Assessment of uterine cavity by hysteroscopy in assisted reproduction programme and its influence on pregnancy outcome

Outpatient hysteroscopy impact on subsequent assisted reproductive technology: a systematic review and meta-analysis in patients with normal transvaginal sonography or hysterosalpingography images

BACKGROUND

Standard management for intrauterine lesions typically involves initial imaging followed by operative hysteroscopy for suspicious findings. However, the efficacy of routine outpatient hysteroscopy in women undergoing assisted reproductive technology (ART) remains uncertain due to a lack of decisive high-quality evidence. This study aimed to determine whether outpatient hysteroscopy is beneficial for infertile women who have unremarkable imaging results prior to undergoing ART.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines, incorporating data up to May 31, 2023, from databases such as PubMed, Embase, and the Cochrane Library. The primary outcome assessed was the live birth rate, with secondary outcomes including chemical pregnancy, clinical pregnancy rates, and miscarriage rates. Statistical analysis involved calculating risk ratios with 95% confidence intervals and assessing heterogeneity with the I2 statistic.

RESULTS

The analysis included ten randomized control trials. Receiving outpatient hysteroscopy before undergoing ART was associated with increased live birth (RR 1.22, 95% CI 1.03-1.45, I2 61%) and clinical pregnancy rate (RR 1.27 95% CI 1.10-1.47, I2 53%). Miscarriage rates did not differ significantly (RR 1.25, CI 0.90-1.76, I2 50%). Subgroup analyses did not show a significant difference in clinical pregnancy rates when comparing normal versus abnormal hysteroscopic findings (RR 1.01, CI 0.78-1.32, I2 38%). We analyzed data using both intention-to-treat and per-protocol approaches, and our findings were consistent across both analytical methods.

CONCLUSIONS

Office hysteroscopy may enhance live birth and clinical pregnancy rates in infertile women undergoing ART, even when previous imaging studies show no apparent intrauterine lesions. Treating lesions not detected by imaging may improve ART outcomes. The most commonly missed lesions are endometrial polyps, submucosal fibroids and endometritis, which are all known to affect ART success rates. The findings suggested that hysteroscopy, given its diagnostic accuracy and patient tolerability, should be considered in the management of infertility.

DATABASE REGISTRATION

The study was registered in the International Prospective Register of Systemic Review database (CRD42023476403).

Endometrial biopsy performed before the first in vitro fertilization does not impact the early pregnancy rate

Endometrial biopsy (EB) has been showed to increase the rate of clinical pregnancy in patients who underwent in vitro fertilization (IVF) failures. The purpose of this work was to assess the impact of an EB performed before the first in IVF on the early pregnancy rate. Be One study is a prospective, single-centre, randomized, open-label study. In this parallel study, patients were evenly split into two groups. In one group, patients underwent an EB between days 17 and 22 of the menstrual cycle that precedes the ovarian stimulation. In the other group (control), no EB was performed. The hCG-positive rate (early pregnancy rate) was evaluated on day 14 after the ovarian puncture. In total, 157 patients were randomized in the EB group and 154 patients were in the control group. The early pregnancy rate was 33.1% (52/157) in the EB group and 29.9% (46/154) in the control group (p = 0.54). Other parameters, including perforation, endometritis, or pain level were reassuring. An EB performed during the luteal phase of the menstrual cycle preceding the stimulation of the first IVF did not increase early pregnancy rate.

Effect of the decision to perform hysteroscopy on asymptomatic patients before undergoing assisted reproduction technologies-a systematic review and meta-analysis

OBJECTIVE

Routine hysteroscopic evaluation before assisted reproductive technology treatment is a novel approach with the potential to reduce assisted reproductive technology failure even in the absence of evidence of uterine pathology. Following the publication of several relatively high-quality trials on this topic, we sought to determine if this practice is beneficial.

DATA SOURCES

We searched Web of Science, MEDLINE, PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov from each database's inception until May 31, 2022 with our search strategy, attempting to locate all randomized controlled trials assessing the use of hysteroscopy in otherwise asymptomatic women undergoing assisted reproductive technology.

STUDY ELIGIBILITY CRITERIA

We included only randomized controlled trials that included at least one of our selected outcomes, and we excluded any studies with suspicion of pathology before the time of hysteroscopy, other than knowledge of the patient's infertility. We included all the aforementioned studies regardless of procedures or modifications performed as a result of hysteroscopic findings. Our initial search yielded 1802 results, which were reduced to 1421 after removal of duplicates. Ultimately, 11 studies were found to meet our criteria and were included in our quantitative synthesis.

METHODS

We used ReviewManager software, version 5.4.1 to analyze the data, which we imported after manually gathering from the 11 studies. Continuous and dichotomous outcomes were imported as standard deviations. Pooled analysis was described as a mean difference, relative to 95 % confidence interval in cases of continuous data. Dichotomous outcomes were analyzed using risk ratios and 95% confidence intervals. In homogeneous outcomes, we used a fixed-effects model, and in heterogeneous outcomes we used a random-effects model.

RESULTS

Our results showed that hysteroscopy was associated with significant improvement in the clinical pregnancy rate (risk ratio, 1.27 [1.11-1.45]; P<.001). We found no differences between the hysteroscopy group and the control group in live birth rate (risk ratio, 1.26 [0.99-1.59]; P=.06), miscarriage rate (risk ratio, 0.99 [0.81-1.19]; P=.88), fertilization rate (risk ratio, 1.01 [0.93-1.09]; P=.88), incidence of multiple gestations (risk ratio, 1.29 [0.98-1.71]; P=.07), number of embryos transferred (mean difference, 0.04 [-0.18 to 0.26]; P=.73), chemical pregnancy rate (risk ratio, 1.01 [0.86-1.17]; P=.93), and number of oocytes retrieved (mean difference, 0.44 [-0.11 to 0.98]; P=.11).

CONCLUSION

We observed an improvement in the clinical pregnancy rate, but no significant improvement in the live birth rate with routine hysteroscopy before assisted reproductive technology treatment. We believe this does not represent sufficient evidence to recommend routine hysteroscopy for otherwise asymptomatic patients before assisted reproductive technology treatment at this time.

Endometrial Biopsy: Indications, Techniques and Recommendations. An Evidence-Based Guideline for Clinical Practice

This practice guideline provides updated evidence for the gynecologist who performs endometrial biopsy (EB) in gynecologic clinical practice. An international committee of gynecology experts developed the recommendations according to AGREE Reporting Guideline. An adequate tissue sampling is mandatory when performing an EB. Blind methods should not be first choice in patients with suspected endometrial malignancy. Hysteroscopy is the targeted-biopsy method with highest diagnostic accuracy and cost-effectiveness. Blind suction techniques are not reliable for the diagnosis of endometrial polyps. In low resources settings, and in absence of the capacity to perform office hysteroscopy, blind techniques could be used for EB. Hysteroscopic punch biopsy allows to collect only limited amount of endometrial tissue. grasp biopsy technique should be considered first choice in reproductive aged women, bipolar electrode chip biopsy should be preferred with hypotrophic or atrophic endometrium. EB is required for the final diagnosis of chronic endometritis. There is no consensus regarding which endometrial thickness cut-off should be used for recommending EB in asymptomatic postmenopausal women. EB should be offered to young women with abnormal uterine bleeding and risk factors for endometrial carcinoma. Endometrial pathology should be excluded with EB in nonobese women with unopposed hyperestrogenism. Hysteroscopy with EB is useful in patients with abnormal bleeding even without sonographic evidence of pathology. EB has high sensitivity for detecting intrauterine pathologies. In postmenopausal women with uterine bleeding, EB is recommended. Women with sonographic endometrial thickness > 4mm using tamoxifen should undergo hysteroscopic EB.

