title: The effectiveness of reproductive surgery in the treatment of female infertility: facts, views and vision.
abstract: BACKGROUND
  The role of reproductive surgery is declining due to the widespread availability of assisted reproductive technology, but an evidence-based fundament for this decline is lacking. We therefore performed a systematic review of the literature.
  
  
  METHODS
  We searched MEDLINE, EMBASE and the Cochrane Library for randomised trials evaluating laparoscopic or hysteroscopic interventions in subfertile women, studying pregnancy or live birth rates. We present an overview of the results and quality of the detected studies.
  
  
  RESULTS
  The methodological quality of the 63 detected studies was mediocre. The laparoscopic treatment of minimal/ mild endometriosis might increase the pregnancy rate but the two major studies report conflicting results. Excision of the endometriotic cyst wall increases the spontaneous conception rate (RR 2.8, 95% CI 1.4-5.5). Laparoscopic ovarian drilling results at least in equal pregnancy rates as gonadotropin treatment (RR 1.0, 95% CI 0.83-1.2) but decreases the multiple pregnancy rate (RR 0.16, 95% CI 0.04-0.58). Laparoscopic tubal surgery for hydrosalpinx prior to IVF increases the pregnancy rate (RR 1.9, 95% CI 1.4-2.7). Removal of polyps prior to IUI increases the pregnancy rate (RR 2.2, 95% CI 1.6-3.1). Myomectomy for submucosal fibroids results in higher pregnancy rates (RR 2.2, 95% CI 1.6-2.9). The removal of intramural/ subserosal fibroids shows a beneficial trend, albeit not statistically significant (RR 1.2, 95% CI 0.75-1.9). Hysteroscopy in patients with recurrent IVF failure increases the pregnancy rates even in the absence of pathology (RR 1.6, 95% CI 1.3-1.9).
  
  
  CONCLUSIONS
  Although the limited evidence indicates a positive role for some surgical reproductive interventions, we should be very cautious in providing guidelines for clinical practice in reproductive surgery since more research is needed.
authors.affiliation: Department of Obstetrics and Gynaecology, Imeldahospitaal, Imeldalaan 9, 2820 Bonheiden, Belgium. ; CEBAM, Centre for evidence-based medicine, the Belgian branch of the Cochrane Collaboration, Capucijnenvoer 33, blok J, 3000 Leuven.
authors.forename: J
authors.initials: J
authors.lastname: Bosteels
authors.affiliation: Universitaire Vrouwenkliniek,Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
authors.forename: S
authors.initials: S
authors.lastname: Weyers
authors.affiliation: Department of Endocrinology, University Hospital Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium.
authors.forename: C
authors.initials: C
authors.lastname: Mathieu
authors.affiliation: Department of Obstetrics and Gynaecology, Academic Medical Centre, 1105 DE, Amsterdam, the Netherlands.
authors.forename: B W
authors.initials: BW
authors.lastname: Mol
authors.affiliation: Leuven University Fertility Centre, Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, -Herestraat 49, 3000 Leuven, Belgium.
authors.forename: T
authors.initials: T
authors.lastname: D'Hooghe
keywords: Laparoscopy; effectiveness; hysteroscopy; live birth rate; pregnancy rate; reproductive surgery