Cantineau A E P, Cohlen B J, Heineman M J
Cochrane Database Syst Rev. 2007 Apr 18(2):CD005356. doi: 10.1002/14651858.CD005356.pub2.
Intrauterine insemination (IUI) combined with ovarian hyperstimulation (OH) has been demonstrated to be an effective form of treatment for subfertile couples. Several ovarian stimulation protocols combined with IUI have been proposed, but it is still not clear which stimulation protocol and which dose is the most cost-effective.
To evaluate ovarian stimulation protocols for intrauterine insemination for all indications.
We searched for all publications which described randomised controlled trials comparing different ovarian stimulation protocols followed by IUI. We searched the Menstrual Disorders and Subfertility Group's Central register of Controlled Trials (CENTRAL). We searched the electronic databases of MEDLINE (January 1966 to present) and EMBASE (1980 to present).
Randomised controlled trials only were considered for inclusion in this review. Trials comparing different ovarian stimulation protocols combined with IUI were selected and reviewed in detail.
Two independent review authors independently assess trial quality and extracted data.
Forty three trials involving 3957 women were included. There were 11 comparisons in this review. Pregnancy rates are reported here since results of live birth rates were lacking. Seven studies (n = 556) were pooled comparing gonadotrophins with anti-oestrogens showing significant higher pregnancy rates with gonadotrophins (OR 1.8, 95% CI 1.2 to 2.7). Five studies (n = 313) compared anti-oestrogens with aromatase inhibitors reporting no significant difference (OR 1.2 95% CI 0.64 to 2.1). The same could be concluded comparing different types of gonadotrophins (9 studies included, n = 576). Four studies (n = 391) reported the effect of adding a GnRH agonist which did not improve pregnancy rates (OR 0.98 95% CI 0.6 to 1.6), although it resulted in significant higher multiple pregnancy rates (OR 2.9 95% CI 1.0 to 8). Data of three studies (n = 299) showed no convincing evidence of adding a GnRH antagonist to gonadotrophins (OR 1.5 95% CI 0.83 to 2.8). The results of two studies (n = 297) reported no evidence of benefit in doubling the dose of gonadotrophins (OR 1.2 95% 0.67 to 1.9) although the multiple pregnancy rates and OHSS rates were increased. For the remaining five comparisons only one or none studies were included.
AUTHORS' CONCLUSIONS: Robust evidence is lacking but based on the available results gonadotrophins might be the most effective drugs when IUI is combined with ovarian hyperstimulation. When gonadotrophins are applied it might be done on a daily basis. When gonadotrophins are used for ovarian stimulation low dose protocols are advised since pregnancy rates do not differ from pregnancy rates which result from high dose regimen, whereas the chances to encounter negative effects from ovarian stimulation such as multiples and OHSS are limited with low dose gonadotrophins. Further research is needed for each comparison made.
宫腔内人工授精（IUI）联合卵巢过度刺激（OH）已被证明是治疗不育夫妇的一种有效方法。已经提出了几种联合IUI的卵巢刺激方案，但仍不清楚哪种刺激方案和哪种剂量最具成本效益。
评估适用于所有适应症的宫腔内人工授精的卵巢刺激方案。
我们检索了所有描述比较不同卵巢刺激方案后进行IUI的随机对照试验的出版物。我们检索了月经失调和不育症组的对照试验中央注册库（CENTRAL）。我们检索了MEDLINE（1966年1月至今）和EMBASE（1980年至今）的电子数据库。
本综述仅考虑纳入随机对照试验。选择并详细回顾了比较不同卵巢刺激方案联合IUI的试验。
两位独立的综述作者独立评估试验质量并提取数据。
纳入了涉及3957名女性的43项试验。本综述中有11项比较。由于缺乏活产率结果，此处报告了妊娠率。汇总了7项研究（n = 556），比较了促性腺激素与抗雌激素，结果显示促性腺激素的妊娠率显著更高（OR 1.8，95% CI 1.2至2.7）。5项研究（n = 313）比较了抗雌激素与芳香化酶抑制剂，报告无显著差异（OR 1.2，95% CI 0.64至2.1）。比较不同类型的促性腺激素（纳入9项研究，n = 576）也可得出相同结论。4项研究（n = 391）报告了添加GnRH激动剂的效果，虽未提高妊娠率（OR 0.98，95% CI 0.6至1.6），但导致多胎妊娠率显著更高（OR 2.9，95% CI 1.0至8）。3项研究（n = 299）的数据显示，没有令人信服的证据表明在促性腺激素中添加GnRH拮抗剂有效果（OR 1.5，95% CI 0.83至2.8）。2项研究（n = 297）的结果报告，没有证据表明将促性腺激素剂量加倍有益（OR 1.2，95% 0.67至1.9），尽管多胎妊娠率和卵巢过度刺激综合征（OHSS）发生率有所增加。对于其余5项比较，仅纳入了1项或未纳入任何研究。
缺乏有力证据，但根据现有结果，当IUI联合卵巢过度刺激时，促性腺激素可能是最有效的药物。应用促性腺激素时可每日进行。当使用促性腺激素进行卵巢刺激时，建议采用低剂量方案，因为低剂量方案的妊娠率与高剂量方案的妊娠率无差异，而低剂量促性腺激素导致卵巢刺激不良反应如多胎和OHSS的几率有限。对于所做的每项比较都需要进一步研究。
