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Chronopoulou E, Gaetano-Gil A, Shaikh S, Raperport C, Al Wattar BH, Ruiz-Calvo G, Zamora J, Bhide P. Optimizing intrauterine insemination: A systematic review and meta-analysis of the effectiveness and safety of clinical treatment add-ons. Acta Obstet Gynecol Scand 2024. [PMID: 38961556 DOI: 10.1111/aogs.14858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Intrauterine insemination (IUI) is one of the most widespread fertility treatments. However, IUI protocols vary significantly amongst fertility clinics. Various add-on interventions have been proposed to boost success rates. These are mostly chosen arbitrarily or empirically. The aim of this systematic review and meta-analysis is to assess the effectiveness and safety of add-on interventions to the standard IUI protocol and to provide evidence-based recommendations on techniques used to optimize the clinical outcomes of IUI treatment. MATERIAL AND METHODS Systematic review and meta-analyses were performed in accordance with PRISMA guidelines. A computerized literature search was performed from database inception to May 2023. Randomized controlled trials (RCTs) were included reporting on couples/single women undergoing IUI with any protocol for any indication using partner's or donor sperm. A meta-analysis based on random effects was performed for each outcome and add-on. Three authors independently assessed the trials for quality and risk of bias and overall certainty of evidence. Uncertainties were resolved through consensus. Primary outcomes were ongoing pregnancy rate (OPR) or live birth rate (LBR) per cycle/per woman randomized. Registration number PROSPERO: CRD42022300857. RESULTS Sixty-six RCTs were included in the analysis (16 305 participants across 20 countries). Vaginal progesterone as luteal phase support in stimulated cycles was found to significantly increase LBR/OPR (RR 1.37, 95% CI 1.09-1.72, I2 = 4.9%) (moderate/low certainty of the evidence). Endometrial scratch prior/during stimulated IUI cycles may increase LBR/OPR (RR 1.44, 95% CI 1.03-2.01, I2 = 1.8%), but evidence is very uncertain. Results from two studies suggest that follicular phase ovarian stimulation increases LBR/OPR (RR 1.39, 95% CI 1.00-1.94, I2 = 0%) (low certainty of evidence). No significant difference was seen for the primary outcome for the other studied interventions. CONCLUSIONS The findings of this systematic review and meta-analysis suggest that vaginal luteal phase progesterone support probably improves LBR/OPR in stimulated IUI treatments. In view of moderate/low certainty of the evidence more research is needed for solid conclusions. Further research is also recommended for the use of endometrial scratch and ovarian stimulation. Future studies should report on results according to subfertility background as it is possible that different add-ons could benefit specific patient groups.
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Affiliation(s)
| | - Andrea Gaetano-Gil
- Clinical Biostatistics Unit, Hospital Universitario Ramon y Cajal (IRYCIS), Madrid, Spain
| | | | - Claudia Raperport
- London North West University Healthcare NHS Trust, London, UK
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Bassel H Al Wattar
- Institute for Women's Health, University College London, London, UK
- Women's Health Department, University College London Hospital, London, UK
| | - Gabriel Ruiz-Calvo
- Clinical Biostatistics Unit, Hospital Universitario Ramon y Cajal (IRYCIS), Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Universitario Ramon y Cajal (IRYCIS), Madrid, Spain
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health CIBERESP), Clinical Biostatistics, Madrid, Spain
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Raperport C, Desai J, Qureshi D, Rustin E, Balaji A, Chronopoulou E, Homburg R, Khan KS, Bhide P. The definition of unexplained infertility: A systematic review. BJOG 2023. [PMID: 37957032 DOI: 10.1111/1471-0528.17697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 09/21/2023] [Accepted: 10/15/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice. OBJECTIVES This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis. SEARCH STRATEGY CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language. DATA COLLECTION AND ANALYSIS Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range. MAIN RESULTS Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies. CONCLUSIONS This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.
