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Cochrane Database of Systematic Reviews

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

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DOI:
https://doi.org/10.1002/14651858.CD009461.pub3Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 21 February 2015see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Gynaecology and Fertility Group

Copyright:
  1. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Jan Bosteels

    Correspondence to: Belgian Branch of the Dutch Cochrane Centre, Leuven, Belgium

    [email protected]

  • Jenneke Kasius

    Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands

  • Steven Weyers

    Obstetrics and Gynaecology, University Hospital Ghent, Ghent, Belgium

  • Frank J Broekmans

    Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands

  • Ben Willem J Mol

    The Robinson Institute, School of Paediatrics and Reproductive Health, The University of Adelaide, Adelaide, Australia

  • Thomas M D'Hooghe

    Leuven University Fertility Centre, University Hospital Gasthuisberg, Gasthuisberg, Belgium

Contributions of authors

JB co‐ordinated the writing of the protocol and review and its update.

JK co‐authored the protocol for the background section and searched the literature.

FB and TD independently assessed the retrieved published reports for inclusion of potentially eligible studies.

SW independently extracted study data.

BWM gave advice on review methodology and content and critically appraised the Cochrane review.

Sources of support

Internal sources

  • CEBAM, Belgium.

    Research grant was obtained through CEBAM, the Centre for Evidence‐based Medicine, Belgian Branch of the Cochrane Collaboration

External sources

  • No sources of support supplied

Declarations of interest

FB and JK (principal investigator) and BWM (co‐investigator) are at present involved in the 'inSIGHT trial' (SIGnificance of Routine Hysteroscopy Prior to a First 'in Vitro Fertilization' Treatment Cycle: NCT 01242852), which is financially supported by ZonMw, a Dutch government operated consortium responsible for granting funds in the field of clinical practice research. This study is still in the recruitment phase.

The first published version of the present Cochrane review has been part of a PhD thesis entitled "Studies on the effectiveness of endoscopic surgery in reproductive medicine" (http://dare.uva.nl/record/497164), which has been successfully defended at the faculty of Medicine of the University of Amsterdam, the Netherlands on 2 September 2014 by the first author (JB).

Acknowledgements

Cochrane Menstrual Disorders and Subfertility Group (MDSG): we wish to thank Prof. Cindy Farquhar, MDSG Editor in Chief; Ms. Jane Clarke, former MDSG Managing Editor; Ms. Helen Nagels, MDSG Managing Editor and Ms. Jane Marjoribanks, MDSG Assistant Managing Editor for their advice and support. Ms. Marian Showell, MDSG Trials Search Co‐ordinator assisted in searching the MDSG Specialised Register and gave advice on the handsearch.

Biomedical Library Gasthuisberg, Catholic University, Leuven, Belgium. Many thanks to Mr. Jens De Groot for skilful assistance in developing the literature search strategy.

Prof. Tirso Pérez‐Medina, head of the department of Gynaecology at the University Hospital Puerta de Hierro, Madrid, Spain, has answered all the queries concerning the randomised controlled trial on the effectiveness of hysteroscopic polypectomy prior to IUI.

The Board of the European Society of Gynaecological Endoscopy (ESGE). Prof. Hans Brolmann (ESGE President) and Dr. Rudi Campo (ESGE Secretary) have been very helpful in contacting a group of experts in hysteroscopy in the field of Reproductive Medicine. Dr. Rudi Campo (ZOL Genk, Belgium), Dr. Dick Schoot (Catharina Hospital, Eindhoven, the Netherlands), Prof. Attilio Di Spiezio Sardo (University of Naples 'Frederico II', Naples, Italy), Prof. Hervé Fernandez (Hôpital Bicêtre, Le Kremin‐Bicêtre, France) have provided data on published or ongoing randomised trials relevant to the research questions.

Dr. Ben Cohlen (Fertility Centre Isala, Zwolle, the Netherlands), Prof. Willem Ombelet (ZOL, Genk, Belgium) and Prof. Carl Spiessens (Leuven University Fertility Centre, Leuven, Belgium) have provided useful data on the clinical pregnancy rates after gonadotropin stimulation and IUI. Dr. Mariette Goddijn (AMC Amsterdam, the Netherlands) has given valuable feedback on the risk of bias assessment for one of the included trials at the occasion of the oral opposition and defence of the PhD thesis of the first author.

Ms.Elizabeth Bosselaers (Managing Secretary CEBAM, the Belgian Branch of the Dutch Cochrane Centre) has given valuable remarks for improving the Plain language summary.

