Напротехнологія (NaProtechnoliogy) – це стандартизований підхід до лікування неплідності та інших розладів у репродуктивній системі, який передбачає сучасне медикаментозне та хірургічне лікування. Уся діагностика і лікування тут спираються на індивідуальні особливості циклу жінки, який сама жінка записує згідно із встановленою стандартизованою системою, а саме крейгтонським методом спостереження за циклом. Напротехнологія дає змогу виявити і скоригувати розлади, які спричинюють неплідність, звичні викидні і передчасні пологи в тих випадках, коли при стандартному підході виявити такі порушення неможливо. Близько половини пацієнтів, які звертаються для застосування цього підходу, звичайно приходять з діагнозом «неплідність через нез’ясовану причину».

Усе обстеження, лікування та контроль здійснюється на основі самоспостережень жінки за проявами плідності у її циклі, а саме на основі стандартизованого спостереження і занотовування проявів слизу, який виділяється шийкою матки, згідно Creigton Model FertilityCare™ System. У такий спосіб вдається максимально пристосувати лікування до індивідуальних потреб організму жінки. Через занотовування ознак шийкового слизу подружні пари навчаються розуміти свій власний природний ритм плідності і долати проблему у тісній співпраці з лікарем. Таким чином, саме подружжя є експертами з питань своєї плідності, причому можуть застосовувати ці знання як з метою досягнення зачаття, так і його відкладання, зокрема, в тих випадках, коли воно тимчасово небажане у процесі лікування через медичні причини.

Винятковість НаПроТехнологій полягає також і в тому, що вони дають змогу подолати проблему звичних викиднів. Ще однієї сферою їх можливостей є рання діагностика та лікування різноманітних гінекологічних розладів: передменструального синдрому, рецидивуючих кіст яєчників, маткових кровотеч, а також післяпологової депресії. Вони дають змогу детально визначити дату зачаття дитини, що дуже важливо для планування обстежень під час вагітності і передбачення дати пологів.

Ситуаціями, коли неможливо застосувати НаПро, є відсутність обох маткових труб або їх непрохідність, яка не піддається хірургічній корекції, інші тяжкі унатомічні ушкодження статевих органів жінки, а також азооспермія у чоловіка.

Треба зауважити, що таке лікування не дає швидких результатів. Перш за все тому, що практика НаПроТехнологій вимагає навчання жінки спостерігати за своїм циклом. На це звичайно йде 2-3 місяці. Починаючи з третього циклу, розпочинається детальне обстеження, на що йде ще 2-3 місяці. Далі приблизно 3 цикли для корекції проблеми, після чого починається підрахунок циклів, у яких подружжя намагається досягнути вагітності; таких циклів може бути від 6 до 12 і навіть більше. Загалом, від першого звернення до лікаря до досягнення вагітності минає приблизно рік; інколи зачати дитину вдається швидше, а в деяких випадках ― пізніше, ніж за 12 циклів.

Інтерес до Напротехнології в Україні з’явивсяся в 2009 році, коли нас кілька лікарів  взяли участь в конференції в Любліні. До теперішнього часу у нас є 5 лікарів і 3 інструктори, що працюють в цій галузі:

Ми провели ретроспективне дослідження, щоб оцінити результати лікування у наших пацієнтів, які зверталися протягом трохи більше ніж 5 років (з травня 2010 по грудень 2015 року). У цей час до нас звернулися 428 подружніх пар із 13 регіонів України . Пацієнти лікувалися в 3 медичних центрах – у Львові, Києві та Вінниці. Ми включили в цей аналіз все пари, які безуспішно намагалися завагітніти протягом більше 1 року, які мали 2 або більше відвідувань, і принаймні погодилися почати спостереження за циклом згідно симптом-термального або крейгтонського методу. До грудня у нас було 138 вагітностей (в тому числі тих, що тривають), 96 успішних пологів, близько 3% наших пацієнтів мали раніше безуспішні IVF / ICSI.

