Two doses of the intervention (injection of 40 ul of tissue culture media with 100 IU or 200 IU of hCG) were initially tested against the control (no injection of tissue culture media). With 80% power and a type I error rate of 5% for each comparison, the stated 10% absolute difference (effect size) in CPR that the authors wished to test would require 1161 participants with complete information on the outcome of interest (387 per arm). When the effect size is a change from a high baseline success rate (here 50%), and the study has three arms, a very large sample size is to be expected. After the first 280 participants, an interim analysis was conducted, no difference was found between 100IU or 200 IU and the controls, and the study testing these two interventions was terminated. It was not specified if this interim analysis was pre-planned, whether it was done to check for harm, and if the trial was stopped for lack of any trend toward benefit. We can readily understand when the previous human study was done with injection of 500 IU in 1,000 ul that they may have chosen the lower doses and done an early interim analysis to mitigate against harm. We can also sympathize with terminating the study when there was no trend toward benefit.

The authors then proceeded to increase the intervention dose to 500 IU and began essentially a new trial, which was not mentioned when the initial comparison was planned, and therefore was an unregistered study. To compare the intervention to controls, this 2 arm study would require a sample size of 774. After 215 patients were enrolled (107 in the hCG 500 IU, 105 in the control group), the study was terminated when the CPR with 500 IU hCG was 75% compared to 60% in the control group (OR 1.9, 95% CI 1.05-3.71, p=0.03). The plan for this interim analysis was also not stated, but presumably it was done looking for major benefit.

In clinical trials, it is common to pre-specify interim analyses, including planned rules for stopping early. Investigators must then complete the trial without examining the data except according to planned interim analysis/es and ideally by an independent data monitoring committee. Otherwise it would be possible for investigators to look at data repeatedly and simply stop when the difference is significant at p<0.05, even though with multiple looks, the overall type I error rate is much higher than 5%, increasing the chance that the difference could be a false positive finding (2).

In addition, the significance level required to terminate a study early for benefit must be more stringent if the significance level for the entire study is to be maintained. Data suggest that terminating trials early for apparent major benefit often result in moderated effects as subsequent studies are reported (3). By stopping the trial early, the power to look at secondary outcomes is also limited. Various models have been proposed which would preserve the overall significance level. For example, a model proposed by Pocock suggests altering the threshold for statistical significance for a study with 2 interim analyses to 0.022, while the Peto method would require a significance level of 0.001 for either interim analysis (Grimes reference table 2). In this study the trial was stopped when implantation (the other primary outcome measure, which is highly correlated with CPR) was significant at 0.002, which is very reassuring. Unfortunately clinicaltrials.gov does not require specifics regarding the number of interim analyses and the model to be followed, which in our view would be very helpful for reassurance of reviewers and editors.

The authors have tested a scientifically plausible and exciting hypothesis, with results that can change clinical care. Future investigators will logically examine the 500 IU dose, and the authors' findings add a level of reassurance that the intervention is very unlikely to be harmful. Provided that the finding of this study is reproduced, considerable laurels will be appropriate for the present authors. Unfortunately as the study was executed, we are left with some uncertainty as to whether a true benefit actually exists and whether it could be considerably smaller than reported. Clearly whenever a further trial is undertaken, it is necessary to register that trial as a new study. This manuscript illustrates the difficulty in conducting trials requiring large sample sizes in even a very large IVF center and the difficulty for clinicians who are also the investigators to balance trial results against wanting to provide all patients with a helpful adjunctive intervention.

While we would strongly urge more randomized controlled trials to confirm the benefit of intrauterine hCG, we realize there are going to be practitioners who wish to offer this adjunct to their patients. We therefore would request that the authors clarify some details regarding precisely how the hCG was prepared and delivered. First, their publication was not sufficiently clear regarding the site of injection of the hCG, which is critical when using such a small volume. Second, we are concerned that harm could occur if the media placed into the vial is allowed to contact the rubber stopper, as rubber is extremely embryotoxic. Clarifying these further details will also aid other investigators in reproducing these important findings.

H. Irene Su, M.D., M.S.C.E.
Moores UCSD Cancer Center
La Jolla, California

Mary D. Sammel, Sc.D.
Center for Clinical Epidemiology and Biostatistics
University of Pennsylvania
Philadelphia, Pennsylvania

References:
1. Mansour R, Tawab N, Kamal O, El-Faissal Y, Serour A, Aboulghar M et al. Intrauterine injection of human chorionic gonadotropin before embryo transfer significantly improves the implantation and pregnancy rates in in vitro fertilization/intracytoplasmic sperm injection: a prospective randomized study. Fertil Steril 2011;96:1370-4.

2. Schulz KF, Grimes DA. Multiplicity in randomised trials II: subgroup and interim analyses. Lancet 2005;365:1657-61.

3. Pocock SJ. When (not) to stop a clinical trial for benefit. JAMA 2005;294:2228-30.

The Authors Respond:

The letter to the editor by Su and Sammel (1) was read with interest and we wish to respond to their comments. We also wish to thank them for congratulating the investigators for exploring the intervention of intrauterine injection of human chorionic gonadotrophin (hCG) before embryo transfer (ET) (2).

An interm analysis was performed after the first 280 participants (100 IU or 200 IU hCG or control), no difference was found and the study using these doses was terminated. This interim analysis was pre-planned, to check for harm, and detect any trend toward benefit. We appreciate the authors (1) understanding and sympathizing with terminating the study when there was no trend toward benefit was found.

We proceeded to increase the dose to 500 IU which was not mentioned in the original plan, therefore a modification was done on the protocol registered at clinicaltrials.gov but apparently it did not go into the system. For this new dose which unfortunately was not registered, an interm analysis was preplanned to check for harm and see trend toward benefit. We terminated the study after the interm analysis when we found the implantation rate was significant at 0.002.

We appreciate that the authors (1) considered this study examining a scientifically plausible and exciting hypothesis which can change clinical care. We are looking forward to see our results reproduced by other IVF colleagues. We agree that clinical trials require large sample size and it is always difficult for clinicians, as investigators, to perform a study and at the same time provide all patients with a helpful intervention.

We would like to clarify some details regarding how precisely the hCG was prepared and delivered. The vial of hCG containing 5000 IU was dissolved in 400 µL tissue culture medium (G.2 plus. ref. 10132, vitrolife). It is important to remove the rubber stopper of the vial as it is embryo toxic. During the dummy ET which is done before the actual ET, 40 µL of this solution containing 500 IU hCG is injected in the mid uterine cavity. Before injection, the screw of the vaginal speculum was loosened so as the two valves of the speculum would press on the portio vaginalis of the cervix and prevent leakage of the injected hCG (3). Then the embryologist will load the embryos in another catheter and bring it for the actual ET.

Ragaa Mansour, M.D., Ph.D.
The Egyptian IVF-ET Center
Cairo, Egypt

References:
1. H.Irene SU, Mary D.Sammel. Interim analysis in clinical trials. Fertil Steril 2012

2. Mansour R, Tawab N, Kamal O, El-Faissal Y, Serour A, Aboulghar M, Serour G. Intrauterine injection of human chorionic gonadotropin before embryo transfer significantly improves the implantation and pregnancy rates in in vitro fertilization/intracytoplasmic sperm injection: a prospective randomized study. Fertil Steril. 2011 Dec;96(6):1370-1374.

3. Mansour R. Minimizing embryo expulsion after embryo transfer: a randomized controlled study. Hum Reprod. 2005 Jan;20(1):170-4.

