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Comparisons of Tertiary Versus Satellite In Vitro Fertilization Programs
Although this policy is clearly appreciated, it should never be forgotten that the actual role of these condensed formats is not to substitute for the full paper. When this occurs, serious misunderstandings may arise. The letter signed by de Ziegler et al., just appears to be a result of such a superficial reading. The authors make a sharp criticism of a marginal finding and apparently do not realize that each experimental design is based on a working hypothesis. In the reported study, 1 the experiments were constructed so as to evaluate the effect of follicular fluid (FF) on the character of sperm motion, not motility, in anticipation of changes similar to those produced by the human cumulus oophorus. The finding that FF improves sperm motility after 24 hours of incubation represented a by-product of this research, but it was considered worthy of publication because many laboratories use the same protocol for sperm preparation.2 The criticism of de Ziegler et al. is based on the presumed lack of appropriate control, but do they really think that the inclusion of patients' sera, a highly variable biological material, would make a good control for a scientific experiment? Finally, we are not convinced that the findings quoted by the authors of the letter as Reference 2 can be opposed to ours. In our study the measure was objective and only spermatozoa moving quicker than a threshold level were considered motile. In the other study the evaluation was subjective and this may have led to inclusion of slowly swimming spermatozoa to the category of motile cells. Polemics between partisans of different scientific concepts can make a never-ending story and are rarely interesting to a wide audience. On the other hand, the question of how to make the best use of the current systems of scientific information is actual to all. It is tempting to read no more than capsules, abstracts, or reader's digests. All of them have their role in the dissemination of knowledge. But the full paper still remains the basic element of science. To realize this fundamental role, more control and self control will obviously be needed by each of us.
Carmen Mendoza, Ph.D. Department of Biochemistry and Molecular Biology University of Granada Faculty of Sciences Campus Universitario Fuentenueva Granada, Spain Vol. 56, No.3, September 1991
Jan Tesarik, M.D., D.Sc. Institute of Health and Medical Research (INSERM) Unit 187, Clamart, France REFERENCES 1. Tesarik J, Mendoza Oltras C, TestartJ: Effect of the human
cumulus oophorus on movement characteristics of human capacitated spermatozoa. J Reprod Fertil 88:665, 1990 2. Mendoza C, Tesarik J: Effect of follicular fluid on sperm movement characteristics. Fertil Steril 54:1135, 1990
Comparisons of Tertiary Versus Satellite In Vitro Fertilization Programs
To the Editor: The paper by Talbert et al. 1 evaluating a satellite system for assisted reproductive technologies raises interesting points concerning patient care. The evaluation and reporting of additional data would have made this manuscript stronger. The following issues and questions should have been addressed: 1. Was every patient who started a stimulating cycle between September, 1984, and January, 1990, included in the authors' figures? A statement of criteria for patient selection would have been helpful in evaluation of the data. 2. Is there an explanation for the fact that more than one in five stimulation cycles did not continue to retrieval? 3. Is there an explanation why in vitro fertilization cycles were cancelled five to nine times more frequently than gamete intrafallopian transfer cycles? 4. The figures quoted in the paper were "clinical pregnancies." Data on deliveries, live births, and take-home babies would be helpful. If an established program organizes a satellite system, it is important to compare the data obtained from the various sites. Reporting of the additional data would assist in maintaining quality and quality control at all locations. In fairness to all programs, data should be reported and published according to the standards promulgated by our professional organizations. 2
George L. Gaunt, M.D., Ph.D. Reproductive Diagnostics Charlotte, North Carolina April30, 1991 Letters-to-the-editor
589
REFERENCES 1. Talbert LM, Hammond M, Bailey L, Wing R: A satellite
system for assisted reproductive technologies: an evaluation. Fertil Steril 55:555, 1991 2. The American Fertility Society: Revised minimum standards for in vitro fertilization, gamete intrafallopian transfer, and related procedures. Fertil Steril 53:225, 1990
Editorial Comment
The authors of the article addressed by Dr. Gaunt have elected not to respond to these comments. Paul G. McDonough, M.D., Editor, Letters Endometriosis: Will the Real Natural History Please Stand Up?
