Comment on “Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study”

6 03 2014

To the Editor:

Ivan Mazzon et al. recently published an interesting paper focusing on “the prevalence and the characteristics of intrauterine adhesions after cold loop resectoscopic myomectomy” for G1 and G2 submucous myomas (1).

Although retrospective, the large number of operated patients (688) and removed myomas (806) make this study robust and relevant. The authors interestingly concluded that “cold loop resectoscopic myomectomy of G1-G2 myomas is effective and safe, with a prevalence of postsurgical intrauterine adhesions that appears to be lower than those reported in the literature. The technique we have described could thus contribute to improving fertility, making it especially noteworthy for patients who desire pregnancy.” Read the rest of this entry »

Toward adhesion-free endoscopy?

3 03 2014

To the Editor:

Although the influence of CO2 insufflation on adhesion formation remains controversial, its non-physiological effects include tissue acidosis combined with metabolic hypoxemia and other respiratory and cardiovascular alterations. Therefore, the suggested hypothesis in a recent article by Corona et al. (1) that CO2-pneumoperitoneum should be supplemented by N2O seems to be promising. Read the rest of this entry »

Should early cleavage (EC) be assessed in routine practice?

28 02 2014

To the Editor:

In a recent study (1), an important question has been mooted, namely, “Should we assess early cleavage between 25 to 27 hours after insemination, with the aim of yielding any benefit in the clinical outcomes?” The message I have been delivered by the results has been, “There was not any benefit of early cleavage assessment, unless all transfer embryos were of sub-optimal quality.” Promoted by ASEBIR with a clear aim to conclude with a scientifically based recommendation to embryologists, I think the results need to be evaluated under scrutiny. Read the rest of this entry »

Male infertility biomarkers and genomic aberrations in azoospermia

17 02 2014

To the Editor:

Estimates indicate that 15-30% (or more) of male infertility is due to whole-organism genetic abnormalities with large numbers of genes already discovered to play important roles (1, 2). Numerous methods have yielded new genetic discoveries with the karyotype, fluorescent in situ hybridization, comparative genomic hybridization and microarrays all contributing (1). All identified genetic aberrations are further complicated by epigenetic modifications (i.e., methylation and protamination), as well as individual differences and environmental influences that make diagnosis and treatment frustrating (1). Unfortunately, in many men, the result of multiple investigations often yields inconclusive, or slightly abnormal results, with a subsequent diagnosis of idiopathic infertility. Read the rest of this entry »

Microbiota of the seminal fluid

22 01 2014

To the Editor:

I read with great interest the article by Hou et al. (1) regarding the microbiota of the seminal fluid from sperm donors and infertile subjects. This study aimed to explore potential causes of male infertility and showed that increased number of bacteria were present in semen samples from infertile subjects as well as sperm donors. The topic of infections and infertility is extremely interesting, and there are still a lot of aspects to be covered.

The significance of bacteriospermia in subfertile men is controversial. When dealing with a sperm sample the possibility of contamination is always probable since the presence of normal flora cannot be overlooked. Moreover, it is quite challenging to evaluate which microorganisms significantly affect male fertility potential. However, bacteriospermia and leukocytospermia have a negative effect on male fertility through multiple proposed mechanisms (2). In the largest study to evaluate bacteriospermia, Domes et al. (2) commonly diagnosed in subfertile men bacteriospermia and leukocytospermia, which were associated with a significantly increased DNA fragmentation index. Read the rest of this entry »

Examining the ovaries by ultrasound for diagnosing hyperandrogenic anovulation: updating the threshold for newer machines

9 01 2014

To the Editor:

We enjoyed reading the article by Christ et al. (1). The discussion about ultrasound criteria, specifically where to put the threshold to distinguish between a polycystic and a normal ovary, has been ongoing for some time and will surely continue for a while yet. Although the results are somewhat predictable since this report is a reassessment of partial data from a previous study (2), the timing of this publication is important because it reinforces a recently published task force report (3). Change is long overdue, but we believe the recommendation of using ≥ 25 follicles per ovary (3) should be adopted promptly as it is clear that the former threshold of 12 follicles is obsolete due to the improvement in the resolution of ultrasound. However, physicians should be aware that a much lower threshold should be used when trying to identify women at high risk of having an excessive response to exogenous gonadotropins used in in vitro fertilization/intracytoplasmic sperm injection cycles. Women with a total antral follicle count (AFC) > 20, considering both ovaries, are already at a higher risk of ovarian hyperstimulation syndrome (4). Another important point to consider when choosing the best threshold are the differences observed in AFC during reproductive age (5). The question of using the same threshold or different thresholds depending on a woman’s age should be balanced between diagnostic test accuracy and ease of implementation. Read the rest of this entry »