Role of Hysteroscopy in Patients with Previous In Vitro Fertilization Failure: An Institutional Experience in Rural Population

Objectives

(1) To evaluate the use of hysteroscopy in the assessment of uterine pathologies, not evident on ultrasonography or hystero-salpingography in women with previous one or more IVF failures and (2) to determine whether correction of such pathologies during hysteroscopy improves clinical pregnancy rates in these women.

Methods

This is a prospective randomized study. The study population included were women with primary and secondary infertility registered at our center, fit into the inclusion and exclusion criteria of this study. The total 180 patients were included.

Results

Hysteroscopies were performed in 90 patients with at least one IVF cycle failure and another 90 patients taken as control with similar demographic parameters. The average duration of infertility between both the groups was not significant. Hysteroscopy was able to detect intrauterine pathologies in around 40% of the cases, which were treated in the same treatment phase. Early ultrasound findings with gestational sac and cardiac activity were found to be significant between two groups.

Conclusion

We noticed clinical improvement in IVF success rate after hysteroscopy. Hysteroscopy may be offered to the patients with previous one or more IVF failures, as clinically some of the previously undiagnosed pathologies could be detected and treated to achieve the positive outcomes.

The effect of hysteroscopy and conventional curretage versus no hysteroscopy on live birth rates in recurrent in vitro fertilisation failure: a retrospective cohort study from a single referral centre experience

This retrospective cohort study aimed to evaluate the effect of hysteroscopy and endometrial scratching (ES) in patients with recurrent implantation failure (RIF) who do not have an intracavity pathology. The authors retrospectively collected data of patients between 2014 and 2019 from a single centre. The study analysed 350 unexplained RIF patients, of whom, 225 underwent hysteroscopy and endometrial scratching, and 125 did not have a hysteroscopy prior to an IVF cycle. Pregnancy rates among post endometrial scratching and no endometrial scratching cycles were 35.6% versus 27.2%, (p = .048), clinical pregnancy rates were 32.9% versus 21.6% (p = .026) and live birth rates were 26.2% versus 19.2% (p = .039). Although it is not possible to distinguish whether hysteroscopy or injury is effective in improving live birth results, the authors thought that endometrial injury with gentle conventional curettage is effective in patients with recurrent implantation failure.IMPACT STATEMENTWhat is already known on this subject? Hysteroscopy and endometrial injury improve pregnancy outcomes in IVF cycles, but definitive conclusions have been uncertain.What do the results of this study add? The study showed that endometrial injury with gentle conventional curettage during hysteroscopy significantly improved the pregnancy rates of RIF patients compared to the non-hysteroscopy group.What are the implications of these findings for clinical practice and/or further research? In cases of recurrent implantation failure, even if hysteroscopy findings are normal, endometrial scratching in the follicular phase increases pregnancy rates compared to the non-hysteroscopy group.

Uterine Cavity Irrigation With Office Hysteroscopy During Ovarian Stimulation for IVF: A Randomized Controlled Trial

OBJECTIVE

This was a non-blinded randomized controlled study to evaluate whether endometrial irrigation via office hysteroscopy during the early follicular phase would lead to a higher level of live birth rates compared to no irrigation in the fresh embryo transfer cycle.

METHOD

The study was conducted in Tehran university of medical sciences from June 2015 to June 2016. women under the age of 40 with primary infertility without history of previous IVF/ICSI or hysteroscopic examination, were included. Controlled ovarian hyperstimulation was done. Hysteroscopy was performed in the early mid-follicular phase of a stimulation cycle (day 5-7) with a vaginoscopy approach and saline irrigation in hysteroscopy group. Embryo-transfer was done in the same cycle.

RESULTS

228 patients completed their participation in the study. In the fresh cycle, clinical pregnancy rate was 46% in the hysteroscopy group and 40.43% in the control group. (p-value= 0.326, RR= 1.16 [95%CI: 0.862 to 1.56]). Live birth rate was 41.28% in the hysteroscopic group and 31.93% in the control group (p-value=0.143, RR= 1.293 [95%CI: 0.916 to 1.825]). For those patients having surplus cryopreserved embryos, after 2 months, a second embryo transfer was performed. The cumulative LBR was 44.05% in the hysteroscopic group and 32.25% in the control group (p-value=0.029, RR= 1.368 [95%CI: 1.031 to 1.815], RD= 11.9% [95%CI: 1.2% to 22.3%] and NNT= 8 [95%CI: 4 to 85]).

CONCLUSION

The current study clearly demonstrated a significantly higher cumulative live birth rate in the intervention group.

CLINICAL TRIAL REGISTRATION

[https://www.irct.ir/trial/19586], identifier IRCT2016011022795N2.

The effect of diagnostic hysteroscopy performed before fresh and frozen-thawed embryo transfer in IVF cycles on reproductive outcomes

Objective

Hysteroscopy is frequently performed in infertile women and thought to improve pregnancy rates. The data obtained from studies investigating the effect of hysteroscopy in in-vitro fertilization (IVF) cycles is variable. We aimed to evaluate the effect of hysteroscopy on pregnancy outcomes of fresh and frozen-thawed embryo transfers (FET) performed during IVF cycles.

Material and Methods

The data of the 765 patients, who had IVF treatment between January 2015 and July 2017 in an infertility center, were retrospectively analyzed. Of those, 586 (76.6%) patients underwent fresh embryo transfer, while 179 (23.4%) patients underwent FET. Hysteroscopy performed by a single experienced surgeon was scheduled two months before transfer. Hysteroscopy was performed in 101/586 (17.2%) in those undergoing fresh embryo transfer and 44/179 (24.6%) patients in the FET group. Pregnancy outcomes of the groups were compared respectively within their own group.

Results

The mean age was similar in patients in the fresh and FET groups (p=0.365, respectively). There was no difference in the number of transferred embryos between the groups (p=0.218). In the fresh embryo group there were 246 pregnancies, of which 44 had undergone diagnostic hysteroscopy while 202 had not, (p=0.516) and 79 pregnancies in the FET group, of which 20 had undergone diagnostic hysteroscopy while 59 had not (p=0.711). There was no statistical difference according to pregnancy rate between the groups (p=0.538).

Conclusion

Performing diagnostic hysteroscopy before fresh or FET does not improve the pregnancy rates.