We acknowledge comments sent by Professor Hossam Eldin Shawki Abdalla MD of the Obstetrics & Gynecology Department, Faculty of Medicine, El ‐Minia University, Egypt. Our formal response was published in October 2014 and the points made were taken into account in this update.

Version history

Published

Title

Stage

Authors

Version

2018 Dec 05

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

Review

Jan Bosteels, Steffi van Wessel, Steven Weyers, Frank J Broekmans, Thomas M D'Hooghe, M Y Bongers, Ben Willem J Mol

https://doi.org/10.1002/14651858.CD009461.pub4

2015 Feb 21

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

Review

Jan Bosteels, Jenneke Kasius, Steven Weyers, Frank J Broekmans, Ben Willem J Mol, Thomas M D'Hooghe

https://doi.org/10.1002/14651858.CD009461.pub3

2013 Jan 31

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

Review

Jan Bosteels, Jenneke Kasius, Steven Weyers, Frank J Broekmans, Ben Willem J Mol, Thomas M D'Hooghe

https://doi.org/10.1002/14651858.CD009461.pub2

2011 Nov 09

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities.

Protocol

Jan Bosteels, Jenneke Kasius, Steven Weyers, Frank J Broekmans, Ben Willem J Mol, Thomas M D'Hooghe

https://doi.org/10.1002/14651858.CD009461

Differences between protocol and review

  1. As a result of further peer review, the objectives of the review have been rephrased. The descriptions in the Types of interventions and Data synthesis sections were modified accordingly. For both comparisons we made a stratification according to the types of uterine pathology; for the second comparison we made a clear distinction between IUI, IVF or ICSI.

  2. A 'Summary of findings' table using the GRADE approach has been added.

  3. In the Assessment of risk of bias in included studies section of the review, the items 'blinding of participants and personnel' and 'blinding of outcome assessors' were reinserted as requested by the editorial reviewers. We assessed all six items including blinding of participants, personnel and outcome assessors in the final review as opposed to the protocol.

  4. In the Assessment of heterogeneity section of the review we have added the Q‐statistic.

  5. In the Subgroup analysis and investigation of heterogeneity section of the review we planned to conduct a further subgroup analysis based on the women's age.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

PRISMA study flow diagram.
Figures and Tables -
Figure 1

PRISMA study flow diagram.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figures and Tables -
Figure 3

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Forest plot of comparison: 1 Hysteroscopic myomectomy vs regular fertility‐oriented intercourse in women with unexplained subfertility and submucous fibroids.Outcome: 1.1 Clinical pregnancy per woman randomised.
Figures and Tables -
Figure 4

Forest plot of comparison: 1 Hysteroscopic myomectomy vs regular fertility‐oriented intercourse in women with unexplained subfertility and submucous fibroids.Outcome: 1.1 Clinical pregnancy per woman randomised.

Forest plot of comparison: 1 Hysteroscopic myomectomy vs regular fertility‐oriented intercourse in women with unexplained subfertility and submucous fibroids. Outcome: 1.2 Miscarriage per clinical pregnancy.
Figures and Tables -
Figure 5

Forest plot of comparison: 1 Hysteroscopic myomectomy vs regular fertility‐oriented intercourse in women with unexplained subfertility and submucous fibroids. Outcome: 1.2 Miscarriage per clinical pregnancy.

Forest plot of comparison: 2 Hysteroscopic removal of polyps vs diagnostic hysteroscopy and biopsy only prior to IUI. Outcome: 2.1 Clinical pregnancy per woman randomised.
Figures and Tables -
Figure 6

Forest plot of comparison: 2 Hysteroscopic removal of polyps vs diagnostic hysteroscopy and biopsy only prior to IUI. Outcome: 2.1 Clinical pregnancy per woman randomised.

Comparison 1 Operative hysteroscopy versus control in women with otherwise unexplained subfertility and suspected major uterine cavity abnormalities, Outcome 1 Clinical pregnancy.
Figures and Tables -
Analysis 1.1

Comparison 1 Operative hysteroscopy versus control in women with otherwise unexplained subfertility and suspected major uterine cavity abnormalities, Outcome 1 Clinical pregnancy.

Comparison 1 Operative hysteroscopy versus control in women with otherwise unexplained subfertility and suspected major uterine cavity abnormalities, Outcome 2 Miscarriage.
Figures and Tables -
Analysis 1.2

Comparison 1 Operative hysteroscopy versus control in women with otherwise unexplained subfertility and suspected major uterine cavity abnormalities, Outcome 2 Miscarriage.

