Advanced Reproductive Age and Fertility
Advanced Reproductive Age and Fertility
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DOI：
10.1016/s1701-2163(16)35087-3
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发表时间：
2011-11-01
影响因子：
1.8
通讯作者：
Wong, Benjamin Chee-Man
中科院分区：
文献类型：
--
作者：
Liu, Kimberly;Case, Allison;Wong, Benjamin Chee-Man
目的：提高对自然生育力和辅助生殖技术(ART)中自然年龄相关的女性和男性生育力下降的认识，并为其提供管理建议，并回顾卵巢老化评估方面的研究。意见：本指南回顾了评估卵巢储备和利用ART对表现为不孕症的高龄女性进行生育治疗的选项。结果：测量的结果是卵巢储备测试的预测价值以及自然和辅助生育的妊娠率。证据：通过搜索PubMed或Medline，CINAHL和Cochrane图书馆，2010年6月发表的文献中使用适当的关键词(卵巢老化，卵巢储备，卵巢储备，高龄产妇、高龄父辈、ART)。结果仅限于系统评价、随机对照试验/对照临床试验和观察性研究。没有日期或语言限制。搜索结果定期更新，并纳入到2010年12月的指南中。价值：根据加拿大预防保健工作组报告中描述的标准对证据质量进行评级。根据该报告(表)中描述的方法对实践建议进行了排名。好处、危害和成本：初级和专科保健提供者和妇女将更好地了解卵巢老化和与年龄相关的自然生育率下降以及辅助生殖技术的选择。当性健康或避孕等其他生殖健康问题被作为基本保健的一部分来解决时，20多岁和30多岁的女性应该得到与年龄相关的不孕不育风险的咨询。育龄妇女应该意识到，自然生育力和辅助生殖技术的成功率(卵子捐赠除外)对于30多岁和40多岁的妇女来说要低得多。2.由于生育率下降，35岁以后怀孕的时间增加，35岁的妇女应在尝试怀孕6个月后进行不孕不育检查。(iii-B)3.卵巢储备测试可考虑用于35岁的妇女或年龄在35岁以上、有卵巢储备减少风险因素的妇女，如单卵巢、既往卵巢手术、对卵泡刺激素反应差、既往接受过化疗或放射治疗或原因不明的不孕症。(三-B)4.辅助生殖技术治疗前的卵巢储备测试可用于咨询，但对非妊娠的预测价值较差，只有在水平明显异常时才应用于排除妇女接受治疗。(II-2A)5.控制性超排卵的妊娠率在40岁的妇女中很低。40岁的女性如果在控制性超排卵的1至2个周期内没有受孕，应考虑试管婴儿。(II-2B)6.卵巢老化的唯一有效治疗方法是捐献卵子。卵巢储备减少的女性应该选择捐献卵子，因为与这种治疗相关的妊娠率明显高于控制性卵巢过度刺激或使用女性自己的卵子进行体外受精的妊娠率。(II-2B)7.应告知妇女，自然流产和染色体异常的风险随着年龄的增长而增加。一旦确定怀孕，就应该对妇女进行咨询并提供适当的产前筛查。(二(III-B)9.父亲年龄越大，自然流产的风险似乎越高，一些常染色体显性疾病、自闭症谱系障碍和精神分裂症的发生率也越高。40岁的男性和他们的伴侣在寻求怀孕时应该被告知这些潜在的风险，尽管风险仍然很小。(II-2C)
Objective: To improve awareness of the natural age-related decline in female and male fertility with respect to natural fertility and assisted reproductive technologies (ART) and provide recommendations for their management, and to review investigations in the assessment of ovarian aging.Options: This guideline reviews options for the assessment of ovarian reserve and fertility treatments using ART with women of advanced reproductive age presenting with infertility.Outcomes: The outcomes measured are the predictive value of ovarian reserve testing and pregnancy rates with natural and assisted fertility.Evidence: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in June 2010, using appropriate key words (ovarian aging, ovarian reserve, advanced maternal age, advanced paternal age, ART). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated into the guideline to December 2010.Values: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table).Benefits, harms, and costs: Primary and specialist health care providers and women will be better informed about ovarian aging and the age-related decline in natural fertility and about options for assisted reproductive technology.Recommendations1. Women in their 20s and 30s should be counselled about the age related risk of infertility when other reproductive health issues, such as sexual health or contraception, are addressed as part of their primary well-woman care. Reproductive-age women should be aware that natural fertility and assisted reproductive technology success (except with egg donation) is significantly lower for women in their late 30s and 40s. (II-2A)2. Because of the decline in fertility and the increased time to conception that occurs after the age of 35, women > 35 years of age should be referred for infertility work-up after 6 months of trying to conceive. (III-B)3. Ovarian reserve testing may be considered for women 35 years of age or for women < 35 years of age with risk factors for decreased ovarian reserve, such as a single ovary, previous ovarian surgery, poor response to follicle-stimulating hormone, previous exposure to chemotherapy or radiation, or unexplained infertility. (III-B)4. Ovarian reserve testing prior to assisted reproductive technology treatment may be used for counselling but has a poor predictive value for non-pregnancy and should be used to exclude women from treatment only if levels are significantly abnormal. (II-2A)5. Pregnancy rates for controlled ovarian hyperstimulation are low for women > 40 years of age. Women > 40 years should consider IVF if they do not conceive within 1 to 2 cycles of controlled ovarian hyperstimulation. (II-2B)6. The only effective treatment for ovarian aging is oocyte donation. A woman with decreased ovarian reserve should be offered oocyte donation as an option, as pregnancy rates associated with this treatment are significantly higher than those associated with controlled ovarian hyperstimulation or in vitro fertilization with a woman's own eggs. (II-2B)7. Women should be informed that the risk of spontaneous pregnancy loss and chromosomal abnormalities increases with age. Women should be counselled about and offered appropriate prenatal screening once pregnancy is established. (II-2A)8. Pre-conception counselling regarding the risks of pregnancy with advanced maternal age, promotion of optimal health and weight, and screening for concurrent medical conditions such as hypertension and diabetes should be considered for women > age 40. (III-B)9. Advanced paternal age appears to be associated with an increased risk of spontaneous abortion and increased frequency of some autosomal dominant conditions, autism spectrum disorders, and schizophrenia. Men > age 40 and their partners should be counselled about these potential risks when they are seeking pregnancy, although the risks remain small. (II-2C)