Reply from the Editorial Editor:

In the July 2011 issue of this journal and in an online supplement, we discussed various aspects of study design and the requirements for registry of clinical trials (1,2). As pointed out by Su and Sammel, when calculating the sample size required for detecting a 20% change from a high baseline, a very large number of subjects is usually required, particularly for a three-arm study. It is always better to limit such a study to only the intervention and control arms to increase its power. The study should not be terminated for lack of benefit until the planned number of randomized subjects has completed the trial; only then can a particular difference (usually 20%) be excluded with the chosen level of power (usually 80%) and significance (usually 0.05). This can require multiple centers or an extended effort in a single large center. An independent data monitoring board can be helpful because clinician-investigators naturally are impatient to find an answer. At the same time we can sympathize with the concept of a pilot study being potentially more efficient, even if not strictly correct from a biostatisticial perspective.

The authors should have registered the second part of their investigation as a new study, which would have avoided any electronic glitches from trying to piggy-back it onto the first one. Investigators should be increasingly aware that they will be judged on whether their registration is complete and appropriate. Although details regarding interim analyses are not a requirement, inserting those aspects into the registry will be very reassuring to editors and reviewers. As Su and Sammel pointed out in their reference to the Pocock model, termination of the study when a primary outcome measure was significant at 0.002 was justified, assuming their interim analyses were prospectively planned for no more than two specified mileposts as results were accumulated.

An important aspect of this discussion is to emphasize that rubber is the most embryo toxic material ever examined. Products designed for injection, such as a vial of hCG, must only pass relatively insensitive tests of tissue irritation. Products that will come in contact with oocytes or embryos are usually tested with mouse embryos or prepared specifically for tissue culture. We did not have the product available that was used in their study, but when we prepared the material from an hCG preparation widely available in the U.S. having a similar rubber stopper, and exactly as the investigators describe, cleaving mouse embryos exposed to the hCG solution immediately stopped dividing. When diluted by a factor of 10, the toxicity was no longer detectable. Clearly the vials themselves or the lyophilized powder can be contaminated by the rubber or other materials during processing or storage. Direct contact of the dissolved hCG with the rubber stopper must be avoided, as these investigators were aware.

Unfortunately there can be no reassurance that individual vials, batches, or products would not have more embryo toxicity than the vial we tested, nor that there would be sufficient intrauterine fluid to dilute out the offending substance/s. We are continuing to evaluate this issue.

The fact that a 1:10 dilution could rid the dissolved fluid of toxicity is consistent with the therapeutic effect that the investigators observed. The intriguing question is whether use of an hCG solution devoid of toxicity might result in a greater degree of benefit. Until such a product is available, it is difficult to recommend this intervention, although use of the identical product would be somewhat reassuring. Mouse embryo testing of individual vials and batches would also be very helpful for those considering offering this treatment.

As Su and Sammel point out, these investigators should be congratulated for carrying out this trial, and they have performed other randomized controlled trials benefiting us all in caring for our infertile couples. However, perfection in design, registry and reporting should not be as elusive as it has been throughout medical journals, and is a goal all investigators should aim toward.

David Meldrum, M.D.
Editorial Editor, Fertility and Sterility
Reproductive Partners Medical Group
Redondo Beach, California

References:
1. Meldrum DR, Sammel MD, Barnhart K. The null hypothesis: closing the gap between good intentions and good studies. Fertil Steril 2011;96:6-10.

2. Meldrum DR, DeCherney AH. The WHO, WHY, WHAT, WHEN, WHERE and HOW of clinical trial registries. Fertil Steril 2011;96:2-5.

We read with interest the article “Use of laptop computers connected to internet through Wi-Fi decreases human sperm motility and increases sperm DNA fragmentation” by Avendano et al.(1). However, we do actually think that the evidence presented in this paper cannot support the claim that the observed effects are nonthermal and caused by exposure to a Wi-Fi radiofrequency electromagnetic field.

Keeping constant the temperature under the computer by an air conditioning system is not sufficient to ensure homogeneity of the temperatures within the experimental area, since the heat source from the laptop is not homogenous itself, and to exclude that there is no local variation in the samples temperatures.

If the exposure design can be justified by the desire of being as close as possible to the actual conditions of use of a laptop computer, the dosimetry used in these experiments is much too simplistic. There is no indication of the homogeneity of the field under the laptop, which may greatly depend upon the location of the Wi-Fi antenna within the computer.

The control samples, “kept in another room away from any computers or electronic devices”, were not actually kept under identical conditions. A more suitable experimental design would have been a sham exposure design in which control samples would have been exposed under the same actively working computer, but with its Wi-Fi emission turned off.

Moreover, Avendano et al. state that “RF-EMW from mobile phones may cause DNA damage” and that “Research has shown negative consequences of electromagnetic fields on biological mechanisms,” and cite in support to their contention a highly controversial paper (2). Genotoxicity of radiofrequencies is not a matter of opinion: radiofrequency energy absorption cannot break DNA molecules, and it should be kept in mind that there is no known biologically plausible mechanism by which nonionizing radio waves of low energy can disrupt DNA (3). Recently, while classifying RF-EMF as “possibly carcinogenic to humans” (Group 2B), the IARC Working Group reached the overall conclusion that there is only weak mechanistic evidnce relevant to RF-EMF-induced cancer in humans (4).

There is a serious message behind our rebuttal. Citing Avendano et al. (1) among the evidence of an association between Wi-Fi exposure and a genotoxic effect on human sperm would demonstrate how studies with an erroneous methodology can be used to support important public health claims and also the weakness of the evidence purporting to demonstrate a nonthermal effect of Wi-Fi RF.

Jean-François Doré, Ph.D.
Marie-Christine Chignol, E.P.H.E.
INSERM
Centre de Recherche en Cancérologie de Lyon
Lyon, France

References
1. Avendano C, Mata A, Sanchez Sarmiento CA, Doncel GF. Use of laptop computers connected to internet through Wi-Fi decreases human sperm motility and increases sperm DNA fragmentation Fertil Steril 2012; on line . doi:10.1016/j.fertnstert.2011.10.012

2. Diem E, Schwarz C, Adlkofer F, Jahn O, Rudiger H. Non-thermal DNA breakage by mobile-phone radiation (1800 MHz) in human fibroblasts and in transformed GFSH-R17 rat granulosa cells in vitro. Mutat Res 2005;583: 178–83.

3. Moulder JE, Foster KR, Erdreich LS, McNamee JP. Mobile phones, mobile phone base stations and cancer: a review. Int J Radiat Biol. 2005;81(3):189–203.

4. Baan R, Grosse Y, Lauby-Secretan B, El Ghissassi F, Bouvard V, Benbrahim-Tallaa L, Guha N, Islami F, Galichet L, Straif ;WHO International Agency for Research on Cancer Monograph Working Group. Carcinogenicity of radiofrequency electromagnetic fields. The Lancet Oncology 2011;12:624-6.

The Authors Respond:

We thank Drs Doré and Chignol (1) for their interest and comments on our article (2). The aim of our study was to evaluate the impact of laptop computers connected to internet through Wi-Fi on human sperm. To assess this potential association we used an in vitro model incubating human sperm in the presence of an active portable computer connected to the internet by Wi-Fi. Dore and Chignol suggest that the sperm damage could have been caused by thermal effects. However, the temperature on each incubation culture medium drop was controlled by an IVF thermometer, and no changes were observed. We have discussed different possible mechanisms responsible for the detrimental effects observed. Decrease of sperm motility and increase in DNA fragmentation may be caused by non-thermal effects such as lipid peroxidation and reactive oxygen species (ROS) generation (3).

Genotoxic effects of radiofrequency have been reported in various studies (4-6). Although the energy of nonionizing electromagnetic field is not sufficient to break DNA directly, as mentioned by Doré and Chignol (1), the effects could be mediated by indirect mechanisms such as ROS production. In fact, both De Iuliis et al. (7) described sperm DNA fragmentation and motility decrease after exposure of human spermatozoa to radio-frequency electromagnetic radiation (RF-EMR) in the range of that emitted by mobile phones. These authors and Agarwal et al. (8), who also observed a decrease in sperm motility, attributed those deleterious effects to increased production of ROS.

