【Cochrane简语概要】孕前生活方式建议真的能帮助不孕症患者怀孕吗？

研究背景
不孕症给个人、家庭和广大社区带来了沉重的负担，影响了全世界范围内的4500多万对夫妇。不孕症的治疗包括简单的干预措施，如生育意识和生活方式建议(关于体重、饮食、体育活动和/或吸烟的咨询)，以及更复杂的辅助生殖技术，如体外受精(IVF)。生活方式因素，如体重、饮食、体育活动和吸烟，可能会影响生育能力和不孕症患者者生育的机会。然而，当前缺乏关于不孕症患者应接受何种孕前生活方式建议的指南。

（图片来源于dnurse.com）

我们为什么要做本综述
我们想查明孕前生活方式建议与常规护理或注意力控制（如没有对生活方式建议的治疗建议）相比对不孕症患者的影响。

我们怎么做的
我们检索了将不孕症患者孕前生活方式建议与常规护理或注意力控制进行比较的随机对照研究。

我们有兴趣了解应该给不孕症患者提供哪些孕前生活方式建议；这些建议对改善这类患者的生活方式以增加他们生育机率起到了怎样的效果；以及它是否有不良影响。

检索日期
我们纳入了截至2021年1月14日公开发表的证据。

我们发现了什么？
我们在2130名不孕症患者中发现了七项研究。只有一项研究纳入了男性伴侣。这些研究在加拿大、伊朗、荷兰、英国和美国开展。三项研究将包含系列主题的孕前生活方式建议与常规护理或注意力控制进行比较。四项研究将针对特定主题(体重、酒精摄入或吸烟)的孕前生活方式建议与不孕女性和特殊生活方式特征的常规护理进行了比较。

关键结局

包含系列主题的孕前生活方式建议和常规护理或注意力控制之间的比较
结合系列主题的孕前生活方式建议可能不会影响活产。有证据表明，如果假设接受常规护理或注意力控制的活产率为48%，那么接受孕前生活方式建议的活产率为38%至53%。我们不确定结合系列主题的孕前生活方式建议是否会影响生活方式的变化，例如女性的体重指数、男性和女性的蔬菜摄入量，或者男性的戒酒和戒烟。结合系列主题的孕前生活方式建议可能不会影响女性对叶酸补充剂的充分使用、戒酒或戒烟。证据表明，如果假设接受常规护理或注意力控制的女性叶酸补充剂充分使用率为93%，那么接受孕前生活方式建议时叶酸补充剂充分使用率为89%至94%。证据还表明，如果假设75%的女性在常规护理或注意力控制下戒酒，那么74%至88%的女性在接受孕前生活方式建议时会戒酒。如果假设95%接受常规护理或注意力控制的女性会戒烟，那么接受孕前生活方式建议的女性中有93%~99%会戒烟。没有研究报告了其他行为变化。

关于体重的孕前生活方式建议和常规护理的比较
我们不确定患有不孕症的肥胖女性的孕前生活方式建议是否会影响活产或不良事件（包括妊娠糖尿病和高血压）和流产。在行为改变方面，关于体重的孕前生活方式建议可能会稍微降低体重指数，但我们不确定它是否会影响其他行为改变:减重的百分比、蔬菜和水果的摄入量、酒精的摄入以及中度至剧烈的体力活动。没有研究报告了其他行为变化。

关于酒精摄入的孕前生活方式建议和常规护理的比较
在患有不孕症的高危饮酒女性中，我们不确定关于酒精摄入的孕前生活方式建议是否会影响活产或流产。一项研究报告了酒精摄入量的行为变化，但不符合本综述方法中的定义。没有研究报告任何其他结局。

关于吸烟的孕前生活方式建议和常规护理的比较
一项研究报告了孕前生活方式建议对吸烟的不孕症女性戒烟这一行为改变的影响，但不符合本综述方法中的定义。没有研究报告任何其他结局。

证据质量
证据质量低至极低。证据的主要局限性在于纳入研究的研究方法不佳（缺乏盲法）和缺乏关于活产、安全结局以及报告行为改变的研究结果（精确度）。

结论: 

低质量证据表明，包含系列主题的孕前生活方式建议对活产的数量几乎没有影响。因为没有研究观察这些结局指标，或者研究质量非常低，所以证据不足以得出孕前生活方式建议对不良事件、流产和安全性的影响的结论。本综述没有为该领域的临床实践提供明确的指导。然而，它的确强调了高质量随机对照临床试验在调查包含系列主题的孕前生活方式建议及评估不孕症患者的相关有效性和安全性结局上的必要性。

作者: Boedt T, Vanhove A-C, Vercoe MA, Matthys C, Dancet E, Lie Fong S；译者：黄粲然，武汉大学健康学院；审校：靳英辉，武汉大学中南医院循证与转化医学中心；编辑排版：索于思、张晓雯，北京中医药大学循证医学中心

相关文章链接

【Cochrane Plain Language Summary】

Does preconception lifestyle advice help people with infertility to have a baby?