The lack of clinical congruence in diagnosis and research in relation to subclinical hypothyroidism

8 01 2014

To the Editor:

We have just read a publication by Bernardi et al. on the topic of subclinical hypothyroidism and recurrent early pregnancy loss (1). Going through the paper we found that the opposite situation was being described, that is, no impact of subclinical hypothyroidism on recurrent early pregnancy loss. This puzzling situation motivated us to dissect the concepts presented by the authors.

One central point of misconception on thyroid function can be tracked down to a 2007 publication cited by Bernardi which recommended a “desirable TSH level” of 2.5 mIU/ml for pregnant women. In that original publication the authors had admitted that this recommendation was done on the basis of a poor level of evidence. Although this recommendation does not fulfill the principles of evidence-based medicine, it has very unfortunately found its way into clinical practice. Choosing a low cut-off value for the upper range of TSH, as Bernardi et al. have done, will result in a misclassification of normal subjects by which the apparent subgroups, euthyroids and women with subclinical hypothyroidism, are not truly subgroups but belong to a same group of subjects having TSH values within the normal range. Therefore it is logical that one cannot expect to find any difference between these artificial subgroups in relation to recurrent early pregnancy loss. Read the rest of this entry »

The effect of methotrexate injection for treatment of an ectopic pregnancy on ovarian reserve

7 01 2014

To the Editor:

We read with great interest the paper “Does methotrexate administration for ectopic pregnancy after in vitro fertilization (IVF) impact ovarian reserve or ovarian responsiveness?” by Boots et al. (1). In the article, the authors evaluated the effects of methotrexate (MTX) on the future fertility of women undergoing IVF by comparing markers of ovarian reserve (day 3 FSH, antral follicle count), measures of ovarian responsiveness (duration of stimulation, peak E2 level, total dose of gonadotropins, number of oocytes retrieved, fertilization rate), and time from MTX administration to subsequent IVF cycle, in the IVF cycle before and after an ectopic pregnancy (EP) treated with MTX. They concluded that MTX treatment of an EP does not compromise ovarian reserve or ovarian responsiveness in subsequent cycles. However, other studies have demonstrated that when gonadotropin stimulation dose remains unchanged, fewer oocytes may be collected after MTX is taken as management of an ectopic pregnancy, suggesting a decrease in ovarian reserve (2). Read the rest of this entry »

The Playing Field is Changing . . .

7 01 2014

To the Editor:

The clinical practice of assisted reproductive technology (ART) has continued to evolve rapidly. The Practice Committee of the American Society for Reproductive Medicine (ASRM) in collaboration with the Society for Assisted Reproductive Technology (SART) in October 2012 e-published a guideline indicating that the cryopreservation of oocytes should no longer be experimental (1). As a direct result, the current system of data collection for SART and the Center for Disease Control and Prevention (CDC) requires revision. Additional data collection is required to comply with the Fertility Clinic Success Rate and Certification Act (FCSRCA) of 1992 (Wyden Law).

Moreover, other trends in ART practice have been identified. The freezing of embryos following blastocyst biopsy is often necessary to allow adequate time to obtain results of genetic testing prior to embryo transfer (2). Some clinics also freeze eggs or embryos from multiple stimulations/retrievals prior to transfer as a strategy to manage low responder patients (3). Critiques of our current reporting system together with suggested changes have recently been published by SART members (4, 5). SART has been well aware of these practice trends and the inability of our current reporting system to handle them. Read the rest of this entry »

First-trimester Down syndrome screening following assisted conception

19 12 2013

To the Editor:

We would like to comment on the article written by Dr. Bellver and colleagues (1) regarding the need for adjustments of first-trimester Down syndrome screening parameters following assisted conception. Although we greatly appreciate their work, which confirms earlier data in the field, we would like to issue some additional remarks.