We agree the best control to conclude that the damage was caused by Wi-Fi is the same laptop working without Wi-Fi. We performed this experiment using different samples of the same donors and preliminary data indicate no impact on DNA structure when the computer is not connected via Wi-Fi. Furthermore, we are currently performing a new study, which examines the relationship between different brands of laptop computers, connected or not to internet via Wi-Fi, and sperm quality. We believe the preliminary results presented in our published paper (2) merited being reported and that further studies are needed to confirm these findings and evaluate the mechanisms by which sperm may be affected.

We also truly believe we have been appropriately cautious in our conclusions, recommending further studies and stating possible caveats to our interpretation and experimental design. The data on the effects of RF-EMR on human sperm, however, should not be ignored.

Conrado Avendano, M.S.
Nascentis Medicina Reproductiva
Cordoba, Argentina

References
1. Doré JF and Chignol MC. Re: Use of laptop computers connected to internet through Wi-Fi decreases human sperm motility and increases sperm DNA fragmentation. Letter to the Editor. Fertil Steril. 2012.

2. Avendano C, Mata A, Sanchez Sarmiento CA, and Doncel GF. Use of laptop computers connected to internet through Wi-Fi decreases human sperm motility and increases sperm DNA fragmentation. Fertil Steril 2012; 97:39-45 e2.

3. Higuchi Y. Chromosomal DNA fragmentation in apoptosis and necrosis induced by oxidative stress. Biochem Pharmacol 2003; 66:1527-35.

4. Garaj-Vrhovac V, Horvat D, and Koren Z. The relationship between colony-forming ability, chromosome aberrations and incidence of micronuclei in V79 Chinese hamster cells exposed to microwave radiation. Mutat Res 1991; 263:143-9.

5. Zotti-Martelli L, Peccatori M, Scarpato R, and Migliore L. Induction of micronuclei in human lymphocytes exposed in vitro to microwave radiation. Mutat Res 2000; 472:51-8.

6. Maes A, Verschaeve L, Arroyo A, De Wagter C, and Vercruyssen L. In vitro cytogenetic effects of 2450 MHz waves on human peripheral blood lymphocytes. Bioelectromagnetics 1993; 14:495-501.

7. De Iuliis GN, Newey RJ, King BV, and Aitken RJ. Mobile phone radiation induces reactive oxygen species production and DNA damage in human spermatozoa in vitro. PLoS One 2009; 4:e6446.

8. Agarwal A, Desai NR, Makker K, Varghese A, Mouradi R, Sabanegh E, and Sharma R. Effects of radiofrequency electromagnetic waves (RF-EMW) from cellular phones on human ejaculated semen: an in vitro pilot study. Fertil Steril 2009; 92:1318-25.

It is widely known that embryo quality affects pregnancy and live birth rates. Nevertheless, in their article, “Increase of success rate for women undergoing embryo transfer by transcutaneous electrical acupoint stimulation: a prospective randomized placebo-controlled study,” Zhang et al. do not mention the quality of transferred embryos at all (1). In addition, there is no information about ovarian stimulation protocols (GnRH agonist? GnRH antagonist? Recombinant or urinary FSH?), length of stimulation, endometrial thickness or day of embryo transfer. One might expect day-5 cycles to be different, for better or worse, considering that the interval between intervention [transcutaneous electrical acupoint stimulation (TEAS)] and embryo implantation would have been shorter.

Another question: why were patients who previously submitted to acupuncture excluded from the study? The authors state that the TEAS parameters in the mock group were “too weak to produce a therapeutic effect.” On the other hand, they say that such parameters produced a “feeling of intermittent tingling sensation.” If there is sensation, there is neural stimulation, so how can one exclude possible “therapeutic” effects for the mock group? This mild stimulation should be considered and discussed as well. I understand that it is difficult to have a perfect control group for acupuncture studies, but I do not believe this particular kind of control “makes the conclusion more convincing and reliable.”

There are many factors that can influence outcomes in ART cycles. This study does not seem to have considered all (or even most) of them. As an ART physician and acupuncturist, I do not feel comfortable, at this point, mentioning the results reported by Zhang et al. to my patients.

Sergio P. Gonçalves, M.D.
São Paulo, Brazil

Reference
1. Zhang R, Feng X-J, Guan Q, Cui W, Zheng Y, Sun W, Han J-S. Increase of success rate for women undergoing embryo transfer by transcutaneous electrical acupoint stimulation: a prospective randomized placebo-controlled study. Fertil Steril 2011; 96:912-6.

The Authors Respond:

We welcome Dr Gonçalves’comments on our study. The answers to his questions are as follow:

1. Concerning embryo quality, only high quality embryos were chosen for transfer. No significant differences were found in the number of high quality embryos among the three groups (mock TEAS: 4.8±4.1; single TEAS 5.5±3.3; double TEAS 5.2±4.4).

2. All participants involved in this study used a GnRH agonist regimen, lasting for 10 days. Recombinant FSH was used in the first five days, and recombinant FSH plus urinary FSH in the second five days. The endometrial thickness was around 9-11 mm, and there were no significant differences among the three groups (mock TEAS: 1.1±0.3; single TEAS: 1.0±0.1; double TEAS: 0.9±0.1). The embryo transfer was executed 3 days after oocyte retrieval. Since the regimen mentioned above is regular procedure in most reproduction centers, we did not describe it in detail. We have compared all factors that might affect the pregnancy rate to confirm the uniformity in the three groups. For details, please see Table 1.

Table 1. Factors that might affect the pregnancy rate (click on table to enlarge)

3．Patients who were previously treated with acupuncture were excluded from the study because we used the placebo transcutaneous electrical acupoint stimulation (TEAS) as a control for the real TEAS. Subjects who have experienced acupuncture may notice the difference between the two types of stimulation, thereby making the placebo design inapplicable. Secondly, previous exposure to acupuncture may affect the results of the current study. Therefore we only recruited acupuncture-naïve subjects for the present study.

4. There are several ways to design a control group for acupuncture research. The easiest way is to place the needle or electrodes on the same anatomical site, but limit the intensity of the stimulation to a very low level. However, if the intensity is near zero, it would not produce any feeling and the subject would guess that he or she is in the control group. If the stimulation is reduced by only 1-2 fold, the mild stimulation per se may produce a therapeutic, albeit weak, effect. In the present study, we used a minimal stimulation by a 9-fold reduction, i.e., the intensity is reduced by 3-fold (5 mA vs 15 mA), and the time of stimulation is reduced by 3-fold (10 seconds on and 20 seconds off). Most subjects said, “I do feel something come and go.” Therefore, the psychological effect remained while the physiological effect became negligible (1).

5. As we mentioned in the introduction and discussion, one key factor in the effect of acupuncture is the timing of intervention. Consistent with previous findings (2,3), treatment on the day of embryo transfer (ET) is effective, but not at some other times (4). That is why we performed TEAS intervention 24 hours before and 30 minutes after ET.

Rong Zhang, M.D., Ph.D.
Ji-Sheng Han. M.D.
Neuroscience Research Institute
Peking University
Beijing, China

References
1. Lambert C, Berlin I, Lee TL, Hee SW, Tan ASL, Picard D, Han JS. A standardized transcutaneous electric acupoint stimulation for relieving tobacco urges in dependent smokers. Evidence-based Complementary and Alternative Medicine. 2009;1-9.

2. Paulus WE, Zhang M, Strehler E, El-Danasouri I, Sterzik K. Influence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril 2002; 77: 721-4.

3. Westergaard LG, Mao Q, Krogslund M, Sandrini S, Lenz S, Grinsted J. Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril 2006; 85: 1341-6.

