Surgical Interventions to Improve In Vitro Fertilization Outcomes: A Systematic Review of the Literature

Abstract

Abstract

Background: Various gynecologic pathologies affect in-vitro fertilization (IVF) treatment detrimentally. Timely management of these pathologies could improve IVF outcomes. However, there is a lack of evidence-based guidelines on the appropriate surgical interventions prior to starting IVF treatment. Materials and Methods: The current authors systematically reviewed the literature published on surgical interventions described for different gynecologic pathologies related to IVF outcomes and summarized the literature available according to its level of evidence (Scottish Intercollegiate Guidelines Network [SIGN] classification). Results: This review found that resection of an endometrial polyp diagnosed before the start of an IVF cycle is recommended (level: 1−), whereas management of polyps diagnosed after the start of controlled ovarian stimulation should be individualized (level: 1−). Removal of subserosal uterine fibroids may not be warranted before IVF (level: 1−). There is insufficient evidence regarding the role of myomectomy for managing noncavity distorting intramural fibroids to improve IVF outcomes (level: 1−). Removal of submucosal fibroids is likely to improve IVF outcomes (level: 1−). Data from observational studies suggested that uterine septum resection before IVF treatment may be of benefit, but further evidence from randomized controlled trials is required (level: 2++). Laparoscopic salpingectomy or tubal occlusion improves IVF pregnancy rates in women with hydrosalpinges (level: 1+). There is no evidence to support surgical treatment (aspiration or cystectomy) of ovarian endometrioma over expectant management (level: 1+). Laparoscopic ovarian drilling could be a useful adjunct prior to IVF for women who have previously had IVF treatment cycles that were abandoned because of the risk of ovarian hyperstimulation syndrome (OHSS) or who have had severe OHSS in a previous treatment cycle (level: 1). There is insufficient evidence available to determine if surgical excision of peritoneal endometriosis enhances pregnancy rates in an IVF cycle (level: 2–). Conclusions: There is good evidence for surgical management of endometrial polyps, submucosal fibroids, and tubal hydrosalpinges to improve IVF outcomes. However, well-designed randomized trials are needed urgently to inform clinical practice better regarding surgical interventions for other gynecologic pathologies found prior to IVF treatment. (J GYNECOL SURG 30:189)