Efficacy of Hysteroscopy in Improving Fertility Outcomes in Women Undergoing Assisted Reproductive Technique: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Usefulness of hysteroscopy before assisted reproductive technique (ART) was considered debatable. However, over the last decade, several new trials have been added to available literature. We aimed to assess the impact of diagnostic and operative hysteroscopy on reproductive outcomes of infertile women with and without intrauterine abnormalities. MATERIALS AND METHODS: MEDLINE, Scopus, SciELO, Embase, Cochrane Library at CENTRAL, PROSPERO, CINAHL, grey literature, conference proceedings, and international controlled trials registries were searched without temporal, geographical, or language restrictions. Randomized controlled trials (RCTs) of infertile women comparing hysteroscopy versus no hysteroscopy prior to the first ART or after at least one failed attempt were included. RCTs of infertile women with intrauterine pathology comparing diagnostic versus operative hysteroscopy were included in separate analysis. Random-effect meta-analysis was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Grading of Recommendations, Assessment, Development and Evaluation and Cochrane criteria were used for quality of evidence and risk of bias assessment. Primary outcome was live birth rate (LBR). Secondary outcomes were clinical pregnancy (CPR) and pregnancy loss rate. RESULTS: Fifteen studies (5,038 women) were included. Compared to no hysteroscopy before first or after failed ART attempts, moderate-quality evidence showed that hysteroscopy increased the LBR (relative risk [RR] 1.24, 95% confidence interval [CI] 1.09-1.43, I2 = 21%), confirmed by subgroup analysis for women with failure after one or more ART cycles (RR 1.43, 95% CI: 1.19-1.72, I2 = 0%) but not before the first ART. Moderate-quality evidence showed that it increased the CPR (RR 1.36, 95% CI: 1.18-1.57; I2 = 51%), confirmed in subgroup analysis for both implantation failure (RR 1.40, 95% CI: 1.12-1.74, I2 = 52%) and before first ART (RR 1.32, 95% CI: 1.11-1.57, I2 = 42%). Low-quality data suggest that operative hysteroscopy increases CPR when used to treat intrauterine pathologies (RR 2.13, 95% CI: 1.56-2.92, I2 = 0%). CONCLUSIONS: Although moderate-quality evidence supports performing hysteroscopy before ART in women with history of implantation failure, hysteroscopic evaluation of uterine cavity should be considered a first-line technique in all infertile women undergoing ART. Additional high-quality RCTs are still needed, particularly to assess yield during couple's initial evaluation even before ART is considered.

Iron status in women with infertility and controls: a case-control study.

Background: Iron deficiency is a common problem in subfertile women. The influence of iron status on unexplained infertility is unknown. Methods: In a case-control study, 36 women with unexplained infertility and 36 healthy non-infertile controls were included. Parameters of iron status including serum ferritin and a serum ferritin <30 µg/dL served as main outcome parameters. Results: Women with unexplained infertility demonstrated a lower transferrin saturation (median 17.3%, IQR 12.7-25.2 versus 23.9%, IQR 15.4-31.6; p= 0.034) and a lower mean corpuscular hemoglobin concentration (median 33.6 g/dL, IQR 33.0-34.1 versus 34.1 g/dL, IQR 33.2-34.7; p= 0.012). Despite the fact that there was no statistically significant difference in median ferritin levels (p= 0.570), women with unexplained infertility had ferritin levels <30µg/L more often (33.3%) than controls (11.1%; p= 0.023). In a multivariate model, unexplained infertility and abnormal thyroid antibodies were associated with ferritin <30µg/L (OR 4.906, 95%CI: 1.181-20.388; p= 0.029 and OR 13.099; 2.382-72.044; p= 0.029, respectively). Conclusion: Ferritin levels <30µg/L were associated with unexplained infertility and might be screened in the future. Further studies with a focus on iron deficiency and iron treatment on women with unexplained infertility are warranted.

Stress and polycystic ovarian morphology in functional hypothalamic amenorrhea: a retrospective cohort study.