4. Wang W, Check JH, Liss JR, Choe JK. A matched controlled study to evaluate the efficacy of acupuncture for improving pregnancy rates following in vitro fertilization-embryo transfer. Clin Exp Obstet Gynecol 2007; 34: 137-8.

We reviewed the manuscript by Nybacka et al. (1) with great interest. The authors randomized overweight/obese women with polycystic ovary syndrome (PCOS) to investigate the effects of different lifestyle modification approaches on ovarian function and endocrine/metabolic parameters. The patients were assigned to diet, exercise or diet plus exercise for 4 months, and at least 1-year after the termination of the programs were invited to participate in a follow-up visit. A total of 14, 17 and 12 women completed, respectively, the diet, exercise and diet plus exercise intervention after 4 months, and 7 of each group completed the follow-up visit. At the end of the study the authors’ conclusion was that “properly managed diet and exercise, alone or in combination, are equally effective in improving reproductive function in overweight/obese women with PCOS, despite the minor weight loss associated with exercise.”

Corroborating with the authors, to our knowledge this is the first report using a randomized design to compare the influence of individualized dietary and exercise intervention with professional support, and a long-term follow-up. In fact, this topic is extremely relevant in the current clinical management of PCOS because lifestyle modification is recommended as the first-line therapy for overweight/obese PCOS patients (2).

In this sense, as exercise is a crucial component of lifestyle modification, we would like to discuss the methodological procedures related to exercise intervention used by Nybacka et al. (1). The authors described that the exercise program was individually adjusted and designed to enhance the type (endurance, aerobic, and/or weight training) conforming the patient’s capacity, goals, and interest at the beginning of this intervention. However, there was no description of the basic variables of exercise training such as type, intensity, duration, frequency and progression. This definition is fundamental because the effects of exercise depend of the organization and manipulation of these basic variables (3). Additionally, the long-term effects promoted by aerobic and resistance exercise are different (4). Moreover, the detailed description of exercise intervention may facilitate its reproduction in clinical practice.

For example, Thomson et al. (5) evaluated the effects of aerobic and aerobic/resistance exercise plus an energy-restricted, high-protein diet on metabolic risk factors and reproductive function in overweight/obese PCOS women. The authors detailed both interventions with regard to basic variables of training. At the end of the study, it was possible to conclude that all interventions improved equally the cardiometabolic risk profile and reproductive function. However, the addition of aerobic or combined aerobic/resistance exercise to diet had better results on the body composition.

Therefore, for a better analysis of the clinical effectiveness and feasibility of the exercise intervention used in lifestyle modification programs designed for PCOS women, we believe that a detailed description of the exercise prescription with regard to the basic variables (i.e., type, intensity, duration, frequency and progression) is crucial.

Eduardo Caldas Costa, Ph.D.^a,b
George Dantas de Azevedo, M.D., Ph.D.^b,c
aDepartament of Physical Education
^bPost-Graduate Program in Health Sciences
^cDepartament of Morphology, Biosciences Center
Federal University of Rio Grande do Norte
Natal-RN, Brazil

References
1. Nybacka A, Carlström K, Ståhle A, Nyrén S, Hellström PM, Hirschberg AL. Randomized comparison of the influence of dietary management and/or physical exercise on ovarian function and metabolic parameters in overweight women with polycystic ovary syndrome. Fertil Steril. 2011 (in press).

2. Wild RA, Carmina E, Diamanti-Kandarakis E, Dokras A, Escobar-Morreale HF, Futterweit W, et al. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: a position statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society. J Clin Endocrinol Metab. 2010; 95(5):2038-49.

3. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, et al. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011; 43(7):1334-59.

4. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA, et al. Resistance exercise in individuals with and without cardiovascular disease: 2007 update: a scientific statement from the American Heart Association Council on Clinical Cardiology and Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2007; 116(5):572-84.

5. Thomson RL, Buckley JD, Noakes M, Clifton PM, Norman RJ, Brinkworth GD. The effect of a hypocaloric diet with and without exercise training on body composition, cardiometabolic risk profile, and reproductive function in overweight and obese women with polycystic ovary syndrome. J Clin Endocrinol Metab. 2008; 93(9):3373-80.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.11.037

The Authors Respond:

We were pleased to read the supportive letter by Costa and Azevedo to our findings of individually adapted programs of dietary management and/or physical exercise applicable in polycystic ovary syndrome (PCOS). The fact that exercise and diet were equally effective to improve reproductive function independently of weight loss, speaks in favor of a common mechanism induced by both diet and exercise. Our preliminary data support that the underlying mechanism involves enhanced insulin sensitivity. In an extension to our study we are investigating this further.

The authors request a more detailed description of the exercise intervention used in our study in order to better evaluate its clinical effectiveness and feasibility in PCOS women. At baseline, most women estimated their level of physical activity as low corresponding to less than two hours of walking or light physical exercise a week. The exercise program, which was supervised by a physiotherapist, was based on each individual’s condition, interest and experience and aimed at increasing their physical activity to a moderate level. The exercise included walking (with or without poles), aerobics, jogging, swimming, strength training etc. with an exertion of moderate to vigorous, performed two to three times a week with a duration of 45-60 minutes each time during the intervention period. This exercise program caused only minor weight loss but improved body composition with a significant reduction of upper body fat and maintained lean body mass.

We believe that structured lifestyle management adapted to the individual’s capacity and needs and with long-term support are the most important prerequisites for successful and sustained improvement of reproductive and metabolic health in women with PCOS.

Åsa Nybacka, B.Sc.^a,b
Kjell Carlström, Ph.D.^a
Agneta Ståhle, Ph.D.^c
Sven Nyrén, M.D., Ph.D.^d
Per Hellström, M.D., Ph.D.^e
Angelica Lindén Hirschberg, M.D., Ph.D.^a
a Division of Obstetrics and Gynecology, Department of Women’s and Children’s Health, Karolinska Institutet and Karolinska
University Hospital, Stockholm
^b Department of Clinical Nutrition and Dietetics, Karolinska University Hospital, Stockholm
^c Division of Physiotherapy, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm
^d Department of Radiology, Karolinska University Hospital, Stockholm
^e Department of Medical Sciences, Uppsala University, Uppsala,
Sweden

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.11.039

The otherwise informative paper “Full-sibling embryos created by anonymous gamete donation in unrelated recipients” by Dicken et al. (1) was marred by use of limited evidence to support the claim that “most parents conceiving with the assistance of donor gametes do not disclose the nature of their conception to their resulting offspring.” A more thorough review of available literature than the two cited sources (2,3) reveals a more nuanced picture, as indicated by several European studies.

A Swedish study published in 2000 (4) reported that 11% of parents of donor insemination (DI)-conceived children had told their child about the nature of her or his conception, while 40% of parents intended to tell their child “later.” When re-interviewed some years later (5), 61% of these parents had already told their child about her or his conception, and a further 22% were still intending to do so.

In a Finnish study reported in 1998 (6), 38% of parents of children aged up to four years conceived following oocyte donation intended to disclose to their child the nature of her or his conception. When re-interviewed when their children were 13–14 years old, 27.8% of parents had already disclosed and 16.6% still intended to do so (7). In the same study, 83.3% of parents of children aged under three years indicated their intention to tell their child.

Two separate United Kingdom studies of oocyte donation draw broadly similar conclusions. In the first study, when the children were aged up to eight years old, one set of parents only had already told their child about the nature of her or his conception, 38% had decided not to tell their child, and the intentions of the remaining 53% are unspecified (8). These parents were re-interviewed when their child was 12 years old (9); 35% had either disclosed to their child already or stated their intention to do so. A separate cohort of parents of children conceived following oocyte donation aged under one year was recruited for a second study (10). No parent had told their child of the circumstances of her or his conception, 56% stated their intention to disclose, 22% were uncertain and 22% planned not to disclose. When these parents were re-interviewed when their child was aged seven years (11), 40.6% had already told their child, 31.3% were planning to disclose, 12.5% were unsure whether or not to disclose, and 15.6% had decided not to tell.