accurate discrimination of surface area of involvement. The cross-sectional findings that neither the number of pelvic areas 3 nor the surface area of peritoneal involvement1 increases with examination of older patients and the longitudinal finding that most untreated patients do not exhibit progression of disease 4 suggests that we actually may already know what the natural history of endometriosis is. Although there is no question that it can be a locally invasive disease in some women, the available evidence suggests that endometriosis is rather static with respect to geographic spread over time. Is it possible that we have been wrong all these years in thinking of spread of the disease like dandelions in the pelvis? Given the confusion surrounding the disease, what other conclusion is possible?
To the Editor: I read with great interest the excellent paper by Koninckx et aU Their depth of scholarship, clinical skill, and hard work were quite apparent. I have a question and a few comments. Previous pelvic mapping studies2 •3 have demonstrated that the ovaries are not the most common site of pelvic involvement by endometriosis, although many clinicians still believe this to be the case. I found no mention in their paper of specific sites of involvement, and I would be interested if they might comment on the frequency of involvement of various pelvic sites in their patients, specifically with reference to the ovaries versus peritoneal sites. I found that the number of pelvic areas involved by endometriosis does not increase as older age groups of patients are examined, although the incidence of ovarian endometriosis increases with advancing age, 2 both findings being very similar to that of the authors'. My interpretation of this is that endometriosis does not spread geographically in the pelvis like dandelions and that it is more difficult to identify early ovarian involvement than early peritoneal involvement by disease. It might be incorrect to state that Thomas and Cooke4 found that endometriosis increased slightly in most women because they found most (53%) untreated patients did not exhibit progression of disease during observation, although their level of awareness of atypical forms of endometriosis is unknown and they used the original American Fertility Society classification system,5 which was heavily weighted toward adhesions and which does not allow
590
Letters-to-the-editor
David B. Redwine, M.D. Endometriosis Institute of Oregon Bend, Oregon June 6, 1991
REFERENCES 1. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie
2. 3. 4. 5.
FJ: Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759, 1991 Fallon J: Endometriosis. Evidence of tubal origin in the distribution of lesions. Arch Surg 62:412, 1951 Redwine DB: The distribution of endometriosis in the pelvis by age groups and fertility. Fertil Steril 47:173, 1987 Thomas EJ, Cooke ID: Impact of gestrinone on the course of asymptomatic endometriosis. Br Med J 294:272, 1987 American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, 1979
Reply of the Authors: In 716 women with endometriosis (1987 to 1991), the fossa ovaricae (F) were involved in 235 (32.8%) women, the utero sacrals and pouch of Douglas (U) in 494 (69%), the vesico uterine fold (V) in 175 (24.4%), and the ovaries (0) in 319 (44.6%). Combined localizations were as follows: F + U 21.8%, U + V 18.4%, V + 0 11.6%, F + V 10.3%, F + 0 14%, and U + 0 29.6%. Subtle, typical, deep (~6 mm), and cystic endometriosis were found (respectively) in the F in 44.1 %, 71.5%, 0%, and 0%; in the U in 38.4%, 74.0%, 19.9%, and 3%; in the V in 34.9%, 82.8%, 1.7%, and 0%; and in the 0 in 39.9%, 12.3%, 0%, and 66.9%.
