Elsevier

Journal of Surgical Research

Volume 192, Issue 2, December 2014, Pages 368-374.e1
Journal of Surgical Research

Gastrointestinal
The effect of appendectomy in future tubal infertility and ectopic pregnancy: a systematic review and meta-analysis

https://doi.org/10.1016/j.jss.2014.08.017Get rights and content

Abstract

Background

Ruptured appendicitis has been implicated in causing scarring, which can lead to infertility and/or ectopic pregnancy. To assess the degree of association and the quality of evidence supporting the relation among appendectomy, female fertility outcomes, and ectopic pregnancy.

Methods

We systematically searched multiple electronic databases from inception through May 2013 for randomized trials and observational studies. Reviewers working independently and in duplicate extracted the study characteristics, the quality of the included studies, and the outcomes of interest. Random effects meta-analysis was used to pool the odds ratio (OR) from the included studies.

Results

Our meta-analysis based on seven observational studies provided evidence that previous appendectomy is not associated with increased incidence of infertility in women (OR = 1.03, 0.86–1.24, P = 0.71). This finding was further augmented by several noncomparative cohorts that discussed the same issue and reported nearly the same conclusion; however, these studies pointed toward putative negative impact of surgery for complicated appendicitis on fertility. Our second meta-analysis revealed the effect of appendectomy on ectopic pregnancy was found to be significant based on a pooled estimate from four studies (OR = 1.78, 95% confidence interval = 1.46–2.16, P < 0.0001).

Conclusions

Appendectomy is significantly associated with an increased risk of ectopic pregnancy but not significantly associated with future infertility in women.

Introduction

Acute appendicitis is thought to start with obstruction of its lumen, followed by an intraluminal inflammation and distension. This leads to the ischemic necrosis of the interior wall that may eventually cause perforation if not treated [1]. It has been postulated that the perforation that complicates appendicitis can lead to intra-abdominal infection and scarring, which can secondarily result in obstruction of the fallopian tubes and subsequently infertility [2].

The aim of this review is to summarize the best available data assessing the magnitude of association between appendectomy, whether complicated or not, and female fertility outcomes namely infertility and ectopic pregnancy. In addition, we wanted to evaluate the body of evidence supporting that link.

Section snippets

Methods

This systematic review is protocol-driven and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement [3].

Search results and included studies

The literature search yielded 350 references. Thirty abstracts met the inclusion after the initial screening, from which 19 eligible studies were selected (Fig. 1). The adjusted agreement between reviewers (kappa) averaged 0.80. We identified 19 observational studies, 9 cohorts, and 10 case-control studies; including data from 67,180 patients. Table 1 summarizes the characteristics of the included studies.

Methodological quality and risk of bias

The quality of the included studies ranges from low–moderate according to the

Discussion

We sought to answer if appendicitis, simple, or complicated is associated with future infertility in women. Although there really was a paucity of excellent data on this subject, our review points toward two main results. First, appendicitis is not significantly associated with subsequent future infertility in women. This is similar to other studies, such as Urbach et al., Andersson et al., and Forsell and Pieper, that have looked at this association, although not in a meta-analysis. Other

Conclusions

Although there is a paucity of excellent prospective studies, this systematic review and meta-analysis shows that appendectomy is significantly associated with an increased risk of ectopic pregnancy and is not significantly associated with future infertility. Appropriate prompt therapy for appendicitis and proper counseling should be given to women who present with appendicitis.

Acknowledgment

Financial support: none.

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