目的:简明不孕症检查后的妊娠成功率是否与传统的广泛不孕症检查后的妊娠成功率相同?
结论:简明不孕症检查后的1年随访中的持续妊娠率明显低于传统和广泛不孕症检查后的妊娠成功率。
背景:基于成本效益研究,主要集中在诊断上,不孕症的治疗变得不那么全面。许多中心甚至对不孕症的治疗采取了一站式方法。
■我们进行了一项历史对照队列研究。在2012年和2013年,所有新的不育夫妇(n=795)进行了广泛的不育检查(A组)。在2014年和2015年,所有新的不育夫妇(n=752)都进行了简明的不育检查(B组)。两组的随访期均为1年。A组中99.0%的夫妇和B组中97.5%的夫妇可以进行完整的随访。
方法:广泛的不孕症检查包括病史检查,妇科超声扫描,精液分析,超声循环监测,定时性交后测试,定时孕酮和衣原体抗体滴度。常规建议进行子宫输卵管造影(HSG)。简明的不孕症检查主要基于历史记录,妇科超声扫描和精液分析。仅在怀疑输卵管病理或IUI开始之前才进行HSG。仅在需要时进行腹腔镜检查和激素检查。夫妇根据诊断采用期待管理(如果Hunault预后评分>30%),排卵诱导(在排卵障碍的情况下),IUI在自然周期中(在宫颈因素的情况下),刺激周期中的IUI(如果Hunault预后评分<30%)或IVF/ICSI(在输卵管因素的情况下,女性高龄,严重的男性因素,如果其他治疗仍然不成功)。两组的主要结局是妊娠时间和持续妊娠率。次要结果是调查的数量,诊断的分布,不孕症检查后的第一次治疗(开始)和受孕方式。
结果:描述性数据,比如年龄,不孕的持续时间,不孕类型和生活习惯,两组具有可比性。在A组中,进行了两倍以上的不孕症调查,与B组相比,在B组中进行HSG的频率较低(33%对42%)和后期。Kaplan-Meier曲线显示A组的妊娠时间较短。在1年的随访中,A组的总体持续妊娠率明显更高(58.7%对46.8%,分别,P<0.001)。在A组中,在不孕症检查期间受孕的夫妇更多(14.7%对6.5%,分别,P<0.05)。仅A组(9.3%)可以诊断为宫颈不孕症。无法解释的不孕症的诊断在组间不同,A组为23.5%,B组为32.2%(P<0.001)。
结论:这是一项历史对照的队列研究;不能排除偏倚的引入。两组的随访率相似,因此无法解释妊娠率的差异。
结论:应考虑重新引入广泛的不孕症检查,因为这可能会导致一年内更高的持续妊娠率。HSG的治疗效果和性交时间可能会提高生育机会。这一发现应该在随机对照试验中得到证实。
背景:这项研究没有获得资助。没有宣布利益冲突。
背景:不适用。
OBJECTIVE: Is pregnancy success rate after a concise infertility work-up the same as pregnancy success rate after the traditional extensive infertility work-up?
CONCLUSIONS: The ongoing pregnancy rate within a follow-up of 1 year after a concise infertility work-up is significantly lower than the pregnancy success rate after the traditional and extensive infertility work-up.
BACKGROUND: Based on cost-effectiveness studies, which have mainly focused on diagnosis, infertility work-up has become less comprehensive. Many centres have even adopted a one-stop approach to their infertility work-up.
UNASSIGNED: We performed a historically controlled cohort study. In 2012 and 2013 all new infertile couples (n = 795) underwent an extensive infertility work-up (group A). In 2014 and 2015, all new infertile couples (n = 752) underwent a concise infertility work-up (group B). The follow-up period was 1 year for both groups. Complete follow-up was available for 99.0% of couples in group A and 97.5% in group B.
METHODS: The extensive infertility work-up consisted of history taking, a gynaecological ultrasound scan, semen analysis, ultrasonographic cycle monitoring, a timed postcoital test, a timed progesterone and chlamydia antibody titre. A hysterosalpingography (HSG) was advised routinely. The concise infertility work-up was mainly based on history taking, a gynaecological ultrasound scan and semen analysis. A HSG was only performed if tubal pathology was suspected or before the start of IUI. Laparoscopy and hormonal tests were only performed if indicated. Couples were treated according to the diagnosis with either expectant management (if the Hunault prognostic score was >30%), ovulation induction (in case of ovulation disorders), IUI in natural cycles (in case of cervical factor), IUI in stimulated cycles (if the Hunault prognostic score was <30%) or IVF/ICSI (in case of tubal factor, advanced female age, severe male factor and if other treatments remained unsuccessful). The primary outcomes were time to pregnancy and the ongoing pregnancy rates in both groups. The secondary outcomes were the number of investigations, the distribution of diagnoses made, the first treatment (started) after infertility work-up and the mode of conception.
RESULTS: The descriptive data, such as age, duration of infertility, type of infertility and lifestyle habits, in both groups were comparable. In group A, more than twice the number of infertility investigations were performed, compared to group B. An HSG was made less frequently in group B (33% versus 42%) and at a later stage. A Kaplan-Meier curve shows a shorter time to pregnancy in group A. Also, a significantly higher overall ongoing pregnancy rate within a follow-up of 1 year was found in group A (58.7% versus 46.8%, respectively, P < 0.001). In group A, more couples conceived during the infertility work-up (14.7% versus 6.5%, respectively, P < 0.05). The diagnosis cervical infertility could only be made in group A (9.3%). The diagnosis unexplained infertility differed between groups, at 23.5% in group A and 32.2% in group B (P < 0.001).
CONCLUSIONS: This was a historically controlled cohort study; introduction of bias cannot be ruled out. The follow-up rate was similar in the two groups and therefore could not explain the differences in pregnancy rate.
CONCLUSIONS: Re-introduction of an extensive infertility work-up should be considered as it may lead to higher ongoing pregnancy rates within a year. The therapeutic effects of HSG and timing of intercourse may improve the fertility chance. This finding should be verified in a randomized controlled trial.
BACKGROUND: No funding was obtained for this study. No conflicts of interest were declared.
BACKGROUND: N/A.