Broekmans F J, Kwee J, Hendriks D J, Mol B W, Lambalk C B
Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands.
Hum Reprod Update. 2006 Nov-Dec;12(6):685-718. doi: 10.1093/humupd/dml034. Epub 2006 Aug 4.
The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.
体外受精成功率随年龄增长而下降，这在很大程度上归因于卵巢卵母细胞质量和数量的逐渐下降。在过去二十年中，已经设计了许多所谓的卵巢储备测试（ORT）来确定卵母细胞储备和质量，并评估它们在预测体外受精结果方面的能力，包括卵母细胞产量和妊娠发生率。这些测试中的许多已经成为接受辅助生殖技术的不孕患者常规诊断程序的一部分。传统上，这些测试的统一目标是了解患者对刺激的反应以及他们的妊娠几率。循证医学已逐渐发展成为生殖医学领域许多诊断程序和治疗选择的标准方法。我们在此提供了第一篇全面的系统文献综述，包括对所有当前可用和应用的测试进行的先验程序化信息检索，即卵泡早期血液中促卵泡激素（FSH）、雌二醇、抑制素B和抗苗勒管激素（AMH）的值、窦卵泡计数（AFC）、卵巢体积（OVVOL）和卵巢血流，此外还有枸橼酸氯米芬激发试验（CCCT）、外源性FSH卵巢储备测试（EFORT）和促性腺激素激动剂刺激试验（GAST），所有这些都作为预测卵巢反应和妊娠几率的指标。我们尽可能提供了所有评估过的各个测试的已发表论文的综合受试者工作特征（ROC）分析和曲线，以及对临床价值的正式判断。我们的分析表明，迄今为止已知的ORT预测性能仅为中等至较差，因此远不适合相关临床应用。对超刺激卵巢反应不良发生率的测试准确性似乎一般。在第一个体外受精周期中预先识别出实际的反应不良者，对于他们在一系列体外受精周期中的受孕几率是否具有任何预后价值仍有待确定。预测妊娠发生率的准确性非常有限。如果使用高阈值以防止夫妇被错误地拒绝体外受精，那么在体外受精治疗周期中，只有极少数（约3%）符合体外受精指征的病例被确定为前景不佳。尽管大多数ORT成本低廉且要求不高，但不支持将任何ORT用于结果预测。由于卵巢反应不良会提供一些关于卵巢储备状态的信息，特别是在刺激最大的情况下，在没有任何预先测试的情况下进入第一个体外受精周期似乎是更可取的策略。