BACKGROUND: Women with functional hypothalamic amenorrhea (FHA) reveal polycystic ovarian morphology (PCOM) in up to 50%. If stress sensitivity in women with polycystic ovary syndrome (PCOS) is the reason why PCOS women are prone to develop FHA, patients with FHA caused by stress should reveal PCOM more often. METHODS: In a retrospective cohort study, 38 stress-associated and 38 excessive exercise-induced FHA women were included. The main outcome parameter was PCOM. In addition, the focus was on general patient characteristics as well as on prolactin, dehydroepiandrosterone-sulphate (DHEAS), and anti-Mullerian hormone (AMH). RESULTS: PCOM was found in 34/76 patients (44.7%). The stress group showed a higher prevalence of PCOM than the excessive exercise group (57.9% versus 31.6%, p = 0.019) as well as higher prolactin levels (median 13.2ng/mL versus 11.7ng/mL, p = 0.008) and a trend towards higher DHEAS levels (p = 0.058). CONCLUSIONS: In FHA women, the PCOM prevalence was significantly higher in the stress-group than in the excessive exercise-group. The well-known stress sensitivity in women with PCOS might explain why PCOS women are prone to develop FHA as well as the high PCOM prevalence in FHA women.

Fertility and Sterility top videos from 2021.

OBJECTIVE: To objectively grade all video publications in Fertility and Sterility during the year 2021 and compile a list of the top 10 surgical videos. DESIGN: A descriptive presentation of the 10 highest-scoring video publications from Fertility and Sterility in the year 2021. SETTING: Not applicable. PATIENT/ANIMALS: Not applicable. INTERVENTIONS: J.F., Z.K., J.P.P., and S.R.L. acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. MAIN OUTCOME MEASURES: Up to 5 points were awarded for each of the following categories: scientific merit or clinical relevance of the topic; clarity of the video; use of an innovative surgical technique; and video editing or the use of marking tools on the video to highlight important features or surgical landmarks. This allowed a maximum score of 20 for each video. The number of YouTube views and likes was used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random effects model was calculated to assess the agreement among the 4 independent reviewers. RESULT(S): A total of 36 videos were published in Fertility and Sterility during the year 2021. After averaging scores from all 4 reviewers, a top-10 list was created. The overall interclass correlation coefficient for the 4 reviews was 0.89 (95% confidence interval, 0.89-0.94). CONCLUSION(S): An overall substantial agreement was noted among the 4 reviewers. A total of 10 videos reigned supreme from a list of very competitive publications that had already undergone the peer review process. The subject matter of these videos ranged from complex surgical procedures, including uterine transplantation, to common procedures, such as GYN ultrasound.

An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review.

Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.

Risk of endometrial cancer in asymptomatic postmenopausal women in relation to ultrasonographic endometrial thickness: systematic review and diagnostic test accuracy meta-analysis.

OBJECTIVE: This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation. DATA SOURCES: MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions. STUDY ELIGIBILITY CRITERIA: Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis. METHODS: This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group. RESULTS: A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I2=74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I2=0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I2=0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I2=86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I2=78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs. CONCLUSION: Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy.

The Prevalence of Fallopian Tube Occlusion in Women with Polycystic Ovary Syndrome Seems Similar to Non-Subfertile Women: A Retrospective Cohort Study.

There are limited data on how non-infectious risk factors influence tubal patency in women with subfertility. With hormonal shifts influencing tubal secretions, it has been argued that subfertile women with polycystic ovary syndrome (PCOS) have lower tubal patency. In a retrospective study, 216 women, who underwent diagnostic evaluation for PCOS and infertility, were included. Fallopian tube patency was tested using HSG, HyCoSy, and laparoscopic chromopertubation in 171 (79.2%), 28 (13.0%), and 17 (7.9%), respectively. Bilateral patency was found in 193 women (89.4%), unilateral patency in 13 (6.0%) and bilateral occlusion in 10 (4.6%) patients. Women with PCOS phenotypes C (odds ratio, OR 0.179, 95% CI: 0.039-0.828) and D (OR 0.256, 95% CI: 0.069-0.947) demonstrated lower risks for Fallopian tube occlusion. In conclusion, our data suggest that about 5% of infertile women with PCOS also have bilateral tubal occlusion, which seems similar to the rate in non-subfertile women. With 11% of participants having unilateral or bilateral tubal occlusion, this should reassure women with PCOS that their hormonal challenges do not seem to increase their risk for tubal factor subfertility.

