#1
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ÝÊÎ ñóáêëèíè÷åñêèé ãèïîòèðåîç
Äîáðûé äåíü, êîëëåãè. Îáðàùàþñü çà ïîìîùüþ. Æåíùèíà, 46 ëåò, ïëàíèðóåò ÝÊÎ -ÒÒà 2.75 ìÅä/ë, ñâ. Ò4 14,3 ïìîëü/ë, àíòèÒÏÎ ìåíåå 3. Ñîãëàñíî ïîñëåäíèì Àìåðèêàíñêèì ðåêîìåíäàöèÿì ÿ äîëæíà íàçíà÷èòü Ë-òèðîêñèí 25 ìêã? Îñòàëüíûå ïîêàçàòåëè â íîðìå.
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#2
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Îòêóäà âîîáùå èäåÿ î ÑÃ?
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Ã.À. Ìåëüíè÷åíêî |
#3
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Óâàæàåìàÿ Ãàëèíà Àôàíàñüåâíà, ÿ îñíîâûâàþñü íà ðåêîìåíäàöèÿõ ATA, 2017, â êîòîðûõ ïðåäëàãàþò òåðàïèþ LT4 ïðè óðîâíå ÒÒà áîëåå 2.5 ìÅä/ë ( ðåêîìåíäàöèÿ 20, âîïðîñ 26) [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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#4
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Êîìó ? Ðå÷ü èä¸ò î öèôðå â ïåðâîì òðèìåñòðå- ïðè ÷åì çäåñü ÒÒà äî ÝÊÎ?
25 ìêã òèðîêñèíà , áåññïîðíî, èëëþçèÿ ëå÷åíèÿ è ñêîðåå èìèòàöèÿ áóðíîé äåÿòåëüíîñòè- íî ýòî äàæå àìåðèêàíöû ïðåäëàãàþò ÷åðåç ÷åðòî÷êó - 25-50 ìêã, åñëè ýòà öèôèðü â ïåðâîì òðèìåñòðå, åñòü àòòïî è óæ òåì áîëåå âûêèäûøè â ïðîøëîì Ðóññêèì ÿçûêîì Àìåðèêàíñêèé Ãàéä ïèøåò:æåíùèíû ñ ñóáêëèíè÷åñêèì ãèïîòèðåîçðì, èäóùèå íà ÝÊÎ ( òî åñòü ëþäè ñ ÒÒà 4,0 è äàëåå äî 10 ñ õâîñòîì äàæå, íî ñ íîðìàëüíûì ñâ Ò4) , èäóùèå íà ÝÊÎ, äîëæíû ïîëó÷àòü ëå÷åíèå òèðîêñèíîì äëÿ äîñòèæåíèÿ ÒÒà < 2,5 Ïðè ÷åì çäåñü óäóøàÿ íà ÝÊÎ çäîðîâàÿ ñ íîðìàëüíûì ÒÒà áåç àíòèòåë?
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Ã.À. Ìåëüíè÷åíêî |
#5
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ß ñ Âàìè ïîëíîñòüþ ñîãëàñíà. Ìåíÿ ñìóùàåò äàííûé âîïðîñ 26, â êîòîðîì ÷¸òêî íàïèñàíî, ÷òî ïðè óðîâíå ÒÒà áîëåå 2,5 ìÅä/ë öåëåñîîáðàçíî ðåêîìåíäîâàòü ëå÷åíèå LT4.
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#6
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Ìÿ òîæå ñòàëêèâàåìñÿ ñ ýòîé ïðîáëåìîé. Íà ÂÐÒ ÍÅ ÂÎÇÜÌÓÒ æåíùèíó ñ ÒÒÃ áîëåå 2,50, ìîòèâèðóÿ, ÷òî îíè ðàáîòàþò ñòðîãî ïî ïðîòîêîëàì.
