- Meta. : (rfsh); (ufsh); (IVF); : R711.6 : A : X(2015) : hmg( FSH LH) [ufsh, (ufsh-p) (ufsh-hp)] (rfsh) [1] 80, rfsh, 90, :

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1 35 2 Vol.35 No Feb Reproduction & Contraception doi: /j.issn X randc_journal@163.com (FSH) - Meta FSH ( ) : (IVF) (ICSI) (rfsh) (ufsh) (COS) : PubMed EMBASE Cochrane CNKI rfsh rfsh ufsh IVF ICSI RevMan 5.2 IVF ICSI FSH (OHSS) Meta : rfsh ufsh FSH ; rfsh ufsh : rfsh ufsh COS : (rfsh); (ufsh); (IVF); (ICSI); ; Meta : R711.6 : A : X(2015) : hmg( FSH LH) [ufsh (ufsh-p) (ufsh-hp)] (rfsh) [1] 80 rfsh 90 : rfsh FSH FSH : ; Tel: ; Fax: ; yehongmed@163.com [2] ufsh rfsh FSH Meta rfsh ufsh [3] FSH FSH ; FSH / [4] Meta rfsh(rfshα rfshβ) ufsh (ufsh-p ufsh-hp) (IVF) (ICSI) FSH (OHSS) 99

2 1 1.1 : PubMed EMBASE Cochrane (CNKI) rfsh FSH (recombinant) (urinary) (gonadotrophin) (purify/purified) PubMed (FSH or Follicle Stimulating Hormone) and (recombinant and Urinary) or (rfsh* and ufsh*) and gonadotrophin : rfsh ufsh IVF (RCT); : GnRH ; : FSH ; : OHSS FSH ; ; Cochrane RCT : RCT A B C 3 A : ; B : ; C : ( ) ( / FSH OHSS ) 3 ; FSH 1.5 I 2 P<0.05 (I 2 50%) OHSS (odds ratio OR) ( ) (mean difference MD) ; MD OR 95% (confidence interval CI) P<0.05 RevMan5.2 Meta ( Mantel-Haenszel ) ( 1) 2 : ufsh-p ufsh-hp Corcoran A B ( 2A 2B) 2.3 Meta [ ] 10 I 2 =76% P<

3 Identification (n=266) Records identified through database searching (n=0) Additional records identified through other sources Screening (n=213) Records excluded after initial screening of titles and abstracts Eligibility Records screened (n=47) (n=26) Full-text articles excluded with reasons (n=21) Included Studies included in quantitative synthesis (meta-analysis) 1 Figure 1 Flow chart of literature search 1 Table 1 Characteristics of included studies ( ) No. of cycles (n) Reference No. of cases age (year) Total rfsh ufsh Protocol Comparison [3] IVF <4 prior OR age 18~ GnRH-a long rfsh vs ufsh [5] 731 IVF <4 prior OR age 21~37 NR NR NR GnRH-a long rfsh vs ufsh/-hp [6] 280 IVF/ICSI no prior OR age 18~37 NR NR NR GnRH-a long rfsh vs ufsh/-hp [7] 781 IVF/ICSI <4 prior OR age 23~ GnRH-a long rfsh vs ufsh/-hp [8] 629 IVF/ICSI prior OR NR age 18~39 NR NR NR GnRH-a long rfsh vs ufsh/-hp [9] 100 IVF 3 prior OR age 18~37 NR NR NR GnRH-a long rfsh vs ufsh/-hp [10] 152 IVF <3 prior OR age 18~ GnRH-a short rfshα vs ufsh/-hp [11] 235 IVF <4 prior OR age 18~ GnRH-a long rfshα vs ufsh/-hp [12] 241 IVF <4 prior OR age 25~ GnRH-a short rfshβ vs ufsh/-hp [13] 120 IVF prior OR NR age 18~ GnRH-a rfshβ vs ufsh/-hp [14] 120 ICSI GnRH-a long rfshα vs ufsh HP [14] 168 IVF no prior OR age 18~ GnRH-a long rfshα vs ufsh HP [15] 278 IVF <4 prior OR age 18~ GnRH-a long rfshα vs ufsh/-hp [16] 169 IVF <3 prior OR age 18~ GnRH-a long rfshβ vs ufsh/-hp [17] 88 IVF prior OR NR age 18~ GnRH-a short rfshα rfshβ vs ufsh/-hp [18] 257 IVF prior OR NR age GnRH-a long rfshα vs ufsh/-hp [19] 496 IVF/ICSI <3 prior OR age 18~ GnRH-a long rfshα vs ufsh/-hp [20] 267 IVF/ICSI no prior OR age 18~ GnRH-a long rfshα vs ufsh/-hp [21] 99 IVF <4 prior OR age 18~ GnRH-a long rfshβ vs ufsh [22] 131 IVF prior OR NR age NR FSH individual rfshβ vs ufsh [23] 127 IVF <4 prior OR age 18~ GnRH-a long rfsh vs ufsh prior OR: prior oocyte retrieval NR: not reported MD %CI=0.79~2.02(Z=4.46 P< 0.001) 2 : ufsh-p ufsh-hp MD 1.81(95%CI=1.11~2.51) 1.31 (95%CI=0.19~2.43) 3 rfsh ufsh 101