Comparison 2 Operative hysteroscopy versus control in women undergoing MAR with suspected major uterine cavity abnormalities, Outcome 1 Clinical pregnancy.
Figures and Tables -
Analysis 2.1

Comparison 2 Operative hysteroscopy versus control in women undergoing MAR with suspected major uterine cavity abnormalities, Outcome 1 Clinical pregnancy.

Summary of findings for the main comparison. Operative hysteroscopy compared with control for unexplained subfertility associated with suspected major uterine cavity abnormalities

Operative hysteroscopy compared with control for unexplained subfertility associated with suspected major uterine cavity abnormalities

Patient or population: women with submucous fibroids and otherwise unexplained subfertility

Settings: infertility centre in Rome, Italy

Intervention: hysteroscopic removal of one submucous fibroid ≤ 40 mm

Comparison: regular fertility‐oriented intercourse

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Myomectomy

Live birth

No data were reported for this primary outcome.

Hysteroscopy complications

No data were reported for this primary outcome.

Clinical pregnancy

ultrasound1

12 months

Medium‐risk population

OR 2.44

(0.97 to 6.17)

94
(1 study)

⊕⊝⊝⊝
very low2,3,4

214 per 1000

399 per 1000
(209 to 627)

Miscarriage

ultrasound5

12 months

Medium‐risk population

OR 0.58

(0.12 to 2.8)

30 pregnancies in 94 women
(1 study)

⊕⊝⊝⊝
very low2,3,4

556 per 1000

421 per 1000
(131 to 778)

*The basis for the assumed risk is the control group risk of the single included study (Casini 2006). The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 A clinical pregnancy was defined by the visualisation of an embryo with cardiac activity at six to seven weeks' gestational age.

2 Unclear allocation concealment.

3 Wide confidence intervals.

4 High risk of selective outcome reporting and unclear whether there is other bias caused by imbalance in the baseline characteristics.

5 Miscarriage was defined by the clinical loss of an intrauterine pregnancy between the 7th and 12th weeks of gestation.

Figures and Tables -
Summary of findings for the main comparison. Operative hysteroscopy compared with control for unexplained subfertility associated with suspected major uterine cavity abnormalities
Summary of findings 2. Operative hysteroscopy compared with control for suspected major uterine cavity abnormalities prior to medically assisted reproduction

Operative hysteroscopy compared with control for suspected major uterine cavity abnormalities prior to medically assisted reproduction

Patient or population: subfertile women with endometrial polyps diagnosed by ultrasonography prior to treatment with gonadotropin and intrauterine insemination

Settings: infertility unit of a university tertiary hospital in the Spanish capital Madrid

Intervention: hysteroscopic polypectomy using a 5.5 mm continuous flow office hysteroscope with a 1.5 mm scissors and forceps

Comparison: diagnostic hysteroscopy using a 5.5 mm continuous flow office hysteroscope and polyp biopsy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Polypectomy

Live birth

No data were reported for this primary outcome.

Hysteroscopy complications

No data were reported for this primary outcome.

Clinical pregnancy

ultrasound1

4 IUI cycles

Low‐risk population2

OR 4.41

(2.45 to 7.96)

204
(1 study)

⊕⊕⊕⊝
moderate5

250 per 1000

595 per 1000
(450 to 726)

Medium‐risk population3

366 per 1000

718 per 1000
(586 to 821)

High‐risk population4

528 per 1000

831 per 1000
(733 to 899)

Miscarriage

No data were reported for this secondary outcome.

*The basis for the assumed risk in the low‐, medium‐ or high‐risk populations is the control group risk of three studies provided in the footnotes below. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; OR: odds ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Clinical pregnancy was defined by the presence of at least one gestational sac on ultrasound.

2 Based on the clinical pregnancy rate per woman after 4 cycles gonadotropins and IUI for male factor subfertility based on data from Bensdorp 2007.

3 Based on the clinical pregnancy rate per woman after 4 cycles gonadotropins and IUI for unexplained subfertility based on data from Veltman‐Verhulst 2012.

4 Based on the clinical pregnancy rate per woman after 4 cycles gonadotropins and IUI for female factor subfertility based on data from Spiessens 2003.

