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Meta-Analysis
. 2019 Nov 20;2019(11):CD013240.
doi: 10.1002/14651858.CD013240.pub2.

Long-term GnRH agonist therapy before in vitro fertilisation (IVF) for improving fertility outcomes in women with endometriosis

Ektoras X Georgiou  1 , Pedro Melo  1 , Philip E Baker  2 , Hassan N Sallam  3 , Aydin Arici  4 , Juan A Garcia-Velasco  5 , Ahmed M Abou-Setta  6 , Christian Becker  7 , Ingrid E Granne  7
Affiliations
Meta-Analysis

Long-term GnRH agonist therapy before in vitro fertilisation (IVF) for improving fertility outcomes in women with endometriosis

Ektoras X Georgiou et al. Cochrane Database Syst Rev. .

Abstract

Background: Endometriosis is known to have an impact on fertility and it is common for women affected by endometriosis to require fertility treatments, including in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI), to improve the chance of pregnancy. It has been postulated that long-term gonadotrophin-releasing hormone (GnRH) agonist therapy prior to IVF or ICSI can improve pregnancy outcomes. This systematic review supersedes the previous Cochrane Review on this topic (Sallam 2006).

Objectives: To determine the effectiveness and safety of long-term gonadotrophin-releasing hormone (GnRH) agonist therapy (minimum 3 months) versus no pretreatment or other pretreatment modalities, such as long-term continuous combined oral contraception (COC) or surgical therapy of endometrioma, before standard in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI) in women with endometriosis.

Search methods: We searched the following electronic databases from their inception to 8 January 2019: Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL via the Cochrane CENTRAL Register of Studies ONLINE (CRSO), MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL). We searched trial registries to identify unpublished and ongoing trials. We also searched DARE (Database of Abstracts of Reviews of Effects), Web of Knowledge, OpenGrey, Latin American and Caribbean Health Science Information Database (LILACS), PubMed, Google and reference lists from relevant papers for any other relevant trials.

Selection criteria: Randomised controlled trials (RCTs) involving women with surgically diagnosed endometriosis that compared use of any type of GnRH agonist for at least three months before an IVF/ICSI protocol to no pretreatment or other pretreatment modalities, specifically use of long-term continuous COC (minimum of 6 weeks) or surgical excision of endometrioma within six months prior to standard IVF/ICSI. The primary outcomes were live birth rate and complication rate per woman randomised.

Data collection and analysis: Two independent review authors assessed studies against the inclusion criteria, extracted data and assessed risk of bias. A third review author was consulted, if required. We contacted the study authors, as required. We analysed dichotomous outcomes using Mantel-Haenszel risk ratios (RRs), 95% confidence intervals (CIs) and a fixed-effect model. For small numbers of events, we used a Peto odds ratio (OR) with 95% CI instead. We analysed continuous outcomes using the mean difference (MD) between groups and presented with 95% CIs. We studied heterogeneity of the studies via the I2 statistic. We assessed the quality of evidence using GRADE criteria.

Main results: We included eight parallel-design RCTs, involving a total of 640 participants. We did not assess any of the studies as being at low risk of bias across all domains, with the main limitation being lack of blinding. Using GRADE methodology, the quality of the evidence ranged from very low to low quality. Long-term GnRH agonist therapy versus no pretreatment We are uncertain whether long-term GnRH agonist therapy affects the live birth rate (RR 0.48, 95% CI 0.26 to 0.87; 1 RCT, n = 147; I2 not calculable; very low-quality evidence) or the overall complication rate (Peto OR 1.23, 95% CI 0.37; to 4.14; 3 RCTs, n = 318; I2 = 73%; very low-quality evidence) compared to standard IVF/ICSI. Further, we are uncertain whether this intervention affects the clinical pregnancy rate (RR 1.13, 95% CI 0.91 to 1.41; 6 RCTs, n = 552, I2 = 66%; very low-quality evidence), multiple pregnancy rate (Peto OR 0.14, 95% CI 0.03 to 0.56; 2 RCTs, n = 208, I2 = 0%; very low-quality evidence), miscarriage rate (Peto OR 0.45, 95% CI 0.10 to 2.00; 2 RCTs, n = 208; I2 = 0%; very low-quality evidence), mean number of oocytes (MD 0.72, 95% CI 0.06 to 1.38; 4 RCTs, n = 385; I2 = 81%; very low-quality evidence) or mean number of embryos (MD -0.76, 95% CI -1.33 to -0.19; 2 RCTs, n = 267; I2 = 0%; very low-quality evidence). Long-term GnRH agonist therapy versus long-term continuous COC No studies reported on this comparison. Long-term GnRH agonist therapy versus surgical therapy of endometrioma No studies reported on this comparison.