Èíîãäà â òàêîé ñèòóàöèè ïðîøó ïåðåñäàòü àíàëèç è â ñëó÷àå ðåçóëüòàòà ìåíåå 2,5 ïîêàçûâàåì åãî. Ñïîðèòü áåñïîëåçíî. Ìíå áûë èíòåðåñåí îòâåò. Ïðîáëåìû ó âñåõ îäíè è òå æå - áþðîêðàòèçàöèÿ, ìàðøðóòåðèçàöèÿ... |
#7
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Íå ïîëó÷àåòñÿ.
Ýòî æåíùèíà áåç àíòèòåë è áåç âûêèäûøåé Âïðî÷åì, ïîñêîëüêó 25 ìêã ôèçè÷åñêè íå ìîãóò ÷òî áû òî íè áûëî èçìåíèòü, à ïðîöåäóðà ÝÊÎ, åñëè âî âðåìÿ îíîé ïîñìîòðåòü ñäóðó ÒÒÃ, ìîæåò îíûé ðåçêî ñíèçèòü, áóäåòå äîëãî ðàññêàçûâàòü, êàê ãîðìîíàìè òðàâèëÈ ß íå ïîíèìàþ, êàê îíè âûðâàëè èç êîíòåêñòà ýòó öèôèðü.
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Ã.À. Ìåëüíè÷åíêî |
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#8
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Áëàãîäàðþ çà îòâåò!
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#9
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Öèòàòà:
Äata generally demonstrate that treatment of more significant elevations in TSH concentrations (although still classified as subclinical hypothyroidism) appears beneficial. íî â ôèíàëüíîì àêêîðäå recommend treatment of subclinically hypothyroid women seeking pregnancy with ART for any TSH elevation >2.5 mU/L. Ýòî ïîõîæå ïîäìåíà ïîíÿòèé èëè áàíàëüíàÿ îïèñêà
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
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Âîïðîñ ïî îïðåäåëåíèþ ÍÅ ÐÅÊÎÌÅÍÄÀÖÈß, âîïðîñ - ýòî âîïðîñ.
Äàëåå îáúÿñíÿåòñÿ, êàê íà ýòîò Âîïðîñ ÷åëîâå÷åñòâî äàâàëî îòâåòû è ïðèâîäÿòñÿ äàííûå êîíêðåòíûõ èññëåäîâàíèé. Ïðè ýòîì â äîñòàòî÷íî ñæàòîé ôîðìå îáúÿñíÿåòñÿ äèçàéí èññëåäîâàíèÿ. Òàê âîò, â òîé ñàìîé èíôîðìàöèè î ïåðâîì èññëåäîâàíèè, ñ èñêóññòâåííîé èíñåìèíàöèåé, ÈÑÑËÅÄÎÂÀÒÅËÈ ( !!!) â êà÷åñòâå îòðåçíîé òî÷êè äëÿ ïðèíÿòèÿ ðåøåíèÿ î äèàãíîñòèêå Ñà ñ÷èòàëè ( ñâåòëûé îáðàç ÝÊ Ñïåíñåð) ÒÒà ìåíåå 2,5 ( ýòî ïàìÿòü î ïîèñêå îòðåçíûõ êðèòåðèåâ) è äàëåå ýïîïåÿ ñ òåì, ÷òî ïîëó÷èëîñü ó íèõ, ÷òî ó äðóãèõ ñ äðóãèì äèçàéíîì- ýòî ìèíèîáçîð, íå ðóêîâîäñòâî ê äåéñòâèþ ß áëàãîäàðíà Âàì çà èäåþ äëÿ ëåêöèè- êàê ìîæíî ïðî÷åñòü ãàéä...
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Ã.À. Ìåëüíè÷åíêî |
#11
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îïÿòü æåæ, õîòÿ
According to the recommendation of the American Society for Reproductive Medicine, the level of TSH before entering the IVF program should not exceed 2.5 mIU/L [5] íèæå èäåò ïîäðàçdåëåíèå ïî öèôðàì: According to a recent statement of the ARSM [5], there is good evidence that thyroid autoimmunity and/or SCH (defined as a serum TSH level ≥4.0 mIU/L) is associated with miscarriage. LT4 treatment may improve pregnancy outcomes in women undergoing ART, especially if the serum TSH level is ≥2.5 mIU/L with thyroid autoimmunity or >4.0 mIU/L in general. èç îáçîðà íèæå: Does subclinical hypothyroidism and/or thyroid autoimmunity influence the IVF/ICSI outcome? Review of the literature [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#12
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Òàêèì îáðàçîì, âîçâðàùàåìñÿ ê íà÷àëó - ýòó ïåñíþ óçíàåì ñ òðåõ íîò- ÒÒà + àòòïî + àíàìíåç áåñïëîäèÿ.