Are the Stage and the Incidental Finding of Endometriosis Associated with Fallopian Tube Occlusion? A Retrospective Cohort Study on Laparoscopic Chromopertubation in Infertile Women.

Endometriosis seems to have a strong negative effect on female fertility. The aim of this study was to assess the rate of tubal occlusion diagnosed via laparoscopic chromopertubation in infertile women with endometriosis and compare the results to infertile women without endometriosis. In this retrospective cohort study, 275 infertile women with endometriosis and 49 infertile women without endometriosis undergoing diagnostic laparoscopy for primary or secondary infertility with chromopertubation at the Medical University of Vienna between January 2012 and December 2020 have been investigated. During the laparoscopic assessment of tubal patency, significantly more fallopian tubes were occluded in the endometriosis group compared to the control group (25.8 versus 15.3%; p = 0.029). Unilateral and bilateral occlusion was found significantly more often in patients with endometriosis (p = 0.021). In the multivariate analysis, only the rASRM stage (the revised classification of endometriosis by the American Society for Reproductive Medicine) showed a significant association with bilateral occlusion (OR 1.400, 95%CI: 1.018-1.926; p = 0.038). Both a higher rASRM stage (OR 2.181, 95%CI: 1.191-3.995; p = 0.012) and secondary infertility (OR 1.514, 95%CI: 1.156-1.983; p = 0.003) were associated with an increased risk for any kind of fallopian tube occlusion. Endometriosis seems to be associated with an increased risk for fallopian tube occlusion. The rate of tubal occlusion increased significantly with the rASRM stage.

Parameters for Calcium Metabolism in Women with Polycystic Ovary Syndrome Who Undergo Stimulation with Letrozole: A Prospective Cohort Study.

For women with polycystic ovarian syndrome (PCOS) and infertility, stimulation with the aromatase-inhibitor letrozole has been recommended as a first-line for ovulation induction. Calcium-associated signaling has also been a component for other ovulation induction and superovulation medications. This study's aim was to evaluate parameters of calcium metabolism in PCOS women. In a prospective cohort study, 61 anovulatory, infertile PCOS patients who underwent letrozole stimulation were included. Outcome measures were: follicular maturation after letrozole stimulation; parathyroid hormone (PTH); 25-hydroxyvitamin D3 (25OHD3); serum levels of calcium, phosphorus, magnesium, albumin, and total protein. Successful recruitment of a dominant follicle was achieved in 35 patients (57.4%). Women with and without successful follicular development did not differ in serum levels of PTH (38.4 ± 19.7 vs. 39.6 ± 16.2 pg/mL), 25OHD3 (62.5 ± 32.1 vs. 65.4 ± 30.9 nmol/L), calcium (2.36 ± 0.08 vs. 2.37 ± 0.12 mmol/L), or protein (70.2 ± 13.3 vs. 74.0 ± 3.7 g/L), respectively (p > 0.05). However, women who were not responsive to letrozole for ovulation induction demonstrated higher anti-Müllerian hormone (AMH) levels (9.7 ± 4.7 vs. 5.0 ± 3.2 ng/mL, p = 0.005). In conclusion, the success of letrozole stimulation in women with PCOS is independent from calcium metabolism parameters. However, AMH levels seem predictive of medication resistance.

Fertility and Sterility top videos of 2020.

