Nastri Carolina O, Gibreel Ahmed, Raine-Fenning Nick, Maheshwari Abha, Ferriani Rui A, Bhattacharya Siladitya, Martins Wellington P
Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil.
Cochrane Database Syst Rev. 2012 Jul 11(7):CD009517. doi: 10.1002/14651858.CD009517.pub2.
Implantation of an embryo within the endometrial cavity is a key step in assisted reproductive techniques (ART). It has been suggested that intentional endometrial injury, such as endometrial biopsy or curettage, prior to embryo transfer improves the chances of implantation and further development thereby increasing the likelihood of live birth. The effectiveness and safety of this procedure is, however, still unclear.
To assess the effectiveness and safety of endometrial injury performed prior to embryo transfer in women undergoing ART.
We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), DARE, MEDLINE, EMBASE, CINAHL, LILACS, and ClinicalTrials.gov. The final search was performed in November 2011.
Randomised controlled trials comparing any kind of intentional endometrial injury prior to embryo transfer in women undergoing ART with no intervention or with a simulated (mock) procedure that could not cause endometrial injury.
Data were extracted by one author and checked by a second. Assessment of the risk of bias was performed independently by two authors. We contacted and corresponded with study investigators as required. Data were analysed using Peto odds ratio (OR) and a fixed-effect model.
A total of 591 women from five trials were included. Clinical pregnancy was reported by all five studies and the combined analysis for clinical pregnancy per woman showed substantial heterogeneity (I(2) = 95.9%). We therefore conducted a planned subgroup analysis including four trials in the subgroup 'injury in the previous cycle' and one trial in the subgroup 'injury on the day of oocyte retrieval'. In the subgroup 'injury in the previous cycle' the procedure was performed within one month before starting ovulation induction in all four trials. This intervention resulted in a significant increase in the odds of live birth (2 trials, Peto OR 2.46; 95% CI 1.28 to 4.72; I(2) = 0%) and clinical pregnancy (4 trials, Peto OR 2.61; 95% CI 1.71 to 3.97; I(2) = 0%). The odds of miscarriage per clinical pregnancy (1 trial, Peto OR 1.13; 95% CI 0.17 to 7.45) and multiple pregnancy per clinical pregnancy (1 trial, Peto OR 0.87; 95% CI 0.23 to 3.30) were very imprecise, limiting any meaningful conclusion. No study reported pain or bleeding. In the subgroup 'injury on the day of oocyte retrieval', the intervention resulted in a significant reduction in the odds of clinical pregnancy (1 trial, Peto OR 0.30; 95% CI 0.14 to 0.63) and ongoing pregnancy (1 trial, Peto OR 0.28; 95% CI 0.13 to 0.61). The single trial in this subgroup did not report any adverse effect outcomes.
AUTHORS' CONCLUSIONS: Endometrial injury performed prior to the embryo transfer cycle improves clinical pregnancy and live birth rates in women undergoing ART. It is advisable not to perform endometrial injury on the day of oocyte retrieval because it appears to significantly reduce clinical and ongoing pregnancy rates. There is insufficient evidence regarding the effect of endometrial injury on multiple pregnancy or miscarriage and none on adverse events such as pain and bleeding.
胚胎在子宫内膜腔内着床是辅助生殖技术（ART）中的关键步骤。有人提出，在胚胎移植前进行有意的子宫内膜损伤，如子宫内膜活检或刮宫术，可提高着床及进一步发育的几率，从而增加活产的可能性。然而，该操作的有效性和安全性仍不明确。
评估在接受ART的女性中，胚胎移植前进行子宫内膜损伤的有效性和安全性。
我们检索了Cochrane月经紊乱与生育力低下小组（MDSG）专业注册库、Cochrane对照试验中心注册库（CENTRAL）、DARE、MEDLINE、EMBASE、CINAHL、LILACS以及ClinicalTrials.gov。最终检索于2011年11月进行。
随机对照试验，比较接受ART的女性在胚胎移植前进行的任何类型的有意子宫内膜损伤与无干预或与不会导致子宫内膜损伤的模拟（假）操作。
由一位作者提取数据，另一位作者进行核对。两位作者独立进行偏倚风险评估。我们根据需要与研究调查人员联系并通信。使用Peto比值比（OR）和固定效应模型进行数据分析。
共纳入了五项试验中的591名女性。所有五项研究均报告了临床妊娠情况，每位女性临床妊娠的合并分析显示存在显著异质性（I² = 95.9%）。因此，我们进行了一项计划中的亚组分析，其中“前一周期损伤组”包含四项试验，“取卵日损伤组”包含一项试验有关。在“前一周期损伤组”中，所有四项试验均在开始促排卵前一个月内进行该操作。此干预导致活产几率显著增加（2项试验，Peto OR 2.46；95%CI 1.28至4.72；I² = 0%）和临床妊娠几率显著增加（4项试验，Peto OR 2.61；95%CI 1.71至3.97；I² = 0%）。每例临床妊娠的流产几率（1项试验，Peto OR 1.13；95%CI 0.17至7.45）和每例临床妊娠的多胎妊娠几率（1项试验，Peto OR 0.87；95%CI 0.23至3.30）非常不精确，限制了得出任何有意义的结论。没有研究报告疼痛或出血情况。在“取卵日损伤组”中，该干预导致临床妊娠几率显著降低（1项试验，Peto OR 0.30；95%CI 0.14至0.63）和持续妊娠几率显著降低（1项试验，Peto OR 0.28；95%CI 0.13至0.61）。该亚组中的单项试验未报告任何不良事件结果。
在胚胎移植周期前进行子宫内膜损伤可提高接受ART的女性的临床妊娠率和活产率。建议不要在取卵日进行子宫内膜损伤，因为这似乎会显著降低临床妊娠率和持续妊娠率。关于子宫内膜损伤对多胎妊娠或流产的影响证据不足，且没有关于疼痛和出血等不良事件的证据。
