背景:患有子宫内膜异位症的女性可能构成妊娠相关并发症风险特别高的群体。此外,入选辅助生殖技术(ART)的女性会暴露于与不良妊娠结局相关的其他内分泌和胚胎因素.
目的:本研究旨在探讨子宫内膜异位症的独立作用,子宫腺肌病,以及各种ART相关因素对不良孕产妇的影响,胎盘,胎儿,和新生儿结局。
方法:已发表的随机对照试验,队列研究,病例对照研究被认为是合格的.PubMed,MEDLINE,ClinicalTrials.gov,Embase,和Scopus进行了系统搜索,直到2024年3月1日。本系统评价和荟萃分析是根据PRISMA和MOOSE报告指南进行的。彻底调查子宫内膜异位症/子宫腺肌病与不良妊娠结局之间的关系,进行了子分析,只要有可能,根据:概念方法(即ART和非ART概念),子宫内膜异位症阶段/表型,子宫内膜异位症和子宫腺肌病并存,子宫内膜异位症的任何孕前手术治疗,和子宫腺肌病的形式。以95%CI的比值比(OR)作为效果量度。使用GRADE方法评估证据质量。
结果:我们显示子宫内膜异位症女性发生前置胎盘的风险高于对照组(34项研究,OR2.84;95%CI:2.47,3.26;I2=83%,中等质量)。无论受孕方法如何,都观察到了这种关联,并且在最严重的子宫内膜异位症(即rASRMIII-IV期子宫内膜异位症和深部子宫内膜异位症(DE))中尤其强烈(OR6.61;95%CI:2.08,20.98;I2=66%和OR14.54;95%CI:3.67,57.67;I2=54%,分别)。我们还展示了一种关联,不管概念的方法,子宫内膜异位症和:(I)早产(PTB)(43项研究,OR1.43;95%CI:1.32,1.56;I2=89%,低质量)和(ii)剖宫产(29项研究,OR1.52;95%CI:1.41,1.63;I2=93%,低质量)。最严重的子宫内膜异位症与PTB密切相关。在主要分析和仅包括ART妊娠的子分析中,有两个结局与子宫腺肌病相关:(i)流产(14项研究,OR1.83;95%CI:1.53,2.18;I2=72%,低质量)和(ii)先兆子痫(7项研究,OR1.70;95%CI:1.16,2.48;I2=77%,低质量)。关于ART相关因素,在主要分析中观察到以下关联,并在通过仅合并对协变量进行调整的风险估计进行的所有子分析中得到证实:(i)囊胚期胚胎移植(ET)和单卵孪生(28项研究,OR2.05;95%CI,1.72,2.45;I2=72%,低质量),(ii)冷冻胚胎移植(FET)和(降低的风险)小于胎龄(21项研究,OR0.59;95%CI,0.57,0.61;P<0.00001;I2=17%,非常低的质量)和(增加的风险)胎龄大(16项研究,OR1.70;95%CI,1.60,1.80;P<0.00001;I2=55%,质量非常低),(iii)人工周期(AC)-FET和先兆子痫(12项研究,OR2.14;95%CI:1.91-2.39;I2=9%,低质量),PTB(21项研究,OR1.24;95%CI1.15,1.34;P<0.0001;I2=50%,低质量),剖宫产(15项研究,OR1.59;95%CI1.49,1.70;P<0.00001;I2=67%,质量非常低)和产后出血(6项研究,OR2.43;95%CI2.11,2.81;P<0.00001;I2=15%,质量非常低)。
结论:重度子宫内膜异位症(即rASRMIII-IV期子宫内膜异位症,DE)构成前置胎盘和PTB的相当大的风险因素。在这里,我们建议不要在这种情况下叠加与相同产科不良结局或不同结局密切相关的其他暴露因素,如果共存,可以确定不祥的产科综合征的发作。具体来说,我们强烈反对在rASRMIII-IV期子宫内膜异位症或DE的排卵女性中使用AC方案进行FET.在这个高危人群中,我们还建议在胚泡阶段进行单ET。
背景:CRD42023401428.
BACKGROUND: Women with endometriosis may constitute a group at a particularly increased risk of pregnancy-related complications. Furthermore, women selected for assisted reproductive technology (ART) are exposed to additional endocrinological and embryological factors that have been associated with adverse pregnancy outcomes.