OBJECTIVE: To objectively grade all video publications in Fertility and Sterility during 2020 and compile a list of the top 5 surgical videos. DESIGN: Descriptive presentation of the 5 highest scoring video publications from Fertility and Sterility in 2020 SETTING: Not applicable. PATIENT(S)/ANIMAL(S): Not applicable. INTERVENTION(S): J.F., Z.K., J.P.P., and S.R.L. acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. MAIN OUTCOME MEASURE(S): Up to 5 points were awarded for each of the following categories: scientific merit or clinical relevance of the topic, the clarity of the video, the use of innovative surgical technique, and video editing or the use of marking tools on the video to highlight the important features or surgical landmarks. This allowed a maximum score of 20 for each video. The numbers of YouTube views and likes were used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random-effects model was calculated to assess for agreement between the 4 independent reviewers. RESULT(S): A total of 20 videos were published in Fertility and Sterility during 2020. After averaging scores from all 4 reviewers, a list of top 5 videos was created (Table 1). The overall interclass coefficient for the 4 reviews was 0.77 (95% confidence interval, 0.56-0.89). CONCLUSION(S): An overall substantial agreement was noted among the 4 reviewers. Five videos particularly stood out within the competitive peer reviewed publications. The subject matter of these videos ranged from complex surgical procedures, including transvaginal natural orifice surgery and advanced endometriosis to basic embryology laboratory topics that covered trophectoderm biopsy and novel intracytoplasmic sperm injection techniques.

Postsurgical barrier strategies to avoid the recurrence of intrauterine adhesion formation after hysteroscopic adhesiolysis: a network meta-analysis of randomized controlled trials.

OBJECTIVE: To assess the efficacy of mechanical strategies to avoid the recurrence of intrauterine adhesions, to evaluate the impact on subsequent fertility after hysteroscopic adhesiolysis and to rank the available antiadhesive options. DATA SOURCES: MEDLINE, Scopus, ClinicalTrials.gov, CINAHL, Scielo, EMBASE, PROSPERO, Cochrane Library, conference proceedings, and international controlled trials registries were searched without temporal, geographic, and language restrictions. STUDY ELIGIBILITY CRITERIA: Randomized trials that analyzed the recurrence, reproductive outcomes, or both in women undergoing hysteroscopic adhesiolysis followed by mechanical prevention of intrauterine adhesions were included. The exclusion criteria included the following: quasi-randomized trials and trials without randomization and studies including patients undergoing hysteroscopic surgery that was different from adhesiolysis. STUDY APPRAISAL AND SYNTHESIS METHODS: The Preferred Reporting Items for Systematic reviews and Meta-Analyses extension statement for network meta-analyses guidelines were followed. We performed a network meta-analysis based on the random effects model for mixed multiple treatment comparisons to rank the antiadhesive strategies by surface under the cumulative ranking curve area. Quality assessment was performed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions. The primary outcome was the recurrent presence of intrauterine adhesions. RESULTS: Eleven studies with data for 1596 women were identified as applicable. A copper intrauterine device together with an intrauterine balloon (surface under the cumulative ranking curve area=46.4%) or with cross-linked hyaluronic acid gel (surface under the cumulative ranking curve area=21.3%) seemed effective in preventing adhesions recurrence. Regarding the fecundity, hyaluronic acid gel demonstrated the highest pregnancy rates (surface under the cumulative ranking curve area=79.8%). The greatest degrees of change in the mean adhesions scores were found with the use of hyaluronic acid gel plus an intrauterine device (surface under the cumulative ranking curve area=38.9%). For postsurgical adhesion severity, hyaluronic acid gel plus intrauterine device (surface under the cumulative ranking curve area=49.9%) followed by intrauterine device alone (surface under the cumulative ranking curve area=30.8%) was ranked the highest. Dried amnion graft (surface under the cumulative ranking curve area=53.8%) and uterine balloon (surface under the cumulative ranking curve area=45%) showed the greatest menstrual pattern improvement. CONCLUSION: Cross-linked hyaluronic acid gel, with or without insertion of a copper intrauterine device, seems to be the most effective approach. However, the lack of a clear best therapy suggests the need for further studies to draw firm conclusions.