ÒÒà áîëüøå 4,0 = ëå÷èì ÒÒà ìåíüøå 4.0, íî áîëüøå 2,5 + ëþáîé èç ïåðå÷èñëåííûõ = ëå÷èì, íî óæ äà¸ì íå÷òî îñÿçàåìîå È ãëàâíîå! ×åãî õî÷åò ñàìà æåíùèíà- ÷òîáû íå òðàòèòü âðåìÿ íà áåñêîíå÷íûå ðàçãîâîðû î åå ãîðìîíàõ
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Ã.À. Ìåëüíè÷åíêî |
#13
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÷òî êàñàåòñÿ ðåôåðåíòíûõ çíà÷åíèé ÒÒà â ïåðâîì òðèìåñòðå, î÷åíü âàæíî ó÷èòûâàòü, êàêàÿ èìåííî íåäåëÿ áåðåìåííîñòè ó æåíùèíû? íèæå ïðèìåð îò äàò÷àí, ãäå áûëî èññëåäîâàíî áîëåå 500-1200 ïàöèåíòîê â êàæäóþ íåäåëþ áåðåìåííîñòè â ïåðèîä ñ 5 ïî 12 íåäåëè áåðåìåííîñòè è çàìåòèëè, ÷òî íîðìàëüíûå öèôðû ÒÒà â 6-7 íåäåëü è 10-12 íåäåëè - äâå áîëüøèå ðàçíèöû: íà 6-7 íåäåëå öèôðà 3.5 âñå åùå íà óðîâíå 97.5 ïåðöåíòèëè, à íà 10-12 íåäåëå 97.5 ïåðöåíòèëü êîëåáëåòñÿ íà óðîâíå 3.1-3.2
Table 2. TSH and fT4 Reference Intervals for Each Gestational Week in 6671 Healthy Danish Pregnant Women [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] èç Dynamics and Predictors of Serum TSH and fT4 Reference Limits in Early Pregnancy: A Study Within the Danish National Birth Cohort [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#14
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À åñòü åù¸ black- òå ñàìûå, ó êîèõ ÒÒà íèæå ïî îïðåäåëåíèþ, èç- çà ÷åãî âåñü ñûð- áîð ñî ñíèæåíèåì ðåôåðåíòîâ è ðàçãîðàëñÿ â êîíöå 90-õ
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Ã.À. Ìåëüíè÷åíêî |
#15
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Áóäóò ëè âíåñåíû èçìåíåíèÿ â Ïðîòîêîëû ÝÊÎ â ÐÔ?
Îíè - ãèíåêîëîãè - íàñ íå ñëûøàò, à æåíùèíû íà êàêèå òîëüêî óõèùðåíèÿ íå èäóò èç-çà ýòèõ äåñÿòûõ, äàæå ñêàçàòü ñìåøíî - âíîñÿò êîððåêòèâû â ëèñòî÷êè ñ àíàëèçàìè èíîãäà, ïðèáåãàÿ ê ôîòîøîïàì è èñïðàâëåíèÿì èëè êîïèðîâàíèÿì. Êñòàòè, ÓÇÈ ùèòîâèäíîé æåëåçû - òîæå îáÿçàòåëüíûé êîìïîíåíò. Òåì íå ìåíåå, íà äíÿõ áûëà æåíùèíà ñ òÿæåëûì ïîðîêîì ñåðäöà - åé êàêèì-òî îáðàçîì ðàçðåøèëè, à åé è âûíàøèâàíèå íå ïîêàçàíî. |