Несмотря на то что изучению миомы матки (ММ) посвящено множество работ, проблема до настоящего времени остается нерешенной. ММ – наиболее часто встречающееся доброкачественное новообразование половой системы женщины. В последние десятилетия ММ все чаще диагностируется у женщин, планирующих беременность, что связано, в первую очередь, с социальным фактором: современные женщины стремятся отложить время деторождения до достижения стабильного материального и социального статуса, что нередко происходит ближе к позднему репродуктивному возрасту, когда распространенность ММ закономерно повышается. Связь между ММ и нарушением фертильности неоднозначна, но, вне всяких сомнений, наличие ММ следует принимать во внимание у женщин с бесплодием и привычным самопроизвольным выкидышем. Оптимального решения задачи восстановления фертильности у пациенток с ММ не существует, однако сегодня помимо хирургических методов лечения появляется возможность консервативного ведения таких больных. Преимущества и недостатки хирургической и консервативной тактики восстановления фертильности у больных ММ должны подвергнуться оценке и дальнейшей разработке. Ключевые слова: миома матки, фертильность, бесплодие, привычный самопроизвольный выкидыш, планирование беременности, миомэктомия, улипристала ацетат.
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Despite the fact that the study of uterine fibroids has been widely discussed, the problem still remains unsolved. Uterine fibroids are the most common benign neoplasm of female genital system. Increasingly diagnosed in recent decades, uterine fibroids in women planning a pregnancy, which is associated primarily with the social factor: modern women tend to postpone the time of childbirth until a stable material and social status, which often occurs close to the late reproductive age, when the prevalence of uterine fibroids naturally increases. The link between uterine fibroids and fertility disorders ambiguous, but, without a doubt, the presence of uterine fibroids should be taken into account in women with infertility and habitual miscarriage. The optimal solution, but today, in addition to surgical treatment task of restoring fertility in women with uterine fibroids do not exist, there is a possibility of conservative management of these patients. Advantages and disadvantages of surgical and conservative tactics restore fertility in patients with uterine myoma should undergo evaluation and further development. Key words: uterine fibroids, fertility, infertility, recurrent spontaneous miscarriage, pregnancy planning, myomectomy, ulipristal acetate.
1. Миома матки: диагностика, лечение и реабилитация (клинические рекомендации по ведению больных). Под ред. Л.В.Адамян. М.: 2014. / Mioma matki: diagnostika, lechenie i reabilitatsiia (klinicheskie rekomendatsii po vedeniiu bol'nykh). Pod red. L.V.Adamian. M.: 2014. [in Russian]
2. Marret H, Fritel X, Ouldamer L et al. Therapeutic management of uterine fibroid tumors: updated French guidelines. Eur J Obstet Gynecol Reprod Biol 2012; 165: 156–64.
3. Parker WH. Etiology, symptomatology and diagnosis of uterine myoma. Fertil Steril 2007; 87: 726–36.
4. Giraudet G, Lucot JP et al. Except fertility, place of myomectomy in perimenopause and after menopause. Gynecol Obstet Biol Reprod 2011; 40 (8): 902–17.
5. Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Pract Res Clin Obstet Gynaecol 2008; 22: 615–26.
6. Levy BS. Management of uterine fibroids. Acta Obstet Gynecol Scand 2008; 87 (8): 812–23. Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons. Myomas and reproductive function. Fertil Steril 2008; 90 (Suppl. 5): S125–130.
7. Somigliana E, Vercellini P, Daguati R et al. Fibroids and female reproduction: a critical analysis of the evidence. Hum Reprod Update 2007; 13: 465–76.
8. Волков В.Г., Гусева Н.В., Горшкова И.А. Оптимизация консервативного лечения миомы матки антипрогестеронами и оценка влияния проводимой терапии на качество жизни женщин. Вестн. новых мед. технологий. 2011; 18 (1): 92. / Volkov V.G., Guseva N.V., Gorshkova I.A. Optimizatsiia konservativnogo lecheniia miomy matki antiprogesteronami i otsenka vliianiia provodimoi terapii na kachestvo zhizni zhenshchin. Vestn. novykh med. tekhnologii. 2011; 18 (1): 92. [in Russian]
9. Duhan N. Current and emerging treatments for uterine myoma an update. Int J Womens Health 2011; 3: 231–41.
10. Sozen I, Arici A. Cellular biology of myomas: interaction of sex steroids with cytokines and growth factors. Obstet Gynecol Clin NA 2006; 33 (1): 41–58.
