Effect of the decision to perform hysteroscopy on asymptomatic patients before undergoing assisted reproduction technologies—a systematic review and meta-analysis

OBJECTIVE: Routine hysteroscopic evaluation before assisted reproductive technology treatment is a novel approach with the potential to reduce assisted reproductive technology failure even in the absence of evidence of uterine pathology. Following the publication of several relatively high-quality trials on this topic, we sought to determine if this practice is beneficial. DATA SOURCES: We searched Web of Science, MEDLINE, PubMed, Scopus, Cochrane Library, and ClinicalTrials.gov from each database's inception until May 31, 2022 with our search strategy, attempting to locate all randomized controlled trials assessing the use of hysteroscopy in otherwise asymptomatic women undergoing assisted reproductive technology. STUDY ELIGIBILITY CRITERIA: We included only randomized controlled trials that included at least one of our selected outcomes, and we excluded any studies with suspicion of pathology before the time of hysteroscopy, other than knowledge of the patient's infertility. We included all the aforementioned studies regardless of procedures or modifications performed as a result of hysteroscopic findings. Our initial search yielded 1802 results, which were reduced to 1421 after removal of duplicates. Ultimately, 11 studies were found to meet our criteria and were included in our quantitative synthesis. METHODS: We used ReviewManager software, version 5.4.1 to analyze the data, which we imported after manually gathering from the 11 studies. Continuous and dichotomous outcomes were imported as standard deviations. Pooled analysis was described as a mean difference, relative to 95 % confidence interval in cases of continuous data. Dichotomous outcomes were analyzed using risk ratios and 95% confidence intervals. In homogeneous outcomes, we used a fixed-effects model, and in heterogeneous outcomes we used a random-effects model. RESULTS: Our results showed that hysteroscopy was associated with significant improvement in the clinical pregnancy rate (risk ratio, 1.27 [1.11–1.45]; P<.001). We found no differences between the hysteroscopy group and the control group in live birth rate (risk ratio, 1.26 [0.99–1.59]; P=.06), miscarriage rate (risk ratio, 0.99 [0.81–1.19]; P=.88), fertilization rate (risk ratio, 1.01 [0.93–1.09]; P=.88), incidence of multiple gestations (risk ratio, 1.29 [0.98–1.71]; P=.07), number of embryos transferred (mean difference, 0.04 [−0.18 to 0.26]; P=.73), chemical pregnancy rate (risk ratio, 1.01 [0.86–1.17]; P=.93), and number of oocytes retrieved (mean difference, 0.44 [−0.11 to 0.98]; P=.11). CONCLUSION: We observed an improvement in the clinical pregnancy rate, but no significant improvement in the live birth rate with routine hysteroscopy before assisted reproductive technology treatment. We believe this does not represent sufficient evidence to recommend routine hysteroscopy for otherwise asymptomatic patients before assisted reproductive technology treatment at this time.