Postoperative procedures for improving fertility following pelvic reproductive surgery

  • Review
  • Intervention

Authors


Abstract

Background

Hydrotubation with oil-soluble contrast media for unexplained infertility and adhesiolysis for infertility due to peritubal adhesions are primary procedures that are of recognised benefit. It is less clear whether postoperative procedures such as hydrotubation or second-look laparoscopy with adhesiolysis are beneficial following pelvic reproductive surgery.

Objectives

To assess the value of postoperative hydrotubation and second-look laparoscopy with adhesiolysis following female pelvic reproductive surgery.

Search methods

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (August 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to August 2008), EMBASE (1980 to August 2008), PsycINFO (1967 to August 2008), Current Contents (1993 to August 2008), Biological Abstracts (1969 to August 2008), CINAHL (1982 to August 2008) and reference lists of identified articles.

Selection criteria

All randomised controlled trials in which a postoperative procedure was compared with a control group following pelvic reproductive surgery were considered for inclusion in the review.

Data collection and analysis

Five randomised controlled trials were identified and included in this updated review. An attempt was made to obtain further information from the authors of all five trials. All trials were assessed for quality. The studied outcomes were pregnancy, live birth, ectopic pregnancy and miscarriage rates, and the rates of tubal patency and procedure-related complications. Review authors extracted the data independently and the odds ratios (OR) were estimated for these dichotomous outcomes.

Main results

Five randomised controlled trials were identified and included in this review. The odds of pregnancy (OR 1.12, 95% confidence interval (CI) 0.57 to 2.21) and live birth (OR 0.61, 95% CI 0.24 to 1.59) were not significantly different with postoperative hydrotubation versus no hydrotubation. The odds of pregnancy (OR 0.96, 95% CI 0.44 to 2.07) or live birth (OR 0.67, 95% CI 0.19 to 2.32) were also not significantly different with second-look laparoscopy and adhesiolysis versus no second-look laparoscopy. Whether hydrotubation was early or late and whether hydrotubation fluid contained steroid or not had no significant impact on the odds of pregnancy or live birth. Late antibiotic hydrotubation increased the odds of at least one patent fallopian tube when compared with early hydrotubation in women (OR 7.72, 95% CI 2.50 to 8.93). The odds of infective morbidity significantly increased with early hydrotubation when compared with late non-antibiotic hydrotubation (OR 4.72, 95% CI 2.50 to 8.93). When comparing late hydrotubation following tubal stent removal with early hydrotubation in women who had no tubal stenting, there was no significant difference in pregnancy or live birth rates.

Authors' conclusions

There is insufficient evidence to support the routine practice of hydrotubation or second-look laparoscopy following female pelvic reproductive surgery. The studies on which this conclusion is based were either of poor quality or underpowered. These interventions should be performed in the context of a good quality, adequately powered randomised controlled trial. Postoperative hydrotubation with fluid containing antibiotic may offer benefit over hydrotubation fluid without antibiotic following tubal surgery. A randomised controlled trial of postoperative hydrotubation with antibiotic-containing fluid versus no hydrotubation for improving fertility following tubal surgery is justified.

摘要

背景

在骨盆腔的生殖手術之後,為了提高生育率而採取的術後程序

針對不明原因的不孕症,在輸卵管通水檢查時加上脂溶性的顯影劑,以及針對因為輸卵管週遭沾黏所造成的不孕症,使用沾黏物剝離,是我們初步會進行的處置且已知會有所幫助。但是術後輸卵管通水檢查,或是二次手術以進行沾黏剝離術,這些手術後的程序是否能夠為後續的骨盆腔生殖手術帶來幫助,目前還不清楚。

目標

評估在婦女們接受完骨盆腔的生殖手術之後,有關於手術後的輸卵管通水檢查,以及合併沾黏剝離術所進行的2次腹腔鏡探查術。

搜尋策略

我們搜尋Cochrane Menstrual Disorders以及Subfertility Group's specialised register of controlled trials (2002年8月22日搜尋)、 Cochrane Controlled Trials Register (Cochrane Library, Issue 3, 2002)、MEDLINE (1966年2002年8月)、 EMBASE (1980年2002年8月)、PsycINFO (1967年2002年8月)、Current Contents (1993年 002年8月)、 Biological Abstracts (1969年2002年6月)、及CINAHL (1982年2002年7月) 以及文章的參考資料清單。

