GnRH antagonists are safer than agonists: an update of a Cochrane review
Notice bibliographique
Résumé
GnRH agonists or antagonists can be used to prevent LH surges during ovarian stimulation for assisted reproduction. GnRH agonists down-regulate GnRH pituitary receptors. GnRH antagonists directly and rapidly inhibit gonadotrophin release. In a 2006 systematic review involving 29 trials, the average clinical pregnancy rate was 4.7% lower with GnRH antagonist treatment and the incidence of ovarian hyperstimulation syndrome (OHSS) was 2% lower compared with GnRH agonist treatment (Al-Inany et al., 2006). The current update includes 45 trials which addressed live birth or ongoing pregnancy rate (OPR) in GnRH antagonist and GnRH agonist protocols among women undergoing assisted reproduction treatment (Youssef et al., 2011). The authors searched electronic databases including MEDLINE, EMBASE and the Cochrane Library, proceedings of major reproductive medicine conferences and reference lists of retrieved articles, until April 2010. Eligible reports were randomized trials comparing GnRH agonist and GnRH antagonist protocols in women undergoing IVF or ICSI cycles. The primary outcome was live birth. Secondary outcomes included OPR and OHSS rates. The meta-analysis calculated summary average rates, rate differences and rate ratios in the individual trials using the inverse variance procedure, or in case of heterogeneity, random effects models (Deeks et al., 2001). Forty-five randomized controlled trials (RCTs) including 7511 participants were eligible for the meta-analyses. Thirty-four trials used computer generated randomization and sealed envelopes, while only six trials involved blinding. In nine trials involving 1515 women, the average live birth rate with GnRH agonist treatment was 31.5% (95% CI 24.3, 39.7). The live birth rate with GnRH antagonist treatment averaged 1.5% lower (95% CI −2.9, 5.9). In 28 RCTs involving 5014 women, the average OPR with GnRH agonist treatment was 29.8% (95% CI 25.4, 34.6). The OPR with GnRH antagonist treatment averaged 2.0% lower (95% CI −0.4, 4.5). The 95% CIs for the risk difference for both live birth rates and OPRs included zero and neither was significant. The summary rate ratios (relative risks) were as follows: live birth 0.89 (95% CI 0.76, 1.04, P = 0.14); OPR 0.91 (95% CI 0.83, 0.99, P = 0.03). In 29 RCTs involving 5417 women, the average OHSS rate in the GnRH agonist group was 6.4% (95% CI 4.3, 9.2), ranging from 0.8 to 38.5%. The OHSS rate in the GnRH antagonist group averaged 2.7% lower (95% CI 0.9, 4.5, P = 0.003). The relative likelihood of OHSS with GnRH antagonist treatment was 50% of that with GnRH agonist treatment (95% CI 37–66). In eight trials involving 783 women with PCOS, the OHSS rate was 10% lower (95% CI 7, 14) with GnRH antagonist (Fig. 1). In addition, with GnRH antagonist treatment the chance of cancellation or coasting due to high risk to develop OHSS was only 53% of that with GnRH agonist treatment (95% CI 36, 78). Women with polycystic ovarian syndrome. Overall Mantel–Haenszel risk difference: −0.10 (95% CI −0.07, −0.14, P-value of <0.001). Heterogeneity χ2 = 39.0, degrees of freedom = 7, P < 0.001, I2 = 82%. In this update of a Cochrane review, OHSS rate in women receiving antagonist is significantly lower compared with the agonist protocols. It may be time to consider the GnRH antagonist protocol for patients at high risk of developing OHSS.
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Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,009 | 0,031 |
| Méta-épidémiologie (sens strict) | 0,002 | 0,001 |
| Méta-épidémiologie (sens large) | 0,008 | 0,005 |
| Bibliométrie | 0,012 | 0,011 |
| Études des sciences et des technologies | 0,000 | 0,001 |
| Communication savante | 0,003 | 0,004 |
| Science ouverte | 0,002 | 0,002 |
| Intégrité de la recherche | 0,003 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,005 | 0,001 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».