5 There was high risk for selective outcome reporting.

Figures and Tables -
Summary of findings 2. Operative hysteroscopy compared with control for suspected major uterine cavity abnormalities prior to medically assisted reproduction
Table 1. Effect of polyp size on clinical pregnancy rates in the intervention group

Polyp size

Clinical pregnancy1

Clinical pregnancy rate (95% CI)2

< 5 mm

19/25

76% (from 72% to 80%)

5 to 10 mm

18/32

56% (from 53% to 59%)

11 to 20 mm

16/26

61% (from 58% to 65%)

> 20 mm

11/18

61% (from 58% to 64%)

1 Clinical pregnancy is defined by a pregnancy diagnosed by ultrasound visualisation of at least one gestational sac per woman randomised.

2 No significant difference was found for the clinical pregnancy rates between the 4 subgroups (P = 0.32).

Figures and Tables -
Table 1. Effect of polyp size on clinical pregnancy rates in the intervention group
Table 2. GRADE evidence profile ‐ unexplained subfertility and submucous fibroids

Quality assessment

Submucous fibroids and unexplained subfertility

No of studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Other considerations

Clinical pregnancy (follow‐up 1 year; ultrasound1)

1

RCT

Serious2

No serious inconsistency

No serious indirectness

Serious3

Reporting bias4

Miscarriage (follow‐up 1 year; ultrasound5)

1

RCT

Serious2

No serious inconsistency

No serious indirectness

Serious3

Reporting bias4

1 A clinical pregnancy was defined by the visualisation of an embryo with cardiac activity at six to seven weeks' gestational age.

2 Unclear allocation concealment.

3 Wide confidence intervals.

4 High risk of selective outcome reporting and unclear whether there is other bias caused by imbalance in the baseline characteristics.

5 Miscarriage was defined by the clinical loss of an intrauterine pregnancy between the 7th and 12th weeks of gestation.

Figures and Tables -
Table 2. GRADE evidence profile ‐ unexplained subfertility and submucous fibroids
Table 3. GRADE evidence profile ‐ endometrial polyps prior to IUI

Quality assessment

Endometrial polyps prior to gonadotropin and IUI treatment

No of studies

Design

Limitations

Inconsistency

Indirectness

Imprecision

Other considerations

Clinical pregnancy (follow‐up 4 IUI cycles; ultrasound1)

1

RCT

No serious limitations

No serious inconsistency

No serious indirectness

No serious imprecision

Selective outcome reporting2

1 Clinical pregnancy was defined by the presence of at least one gestational sac on ultrasound.

2 There was high risk for selective outcome reporting bias.

Figures and Tables -
Table 3. GRADE evidence profile ‐ endometrial polyps prior to IUI
Comparison 1. Operative hysteroscopy versus control in women with otherwise unexplained subfertility and suspected major uterine cavity abnormalities

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Clinical pregnancy Show forest plot

1

94

Odds Ratio (M‐H, Fixed, 95% CI)

2.44 [0.97, 6.17]

1.1 Removal of submucous fibroids only vs regular fertility‐oriented intercourse

1

52

Odds Ratio (M‐H, Fixed, 95% CI)

2.04 [0.62, 6.66]

1.2 Removal of mixed submucous‐intramural fibroids vs regular fertility‐oriented intercourse

1

42

Odds Ratio (M‐H, Fixed, 95% CI)

3.24 [0.72, 14.57]

2 Miscarriage Show forest plot

1

30

Odds Ratio (M‐H, Fixed, 95% CI)

0.58 [0.12, 2.85]

2.1 Removal of submucous fibroids only vs regular fertility‐oriented intercourse

1

19

Odds Ratio (M‐H, Fixed, 95% CI)

0.63 [0.09, 4.40]

2.2 Removal of mixed submucous‐intramural fibroids vs regular fertility‐oriented intercourse

1

11

Odds Ratio (M‐H, Fixed, 95% CI)

0.5 [0.03, 7.99]

Figures and Tables -
Comparison 1. Operative hysteroscopy versus control in women with otherwise unexplained subfertility and suspected major uterine cavity abnormalities
Comparison 2. Operative hysteroscopy versus control in women undergoing MAR with suspected major uterine cavity abnormalities

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Clinical pregnancy Show forest plot

1

204

Odds Ratio (M‐H, Fixed, 95% CI)

4.41 [2.45, 7.96]

1.1 Hysteroscopic polypectomy vs diagnostic hysteroscopy and biopsy only prior to IUI

1

204

Odds Ratio (M‐H, Fixed, 95% CI)

4.41 [2.45, 7.96]

Figures and Tables -
Comparison 2. Operative hysteroscopy versus control in women undergoing MAR with suspected major uterine cavity abnormalities