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Meta-Analysis
. 2020 Oct 22;10(10):CD002125.
doi: 10.1002/14651858.CD002125.pub4.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

Pedro Melo  1 , Ektoras X Georgiou  1 , Neil Johnson  2 , Sabine F van Voorst  3 , Annika Strandell  4 , Ben Willem J Mol  5 , Christian Becker  6 , Ingrid E Granne  6
Affiliations
Meta-Analysis

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

Pedro Melo et al. Cochrane Database Syst Rev. .

Abstract

Background: Tubal disease accounts for 20% of infertility cases. Hydrosalpinx, caused by distal tubal occlusion leading to fluid accumulation in the tube(s), is a particularly severe form of tubal disease negatively affecting the outcomes of assisted reproductive technology (ART). It is thought that tubal surgery may improve the outcome of ART in women with hydrosalpinges.

Objectives: To assess the effectiveness and safety of tubal surgery in women with hydrosalpinges prior to undergoing conventional in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

Search methods: We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, DARE, and two trial registers on 8 January 2020, together with reference checking and contact with study authors and experts in the field to identify additional trials.

Selection criteria: Randomised controlled trials (RCTs) comparing surgical treatment versus no surgical treatment, or comparing surgical interventions head-to-head, in women with tubal disease prior to undergoing IVF.

Data collection and analysis: We used Cochrane's standard methodological procedures. The primary outcomes were live birth rate (LBR) and surgical complication rate per woman randomised. Secondary outcomes included clinical, multiple and ectopic pregnancy rates, miscarriage rates and mean numbers of oocytes retrieved and of embryos obtained.

Main results: We included 11 parallel-design RCTs, involving a total of 1386 participants. The included trials compared different types of tubal surgery (salpingectomy, tubal occlusion or transvaginal aspiration of hydrosalpingeal fluid) to no tubal surgery, or individual interventions to one another. We assessed no studies as being at low risk of bias across all domains, with the main limitations being lack of blinding, wide confidence intervals and low event and sample sizes. We used GRADE methodology to rate the quality of the evidence. Apart from one moderate-quality result in one review comparison, the evidence provided by these 11 trials ranged between very low- to low-quality. Salpingectomy versus no tubal surgery No included study reported on LBR for this comparison. We are uncertain of the effect of salpingectomy on surgical complications such as the rate of conversion to laparotomy (Peto odds ratio (OR) 5.80, 95% confidence interval (CI) 0.11 to 303.69; one RCT; n = 204; very low-quality evidence) and pelvic infection (Peto OR 5.80, 95% CI 0.11 to 303.69; one RCT; n = 204; very low-quality evidence). Salpingectomy probably increases clinical pregnancy rate (CPR) versus no surgery (risk ratio (RR) 2.02, 95% CI 1.44 to 2.82; four RCTs; n = 455; I2 = 42.5%; moderate-quality evidence). This suggests that in women with a CPR of approximately 19% without tubal surgery, the rate with salpingectomy lies between 27% and 52%. Proximal tubal occlusion versus no surgery No study reported on LBR and surgical complication rate for this comparison. Tubal occlusion may increase CPR compared to no tubal surgery (RR 3.21, 95% CI 1.72 to 5.99; two RCTs; n = 209; I2 = 0%; low-quality evidence). This suggests that with a CPR of approximately 12% without tubal surgery, the rate with tubal occlusion lies between 21% and 74%. Transvaginal aspiration of hydrosalpingeal fluid versus no surgery No study reported on LBR for this comparison, and there was insufficient evidence to identify a difference in surgical complication rate between groups (Peto OR not estimable; one RCT; n = 176). We are uncertain whether transvaginal aspiration of hydrosalpingeal fluid increases CPR compared to no tubal surgery (RR 1.67, 95% CI 1.10 to 2.55; three RCTs; n = 311; I2 = 0%; very low-quality evidence). Laparoscopic proximal tubal occlusion versus laparoscopic salpingectomy We are uncertain of the effect of laparoscopic proximal tubal occlusion versus laparoscopic salpingectomy on LBR (RR 1.21, 95% CI 0.76 to 1.95; one RCT; n = 165; very low-quality evidence) and CPR (RR 0.81, 95% CI 0.62 to 1.07; three RCTs; n = 347; I2 = 77%; very low-quality evidence). No study reported on surgical complication rate for this comparison. Transvaginal aspiration of hydrosalpingeal fluid versus laparoscopic salpingectomy No study reported on LBR for this comparison, and there was insufficient evidence to identify a difference in surgical complication rate between groups (Peto OR not estimable; one RCT; n = 160). We are uncertain of the effect of transvaginal aspiration of hydrosalpingeal fluid versus laparoscopic salpingectomy on CPR (RR 0.69, 95% CI 0.44 to 1.07; one RCT; n = 160; very low-quality evidence).