Hysteroscopic cervical features associated with difficult embryo transfer in unselected patients undergoing in vitro fertilization

Background

The most appropriate diagnostic tests for the assessment of the uterine cavity in patients undergoing standard infertility evaluation in daily practice remain unclear. Routine hysteroscopic uterine cavity evaluation before an in vitro fertilization-embyo transfer (IVF-ET) cycle is not a uniformly accepted procedure. However, cervical findings associated with difficult ET have rarely been reported in previous hysteroscopic studies. The main objective of this study was to examine the relationship between cervical finding under flexible outpatient hysteroscopy (OH) and difficult ET.

Methods

A cohort clinical study was conducted with 650 patients undergoing their first in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) from January 2010 to December 2017. Of them, 605 women with available embryos underwent transfer cycles. Outpatient hysteroscopies were scheduled during the follicular phase of the menstrual cycle, 1–3 months before starting IVF/ICSI treatment.

Results

Among the 650 women who underwent transvaginal sonography (TVS) and OH, abnormal sonographic findings were observed in 51 women (7.8%) in which submucous myoma, endometrial polyp, and endometrial hyperplasia were the most common. Abnormal hysteroscopic intracavitary findings were observed in 158 cases (24.3%) in which endometrial polyp, submucous myoma, and intrauterine adhesions were the most common. These results showed that TVS was specific (100%) but not sensitive (32.3%) compared with OH. Embryo transfer (ET) was difficult in 25% of women with cervical stenosis (CS) or tortuous cervical canal (TC) and was significantly more difficult in women in the TC group (30.7%) than in the CS group (19.6%).

Conclusion

OH can identify cervical charactistics associated with a high incidence of difficult ET.

Hysteroscopy as An Investigational Operative Procedure in Primary and Secondary Infertility: A Systematic Review

Background

The aim of this study is to review current indications to diagnostic and/or operative hysteroscopy in primary and secondary infertility, as well as to determine its efficacy in improving fertility.

Materials and Methods

We gathered available evidence about the role of hysteroscopy in the management of vari- ous infertility conditions. Literature from 2000 to 2020 that pertained to this topic were retrieved and appropriately selected.

Results

Hysteroscopy does not appear as a first line diagnostic procedure for every clinical scenario. However, its di- agnostic sensitivity and specificity in assessing intrauterine pathology is superior to all other non-invasive techniques, such as saline infusion/gel instillation sonography (SIS/GIS), transvaginal sonography (TVS) and hysterosalpingog- raphy (HSG). Hysteroscopy allows not only a satisfactory evaluation of the uterine cavity but also, the eventual treat- ment of endocavitary pathologies that may affect fertility both in spontaneous and assisted reproductive technology (ART) cycles.

Conclusion

Hysteroscopy, due to its diagnostic and therapeutic potential, should be regarded as a necessary step in infertility management. However, in case of suspected uterine malformation, hysteroscopy should be integrated with other tests [three-dimensional (3D) ultrasound or magnetic resonance imaging (MRI)] for diagnostic confirmation.

Virtual sonographic hysteroscopy in assisted reproduction: A retrospective cost-effectiveness analysis

OBJECTIVE

To analyze the cost-effectiveness of virtual sonographic hysteroscopy (VSH) performed before in vitro fertilization (IVF) (Scenario 1), frozen embryo transfer (Scenario 2), and oocyte donation (Scenario 3) attempts.

METHODS

A retrospective analysis of data extracted from patients' files was conducted. Before undergoing the assigned treatment, VSH was offered to all patients. Cost-effectiveness was calculated on the basis of cost per live birth. The total cost was compared with a control group of patients who declined to have hysteroscopy before their treatment.

RESULTS

A total of 292 women were involved. Virtual sonographic hysteroscopy was performed in 192 women. Conventional operative hysteroscopy was subsequently required in 34 of them (17.7%). Subsequent assisted reproduction attempts resulted in live birth in 111 women-34/69 (49.3%), 35/69 (50.7%), and 42/54 (77.8%) in Scenarios 1, 2, and 3, respectively. This compared favorably with 100 women who declined VSH, with live birth achieved in 15/39 (38.5%), 14/37 (37.8%), and 15/24 (62.5%) in Scenarios 1, 2, and 3, respectively. The overall cost-effectiveness of VSH compared favorably with straightforward treatment performed without this test.

CONCLUSION

The overall cost-effectiveness of treatment attempts carried out after previous VSH compared favorably with straightforward treatment performed without this test.

Efficacy of therapies and interventions for repeated embryo implantation failure: a systematic review and meta-analysis

The aim of the present systematic review and meta-analysis was to assess the effect of the different therapeutic options for repeated embryo implantation failure (RIF) on a subsequent IVF cycle outcome. Twenty-two RCTs and nineteen observational studies were included. Pooling of results showed a beneficial effect of intrauterine PBMC infusion on both CPR (RR 2.18; 95% CI 1.58-3.00; p < 0.00001; OR 2.03; 95% CI 1.22-3.36; p = 0.006) and LBR (RR 2.41; 95% CI 1.40-4.16; p = 0.002; OR 3.73; 95% CI 1.13-12.29; p = 0.03), of subcutaneous G-CSF administration on CPR (RR 2.29; 95% CI 1.58-3.31; p < 0.0001) and of intrauterine PRP infusion on CPR (RR 2.45; 95% CI 1.55-3.86; p = 0.0001). Observational studies also demonstrated a positive effect of IVIG and intrauterine hCG infusion on both CPR and LBR and of atosiban on CPR. Studies investigating intrauterine G-CSF infusion, LMWH, intravenous intralipid, hysteroscopy, blastocyst-stage ET, ZIFT, PGT-A and AH failed to observe an impact on IVF outcome. The quality of the evidence that emerged from RCTs focused on intrauterine PBMC infusion and subcutaneous G-CSF administration was moderate. For all other therapies/interventions it varied from low to very low. In conclusion, intrauterine PBMC infusion and subcutaneous G-CSF administration are the most promising therapeutic options for RIF. However, further well conducted RCTs are necessary before their introduction into clinical practice.

Can three-dimensional transvaginal sonography replace office hysteroscopy in detecting uterine abnormalities in infertility patients?

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Aim:

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Statistical Analysis:

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The effects of diagnostic hysteroscopy on the reproductive outcomes of infertile women without intrauterine pathologies: a systematic review and meta-analysis

Purpose

Hysteroscopy can be used both to diagnose and to treat intrauterine pathologies. It is well known that hysteroscopy helps to improve reproductive outcomes by treating intrauterine pathologies. However, it is uncertain whether hysteroscopy is helpful in the absence of intrauterine pathologies. This study aimed to confirm whether hysteroscopy improves the reproductive outcomes of infertile women without intrauterine pathologies.

Methods

We conducted a systematic review of 11 studies retrieved from Ovid-MEDLINE, Ovid-Embase, and the Cochrane Library. Two independent investigators extracted the data and used risk-of-bias tools (RoB 2.0 and ROBINS-I) to assess their quality.