選擇標準

在骨盆腔的生殖手術之後,所採取的手術後程序曾被拿來跟對照組進行比較,而這樣的對照組又是由隨機化過程所產生的時候,納入為本篇回顧中的收集條件。

資料收集與分析

對於所有的5份試驗來說,我們曾經試著要向這些作者取得更深入的資訊,在此之後,我們共確認了5份隨機對照試驗,並將它們收集在本篇回顧之中。所有的試驗都會針對品質方面的標準來加以評估。這些研究的結果包括了懷孕、產下活胎、子宮外孕與流產的比率,以及輸卵管通暢的比率,還有發生與程序相關之併發症的比率。審稿者都獨立地擷取出了這些資料,而且針對用於這些二元性結果的勝算比,我們都會從這些資料中加以估算。

主要結論

跟不採用輸卵管通水檢查比較起來,當使用了手術後的輸卵管通水檢查時,或是採不採用2次腹腔鏡探查沾黏剝離術比較起來,對於懷孕、產下活胎、子宮外孕,以及流產方面的可能性而言,都不會有很明顯的差異。輸卵管通水檢查是否在初期或是後期使用,以及輸卵管通水檢查的流體中是否含有類固醇,對於懷孕、產下活胎、子宮外孕,或是流產方面的可能性而言,都不會帶來任何顯著的影響。在輸卵管手術之後的6個星期,若是在拆除了輸卵管的支架之後,對於在後期才採取輸卵管通水檢查而言,跟輸卵管通水檢查之流體中不添加抗生素的情況比較起來,假使在輸卵管通水檢查之流體中添加了抗生素的話,那麼懷孕與產下活胎的可能性都會大幅地提高,至於因為感染而引起併發症的可能性則會顯著地下降。對於沒有使用輸卵管支架的婦女們而言,且初期就使用了輸卵管通水檢查的情況比較起來,若是在拆除了輸卵管的支架之後,到了後期才採取輸卵管通水檢查,那麼至少有1條輸卵管呈現開放式的可能性則會明顯地提高,但是這樣的介入行為並不會對於懷孕、產下活胎、子宮外孕,或是流產的可能性方面,帶來明顯的影響。

作者結論

當婦女們接受了骨盆腔的生殖手術之後,不論是按照例行性地使用輸卵管通水檢查或是2次腹腔鏡探查術,都沒有充分的證據能夠加以支持。對於這些研究而言,結論的部分就是以它們為基礎,但是這些研究若不是品質方面顯得拙劣,就是缺乏足夠的說服力。若是想要執行這些介入行為,則應該要在具備某種良好品質的背景之下,而且還需要有獲得適當之說服力的隨機對照試驗。在手術之後,跟不在流體當中添加抗生素的輸卵管通水檢查比較起來,使用手術後的輸卵管通水檢查,並且在流體當中添加抗生素時,或許可以提供幫助。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於婦女的生殖系統進行完手術之後,不論是按照例行性地使用輸卵管通水檢查或是2次腹腔鏡探查術,關於其中所產生的優點或是危害,都沒有足夠的證據能夠說明。手術進行的位置是在婦女的骨盆腔,可以用來增加懷孕與產下活胎的機會。手術可能會帶來沾黏的現象,而且有時候會用流體來沖洗輸卵管(輸卵管通水檢查),以抒通阻塞輸卵管的鬆脫組織。我們也會使用腹腔鏡(透過腹部的手術切口來檢查肚子面的器官)來改善生殖的能力。本篇試驗的回顧發現,若是要在骨盆腔的生殖手術之後,不論是按照例行性地使用輸卵管通水檢查或是2次腹腔鏡探查術,都沒有足夠的證據能夠加以支持。還需要有更多的研究。

Plain language summary

Postoperative procedures for improving fertility following pelvic reproductive surgery

There is insufficient evidence to show the benefit or harm of routine hydrotubation or second-look laparoscopy following surgery on a woman's reproductive system. Surgery to correct tubal damage is undertaken to improve pregnancy and live birth rates. Laparoscopy (where the abdominal organs are examined through a small surgical cut in the abdomen) to treat postoperative adhesions and postoperative hydrotubation (flushing out of the fallopian tubes) have been used to improve the results of tubal surgery. The review of trials found there is insufficient evidence to support the routine practice of hydrotubation or this second-look laparoscopy after pelvic reproductive surgery. More research is needed.