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Affiliation(s)
- Claudia Raperport
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Jessica Desai
- Queen Mary University of London Medical School, London, UK
| | | | | | - Aparna Balaji
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- North West Anglia NHS Foundation Trust, Peterborough, UK
| | | | - Roy Homburg
- Hewitt Fertility Centre, Liverpool Women's Hospital, Liverpool, UK
| | - Khalid Saeed Khan
- Department of Preventative Medicine and Public Health, Faculty of Medicine, University of Granada, Granada, Spain
- CIBER Epidemiology and Public Health, Madrid, Spain
| | - Priya Bhide
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Bui BN, Lensen SF, Gibreel A, Martins WP, Torrance H, Broekmans FJ. Endometrial injury for pregnancy following sexual intercourse or intrauterine insemination. Cochrane Database Syst Rev 2022; 10:CD011424. [PMID: 36278845 PMCID: PMC9590232 DOI: 10.1002/14651858.cd011424.pub4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Intentional endometrial injury is being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such as in vitro fertilisation (IVF). Endometrial injury is often performed by pipelle biopsy and is a common gynaecological procedure with established safety. However, it causes a moderate degree of discomfort/pain and requires an additional pelvic examination. The effectiveness of this procedure outside of ART, in women or couples attempting to conceive via sexual intercourse or with intrauterine insemination (IUI), remains unclear. OBJECTIVES To assess the effectiveness and safety of intentional endometrial injury performed in infertile women or couples attempting to conceive through sexual intercourse or intrauterine insemination (IUI). SEARCH METHODS The Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Knowledge, and clinical trial registries were searched from inception to 21 May 2020, as were conference abstracts and reference lists of relevant reviews and included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated any kind of intentional endometrial injury in women planning to undergo IUI or attempting to conceive spontaneously (with or without ovarian stimulation (OS)) compared to no intervention, a mock intervention, or intentional endometrial injury performed at a different time. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. Primary outcomes were live birth/ongoing pregnancy and pain experienced during the procedure. Due to high risk of bias associated with many of the studies, primary analyses of all review outcomes were restricted to studies at low risk of bias. Sensitivity analysis including all studies was then performed. MAIN RESULTS We included 22 RCTs (3703 women). Most of these studies included women with unexplained infertility. Intentional endometrial injury versus either no intervention or a sham procedure The primary analysis was restricted to studies at low risk of bias, which left only one study included. We are uncertain whether endometrial injury has an effect on the probability of live birth, as only one study is included in the analysis and the confidence interval is wide (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.78 to 1.59; 1 RCT, 210 participants). Evidence suggests that if the chance of live birth with no intervention/a sham procedure is assumed to be 34%, then the chance with endometrial injury would be 27% to 55%. When all studies were included in the sensitivity analysis, we were uncertain whether endometrial injury improves live birth/ongoing pregnancy, as the evidence was of very low quality (RR 1.71, 95% CI 1.32 to 2.21; 8 RCTs, 1522 participants; I² = 16%). Evidence suggests that if the chance of live birth/ongoing pregnancy with no intervention/a sham procedure is assumed to be 13%, then the chance with endometrial injury would be 17% to 28%. A narrative synthesis conducted for the other primary outcome of pain during the procedure included studies measuring pain on a zero-to-ten visual analogue scale (VAS) or grading pain as mild/moderate/severe, and showed that most often mild to moderate pain was reported (6 RCTs, 911 participants; very low-quality evidence). Timing of intentional endometrial injury Four trials compared endometrial injury performed in the cycle before IUI to that performed in the same cycle as IUI. None of these studies reported the primary outcomes of live birth/ongoing pregnancy and pain during the procedure. One study compared endometrial injury in the early follicular phase (EFP; Day 2 to 4) to endometrial injury in the late follicular phase (LFP; Day 7 to 9), both in the same cycle as IUI. The primary outcome live birth/ongoing pregnancy was not reported, but the study did report the other primary outcome of pain during the procedure assessed by a zero-to-ten VAS. The average pain score was 3.67 (standard deviation (SD) 0.7) when endometrial injury was performed in the EFP and 3.84 (SD 0.96) when endometrial injury was performed in the LFP. The mean difference was -0.17, suggesting that on average, women undergoing endometrial injury in the EFP scored 0.17 points lower on the VAS as compared to women undergoing endometrial injury in the LFP (95% CI -0.48 to 0.14; 1 RCT, 110 participants; very low-quality evidence). AUTHORS' CONCLUSIONS Evidence is insufficient to show whether there is a difference in live birth/ongoing pregnancy between endometrial injury and no intervention/a sham procedure in women undergoing IUI or attempting to conceive via sexual intercourse. The pooled results should be interpreted with caution, as the evidence was of low to very low quality due to high risk of bias present in most included studies and an overall low level of precision. Furthermore, studies investigating the effect of timing of endometrial injury did not report the outcome live birth/ongoing pregnancy; therefore no conclusions could be drawn for this outcome. Further well-conducted RCTs that recruit large numbers of participants and minimise bias are required to confirm or refute these findings. Current evidence is insufficient to support routine use of endometrial injury in women undergoing IUI or attempting to conceive via sexual intercourse.