It is essential to be aware that parental intentions to tell may not result in actual disclosure. Nevertheless, the evidence currently available means that unqualified assertions that “most parents conceiving with the assistance of donor gametes do not disclose the nature of their conception to their resulting offspring” are no longer sustainable.

Eric Blyth, C.Q.S.W., B.A., M.A., Ph.D.
Professor of Social Work
School of Human and Health Sciences
University of Huddersfield
Queensgate
Huddersfield, United Kingdom

References
1. Dicken C L, Zapantis A, Illions E, Pollack S, Lieman HJ, Bevilacqua K, et al. Full-sibling embryos created by anonymous gamete donation in unrelated recipients Fertil Steril 2011; 96:641–2.

2. Golombok S, Readings J, Blake L, Casey P, Mellish L, Marks A, et al. Children conceived by gamete donation: Psychological adjustment and mother-child relationships at age 7. J Fam Psychol 2011;25: 230–9.

3. Readings J, Blake L, Casey P, Jadva V, Golombok S. Secrecy, disclosure and everything in-between: decisions of parents of children conceived by donor insemination, egg donation and surrogacy. Reprod Biomed Online 2011;22:485–95.

4. Gottlieb C, Lalos O, Lindblad F. Disclosure of donor insemination to the child: the impact of Swedish legislation on couples’ attitudes. Hum Reprod 2000; 15: 2052-2056.

5. Lalos A, Gottlieb C, Lalos O. Legislated right for donor-insemination children to know their genetic origin: a study of parental thinking. Hum Reprod 2007; 22(6): 1759–1768.

6. Söderström-Anttila, V., Sajaniemi N, Tiitinen A, Hovatta O. Health and development of children born after oocyte donation compared with that in those born after in vitro fertilization, and the parents’ attitudes regarding secrecy. Hum Reprod 1998; 13: 2009-2015.

7. Söderström-Anttila, V., Sälevaara, M. and Suikkari, A. M. Increasing openness in oocyte donation families regarding disclosure over 15 years. Hum. Reprod 2010; 25: 2535-2542.

8. Golombok S, Murray C, Brinsden P, Abdalla H. Social versus biological parenting: family functioning and the socioemotional development of children conceived by egg or sperm donation. J Child Psychol Psychiat 1999;40:519 –27.

9. Murray C, MacCallum F, Golombok S. Egg donation parents and their children: follow-up at age 12. Fertil Steril 2006;85:610-618.

10. Golombok, S., Lycett, E., MacCallum, F., Jadva, V., Murray, C., Rust, J., Abdalla, H., Jenkins, J., Margara, R. Parenting infants conceived by gamete donation. J. Fam. Psychol. 2004; 18: 443-452.

11. Readings J, Blake L, Casey P, Jadva V and Golombok S. Secrecy, disclosure and everything in-between: decisions of parents of children conceived by donor insemination, egg donation and surrogacy. Reprod. Biomed. Online 2011; 22:485-495.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.11.006

The authors declined to reply to this letter.

Paolo Casadio et al. recently published an interesting paper focusing on the dynamic changes of the myometrial free margin separating type II submucous fibroids from the serosa during hysteroscopic resection (1). Although the number of patients of this prospective observational study is limited (n = 13), the authors interestingly concluded that “myometrial free margin increases progressively with each step of the procedure probably leading to an increasing margin of safety.” This study updates and reinforces the previous observation by Yang et al., which first demonstrated that the myometrial free margin is not a static parameter but it “increased gradually after each step of the resection, reaching its maximum after the completion of the procedure” (2). They observed the progressive thickening of myometrium at transabdominal sonography while the myoma is progressively enucleated, suggesting two possible mechanism for this phenomenon: the reshaping of the distended uterine myometrial fibers and the contractions induced by electrosurgery and the myoma grasping by forceps.

In the last decade, my group and I extensively focused on this topic by standardizing the classification of submucous myomas using 2D and 3D saline contrast sonohysterography (3). During 2D saline infusion, the dynamic changes of the myometrial free margin could be easily observed (see the video-clip).

Also, we investigated the intraoperative changes of the myometrium during hysteroscopic myomectomy performed by the combined use of electrical monopolar and “non-electrical” cold loops (unpublished data). By repeated traction maneuvers on the myoma and continuous intrauterine pressure changes obtained by the use of inflow and outflow stopcocks, results similar to the above-reported were observed, but in presence of adjacent coexisting intramural and/or subserous myomas.

In our recently accepted paper on hysteroscopic myomectomy on 169 hysteroscopic procedures for type I and type II submucous fibroids, we reported one uterine perforation (4). It occurred in a case of a type II 3-cm submucous myoma, with a 5-mm myometrial free margin, located near a 3-cm intramural-subserosal fibroid. During the cold-loop enucleation, at the end of the removal of the deep intramural part, a uterine perforation occurred because of the loss of the described progressive myometrial contraction. Because of the cold loop’s use, no further surgery was needed and clinico-sonographic monitoring was successfully applied.

This episode confirmed the indication by Perrot et al., which suggested the presence of co-existing adjacent myomas as a risk factor for uterine perforation (5).

To sum up, I do absolutely agree with the data reported by Casadio et al., which should reassure and strengthen the confidence of the hysteroscopist in the treatment of type II myoma. Furthermore, I would stress the need of a proper presurgical sonographic evaluation and consideration of the presence of co-existing adjacent myomas as a risk factor for uterine perforation (Figure 1), because of sliding and the reduced contraction and thickening of the myometrial free margin.

Figure 1. a. Type II submuocous myoma at beginning of the procedure with its myometrial free margin. b. Thickened myometrial free margin at mid-procedure.
c. Unchanged myometrial free margin at mid-procedure because of the presence of a co-existing adjacent myoma.

Francesco P.G. Leone, M.D.
Department of Obstetrics and Gynecology
Clinical Sciences Institute L. Sacco
University of Milan
Milan, Italy

References
1. Casadio P, Youssef AM, Spagnolo E, Rizzo MA, Talamo MR, De Angelis D, Marra E, Ghi T, Savelli L, Farina A, Pelusi G, Mazzon I. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril. 2011 Apr;95(5):1764-1768.

2. Yang JH, Lin BL. Changes in myometrial thickness during hysteroscopic resection of deeply invasive submucous myomas. J Am Assoc Gynecol Laparosc 2001;8:501–5.

3. Leone FP, Bignardi T, Marciante C, Ferrazzi E. (2007) Sonohysterography in the preoperative grading of submucous fibroids: considerations on three-dimensional methodology. Ultrasound Obstet Gynecol 29:717–718.

4. Leone FP, Calabrese S, Marciante C, Cetin I, Ferrazzi E. Feasibility and long-term efficacy of hysteroscopic myomectomy for myomas with intramural development by the use of non-electrical “cold” loops. Gynecol Surg., DOI: 10.1007/s10397-011-0706-4

5. Perrot N, Mergui JL, Frey I, Uzan M. Menorrhagia after age 40. Contribution of ultrasonic examination. Gynecol Obstet Fertil. 2002 Jun;30(6):523-31.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.10.029

The Authors Respond:

We would like to thank Dr. Leone for his comment. His experience and observations on the resection of submucous fibroids are extremely interesting and address some important issues which undoubtedly need further evaluation by other studies.

It is important to point out the dynamic nature of the myometrial free margin. We believe that both safety and success of submucous myoma resection are strictly dependent upon this feature. We agree with Dr. Leone that this change is not expected to be similar in all women and that it may be affected by several factors.

Dr. Leone has stressed the importance of the presence of adjacent multiple fibroids. He mentioned that in the only case of uterine perforation in his series, an adjacent intramural-subserosal fibroid was present close to the fibroid removed.