11. Chen B, Wen Y, Yu XY, Polan ML. Relaxin increases elastase activity and protease inhibitors in smooth muscle cells from tye myometrium compared with cells from leiomyomas. Fertil Steril 2009; 91 (4): 1351–4.
12. Georgieva B, Milev I, Minkov I et al. Charactrisation of the uterine leiomyoma microRNAome by deep sequencing. Genomics 2012; 99: 275–81.
13. Mäkinen N, Mehine M, Tolvanen J et al. MED12, the mediator complex subunit 12 gene, is mutated at high frequency in uterine leiomyomas. Science 2011; 334: 252–9.
14. Vegan K. MED12 mutations and uterine fibrinoids. Nature Genetics 2011; 43: 928–31.
15. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an update systematic review of the evidence. Fertil Steril 2009; 91 (4): 1215–23.
16. Indman PD. Hysteroscopic treatment of submucous fibroids. Clin Obstet Gynecol 2006; 49: 811–20.
17. Kolankaya A, Arici A. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am 2006; 33: 145–52.
18. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008; 198: 357–66.
19. Chalazonitis A, Tzovara I, Laspas F et al. Hysterosalpingography: technique and applications. Curr Probl Diagn Radiol 2009; 38 (5): 199–205.
20. Dixon D, Parrott EC, Segars JH et al. The second National Institutes of Health International Congress on advances in uterine leiomyoma research: conference summary and future recommendations. Fertil Steril 2006; 86: 800–6.
21. Polena V, Merqui JL, Perrot N et al. Long-term results of hysteroscopic myomectomy in 235 patients. Eur J Obstet Gynecol Reprod Biol 2007; 130: 232–7.
22. Di Spezio Sardo A, Mazzon I, Bramante S et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update 2008; 14: 10–9.
23. Петракова С.А., Буянова С.Н., Мгелиашвили М.В. Возможности миомэктомии в коррекции репродуктивного здоровья женщин с миомой матки. Рос. вестн. акушера-гинеколога. 2009; 1: 30–5. / Petrakova S.A., Buianova S.N., Mgeliashvili M.V. Vozmozhnosti miomektomii v korrektsii reproduktivnogo zdorov'ia zhenshchin s miomoi matki. Ros. vestn. akushera-ginekologa. 2009; 1: 30–5. [in Russian]
24. Кулинич С.И., Бурлакова О.А. Предгравидарная подготовка женщин репродуктивного возраста и профилактика рецидива миомы матки в послеоперационном периоде после миомэктомии. Сиб. мед. журн. 2011; 6: 119–22. / Kulinich S.I., Burlakova O.A. Predgravidarnaia podgotovka zhenshchin reproduktivnogo vozrasta i profilaktika retsidiva miomy matki v posleoperatsionnom periode posle miomektomii. Sib. med. zhurn. 2011; 6: 119–22. [in Russian]
25. Meng X, He G, Zhang J. A comparative study of fibroid ablation rates using radio frequency and high-intensity focused ultrasound. Cvir 2010; 33: 794–9.
26. Toor SS, Tan KT, Simons ME. Clinical Failure after Uterine Artery Embolization: Evaluation of Patient and MR Imaging Characteristics. J Vasc Int Radiol 2008; 19: 662–7.
27. Scheurig C, Gauruder-Burmester A, Kluner C. Uterine artery embolization for symptomatic fibroids: short-term versus mid-term changes in disease-specific symptoms, quality of life and magnetic resonance imaging results. Hum Reprod 2006; 21: 3270–7.
28. Smeets AJ, Nijenhuis RJ, Jan van Rooij W. Embolization of Uterine Leiomyomas with Polyzene F-coated Hydrogel Microspheres: Initial Experience. J Vasc Intervent Radiol 2010; 21: 1830–4.
