B GIO DC V O TO B Y T

TRNG I HC Y H NI

PHAN TH KHNH VY

NGHIN CU MT S YU T LIN
QUAN VI LCH BI NHIM SC TH
CA PHI NGI TRC LM T

LUN N TIN S Y HC

H NI - 2015
B GIO DC V O TO B Y T
TRNG I HC Y H NI

PHAN TH KHNH VY

NGHIN CU MT S YU T LIN
QUAN VI LCH BI NHIM SC TH
CA PHI NGI TRC LM T

Chuyn ngnh : M phi thai hc

M s : 62720103

LUN N TIN S HC

Ngi hng dn khoa hc:

1. PGS.TS. Nguyn Th Bnh
2. PGS. Eva Littman

H NI - 2015
 LI CM N

Trong qu trnh hon thnh lun n ny, ti nhn c s gip

chn tnh, hiu qu ca nhiu c nhn, tp th, cc thy c gio, cc ng
nghip cng gia nh v bn b.
Trc tin, ti xin by t lng bit n ti PGS.TS. Nguyn Th Bnh v
PGS. Eva Littman trc tip hng dn khoa hc cho ti trong sut qu
trnh hc tp, nghin cu v hon thnh lun n nghin cu sinh.
Xin cm n cc thy (c) trong B mn M-Phi v Di truyn trng
i Hc Y H ni v Hc vin Qun Y cho ti nhng li khuyn v kin
qu bu ti hon thnh lun n ny.
Xin cm n B Mn M-Phi, Phng Sau i Hc trng i hc Y
H ni, Trung tm th tinh ng nghim Red Rock, Trung tm di truyn
Genesis Genetics gip h tr v to iu kin cho ti trong qu trnh
hc tp, nghin cu thc hin ti ny. .
c bit bn lun n ny l mn qu ti dnh tng cc thnh vin
trong gia nh ti, nhng ngi lun bn ti, c v v ng vin ti
nhng lc kh khn c th vt qua v hon thnh lun vn ny.
Ti xin chn thnh cm n!

Tc gi lun n
 LI CAM OAN

Ti l Phan Th Khnh Vy, nghin cu sinh kha 31 Trng i Hc Y

H Ni, chuyn ngnh M phi - Thai hc, xin cam oan:

1. y l lun n do bn thn ti trc tip thc hin di s hng dn

ca PGS.TS. Nguyn Th Bnh v PGS. Eva Littman.

2. Cng trnh ny khng trng lp vi bt k nghin cu no khc

c cng b ti Vit Nam.

3. Cc s liu v thng tin trong nghin cu l hon ton chnh xc, trung
thc v khch quan, c xc nhn v chp thun ca c s ni
nghin cu.

Ti xin hon ton chu trch nhim trc php lut v nhng cam kt ny.

H Ni, ngy thng nm 2015

Tc gi lun n

Phan Th Khnh Vy
 CC THUT NG V CH VIT TT
a-CGH : Array Comparative Genomic Hybridization/lai so snh/i chiu b
gen dng chp DNA
a-SNP : Array Single Nucleotide Polymorphism/phn tch a hnh n
dng chp DNA
DNA : DeoxyriboNucleic Acid
FISH : Fluorescent In Situ Hybridization/lai hunh quang ti ch
FSH : Follicle Stimulating Hormone
GnRH : Gonadotropin Releasing Hormone
GnRHa : GnRH agonist/cht ng vn
GnRH anta : GnRH antagonist/cht i vn
hCG : Human Chorionic Gonadotropin
ICM : Inner Cell Mass/nguyn bo phi-mm phi
ICSI : IntraCytoplasmic Sperm Injection/tim tinh trng vo bo tng
ca non
IU : International Unit/n v quc t
IUI : Intra-Uterine Insemination/Bm tinh trng vo bung t cung
IVF : In-Vitro Fertiliztion/th tinh trong ng nghim
LBNST : Lch bi nhim sc th
LH : Luteinizing Hormone
LR : Likelyhood Ratio/t s kh nng
NGS : Next Generation Sequencing/gii trnh t gene th h mi
NST : Nhim sc th
PB : Phi bo
qPCR : Quantitative Polymerase Chain Reaction/Phn ng chui nh lng
RNA : RiboNucleic Acid
RR : Relative Risk/nguy c tng i
RRFC : Red Rock Fertility Center/trung tm th tinh ng nghim Red Rock
TE : Trophectoderm/nguyn bo l nui
 MC LC
T VN ............................................................................................... 1
Chng 1: TNG QUAN .............................................................................. 4
1.1 S pht trin ca phi trc khi lm t. ................................................. 4
1.1.1 Phi giai on tin nhn. .............................................................. 4
1.1.2. Phi giai on phn chia (ngy 2-3 sau th tinh). ........................ 4
1.1.3 Phi du (phi ngy 4). ................................................................... 8
1.1.4 Phi nang (phi ngy 5-6). .............................................................. 9
1.1.5 Cc phng php nh gi cht lng phi. .................................. 11
1.2. Hin tng lch bi nhim sc th ca non v phi. ......................... 14
1.3. Phi th khm..................................................................................... 17
1.4. Cc phng php phn tch nhim sc th ca non v phi............... 18
1.4.1. Phng php lai hunh quang ti ch (fluorescent in situ
hybridization/FISH). .................................................................... 19
1.4.2. Phng php lai so snh b gen (comparative genomic
hybridization/CGH). .................................................................... 20
1.4.3. Phng php lai so snh b gen dng chp DNA (array
comparative genomic hybridization/a-CGH)................................ 21
1.4.4. Phng php phn tch a hnh n nucleotide dng chp DNA
(array Single Nucleotide Polymorphism /a-SNP). ........................ 21
1.4.5. Phng php phn ng chui Polymerase (Polymerase chain
reaction/PCR). ............................................................................. 21
1.4.6. Phng php gii trnh t gen th h mi (Next Generation
Sequencing/NGS). ....................................................................... 22
1.5. T l lch bi nhim sc th non, phi v mt s yu t lin quan. ... 22
1.5.1. T l lch bi nhim sc th non. ............................................ 22
1.5.2. T l lch bi nhim sc th tin nhn. ..................................... 22
 1.5.3. T l lch bi nhim sc th phi ngy 3. ................................. 23
1.5.4. T l lch bi nhim sc th phi nang. .................................... 24
1.6. Hin tng t sa cha ca phi lch bi nhim sc th ngy 3. ........ 25
1.7. Mt s yu t lin quan n t l lch bi nhim sc th. .................. 26
1.7.1. S pht trin ca phi v t l lch bi nhim sc th. ................. 26
1.7.2. Hnh thi phi v t l lch bi nhim sc th. ............................. 29
1.7.3. Hormon kch thch bung trng, s p ng ca bung trng
v t l lch bi nhim sc th. .................................................... 34
1.7.4. Mt s nguyn nhn gy v sinh c lin quan n t l lch
bi nhim sc th. ........................................................................ 35
1.7.5. K thut th tinh trong ng nghim nh hng n t l lch
bi nhim sc th. ........................................................................ 36
1.7.6. Cc cp nhim sc th v t l lch bi nhim sc th. ................ 38
1.7.7. Tui m v t l lch bi nhim sc th. ...................................... 39
1.7.8. Yu t mi trng nh hng n lch bi nhim sc th............ 40
Chng 2: I TNG V PHNG PHP NGHIN CU.................. 41
2.1. i tng nghin cu. ........................................................................ 41
2.1.1. Tiu chun chn lc i tng. .................................................... 41
2.1.2. Tiu chun loi tr. ...................................................................... 41
2.1.3. S lng i tng. ...................................................................... 41
2.2. Phng php nghin cu v thu thp s liu....................................... 42
2.2.1. Thit k nghin cu. ..................................................................... 42
2.2.2. Phng php tin hnh v thu thp s liu.................................... 43
2.3. Phng tin nghin cu. ..................................................................... 48
2.4. Cc ch s, bin s nghin cu............................................................ 48
2.4.1. Cc ch s v c im mu nghin cu: ...................................... 48
2.4.2. Cc ch s v kt qu a-CGH:....................................................... 49
2.4.3. Cc tiu chun c lin quan n nghin cu. ................................ 49
 2.5. X l s liu. ...................................................................................... 51
2.6. Vn o c trong nghin cu. ...................................................... 53
Chng 3: KT QU .................................................................................. 54
3.1. c im bnh nhn c xt nghim phi bng phng php a-CGH ... 54
3.2. T l lch bi nhim sc th phi ngy 3 sau th tinh. ..................... 55
3.2.1. T l lch bi nhim sc th v mc lch bi nhim sc th. ... 55
3.2.2. T l lch bi nhim sc th phn b theo cp nhim sc th. ...... 58
3.3. Kh nng t sa cha ca phi ngy 3 b lch bi nhim sc th........ 59
3.3.1. Kh nng pht trin thnh phi nang ca phi lch bi nhim
sc th ngy 3. ............................................................................. 59
3.3.2. Kh nng t sa cha ca phi ngy 3 b lch bi nhim sc th. ... 59
3.3.3. Mi lin quan gia kh nng t sa cha ca phi LBNST ngy
3 v tui m. ................................................................................ 60
3.4. Mt s yu t lin quan n lch bi nhim sc th qua phn tch
n bin. ................................................................................................... 61
3.4.1. Tin s sy thai, iu tr v sinh v lch bi nhim sc th. ......... 61
3.4.2. Nguyn nhn v sinh v lch bi nhim sc th. .......................... 61
3.4.3. Tui m lin quan n lch bi nhim sc th. ............................. 62
3.4.4. Nng FSH c bn ca m lin quan n lch bi nhim sc th. ... 62
3.4.5. Tc pht trin v hnh thi ca phi ngy 3 v lch bi
nhim sc th. ............................................................................. 63
3.4.6. Tc pht trin thnh phi nang, hnh thi ca phi nang v
lch bi nhim sc th.................................................................. 69
3.5. Mt s yu t lin quan n lch bi nhim sc th qua phn tch
a bin. ..................................................................................................... 77
3.5.1. Phn tch a bin 2 yu t: S lng phi bo v tui m. ........... 77
 3.5.2. Phn tch a bin 2 yu t: s lng phi bo v s c mt mnh
vn. .............................................................................................. 78
3.5.3. Phn tch a bin 2 yu t: ng u v kch thc phi bo
v s c mt mnh vn. ............................................................... 79
3.5.4. Phn tch a bin 3 yu t: S phi bo, ng u v s c
mt mnh vn. ............................................................................. 80
3.5.5. Phn tch a bin 3 yu t: S phi bo, s c mt mnh vn,
v v tr mnh vn. ....................................................................... 83
Chng 4: BN LUN ............................................................................... 89
4.1. Bn lun v phng php phn tch di truyn. .................................... 89
4.1.1. Bn lun v vic sinh thit phi. .................................................. 89
4.1.2. Bn lun v phng php a-CGH. ............................................... 92
4.2. Bn lun v t l lch bi nhim sc th ca phi ngy 3. .................. 94
4.3. Bn lun v kh nng t sa cha ca phi lch bi nhim sc th. ... 96
4.4. Bn lun v mt s yu t lin quan n lch bi nhim sc th
qua phn tch n bin. ........................................................................... 102
4.4.1. Tin s iu tr th tinh trong ng nghim tht bi lin quan n
lch bi nhim sc th................................................................ 102
4.4.2. Nguyn nhn v sinh lin quan n lch bi nhim sc th........ 103
4.4.3. Tui m lin quan n lch bi nhim sc th. ........................... 105
4.4.4. Nng FSH c bn lin quan n lch bi nhim sc th. ....... 107
4.4.5. Tc pht trin ca phi ngy 3 sau th tinh (biu th qua
s lng phi bo) lin quan n lch bi nhim sc th. .......... 109
4.4.6. Hnh thi ca phi ngy 3 lin quan n lch bi nhim sc th. ...... 112
4.4.7. S pht trin ca phi t ngy 3 n giai on phi nang lin
quan n lch bi nhim sc th................................................. 116
4.4.8. Mc lch bi nhim sc th v kh nng hnh thnh phi nang.... 119
 4.4.9. Kh nng pht trin thnh phi nang vo ngy 5 v gii tnh
ca phi lin quan n lch bi nhim sc th. .......................... 119
4.4.10. Cht lng ca phi nang (biu th qua cht lng ca mm phi
v nguyn bo l nui) lin quan n lch bi nhim sc th. ...... 121
4.5. Bn lun v mt s yu t lin quan n lch bi nhim sc th qua
phn tch a bin. .................................................................................... 122
4.5.1. Hai yu t: tui m v tc pht trin ca phi vo ngy 3 lin
quan n lch bi nhim sc th................................................. 123
4.5.2. Hai yu t: s lng phi bo v s c mt mnh vn lin quan
n lch bi nhim sc th. ........................................................ 124
4.5.3. Hai yu t: ng u v kch thc ca phi bo v s c
mt ca mnh vn c lin quan n lch bi nhim sc th........ 125
4.5.4. Ba yu t: s lng phi bo, ng u v s c mt ca
mnh vn lin quan n lch bi nhim sc th. ........................ 126
4.5.5. Ba yu t: s lng phi bo, s c mt mnh vn v v tr
mnh vn lin quan n lch bi nhim sc th. ........................ 127
KT LUN ................................................................................................ 129
NHNG NG GP MI CA NGHIN CU ..................................... 131
KIN NGH ............................................................................................... 132
HNG NGHIN CU TIP THEO ....................................................... 133
CC CNG TRNH CNG B LIN QUAN N LUN N
TI LIU THAM KHO
PH LC
 DANH MC BNG
Bng 1.1: ng thun v h thng nh gi tin nhn ca t chc
Alpha. ....................................................................................... 11
Bng 1.2: ng thun v h thng nh gi phi giai on phn chia
ca t chc Alpha. .................................................................... 12
Bng 2.1: Bng tnh thng k lin quan gia yu t ch bo v t l
LBNST. .................................................................................... 52
Bng 3.1: c im tui m...................................................................... 54
Bng 3.2: c im v nguyn nhn v sinh. ........................................... 54
Bng 3.3: Tin s sn khoa c lin quan. .................................................. 55
Bng 3.4: T LBNST th phn b theo cc cp nhim sc th t thp
n cao. .................................................................................... 58
Bng 3.5: Kh nng pht trin thnh phi nang ca phi LBNST ngy 3..... 59
Bng 3.6: Kt qu nh gi li bng sinh thit t bo l nui ngy 5-6
ca phi nang pht trin t phi ngy 3 c LBNST. ................. 60
Bng 3.7: Kh nng t sa cha ca phi v tui m................................ 60
Bng 3.8: Tin s sy thai, iu tr v sinh v LBNST. ............................ 61
Bng 3.9: Nguyn nhn v sinh v LBNST. ............................................. 61
Bng 3.10: Tui m v nguy c LBNST. .................................................... 62
Bng 3.11: Nng FSH c bn v LBNST. ............................................. 62
Bng 3.12: S pht trin ca phi ngy 3 v LBNST.................................. 63
Bng 3.13: S ng u ca cc phi bo v LBNST. ................................ 65
Bng 3.14: S xut hin mnh vn trong phi v LBNST. ......................... 66
Bng 3.15: S phn b mnh vn v LBNST. ............................................ 67
Bng 3.16: S pht trin thnh phi nang v LBNST. ................................ 69
Bng 3.17: So snh gia phi pht trin chm n ngy 6 mi hnh thnh
phi nang v phi pht trin nhanh n ngy 5 thnh phi
nang v LBNST. ....................................................................... 70
Bng 3.18: Tc pht trin ca phi vo ngy 5 v LBNST. ................... 71
Bng 3.19: Mc LBNST v kh nng hnh thnh phi nang. ................. 72
Bng 3.20: Gii tnh ca phi nang ngy 5 v LBNST. .............................. 73
Bng 3.21: Cht lng ca mm phi v LBNST. ...................................... 73
Bng 3.22: Cht lng ca nguyn bo l nui phi v LBNST. ................ 74
Bng 3.23: Cht lng phi nang ni chung v LBNST. ............................ 74
Bng 3.24: Cht lng phi nang ngy 5 v LBNST. ................................. 75
Bng 3.25: Cht lng phi nang ngy 6 v LBNST. ................................. 76
Bng 3.26: Lin quan gia tui m; s lng phi bo v LBNST. ............ 77
Bng 3.27: Lin quan gia s lng phi bo; t l mnh vn v LBNST. ..... 78
Bng 3.28: Phi bo khng u, mnh vn > 15% v LBNST. ................... 79
Bng 3.29: Phi bo khng u, mnh vn >5% v LBNST....................... 80
Bng 3.30: Phi pht trin nhanh/chm, kch thc phi bo khng u,
mnh vn >15% v LBNST...................................................... 81
Bng 3.31: Phi pht trin nhanh/chm, kch thc phi bo khng u,
mnh vn >5% v LBNST........................................................ 82
Bng 3.32: Phi pht trin nhanh/chm, mnh vn > 15%; phn b ri
rc v LBNST........................................................................... 83
Bng 3.33: Phi pht trin nhanh/chm, mnh vn >5% phn b ri rc
v LBNST. ............................................................................... 84
Bng 3.34: Cc yu t ch bo (CB) c gi tr d on LBNST ca phi
xp t cao xung thp. .............................................................. 85
 DANH MC HNH
Hnh 1.1: S pht trin ca phi ngy 2 v 3 .............................................. 7
Hnh 1.2: Phi du ngy 4 .......................................................................... 8
Hnh 1.3: Phi giai on to nang/ cavitation .............................................. 9
Hnh 1.4: Phn loi phi nang ................................................................... 14
Hnh 2.1: Phng php tim tinh trng vo bo tng non ...................... 44
Hnh 2.2: Phng php sinh thit phi bo ngy 3 ..................................... 45
Hnh 2.3: Kt qu a-CGH phi 46,XX . ..................................................... 46
Hnh 2.4: Kt qu a-CGH phi 46,XY . ..................................................... 46
Hnh 2.5: Phng php sinh thit nguyn bo l nui ............................... 47
Hnh 3.1: Kt qu a-CGH ca 1257 phi ngy 3. ....................................... 55
Hnh 3.2: Th loi (mc LBNST) ca 1257 phi ngy 3 ....................... 56
Hnh 3.3: Lch bi NST th phc tp ( 4 cp NST). ............................... 56
Hnh 3.4: Lch bi 3 cp NST (45,XY;+15,-16,-19). .............................. 57
Hnh 3.5: Lch bi 2 cp NST (44,XX;-17,-19). ..................................... 57
Hnh 3.6: Lch bi NST 18 (47,XY; +18)............................................... 57
Hnh 3.7: Lch bi NST 22 (45,XX;-22). ............................................... 57
Hnh 3.8: Phi s 4 vo ngy 3 ca bnh nhn Zaic.S................................ 64
Hnh 3.9: Phi s 2 vo ngy 3 ca bnh nhn Garcia.A............................ 64
Hnh 3.10: Phi s 9 vo ngy 3 ca bnh nhn Borchardt.M. ..................... 65
Hnh 3.11: Phi s 7 vo ngy 3 ca bnh nhn Waner.T. ........................... 66
Hnh 3.12: Phi s 4 vo ngy 3 ca bnh nhn Lucente.M. ........................ 67
Hnh 3.13: Phi s 5 vo ngy 3 ca bnh nhn Dacy.S. ............................. 68
Hnh 3.14: Phi s 8 vo ngy 3 ca bnh nhn Dittrich.J. .......................... 68
Hnh 3.15: Phi s 6 vo ngy 3 ca bnh nhn Shen.M.............................. 69
Hnh 3.16: Phi s 7 v 8 vo ngy 5 ca bnh nhn Guarino.T. ................. 76
Hnh 3.17: Phi s 3 ca vo ngy 6 ca bnh nhn Cherry.E. .................... 77
 1

T VN

Phng php th tinh trong ng nghim (In-Vitro Fertilizaion/ IVF)

ng mt vai tr quan trng trong lnh vc h tr sinh sn, v ngy cng c
pht trin rng khp trn th gii. iu tr th tinh trong ng nghim t
kt qu cao m bo cho ra i mt th h kho mnh v th lc, sng sut v
tinh thn, gp phn nng cao cht lng dn s th vic nghin cu mt
phng php u vit la chn phi tt c b nhim sc th (NST) bnh
thng l yu cu cp thit v thc tin.
Hin nay, vic la chn phi thng ch da trn nhng tiu chun v
hnh thi ca phi nh: kch thc v s lng cc phi bo, s lng nhn
ca phi bo v t l cc mnh vn t bo trong phi [1]. Chng ta u bit
rng nh gi v hnh thi khng phn nh y cht lng thc ca phi,
hn ch n kt qu iu tr th tinh trong ng nghim. Nhiu khi phi c
ch s hnh thi cao li khng lm t c hoc khng to ra tr kho mnh,
ngc li, mt s lng phi c ch s hnh thi thp li c th to ra em b
bnh thng. Trong nhiu trng hp, phi khng pht trin v khng lm t
c hoc b sy sm l do phi b ri lon v s lng nhim sc th nh: v
nhim (thiu c hai nhim sc th tng ng), n nhim (thiu mt nhim
sc th), tam nhim (tha mt nhim sc th). Hin tng thiu, tha nhim
sc th ni trn gi l lch bi nhim sc th (LBNST/aneuploidy).
Lch bi nhim sc th non v phi ngi thu c trong qu trnh
iu tr th tinh trong ng nghim c nu ln t lu v rt nhiu nghin
cu cng cng nhn l hin tng lch bi nhim sc th xy ra giai
on trc khi lm t. Ri lon lch bi nhim sc th tng theo tui, hn mt
na s non thu c ca ph n trn bn mi tui c ri lon lch bi
nhim sc th. T l lch bi nhim sc th cng tng trn phi ca cc cp v
chng b sy thai lin tip hoc tng iu tr th tinh trong ng nghim
 2

hoc bm tinh trng vo bung t cung (IUI/ Intra-Uterine Insemination)

nhiu ln tht bi. Phn ln cc trng hp, lch bi nhim sc th gy nh
hng n s sng v pht trin ca phi. Phi b lch bi nhim sc th c
th biu hin qua hnh thi ca phi.
Nhiu nghin cu cp n hnh thi ca phi nh phi c nhiu
mnh vn t bo, phi c kch thc cc phi bo khng ng u, phi bo
a nhn, phi c s lng phi bo khng in hnh u c lin quan n lch
bi nhim sc th [2]. Tuy nhin, nhiu nghin cu cho rng mi lin quan
ny khng cht ch do nhng gii hn v mt k thut, hoc cha c k thut
kim tra ton b nhim sc th ca phi.
Hu ht cc nghin cu cng nh th nghim lm sng trc y ch p
dng k thut lai hunh quang ti ch (FISH/Fluorescence In Situ
Hybridization) ch cho php kim tra mt s lng gii hn nhim sc th ca
phi (mt s lng ln nhim sc th khng c kim tra) suy lun nh
gi ton b phi nn t l chn on m tnh gi cao (phi b lch bi nhim
sc th m nh gi l bnh thng). Cc sai lm v nh gi phi ni trn s
lm cho t l phi chuyn b lch bi nhim sc th cao, lm gim t l c
thai, v quan trng hn l cho ra i nhng tr mang b nhim sc th bt
thng, gy ni au cho gia nh, gim cht lng dn s, thm gnh nng
cho x hi.
Trong vi nm gn y, mt s phng php xt nghim di truyn mi
c p dng xt nghim ton b 23 cp nhim sc th ca phi nh
phng php lai so snh b gen dng chp DNA (a-CGH/array-comparative
genomic hybridization), phng php phn tch a hnh n dng chp DNA
(a-SNP/Single-nucleotide polymorphism), phng php phn ng chui nh
lng (qPCR/quantitative polymerase chain reaction). Nh kt hp nhng
phng php mi ny cng vi tin b trong sinh thit phi ni chung v sinh
 3

thit phi giai on phi nang m cc nh lm sng c th chn la tng

i chnh xc 1-2 phi c s lng nhim sc th bnh thng, c kh nng
lm t cao chuyn phi, gp phn lm tng t l lm t, gim t l sy thai
v a thai.
Do vy k vng ca nghin cu ny l p dng mt k thut di truyn
phn t mi, s dng b th chp DNA gi l phng php lai so snh b gen
(array comparative genomic hybridization/ a-CGH) phn tch ton b 46
nhim sc th ca phi, lm c s khuyn co ng dng mt phng php
chn lc phi hu hiu, chnh xc hn gp phn lm tng hiu qu ca k
thut iu tr th tinh trong ng nghim, ng thi c d liu chnh xc
hn nghin cu mt s yu t lin quan n lch bi nhim sc th, lm c
s phng bnh, d on v t vn.
p ng c yu cu trn, nghin cu cn c cc mc tiu sau:
1. Xc nh t l lch bi nhim sc th trn 23 i nhim sc th ca
phi ngy 3 sau th tinh trong ng nghim bng k thut lai so snh
b gen (a-CGH) v kh nng t sa cha ca phi ngy 3 b lch
bi nhim sc th khi pht trin thnh phi nang.
2. Nghin cu mt s yu t lin quan vi lch bi nhim sc th ca
phi ngy 3 trc lm t.
 4

Chng 1
TNG QUAN

1.1 S pht trin ca phi trc khi lm t.

1.1.1 Phi giai on tin nhn.
Non c th tinh to thnh hp t v pht trin thnh phi qua nhiu
giai on, khi u l giai on tin nhn. Tin nhn c v tin nhn ci
thng hnh thnh cng mt lc. Tin nhn c hnh thnh gn v tr tinh
trng thm nhp v tin nhn ci hnh thnh cc bo tng c thoi phn bo
[3]. Khong 4 gi sau khi tim tinh trng vo bo tng ca non hoc 5-6
gi sau cy non vi tinh trng c th nhn thy hnh nh cc tin nhn c
kch thc nh v m. Khong 15 gi sau khi th tinh, hai tin nhn nm st
nhau v c hnh s 8, v phn tip xc st nhau to thnh mt mt phng,
ng thi cc ht nhn (nucleoli) s di chuyn v xp hng cnh vng tip
xc hai tin nhn. Mi tin nhn c khong 1 n 9 ht nhn. Tin nhn nh
c t ht nhn hn [4].
1.1.2. Phi giai on phn chia (ngy 2-3 sau th tinh).
* S phn chia bo tng (cytokinesis.)
S phn chia ca phi bao gm mt lot cc chu k phn bo ca bo
tng, mc d kch thc phi thay i khng ng k. Trung th ca tinh
trng kim sot s phn chia u tin sau th tinh [5].
Trong chu k phn bo u tin giai on cui, bo tng ca hp t
ko di ra v tht li dn gia cho n khi hp t phn chia thnh hai phi
bo. Qu trnh ny tip tc trong nhng chu k phn bo tip theo v kch
thc ca phi bo gim khong 28,5% cho mi chu k phn bo. Trong 3
chu k phn bo u tin, kch thc ca phi thng t thay i. Phi c 2
 5

n 8 phi bo ph thuc ch yu vo s dch m (translation) t cc cht liu

RNA ca m phn chia [6].
* Hnh thi bt thng ca phi xy ra trong qu trnh pht trin ca phi.
nh gi hnh thi ca phi to ra trong ng nghim ng vai tr quan
trng lm tng t l lm t v c thai trong iu tr th tinh trong ng nghim.
Phi to ra trong ng nghim c cc hnh thi khc nhau. hu ht cc trung
tm h tr sinh sn, nh gi cht lng ca phi thng da vo cc ch
s hnh thi nh s lng mnh vn t bo, kch thc ng nht ca phi
bo, s lng nhn t bo.
- Mnh vn t bo.
Mnh vn c to ra l do cc phi bo lun lun thay i hnh dng,
cc phi bo tip xc hoc khng tip xc vi nhau trong qu trnh phn chia,
v vy to nn nhng mnh vn t bo sau phn chia.
Phi c s lng mnh vn nhiu thng lm t km hn c th l do
gim lng bo tng sau chu k phn bo bnh thng v dn n gim s
lng phi bo phi nang. Nhiu mnh vn cng lm nh hng ti qu
trnh phi kt c li do gim tip xc gia cc phi bo vi nhau. Cc mnh
vn xut hin sm sau chu k phn bo u tin thng nh hng nhiu hn
n s pht trin ca phi. Mt khc, nhng mnh vn nh xut hin chm s
t hoc khng nh hng n phi.
- Phi bo a nhn (multinucleated blastomeres/MNB).
Phi bo a nhn c th xut hin bt k chu k phn chia no t 2
phi bo n giai on phi nang, nhng quan st r giai on 2 phi bo.
cc giai on sau s kh quan st hn do phi c nhiu phi bo v mnh
vn. Phi bo a nhn c kh nng lm t km do gim t l c thai v t
l sng st [7].
 6

- Kch thc phi bo khng u.

Mt trong nhng nguyn nhn lm kch thc phi bo khng u l
do s phn chia khng ng b v thiu cn i (asynchronous and
asymmetrical) hoc 1 hay nhiu phi bo ngng phn chia. Phi c kch
thc phi bo to nh khng ng u cng c kh nng lm t thp hn phi
c kch thc phi bo ng u [8].
- Phi c kch thc ln bt thng.
Phi c kch thc ln bt thng l kt qu ca s th tinh vi non
ln bt thng (giant egg). Phi hoc non ny c kch thc khong 200 m
(bao gm c mng trong sut). Phi loi ny thng l tam bi hoc tam bi
th khm v c th pht trin thnh phi nang [9].
- Phi c mt phi bo to ni tri.
Phi c mt phi bo to v xung quanh l cc mnh vn t bo c kch
thc nh hn kch thc phi bo thng thng v thng l a bi hon
ton hoc th khm. Phi bo to ni tri ny thng l a nhn [10] v khng
bao gi c chn chuyn phi.
- Phi c bo tng bt thng khng u (irregularities).
Bo tng ca phi loi ny thng c cha khng bo (vaculoles)
hoc th vi ti mu (dark inclusions) v lin quan nhiu n ri lon v
nhim sc th nn kh nng pht trin v lm t km [10].
- Phi c hnh thon di (elongated shape embryos).
Phi c hnh thon di thng pht trin v c kh nng lm t nh phi
c hnh dng bnh thng [10].
* Tc phn chia ca phi.
Tc phn chia c lin quan n kh nng sng ca phi. Phi phn
chia chm thng c kh nng lm t km hn. Tc nhn i t bo phi
ngi t ngy 2 n 6 sau th tinh l khong 31 gi, tc nhn i ny cng
nhanh hn sau hai ln phn chia u [6]. Phi to ra trong ng nghim thng
 7

c tc nhn i di 24 gi. Phi khe mnh c tc phn chia vo

khong 18-20 gi (2 phi bo sau 24 gi th tinh, 4 phi bo sau di 48 gi
v 8 phi bo hoc hn trc 72 gi).
Phi phn chia chm thng c kh nng lm t v sinh sng thp hn
phi pht trin bnh thng. V vy khi nh gi la chn phi, chng ta
thng kt hp cc yu t: tc pht trin phi, hnh thi ca phi nh s
lng mnh vn, dy mng ca mng trong sut, pht trin ca phi
bo, v s lng nhn t bo.
Trong thc tin, phi c 2 phi bo thng thy thi im 24 gi sau
th tinh (c khi sm hn vo khong 20 gi) v tn ti cho n 42 gi. Phi
c 4 phi bo thi im 36-60 gi sau th tinh. Phi c 8 phi bo thi
im sau 54 gi v thng trc 72 gi (hnh 1.1). ngi, cn thy phi c
3-5 v 7 phi bo l do phi c quan st khi ang phn chia. Mt s
nghin cu thy rng phi nam pht trin nhanh hn phi n [11],[12].
i vi trng th tinh bnh thng, nu khng phn chia trong vng 24
gi thng dn n gim kh nng sng, nhng nu phn chia nhanh qu
(phn chia trong vng 12 gi) cng khng phi l du hiu phi tt [13].
Phi c 3 tin nhn c th phn chia vi tc nhanh hn cho n giai
on phi du v sau thng ngng pht trin. Nhng hp t ny c thoi
phn bo c 3 cc phn chia thnh 3 phi bo giai on phn chia u tin
dn n phi c nhiu phi bo hn sau phn chia ch khng phi l phi
pht trin nhanh hn.

