Corsan G H, Kemmann E
Long Island Jewish Medical Center, Long Island Campus for Albert Einstein College of Medicine, New Hyde Park, New York.
Fertil Steril. 1991 Mar;55(3):468-77. doi: 10.1016/s0015-0282(16)54169-7.
The risks of menotropin therapy (ovarian hyperstimulation syndrome, multiple gestation, adnexal torsion) are well known and have been previously described. Superovulation should not be considered for the indications described herein until more traditional therapies for infertility have been tried and found unsuccessful and sufficient time has elapsed for conception to occur. The cost of superovulation is high: the medications are expensive, frequent E2 monitoring and US studies are costly, and pregnancy complications relating to the higher rate of pregnancy loss and multiple gestation may add substantially to the overall cost. Yet, compared with IVF and GIFT, superovulation cycles combined with IUI cost between one third to one sixth that of an IVF cycle. Protocols involving combined CC/hMG/hCG, which reduce the total number of ampules of Pergonal needed per cycle and still provide multiple follicular development, may further reduce costs. There is a growing consensus that superovulation-IUI protocols should be attempted before GIFT and IVF in couples with normal pelvic viscera. There is little doubt that IVF and GIFT cycles are more costly, stressful, and complex. No comparative data have clearly shown IVF and GIFT to be superior to superovulation protocols in ovulatory women with normal pelvic anatomy. In the only study examining this issue published to date, Kaplan et al. retrospectively analyzed all GIFT and superovulation/IUI cycles at a single university center and found GIFT to be three times more efficient. However, the inherent limitations of a nonrandomized, nonprospective study of this kind are obvious as these authors have suggested. Therefore, it may be wise to consider the use of superovulation before assisted reproductive technologies until this issue is settled. It would be interesting to determine if the high PRs reported for couples with unexplained infertility or mild endometriosis in IVF and GIFT cycles in some centers not incorporating superovulation/IUI protocols would hold up if such an approach was routinely followed. Despite the increasing acceptance of superovulation protocols, we must be aware that many of the studies suggesting a role of hMG in treating ovulatory infertile women with normal pelvic anatomy suffer from deficiencies in experimental design. In a payor-driven system, such as in the United States, the difficulties in designing and carrying out scientifically sound clinical studies examining infertility therapies are obvious. The lack of federal or outside funding for the study of infertility issues contributes to the problem. It is our hope that better designed studies examining the role of superovulation in the treatment of ovulatory infertile women with normal pelvic anatomy will be forthcoming.
促性腺素治疗的风险（卵巢过度刺激综合征、多胎妊娠、附件扭转）已为人熟知且先前已有描述。在尝试了更传统的不孕症治疗方法且未成功，并且有足够时间受孕之前，不应考虑针对本文所述适应症进行超排卵。超排卵的成本很高：药物昂贵，频繁的雌二醇（E2）监测和超声检查费用高昂，与较高的流产率和多胎妊娠相关的妊娠并发症可能会大幅增加总体成本。然而，与体外受精（IVF）和配子输卵管内移植（GIFT）相比，超排卵周期联合宫腔内人工授精（IUI）的成本仅为IVF周期的三分之一至六分之一。涉及克罗米芬（CC）/人绝经期促性腺激素（hMG）/人绒毛膜促性腺激素（hCG）联合使用的方案，可减少每个周期所需的 Pergonal 安瓿总数，同时仍能实现多个卵泡发育，可能会进一步降低成本。越来越多的人达成共识，对于盆腔脏器正常的夫妇，应在进行GIFT和IVF之前尝试超排卵-IUI方案。毫无疑问，IVF和GIFT周期成本更高、压力更大且更复杂。没有比较数据明确表明IVF和GIFT在盆腔解剖结构正常的排卵女性中优于超排卵方案。在迄今为止发表的唯一一项研究此问题的研究中，卡普兰等人回顾性分析了一所大学中心的所有GIFT和超排卵/IUI周期，发现GIFT的效率高出三倍。然而，正如这些作者所指出的，这类非随机、非前瞻性研究存在明显的固有局限性。因此，在这个问题得到解决之前，在辅助生殖技术之前考虑使用超排卵可能是明智的。如果常规采用这种方法，某些未纳入超排卵/IUI方案的中心在IVF和GIFT周期中报道的不明原因不孕症或轻度子宫内膜异位症夫妇的高妊娠率是否依然成立，这将是一个有趣的问题。尽管超排卵方案越来越被接受，但我们必须意识到，许多表明hMG在治疗盆腔解剖结构正常的排卵性不孕女性中起作用的研究在实验设计上存在缺陷。在像美国这样由支付方驱动的系统中，设计和开展科学合理的不孕症治疗临床研究存在明显困难。缺乏联邦或外部资金用于不孕症问题的研究加剧了这一问题。我们希望能有设计更完善的研究来探讨超排卵在治疗盆腔解剖结构正常的排卵性不孕女性中的作用。