 Включення пацієнтів за роками

У нас була на лікуванні тільки одна подружня пара в 2010 році, натомість число пацієнтів щороку різко зростало, і в останні роки стабільно перевищувало 100 за рік.

Загальна характеристика пар за діагнозами

Найбільш поширеними діагнозами були гіперпролактинемія, підвищені рівні 17 ОНР, СПКЯ і розлади з боку щитовидної залози. Цікаво, що м не було ні однієї пари, в якій чоловічий фактор був єдиний діагноз.

Майже у всіх пацієнток були субоптимальні рівні прогестерону й естрадіолу, а в більш ніж половини неоптимальні характеристики цервікального слизу

3% пар має перед невдалими IVF / ICSI.

При порівнянні всіх пацієнтів і групу з них, хто успішно народив дитину, можна помітити різницю в таких характеристиках, як звичні викидні (частіше в групі успішних вагітності), низький резерв яєчників, гіпоталамічної аменореї і чоловічого фактора (останні частіше траплялися в загальній групі пар, ніж у тих, хто успішно народив)

Репродуктивні характеристики пар

Середній вік жінок був 29 років з коливаннями від 21 до 46 років, середня тривалість спроб народити дитину 3 роки (коливання від 1 до 20 місяців) (без різниці в групах). Знову ж, попередні успішні пологи і невдалі вагітності були більш поширені в групі жінок, що народили. Цікаво відзначити, що частка пар, які раніше мали невдалі IVF / ICSI була схожа в обох групах – близько 3%.

Тривалість лікування для досягнення вагітності коливалося від 1 до 32 місяців з середньою 8 місяців. Найкоротший цей час було в наймолодшій групі і, як не дивно, в найстаршій. Можливо, що якщо нам вдасться “знайти кнопку” і “перемкнути” плідність у старшої жінки, вона дуже швидко вагітніє, в іншому випадку доводиться конкурувати з менопаузою.

Система спостереження

Всі пари проводили спостереження відповідно до крейгтонського методу (72%) або симптотермального методу (28%). В Україні є багато інструкторів симптотермального методу , як правило, вони прислали нам пацієнтів, які вже були вишколені в цій системі. З іншого боку, кількість інструкторів крейгтонського методу дуже невелика, тому навчання не завжди доступне, особливо для віддалених пацієнтів.

Лікування

Загальне лікування включало звичайні препарати, що сприяють зачаттю, ліки для підвищення якості цервікальногослизу (віт В6, ацетилцистеїну,  сироп подорожника або плюща, ампіцилін). Ми просили пацієнтів не використовувати трави і харчові добавки під час лікування через можливість непередбачуваної взаємодії.

Деякі пацієнти мали хірургічне лікування і близько половини пацієнтів (в основному жінки) мали певну харчову програму. Вона включала в себе низькокалорійні дієти з низьким вмістом вуглеводів, а також харчову програму на основі IgG залежної харчової непереносимості.

Результати

За 5 років у наших пацієнтів були 138 клінічно підтверджених вагітностей і 96 успішних пологів.

Для того, щоб оцінити ефективність лікування, ми застосували математичну методику «кривих виживання», які дають змогу оцінити шанси на настання вагітності та успішні пологи в тій ситуації, коли частка пацієнтів протягом курсу лікування вибуває. Отже, протягом 24 місяців після початку лікування сукупна нескоригована частка («песимістична» частка, або абсолютна кількість) успішних пологів становила 22% протягом 24 місяців лікування. Скоригована («оптимістична») частка перших народжених живими склав 65% на 24 місяців. Частка будь-якого зачаття була вища: 32% (нескоригована) і 74% (скоригована) протягом 24 місяців. Ці результати є порівняльними з даними ірландського і канадського досліджень ефективності напротехнології – відповідно 52% і 66% шанси на народження живої дитини протягом 24 місяців лікування.

