van Hoogenhuijze N E, Kasius J C, Broekmans F J M, Bosteels J, Torrance H L
Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht University, Room Number: F05.126, Utrecht, The Netherlands.
Department of Gynaecology, Amsterdam University Medical Centre, location AMC, Amsterdam, The Netherlands.
Hum Reprod Open. 2019 Jan 29;2019(1):hoy025. doi: 10.1093/hropen/hoy025. eCollection 2019.
What is the effect of endometrial scratching in patients with or without prior failed ART cycles on live birth (LBR) and clinical pregnancy rates (CPR)?
It remains unclear if endometrial scratching improves the chance of pregnancy and, if so, for whom.
Endometrial scratching is hypothesized to improve embryo implantation in ART. Multiple studies have been published, but it remains unclear if endometrial scratching actually improves pregnancy rates and, if so, for which patients.
For this review, a systematic search for published articles on endometrial scratching and ART was performed on 12 February 2018, in Pubmed, Embase and the Cochrane Library.
PARTICIPANTS/MATERIALS SETTING METHODS: Randomized controlled trials (RCTs) that evaluated endometrial scratching in the cycle prior to the stimulation cycle and reported CPR or LBR were included. RCTs investigating the effect of scratching during the stimulation cycle, or prior to cryo-thaw cycles were excluded. Studies were assessed using the Cochrane Risk of Bias tool. The effect of scratching was assessed for three different patient groups: patients with no prior IVF/ICSI treatment (Group 0), patients with one failed full IVF/ICSI cycle, including cryo-thaw cycles (Group 1) and patients with two or more failed full IVF/ICSI cycles (Group 2). A meta-analysis was performed when statistical heterogeneity was low; otherwise, a descriptive analysis was performed.
Fourteen RCTs involving 2537 participants were included. Most RCTs contained a high or unclear risk of bias on one or more items. Substantial clinical and statistical heterogeneity was present; therefore meta-analysis for LBR and CPR could only be performed on Group 1. For this group, no differences between scratch and control were found for both LBR (risk ratio (RR) 1.01 [95%CI 0.68-1.51]) and CPR (RR 1.04 [95%CI 0.74-1.45]). For Groups 0 and 2, pooled analysis could not be performed, and for both groups the results of the individual RCTs were negative, neutral and positive. Miscarriage and multiple pregnancy rates were evaluated for the three groups (0, 1 and 2) together. Both outcomes were not significantly different between scratch and control (miscarriage rate RR 0.82 [95%CI 0.57-1.17] and multiple pregnancy rate RR 1.06 [95%CI 0.84-1.35]). Subgroup analysis, excluding trials with a risk of unintentional endometrial injury in the control group, was performed for Group 0 and 2 for LBR and CPR, and for the overall groups for miscarriage rate and multiple pregnancy rate. This reduced the heterogeneity and allowed for pooled analysis in these subgroups. Results of pooled analysis for the subgroups of Group 0 and 2 showed no significant difference for LBR, but CPR was significantly improved after endometrial scratching (Group 0 RR 1.28 [95%CI 1.02-1.62] and Group 2 RR 2.03 [95%CI 1.20-3.43]). Subgroup analysis of the overall groups showed no significant difference for miscarriage and multiple pregnancy rate.
The main limitations were that many RCTs had a high or unclear risk of bias on one or several items, clinical heterogeneity was still present despite categorizing into three populations, and that not all RCTs could be included in the analyses because separate data for our three groups could not be provided.
It remains unclear if endometrial scratching improves the chance of pregnancy for women undergoing ART and, if so, for whom. This means endometrial scratching should not be offered in daily practice until results from large and well-designed RCTs and an individual patient data analysis become available.
STUDY FUNDING/COMPETING INTERESTS: No specific funding was sought for the study. The Department of Reproductive Medicine and Gynaecology funds of the University Medical Center of Utrecht were used to support the authors throughout the study period and preparation of the manuscript. None of the authors has a conflict of interest to declare.
Not applicable.
对于既往辅助生殖技术（ART）周期失败或未失败的患者，子宫内膜搔刮术对活产率（LBR）和临床妊娠率（CPR）有何影响？
目前尚不清楚子宫内膜搔刮术是否能提高妊娠几率，若能提高，对哪些患者有效仍不明确。
子宫内膜搔刮术被认为可改善ART中的胚胎着床。已发表了多项研究，但子宫内膜搔刮术是否真能提高妊娠率，若能提高，对哪些患者有效，仍不明确。
研究设计、规模、持续时间：本综述于2018年2月12日在PubMed、Embase和Cochrane图书馆对已发表的关于子宫内膜搔刮术和ART的文章进行了系统检索。
研究对象/材料、研究环境、方法：纳入在刺激周期前一个周期评估子宫内膜搔刮术并报告CPR或LBR的随机对照试验（RCT）。排除研究刺激周期中或冻融周期前搔刮术效果的RCT。使用Cochrane偏倚风险工具评估研究。针对三个不同患者组评估搔刮术的效果：既往未接受体外受精/卵胞浆内单精子注射（IVF/ICSI）治疗的患者（0组）、有一次完整IVF/ICSI周期失败（包括冻融周期）的患者（1组）以及有两次或更多次完整IVF/ICSI周期失败的患者（2组）。当统计异质性较低时进行荟萃分析；否则，进行描述性分析。
纳入了14项涉及2537名参与者的RCT。大多数RCT在一个或多个项目上存在高偏倚风险或不明确的偏倚风险。存在大量临床和统计异质性；因此，仅能对1组进行LBR和CPR的荟萃分析。对于该组，搔刮组和对照组在LBR（风险比（RR）1.01 [95%置信区间（CI）0.68 - 1.51]）和CPR（RR 1.04 [95%CI 0.74 - 1.45]）方面均未发现差异。对于0组和2组，无法进行汇总分析，且两组中各RCT的结果有阴性、中性和阳性。对三组（0、1和2）一起评估流产率和多胎妊娠率。搔刮组和对照组在这两个结果上均无显著差异（流产率RR 0.82 [95%CI 0.57 - 1.17]，多胎妊娠率RR 1.06 [95%CI 0.84 - 1.35]）。对0组和2组进行了排除对照组存在无意子宫内膜损伤风险的试验后的亚组分析，分析LBR和CPR，对总体组分析流产率和多胎妊娠率。这降低了异质性，并允许在这些亚组中进行汇总分析。0组和2组亚组汇总分析结果显示LBR无显著差异，但子宫内膜搔刮术后CPR显著改善（0组RR 1.28 [95%CI 1.02 - 1.62]，2组RR 2.03 [95%CI 1.20 - 3.43]）。总体组的亚组分析显示流产率和多胎妊娠率无显著差异。
局限性、谨慎理由：主要局限性在于许多RCT在一个或几个项目上存在高偏倚风险或不明确的偏倚风险，尽管分为三类人群但临床异质性仍然存在，且并非所有RCT都能纳入分析，因为无法提供我们三组的单独数据。
目前尚不清楚子宫内膜搔刮术是否能提高接受ART治疗女性的妊娠几率，若能提高，对哪些患者有效仍不明确。这意味着在大型且设计良好的RCT结果和个体患者数据分析可用之前，日常实践中不应提供子宫内膜搔刮术。
研究资金/利益冲突：本研究未寻求特定资金。乌得勒支大学医学中心生殖医学和妇科系的资金在整个研究期间及稿件准备过程中用于支持作者。作者均无利益冲突声明。
不适用