29. Horhoianu IA, Horhoianu VV, Joita D, Carstoiu M, Dorobat B. Uterine artery embolization for leioyomas, ultrasonography and angiography aspects. J Med Life 2012; 5 (4): 491–5.
30. Naguib NNN, Mbalisike E, Nour-Eldin NEA. Leiomyoma Volume Changes at Follow-up after Uterine Artery Embolization: Correlation with the Initial Leiomyoma Volume and Location. J Vasc Intervent Radiol 2010; 21: 490–5.
31. Scheurig-Muenkler C, Koesters C, Grieser C. Treatment failure after uterine artery embolization: Prospective cohort study with multifactorial analysis of possible predictors of long-term outcome. Eur J Radiol 2012; 81: 727–31.
32. Kim HS, Tsai J, Patra A. Effects of Utero-ovarian Anastomoses on Clinical Outcomes and Repeat Intervention Rates after Uterine Artery Embolization. J Vasc Intervent Radiol 2006; 17: 783–9.
33. Smeets AJ, Nijenhuis RJ, Boekkooi PF. Safety and Effectiveness of Uterine Artery Embolization in Patients with Pedunculated Fibroids. J Vasc Intervent Radiol 2009; 20: 1172–5.
34. Firouznia K, Ghanaati H, Sanaati M et al. Pregnancy after uterine artery embolization for symptomatic fibroids: a series of 15 pregnancies. AJR Am J Roentgenol 2009; 192 (6): 1588–92.
35. Mara M, Maskova J, Fucikova Z et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol 2008; 31 (1): 73–85.
36. Hovsepian DM, Ratts VS, Rodriguez M et al. A prospective comparison of the impact of uterine artery embolization, myomectomy, and hysterectomy on ovarian function. J Vasc Interv Radiol 2006; 17 (7): 1111–5.
37. Hehenkamp WJK, Volkers NA, Broekmans FJM et al. Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy. Hum Reprod 2007; 22 (7): 1996–2005.
38. Yin P, Lin Z, Reierstad S et al. Transcription factor KLF11 integrates progesterone receptor signaling and proliferation in uterine leiomyoma cells. Cancer Res 2010; 70 (4): 1722–30.
39. Kim JJ, Sefton EC. The role of progesterone signaling in the pathogenesis of uterine leiomyoma. Mol Cell Endocrinol 2012; 35(2): 223–31.
40. Donnez J, Tomaszewski J, Vázquez F et al.; PEARL II Study Group. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med 2012; 366 (5): 421–32.
41. Islam MS, Protic O, Giannubilo SR et al. Uterine leiomyoma: available medical treatments and new possible therapeutic options. J Clin Endocrinol Metab 2013; 98: 921–34.
42. Spitz AM. Clinical utility of progesterone receptor modulators and their effect on the endometrium. Curr Opin Obtet Gynecol 2009; 21: 318–24.
43. Maruo T. Translation research in women’s health: From bedside to bench and from bench to bedside. Int J Gynecol Obstet 2010; 109: 83–3.
44. Xu Q, Ohara N, Liu J et al. Progesterone receptor modulator CDB-2914 induces extracellular matrix metalloproteinase inducer in cultured human uterine leiomyoma cells. Mol Hum Reprod 2008; 14: 181–91.
45. Yoshida S, Ohara N, Xu Q et al. Cell-type specific actions of progesterone receptor modulators in regulation of uterine leiomyoma growth. Semin Reprod Med 2010; 28: 260–73.
46. Donnez J, Tatarchuk TF, Bouchard P et al. PEARL I Study Group. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012; 366: 409–20.
47. Donnez J, Vazquez F, Tomaszewski J et al. Long-term treatment of uterine fibroids with ulipristal acetate. Fertil Steril 2014; 101: 1565–73.
48. Donnez J, Hudecek R, Donnez O et al. Efficacy and safety of repeated use of ulipristal acetate in uterine fibroids. Fertil Steril 2015; 103: 519–27.
