目的:比较治疗输卵管积水的不同方法,基于烧蚀和非烧蚀方法,在接受IVF-ET的不育患者中。
方法:系统评价和网络荟萃分析(NMA)比较接受IVF的不孕患者输卵管积水的不同治疗方法。
方法:常见引文数据库中的结构化搜索。研究纳入标准:同行评审的随机试验(RCT)或队列研究比较输卵管切除术的效果,腹腔镜近端输卵管闭塞(LTO),插入输卵管内装置(ITD),硬化疗法,超声引导抽吸,不治疗,在活产时,正在怀孕,临床妊娠为主要结局,考虑到流产,异位妊娠和并发症作为次要结局。主要NMA包括RCT,并进行了RCT和观察性研究的汇总NMA。通过直接和间接混合比较的几率比(OR)及其95%置信区间(CI)估计了集合效应,源自随机效应模型。通过比较其95%CI与临床相关效应大小的预定间隔(OR<0.9或>1.1)来评估NMA估计的不精确性和异质性。使用累积排序曲线下的表面(SUCRA)来预测每个结果的治疗排序。
结果:9项RCT纳入主要分析,在额外的分析中加上17项额外的观察性研究。RCT的NMA没有发现比较治疗对活产率的影响的显着差异,LTO是SUCRA值最高的选项(0.92,平均排名:1.2)。与没有治疗相比,输卵管切除术和US-抽吸与持续妊娠率的显着增加有关。根据NMA结果(NMAOR:4.35;95%CI:1.7,11.14和2.8;95%CI:1.03,7.58)。输卵管切除术的SUCRA值最高(0.88,平均等级:1.4)。NMA估计,与未治疗相比,输卵管切除术的临床妊娠率显着增加(NMAOR:2.24;95%CI:1.3,3.86)以及LTO与未治疗相比(NMAOR:2.55;95%CI:1.2,5.41)。两种比较都受到高度异质性的影响。对于临床妊娠,LTO是SUCRA最高的干预措施(0.85;平均排名:1.6)。关于次要结果,可行的NMA估计不支持治疗效果之间的显著差异。根据汇总的NMA,包括随机和观察性研究,与未治疗相比,硬化疗法对活产率显示出显着的有益作用(NMA(OR:4.6;95%CI:1.21,17.46)。与未经治疗的患者相比,汇总的NMA估计接受输卵管切除术治疗的患者的持续妊娠率更高(NMAOR:3.35;95%CI:2.12,5.12),美国期望(NMAOR:2.16;95%CI:1.28,3.65)和LTO(NMAOR:2.46;95%CI:1.11,5.43)。与ITD相比,输卵管切除术和LTO产生了更高的有益效果,基于直接和间接的比较。在对持续妊娠的影响等级中,输卵管切除术获得了最高的SUCRA值(0.94;平均等级:1.2)。NMA发现,与不治疗相比,不同的积极管理程序之间的比较对临床妊娠有显著影响。除了ITD插入。LTO对临床妊娠率的影响大于US-误吸(NMAOR:2.04;95%CI:1.05,3.97),而对于其余程序之间的比较,未发现显着差异。NMA将LTO列为具有最高SUCRA值的治疗(0.91;平均等级:1.5)。NMA预测模型将LTO确定为减少流产的最佳干预措施(SUCRA值:0.84;平均排名:1.8),在卵巢对IVF刺激的反应方面,硬化疗法是更安全的选择。
结论:目前的NMA未能支持在IVF之前治疗输卵管积水的任何选择的有效性,以提高活产率,尽管我们的分析显示了输卵管切除术和美国愿望对持续妊娠率以及输卵管切除术和LTO对临床妊娠率的有益影响,这加强了目前的建议。根据汇总的分析,硬化疗法可能是传统腹腔镜技术的一种有希望的替代方法,结合良好的安全性。本文受版权保护。保留所有权利。
OBJECTIVE: To compare different methods to treat
hydrosalpinx, based on both ablative and non-ablative approaches, in infertile patients before undergoing IVF-ET.
