Kdous Moez, Chaker Anis, Bouyahia Maha, Zhioua Fethi, Zhioua Amel
Centre de PMA, Service de gynécologie obstétrique et de médecine de la reproduction. Hôpital Aziza Othmana de Tunis, Tunis, Tunisie.
Tunis Med. 2009 Dec;87(12):834-42.
to compare standard long GnRH agonist protocol (Triptorelin) and GnRH antagonist regimens (Cetrorelix) in polycystic ovary syndrome (PCOS) patients undergoing controlled ovarian stimulation (COS) for ICSI cycles.
Retrospective case-control study. 106 PCOS patients undergoing COS for ICSI with long GnRH agonist protocol (Triptorelin) were matched with age and BMI to 106 PCOS patients undergoing COS for ICSI with GnRH antagonist (Cetrorelix) during the same period. Ovarian stimulation with recombinant follicle stimulating hormone (rFSH) was used in the two groups. Oral contraceptive pill pretreatment was used in all patients undergoing ovarian stimulation using GnRH antagonists. ICSI was performed for male infertility in all cases. The main outcome measures evaluated were: cancellation of the cycles, number of aspirated follicles, oocyte maturity, fertilization rate, Embryo quality, pregnancy and implantation rates, clinical abortion rate, multiple pregnancy rate and the live birth rate rate. Kchi2 test and t Student test were used for differences between normo-ovulatory and PCOS patients and the limit of significance was set at p < 0.05.
There was no significant difference in term of cancellation rate (2.8% vs 1.8%; NS). Duration of gonadotrophin stimulation (9.7 +/- 0.7 vs. 11.2 +/- 1.9 days; p < 0.001) and gonadotrophin consumption (2209.0 +/- 548.3 vs. 1411.1 +/- 217.9 UI: p < 0.001) were significantly decreased with GnRH antagonist. The mean oestradiol level on the triggering day was significantly higher in the agonist group (3347.85 +/- 99 vs. 2354.45 +/- 839; p < 0.001 ).A fall in LH level of > or = 50% from stimulation day 8 (S8) to S1 was observed in GnRH antagonist group. Risk of ovarian hyperstimulation syndrome (OHSS) was significantly decreased with GnRH antagonist (1.8% vs 10.7%; p = 0.01). The mean number of retrival oocytes (15.9 +/- 5.9 vs. 17.3 +/- 8.3; ns) and the mean number of mature oocytes (11.43 +/- 4.2 vs. 11.91 6.4; ns) were similar in the two groups, fertilization rate (73.3% vs 75.8%; NS), mean number of grade 1 and 2 embryos (6.3 +/- 2.7 vs. 6.9 +/- 3.9; NS), mean number of transferred embryos (1.9 +/- 0.7 vs. 1.8 +/- 0.7; NS), implantation rate (13.3% vs. 18.45%; ns) and clinical pregnancy rate per transfer (28.6% vs 31.1% ; NS) did not differ statistically in the two groups. Twin and triplet pregnancies rates were also similar in the two groups (7.1% vs. 9.3%; NS) and (3.5% vs. 3.1%; NS) respectively. Live birth rate (12.2% vs. 20.7%; p < 0.001) was significantly lower in GnRH antagonist group and miscarrage rate was significantly higher in this same group (42.8% vs. 18.7%; p < 0.001).
GnRH antagonist protocol is a short and simple protocol with a significant reduction in incidence of OHSS and amount of gonadotrophins. However, GnRH antagonist protocol provides a lower live birth rate and an increased risk of early pregnancy loss compared to the GnRH agonist long protocol. Further studies are necessary for more solid conclusions.
比较标准长效促性腺激素释放激素（GnRH）激动剂方案（曲普瑞林）和GnRH拮抗剂方案（西曲瑞克）在接受体外受精-胞浆内单精子注射（ICSI）周期控制性卵巢刺激（COS）的多囊卵巢综合征（PCOS）患者中的应用效果。
回顾性病例对照研究。将106例接受ICSI且采用长效GnRH激动剂方案（曲普瑞林）进行COS的PCOS患者，按照年龄和体重指数与同期106例接受ICSI且采用GnRH拮抗剂（西曲瑞克）进行COS的PCOS患者进行匹配。两组均使用重组促卵泡生成素（rFSH）进行卵巢刺激。所有使用GnRH拮抗剂进行卵巢刺激的患者均采用口服避孕药预处理。所有病例均因男性不育而行ICSI。评估的主要结局指标包括：周期取消率、抽吸卵泡数、卵母细胞成熟度、受精率、胚胎质量、妊娠率和着床率、临床流产率、多胎妊娠率和活产率。采用卡方检验和t检验比较正常排卵患者和PCOS患者之间的差异，显著性水平设定为p<0.05。
取消率方面无显著差异（2.8%对1.8%；无统计学意义）。GnRH拮抗剂组促性腺激素刺激时间（9.7±0.7天对11.2±1.9天；p<0.001）和促性腺激素用量（2209.0±548.3单位对1411.1±217.9单位；p<0.001）显著降低。激动剂组触发日的平均雌二醇水平显著更高（3347.85±99对2354.45±839；p<0.001）。GnRH拮抗剂组从刺激第8天（S8）到S1，促黄体生成素（LH）水平下降≥50%。GnRH拮抗剂组卵巢过度刺激综合征（OHSS）风险显著降低（1.8%对10.7%；p=0.01）。两组的平均取卵数（15.9±5.9对17.3±8.3；无统计学意义）和平均成熟卵母细胞数（11.43±4.2对11.91±6.4；无统计学意义）相似，受精率（73.3%对75.8%；无统计学意义）、1级和2级胚胎平均数量（6.3±2.7对6.9±3.9；无统计学意义）、平均移植胚胎数（1.9±0.7对1.8±0.7；无统计学意义）、着床率（13.3%对18.45%；无统计学意义）和每次移植的临床妊娠率（28.6%对31.1%；无统计学意义）在两组间无统计学差异。两组的双胎和三胎妊娠率也相似（分别为7.1%对9.3%；无统计学意义）和（3.5%对3.1%；无统计学意义）。GnRH拮抗剂组的活产率显著更低（12.2%对20.7%；p<0.001），且该组的流产率显著更高（42.8%对18.7%；p<0.001）。
GnRH拮抗剂方案是一种简短且简单的方案，OHSS发生率和促性腺激素用量显著降低。然而，与GnRH激动剂长效方案相比，GnRH拮抗剂方案的活产率更低，早期妊娠丢失风险增加。需要进一步研究得出更确凿的结论。