49. Mutter GL, Bergeron C, Deligdisch L et al. The spectrum of endometrial pathology induced by progesterone receptor modulators. Mod Pathol 2008; 21 (5): 591–98.
50. Williams AR, Bergeron C, Barlow DH, Ferenczy A. Endometrial morphology after treatment of uterine fibroids with the selective progesterone receptor modulator, ulipristal acetate. Int J Gynecol Pathol 2012; 31: 556–69.
51. Chabbert-Buffet N, Pintiaux-Kairis A, Bouchard P. Effects of the progesterone receptor modulator VA2914 in a continuous low dose on the hypothalamic-pituitary-ovarian axis and endometrium in normal women: a prospective, randomized, placebo-controlled trial. J Clin Endocrinol Metab 2007; 92 (9): 3582–9.
52. Luyckx M, Squifflet JL, Jadoul P et al. First series of 18 pregnancies after ulipristal acetate treatment for uterine fibroids. Fertil Steril 2014; 102 (5): 1404–9.
________________________________________________
1. Mioma matki: diagnostika, lechenie i reabilitatsiia (klinicheskie rekomendatsii po vedeniiu bol'nykh). Pod red. L.V.Adamian. M.: 2014. [in Russian]
2. Marret H, Fritel X, Ouldamer L et al. Therapeutic management of uterine fibroid tumors: updated French guidelines. Eur J Obstet Gynecol Reprod Biol 2012; 165: 156–64.
3. Parker WH. Etiology, symptomatology and diagnosis of uterine myoma. Fertil Steril 2007; 87: 726–36.
4. Giraudet G, Lucot JP et al. Except fertility, place of myomectomy in perimenopause and after menopause. Gynecol Obstet Biol Reprod 2011; 40 (8): 902–17.
5. Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Pract Res Clin Obstet Gynaecol 2008; 22: 615–26.
6. Levy BS. Management of uterine fibroids. Acta Obstet Gynecol Scand 2008; 87 (8): 812–23. Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons. Myomas and reproductive function. Fertil Steril 2008; 90 (Suppl. 5): S125–130.
7. Somigliana E, Vercellini P, Daguati R et al. Fibroids and female reproduction: a critical analysis of the evidence. Hum Reprod Update 2007; 13: 465–76.
8. Volkov V.G., Guseva N.V., Gorshkova I.A. Optimizatsiia konservativnogo lecheniia miomy matki antiprogesteronami i otsenka vliianiia provodimoi terapii na kachestvo zhizni zhenshchin. Vestn. novykh med. tekhnologii. 2011; 18 (1): 92. [in Russian]
9. Duhan N. Current and emerging treatments for uterine myoma an update. Int J Womens Health 2011; 3: 231–41.
10. Sozen I, Arici A. Cellular biology of myomas: interaction of sex steroids with cytokines and growth factors. Obstet Gynecol Clin NA 2006; 33 (1): 41–58.
11. Chen B, Wen Y, Yu XY, Polan ML. Relaxin increases elastase activity and protease inhibitors in smooth muscle cells from tye myometrium compared with cells from leiomyomas. Fertil Steril 2009; 91 (4): 1351–4.
12. Georgieva B, Milev I, Minkov I et al. Charactrisation of the uterine leiomyoma microRNAome by deep sequencing. Genomics 2012; 99: 275–81.
13. Mäkinen N, Mehine M, Tolvanen J et al. MED12, the mediator complex subunit 12 gene, is mutated at high frequency in uterine leiomyomas. Science 2011; 334: 252–9.
14. Vegan K. MED12 mutations and uterine fibrinoids. Nature Genetics 2011; 43: 928–31.
15. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an update systematic review of the evidence. Fertil Steril 2009; 91 (4): 1215–23.
16. Indman PD. Hysteroscopic treatment of submucous fibroids. Clin Obstet Gynecol 2006; 49: 811–20.
17. Kolankaya A, Arici A. Myomas and assisted reproductive technologies: when and how to act? Obstet Gynecol Clin North Am 2006; 33: 145–52.
18. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008; 198: 357–66.