Unsurprisingly, he has described a loss of the progressive myometrial contraction in this specific case. Although in our study we included only cases with single fibroids (1), our experience is in line with his data. Together with the alteration of myometrial contractility, we think that the presence of an adjacent fibroid may further increase the technical difficulty of hysteroscopic resection through an increased difficulty in finding a clear plane of cleavage. For this reason an adequate detailed pre-operative sonographic fibroid evaluation of fibroids’ number, location (anterior/posterior, fundal/isthmic/angular), depth, dimensions, morphology (contour, unilobed/bilobed) and shape may allow safe and successful hysteroscopic fibroid resection.

Other important factors which may have an impact on the intraoperative myometrial response to resection may include age, parity, previous uterine surgeries, and medical therapies (e.g., administration of GnRH analogues). We believe that these factors may significantly alter the normal contractility of the normal myometrial fibers surrounding the fibroid, thus affecting both the success and complication rates. With adequate consideration of several parameters, women may be offered proper preoperative counseling prior to undergoing hysteroscopic fibroid resection (2).
Further data are clearly needed in order to better correlate preoperative ultrasound parameters and patient characteristics with myometrial behavior, possibly leading to a better evaluation of success and complication probability prior to resectoscopic resection of submucous fibroids.

Paolo Casadio, M.D.
Aly Youssef, M.D.
Luca Savelli, M.D.
Tullio Ghi, M.D.
Emanuela Spagnolo, M.D.
Francesca Guasina, M.D.
Renato Seracchioli, M.D.
Department of Obstetrics and Gynecology
S. Orsola Malpighi University Hospital
University of Bologna
Bologna, Italy

References
1. Casadio P, Youssef AM, Spagnolo E, Rizzo MA, Talamo MR, De Angelis D, Marra E, Ghi T, Savelli L, Farina A, Pelusi G, Mazzon I. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril 2011; 95:1764-8.

2. Mavrelos D, Naftalin J, Hoo W, Ben-Nagi J, Holland T, Jurkovic D. Preoperative assessment of submucous fibroids by three-dimensional saline contrast sonohysterography. Ultrasound Obstet Gynecol 2011; 38: 350-4.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.10.030

In the context of the excellent Views and Reviews devoted to the endometrium (1), Dr. Bruce A. Lessey offers a thorough analysis of 186 publications that are of significance to the window of implantation (WOI) (2). We feel this already exhaustive effort needs to be expanded further. Although one histological hallmark of midluteal endometrium – pinopodes (whose significance as markers of endometrial receptivity has been questioned) – is reviewed in detail, another, the nucleolar channel system (NCS), went unmentioned. The presence of NCSs distinctly marks the midluteal phase of human endometrium overlapping with the WOI.

NCSs were identified over half a century ago using electron microscopy and can now be readily detected by marker proteins using indirect immunofluorescence (3). These 1-µm-sized organelles are found exclusively in the nuclei of human endometrial epithelial cells of the secretory phase. NCSs are specific to healthy human endometrium, being absent from other hormone-sensitive tissue (such as breast epithelium), from endometrial carcinoma specimens, or from baboon endometrium. The presence of NCSs peaks during cycle days LH+5 to LH+10 (menstrual cycle days 19-24), and subsequently trails off (3,4). NCSs are absent before LH+4, after LH+13 and during the proliferative phase. In fact, their midluteal/WOI presence is so robust that it is independent of fertility status (5).

Despite a lack of functional definition, NCSs are cell biological marvels with a unique protein composition and as membranous organelles in the otherwise membrane-free cell nucleus. Now that they can be easily detected in endometrial biopsy specimens, NCSs should not be discounted as potential markers of the WOI and certainly deserve an honorable mention.

Edward J Nejat, M.D., M.B.A.
Gregory Zapantis, M.D.
Eli A Rybak, M.D., M.P.H.
U. Thomas Meier, Ph.D.
Albert Einstein College of Medicine
Bronx, New York

References
1. Casper, RF. It’s time to pay attention to the endometrium. Fertility and Sterility 96, 519-521, (2011).

2. Lessey, BA. Assessment of endometrial receptivity. Fertility and Sterility 96, 522-529, (2011).

3. Guffanti E, Kittur N, Brodt ZN, Polotsky AJ, Kuokkanen SM, Heller DS, et al. Nuclear pore complex proteins mark the implantation window in human endometrium. J. Cell Sci. 121, 2037-2045, (2008).

4. More IA, McSeveney D. The three dimensional structure of the nucleolar channel system in the endometrial glandular cell: serial sectioning and high voltage electron microscopic studies. J Anat 130, 673-682, (1980).

5. Rybak EA, Szmyga, MJ, Zapantis G, Rausch M, Beshay VE, Polotsky, AJ, et al. The nucleolar channel system reliably marks the midluteal endometrium regardless of fertility status: a fresh look at an old organelle. Fertility and Sterility 95, 1385-1389.e1381, (2011).

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.053

The Author Responds:

Thank you for your letter to the editor regarding the new Views and Reviews feature in the September issue of Fertility and Sterility regarding the endometrium.

You note our omission of the nucleolar channel system (NCS) as one of the ultrastructural entities of a receptive endometrium. Indeed there are 22 references on PubMed dating back to 1965 on these fascinating and unique subcellular features of mid-secretory endometrium. I was aware of the NCS during endometrial development and we discussed the potential importance of these structures (complete with photomicrographs) in the latest version of Yen and Jaffe’s textbook in the chapter entitled, “The structure, function and evaluation of the female reproductive tract” (1). It is likely that I left out other favorite endometrial moieties as well, and I apologize to you and everyone else that might find that the article falls short of the mark.

As you point out, the expression pattern of NCS, while present in the mid-secretory phase, is unperturbed in the endometrium of women with unexplained infertility and present regardless of fertility status (2). In thinking about what to include in an article about endometrial receptivity (with too many references), I considered that the ideal biomarker would have functional significance to the process of implantation. By that, I also inferred that the loss of that biomarker would logically be associated with a deficit as evidenced by infertility or pregnancy loss. Since this particular biomarker does not appear to bear that attribute, I did not include it. In thinking about this further in response to your letter, I think it is indeed unusual and even unlikely that a progesterone mediated event (directly or indirectly) (3) would not be affected by endometriosis or other gynaecologic disorders that have been shown to cause progesterone resistance in some women (4). Such a robust biomarker certainly deserves future study and is a feature that might be examined in the luteal phase defect model of endometrial development on which Dr. Steven Young and Dr. Marc Fritz at the University of North Carolina have been working (5). There must be levels of progesterone, below which, the NCS do not correctly assemble or form and this model would certainly address that question.

I hope that readers of this exchange will now go and read more about these interesting structures and appreciate, as I do, the ever-growing complexities and mysteries of the human endometrium.

Bruce A. Lessey, M.D., Ph.D.
Greenville Hospital System
Center for Women’s Medicine
Greenville, South Carolina

References
1. Strauss JF III, Lessey BA. The structure, function, and evaluation of the female reproductive tract. In: Strauss JF, III, Barbieri RL, eds. Reproductive Endocrinology: Physiology, pathophysiology, and clinical management. Philadelphia, PA: Saunders Elsevier, 2009:191-233.

2. Rybak EA, Szmyga MJ, Zapantis G, Rausch M, Beshay VE, Polotsky AJ et al. The nucleolar channel system reliably marks the midluteal endometrium regardless of fertility status: a fresh look at an old organelle. Fertil Steril;95:1385-9 e1.

3. Kohorn EI, Rice SI, Gordon M. In vitro production of nucleolar channel system by progesterone in human endometrium. Nature 1970;228:671-2.

4. Young SL, Lessey BA. Progesterone function in human endometrium: clinical perspectives. Semin Reprod Med 2010;28:5-16.