METHODS: Systematic review and network meta-analysis (NMA) of comparisons between different treatments of
hydrosalpinx in infertile patients undergoing IVF.
METHODS: structured searches in common citation databases. Study inclusion criteria: peer-reviewed randomized trials (RCT) or cohort studies comparing effects of salpingectomy, laparoscopic proximal tubal occlusion (LTO), insertion of intratubal device (ITD), sclerotherapy, ultrasound-guided aspiration and no treatment, on live birth, ongoing pregnancy, clinical pregnancy as main outcomes, considering also miscarriage, ectopic pregnancy and complications as secondary outcomes. Principal NMA included RCT, and aggregated NMA of RCT and observational studies was carried out. Pooled effects have been estimated by Odds Ratio (OR) and its 95% confidence interval (CI) for direct and indirect-mixed comparisons, derived from random-effects models. Imprecision and heterogeneity of NMA estimations was assessed by comparison of its 95% CI with predefined intervals for clinically relevant size of effect (OR <0.9 or >1.1). Surface under the cumulative ranking curve (SUCRA) were used to predict treatment rankings for each outcome.
RESULTS: Nine RCT were included in main analysis, plus 17 additional observational studies in additional analysis. NMA of RCT did not identify significant differences in the effect of compared treatments on live birth rate, and LTO was the option with the highest value of SUCRA (0.92, mean rank: 1.2). Salpingectomy and US-aspiration associated to a significant increase of ongoing pregnancy rate compared to no treatment, according to NMA results (NMA OR: 4.35; 95% CI: 1.7, 11.14 and 2.8; 95% CI: 1.03, 7.58 respectively). Salpingectomy had the highest SUCRA value (0.88, mean rank: 1.4). NMA estimated significant increase of clinical pregnancy rate for salpingectomy compared with no treatment (NMA OR: 2.24; 95% CI: 1.3, 3.86) as well as for LTO versus no treatment (NMA OR: 2.55; 95% CI: 1.2, 5.41). Both comparisons were affected by a high grade of heterogeneity. For clinical pregnancy, LTO was the intervention with highest SUCRA (0.85; mean rank: 1.6). Regarding secondary outcomes, feasible NMA estimates did not support significant differences between treatments effects. According to aggregated NMA including randomized and observational studies, sclerotherapy showed significant beneficial effects on live birth rate compared to no treatment (NMA (OR: 4.6; 95% CI: 1.21, 17.46). Compared with untreated patients, the aggregated NMA estimates a higher ongoing pregnancy rate in patients treated with salpingectomy (NMA OR: 3.35; 95% CI: 2.12, 5.12), US-aspiration (NMA OR: 2.16; 95% CI: 1.28, 3.65) and LTO (NMA OR: 2.46; 95% CI: 1.11, 5.43). Salpingectomy and LTO produced a higher beneficial effect compared to ITD, based on both direct and indirect comparisons. Salpingectomy obtained the highest SUCRA value in rank of effects on ongoing pregnancy (0.94; mean rank: 1.2). NMA found significant effects on clinical pregnancy for comparisons between the different active management procedures compared with no treatments, with the exception of ITD insertion. LTO had more increasing effect on clinical pregnancy rate compared with US-aspiration (NMA OR: 2.04; 95% CI: 1.05, 3.97), while for the rest of the comparisons between procedures no significant differences were identified. NMA ranked LTO as the treatment with a highest SUCRA value (0.91; mean rank: 1.5). NMA prediction models identified LTO as best intervention to reduce miscarriage (SUCRA value: 0.84; mean rank: 1.8), as sclerotherapy as safer option in terms of ovarian response to IVF stimulation.
CONCLUSIONS: The present NMA fails to support the effectiveness of any option to treat
hydrosalpinx before IVF in order to improve live birth rates, although the beneficial effect of salpingectomy and US aspirations on ongoing pregnancy rates and of both salpingectomy and LTO on clinical pregnancy rates emerges from our analysis, which reinforces current recommendations. Based on the aggregated analyses, sclerotherapy could be a promising alternative to conventional laparoscopic techniques, combined with a favorable safety profile. This article is protected by copyright. All rights reserved.