Background
Infertility places a significant burden on individuals, families, and the wider community and impacts more than 45 million couples worldwide. Treatment for infertility includes simple interventions such as fertility awareness and lifestyle advice (counselling about weight, diet, physical activity, and/or smoking) to more complex assisted reproductive technologies such as in vitro fertilisation (IVF). Lifestyle factors such as weight, diet, physical activity, and smoking may affect fertility and the chance of people with infertility having a baby. However, guidelines about what preconception lifestyle advice should be offered are lacking.

Why we did this Cochrane Review
We wanted to find out the effects of preconception lifestyle advice compared to routine care or attention control (e.g. treatment advice without lifestyle advice) for people with infertility.

What we did
We searched for randomised controlled studies that compared preconception lifestyle advice for people with infertility with routine care or attention control.

We were interested in finding out what preconception lifestyle advice should be given to people with infertility; how well it works for improving lifestyle to increase their chance of having a baby; and whether it had any unwanted effects.

Search date
We included evidence published up to 14 January 2021.

What we found
We found seven studies in 2130 people with infertility. Only one study also included male partners. The studies were conducted in Canada, Iran, The Netherlands, UK, and USA. Three studies compared preconception lifestyle advice on a combination of topics with routine care or attention control. Four studies compared preconception lifestyle advice on one topic (weight, alcohol intake, or smoking) with routine care in women with infertility and specific lifestyle characteristics.

Key results

Preconception lifestyle advice on a combination of topics versus routine care or attention control
Preconception lifestyle advice on a combination of topics may not affect live birth. The evidence suggests that if live birth is assumed to be 48% for those receiving routine care or attention control, then live birth when preconception lifestyle advice is received would be between 38% and 53%. We are uncertain whether preconception lifestyle advice on a combination of topics affects lifestyle behaviour changes such as body mass index (BMI) in women, vegetable intake in men and women, or alcohol abstinence and smoking cessation in men. Preconception lifestyle advice on a combination of topics may not affect adequate use of folic acid supplement, alcohol abstinence, or smoking cessation in women. The evidence suggests that if adequate folic acid supplement use in women is assumed to be 93% for those receiving routine care or attention control, then adequate folic acid supplement use when preconception lifestyle advice is received would be between 89% and 94%. Evidence also suggests that if it is assumed that 75% of women abstain from alcohol with routine care or attention control, then between 74% and 88% of women would abstain from alcohol when receiving preconception lifestyle advice. If it is assumed that smoking cessation is seen in 95% of women receiving routine care or attention control, then smoking cessation would be seen in 93% to 99% of women when they receive preconception lifestyle advice. No study reported on other behavioural changes.

Preconception lifestyle advice on weight versus routine care
We are uncertain whether preconception lifestyle advice on weight for women with infertility and obesity affects live birth or adverse events (including gestational diabetes and hypertension) and miscarriage. Regarding behavioural changes, preconception lifestyle advice on weight may slightly reduce BMI, but we are uncertain whether it affects other behavioural changes: percentage of weight loss, vegetable and fruit intake, alcohol intake, and total moderate to vigorous physical activity. No study reported on other behavioural changes.

Preconception lifestyle advice on alcohol intake versus routine care
In at-risk drinking women with infertility, we are uncertain whether preconception lifestyle advice on alcohol intake affects live birth or miscarriage. One study reported behavioural changes in alcohol intake but not as defined in the Review methods. No study reported on any other outcome.

Preconception lifestyle advice on smoking versus routine care
One study reported on preconception lifestyle advice with a focus on behavioural changes for smoking cessation in women with infertility who smoke, but not as defined in the Review methods. No study reported on any other outcome.

Quality of the evidence
The evidence was of low to very low quality. The main limitations of the evidence were poor study methods in included studies (lack of blinding) and lack of (precision in) findings for live birth, safety outcomes, and reported behavioural changes.

Authors' conclusions: 

Low-quality evidence suggests that preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births. Evidence was insufficient to allow conclusions on the effects of preconception lifestyle advice on adverse events and miscarriage and on safety, as no studies were found that looked at these outcomes, or the studies were of very low quality. This review does not provide clear guidance for clinical practice in this area. However, it does highlight the need for high-quality RCTs to investigate preconception lifestyle advice on a combination of topics and to assess relevant effectiveness and safety outcomes in men and women with infertility.

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