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Meta-Analysis
. 2009 Apr 15;2009(2):CD001897.
doi: 10.1002/14651858.CD001897.pub2.

Postoperative procedures for improving fertility following pelvic reproductive surgery

James M N Duffy  1 , Neil Johnson, Gaity Ahmad, Andrew Watson
Affiliations
Meta-Analysis

Postoperative procedures for improving fertility following pelvic reproductive surgery

James M N Duffy et al. Cochrane Database Syst Rev. .

Abstract

Background: Hydrotubation with oil-soluble contrast media for unexplained infertility and adhesiolysis for infertility due to peritubal adhesions are primary procedures that are of recognised benefit. It is less clear whether postoperative procedures such as hydrotubation or second-look laparoscopy with adhesiolysis are beneficial following pelvic reproductive surgery.

Objectives: To assess the value of postoperative hydrotubation and second-look laparoscopy with adhesiolysis following female pelvic reproductive surgery.

Search strategy: We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (August 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to August 2008), EMBASE (1980 to August 2008), PsycINFO (1967 to August 2008), Current Contents (1993 to August 2008), Biological Abstracts (1969 to August 2008), CINAHL (1982 to August 2008) and reference lists of identified articles.

Selection criteria: All randomised controlled trials in which a postoperative procedure was compared with a control group following pelvic reproductive surgery were considered for inclusion in the review.

Data collection and analysis: Five randomised controlled trials were identified and included in this updated review. An attempt was made to obtain further information from the authors of all five trials. All trials were assessed for quality. The studied outcomes were pregnancy, live birth, ectopic pregnancy and miscarriage rates, and the rates of tubal patency and procedure-related complications. Review authors extracted the data independently and the odds ratios (OR) were estimated for these dichotomous outcomes.

Main results: Five randomised controlled trials were identified and included in this review. The odds of pregnancy (OR 1.12, 95% confidence interval (CI) 0.57 to 2.21) and live birth (OR 0.61, 95% CI 0.24 to 1.59) were not significantly different with postoperative hydrotubation versus no hydrotubation. The odds of pregnancy (OR 0.96, 95% CI 0.44 to 2.07) or live birth (OR 0.67, 95% CI 0.19 to 2.32) were also not significantly different with second-look laparoscopy and adhesiolysis versus no second-look laparoscopy. Whether hydrotubation was early or late and whether hydrotubation fluid contained steroid or not had no significant impact on the odds of pregnancy or live birth. Late antibiotic hydrotubation increased the odds of at least one patent fallopian tube when compared with early hydrotubation in women (OR 7.72, 95% CI 2.50 to 8.93). The odds of infective morbidity significantly increased with early hydrotubation when compared with late non-antibiotic hydrotubation (OR 4.72, 95% CI 2.50 to 8.93). When comparing late hydrotubation following tubal stent removal with early hydrotubation in women who had no tubal stenting, there was no significant difference in pregnancy or live birth rates.

Authors' conclusions: There is insufficient evidence to support the routine practice of hydrotubation or second-look laparoscopy following female pelvic reproductive surgery. The studies on which this conclusion is based were either of poor quality or underpowered. These interventions should be performed in the context of a good quality, adequately powered randomised controlled trial. Postoperative hydrotubation with fluid containing antibiotic may offer benefit over hydrotubation fluid without antibiotic following tubal surgery. A randomised controlled trial of postoperative hydrotubation with antibiotic-containing fluid versus no hydrotubation for improving fertility following tubal surgery is justified.

