Centre de recherche du CHU de Québec, Université Laval, and the Department of Obstetrics and Gynecology, CHU de Québec, Québec City, Québec, and the Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
Obstet Gynecol. 2022 Jun 1;139(6):1169-1179. doi: 10.1097/AOG.0000000000004811. Epub 2022 May 2.
To evaluate the effect of hormonal suppression on fertility when administered to infertile patients or patient wishing to conceive after surgery for endometriosis.
A systematic search of MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov was performed by two independent reviewers from the databases' inception until December 2020.
We included randomized controlled trials comparing any suppressive hormonal therapy to an inactive control (placebo or absence of treatment) after conservative surgery for endometriosis. Studies that did not report fertility outcomes after surgery were excluded.
TABULATION, INTEGRATION AND RESULTS: This systematic review and meta-analysis was registered in PROSPERO. Two reviewers extracted data and assessed the risk of bias as well as the strength of evidence using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines were followed. Relative risks (RRs) were pooled by quantitative random effect meta-analysis. From 3,138 citations, 19 trials (2,028 patients) were included. Overall, no difference was observed between the treatment and the control group for pregnancy (RR 1.15; 95% CI 1.00-1.32) and live births (RR 1.05; 95% CI 0.84-1.32). When pooling all hormonal therapies, the duration of administration of postoperative therapy was identified as a substantial source of heterogeneity between studies (I2 difference=74%) with increased chances of pregnancy compared with control when administered for at least 3 months (RR 1.22; 95% CI 1.04-1.43). Gonadotropin-releasing hormone (GnRH) agonists (14 trials, 1,721 patients) were associated with increased chances of pregnancy compared with placebo or no treatment (RR 1.20; 95% CI 1.03-1.41; I2=25%). Data were limited for other hormonal treatments with no significant difference between groups. Subgroup analyses taking into account the use of fertility treatments (insemination or in vitro fertilization), stages of the disease and risk of bias of included trials did not modify the results.
Postoperative hormonal suppression should be considered on a case-by-case basis to enhance fertility while balancing this benefit with the risks of delaying conception. If chosen, GnRH agonists would be the treatment of choice, and a duration of at least 3 months should be favored.
PROSPERO, CRD42021224424.
评估在不孕患者中或在子宫内膜异位症手术后希望怀孕的患者中给予激素抑制对生育的影响。
两位独立审查员从数据库创建开始到 2020 年 12 月，对 MEDLINE、EMBASE、CENTRAL 和 ClinicalTrials.gov 进行了系统搜索。
我们纳入了比较任何抑制性激素治疗与子宫内膜异位症保守手术后无活性对照（安慰剂或无治疗）的随机对照试验。排除了未报告手术后生育结果的研究。
表格、综合和结果：本系统评价和荟萃分析已在 PROSPERO 中注册。两位审查员提取数据，并使用 GRADE（推荐评估、制定和评估分级）方法评估偏倚风险和证据强度。遵循 PRISMA（系统评价和荟萃分析的首选报告项目）指南。通过定量随机效应荟萃分析汇总相对风险 (RR)。从 3138 条引用中，纳入了 19 项试验（2028 名患者）。总体而言，治疗组和对照组之间的妊娠（RR 1.15；95%CI 1.00-1.32）和活产（RR 1.05；95%CI 0.84-1.32）无差异。当汇总所有激素治疗时，发现术后治疗的给药持续时间是研究之间异质性的一个重要来源（I2 差异=74%），与对照组相比，至少给药 3 个月时妊娠的机会增加（RR 1.22；95%CI 1.04-1.43）。与安慰剂或无治疗相比，促性腺激素释放激素 (GnRH) 激动剂（14 项试验，1721 名患者）与妊娠机会增加相关（RR 1.20；95%CI 1.03-1.41；I2=25%）。关于其他激素治疗的数据有限，各组之间无显著差异。考虑生育治疗（授精或体外受精）的使用、疾病阶段和纳入试验的偏倚风险的亚组分析并未改变结果。
应根据具体情况考虑术后激素抑制以提高生育能力，同时平衡这一益处与延迟受孕的风险。如果选择，GnRH 激动剂将是首选治疗方法，且至少 3 个月的疗程更为有利。
PROSPERO，CRD42021224424。