Hnh 1.1: S pht trin ca phi ngy 2 v 3 (t tri qua phi: phi c 2 phi
bo, 4 phi bo, 6 phi bo v 8 phi bo) (Ngun: RRFC)
 8

1.1.3 Phi du (phi ngy 4).

ngi phi du bt u hnh thnh khi phi giai on 8 phi bo v
bt u qu trnh kt c (compaction). Qu trnh phi kt c l mt qu
trnh hnh thnh cc lin kt cht ch gia cc phi bo, phn phi bo tip
xc vi nhau tng ln v dn phng ra to thnh mt khi khng nhn r cc
ranh gii gia cc phi bo, b mt ca phi c ph mt lp vi nhung mao
(microvilli). Cc phi bo hoc mnh vn t bo m khng hnh thnh lin kt
vi cc phi bo khc s b y ra ngoi khi phi nhng vn pha trong
mng trong sut cho ti khi phi thot mng [14]. Khi phi bt u kt c
li, cc phi bo tng tc vi nhau lm cc phi bo khng cn c tnh ton
nng (totipotency) na v y l s khi u cho s sao m DNA ca phi.
Di knh hin vi, hnh thi ca phi du c th hin bng s tng
tip xc gia cc phi bo, nhng ranh gii gia cc phi bo cn nhn thy.
Khi qu trnh kt c tng dn, ranh gii gia cc phi bo tr nn kh phn
bit do cc phi bo dn phng ra v kt lin vi nhau. Phi du lc giai
on ny hon ton trng nh mt t bo c nhiu nhn (hnh 1.2). Phi du
ngi c th xut hin sm khong 65 gi sau th tinh, nhng thng xut
hin gia ngy th 3 v th 4 sau th tinh [15].

Hnh 1.2: Phi du ngy 4 (t tri qua phi: cc phi bo bt u kt c

vi im nhng vn nhn r ranh gii gia cc phi bo; cc phi bo kt c
nhng thy ranh gii gc 9-12 gi, c nhiu nhn; kt c hon ton khng
r ranh gii cc phi bo) (Ngun: RRFC)
 9

1.1.4 Phi nang (phi ngy 5-6).

Sau khi phi kt c, phi bt u ln dn v to nang dch bn trong
(hnh 1.3) to iu kin cho s pht trin phi bo bit ha thnh nguyn
bo l nui v mm phi. Qu trnh to nang bao gm s tch ly dch vn
chuyn bi cc nguyn bo l nui. hon thnh qu trnh ny, nguyn bo
l nui u tin ph thuc vo s hon thnh qu trnh phn cc t bo v
hnh thnh mi lin kt cht gia cc nguyn bo l nui. S lin kt v v tr
cc phi bo trong phi kim sot s phn cc t bo.

Hnh 1.3: Phi giai on to nang/ cavitation (t tri qua phi: xut hin khe
dch gc 2 gi; cc khe dch ln dn, nhiu ln, khe dch chim di 1/2 th
tch phi) (Ngun: RRFC)
S hnh thnh v pht trin phi nang ph thuc vo mt s yu t lin
quan n bnh nhn nh: cht lng tinh trng, tui ca m cng nh cc yu
t khc lin quan n s pht trin ca phi giai on trc . S lng
non thu c, s lng trng th tinh, s lng hp t, v s lng phi
pht trin n giai on 8 phi bo vo ngy 3 cng nh hng n s hnh
thnh phi nang.
Phi nang thng hnh thnh khong 100 gi sau khi th tinh. Sau 5-6
ngy nui cy, 26-65% phi s pht trin n giai on ny. S pht trin cn
ty thuc vo phng php nui cy v thnh phn ca mi trng nui cy.
* S bit ha t bo.
ngi, phi giai on 8 phi bo vn c c tnh ton nng
(toptipotent), bng chng l khi tin hnh chn on trc lm t, nu sinh
 10

thit mt hoc hai phi bo th phi vn c kh nng pht trin bnh thng.
Tuy nhin, nu sinh thit mt phi bo giai on 4 phi bo s nh hng
n s pht trin ca phi v gim s lng nguyn bo phi (mm phi)
[16]. Trong qu trnh hnh thnh phi nang, 2 loi phi bo c hnh thnh l
nguyn bo phi (Inner Cell Mass/ICM) v nguyn bo l nui
(Trophectoderm/TE). Nguyn bo l nui l loi phi bo c bit ha u
tin trong qu trnh hnh thnh thai. Hai loi phi bo ny ngy cng khc
nhau khi chng di chuyn ti cc v tr mi trong qu trnh to nang. Nguyn
bo l nui c hnh bu dc v phn cc (polarization) trong khi nguyn
bo phi c vn gi hnh trn v hnh thi khng thay i. Cc nguyn bo l
nui ni vi nhau qua nhng phn tip xc b mt nh, trong khi nguyn
bo phi tip xc cht ch vi nhau to thnh mt khi. V tr v s pht trin
ca nguyn bo l nui v nguyn bo phi ph thuc vo s phn cc v s
hnh thnh trc phn bo ca phi c hnh thnh t khi trng mi bt u
c th tinh. Cc nguyn bo phi di chuyn v pha mt cc ca phi gi l
cc phi (embryonic pole), cc phi bo ny lin kt cht vi nhau v c c
tnh a nng (pluripotent). Cc nguyn bo l nui to thnh hng ro bn
ngoi bo v mm phi v c bit ha thc hin chc nng ny [17].
* S lng phi bo ca phi nang.
m bo phi pht trin v lm t, s lng phi bo ca phi nang
v t l gia s lng nguyn bo phi v s lng nguyn bo l nui c
chi phi v iu ha bi h thng gen. ngi, tc phn chia ca nguyn
bo l nui nhanh hn so vi tc phn chia ca nguyn bo phi. Nguyn
bo l nui nhn i khi bt u qu trnh to nang vo ngy th 4 to
thnh phi nang vo ngy th 5, trong khi nguyn bo phi nhn ln vo
ngy th 5 v 6. Khi phi nang ln dn, tc nhn ln ca nguyn bo l
nui l 1.5 chu k/ 24 gi nhanh hn so vi nguyn bo phi [18]. Thng
 11

thng tng s phi bo ca phi nang l trn 60 phi bo. ngi, phi
nang ngy 5 c khong 60 phi bo, tng n 160 vo ngy 6 v trn 200 sau
khi thot mng vo ngy 7; 40% s phi bo to mm phi [18].
1.1.5 Cc phng php nh gi cht lng phi.
S phn chia phi bo xy ra ng thi vi hin tng sao li cc cht
liu di truyn, nu s phn chia bt thng s lm thay i s lng phi bo,
hnh dng phi bo, ri lon cc nhim sc th nh hng n cht liu di
truyn nm trong gen trn cc nhnh ca nhim sc th. Hu qu l phi
khng pht trin c v phi cht, hoc th thai cht lng km sinh ra
nhng a tr tt nguyn.V vy nh gi phi chn lc phi mang ngha
nhn vn, cn c nghin cu thn trng p dng c hiu qu. Sau y l
cc phng php nh gi phi c cng b v p dng.
* nh gi tin nhn.
nh gi tin nhn ph thuc vo kch thc ca tin nhn v v tr ca
tin nhn. C nhiu h thng thang im nh gi tin nhn. H thng
c s dng ph bin Vit Nam l ng thun v h thng nh gi tin
nhn ca t chc Alpha (bng 1.1) [19].
Bng 1.1: ng thun v h thng nh gi tin nhn ca t chc Alpha.
Thang
Phn loi M t
im
1 i xng 2 tin nhn c kch thc tng i u; kch
thc v s ht nhn nh nhau (3-7); cc ht
nhn nm song song vi ng tip xc gia 2
tin nhn hay phn b ri rc
2 Khng i xng Nhng cch sp xp khc ca tin nhn nh nm
vng ngoi vi ca trng
3 Bt thng Tin nhn vi 1 hoc khng c ht nhn
 12

* nh gi phi vo thi im ngy th 3 k t khi th tinh.

- nh gi da vo quan st cc c im phi bo.
Phi bo phn chia theo quy lut nhn 2, nh vy s lng phi bo
thng l chn. S lng phi bo c th l s l 3, 5, 7 khi quan st giai
on phn chia hay khi xut hin s phn chia khng ng b. Hin tng
ny xy ra cn c th do mt phn bo tng trong phi b v ra to thnh
mnh vn t bo khng c nhn, khng to thnh mt phi bo trong qu
trnh phn chia (to ra s phi bo l). Bnh thng, phi gm cc phi bo c
kch thc gn nh bng nhau sp xp cnh nhau to thnh hnh ci bnh
trn, kch thc phi hu nh khng thay i mc du s phi bo tng sau
phn chia. C nhiu h thng im nh gi phi. H thng c dng ph
bin Vit Nam v chu u gi l nh gi phi ng thun ca t chc
Alpha (bng 1.2) [19].
Bng 1.2: ng thun v h thng nh gi phi giai on phn chia ca t
chc Alpha.
Thang
nh gi M t
im
1 Tt <10% mnh vn t bo
Kch thc phi bo ph hp theo giai on pht trin
Khng c phi bo a nhn
2 Trung 10-25% mnh vn t bo
bnh Phn ln phi bo c kch thc ph hp vi giai on
pht trin
Khng c phi bo a nhn
3 Xu >25% mnh vn t bo
Kch thc phi bo khng ph hp giai on pht trin
C phi bo a nhn
 13

* nh gi phi nang ngy 5 v 6.

nh gi phi nang da vo pht trin rng ca khoang phi nang
v hin tng thot mng (hnh1.4). Phi nang c nh gi da vo tiu
chun ca Gardner [20].
- nh gi bc 1 da vo khoang phi nang v hin tng thot mng.
Giai on 1: phi nang giai on sm (early blastocyst) khi khoang
dch chim di tng th tch ca phi.
Giai on 2: phi nang (blastocyst) khi khoang dch chim trn tng
th tch ca phi.
Giai on 3: phi nang y (full blastocyst) khi khoang dch chim hu
ht th tch ca phi.
Giai on 4: phi nang rng (expanded blastocyst) khi khoang dch
pht trin rng lm cho mng trong sut bt u mng dn.
Giai on 5: phi nang ang thot mng (hatching blastocyst) khi
nguyn bo l nui bt u thot ra khi mng trong sut.
Giai on 6: phi nang thot mng (hatched blastocyst) khi phi
nang hon ton thot ra khi mng trong sut.
- nh gi bc 2:
i vi phi nang t giai on 2 n giai on 6, cn phi nh gi
bc 2 di knh hin vi o ngc v c im mm phi (inner cell
mass/ICM) v nguyn bo l nui (trophectoderm cells /TE ) nh sau:
nh gi mm phi (inner cell mass /ICM):
o Loi A =khi c rt nhiu t bo lin kt cht ch.
o Loi B =khi vi t bo lin kt lng lo.
o Loi C =khi c rt t t bo.
o Loi D =khng nhn thy mm phi.
 14

nh gi nguyn bo l nui (trophectoderm cell /TE ):

o Loi A = nhiu t bo lin kt to thnh biu m kt.
o Loi B = vi t bo to thnh biu m ri rc.
o Loi C = c vi t bo ln.

Phi nang giai on sm Phi nang Phi nang y

Phi nang rng Phi nang ang thot mng Phi nang thot mng
Hnh 1.4: Phn loi phi nang (Ngun: RRFC).

1.2. Hin tng lch bi nhim sc th ca non v phi.

Lch bi nhim sc th l hin tng s lng nhim sc th ca t bo
tng ln hoc gim i mt hoc vi nhim sc th so vi b nhim sc th
lng bi. Mt cn bng v nhim sc th s dn n tnh trng phi ngng
pht trin trc khi lm t, sy hoc thai cht lu, tuy nhin phi b lch bi
nhim sc th c th sng nhng pht trin thnh thai bt thng nh trong
trng hp hi chng Down hoc hi chng Klinefelter. Lch bi nhim sc
th l yu t quan trng lm cho t l sinh sn ngi thp.
Hn 50 nm tri qua k t nhng ca u tin pht hin tnh trng lch
bi nhim sc th, cc nh khoa hc trn th gii thu thp c nhiu
thng tin v ngun gc cng nh nguyn nhn gy ra tnh trng lch bi
 15

nhim sc th. Nhiu nghin cu thy rng phi ngi giai on sm

thng c lch bi nhim sc th v trn 50% phi to ra trong ng nghim
c cha phi bo b lch bi nhim sc th. Bt thng v nhim sc th dn
n kt qu khng tt nh phi khng lm t c, sy thai v sinh ra nhng
a tr b tam th. Nhng hiu bit v c ch, ngun gc cng nh nhng yu
t nh hng n hin tng lch bi nhim sc th s gp phn lm tng
hiu qu ca vic iu tr th tinh trong ng nghim mt cch ng k.
Lch bi nhim sc th l hin tng c bit hay gp giao t v phi
ngi do s sai lch trong phn ly ca nhim sc th. C ch c bn n
nhiu nht l hin tng khng phn ly (non-disjunction) tuy nhin, trong
nhng nm gn y vn ny c nghin cu nhiu v cc c ch mi
c xut.
Mt s nghin cu cho rng gn mt na non ngi l b lch bi
nhim sc th, t l ny tng ln ng k khi ngi ph n trn 35 tui
[21],[22]. Ngc li, t l lch bi nhim sc th tinh trng ca nam gii c
kh nng sinh sn bnh thng l tng i thp 4-7% [23],[24]. Tuy nhin,
t l ny c th tng ng k trong mt s trng hp v sinh nam nng.
Tnh trng lch bi nhim sc th phi to ra trong ng nghim hoc
phi to ra t nhin trong c th ch yu xy ra trong 3 giai on pht trin
u tin: giai on trc phn bo gim nhim to giao t; trong qu trnh
phn bo gim nhim to giao t v trong giai on phn bo sm ca
phi. Nhng hiu bit v c ch gy nn hin tng lch bi nhim sc th
nhng giai on ny gip chng ta hiu thm v nhng hn ch ca
phng php sng lc trc lm t khi ng dng trn lm sng v tm ra
cc bin php ci tin.
* Lch bi nhim sc th do yu t ni ti, t bo sinh dc gc th khm:
Nhng sai lch trong qu trnh t bo sinh dc gc (germ cell) phn chia dn
 16

n tnh trng lch bi nhim sc th th khm t bo gc dn n hnh

thnh lch bi nhim sc th giao t. y l giai on t c quan tm v
nghin cu nht. Trong tt c cc trng hp, kt qu l to ra giao t c
nhiu hoc t hn v s lng nhim sc th.
* Lch bi nhim sc th sinh ra trong qu trnh phn bo: Trong trng hp
ny t bo gc bnh thng nhng nhim sc th b thay i xy ra trong qu
trnh phn bo. Trong phn bo gim nhim, nhng sai lch trong vic phn
ly nhim sc th trong giai on ny s to ra giao t b lch bi nhim sc th
v s hp nht giao t b lch bi nhim sc th s to ra phi b lch bi
nhim sc th. ngi, nhng sai lch trong qu trnh phn bo nguyn
nhim thng xy ra khi phi giai on phn chia sm, cc phi bo cn c
xu hng phn chia sai lch. Hu ht s sai lch trong phn bo nguyn
nhim phi giai on u s dn n to ra phi th khm ngha l phi c
2 dng phi bo c thnh phn nhim sc th khc nhau. C ba gi thit v
c ch gy nn lch bi nhim sc th trong phn bo nguyn nhim: (1) thiu
nhim sc th do s chm tr ca k sau (anaphase); (2) s nhn ln ca mt
nhim sc th (c ch vn cha c hiu r); (3) nhim sc th thiu, tha
tng ng (recprocal chromosome loss and gain) do nhim sc th khng
phn ly hoc giai on k sau b ngng tr to nn mt phi bo thiu nhim
sc th v mt phi bo tha nhim sc th tng ng.
* Lch bi th sinh ra do nhng bt thng trong th tinh: Khong 1% thai
c b nhim sc th ln hn 2n do b nhim sc th c tng mt s chn
hoc l ln v c gi l a bi. C 3 c ch dn n hin tng a bi (1)
tinh trng hoc non lng bi tham gia vo qu trnh th tinh; (2) hai hay
nhiu tinh trng tham gia vo qu trnh th tinh; (3) s tn li ca cc cu 2
(second polar body retention). 60% cc trng hp a bi l do th tinh vi
nhiu tinh trng [25].
 17

1.3. Phi th khm.

Nh c k thut th tinh trong ng nghim m cc bt thng v nhim
sc th ca phi ngi giai on tin lm t c pht hin. Vo nm
1993, Delhanty v cng s ln u tin cng b hin tng phi th khm
giai on trc lm t [26]. Phi th khm l phi c 2 hay nhiu dng phi
bo c s lng nhim sc th khc nhau c trong mt phi.
Phi th khm c th cha dng phi bo bnh thng vi dng phi
bo bt thng, hoc c th cha cc dng phi bo bt thng khc nhau. T
l phi th khm thay i t 15% [27] ln n trn 90% [28]. Mt trong
nhng l do khin t l phi th khm chnh lch kh nhiu cc nghin cu
khc nhau l do tiu chun xc nh phi th khm c s dng khc nhau.
V d, trong nghin cu ca Baart v cng s (2006), v nghin cu ca
Ziebe v cng s (2003), phi c cho l bnh thng mc d vn c mt
mt s lng nh phi bo bt thng trong phi [29],[30]. Cc tc gi ny
cho rng nhng phi ny vn c kh nng pht trin bnh thng.
Mt nguyn nhn khc l nhiu nghin cu v phi th khm c tin
hnh trn nhng phi tha, khng c s dng chuyn phi hoc d tr
ng lnh, nhng phi ny thng c cht lng km hn. Van Echten-
Arends nm 2011 phn tch tng hp (meta-analysis) 36 nghin cu ring l
v hin tng phi th khm ngy 3, thy rng trong tng s 815 phi tha,
ch c 177 (22%) phi l bnh thng, 599 (73%) phi th khm v 39 (5%)
phi c cha cc bt thng nhim sc th khc. Trong s cc phi th khm,
480 phi (59% tng s 815 phi nghin cu) c cha c dng phi bo bnh
thng v dng phi bo bt thng [31].
ng thi phng php nghin cu di truyn, s lng nhim sc th
c nh gi cng nh hng n t l phi th khm. T l phi bnh
thng thp hn v t l phi th khm c cha dng phi bo bnh thng
 18

v bt thng cao hn khi nhiu nhim sc th c nh gi. nh gi ton

b 23 cp nhim sc th bng phng php a-CGH s c t l lch bi nhim
sc th v th khm cao hn khi dng phng php FISH. T l phi th
khm cao hu ht cc nghin cu ch ra rng nhng sai st trong phn bo
rt thng gp phi ngi giai on trc lm t.
Qu trnh kch thch bung trng v iu kin nui cy phi c th gy
hin tng phi th khm. Kt qu nghin cu ca Bean v cng s (2002) v
ca Baart v cng s (2007) thy rng kch thch bung trng qu mnh cng
nh nui cy phi trong iu kin nng oxygen cao c nh hng n t l
phi th khm [32],[33].
Phi th khm thng pht trin ch n giai on phi du v ngng
khng pht trin n giai on phi nang [34],[35]. Baart v cng s nghin
cu 12 phi du tan ng thy l c 12 phi u l phi th khm [34].
Santos v cng s nghin cu 18 phi du, v cng b l t l phi th khm
gim t 83% trong ngy 4 xung cn 42% phi nang ngy 8 [35].
1.4. Cc phng php phn tch nhim sc th ca non v phi.
Chn on phi trc lm t (PGD/ preimplantation genetic diagnosis)
l mt k thut dng pht hin nhng bt thng v cht liu di truyn ca
phi to ra trong ng nghim trc khi chuyn phi vo bung t cung. Chn
on trc lm t c ch nh khi hoc b m hoc c hai bit l c bt
thng v di truyn v xt nghim c tin hnh trn phi xem phi c
mang bt thng v di truyn hay khng.
Ngc li, sng lc trc lm t (PGS/ preimplantation genetic
screening) c ch nh khi phi to ra t cp v chng c xem l bnh
thng v nhim sc th c kim tra xem c b lch bi nhim sc th
hay khng.
 19

Hin nay c rt nhiu phng php di truyn hc phn t nh gi

nhim sc th ca con ngi, di y l nhng k thut c kim chng
v c s dng rng ri trong lnh vc iu tr h tr sinh sn.
1.4.1. Phng php lai hunh quang ti ch (fluorescent in situ
hybridization/FISH).
Phng php ny c dng pht hin hoc nh v s c mt hay
khng ca mt on DNA no trn nhim sc th. Trong phng php
FISH ngi ta s dng u d hunh quang c hiu cho trng thi ca nhim
sc th gn kt vi mt on nhim sc th c tn sut din bin cao.
Knh hin vi hunh quang c s dng xem u d hunh quang
bm vo nhim sc th no s l ch bo trng thi ca nhim sc th .
Phng php FISH c s dng ln u tin xt nghim phi
ngi vo nm 1992 [36]. T , hng trm ngn bnh nhn lm th tinh
trong ng nghim c sng lc phi bng phng php ny. Sau mt thi
gian ng dng nhiu nghin cu cho thy gim t l sy thai, tng t l thai
lm t v t l sinh sng khi chuyn cc phi c sng lc bng phng
php ny.
Mc d phng php FISH c ci tin v gp phn lm tng hiu
qu iu tr th tinh trong ng nghim nhng cn khim khuyt quan trng
trong chn on l ch kim tra c mt lng gii hn nhim sc th (ti a
l 12 cp nhim sc th) nn t l chn on m tnh gi cao.
Mt im hn ch na ca phng php ny l k thut thc hin kh,
i hi kinh nghim khi c nh v dn tri mt phi bo ra phin knh. iu
ny khng phi bt k trung tm th tinh trong ng nghim no cng c
ngi thc hin c k nng thao tc ni trn [37].
 20

1.4.2. Phng php lai so snh b gen (comparative genomic

hybridization/CGH).
Phng php lai so snh b gen l mt phng php di truyn t bo
phn t dng phn tch nh gi nhng thay i trong qu trnh sao chp
v s lng (nhiu/t) trong thnh phn DNA ca mu c xt nghim.
Cng mt lc phng php c th kim tra c ton b nhim sc th
trong mt t bo bt c giai on phn chia no m khng cn k thut c
nh t bo. Trong phng php ny, s dng k thut lai so snh/i chiu
ca DNA cn xt nghim c nh du mu xanh vi DNA ca nhim
sc th bnh thng s dng lm chng c nh du mu . T l gia
phn hunh quang xanh/ phn hunh quang dc theo nhim sc th th
hin s lng nhim sc th ca mu th vi mu chng. Nu mu hunh
quang xanh c hiu cho nhim sc th tng d ra chng t c tng thm
nhim sc th (th tam nhim), tri li nu mu hunh quang tng d ra l
biu hin thiu nhim sc th. Phng php ny c p dng ln u tin
trn phi ngi vo nm 1996 [38].
ng dng phng php CGH tm sot phi pht hin ra s a
dng v tn sut ri lon nhim sc th ca phi, khng nh rng tt c
cc nhim sc th ca phi u c th b ri lon trong giai on trc khi
lm t. Mt s ri lon cha tng c pht hin trong chn on trc sinh
nay phn no sng t v c coi l nguyn nhn dn n phi ngng pht
trin, khng lm t hoc sy giai on rt sm.
Phng php CGH cng c th pht hin c nhng bt thng m
phng php FISH khng th pht hin c, v d nh t on nhim sc
th [39]. Mt im hn ch v lm sng ca phng php CGH l phc tp
ca k thut v tr li kt qu chm phi sau 4 ngy.
 21

1.4.3. Phng php lai so snh b gen dng chp DNA (array comparative
genomic hybridization/a-CGH).
Gn y, mt phng php n gin hn v cho kt qu nhanh hn
c pht trin t phng php CGH l phng php lai so snh b gen dng
chp DNA (a-CGH). Nguyn l ca phng php ny cng gn ging nh
phng php CGH nhng c nhy cao hn, k thut thao tc n gin v
nhanh hn.
Phng php ny c p dng thnh cng trong chn on tin lm
t t nm 2004 [40]. Nm 2010, phng php ny c kim chng xc
minh v c ng dng trong iu tr lm sng phc v chn on tin lm t
mt s nc tn tin nh Hoa k v chu u [41],[42].
1.4.4. Phng php phn tch a hnh n nucleotide dng chp DNA
(array Single Nucleotide Polymorphism /a-SNP).
Phng php ny cng c th nh gi c c 23 cp nhim sc th
da trn vic phn tch a hnh n nucleotide (single nucleotide
polymorphism /SNP). a hnh n nucleotide (SNP) l mt chui DNA bin
i xy ra khi nucleotide n A, T, C hoc G - trong b gen khc nhau gia
cc thnh vin ca mt loi sinh hc hoc cp nhim sc th trong mt c th.
Chp SNP c to bi cc on DNA gi l oligonucleotide, n c kh nng
phn bit s thay i ca cc SNP v v vy em li thng tin v di truyn ca
mt t bo.
1.4.5. Phng php phn ng chui Polymerase (Polymerase chain
reaction/PCR).
Phng php phn ng chui Polymerase (PCR) c dng chn
on ri lon ca mt gen, bao gm c ri lon gen ln v gen tri. Phng
php phn ng chui polymerase cn c gi l phng php nhn ln DNA
(DNA amplification). Khi cn phn tch mt on DNA no , ngi ta
 22

dng k thut ny nhn ln on DNA , to ra nhiu bn sao ca phn t

ADN rt nhanh chng phn tch c d dng v chnh xc.
1.4.6. Phng php gii trnh t gen th h mi (Next Generation
Sequencing/NGS).
Cng ngh ny thc t l phng thc gii trnh t ng thi v lng
ln cc on ngn nucleotide. Phng php ny c k vng l lm gim
gi thnh chi ph sng lc trc lm t v c chnh xc cao. Phng php
ny bt u c p dng rng ri mt s nc chu u v M t nm
2014 phn tch nhim sc th ca phi nang.

1.5. T l lch bi nhim sc th non, phi v mt s yu t lin quan.

1.5.1. T l lch bi nhim sc th non.
T l lch bi nhim sc th non tng i cao v tng dn ph n
ln tui. Munne v cng s s dng phng php FISH cho 7 cp nhim sc
th (13, 15, 16, 18, 21, 22, XY) nghin cu cc cu I 226 bnh nhn (26-
47 tui, trung bnh 38,2 tui) thy l t l lch bi nhim sc th nhm di
35 tui l 50%; 35-39 tui l 60% v trn 40 tui l 66,7%) [22].
Sher v cng s khi s dng phng php CGH cho non ca ph n
di 35 tui thy 64% b lch bi nhim sc th. Non b lch bi nhim sc
th s dn ti phi b lch bi nhim sc th. 80% non bnh thng sau th
tinh s dn ti phi bnh thng v 87% phi khng pht trin thnh phi
nang l b lch bi nhim sc th [21].
1.5.2. T l lch bi nhim sc th tin nhn.
Giannaroli v cng s 2003, dng phng php FISH 8 du d (X, Y,
13, 15, 16, 18, 21, 22) kim tra 496 phi thy t l lch bi nhim sc th l
70%. Cc phi c tin nhn nm cch xa nhau, c kch thc khc nhau nhiu
hoc c ht nhn nh nm ri rc c lin quan n tc pht trin chm, v
tng t l lch bi nhim sc th [43].
 23

Chen v cng s 2003 s dng phng php FISH cho nhim sc th

18, X, Y nh gi hnh thi ca tin nhn theo tiu chun ca Scott thy l t
l phi ngy 3 bnh thng Z1=71%; Z2=54%, Z3-4=35%. nh gi tin
nhn c gi tr chn lc hiu qu phi c s lng nhim sc th bnh thng,
c bit l phi c im Z1 (phi tt nht) [44].
Balaban v cng s nm 2004 s dng phng php FISH 5 u d
(13, 18, 21, X, Y) kim tra 267 phi thy t l lch bi nhim sc th ni
chung l 69,2% v kt lun hnh thi ca tin nhn c gi tr tin lng kh
nng pht trin ca phi v l ch bo lch bi nhim sc th. T l lch bi
nhim sc th phi c tin nhn bnh thng l 25,6%, t l ny l 73% v
83% tng ng ln lt vi phi c 1 tin nhn bt thng v phi c hai tin
nhn bt thng [45].
1.5.3. T l lch bi nhim sc th phi ngy 3.
Sau khi th tinh phi thng c nui cy thm khong 3 ngy (giai
on phn chia) n 5-6 ngy (giai on phi nang). Trn 50% phi to ra
trong ng nghim giai on phn chia c lch bi nhim sc th, t l ny
tng ln n trn 80% ph n ln tui. Nm 2012 Al-Asma v cng s
dng phng php FISH 9 u d (13, 15, 16, 17, 18, 21, 22, XY) nh gi
393 phi ngy 3 ca 70 bnh nhn c tui trung bnh 34,6 c tin s sy thai
b lch bi nhim sc th (thai t nhin hay thai to ra trong th tinh ng
nghim), t l lch bi nhim sc th l 67,8%. Nhim sc th c t l lch
bi nhim sc th cao l 16 v 22 [46].
Rabinowitz v cng s nm 2012 s dng phng php a-SNP nh
gi 274 phi ngy 3 ca 32 ph n (tui t 26-47, trung bnh 38) nu t l
lch bi nhim sc th l 72,3%, t l ny l 65,7% v 76,2% tng ng ln
lt vi ph n 36 tui v trn 36 trong 19,7% mt nhim sc th b nh
hng, 52,5% nhiu nhim sc th b nh hng [47].
 24

Trong th nghim lm sng ngu nhin ca Rubio v cng s nm

2013 s dng phng php FISH vi 9 u d 13, 15, 16, 17, 18, 21, 22 v
XY nghin cu 265 phi ngy 3 ca 91 ph n c phi khng lm t lin tip
(tui trung bnh 35,2), v 485 phi ca 93 ph n ln tui (41-44 vi tui
trung bnh l 41,8), t l lch bi nhim sc th tng ng l 57,3% v 69,2%.
Trong nghin cu ny nhim sc th b nh hng nhiu nht ph n b
phi khng lm t lin tip ln lt l 22, 13, 16, 21, 18, XY, 15 v 17, v
nhm ph n ln tui l 22, 16, 21, 15, 13, 18, 17 v XY [48].
Trong mt nghin cu khc ca Rubio v cng s nm 2013 s dng
phng php a-CGH kim tra phi ca 556 bnh nhn c tin s sy thai lin
tip, phi khng lm t lin tip, v sinh nam, v ph n ln tui, thy t l
lch bi nhim sc th l 73,5% [49].
Vit Nam sng lc phi trc lm t ang bt u pht trin, trong
mt nghin cu s b bc u nh gi kt qu sng lc trc lm t,
Nguyn Vit Tin v cng s nm 2014 s dng phng php FISH nh gi
5 nhim sc th 13, 18, 21, XY cng b t l lch bi nhim sc th ca 37
phi ngy 3 l 45,9%, hay gp nht nhim sc th 21, thp nht nhim sc
th gii tnh v nhim sc th 13 [50]. Trong mt nghin cu khc ca Hong
Th Hng v cng s nm 2014, cng s dng phng php FISH 5 u d
cho 127 phi ngy 3 c 6-8 phi bo, thy t l lch bi nhim sc th l
46,4%, hay gp nht l nhim sc th 21, sau l 13 v thp nht l nhim
sc th gii tnh [51].
1.5.4. T l lch bi nhim sc th phi nang.
Mc d mt s phi bt thng ngng pht trin t giai on ngy 3
v 5 nhng phn ln vn pht trin n giai on phi nang. giai on
phi nang, trn 40% phi b lch bi nhim sc th, t l ny tng cng vi
tui m.
 25

Schoolcraft v cng s nm 2010, s dng phng php CGH trn 269

phi nang ca 45 bnh nhn c tui trung bnh l 37 tui thy t l lch bi
nhim sc th l 51,3% [52].
Fragouli v cng s nm 2010 cng s dng phng php CGH
nhm bnh nhn tui trung bnh 39,8 thy t l lch bi nhim sc th phi
nang l 45,2% [53].
Traversa v cng s nm 2011, s dng phng php a-CGH thy 43%
phi nang b lch bi nhim sc th trong 55% lch bi nhim sc th 1
cp nhim sc th, 41% 2 cp v 7% phc tp (3 cp nhim sc th) [54].

1.6. Hin tng t sa cha ca phi lch bi nhim sc th ngy 3.

Phi ngy 3 c t l lch bi nhim sc th v phi th khm kh cao
[55] nhng n giai on phi nang t l ny gim ng k [56]. Mt s phi
lch bi nhim sc th ngy 3 c th t sa cha thnh phi bnh thng khi
pht trin thnh phi nang. Nm 2001, Sandalinas s dng phng php
FISH cho 8 cp nhim sc th (1, 13, 15, 16, 18, 21, 22 v XY) nghin cu
li nhng phi c kt lun l bt bnh thng theo kt qu ca FISH ngy 3
thy rng 15% (32/216) c kt qu bnh thng sau khi phn tch li. 66%
phi sa cha thnh bnh thng pht trin n giai on phi nang trong khi
19% phi c lch bi th pht trin n giai on phi nang [57]. Li v
cng s (nm 2005) s dng phng php FISH theo di 5 cp nhim sc th
13, 18, 21, X v Y ca phi nang (ngy 5-6 ) pht trin t phi m ngy 3
chn on l lch bi nhim sc th kt lun: 19,6% phi lch bi nhim
sc th ngy 3 pht trin n giai on phi nang trong s 40% c chn
on li bnh thng [58].
gii thch cho hin tng phi t sa cha ny, mt s nh nghin
cu l gii nh sau:
 26

* nhng phi ny th cc phi bo c s lng nhim sc th bnh

thng c kh nng phn chia tt hn, cc phi bo bt thng b ngng pht
trin; ng thi nhng phi bo bnh thng ny s c xu hng di chuyn v
bit ha thnh mm phi [59],[60].
* H thng gen ca phi cha hon ton hot ha vo ngy th 3 ca
giai on phn chia [61]. Cht lng ca non v cc protein, cc cht sao
chp gen ca non b gim i theo thi gian do s tch t ca cc tia x, cc
cht c hi, cc tc ng oxy ha gy tn thng ty th, cc telomere ngn
li dn n mt kim sot chu k t bo to ra nhng sai lch v nhim sc
th. Hin tng ny c bit nghim trng nhng ph n ln tui, to nn
nhng sai st trong s phn ly ca nhim sc th trong ln phn chia u tin,
to nn phi b th khm. Sau khi gen ca phi c hot ha, c ch cht
theo chng trnh (apoptosis) v cc im kim sot trong chu k t bo tr
nn hot ha, lm gim s lng cc phi bo bt thng nhim sc th giai
on phi nang.

