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Intervention Review

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

  1. Jan Bosteels1,*,
  2. Jenneke Kasius2,
  3. Steven Weyers3,
  4. Frank J Broekmans2,
  5. Ben Willem J Mol4,
  6. Thomas M D'Hooghe5

Editorial Group: Cochrane Menstrual Disorders and Subfertility Group

Published Online: 31 JAN 2013

Assessed as up-to-date: 7 AUG 2012

DOI: 10.1002/14651858.CD009461.pub2


How to Cite

Bosteels J, Kasius J, Weyers S, Broekmans FJ, Mol BWJ, D'Hooghe TM. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD009461. DOI: 10.1002/14651858.CD009461.pub2.

Author Information

  1. 1

    Belgian Branch of the Dutch Cochrane Centre, Leuven, Belgium

  2. 2

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

  3. 3

    University Hospital Ghent, Obstetrics and Gynaecology, Ghent, Belgium

  4. 4

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

  5. 5

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

*Jan Bosteels, Belgian Branch of the Dutch Cochrane Centre, Kapucijnenvoer 33 blok J bus 7001, 3000 Leuven, Leuven, Belgium. Jan.bosteels@cebam.Be.

Publication History

  1. Publication Status: Edited (no change to conclusions), comment added to review
  2. Published Online: 31 JAN 2013

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are detectable in 10% to 15% of women seeking treatment for subfertility.

Objectives

To assess the effects of the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions suspected on ultrasound, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods in women with otherwise unexplained subfertility or prior to intrauterine insemination (IUI), in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

Search methods

We searched the Cochrane Menstrual Disorders and Subfertility Specialised Register (6 August 2012), the Cochrane Central Register of Controlled Trials (T he Cochrane Library 2012, Issue 7), MEDLINE (1950 to October 2012), EMBASE (1974 to October 2012), CINAHL (from inception to October 2012) and other electronic sources of trials including trial registers, sources of unpublished literature and reference lists. We handsearched the American Society for Reproductive Medicine (ASRM) conference abstracts and proceedings (from January 2008 to October 2012) and we contacted experts in the field.

Selection criteria

Randomised comparisons between operative hysteroscopy versus control in women with otherwise unexplained subfertility or undergoing IUI, IVF or ICSI and suspected major uterine cavity abnormalities diagnosed by ultrasonography, saline infusion/gel instillation sonography, hysterosalpingography, diagnostic hysteroscopy or any combination of these methods. Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

Data collection and analysis

Two authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

Main results

Two studies met the inclusion criteria and neither reported the primary outcomes of live birth and complications from the procedure. In women with otherwise unexplained subfertility and submucous fibroids, there is no evidence of benefit with hysteroscopic myomectomy compared to regular fertility-oriented intercourse during 12 months for clinical pregnancy (odds ratio (OR) 2.4, 95% confidence interval (CI) 0.97 to 6.2, P = 0.06, 94 women) and miscarriage (OR 1.5, 95% CI 0.47 to 5.0, P = 0.47, 94 women) (very low-quality evidence). The hysteroscopic removal of polyps prior to IUI increases the odds of clinical pregnancy (experimental event rate (EER) 63%) compared to diagnostic hysteroscopy and polyp biopsy only (control event rate (CER) 28%) (OR 4.4, 95% CI 2.5 to 8.0, P < 0.00001, 204 women, high-quality evidence).

Authors' conclusions

Hysteroscopic myomectomy might increase the odds of clinical pregnancy in women with unexplained subfertility and submucous fibroids, but the evidence is at present not conclusive. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI might increase the clinical pregnancy rate. More randomised studies are needed to substantiate the effectiveness of the hysteroscopic removal of suspected endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions in women with unexplained subfertility or prior to IUI, IVF or ICSI.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Hysteroscopy for treating suspected abnormalities of the cavity of the womb in women having difficulty becoming pregnant

Human life starts when a fertilised egg has successfully implanted in the inner layer of the cavity of the womb. It is believed that abnormalities originating from this site, such as polyps, fibroids, septa or adhesions, may disturb this important event. The removal of these abnormalities by doing a so-called hysteroscopy using a very small diameter inspecting device might therefore increase the chance of becoming pregnant either spontaneously or after specialised fertility treatment, such as intrauterine insemination or in vitro fertilisation. This review identified no studies reporting live birth as an outcome. We found one study on the removal of fibroids in women with unexplained infertility. It suggests that there might be a higher chance of conceiving after surgery compared to regular sexual intercourse for 12 months. Due to the low number of women (94) and the low number of pregnancies (30) the differences are not statistically significant. The quality of the study is very low. Therefore uncertainty remains about the real value of removal of fibroids in raising the chance of conception in women having difficulty becoming pregnant. We found only one study on hysteroscopy in 215 women with polyps who were to be treated with insemination for various fertility problems. The findings support an important increase in the pregnancy rates after the hysteroscopic removal of polyps. Although the quality of this study is high, further studies are needed to confirm this result. Neither of the two studies reported data on the surgical complications of hysteroscopy.

More studies are needed before hysteroscopy can be proposed as a fertility-enhancing procedure in the general population of women having difficulty becoming pregnant.