I think that takes the you alluded earlier about patients who are worried about the high cost if they have no insurance, about spreading out the transfers instead of just doing multiple embryo transfers, and I kind of get that.

我认为如果人们有保险覆盖，那就能减轻他们的经济压力，因为除了几次监测访视的轻微不便之外，分次移植不会产生额外费用，而一次移植多个胚胎则不然。

I think if people have insurance coverage, that that takes that financial pressure off of their shoulders because there won't be, except for the slight inconvenience of having a few monitoring visits, any additional cost to spreading out the transfers instead of multiple embryos at one time.

而且有些保险公司，我不知道现在是否还普遍，但有些保险公司会和医疗机构协商，说：只有你们每次只移植一个胚胎，我们才覆盖这项服务。

And there were some insurance companies, I don't know that it's still a common practice, but there were insurance companies that negotiated with the providers to say, We'll cover this service if and only if you put back one embryo at a time.

我觉得这个政策也不错，因为多胎妊娠不仅风险大，

And I think that's also not a bad policy because not only is multiple pregnancy risky

对

to

对妈妈和孩子都有风险，而且对保险公司来说，费用也高得多。

the mom and the children, but they also, for the insurance company, present at much, much higher cost.

所以他们愿意提供保险覆盖，做正确的事，这样就不用承担三胞胎、四胞胎住新生儿重症监护室的高额费用，如果他们不控制胚胎移植方式的话。

So they had been willing to maybe offer coverage to do the right thing so they won't have to take a big hit to support the NICU stays of triplets and quadruplets that come if they don't provide some control of how we're putting embryos in.

这方面我有点经验。

I can speak from some experience with that.

我在马萨诸塞州执业了二十一年，那里有非常慷慨的保险强制规定，而马萨诸塞州在九十年代初是全国双胞胎出生率最高的州。

I practiced in Massachusetts for twenty one years where there's a very generous insurance mandate and Massachusetts had the highest rate of twin birth in the nation in the early nineties.

他们让蓝十字和TEFFS，我记得是让医疗总监协助推行了单胚胎移植的强制规定，这确实大大降低了多胎妊娠的风险。

They instituted Blue Cross and TEFFS, I believe instituted a mandate, a single embryo transfer mandate with the help of the medical directors, and it did help to dramatically reduce the risk of multiples.

据我所知，确实如此。

As I understand it, can confirm it.

如果患者同意单胚胎移植，保险公司就会覆盖费用。

The patients would be covered if they agreed to a single embryo transfer,

但是

but

如果选择双胚胎移植，就不覆盖。

not if they chose a double embryo transfer.

而且他们还延长了保险覆盖范围。

And they also extended the coverage.

如果他们同意单胚胎移植，保险公司会为他们覆盖更多的周期。

If they agreed to single embryo transfer, they would cover more cycles for them.

他们会延长保险，覆盖更多的移植和周期，这对双方都有好处，是的。

They would extend their coverage to include more transfers and more cycles, which was a win for both, Yeah.

回到你最初提到的点，我们都理解不孕不育患者那种急切想要孩子、甚至想尽快要孩子的心情。

Getting back to one of your original points, think we all get the feeling of urgency, people with infertility, to have their children and maybe have them as quick as possible.

如果不知道双胞胎的风险，他们当然会说，那就放两个吧，这完全可以理解。

And without knowing the risks of twins, it's certainly understandable why they would say, Let's put two in.

但话说回来，既然我们现在已经知道并承认了确实存在风险，我们的一般默认做法也和以前不一样了。

But again, now that we know and have kind of acknowledged that there is real risk there, our general default approach is different than it used to be.

而且现在怀孕率相对较高，即使每次只移植一个胚胎，成功率也能达到百分之五十、六十、六十五。

And with the relatively high pregnancy rates, even with whenever you're going back at one at a time, fifty, sixty, sixty five percent.

很多人第一次移植就成功了，如果第一次没成功，四周后再来试一次。

Many people are pregnant right out of the gate, and if the first transfer doesn't work, you come back four weeks later and try another transfer.

所以实际上，这并不会明显推迟第一次怀孕的时间。

So it really doesn't even involve an appreciable delay to the first pregnancy.

对，我觉得患者需要知道，试管婴儿整体上成功率很高，真的不必第一次就移植两个胚胎，除非年龄较大且没有做基因检测。

Right, I think patients need to know that IVF in general offers patients high chances of success and that they really don't have to transfer two embryos in their first transfer, unless they're older and they're not testing.

所以对很多患者来说，移植单个胚胎是合理的。

So single embryo transfer makes sense for a lot of patients.

再说，根据全国的经验，现在大约百分之六十五的胚胎移植都是单胚胎移植，而十五年前这个比例还不到百分之五。

Again, based on the national experience, now about sixty five percent of all the embryo transfers are single embryo transfers, and it used to be under five percent fifteen years ago.

所以还没有达到百分之百。

So it isn't at one hundred percent.

不过，在某些情况下，移植两个胚胎可能还是合适的，通常是在不知道胚胎基因检测结果的情况下。

There's still some situations where a double embryo transfer might be appropriate, usually in the context of embryos where you don't know the genetic testing results.

但如果你知道基因检测结果，同时移植两个正常的胚胎，可能会给将来出生的孩子的健康带来一些挑战。

But if you do know the genetic testing results, putting back two normal ones at once is inviting some challenges for the health of the children that result.

好的，非常感谢您抽出时间和我们聊聊您在这个领域的专业见解，医生。

Well, thank you so much for taking the time to speak with us about your expertise in this area, Doctor.

托纳医生。

Toner.

患者们真的会从您的分享中受益匪浅，这是一个非常重要的话题，也真正代表了体外受精领域的巨大进步。

Patients really would benefit from hearing what you have to say, and this is a really important topic and really represents tremendous progress in in vitro fertilization.

我们在减少多胎妊娠方面取得的进展，真的能帮助婴儿和儿童过上更健康的生活。

The progress we've made in reducing multiples really will help babies and children go on to lead healthier lives.

好的，也感谢您给我这个机会和您讨论。

Well, you for the chance to discuss this with you.

是的，恭喜您发表了这篇非常出色的论文。

Yeah, congratulations on this really excellent paper.

本播客中表达的信息和观点不一定代表ASRM及其附属机构的立场。

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and its affiliates.

这些内容仅供一般信息参考，不能替代医生的专业咨询。

These are provided as a source of general information and are not a substitute for consultation with a physician.