Anxiety, Depression, and Quality of Life After Procedural Intervention for Uterine Fibroids.

Background: Quality of life (QOL) and psychological health has been reported to be decreased among women with gynecological conditions such as uterine fibroids (UFs). Materials and Methods: Women enrolled in the Comparing Options for Management: PAtient-centered REsults for Uterine Fibroids (COMPARE-UF) registry, receiving procedural therapy for symptomatic UFs, were eligible for this analysis if they completed a series of health-related QOL surveys administered at three time points (baseline, 6-12 weeks postprocedure, and 1 year postprocedure; n = 1486). Ethical approval for this study was obtained at each recruiting site and the coordinating center (NCT02260752, clinicaltrials.gov). Results: More than 26% (n = 393) of women reported moderate anxiety/depression on the baseline anxiety/depression domain of the Euro-QOL 5-dimension instrument. At both the 6-12 weeks and 1-year postprocedural follow-up, there was significant improvement in the UF QOL symptom severity score (p < 0.001, p < 0.001), the total UF symptom QOL score (p < 0.001, p < 0.001), and the Euro-QOL 5-dimension visual analog scale (p < 0.001, p = 0.004) compared with the preprocedural baseline scores. The reporting of anxiety/depression decreased by 66.4% among women who were at baseline, whereas 5.6% of women previously reporting no anxiety/depression reported anxiety/depression at the 1-year follow-up. Conclusion: UF symptoms were more severe among women reporting anxiety/depression at baseline. At the 1-year follow-up, health-related QOL scores improved among all women and the prevalence of anxiety/depression decreased in most, but not all women, whereas severity of anxiety/depression worsened in a small percentage of women (5.6%). Overall, these results suggest that UF treatment improves symptoms of anxiety/depression associated with symptomatic UFs.

Fertility and Sterility top videos from 2017 to 2019.

OBJECTIVE: To objectively grade all video publications in Fertility and Sterility during the years 2017-2019 and compile a list of the top 10 surgical videos. DESIGN: Descriptive presentation of the 10 highest-scoring video publications from Fertility and Sterility in the years 2017-2019. SETTING: Not applicable. PATIENT(S)/ANIMAL(S): Not applicable. INTERVENTION(S): All 4 authors acted as independent reviewers of all video publications. A standardized scoring method was used to score all videos. MAIN OUTCOME MEASURE(S): Up to 5 points were awarded for each of the following categories: Scientific merit or clinical relevance of the topic; clarity of video; use of innovative surgical technique; and video editing or use of marking tools on the video to highlight important features or surgical landmarks. This allowed a maximum score of 20 for each video. The number of YouTube views and likes were used as a tiebreaker if ≥2 videos scored similarly. The interclass coefficient from a 2-way random effects model was calculated to assess for agreement between the 4 independent reviewers. RESULT(S): A total of 40 videos were published in Fertility and Sterility during the years 2017-2019. After averaging scores from all 4 reviewers, a top 10 list was created (Table). Only 2 videos (number 6 and 7 spots) had the same average score, and the number of YouTube views and likes were used as a tiebreaker. The overall interclass coefficient for the 4 reviewers was 0.68 (95% confidence interval, 0.52-0.76). CONCLUSION(S): An overall substantial agreement was noted between the 4 reviewers. Ten videos reigned supreme from a list of very competitive publications that had already undergone the peer review process. The subject matter of these videos ranged from complex surgical procedures, including uterus transplantation and use of a biologic graft for neovaginoplasty, to common procedures like hysteroscopic removal of intrauterine devices during pregnancy and approaches to the stenotic cervix.

Detection of hysteroscopic fluid in the pouch of Douglas: a prospective cohort study about the predictability of bilateral tubal occlusion.