4 2 (A) (B) Figure 2 Funnel plot of birth rate of each cycle (A) and clinical pregnancy (B) 3 rfsh ufsh Figure 3 Comparison of oocytes retrieved numbers between rfsh and ufsh rfsh FSH 8 [ ] FSH 8 P<0.001 MD %CI= (Z=2.71 P=0.007) 2 : rfsh ufsh-p rfsh ufsh-hp MD %CI= ~ %CI= ~ FSH rfsh ufsh-p rfsh FSH [ ] 16 I 2 =8.29 P=0.73 OR %CI=0.86~1.08(Z= 0.66 P=0.51) 2 : rfsh ufsh-p rfsh ufsh-hp OR 1.22(95%CI= 0.92~1.60) 1.02(95%CI=0.85~1.22) 5 102

5 4 rfsh ufsh FSH Figure 4 Comparison of FSH dosage between rfsh and ufsh 5 rfsh ufsh Figure 5 Comparison of birth rate between rfsh and ufsh 103

6 6 rfsh ufsh Figure 6 Comparison of clinical pregnancy rate between rfsh and ufsh rfsh ufsh-p [48-23] 16 (I 2 =18.53 P=0.73) OR %CI=0.83~1.04(Z=1.35 P= 0.18) rfsh ufsh-p rfsh ufsh-hp OR 1.25(95%CI=0.76~2.06) 1.02 (95%CI=0.83~1.04) 6 rfsh ufsh-p [ ] 5 I 2 =7.63 P=0.47 OR %CI=0.87~1.17(Z=0.11 P=0.90) rfsh ufsh-p rfsh ufsh- HP OR 1.24(95%CI=0.94~1.63) 0.98(95%CI=0.71~1.36) 7 rfsh ufsh-p OHSS 10 OHSS [ ] 10 I 2 =13.83 P=0.61 OR %CI=0.91~1.79(Z= 1.39 P=0.17) rfsh ufsh-p rfsh ufsh- HP OR 1.24(95%CI=0.94~1.63) 0.98(95%CI=0.71~1.36) 8 OHSS rfsh ufsh-p 104

7 7 rfsh ufsh Figure 7 Comparison of ongoing pregnancy rate between rfsh and ufsh 8 rfsh ufsh Figure 8 Comparison of OHSS between rfsh and ufsh 105

