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Meta-Analysis
. 2015 Sep 29;2015(9):CD008478.
doi: 10.1002/14651858.CD008478.pub2.

Fertility and early pregnancy outcomes after conservative treatment for cervical intraepithelial neoplasia

Maria Kyrgiou  1 , Anita Mitra, Marc Arbyn, Maria Paraskevaidi, Antonios Athanasiou, Pierre P L Martin-Hirsch, Phillip Bennett, Evangelos Paraskevaidis
Affiliations
Meta-Analysis

Fertility and early pregnancy outcomes after conservative treatment for cervical intraepithelial neoplasia

Maria Kyrgiou et al. Cochrane Database Syst Rev. .

Abstract

Background: Cervical intra-epithelial neoplasia (CIN) typically occurs in young women of reproductive age. Although several studies have reported the impact that cervical conservative treatment may have on obstetric outcomes, there is much less evidence for fertility and early pregnancy outcomes.

Objectives: To assess the effect of cervical treatment for CIN (excisional or ablative) on fertility and early pregnancy outcomes.

Search methods: We searched in January 2015 the following databases: the Cochrane Gynaecological Cancer Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library, Issue 12, 2014), MEDLINE (up to November week 3, 2014) and EMBASE (up to week 52, 2014).

Selection criteria: We included all studies reporting on fertility and early pregnancy outcomes (less than 24 weeks of gestation) in women with a history of CIN treatment (excisional or ablative) as compared to women that had not received treatment.

Data collection and analysis: Studies were classified according to the treatment method used and the fertility or early pregnancy endpoint. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated using a random-effects model and inter-study heterogeneity was assessed with I(2). Two review authors (MK, AM) independently assessed the eligibility of retrieved papers and risk of bias. The two review authors then compared their results and any disagreements were resolved by discussion. If still unresolved, a third review author (MA) was involved until consensus was reached.

Main results: Fifteen studies (2,223,592 participants - 25,008 treated and 2,198,584 untreated) that fulfilled the inclusion criteria for this review were identified from the literature search. The meta-analysis demonstrated that treatment for CIN did not adversely affect the chances of conception. The overall pregnancy rate was higher for treated (43%) versus untreated women (38%; RR 1.29, 95% CI 1.02 to 1.64; 4 studies, 38,050 participants, very low quality), although the inter-study heterogeneity was considerable (P < 0.01). The pregnancy rates in treated and untreated women with an intention to conceive (88% versus 95%, RR 0.93, 95% CI 0.80 to 1.08; 2 studies, 70 participants, very low quality) and the number of women requiring more than 12 months to conceive (14% versus 9%, RR 1.45, 95% CI 0.89 to 2.37; 3 studies, 1348 participants, very low quality) were no different. Although the total miscarriage rate (4.6% versus 2.8%, RR 1.04, 95% CI 0.90 to 1.21; 10 studies, 39,504 participants, low quality) and first trimester miscarriage rate (9.8% versus 8.4%, RR 1.16, 95% CI 0.80 to 1.69, 4 studies, 1103 participants, low quality) was similar for treated and untreated women, CIN treatment was associated with an increased risk of second trimester miscarriage, (1.6% versus 0.4%, RR 2.60, 95% CI 1.45 to 4.67; 8 studies, 2,182,268 participants, low quality). The number of ectopic pregnancies (1.6% versus 0.8%, RR 1.89, 95% CI 1.50 to 2.39; 6 studies, 38,193 participants, low quality) and terminations (12.2% versus 7.4%, RR 1.71, 95% CI 1.31 to 2.22; 7 studies, 38,208 participants, low quality) were also higher in treated women.The results should be interpreted with caution. The included studies were often small with heterogenous design. Most of these studies were retrospective and of low or very low quality (GRADE assessment) and were therefore prone to bias. Subgroup analyses for the individual treatment methods and comparison groups and analysis to stratify for the cone length was not possible.