5. Young SL, Lessey BA, Balthazar U, Zaino RJ, Jin JP, Sherwin JRA et al. Defining the relationship between progesterone dose, endometrial histology and gene expression using an in vivo luteal phase defect model. Reprod Sci 2011;18:272A.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.054

We thank Cepni et al. for sharing their recent case series, “An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by single-dose methotrexate administration” (1). This was of great interest to us, as we have used a similar aspiration and instillation technique using hyperosmolar glucose to treat a heterotopic pregnancy created after in vitro fertilization (IVF).

Our patient was a 29-year-old nulligravida with longstanding infertility and a history of stage IV endometriosis and severe pelvic adhesive disease. She underwent IVF with a transfer of 2 blastocysts. She presented 20 days after transfer (5+4 weeks estimated gestational age) for ultrasound and was diagnosed with a heterotopic pregnancy. Options including surgical intervention, systemic methotrexate, and adnexal aspiration with instillation of hyperosmolar glucose and/or methotrexate were discussed. The patient strongly desired to preserve the intrauterine pregnancy and wished to avoid surgical intervention. We performed transvaginal ultrasound-guided aspiration of the ectopic gestational sac, followed by instillation of hyperosmolar (50%) glucose. Pathology revealed fetal tissue within the aspirated material. The patient tolerated the procedure well and delivered a term infant via cesarean section.

Aspiration of an ectopic pregnancy with instillation of hyperosmolar glucose has rarely been reported (2), but it appears to be an effective treatment modality for a select group of patients with early heterotopic or possibly even ectopic pregnancies. Particularly in cases of heterotopic pregnancy – where patients may be anxious to minimize any possible risk to the intrauterine pregnancy – aspiration and local instillation of hyperosmolar glucose may be an attractive therapeutic option.

Nanette L. Rollene, M.D.
Division of Reproductive Endocrinology
Naval Medical Center
Portsmouth, Virginia

Jani R. Jensen, M.D.
Reproductive Endocrinology and Infertility
Mayo Clinic
Rochester, Minnesota

References
1. Cepni I, et al. An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by a single-dose methotrexate administration. Fertil Steril 2011;96:79-83.

2. Goldberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancies. Obstet Gynecol 2006;107(2 Pt 2):509-10.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.027

The Authors Respond:

We are pleased to hear that Rollene and Jensen treated a heterotopic pregnancy without the need for salpingostomy or salpingotomy. We had a similar patient who had tubal heterotopic pregnancy (HP) treated conservatively with transvaginal ultrasound-guided aspiration of the fluid in the gestational sac and instillation of hyperosmolar glucose (1). According to the preliminary data of our unpublished studies aspiration of fetal tissues give better results than aspiration and instillation of only the fluid. Aspiration of fetal tissues may seem difficult although it is not much different than oocyte pick-up procedure. The most important limitation of our technique is ectopic gestations older than 8 weeks where ossification begins, since the ossified structures may obstruct the aspiration needle and the operation would probably be ineffective. However, considering that ectopic pregnancies are mostly diagnosed around 6 to 8 weeks, our technique has a wide array of usages.

The use of hyperosmolar glucose may be safer than methotrexate (MTX) since MTX may have some adverse effects. If used in combination with aspiration of the fetal tissues, hyperosmolar glucose may eliminate the need for MTX even in non-heterotopic cases. However the success of the two methods should be compared in further studies.

Onur Guralp, M.D.
Hazel Gurleyen, M.D.
Ismail Cepni, M.D.
Department of Obstetrics and Gynecology
Istanbul University
Cerrahpasa School of Medicine
Istanbul, Turkey

REFERENCES
1. Ocal P, Erkan S, Cepni I, Idil MH. Transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose for treatment of unruptured tubal heterotopic pregnancy. Arch Gynecol Obstet. 2007 Sep;276(3):281-3.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.026

An example of a policy of limitless rounds of IVF cycles (looked upon by many as the north star for IVF policies) can be found in Israel, where the Israeli National Health Insurance (NHI) covers unlimited cycles of IVF for all female Israeli citizens up to two children in a given relationship (even if the woman already has children). While at first look the Israeli policy might be taken as an example to be followed worldwide (as it seems to be a win-win situation, with all the stakeholders enjoying equally under the ultra-permissive policy), a closer examination suggests that this may not be the case. Israeli women seem to enroll in massive IVF treatment for many years, ending up worse off in too many cases (4, 5).

The implication of a policy of unlimited rounds of IVF from the perspective of the “culture of perseverance” that develops in IVF clinics has not yet been fully assessed, either in Israel or elsewhere (3). Moreover, the number of IVF cycles a woman in Israel may go through remains unknown. Equally, the effectiveness of the open-ended IVF policy is unclear, as well as the side effects of long-term treatment with IVF. Further, while the equitable access to IVF in Israel should be applauded, in the context of NHI constraints, a scheme of (almost) limitless rounds of IVF remains questionable.

The authors of this short rejoinder have been recently awarded a grant from the Gertner Israeli Institute for Health Policy Research to analyze the effect/s of the open-ended Israeli IVF policy from the perspective of the “culture of perseverance” that develops in IVF clinics. We believe that before reassuring women to persevere with IVF, a systematic long-term assessment of the health and welfare of the women after IVF – especially after prolonged treatment with IVF – is necessary. In a global context, an evidence-based policy about Israeli ART may improve both the allocation of resources and the duty of care, not only in Israel, but also in other countries.

Frida Simonstein, Ph.D.
Michal Mashiach, Ph.D.
Dept. of Health System Management
Yezreel Valley College
Israel

References
1. Stewart LM, Holman CDJ, Hart R, Finn J, Mai Q, Preen DB. How effective is in vitro fertilization, and how can it be improved? Fertility and Sterility 2011;95:1677-83.

2. Holm S. The medicalization of reproduction – a 30 year retrospective. In: Simonstein F, ed. Reprogen-ethics and the Future of Gender. London: Springer, 2009:29-36.

3. Simonstein F. Assisted reproduction policies with emphasis on Israeli practices. Health Policy 2010;97:202–8.

4. Remennick, L. Childless in the land of imperative motherhood: Stigma and coping among infertile Israeli women. Sex Roles 2000;43:821-41.

5. Birenbaum-Carmeli D. ‘Cheaper than a Newcomer’: On the political economy of IVF in Israel. The Sociology of Health and Illness 2004;26 (7):897-924.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.016

The Authors Respond:

We thank Drs. Simonstein and Mashiach for their interest in our article (1). Unfortunately, they appear to have misinterpreted some of our findings. Our results did not show that “women may continue with IVF treatment even when the probability of a successful outcome is ‘zero’,” and our paper does not provide support for a policy of limitless IVF. Rather, we found that many women cease IVF cycles at a point well before the success curve appears to saturate, thus raising the possibility that for some women additional cycles could confer reproductive benefit.

We agree with Drs. Simonstein and Mashiach that the long-term health consequences of IVF treatment need to be investigated. This is the subject of our current research.

Louise Maree Stewart, B.Sc.(Hons), GradDipPH^a
C D’Arcy J. Holman, M.P.H., Ph.D., F.A.F.P.H.M.^a
Roger Hart, M.D., C.R.E.I.^b
Judith Finn, Ph.D., R.N.^c
Qun Mai, M.B.B.S., M.P.H.^a
David B Preen, Ph.D.^a
aSchool of Population Health
The University of Western Australia
^bSchool of Women’s and Infants Health
The University of Western Australia and Fertility Specialists of Western Australia
^cDiscipline of Emergency Medicine
The University of Western Australia
Crawley, Australia

Reference
1. Stewart LM, Holman CD, Hart R, Finn J, Mai Q, Preen DB. How effective is in vitro fertilization, and how can it be improved? Fertil Steril 2011;95:1677-83.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.09.017

We read with interest the retrospective analysis by Goldman et al (1). The authors attempt to determine the minimum number of procedures required for proficiency in oocyte retrieval (OR). Assessing and classifying the technical competence of a trainee objectively is quite difficult for two reasons: first, there is no clear definition of “competence,” as operative skill is a combination of knowledge, judgment, and technical ability (2). Second, the success of an OR depends on additional parameters, such as patient, nurse and embryologist compliance. We would like to share our thoughts on their work.