Results

Diagnostic hysteroscopy prior to in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) was associated with a higher clinical pregnancy rate (CPR) and live birth rate (LBR) than non-hysteroscopy in patients with recurrent implantation failure (RIF) (odds ratio, 1.79 and 1.46; 95% confidence interval, 1.40–2.30 and 1.08–1.97 for CPR and LBR, respectively) while hysteroscopy prior to first IVF was ineffective. The overall meta-analysis of LBR showed statistically significant findings for RIF, but a subgroup analysis showed effects only in prospective cohorts (odds ratio, 1.40 and 1.47; 95% confidence interval, 0.62–3.16 and 1.04–2.07 for randomized controlled trials and prospective cohorts, respectively). Therefore, the LBR should be interpreted carefully and further research is needed.

Conclusion

Although further research is warranted, hysteroscopy may be considered as a diagnostic and treatment option for infertile women who have experienced RIF regardless of intrauterine pathologies. This finding enables nurses to educate and support infertile women with RIF prior to IVF/ICSI.

Comparative retrospective study on transvaginal sonography versus office hysteroscopy in the diagnosis of endometrial pathology among different subgroups

BACKGROUND

Transvaginal sonography (TVS) and office hysteroscopy are considered essential diagnostic tool for the gynecologic everyday practice. Through the years equipment developments in both techniques along with cumulative experience gained by the gynecologists result in a disunity among clinicians in choosing optimal diagnostic approach with regards to endometrial pathology.

AIM

To evaluate the diagnostic accuracy of TVS versus office hysteroscopy (OHSC) in detecting endometrial pathology. Results were compared to available scientific evidence available among similar published studies.

METHODS

Comparative Retrospective study performed at the Endoscopic Unit, Department of Gynecology, University Hospital of Ioannina, Greece. A total of 2675 cases were collected for this study from January 1997 until August 2019. All cases recruited underwent a TVS followed by office hysteroscopy (OHSC) for various indications according to the local protocol. Endometrial samples from all cases were obtained and histology confirmed the diagnosis. Sonographic and hysteroscopic results were correlated with histologic reports to assess the diagnostic accuracy of both techniques.

RESULTS

In a total of 2675 cases recruited for this study, 23.2% were postmenopausal while the majority (76.7%) was of reproductive age. The commonest indication for hysteroscopy was abnormal uterine bleeding (AUB) accounting for 29.7% of the cases. Overall, TVS demonstrated diagnostic accuracy of 84.7%% in detecting endometrial pathology, compared to 97.3% of OHSC. Sensitivity, specificity, positive prognostic value (PPV) and negative prognostic value (NPV) of TVS detecting endometrial pathology were 84.0, 86.8, 95.3 and 63.0%, respectively. The corresponding values for hysteroscopy were 98.9, 95.1, 98.4 and 93.9%, respectively. Diagnostic value of both techniques was estimated in 6 (six) additional subgroups: total sample with AUB, women of reproductive age, women of reproductive age with AUB, women of reproductive age with infertility issues, postmenopausal women and postmenopausal women suffering from postmenopausal bleeding (PMB). All values were calculated with regards to histologic findings as gold standard technique. All results were correlated with scientific evidence collected from the international literature.

CONCLUSION

Office hysteroscopy is a more reliable tool in detecting endometrial pathologies compared to TVS regardless of reproductive status or clinical presentation. TVS is likely to orientate and guide specialists on what to expect prior to an hysteroscopic intervention.

Does Laparoscopy and Hysteroscopy Have a Place in the Diagnosis of Unexplained Infertility?

The standard fertility workup includes assessment of ovulation, semen analysis, and evaluation of tubal patency. If the fertility workup is found to be normal, a diagnosis of unexplained infertility is made. The role of laparoscopy in fertility workup has been a matter of debate. The current review presents the evidence for and against laparoscopy and hysteroscopy during fertility workup and subsequently prior to fertility treatment. After appraising the literature, we found the role of diagnostic laparoscopy in fertility workup is limited and is dependent on factors like prevalence of pelvic infection, setting, and availability of expertise. Moreover, whenever a laparoscopy is planned as a part of the fertility workup, the preparation should include ability to carry out simultaneous therapeutic intervention to maximize the benefit. Similarly, the routine use of hysteroscopy in women with unexplained infertility cannot be recommended. There is a need to investigate the impact of choice of tubal test on chances of spontaneous conception and treatment outcomes in women with unexplained infertility. Our future research agenda should also include high-quality multicenter randomized trials assessing the cost-effectiveness of screening and operative hysteroscopy prior to intrauterine insemination or in vitro fertilization.

The impact of intentional endometrial injury on reproductive outcomes: a systematic review and meta-analysis

BACKGROUND

Endometrial injury is an intentional damage made to the endometrium, usually produced by a Pipelle catheter. Over the last two decades, endometrial injury has been studied to improve implantation rates and decrease the incidence of implantation failure in invitro fertilization (IVF) cycles. Recently, additional studies of endometrial injury, performed not only in patients with implantation failure but also in intrauterine insemination cycles, have been conducted, and the endometrial injury made by hysteroscopy has been researched. The evidence describing the impact of endometrial injury is controversial; therefore, we conducted a systematic review and meta-analysis to examine the issue.

OBJECTIVE AND RATIONALE

Our objective is to review the research that has been done until now and perform a meta-analysis regarding endometrial injury and its influence on implantation success and pregnancy rates in patients with at least one failed IVF cycle. In particular, we aim to study the efficacy of the procedure and look for confounding factors, such as maternal age, in assessing the efficacy of endometrial injury.

SEARCH METHODS

The systematic review of the literature was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Study protocol can be assessed at PROSPERO International prospective register of systematic reviews (registration number CRD42018092773). Searches were conducted by an experienced research librarian in the following databases: MEDLINE(R) using the OvidSP interface and PUBMED, Embase, Web of Science and Cochrane Library. This review considered for inclusion randomized-controlled trials examining the success of performing local endometrial injury on IVF outcomes in women with previous failed IVF cycles.

OUTCOMES

Ten studies, comprising a total of 1260 patients, were selected. Overall, when studying the effect of endometrial injury on clinical pregnancy rates (CPRs) and live birth rates (LBRs), higher rates were shown in the endometrial injury group. However, endometrial injury did not significantly improve CPRs and LBRs, when considering sub-group analyses of studies including patients with two or more failed IVF cycles, studies examining older patients or studies which did not include hysteroscopy. There was no significant difference found regarding multiple pregnancy rates, while a handful of studies showed an improvement in miscarriage rates.

WIDER IMPLICATIONS

Endometrial injury should be used restrictively and not routinely in clinics. Maternal age and number of previous failed treatment cycles may be contributing factors which can influence the results when studying the effect of endometrial local injury. It is possible that the relative contribution of endometrial receptivity to the chances of implantation decreases with any additional failed cycle. The optimal study to prove the efficacy of local endometrial injury on implantation and pregnancy rates, should be a random-controlled trial studying the effect of local endometrial injury in oocyte donation cycles, in recipients with repeated implantation failure. This kind of study will conclude whether local endometrial injury is an efficient procedure with minimum confounding factors, and may assist in defining the population, even outside of donation cycles, that will benefit from the procedure.

