The effectiveness of reproductive surgery in the treatment of female infertility: facts, views and vision

Abstract

Background: The role of reproductive surgery is declining due to the widespread availability of assisted reproductive technology, but an evidence-based fundament for this decline is lacking. We therefore performed a systematic review of the literature.

Methods: We searched MEDLINE, EMBASE and the Cochrane Library for randomised trials evaluating laparoscopic or hysteroscopic interventions in subfertile women, studying pregnancy or live birth rates. We present an overview of the results and quality of the detected studies.

Results: The methodological quality of the 63 detected studies was mediocre. The laparoscopic treatment of minimal/ mild endometriosis might increase the pregnancy rate but the two major studies report conflicting results. Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5). Laparoscopic ovarian drilling results at least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) but decreases the multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58). Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7). Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1). Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9). The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant (RR 1.2, 95% CI 0.75-1.9). Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9).

Conclusions: Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.

Keywords: Laparoscopy; effectiveness; hysteroscopy; live birth rate; pregnancy rate; reproductive surgery.

1. PRISMA 2009 Flow Diagram: Systematic Review of benefit after reproductive surgery.

2. LOD with or without clomiphene versus gonadotrophins. Outcome: ongoing pregnancy rate per couple.

3. LOD with or without clomiphene versus gonadotrophins. Outcome: multiple pregnancy rate per couple.

4. Unilateral versus bilateral laparoscopic ovarian diathermy in clomiphene-resistant PCOS patients. Outcome: clinical pregnancy rate per patient.

5. Laparoscopic surgery on the Fallopian tubes (all types) versus no surgery on the Fallopian tubes (all types). Outcome: pregnancy rate (any definition).

6. Tubal occlusion versus salpingectomy in subfertile women with hydrosalpinx prior to IVF. Outcome: clinical pregnancy rate.

7. Hysteroscopic myomectomy versus expectant management in women with ultrasonographically diagnosed submucosal myomas and otherwise unexplained infertility. Outcome: clinical pregnancy rates.

8. Risk of bias graph of all included studies

9. Summary of the risk of bias of individual studies