PURPOSE: To determine whether an increase in cul de sac (CDS) fluid after hysteroscopy is predictive of tubal patency. METHODS: In a prospective clinical cohort study, 115 subfertile women undergoing laparoscopic and hysteroscopic surgery at the Medical University of Vienna were invited to participate. The primary outcome was determining whether an increase in fluid in the pouch of Douglas was reflective of unilateral or bilateral tubal patency. Vaginal sonography before and after hysteroscopy was performed to detect fluid in the pouch of Douglas, directly followed by laparoscopy with chromopertubation. RESULTS: Laparoscopic chromopertubation revealed bilateral Fallopian tube occlusion in 28 women (24.3%). Twenty-seven/40 patients (67.5%) with no fluid shift had bilateral occlusion during the consecutive laparoscopy (p < 0.001). One/75 patients (1.3%) showing a fluid shift had bilateral occlusion (sensitivity of a present fluid shift for uni- or bilateral patency 85.1%, 95% CI: 81.7-99.9, specificity: 96.4%, 95% CI: 75.8-91.8). Intracavitary abnormalities (odds ratio, OR, 0.038; p = 0.030) and adhesions covering one or both tubes (OR 0.076; p = 0.041) increased the risk for a false abnormal result, i.e., uni- or bilateral tubal patency despite the lack of a fluid shift. CONCLUSION: When CDS fluid does not change after hysteroscopy, this is a sensitive test for tubal occlusion and further testing may be warranted. However, if there is an increase in CDS fluid after hysteroscopy, particularly for a patient without fluid present prior, this is both sensitive and specific for unilateral or bilateral tubal patency.

Hysteroscopy for Assessing Fallopian Tubal Obstruction: A Systematic Review and Diagnostic Test Accuracy Meta-analysis.

OBJECTIVE: To assess the diagnostic accuracy of hysteroscopy compared with that of laparoscopic chromopertubation for the detection of fallopian tubal obstruction. DATA SOURCES: An electronic search from inception to March 31, 2020, was performed in Medline, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials. METHODS OF STUDY SELECTION: This diagnostic accuracy meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesizing Evidence from Diagnostic Accuracy Tests recommendations. A combination of the following Medical Subject Headings terms and keywords was included in the search strategy: "hysteroscopy[MeSH]," "tubal obstruction," "tubal patency," "tubal dysfunction," and "tubal blockage." Quality assessment of the included studies was conducted using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 (University of Bristol, Bristol, United Kingdom). Publication bias was evaluated by means of the Deek funnel plot asymmetry test. The following outcomes were analyzed: diagnostic odds ratio, area under hierarchical summary receiver operating characteristic and area under receiver operating characteristic curve, sensitivity, specificity, and positive and negative likelihood ratios. TABULATION, INTEGRATION, AND RESULTS: Six studies comparing hysteroscopy with laparoscopic chromopertubation were included in the meta-analysis. After pooling all the studies, the diagnostic odds ratio was 43. The evaluated area under receiver operating characteristic curve was 0.93, correlating with high diagnostic accuracy for the index test. Sensitivity and specificity were 88% and 85%, respectively. In addition, the positive and negative likelihood ratios were 5.88 and 0.16, respectively. CONCLUSION: Hysteroscopic techniques are highly accurate and sensitive for detecting fallopian tubal obstruction. Interventional assessment enhances diagnostic accuracy compared with observational assessment, as does the office setting compared with the operating room. Additional studies, along with a refinement of the techniques, could facilitate the widespread use of hysteroscopic techniques for the detection of fallopian tube occlusion.