Authors' conclusions: This review raises important questions regarding the merit of long-term GnRH agonist therapy compared to no pretreatment prior to standard IVF/ICSI in women with endometriosis. Contrary to previous findings, we are uncertain as to whether long-term GnRH agonist therapy impacts on the live birth rate or indeed the complication rate compared to standard IVF/ICSI. Further, we are uncertain whether this intervention impacts on the clinical pregnancy rate, multiple pregnancy rate, miscarriage rate, mean number of oocytes and mean number of embryos. In light of the paucity and very low quality of existing data, particularly for the primary outcomes examined, further high-quality trials are required to definitively determine the impact of long-term GnRH agonist therapy on IVF/ICSI outcomes, not only compared to no pretreatment, but also compared to other proposed alternatives to endometriosis management.

PubMed Disclaimer

Conflict of interest statement

EXG has no interests to declare.

PM has no interests to declare.

PB has no interests to declare.

AA has no interests to declare

AMAS has no interests to declare. HNS is a co‐editor of two textbooks on infertility and has received royalties from the publishers. JGV has received consultancy and lecture fees from MSD, Merck Serono, Ferring and Gedeon Richter. CMB has received research support by Bayer, Volition Rx, Roche Diagnostics and MDNA Life Sciences. He has received consultancy fees from ObsEva, AbbVie and Myovant. IEG has received research support from Finox and Bayer.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 GnRH agonist therapy versus standard IVF/ICSI alone, outcome: 1.1 Live birth rate.
5
5
Forest plot of comparison: 1 GnRH agonist therapy versus standard IVF/ICSI alone, outcome: 1.2 Complication rate.
6
6
Forest plot of comparison: 1 GnRH agonist therapy vs Standard IVF/ICSI alone, outcome: 1.3 Clinical Pregnancy Rate.
1.1
1.1. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 1 Live birth rate.
1.2
1.2. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 2 Complication rate.
1.3
1.3. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 3 Clinical Pregnancy Rate.
1.4
1.4. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 4 Multiple pregnancy rate (per woman randomised).
1.5
1.5. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 5 Miscarriage rate (per woman randomised).
1.6
1.6. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 6 Ectopic pregnancy rate (per woman randomised).
1.7
1.7. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 7 Foetal abnormality rate (per woman randomised).
1.8
1.8. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 8 Mean number of oocytes.
1.9
1.9. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 9 Mean number of embryos.
1.10
1.10. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 10 Complication rate (totals).
1.11
1.11. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 11 Multiple pregnancy rate (per clinical pregnancy).
1.12
1.12. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 12 Miscarriage rate (per clinical pregnancy).
1.13
1.13. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 13 Ectopic pregnancy (per clinical pregnancy).
1.14
1.14. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 14 Foetal abnormality rate (per clinical pregnancy).
1.15
1.15. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 15 Live birth rate (ASRM I/II endometriosis).
1.16
1.16. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 16 Live birth rate (ARSM III/IV endometriosis).
1.17
1.17. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 17 Complication rate (ARSM I/II endometriosis.
1.18
1.18. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 18 Complication rate (ARSM III/IV endometriosis).
1.19
1.19. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 19 Clinical pregnancy rate (ARSM I/II endometriosis).
1.20
1.20. Analysis
Comparison 1 GnRH agonist therapy versus standard IVF/ICSI alone, Outcome 20 Clinical pregnancy rate (ARSM III/IV endometriosis).
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References to studies awaiting assessment

NCT02737800 {published data only}
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References to ongoing studies

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