Authors' conclusions: This meta-analysis suggests that treatment for CIN does not adversely affect fertility, although treatment was associated with an increased risk of miscarriage in the second trimester. These results should be interpreted with caution as the included studies were non-randomised and many were of low or very low quality and therefore at high risk of bias. Research should explore mechanisms that may explain the increase in mid-trimester miscarriage risk and stratify this impact of treatment by the length of the cone and the treatment method used.

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Conflict of interest statement

The authors have no conflicts of interest to declare.

Figures

1
1
PRISMA flowchart
2
2
Forest plot of comparison: 1 Fertility outcomes, outcome: 1.1 Total pregnancy rates.
3
3
Forest plot of comparison: 1 Fertility outcomes, outcome: 1.9 Conception >12 months (treatment versus no treatment).
4
4
Forest plot of comparison: 2 Early pregnancy outcomes, outcome: 2.2 Miscarriage rates (treatment versus no treatment).
5
5
Forest plot of comparison: 2 Early pregnancy outcomes, outcome: 2.3 1st trimester Miscarriage rates (treatment versus no treatment).
6
6
Forest plot of comparison: 2 Early pregnancy outcomes, outcome: 2.4 2nd trimester miscarriage rates (treatment versus no treatment).
1.1
1.1. Analysis
Comparison 1 Fertility outcomes, Outcome 1 Total pregnancy rates.
1.2
1.2. Analysis
Comparison 1 Fertility outcomes, Outcome 2 Pregnancy rate in women with intention to conceive.
1.3
1.3. Analysis
Comparison 1 Fertility outcomes, Outcome 3 Conception within 0‐3 months (excisional treatment versus no treatment).
1.4
1.4. Analysis
Comparison 1 Fertility outcomes, Outcome 4 Conception within 0‐6 months (excisional treatment versus no treatment).
1.5
1.5. Analysis
Comparison 1 Fertility outcomes, Outcome 5 Conception within 0‐9 months (excisional treatment versus no treatment).
1.6
1.6. Analysis
Comparison 1 Fertility outcomes, Outcome 6 Conception within 0‐12 months (excisional treatment versus no treatment).
1.7
1.7. Analysis
Comparison 1 Fertility outcomes, Outcome 7 Conception within 0‐24 months (excisional treatment versus no treatment).
1.8
1.8. Analysis
Comparison 1 Fertility outcomes, Outcome 8 Conception >12 months (treatment versus no treatment).
1.9
1.9. Analysis
Comparison 1 Fertility outcomes, Outcome 9 Conception >12 months (treatment versus no treatment).
1.10
1.10. Analysis
Comparison 1 Fertility outcomes, Outcome 10 Conception >12 months (colposcopy only versus no treatment).
1.11
1.11. Analysis
Comparison 1 Fertility outcomes, Outcome 11 Conception >12 months (treatment versus colposcopy only).
1.12
1.12. Analysis
Comparison 1 Fertility outcomes, Outcome 12 Conception >12 months (treatment versus colposcopy only).
1.13
1.13. Analysis
Comparison 1 Fertility outcomes, Outcome 13 Conception >36 months (treatment versus no treatment).
2.1
2.1. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 1 Miscarriage rates (treatment versus no treatment).
2.2
2.2. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 2 Miscarriage rates (treatment versus no treatment).
2.3
2.3. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 3 1st trimester Miscarriage rates (treatment versus no treatment).
2.4
2.4. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 4 2nd trimester miscarriage rates (treatment versus no treatment).
2.5
2.5. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 5 Ectopic pregnancy (treatment versus no treatment).
2.6
2.6. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 6 Ectopic pregnancy (treatment versus no treatment).
2.7
2.7. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 7 Molar pregnancy rates (treatment versus no treatment).
2.8
2.8. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 8 Termination of pregnancy rates (Treatment versus no treatment).
2.9
2.9. Analysis
Comparison 2 Early pregnancy outcomes, Outcome 9 Termination of pregnancy rates (treatment versus no treatment).
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Update of

  • doi: 10.1002/14651858.CD008478

References

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References to other published versions of this review

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