1.7. Mt s yu t lin quan n t l lch bi nhim sc th.

1.7.1. S pht trin ca phi v t l lch bi nhim sc th.
* Phi giai on phn chia.
Lch bi nhim sc th c lin quan vi tc pht trin ca phi.
Nm 1995 Munne v cng s s dng phng php FISH nghin cu nhim
sc th ca phi thy rng phi ngng pht trin c t l lch bi nhim sc
th cao hn phi pht trin bnh thng (71% so vi 29%), nhng ri lon
nhim sc th ny s lm cho phi bo ngng phn chia hoc phn chia chm,
nh hng trc tip ti s pht trin ca phi [62].
Da vo tc pht trin, phi ngy 3 lin quan n s lng phi bo
c phn thnh 4 loi [62]:
Phi ngng pht trin l phi khng phn chia trong giai on 24gi.
 27

Phi chm pht trin l phi khng t c 7 phi bo vo ngy th 3

nhng vn phn chia trong vng 24 gi.
Phi bnh thng l phi c t 7 n 9 phi bo, khng c a nhn,
phn chia trong vng 24 gi, c di 15% mnh vn t bo.
Phi pht trin qu nhanh l phi c trn 9 phi bo ngy th 3.
Mt s nghin cu chng minh chuyn phi chm pht trin hoc
pht trin qu nhanh c t l c thai thp hn so vi chuyn phi pht trin
bnh thng [63],[64].
Theo Alikani v cng s th 13,8% phi c di 7 phi bo, 41,9%
phi c 7-9 phi bo v 27,5% phi c trn 9 phi bo ngy 3 s pht trin
c thnh phi nang [63]. Tng t nh vy, Rakowsky v cng s nghin
cu thy rng , phi c 8 phi bo, 7 phi bo, v < 7 phi bo c chuyn
vo ngy 3 c t l sinh sng tng ng ln lt l 25%, 18% v 3% [64].
Nm 2001, Magli v cng s s dng phng php FISH nghin cu
v mi lin quan gia bt thng nhim sc th v s lng phi bo v so
snh phi bnh thng ngy 3 c 7 hoc 8 phi bo, phi chm pht trin c
s lng phi bo l 4, v phi pht trin qu nhanh trn 9 phi bo c t l
lch bi nhim sc th tng ng l 55%, 74%, v 79% [10].
Nm 2007, Magli v cng s s dng phng php FISH cho 7 cp
nhim sc th (13, 15, 16, 18, 21, 22 v XY) thy t l lch bi nhim sc th
cao ng k nhng phi ngng hoc chm pht trin hay pht trin qu
nhanh:
Phi ngy 3 c di 4 phi bo c t l lch bi nhim sc th l 85%.
Phi ngy 3 c 4 phi bo c t l lch bi nhim sc th l 74%.
Phi ngy 3 c 5-6 phi bo c t l lch bi nhim sc th l 73%.
Phi ngy 3 c 7-8 phi bo c t l lch bi nhim sc th l 50%.
 28

Phi ngy 3 pht trin qu nhanh c 9 phi bo c t l lch bi

nhim sc th l 78% [2].
Finn 2010, cng s dng phng php FISH kim tra cho 7 cp nhim
sc th (13, 15, 16, 18, 21, 22 v XY) trn 2244 phi cho kt qu:
Phi ngy 3 c 7-8 phi bo c t l nhim sc th bnh thng l 31%
v chim 66% tng s phi bnh thng
Phi c 6 phi bo c t l bnh thng v nhim sc th l 17% v
ch chim 27% tng s phi bnh thng.
Phi c trn 8 phi bo c t l bnh thng v nhim sc th l 23%
v ch chim 7% tng s phi bnh thng [65].
* Phi giai on phi nang.
Nhiu nghin cu nu ln t l lch bi nhim sc th giai on phn
chia v giai on phi nang nh nhau khi dng phng php FISH
[66],[67],[68],[69]. Tuy nhin, mt s nh nghin cu khc li thy rng lch
bi nhim sc th cng nh tnh trng phi th khm u xut hin giai
on phi nang nhng t l thp hn so vi phi giai on phn chia
[68],[70]. c bit khi nghin cu s dng phng php a-CGH thy t l
lch bi nhim sc th giai on phi nang thp hn so vi giai on phn
chia [56],[59],[71]. T l lch bi nhim sc th giai on phi nang thp
hn l do phi b lch bi nhim sc th giai on phn chia b dng pht
trin trc khi n c ngy 5.
Nm 2008, Fragouli v cng s tin hnh CGH trn 64 phi nang thy
rng: 42% phi nang xt nghim l bnh thng tt c cc phi bo, 30% l
b lch bi nhim sc th tt c cc phi bo; 15,4% phi th khm gm cc
dng phi bo b lch bi nhim sc th khc nhau (mosaic aneuploidy) v
17% phi th khm bao gm phi bo bnh thng v phi bo b lch bi
 29

nhim sc th. Hn na khng c khc bit v t l lch bi nhim sc th

gia cc t bo mm phi v t bo l nui [59].
* Kh nng pht trin thnh phi nang ca phi lch bi nhim sc th ngy 3.
Phi lch bi nhim sc th c kh nng pht trin thnh phi nang
km hn phi bnh thng. Nm 2000, Magli dng phng php FISH kim
tra 5 cp nhim sc th (13, 18, 21, 22 v XY) thy rng 34,3 % phi c s
lng nhim sc th bnh thng pht trin n giai on phi nang trong khi
21,9 % phi lch bi nhim sc th pht trin n giai on phi nang.
khong 59% phi bt thng ngy 3 ngng pht trin so vi 36% phi bnh
thng (P<0,001) [72].
Nm 2003, Rubio cng s phng php trn cho 6 cp nhim sc th
(13,16, 18, 21, 22 v XY) trn nhng bnh nhn c tin s sy thai lin tip
thy rng phi bnh thng pht trin n giai on phi nang cao hn phi
bt thng (61,7% so vi 24,9%; P<0,0001) [73].
Li v cng s (nm 2005) s dng phng php FISH theo di 5 cp
nhim sc th 13, 18, 21, X v Y ca phi thy l 73,7% phi b lch bi
nhim sc th ngy 3 v 37,2% phi bnh thng ngy 3 u ngng pht trin
thnh phi nang [58].
1.7.2. Hnh thi phi v t l lch bi nhim sc th.
* Hnh thi phi bo khng ng u.
Phi bo khng ng u c lin quan n kh nng sng v pht trin
ca phi. Racowsky v cng s vo nm 2003 thy rng phi ngy 3 c cc
phi bo khng ng u th kt qu thai sng l 13,3%, t l ny l 22,4%
khi phi c cc phi bo ng u (p<0,0001) [64]. Tuy nhin nu phi c 8
phi bo ngy 3 v pht trin n phi nang rng vo ngy 5 th hin tng
cc phi bo khng ng u ngy 3 khng nh hng ti s lm t ca
 30

phi. Theo quan st ca Hardarson v cng s (2001), nhng phi bo khng

ng u c lin quan vi t l lch bi nhim sc th [74].
Finn 2010, s dng phng php FISH kim tra 7 cp nhim sc th
(13, 15, 16, 18, 21, 22 v XY) trn 2244 phi ngy 3 thy rng phi c kch
thc phi bo ng nht vo ngy 2 c 31% l bnh thng v s lng
nhim sc th v chim 73% tng s phi bnh thng. Phi c kch thc
phi bo khng ng u ch c 19% l bnh thng v chim 18% tng s
phi bnh thng [65].
* S lng, t l mnh vn t bo trong phi.
S lng mnh vn ca phi cng nhiu th t l lch bi nhim sc th
cng cao, kh nng pht trin v sng ca phi cng gim. T l mnh vn c
lin quan vi lch bi nhim sc th. T l lch bi nhim sc th tng t 50-
60% phi khng c mnh vn ln n 70-90% phi c trn 35% mnh
vn [2],[10],[75].

Nm 2000, Alikani v cng s cng b rng phi c mnh vn trn

15% pht trin thnh phi nang vi tn sut thp hn phi c t l mnh vn
di 15% (16,5 so vi 33,3%, p<0,001). Phi ngy 3 vi trn 15% mnh vn
t bo c kh nng lm t l 18%. Phi khng c bt thng v hnh thi v
c tc pht trin bnh thng c kh nng lm t cao (40,1 v 49%) [63].

Trong mt nghin cu khc ca Racowsky 2003, khi phi c t l

mnh vn di 10% th kh nng to ra tr sinh sng l 23% so vi 11% nu
phi c 10-25% mnh vn v 0,8% nu phi c trn 25% mnh vn [64].

Magli 2007 s dng phng php FISH cho 7 cp nhim sc th (13,

15, 16, 18, 21, 22, v XY) phi 62 gi sau khi th tinh phn tch nghin
cu trn phi c 7 phi bo, i vi phi khng c mnh vn t bo, t l lch
bi nhim sc th l 53%; t l ny l 55%, 58%, 67% v 66% tng ng ln
lt vi phi c 1-10%, 11-20%, 11-20%, 31-40% mnh vn t bo. Phn
 31

tch cc phi 8 phi bo c t l mnh vn ln lt l di 10%, 11-20%, 21-

30%, 31-40% mnh vn th c t l lch bi nhim sc th tng ng l 47%,
49%, 56%, 60% [2].

Theo Munne 2007, trong tng s phi c tc pht trin v hnh thi
tt nht (trn 6 phi bo vo ngy 3, c mnh vn di 20%,) th 44% c s
lng nhim sc th bnh thng trn bnh nhn di 35 tui, t l ny gim
xung cn 42% trn bnh nhn 35-37 tui, 30% trn bnh nhn 38-40 tui v
21% bnh nhn trn 41 tui. Ngc li, i vi phi c cht lng km
(di 6 phi bo vo ngy 3 v c mnh vn trn 20%) ch c 30% phi c s
lng nhim sc th bnh thng bnh nhn di 35 tui v 12% bnh
nhn trn 41 tui [69].

* S phn b mnh vn t bo trong phi.

Magli 2007 phn tch v s phn b ca nhiu mnh vn t bo nm ri

rc c t l lch bi nhim sc th cao hn so vi phi c cc mnh vn nm
tp trung ti mt v tr, c th phi 7 phi bo c 21-40% mnh vn t bo
nrn ri rc c t l lch bi nhim sc th l 80% so vi phi c t l mnh
vn nh vy nhng nm tp trung c t l lch bi nhim sc th l 57% , s
khc nhau c ngha thng k ( p<0.03) [2].

Tm li phn ln nghin cu u thng nht l hnh thi ca phi bt

thng v kch thc, v s lng phi bo, c bit c mnh vn cng tng
th t l lch bi nhim sc th tng t 60 n 80%. Lch bi nhim sc th
lin quan cht ch vi mnh vn t bo l nguyn nhn lm cho t l phi
pht trin n giai on phi nang gim, hoc hnh thnh phi nang km cht
lng bt thng v hnh thi phi nang, kt qu l kh nng lm t ca phi
v t l c thai bnh thng gim.
 32

* Phi bo a nhn.
C th thy phi bo c nhiu nhn bt k giai on no t ln phn
chia u tin cho n giai on phi nang, nhng thng gp nhiu phi c
hai phi bo. Tn sut chu k c phi c nhiu nhn c cng b l t
14-79% v tn s phi c nhiu nhn cho tng bnh nhn l t 15-33,6%
[76],[77],[78]. Tn sut khc nhau gia cc trung tm th tinh ng nghim c
th do cch kch thch hormone v iu kin mi trng nui cy khc nhau
[79]. Trong nghin cu ca Walmsley nm 2007 thy rng 12,5 % ca 55612
hp t ngy 1 c phi bo nhiu nhn vo ngy 2 v 5% c phi bo nhiu
nhn vo ngy 3, v vy khong 17,6% phi c phi bo nhiu nhn cc
mc khc nhau [80]. Van Royen v cng s cng thy rng phi bo c
nhiu nhn thy nhiu hn ngy 2 (27%) so vi ngy 3 (15%) [78].
Alikani v cng s cng b rng 16% phi c phi bo nhiu nhn
c th pht trin thnh phi nang so vi t l ca phi bnh thng l 32%
[63]. Tuy nhin t l phi c phi bo hai nhn s pht trin thnh phi nang
cao hn so vi phi c phi bo c nhiu hn hai nhn (38% so vi 9%) [77].
Tuy nhin, chuyn phi c phi bo nhiu nhn s dn n t l sy thai cao
hn 6 ln (19% so vi 3%) [81].
S dng phng php FISH trn phi c phi bo nhiu nhn thy rng
t l bt thng nhim sc th cao t 55-100%. T l khc nhau l do s
lng nhim sc th c nghin cu [10],[82],[83],[84]. Phi c phi bo
hai nhn ngy 3 c t l bt thng t hn phi c phi bo nhiu hn hai
nhn (68% so vi 96%) [85]. Phi c phi bo nhiu nhn thng lin quan
vi s hnh thnh mnh vn t bo v nhng bt thng hnh thi khc [62].
* Non v phi khng l/c kch thc ln (Giant eggs and embryos).
Non khng l thng c kch thc bao gm c mng trong sut trung
bnh khong 200 m v tn sut gp khong 0,3% [86]. Phi pht trin t
 33

non khng l thng l tam bi hoc tam bi th khm dng XXX hoc
XXY v gi l c ngun gc t m [87]. Theo Balakier th phi to ra t
non khng l c th pht trin thnh phi nang v c th to nn thai tam bi
c ngun gc t m (digynic triploid fetuses) [86].
* Phi c mt phi bo to ni tri.
Nhng phi c mt phi bo to bao quanh l nhng phi bo nh nh
nhng mnh vn, hay pht trin thnh a bi (polyploidy) hoc a bi th
khm, phi bo to thng c nhiu nhn [87]. Theo nghin cu ca Magli v
cng s nm 2001 nghin cu trn 20 phi c phi bo ni tri th 14/20 phi
c phi bo ni tri c nhiu nhn. Trong 12 phi l a bi, 8 phi c bt
thng phc tp [10].
* Phi c bo tng khng ng nht (cytoplasm irregularities).
Theo Magli v cng s, bo tng ca non c khng bo (vacuole)
hoc cc im vi sm mu (dark inclusion) khng c lin quan n lch bi
nhim sc th. Tuy nhin phi m bo tng c nhng vng m g gh
(cytoplasm concentration) c t l lch bi nhim sc th cao hn nhng phi
c bo tng bnh thng (86% so vi 63%) [10].
* Phi c hnh bu dc, ko di.
Magli v cng s nghin cu thnh phn nhim sc th ca 18 phi c
hnh bu dc v thy rng t l lch bi nhim sc th khng khc so vi phi
c hnh cu bnh thng [10]. Nhng phi ny c th pht trin thnh thai
sng [88].
* Hnh thi phi nang v lch bi nhim sc th.
Lch bi nhim sc th c nh hng xu ti s pht trin ca phi
giai on phi nang dn ti gim cht lng ca mm phi v nguyn bo l
nui cng nh tc pht trin ca phi nang [89]. Trong nghin cu ca
Alfarawati v Kroener s dng phng php a-CGH trn phi nang cng thy
 34

t l lch bi nhim sc th tng khi cht lng ca mm phi v nguyn bo

l nui gim dn [90],[91].

1.7.3. Hormon kch thch bung trng, s p ng ca bung trng v t l

lch bi nhim sc th.
Mc d lch bi nhim sc th xut pht t qu trnh to giao t, tuy
nhin qu trnh kch thch hormone v p ng ca bnh nhn c th nh
hng ti s hnh thnh lch bi nhim sc th.
* Bnh nhn c p ng km vi kch thch bung trng (low responders).
Gianaroli nm 2001 thy rng i vi bnh nhn m bung trng p
ng km vi hormone kch thch th phi to ra c lch bi nhim sc th l
68% [92]. Mt s tc gi khc thy rng, bnh nhn c p ng bung trng
km, s gim s lng phi chuyn vo bung t cung nn t l c thai
gim [93].
* Bnh nhn c d tr bung trng gim (Reduced ovarian reserve).
Kh nng d tr ca bung trng c nh gi da vo nng FSH
vo ngy th 3 ca chu k kinh. Tng nng FSH l ch bo gim kh nng
d tr bung trng [94], dn n gim s lng non thu c sau khi kch
thch v gim t l c thai. Tng nng FSH khng nhng thy ph n
ln tui m cn gp ph n b ct mt bn bung trng v ph n tr b
mn kinh sm (premature menopause).
Trong nghin cu ca Munne (1998) thy l i vi ph n di 40
tui nng FSH cao, c t l lch bi nhim sc th tng ng k (p<0,02),
nhng ph n trn 40 tui, t l lch bi nhim sc th tng cao khng ph
thuc vo nng FSH v tng nng FSH l ch bo bt thng mun v
mt kh nng d tr bung trng v ph hp vi t l c thai thp nhm
bnh nhn ny [75].
 35

Mt s nghin cu khc thy rng t l tr sinh ra b tam th 21 tng

ng k ph n tr tui c kh nng d tr bung trng gim. Tng nng
FSH c th lin quan trc tip n n t l lch bi nhim sc th mi la
tui [95],[96].
* Bnh nhn c qu mn bung trng (high ovarian response).
Reis v cng s nm 2003, nghin cu trn nhng bnh nhn c qu
mn bung trng, to ra nhiu non, thy rng t l lch bi nhim sc th cao
hn so vi nhm chng [97]. Hn na, qu mn bung trng thng to ra
phi c nhiu nhn [81] v tin nhn khng cn xng [98]. C 2 hin tng
ny u c lin quan n lch bi nhim sc th.

1.7.4. Mt s nguyn nhn gy v sinh c lin quan n t l lch bi nhim

sc th.
Theo Fasolino v cng s, nguyn nhn gy v sinh c lin quan ng
k vi nhng ri lon phn bo gim phn dn n lch bi nhim sc th
phi [99].
T l lch bi nhim sc th tng ng k trong cc trng hp: thai
ph b lc ni mc t cung, tc ng ca cc yu t nh hng n qu trnh
phng non v nhng ph n c tin s sy thai. Lc ni mc t cung lm
nh hng n cht lng ca non do lm thay i thnh phn khung t bo
(cytoskeleton) [100]. Tc gi cho rng, lc ni mc t cung nh hng xu ti
thoi phn bo v nhim sc th v iu ny ph hp vi nhng kin cho
rng c mi lin quan gia lc ni mc t cung v s hnh thnh giao t b
lch bi nhim sc th.
Weghofer v cng s thy c mi quan h m tnh gia cc yu t gy
phng non v s lng non b lch bi nhim sc th, chng t bung trng
tri qua qu trnh gi ha sinh hc [101].
 36

ph n c tin s b sy thai, kh nng phi b lch bi nhim sc th

cao hn. iu ny c th gii thch l do nhng ph n ny, bung trng c
xu hng b gi ha, dn n gim s lng non giai on trng thnh
[95]. iu ny ph hp vi kt qu ca Warburton [102] l ph n c thai b
th tam nhim s mn kinh sm hn so vi ph n sinh ra tr bnh thng, v
cng ph hp vi kt qu ca Munne [103] l t l lch bi nhim sc th
phi cao hn ph n c tin s sinh con b ri lon nhim sc th.

1.7.5. K thut th tinh trong ng nghim nh hng n t l lch bi

nhim sc th.
giai on phn chia, c nhiu yu t nh hng n b nhim sc th
ca phi, c bit t l phi b lch bi nhim sc th khc nhau gia cc
trung tm th tinh trong ng nghim, nhng n nay c rt t cc nghin cu
i su v vn ny. Trong phn ny s tm tt mt s yu t nh hng n
t l lch bi nhim sc th nh phng php kch thch trng, sng, nhit
, cht lng nc dng trong phng th nghim, phng php tim tinh
trng vo bo tng ca non (IntraCytoplasmic Sperm Injection/ICSI), nng
FSH c bn v s la chn bnh nhn nh hng n tnh trng nhim sc
th ca phi.
* Phng php s dng hormon kch thch.
Tn sut nhim sc th co ngn sm non ngi ph thuc vo phc
s dng hormon. Munne s dng phng php FISH nh gi nhim
sc th ca phi thy rng khi dng thuc kch thch l clomiphene citrate
hoc gonadotrophin, t l lch bi nhim sc th phi tng so vi dng
phng php iu ho xung (agonist) (p<0,05) [79].

Liu lng hormone FSH cng nh hng n t l lch bi nhim sc

th. Fragouli v cng s 2009 thy rng khi s dng liu FSH thp th nguy
c b lch bi nhim sc th gim [104]. Nguyn nhn c th ch nhng non
 37

c cht lng tt, c kh nng pht trin v trng thnh c thu np sau
p ng vi hormone kch thch liu thp. Ngc li, mt s nghin cu
khc, cc tc gi li thy rng nu kch thch liu cao, thm ch c bnh
nhn tr tui, t l lch bi nhim sc th tng cao [21]. V vy, Baart v cng
s thc y vic kch thch bung trng nh (mild stimulation) gim s
lng phi b lch bi nhim sc th [33].

* Nhit v cht lng ca nc dng trong phng th nghim.

Thoi phn bo ca non rt nhy cm vi s thay i nhit .

Pickering v cng s nm 1990 nhn thy non ngi khong 50% trng
hp thoi phn bo b phn r nhit phng (24-250C) trong khong 10
pht, v tan r 100% sau 30 pht, gy nn nhng ri lon nhim sc th [105].

Nm 1997, Cohen v cng s nghin cu thy t l phi lm t gim c

lin quan n cht lng ca nc v h thng lc kh trong phng th nghim.
Tuy nhin, vic nghin cu v nhim sc th cha c tin hnh trn cc phi
. Mt s cht ho hc gy tn thng mc gen ch khng ch mc
nhim sc th, l nguyn nhn lm gim t l phi lm t [106].

* Nhng yu t t tinh trng v phng php tim tinh trng vo bo tng

non.

Nghin cu so snh gia phng php cy tinh trng vi non trong

th tinh trong ng nghim v phng php tim tinh trng vo bo tng
non thy rng t l lch bi th phi to ra t 2 phng php trn nh nhau.
Tuy nhin, t l bt thng cao hn mt t nhm bnh nhn dng phng
php tim tinh trng vo bo tng non, khi nhng bnh nhn ny l ngi
mang nhng ri lon v nhim sc th, c tinh trng t, yu v d dng [107].

Nm 2007, Adams v cng s nghin cu trn 23 chu k s dng non

ca ngi cho, thy rng tui ca b khng nh hng n t l lch bi
 38

nhim sc th phi. Tuy nhin, bnh nhn c cht lng tinh trng km,
gim kh nng chuyn ng v tng cc mnh vn DNA, th kh nng phi b
lch bi nhim sc th cao. Phng php tim tinh trng vo bo tng non
khng th chn la tinh trng c cht lng cao nht. iu ny c th gii
thch l nhng yu t t tinh trng nh hng n cht lng ca phi thng
qua nhng sai st ca trung th, ri lon hot ng ca cc ty th v kh nng
hot ha non b ri lon [108].
1.7.6. Cc cp nhim sc th v t l lch bi nhim sc th.

Tn sut lch bi nhim sc th khc nhau ty tng cp nhim sc th.

Tn sut lch bi nhim sc th cng khc nhau ty thuc vo phng php
nh gi phi. Cc phng php c thng c nhy thp nn c t l chn
on m tnh gi cao, v vy cc nghin cu trc y u nu t l lch bi
nhim sc th thp v tn sut lch bi nhim sc th trn cc cp nhim sc
th sai khc nhiu so vi kt qu ca cc phng php hin i.

S dng phng php FISH, ngi ta nhn thy rng nhng nhim sc
th thng b lch bi giai on trc khi lm t l 16, 22, 21 v 15 [109].

Nm 2003, Rubio cng dng phng php FISH kim tra 6 cp nhim
sc th (13, 16, 18, 21, 22 v XY) nhng bnh nhn c tin s sy thai lin
tip thy lch bi nhim sc th 16 v 22 l thng gp nht [73].

S dng phng php CGH, Gutierrez thy lch bi nhim sc th t

xy ra nhim sc th 4 v 6. Hin tng tng s lng nhim sc th gp
nhiu hn l gim s lng nhim sc th [41].

Cng bng phng php a-CGH, nm 2011, Mariona cng b nhim sc

th 16 b lch bi nhiu nht sau ln lt n cc nhim sc th 22, 15, 21,
18, 20, 19, 13, 6, X, Y, 3, 17, 4, 11, 14, 2, 8, 7, 5, 12, 1 v 9; ch c nhim sc
th 10 l khng b lch bi [42].
 39

1.7.7. Tui m v t l lch bi nhim sc th.

Mt s nghin cu cho rng t nht 20% non ngi l b lch bi
nhim sc th, t l ny tng ln ng k khi ngi ph n trn 35 tui [110].
Nghin cu v di truyn trn non v cc cu th nht to ra trong ng
nghim thy rng trn 20% non ca bnh nhn di 35 tui l b lch bi
nhim sc th [111],[112]. T l non b lch bi nhim sc th tng ng k
cng vi tui ca ngi ph n. i vi ph n ln tui, t l ny trung
bnh khong 70% [113],[114],[115], tuy nhin cc tc gi ny cho rng bt
thng loi th khm thng khng ph thuc vo tui, trong khi Munne li
cho rng th khm l do c ch khng phn ly v c th tng ln cng vi
tui m tng [67].
Nm 1995, s dng phng php FISH, Munne nhn thy rng t l
phi b lch bi nhim sc th tng dn theo tui ca ngi m: 16% trn ph
n 20 n 34 tui; 37% trn ph n t 35 n 39 tui v cao nht 53% ph
n trn 40 tui [62]. Tc gi ny nm 2002 nghin cu da trn 1 phi bo
sinh thit (94 phi) v 2 phi bo sinh thit (304 phi) thy rng t l lch bi
nhim sc th tng theo tui m, t 12,2% la tui di 35, n 31% la
tui trn 40 [67].
Cng bng phng php ny Rubio nh gi 7 cp nhim sc th thy
rng ph n di 37 tui iu tr th tinh ng nghim c 33% s phi to b
lch bi nhim sc th, trong khi i vi ph n trn 37 tui, t l ny tng
ln gp i [73].
Nm 2007, Munne v cng s s dng phng php FISH kim tra
8 cp nhim sc th (13, 16, 18, 21, 22, X,Y, 15, 17) nhn thy rng tui
m, tc pht trin v hnh thi ca phi l 3 yu t nh hng rt ln n
s lng phi bnh thng, s tc ng ca 3 yu t mang tnh c lp, c
 40

bit tui ca m nh hng n t l lch bi nhim sc th rt r rng

(P<0,001) [69].

Nm 2011, Alfarawati s dng phng php a-CGH kim tra 500 phi
nang v thy 283 (56,7%) c lch bi nhim sc th vi nhiu th loi khc
nhau. Cc bt thng trn lin quan cht ch vi tui ca ngi m , t l ny
tng t 51% n 60,7% tng ng vi nhm tui m t 31-37 v 38-47 tui.
Ph n trn 37 tui c nguy c cao so vi ph n di 37 tui, c th l: t l
lch bi nhim sc th 21 tng gp 10 ln, t l lch bi nhim sc th 12, 14
v 18 tng gp 5 n 6 ln, t l lch bi nhim sc th 1, 2, 11, 15, 17, 20 v
22 tng gp 2 ln [90].

1.7.8. Yu t mi trng nh hng n lch bi nhim sc th.

Yu t mi trng bao gm cc tc nhn to ra ri lon nhim sc th

v t bin gen ca t bo trong c lch bi nhim sc th. Cc tc nhn
quan trng bao gm:

* Ht thuc l: Nm 2001, Shi v cng s cng b l cc cht trong

thuc l lm tng tn thng DNA ca tinh trng v lm gim cht lng tinh
trng [116]. ngi m ht thuc l, cc t bo sinh dc gc c xu hng b
nhim sc th khng phn ly dn n hnh thnh phi th khm v lch bi
nhim sc th bo thai v gy sy thai sm [117].

* Cocain: C mi lin quan gia thai ph s dng cocain v thai b d tt

v tim phi v thn kinh do t bin gen v ri lon nhim sc th [118].

* Phng x; tia X; tia , tia t ngoi: cng lin quan n d tt bm sinh

v ri lon nhim sc th.
 41

Chng 2
I TNG V PHNG PHP NGHIN CU

2.1. i tng nghin cu.

2.1.1. Tiu chun chn lc i tng.
i tng nghin cu l phi ngy 3 to ra bng phng php tim tinh
trng vo bo tng non ca cc cp v chng lm th tinh trong ng
nghim ti trung tm th tinh ng nghim Red Rock. Cc phi ny c cc tiu
chun sau:
Ton b phi 3 ngy tui ly ln lt t khi nghin cu cho n khi
s lng nghin cu.
Phi ngy 3 c kh nng sng (t nht 4 phi bo v s lng mnh vn
trong phi khng qu 30%).
Tinh trng c chn th tinh phi c tiu chun l c kh nng
chuyn ng.
Bnh nhn c kch thch bung trng ly non u t nguyn n
trung tm th tinh ng nghim iu tr, khng c bnh l di truyn,
ni khoa cp tnh hay mn tnh khc. Non c ly sau khi kch thch
bung trng trn bnh nhn c t nht 4 non trng thnh (nhn r
th cc 1).
2.1.2. Tiu chun loi tr.
Cc phi khng ng vi tiu chun nu mc 2.1.1
2.1.3. S lng i tng.
Nghin cu theo phng php m t, tin hnh loi tin cu nn c
mu c tnh theo cng thc sau:
Z (1-/2) .p .q
N= ----------------------- trong
(p. )
 42

N = c mu ti thiu
Z(1-/2) biu th tin cy; Nu tin cy ca nghin cu l 95%, tng ng
vi = 5% th Z (1-/2) = 1,96.
l sai lch ca nghin cu so vi thc t (v khi nghin cu ch l kt
qu ca mt qun th =N m khng phi ton th cng ng nn khi p dng
cho cng ng s c sai lch . sai lch ch trong gii hn t 0,1%
(0,01) n 10% (0,1).
p biu th mt t l i din cho 1 tiu thc nghin cu (t l bnh, t l ri
lon nhim sc th) c xc nh mc tiu nghin cu v lin quan n
su ca nghin cu.
q = 1-p biu th t l bnh thng.
p dng vo nghin cu ny:
tin cy = 95% tng ng = 5% th Z 1-/2 = 1,96
p = 53% = 0,53 (t l phi pht trin bnh thng khng c mnh vn
m b lch bi th, trich dn ti liu ca Magli 2007 [2].
q = 1- 0,53 = 0,47
= 0,055 (gii hn cho php v thng k )
Thay s li vo cng thc trn ta c:

1,96 x 0,53 x 0,47

N = -------------------------------- = 1126
(0.53 x 0.055)

S phi ti thiu c thu thp nghin cu l 1126

2.2. Phng php nghin cu v thu thp s liu.

2.2.1. Thit k nghin cu.
Nghin cu theo phng php m t tin hnh theo cch tin cu.
 43

2.2.2. Phng php tin hnh v thu thp s liu.

* a im nghin cu.
Nghin cu c tin hnh ti trung tm th tinh ng nghim Red
Rock (Red Rock Fertility Center/RRFC), thnh ph Las Vegas, bang
Nevada, USA.
* Quy trnh tin hnh, thu thp s liu.
Tt c bnh nhn u c tin hnh theo quy trnh sau:
Xt nghim ni tit.
Vo ngy th 3 ca chu k kinh, cc bnh nhn c xt nghim cc ni
tit sau: FSH, E2, LH, P4, prolactin, TSH v beta hCG bng phng php
Immuno assay (ROCHE E411, Indiana, USA).
Kch thch bung trng.
Chn ngu nhin trong s i tng c chn lc p dng phng
php kch thch bung trng. C 2 phng php kch thch bung trng c
s dng:
o S dng Lupron (Leuprolide acetate; TAP Pharmaceuticals, Lake
Forest, IL) iu ho xung trn 14 ngy, bt u t ngy 21 ca chu
k kinh trc. FSH tng hp (Gonal-F, EMD Serono hay Follistim,
Organon USA) c th kt hp vi Menopur (Ferring Pharmaceticals,
Parsippany, NJ) c s dng t ngy th 3 ca chu k kinh.
o S dng phc dng GnRH antagonists (Cetrotide, EMD Serono,
Rockland, MA hay Ganirelix, Organon USA, Roseland, NJ): Bnh
nhn c kch thch bng FSH tng hp (Gonal-F hay Follistim), c
th kt hp vi Menopur t ngy th 3 ca chu k kinh. Antagon c
s dng sau 5-6 ngy dng FSH (khi nang trng t 14mm).
HCG (5000-10000 IU Profasi, Serono; Pregnyl, Organon) c ch
nh khi c t nht trn 2 nang non c kch thc trn 17 mm.
 44

Chc ly non.
Non c ly qua ng m o di s ch dn ca siu m 36 gi
sau khi dng hCG. Non ly ra c nui cy trong mi trng Global
(LifeGlobal, USA) vi 10% SSS (Serum Substitute Supplement, Irvine
Scientific, USA) trong t cy CO2 6,5 %, O2 5%, N2 88,5 % nhit 370C.
Tim tinh trng vo bo tng ca non (ICSI).
Tt c non trng thnh c th tinh bng phng php tim tinh
trng vo bo tng ca non vi tinh trng ca chng hoc ca ngi hin
tinh trng (hnh 2.1).