Прогностичні фактори успішних пологів

Сукупна частка вагітностей знижувалася зі збільшенням віку жінок

Для жінок у віці до 30 років, скоригована частка зачаття після 24 місяців склала близько 90%, в 31-35 років – 67%, в 36-40 – близько 60%. В цілому результати лікування були рівні між 30 і 40, але й для жінок старше 40 років прогноз був досить добрим.

Тривалість спроб народити дитину

У групі пар, які намагалися народити дитину менш ніж за 3 роки, прогноз був відмінний і перевищував 90%. Коли цей показник зростав до 6 і 9 років, частка зачаттів знижувалася приблизно до 60%, а в групі 9 років або більше до приблизно 45. Тривалість часу, протягом якого намагаються народити, здається, є більш сильним прогностичним фактором, ніж вік жінки.

Серед інших сприятливих предикторів зачаття були вагітність в анамнезі (навіть невдала), пологи в анамнезі, звичні викидні, а також дотримання рекомендацій. Несприятливі прогностичні чинники: гіперпролактинемія, проблеми щитовидної залози, міома матки, чоловічий фактор і хірургічне лікування після початку програми.

Характеристики дітей

Усі пологи були від одно плодових вагітностей. Всі діти, крім 2, народилися з масою тіла при більше 2500 г. Було лише 2 передчасні пологи, як сталися в терміні 31-32 тижнів. Одні з них були у пацієнтки з великими множинними міоматозними вузлами, пологи відбулися шляхом ургентного цісарського розтину через дистрес плода і прееклампсію у матері (хлопчика 1100 г, лікувався у відділенні інтенсивної терапії новонароджених, виписаний з лікарні через 2 місяці після народження в доброму стані), ще одні спонтанні передчасні пологи трапилися в жінки, яка жила в іншій області  і не дотримувалася нашого протоколу (дівчинка 1 600 г, виписана в доброму стані). Тільки ці двоє дітей мали вагу при народженні менше 2500 р Жодна дитина не мала вроджених вад розвитку.

Варто відзначити, що невдалі вагітності відбулося в основному в пацієнток, які не дотримувалися рекомендацій, а їх частина була дуже низькою (5% ектопічні вагітності, 10% самовільні викидні).

Клінічні випадки

Випадок 1 – Мати 29 років, батько 30 років, намагалися народити протягом 10 років. За цей час відбулося 7 викиднів, 1 позаматкова вагітність (маткова труба збережена). У матері недіагностований раніше гіпотиреоз і низка інших соматичних станів. В результаті лікування вагітність настала  в 3-му циклі лікування і закінчилася успішно. Шляхом цісарського розтину в 36 тижнів (передчасний розрив плодових оболонок, косе положення дитини) 13 квітня 2011 року народився хлопчик вагою 3050 г, довжиною 51 см

Випадок 2

Батьки віком близько 35 років, невстановлений  діагноз у жінки, рекомендовано IVF

Діагностика за методом Напротехнології засвідчила тип 2 недостатності фази жовтого тіла. Після лапароскопії та адекватного фармакологічного лікування  в 1-му циклі після операції настала вагітність (8 місяців загальної тривалості лікування)

Пологи відбулися природним шляхом, народилася дівчинка вагою 3360 г, довжиною 54 см

Випадок 3

Батьки близько 40, намагалися народити протягом 7 років. За цей час 2 викидні, у жінки хвороба Вільсона – дуже рідкісна вроджена патологія, яка полягає в порушені обміну міді та нокапиченні її в організмі. В літературі описали лише близько 100 жінок з успішними вагітностями при цьому стані.

Лікування полягало в основному у  підтримці фази жовтого тіла і  прогестероновій підтримці під час вагітності

Пологи відбулися через природні родові шляхи, народився хлопчик 3530 г, 50 см

Отже, ці випадки засвідчують, що Напротехнологія , чи лікування, як коректне з моральної точки зору, також і дуже ефективне з точки зору медичної.

Зореслава Городенчук

лікар акушер-гінеколог,  NFPMC, FCP

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