The Bellver et al. study suggests a reduced maternal serum pregnancy-associated plasma protein A (PAPP-A) and increased false positive rates (FPR) in singleton pregnancies achieved by in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI), compared with naturally conceived pregnancies. However, the latter showed to be significant when including only ICSI cycles using non-donor oocytes. The authors discuss several other groups according mode of conception (IUI with partner or donor sperm, IVF, non-donor versus donor oocytes, fresh versus frozen embryo transfer), which veils the main message of the article, namely that (at least in their cohort) only in ICSI non-donor cycles serum PAPP-A level at first-trimester Down screening is significantly different from that seen in natural pregnancies. In their manuscript the authors describe a « diminished » PAPP-A level, even in cases where these levels are not significantly different, which is confusing. Read the rest of this entry »

The postreproductive salpingectomy

13 12 2013

To the editor:

Findley et al. report (1) that simultaneous salpingectomy performed at the time of hysterectomy has no short-term negative effects on ovarian reserve. To add plausibility to this finding, we would like to point to the vascular connections: In the ovaries, blood supply is mainly secured via the arteria ovarica from the aorta and via the ramus ovaricus from the arteria uterina. These two arteries naturally anastomose with each other. A further branch of the arteria uterina, the ramus tubarius, connects the fallopian tube. During hysterectomy, the arteria uterina is ligated. Nevertheless, the central branch of the arteria ovarica in the infundibulopelvic ligament still guarantees sufficient blood flow from the aorta to the ovaries. A collateral connection of the remaining branch of the ramus tubarius from the anastomosis with the arteria ovarica also secures the vascular supply of the fallopian tube. However, when salpingectomy is performed concomitant to hysterectomy, the ramus tubarius will be removed. Accordingly, all the blood passing through the ligamentum infundibulo pelvicum will now become available to the ovaries. Blood circulation through the ovaries should thus remain unaffected or even increase when hysterectomy is combined with salpingectomy.

The few available studies support the hypothesis that removal of both uterus and fallopian tubes causes a redistribution of the blood flow in favor of the ovaries. Moreover, hormone production by the ovaries was also found to be unaffected even months after the intervention (2, 3). Read the rest of this entry »

Microdissection testicular sperm extraction in older men

10 12 2013

To the Editor:

Women experience a notable decrease in oocyte production in their late thirties; however, the effect of age on spermatogenesis is less well described. Indeed, while there are no known limits to the age at which men can father children, the effects of advanced paternal age are incompletely understood. Reproductive concerns related to advanced paternal age are less well defined (1) with a recent whole-genome sequencing study suggesting an increased risk for rare de novo mutations for older fathers (2). Whether the risk for major birth defects from de novo mutations is greater than the risk from assisted reproduction remains unknown (3).

Our retrospective study showed that sperm retrieval rates in men undergoing microdissection testicular sperm extraction (TESE) was not negatively affected by age (4). Despite the limited number of men in this study as pointed out by Kim (5), it remains the largest study to evaluate the effect of male age on sperm retrieval in nonobstructive azoospermia (NOA). The sperm retrieval rates were similar in men <30 years of age, 30 to 50 years of age, and older than 50 years of age (~50 – 60%). We identified that most men over 50 years of age who had successful sperm retrieval had hypospermatogenesis histology on previous diagnostic biopsy. It is possible that some older men with NOA may have secondary azoospermia with sperm detectable in the ejaculate at an earlier age. Therefore, it is likely that older men may be more likely to have acquired NOA (i.e., secondary infertility), whereas younger men may be more likely to have congenital NOA. Read the rest of this entry »

Response to commentary on manuscript: “The impact of fresh versus cryopreserved testicular sperm on intracytoplasmic sperm injection (ICSI) pregnancy outcomes in men with azoospermia due to spermatogenic dysfunction: a meta-analysis”

9 12 2013

To the Editor:

