|The value of medical history taking as risk indicator for tuboperitoneal pathology: a systematic review
|Luttjeboer FY, Verhoeve HR, van Dessel HJ, van der Veen F, Mol BW, Coppus SF
This well-conducted review found that subfertile women who reported a history of pelvic inflammatory disease, complicated appendicitis, pelvic surgery, ectopic pregnancy and endometriosis were at increased risk of having tuboperitoneal pathology. These conclusions are likely to be reliable, but should be interpreted with some caution as most items were assessed by only a small number of studies.
To evaluate the association between items reported during medical history taking and tuboperitoneal pathology.
MEDLINE (1966 to May 2007) and EMBASE (1960 to January 2007) were searched. Search terms were reported. No language restrictions were applied. Reference lists of included studies were screened.
Cohort, cross-sectional or case-control studies that evaluated items reported during medical history taking against the reference standard of hysterosalpingography (HSG) and/or laparoscopy with dye were eligible for inclusion. Case-control studies in which controls were determined not to have tubal pathology because the woman was pregnant or had delivered a live-born child were eligible. Studies had to report sufficient data to construct 2x2 tables of the association between items from medical history and tubal pathology.
The risk factors considered were: pelvic surgery, appendicectomy, normal appendicectomy, appendicitis, complicated appendicitis, pelvic inflammatory disease, sexually transmitted disease (STD), Chlamydia, intrauterine contraceptive device, induced abortion, miscarriage, history of endometriosis, abnormal vaginal discharge, dysmenorrhoea, chronic abdominal pain, ectopic pregnancy, number of sexual partners and dyspareunia. Tubal pathology was defined as unilateral or bilateral tubal occlusion, tubo-ovarian or pelvic adhesions.
Included studies evaluated women referral for tubal assessment with normal semen analysis and ovulation with primary or secondary infertility (in some studies for more than one year or two years; some specified additional criteria), infertile women who were surgically evaluated and women who consulted fertility clinics. Prevalence of tubal pathology ranged from 19% to 83%. Cohort studies were both prospective and retrospective. Studies were conducted in UK, France, Mexico, Poland, Netherlands, USA, Sweden, Gabon, Nigeria, Vietnam, Switzerland and Canada.
Two reviewers independently assessed studies for inclusion. Disagreements were resolved through consensus or referral to a third reviewer.
Assessment of study quality
Three reviewers independently assessed studies for methodological quality based on criteria adapted from the QUADAS tool for study design, sampling, data collection, blinding, verification bias, definition of tubal pathology and missing results or withdrawals.
Data were extracted as 2x2 tables that related items from the medical history to the presence or absence of tubal pathology. These data were used to calculate odds ratios (ORs) together with 95% confidence intervals.
The authors did not state how many reviewers performed data extraction.
Methods of synthesis
Summary odds ratios were estimated using the Mantel-Haenszel fixed-effect model in the absence of heterogeneity and using a random-effects model if heterogeneity could not be rejected. Heterogeneity was assessed using the Breslow-Day test.
Results of the review
Thirty-two studies were included (n=32,363 patients): 18 case-control studies (n=26,661) and 14 cohort studies (n=5,702). Most studies assessed tubal pathology using predefined criteria; insufficient information was reported to judge this for nine studies. There was a possibility of verification bias in 15 studies. Differential verification bias was present in 10 case-control studies. Most studies did not provide information on blinding.
Surgery-related risk factors: Types of surgery that showed strong associations with tubal pathology were complicated appendicitis (OR 7.2, 95% CI 2.2 to 23.8; one cohort study and OR 3.3, 95% CI 1.8 to 6.3; two case-control studies), pelvic surgery (OR 3.6, 95% CI 1.4 to 9.0; five cohort studies), appendicectomy (OR 2.0, 95% 1.5 to 2.6; four case-control studies) and induced abortion (OR 1.7, 95% 1.3 to 2.1). There were no significant differences for pelvic surgery in two case-control studies or appendicectomy in four cohort studies.
Inflammation: Inflammatory diseases that showed strong associations with tubal pathology were pelvic inflammatory disease(OR 3.2, 95% CI 1.6 to 6.6; nine cohort studies and OR 5.5, 95% CI 2.7 to 11.0; 12 cohort studies) and STD (OR 11.9, 95% CI 4.3 to 33.3; two case-control studies). Three cohort studies did not find an association between STDs and tubal pathology. One cohort study and one case-control study investigated the association of Chlamydia with tubal pathology and found no significant association with tubal pathology.
Other features strongly associated with tubal pathology were endometriosis (OR 5.9, 95% CI 3.2 to 10.8; two case-control studies), intrauterine contraceptive device (OR 1.9, 95% CI 1.3 to 2.8; five cohort studies and OR 2.0, 95% CI 1.6 to 2.6; 11 case-control studies), ectopic pregnancy (OR 16.0, 95% CI 12.5 to 20.4; five case-control studies) and chronic or severe pelvic pain (OR 1.9, 95% CI 1.0 to 3.6; two case-control studies). There was no significant association with ectopic pregnancy in two cohort studies or with vaginal discharge in three cohort studies.
Most comparisons were homogeneous; only four of the 20 meta-analyses showed evidence of heterogeneity.
Subfertile women who reported a history of pelvic inflammatory disease, complicated appendicitis, pelvic surgery, ectopic pregnancy and endometriosis were at increased risk of having tuboperitoneal pathology. In these women, diagnostic laparoscopy should be offered early in the fertility work-up.
The review addressed a clear question and inclusion criteria were defined. The literature search was appropriate, but no specific attempts were made to locate unpublished data and so there was a possibility of publication bias. Appropriate steps were taken to minimise bias and errors when selecting studies and assessing quality; it was unclear whether such steps were taken when extracting data. Study quality was assessed using appropriate criteria and the results were presented. Appropriate details of individual studies were summarised using tables. Appropriate methods were used to pool data and results were presented clearly.
This was generally a well-conducted review. The results are likely to be reliable, but should be interpreted with some caution as most items were assessed only by a small number of studies.
Implications of the review for practice and research
Practice: The authors stated that women with a history of pelvic inflammatory disease, complicated appendicitis, pelvic surgery, ectopic pregnancy and endometriosis should be offered a diagnostic laparoscopy with possible surgical procedures by competent surgeons early in the fertility work-up.
Research: The authors stated a need for large cohort studies that addressed all possible risk indicators for tubal pathology and their mutual independence.
Luttjeboer FY, Verhoeve HR, van Dessel HJ, van der Veen F, Mol BW, Coppus SF. The value of medical history taking as risk indicator for tuboperitoneal pathology: a systematic review. BJOG. An International Journal of Obstetrics and Gynaecology 2009; 116(5): 612-625
Subject indexing assigned by NLM
Adult; Cohort Studies; Fallopian Tube Diseases /complications /diagnosis; Female; Humans; Infertility, Female /etiology; Medical History Taking; Odds Ratio; Pelvic Inflammatory Disease /complications /diagnosis; Risk Assessment /methods; Risk Factors; Sexually Transmitted Diseases /complications /diagnosis
Date bibliographic record published
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