2012-08-012024-05-14https://scholars.lib.ntu.edu.tw/handle/123456789/660830摘要：卵巢過度刺激症候群(OHSS)是刺激排卵所併發的後遺症。致病機轉目前尚不完全清楚，僅知卵巢和全身微血管通透性增加，造成大量腹水或胸水形成。我們先前研究發現引發卵巢過度刺激症候群的反應可能經由血管上皮生長因子(vascular endothelial growth factor, VEGF)媒介。VEGF是一種很強的血管生成物，透過VEGF專一接受器(VEGF receptor-1, 2)，對血管上皮細胞有專一的促進作用。血管增生的同時，血管通透性也隨之增加。最近研究報告顯示VEGF受到細胞間質金屬蛋白酵素的調控。細胞間質金屬蛋白酶促進血管新生不僅分解細胞外基質（ECM）的組成部分，但也釋放如VEGF，從而調節其生物利用度。我們以前的研究顯示子宮腺肌病的子宮內膜基質細胞同時釋放細胞間質金屬蛋白酵素-2和組織金屬蛋白酶抑製劑1。由於卵巢過度刺激症候群常伴有毛細血管通透性增加，細胞間質金屬蛋白酶及抑制因子有可能增加。目前沒有報告關於細胞間質金屬蛋白酶的作用及其抑製劑在卵巢過度刺激症候群致病機轉的角色。我們假設細胞間質金屬蛋白酶系統在卵巢刺激造成通透性改變佔有一定角色。Corifollitropin是一種新型的基因重組激素。最常見的藥物不良反應是治療過程中發生卵巢過度刺激症候群（3.4％）。我們假設Corifollitropin可作為一種更有效的細胞間質金屬蛋白酶誘導劑。研究Corifollitropin對卵巢刺激，細胞間質金屬蛋白酶及其抑製劑的改變，可能給我們更多卵巢過度刺激症候群致病機轉的信息。目前只有Periostat ®（doxycycline hyclate），一種非特異性蛋白酶抑製劑，通過美國FDA用於牙周疾病。然而，這一蛋白酶抑製劑抑制細胞間質金屬蛋白酵素尚未完全闡明。Fainaru等報告doxycycline抑制卵巢過度刺激小鼠血管滲漏和腹水腹腔的積累。doxycycline抑制細胞間質金屬蛋白酵機轉值得進一步研究。doxycycline在預防卵巢過度刺激值得進一步研究。羥甲基戊二酰輔酶A（HMG - CoA）還原酶抑製劑（statins類）已被廣泛用於治療高脂血症。 HMG - CoA還原酶抑製劑pravastatin降低了內皮細胞和巨噬細胞釋放sVEGFR - 1，但其影響對血管內皮細胞尚未確定。 HMG - CoA還原酶抑製劑（statin類藥物）也抑制血管平滑肌細胞和巨噬細胞分泌金屬蛋白酶- 1，-2，-3，-9。我們假設基質金屬蛋白酶抑製劑（如doxycycline），或HMG - CoA還原酶抑製劑（fluvastatin and pravastatin）如果在適當的時間點給予，可能是預防OHSS的備選藥物。組織金屬蛋白酶抑製劑 1（TIMP - 1的）增加了生產 sVEGFR - 1在血管內皮細胞血管內皮生長因子，從而可能減少生物利用度，從而降低血液中血管生長的卵巢。據報導，MMP - 7的誘導血管內皮細胞增生，而且還會降低sVEGFR - 1和VEGF的生物利用度，從而增加內皮細胞周圍。通過抑制MMP - 7的行動，TIMP - 1的可能會阻止sVEGFR - 1降解，從而降低血管內皮生長因子的數量和血管內皮細胞遷移和增殖。該規例的sVEGFR - 1的生產內皮細胞仍知之甚少。我們以前的研究發現溶血磷脂酸（LPA）會刺激顆粒黃體細胞產生大量的IL-6 和IL-8，誘導內皮細胞通透性增加。研究LPA和細胞間質金屬蛋白酶在排卵前的卵泡液和腹水內的變化可能對這種疾病的診斷及預後有幫助。我們的研究目的：第一年 1。要充分認識細胞間質金屬蛋白酶及其抑製劑和蛋白酶抑製劑在卵巢過度刺激過程中的變化。2。研究卵巢細胞間質金屬蛋白酶和蛋白酶抑製劑的細胞來源。3。研究Corifollitropin在卵巢過度刺激過程中對細胞間質金屬蛋白酶及其抑製劑影響。第二年 4。研究doxycycline抗血管生成作用在卵巢過度刺激過程中對細胞間質金屬蛋白酶及其抑製劑影響。5。doxycycline預防卵巢過度刺激綜合徵。6。探討HMG - CoA還原酶抑製劑在卵巢過度刺激過程中對基質金屬蛋白酶及其抑製劑影響。第三年 7。研究LPA對血管內皮細胞通透性和細胞間質金屬蛋白酶的活動的影響。8。研究細胞間質金屬蛋白酶及其抑製劑造成增加血管通透性的潛在機轉。9。研究HCG對細胞間質金屬蛋白酶及其抑製劑在sVEGFR - 1的影響。<br> Abstract: Ovarian hyperstimulation syndrome (OHSS) is a relatively common complication of ovarian stimulation and can be life threatening. The underlying mechanism responsible for the clinical manifestations of OHSS appears to be an increase in capillary permeability. The increase in capillary permeability remains unclear. Our previous studies have shown a possible association between vascular endothelial growth factor (VEGF) and the evolution of OHSS. VEGF and its soluble receptor (sVEGFR-1) are key regulators in human ovarian angiogenesis. Recent studies have shown that VEGF expression and bioavailability can be modulated by matrix metalloproteinases (MMPs).MMPs contribute to angiogenesis not only by degrading extracellular matrix (ECM) components but also by releasing ECM-bound proangiogenic factors such as VEGF and thus modulating its bioavailability. Our previous study demonstrated concurrent elevation of MMP-2 and tissue inhibitor of metalloproteinase 1 (TIMP-1) released by endometrial stromal cells in women with adenomyosis.Because OHSS is often accompanied with marked capillary permeability, levels of MMPs or TIMPs are likely increased in this complication. To our best knowledge, today there is no report regarding the role of MMPs and their inhibitors in the mechanism of increased capillary permeability in OHSS. We hypothesize that ovarian stimulation induced a modification in MMPs-TIMPs system during multiple follicular development. Several MMPs exist which could contribute to permeability changes.Corifollitropin alfa is a novel recombinant hormone designed as a sustained follicle stimulant. A single dose administered in the early follicular phase of the menstrual cycle initiates and sustains multiple follicular development for 7 days. The most frequently reported adverse drug reactions during treatment in clinical trials are OHSS (3.4%). We