Duffy, J. M., Johnson, N., Ahmad, G., & Watson, A. (2009). Postoperative procedures for improving fertility following pelvic reproductive surgery. The Cochrane database of systematic reviews. https://doi.org/10.1002/14651858.CD001897.pub2
Duffy JM, Johnson N, Ahmad G, Watson A. Postoperative procedures for improving fertility following pelvic reproductive surgery. The Cochrane database of systematic reviews. 2009. doi:10.1002/14651858.CD001897.pub2
Duffy, James M. N., et al. "Postoperative procedures for improving fertility following pelvic reproductive surgery." The Cochrane database of systematic reviews, 2009.
Tube flushing and second-look surgery showed no clear pregnancy gain
A 2009 Cochrane review examined five trials of women with infertility after pelvic surgery. Neither tube flushing nor a second look with the camera clearly raised pregnancy or live birth odds. Adding an antibiotic to delayed tube flushing was linked with higher odds of both pregnancy and live birth.
Study at a glance, Cochrane review: Tube flushing and second-look surgery showed no clear pregnancy gain. Source: Duffy JM et al., 2009, PMID 19370571.
Key Findings
Flushing the tubes (hydrotubation) against no flushing, one trial of 86 women: OR 1.12 for pregnancy (95% CI 0.57-2.21) and OR 0.61 for live birth (95% CI 0.24-1.59). Neither differed significantly.
Second-look laparoscopy with adhesiolysis against none, two trials combined: OR 0.96 for pregnancy (95% CI 0.44-2.07) and OR 0.67 for live birth (95% CI 0.19-2.32). Neither differed significantly.
In one trial of 67 women, early hydrotubation carried higher odds of infection than hydrotubation done later without an antibiotic: OR 4.72 (95% CI 2.50-8.93).
Among those 67 women, early hydrotubation had lower odds of a patent fallopian tube on at least one side: OR 0.29 (95% CI 0.16-0.55).
One trial of 55 women added antibiotic to later flushing. Against later flushing without it: OR 2.23 for pregnancy (95% CI 1.12-4.44) and OR 2.37 for live birth (95% CI 1.11-5.05).
Interpretation
This systematic review combined five randomized trials of surgery follow-up steps after pelvic surgery. Tube flushing and a second look with the camera did not raise the odds of pregnancy or live birth. Adding an antibiotic to delayed tube flushing was linked with higher odds of both. The authors note that the antibiotic group also had an extra tube-support procedure, which they say makes that one finding harder to read on its own. The findings support larger trials of antibiotics added to tube flushing after surgery.
RRM Context
Restorative reproductive medicine judges surgery by whether fertility returns. Scar tissue and blocked tubes can make surgery fail. These trials measured pregnancy and live birth. The antibiotic-flushing step raised both.
Our editorial summary of this paper, not the article's abstract.
Abstract
Background
Hydrotubation with oil-soluble contrast media for unexplained infertility and adhesiolysis for infertility due to peritubal adhesions are primary procedures that are of recognised benefit. It is less clear whether postoperative procedures such as hydrotubation or second-look laparoscopy with adhesiolysis are beneficial following pelvic reproductive surgery.
Objectives
To assess the value of postoperative hydrotubation and second-look laparoscopy with adhesiolysis following female pelvic reproductive surgery.
Search Strategy
We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (August 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to August 2008), EMBASE (1980 to August 2008), PsycINFO (1967 to August 2008), Current Contents (1993 to August 2008), Biological Abstracts (1969 to August 2008), CINAHL (1982 to August 2008) and reference lists of identified articles.
Selection Criteria
All randomised controlled trials in which a postoperative procedure was compared with a control group following pelvic reproductive surgery were considered for inclusion in the review.
Data Collection and Analysis
Five randomised controlled trials were identified and included in this updated review. An attempt was made to obtain further information from the authors of all five trials. All trials were assessed for quality. The studied outcomes were pregnancy, live birth, ectopic pregnancy and miscarriage rates, and the rates of tubal patency and procedure-related complications. Review authors extracted the data independently and the odds ratios (OR) were estimated for these dichotomous outcomes.
Main Results
Five randomised controlled trials were identified and included in this review. The odds of pregnancy (OR 1.12, 95% confidence interval (CI) 0.57 to 2.21) and live birth (OR 0.61, 95% CI 0.24 to 1.59) were not significantly different with postoperative hydrotubation versus no hydrotubation. The odds of pregnancy (OR 0.96, 95% CI 0.44 to 2.07) or live birth (OR 0.67, 95% CI 0.19 to 2.32) were also not significantly different with second-look laparoscopy and adhesiolysis versus no second-look laparoscopy. Whether hydrotubation was early or late and whether hydrotubation fluid contained steroid or not had no significant impact on the odds of pregnancy or live birth. Late antibiotic hydrotubation increased the odds of at least one patent fallopian tube when compared with early hydrotubation in women (OR 7.72, 95% CI 2.50 to 8.93). The odds of infective morbidity significantly increased with early hydrotubation when compared with late non-antibiotic hydrotubation (OR 4.72, 95% CI 2.50 to 8.93). When comparing late hydrotubation following tubal stent removal with early hydrotubation in women who had no tubal stenting, there was no significant difference in pregnancy or live birth rates.
Authors' Conclusions
There is insufficient evidence to support the routine practice of hydrotubation or second-look laparoscopy following female pelvic reproductive surgery. The studies on which this conclusion is based were either of poor quality or underpowered. These interventions should be performed in the context of a good quality, adequately powered randomised controlled trial. Postoperative hydrotubation with fluid containing antibiotic may offer benefit over hydrotubation fluid without antibiotic following tubal surgery. A randomised controlled trial of postoperative hydrotubation with antibiotic-containing fluid versus no hydrotubation for improving fertility following tubal surgery is justified.
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