Human Reproduction Update Advance Access published online on September 10, 2009
Human Reproduction Update, doi:10.1093/humupd/dmp033
The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review
1 Department of Obstetrics and Gynaecology, Imeldahospital, Imeldalaan 9, 2820 Bonheiden, Belgium 2 Universitaire Vrouwenkliniek, University Hospital Gent, De Pintelaan 185, 9000 Gent, Belgium 3 Leuven Institute for Fertility and Embryology, Tiensevest 168, 3000 Leuven, Belgium 4 Endoscopic Training Centre Antwerp, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060 Antwerpen, Belgium 5 Department of Obstetrics and Gynaecology, University of British Columbia, BC Women's Hospital and Women's Health Centre, 4500 Oak Street, Vancouver, BC, Canada 6 Department of Obstetrics and Gynaecology, Academic Medical Centre, 1105 DE Amsterdam, The Netherlands 7 Department of Endocrinology, KULeuven, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium 8 Department of Obstetrics and Gynaecology, KULeuven, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium
To whom correspondence should be addressed at: 9 Corresponding author. Tel: +32 15 505205; E-mail: jan.bosteels{at}imelda.be
BACKGROUND: Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking.
METHODS: We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied.
RESULTS: We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6–3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0–3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5–0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5–2.0).
CONCLUSIONS: Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.
Key words: hysteroscopy / subfertility / RCT / IVF / intrauterine insemination
Received on January 28, 2009; revised July 18, 2009; accepted on August 14, 2009