Department of Obstetrics and Gynaecology, University of Cologne, Kerpener Str. 34, 50931 Cologne, Germany
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We read with interest the paper by Check and colleagues (Check et al., 2002). In their study, the authors focus on the highly interesting question of the possible influence of intramural myoma on the outcome of IVF.
We think it is appropriate to discuss two points critically, which should be considered in the nomenclature and diagnosis of intramural myoma in future multicentre studies.
Myoma compressing the uterine cavity with an intramural portion >50% are termed submucous myoma type II (Wamsteker and de Blok, 1993; Wamsteker et al., 1993
). Intramural myoma per se do not compress the uterine cavity. Thus, the nomenclature `small intramural fibroids not compressing the uterine cavity' is not correct. Therefore, making the distinction between intramural myoma and submucous myoma type II is decisive in the diagnosis in view of the inclusion criteria of the study.
The authors determined the type of myoma by hysterosalpingography and transvaginal sonography. In the light of numerous studies, these methods alone do not seem efficient enough for the above-mentioned differential diagnosis. Hysterosonography offers a discerning diagnostic supplement to transvaginal sonography resulting in increased sensitivity (Schwarzler et al., 1998; Becker et al., 2002
). Hysteroscopy, andusing the remaining intracavitary fluida subsequent hysterosonography, present another option for an exact diagnosis of possible myoma compressions of the uterine cavity (Cheng and Lin, 2002
). With the aid of minioptics, a diagnostic hysteroscopy can be performed without anaesthesia. In contrast to indirect sonographical and radiological methods, hysteroscopy offers a direct visualization of the uterine cavity. The subsequent hysterosonography achieves results comparable with those of a hysterosalpingography while avoiding radiation (Lindheim and Sauer, 1998
).
To answer the question posed by the authors' demands an exact exclusion of intracavity myoma. To achieve this, it is, in our opinion, necessary to perform a hysteroscopy and/or a transvaginal hysterosonography.
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References |
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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, 12441248.
Cheng, Y.M. and Lin, B.L. (2002) Modified sonohysterography immediately after hysteroscopy in the diagnosis of submucous myoma. J. Am. Assoc. Gynecol. Laparosc., 9, 2428.[ISI][Medline]
Lindheim, S.R. and Sauer, M.V. (1998) Upper genital-tract screening with hysterosonography in patients receiving donated oocytes. Int. J. Gynaecol. Obstet., 60, 4750.[ISI][Medline]
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, 337342.[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.
Wamsteker, K., Emanuel, M.H. and de Kruif, J.H. (1993) Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet. Gynecol., 82, 736740.[Abstract]