Surgical and Reproductive Outcomes after Hysteroscopic Removal of Retained Products of Conception: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the impact of hysteroscopy for retained products of conception (RPOC) removal on surgical and reproductive outcomes. DATA SOURCES: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, SciELO, EMBASE, and the Cochrane Central Register of Controlled Trials at the Cochrane Library) were searched from inception to March 2020. METHODS OF STUDY SELECTION: Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were followed. Medical Subject Headings terms and text words such as "retained products of conception," "placental remnants," "placenta," and "hysteroscopy" were used for the identification of relevant studies. We included observational and randomized studies that analyzed surgical and/or reproductive outcomes of women who underwent hysteroscopic removal of RPOC. The primary outcome was the complete resection rate after 1 procedure. TABULATION, INTEGRATION, AND RESULTS: Twenty out of 245 studies were applicable, with data provided for 2112 women. The pooled complete resection rate was 91% (95% confidence interval [CI], 0.83-0.96). The incomplete resection rate evaluated was 7% (95% CI, 0.03-0.14), with a complication rate of 2% (95% CI, 0.00-0.04). Out of 1478 procedures, only 12 cases (0.8%) of postsurgical intrauterine adhesions were reported. Regarding post-therapy fecundity, women attempting postoperative conception had a clinical pregnancy rate of 87% (95% CI, 0.75-0.95), with a live birth rate of 71% (95% CI, 0.60-0.81) and a pregnancy loss rate of 9% (95% CI, 0.06-0.12). CONCLUSION: Hysteroscopy has a high rate of completely removing RPOC in a single surgical step, with low complication rates. Subsequent fecundity seems reassuring, with appropriate clinical pregnancy and live birth rates. However, standardization of approach and comparative trials of different hysteroscopic approaches are needed.

Hysteroscopic Assessment of Tubal Patency: A Randomized Comparison between the Flow and Parryscope Techniques.

STUDY OBJECTIVE: To evaluate the accuracy of the "Parryscope" and "flow" techniques for hysteroscopic assessment of tubal patency. DESIGN: Prospective randomized clinical trial. SETTING: From May to October 2019, women with subfertility undergoing laparoscopic and hysteroscopic surgery at the Medical University of Vienna were invited to participate in the study. The primary outcome was accuracy of Fallopian tube patency relative to the gold standard of laparoscopic chromopertubation. PATIENTS: Sixty women with subfertility. INTERVENTIONS: Hysteroscopy with either the "Parryscope" or the "flow" techniques for tubal assessment, directly followed by laparoscopy with chromopertubation. MEASUREMENTS AND MAIN RESULTS: Hysteroscopic prediction of fallopian tube patency was possible in a statistically significant manner in both study groups (p <0.05). The Parryscope technique achieved higher sensitivity (90.6%, 95% CI: 61.7-98.4) and specificity (100%, 95% CI: 90.0-100.0) than the flow technique (sensitivity: 73.7%, 95% CI: 48.8-90.9 and specificity: 70.7%, 95% CI: 54.5-83.9). CONCLUSION: Using the Parryscope technique to determine if air bubbles traverse the ostia can provide valuable additional information during hysteroscopy and is more accurate in predicting fallopian tubal occlusion than the flow method.

Efficacy and safety of intrauterine insemination and assisted reproductive technology in populations serodiscordant for human immunodeficiency virus: a systematic review and meta-analysis.

OBJECTIVE: To assess procreative outcomes for HIV-positive men and women with seronegative partners. DESIGN: Systematic review and meta-analysis. SETTING: Not applicable. PATIENT(S): Twenty-four studies with extractable data for HIV-serodiscordant couples undergoing intrauterine insemination (IUI) or in vitro fertilization (IVF). INTERVENTION(S): None. PRIMARY OUTCOMES: HIV transmission to a seronegative partner and per cycle fecundability; secondary outcomes: analysis of multiple gestation rates, miscarriage rates, and cancellation rates. RESULT(S): For serodiscordant couples, HIV-positive men or women undergoing IUI and IVF treatment had a 17%, 30%, 14%, and 16% per cycle fecundability, respectively. Multiple gestation rates were 10%, 33%, 14%, and 29%, respectively. Miscarriage rates were 19%, 25%, 13%, and 20%, respectively. No HIV transmission was observed in 8,212 IUI and 1,254 IVF cycles, resulting in 95% confidence that the true rate is 4.5 transmissions per 10,000 IUI cycles or less. CONCLUSION(S): In serodiscordant couples, IUI and IVF seem effective and safe based on the literature. Evidence-based practice and social justice suggest that our field should increase access to care for HIV-serodiscordant couples.