hypothesize that Corifollitropin alfa may serve as a more potent inducer of the MMPs during ovarian hyperstimulation. Study the effect of Corifollitropin alfa on the effects of the MMPs and their inhibitors may give us more information on the mechanism of OHSS during ovarian hyperstimulation.So far only Periostat® (doxycycline hyclate), a nonspecific MMP inhibitor, has been approved by the FDA for periodontal disease. However, the mechanism of MMP inhibition by doxycycline has not been fully elucidated. Fainaru et al. reported that doxycycline inhibited peritoneal vascular leakage and ascites accumulation in the hyperstimulated mice. This is the only report in the literature regarding using a MMP inhibitor for the treatment of OHSS. Unfortunately, they do not study the plasma or intracellular levels of any MMPs and their inhibitors before and after the administration of doxycycline. The antiangiogenic effect of doxycycline in MMPs in OHSS rat model warrants further studies. It is also worthy to study the effect of doxycycline in the prevention of OHSS.Hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) have been widely used for treatment of hyperlipidemia. HMG-CoA reductase inhibitors pravastatin decreased the release of sVEGFR-1 from endothelial cells and macrophage, but their effects on vascular endothelial cells (ECs) have not been determined. HMG-CoA reductase inhibitors (statins) also inhibit secretion of metalloproteinases-1, -2, -3, and -9 from vascular smooth muscle cells and macrophages. We hypothesize that MMP inhibitors (e.g. doxycycline), or HMG-CoA reductase inhibitors (fluvastatin and pravastatin) could be excellent candidate therapeutics for preventing OHSS if administered selectively at the appropriate time points.Tissue inhibitor of metalloproteinase 1(TIMP-1) increases the production of sVEGFR-1 in endothelial cells and thus may reduce VEGF bioavailability, leading to reduced blood vessel growth in the ovary. It has been reported that MMP-7 induces HUVEC proliferation and also degrades sVEGFR-1 and thus increases VEGF bioavailability around the endothelial cells. By inhibiting MMP-7 action, TIMP-1 may prevent sVEGFR-1 degradation and therefore reduce the amount of VEGF and the endothelial cell migration and proliferation. The regulation of sVEGFR-1 production in endothelial cells is still poorly understood.Our previous study shows that Lysophosphatidic acid (LPA)-induced IL-8 and IL-6 ingranulosa-lutein cells functionally increased permeability of endothelial cells. The LPA in preovulatory follicles may play a role in the angiogenesis of corpus luteum. Correlations of LPA and MMPs expression in follicular fluid and ascites with grades in patients with OHSS may provide potential information for the diagnosis and prognosis of this disease.We propose studies with the following aims:Year 11.To full understand the changes of the MMPs and their inhibitors TIMPs during ovarian hyperstimulation.2.To investigate the cellular source of ovarian MMPs and TIMPs.3.To study the effect of Corifollitropin alfa on the MMPs and their inhibitors using the OHSS rat model.Year 24.To study the antiangiogenic effect of doxycycline in MMPs in OHSS rat model.5.To study the timing of doxycycline administration at the appropriate time points in the prevention of OHSS.6.To investigate the effect of HMG-CoA reductase inhibitors on the influence of TIMP-1.Year 37.To study LPA effects on HUVEC permeability and MMPs activity.8.To investigate the potential role of MMPs and TIMPs contributed to the increased vascular permeability.9.To study the role of MMPs and their inhibitors in the regulation sVEGFR-1 production in endothelial cells after hCG stimulation.細胞間質金屬蛋白酶組織金屬蛋白酶抑製劑卵巢過度刺激症候群matrix metalloproteinasestissue inhibitor of metalloproteinase 1OHSS