Successful pregnancy for primary amenorrhea and recurrent implantation failure and the role of hysteroscopic adhesiolysis: a case report

Background

Infertility continues to be an enigmatic and emerging problem. Although in vitro fertilization has proved to be revolutionary and immensely beneficial to many people, it is far from perfect, and many women experience recurrent in vitro fertilization failures. There can be a multitude of factors involved in recurrent in vitro fertilization failures. The aim of this report was to explore the role of hysteroscopy in determining potential causes of in vitro fertilization failure and how the relevant hysteroscopic findings can address the issue of infertility in terms of a subsequent successful in vitro fertilization.

Case presentation

A 37-year-old white Arab woman with a history of eight in vitro fertilization failures and one curettage performed for a blighted ovum presented to our hospital because of inability to conceive. Her past medical history was significant for hypothyroidism and positive factor V Leiden. She underwent hystero contrast sonography, which revealed a normal uterine cavity with irregular fillings in the right corner. To explore this further, hysteroscopy was performed, which showed dense adhesions in the right upper corner and first-degree adhesions in the lower half of the uterus. After undergoing adhesiolysis and a cycle of estradiol valerate and progesterone, the patient successfully conceived twins.

Conclusions

Hysteroscopy may play an important role before or in conjunction with assisted reproductive techniques to help infertile women and couples achieve their goals of pregnancy and live birth of a child.

[Impact of luteal phase support by human chorionic gonadotropin (hCG) in intrauterine inseminations]

OBJECTIVES

The objective of our study is to evaluate the impact of luteal phase support by hCG in intrauterine inseminations preceded by ovarian gonadotropin stimulation.

METHODS

A retrospective study was conducted at the CHU of Nice between March 1, 2016 and October 31, 2017. During this period, 300 intrauterine inseminations were included in data analysis. Ovarian stimulation was performed by gonadotropins and a GnRH antagonist was added, if needed. Following a modification of standard operative procedure in the department, patients who performed an intrauterine insemination from December 1, 2016 received luteal phase support with two injections of hCG 1500 IU, performed at three days of interval. Pregnancy and ovarian hyperstimulation syndrome were the primary and secondary study endpoints, respectively.

RESULTS

Out of 300 inseminations included in the analysis, 144 were performed with luteal phase support and 156 without support. No statistically significant difference in pregnancy rate was observed between these two groups (19.4% of pregnancy in the luteal phase support group and 15.38% in the group without luteal phase support, P=0.353). No ovarian hyperstimulation syndrome occurred over the course of the study.

CONCLUSION

Our study shows a slight improvement of pregnancy rate in the group subjected to luteal phase support by hCG after intrauterine insemination, but the benefit was not significant. A randomised prospective study based on a large cohort could help to assess the effect of luteal phase support during intrauterine inseminations.

The clinical effects of antibiotic prophylaxis for hysteroscopic procedures: A meta-analysis

BACKGROUND

Hysteroscopic procedures were widely applied but the clinical effects of antibiotic prophylaxis for these operations were not specifically addressed. In current study, we aimed to investigate the role of prophylactic antibiotics in hysteroscopic procedures by meta-analysis.

METHODS

We conducted literature retrieval in electronic databases, including MEDLINE, EMBASE, and Cochrane Central, to identify relevant randomized controlled trials (RCTs) investigating the clinical effects of antibiotic prophylaxis for hysteroscopic procedures. The postoperative infection rate was selected for pooled estimation. The I index statistic was used to assess heterogeneity. Publication bias was evaluated using funnel plots and Egger test. Sensitivity analysis based on different subcategories was conducted to examine the stability of the main results.

RESULTS

Four RCTs including 2221 patients were identified for the final quantitative analysis. Pooled estimation indicated no significant difference in infection rate between the antibiotic prophylaxis group and control group (test for OR: Z = 0.50, P = .616; 95% CI: 0.987-1.008). Sensitivity analysis based on surgical procedure, antibiotic application, follow-up time and administration time revealed similar results.

CONCLUSION

Based on current objective evidence, we conclude that antibiotic prophylaxis exhibits no clinical benefit for hysteroscopic procedures. Therefore, it is not recommended. Meanwhile, more high-quality RCTs are needed to support our conclusion.

The effect of performing hysteroscopy prior to the first in vitro fertilization (IVF) cycle on live birth rate

In this retrospective cohort study, a total of 707 couples underwent in vitro fertilization (IVF) at Hacettepe University Hospital between 01 January 2010 and 01 November 2014 with their chronologically first cycle were evaluated. Patients who have diagnostic hysteroscopy prior to first IVF cycle served as a study group (n = 42) and patients without diagnostic hysteroscopy served as control group (n = 282). In study group in all patients, diagnostic hysteroscopy was performed at the follicular phase of previous menstrual cycle, namely immediately before ovarian stimulation (OS) cycle. Demographic features, clinical characteristics and treatment outcomes were compared between the groups. The logistic regression analysis was performed in order to assess independent predictors of live birth rates (LBRs). There was no statistically significant difference between the groups for demographic features and OS cycle characteristics. Implantation rate (22.2% vs. 21.5%, p=.840), clinical pregnancy rate (33.3% vs. 28.7%, p=.541), and LBRs (23.8% vs. 18.5%, p=.420) were comparable. In logistic regression analysis, performing hysteroscopy prior to first IVF cycles per se without correcting anatomic abnormalities was not an independent predictor of LBRs (OR: 0.72, 95% CI: 0.310-1.68, p=.45). In conclusion, performing diagnostic hysteroscopy prior to first IVF treatment cycle without correcting any anatomic abnormalities did not improve LBRs.

Screening hysteroscopy in subfertile women and women undergoing assisted reproduction

BACKGROUND

Screening hysteroscopy in infertile women with unexplained infertility, or prior to intrauterine insemination (IUI) or in vitro fertilisation (IVF) may reveal intrauterine pathology that may not be detected by routine transvaginal ultrasound. Hysteroscopy, whether purely diagnostic or operative may improve reproductive outcomes.

OBJECTIVES

To assess the effectiveness and safety of screening hysteroscopy in subfertile women undergoing evaluation for infertility, and subfertile women undergoing IUI or IVF.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL CRSO, MEDLINE, Embase, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (September 2018). We searched reference lists of relevant articles and handsearched relevant conference proceedings.

SELECTION CRITERIA

Randomised controlled trials comparing screening hysteroscopy versus no intervention in subfertile women wishing to conceive spontaneously, or before undergoing IUI or IVF.

DATA COLLECTION AND ANALYSIS

We independently screened studies, extracted data, and assessed the risk of bias. The primary outcomes were live birth rate and complications following hysteroscopy. We analysed data using risk ratio (RR) and a fixed-effect model. We assessed the quality of the evidence by using GRADE criteria.