Authors' conclusions: We found moderate-quality evidence that salpingectomy prior to ART probably increases the CPR compared to no surgery in women with hydrosalpinges. When comparing tubal occlusion to no intervention, we found that tubal occlusion may increase CPR, although the evidence was of low quality. We found insufficient evidence of any effect on procedure- or pregnancy-related adverse events when comparing tubal surgery to no intervention. Importantly, none of the studies reported on long term fertility outcomes. Further high-quality trials are required to definitely determine the impact of tubal surgery on IVF and pregnancy outcomes of women with hydrosalpinges, particularly for LBR and surgical complications; and to investigate the relative efficacy and safety of the different surgical modalities in the treatment of hydrosalpinges prior to ART.

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Conflict of interest statement

PM has no interests to declare.

EXG has no interests to declare.

NJ works as a gynaecologist at Auckland Gynaecology Group and Fertility Specialist at Repromed Auckland. Within the last 3 years NJ has had consultancy with Guerbet, Myovant Sciences, Vifor Pharma and Roche Diagnostics and has received research funding from Guerbet, AbbVie and Myovant Sciences.

SVV ‐ at the time of the update in 2010 ‐ was a medical student of the faculty of Health, Medicine and Life Sciences of the University of Maastricht. She is now a resident in Obstetrics and Gynaecology at the Erasmus Medical Center, Rotterdam, the Netherlands. She has no financial conflicts of interest.

AS led one of the trials included in this review (Strandell 1999). She is a gynaecologist at Sahlgrenska Hospital, associate professor at the University of Gothenburg and employed at the regional centre for Health Technology Assessment in Göteborg, Sweden. She has received fees from Guerbet for an expert consultancy.

BWJM is an author on one of the trials included in this review (Dreyer 2016) and confirms he took no part in selecting this study, extracting data or assessing risk of bias. In addition, BWJM is supported by a NHMRC Investigator grant (GNT1176437) and reports consultancy for ObsEva, Merk KGaA, iGenomix and Guerbet.

CMB has received research support by Bayer, Volition Rx, Roche Diagnostics and MDNA Life Sciences. He has also received consultancy fees from ObsEva, AbbVie and Myovant.

IEG's institution has received research support from Finox and Bayer.

Figures

1
1
Study flow diagram.
2
2
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
4
4
Forest plot of comparison: Tubal surgery (all methods) versus no tubal surgery, outcome: 8.1 Clinical pregnancy rate.
5
5
Forest plot of comparison: 2 Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, outcome: 2.1 Live birth rate.
6
6
Forest plot of comparison: 2 Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, outcome: 2.4 Clinical pregnancy rate.
1.1
1.1. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 1: Surgical complication rate ‐ conversion to laparotomy
1.2
1.2. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 2: Surgical complication rate ‐ pelvic infection
1.3
1.3. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 3: Clinical pregnancy rate
1.4
1.4. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 4: Multiple pregnancy rate
1.5
1.5. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 5: Miscarriage rate
1.6
1.6. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 6: Ectopic pregnancy rate
1.7
1.7. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 7: Mean number of oocytes
1.8
1.8. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 8: Mean number of embryos
1.9
1.9. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 9: Multiple pregnancy rate (per clinical pregnancy)
1.10
1.10. Analysis
Comparison 1: Tubal surgery (all methods) vs no tubal surgery, Outcome 10: Miscarriage rate (per clinical pregnancy)
2.1
2.1. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 1: Live birth rate
2.2
2.2. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 2: Surgical complication rate ‐ wound infection
2.3
2.3. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 3: Surgical complication rate ‐ pelvic infection
2.4
2.4. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 4: Clinical pregnancy rate
2.5
2.5. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 5: Multiple pregnancy rate
2.6
2.6. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 6: Miscarriage rate
2.7
2.7. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 7: Ectopic pregnancy rate
2.8
2.8. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 8: Mean number of oocytes
2.9
2.9. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 9: Mean number of embryos
2.10
2.10. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 10: Multiple pregnancy rate (per clinical pregnancy)
2.11
2.11. Analysis
Comparison 2: Proximal tubal occlusion (all methods) vs laparoscopic salpingectomy, Outcome 11: Miscarriage rate (per clinical pregnancy)
3.1
3.1. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 1: Surgical complication rate
3.2
3.2. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 2: Clinical pregnancy rate
3.3
3.3. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 3: Miscarriage rate
3.4
3.4. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 4: Ectopic pregnancy rate
3.5
3.5. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 5: Mean number of oocytes
3.6
3.6. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 6: Mean number of embryos
3.7
3.7. Analysis
Comparison 3: Transvaginal aspiration of hydrosalpingeal fluid vs laparoscopic salpingectomy, Outcome 7: Miscarriage rate (per clinical pregnancy)
See this image and copyright information in PMC

Update of

References

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References to ongoing studies

ChiCTR‐IOR‐16008961 {unpublished data only}
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IRCT2014011116161N1 {unpublished data only}
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NCT03521128 {unpublished data only}
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References to other published versions of this review

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