Diagnosis and Management of Infertility: A Review.
Diagnosis and Management of Infertility: A Review.
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不孕不育的诊断和治疗：综述。
DOI：
10.1001/jama.2021.4788
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发表时间：
2021-07-06
影响因子：
120.7
通讯作者：
Kallen, Amanda N.
中科院分区：
文献类型：
--
作者：
Carson, Sandra Ann;Kallen, Amanda N.
在美国，每年约有12.7%的育龄妇女寻求不孕症治疗。本文综述了目前有关不孕症的诊断和治疗的证据。不孕症被定义为在12个月的定期无保护性交后未能怀孕。大约85%的不孕夫妇有一个可识别的原因。不孕症最常见的原因是排卵功能障碍、男性因素不孕和输卵管疾病。其余15%的不孕夫妇患有“不明原因的不孕症”。生活方式和环境因素，如吸烟和肥胖，会对生育能力产生不利影响。排卵障碍约占不孕症诊断的25%; 70%的无排卵妇女患有多囊卵巢综合征。不孕症也可能是与不孕症相关的潜在慢性疾病的标志。克罗米芬、芳香酶抑制剂如来曲唑和促性腺激素用于体外受精（IVF）周期中诱导排卵或刺激卵巢。促性腺激素的不良反应包括多胎妊娠（高达36%的周期，取决于特定的治疗）和卵巢过度刺激综合征（1%-5%的周期），包括腹水，电解质失衡和高凝状态。对于出现无排卵的个体，诱导排卵和定时性交通常是适当的初始治疗选择。对于不明原因的不孕症，子宫内膜异位症或轻度男性因素不孕症的夫妇，可以进行最初的3至4个周期的卵巢刺激;如果这些方法不会导致怀孕，则应考虑IVF。由于女性生育力随着年龄的增长而下降，这一因素应该指导决策。立即IVF可以被认为是38至40岁以上女性的一线治疗策略。IVF也适用于严重的男性因素不育或未经治疗的双侧输卵管因素。15至49岁的妇女中约有八分之一接受不孕症服务。虽然成功率因年龄和诊断而异，但准确的诊断和有效的治疗沿着共同的决策可以促进许多不孕症治疗夫妇实现生育目标。
In the US, approximately 12.7% of reproductive age women seek treatment for infertility each year. This review summarizes current evidence regarding diagnosis and treatment of infertility. Infertility is defined as the failure to achieve pregnancy after 12 months of regular unprotected sexual intercourse. Approximately 85% of infertile couples have an identifiable cause. The most common causes of infertility are ovulatory dysfunction, male factor infertility, and tubal disease. The remaining 15% of infertile couples have “unexplained infertility.” Lifestyle and environmental factors, such as smoking and obesity, can adversely affect fertility. Ovulatory disorders account for approximately 25% of infertility diagnoses; 70% of women with anovulation have polycystic ovary syndrome. Infertility can also be a marker of an underlying chronic disease associated with infertility. Clomiphene citrate, aromatase inhibitors such as letrozole, and gonadotropins are used to induce ovulation or for ovarian stimulation during in vitro fertilization (IVF) cycles. Adverse effects of gonadotropins include multiple pregnancy (up to 36% of cycles, depending on specific therapy) and ovarian hyperstimulation syndrome (1%–5% of cycles), consisting of ascites, electrolyte imbalance, and hypercoagulability. For individuals presenting with anovulation, ovulation induction with timed intercourse is often the appropriate initial treatment choice. For couples with unexplained infertility, endometriosis, or mild male factor infertility, an initial 3 to 4 cycles of ovarian stimulation may be pursued; IVF should be considered if these approaches do not result in pregnancy. Because female fecundity declines with age, this factor should guide decision-making. Immediate IVF may be considered as a first-line treatment strategy in women older than 38 to 40 years. IVF is also indicated in cases of severe male factor infertility or untreated bilateral tubal factor. Approximately 1 in 8 women aged 15 to 49 years receive infertility services. Although success rates vary by age and diagnosis, accurate diagnosis and effective therapy along with shared decision-making can facilitate achievement of fertility goals in many couples treated for infertility.
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