Postoperative procedures for improving fertility following pelvic reproductive surgery.

BACKGROUND: Hydrotubation with oil-soluble contrast media for unexplained infertility and adhesiolysis for infertility due to peritubal adhesions are primary procedures 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: The search strategy of the Menstrual Disorders and Subfertility Group was used for the identification of all relevant randomised controlled trials.

SELECTION CRITERIA: All trials where a postoperative procedure following pelvic reproductive surgery was compared with a control group generated by randomisation were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS: Five randomised controlled trials were identified and included in this review, after an attempt to obtain further information from authors of all five trials. All trials were assessed for quality criteria. The studied outcomes were pregnancy, live birth, ectopic pregnancy and miscarriage rates and the rates of tubal patency and procedure-related complications. Reviewers extracted the data independently and odds ratios for these dichotomous outcomes were estimated from the data.

MAIN RESULTS: The odds of pregnancy, live birth, ectopic pregnancy and miscarriage were not significantly different with postoperative hydrotubation versus no hydrotubation nor 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, live birth, ectopic pregnancy or miscarriage. The odds of pregnancy and live birth were significantly increased and infective complications significantly decreased by hydrotubation with fluid containing antibiotic versus hydrotubation with fluid containing no antibiotic, in late hydrotubation following tubal stent removal six weeks after tubal surgery. The odds of at least one patent fallopian tube were significantly increased with late hydrotubation following tubal stent removal versus early hydrotubation in women who had no tubal stenting, but this intervention had no significant impact on the odds of pregnancy, live birth, ectopic pregnancy or miscarriage.

REVIEWER'S 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 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 following tubal surgery may offer benefit over hydrotubation fluid without antibiotic. A randomised controlled trial of postoperative hydrotubation with antibiotic-containing fluid versus no hydrotubation for improving fertility following tubal surgery is justified.