Youssef Mohamed Afm, Van der Veen Fulco, Al-Inany Hesham G, Griesinger Georg, Mochtar Monique H, van Wely Madelon
Center for Reproductive Medicine, Department of Obstetrics & Gynaecology, Academic Medical Center, University of Amsterdam, H4-250- Meibergdreef, Amsterdam, Netherlands, 1105AZ.
Cochrane Database Syst Rev. 2010 Nov 10(11):CD008046. doi: 10.1002/14651858.CD008046.pub2.
Gonadotropin-releasing hormone (GnRH) antagonist protocols for pituitary down regulation in in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) allow the use of GnRH agonists for triggering final oocyte maturation. Currently, human chorionic gonadotropin (HCG) is still the standard medication for this purpose. The effectiveness of triggering with a GnRH agonist compared to HCG measured as pregnancy and ovarian hyperstimulation(OHSS) rates are unknown.
To compare the effectiveness of a GnRH agonist with HCG for triggering final oocyte maturation in IVF and ICSI patients undergoing controlled ovarian hyperstimulation in a GnRH antagonist protocol followed by embryo transfer.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE , EMBASE, the National Research Register, the Medical Research Council's Clinical Trials Register, and the NHS Centre for Reviews and Dissemination database. We also examined the reference lists of all known primary studies and review articles, citation lists of relevant publications and abstracts of major scientific meetings.
All randomised controlled studies (RCTs) reporting data comparing clinical outcomes for women undergoing IVF and ICSI cycles and using a GnRH agonist in comparison with HCG for final oocyte maturation triggering.
Two review authors independently assessed trial quality and extracted data.
We identified 11 RCTs (n = 1055). Eight studies assessed fresh autologous cycles and three studies assessed donor-recipient cycles. In fresh-autologous cycles, GnRH agonist was less effective than HCG in terms of the live birth rate per randomised woman (OR 0.44, 95% CI 0.29 to 0.68; 4 RCTs) and ongoing pregnancy rate per randomised woman (OR 0.45, 95% CI 0.31 to 0.65; 8 RCTs). For a group with a 30% live birth or ongoing pregnancy rate using HCG, the rate would be between 12% and 22% using an GnRH agonist. Moderate to severe ovarian hyperstimulation syndrome (OHSS) incidence per randomised woman was significantly lower in the GnRH agonist group compared to the HCG group (OR 0.10, 95% CI 0.01 to 0.82; 5 RCTs). For a group with a 3% OHSS rate using HCG the rate would be between 0% and 2.6% using GnRH agonist. In donor recipient cycles, there was no evidence of a statistical difference in the live birth rate per randomised woman (OR 0.92, 95% CI 0.53 to 1.61; 1 RCT).
AUTHORS' CONCLUSIONS: We do not recommend that GnRH agonists be routinely used as a final oocyte maturation trigger in fresh autologous cycles because of lowered live birth rates and ongoing pregnancy rates. An exception could be made for women with high risk of OHSS, after appropriate counselling.
在体外受精（IVF）和卵胞浆内单精子注射（ICSI）中，用于垂体降调节的促性腺激素释放激素（GnRH）拮抗剂方案允许使用GnRH激动剂来触发最终的卵母细胞成熟。目前，人绒毛膜促性腺激素（HCG）仍然是用于此目的的标准药物。与HCG相比，使用GnRH激动剂触发的有效性，以妊娠率和卵巢过度刺激（OHSS）率来衡量，尚不清楚。
比较GnRH激动剂与HCG在接受GnRH拮抗剂方案随后进行胚胎移植的IVF和ICSI患者中触发最终卵母细胞成熟的有效性。
我们检索了Cochrane对照试验中心注册库（CENTRAL）、MEDLINE、EMBASE、国家研究注册库、医学研究理事会临床试验注册库以及NHS综述与传播中心数据库。我们还查阅了所有已知的主要研究和综述文章的参考文献列表、相关出版物的引用列表以及主要科学会议的摘要。
所有随机对照研究（RCT），报告比较接受IVF和ICSI周期的女性的临床结局，并使用GnRH激动剂与HCG进行最终卵母细胞成熟触发比较的数据。
两位综述作者独立评估试验质量并提取数据。
我们识别出11项RCT（n = 1055）。8项研究评估了新鲜自体周期，3项研究评估了供体 - 受体周期。在新鲜自体周期中，就每个随机分组女性的活产率而言，GnRH激动剂比HCG效果差（比值比0.44，95%可信区间0.29至0.68；4项RCT），且每个随机分组女性的持续妊娠率也较低（比值比0.45，95%可信区间0.31至0.65；8项RCT）。对于使用HCG活产率或持续妊娠率为30%的一组，使用GnRH激动剂时该率将在12%至22%之间。与HCG组相比，GnRH激动剂组中每个随机分组女性的中重度卵巢过度刺激综合征（OHSS）发生率显著更低（比值比0.10，95%可信区间0.01至0.82；5项RCT）。对于使用HCG时OHSS率为3%的一组，使用GnRH激动剂时该率将在0%至2.6%之间。在供体 - 受体周期中，没有证据表明每个随机分组女性的活产率存在统计学差异（比值比0.92，95%可信区间0.53至1.61；1项RCT）。
我们不建议在新鲜自体周期中常规使用GnRH激动剂作为最终卵母细胞成熟触发剂，因为活产率和持续妊娠率会降低。对于OHSS高风险女性，可以在适当咨询后例外使用。