OBJECTIVE: This study aimed to investigate the independent effect of endometriosis, adenomyosis, and various ART-related factors on adverse maternal, placental, fetal, and neonatal outcomes.
METHODS: Published randomized controlled trials, cohort studies, and case-control studies were considered eligible. PubMed, MEDLINE, ClinicalTrials.gov, Embase, and Scopus were systematically searched up to 1 March 2024. This systematic review and meta-analysis was performed in line with the PRISMA and the MOOSE reporting guidelines. To thoroughly investigate the association between endometriosis/adenomyosis and adverse pregnancy outcomes, sub-analyses were conducted, whenever possible, according to: the method of conception (i.e. ART and non-ART conception), the endometriosis stage/phenotype, the coexistence of endometriosis and adenomyosis, any pre-pregnancy surgical treatment of endometriosis, and the form of adenomyosis. The odds ratio (OR) with 95% CI was used as effect measure. The quality of evidence was assessed using the GRADE approach.
RESULTS: We showed a higher risk of placenta previa in women with endometriosis compared to controls (34 studies, OR 2.84; 95% CI: 2.47, 3.26; I2 = 83%, moderate quality). The association was observed regardless of the method of conception and was particularly strong in the most severe forms of endometriosis (i.e. rASRM stage III-IV endometriosis and deep endometriosis (DE)) (OR 6.61; 95% CI: 2.08, 20.98; I2 = 66% and OR 14.54; 95% CI: 3.67, 57.67; I2 = 54%, respectively). We also showed an association, regardless of the method of conception, between endometriosis and: (i) preterm birth (PTB) (43 studies, OR 1.43; 95% CI: 1.32, 1.56; I2 = 89%, low quality) and (ii) cesarean section (29 studies, OR 1.52; 95% CI: 1.41, 1.63; I2 = 93%, low quality). The most severe forms of endometriosis were strongly associated with PTB. Two outcomes were associated with adenomyosis both in the main analysis and in the sub-analysis that included only ART pregnancies: (i) miscarriage (14 studies, OR 1.83; 95% CI: 1.53, 2.18; I2 = 72%, low quality) and (ii) pre-eclampsia (7 studies, OR 1.70; 95% CI: 1.16, 2.48; I2 = 77%, low quality). Regarding ART-related factors, the following associations were observed in the main analysis and confirmed in all sub-analyses conducted by pooling only risk estimates adjusted for covariates: (i) blastocyst stage embryo transfer (ET) and monozygotic twinning (28 studies, OR 2.05; 95% CI, 1.72, 2.45; I2 = 72%, low quality), (ii) frozen embryo transfer (FET) and (reduced risk of) small for gestational age (21 studies, OR 0.59; 95% CI, 0.57, 0.61; P < 0.00001; I2 = 17%, very low quality) and (increased risk of) large for gestational age (16 studies, OR 1.70; 95% CI, 1.60, 1.80; P < 0.00001; I2 = 55%, very low quality), (iii) artificial cycle (AC)-FET and pre-eclampsia (12 studies, OR 2.14; 95% CI: 1.91-2.39; I2 = 9%, low quality), PTB (21 studies, OR 1.24; 95% CI 1.15, 1.34; P < 0.0001; I2 = 50%, low quality), cesarean section (15 studies, OR 1.59; 95% CI 1.49, 1.70; P < 0.00001; I2 = 67%, very low quality) and post-partum hemorrhage (6 studies, OR 2.43; 95% CI 2.11, 2.81; P < 0.00001; I2 = 15%, very low quality).
CONCLUSIONS: Severe endometriosis (i.e. rASRM stage III-IV endometriosis, DE) constitutes a considerable risk factor for placenta previa and PTB. Herein, we recommend against superimposing on this condition other exposure factors that have a strong association with the same obstetric adverse outcome or with different outcomes which, if coexisting, could determine the onset of an ominous obstetric syndrome. Specifically, we strongly discourage the use of AC regimens for FET in ovulatory women with rASRM stage III-IV endometriosis or DE. We also recommend single ET at the blastocyst stage in this high-risk population.
BACKGROUND: CRD42023401428.