We appreciate the insightful comments of Dr. Kim (1). As he correctly states, the use of fresh versus cryopreserved sperm has been controversial. While the use of frozen sperm from men with obstructive azoospermia appears to yield equivalent outcomes to fresh sperm, the application to men with nonobstructive azoospermia (NOA) is less certain (2). However, if proven equivalent, Dr. Kim correctly emphasizes the significant logistical and economic burdens that could be improved for couples. Additionally, we agree with his assessment on the importance of methodology. We as male reproductive specialists do not have a standardized, evidence-based protocol for the cryopreservation of sperm. As such, we believe that there should be some caution in mentioning an established detrimental effect of cryopreservation. The analyses that produced such findings suffer the same methodological dependence that is inherent within essentially any cryopreservation data to date (3). Moreover, as data from men with obstructive azoospermia suggest equivalent outcomes, it appears that cryopreservation does not irreparably impact sperm function (2). Read the rest of this entry »

Regarding “Medical treatment of ectopic pregnancy: a committee opinion”

6 12 2013

To the Editor:

We welcome the recently published article by the Practice Committee of the American Society for Reproductive Medicine on the medical treatment of ectopic pregnancy (EP) (1). In selected patients, Methotrexate (MTX) is an effective treatment for unruptured EP and helps to avoid surgical intervention.

We are however concerned about some aspects of the committee’s opinion. The document advocates the use of single measurements of serum human chorionic gonadotropin (hCG) as a discriminatory zone to separate abnormal from normal gestations at the first presentation, if a transvaginal ultrasound scan (TVS) fails to identify the location of a pregnancy. This approach is not without risk. For example, it does not take into account the possibility of a multiple pregnancy where for a given gestational age serum hCG levels are higher than in a singleton. Consequently, hCG levels in multiple pregnancies are usually much higher before the pregnancy reaches a size that may be visualized on TVS (2). This could result in the administration of MTX to a woman with a pregnancy of unknown location (PUL) who has a developing twin pregnancy rather than an underlying EP. Such an outcome would in all likelihood lead to major congenital abnormalities in the developing fetuses. We recommend that the diagnosis of EP be based on the positive identification of an EP mass if inappropriate use of MTX is to be avoided. In the event of a PUL, waiting 48 hours to determine the hCG ratio has been shown to be a safe management approach, which offers further reassurance if the ratio is incompatible with a viable IUP (3). Read the rest of this entry »

Reply to commentary “Methotrexate treatment of ectopic pregnancies does not affect ovarian reserve in IVF patients”

26 11 2013

To the Editor:

We read with interest the editorial commentary by Dr. Moragianni (1) on our recent publication, evaluating the effect of methotrexate on ovarian reserve and subsequent assisted reproductive technology (ART) treatment outcomes (2). The potential adverse effects of methotrexate, specifically when used in infertile patients following ovarian hyperstimulation for ART, remain an important issue. As Dr. Moragianni summarizes, the majority of the literature does not demonstrate an adverse effect of methotrexate. However, these data are limited by the fact that all of the current studies are retrospective. An adequately powered randomized controlled trial would be the most appropriate way to answer this question definitively. However, the low rate of ectopic pregnancy occurring after ART has made addressing this issue in a prospective manner a challenge. Our study required a 7-year time span at a busy ART program to accrue 189 patients.

The DEMETER trial published earlier this year serves as a good study model to address this question (3). The DEMETER trial took place in 17 centers in France over a 5-year time frame, randomizing spontaneously occurring ectopic pregnancies in fertile women to methotrexate or conservative surgery. Two-hundred subjects were necessary to have a power of 80% to detect a 20% difference in subsequent cumulative fertility rates. Two years after treatment, the cumulative pregnancy rates were 67% in the methotrexate arm and 71% in the surgical arm, demonstrating no significant adverse effect of methotrexate on fertility in a spontaneously fertile population. We agree with Dr. Moragianni that a large randomized controlled trial is needed to definitively address this question in infertile patients who may be more vulnerable to treatment effects due to diminished ovarian reserve and ovarian hyperstimulation. Based on the large expected sample size, it is clear that a multicenter collaborative effort similar to the DEMETER trial would be needed to recruit a sufficient number of patients to be appropriately powered. Nevertheless, the current collective literature on methotrexate use in ART and naturally occurring ectopic pregnancies appears to be reassuring with respect to effects on ovarian reserve parameters and subsequent pregnancy.