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Affiliation(s)
- Bich Ngoc Bui
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands
| | - Sarah F Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Ahmed Gibreel
- Obstetrics & Gynaecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Helen Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands
| | - Frank J Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands
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Baradwan S, Alshahrani MS, AlSghan R, Alkhamis WH, Alsharif SA, Alanazi GA, Abdelwahed RM, Alkholy EA, Fouad M, Saleh M, Abdelati MG, Alazazy HEM, Elsenity MA, Abdelhakim AM, Mohamed MA, Abbas AM, Mojahed EM. The Effect of Endometrial Scratch on Pregnancy Rate in Women with Previous Intrauterine Insemination Failure: a Systematic Review and Meta-analysis of Randomized Controlled Trials. Reprod Sci 2022; 30:1399-1407. [PMID: 36121616 DOI: 10.1007/s43032-022-01081-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 09/09/2022] [Indexed: 11/29/2022]
Abstract
The objective of this study was to evaluate the impact of endometrial scratch on the pregnancy rate among women with previous failed intrauterine insemination (IUI). A systematic search was done in PubMed, Cochrane Library, Scopus, and ISI web of science from inception to November 2021. We selected randomized clinical trials (RCTs) that compared endometrial scratch in the intervention group versus placebo or no intervention in the control group among infertile women with previous failure of IUI regarding different pregnancy outcomes. Revman software was utilized for performing our meta-analysis. Our main outcomes were biochemical pregnancy, clinical pregnancy, and live birth rates. Five RCTs met our inclusion criteria with a total number of 989 patients. We found endometrial scratch significantly improved the biochemical and clinical pregnancy rates in comparison with the control group among women with previous IUI failure (p < 0.001). Moreover, the live birth rate was significantly increased among the endometrial scratch group (RR = 2.00, 95% CI [1.20, 3.34], p = 0.008). In conclusion, endometrial scratch is effective in improving pregnancy outcomes among women with previous IUI failure. More trials are required to confirm our findings.