Hnh 2.1: Phng php tim tinh trng vo bo tng non (Ngun: RRFC).
nh gi th tinh v qu trnh nui cy phi.
Khong 16-18 gi sau khi tim tinh trng vo non, trng c c
nh gi xem c th tinh hay khng. Nu th tinh to thnh phi s xut
hin 2 tin nhn v 2 cc cu. Sau phi c nh gi ghi im tng thi
im 40 gi, 68 gi v 112 gi sau khi th tinh. S lng v hnh th ca
nhn, s phi bo, v th loi mnh vn c thu thp nh gi cht lng.
Sinh thit phi bo.
Phi ngy 3 c sinh thit trong mi trng khng c Mg v Ca. S
dng laser khng tip xc 1,48 micron (Saturn active, Research Instruments)
m l mng trong sut. Trnh tia laser tip xc vi phi bo. Khi
mng trong sut c m, dng kim sinh thit c ng knh 30-35mm
ht nh nhng 1 phi bo vo ngy th 3 (66-68 gi sau tim tinh trng) (hnh
 45

2.2) khi phi c t nht 4 phi bo v c s lng mnh vn khng qu 30%.

Sau , phi li c chuyn vo mi trng nui cy cho n ngy 5 hay 6.
Phi bo c chn sinh thit phi cn nguyn vn v nhn r nhn.

Hnh 2.2: Phng php sinh thit phi bo ngy 3 (Ngun: RRFC).
Phn tch di truyn bng phng php a-CGH.
Phi bo ly ra c ra sch ri cho vo PCR tube c cha 2 l mi
trng (cung cp bi genesis genetics). Cc PCR tube c lm ng lnh t
nht 1 gi trc khi c gi ti phng xt nghim di truyn Genesis
Genetics (Detroit, Michigan, USA) nh gi 23 cp nhim sc th ca phi
bng phng php a-CGH. Trong qu trnh di chuyn, cc PCR tube c gi
lnh nh kh (dry ice).
Ti phng xt nghim di truyn, phi bo c lm phn r (lysed).
DNA ca phi bo cn xt nghim v DNA chng c nhn ln bng
phng php SurePlex (BlueGnome, UK). DNA ca phi bo cn xt nghim
v DNA chng c c nh du bng h thng nh du hunh quang
theo s hng dn ca nh sn xut (BlueGnome, UK). Thi gian nh
du l 3 gi. Sau , DNA c nh du s c tip xc vi chp DNA
(24Sure-BlueGnome) v c qua m. Sng hm sau, chp DNA c
ngm 10 pht dung dch 2x SSC/0,05% Tween-20 nhit khong 25
C, sau 10 pht dung dch 1x SSC nhit 25 C, tip theo 0,1x
SSC trong 5 pht nhit 59 C v cui cng 1 pht trong dung dch 0,1
 46

x SSC nhit 25 C. Chp DNA c lm kh trong 3 pht v c a

vo my qut hnh. Hnh nh thu c s c phn tch s dng phn mm
Bluefuse (BlueGnome, UK) (hnh 2.3 v 2.4). Chn on tha thiu nhim
sc th nu 15 hay hn 15 u d b lch khi gii hn bnh thng theo
phng php 24Sure.

Hnh 2.3: Kt qu a-CGH phi 46,XX (Ngun: RRFC).

Hnh 2.4: Kt qu a-CGH phi 46,XY (Ngun: RRFC).

Chuyn phi vo bung t cung.
Phi bnh thng (sau xt nghim) s c chuyn vo bung t cung
ca ngi m hoc c d tr ng lnh khi pht trin thnh phi nang vo
ngy th 5 hoc 6.
Theo di cc phi b lch bi th (sau khi xt nghim).
Phi c kt qu bt thng lch bi nhim sc th vn c nui cy
trong t cy theo di s pht trin thnh phi nang vo ngy 5 hoc 6.
Nhng phi ny nu pht trin thnh phi nang v nu c s chp thun
ca bnh nhn s c sinh thit ln 2 bng phng php sinh thit nguyn
bo l nui. T 2 n 6 nguyn bo l nui c sinh thit ra t mi phi,
sau s c chuyn vo ng xt nghim PCR gi i xt nghim
 47

phng xt nghim di truyn Genesis Genetics xt nghim s dng

phng php a-CGH nh m t trn. Kt qu xt nghim c thu thp
x l v phn tch.

Hnh 2.5: Phng php sinh thit nguyn bo l nui (Ngun: RRFC).

S tm tt quy trnh nghin cu

1257
Phi c k t qu a-CGH

474 783
Phi bnh th ng Phi LBNST

319 155 530 253

Phi nang Phi ng ng pht tri n Phi ng ng/ch m pht tri n Phi nang
lo i b lo i b

241 141
Phi nang ngy 5 Lo i b /
Dng cho NC khc

78
Phi nang ngy 6 112
Xt nghi m l i

Chuy n phi/ 33 79
ng l nh Phi Bnh th ng Phi LBNST
 48

2.3. Phng tin nghin cu.

Knh hin vi cc loi: o ngc, ni (Olympus v Nikon, Nht bn)
T cy CO 2 (Sanyo, Nht bn).
Bung lc kh (K-system, an mch).
H thng vi iu khin tim tinh trng v sinh thit phi (Narashige)
My ht ly non (Cook, c).
My li tm (Eppendorg, M).
T lnh (Sanyo, Nht bn).
Kim tim tinh trng v sinh thit t bo (Humagen, M).
Cc vt dng dng trong qu trnh nui cy non, tinh trng v phi
nh a cy phi, ng, chai, pipet(Origio, M).
Mi trng nui cy non, tinh trng, phi (Vitrolife, Irvine, Global
IVF, M).
2.4. Cc ch s, bin s nghin cu.
2.4.1. Cc ch s v c im mu nghin cu:
S lng phi bo.
ng u ca phi bo.
T l mnh vn.
Kh nng pht trin thnh phi nang.
Tc pht trin ca phi nang (cc giai on ca phi nang).
Cht lng phi nang.
Kh nng t sa cha ca phi.
Tui m.
Nguyn nhn v sinh.
tin s sn khoa.
nng FSH c bn.
 49

2.4.2. Cc ch s v kt qu a-CGH:
T l lch bi th.
T l phi bnh thng.
T l lch bi th trn 1 cp, 2 cp, 3 cp v 3 cp nhim sc th.
2.4.3. Cc tiu chun c lin quan n nghin cu.
* Nng FSH trong mu.
Nng FSH trong huyt thanh ca bnh nhn c xt nghim vo
ngy th 2 hay 3 ca chu k kinh bng phng php Immuno assay (ROCHE
E411, Indiana, USA) v c tnh bng n v mIU/ml. Nng FSH 10
mIU/ml c ly lm im ct phn bit gia bnh nhn b gim d tr
bung trng v bnh nhn c bung trng bnh thng v sinh l [122].
* nh gi phi giai on phn chia (3 ngy sau th tinh).
nh gi phi giai on phn chia da vo c im quan st phi
nh: s lng phi bo:
o Phi c 4-6 phi bo = phi chm pht trin.
o Phi c 7-9 phi bo = phi pht trin bnh thng.
o Phi c 10 phi bo = phi pht trin nhanh.
S lng mnh vn trong phi: % mnh vn so vi tng th tch
phi:
o 5% mnh vn = s lng mnh vn t.
o 6-15% mnh vn = s lng mnh vn trung bnh.
o 16-30% mnh vn = s lng mnh vn nhiu.
o >30% mnh vn = s lng mnh vn rt nhiu.
S phn b mnh vn trong phi:
o Tp trung: cc mnh vn nm tp trung ti mt v tr trong
phi thng vng ngoi vi.
o Ri rc: cc mnh vn nm ri rc trong phi gia cc phi bo.
 50

Kch thc phi bo:

o ng u: cc phi bo c kch thc tng i bng nhau.
o Khng ng u: cc phi bo c kch thc khc nhau (25%).
* nh gi phi nang ngy 5 v 6.

Phi nang c nh gi phn ln da vo tiu chun ca Gardner [20]

(theo thang im t 1 n 6 ph thuc vo pht trin rng ca khoang phi
nang v hin tng thot mng (Hnh 1.4).

nh gi bc 1 da vo khoang phi nang v hin tng thot mng.

o Giai on 1: phi nang giai on sm (early blastocyst) khi khoang

dch chim di tng th tch ca phi.

o Giai on 2: phi nang (blastocyst) khi khoang dch chim trn

tng th tch ca phi.

o Giai on 3: phi nang y (full blastocyst) khi khoang dch chim

hu ht th tch ca phi.

o Giai on 4: phi nang rng (expanded blastocyst) khi khoang dch

pht trin rng lm cho mng trong sut (zona pellucida/ZP) bt u
mng dn.

o Giai on 5: phi nang ang thot mng (hatching blastocyst) khi

nguyn bo l nui (trophectoderm cell /TE) bt u thot ra khi
mng trong sut.

o Giai on 6: phi nang thot mng (hatched blastocyst) khi phi

nang hon ton thot ra khi mng trong sut.
 51

nh gi bc 2:
i vi phi nang t giai on 2 n giai on 6, cn phi nh gi bc
2 di knh hin vi o ngc v c im nguyn bo phi (inner cell
mass/ICM) v nguyn bo l nui (trophectoderm cells /TE) nh sau:
o nh gi nguyn bo phi (inner cell mass /ICM):
Loi A =khi c rt nhiu t bo lin kt cht ch.
Loi B =khi vi t bo lin kt lng lo.
Loi C =khi c rt t t bo.
Loi D =khi khng thy ICM.
o nh gi t bo l nui (trophectoderm cell /TE )
Loi A = nhiu t bo lin kt to thnh biu m kt.
Loai B = vi t bo to thnh biu m ri rc.
Loi C = c vi t bo ln.
2.5. X l s liu.
Cc s liu thu c s c x l bng phng php tnh thng k
nh sau:
* Php tnh thp phn xc nh t l.
Khi bnh phng /Chi-square/ X2 xc nh s khc nhau gia 2 t l
c ngha thng k khi 2 3,84 tng ng vi p<0,05 (nh tnh).
(ad bc). N
Khi bnh phng (Chi square ) = ------------------------------
(a+b) (c+d) (a+c) (b+d)
* Php tnh nguy c tng i (Relative Risk/RR).
RR biu th c th cch o lng hng nh lng v hu qu (lch
bi nhim sc th) tng cao gp bao nhiu ln khi c yu t nguy c tc ng
so vi nhm chng khng c yu t nguy c tc ng. Cch tnh da vo
bng 2x2 nh sau (bng 2.1):
 52

Bng 2.1: Bng tnh thng k lin quan gia yu t ch bo v t l LBNST.

Tnh trng tht v NST ca phi
Yu t nguy c
LBNST Bnh thng
(ch bo) Cng
(c bnh) (khng c bnh)
C mt (+) a (+ tht) b (+ gi) a+b
Khng c mt (-) c (- gi) d (- tht) c+d
Cng a+c b+d a+b+c+d = N
Nguy c tng i (relative risk) RR= (a/a+b) / (c/c+d )
* T s kh nng (likelyhood ratio/ LR).
LR dng nh gi gi tr (hay s chnh xc) ca mt yu t (phng
php) chn on. C 2 loi LR:
T s kh nng khi xt nghim dng tnh (LR+) l t s ca t l
dng tnh tht (c mt yu t ch bo th phi b lch bi nhim sc th) v
t l dng tnh gi (c yu t ch bo, nhng phi bnh thng). Ni cch
khc, LR + l t s gia xc sut phi c mt c im no (+) (yu t ch
bo) th b lch bi nhim sc th v xc xut phi c mt c im no
(+) m khng b lch bi nhim sc th.
LR (+) = (a/a+c) / (b/b+d)
LR(+) c ngha khi >1. LR (+) cng cao cng c gi tr.
Mc LR(+) v nh hng n kh nng lch bi nhim sc th:
LR >5 : kh nng LBNST kh cao
LR = 2-5 : kh nng LBNST trung bnh
LR <2 : kh nng LBNST thp
LR = 1 : Xt nghim v dng
T s kh nng khi xt nghim m tnh (LR(-)) l t s ca t l m tnh
gi (phi b lch bi nhim sc th khi khng c yu t ch bo) v t l m
tnh tht (khng c yu t ch bo th phi bnh thng). Ni cch khc, LR(-)
 53

l t s gia xc sut phi khng c mt c im no (-) (khng c yu t

ch bo) m b lch bi nhim sc th v xc xut phi khng c mt c
im no m khng b lch bi nhim sc th.
LR (-) = (c/a+c) / (d/b+d) thng di 1, cng thp cng c gi tr.
Mc LR(-) v nh hng ti kh nng khng lch bi nhim sc th:
LR < 0,2 : kh nng khng LBNST kh cao
LR = 0,2-0,5 : kh nng khng LBNST trung bnh
LR > 0,5 : kh nng khng LBNST thp
LR = 1 : xt nghim v dng
2.6. Vn o c trong nghin cu.
Trong mt nghin cu ln nht mi c cng b nm 2010 v nh
hng ca vic sinh thit phi bo ln sc khe ca tr c sinh ra nh
phng php tim tinh trng vo bo tng ca non v sng lc phi trc
lm t, cc tc gi nu ln rng khng gy nh hng g n sc khe ca
tr s sinh [119].
Rt nhiu cc nghin cu cng b l vic p dng sng lc tin lm
t lm t gp phn lm tng t l thai lm t v tng t l sinh ng k
[104],[120],[121].
Nghin cu ny ch nhm mc ch nng cao hiu qu iu tr trong
th tinh ng nghim m khng nhm bt c mt mc ch no khc.
Nghin cu ny c tin hnh sau khi cng nghin cu c
s chp thun ca hi ng khoa hc, o c ca Trng i hc Y H Ni.
i tng nghin cu t nguyn tham gia nghin cu sau khi c
cung cp y cc thng tin cn thit v nghin cu v h t quyt nh
tham gia vo nghin cu. Nghin cu ch c tin hnh khi c s cam kt
gia bnh nhn v c quan ch qun l Red Rock Fertility Center.
Cc thng tin c nhn do bnh nhn cung cp c m bo b mt.
 54

Chng 3
KT QU
3.1. c im bnh nhn c xt nghim phi bng phng php a-
CGH:
Tng cng c 203 bnh nhn vi tng s 1257 phi c sinh thit
chn on lch bi NST c mt s c im sau:
Bng 3.1: c im tui m.
Tui S bnh nhn c ly phi S lng phi
<35 93 (45,8 %) 640 (51 %)
35-40 83 (40,9 %) 481 (38,3 %)
>40 27 (13,3%) 136 (10,7 %)
Cng 203 (100%) 1257 (100 %)

Nhn xt: Gn s bnh nhn n sinh thit phi chn on LBNST di

35 tui (45,8 %) vi tng s phi chim hn 50%. Tuy nhin c khong trn
1/3 (37%) bnh nhn ln tui t > 38 tui. c bit trn 13% bnh nhn trn
40 tui vi tng s phi chim hn 10%.
Bng 3.2: c im v nguyn nhn v sinh.
Nguyn nhn v sinh S bnh nhn S lng phi
Do yu t tinh trng 67 (33 %) 418 (33,25 %)
Ri lon phng non 4 (1,97 %) 21 (1,67 %)
Bung trng a nang 17 (8,38 %) 121 (9,63 %)
Do vi trng 8 (3,94 %) 53 (4,22 %)
Do lc ni mc t cung 16 (7,88 %) 88 (7 %)
Do t cung 2 (0,99 %) 11 (0,87 %)
Khng r nguyn nhn 89 (43,84 %) 545 (43,36 %)
Cng 203 (100%) 1257 (100 %)

Nhn xt: i tng n lm th tinh trong ng nghim phn ln l khng r

nguyn nhn hoc do yu t tinh trng.
 55

Bng 3.3: Tin s sn khoa c lin quan.

Tin s S bnh nhn S lng phi
b sy thai/ hcg (+) 15 (7,39 %) 80 (6,36 %)
Sau k thut IUI b tht bi 24 (11,82 %) 172 (13,68 %)
Sau k thut IVF b tht bi 10 (4,93 %) 66 (5,25 %)
b sy thai + IUI tht bi 18 (8,87 %) 93 (7,4 %)
b sy thai + IVF tht bi 9 (4,43 %) 59 (4,69 %)
IUI + IVF tht bi 5 (2,46 %) 26 (2,07 %)
b sy thai + IUI + IVF tht bi 6 (2,96 %) 41 (3,26 %)
Cha can thip g 116 (57,14 %) 720 (57,29 %)
Cng 203 (100 %) 1257 (100%)

Nhn xt: Hn 35% bnh nhn n iu tr th tinh ng nghim kt hp vi

sng lc LBNST sau khi p dng k thut bm tinh trng vo bung t
cung (IUI) hoc iu tr th tinh trong ng nghim (IVF) b tht bi.
3.2. T l lch bi nhim sc th phi ngy 3 sau th tinh.
1257 phi c chn lc ng theo tiu chun la chn p dng ng
theo quy trnh k thut nu trong phn phng php nghin cu, c xt
nghim cc NST (23 i) cho kt qu sau:
3.2.1. T l lch bi nhim sc th v mc lch bi nhim sc th.

Kt qu aCGH ca 1257 phi ngy 3

474
(3 7 , 7 % )
783
(6 2 , 3 % )

B nh thng Lch bi nhim sc th

Hnh 3.1: Kt qu a-CGH ca 1257 phi ngy 3.

 56

Th loi (mc lch bi nhim sc th) ca 1257 phi ngy 3

30.2%
37.7%

3.6% 10.1%
18.4%

Bnh thng LB 1 cp NST LB 2 cp NST LB 3 cp NST LB 4 cp NST

Hnh 3.2: Th loi (mc LBNST) ca 1257 phi ngy 3

sau xt nghim a-CGH.
Nhn xt: Trong tng s 1257 phi ngy 3 c xt nghim a-CGH, 474
(37,7%) phi c s lng NST bnh thng v 783 phi (62,3%) b LBNST
(Hnh 3.1) trong 380 phi (48%) b LBNST phc tp khng xc nh r
lch bi i NST no (Hnh 3.2, 3.3). 877 phi c xc nh r tnh trng ca
cc cp NST (Hnh 3.4, 3.5, 3.6, 3.7) . Kt qu xt nghim ca 877 phi theo
tng cp NST c ghi trong bng 3.4.

Hnh 3.3: Lch bi NST th phc tp ( 4 cp NST).

(Ngun: kt qu a-CGH ca phi s 1 ca bnh nhn Waner.T)
 57

Hnh 3.4: Lch bi 3 cp NST (45,XY;+15,-16,-19).

(Ngun: kt qu a-CGH ca phi s 2 ca bnh nhn Cox.J)

Hnh 3.5: Lch bi 2 cp NST (44,XX;-17,-19).

(Ngun: kt qu a-CGH ca phi s 2 ca bnh nhn Polsfut.A)

Hnh 3.6: Lch bi NST 18 (47,XY; +18).

(Ngun: kt qu a-CGH ca phi s 1 ca bnh nhn Cade.M)

Hnh 3.7: Lch bi NST 22 (45,XX;-22).

(Ngun: kt qu a-CGH ca phi s 5 ca bnh nhn Kozey.R)
 58

3.2.2. T l lch bi nhim sc th phn b theo cp nhim sc th.

Bng 3.4: T LBNST th phn b theo cc cp nhim sc th t thp n cao.
S lng cp S cp khng
Cp NST S cp b LBNST RR
NST LBNST
Cp s 5 877 10 (1,1%) 867 (98,9%) 1,0
Cp s 10 877 10 (1,1%) 867 (98,9%) 1,0
Cp s 8 877 11 (1,3%) 866 (98,7%) 1,18
Cp s 7 877 12 (1,4%) 865 (98,6%) 1,27
Cp s 17 877 12 (1,4%) 865 (98,6%) 1.27
Cp s 3 877 13 (1,5%) 864 (98,5%) 1,36
Cp s 6 877 15 (1,7%) 862 (98,3%) 1,55
Cp s 2 877 17 (1,9%) 860 (98,1%) 1.73
Cp s 12 877 17 (1,9%) 860 (98,1%) 1,73
Cp s 4 877 18 (2,1%) 859 (97,9%) 1,91
Cp s 11 877 18 (2,1%) 859 (97,9%) 1,91
Cp s 14 877 19 (2,2%) 858 (97,8%) 2,0
Cp s 20 877 24 (2,7%) 853 (97,3%) 2,45
Cp s 1 877 25 (2,9%) 852 (97,1%) 2,64
Cp s 18 877 28 (3,2%) 849 (96,8%) 2,91
Cp s 13 877 29 (3,3%) 848 (96,7%) 3,0
Cp s 9 877 30 (3,4%) 847 (96,6%) 3,09
Cp XY 877 35 (4%) 842 (96%) 3,64
Cp s 21 877 44 (5,0%) 833 (95%) 4,55
Cp s 15 877 49 (5,6%) 828 (94,4%) 5,09
Cp s 16 877 54 (6,2%) 823 (93,8%) 5,64
Cp s 19 877 56 (6,4%) 821 (93,6%) 5,82
Cp s 22 877 74 (8,4%) 803 (91,6%) 7,64

Nhn xt: Tt c cc cp NST u b lch bi theo cc t l khc nhau; T l

LBNST gp t nht (<1,5%) cc cp 5, 10, 8, 7, 17 v t l LBNST gp
nhiu nht (trn 3,5%) cc cp 22, 19, 16, 15, 21 v XY.
 59

3.3. Kh nng t sa cha ca phi ngy 3 b lch bi nhim sc th.

Tt c phi ngy 3 sau xt nghim chn on c LBNST u tip tc
nui cy nhm nh gi:
T l phi ngy 3 c LBNST pht trin thnh phi nang.
Mt s phi c xt nghim li qua xt nghim t bo l nui
xc nh kh nng t iu chnh ca phi t ngy 3 n ngy
5-6 khi phi pht trin thnh phi nang.
3.3.1. Kh nng pht trin thnh phi nang ca phi lch bi nhim sc th
ngy 3.
Bng 3.5: Kh nng pht trin thnh phi nang ca phi LBNST ngy 3.
Pht trin thnh Chm/
Kt qu
phi nang Ngng pht trin Cng RR p
a-CGH
S phi % S phi %

Bnh thng 319 67,3 155 32,7 474 2,1

LBNST 253 32,3 530 67,7 783 1 <0,001

Cng 572 685 1257

Nhn xt: Phi b LBNST c kh nng pht trin thnh phi nang vi t l
bng na phi bnh thng (RR=2,1).
3.3.2. Kh nng t sa cha ca phi ngy 3 b lch bi nhim sc th.
Trong tng s 1257 phi c sinh thit ngy 3 c 253 phi b LBNST
nhng vn c th pht trin c thnh phi nang. Trong s 253 phi ny vo
ngy 5 v 6 sau khi th tinh, 112 phi nang c s ng ca bnh nhn
tin hnh sinh thit xt nghim da trn phn tch nguyn bo l nui cho kt
qu sau (bng 3.6):
 60

Bng 3.6: Kt qu nh gi li bng sinh thit t bo l nui ngy 5-6 ca

phi nang pht trin t phi ngy 3 c LBNST.
S phi nang ngy 5-6 pht trin t Bnh thng
LBNST %
phi c LBNST ngy 3 (t sa cha)

112 79 (70,5%) 33 (29,5%)

Nhn xt: 29,5% phi b LBNST ngy th 3 c kh nng pht trin thnh
phi nang vo ngy th 5, 6 v c kh nng t sa cha tr li bnh thng
(qua xt nghim t bo l nui).
3.3.3. Mi lin quan gia kh nng t sa cha ca phi LBNST ngy 3 v
tui m.
Bng 3.7: Kh nng t sa cha ca phi v tui m.
S phi T sa cha Khng t sa cha
Tui RR
xt nghim (bnh thng) (LBNST)

< 35 46 22 (47,8%)a 24 (52,2%) 1

35-40 50 11 (22%)b 39 (78%) 2,17

>40 16 0 (0%)c 16 (100%)

Cng 112 33 (29,5%) 79 (70,5%)

Pa,b<0,025; Pa,c<0,005
Nhn xt: Kh nng phi t sa cha (phi b LBNST ngy 3 tr li bnh
thng ngy 5 v 6 khi giai on phi nang) ph thuc vo tui m:
* Tui m 35-40 th kh nng t sa cha gim trn 2 ln so vi khi tui
m tr < 35.
* Tui m > 40, phi b LBNST c th pht trin thnh phi nang nhng
khng c kh nng t sa cha.
 61

3.4. Mt s yu t lin quan n lch bi nhim sc th qua phn tch

n bin.
3.4.1. Tin s sy thai, iu tr v sinh v lch bi nhim sc th.
Bng 3.8: Tin s sy thai, iu tr v sinh v LBNST.
Tin s LBNST Bnh thng Cng RR
b sy thai/ hcg (+) 48 (60%) 32 80 1,04
Sau k thut IUI b tht bi 175 (66%) 90 265 1,15
Sau k thut IVF b tht bi 146 (76%) 46 192 1,32
Cha iu tr/phng php khc 414 (57,5%) 306 720 1
Cng 783 474 1257

Nhn xt: bnh nhn tht bi iu tr th tinh trong ng nghim (IVF),

t l LBNST cao 76%, tng 1,3 ln so vi iu tr thng thng khc.
3.4.2 Nguyn nhn v sinh v lch bi nhim sc th.
Bng 3.9: Nguyn nhn v sinh v LBNST.
Nguyn nhn v sinh LBNST Bnh thng Cng RR
Ri lon phng non 14 (66,7%) 7 (33,3%) 21 2,44
Khng r nguyn nhn 359 (65,9%) 186 (34,1%) 545 2,41
Do yu t tinh trng 258 (61,7%) 160 (38,3%) 418 2,26
Bung trng a nang 73 (60,3%) 48 (39,7%) 121 2,21
Do vi trng 29 (54,7%) 24 (45,3%) 53 2
Do lc ni mc t cung 47 (53,4%) 41 (46,6%) 88 1,96
Do t cung 3 (27,3%) 8 (72,7%) 11 1
Cng 783 474 1257

Nhn xt: Ri lon phng non, bung trng a nang v yu t tinh trng l 3
yu t tng ng vi LBNST cao > 60%, tng trn 2 ln so vi yu t t
cung; V sinh khng r nguyn nhn s khng c phc iu tr r rng v
kh phc tp, ng thi cng lin quan nhiu n t l LBNST cao (65,9%).
 62

3.4.3 Tui m lin quan n lch bi nhim sc th.

Bng 3.10: Tui m v nguy c LBNST.
LBNST Bnh thng
Tui m Cng RR LR(+) LR(-)
S phi % S phi %
>40 125 91,9a 11 8,1 136 1,85 8,5 0,74
35-40 340 70,7b 141 29,3 481 1,42 1,7 0,69
<35 318 49,7c 322 50,3 640 1
Cng 783 474 1257
(Ghi ch: RR v LR so snh vi tui m tr <35)
Pa,b <0,001; Pa,c <0,001; Pb,c <0,001
Nhn xt: Tui m cng tng th t l LBNST cng cao. c bit khi tui m
trn 40 tui, t l LBNST tng cao gn 92%, gp gn 2 ln so vi khi tui m
<35 (RR=1,85; P<0,001); Yu t tui m cao >40 l ch bo trong tin lng
phi LBNST vi gi tr cao (LR(+) = 8,5 v LR(-) = 0,74).
3.4.4. Nng FSH c bn ca m lin quan n lch bi nhim sc th.
Bng 3.11: Nng FSH c bn v LBNST.
LBNST Bnh thng
FSH
S S Cng RR P LR(+) LR (-)
(mIU/ml) % %
phi phi

>15 106 76,3 33 23,7 139 1,3

15 677 60,5 441 39,5 1118 1 <0,001 1,93 0,93

Cng 783 474 1257

Nhn xt: FSH c bn >15 mIU/ml tng ng vi t l LBNST 76,3% tng

nguy c b LBNST ln gn 1,3 ln so vi FSH 15 mIU/ml (RR=1,3;
P<0,001);
Yu t nng FSH c bn cao >15 mIU/ml l ch bo trong tin
lng phi LBNST tuy nhin gi tr thp (LR(+) = 1,93 v LR(-) = 0,93).
 63

3.4.5. Tc pht tri n v hnh thi ca phi ngy 3 v lch b i nhim

s c th .
* Tc pht trin ca phi ngy 3 sau th tinh (biu th qua s lng phi
bo) v lch bi nhim sc th.
Bng 3.12: S pht trin ca phi ngy 3 v LBNST.
LBNST Bnh thng
S phi
Cng RR LR(+) LR (-)
bo S phi % S phi %

4-6 148 83,1a 30 16,9 178 1,48 3,1 0,82

7-9 445 56,3b 345 43,7 790 1
10 190 65,7c 99 34,3 289 1,17 1,35 0.9
Cng 783 1257
(Ghi ch: RR v LR so snh vi phi c 7-9 phi bo)
Pa,b <0,001; Pb,c <0,001; Pa,c <0,001
Nhn xt: S pht trin ca phi t 7-9 phi bo ngy 3 (Hnh 3.8) tng
ng vi t l LBNST thp nht (56,3%).
Phi pht trin chm hay qu nhanh u c nguy c b LBNST cao hn
phi pht trin bnh thng (P<0,001); c bit phi pht trin chm n ngy
3 ch c 4-6 phi bo (Hnh 3.9) s tng ng vi t l LBNST tng gn 1,5
ln so vi phi c 7-9 phi bo (P <0,001).
Yu t phi pht trin chm 4-6 phi bo l ch bo trong tin lng
phi LBNST vi gi tr trung bnh (LR(+) = 3,1 v LR(-) = 0,82).
Phi pht trin chm c 4-6 phi bo ngy 3 c t l LBNST cao hn
phi pht trin nhanh c 10 phi bo ngy 3 (Hnh 3.10) (P < 0,001).
 64

Hnh 3.8: Phi s 4 vo ngy 3 ca bnh nhn Zaic.S.

Phi pht trin bnh thng (8 phi bo) vo ngy 3 sau th tinh; cc phi bo
ng u, khng c mnh vn (knh hin vi o ngc x 400)

Hnh 3.9: Phi s 2 vo ngy 3 ca bnh nhn Garcia.A.

Phi pht trin chm vo ngy th 3 sau th tinh (c 5 phi bo)
(knh hin vi o ngc x 200)
 65

Hnh 3.10: Phi s 9 vo ngy 3 ca bnh nhn Borchardt.M.

Phi pht trin nhanh vo ngy th 3 sau th tinh
(c trn 10 phi bo c kch thc khng u)
(knh hin vi o ngc x 200)
* ng u ca kch thc phi bo ngy 3 v lch bi nhim sc th.
Bng 3.13: S ng u ca cc phi bo v LBNST.
LBNST Bnh thng

S S Cng RR P LR(+) LR (-)
ng u % %
phi phi

Khng u 497 81,6 112 18,4 609 1,85

u 286 44,1 362 55,9 648 1 <0,001 2,69 0,48

Cng 783 474 1257

Nhn xt: Kch thc phi bo ngy 3 khng ng u (Hnh 3.10 v 3.11)
tng ng vi LBNST kh cao 81,6% tng gp gn 2 ln so vi phi c kch
thc phi bo ng u (44,1%); Kch thc phi bo ngy 3 khng ng
u l ch bo trong tin lng phi LBNST vi gi tr trung bnh (LR(+) =
2,69 v LR(-) = 0,48).
 66

Hnh 3.11: Phi s 7 vo ngy 3 ca bnh nhn Waner.T.