In cases of ORs, competence can be measured quantitatively. However, we are in agreement with the authors that there is a lack of structured assessments and limited acceptance of those which exist. In this study, the CUSUM methodology–reported by them (1)–could be used in their trial to accurately indicate when the trainee learning curve is complete, adding a qualitative element to their assessment.

The investigators adopted a proficiency score utilizing follicles ≥12 mm: we cannot be certain if, at that diameter, an oocyte exists for sure and that therefore its retrieval could be used to define trainees’ competence (3). For that reason, we feel it would be better to employ diameters of >14mm as a quantitative assessment tool. In addition, the score was calculated based on the ratio between oocytes retrieved to those expected. Parameters such as the suction pressure at recovery, the technique itself (use and number of flushings, type of puncturing the ovary, the operative time), the nurse’s and embryologists’ ability of locating and manipulating the oocyte and the operative room conditions are equally important and play a distinct role during an OR. We would thus suggest implantation, clinical pregnancy or, ultimately, live-birth rate as more significant primary outcomes.

Moreover, we would propose that supplementary data on complications during OR have to be taken into account. Although rare, during training they are a significant endpoint. Pain scores, vaginal or intraperitoneal bleeding, organs’ injuries, infections or pelvic abscesses and need for an extra surgery (4) are complications that could improve and solidify the assessment scheme credibility. The latter could be further improved upon with a larger number and especially the randomization of the trainees in a well-designed RCT, so that conclusions would be more robust.

Finally, we would like to comment on the operative conditions that the assessment took place. Exclusion of difficult cases constitutes an environment we feel is removed from clinical reality. The real meaning of training clinicians is to render them capable to handle the difficult situations independently. In many Assisted Reproduction Units the OR is performed under conscious sedation delivered by the provider, with the husband sitting next to the patient, a nurse and an embryologist participating in the procedure, while time is of the essence, creating a demanding and stressful environment.

We appreciate the effort made by authors to assess the competence in a data driven fashion. Nevertheless, perception, integration, and automatization are the three steps required to develop technical competence (5). Trainees’ development into competent specialists entails acquisition of both cognitive and motor skills (2), together with communicational properties.

Charalampos Siristatidis, M.D., Ph.D.
Antonis Lykakis, M.D.
Charalampos Chrelias, M.D., Ph.D.
University of Athens
Athens, Greece

References
1. Goldman KN, Moon KS, Yauger BJ, Payson MD, Segars JH, Stegmann BJ. Proficiency in oocyte retrieval: how many procedures are necessary for training? Fertil Steril 2011;95:2279-82.

2. Kenton K. How to Teach and Evaluate Learners in the Operating Room. Obstet Gynecol Clin North Am 2006;33:325-32.

3. Wittmaack FM, Kreger DO, Blasco L, Tureck RW, Mastroianni JL, Lessey BA. Effect of follicular size on oocyte retrieval, fertilization, cleavage, and embryo quality in in vitro fertilization cycles: a 6-year data collection. Fertil Steril 1994;62:1205-10.

4. Ludwig AK, Glawatz M, Griesinger G, Diedrich K, Ludwig M. Perioperative and post-operative complications of transvaginal ultrasound-guided oocyte retrieval: prospective study of >1000 oocyte retrievals. Hum Reprod 2006;21:3235-40.

5. Kopta JA. An approach to the evaluation of operative skills. Surgery 1971;70:297-303.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.08.030

The Authors Respond:

We thank the correspondents for their interest in our paper and appreciate the suggestion that the cumulative summation test for learning curve, or CUSUM, methodology could have been employed in our study to assess competence. However, we assert that this methodology mirrors the quantitative assessment that we employed.

The CUSUM methodology utilizes objective data to compile a graphical representation indicating when a learner has reached a predefined level of performance (1). But as we explained in our previous response, this model is simply not appropriate to this training situation (http://fertstert.wordpress.com/2011/06/07/proficiency-in-oocyte-retrieval/). Oocyte retrieval is a skill that can be measured quantitatively, and therefore we used quantitative data as a surrogate for proficiency. However, we do not dispute that an ideal assessment tool would synthesize both quantitative and qualitative measures to discern competence in a trainee.

We acknowledge the suggestion that follicles ≥14mm could have been used as an alternative to follicles >12mm. Our decision was based on a study by Wittmaack et al, in which follicular fluid volume of >1 mL (follicular size ≥12mm) corresponded with optimal oocyte recovery, fertilization, and cleavage in IVF cycles (2). Our data ultimately supported this assumption given that a greater number of oocytes were retrieved than were expected based on the number of 12 mm follicles.

We agree that multiple parameters influence the success of oocyte retrieval, and to minimize the influence of these parameters, all oocyte retrievals were performed at the Walter Reed Army Medical Center with the same experienced staff and embryologists. While implantation, clinical pregnancy, or live birth are also acceptable outcomes, given the many steps following oocyte retrieval that are often performed by other providers, it would be difficult to adequately attribute those outcomes to the trainee performing the retrieval.

We also know that provider plays a role in the success of embryo transfer (3), and therefore clinical pregnancy outcomes would only be attributable to the trainee if he or she performed both the oocyte retrieval and the embryo transfer and if the embryo quality was identical. And while complications during oocyte retrieval are rare, they are an important endpoint. However, our database did not contain information on complications and we were, therefore, unable to adequately assess the rate of complications in relation to a trainee’s proficiency.

Finally, we agree that a clinician must be capable of handling challenging situations independently. However, training is precisely the time when a clinician should be supervised in order to gain these skills. As clinicians, our ultimate responsibility is to the patient and it is in the patient’s best interest that difficult and high risk procedures are performed by experienced clinicians. Oocyte retrievals can certainly become stressful, particularly when a patient’s family member is present and observing, but this is precisely why it is crucial to learn the procedure in a supervised fashion in order to strengthen one’s skills in a controlled environment.

Kara N. Goldman, M.D. ^a,b
Kimberly S. Moon, M.D.^a
Belinda J. Yauger, M.D.^a
Mark D. Payson, M.D.^a,c
James H. Segars, M.D.^a
Barbara J. Stegmann, M.D., M.P.H.^d

^aProgram of Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
^bDepartment of Obstetrics and Gynecology, Northwestern University, Prentice Women’s Hospital, Chicago, Illinois
^cAssisted Reproductive Technologies Program, Division of Reproductive Endocrinology and Infertility, Walter Reed Army Medical Center, Washington, D.C.
^dDepartment of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Iowa Hospitals and Clinics, Iowa City, Iowa

References
1. Dessolle L, Fréour T, Barrière P, Jean M, Ravel C, Daraï E, et al. How soon can I be proficient in embryo transfer? Lessons from the cumulative summation test for learning curve (LC-CUSUM). Hum Reprod 2010;25:380-386.

2. Wittmaack FM, Kreger DO, Blaso L, Tureck RW, Mastroianni JL, Lessey BA. Effect of follicular size on oocyte retrieval, fertilization, cleavage, and embryo quality in in vitro fertilization cycles: a 6-year data collection. Fertil Steril 1994;62:1205-10.

3. Hearns-Stokes RM, Miller BT, Scott L, Creuss D, Chakraborty PK, Segars JH. Pregnancy rates after embryo transfer depend on the provider at embryo transfer. Fertil Steril 2000;74(1):80-6.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.08.031