Department of Gynecology, Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Faculty of Medicine, University of Barcelona (Drs. Casals and Carmona), Barcelona.
Assisted Reproduction Unit, Hospital Universitario Doce de Octubre (Dr. Carrera), Madrid.
J Minim Invasive Gynecol. 2021 Jul;28(7):1303-1312.e5. doi: 10.1016/j.jmig.2021.02.007. Epub 2021 Feb 11.
The aims of this systematic review and meta-analysis were to compare reproductive outcomes in patients who underwent surgery for deep infiltrative endometriosis (DIE) before in vitro fertilization (IVF) with those in patients who underwent IVF without a previous surgery for DIE, to analyze data according to different types of surgery (complete or incomplete) or subgroups of patients (DIE with or without bowel involvement), and to assess surgical and IVF complications and data regarding safety concerns.
A systematic literature search from January 1980 to November 2019 with no language restriction was performed in PubMed, MEDLINE, Embase, and Web of Science. The search strategy used the following Medical Subject Headings terms: "in vitro," "fertilization," "IVF," "assisted reproduction," "colorectal," "endometriosis," "deep," "infiltrating," "deep infiltrative endometriosis," "intestinal," "bowel," "rectovaginal," "uterosacral," "vaginal," and "bladder."
We included studies that compared reproductive outcomes in women with infertility with DIE who received IVF with or without a previous surgery for DIE lesions. Meta-analysis was performed using Review Manager (RevMan v.5.3; Cochrane Training, London, United Kingdom). The risk of bias of the included studies was assessed using the method recommended by Cochrane Collaboration.
TABULATION, INTEGRATION, AND RESULTS: The systematic search retrieved 150 articles; 98 studies were potentially eligible, and their full texts were reviewed. Of these, 12 studies met our inclusion criteria, and 5 presented data suitable for inclusion in a meta-analysis; however, 2 of the studies provided overlapping data, and only the larger study was finally included. No randomized controlled trials (RCTs) were found. The pregnancy rate per patient was 1.84 (95% confidence interval [CI], 1.28-2.64), the pregnancy rate per cycle was 1.84 (95% CI, 1.26-2.70), and the live birth rate per patient was 2.22 (95% CI, 1.42-3.46) times more likely for operated patients than for nonoperated ones. The addition of data from the incomplete surgery groups also showed a higher pregnancy rate per patient for surgery before IVF (odds ratio [OR] 1.63; 95% CI, 1.16-2.28). The results favor previous surgery in DIE with digestive involvement (OR 2.43; 95% CI, 1.13-5.22) and also in DIE without digestive involvement (OR 1.55; 95% CI, 0.61-3.95). A qualitative analysis of the complications of surgery and IVF showed a partial or complete lack of information on these issues as well as high heterogeneity in the reported data. None of these studies is an RCT; therefore, all have a high risk of selection and allocation bias, except for 1 study that statistically controlled the latter risk by using propensity scores. Funnel plots showed no asymmetry.
The results were very consistent for all the studied outcomes, showing a statistically significant benefit for surgery before IVF, although they should be confirmed with RCTs. In addition to the reproductive outcomes, safety data should also be reported to obtain a complete assessment of the risks and benefits.
本系统评价和荟萃分析的目的是比较在体外受精 (IVF) 前接受深部浸润性子宫内膜异位症 (DIE) 手术治疗的患者与未接受 DIE 手术仅接受 IVF 的患者的生殖结局，根据不同类型的手术（完全或不完全）或患者亚组（有或无肠道受累的 DIE）分析数据，并评估手术和 IVF 并发症以及与安全性相关的数据。
从 1980 年 1 月至 2019 年 11 月，我们对 PubMed、MEDLINE、Embase 和 Web of Science 进行了系统的文献检索，无语言限制。使用以下医学主题词术语进行搜索策略：“体外”、“受精”、“IVF”、“辅助生殖”、“结直肠”、“子宫内膜异位症”、“深部”、“浸润性”、“深部浸润性子宫内膜异位症”、“肠道”、“肠”、“直肠阴道”、“子宫骶骨”、“阴道”和“膀胱”。
我们纳入了比较患有深部浸润性子宫内膜异位症 (DIE) 不孕症并接受 IVF 治疗的患者与接受 DIE 病变手术治疗的患者的生殖结局的研究。使用 Review Manager（RevMan v.5.3；Cochrane Training，伦敦，英国）进行荟萃分析。使用 Cochrane 协作推荐的方法评估纳入研究的偏倚风险。
表格、整合和结果：系统检索检索到 150 篇文章；98 项研究可能符合纳入标准，并对其全文进行了审查。其中，12 项研究符合我们的纳入标准，5 项研究提供了适合纳入荟萃分析的数据；然而，其中 2 项研究提供了重叠的数据，最终只纳入了规模较大的研究。未发现随机对照试验 (RCT)。手术患者的妊娠率为每患者 1.84（95%置信区间 [CI]，1.28-2.64），每周期妊娠率为 1.84（95% CI，1.26-2.70），每患者活产率为 2.22（95% CI，1.42-3.46）倍高于未手术患者。从不完全手术组添加的数据也显示手术前 IVF 的妊娠率更高（比值比 [OR] 1.63；95% CI，1.16-2.28）。结果有利于 DIE 伴消化受累（OR 2.43；95% CI，1.13-5.22）和无消化受累（OR 1.55；95% CI，0.61-3.95）的手术。对手术和 IVF 并发症的定性分析显示，这些问题的信息部分或完全缺失，并且报告的数据存在高度异质性。这些研究均不是 RCT；因此，除了 1 项研究通过使用倾向评分统计学控制后者风险外，所有研究都存在高选择和分配偏倚风险。漏斗图显示无不对称性。
所有研究结果都非常一致，表明 IVF 前手术具有统计学上的显著获益，但需要 RCT 进一步证实。除了生殖结局外，还应报告安全性数据，以全面评估风险和获益。