(7 phi bo: cc phi bo c kch thc khng u)
(Knh hin vi o ngc x400)
* Xut hin mnh vn trong phi ngy 3 v lch bi nhim sc th.
Bng 3.14: S xut hin mnh vn trong phi v LBNST.
% mnh LBNST Bnh thng
Cng RR LR (+) LR (-)
vn S phi % S phi %
16-30% 193 75,1a 64 24,9 257 1,39 1,96 0,77
b
6-15% 276 65,7 144 34,3 420 1,21 1,33 0,82
0-5% 314 54,1c 266 45,9 580 1
Cng 783 474 1257
(Ghi ch: RR v LR so snh vi phi c 0-5% mnh vn)
Pa,b <0,025; Pa,c <0,001; Pb,c <0,001
Nhn xt: Phi cng c nhiu mnh vn th kh nng b LBNST cng cao
(P<0,05). Phi c s lng mnh vn nhiu 16-30% (Hnh 3.12) tng ng
vi t l LBNST cao nht (75,1%) cao gp 1,39 ln phi c t mnh vn 0-5%
(Hnh 3.15) (RR=1,39; P<0,001); Phi c nhiu mnh vn l ch bo tin
lng phi LBNST vi gi tr thp (LR(+)=1,96 v LR(-)=0,77).
 67

Hnh 3.12: Phi s 4 vo ngy 3 ca bnh nhn Lucente.M.

Phi c 8 phi bo vi khong 16-20% mnh vn nm ri rc, cc phi bo
c kch thc ng u. (Knh hin vi o ngc x 200)
* S phn b v tr mnh vn trong phi ngy 3 v lch bi nhim sc th.
Trong tng s 1257 phi c xt nghim a-CGH, c 28 phi khng c
mnh vn, cn li 1229 phi c mnh vn. Sau y l kt qu nghin cu ca
1229 phi ni trn (bng 3.15).
Bng 3.15: S phn b mnh vn v LBNST.
LBNST Bnh thng
Phn b
Cng RR P LR(+) LR (-)
mnh vn S %
S
%
phi phi
Ri rc 584 77,6 169 22,4 753 1,94
Tp trung
191 40,1 285 59,9 476 1 <0,001 2 0,39
ngoi vi
Cng 775 454 1229
Nhn xt: Mnh vn c th phn b ri rc (Hnh 3.12, 3.14, 3.15) trong phi
hoc tp trung vng ngoi vi (Hnh 3.13). Phi c mnh vn phn b ri rc l
ch bo phi c t l LBNST cao 77,6%, tng gp gn 2 ln so vi phi c
mnh vn tp trung ngoi vi (40,1%) (RR=1,94; P<0,001); Mnh vn phn
b ri rc l ch bo trong tin lng phi LBNST vi gi tr trung bnh (LR(+)
= 2; LR(-) = 0,39).
 68

Hnh 3.13: Phi s 5 vo ngy 3 ca bnh nhn Dacy.S.

Phi c 4 phi bo vi khong 15 % mnh vn nm tp trung, cc phi bo c
kch thc ng u (Knh hin vi o ngc x 400)

Hnh 3.14: Phi s 8 vo ngy 3 ca bnh nhn Dittrich.J.

Phi c 8 phi bo vi khong 6-15% mnh vn nm ri rc.
(Knh hin vi o ngc x 400)
 69

Hnh 3.15: Phi s 6 vo ngy 3 ca bnh nhn Shen.M.

Phi c 6 phi bo vi 5% mnh vn nm ri rc.
(Knh hin vi o ngc x 400)
3.4.6. Tc pht trin thnh phi nang, hnh thi ca phi nang v lch
bi nhim sc th.
* S pht trin ca phi t ngy 3 n giai on phi nang (biu th bng kh
nng hnh thnh phi nang) v lch bi nhim sc th.

Bng 3.16: S pht trin thnh phi nang v LBNST.

LBNST Bnh thng

Pht trin S S Cng RR P LR(+) LR (-)
% %
phi phi
Chm/
530 77,4 155 22,6 685 1,75
ngng
<0,001 2,1 0,48
Phi nang 253 44,2 319 55,8 572 1
Cng 783 474 1257
 70

Nhn xt: Phi chm hoc ngng pht trin t ngy 3 n giai on phi
nang c nguy c tng LBNST ln 1,75 ln so vi phi pht trin thnh phi
nang. Phi ngng pht trin l ch bo trong tin lng phi LBT vi gi tr
trung bnh (LR(+) = 2,1 v LR(-) = 0,48).

* S pht trin ca phi t ngy 3 n giai on phi nang (biu th bng

thi im hnh thnh phi nang sm hay mun) v lch bi nhim sc th.

Trong tng s 1257 phi c 685 (54,5%) phi ngng pht trin giai
on phn chia hay chm pht trin giai on phi du hay phi nang sm
(giai on 1); cn li 572 phi tip tc pht trin theo tc khc nhau thnh
phi nang (giai on 2-6) tng ng vi t l LBNST cng khc nhau c
nu trong bng sau (bng 3.17).
Bng 3.17: So snh gia phi pht trin chm n ngy 6 mi hnh thnh
phi nang v phi pht trin nhanh n ngy 5 thnh phi nang v LBNST.

LBNST Bnh thng

Pht trin
S S Cng RR P LR (+) LR (-)
Phi nang % %
phi phi
Ngy 6 156 66,7 78 33,3 234 2,3
Ngy 5 97 28,7 241 71,3 338 1 <0,001 2,52 0,51

Cng 253 319 572

Nhn xt: Phi pht trin chm (thnh phi nang vo ngy 6) tng ng vi
t l LBNST 66,7%; cao hn khong 2,3 ln so vi phi nang pht trin bnh
thng (thnh phi nang vo ngy 5) (RR = 2,3 v P <0,001);
Phi pht trin chm thnh phi nang vo ngy th 6 l ch bo trong
tin lng phi LBNST vi gi tr trung bnh (LR(+) =2,52 v LR(-) = 0,51).
 71

* Tc pht trin ca phi nang vo ngy 5 v lch bi nhim sc th.

Bng 3.18: Tc pht trin ca phi vo ngy 5 v LBNST.
Bnh
LBNST
Giai on pht trin thng
Cng RR LR(+) LR(-)
ca phi nang S S
% %
phi phi
Ngng pht trin 274 91,6a 25 8,4 299 4,2 6,58 0,16
Pht trin chm: phi du 97 80,8b 23 19,2 120 3,7 5,6 0,37
Pht trin chm: Giai on 1 315 63c 185 37 500 2,9 1,67 0,27
Giai on 2 33 43,4d 43 56,6 76 2 2,04 0,73
Giai on 3-4 18 36,7e 31 63,3 49 1,7 1,8 0,85
Giai on 5-6 46 21,6f 167 78,4 213 1
Cng 783 474 1257
(Ghi ch: RR v LR so snh vi giai on 5-6)
Pa,b<0,005; Pa,c<0,001; Pa,d<0,001; Pa,e<0,001; Pa,f<0,001;
Pb,c<0,001; Pb,d<0,001; Pb,e<0,001; Pb,f<0,001;
Pc,d<0,005; Pc,e<0,001; Pc,f<0,001;
Pd,e>0,05; Pd,f<0,001;
Pe,f<0,05

Nhn xt: Phi LBNST pht trin thnh phi nang vo ngy 5 sau khi th
tinh vi tc chm hn phi bnh thng.

Phi nang pht trin cng chm cc mc khc nhau (t giai on

3-4, giai on 2, giai on 1, n giai on phi du) lm cho nguy c
LBNST tng ln lt l 1,7 2 2,9 3,7 v 4,2 ln so vi khi phi nang
pht trin tt bnh thng (giai on 5-6).

Phi nang pht trin chm c bit l khi ngng pht trin hay giai
on phi du l ch bo tin lng LBNST vi gi tr cao (LR (+) >5).
 72

* Mc lch bi nhim sc th v kh nng hnh thnh phi nang.

Bng 3.19: Mc LBNST v kh nng hnh thnh phi nang.
Ngng,
Phi nang
chm pht trin
Mc LBNST RR1 RR2 Tng
S
% S phi %
phi
Bnh thng 319 67,3a 155 32,7 1 474
LB 1 cp NST 121 52,4b 110 47,6 0,78 1 231
LB 2 cp NST 53 41,7c 74 58,3 0,62 0,8 127
LB 3 cp NST 14 31,1d 31 68,9 0,46 0,59 45
LB >3 cp NST 65 17,1e 315 82,9 0,25 0,33 380
Tng 572 685 1257
Pa,b<0,001; Pa,c<0,001; Pa,d<0,001; Pa,e<0,001;
Pb,c>0,05; Pb,d<0,025; Pb,e<0,001;
Pc,d>0,05; Pc,e<0,001;
Pd,e<0,05
Nhn xt: Kh nng pht trin thnh phi nang c xu hng gim dn khi
mc LBNST tng (hay s cp NST ca phi b LBNST cng nhiu). Nu
so snh vi phi bnh thng th kh nng pht trin thnh phi nang gim
bng 0,25 0,46 0,62 - 0,78 ln lt tng ng vi LBNST xy ra > 3 cp
NST, 3 cp NST, 2 cp NST v 1 cp NST.
*Gii tnh ca phi (xc nh trn phi nang pht trin bnh thng giai
on 2-6) vo ngy 5 sau th tinh v lch bi nhim sc th
Trong tng s 1257 phi c xt nghim a-CGH, 685 phi chm hay
ngng pht trin, cn li 572 phi pht trin thnh phi nang (ngy 5 v 6),
trong 338 phi pht trin thnh phi nang ngy 5. Trong s 338 phi nang
ngy 5 c 317 phi nang c kt qu s lng NST gii tnh bnh thng. Sau
y l kt qu phn tch gii tnh v LBNST trn 317 phi nang ni trn.
 73

Bng 3.20: Gii tnh ca phi nang ngy 5 v LBNST.

LBNST Bnh thng
Gii tnh P Tng
S phi % S phi %
XX 41 25,8 118 74,2 159
>0,05
XY 35 22,2 123 77,8 158
Tng 76 241 317

Nhn xt: T l gii tnh 1:1 i vi phi pht trin bnh thng vo ngy
th 5. T l LBNST ca phi c gii tnh nam v n khc bit khng c
ngha thng k, c ngha l nguy c phi b LBNST khng b chi phi bi
gii tnh.
* Cht lng ca mm phi (ICM) v lch bi nhim sc th.
Trong tng s 1257 phi c xt nghim a-CGH, c 685 phi chm
hay ngng pht trin, cn li 572 phi pht trin thnh phi nang (giai on 2-
6) vo ngy 5 v 6. Sau y l kt qu nghin cu mt s yu t lin quan
LBNST ca 572 phi nang ni trn (bng 3.21).
Bng 3.21: Cht lng ca mm phi v LBNST.
LBNST Bnh thng
Mm phi S S Cng RR LR (+) LR(-)
% %
phi phi
Loi C-D 58 80,6a 14 19,4 72 2,74 6 0,57
Loi B 131 46,3b 152 53,7 283 1,57 1,34 0,66
Loi A 64 29,5c 153 70,5 217 1
Cng 253 319 572
(Ghi ch: RR v LR so snh vi mm phi loi A)
Pa,b<0,001; Pa,c<0,001; Pb,c<0,001
Nhn xt: nh gi hnh thi cht lng ca mm phi (ICM) cho thy nh
hng ca LBNST. Cht lng ICM gim dn khi t l LBNST tng
(P<0,001). Phi c ICM loi A (cht lng tt) thy 70,5% phi bnh
 74

thng so vi 29,5% phi LBNST. Phi c ICM loi C-D (khng c hay c
cht lng km) c t l LBNST cao gp gn 3 ln so vi phi c ICM loi A
(cht lng tt) (RR=2,74; P<0,001); ICM loi C-D l ch bo tin lng
LBNST c gi tr cao vi LR(+)=6 v LR(-)=0,57.
* Cht lng ca nguyn bo l nui phi (TE) v lch bi nhim sc th.
Bng 3.22: Cht lng ca nguyn bo l nui phi v LBNST.
Nguyn bo l LBNST Bnh thng
Cng RR LR(+) LR(-)
nui S phi % S phi %
Loi C 67 79,8a 17 20,2 84 2,1 2,69 0,41
Loi B 157 38,1b 255 61,9 412 0,99 0,99 1
Loi A 29 38,2c 47 61,8 76 1
Cng 253 319 572
(Ghi ch: RR v LR so snh vi loi A)
Pa,b<0,001; Pa,c<0,001; Pb,c>0,05
Nhn xt: phi nang c nguyn bo l nui phi (TE) cht lng km (loi
C), t l lch LBNST tng gp 2,1 ln phi c c TE cht lng tt (loi A)
(RR=2,1; P<0,001); TE loi C (cht lng km) l ch bo trong tin lng
phi LBNST vi gi tr trung bnh (LR(+)=2,69 v LR(-)=0,41).
* Cht lng phi nang v lch bi nhim sc th.
Bng 3.23: Cht lng phi nang ni chung v LBNST.
Cht lng LBNST Bnh thng
Cng RR LR(+) LR(-)
phi nang S phi % S phi %
CL km
88 78,6(c) 24 21,4 112 2,53 4,3 0,53
(BC,CB,CC,DC)
CL trung bnh (BB) 89 41,2(b) 127 58,8 216 1,32 1,25 0,81
CL tt (AA, AB, BA) 76 31,1 (a) 168 68,9 244 1
Cng 253 319 572
(Ghi ch : RR v LR so snh vi tiu chun cht lng phi tt)
Pa,b < 0,05; Pa,c <0,001; Pb,c < 0,001
 75

Nhn xt: T l LBNST tng dn khi cht lng ca phi nang gim. Phi c
cht lng km (BC, CB, CC, DC) tng ng vi t l LBNST tng gp 2,5
ln so vi phi c cht lng tt (AA, AB, BA); Phi nang c cht lng km
l ch bo trong tin lng phi LBNST vi gi tr trung bnh (LR(+) = 4,3 v
LR(-) = 0,53).
* Cht lng phi nang vo ngy 5 v t l lch bi nhim sc th.
Trong s 1257 phi xt nghim a-CGH, 685 phi chm hay ngng pht
trin cn li 572 phi pht trin thnh phi nang (giai on 2-6) vo ngy 5 v
6. Trong s 572 phi pht trin thnh phi nang c 338 phi pht trin thnh
phi nang ngy 5. Sau y l kt qu nghin cu v LBNST trn 338 phi
nang ngy 5 (bng 3.24):
Bng 3.24: Cht lng phi nang ngy 5 v LBNST.
LBNST Bnh thng
Cht lng phi nang Cng RR LR(+) LR(-)
S S %
%
phi phi
CL km (BC,CB,CC,DC) 13 56,5 (a) 10 43,5 23 2,29 3,5 0,84
(b)
CL trung bnh (BB) 35 29,9 82 70,1 117 1,21 1,17 0,9
(c)
CL tt (AA, AB, BA) 49 24,7 149 75,3 198 1
Cng 97 241 338
(Ghi ch: RR v LR so snh vi phi nang c cht lng tt)
Pa,b<0,05; Pa,c<0,005; Pb,c>0,05.
Nhn xt: Vo ngy th 5 sau th tinh, phi nang c cht lng km, t l
LBNST cao gp 2,3 ln so vi phi nang c cht lng tt (Hnh 3.16)
(RR=2,29; P<0,005); Phi c cht lng km l ch bo trong tin lng phi
LBNST c gi tr trung bnh vi LR(+)=3,5 v LR(-)=0,84.
* Cht lng phi nang ngy 6 v t l lch bi nhim sc th.
Trong s 1257 phi xt nghim, vo ngy 5: 247 phi bnh thng
c chn chuyn vo bung t cung m; 92 phi c ng lnh d tr;
94 phi c hin cho nghin cu khoa hc; 299 phi b loi b do ngng
pht trin. Sau y l kt qu nghin cu ca 525 phi c nui cy theo di
tip n ngy 6 (bng 3.25).
 76

Bng 3.25: Cht lng phi nang ngy 6 v LBNST.

LBNST Bnh thng
Cht lng phi nang S S Cng RR LR(+) LR(-)
% %
phi phi
Thoi ha, Chm pht trin
255 87,6(a) 36 12,4 291 1,49 1,38 0,28
(Phi du, phi nang sm)
CL km (BC, CB, CC) 75 84,3(b) 14 15,7 89 1,44 1,76 0,45
CL trung bnh (BB) 54 54,5(c) 45 45,5 99 0,93 0,96 1,1
CL tt (AA, AB, BA) 27 58,7(d) 19 41,3 46 1
Cng 411 114 525
(Ghi ch: RR v LR so snh vi phi nang c cht lng tt)
Pa,d<0.001; Pa,c<0.001; Pb,d<0.001; Pb,c<0.001
Nhn xt: Vo ngy th 6 sau th tinh, phi nang pht trin c cht lng
km, t l LBNST tng ng vi phi pht trin chm giai on thoi
ha, phi du hoc phi nang sm (tng ng 84,3% v 87,6%), cao hn
khong 1,5 ln so vi phi nang pht trin c cht lng tt v trung bnh
(Hnh 3.17).

Hnh 3.16: Phi s 7 v 8 vo ngy 5 ca bnh nhn Guarino.T.

Phi nang cht lng tt giai on 5 (ang thot mng) vo ngy 5 sau khi
sinh thit phi vo ngy 3. (Knh hin vi o ngc x 200)
 77

Hnh 3.17: Phi s 3 ca vo ngy 6 ca bnh nhn Cherry.E.

Phi nang c cht lng trung bnh giai on 5 (ang thot mng) vo ngy 6
sau khi sinh thit phi vo ngy 3. (Knh hin vi o ngc x 200)
3.5. Mt s yu t lin quan n lch bi nhim sc th qua phn tch
a bin.
3.5.1. Phn tch a bin 2 yu t: S lng phi bo v tui m.
Bng 3.26: Lin quan gia tui m; s lng phi bo v LBNST.
YT lin quan tc ng LBNST Bnh thng
Cng RR LR(+) LR(-)
S phi bo Tui m S phi % S phi %
a
<35 50 75,8 16 24,2 66 1,75 3,5 0,84
4-6 35-40 68 87,2b 10 12,8 78 2,0 6,75 0,76
c
>40 30 88,2 4 11,8 34 2,03 8,75 0,88
<35 185 43,4d 241 56,6 426 1
7-9 35-40 194 66,7e 97 33,3 291 1,54 1,76 0,69
f
>40 66 90,4 7 9,6 73 2,08 9,29 0,76
<35 83 56,1g 65 43,9 148 1,29 1,48 0,87
h
10 35-40 78 69,6 34 30,4 112 1,6 2,5 0,8
>40 29 100i 0 0 29 2,3 N/A 0,86
Cng 783 474 1257
(Ghi ch: RR v LR so snh vi phi c 7-9 t bo m <35 tui)
Pa,b,c>0,05; Pa,d<0,001; Pa,e>0,05; Pa,f<0,05; Pa,g<0,01; Pa,h>0,05; Pa,i<0,01;
Pb,d<0,001; Pb,e<0,001; Pb,f>0,05; Pb,g<0,001; Pb,h<0,01; Pb,i>0,05; Pc,d<0,001;
Pc,e<0,025; Pc,f>0,05; Pc,g<0,005; Pc,h>0,05; Pc,i>0,05; Pd,e<0,001; Pd,f<0,001;
Pd,g<0,025; Pd,h<0,001; Pd,i<0,001; Pe,f<0,001; Pe,g<0,05; Pe,h>0,05; Pe,i<0,001;
Pf,g<0,001; Pf,h<0,005; Pf,i>0,05; Pg,h<0,05; Pg,i<0,001; Ph,i<0,005
 78

Nhn xt: Phi 4-6 phi bo t l LBNST cao khng ph thuc vo tui m
(P>0,05). phi c > 6 phi bo, t l LBNST tng theo tui m (P<0,05).
m trn 40 tui, t l LBNST u cao khng ph thuc vo s lng phi bo
(P>0,05). Khi so snh vi phi 7-9 phi bo ph n tr <35 tui: *nu 2 yu
t s phi bo 6 v tui m >35 cng tc ng, s tng nguy c LBNST ln
khong 2 ln; hai yu t s phi bo 6 v tui m >35 l ch bo trong tin
lng phi LBNST c gi tr cao vi LR(+)=6,5 v 8,75; *nu 2 yu t s phi
bo 10 v tui m >35 cng tc ng s tng nguy c LBNST ln 1,6- 2,3
ln; 2 yu t phi bo 10 v tui m 35-40 l ch bo trong tin lng phi
LBNST c gi tr trung bnh vi LR(+)=2,5 v LR(-)=0,8.
3.5.2. Phn tch a bin 2 yu t: s lng phi bo v s c mt mnh vn.
Bng 3.27: Lin quan gia s lng phi bo; t l mnh vn v LBNST.
YT lin quan tc ng LBNST Bnh thng
S phi % mnh Cng RR LR(+) LR(-)
S phi % S phi %
bo vn
0-5% 19 82,6 a 4 17,4 23 1,68 4,7 0,94
4-6 6-15% 50 86,2 b 8 13,8 58 1,75 5,4 0,83
16-30% 79 81,4 c 18 18,6 97 1,65 3,5 0,78
0-5% 206 49,2 d 213 50,8 419 1
7-9 6-15% 158 62 e 97 38 255 1,26 1,4 0,81
16-30% 81 69,8 f 35 30,2 116 1,42 2 0,84
0-5% 89 64,5 g 49 35,5 138 1,31 1,58 0,86
10 6-15% 68 63,6 h 39 36,4 107 1,29 1,67 0,88
16-30% 33 75 i 11 25 44 1,52 2,86 0,91
Cng 783 474 1257
(Ghi ch: RR v LR so snh vi phi c 7-9 t bo v 0-5% mnh vn)
Pa,b,c>0,05; Pa,d<0,01; Pa,e>0,05; Pa,f>0,05; Pa,g>0,05; Pa,h>0,05; Pa,i>0,05;
Pb,d<0,001; Pb,e<0,001; Pb,f<0,05; Pb,g<0,005; Pb,h<0,005; Pb,i>0,05; Pc,d<0,001;
Pc,e<0,001; Pc,f>0,05; Pc,g<0,01; Pc,h<0,01; Pc,i>0,05; Pd,e<0,005; Pd,f<0,001;
Pd,g<0,005; Pd,h<0,025; Pd,i<0,005; Pe,f>0,05; Pe,g>0,05; Pe,h>0,05; Pe,i>0,05;
Pf,g>0,05; Pf,h>0,05; Pf,i>0,05; Pg,h>0,05; Pg,i>0,05; Ph,i>0,05.
 79

Nhn xt: phi pht trin chm (4-6 phi bo), t l LBNST cao >80%
khng lin quan n t l mnh vn (P>0,05). phi pht trin nhanh (10
phi bo) t l LBNST cao >63% khng lin quan n t l mnh vn
(P>0,05). Khi so snh vi phi 7-9 phi bo c t mnh vn (0-5%) (c nguy
c LBNST thp nht): *nu 2 yu t s phi bo 6 v t l mnh vn >5%
cng tc ng, s tng nguy c lch bi th ln 1,65 n1,75 ln; hai yu t s
phi bo 6 v s lng mnh vn >5% l ch bo trong tin lng phi
LBNST c gi tr tng i cao vi LR(+) 3,5; *nu 2 yu t s phi bo
10 v s lng mnh vn trung bnh >5% cng tc ng s tng nguy c
LBNST ln 1,29 -1,52; hai yu t s t bo phi 10 v s lng mnh vn
>5% l ch bo trong tin lng phi LBNST vi LR(+)=1,67 v 2,86.

3.5.3. Phn tch a bin 2 yu t: ng u v kch thc phi bo v s

c mt mnh vn.
Trong tng s 1257 phi c xt nghim a-CGH, c 427 phi c phi
bo khng u vi 15% mnh vn; 75 phi c phi bo u vi >15%
mnh vn; cn li 755 phi, trong 182 phi c phi bo khng u vi
>15% mnh vn v 573 phi c phi bo u vi 15% mnh vn. Sau y
l kt qu nghin cu ca 755 phi ni trn (bng 3.28):

Bng 3.28: Phi bo khng u, mnh vn > 15% v LBNST.

LBNST Bnh thng

2 Yu t Cng RR P LR(+) LR (-)
S phi % S phi %

Khng u
157 86,3 25 13,7 182 1,98
MV >15%
u <0,001 5,36 0,66
250 43,6 323 56,4 573 1
MV 15%
Cng 407 348 755
 80

Nhn xt: Khi so snh vi phi c phi bo u vi 15% mnh vn, th 2

yu t phi bo khng u v mnh vn >15% tc ng kt hp lm tng
nguy c LBT ln 1,98 ln; 2 yu t phi bo khng u v mnh vn >15%
tc ng kt hp l ch bo trong tin lng phi LBT vi gi tr cao (LR(+) =
5,36 v LR(-) = 0,66).
Trong tng s 1257 phi c xt nghim a-CGH, c 190 phi c phi
bo khng u vi 5% mnh vn v 258 phi c phi bo u vi >5%
mnh vn, cn li 809 phi, trong 419 phi c phi bo khng u vi
>5% mnh vn v 390 phi c phi bo u vi 5% mnh vn. Sau y l
kt qu nghin cu ca 809 phi ni trn (bng 3.29):
Bng 3.29: Phi bo khng u, mnh vn >5% v LBNST.
LBNST Bnh thng
2 Yu t Cng RR P LR(+) LR (-)
S phi % S phi %
Khng u
353 84,2 66 15,8 419 1,93
MV >5%
u <0,001 2,92 0,42
170 43,6 220 56,4 390 1
MV 5%
Cng 523 286 809

Nhn xt: So vi phi c phi bo u vi 5% mnh vn th khi 2 yu t

phi bo khng u vi >5% mnh vn tc ng kt hp lm tng nguy c
LBNST ln 1,93 ln; khi 2 yu t phi bo khng u v mnh vn >5% tc
ng kt hp l ch bo trong tin lng phi LBNST vi gi tr trung bnh
(LR(+) = 2,9 v LR(-) = 0,42).
3.5.4. Phn tch a bin 3 yu t: S phi bo, ng u v s c mt
mnh vn.
Trong tng s 1257 phi c xt nghim a-CGH c 724 phi khng
ph hp trong bng phn tch sau bao gm: 105 phi c 6 phi bo kch
 81

thc u vi 0-30% mnh vn v kch thc phi bo khng u vi 15%

mnh vn; 36 phi c 7-9 phi bo u vi >15% mnh vn; 323 phi c 7-9
phi bo c kch thc khng u vi 0-30% mnh vun; 122 phi c 10
phi bo kch thc khng u vi 15% mnh vn; v 138 phi c 10 phi
bo c kch thc u vi 0-30% mnh vn). Cn li 533 phi ng tiu
chun c phn tch bng 3.30 di y.
Bng 3.30: Phi pht trin nhanh/chm, kch thc phi bo khng u,
mnh vn >15% v LBNST.
LBNST Bnh thng
3 Yu t Cng RR LR(+) LR(-)
S phi % S phi %
10 phi
bo
26 89,7a 3 10,3 29 2,3 12 0,88
khng u
MV >15%
7-9 phi bo
u 168 39b 263 61 431 1
MV 15%
6 phi bo
khng u 62 84,9c 11 15,1 73 2,2 6,75 0,76
MV >15%
Cng 256 277 533
Pa,b<0,001; Pb,c<0,001; Pa,c>0,05
Nhn xt: So vi phi c 7-9 phi bo u vi 15% mnh vn th *khi c 3
yu t s phi bo10, phi bo khng u, mnh vn >15% tc ng kt hp
lm tng nguy c LBNST ln 2,3 ln; 3 yu t ny kt hp l ch bo trong
tin lng phi LBNST c gi tr rt cao vi LR(+) = 12 v LR(-) = 0,88. * khi
3 yu t s phi bo 6, phi bo khng u, mnh vn >15% tc ng kt
hp lm tng nguy c LBNST ln 2,2 ln; 3 yu t ny khi kt hp ch bo
trong tin lng phi LBNST c gi tr cao vi LR(+) = 6,75 v LR(-) = 0,76.
 82

Trong tng s 1257 phi c xt nghim a-CGH, c 741 phi khng

ph hp trong bng phn tch di y bao gm: 196 phi c 10 phi bo
kch thc u mnh vn 0-30% v phi bo kch thc khng u vi 5%
mnh vn; 166 phi c 7-9 phi bo u vi >5% mnh vn; 323 phi c 7-9
phi bo c kch thc khng u vi 0-30% mnh vn; 13 phi c 6 phi
bo kch thc khng u vi 5% mnh vn; v 43 phi c 6 phi bo c
kch thc u vi 0-30% mnh vn. Cn li 516 phi ng tiu chun c
phn tch bng 3.31 di y.
Bng 3.31: Phi pht trin nhanh/chm, kch thc phi bo khng u,
mnh vn >5% v LBNST.
LBNST Bnh thng
3 Yu t Cng RR LR(+) LR(-)
S phi % S phi %
10 phi bo
khng u 75 80,6a 18 19,4 93 2,1 4,5 0,66
MV >5%
7-9 phi bo
u 115 38,2 b 186 61,8 301 1
MV 5%
6 phi bo
khng u 105 86,1c 17 13,9 122 2,3 5,7 0,57
MV >5%
Cng 295 221 516
Pa,b<0,001; Pb,c<0,001; Pa,c>0,05
Nhn xt: Khi so snh vi phi c 7-9 phi bo kch thc u vi 5%
mnh vn th *khi 3 yu t s phi bo 6, phi bo khng u, mnh vn
>5% tc ng kt hp lm tng nguy c LBNST ln 2,3 ln; 3 yu t ny khi
kt hp l ch bo trong tin lng phi LBNST c gi tr cao vi LR(+) = 5,7
v LR(-) = 0,57; *khi 3 yu t s phi bo10, phi bo khng u, mnh vn
>5% tc ng kt hp lm tng nguy c LBNST ln 2,1; 3 yu t ny khi kt
hp l ch bo trong tin lng LBNST c gi tr trung bnh vi LR(+) =4,5 v
LR(-) = 0,66.
 83

3.5.5. Phn tch a bin 3 yu t: S phi bo, s c mt mnh vn, v v tr

mnh vn.
Trong tng s 1257 phi c xt nghim a-CGH, c 799 phi khng
ng tiu chun phn tch trong bng di bao gm: 246 trng hp c 10
phi bo vi 15% mnh vn ri rc v 10 phi bo vi 0-30% mnh vn
tp trung; 16 trng hp 7-9 TB vi > 15% mnh vn tp trung; 448 trng
hp 7-9 TB vi 0-30% mnh vn ri rc; 37 trng hp 6 TB vi 0-30%
mnh vn tp trung; v 52 trng hp 6 TB vi 15% mnh vn ri rc.
Cn li 458 phi ng tiu chun c phn tch bng 3.32 di y.
Bng 3.32: Phi pht trin nhanh/chm, mnh vn > 15%; phn b ri rc v
LBNST.
LBNST Bnh thng
3 Yu t Cng RR LR(+) LR(-)
S phi % S phi %
10 phi bo
MV >15% 34 79,1a 9 20,9 43 2,3 5,61 0,8
Ri rc
7-9 phi bo
MV 15% 114 35 b 212 65 326 1
Tp trung
6 phi bo
MV >15% 77 86,5c 12 13,5 89 2,5 7,5 0,63
Ri rc
Cng 225 233 458
Pa,b<0,001; Pb,c<0,001; Pa,c>0,05
Nhn xt: Khi so snh vi phi c 7-9 phi bo vi 15% mnh vn nm tp
trung th *khi c 3 yu t s t bo 10, mnh vn >15% ri rc tc ng kt
hp lm tng nguy c LBNST ln 2,3 ln; 3 yu t ny khi kt hp l ch bo
trong tin lng phi LBNST c gi tr cao vi LR(+) = 5,61 v LR(-) = 0,8; *
khi 3 yu t s phi bo 6, mnh vn >15% ri rc tc ng kt hp lm
 84

tng nguy c LBNST ln 2,5 ln; 3 yu t ny kt hp l ch bo trong tin

lng phi LBT c gi tr cao vi LR(+) = 7,5 v LR(-) = 0,63.
Trong tng s 1257 phi c xt nghim a-CGH, c 719 phi khng
ng tiu chun phn tch trong bng di bao gm: 289 phi c 10 phi
bo vi 0-30% mnh vn nm tp trung v 10 phi bo vi 0-5% mnh vn
nm ri rc ; 74 phi c 7-9 phi bo vi > 5% mnh vn tp trung; 448 phi
c 7-9 phi bo vi 0-30% mnh vn ri rc; 37 phi c 6 phi bo vi 0-
30% mnh vn tp trung; v 7 phi c 6 phi bo vi 5% mnh vn ri
rc. Cn li 538 phi ng tiu chun c phn tch bng 3.33 di y.
Bng 3.33: Phi pht trin nhanh/chm, mnh vn >5% phn b ri rc v
LBNST.
LBNST Bnh thng
3 Yu t Cng RR LR(+) LR(-)
S phi % S phi %
10 phi bo
MV >5% 99 72,8a 37 27,2 136 2 2,84 0,6
Ri rc
7-9 phi bo
MV 5% 97 36,2 b 171 63,8 268 1
Tp trung
6 phi bo
MV >5% 116 86,6 c 18 13,4 134 2,4 5,74 0,5
Ri rc
Cng 312 226 538
Pa,b<0,001; Pb,c<0,001; Pa,c>0,05
Nhn xt: Khi so snh vi phi c 7-9 phi bo c 5% mnh vn nm tp
trung th *khi 3 yu t s phi bo 10, mnh vn >5% ri rc tc ng kt
hp lm tng nguy c LBNST ln 2,0 ln; 3 yu t ny khi kt hp l ch bo
trong tin lng phi LBNST c gi tr trung bnh vi LR(+) = 2,84 v LR(-)=
0,6; *khi c 3 yu t s phi bo 6, mnh vn >5% ri rc tc ng kt hp
 85

lm tng nguy c lch bi th ln 2,4 ln; 3 yu t ny khi kt hp l ch bo

trong tin lng phi LBNST c gi tr cao vi LR(+) = 5,74 v LR(-) = 0,5.
Tm li, phn tch cc yu t lin quan vi LBNST s xc nh c
nguy c c lin quan n LBNST, nhng nu ch da vo phn tch n bin
xc nh nguy c tng i (RR) s cha ph hp vi thc t lm sng.
Kh nng phi hp cc nguy c (cc nguy c cng ng tc ng) l thng
gp nn phn tch a bin trn s xc nh RR gn st thc t hn, xc nh
c mc gi tr ca tng ch bo, ca cc ch bo kt hp chn lc ng
dng trong d on phi b LBNST gp phn x tr lm sng c kp thi v
chnh xc.
Sau y l bng tm tt v gi tr ca mt s ch bo d on LBNST
ca phi qua phn tch nguy c tng i (RR) v t s kh nng (LR).

