Attilio Di Spiezio Sardo1, Costantino Di Carlo2, Silvia Minozzi3, Marialuigia Spinelli2, Vanna Pistotti4, Carlo Alviggi2, Giuseppe De Placido2, Carmine Nappi5, Giuseppe Bifulco2. 1. Division of Obstetrics and Gynecology, Department of Public Health, School of Medicine, 'Federico II' University of Naples, Via Pansini 5, 80131 Naples, Italy cdispie@tin.it attiliodispiezio@libero.it. 2. Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Odontostomatological Sciences, School of Medicine, 'Federico II' University of Naples, Via Pansini 5, 80131 Naples, Italy. 3. Department of Epidemiology, Lazio Regional Health Service, Via di Santa Costanza 53, 00198 Rome, Italy. 4. Italian Cochrane Centre and IRCCS Mario Negri Institute for Pharmacological Research, Via Eritrea 62, 20157 Milan, Italy. 5. Division of Obstetrics and Gynecology, Department of Public Health, School of Medicine, 'Federico II' University of Naples, Via Pansini 5, 80131 Naples, Italy.
Abstract
BACKGROUND: The scientific community has been re-evaluating the clinical relevance of hysteroscopy in the diagnosis and treatment of uterine factors and its role in the infertility work-up, thanks to its potential capability to improve reproductive outcomes and reduce time to pregnancy. OBJECTIVE AND RATIONALE: The objective of this systematic review and meta-analysis was to assess the efficacy of diagnostic and operative hysteroscopy in improving the live birth rate (LBR) of infertile women, with and without intrauterine abnormalities, at any stage of the infertility work-up. SEARCH METHODS: PubMed, Embase, the Cochrane Library and the Clinical Trials Registry using Medical Subject Headings and free text terms were searched up to June 2014, without language or year restrictions. Randomized controlled trials (RCTs) enrolling infertile women with no suspected intrauterine cavity abnormalities and comparing hysteroscopy versus no hysteroscopy at any stage of the diagnostic work-up, but prior to the first attempt of standard IVF or ICSI or after (one or more) failed attempts of IVF/ICSI were included. RCTs enrolling infertile women with intrauterine abnormalities and comparing operative versus diagnostic hysteroscopy were also included. Risk of bias was assessed using the criteria recommended by the Cochrane Collaboration and the overall quality of evidence was assessed using the GRADE approach. Results were pooled by meta-analysis using the random effect model. OUTCOMES: The primary outcome evaluated was the LBR, while secondary outcomes were pregnancy rate, miscarriage rate and procedure-related complications. Five hundred and eighty-eight records were retrieved after removing duplicates. Nine studies were included, with 2976 participants. Four studies included infertile women with one or more failed IVF/ICSI cycles. Two studies included infertile women who were candidates for their first IVF/ICSI. One study included candidates both for first IVF/ICSI and with one or more failed IVF/ICSI cycles. Two studies included infertile women affected by uterine fibroids and endometrial polyps, who had not received IVF/ICSI nor were candidates. Seven studies were included in the meta-analysis. Comparing hysteroscopy with no hysteroscopy prior to any (first or subsequent) IVF/ICSI attempt in infertile women without intrauterine abnormalities, there was very low-quality evidence that hysteroscopy increased LBR (relative risk (RR) 1.48, 95% confidence interval (CI) 1.20-1.81; three studies with 1088 participants) and moderate quality evidence that it increased pregnancy rate (RR 1.45, 95% CI 1.26-1.67; seven studies, 2545 participants). Results on pregnancy rate were confirmed in the subgroup analysis of five studies including only women with one or more implantation failures (RR 1.41, 95% CI 1.14-1.75) and three studies where hysteroscopy was performed before the first IVF/ICSI attempt (RR 1.55, 95% CI 1.26-1.91). Comparing operative hysteroscopy for intrauterine abnormalities in infertile women with already diagnosed polyps or fibroids, there was low-quality evidence that operative hysteroscopy increases pregnancy rate (RR 2.13, 95% CI 1.56-2.92). None of the studies comparing operative versus diagnostic hysteroscopy assessed LBR. WIDER IMPLICATIONS: Robust and high-quality RCTs are still needed before hysteroscopy can be regarded as a first-line procedure in all infertile women, especially during the basal clinical assessment of the couple, when assisted reproductive treatment is not indicated yet.