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Affiliation(s)
- Saeed Baradwan
- Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Majed Saeed Alshahrani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Najran University, Najran, Saudi Arabia
| | - Rayan AlSghan
- Department of Obstetrics and Gynecology, Maternity and Children Hospital, AlKharj, Saudi Arabia
| | - Waleed H Alkhamis
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | | | | | - Rania Mahfouz Abdelwahed
- Department of Obstetrics and Gynecology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Eman A Alkholy
- Department of Obstetrics and Gynecology, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt
| | - Mahmoud Fouad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Mohamed Saleh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | - Manal G Abdelati
- Department of Obstetrics and Gynecology, Faculty of Medicine, Al-Azhar University, Assiut, Egypt
| | | | - Mohamed A Elsenity
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | | | - Ahmed M Abbas
- Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Eman M Mojahed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fayoum University, Fayoum, Egypt
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Maged AM, Ogila AI, Mohsen RA, Mahmoud SI, Fouad MA, El Komy RO, Lasheen Y, El-Nassery N, Dahab S, Hussein EA. Endometrial scratch injury in infertile women seeking conception through natural or intrauterine insemination cycles: A systematic review and meta-analysis. Int J Gynaecol Obstet 2021. [PMID: 34787914 DOI: 10.1002/ijgo.14030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/05/2021] [Accepted: 11/16/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Implantation failure is a major cause of infertility. To evaluate the value of ESI in infertile women undergoing natural or IUI cycles. METHODS Screening of MEDLINE, CENTRAL, other bases from inception to June 2021 using the keywords related to endometrial scratch, implantation, infertility, and IUI. RCTs of intentional endometrial injury in couples seeking fertility through natural or IUI cycles were included. All types of ESI with variable intensity (mild to moderate or severe), at different times of the cycle (preceding follicular, preceding luteal, same follicular or two times), single or double compared to none, placebo or other active interventions were included. Twenty-five studies included 4234 women (five natural [774 women], 20 IUI [3460 women]) fulfilled the inclusion criteria. Extracted data included settings of the study, sample size, participant characteristics, intervention details and outcome parameters. The primary outcome was the clinical pregnancy rate. RESULTS ESI increased clinical pregnancy rate from 16.1% (62/386) to 26.5% (103/388) and from 11.4% (186/1627) to 22.25% (408/1833), P = 0.004 and <0.001 in natural and IUI cycles, respectively. ESI increased live birth rate from 26.6% (42/158) to 37.6% (59/157) (P = 0.250) and from 11.2% (36/322) to 18% (58/322) (P = 0.020) in natural and IUI cycles, respectively. CONCLUSION ESI increased both clinical pregnancy and ongoing pregnancy rates significantly in natural and IUI cycles. However, there is marked methodological heterogeneity among the different studies in defining the outcome parameters.
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Affiliation(s)
- Ahmed M Maged
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Asmaa I Ogila
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Reham A Mohsen
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Safaa I Mahmoud
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Mona A Fouad
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Rasha O El Komy
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Yossra Lasheen
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Noura El-Nassery
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Sherif Dahab
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
| | - Eman A Hussein
- Department of Obstetrics and Gynecology, Kasr Al-Ainy Hospital, Cairo University, Cairo, Egypt
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Bui BN, Lensen SF, Gibreel A, Martins WP, Torrance H, Broekmans FJ. Endometrial injury for pregnancy following sexual intercourse or intrauterine insemination. Cochrane Database Syst Rev 2021; 3:CD011424. [PMID: 33734431 PMCID: PMC8094383 DOI: 10.1002/14651858.cd011424.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Intentional endometrial injury is being proposed as a technique to improve the probability of pregnancy in women undergoing assisted reproductive technologies (ART) such as in vitro fertilisation (IVF). Endometrial injury is often performed by pipelle biopsy and is a common gynaecological procedure with established safety. However, it causes a moderate degree of discomfort/pain and requires an additional pelvic examination. The effectiveness of this procedure outside of ART, in women or couples attempting to conceive via sexual intercourse or with intrauterine insemination (IUI), remains unclear. OBJECTIVES To assess the effectiveness and safety of intentional endometrial injury performed in infertile women or couples attempting to conceive through sexual intercourse or intrauterine insemination (IUI). SEARCH METHODS The Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Knowledge, and clinical trial registries were searched from inception to 21 May 2020, as were conference abstracts and reference lists of relevant reviews and included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated any kind of intentional endometrial injury in women planning to undergo IUI or attempting to conceive spontaneously (with or without ovarian stimulation (OS)) compared to no intervention, a mock intervention, or intentional endometrial injury performed at a different time or to a higher/lower degree. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. Primary outcomes were live birth/ongoing pregnancy and pain experienced during the procedure. Due to high risk of bias associated with many of the studies, primary analyses of all review outcomes were restricted to studies at low risk of bias. Sensitivity analysis including all studies was then performed. MAIN RESULTS We included 23 RCTs (4035 women). Most of these studies included women with unexplained infertility. Intentional endometrial injury versus either no intervention or a sham procedure The primary analysis was restricted to studies at low risk of bias, which left only one study included. We are uncertain whether endometrial injury has an effect on the probability of live birth, as only one study is included in the analysis and the confidence interval is wide (risk ratio (RR) 1.11, 95% confidence interval (CI) 0.78 to 1.59; 1 RCT, 210 participants). Evidence suggests that if the chance of live birth with no intervention/a sham procedure is assumed to be 34%, then the chance with endometrial injury would be 27% to 55%. When all studies were included in the sensitivity analysis, we were uncertain whether endometrial injury improves live birth/ongoing pregnancy, as the evidence was of very low quality (RR 1.71, 95% CI 1.32 to 2.21; 8 RCTs, 1522 participants; I² = 16%). Evidence suggests that if the chance of live birth/ongoing pregnancy with no intervention/a sham procedure is assumed to be 13%, then the chance with endometrial injury would be 17% to 28%. A narrative synthesis conducted for the other primary outcome of pain during the procedure included studies measuring pain on a zero-to-ten visual analogue scale (VAS) or grading pain as mild/moderate/severe, and showed that most often mild to moderate pain was reported (6 RCTs, 911 participants; very low-quality evidence). Higher versus lower degree of intentional endometrial injury Evidence was insufficient to show whether there is a difference in ongoing pregnancy rates (RR 1.29, 95% CI 0.71 to 2.35; 1 RCT, 332 participants; low-quality evidence) between hysteroscopy with endometrial injury and hysteroscopy alone. Evidence suggests that if the chance of ongoing pregnancy with hysteroscopy alone is 10%, then the chance with hysteroscopy with endometrial injury would be 7% to 24%. This study did not report the primary outcomes of live birth and pain during the procedure. Timing of intentional endometrial injury Four trials compared endometrial injury performed in the cycle before IUI to that performed in the same cycle as IUI. None of these studies reported the primary outcomes of live birth/ongoing pregnancy and pain during the procedure. One study compared endometrial injury in the early follicular phase (EFP; Day 2 to 4) to endometrial injury in the late follicular phase (LFP; Day 7 to 9), both in the same cycle as IUI. The primary outcome live birth/ongoing pregnancy was not reported, but the study did report the other primary outcome of pain during the procedure assessed by a zero-to-ten VAS. The average pain score was 3.67 (standard deviation (SD) 0.7) when endometrial injury was performed in the EFP and 3.84 (SD 0.96) when endometrial injury was performed in the LFP. The mean difference was -0.17, suggesting that on average, women undergoing endometrial injury in the EFP scored 0.17 points lower on the VAS as compared to women undergoing endometrial injury in the LFP (95% CI -0.48 to 0.14; 1 RCT, 110 participants; very low-quality evidence). AUTHORS' CONCLUSIONS Evidence is insufficient to show whether there is a difference in live birth/ongoing pregnancy between endometrial injury and no intervention/a sham procedure in women undergoing IUI or attempting to conceive via sexual intercourse. The pooled results should be interpreted with caution, as the evidence was of low to very low quality due to high risk of bias present in most included studies and an overall low level of precision. Furthermore, studies investigating the effect of timing of endometrial injury did not report the outcome live birth/ongoing pregnancy; therefore no conclusions could be drawn for this outcome. Further well-conducted RCTs that recruit large numbers of participants and minimise bias are required to confirm or refute these findings. Current evidence is insufficient to support routine use of endometrial injury in women undergoing IUI or attempting to conceive via sexual intercourse.
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Affiliation(s)
- Bich Ngoc Bui
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands
| | - Sarah F Lensen
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Ahmed Gibreel
- Obstetrics & Gynaecology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | - Helen Torrance
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands
| | - Frank J Broekmans
- Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, Netherlands
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