Bng 3.34: Cc yu t ch bo (CB) c gi tr d on LBNST ca phi xp

t cao xung thp.
CB c RR so vi
C s khoa hc LR(+) LR(-)
gi tr Ch bo hin din nhm
chng minh
d bo chng
Phi pht trin nhanh 10 PB
Phn tch a bin
1 T bo phi khng u 12 0,88 2,3
xc nh LR, RR
Mnh vn>15%
Phi pht trin chm 4-6 PB Phn tch a bin
2 8,75 0,88 2,03
Tui m >40 xc nh LR, RR
Phn tch n bin
3 Tui m > 40 8,5 0,74 1,85
xc nh LR, RR
Phi pht trin chm 4-6 PB
Phn tch a bin
4 Mnh vn>15% 7,5 0,63 2,5
xc nh LR, RR
Mnh vn nm ri rc
Phi pht trin chm 4-6 PB Phn tch a bin
5 6,75 0,88 2,0
Tui m 35-40 xc nh LR, RR
 86

CB c RR so vi
C s khoa hc LR(+) LR(-)
gi tr Ch bo hin din nhm
chng minh
d bo chng
Phi pht trin chm 4-6 PB
Phn tch a bin
6 T bo phi khng u 6,75 0,76 2,2
xc nh LR, RR
Mnh vn >15%
Phi ngng pht trin thnh Phn tch n bin
7 6,58 0,16 4,2
phi nang ngy 5 xc nh LR, RR
Cht lng mm phi (ICM) Phn tch n bin
8 6 0,57 2,74
km loi C-D xc nh LR, RR
Phi pht trin chm 4-6 PB
Phn tch a bin
9 Mnh vn>5% 5,74 0,5 2,4
xc nh LR, RR
Mnh vn nm ri rc
Phi pht trin chm 4-6 PB
Phn tch a bin
10 T bo phi khng u 5,7 0,57 2,3
xc nh LR, RR
Mnh vn>5%
Phi pht trin nhanh 10 PB
Phn tch a bin
11 Mnh vn>15% 5,61 0,8 2,3
xc nh LR, RR
Mnh vn nm ri rc
Phi pht trin chm: phi du Phn tch n bin
12 5,6 0,37 3,7
ngy 5 xc nh LR, RR
Phi pht trin chm 4-6 PB Phn tch a bin
13 5,4 0,83 1,75
Mnh vn trung bnh 6-15% xc nh LR, RR
T bo phi khng u Phn tch a bin
14 5,36 0,66 1,98
Mnh vn >15% xc nh LR, RR

Phi pht trin nhanh 10 PB

Phn tch a bin
15 T bo phi khng u 4,5 0,66 2,1
xc nh LR, RR
Mnh vn>5%
Cht lng phi nang km Phn tch n bin
16 4,3 0,53 2,53
(BC,CB,CC, DC) xc nh LR, RR
 87

CB c RR so vi
C s khoa hc LR(+) LR(-)
gi tr Ch bo hin din nhm
chng minh
d bo chng
Phi pht trin chm 4-6 PB Phn tch a bin
17 3,5 0,78 1,65
Mnh vn nhiu 16-30% xc nh LR, RR
Phi pht trin chm (4-6 PB) Phn tch n bin
18 3,1 0,82 1,48
ngy 3 xc nh LR, RR
T bo phi khng u Phn tch a bin
19 2,92 0,42 1,93
Mnh vn >5% xc nh LR, RR
Phi pht trin nhanh 10 PB Phn tch a bin
20 2,86 0,91 1,52
Mnh vn nhiu (16-30%) xc nh LR, RR
Phi pht trin nhanh 10 PB
Phn tch a bin
21 Mnh vn>5% 2,84 0,6 2
xc nh LR, RR
Mnh vn nm ri rc
Phi bo kch thc Phn tch n bin
22 2,69 0,48 1,85
khng u xc nh LR, RR
Cht lng nguyn bo l Phn tch n bin
23 2,69 0,41 2,1
nui (TE) km loi C xc nh LR, RR
Pht trin chm thnh phi
Phn tch n bin
24 nang ngy 6 2,52 0,51 2,3
xc nh LR, RR

Phi pht trin nhanh 10 PB Phn tch a bin

25 2,5 0,8 1,6
Tui m 35-40 xc nh LR, RR
Phi chm ngng pht trin Phn tch n bin
26 2,1 0,48 1,75
thnh phi nang xc nh LR, RR
Phi nang giai on 2 Phn tch n bin
27 2,04 0,73 2
vo ngy 5 xc nh LR, RR
Phn tch n bin
28 Mnh vn ri rc 2 0,39 1,94
xc nh LR, RR
Phn tch n bin
29 Mnh vn 16-30% 1,96 0,77 1,39
xc nh LR, RR
 88

CB c RR so vi
C s khoa hc LR(+) LR(-)
gi tr Ch bo hin din nhm
chng minh
d bo chng
Phn tch n bin
30 FSH >15 mIU/ml 1,93 0,93 1,3
xc nh LR, RR
Phi nang giai on 3-4 Phn tch n bin
31 1,8 0,85 1,7
vo ngy 5 xc nh LR, RR
Phn tch n bin
32 Tui m 35-40 1,7 0,69 1,42
xc nh LR, RR
Phi pht trin nhanh 10 PB Phn tch a bin
33 1,67 0,88 1,29
Mnh vn trung bnh (6-15%) xc nh LR, RR
Phi pht trin chm: phi
Phn tch n bin
34 nang sm (giai on1) 1,67 0,27 2,9
xc nh LR, RR
vo ngy 5
Phi pht trin nhanh Phn tch n bin
35 1,35 0,9 1,17
( 10 PB) xc nh LR, RR
Cht lng mm phi (ICM) Phn tch n bin
36 1,34 0,66 1,57
loi trung bnh xc nh LR, RR
Phn tch n bin
37 Mnh vn 6-15% 1,33 0,82 1,21
xc nh LR, RR
Cht lng phi nang trung Phn tch n bin
38 1,25 0,81 1,32
bnh (BB) xc nh LR, RR

Nhn xt: T bng trn thy phn tch a bin c hiu qu chn lc ch bo
c gi tr tuy nhin qua phn tch n bin ch cn 1 ch bo: tui m>40, phi
chm pht trin ngy 3, phi ngng chm pht trin thnh phi nang, cht
lng phi nang km cng c gi tr d on LBNST cao.
 89

Chng 4
BN LUN

4.1. Bn lun v phng php phn tch di truyn.

4.1.1. Bn lun v vic sinh thit phi.
* Sinh thit phi ngy 3.
Hin ti cn hai quan im lin quan n nh hng ca sinh thit phi
n s pht trin phi v sau:
- Quan im cho rng sinh thit phi bo khng nh hng n phi
Vic sinh thit mt phi bo m khng lm tn thng n phi l mt
k thut kh v i hi kinh nghim. Tuy nhin kh nng ny vn c th xy
ra khong 0,1%. Nhiu nghin cu chng minh l sinh thit mt phi bo
ca phi ngy 3 khng nh hng n s pht trin ca phi n giai on
phi nang [122],[123],[124].
Trong mt nghin cu gn y nm 2013 ca Nguyn Ngc Dip v
cng s tin hnh nghin cu nh gi thay i hnh thi ca 30 phi ngy
3 sau sinh thit 1 phi bo thy l t l mnh vn t bo, t l phi sng st,
t l pht trin thnh phi nang, ng knh phi v dy mng trong sut
thay i khng c ngha thng k so vi nhm phi khng sinh thit
[125],[126].
Sinh thit phi ngy 3 cho php cc nh di truyn hc c 2-3 ngy
phn tch nh gi nhim sc th ca phi v c kt qu trc khi chuyn
phi ti.
- Quan im cho rng sinh thit phi bo c nh hng n phi t
hoc nhiu.
Nghin cu ca Scott v cng s nu rng sinh thit phi ngy 3 nh
hng n s lm t ca phi trong khi sinh thit phi nang th khng nh
hng [127].
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Khong 7-10% phi bo sinh thit ra nhng khng em li kt qu di

truyn do phi bo khng c nhn nguyn vn, hoc DNA trong nhn b phn
r do phi ang trong giai on ngng pht trin. i khi, c th do phi bo
khng c chuyn vo ng PCR hoc phi bo khng c nhn [41].
Nhiu nghin cu chng minh rng phi giai on phn chia c t
l phi th khm cao, ng thi phi th khm c mt s lng nh phi bo
bt thng trong phi vn c kh nng pht trin bnh thng (xem phn 1.3).
Tuy nhin cho n nay cha chng minh c phi cn c bao nhiu phi
bo c s lng nhim sc th bnh thng c th pht trin thnh a tr
sinh ra khe mnh v vy chn on ch da vo vic phn tch mt phi bo
khng i din cho ton b phi do vy chn on khng hon ton ng tin
cy. Mt im cn ch l nh hng ca vic sinh thit phi. Do vic ly ra
mt hay nhiu phi bo s nh hng ti thnh phn cc phi bo bnh
thng, bt thng phi th khm. Khi 2 phi bo c ly ra, thng 2
phi bo nm cnh nhau c ht ra. V vy vic sinh thit khng phi l
ngu nhin, rt c th kh nng ly ra phi bo c tha hay thiu nhim sc
th tng ng l 25%. Baart v cng s thy rng sinh thit 2 phi bo c th
to nn phi bnh thng vo ngy 5. S pht trin ca phi th khm hon
ton ph thuc vo thnh phn ca phi bo bnh thng [29]. Nhiu tc gi
a ra gi thuyt l phi vi <50% phi bo bnh thng thng khng th
sng st qua giai on lm t, nhng gi thuyt ny cha c chng minh c
th [68].
* Sinh thit phi nang.
giai on phi nang, 2-9 nguyn bo l nui c nh gi nn nhiu
cht liu di truyn hn so vi 1 phi bo ngy 3 nn kt qu chnh xc hn.
Sinh thit phi nang an ton hn so vi sinh thit phi ngy 3 do mt
lng nh trong tng s phi bo c ly ra. V d nh 1 phi bo c sinh
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thit t phi c 8 phi bo (chim khon 13% tng s phi), trong khi trung
bnh khong 5 nguyn bo l nui c sinh thit (chim khong 2-3% tng
s khong 200 phi bo ca phi nang pht trin).
Phi nang c kh nng chu c nhng thao tc trong qu trnh sinh
thit hn do tri qua qu trnh hot ha phi [127].
Phi c kh nng sng pht trin vi tc bnh thng thnh phi
nang c kh nng t sa cha lch bi nhim sc th. Hn na, phi c kh
nng t sa cha cao c th ui kp cc phi bnh thng vi tc pht
trin bnh thng. Phi tam th c kh nng t sa cha cao hn cc dng
khc c th do c ch hi phc th tam nhim.
Hn ch ca vic sinh thit phi nang l s khc nhau v thnh phn
phi bo trong phi nang. Phi nang c 2 phn chnh l mm phi (ICM) v
nguyn bo l nui (TE). Mm phi bao gm cc phi bo s pht trin thnh
t chc thai sau ny v nguyn bo l nui gm cc phi bo s pht trin
thnh rau thai. Sinh thit phi nang ch ly cc ngyn bo l nui nhm gim
thng tn cho mm phi. Mc d nhiu nghin cu cho rng thnh phn
phi bo ca mm phi v nguyn bo l nui c ng nht cao nhng mt
s tc gi chng minh l khong 10% phi nang c lch bi nhim sc th
nguyn bo l nui nhng khng c mm phi hay ngc li [128]. V vy,
sinh thit nguyn bo l nui vn khng hon ton i din cho ton b phi
nang. Hin tng phi th khm vn xut hin phi nang tuy nhin nhiu
nghin cu gn y cho rng t l phi th khm phi nang gim nhiu so
vi phi giai on phn chia [129]. Vi tin b v k thut phn tch di
truyn hin nay c th pht hin c hu ht phi th khm nhng nu th
khm mc t th khng pht hin c.
Mt im hn ch na ca sinh thit phi nang l nhng trung tm
th tinh trong ng nghim khng c trung tm phn tch di truyn ti ch th
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phi sau khi sinh thit thng phi ng v chuyn vo chu k chuyn phi
ng lnh. Trong trng hp ny cc nh lm sng cn phi cn nhc v nh
hng ca qu trnh ng lnh v tan ng cng nh nh hng nu chuyn
phi vo bung t cung qu mun khi ni mc t cung giai on qu mn
(hyperstimulated endometrium).
4.1.2. Bn lun v phng php a-CGH.
Trong nghin cu ny chng ti s dng mt phng php di truyn
hc phn t mi gi l phng php lai so snh b gen dng chp DNA
(Array comparative genomic hybridization/a-CGH) tin hnh phn tch
nhim sc th ca phi ngy 3 sau th tinh trong ng nghim.
* u im ca phng php a-CGH.
u im ni bt ca k thut a-CGH l kh nng nh gi trn ton b
46 nhim sc th. Ch trong mt xt nghim duy nht c th pht hin cc bt
thng ca nhim sc th bao gm: lch bi nhim sc th, mt hoc nhn
on ca nhim sc th c chnh xc hn nhiu so vi phng php FISH
(ch nh gi ti a 12 cp nhim sc th).
K thut a-CGH cho php pht hin cc bt thng ca nhim sc th
ngay c khi khng c nh hng trong chn on, y cng l mt u th
ca a-CGH so vi k thut FISH hay PCR.
A-CGH cng pht hin c cc trng hp phi th khm, tuy nhin
s chnh xc trong chn on cn ph thuc vo t l gia dng phi bo bnh
thng v phi bo b ri lon nhim sc th.
Mt u im khc ca a-CGH l c th thc hin trn mt phi bo v
hon ton t ng ha nh gim thiu c thi gian xt nghim v tng
mc chnh xc ca chn on.
Cc u im trn lm tng gi tr ca k thut a-CGH, l mt trong
s t nhng k thut hiu qu nht trong chn on phi trc lm t.
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* Hn ch ca phng php a-CGH.

Xut pht t nguyn tc ca k thut, hn ch ca a-CGH l khng th
pht hin cc trng hp bt thng trong cu trc ca nhim sc th dng
cn bng nh chuyn on tng h cn bng v o on do cc bt thng
trn khng xy ra tnh trng tha hay thiu vt liu di truyn.
A-CGH khng th pht hin c cc trng hp phi th khm c t
l thp hn 25% [130].
Mt s loi a-CGH khng cho php pht hin c mt s a bi nh
tam bi (triploid) (69,XXX); t bi (tetraploidies) (92,XXXX hay 92,XXYY)
nhng c th pht hin 69,XXY v 92,XXXY hay 92,XYYY. Tuy nhin
nhng phi ny thng c thm nhng bt thng c th pht hin c
bng a-CGH, ch 1,7% phi a bi ng nht (v d: 69,XXX hay
92,XXYY) khng pht hin c bng a-CGH. Hn na 87% nhng phi
ny ngng pht trin hay c bt thng v hnh thi v khng c chn
chuyn phi [41].
Thi gian tin hnh xt nghim v phn tch 14-24 gi, v vy trong
mt s trng hp sinh thit phi nang, cn phi ng phi v tin hnh
chuyn phi ng lnh.
Mt hn ch na ca k thut a-CGH l gi xt nghim kh cao nn
kh c th thc hin ch nh rng ri k thut ny cho mi i tng.
Tm li, cho d cc k thut chun on di truyn c pht trin n u
vn khng th chn on chnh xc 100% tnh trng nhim sc th ca phi.
Tuy nhin, sng lc phi trc lm t vn em li nhng ch s v cht lng
ca phi, v v vy ng gp vo vic tng hiu qu iu tr th tinh trong
ng nghim [129]. Vi nhng hn ch trn, bnh nhn cn c t vn k v
nguy c cng nh nhng mt hn ch ca k thut sng lc phi trc lm t.
ng thi, k thut sng lc trc sinh vn c khuyn co cho cc bnh
nhn s dng sng lc tin lm t.
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4.2. Bn lun v t l lch bi nhim sc th ca phi ngy 3.

Sau khi th tinh, phi thng c nui cy thm khong 3 ngy (giai
on phn chia) n 5-6 ngy (giai on phi nang). Trn 50% phi to ra
trong ng nghim giai on phn chia b lch bi nhim sc th, t l ny
tng ln n trn 80% ph n trn 42 tui [46],[47],[48],[49]. Mc d mt
s phi bt thng ngng pht trin t giai on ngy 3 v 5 nhng phn ln
vn pht trin n giai on phi nang. giai on phi nang, trn 40% phi
bt thng, t l ny cng tng cng vi tui m [52],[54],[131].

Trong nghin cu ny, t l lch bi nhim sc th l 62,3%

(783/1257), ph hp vi cc nghin cu trc y cho l phi ngi trc khi
lm t c t l lch bi nhim sc th kh cao [41],[46],[131],[132] (hnh3.1).
T l ny cao hn so vi mt s nghin cu khc nh trong nghin cu ca
Rubio v cng s nm 2013, s dng phng php FISH vi 9 u d cho
nhim sc th 13, 15, 16, 17, 18, 21, 22, v XY nghin cu 265 phi ngy
3 ca 91 bnh nhn c tin s phi khng lm t lin tip. Tc gi thy rng
t l lch bi nhim sc th l 57,3% [48]. T l lch bi nhim sc th
nghin cu ca Rubio thp hn nghin ny l do tc gi s dng phng
php FISH, ch nh gi 9 cp nhim sc th nn b st nhiu cp nhim
sc th khng c kim tra. Hu qu l nhiu phi b chn on sai, b lch
bi nhim sc th nhng li c coi l bnh thng. Trong nghin cu ny
s dng phng php a-CGH nh gi ton b 23 cp nhim sc th ca phi
nn t l lch bi nhim sc th tng hn l hp l. Nguyn nhn chnh gy
nn tnh trng phi khng lm t lin tip trong nghin cu ca Rubio l do
chuyn cc phi b lch bi nhim sc th m khng c pht hin do
nguyn nhn nu trn. Trong mt nghin cu khc ca Rubio v cng s
nm 2013, s dng phng php a-CGH ging nh trong nghin cu ny
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nu t l lch bi nhim sc th ni chung l 73,5% cao hn so vi nghin

cu ca chng ti do i tng nghin cu ca tc gi l phi ca cc bnh
nhn b sy thai lin tip, phi khng lm t lin tip, v sinh nam v ph n
ln tui thuc nhm c nguy c b lch bi nhim sc th cao [49].

Nm 2012, Rabinowitz v cng s s dng phng php a-SNP, mt

phng php di truyn phn t khc cng cho php nh gi ton b 23 cp
nhim sc th ca phi cng thy rng t l lch bi nhim sc th phi
ngy 3 ni chung l rt cao 72,3% [47]. T l ny cao hn so vi nghin cu
ny l do cc tc gi ny nh gi phi ca nhm bnh nhn c tui trung
bnh 38 (26-47 tui) cao hn nhm bnh nhn trong nghin ca chng ti c
tui trung bnh l 34,5 (18-45 tui).

Kt qu ca nghin cu ny thy rng cc cp nhim sc th ca phi

ngy 3 u c nguy c b lch bi nhim sc th. Trong mt phi, hin tng
lch bi nhim sc th c th xy ra 1 cp nhim sc th vi tn s 29,5%
(231/783), hoc 2 cp nhim sc th vi tn s 16,2% (127/783), hay 3
cp nhim sc th vi tn s 5,7% (45/783), hay thm ch lch bi th c th
xy ra 4 cp nhim sc th trong mt phi hay cn gi l lch bi nhim
sc th th phc tp vi tn s 48,5% (380/783) (hnh 3.2). Traversa v cng
s nm 2011, nghin cu trn phi nang thy s phi b lch bi nhim sc
th thp hn phi ngy 3 (43%). Khi nh gi mc lch bi nhim sc
th th h thy lch bi mt cp nhim sc th l cao nht (55%) sau l
lch bi 2 cp nhim sc th (41%), lch bi 3 cp nhim sc th tr ln ch
chim 7% [54]. S khc bit v t l cng nh mc lch bi nhim sc th
gia phi ngy 3 v ngy 5 c th l do phi lch bi nhim sc th th phc
tp thng b ngng pht trin trc khi pht trin thnh phi nang, ng vo
thi im m Traversa chn phi nghin cu.
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Kh nng sng lc cc bt thng ca 23 cp nhim sc th c li th

hn phng php FISH v thy tt c cc nhim sc th u c th b lch
bi v lch bi hay gp nht cc cp nhim sc th 22, 19, 16, 15, 21, XY,
9, 13, 18 (vi tn sut >3%), y cng l sai lch nhim sc th lin quan n
thai bt thng c th pht hin c trong thi gian mang thai. Kt qu ny
ph hp vi kt qu ca Al-Asma v cng s 2012 v Rubio v cng s nm
2013 s dng phng php FISH 9 u d (13, 15, 16, 17, 18, 21, 22, XY)
[46],[48]. Trong nghin cu ca Rubio v cng s nm 2013, cc nhim sc
th b nh hng nhiu nht i vi c bnh nhn c phi khng lm t lin
tip v bnh nhn ln tui l nhim sc th 22 v 16 sau l nhim sc th
13, 21, 18, XY, 15, 17 cho nhm bnh nhn b phi khng lm t lin tip v
21, 15, 13, 18, 17 v XY nhm bnh nhn ln tui [48]. Trong nghin cu
ca Al-Asma v cng s nm 2012, thy cc nhim sc th b lch bi nhiu
nht cng l nhim sc th 22 v 16 cho nhm bnh nhn c tin s sy thai
(thai t nhin hay thai to ra trong th tinh ng nghim) [46]. Kt qu nghin
cu ca chng ti (bng 3.4) cng ph hp vi kt qu nghin cu ca
Guitierez v cng s nm 2011, s dng phng php a-CGH thy lch bi
tt c cc cp nhim sc th v nhim sc th hay b lch bi l 16, 22, 21 v
15 [41]. Franasiak v cng s nm 2014, s dng phng php RT-PCR v
SNP, cng nh gi 23 cp nhim sc th ca phi nang thy l nhim sc th
hay b lch bi nht cng l 13, 15, 16, 18, 19, 21 v 22 [133].
4.3. Bn lun v kh nng t sa cha ca phi lch bi nhim sc th.
Phi b lch bi nhim sc th l kt qu ca vic th tinh gia non
hay tinh trng b lch bi nhim sc th do sai st trong qu trnh gim phn
hoc do nhng sai st ti ch trong qu trnh phn bo nguyn nhim xy ra
sau khi th tinh. Nhng sai st trong qu trnh gim phn thng dn ti hnh
thnh phi lch bi nhim sc th ng nht, trong khi nhng sai st trong
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phn bo nguyn nhim thng dn ti phi b th khm. Sng lc phi trc

lm t s pht hin nhng bt thng nhim sc th xy ra trc hay sau khi
th tinh. Tuy nhin, kt qu ch da vo s phn tch 1 hay 2 phi bo khng
phn nh ng tnh trng nhim sc th ca c phi s lm t trong 3-4 ngy
sau . Cc nghin cu trc y cho l qua qu trnh nui cy ti giai on
phi nang, phi c th t sa cha. V l do ny m Hip hi chn on phi
trc lm t (PGD Consortium) khuyn co rng phi b lch bi nhim
sc th ngy 3 nn c sinh thit v phn tch li vo ngy 5-6 [134]. Mt s
nghin cu sau tin hnh li FISH trn phi ngy 5 v cng b l thnh
phn nhim sc th ca phi c th thay i trong giai on u phn chia
[58],[60],[68]. Thc vy mt s phi b lch bi nhim sc th ngy 3 c th
pht trin thnh phi bnh thng hay phi c s lng phi bo bnh thng
tng ln gp phn hnh thnh phi nang. Mt s nghin cu khc li cho rng
nhng phi ny s c thm nhng bt thng khc [58],[68].
Nghin cu ca Barbash-Hazan v cng s cho rng c mi lin quan
gia s pht trin ca phi v kh nng t sa cha. Trong nghin cu ny
ng kt hp phi c trn 50% phi bo t sa cha v phi t sa cha
hon ton vi l do l khi c t nht 2/3 phi bo phi th khm l bnh
thng th phi c th pht trin thnh phi nang v sinh ra thai sng [60].
V vy, mc d phi th khm l hin tng kh ph bin phi giai on
trc lm t, nhng s chn lc t nhin c th loi b nhng giai on
pht trin sau ny. Peura v cng s thy l t bo gc ca phi lch bi
nhim sc th hu nh l bnh thng, iu ny gi l hin tng lch bi
nhim sc th khng phi l vnh cu [135].

Thng nht vi kt lun ca cc nghin cu s dng phng php

FISH, trong nghin cu ny ca chng ti s dng phng php a-CGH
nh gi liu kt qu phn tch mt phi bo ngy 3 c hon ton i din cho
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phi khi pht trin n giai on phi nang, chng ti thy l trong s 112
phi ngy 3 b lch bi nhim sc th pht trin thnh phi nang, c 29,5%
cho kt qu bnh thng sau sinh thit li (bng 3.6). T l ny thp hn trong
nghin cu ca Li v cng s khi h thy t l phi t sa cha l 40% [58],
hay nghin cu ca Munne v cng s khi t l t sa cha rt cao gn 70%
[68]. Gii thch cho s khc nhau ny l trong nghin cu ca Li v Munne s
dng FISH 5-9 u d nn t l m tnh gi cao, mt s phi bt thng cc
nhim sc th khng c nh gi li c cho l bnh thng.

C hai c ch gii thch hin tng phi t sa cha: hin tng phi
th khm cao phi trc lm t v hin tng phc hi th ba nhim
(trisomy rescue):

C ch th khm cao phi trc lm t.

C ch ph bin to ra phi th khm l do tha, thiu nhim sc th

hay hin tng khng phn ly nhim sc th trong phn bo nguyn nhim
[31]. Khng phn ly trong phn bo nguyn nhim khi nhim sc t ch em
(sister chromatids) khng phn ly hon ton dn n to ra mt phi bo c
tha nhim sc th v mt phi bo thiu nhim sc th tng ng.

Chm tr k sau (anaphase lagging) xy ra khi mt nhim sc t

(chromatid) khng gn vi thoi phn bo do s chm ch (delayed
movement) trong k cui v b mt i, dn ti to mt phi bo con c s
lng nhim sc th bnh thng v mt phi bo con mt i nhim sc th b
chm ch .

