原因不明性不孕的治疗证据

Clinical Evidence of Treatment for Unexplained Infertility

目的对原因不明性不孕治疗的相关临床研究证据进行评价。方法运用循证医学基本原理和方法检索ACP Journal Club(1991至2007年)、Clinical Evidence(1995至2007年)、Cochrane图书馆(2007年)、Pubmed(1951至2007年)和中国生物医学文献数据库、中国期刊全文数据库(CNKI)(1979至2007年),收集与原因不明性不孕治疗相关的临床证据。结果期待疗法、克罗米酚(clomiphene citrate,CC)或促性腺激素(gonadotropin,Gn)促排卵联合或不联合宫腔内人工授精、配子或合子输卵管内移植和体外授精与胚胎移植,是目前临床治疗原因不明性不孕的常用方法,有一定疗效。结论在彻底完成不孕原因筛查的前提下,对年轻和不孕年限短的患者,可尝试期待治疗。进一步的治疗可采用克罗米酚促排卵结合宫腔内人工授精(intra-uterine insemination,I UI),促性腺激素联合宫腔内人工授精及体外授精与胚胎移植(in vitrofertilization and embryo transfer,IVF-ET)。对原因不明性不孕的治疗,目前证据仍支持长期以来确定的从低技术到高技术的临床治疗策略。不论促性腺激素联合宫腔内人工授精,还是体外授精与胚胎移植等治疗原因不明性不孕的先进措施,效果并非很好,费用却很高。其中,体外授精与胚胎移植的费用最高。由于迄今尚缺乏对原因不明性不孕的精确界定,同时缺少足够的高质量研究,应谨慎对待目前的结果。

Objective To evaluate the clinical evidence of treatment for unexplained infertility. Methods This study searched ACP Journal Club（ from 1991 to 2007）, Clinical Evidence（from 1995 to 2007）, Cochrane Library （2007）, Pubmed （from 1951 to 2007） and Chinese Biomedicine Literature Data-base, Chinese National Knowledge Infrastructure（CNKI,from 1979 to 2007）, and collected the evidence of treatments for unexplained infertility by the method of evidence-based medicine. Results There are many methods to treat the unexplained infertility such as expectant management, ovarian stimulation with clomiphene citrate or gonadotropin, intra-uterine insemination with or without ovarian stimulation, gamete intrafallopin transfer, zygote intrafallopian transfer, and in vitro fertilization and embryo transfer. And they may have different effects. Conclusion Before the expectant management for those who are young and whose duration of infertility are short, the diagnostic tests should be completed thoroughly. When expectant management fails, further treatments include：ovarian stimulation with clomiphene citrate or gonadotropin with intra-uterine insemination, and in vitro fertilization and embryo transfer. The current best evidence continues to support the long-established clinical strategy based on a progression from low-tech to high-tech treatment for unexplained infertility. The most relevant evidence indicates, however, that the effects of advanced treatment with either gonadotropin with intra-uterine insemination or in vitro fertilization and embryo transfer are not large, while the costs are considerable, and of course, highest for in vitro fertilization and embryo transfer. Because of the lack of clear definition of unexplained infertility, and high qualified studies, the evidence of treatment is not enough for pooling. And doctors need to be cautious to the results.