8 3 rfsh ufsh IVF/ICSI Meta FSH 2 rfsh OHSS rfsh ufsh FSH DNA rfsh ufsh rfsh IVF ( FSH ) [424] rfsh [25] IVF [26] Meta rfsh ufsh 40 IVF [27] : 10% 4% rfsh rfsh ufsh ( 25%~30%) [29] Meta rfsh FSH ufsh rfsh ; Meta rfsh rfsh [28] rfsh rfsh Meta rfsh ufsh Meta [1] Zwart-van Rijkom JE Broekmans FJ Leufkens HG. From HMG through purified urinary FSH preparations to recombinant FSH: a substitution study. Hum Reprod (4): [2] Lispi M Bassett R Crisci C et al. Comparative assessment of the consistency and quality of a highly purified FSH extracted from human urine (urofollitropin) and a recombinant human FSH (follitropin α). Reprod Biomed Online (2): [3] Out HJ Mannaerts BM Driessen SG et al. A prospective randomized assessor-blind multicentre study comparing recombinant and urinary follicle stimulating hormone (Puregon versus Metrodin) in in-vitro fertilization. Hum Reprod (10): [4] Lenton E Soltan A Hewitt J et al. Induction of ovulation in women undergoing assisted reproductive techniques: recombinant human FSH (follitropin alpha) versus highly purified urinary FSH (urofollitropin HP). Hum Reprod (5): [5] Andersen AN Devroey P Arce JC. Clinical outcome following stimulation with highly purified hmg or recombinant FSH in patients undergoing IVF: a randomized assessor-blind controlled trial. Hum Reprod (12): [6] Bosch E Vidal C Labarta E et al. Highly purified hmg versus recombinant FSH in ovarian hyperstimulation with GnRH antagonists a randomized study. Hum Reprod (10): [7] Diedrich K Devroey P Engels S et al. Efficacy and safety of highly purified menotropin versus recombinant follicle-stimulating hormone in in vitro fertilization/intracytoplasmic sperm injection cycles: a randomized comparative trial. Fertil Steril (3): [8] Dickey RP Thornton M Nichols J et al. Comparison of the efficacy and safety of a highly purified human follicle-stimu- 106

9 lating hormone (Bravelle) and recombinant follitropin-β for in vitro fertilization: a prospective randomized study. Fertil Steril (4): [9] Nardo LG Bellanca SA Burrello N et al. Concentrations of insulin-like growth factor (IGF)-I and IGF binding protein-3 in the follicular fluid of women undergoing ovarian hyperstimulation with different gonadotropin preparations. Gynecol Endocrinol (6): [10] Baker VL Fujimoto VY Kettel LM et al. Clinical efficacy of highly purified urinary FSH versus recombinant FSH in volunteers undergoing controlled ovarian stimulation for in vitro fertilization: a randomized multicenter investigator-blind trial. Fertil Steril (4): [11] Bergh C Howles C Borg K et al. Recombinant human follicle stimulating hormone (r-hfsh; Gonal-F) versus highly purified urinary FSH (Metrodin HP): results of a randomized comparative study in women undergoing assisted reproductive techniques. Hum Reprod (10): [12] Cheon KW Byun HK Yang KM et al. Efficacy of recombinant human follicle-stimulating hormone in improving oocyte quality in assisted reproductive techniques. J Reprod Med (9): [13] Dickey RP Nichols JE Steinkampf MP et al. Highly purified human-derived follicle-stimulating hormone (Bravelle) has equivalent efficacy to follitropin-beta (Follistim) in infertile women undergoing in vitro fertilization. Reprod Biol Endocrinol (1):63. [14] Franco J Baruffi R Coelho J et al. A prospective and randomized study of ovarian stimulation for ICSI with recombinant FSH versus highly purified urinary FSH. Gynecol Endocrinol (1):5-10. [15] Frydman R Howles C Truong F. A double-blind randomized study to compare recombinant human follicle stimulating hormone (FSH; Gonal-F) with highly purified urinary FSH (Metrodin-HP) in women undergoing assisted reproductive techniques including intracytoplasmic sperm injection. Hum Reprod (3): [16] Hoomans EH Andersen AN Loft A et al. A prospective randomized clinical trial comparing 150 IU recombinant follicle stimulating hormone (Puregon) and 225 IU highly purified urinary follicle stimulating hormone (Metrodin-HP) in a fixed-dose regimen in women undergoing ovarian stimulation. Hum Reprod (10): [17] Hugues JN Bstandig B Bry-Gauillard H et al. Comparison of the effectiveness of recombinant and urinary FSH preparations in the achievement of follicular selection in chronic anovulation. Reprod Biomed Online (3): [18] Mohamed MA Sbracia M Pacchiarotti A et al. Urinary follicle-stimulating hormone (FSH) is more effective than recombinant FSH in older women in a controlled randomized study. Fertil Steril (5): [19] Schats R De Sutter P Bassil S et al. Ovarian stimulation during assisted reproduction treatment: a comparison of recombinant and highly purified urinary human FSH. Hum Reprod (8): [20] Selman HA De Santo M Sterzik K et al. Effect of highly purified urinary follicle-stimulating hormone on oocyte and embryo quality. Fertil Steril (5): [21] Hedon B Out H Hugues J et al. Efficacy and safety of recombinant follicle stimulating hormone (Puregon) in infertile women pituitary-suppressed with triptorelin undergoing in-vitro fertilization: a prospective randomized assessorblind multicentre trial. Hum Reprod (12): [22] Meden-Vrtovec H Mocnik-Roznik S Tomazevic T et al. Recombinant FSH vs. urinary FSH for ovarian stimulation in in vitro fertilization. J Reprod Med (10): [23] Recombinant Human F. Study Group. Clinical assessment of recombinant human follicle-stimulating hormone in stimulating ovarian follicular development before in vitro fertilization. Fertil Steril (1): [24]. (rfsh) (1): [25] Out HJ Mannaerts BM Driessen SG et al. Recombinant follicle stimulating hormone (rfsh; Puregon) in assisted reproduction: more oocytes more pregnancies. Results from five comparative studies. Hum Reprod Update (2): [26] Al-Inany H Aboulghar M Mansour R et al. Meta-analysis of recombinant versus urinary-derived FSH: an update. Hum Reprod (2): [27] Sunkara SK Rittenberg V Raine-Fenning N et al. Association between the number of eggs and live birth in IVF treatment: an analysis of treatment cycles. Hum Reprod (7): [28] Bayram N Van Wely M van Der Veen F. Recombinant FSH versus urinary gonadotrophins or recombinant FSH for ovulation induction in subfertility associated with polycystic ovary syndrome. Cochrane Database Syst Rev (2): CD [29] (5): ( ) 107