19. Chalazonitis A, Tzovara I, Laspas F et al. Hysterosalpingography: technique and applications. Curr Probl Diagn Radiol 2009; 38 (5): 199–205.
20. Dixon D, Parrott EC, Segars JH et al. The second National Institutes of Health International Congress on advances in uterine leiomyoma research: conference summary and future recommendations. Fertil Steril 2006; 86: 800–6.
21. Polena V, Merqui JL, Perrot N et al. Long-term results of hysteroscopic myomectomy in 235 patients. Eur J Obstet Gynecol Reprod Biol 2007; 130: 232–7.
22. Di Spezio Sardo A, Mazzon I, Bramante S et al. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update 2008; 14: 10–9.
23. Petrakova S.A., Buianova S.N., Mgeliashvili M.V. Vozmozhnosti miomektomii v korrektsii reproduktivnogo zdorov'ia zhenshchin s miomoi matki. Ros. vestn. akushera-ginekologa. 2009; 1: 30–5. [in Russian]
24. Kulinich S.I., Burlakova O.A. Predgravidarnaia podgotovka zhenshchin reproduktivnogo vozrasta i profilaktika retsidiva miomy matki v posleoperatsionnom periode posle miomektomii. Sib. med. zhurn. 2011; 6: 119–22. [in Russian]
25. Meng X, He G, Zhang J. A comparative study of fibroid ablation rates using radio frequency and high-intensity focused ultrasound. Cvir 2010; 33: 794–9.
26. Toor SS, Tan KT, Simons ME. Clinical Failure after Uterine Artery Embolization: Evaluation of Patient and MR Imaging Characteristics. J Vasc Int Radiol 2008; 19: 662–7.
27. Scheurig C, Gauruder-Burmester A, Kluner C. Uterine artery embolization for symptomatic fibroids: short-term versus mid-term changes in disease-specific symptoms, quality of life and magnetic resonance imaging results. Hum Reprod 2006; 21: 3270–7.
28. Smeets AJ, Nijenhuis RJ, Jan van Rooij W. Embolization of Uterine Leiomyomas with Polyzene F-coated Hydrogel Microspheres: Initial Experience. J Vasc Intervent Radiol 2010; 21: 1830–4.
29. Horhoianu IA, Horhoianu VV, Joita D, Carstoiu M, Dorobat B. Uterine artery embolization for leioyomas, ultrasonography and angiography aspects. J Med Life 2012; 5 (4): 491–5.
30. Naguib NNN, Mbalisike E, Nour-Eldin NEA. Leiomyoma Volume Changes at Follow-up after Uterine Artery Embolization: Correlation with the Initial Leiomyoma Volume and Location. J Vasc Intervent Radiol 2010; 21: 490–5.
31. Scheurig-Muenkler C, Koesters C, Grieser C. Treatment failure after uterine artery embolization: Prospective cohort study with multifactorial analysis of possible predictors of long-term outcome. Eur J Radiol 2012; 81: 727–31.
32. Kim HS, Tsai J, Patra A. Effects of Utero-ovarian Anastomoses on Clinical Outcomes and Repeat Intervention Rates after Uterine Artery Embolization. J Vasc Intervent Radiol 2006; 17: 783–9.
33. Smeets AJ, Nijenhuis RJ, Boekkooi PF. Safety and Effectiveness of Uterine Artery Embolization in Patients with Pedunculated Fibroids. J Vasc Intervent Radiol 2009; 20: 1172–5.
34. Firouznia K, Ghanaati H, Sanaati M et al. Pregnancy after uterine artery embolization for symptomatic fibroids: a series of 15 pregnancies. AJR Am J Roentgenol 2009; 192 (6): 1588–92.
35. Mara M, Maskova J, Fucikova Z et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol 2008; 31 (1): 73–85.
36. Hovsepian DM, Ratts VS, Rodriguez M et al. A prospective comparison of the impact of uterine artery embolization, myomectomy, and hysterectomy on ovarian function. J Vasc Interv Radiol 2006; 17 (7): 1111–5.
