Pandian Zabeena, McTavish Alison R, Aucott Lorna, Hamilton Mark Pr, Bhattacharya Siladitya
Obstetrics & Gynaecology, Aberdeen Maternity Hospital, Foresterhill, Aberdeen, UK, AB25 2ZD.
Cochrane Database Syst Rev. 2010 Jan 20(1):CD004379. doi: 10.1002/14651858.CD004379.pub3.
The success of in-vitro fertilisation (IVF) depends on adequate follicle recruitment by using controlled ovarian stimulation with gonadotrophins. Failure to recruit adequate follicles is called 'poor response'. Various treatment protocols have been proposed that are targeted at this cohort of women, aiming to increase their ovarian response.
To compare the effectiveness of different treatment interventions in women who have poor response to controlled ovarian hyperstimulation (are poor responders) in the context of IVF.
We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials (MDSG) (5/1/2009), the Cochrane Central Register of Controlled trials (CENTRAL) (4th Quarter 2008), MEDLINE (1950 to November week 3 2008), EMBASE (1980 to 2008 week 52) and The National Research Register (NRR). The citation lists of relevant publications, review articles, abstracts of scientific meetings and included studies were also searched. The authors were contacted to clarify data that were unclear from the trial reports.
Only randomised controlled trials (RCTs) comparing one type of intervention versus another for controlled ovarian stimulation of poor responders to a previous IVF treatment, using a standard long protocol were included.
Two reviewers independently scanned the abstracts, identified relevant papers, assessed trial quality and extracted relevant data for inclusion. Validity was assessed in terms of method of randomisation, completeness of treatment cycle and co-intervention. Where possible, data were pooled for analysis.
The new search identified fifteen trials. Three trials were eligible for inclusion. Ten trials involving eight different comparison groups have been included. Only one trial reported live birth rates.The number of oocytes retrieved were significantly less in the conventional GnRHa long protocol compared to stop protocol and GnRH antagonist protocol.Total dose of gonadotrophins used was significantly higher in the GnRHa long protocol group compared to the Stop protocol and GnRH antagonist groups.Cancellation rates were significantly higher in the GnRHa flare up group compared to the GnRHa long protocol group.None of the studies reported a difference in the miscarriage and ectopic pregnancy rates.
AUTHORS' CONCLUSIONS: There is insufficient evidence to support the routine use of any particular intervention either for pituitary down regulation, ovarian stimulation or adjuvant therapy in the management of poor responders to controlled ovarian stimulation in IVF. More robust data from good quality RCTs with relevant outcomes are needed.
体外受精（IVF）的成功取决于使用促性腺激素进行控制性卵巢刺激以充分募集卵泡。未能充分募集卵泡被称为“反应不良”。已经提出了各种针对这一群体女性的治疗方案，旨在提高她们的卵巢反应。
比较不同治疗干预措施对体外受精中控制性卵巢过度刺激反应不良（反应不佳者）的有效性。
我们检索了Cochrane月经紊乱与不育症小组专门的对照试验注册库（MDSG）（2009年1月5日）、Cochrane对照试验中心注册库（CENTRAL）（2008年第4季度）、MEDLINE（1950年至2008年11月第3周）、EMBASE（1980年至2008年第52周）以及国家研究注册库（NRR）。还检索了相关出版物的引用列表、综述文章、科学会议摘要以及纳入研究。与作者联系以澄清试验报告中不明确的数据。
仅纳入使用标准长方案对既往体外受精治疗反应不佳者进行控制性卵巢刺激时比较一种干预措施与另一种干预措施的随机对照试验（RCT）。
两名评审员独立浏览摘要、识别相关论文、评估试验质量并提取纳入的相关数据。根据随机化方法、治疗周期的完整性和共同干预评估有效性。尽可能合并数据进行分析。
新的检索识别出15项试验。3项试验符合纳入标准。已纳入涉及8个不同比较组的10项试验。只有1项试验报告了活产率。与停止方案和GnRH拮抗剂方案相比，传统GnRHa长方案中获取的卵母细胞数量显著更少。与停止方案和GnRH拮抗剂组相比，GnRHa长方案组使用的促性腺激素总剂量显著更高。与GnRHa长方案组相比，GnRHa激发组的取消率显著更高。没有研究报告流产率和异位妊娠率存在差异。
没有足够的证据支持在体外受精中对控制性卵巢刺激反应不佳者的管理中常规使用任何特定的干预措施来进行垂体降调节、卵巢刺激或辅助治疗。需要来自高质量RCT且有相关结局的更有力数据。