Hin tng nhn ln ni sinh (endoreduplication) xy ra khi mt nhim

sc t cui giai on S (S-phase) ca chu k t bo nhn i to nn s c
mt ca 3 nhim sc t. Tip theo giai on phi bo phn chia, mt phi bo
s l lng bi (disomy) v mt phi bo l th tam nhim (trisomy) [136].
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Hin tng ny gii thch khi mt phi bo con l th tam nhim (trisomy)
trong khi phi bo con th hai khng b thiu ht nhim sc th tng ng.
iu kin nui cy c th lm tng xy ra sai st phn bo phi to ra
trong ng nghim [79]. Th khm c pht hin khong 1-2% mu sinh
thit gai rau thai 3 thng u [137]. Mt s trng hp th khm ch sy ra
rau thai s tri qua qu trnh t sa cha [137]. n giai on 3 thng gia
ca thai, th khm ca rau v thai ch thy 0,1%-0,4% thai sng, pht hin
bng phng php chc i [138].
Mt s nghin cu cho l phi bo bnh thng thng tp trung hnh
thnh mm phi trong khi phi bo lch bi nhim sc th tp trung nguyn
bo l nui [31]. Mt s nghin cu khc li cho rng phi nang, t l lch
bi nhim sc th mm phi v nguyn bo l nui l nh nhau [139]. Khi
phi th khm c phi bo lng bi (disomic cells), nhng phi bo ny s
pht trin khc vi cc phi bo bt thng v s khc nhau v mt phn chia
gia phi bo lng bi v phi bo lch bi nhim sc th s to nn phi c
nhiu phi bo lng bi c bit trong giai on pht trin n phi nang
[68]. Hn na, b gen ca phi cha hon ton hot ha chu k phn bo
th 3 [61] nn nhng cht liu sao chp t m cn thit cho kim sot chu k
t bo b thiu ht dn n sai lch v nhim sc th. Cho n khi b gen ca
phi c hot ha, c ch cht theo chng trnh t bo (apoptosis) v cc
im kim sot chu k t bo c hot ha s trnh nhng sai st trong cc
chu k phn bo nguyn nhim ca phi bo tip theo, cc phi bo bt
thng b loi b, gim s lng phi bo bt thng giai on phi nang.
C ch phc hi th tam nhim.
C ch th hai gii thch hin tng phi t sa cha l hin tng
phc hi th tam nhim (trisomy rescue), qua 3 cch sau: (1) s chm tr ca
k sau (anaphase-lag), (2) khng phn ly hay (3) nhim sc th b ph hy. S
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sa cha theo c ch chm tr k sau s to nn 1 phi bo lng th

(disomy) v mt phi bo th tam nhim (trisomy). S sa cha theo c ch
khng phn ly s to ra 1 phi bo lng th sng (viable disomic cell) v 1
phi bo t th cht (lethal tetrasomic cell), trong trng hp ny, s lng
phi bo s gim, lm gim s pht trin bnh thng. S sa cha theo cch
nhim sc th b ph hy do mt trong 3 nhim sc th b v trong giai on
bin k (metaphase) hay k sau (anaphase), to nn 2 phi bo con lng th.
S chm tr trong k sau ca qu trnh phn bo hay nhim sc th
khng phn ly trong giai on u phn chia l c ch c nghin cu nhiu
nht c Munne v cng s nu ra nm 2005, y l c ch pht sinh cc
bt thng v s lng nhim sc th [68]. Trong nghin cu ca Barbash-
Hazan v cng s, nghin cu 83 phi c bt thng v nhim sc th ngy 3,
trong 26,5% phi c th tam nhim (trisomy) ngy 3. Trong s phi c th
tam nhim, 41% tri qua t sa cha (trn 50% phi bo bnh thng phi
giai on phi nang), tc gi gii thch hin tng ny c th do c ch hi
phc th tam nhim [60]. Rubio v cng s cho rng phi c th tam nhim
thng pht trin thnh phi nang cao hn cc bt thng lch bi nhim sc
th khc [140].
Mt iu th v cha c nu ln trong cc nghin cu trc y l
chng ti thy phi lch bi nhim sc th c th pht trin thnh phi nang
c ph n ln tui nhng kh nng t sa cha ngi m trn 35 tui gim
ng k so vi m tr di 35 tui (bng 3.7). Nguyn nhn ph n ln tui
kh nng t sa cha km l do nhm ny t l lch bi nhim sc th ca
non rt cao do nhng bt thng xy ra trong giai on gim phn v to nn
bt thng ng nht xy ra tt c cc phi bo sau ny [141]. Theo
Fragouli v cng s nm 2011, 30% phi b nh hng c ngun gc t phn
bo gim phn. [56]. Theo Hanson v cng s khi phn tch chn on li
phi lch bi nhim sc th ngy 3 ph n trn 37 tui s dng phng
 101

php FISH thy l ph n ln tui phi c 1 phi bo bt thng th c

nguy c cao cc phi bo khc c bt thng nh vy hay c nhng bt
thng khc [142]. V vy, sng lc trc lm t dng nh thnh cng trong
vic chn la phi c bt thng v nhim sc th nhm ph n ln tui.
Cc bt thng c ngun gc t phn bo gim phn dn lch bi nhim sc
th ng nht v th khm phc tp gy nn khng c dng phi bo bnh
thng trong nhm ny [67]. Theo Delhanty v cng s 2005 th nguyn nhn
ch yu gy th khm lch bi nhim sc th (aneuploidy mosaics) l do
nhim sc th mt, tip theo l nhim sc th tha do khng phn ly trong
phn bo v u c lin quan n tui m. Phi th khm phc tp hn n
(chaotic) c th xy ra c lp vi tui m, c lin quan n bt thng trung
th v c ngun gc t b [143]. Wilding v cng s gi mt gi thuyt
khc lin quan n ngun gc ca th khm phc tp, v c mi lin quan
gia tui m v tn sut phi b th khm phc tp do tui m c nh hng
rt ln n cht lng ca non. Cc nh hng ti ty th c tch dn li
trong trong cuc i ngi ph n dn ti gim hot ng ca ty th non.
Cc tc gi ny thy rng phi th khm phc tp tng ng k ph n trn
37 tui, c ngha l ty th b thoi ha lm gim hot ng ca ty th dn n
nhng sai st thoi phn bo. Tui m nh hng n phi cn th hin c
nhiu phi lch bi nhiu cp nhim sc th [144].
Tm li tin b trong iu kin nui cy phi lm tng cht lng
ca phi. Tuy nhin, ch da vo s pht trin thnh phi nang khng phi l
phng php ng tin cy chn phi c nhim sc th bnh thng. Sng
lc trc lm t s dng a-CGH c th kt hp vi tng cht lng mi
trng nui cy tng t l c thai v gim t l sy thai. Tuy nhin, bnh
nhn cng nh bc s lm sng cn ch l k thut sng lc trc lm t cn
c nhng mt hn ch. Nu c nghi ng trong chn on, th nn phn tch li
gp phn lm tng chnh xc ca kt qu v lm tng t l lm t.
 102

4.4. Bn lun v mt s yu t lin quan n lch bi nhim sc th qua

phn tch n bin.
4.4.1. Tin s iu tr th tinh trong ng nghim tht bi lin quan n lch
bi nhim sc th.
Trong nghin cu ny, nhm bnh nhn b tht bi sau iu tr th tinh
trong ng nghim (phi khng lm t c hay sy thai sm sau khi chuyn
phi) c t l lch bi nhim sc th cao nht 76% (bng 3.8). Phi khng
lm t thng gp trong iu tr th tinh trong ng nghim, ngay c khi phi
c cht lng tt c chuyn vo bung t cung. Mc d cc phng php
iu tr c ti u ha v nhng pht trin vt bc trong phng th
nghim nui cy phi, vic kim sot phi khng lm t vn l mt thch
thc i vi cc bc s v cc nh phi thai hc trn ton cu. Vic lm t ca
phi trong bung t cung ph thuc vo s ng b ca cc yu t khc nhau
v d nh l cht lng ca phi, iu kin nui cy ti u, tnh trng t cung
ca ngi m, kh nng tip nhn bo thai ca ni mc t cung v h thng
min dch ca ngi m. Cho n nay ngi ta bit r l nguyn nhn
chnh gy phi khng lm t lin tip trong iu tr th tinh trong ng nghim
l do phi b lch bi nhim sc th. Bt thng v nhim sc th cng tng
cao nhng ph n c tin s c phi khng lm t lin tip. Nhng s liu
thu c t phi v non ca bnh nhn tham gia sng lc trc lm t trn
bnh nhn ln tui, sy thai lin tip, tht bi iu tr th tinh trong ng
nghim nhiu ln cho thy rng nhiu phi v non to ra trong ng
nghim b bt thng v v vy khng lm t c. T l lch bi nhim sc
th cho nhm bnh nhn b tht bi iu tr th tinh trong ng nghim trc
trong nghin cu ny cao hn mt s nghin cu khc [46],[48]. Kt qu
nghin cu ca Rubio v cng s 2013 c t l lch bi nhim sc th l
57,3% nhm bnh nhn tin s c phi khng lm t lin tip [48] v trong
 103

nghin cu ca Al-Asmar v cng s 2012, t l lch bi nhim sc th l

67,8% [46]. L gii cho s khc nhau ny l cc nghin cu trc y s
dng phng php FISH ch nghin cu 9 cp nhim sc th cn trong nghin
cu ny s dng phng php a-CGH cho php nh gi 23 cp nhim sc
th ca phi cng mt lc nn c th pht hin thm nhiu ri lon nhim sc
th hn.
4.4.2. Nguyn nhn v sinh lin quan n lch bi nhim sc th.

Nguyn nhn v sinh c lin quan n t l lch bi nhim sc th ca

phi to ra trong ng nghim. Ri lon phng non, bung trng a nang
tng ng vi t l phi b lch bi nhim sc th cao trn 60% so vi nhm
v sinh do bt thng t cung (27,3%) (bng 3.9). Kt qu ny ph hp vi
nghin cu ca Gianaroli v cng s nm 2010, cho l nhng ph n c ri
lon phng non (bt k do nguyn nhn no), thng hay xy ra cc sai st
trong gim phn hay bung trng tri qua qu trnh gi ha sinh hc (do mi
trng hormone ca bung trng) cng lm tng nguy c sai st trong qu
trnh ny [145].

V sinh do yu t tinh trng cng tng ng vi t l lch bi th kh

cao phi to ra trong ng nghim (>60%) (bng 3.9). Kt qu ny ph hp
vi nghin cu ca Magli v cng s nm 2009 s dng phng php FISH
thy rng t l lch bi nhim sc th trn phi ca phi bnh nhn c tinh
trng t, yu, hnh thi bt thng l 62% v bnh nhn khng c tinh trng
trong tinh dch (phi ly tinh trng mo tinh hay tinh hon) l 69% [146].
nhm bnh nhn c tinh trng bt thng (t, yu, hnh thi bt thng) nh
hng ti kh nng c thai t nhin, t l lch bi nhim sc th tinh trng
cao (2-14%). Tng bt thng v nhim sc th ca tinh trng c lin quan
mt thit vi mc v sinh. Tng lch bi nhim sc th tinh trng s lm
 104

tng nguy c phi b lch bi nhim sc th [147]. Mc d t l lch bi

nhim sc th tinh trng khng ng k so vi lch bi nhim sc th
non nhng vi pht trin ca cng ngh h tr sinh sn v di truyn hc hin
nay vn cha th nh gi c thnh phn nhim sc th ca tinh trng dng
trong k thut cy tinh trng vi non hay tim tinh trng vo bo tng non
chn lc chnh xc tinh trng dn ti tng t l bt thng nhim sc
th gii tnh phi to ra bng phng php tim tinh trng vo bo tng
non [148]. Mt nguyn nhn na dn n tng t l lch bi nhim sc th
ca phi bnh nhn v sinh nam l bt thng ca trung th ca tinh
trng, c bit tinh trng khng chuyn ng hay chuyn ng km. Bt
thng ny nh hng n hnh thnh thoi phn bo phi nh hng n
s phn chia, pht trin phi, to nn phi b lch bi nhim sc th hay
phi th khm.

V sinh khng r nguyn nhn l mt chn on gy tranh ci v nn

lng nht cho bc s cng nh bnh nhn v khng tm ra c bt thng c
bit no tp trung iu tr. Chn on v sinh khng r nguyn nhn
thng c a ra khi bnh nhn c chu k phng non bnh thng, xt
nghim tinh dch bnh thng, chp t cung-vi trng bnh thng v
khng c tin s au dnh vng h chu hay lc ni mc t cung. Trong
trng hp v sinh khng r nguyn nhn, thc cht vn c nguyn nhn m
khoa hc hin nay cha th pht hin ra. Trong nghin cu ny, chng ti
thy rng nhm bnh nhn v sinh cha r nguyn nhn c t l lch bi th
phi cao 65,9% do bt thng nhim sc th ca giao t (non hay tinh
trng) (bng 3.9).
 105

4.4.3. Tui m lin quan n lch bi nhim sc th.

S lng non bung trng gim dn trong cuc i sinh sn ca
ngi ph n do c ch thoi ha (atresia). thai khong 20 tun, s lng
non l 6-7 triu, sau gim cn 1-2 triu non lc sinh; 300.000 500.000
tui dy th; 25.000 tui 37 v 1.000 tui 51 (thng l tui ph n mn
kinh). Kh nng sinh ca ngi ph n gim dn nhng gim r rng t
tui 35 v gim mnh sau 37 tui th hin qua gim cht lng ca non cng
vi tng dn nng FSH c bn v gim AMH v inhibin B. Trong mt
nghin cu ca Schwartz v cng s trn nhng ph n khe mnh s dng
tinh trng ca ngi cho thy rng t l c thai gim mnh khi tui ca ngi
ph n tng [149]. T l c thai gim t 74% ph n di 31 tui xung
cn 62% ph n 31-35 tui v gim mnh cn 54% ph n trn 35 tui
[149]. Xu hng ny cng thy bnh nhn iu tr th tinh trong ng
nghim Hoa k nm 2012 do trung tm kim sot v phng chng dch
bnh Hoa k (Center for Disease Control and Prevention/CDC) cng b nm
2014: t l sinh sng gim t 40,5% ph n di 35 tui cn 31,3% ph
n 35-37 tui, 22,2% ph n 38-40 tui; 11,7% ph n 41-42 tui; 4,5%
ph n 43-44 tui v 1,8% ph n trn 44 tui [150]. Khi tui ca ngi
ph n tng, nguy c b cc ri lon lin quan n sinh sn nh u t cung,
bnh l ca vi t cung, bnh l lc ni mc t cung cng tng cao. Tui ca
ngi ph n cao lm tng cc bt thng n thoi phn bo dn n hin
tng nhim sc th khng phn ly c lin quan n tng t l lch bi nhim
sc th v t l sy thai [22],[151].
C ch lch bi nhim sc th ch yu l kt qu ca s khng phn
ly trong gim phn I, qu trnh to non cn t nht 10-13 nm thm ch 45-
55 nm hon thnh. Qu trnh gim phn II hon thnh sau khi th tinh.
S chm ch ca k sau v sai st trong vic hp nht c th xy ra trong
 106

giai on ny. V vy ph n ln tui, do ngng pht trin giai on

gim phn I (tnh trng G 0) lu hn nn c nguy c b lch bi nhim sc
th cao hn.
T l lch bi nhim sc th tng cng vi tui m c chng minh
trong hu ht cc nghin cu [41],[47],[48],[152] v hin tng lch bi
nhim sc th xy ra tt c cc giai on pht trin ca phi: giai on phn
chia [48] hay giai on phi nang [133]. Sng lc phi trc lm t thng
c ch nh trong trng hp ph n ln tui, nhiu ln tht bi iu tr th
tinh trong ng nghim, tin s sy thai. Gn y sng lc phi trc lm t
cn c tin hnh nhng bnh nhn tr tui c tin lng lng tt nhm
nng cao hiu qu chuyn mt phi c chn lc [153],[154]. Sng lc phi
trc lm t c chng minh qua li im: lm tng kh nng c thai cho
mi chu k iu tr, rt ngn thi gian c thai, trnh nhng trng hp
chuyn phi khng cn thit v trnh ng nhng phi khng c kh nng
sng; gim sy thai, gim sinh ra nhng a tr b bnh Down, ng thi em
li thng tin hu ch v mt tin lng cho bnh nhn [48],[49],[132]. Trong
nghin cu ca chng ti thuyt phc c ph n mi la tui t nguyn
tham gia sng lc phi tin lm t v c bit la tui t 18-46 (trung bnh
34,5 5,7) vi khong 50% l tr di 35 tui (bng 3.1).
Kt qu nghin cu ca chng ti cng trng hp vi kt qu ca cc
nghin cu ca cc tc gi khc s dng phng php FISH, a-CGH hay a-
SNP, l tui m c lin quan mt thit n t l lch bi th ca phi ngy
3 to ra trong ng nghim [67], [90]. Nghin cu ca chng ti thy l phi
to ra ngi m tr di 35 tui c t l lch bi th l 49,7% v tng ti
91,9% ngi m trn 40 tui. Kh nng phi b lch bi th m 35-40 tui
cao gp gn 1,5 ln v m trn 40 tui cao gp gn 2 ln so vi phi ca
ngi m tr tui di 35. Bng 3.10 v 3.34 trong phn kt qu nghin cu
 107

chng minh khi c mt ca ch bo tui m trn 40 th t s kh nng l

LR(+) = 8,5 v LR(-)=0,74 khi so snh t l phi b lch bi nhim sc th
ngi m tr tui di 35. Do vy tui m trn 40 l ch bo rt quan trng
trong tin lng lch bi nhim sc th. Bng 3.26 ch r khi tui m 35-40
v c bit >40 c nguy c lch bi nhim sc th tng ng l 66,7% v
90,4%; mc d phi ngy 3 pht trin bnh thng c 7-9 phi bo. Kt qu
nghin cu trn chng minh ch ring tui m >40 cng l yu t c
lp c lin quan n nguy c lch bi nhim sc th cao. V vy khi iu tr
cho nhm bnh nhn ny, cc nh lm sng hc cn phi t vn k v kh
nng phi bt thng cao, kh nng khng c phi chuyn phi cao,
nguyn nhn, v ra hng gii quyt trong trng hp xu.

4.4.4. Nng FSH c bn lin quan n lch bi nhim sc th.

T lu chng ta bit rng, tng nng FSH c bn v tui m tng c
lin quan n gim kh nng sinh . Cho n nay, vn cn nhiu tranh ci v
bnh sinh (etiology) ca hin tng gim kh nng sinh ph n c nng
FSH c bn cao, c bit ph n tr tui. Sinh bnh hc ca bnh l trn
li lin quan n n gim cht lng non hay gim d tr bung trng cng
cha c sng t. Trong nghin cu ny chng ti thy ph n c nng
FSH c bn cao trn 15mIU/ml tng ng vi t l lch bi nhim sc th
cao gp 1,3 ln so vi ph n c nng FSH c bn thp 15 mIU/ml
(bng 3.11). Kt qu ny gn ph hp vi kt qu ca Nasseri v cng s
cng b l tng nng FSH c bn 15 mIU/ml c lin quan n thai b
lch bi nhim sc th. Cc tc gi cho rng nng FSH c bn l ch bo
tin lng thai b lch bi nhim sc th c gi tr hn yu t tui m
cao. y l im tri ngc vi kt qu nghin cu ca chng ti v tc gi
Nasseri ch nghin cu v xt nghim lch bi nhim sc th trn t chc thai
sy v mt s trng hp c thai t nhin hoc bm tinh trng vo bung t
 108

cung ch khng hon ton l sau iu tr th tinh trong ng nghim. Phi lch
bi nhim sc th thng c kh nng lm t km. Xt nghim lch bi nhim
sc th trn t chc thai sy c th khng hon ton phn nh t l tht ca
phi b lch bi nhim sc th [155]. Kt qu ca nghin cu ca chng ti
cng ph hp vi nhng nhn nh ca El-Touky v cng s nm 2002 cho l
tui ca ngi ph n l yu t tc ng tt nhin gy ra hin tng gim d
tr bung trng th hin bng tng nng FSH c bn ngy 3 t gim
p ng iu tr, to nn non c cht lng km, dn n gim t l c thai
v tng t l sy thai l l ng nhin [156]. Tng nng FSH cn thy
ph n tr c gim s lng non l hu qu ca hin tng thoi ha bung
trng sm (premature ovarian failure/POF). Nng FSH c bn cao l ch
bo cho cht lng ca non trong nhm bnh nhn ny c chng minh
[155]. V lm sng, mi lin quan ny c nh hng ti vic t vn cho nhm
bnh nhn tr c tng nng FSH v nguy c sy thai cng nh nguy c c
thai b lch bi nhim sc th.
Nu tng nng FSH l ch bo gim cht lng non v c nh
hng ti t l lch bi nhim sc th phi. iu ny cung cp nhng thng
tin c gi tr trong vic t vn bnh nhn, ng thi gii thch nguyn nhn
gim sinh ph n c tng nng d FSH. Bng 3.11 trong phn kt qu
ca nghin cu ny chng minh khi c mt ca yu t tng nng FSH
c bn th kh nng d on lch bi nhim sc th khng cao tng ng vi
t s kh nng LR(+)=1,93 v LR(-)=0,93. Hin ti mt s trung tm iu tr
th tinh ng nghim s dng nng FSH c bn sng lc bnh nhn iu
tr. Tuy nhin, mt s nghin cu thy l ph n tr c nng FSH cao vn
c kh nang c thai mc d thp hn t l chung mt t [157]. Kt qu nghin
cu ca Thum cho rng tng nng FSH c bn 10 mIU/ml khng c nh
hng ti cht lng ca non, ph n c tng nng FSH c bn khng c
 109

nguy c cao to ra phi lch bi nhim sc th. Tc gi thy rng tng nng
FSH c bn c lin quan n s lng hn l cht lng d tr bung
trng v ph n tr c tng nng FSH c kt qu iu tr tt hn ph n
ln tui c FSH bnh thng. V vy nng FSH c bn c t gi tr trong
vic tin lng kt qu iu tr th tinh trong ng nghim v ch nn s dng
FSH c bn nh mt gi n mt phng php iu tr thch hp.

4.4.5. Tc pht trin ca phi ngy 3 sau th tinh (biu th qua s lng
phi bo) lin quan n lch bi nhim sc th.

Tc pht trin ca phi giai on phn chia biu th bng s lng

phi bo ngy 2 v 3 sau th tinh v c gi tr trong tin lng kh nng
lm t v c thai. Theo phng php nh gi phi ng thun ca t chc
Alpha th tc pht trin l tng nht l phi ngy 1 c 2 phi bo thi
im 261 gi sau tim tinh trng vo bo tng non v 281 gi sau cy
tinh trng vi non; phi ngy 2 c 4 phi bo thi im 441 gi v phi
ngy 3 c 8 phi bo thi im 681 gi [19]. Phi pht trin theo ng
thi im thch hp thng c kh nng pht trin thnh phi nang v lm t
cao hn [158]. Sau rt nhiu nghin cu khng nh mc pht trin 8
phi bo l mt ch s hu ch trong vic la chn phi vi kh nng lm t
cao nht vo ngy 3 sau th tinh [64],[159],[160],[161],[162].

Sau khi th tinh, s pht trin ca phi bt u bng hin tng hp

nht gia tin nhn ca b v ca m. Kh nng pht trin tip ca phi mt
phn no b nh hng bi giai on sm ny. Cc yu t di truyn (gene)
v biu sinh hc (epigenetics) t giao t b v m iu khin v chi phi
chng trnh pht trin ni trn. Nhng sai st trong chng trnh pht
trin c nh sn v thi gian to hp t v cc chui s kin tip theo
s dn n phi b cht.
 110

Gim phn l mt c ch to ra giao t c s lng nhim sc th

gim i mt na. Nhng sai st trong qu trnh gim phn t xy ra hu ht
cc sinh vt, tuy nhin ngi th c bit, khong 50% non to ra c nhim
sc th bt thng [21],[22]. Phi c lch bi nhim sc th thng t khi c
kh nng sng st, khong 1/3 cc trng hp sy thai l do lch bi nhim
sc th.
Tc phn chia ca phi thi im chuyn phi cng c gi tr
trong tin lng sy thai sm. Hourvitz v cng s thy rng phi c t phi
bo vo ngy 3 ( 6) thng c lin quan n sy thai sm. Mi lin h gia
s lng phi bo v ri lon nhim sc th c cng b. S dng
phng php FISH nh gi tnh trng 5-10 cp nhim sc th ca phi
ngy 3 sau th tinh, mt s nh nghin cu thy rng phi c nhim sc th
bt thng thng phn chia khng theo ng mt thi gian thch hp; t l
bt thng cao nht phi pht trin chm [2],[65]. Munne v cng s thy
rng phi ngy 2 c 4 phi bo c t l lch bi nhim sc th thp nht
[163], trong khi Magli v cng s cng cho l iu ny ng vi phi ngy
3 c 7-8 phi bo thi im 62 gi sau th tinh [2]. Finn v cng s cng
thy phi bnh thng v s lng nhim sc th gp nhiu nht phi c 7
ti 8 phi bo thi im 64 gi sau th tinh khi so vi phi c 6 phi bo
hay phi c 9 phi bo [65]. Trong nghin cu ca chng ti s dng
phng php a-CGH nh gi ton b 23 cp nhim sc th ca phi 67-68
gi sau th tinh cng thy rng c mi lin quan cht ch gia s lng
nhim sc th v kh nng pht trin ca phi biu th qua s lng phi bo
(bng 3.12). iu c ngha l thi gian phn chia ca phi chu nh hng
bi tnh trng ca nhn t bo phi. T l lch bi nhim scth cao nht
nhng phi pht trin chm ( 6 phi bo) gp gn 1,5 ln so vi phi pht
trin bnh thng (7-9 phi bo). Yu t pht trin chm c xem nh l
 111

mt ch bo c gi tr tng i cao trong d on phi lch bi nhim sc th

tng ng vi t s kh nng LR(+)=3,1 v LR(-)=0,82 (bng 3.12). Khc vi
nghin cu ca Magli v Finn, h nh gi phi thi im 62-64 gi sau th
tinh nn phi 9 phi bo c xp vo loi phi pht trin nhanh [2],[65], tuy
nhin trong nghin cu ca chng ti nh gi phi thi im 67-68 gi
v phi thi im ny c 9 phi bo c coi l bnh thng ging nh kt
lun ca Munne v cng s [163]. Trong nghin cu gn y ca Campbell
v cng s nm 2014, s dng phng php theo di phi lin tc (time-lapse
imaging) cng khng nh rng phi lch bi nhim sc th pht trin chm
hn phi bnh thng [164]. Nhng bt thng v nhim sc th nh phi b
lch bi nhim sc th, phi th khm c nh hng xu lm cho phi phn
chia chm. Mt nguyn nhn chnh gy nn hin tng pht trin khng bnh
thng ny c th l do yu t mi trng hay iu kin nui cy phi
[79],[165] hoc do gim nng oxy (oxygen tension) trong dch nang [166].
Hu qu l xy ra qu trnh nhn ln (replication) trong nhn t bo nhng
li khng c s phn chia bo tng (cytokinesis), nhn phn mnh
(fragmentation of the nuclei) hoc vic di chuyn ca cc nhim sc th k
sau (anaphase) b sai st to nn nhng bt thng phc tp nh phi th
khm hay a nhn. Mt nguyn nhn khc l do ri lon chc nng trung th
ca tinh trng dn n sai st khi hnh thnh thoi phn bo lm cho cc nhim
sc th cp i v phn chia ri lon khi phn chia nguyn nhim, to ra tnh
trng lch bi nhim sc th v phi th khm [167].
Mt iu th v l phi pht trin qu nhanh cng lin quan n ri lon
nhim sc th ging nh phi pht trin chm, tuy nhin mc lin quan
khng cht ch nh i vi phi pht trin chm. Phi c 10 phi bo thi
im 67-68 gi sau th tinh cng c kh nng b lch bi nhim sc th cao so
vi phi pht trin bnh thng (bng 3.12). Tuy nhin, t l lch bi nhim
 112

sc th phi pht trin nhanh cao hn phi pht trin bnh thng khong
1,2 ln, v t s kh nng l LR(+)=1,35; LR(-)=0,9 chng t yu t phi pht
trin nhanh l mt trong nhng ch bo tin lng phi b lch bi nhim
sc th nhng c gi tr thp. Nhng quan st ny ch ra rng thi gian l
yu t quan trng nh gi kh nng pht trin ca phi, ph hp vi
nhng quan st ca cc tc gi trc y nu ln l phi pht trin nhanh
c t l pht trin thnh phi nang cao hn so vi phi pht trin chm
[2],[158],[161], v bt c thay i v tc phn chia ca phi u c th
nh hng ti s lm t ca phi [64],[159],[161],[162]. Nghin cu ny
cng chng minh l phi hon thnh chu k phn chia th 3 thi im
67-68 gi sau th tinh c kh nng nhim sc th bnh thng cao nht.

4.4.6. Hnh thi ca phi ngy 3 lin quan n lch bi nhim sc th.
Cc nghin cu s dng phng php FISH trc y u ch ra rng
phi c bt thng v hnh thi thng c t l bt thng v nhim sc th
cao hn phi c hnh thi bnh thng [2],[163]. Tuy nhin rt kh phn bit
hnh thi phi c nhim sc th bnh thng v phi c nhim sc th bt
thng, c th do nhim sc th bt thng giai on 2-8 phi bo kh gy
nn bt thng hnh thi khi b gen ca phi cha c hot ha.
* S xut hin mnh vn v s phn b mnh vn trong phi lin quan n
lch bi nhim sc th.
Mnh vn l mt phn ca bo tng c bao bi mng t bo nhng
thng khng c cha DNA hnh thnh trong qu trnh phn bo. V vy
mnh vn c ngun gc t phi bo v vic phn tch t l mnh vn trong
phi c cp n trong tt c cc h thng im nh gi phi. T l
mnh vn thng c tnh theo t l phn trm so vi th tch bo tng
trong phi (cytoplasmic volume). Theo h thng nh gi phi ca chng ti
th t l mnh vn t ( 5%), trung bnh (6-15%), nhiu (16-30%) v rt nhiu
 113

(>30%). Thng thng kh phn bit mnh vn ln vi phi bo c kch

thc nh. Theo Johansson v cng s th phn bo tng c kch thc nh
hn 45m vo ngy 2 v nh hn 40m vo ngy 3 khng cha DNA th
c gi l mnh vn [168].
T l mnh vn nhiu c nh hng xu n t l lm t v c thai
[169], trong khi t l mnh vn t khng c nh hng xu [85]. S dng
phng php theo di phi lin tc, Hardarson v cng s thy rng mt s t
mnh vn c th c nhng phi bo mi to ra hp th v vy, phi c t
mnh vn c th xem l bnh thng [74].
Tng t l mnh vn cng lm gim kh nng hnh thnh phi nang v
nh hng ti s phn b ca cc phi bo trong qu trnh bit ha phi nang
[170]. S phn b ca mnh v trong khoang quanh phi (perivitelline
space/PVS) c phn ra lm hai loi ri rc v tp trung. Khi c nhiu mnh
vn th kh phn bit mnh vn nm tp trung hay ri rc. Vic nh gi
mnh vn l mt thng s quan trng trong cc h thng nh gi hnh thi
phi v phi c nhiu mnh vn v mnh vn tn ti trong hu ht cc giai
on pht trin thng t c kh nng sng.
Kt qu nh gi v mnh vn t bo trong nghin cu ca chng ti
thng nht vi cc nghin cu trc y ca Wilton v cng s (2003) s
dng phng php CGH [171] v Magli v cng s (2007) s dng phng
php FISH nh gi 5-7 cp nhim sc th [2]. Kt qu nghin cu ny cng
thy t l lch bi nhim sc th tng cng vi hin tng tng s lng
mnh vn trong phi: phi c nhiu mnh vn (16-30%) t l lch bi nhim
sc th tng gp gn 1,4 ln so vi phi c t mnh vn; phi c s lng
mnh vn trung bnh, t l lch bi th tng 1,2 ln. Tuy nhin tng s lng
mnh vn trong phi ch l ch bo tin lng phi b lch bi th tng i
thp LR(+)= 1,96; LR(-)= 0,77 i vi phi c nhiu mnh vn v LR(+)=1,33;
 114

LR(-)=0,82 i vi phi c s lng mnh vn trung bnh (bng 3.14). V vy,

khi nh gi phi nu ch da vo yu t t l mnh vn trong phi th khng
th tin lng phi b lch bi nhim sc th c hiu qu. Mt im khc bit
trong nghin cu ca chng ti so vi nghin cu ca Magli v Finn l chng
ti ch nh gi phi c s lng mnh vn t 30% tr xung cn trong
nghin cu ca Magli v Finn nh gi c phi c rt nhiu mnh vn ti
50% [2],[65]. L do chng ti khng nh gi phi c rt nhiu mnh vn
(>30%) vo ngy 3 sau th tinh l do s lng cc phi ny t v cc phi ny
thng ngng pht trin trc khi hnh thnh phi nang [73] ng thi vic
s dng nh gi phi bng phng php a-CGH rt tn km. Nu nhng
phi ny c th pht trin n giai on phi nang chng ti s nh gi qua
sinh thit nguyn bo l nui, nh vy s gim chi ph iu tr cho bnh nhn.
Cng ging nh nghin cu ca Magli v cng s [2], chng ti thy
khi mnh vn phn b ri rc, t l lch bi nhim sc th tng 1,94 ln so vi
khi mnh vn nm tp trung. Tuy nhin y cng l yu t tin lng phi b
lch bi nhim sc th khng c cao (LR(+)=2 v LR(-)=0,39) (bng 3.15).
Mt s nghin cu thy l mnh vn c lin quan n tnh trng phi th
khm c th l do cc mnh vn c th cha nhim sc th st li (lagging
chromosomes) hay mnh vn ca nhim sc th pht sinh t nhng sai st ca
thoi phn bo [75],[172]. Hn na, mt s protein gip cho s phn cc b
gim i do nm trong cc mnh vn cng s nh hng xu ti s pht trin
ca phi [173]. Khi mnh vn nm ri rc chng t mnh vn xut pht t
nhiu phi bo gy nh hng cng xu [55].
* ng u ca kch thc phi bo lin quan n lch bi nhim sc th.
Kt qu nghin cu ny thy rng phi c kch thc cc phi bo
khng ng u tng ng vi t l lch bi nhim sc th cao hn gn 2 ln
so vi phi c kch thc cc phi bo ng u. Bng 3.13 trong phn kt
 115

qu chng minh phi bo khng u l ch s tin lng phi b lch bi

nhim sc th c gi tr trung bnh tng ng LR(+)= 2,69 v LR(-)=0,48. iu
ny gii thch l do ti sao phi c kch thc khng ng u thng nh
hng n t l lm t v c thai [74],[163].
Kt qu ca nghin cu ny ph hp vi kt lun ca ca cc nghin
cu trc y ca Magli v cng s l phi c kch thc phi bo khng u
b lch bi nhim sc th nhiu hn, nhiu cp nhim sc th b nh hng
hn v iu ny nh hng ti s pht trin ca phi [2],[10]. C th suy lun
l khi phi bo phn chia khng ng u, 2 phi bo con s nhn c lng
protein, mRNA, ty th v cc thnh phn khc khng ng u v phi bo
cn mt lng cc thnh phn bo tng duy tr s sng, v vy nhng
phi c kch thc phi bo khng ng u thng chm pht trin v kh
nng lm t km [74].
Kch thc ca phi bo bo ph thuc vo thi im phn chia (stage
specific) cng nh tnh cn i ca mi chu k phn chia. Bnh thng phi
bo ca phi-2, -4, -8, v -10 phi bo phi c kch thc nh nhau c
ngha l ph hp vi thi im phn chia v phi c kch thc khng ph
hp thi im phn chia l khi cc phi bo c kch thc khc nhau. Ngc
li nu s lng phi bo l s l (3, 5, 7, 9) thng c kch thc khc nhau
do c s phn chia khng ng b (asynchrony) ca mt hay nhiu phi bo
[9]. Tuy nhin trong nghin cu ny ch tp trung nghin cu so snh gia
phi c kch thc phi bo ng u v phi c kch thc phi bo khng
u ch khng tnh n yu t ph hp vi thi im phn chia nn kt lun
ca chng ti c th khng hon ton ph hp vi trng hp phi c s
lng phi bo l nhng ph hp vi thi im phn phn chia (phi 5-t bo
c 3 phi bo ln v 2 phi bo nh, phi 7-t bo c 1 phi bo ln v 6 phi
bo nh, hay phi 9-t bo c 1 phi bo ln v 8 phi bo nh). Cn phi
 116

c mt nghin cu i su hn phn tch mi lin quan a bin gia t l lch

bi nhim sc th v s lng phi bo chn, l, ng u ca kch thc
phi bo; ph hp vi thi dim phn chia hay khng c th tin lng
phi t c kh nng b lch bi nhim sc th nht.