BACKGROUND: The scientific community has been re-evaluating the clinical relevance of hysteroscopy in the diagnosis and treatment of uterine factors and its role in the infertility work-up, thanks to its potential capability to improve reproductive outcomes and reduce time to pregnancy. OBJECTIVE AND RATIONALE: The objective of this systematic review and meta-analysis was to assess the efficacy of diagnostic and operative hysteroscopy in improving the live birth rate (LBR) of infertile women, with and without intrauterine abnormalities, at any stage of the infertility work-up. SEARCH METHODS: PubMed, Embase, the Cochrane Library and the Clinical Trials Registry using Medical Subject Headings and free text terms were searched up to June 2014, without language or year restrictions. Randomized controlled trials (RCTs) enrolling infertile women with no suspected intrauterine cavity abnormalities and comparing hysteroscopy versus no hysteroscopy at any stage of the diagnostic work-up, but prior to the first attempt of standard IVF or ICSI or after (one or more) failed attempts of IVF/ICSI were included. RCTs enrolling infertile women with intrauterine abnormalities and comparing operative versus diagnostic hysteroscopy were also included. Risk of bias was assessed using the criteria recommended by the Cochrane Collaboration and the overall quality of evidence was assessed using the GRADE approach. Results were pooled by meta-analysis using the random effect model. OUTCOMES: The primary outcome evaluated was the LBR, while secondary outcomes were pregnancy rate, miscarriage rate and procedure-related complications. Five hundred and eighty-eight records were retrieved after removing duplicates. Nine studies were included, with 2976 participants. Four studies included infertile women with one or more failed IVF/ICSI cycles. Two studies included infertile women who were candidates for their first IVF/ICSI. One study included candidates both for first IVF/ICSI and with one or more failed IVF/ICSI cycles. Two studies included infertile women affected by uterine fibroids and endometrial polyps, who had not received IVF/ICSI nor were candidates. Seven studies were included in the meta-analysis. Comparing hysteroscopy with no hysteroscopy prior to any (first or subsequent) IVF/ICSI attempt in infertile women without intrauterine abnormalities, there was very low-quality evidence that hysteroscopy increased LBR (relative risk (RR) 1.48, 95% confidence interval (CI) 1.20-1.81; three studies with 1088 participants) and moderate quality evidence that it increased pregnancy rate (RR 1.45, 95% CI 1.26-1.67; seven studies, 2545 participants). Results on pregnancy rate were confirmed in the subgroup analysis of five studies including only women with one or more implantation failures (RR 1.41, 95% CI 1.14-1.75) and three studies where hysteroscopy was performed before the first IVF/ICSI attempt (RR 1.55, 95% CI 1.26-1.91). Comparing operative hysteroscopy for intrauterine abnormalities in infertilewomen with already diagnosed polyps or fibroids, there was low-quality evidence that operative hysteroscopy increases pregnancy rate (RR 2.13, 95% CI 1.56-2.92). None of the studies comparing operative versus diagnostic hysteroscopy assessed LBR. WIDER IMPLICATIONS: Robust and high-quality RCTs are still needed before hysteroscopy can be regarded as a first-line procedure in all infertile women, especially during the basal clinical assessment of the couple, when assisted reproductive treatment is not indicated yet.
Authors: Mohan S Kamath; Jan Bosteels; Thomas M D'Hooghe; Srividya Seshadri; Steven Weyers; Ben Willem J Mol; Frank J Broekmans; Sesh Kamal Sunkara Journal: Cochrane Database Syst Rev Date: 2019-04-16
Authors: S Spanou; D Kalogiannis; E Zapanti; M Gazouli; I A Sfontouris; C Siristatidis; George Mastorakos Journal: J Assist Reprod Genet Date: 2018-04-04 Impact factor: 3.412
Authors: Jan Bosteels; Steffi van Wessel; Steven Weyers; Frank J Broekmans; Thomas M D'Hooghe; M Y Bongers; Ben Willem J Mol Journal: Cochrane Database Syst Rev Date: 2018-12-05
Authors: Ilaria Romito; Ferdinando Antonio Gulino; Antonio Simone Laganà; Salvatore Giovanni Vitale; Attilio Tuscano; Gianluca Leanza; Giulia Musmeci; Vito Leanza; Agnese Maria Chiara Rapisarda; Marco Antonio Palumbo Journal: Int J Fertil Steril Date: 2016-11-11