MAIN RESULTS

We retrieved 11 studies. We included one trial that evaluated screening hysteroscopy versus no hysteroscopy, in women with unexplained subfertility, who were trying to conceive spontaneously. We are uncertain whether ongoing pregnancy rate improves following a screening hysteroscopy in women with at least two years of unexplained subfertility (RR 4.30, 95% CI 2.29 to 8.07; 1 RCT; participants = 200; very low-quality evidence). For a typical clinic with a 10% ongoing pregnancy rate without hysteroscopy, performing a screening hysteroscopy would be expected to result in ongoing pregnancy rates between 23% and 81%. The included study reported no adverse events in either treatment arm. We are uncertain whether clinical pregnancy rate is improved (RR 3.80, 95% CI 2.31 to 6.24; 1 RCT; participants = 200; very low-quality evidence), or miscarriage rate increases (RR 2.80, 95% CI 1.05 to 7.48; 1 RCT; participants = 200; very low-quality evidence), following screening hysteroscopy in women with at least two years of unexplained subfertility.We included ten trials that included 1836 women who had a screening hysteroscopy and 1914 women who had no hysteroscopy prior to IVF. Main limitations in the quality of evidence were inadequate reporting of study methods and higher statistical heterogeneity. Eight of the ten trials had unclear risk of bias for allocation concealment.Performing a screening hysteroscopy before IVF may increase live birth rate (RR 1.26, 95% CI 1.11 to 1.43; 6 RCTs; participants = 2745; I² = 69 %; low-quality evidence). For a typical clinic with a 22% live birth rate, performing a screening hysteroscopy would be expected to result in live birth rates between 25% and 32%. However, sensitivity analysis done by pooling results from trials at low risk of bias showed no increase in live birth rate following a screening hysteroscopy (RR 0.99, 95% CI 0.82 to 1.18; 2 RCTs; participants = 1452; I² = 0%).Only four trials reported complications following hysteroscopy; of these, three trials recorded no events in either group. We are uncertain whether a screening hysteroscopy is associated with higher adverse events (Peto odds ratio 7.47, 95% CI 0.15 to 376.42; 4 RCTs; participants = 1872; I² = not applicable; very low-quality evidence).Performing a screening hysteroscopy before IVF may increase clinical pregnancy rate (RR 1.32, 95% CI 1.20 to 1.45; 10 RCTs; participants = 3750; I² = 49%; low-quality evidence). For a typical clinic with a 28% clinical pregnancy rate, performing a screening hysteroscopy would be expected to result in clinical pregnancy rates between 33% and 40%.There may be little or no difference in miscarriage rate following screening hysteroscopy (RR 1.01, 95% CI 0.67 to 1.50; 3 RCTs; participants = 1669; I² = 0%; low-quality evidence).We found no trials that compared a screening hysteroscopy versus no hysteroscopy before IUI.

AUTHORS' CONCLUSIONS

At present, there is no high-quality evidence to support the routine use of hysteroscopy as a screening tool in the general population of subfertile women with a normal ultrasound or hysterosalpingogram in the basic fertility work-up for improving reproductive success rates.In women undergoing IVF, low-quality evidence, including all of the studies reporting these outcomes, suggests that performing a screening hysteroscopy before IVF may increase live birth and clinical pregnancy rates. However, pooled results from the only two trials with a low risk of bias did not show a benefit of screening hysteroscopy before IVF.Since the studies showing an effect are those with unclear allocation concealment, we are uncertain whether a routine screening hysteroscopy increases live birth and clinical pregnancy, be it for all women, or those with two or more failed IVF attempts. There is insufficient data to draw conclusions about the safety of screening hysteroscopy.

Effect of hysteroscopy before starting in-vitro fertilization for women with recurrent implantation failure: A meta-analysis and systematic review

OBJECTIVE

To study if hysteroscopy (HSC) before starting an in-vitro fertilization (IVF) cycle improves IVF outcomes in women with recurrent implantation failure (RIF).

METHODS

The Medline, Cochrane, EMBASE, and Google Scholar databases were searched using the following keywords until March 31, 2017: in-vitro fertilization; infertility; hysteroscopy; recurrence; embryo implantation; and pregnancy. Randomized controlled trials (RCTs), two-arm prospective studies, and retrospective studies were included.

RESULTS

Three RCTs, 3 nonrandomized prospective studies, and 2 retrospective cohort studies were included. The eligible studies included 3932 women with RIF: 1841 in the HSC group and 2091 in the control group. The clinical pregnancy rate and implantation rate was significantly higher in the HSC group compared with the control group (for clinical pregnancy rate, pooled odds ratio [OR] = 1.64, 95% confidence intervals [CI]: 1.30-2.07, P < 0.001; for implantation rate, pooled OR = 1.22, 95% CI: 1.02-1.45, P = 0.025). The live birth rate (pooled OR = 1.30, 95% CI: 0.90-1.88, P = 0.168) and the miscarriage rate (pooled OR = 0.94, 95% CI: 0.66-1.35, P = 0.744) of the 2 groups were not statistically significantly.

CONCLUSIONS

HSC improved the implantation rate and clinical pregnancy rates, but failed to improve live birth rate and did not affect the miscarriage rate in women with RIF undergoing IVF. Since HSC plays a significant role in pregnancy and birth outcomes of women with RIF, further studies are warranted.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

BACKGROUND

Observational studies suggest higher pregnancy rates after the hysteroscopic removal of endometrial polyps, submucous fibroids, uterine septum or intrauterine adhesions, which are present 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 following databases from their inception to 16 April 2018; The Cochrane Gynaecology and Fertility Group Specialised Register, the Cochrane Central Register of Studies Online, ; MEDLINE, Embase , CINAHL , 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 1 January 2014 to 12 May 2018) and we contacted experts in the field.

SELECTION CRITERIA

Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.Primary outcomes were live birth and hysteroscopy complications. Secondary outcomes were pregnancy and miscarriage.

DATA COLLECTION AND ANALYSIS

Two review 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.1. Randomised comparison between operative hysteroscopy versus control for unexplained subfertility associated with suspected major uterine cavity abnormalities.In women with otherwise unexplained subfertility and submucous fibroids, we were uncertain whether hysteroscopic myomectomy improved the clinical pregnancy rate compared to expectant management (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17; P = 0.06, 94 women; very low-quality evidence). We are uncertain whether hysteroscopic myomectomy improves the miscarriage rate compared to expectant management (OR 1.54, 95% CI 0.47 to 5.00; P = 0.47, 94 women; very low-quality evidence). We found no data on live birth or hysteroscopy complication rates. We found no studies in women with endometrial polyps, intrauterine adhesions or uterine septum for this randomised comparison.2. Randomised comparison between operative hysteroscopy versus control for suspected major uterine cavity abnormalities prior to medically assisted reproduction.The hysteroscopic removal of polyps prior to IUI may have improved the clinical pregnancy rate compared to diagnostic hysteroscopy only: if 28% of women achieved a clinical pregnancy without polyp removal, the evidence suggested that 63% of women (95% CI 45% to 89%) achieved a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96; P < 0.00001, 204 women; low-quality evidence). We found no data on live birth, hysteroscopy complication or miscarriage rates in women with endometrial polyps prior to IUI. We found no studies in women with submucous fibroids, intrauterine adhesions or uterine septum prior to IUI or in women with all types of suspected uterine cavity abnormalities prior to IVF/ICSI.