Micah J. Hill, D.O.a
Eric D. Levens, M.D.b
Erin F. Wolff, M.D.a
aProgram in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD
bShady Grove Fertility Reproductive Science Center, Rockville, MD


1. Moragianni VA. Methotrexate treatment of ectopic pregnancies does not affect ovarian reserve in IVF patients. Fertil Steril, in press.

2. Hill MJ, Cooper JC, Levy G, Alford C, Richter KS, DeCherney AH, et al. Ovarian reserve and subsequent ART outcomes following methotrexate therapy for ectopic pregnancy and pregnancy of unknown location. Fertil Steril, in press.

3. Fernandez H, Capmas P, Lucot JP, Resch B, Panel P, Bouyer J. Fertility after ectopic pregnancy: the DEMETER randomized trial. Hum Reprod 2013;28:1247-53.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2013.11.124

Consumer-friendly reporting of in vitro fertilization outcomes

29 10 2013

To the Editor:

Dr. David Meldrum proposes a revision of the clinic-specific Society for Assisted Reproductive Technology (SART)/Centers for Disease Control and Prevention (CDC) reporting format to better reflect the current practice of in vitro fertilization (IVF) by combining the outcomes of fresh and frozen embryo transfers in the numerator while making transfer procedure the denominator of choice (1). I concur with the first but disagree with the second part of his proposal, making transfer the preferred denominator without regard to the number of retrievals contributing embryos to the transfer. In addition to accuracy, a reporting system needs to be readily accessible to potential consumers.

With accumulation of eggs from multiple retrievals for a single transfer, this metric fails to differentiate between two distinct scenarios: A) one live birth from one transfer and one retrieval; B) one birth from one transfer following, say, four retrievals (2). Both scenarios generate 100% delivery rate per transfer, but the delivery rate per retrieval is 100% for scenario A but only 25% for scenario B. Such a reporting system would be misleading and leave patients vulnerable to exploitation by volume-driven clinics.

In the case of high responders, a single retrieval may lead to more than one live birth from sequential frozen embryo transfers (FETs), thus elevating the delivery rate per retrieval above 100% unless all births after the first one are censored—a crucial point the author does not address. Read the rest of this entry »

Comment on “Progesterone elevation does not compromise pregnancy rates in high responders: a pooled analysis of in vitro fertilization patients treated with recombinant follicle-stimulating hormone/releasing hormone antagonist in six trials”

24 10 2013

To the Editor:

I read with great interest and attention the original article published recently by Griesinger et al. (1) entitled “Progesterone elevation does not compromise pregnancy rates in high responders: a pooled analysis of in vitro fertilization patients treated with recombinant follicle-stimulating hormone/releasing hormone antagonist in six trials.” In this article, Griesinger et al. conclude that a progesterone (P) elevation > 1.5 ng/mL on the day of hCG administration is associated with a lower ongoing pregnancy rate (OPR) in the general population, but not in patients with a high ovarian response, defined as an oocyte yield > 18 oocytes.

These authors performed excellent statistical work, pooling data from six multicenter randomized controlled trials relatively similar in their design, and presented the results as if all came from one single study. However, the study deserves several comments that question the unequivocal conclusion that is presented even in the title of the manuscript. Read the rest of this entry »

Haplotypes and polymorphisms of the ANXA5 nontranslated region in Japanese and European women with recurrent miscarriage and in controls

9 10 2013

To the Editor:

Yuko Hayashi and coauthors confirm single nucleotide polymorphism (SNP) rs1050606 (SNP5) of the nontranslated region of the ANXA5 gene as a risk factor for recurrent miscarriage (RM) in Japanese patients (1). They also conclude that the risk allele has no influence on pregnancy outcome from 79 abortions that occurred from November 2012 to February 2013 in a group of 264 Japanese women with RM history in Nagoya City University Hospital. Almost two-thirds of the 79 aborted fetuses, or ~ 64% had abnormal karyotypes, which leaves only n = 17 cases possibly influenced by thrombophilia through carriage of common ANXA5 SNPs/haplotypes, among other factors. Moreover, since no data about the timing of miscarriages are shared, but the majority of abortions in the patient group are apparently due to chromosomal aberrations, it is rather likely this is an early (predominantly before 10th week of gestation) RM group. It is certainly very plausible that live birth rates in such a preselected cohort would not be notably influenced by carriage of ANXA5 SNPs/haplotypes, as M2/ANXA5 for example should not be significant as a risk factor before weeks 10 to 12 of gestation (2). Read the rest of this entry »

