Review question
Cochrane authors investigated the effectiveness and safety of cyst aspiration before ovarian stimulation versus a conservative approach (no aspiration) in women undergoing In vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Our primary outcomes were live birth rate and adverse events. We also assessed pregnancy rates, number of follicles recruited, and number of oocytes retrieved.
Background
IVF is a treatment for infertility in which a woman's eggs (oocytes) are fertilized by sperm in a laboratory dish. One or more of the fertilized eggs (embryos) are then transferred into the woman's uterus, where it is hoped the egg will implant and result in a pregnancy.
The woman's ovaries are stimulated to produce multiple eggs which are then retrieved for fertilization by sperm. This differs from what usually occurs, when one egg is produced by the ovary. Stimulation of the ovaries is achieved by a woman taking several different drugs to maximise the chance of getting several eggs suitable for fertilization. Prior to controlled ovarian hyperstimulation (COH) a baseline ultrasound is performed to detect the presence of any functional ovarian cysts. The evidence on the effect of draining such an ovarian cyst on the end result of IVF was examined in this review.
Study characteristics
Three randomized controlled trials were included involving 339 women of reproductive age who required IVF treatment due to tubal factor infertility, anovulation, male factor infertility, endometriosis or fertility of unknown cause. These studies compared the outcome of IVF cycles in women whose cyst was drained versus the outcomes when the cyst was not drained. The evidence was current to April 2014.
Key results
None of the included studies reported live birth rates or adverse event rates. There was insufficient evidence to determine whether there was any difference in the pregnancy rate, the number of follicles recruited, or the number of eggs retrieved, between women who had their cyst drained and women who did not.
Quality of the evidence
The quality of the evidence was low or very low for all comparisons, the main reasons for this being small study numbers, low numbers of events and poor reporting of study methods. There was inconsistent reporting of study findings in one RCT, which meant that some of the data could not be used
There is insufficient evidence to determine whether drainage of functional ovarian cysts prior to controlled ovarian hyperstimulation influences rates of live birth, clinical pregnancy, number of follicles recruited, or number of oocytes collected in women with a functional ovarian cyst. The findings of this review do not provide supportive evidence for this approach, particularly in view of the requirement for anaesthesia, extra cost, psychological stress and risk of surgical complications.
Ten per cent to 15% of couples have difficulty in conceiving. A proportion of these couples will ultimately require assisted reproduction. Prior to controlled ovarian hyperstimulation (COH) a baseline ultrasound is performed to detect the presence of ovarian cysts.
Previous research has suggested that there is a relationship between the presence of an ovarian cyst prior to COH and poor outcome of in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).
The aim of this review was to determine the effectiveness and safety of functional ovarian cyst aspiration prior to ovarian stimulation versus a conservative approach in women with an ovarian cyst who were undergoing IVF or ICSI.
We searched the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, ClinicalTrials.gov, Google Scholar and PubMed. The evidence was current to April 2014 and no language restrictions were applied.
We included all randomized controlled trials (RCTs) comparing functional ovarian cyst aspiration versus conservative management of ovarian cysts that have been seen on transvaginal ultrasound (TVS) prior to COH for IVF or ICSI. Ovarian cysts were defined as simple, functional ovarian cysts > 20 mm in diameter. Oocyte donors and women undergoing donor oocyte cycles were excluded.
Study selection, data extraction and risk of bias assessments were conducted independently by two review authors. The primary outcome measures were live birth rate and adverse events. The overall quality of the evidence for each comparison was rated using GRADE methods.
Three studies were eligible for inclusion (n = 339), all of which used agonist protocols. Neither live birth rate nor adverse events were reported by any of the included studies. There was insufficient evidence to determine whether there was a difference in the clinical pregnancy rate between the group who underwent ovarian cyst aspiration and the conservatively managed group (OR 1.19, 95% CI 0.33 to 4.29, two RCTs, 159 women, I2 = 0%, very low quality evidence). This suggested that if the clinical pregnancy rate in women with conservative management was assumed to be 6%, the chance following cyst aspiration would be between 2% and 22%. There was no evidence of a difference between the groups in the mean number of follicles recruited (0.55 follicles, 95% CI -0.48 to 1.59, 2 studies, 159 women, I2 = 0%, very low quality evidence) mean number of oocytes collected (0.41 oocytes, 95% CI -0.04 to 0.85, 3 studies, 339 women, I2 = 0%, low quality evidence) or cancellation rate (OR 0.99, 95% CI 0.42 to 2.33, one RCT, 122 women, very low quality evidence). The main limitations of the evidence were imprecision, risk of bias associated with poor reporting of study methods, and inconsistent reporting of study findings in one RCT which meant that some of the data could not be used.