AUTHORS' CONCLUSIONS

Uncertainty remains concerning an important benefit with the hysteroscopic removal of submucous fibroids for improving the clinical pregnancy rates in women with otherwise unexplained subfertility. The available low-quality evidence suggests that the hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may improve the clinical pregnancy rate compared to simple diagnostic hysteroscopy. More research is needed to measure the effectiveness of the hysteroscopic treatment of suspected major uterine cavity abnormalities in women with unexplained subfertility or prior to IUI, IVF or ICSI.

Hysteroscopy after repeated implantation failure of assisted reproductive technology: A meta-analysis

We conducted this meta-analysis to explore the prognostic value of outpatient (or office) hysteroscopy (OH) preceding in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles in women who had experienced repeated implantation failure (RIF), particularly in regard to the conflicting evidence reported by previous studies. Two reviewers independently searched Pubmed, MEDLINE, Web of Science, Cochrane Library and Embase to identify all publications of clinical trials of hysteroscopy with or without endometrial biopsy in RIF patients. The primary outcome measures were clinical pregnancy rate (CPR) and live birth rate (LBR). Pooled relative ratios (RRs) with 95% confidence intervals (CIs) were calculated. Publication bias was detected using funnel plots and Egger's regression tests. Six eligible studies comprising 4143 patients were included. The CPR and LBR were both significantly higher in RIF patients with OH than RIF patients without OH (CPR: RR 1.34, 95% CI 1.14-1.57, P < 0.05; LBR: RR 1.29, 95% CI 1.03-1.62, P < 0.05). Subgroup analysis revealed a significant association between OH and CPR in Asia (CPR: RR 1.49, 95% CI 1.31-1.69; P < 0.05) rather than in Europe (CPR: RR 1.08, 95% CI 0.93-1.26; P = 0.291). However, there was no evidence of a significant difference in either CPR or LBR between the normal and abnormal OH groups (CPR: RR 0.92, 95% CI 0.83-1.02, P = 0.12; LBR: RR 0.76, 95% CI 0.37-1.56, P = 0.450). Hysteroscopy may potentially improve pregnancy outcomes in patients with RIP.

Comparison of pregnancy rates between patients with and without local endometrial scratching before intrauterine insemination

OBJECTIVES

To determine the implantation success of local endometrial injury in patients undergoing intrauterine insemination following ovulation induction with gonadotropins as an infertility treatment.

MATERIAL AND METHODS

In this prospective randomized controlled trial, ovulation induction was performed with gonadotropins in 80 patients following intrauterine insemination. In 40 patients, local endometrial injury (scratch) was performed in the midluteal phase of the cycle preceding ovarian stimulation with a Novak curette to the posterior side of the endometrial cavity.

RESULTS

Fifteen pregnancies (37.5%) and 11 clinical pregnancies (27.5%) occurred in the intervention group, whereas eight pregnancies (20%) and five clinical pregnancies (12.5%) occurred in the control group. Although the pregnancy rates and clinical pregnancy rates were increased in the intervention group, no statistically significant difference was found between the intervention and control groups (pregnancy rates: P=0.084; clinical pregnancy rates: P=0.094).

CONCLUSION

Performing local endometrial injury (scratch) in the cycle preceding ovulation induction in patients with a diagnosis of infertility and indication for intrauterine insemination increased the pregnancy and clinical pregnancy rates. This increase was not, however, statistically significant. More randomized, controlled, prospective studies with larger patient numbers are required before the use of iatrogenic induction of local endometrial injury can be recommended in routine clinical practice.

The effect of frozen-thawed embryo transfer performed concurrently with hysteroscopy on the reproductive outcomes during assisted reproductive treatments

The uterine environment is vital to the successful conception; recently, hysteroscopy was used to remove uterine anomalies in patients undergoing assisted reproductive treatments in combination with a “freeze-all” strategy. However, the rapid recurrence of uterine anomalies impose a negative impact on pregnancy. A possible way to avoid this issue is to implement frozen-thawed embryo transfer (FET) as soon as possible. Thus, we sought to investigate the impact of performing FET concurrently with hysteroscopy in the same mense on the pregnancy outcome. Patients enrolled were divided into two groups: group 1 (n = 272, FET in this mense) and group 2 (n = 251, FET in the next mense). There were no differences in the clinical pregnancy rate (55.15% vs. 53.78%), implantation rate (39.32% vs. 37.2%), spontaneous miscarriage rate (10% vs. 8.89%), or live birth rate (45.96% vs. 45.02%) when comparing the two groups. Binary logistic regression indicated maternal age was negatively associated with the live birth rate, while FET following hysteroscopy in the same mense had no adverse effects on the live birth rate. Our data indicate performing FET concurrently with hysteroscopy in the same menstrual cycle does not impair the pregnancy outcomes, but additional studies with larger populations are needed to confirm these results.

Hysteroscopy before in-vitro fertilisation (inSIGHT): a multicentre, randomised controlled trial

BACKGROUND

Hysteroscopy is often done in infertile women starting in-vitro fertilisation (IVF) to improve their chance of having a baby. However, no data are available from randomised controlled trials to support this practice. We aimed to assess whether routine hysteroscopy before the first IVF treatment cycle increases the rate of livebirths.

METHODS

We did a pragmatic, multicentre, randomised controlled trial in seven university hospitals and 15 large general hospitals in the Netherlands. Women with a normal transvaginal ultrasound of the uterine cavity and no previous hysteroscopy who were scheduled for their first IVF treatment were randomly assigned (1:1) to either hysteroscopy with treatment of detected intracavitary abnormalities before starting IVF (hysteroscopy group) or immediate start of the IVF treatment (immediate IVF group). Randomisation was done with web-based concealed allocation and was stratified by centre with variable block sizes. Participants, doctors, and outcome assessors were not masked to the assigned group. The primary outcome was ongoing pregnancy (detection of a fetal heartbeat at >12 weeks of gestation) within 18 months of randomisation and resulting in livebirth. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01242852.

FINDINGS

Between May 25, 2011, and Aug 27, 2013, we randomly assigned 750 women to receive either hysteroscopy (n=373) or immediate IVF (n=377). 209 (57%) of 369 women eligible for assessment in the hysteroscopy group and 200 (54%) of 373 in the immediate IVF group had a livebirth from a pregnancy during the trial period (relative risk 1·06, 95% CI 0·93-1·20; p=0·41). One (<1%) woman in the hysteroscopy group developed endometritis after hysteroscopy.

INTERPRETATION

Routine hysteroscopy does not improve livebirth rates in infertile women with a normal transvaginal ultrasound of the uterine cavity scheduled for a first IVF treatment. Women with a normal transvaginal ultrasound should not be offered routine hysteroscopy.