4.4.7. S pht trin ca phi t ngy 3 n giai on phi nang lin quan
n lch bi nhim sc th.

Trong mt vi ngy u ca s pht trin, h thng gene ca phi cha

c hot ha, phi hu nh pht trin da vo ngun protein v mRNA t
non. Khi phi pht trin thm, ngun d tr t non cn kit dn, h thng
gen ca phi bt u hot ng khi phi c 4-8 t bo. Khi h thng gen ca
phi c hot ha, hu qu ca cc bt thng v di truyn bt u tng
mnh v nh hng n hnh thi ca phi. V mt l thuyt th khi c mt
cc bt thng v di truyn s nh hng ti qu trnh pht trin ca phi nh
kh nng phn chia, kt c, bit ha to nguyn bo phi v nguyn bo l
nui phi nang. V l do ny, phn tch v hnh thi ca phi giai on
sau khi b gen ca phi c hot ha l c bit c gi tr.

Chng ti thy rng t l phi bnh thng pht trin thnh phi nang
cao hn 2 ln so vi phi b lch bi th (67,3% so vi 32,3%) (bng 3.5;
3.16). Vega v cng s khi nghin cu 385 phi sinh thit ngy 3 cng thy
rng t l phi bnh thng pht trin thnh phi nang cao gp 2 ln phi lch
bi nhim sc th v t l pht trin thnh phi nang giai on thot mng cao
gp 3 ln [174]. Nghin cu ca chng ti thy rng 44,2% cc phi c
phn tch c th pht trin n giai on phi nang l lch bi nhim sc th
(bng 3.16), trong khi nghin cu gn y ca Vega v cng s cng b l
45,5% phi xt nghim c th pht trin n giai on phi thot mng l b
lch bi nhim sc th [174]. T l lch bi nhim sc th cao ny c th do
 117

bn cht ca nhm i tng nghin cu hoc do cc nghin cu s dng cc

k thut khc nhau phn tch nhim sc th.
Nhiu nghin cu u khng nh rng trn 50% s phi nang c kh
nng chuyn phi vo ngy 5 l b lch bi nhim sc th gp phn khng
nh vai tr quan trng ca vic sng lc trc lm t. Tin hnh sng lc
phi ngy 3 hay ngy 5 u c chng minh l lm tng t l lm t v to
ra tim nng ch chuyn mt phi bnh thng cho tt c cc la tui
[132],[154]. Basile v cng s nm 2014, s dng phng php theo di phi
lin tc (time-lapse) kt hp a-CGH thy rng 79% phi c chn on l
bnh thng c kh nng pht trin thnh phi nang [175]. Trong nghin cu
ca chng ti 67,3% phi c chn on l bnh thng pht trin thnh
phi nang v 32,7% phi bnh thng khng pht trin n giai on phi
nang (bng 3.5) v vy khng c kh nng sinh thit phi nang. iu ny
cn c cn nhc v kh nng tn hi v khng chnh xc ca sinh thit phi
ngy 3. Gn y c mt th nghim lm sng nu ln kh nng c hi ca
vic sinh thit phi ngy 3 ln t l lm t, nhng nghin cu ny khng nu
ln kh nng hnh thnh phi nang hay tnh trng nhim sc th ca phi b
nh hng [127]. Mc d nghin cu ny c th nh gi chnh xc t l hnh
thnh phi nang ca phi sinh thit ngy 3 b lch bi nhim sc th v khng
lch bi nhim sc th, nhng vic sinh thit cng c nh hng n t l
hnh thnh phi nang. V vy, t l hnh thnh phi nang sau khi sinh thit
ngy 3 khng hon ton phn nh t l hnh thnh phi nang ca phi bnh
thng sau khi sinh thit vo ngy 5.
Nghin cu ca chng ti khng nh cc nghin cu s dng FISH
trc y l phi bnh thng c kh nng hnh thnh phi nang cao hn phi
lch bi th [140],[176]. Xt nghim phi vo ngy 5 s c t l phi bnh
thng cao hn khi xt nghim phi ngy 3 [177]. iu ny h tr xu hng
chuyn phi vo ngy 5.
 118

Mt im ng ch trong nghin cu ca chng ti l vo ngy 5 sau

khi th tinh, phi nang pht trin nhanh n giai on ang thot mng hay
thot mng (giai on 5-6) c t l lch bi nhim sc th thp nht. Tc
pht trin ca phi nang cng chm th t l lch bi nhim sc th cng cao
(bng 3.18). Phi pht trin chm giai on phi du hay ngng pht trin
vo ngy 5 l ch bo kh nng phi b lch bi th cao ln lt tng ng vi
t s kh nng LR(+) = 5,6; LR(-)=0,37 v LR(+)=6,58; LR(-)=0,16 khi so snh
vi phi pht trin tt thnh phi nang giai on 5-6 vo ngy 5. Kt qu ca
chng ti ph hp vi kt qu ca Alfarawati v cng s khi tin hnh sinh
thit phi nang, tc gi ny cng thy l phi nang pht trin nhanh (giai on
5-6) c t l phi bnh thng cao hn phi nang pht trin chm giai on
1-2 [90]. V vy khi chn phi chuyn vo ngy 5, nu phi giai on
phi du hay phi nang giai on sm th khng nn tin hnh chuyn phi
m nn i thm mt ngy na c th chn lc phi hiu qu hn.

Mt im th v l phi pht trin chm thnh phi nang vo ngy 6 c

t l lch bi nhim sc th cao hn 2,3 ln so vi phi pht trin thnh phi
nang vo ngy 5 (bng 3.17). Phi pht trin chm thnh phi nang vo ngy
6 l ch bo c gi tr trung bnh chn on tin lng phi lch bi nhim
sc th tng ng vi t s kh nng LR(+)=2,52 v LR(-)=0,51 (bng 3.17).
Kt qu ny cng ph hp vi nhn nh ca Taylor v cng s khi tin hnh
xt nghim nguyn bo l nui ca phi nang ngy 5 v ngy 6 thy l phi
nang ngy 5 c kh nng c nhim sc th bnh thng cao hn ngy 6
(54,6% v 42,8%) [90]. Kt qu ny c phn khc vi kt qu ca Kroner v
cng s nm 2012 cho rng s hnh thnh phi nang chm khng lin quan
ti t l lch bi nhim sc th nhng nu khng hnh thnh phi nang s c
lin quan vi tng t l lch bi nhim sc th. Tuy nhin trong nghin cu
ca Kroner, s lng phi nghin cu t (530 phi so vi 1257 phi trong
 119

nghin cu ca chng ti) v s phi nang ngy 6 l 109 phi cng t hn

trong nghin cu ca chng ti l 234 phi [91]. S khc bit v s lng
nghin cu ni trn c th l nguyn nhn khc bit v kt qu ca 2 nghin
cu. Kt lun ca nghin cu ny cng ph hp vi cc kt qu lm sng thy
l phi nang ngy 5 thng lm t tt hn phi nang hnh thnh vo ngy 6
ph hp vi nhn nh ca Shapiro nm 2001 v Barenetxea nm 2005
[178],[179].

4.4.8. Mc lch bi nhim sc th v kh nng hnh thnh phi nang.

Cng nh nghin cu ca Alfarawati v cng s (2011) [90] v ca

Vegas v cng s (2014) [174] nh gi 23 cp nhim sc th ca phi chng
ti cng thy lch bi c th xy ra trn tt c cc cp nhim sc th v kh
nng pht trin thnh phi nang (giai on 2 n 6) gim khi mc lch bi
nhim sc th tng. So vi phi khng b lch bi nhim sc th, kh nng
pht trin thnh phi nang gim 22% khi phi b lch bi mt cp nhim sc
th, gim 38% khi lch bi xy ra 2 cp nhim sc th, gim 54% khi lch
bi xy ra 3 cp nhim sc th v gim 75% khi lch bi phc tp xy ra
trn 3 cp nhim sc th (bng 3.19). Kt qu ny cng thng nht vi kt qu
ca Vega v cng s cho l kh nng pht trin thnh phi nang giai on 5
v 6 v tng s lng nhim sc th b lch bi c mi lin quan tuyn tnh
m vi nhau [174].

4.4.9. Kh nng pht trin thnh phi nang vo ngy 5 v gii tnh ca
phi lin quan n lch bi nhim sc th.

Nh vo nhng tin b trong s pht trin ca mi trng nui cy,

ngy cng nhiu cc trung tm IVF trn th gii tin hnh chuyn phi nang.
Theo l thuyt th chuyn phi nang s lm tng s ng nht gia nim mc
t cung v phi, cng nh tng kh nng la chn phi. La chn phi ch
 120

da vo hnh thi ca phi cho n nay vn cha hon ho, v l nguyn nhn
gy gim t l lm t. Phi pht trin thnh phi nang ngy 5 c cho l c
nhim sc th bnh thng cao hn, tuy nhin t l lch bi nhim sc th
phi nang vn cn cao. Mc d nhiu bng chng chng minh l chuyn phi
nang s lm tng kt qu iu tr IVF tuy nhin vn cn nhng hn ch nh:
nguy c phi hy chu k iu tr cao, t phi ng lnh hn, v tng nguy
c sinh i (monozygotic twins), v thay i t l gii tnh [180]. Mt c ch
c th gy nn s thay i t l gii tnh l phi nam gii c kh nng pht
trin nhanh hn. Mt vi nghin cu thy rng phi nam giai on phn chia
v lm t ngi c s lng phi bo nhiu hn phi n (pht trin nhanh
hn) v vy iu quan tm l chuyn phi nang c th dn n s la chn u
tin i vi phi nam [11],[12]. Hin nay, vn cn nhiu tranh ci v ch nh
chuyn phi nang s nh hng n t l gii tnh. Cc s liu hin ti u
da vo t l gii tnh tr sinh ra [181],[182] suy lun ra kh nng pht
trin ca phi ch khng tnh n cc yu t khc nh s khc nhau gia kh
nng lm t v t l sy gia phi nam v n.

Cho n nay c 3 nghin cu v t l gii tnh ca phi nang u cho l

khng c s khc nhau v gii tnh [90],[183],[184]. Tuy nhin trong nghin
cu ca Alfarawati v cng s nm 2011, thy l phi cha XY thng c
hnh thi tt hn [90]. Nguyn nhn sinh hc cho n ny vn cha c
chng minh, c th l do lin quan gia s gen nm trn nhim sc th X
khng hot ng (X-chromosome inactivation) hay s c mt ca gen hot
ha hormone sinh trng (growth factor gene) trn nhim sc th Y. Vi gi
thuyt l phi nam s pht trin thnh phi nang nhanh hn phi n v phi
nang ngy 5 c t l nhim sc th bnh thng cao hn phi ngy 3 th kh
nng phi nam b lch bi nhim sc th s t hn phi n. Tuy nhin, s liu
ca chng ti chng minh khc l phi nam v phi n c kh nng pht trin
 121

thnh phi nang v kh nng b lch bi nhim sc th nh nhau (bng 3.20).

C ngha l nui cy n phi nang khng lm cho khuynh hng chn nhiu
phi nam hn.
4.4.10. Cht lng ca phi nang (biu th qua cht lng ca mm phi
v nguyn bo l nui) lin quan n lch bi nhim sc th.
Nghin cu ny chng minh l phi b lch bi nhim sc th c th
pht trin thnh phi nang. Tuy nhin, c nhng bng chng cho l lch bi
nhim sc th c nh hng xu ti s pht trin ca phi giai on phi
nang dn ti gim cht lng ca mm phi v nguyn bo l nui, cng nh
tc pht trin ca phi nang [89]. Cho n ngy 3 sau khi th tinh, s sng
ca phi b lch bi nhim sc th ch yu da vo cc protein t non. Tuy
nhin, sau khi phi hot ha, 4-8 t bo, phi ch yu da vo sn phm ca
chnh n. V vy, lch bi nhim sc th c nh hng mnh hn khi phi
pht trin qua ngy th 3. Nhiu phi nang bt thng (trong nghin cu ny)
c nguyn bo l nui cht lng km v c th khng lm t c. Mt s
phi khc c mm phi cht lng km c th lm t nhng c th dn n
sy thai sm. Khi xem xt n hnh thi ca phi nang l ch bo lch bi
nhim sc th, chng ti thy rng t l lch bi nhim sc th tng khi phi
nang c cht lng hnh thi km (bng 3.23; 3.24; 3.25) c th t l lch bi
nhim th thp 31,1% phi c cht lng tt so vi 41,2% phi c cht
lng trung bnh v 78,6% phi c cht lng km (bng 3.21). Theo
nghin cu ny th kh nng chuyn phi nang b lch bi nhim sc th c
th gim t 44,2% (bng 3.16) (nu ch chuyn phi nang giai on 2-6 m
khng nh gi v cht lng mm phi v nguyn bo l nui) xung cn
31,1% nu ch chuyn phi nang c cht lng tt (bng 3.23). Trn thc t,
khng phi chu k iu tr no cng c th to c nhng phi tt.
 122

Kt qu ca nghin cu ny cng chng minh t l lch bi nhim

sc th tng khi cht lng ca mm phi gim (P<0,05) (bng 3.21), tuy
nhin i vi nguyn bo l nui th t lch bi nhim sc th ch tng c
ngha thng k khi cht lng nguyn bo l nui gim xung loi C
(bng3.22). Kt qu ny ph hp vi kt qu nghin cu ca Alfarawati v
Kroener [90],[91].
Cht lng mm phi km (loi C-D) l ch bo tin lng phi b lch
bi th c gi tr cao hn cht lng nguyn bo l nui km (loi C). Gi tr
ch bo tin lng lch bi th ca mm phi loi C-D tng ng vi t s
kh nng LR(+)=6, LR(-)=0,57 (bng 3.21) so vi khi s dng cht lng ca
nguyn bo l nui phi loi C lm ch bo lch bi th tng ng vi t s
kh nng LR(+)=2,69, LR(-)=0,41 (bng 3.22). iu ny ph hp vi nhng
kt lun lm sng cho rng mm phi v nguyn bo l nui cht lng tt
ng vai tr quan trng i vi s pht trin ca phi sau ny, cng nh kh
nng lm t ca phi [185].
4.5. Bn lun v mt s yu t lin quan n lch bi nhim sc th qua
phn tch a bin.
Phn tch n bin c gi tr nu ln c mt s yu t lin quan
lm cho t l lch bi th tng v cho php s dng cc yu t nh mt
yu t nguy c. Tuy nhin, nguy c (RR) ca cc yu t cha phn nh
ng vi thc t v trn thc t lm sng thng c nhiu yu t nguy c
cng tc ng. Do vy phn tch a bin s gip s nh gi nguy c gn
vi thc t hn.
Nu ly kt qu chn on phi b lch bi nhim sc th bng k thut
a-CGH lm tiu chun vng lm chun nghin cu v mi lin quan gia
nhiu yu t c phn tch trong phn phn tch n bin cng tc ng
n phi gy ra lch bi nhim sc th s hp vi qui lut t nhin v s l c
 123

s nh gi hon thin hn phng php chn on v tin lng phi ngy 3

c gi tr. T phng php nghin cu v phn tch khoa hc ny c phn no
phc tp nhng s lm c s ra mt phng php n gin c gi tr
thc thi ti cc c s lm sng qua cc du hiu quan st phi ngy 3
chuyn phi c hiu qu, gim t l lch bi nhim sc th ti cc c s cha
p dng k thut a-CGH.
4.5.1. Hai yu t: tui m v tc pht trin ca phi vo ngy 3 lin quan
n lch bi nhim sc th.
T phn tch a bin ny, chng ti thy l (1) Khi tui m tng trn 35
tui, th t l lch bi nhim sc th cng tng theo: t l ny tng mnh c
ngha thng k khi tui m tng trn 40 tui c phi pht trin bnh thng
cng nh phi pht trin nhanh; (2) i vi phi pht trin chm (mt ch bo
quan trng trong tin lng phi lch bi nhim sc th) t l lch bi nhim
sc th cao tt c cc la tui m. Phi chm pht trin ph n ln tui l
ch bo tin lng phi lch bi nhim sc th rt cao (LR(+)=6,75; LR(-)=0,76
khi tui m 35-40 tui v LR(+)=8,75; LR(-)=0,88 khi tui m trn 40) (bng
3.26); (3) Khi phi pht trin nhanh vo ngy 3, k c m tr tui th kh
nng lch bi nhim scth cao hn phi pht trin bnh thng nhng thp
hn phi pht trin chm. Kt qu ny khc vi kt qu ca Eaton v cng
s khi cho l tui m khng c lin quan n t l lch bi nhim sc th
phi c 7-10 phi bo vi di 20% mnh vn vo ngy 3 sau th tinh v
hnh thi ca phi ngy 3 (s lng phi bo, t l mnh vn) [186]. Tuy
nhin, nghin cu ca Eaton s dng phng php FISH kim tra 9 cp
nhim sc th ca 438 phi ngy 3 (ng ngha l s phi ca mi nhm tui
t). Cn nghin cu ca ti s dng phng php a-CGH cng lc nh gi
23 cp nhim sc th v s lng phi nghin cu ca chng ti gn gp 3 ln
nn kt qu v mi lin quan gia tui m, tc pht trin ca phi ngy 3
 124

v t l lch bi nhim sc th c tin cy cao hn. Nhng nu ch da vo

2 yu t tui m v tc pht trin ca phi th cng cha chn lc
phi bnh thng, k c nhm bnh nhn tr tui, v t l phi bnh thng
cng ch l 56,6% phi c cho l pht trin bnh thng (7-9 phi bo
ngy 3) (bng 3.26). Kt hp 2 yu t ny c th tin lng thm 6,3% -
12,9% phi bnh thng so vi khi ch da vo mt yu t tui m tr (50,3%
phi bnh thng) (bng 3.10) hay tc pht trin ca phi bnh thng
(43,7% phi bnh thng) (bng 3.12).

4.5.2. Hai yu t: s lng phi bo v s c mt mnh vn lin quan n

lch bi nhim sc th.
S lng phi bo v t l mnh vn l hai yu t rt quan trng trong
nh gi hnh thi ca phi ngy 3. T phn tch n bin chng ti thy
khi c mt mt trong hai yu t ny th tin lng phi b lch bi nhim sc
th cng tng. Trong thc tin lm sng, phi c mt c hai yu t pht trin
bt thng v c nhiu mnh vn trong phi thng c kh nng kt c hnh
thnh phi nang km, kh nng lm t v c thai km. V vy trong nghin
cu ny, chng ti nh gi s c mt ca hai yu t ny lin quan n t l
lch bi nhim sc th ca phi c kt qu l: (1) phi chm pht trin c t l
lch bi nhim sc th u rt cao khng ph thuc vo t l mnh vn trong
phi; (2) i vi phi tuy c tc pht trin bnh thng m t l mnh vn
tng th t l lch bi nhim sc th cng c xu hng tng, c bit khi s
lng mnh vn tng trn 5%; tng ng vi phi pht trin nhanh c s
lng mnh vn t hay trung bnh; (3) Phi pht trin nhanh th t l lch bi
nhim sc th tng cao ng k khi phi c nhiu mnh vn (16-30%) th
nguy c lch bi nhim sc th tng cao ng k, tuy nhin t l lch bi
nhim sc th vn thp hn so vi phi chm pht trin (bng 3.27). Kt qu
nghin cu ca chng ti phn no ph hp vi kt qu ca cc nghin cu
 125

trc y s dng phng php FISH [2],[69]. Munne v cng s khi s

dng phng php FISH (nh gi 9 cp nhim sc th) kt lun l c s khc
nhau ng k v t l phi bnh thng nhm phi pht trin c 6 phi
bo v t l mnh vn <20% so vi nhm phi pht trin chm (bt k t l
mnh vn nhiu hay t) v nhm pht trin c 6 phi bo v nhiu mnh
vn >20% [69]. Trong nghin cu ca Magli v cng s cng s dng
phng php FISH (nh gi 8 cp nhim sc th) kt lun l khi phi khng
c mnh vn t l lch bi nhim sc th dng nh thay i theo s lng
phi bo. Mt khc, phi chm pht trin, khng c mi lin quan gia
mnh vn v t l lch bi nhim sc th; c th l do yu t chm pht trin
l yu t mnh nh hng ti lch bi nhim sc th. Khi phi c hnh thi tt
(8 phi bo khng c mnh vn) th t l lch bi nhim sc th vn gn 50%,
V vy, sng lc phi trc lm t vn l s la chn tt nht hin nay [2].
Cng ging kt qu ca Magli, trong nghin cu ca chng ti thy phi pht
trin bnh thng khng c hay c t mnh vn th vn c gn mt na s
phi (49,2%) l b lch bi nhim sc th v 50,8% phi bnh thng (bng
3.27). Kt hp 2 yu t ny c th tin lng thm 4,9% - 7,1% phi bnh
thng so vi khi ch da vo mt yu t phi c t mnh vn (45,9% phi
bnh thng) (bng 3.14) hay tc pht trin ca phi bnh thng (43,7%
phi bnh thng) (bng 3.12).

4.5.3. Hai yu t: ng u v kch thc ca phi bo v s c mt ca

mnh vn c lin quan n lch bi nhim sc th.

Phi c kch thc phi bo khng u c t l c thai thp, t l lm

t thp hn phi c phi bo ng u [74]. Phi c kch thc phi bo
khng u thng lin quan n t l lch bi nhim sc th cao nh nu
trong phn tch n bin. T l mnh vn phi ngy 3 l ch bo c gi tr
tin lng tnh trng nhim sc th ca phi [187]. Trong nghin cu ny
 126

chng ti thy khi phi c c 2 yu t c mnh vn >5% v kch thc phi

bo khng ng u th t l lch bi nhim sc th tng gn 2 ln (bng 3.28;
3.29), c bit khi nhng phi ny c nhiu mnh vn (16-30%) th kh nng
tin lng phi b lch bi nhim sc th cng cao tng ng vi t s kh
nng LR(+)=5,36 v LR(-)=0,66 (bng 3.28). Khi kch thc phi bo ng
u, s lng mnh vn t th t l phi bnh thng l 56,4%. Kt hp 2 yu
t ny c th tin lng thm 0,5% - 10,5% phi bnh thng so vi khi ch
da vo mt yu t kch thc phi ng u (55,9% phi bnh thng)
(bng 3.13) hay ch da vo phi c t mnh vn (45,9% phi bnh thng)
(bng 3.14). Kt qu ca nghin cu ny ph hp vi kt qu ca Moayeri v
cng s khi h thy rng phi c kch thc phi bo ng u khng c hay
c t mnh vn (di 10%) tng ng vi t l lch bi nhim sc th thp
nht. T l mnh vn phi ngy 3 l ch s c gi tr hn tin lng tnh
trng nhim sc th ca phi [187].

4.5.4. Ba yu t: s lng phi bo, ng u v s c mt ca mnh

vn lin quan n lch bi nhim sc th.

S lng phi bo, ng u v kch thc ca phi bo cng nh

t l mnh vn l 3 yu t rt quan trng nh gi cht lng hnh thi ca
phi giai on phn chia trong bt k h thng nh gi phi no. Trong
nghin cu ny chng ti thy khi phi pht trin qu nhanh hay chm, c
kch thc phi bo khng u v c t l mnh vn trung bnh hay nhiu th
t l lch bi nhim sc th tng trn 2 ln so vi phi bnh thng, c kch
thc phi bo u v t mnh vn (bng 3.30; 3.31). Khi kt hp c 3 yu t
trong c yu t mnh vn >15% ny th kh nng tin lng phi b lch
bi th cao tng ng vi t s kh nng LR(+)= 12 v 6,75; LR(-)= 0,88 v
0,76 tng ng vi phi pht trin nhanh v chm (bng 3.30). Tuy nhin khi
phi pht trin bnh thng, kch thc phi bo ng u, c t mnh vn,
 127

th t l phi bnh thng l 61,8% (bng 3.31). Kt hp 3 yu t c th tin

lng thm khong 6,1% - 18,1% phi bnh thng so vi khi ch da vo
mt yu t nh kch thc phi ng u (55,9% phi bnh thng) (bng
3.15) hay phi c t mnh vn (45,9% phi bnh thng) (bng 3.16), hay tc
pht trin ca phi bnh thng (43,7% phi bnh thng) (bng 3.14).

4.5.5. Ba yu t: s lng phi bo, s c mt mnh vn v v tr mnh vn

lin quan n lch bi nhim sc th.

i vi phi chm pht trin, c s lng mnh vn >5% nm ri rc

th t l lch bi nhim sc th tng gn 2,5 ln so vi phi pht trin bnh
thng c t mnh vn nm tp trung. Khi kt hp c 3 yu t ny th kh
nng tin lng phi b lch bi nhim sc th cao tng ng vi t s kh
nng LR(+)= 5,74, LR(-)=0,5 (bng 3.33). i vi phi pht trin nhanh th khi
mnh vn nhiu hn (>5%) nm ri rc th t l lch bi nhim sc th cng
tng 2 ln so vi phi pht trin bnh thng, mnh vn 5% nm tp trung.

Kt hp c 3 yu t phi pht trin nhanh, c s lng mnh vn >5%

nm ri rc ny th kh nng tin lng phi b lch bi nhim sc th trung
bnh tng ng vi t s kh nng LR(+)=2,84 v LR(-)=0,6 (bng 3.33). Tuy
nhin nu mnh vn tng trn 15%, th c gi tr tin lng phi lch bi
nhim sc th cao vi LR(+)= 5,61 v LR(-)=0,8 (bng 3.32). Kt qu ny cng
gn ging vi kt qu ca Magli v cng s khi s dng phng php FISH
(phn tch 8 cp nhim sc th) thy l phi 7-8 phi bo, t l lch bi
nhim sc th cao hn phi c 21-40% mnh vn khi mnh vn nm ri rc
so vi mnh vn nm tp trung [2]. Phi pht trin bnh thng c t mnh
vn nm tp trung, t l phi bnh thng l 63,8%. Kt hp 3 yu t c th
tin lng thm khong 3,9% - 20,1% phi bnh thng so vi khi ch da
vo mt yu t nh mnh vn nm tp trung (59,9% phi bnh thng) (bng
 128

3.15) hay phi c t mnh vn (45,9% phi bnh thng) (bng 3.14), hay tc
pht trin ca phi bnh thng (43,7% phi bnh thng) (bng 3.12).

Tm li khi kt hp cng nhiu yu t th kh nng chn lc phi

khng b lch bi nhim sc th cng cao. Tuy nhin c mt s yu t n
bin cng c gi tr tin lng phi b lch bi nhim sc th cao nh tui m
trn 40; Phi pht trin chm vo ngy 3 v ngy 5 v cht lng ca phi
nang km (xem bng 3.34 xp th t v gi tr tin lng d on lch bi
nhim sc th ca cc ch bo t cao xung thp sau khi phn tch n bin v
a bin).
 129

KT LUN

S dng phng php a-CGH nh gi ton b 23 cp nhim sc th

ca 1257 phi th tinh trong ng nghim chng ti c nhng kt lun sau:
Mc tiu 1
- Phi ngy 3 sau th tinh trong ng nghim c t l lch bi nhim sc
th cao (62,3%) v thng gp cp nhim sc th 22, 19, 16, 15, 21 v XY
(3,3%-8,4%); cao nht l cp 22.
- Phi lch bi nhim sc th ngy 3 c th pht trin thnh phi nang,
trong 29,5% t sa cha thnh bnh thng. Kh nng t sa cha gim
47,8% xung 22% v 0% tng ng ln lt vi tui m di 35 tui, 35-40
tui v trn 40 tui.
Mc tiu 2. Mt s yu t lin quan vi lch bi nhim sc th
- Bnh nhn v sinh c tin s tht bi iu tr th tinh trong ng
nghim, ri lon phng non, bung trng a nang, tinh trng bt thng v
khng r nguyn nhn tng ng ln lt vi t l lch bi nhim sc th l
66,7%; 60,3%; 61,7% v 65,9%.
- Tui m di 35, 35-40 v trn 40 tng ng vi t l lch bi nhim
sc th tng dn t 49,7% ln 70,7% v 90%.
- Nng FSH c bn>15mIU/ml lin quan n tng t l lch b nhim
sc th l 76,3%.
- Phi pht trin chm hay nhanh c t l lch bi nhim sc th tng
tng ng l 83,1% v 65,7% (so vi phi pht trin bnh thng l 56,3%).
- Phi c kch thc phi bo khng u, cng c nhiu mnh vn v
mnh vn nm ri rc c t l lch bi nhim sc th cao (tng ng 81,6%;
75,1% v 77,6%).
- Phi lch bi nhim sc th c kh nng pht trin thnh phi nang
km hn so vi phi bnh thng (32,3% so vi 67,3%) v ph thuc vo
 130

mc lch bi nhim sc th. Vo ngy 5 sau th tinh, t l lch bi

nhim sc th gim dn theo tc pht trin ca phi. Phi nang hnh
thnh vo ngy 6 c nguy c lch bi nhim sc th cao hn vo ngy 5
(66,7% so vi 28,7%).
- Cht lng ca mm phi gim t loi A xung loi B, C tng ng
vi t l lch bi nhim sc th tng t 29,5% ln 46,3% v 80,6%.
- Cht lng ca nguyn bo l nui gim xung loi C tng ng vi t
l lch bi nhim sc th tng 79,8% so vi 38% (loi A-B).
- S kt hp nh gi 2 hoc 3 ch bo lm tng kh nng tin lng lch
bi nhim sc th:
* Tui m v tc pht trin ca phi: tui m 35-40 v >40 vi phi
chm pht trin t l lch bi nhim sc th tng ng l 87,2% v 88,2%;
tui m 35-40 v >40 vi phi pht trin nhanh t l lch bi nhim sc th
tng ng l 69,6% v 100%.
* Phi chm pht trin v c mnh vn >5 %, t l lch bi nhim sc
th 86,2%.
* Kch thc phi bo khng u v c mnh vn >15 %, t l lch bi
nhim sc th cao 86,3%.
* Tc pht trin ca phi chm/nhanh, phi bo khng u, mnh vn
> 5% lm tng t l lch bi th tng ng l 86,1% v 80,6%.
* Tc pht trin ca phi chm/nhanh, mnh vn>15%, phn b ri
rc lm tng t l lch bi nhim sc th tng ng l 86,5% v 79,1%.
 131

NHNG NG GP MI CA NGHIN CU

1. p dng phng php a-CGH l phng php hin i xt nghim

cho ton b 23 i nhim sc th ca 1257 phi cho kt qu kh chnh
xc v t l lch bi nhim sc th ca phi ngy 3 v cc yu t lin
quan n lch bi nhim sc th.
2. Xc nh c gi tr ca mt s ch bo quan trng v khoa hc
d on phi lch bi nhim sc th da vo phn tch n bin, a
bin kt hp vi phn tch t s kh nng LR. Nhng ch bo ny c
gi tr ng dng lm sng cao.
3. Chng minh c kh nng t sa cha ca phi ngy 3 khi pht trin
thnh phi nang v kh nng ny lin quan cht ch vi tui m.
 132

KIN NGH

Do t l lch bi nhim sc th ca phi ngy 3 tng i cao v c

nhiu yu t lin quan n t l lch bi nhim sc th ca phi, khi chn lc
phi c bit cc trung tm th tinh trong ng nghim cha thc hin c
k thut sng lc phi trc lm t cn phi ch n nhng ch bo tin
lng phi lch bi nhim sc th c gi tr cao; kt hp nh gi cc yu t
cng mt lc (xp hng trong bng 3.34) c kh nng chn phi t b ri
lon nhim sc th hn.

Tin hnh nui cy v chuyn phi vo giai on phi nang gip cho
kh nng la chn phi t b lch bi nhim sc th cao hn.

ng thi khi t vn, iu tr cho nhm bnh nhn c nguy c cao, cc

nh lm sng hc cn phi t vn k v kh nng phi bt thng cao, kh
nng khng c phi chuyn phi cao, nguyn nhn, v ra hng gii
quyt trong trng hp xu.

Mc d c mi lin quan gia hnh thi, tc pht trin ca phi

nhng mi lin quan ny khng hon ton cht ch, phi c hnh thi v tc
pht trin tt vn c kh nng b lch bi nhim sc th kh cao. V vy,
hin nay sng lc trc lm t vn l phng php c kh nng chn on
phi lch bi nhim sc th tng i chnh xc nht.
 133

HNG NGHIN CU TIP THEO

Kt hp nh gi phi cc giai on khc nhau: nh gi tin nhn,

nh gi phi thi im 24 gi, phi ngy 2, 3, ngy 4 v phi nang tm
ra cc yu t kt hp c lin quan n kh nng pht hin lch bi nhim sc
th, gp phn chn phi t b lch bi nhim sc th nht.

nh gi theo di phi lin tc s dng phng php timelapse kt hp

vi sng lc trc lm t.

Phn tch nh gi nhim sc th ca phi giai on phi nang (sinh

thit nguyn bo l nui) nhm gim nhng hn ch do vic phn tch mt
phi bo giai on phn chia.

Nghin cu thm cc yu t lin quan khc nh: AMH, kch thc th

tch bung trng

Nghin cu sinh thit li phi ngy 3 b lch bi nhim sc th giai

on phi nang nhiu hn tm ra thm cc yu t lin quan n kh nng t
sa cha ca phi nh cht lng ca phi nang, mc lch bi nhim sc
th ngy 3, tnh trng lch bi nhim sc th: th n nhim (monosomy) hay
th tam nhim (trisomy).
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