Mathew Leonardi1, Tatjana Gibbons2, Mike Armour2, Rui Wang2, Elizabeth Glanville2, Ruth Hodgson2, Adele E Cave2, Jozarino Ong2, Yui Yee Felice Tong2, Tal Z Jacobson2, Ben W Mol2, Neil P Johnson2, George Condous2. 1. Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, New South Wales, Australia (Drs. Leonardi, Ong, and Condous); Sydney Medical School Nepean, The University of Sydney, Sydney, Australia (Drs. Leonardi, Condous, and Tong); Imperial College London Medical School, London, United Kingdom (Dr. Gibbons); NICM Health Research Institute, Western Sydney University, Penrith, Australia (Drs. Armour and Cave); Translational Health Research Institute, Western Sydney University, Sydney, Australia, (Drs. Armour and Mol); Robinson Research Institute, The University of Adelaide, Adelaide, Australia (Drs. Wang and Johnson); Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia (Dr. Wang); Fertility Plus, National Women's Hospital, Auckland, New Zealand (Drs. Glanville and Johnson); Department of Obstetrics & Gynaecology, Cairns Hospital, Cairns, Australia (Dr. Hodgson); Department of Obstetrics and Gynaecology, Mater Hospital Brisbane, Brisbane, Australia (Dr. Jacobson); Auckland Gynaecology Group and Repromed Auckland, Auckland, New Zealand (Dr. Johnson). Electronic address: mathew.leonardi@sydney.edu.au. 2. Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, New South Wales, Australia (Drs. Leonardi, Ong, and Condous); Sydney Medical School Nepean, The University of Sydney, Sydney, Australia (Drs. Leonardi, Condous, and Tong); Imperial College London Medical School, London, United Kingdom (Dr. Gibbons); NICM Health Research Institute, Western Sydney University, Penrith, Australia (Drs. Armour and Cave); Translational Health Research Institute, Western Sydney University, Sydney, Australia, (Drs. Armour and Mol); Robinson Research Institute, The University of Adelaide, Adelaide, Australia (Drs. Wang and Johnson); Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia (Dr. Wang); Fertility Plus, National Women's Hospital, Auckland, New Zealand (Drs. Glanville and Johnson); Department of Obstetrics & Gynaecology, Cairns Hospital, Cairns, Australia (Dr. Hodgson); Department of Obstetrics and Gynaecology, Mater Hospital Brisbane, Brisbane, Australia (Dr. Jacobson); Auckland Gynaecology Group and Repromed Auckland, Auckland, New Zealand (Dr. Johnson).
Abstract
OBJECTIVE: We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis compared with alternative treatments. Moreover, we aimed to assess the risks of operative laparoscopy compared with those of alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision making around surgery. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. In addition, a manual search of reference lists of relevant studies was conducted. METHODS OF STUDY SELECTION: Published and unpublished randomized controlled trials (RCTs) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible. TABULATION, INTEGRATION, AND RESULTS: In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies of interest were identified to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at 6 months compared with diagnostic laparoscopy (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61-4.34; p <.001; 2 RCTs, 102 participants; low-quality evidence). Because the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference regarding clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99-1.92; p = .06; 4 RCTs, 624 participants; moderate-quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared with diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84-4.65; p = .12; 5 RCTs, 554 participants; very-low-quality evidence). No studies reported on the progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and locations in asymptomatic women with endometriosis. We found no studies that reported on the timing of surgery. No quantitative or qualitative studies specifically aimed at elucidating the factors informing a woman's choice for surgery were identified. CONCLUSION: Operative laparoscopy may improve overall pain levels but may have little or no difference with respect to fertility-related or adverse outcomes when compared with diagnostic laparoscopy. Additional high-quality RCTs, including comparing surgery to medical management, are needed, and these should report adverse events as an outcome. Studies on patient preference in surgical decision making are needed (International Prospective Register of Systematic Review registration number: CRD42019135167).
OBJECTIVE: We performed a systematic review and meta-analysis with the aim to answer whether operative laparoscopy is an effective treatment in a woman with demonstrated endometriosis compared with alternative treatments. Moreover, we aimed to assess the risks of operative laparoscopy compared with those of alternatives. In addition, we aimed to systematically review the literature on the impact of patient preference on decision making around surgery. DATA SOURCES: We searched MEDLINE, Embase, PsycINFO, ClinicalTrials.gov, CINAHL, Scopus, OpenGrey, and Web of Science from inception through May 2019. In addition, a manual search of reference lists of relevant studies was conducted. METHODS OF STUDY SELECTION: Published and unpublished randomized controlled trials (RCTs) in any language describing a comparison between surgery and any other intervention were included, with particular reference to timing and its impact on pain and fertility. Studies reporting on keywords including, but not limited to, endometriosis, laparoscopy, pelvic pain, and infertility were included. In the anticipated absence of RCTs on patient preference, all original research on this topic was considered eligible. TABULATION, INTEGRATION, AND RESULTS: In total, 1990 studies were reviewed. Twelve studies were identified as being eligible for inclusion to assess outcomes of pain (n = 6), fertility (n = 7), quality of life (n = 1), and disease progression (n = 3). Seven studies of interest were identified to evaluate patient preferences. There is evidence that operative laparoscopy may improve overall pain levels at 6 months compared with diagnostic laparoscopy (risk ratio [RR], 2.65; 95% confidence interval [CI], 1.61-4.34; p <.001; 2 RCTs, 102 participants; low-quality evidence). Because the quality of the evidence was very low, it is uncertain if operative laparoscopy improves live birth rates. Operative laparoscopy probably yields little or no difference regarding clinical pregnancy rates compared with diagnostic laparoscopy (RR, 1.29; 95% CI, 0.99-1.92; p = .06; 4 RCTs, 624 participants; moderate-quality evidence). It is uncertain if operative laparoscopy yields a difference in adverse outcomes when compared with diagnostic laparoscopy (RR, 1.98; 95% CI, 0.84-4.65; p = .12; 5 RCTs, 554 participants; very-low-quality evidence). No studies reported on the progression of endometriosis to a symptomatic state or progression of extent of disease in terms of volume of lesions and locations in asymptomatic women with endometriosis. We found no studies that reported on the timing of surgery. No quantitative or qualitative studies specifically aimed at elucidating the factors informing a woman's choice for surgery were identified. CONCLUSION: Operative laparoscopy may improve overall pain levels but may have little or no difference with respect to fertility-related or adverse outcomes when compared with diagnostic laparoscopy. Additional high-quality RCTs, including comparing surgery to medical management, are needed, and these should report adverse events as an outcome. Studies on patient preference in surgical decision making are needed (International Prospective Register of Systematic Review registration number: CRD42019135167).
Authors: Mathew Leonardi; Andrew W Horne; Katy Vincent; Justin Sinclair; Kerry A Sherman; Donna Ciccia; George Condous; Neil P Johnson; Mike Armour Journal: Hum Reprod Open Date: 2020-06-01
Authors: Elizabeth Ball; Babu Karavadra; Bethany Jade Kremer-Yeatman; Connor Mustard; Kim May Lee; Sharandeep Bhogal; Julie Dodds; Andrew W Horne; John Allotey; Carol Rivas Journal: Reprod Fertil Date: 2021-03-03