Hamilton J A M, van der Steeg J W, Hamilton C J C M, de Bruin J P
Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands.
Hum Reprod Open. 2021 Aug 20;2021(4):hoab033. doi: 10.1093/hropen/hoab033. eCollection 2021.
Is pregnancy success rate after a concise infertility work-up the same as pregnancy success rate after the traditional extensive infertility work-up?
The ongoing pregnancy rate within a follow-up of 1 year after a concise infertility work-up is significantly lower than the pregnancy success rate after the traditional and extensive infertility work-up.
Based on cost-effectiveness studies, which have mainly focused on diagnosis, infertility work-up has become less comprehensive. Many centres have even adopted a one-stop approach to their infertility work-up.
We performed a historically controlled cohort study. In 2012 and 2013 all new infertile couples (n = 795) underwent an extensive infertility work-up (group A). In 2014 and 2015, all new infertile couples (n = 752) underwent a concise infertility work-up (group B). The follow-up period was 1 year for both groups. Complete follow-up was available for 99.0% of couples in group A and 97.5% in group B.
PARTICIPANTS/MATERIALS SETTING METHODS: The extensive infertility work-up consisted of history taking, a gynaecological ultrasound scan, semen analysis, ultrasonographic cycle monitoring, a timed postcoital test, a timed progesterone and chlamydia antibody titre. A hysterosalpingography (HSG) was advised routinely. The concise infertility work-up was mainly based on history taking, a gynaecological ultrasound scan and semen analysis. A HSG was only performed if tubal pathology was suspected or before the start of IUI. Laparoscopy and hormonal tests were only performed if indicated. Couples were treated according to the diagnosis with either expectant management (if the Hunault prognostic score was >30%), ovulation induction (in case of ovulation disorders), IUI in natural cycles (in case of cervical factor), IUI in stimulated cycles (if the Hunault prognostic score was <30%) or IVF/ICSI (in case of tubal factor, advanced female age, severe male factor and if other treatments remained unsuccessful). The primary outcomes were time to pregnancy and the ongoing pregnancy rates in both groups. The secondary outcomes were the number of investigations, the distribution of diagnoses made, the first treatment (started) after infertility work-up and the mode of conception.
The descriptive data, such as age, duration of infertility, type of infertility and lifestyle habits, in both groups were comparable. In group A, more than twice the number of infertility investigations were performed, compared to group B. An HSG was made less frequently in group B (33% versus 42%) and at a later stage. A Kaplan-Meier curve shows a shorter time to pregnancy in group A. Also, a significantly higher overall ongoing pregnancy rate within a follow-up of 1 year was found in group A (58.7% versus 46.8%, respectively, < 0.001). In group A, more couples conceived during the infertility work-up (14.7% versus 6.5%, respectively, < 0.05). The diagnosis cervical infertility could only be made in group A (9.3%). The diagnosis unexplained infertility differed between groups, at 23.5% in group A and 32.2% in group B ( < 0.001).
This was a historically controlled cohort study; introduction of bias cannot be ruled out. The follow-up rate was similar in the two groups and therefore could not explain the differences in pregnancy rate.
Re-introduction of an extensive infertility work-up should be considered as it may lead to higher ongoing pregnancy rates within a year. The therapeutic effects of HSG and timing of intercourse may improve the fertility chance. This finding should be verified in a randomized controlled trial.
STUDY FUNDING/COMPETING INTERESTS: No funding was obtained for this study. No conflicts of interest were declared.
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简明不孕症检查后的妊娠成功率与传统全面不孕症检查后的妊娠成功率是否相同？
简明不孕症检查后1年随访期内的持续妊娠率显著低于传统全面不孕症检查后的妊娠成功率。
基于主要关注诊断的成本效益研究，不孕症检查已变得不那么全面。许多中心甚至采用了一站式不孕症检查方法。
我们进行了一项历史对照队列研究。2012年和2013年，所有新的不孕夫妇（n = 795）接受了全面的不孕症检查（A组）。2014年和2015年，所有新的不孕夫妇（n = 752）接受了简明的不孕症检查（B组）。两组的随访期均为1年。A组99.0%的夫妇和B组97.5%的夫妇有完整的随访记录。
参与者/材料设置方法：全面的不孕症检查包括病史采集、妇科超声扫描、精液分析、超声周期监测、定时性交后试验、定时孕酮和衣原体抗体滴度检测。常规建议进行子宫输卵管造影（HSG）。简明的不孕症检查主要基于病史采集、妇科超声扫描和精液分析。仅在怀疑输卵管病变或开始宫内人工授精（IUI）之前进行HSG。仅在有指征时进行腹腔镜检查和激素检测。根据诊断对夫妇进行治疗，采用期待管理（如果Hunault预后评分>30%）、促排卵（排卵障碍时）、自然周期IUI（宫颈因素时）、刺激周期IUI（如果Hunault预后评分<30%）或体外受精/卵胞浆内单精子注射（IVF/ICSI）（输卵管因素、女性高龄、严重男性因素以及其他治疗均未成功时）。主要结局是两组的妊娠时间和持续妊娠率。次要结局是检查次数、所做诊断的分布、不孕症检查后的首次治疗（开始）以及受孕方式。
两组的描述性数据，如年龄、不孕持续时间、不孕类型和生活习惯，具有可比性。与B组相比，A组进行的不孕症检查次数多出两倍多。B组HSG的检查频率较低（33%对42%）且时间较晚。Kaplan-Meier曲线显示A组的妊娠时间较短。此外，在1年的随访期内，A组的总体持续妊娠率显著更高（分别为58.7%对46.8%，P<0.001）。在A组，更多夫妇在不孕症检查期间受孕（分别为14.7%对6.5%，P<0.05）。仅在A组能够做出宫颈不孕的诊断（9.3%）。两组间不明原因不孕的诊断有所不同，A组为23.5%，B组为32.2%（P<0.001）。
这是一项历史对照队列研究；不能排除引入偏差。两组的随访率相似，因此无法解释妊娠率的差异。
应考虑重新采用全面的不孕症检查，因为这可能会使1年内的持续妊娠率更高。HSG的治疗效果和性交时间可能会提高受孕几率。这一发现应在随机对照试验中得到验证。
研究资金/利益冲突：本研究未获得资金。未申报利益冲突。
无。
