Abstract：
OBJECTIVE: To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples.
METHODS: Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.
RESULTS: The fertility work-up is recommended to be prescribed according to the woman\'s age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple\'s initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.
CONCLUSIONS: Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.
METHODS: Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts.
RESULTS: The fertility work-up is recommended to be prescribed according to the woman\'s age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple\'s initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery.
CONCLUSIONS: Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.
摘要：
目的：更新2010年CNGOF不孕夫妇一线管理临床实践指南。
方法：五个主要主题（对不育妇女的一线评估，对不育男子的一线评估，防止接触环境因素，使用排卵诱导方案的初始管理，一线生殖手术)被确定，使用PICO(患者，干预,比较,结果)格式。每个问题都由一个工作组解决，该工作组自2010年以来对文献进行了系统的审查，并遵循GRADE®（建议评估，开发和评估）评估建议所依据的科学数据质量的方法。这些建议随后在40名国家专家的国家审查中得到验证。
结果：建议根据女性年龄规定生育检查：35岁前不孕1年后，35岁后6个月后。一对夫妇最初的不孕症检查包括单3D超声扫描与窦卵泡计数，通过子宫造影或HyFOSy评估输卵管通透性，辅助生殖前的抗苗勒管激素测定，阴道拭子检查阴道病.如果3D超声是正常的，宫腔镜检查和诊断性宫腔镜检查不推荐作为一线手术。沙眼衣原体血清学没有必要的性能来预测输卵管通畅。不再推荐性交后测试。在男人中，精子图,建议将精子细胞图和精子培养作为一线测试。如果精子图正常,不建议检查精子图。如果精子图异常,一个男科医生的检查,建议对睾丸进行超声扫描和激素测试。根据文献中的数据，我们无法为女性推荐BMI阈值，以禁止不孕症的医疗管理。平衡的地中海式饮食，建议不育夫妇进行体育锻炼，戒烟和大麻。对于生育问题，建议将酒精摄入量限制在每周少于5杯。如果不孕症检查没有发现异常，排卵诱导不建议正常排卵的妇女。如果根据异常的不孕症检查指示宫腔内授精，建议促性腺激素刺激和排卵监测，以避免多胎妊娠。如果不孕症检查没有发现异常，可能建议在30岁之前进行腹腔镜检查，以增加自然妊娠率。在输卵管积水的情况下，建议在ART之前进行手术管理，根据输卵管评分进行输卵管切开术或输卵管切除术。建议对息肉>10毫米进行手术，在ART之前的肌瘤0、1、2和粘连。文献中的数据不允许我们系统地推荐无症状的子宫间隔和峡部作为一线手术。
结论：基于专家之间的强烈共识，我们已经在28个领域制定了有关不育夫妇初步管理的最新建议。
方法：五个主要主题（对不育妇女的一线评估，对不育男子的一线评估，防止接触环境因素，使用排卵诱导方案的初始管理，一线生殖手术)被确定，使用PICO(患者，干预,比较,结果)格式。每个问题都由一个工作组解决，该工作组自2010年以来对文献进行了系统的审查，并遵循GRADE®（建议评估，开发和评估）评估建议所依据的科学数据质量的方法。这些建议随后在40名国家专家的国家审查中得到验证。
结果：建议根据女性年龄规定生育检查：35岁前不孕1年后，35岁后6个月后。一对夫妇最初的不孕症检查包括单3D超声扫描与窦卵泡计数，通过子宫造影或HyFOSy评估输卵管通透性，辅助生殖前的抗苗勒管激素测定，阴道拭子检查阴道病.如果3D超声是正常的，宫腔镜检查和诊断性宫腔镜检查不推荐作为一线手术。沙眼衣原体血清学没有必要的性能来预测输卵管通畅。不再推荐性交后测试。在男人中，精子图,建议将精子细胞图和精子培养作为一线测试。如果精子图正常,不建议检查精子图。如果精子图异常,一个男科医生的检查,建议对睾丸进行超声扫描和激素测试。根据文献中的数据，我们无法为女性推荐BMI阈值，以禁止不孕症的医疗管理。平衡的地中海式饮食，建议不育夫妇进行体育锻炼，戒烟和大麻。对于生育问题，建议将酒精摄入量限制在每周少于5杯。如果不孕症检查没有发现异常，排卵诱导不建议正常排卵的妇女。如果根据异常的不孕症检查指示宫腔内授精，建议促性腺激素刺激和排卵监测，以避免多胎妊娠。如果不孕症检查没有发现异常，可能建议在30岁之前进行腹腔镜检查，以增加自然妊娠率。在输卵管积水的情况下，建议在ART之前进行手术管理，根据输卵管评分进行输卵管切开术或输卵管切除术。建议对息肉>10毫米进行手术，在ART之前的肌瘤0、1、2和粘连。文献中的数据不允许我们系统地推荐无症状的子宫间隔和峡部作为一线手术。
结论：基于专家之间的强烈共识，我们已经在28个领域制定了有关不育夫妇初步管理的最新建议。