FUNDING

The Dutch Organisation for Health Research and Development (ZonMW).

Autologous endometrial coculture biopsy: is timing everything?

OBJECTIVE

To determine whether endometrial biopsy timing affects implantation rates and pregnancy outcomes in patients undergoing in vitro fertilization (IVF) with autologous endometrial coculture (AECC).

DESIGN

Retrospective cohort study.

SETTING

Academic medical center.

PATIENT(S)

All patients with a history of at least one failed IVF cycle who underwent an IVF-AECC cycle at our center from May 2004 to November 2013 were included.

INTERVENTION(S)

Patients underwent luteal-phase endometrial biopsy in preparation for IVF. Biopsy samples were used for IVF in either the subsequent menstrual cycle or a future cycle. Embryos were cultured in AECC media and transferred on day 3.

MAIN OUTCOME MEASURE(S)

A total of 2,533 cycles of 1,719 patients who underwent an IVF-AECC cycle were identified. Cycles were stratified by endometrial biopsy timing. Clinical outcomes, including implantation, pregnancy, and live birth rates, were analyzed and compared between the two groups.

RESULT(S)

A total of 1,416 coculture biopsies were performed in the menstrual cycle before IVF and 1,117 were performed more than one cycle before IVF. The two groups were similar in age, body mass index, number of mature oocytes retrieved, and best embryo grade. There were no significant differences in implantation, clinical pregnancy, or live birth rates, with adjusted relative risks of 1.02 (95% confidence interval [CI] 0.92-1.13), 1.02 (95% CI 0.91-1.14), and 0.99 (95% CI 0.86-1.16), respectively.

CONCLUSION(S)

Coculture biopsy in the cycle preceding IVF does not increase implantation, clinical pregnancy, or live birth rates compared with biopsies performed more than one cycle before IVF. Previously demonstrated improvements in embryo quality and pregnancy outcomes in patients undergoing IVF with AECC are probably not attributable to biopsy-induced endometrial injury.

Morphological Changes and Expression of Cytokine After Local Endometrial Injury in a Mouse Model

OBJECTIVE

To establish a mouse model for endometrial injury and determine the underlying mechanism regarding its favorable effect on embryo implantation.

STUDY DESIGN

Female Kunming mice were randomly allocated into 4 groups: group I, normal control; group II, injury procedure control; and group III and group IV, the mice being scratched with a blunt syringe on the right uterine horn or both, respectively. All the mice were mated with the males during the next estrus phase. The number of implanted embryos on each side of uterus was calculated on day 8 of pregnancy. The endometrial samples were taken on day 4 of pregnancy, and the local morphological changes and cytokine expressions were examined.

RESULTS

Compared to group II, our results showed that in group IV (1) there were significantly higher numbers of implanted embryos, (2) the endometrial glands and vasculatures in stroma were obviously increased and the pinopodes were abundant and well developed, and (3) the local levels of cytokines leukemia inhibitory factor (LIF) and oncostatin M (OSM) messenger RNA and protein expression were significantly increased.

CONCLUSIONS

Local mechanical injury on mouse uteri enhanced endometrial receptivity and improved embryo implantation, which were correlated with the characteristic changes in endometrial morphology and the upregulation of LIF and OSM gene and protein expression.

Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities

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 (8 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 9), MEDLINE (1950 to 12 October 2014), EMBASE (inception to 12 October 2014), CINAHL (inception to 11 October 2014) 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 2013 to October 2014) 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 review authors independently assessed studies for inclusion and risk of bias, and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We retrieved 12 randomised trials possibly addressing the research questions. Only two studies (309 women) met the inclusion criteria. Neither reported the primary outcomes of live birth or procedure related complications. In women with otherwise unexplained subfertility and submucous fibroids there was no conclusive evidence of a difference between the intervention group treated with hysteroscopic myomectomy and the control group having regular fertility-oriented intercourse during 12 months for the outcome of clinical pregnancy. A large clinical benefit with hysteroscopic myomectomy cannot be excluded: if 21% of women with fibroids achieve a clinical pregnancy having timed intercourse only, the evidence suggests that 39% of women (95% CI 21% to 58%) will achieve a successful outcome following the hysteroscopic removal of the fibroids (odds ratio (OR) 2.44, 95% confidence interval (CI) 0.97 to 6.17, P = 0.06, 94 women, very low quality evidence). There is no evidence of a difference between the comparison groups for the outcome of miscarriage (OR 0.58, 95% CI 0.12 to 2.85, P = 0.50, 30 clinical pregnancies in 94 women, very low quality evidence). The hysteroscopic removal of polyps prior to IUI can increase the chance of a clinical pregnancy compared to simple diagnostic hysteroscopy and polyp biopsy: if 28% of women achieve a clinical pregnancy with a simple diagnostic hysteroscopy, the evidence suggests that 63% of women (95% CI 50% to 76%) will achieve a clinical pregnancy after the hysteroscopic removal of the endometrial polyps (OR 4.41, 95% CI 2.45 to 7.96, P < 0.00001, 204 women, moderate quality evidence).

AUTHORS' CONCLUSIONS

A large benefit with the hysteroscopic removal of submucous fibroids for improving the chance of clinical pregnancy in women with otherwise unexplained subfertility cannot be excluded. The hysteroscopic removal of endometrial polyps suspected on ultrasound in women prior to IUI may 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.

Chronic endometritis due to common bacteria is prevalent in women with recurrent miscarriage as confirmed by improved pregnancy outcome after antibiotic treatment

Recurrent miscarriage (RM) is defined as 3 or more miscarriages before 20 weeks' pregnancy. In recent years, interest has been focused on chronic endometritis (CE), a subtle inflammation thought to be associated with RM. We aimed to evaluate the relationships between CE and RM. The records of 360 women with unexplained RM were retrospectively analyzed. Data from hysteroscopy, endometrial histology, endometrial culture, and polymerase chain reaction for chlamydia, performed before and after antibiotic treatment for CE, were analyzed. The occurrence of successful pregnancies within 1 year after treatment was also evaluated. Results showed that 208 (57.8%) women with RM showed CE at hysteroscopy; 190 (91.3%), positive at hysteroscopy, were also positive at histology, and 142 (68.3%) had positive cultures. Common bacteria were found in 110 (77.5%) patients. Mycoplasma and Ureaplasma were found in 36 (25.3%) patients and Chlamydia in 18 patients (12.7%). In 102 (71%) women, antibiogram-based antibiotic treatment normalized hysteroscopy, histology, and cultures (group 1); while in 40 (28.2%) patients, CE was still present at hysteroscopy (group 2). In 16 of the 66 patients positive at hysteroscopy, but not at cultures, the hysteroscopy becomes normal (group 3) after a Centers for Disease Control and Prevention-based therapy; while in 50 women, CE was still present (group 4). One year after treatment, group 1 showed a significantly higher number of pregnancies (78.4%) compared to group 2 (17.5%; P < .001) and group 4 (15.3%; P = .005). The CE is frequent in women with RM. Antibiotic treatment seems to be associated with an improved reproductive outcome.