The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance
The management of anovulatory infertility in women with polycystic ovary syndrome: an analysis of the evidence to support the development of global WHO guidance
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DOI：
10.1093/humupd/dmw025
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发表时间：
2016-11-01
影响因子：
13.3
通讯作者：
Teede, Helena
中科院分区：
文献类型：
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作者：
Balen, Adam H.;Morley, Lara C.;Teede, Helena
在这里，我们描述了共识指南的方法，总结了我们向世界卫生组织（WHO）提供的基于证据的建议，供他们在制定全球指南时考虑，并对多囊卵巢综合征（PCOS）妇女无排卵性不孕的治疗进行了叙述性回顾。本文旨在为无排卵性多囊卵巢综合征的治疗提供依据。支持提供建议的证据涉及一个协作过程：(i)确定优先问题和关键结果，（ii）检索最新证据和现有指南，（iii）评估和综合证据，以及（iv）制定用于与广泛的全球利益攸关方达成共识的建议草案。对于每个建议草案，方法学家评估支持证据的质量，然后将其分为非常低，低，中等或高，以供协商一致时考虑。综合证据，我们对多囊卵巢综合征的定义提出了建议，包括高雄激素症、月经周期调节和卵巢评估。包括代谢特征和种族的影响。治疗包括生活方式的改变，减肥手术，药物治疗（包括克罗米芬柠檬酸（CC），芳香酶抑制剂，二甲双胍和促性腺激素），以及腹腔镜手术。体外受精（IVF）被认为是PCOS患者诱导排卵和妊娠的风险。大约80%患有无排卵性不孕症的女性患有多囊卵巢综合征。生活方式干预首先被推荐给肥胖妇女，主要是基于总体健康益处。当体重指数（BMI）为>= 35 kg/m(2)，生活方式治疗失败时，可以考虑进行减肥手术。仔细进行和监测的药物促排卵可以达到良好的累积妊娠率和多胎妊娠率可以减少遵守推荐方案。CC应作为促排卵的一线药物治疗，来曲唑也可作为一线药物治疗。单用二甲双胍提高活产率的效果有限。促性腺激素和腹腔镜手术可作为二线治疗。没有明确的证据表明针灸或草药混合物对女性多囊卵巢综合征的疗效。对于生活方式和促排卵治疗失败或有其他不孕因素的多囊卵巢综合征妇女，IVF可与更安全的促性腺激素释放激素（GnRH）拮抗剂方案一起使用。如果使用gnrh激动剂方案，二甲双胍作为辅助可能会降低卵巢过度刺激综合征的风险。应告知患者促排卵剂和体外受精对胎儿的潜在副作用，以及多胎妊娠的风险。还应讨论怀孕期间母亲和儿童的风险增加，包括肥胖对不良后果的加剧影响。本指南的生成和证据综合分析的进行方式被认为是全球适用于无排卵妇女PCOS诱导排卵的安全管理。
Here we describe the consensus guideline methodology, summarise the evidence-based recommendations we provided to the World Health Organisation (WHO) for their consideration in the development of global guidance and present a narrative review on the management of anovulatory infertility in women with polycystic ovary syndrome (PCOS).The aim of this paper was to present an evidence base for the management of anovulatory PCOS.The evidence to support providing recommendations involved a collaborative process for: (i) identification of priority questions and critical outcomes, (ii) retrieval of up-to-date evidence and exiting guidelines, (iii) assessment and synthesis of the evidence and (iv) the formulation of draft recommendations to be used for reaching consensus with a wide range of global stakeholders. For each draft recommendation, the methodologist evaluated the quality of the supporting evidence that was then graded as very low, low, moderate or high for consideration during consensus.Evidence was synthesized and we made recommendations across the definition of PCOS including hyperandrogenism, menstrual cycle regulation and ovarian assessment. Metabolic features and the impact of ethnicity were covered. Management includes lifestyle changes, bariatric surgery, pharmacotherapy (including clomiphene citrate (CC), aromatase inhibitors, metformin and gonadotropins), as well as laparoscopic surgery. In-vitro fertilization (IVF) was considered as were the risks of ovulation induction and of pregnancy in PCOS. Approximately 80% of women who suffer from anovulatory infertility have PCOS. Lifestyle intervention is recommended first in women who are obese largely on the basis of general health benefits. Bariatric surgery can be considered where the body mass index (BMI) is >= 35 kg/m(2) and lifestyle therapy has failed. Carefully conducted and monitored pharmacological ovulation induction can achieve good cumulative pregnancy rates and multiple pregnancy rates can be minimized with adherence to recommended protocols. CC should be first-line pharmacotherapy for ovulation induction and letrozole can also be used as first-line therapy. Metformin alone has limited benefits in improving live birth rates. Gonadotropins and laparoscopic surgery can be used as second-line treatment. There is no clear evidence for efficacy of acupuncture or herbal mixtures in women with PCOS. For women with PCOS who fail lifestyle and ovulation induction therapy or have additional infertility factors, IVF can be used with the safer gonadotropin releasing hormone (GnRH) antagonist protocol. If a GnRH-agonist protocol is used, metformin as an adjunct may reduce the risk of ovarian hyperstimulation syndrome. Patients should be informed of the potential side effects of ovulation induction agents and of IVF on the foetus, and of the risks of multiple pregnancy. Increased risks for the mother during pregnancy and for the child, including the exacerbating impact of obesity on adverse outcomes, should also be discussed.This guidance generation and evidence-synthesis analysis has been conducted in a manner to be considered for global applicability for the safe administration of ovulation induction for anovulatory women with PCOS.