ABSTRACT
OBJECTIVE: To update the 2010 CNGOF clinical practice guidelines for the first-line management of infertile couples. MATERIALS AND METHODS: Five major themes (first-line assessment of the infertile woman, first-line assessment of the infertile man, prevention of exposure to environmental factors, initial management using ovulation induction regimens, first-line reproductive surgery) were identified, enabling 28 questions to be formulated using the Patients, Intervention, Comparison, Outcome (PICO) format. Each question was addressed by a working group that had carried out a systematic review of the literature since 2010, and followed the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) methodology to assess the quality of the scientific data on which the recommendations were based. These recommendations were then validated during a national review by 40 national experts. RESULTS: The fertility work-up is recommended to be prescribed according to the woman's age: after one year of infertility before the age of 35 and after 6months after the age of 35. A couple's initial infertility work-up includes a single 3D ultrasound scan with antral follicle count, assessment of tubal permeability by hysterography or HyFOSy, anti-Mullerian hormone assay prior to assisted reproduction, and vaginal swabbing for vaginosis. If the 3D ultrasound is normal, hysterosonography and diagnostic hysteroscopy are not recommended as first-line procedures. Chlamydia trachomatis serology does not have the necessary performance to predict tubal patency. Post-coital testing is no longer recommended. In men, spermogram, spermocytogram and spermoculture are recommended as first-line tests. If the spermogram is normal, it is not recommended to check the spermogram. If the spermogram is abnormal, an examination by an andrologist, an ultrasound scan of the testicles and hormonal test are recommended. Based on the data in the literature, we are unable to recommend a BMI threshold for women that would contraindicate medical management of infertility. A well-balanced Mediterranean-style diet, physical activity and the cessation of smoking and cannabis are recommended for infertile couples. For fertility concern, it is recommended to limit alcohol consumption to less than 5 glasses a week. If the infertility work-up reveals no abnormalities, ovulation induction is not recommended for normo-ovulatory women. If intrauterine insemination is indicated based on an abnormal infertility work-up, gonadotropin stimulation and ovulation monitoring are recommended to avoid multiple pregnancies. If the infertility work-up reveals no abnormality, laparoscopy is probably recommended before the age of 30 to increase natural pregnancy rates. In the case of hydrosalpinx, surgical management is recommended prior to ART, with either salpingotomy or salpingectomy depending on the tubal score. It is recommended to operate on polyps>10mm, myomas 0, 1, 2 and synechiae prior to ART. The data in the literature do not allow us to systematically recommend asymptomatic uterine septa and isthmoceles as first-line surgery. CONCLUSION: Based on strong agreement between experts, we have been able to formulate updated recommendations in 28 areas concerning the initial management of infertile couples.
Subject(s)
Infertility, Female , Infertility, Male , Humans , Female , Infertility, Female/therapy , Male , France , Infertility, Male/therapy , Infertility, Male/etiology , Gynecology/methods , Obstetrics/methods , Ovulation Induction/methods , Reproductive Techniques, Assisted , Adult , Societies, Medical , Pregnancy , Obstetricians , GynecologistsABSTRACT
STUDY QUESTION: Is serum anti-Müllerian hormone (AMH) level predictive of cumulative live birth (CLB) rate after ART or in women trying to conceive naturally? SUMMARY ANSWER: Serum AMH level is linked to CLB after IVF/ICSI but data are lacking after IUI or in women trying to conceive without ART. WHAT IS KNOWN ALREADY: Serum AMH level is a marker of ovarian reserve and a good predictor of ovarian response after controlled ovarian stimulation. It is unclear whether AMH measurement can predict CLB in spontaneous or assisted conception. STUDY DESIGN, SIZE, DURATION: A systematic review and meta-analysis was undertaken to assess whether serum AMH level may predict chances of CLB in infertile women undergoing IVF/ICSI or IUI and/or chances of live birth in women having conceived naturally. PARTICIPANTS/MATERIALS, SETTING, METHODS: A systematic review and meta-analysis was performed using the following keywords: 'AMH', 'anti-mullerian hormone', 'live-birth', 'cumulative live birth'. Searches were conducted from January 2004 to April 2021 on PubMed and Embase. Two independent reviewers carried out study selection, quality, and risk of bias assessment as well as data extraction. Odds ratios were estimated using a random-effect model. Pre-specified sensitivity analyses and subgroup analyses were performed. The primary outcome was CLB. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 32 studies were included in the meta-analysis. Overall, 27 articles were included in the meta-analysis of the relation between AMH and CLB or AMH and LB after IVF/ICSI. A non-linear positive relation was found in both cases. A polynomial fraction was the best model to describe it but no discriminant AMH threshold was shown, especially no serum AMH level threshold below which live birth could not be achieved after IVF/ICSI. After IVF-ICSI, only four studies reported CLB rate according to AMH level. No statistically significant differences in mean serum AMH levels were shown between patients with and without CLB, but with a high heterogeneity. After exclusion of two studies with high risks of bias, there was no more heterogeneity [I2 = 0%] and the mean AMH level was statistically significantly higher in women with CLB. There were not enough articles/data to assess the ability of AMH to predict CLB rate or find an AMH threshold after IUI or in women without history of infertility trying to conceive without ART. LIMITATIONS, REASONS FOR CAUTION: The systematic review and meta-analysis had some limitations owing to the limits and bias of the studies included. In the present meta-analysis, heterogeneity may have been caused by different baseline characteristics in study participants, different stimulating protocols for ART, different serum AMH level thresholds used and the use of various assays for serum AMH. This could explain, in part, the absence of a discriminating AMH threshold found in this analysis. WIDER IMPLICATIONS OF THE FINDINGS: Serum AMH level is linked to CLB rate after IVF/ICSI but no discriminating threshold can be established, therefore low serum AMH level should not be used as the sole criterion for rejecting IVF treatment, especially in young patients. Data are lacking concerning its predictive value after IUI or in women trying to conceive without ART. Our findings may be helpful to counsel candidate couples to IVF-ICSI. STUDY FUNDING/COMPETING INTERESTS: No external funding was obtained for this study. There are no conflicts of interest. REGISTRATION NUMBER: PROSPERO CRD42021269332.
Subject(s)
Infertility, Female , Pregnancy , Humans , Female , Infertility, Female/therapy , Pregnancy Rate , Anti-Mullerian Hormone , Live Birth , Fertilization in Vitro/methods , Birth Rate , Retrospective StudiesABSTRACT
BACKGROUND: Non-obstructive azoospermia (NOA) with history of cryptorchidism and idiopathic NOA are the most common forms of NOA without genetic aetiology. Of all patients with one of these two types of NOA, only a few will have a positive TEsticular Sperm Extraction (TESE). Of those with positive extraction followed by sperm freezing, not all will have a child after TESE-ICSI. What are the ways and probabilities of taking home a baby for patients with NOA and a history of cryptorchidism compared with patients with idiopathic NOA? RESULTS: Patients with idiopathic NOA or NOA and a history of cryptorchidism who underwent their first TESE were included. The patients were divided into two groups: Group 1 was composed of 125 patients with idiopathic NOA and Group 2 of 55 patients with NOA and a history of surgically treated cryptorchidism. Our results showed that more than half of the NOA patients succeeded in becoming parents. The main way to fulfil their plans for parenthood is to use sperm or embryo donation (72%) for men with idiopathic NOA, whereas the majority of men with NOA and a history of cryptorchidism had a child after TESE-ICSI (58.8%). CONCLUSIONS: In our centre, before considering TESE for a patient with NOA, we explain systematically TESE-ICSI alternatives (sperm donation, embryo donation or adoption). As a result, the couple can consider each solution to become parents.
RESUME: CONTEXTE: L'azoospermie non obstructive (ANO) avec un antécédent de cryptorchidie et l'ANO idiopathique sont les causes les plus fréquentes d'ANO sans étiologie génétique. Parmi les patients présentant un de ces 2 types d'ANO, seuls quelques-uns auront une extraction positive de spermatozoïdes testiculaires (TESE). Parmi les patients ayant une extraction positive suivie d'une congélation de spermatozoïdes, tous n'obtiendront pas de naissance après TESE-ICSI. Quels sont les moyens et les probabilités de « ramener un enfant à la maison ¼ pour les patients avec une ANO associée à un antécédent de cryptorchidie en comparaison à ceux présentant une ANO idiopathique ? RéSULTATS: De tels patients ont été inclus dans notre étude et divisés en deux groupes : Groupe 1 composé de 125 patients avec une ANO idiopathique et Groupe 2 de 55 patients avec une ANO associée à un antécédent de cryptorchidie traitée chirurgicalement. Nos résultats ont montré que plus de la moitié des patients atteints d'ANO ont réussi à devenir parents. Le principal moyen pour réaliser leur projet parental était le recours au don de sperme ou l'accueil d'embryons (72%) pour les hommes avec ANO idiopathique, alors que la majorité des hommes avec ANO et antécédent de cryptorchidie (58.8%) achevaient leur projet parental par TESE-ICSI. CONCLUSIONS: Dans notre centre, avant d'envisager une biopsie testiculaire chez un patient présentant une ANO, les alternatives (don de sperme, accueil d'embryon ou adoption) à la TESE-ICSI sont explicitées systématiquement. En conséquence, le couple peut envisager chaque solution pour devenir parent.
