Human Reproduction, Vol. 17, No. 9, 2485-2486,
September 2002
© 2002 European Society of Human Reproduction and Embryology
IVF outcome and intramural fibroids not compressing the uterine cavity
7447 Old York Road, Melrose Park, PA19027, USA E-mail: laurie{at}ccivf.com
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Dear Sir,
We thank Drs Nawroth and Foth for their comments. We agree that we could have simplified the nomenclature by merely stating that all patients with submucosal fibroids type 1 or 2 were excluded (Wamsteker and de Blok, 1993
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We perform hysterosalpingograms rather than hysterosonographs because we believe that the former is far better to diagnose hydrosalpinges with the possible need for salpingectomy prior to IVF–embryo transfer. Thus, given the alternative of either sonohysterogram or hysterosalpingography (HSG) or transvaginal ultrasound we would prefer the later, for both economic reasons and/or to minimize patient discomfort, by not making them undergo two uncomfortable procedures.
Nevertheless we agree that for the purposes of just determining if there is any uterine cavity compromise, the sonohysterogram might be superior to the HSG. Thus we agree with Drs Nawroth and Foth that for a multicentre study, hysterosonography should be performed in addition to the HSG to best distinguish submucosal from intramural fibroids. However, it should be pointed out that neither of the two quoted studies (Schwarzler et al., 1998; Becker et al., 2002) determined if sono-hysterography was superior to the combination of transvaginal sonography and HSG in diagnosing submucosal fibroids.
We do not necessarily agree that the best way to evaluate the cavity is in-office `micro'-hysteroscopy. It is very difficult to adequately examine the endometrial cavity in the office under local, or no anaesthesia with these small scopes. Even the most experienced hysteroscopist can `miss' significant pathology with these small hysteroscopes in the outpatient setting. A multicentre study would suffer from the various levels of expertise by the physicians performing hysteroscopy.
If hystersonography could establish that some of the cases that we determined as intramural were really submucosal type 2 fibroids, and if the prognosis for this group is worse than the intramural, the adjusted data would not have altered the conclusions of our study, that the presence of intramural fibroids <5 cm do not lower implantation rates or increase miscarriage rates. However since the basis for a larger multicentre study was the trend for higher miscarriage rates with intramural fibroids, we agree with Drs Nawroth and Foth that sonohysterography should be added for evaluation in a multicentre study in case it could add accuracy. Nevertheless we want to state that for our published study (Check et al., 2002) when we stated that the patients had intramural fibroids, the walls of the fibroid were clearly seen to be separate from and not directly next to the walls of the uterine cavity so that one could consider them `pure intramural fibroids' according to published criteria (Buttram and Snabes, 1992).
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Becker, E., Lev-Toaff, A.S., Kaufman, E.P., Halpern, E.J., Edelweiss, M.I. and Kurtz, A.B. (2002) The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J. Ultrasound. Med., 21, 237–247.
Buttram and Snabes (1992) Indications for myomectomy. Semin. Reprod. Endo., 10, 378–384.
Check, J.H., Choe, J.K., Lee, G. and Dietterich, C. (2002) The effect on IVF outcome of small intramural fibroids not compressing the uterine cavity as determined by a prospective matched control study. Hum. Reprod., 17, 1244–1248.
Schwarzler, P., Concin, H., Bosch, H., Berlinger, A., Wohlgenannt, K., Collins, W.P. and Bourne, T.H. (1998) An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet. Gynecol., 11, 337–342.[ISI][Medline]
Wamsteker, K. and de Blok, S. (1993) Resection of intrauterine fibroids. In Lewis, B.V. and Magos, A.L. (eds.) Endometrial Ablation. Churchill Livingstone, Edinburgh, UK.
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