Focus on the importance of soluble HLA-G as a marker for embryo selection in ART

8 10 2013

To the Editor:

We have read with interest the paper by Kotze et al. (1), reporting the retrospective analysis of 2,040 patients for the expression of soluble HLA-G (sHLA-G) by day-2 embryos after intracytoplasmic injection. The data represent further confirmation of the role of sHLA-G molecule quantification in embryo culture supernatants as a marker for embryo selection (2). In pregnancy several tolerance mechanisms have been demonstrated to counteract the maternal immune response. Among these, the expression of HLA-G by invasive cytotrophoblasts has been shown to play a fundamental role in creating a tolerogenic condition at the feto-maternal interface (2).

By now, more than 15,000 embryo culture supernatants have been evaluated for sHLA-G expression, with a positive correlation with embryo implantation rate and pregnancy outcome. However, further research is needed in HLA-G investigation in assisted reproductive technology (ART). Three aspects should be taken into consideration: 1) recognition of a common sHLA-G detection protocol; 2) necessity to identify a standardized range for positivity, as reported by Kotze et al. (1); 3) comprehension of the factors involved in the differential expression of sHLA-G between equal stage embryos originating from the same woman (3). Read the rest of this entry »

Uterus transplantation research at the cutting edge?

13 09 2013

To the Editor:

We appreciate Dr. Donnez’s interest in our recent manuscript and his insightful remarks on uterus transplantation (1).

Uterine factor infertility affects 3% to 5% of the population (2). Uterus transplantation aims to increase the quality of life in uterine factor infertility patients facing psychological and social problems related to the loss of female identity. Gestational surrogacy offers the only current option for being a genetic parent, with limited availability and potential ethical and psychological problems (3).

Research experience in animals is essential prior to the introduction and attainment of the clinical application of a new surgical innovation. This is especially important when the indication is not life-threatening. Dr. Brannstrom’s group remains the leading team in uterus transplantation research (4). His group has described the basic techniques for uterus transplantation and reported the first pregnancy following uterus transplantation in an experimental animal model.

Due to limitations in postoperative care, assisted reproductive technology (ART), poor control of serum immunosuppressive levels, and financial issues, animal models have not been able to give sufficient information regarding its feasibility and role in acquirement of fertility potential. Read the rest of this entry »

Preimplantation genetic screening is alive and very well: Really?

12 09 2013

To the Editor:

The September issue featured Views and Reviews on preimplantation genetic screening (PGS), including an editorial by Meldrum (1), declaring PGS “alive and very well,” four reviews of technical aspects of the procedure, and three articles by the Scott group. Unfortunately, lacking was a critical and balanced presentation of the subject.

The concept of PGS is not new. It was proven useless in a prior incarnation, though unfortunately only after thousands of women reduced pregnancy chances by utilizing the procedure (2). Now history appears to repeat itself, with many investigators promoting an improved version involving day 5/6-blastocyst trophectoderm biopsy in place of day-3 embryo biopsy and 24-chromosome copy number analysis by various available technologies in place of fluorescence in-situ hybridization (FISH).

All above noted articles uncritically accept that the earlier PGS failure was due to technical shortcomings of day-3 biopsies and chromosomal analyses by FISH. They assume that these shortcomings are remedied by the utilization of trophectoderm biopsy and new 24-chromosome copy analyses, and that PGS now fulfills its presumed destiny of improving in vitro fertilization (IVF) outcomes.

But what if PGS did not fail because of technical shortcomings? What if it failed because PGS should not be applied indiscriminately to every patient or because embryo selection by PGS statistically simply does not work in older women or with low ovarian reserve? Wouldn’t we then only repeat the same mistakes all over? Read the rest of this entry »

Comment on: “Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question.”

24 10 2011

To the Editor:

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. Read the rest of this entry »

It’s time to pay attention to the endometrium, including the nucleolar channel system

29 09 2011

To the Editor:

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. Read the rest of this entry »


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