37. Hehenkamp WJK, Volkers NA, Broekmans FJM et al. Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy. Hum Reprod 2007; 22 (7): 1996–2005.
38. Yin P, Lin Z, Reierstad S et al. Transcription factor KLF11 integrates progesterone receptor signaling and proliferation in uterine leiomyoma cells. Cancer Res 2010; 70 (4): 1722–30.
39. Kim JJ, Sefton EC. The role of progesterone signaling in the pathogenesis of uterine leiomyoma. Mol Cell Endocrinol 2012; 35(2): 223–31.
40. Donnez J, Tomaszewski J, Vázquez F et al.; PEARL II Study Group. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med 2012; 366 (5): 421–32.
41. Islam MS, Protic O, Giannubilo SR et al. Uterine leiomyoma: available medical treatments and new possible therapeutic options. J Clin Endocrinol Metab 2013; 98: 921–34.
42. Spitz AM. Clinical utility of progesterone receptor modulators and their effect on the endometrium. Curr Opin Obtet Gynecol 2009; 21: 318–24.
43. Maruo T. Translation research in women’s health: From bedside to bench and from bench to bedside. Int J Gynecol Obstet 2010; 109: 83–3.
44. Xu Q, Ohara N, Liu J et al. Progesterone receptor modulator CDB-2914 induces extracellular matrix metalloproteinase inducer in cultured human uterine leiomyoma cells. Mol Hum Reprod 2008; 14: 181–91.
45. Yoshida S, Ohara N, Xu Q et al. Cell-type specific actions of progesterone receptor modulators in regulation of uterine leiomyoma growth. Semin Reprod Med 2010; 28: 260–73.
46. Donnez J, Tatarchuk TF, Bouchard P et al. PEARL I Study Group. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012; 366: 409–20.
47. Donnez J, Vazquez F, Tomaszewski J et al. Long-term treatment of uterine fibroids with ulipristal acetate. Fertil Steril 2014; 101: 1565–73.
48. Donnez J, Hudecek R, Donnez O et al. Efficacy and safety of repeated use of ulipristal acetate in uterine fibroids. Fertil Steril 2015; 103: 519–27.
49. Mutter GL, Bergeron C, Deligdisch L et al. The spectrum of endometrial pathology induced by progesterone receptor modulators. Mod Pathol 2008; 21 (5): 591–98.
50. Williams AR, Bergeron C, Barlow DH, Ferenczy A. Endometrial morphology after treatment of uterine fibroids with the selective progesterone receptor modulator, ulipristal acetate. Int J Gynecol Pathol 2012; 31: 556–69.
51. Chabbert-Buffet N, Pintiaux-Kairis A, Bouchard P. Effects of the progesterone receptor modulator VA2914 in a continuous low dose on the hypothalamic-pituitary-ovarian axis and endometrium in normal women: a prospective, randomized, placebo-controlled trial. J Clin Endocrinol Metab 2007; 92 (9): 3582–9.
52. Luyckx M, Squifflet JL, Jadoul P et al. First series of 18 pregnancies after ulipristal acetate treatment for uterine fibroids. Fertil Steril 2014; 102 (5): 1404–9.
Авторы
И.В.Кузнецова*1, Л.В.Евсюкова2
1. ГБОУ ВПО Первый Московский государственный медицинский университет им. И.М.Сеченова Минздрава России. 119991, Россия, Москва, ул. Трубецкая, д. 8, стр. 2;
2. ГБОУ ВПО Рязанский государственный медицинский университет им. акад. И.П.Павлова Минздрава России. 390026, Россия, Рязань, ул. Высоковольтная, д. 9
*ms.smith.ivk@gmail.com
________________________________________________
I.V.Kuznetsova*1, L.V.Evsyukova2
1. I.M.Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation. 119991, Russian Federation, Moscow, ul. Trubetskaia, d. 8, str. 2;
2. I.P.Pavlov Ryazan State Medical University of the Ministry of Health of the Russian Federation. 390026, Russian Federation, Ryazan, ul. Vysokovol'tnaia, d. 9
*ms.smith.ivk@gmail.com