10 Application of recombinant human FSH and urinary FSH in IVF-ET: a Meta analysis Hong YE Guo-ning HUANG (Chongqing Health Center for Women and Children Chongqing ) ABSTRACT Objective: To evaluate the role and efficacy in controlled ovarian stimulation (COS) of recombinant FSH (rfsh) and urinary FSH (ufsh) during in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) therapy. Methods: Prospectively randomized controlled studies of the use of rfsh and ufsh in IVF and ICSI treatment were enrolled in this study from PubMed EMBASE Cochrane CNKI and Data Base of Wanfang. After quality assessment and data extraction Meta analysis was conducted under the assessment of odds ratio (OR) and mean difference (MD) by RevMan 5.2 software. Results: A total of 21 randomized controlled trail (RCT) studies were enrolled in this study after excluding poor quality and repeat published studies. The patients were further divided into 3 subgroups according to the types of ufsh. There was a significant difference in oocytes retrieved numbers between the two groups rfsh was more effective [MD= %CI= (Z=4.46 P< )]. There was a significant difference in FSH dosage between the two groups rfsh needed less total dosage of FSH [MD= %CI= (Z=2.71 P=0.007)]. There was no significant difference in the birth rate of cycle clinical pregnancy rate. Conclusions: rfsh is more effective than ufsh in COS during assiting reproduction. Key words: recombinant FSH (rfsh); urinary FSH (ufsh); in vitro fertilization (IVF); intracytoplasmic sperm injection (ICSI); reproduction; Meta analysis &&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&& ~ ; ; : ; : 108

IVF (,, ) : (HP-hMG) - (IVF- ET) : GnRH, HP-hMG (HP-hMG )57, (rfsh )140, (Gn)

IVF (,, ) : (HP-hMG) - (IVF- ET) : GnRH, HP-hMG (HP-hMG )57, (rfsh )140, (Gn) 34 11 Vol.34 No.11 2014 11 Nov. 2014 Reproduction & Contraception doi: 10.7669/j.issn.0253-3X.2014.11.0892 E-mail: randc_journal@163.com IVF ( 710003) : (H-hMG) - (IVF- ET) : GnRH H-hMG (H-hMG ) (rfsh