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Conflict of interest statement

None known

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Hydrotubation (all types) versus no hydrotubation, Outcome 1 Total pregnancy rate.
1.2
1.2. Analysis
Comparison 1 Hydrotubation (all types) versus no hydrotubation, Outcome 2 Livebirth rate.
1.3
1.3. Analysis
Comparison 1 Hydrotubation (all types) versus no hydrotubation, Outcome 3 Ectopic pregnancy rate.
1.4
1.4. Analysis
Comparison 1 Hydrotubation (all types) versus no hydrotubation, Outcome 4 Miscarriage rate.
1.5
1.5. Analysis
Comparison 1 Hydrotubation (all types) versus no hydrotubation, Outcome 5 Infection rate.
1.6
1.6. Analysis
Comparison 1 Hydrotubation (all types) versus no hydrotubation, Outcome 6 Complication rate.
2.1
2.1. Analysis
Comparison 2 Hydrotubation with steroid versus hydrotubation without steroid, Outcome 1 Total pregnancy rate.
2.2
2.2. Analysis
Comparison 2 Hydrotubation with steroid versus hydrotubation without steroid, Outcome 2 Livebirth rate.
2.3
2.3. Analysis
Comparison 2 Hydrotubation with steroid versus hydrotubation without steroid, Outcome 3 Ectopic pregnancy rate.
2.4
2.4. Analysis
Comparison 2 Hydrotubation with steroid versus hydrotubation without steroid, Outcome 4 Miscarriage rate.
2.5
2.5. Analysis
Comparison 2 Hydrotubation with steroid versus hydrotubation without steroid, Outcome 5 Infection rate.
2.6
2.6. Analysis
Comparison 2 Hydrotubation with steroid versus hydrotubation without steroid, Outcome 6 Complication rate.
3.1
3.1. Analysis
Comparison 3 Hydrotubation with antibiotic versus hydrotubation without antibiotic, Outcome 1 Total pregnancy rate.
3.2
3.2. Analysis
Comparison 3 Hydrotubation with antibiotic versus hydrotubation without antibiotic, Outcome 2 Livebirth rate.
3.3
3.3. Analysis
Comparison 3 Hydrotubation with antibiotic versus hydrotubation without antibiotic, Outcome 3 Ectopic pregnancy rate.
3.4
3.4. Analysis
Comparison 3 Hydrotubation with antibiotic versus hydrotubation without antibiotic, Outcome 4 Infection rate.
3.5
3.5. Analysis
Comparison 3 Hydrotubation with antibiotic versus hydrotubation without antibiotic, Outcome 5 Tubal patency rate.
4.1
4.1. Analysis
Comparison 4 Early hydrotubation versus late hydrotubation, Outcome 1 Total pregnancy rate.
4.2
4.2. Analysis
Comparison 4 Early hydrotubation versus late hydrotubation, Outcome 2 Livebirth rate.
4.3
4.3. Analysis
Comparison 4 Early hydrotubation versus late hydrotubation, Outcome 3 Ectopic pregnancy rate.
4.4
4.4. Analysis
Comparison 4 Early hydrotubation versus late hydrotubation, Outcome 4 Infection rate.
4.5
4.5. Analysis
Comparison 4 Early hydrotubation versus late hydrotubation, Outcome 5 Tubal patency rate.
5.1
5.1. Analysis
Comparison 5 Early hydrotubation versus tubal stent, Outcome 1 Total pregnancy rate.
5.2
5.2. Analysis
Comparison 5 Early hydrotubation versus tubal stent, Outcome 2 Ectopic pregnancy rate.
5.3
5.3. Analysis
Comparison 5 Early hydrotubation versus tubal stent, Outcome 3 Miscarriage rate.
5.4
5.4. Analysis
Comparison 5 Early hydrotubation versus tubal stent, Outcome 4 Tubal patency rate.
6.1
6.1. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 1 Total pregnancy rate.
6.2
6.2. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 2 Livebirth rate.
6.3
6.3. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 3 Ectopic pregnancy rate.
6.4
6.4. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 4 Miscarriage rate.
6.5
6.5. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 5 Infection rate.
6.6
6.6. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 6 Complication rate.
6.7
6.7. Analysis
Comparison 6 Second‐look laparoscopy versus no second‐look laparoscopy, Outcome 7 Tubal patency rate.
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References

References to studies included in this review

Comninos 1977 {published data only}
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