Fertility and Sterility
Carmen Mendoza, Ph.D. Department of Biochemistry and Molecular Biology University of Granada Faculty of Sciences Campus Universitario Fuentenueva Granada, Spain Vol. 56, No.3, September 1991
Jan Tesarik, M.D., D.Sc. Institute of Health and Medical Research (INSERM) Unit 187, Clamart, France REFERENCES 1. Tesarik J, Mendoza Oltras C, TestartJ: Effect of the human
cumulus oophorus on movement characteristics of human capacitated spermatozoa. J Reprod Fertil 88:665, 1990 2. Mendoza C, Tesarik J: Effect of follicular fluid on sperm movement characteristics. Fertil Steril 54:1135, 1990
Comparisons of Tertiary Versus Satellite In Vitro Fertilization Programs
To the Editor: The paper by Talbert et al. 1 evaluating a satellite system for assisted reproductive technologies raises interesting points concerning patient care. The evaluation and reporting of additional data would have made this manuscript stronger. The following issues and questions should have been addressed: 1. Was every patient who started a stimulating cycle between September, 1984, and January, 1990, included in the authors' figures? A statement of criteria for patient selection would have been helpful in evaluation of the data. 2. Is there an explanation for the fact that more than one in five stimulation cycles did not continue to retrieval? 3. Is there an explanation why in vitro fertilization cycles were cancelled five to nine times more frequently than gamete intrafallopian transfer cycles? 4. The figures quoted in the paper were "clinical pregnancies." Data on deliveries, live births, and take-home babies would be helpful. If an established program organizes a satellite system, it is important to compare the data obtained from the various sites. Reporting of the additional data would assist in maintaining quality and quality control at all locations. In fairness to all programs, data should be reported and published according to the standards promulgated by our professional organizations. 2
George L. Gaunt, M.D., Ph.D. Reproductive Diagnostics Charlotte, North Carolina April30, 1991 Letters-to-the-editor
589
REFERENCES 1. Talbert LM, Hammond M, Bailey L, Wing R: A satellite
system for assisted reproductive technologies: an evaluation. Fertil Steril 55:555, 1991 2. The American Fertility Society: Revised minimum standards for in vitro fertilization, gamete intrafallopian transfer, and related procedures. Fertil Steril 53:225, 1990
Editorial Comment
The authors of the article addressed by Dr. Gaunt have elected not to respond to these comments. Paul G. McDonough, M.D., Editor, Letters Endometriosis: Will the Real Natural History Please Stand Up?
accurate discrimination of surface area of involvement. The cross-sectional findings that neither the number of pelvic areas 3 nor the surface area of peritoneal involvement1 increases with examination of older patients and the longitudinal finding that most untreated patients do not exhibit progression of disease 4 suggests that we actually may already know what the natural history of endometriosis is. Although there is no question that it can be a locally invasive disease in some women, the available evidence suggests that endometriosis is rather static with respect to geographic spread over time. Is it possible that we have been wrong all these years in thinking of spread of the disease like dandelions in the pelvis? Given the confusion surrounding the disease, what other conclusion is possible?
To the Editor: I read with great interest the excellent paper by Koninckx et aU Their depth of scholarship, clinical skill, and hard work were quite apparent. I have a question and a few comments. Previous pelvic mapping studies2 •3 have demonstrated that the ovaries are not the most common site of pelvic involvement by endometriosis, although many clinicians still believe this to be the case. I found no mention in their paper of specific sites of involvement, and I would be interested if they might comment on the frequency of involvement of various pelvic sites in their patients, specifically with reference to the ovaries versus peritoneal sites. I found that the number of pelvic areas involved by endometriosis does not increase as older age groups of patients are examined, although the incidence of ovarian endometriosis increases with advancing age, 2 both findings being very similar to that of the authors'. My interpretation of this is that endometriosis does not spread geographically in the pelvis like dandelions and that it is more difficult to identify early ovarian involvement than early peritoneal involvement by disease. It might be incorrect to state that Thomas and Cooke4 found that endometriosis increased slightly in most women because they found most (53%) untreated patients did not exhibit progression of disease during observation, although their level of awareness of atypical forms of endometriosis is unknown and they used the original American Fertility Society classification system,5 which was heavily weighted toward adhesions and which does not allow
590
Letters-to-the-editor
David B. Redwine, M.D. Endometriosis Institute of Oregon Bend, Oregon June 6, 1991
REFERENCES 1. Koninckx PR, Meuleman C, Demeyere S, Lesaffre E, Cornillie
2. 3. 4. 5.
FJ: Suggestive evidence that pelvic endometriosis is a progressive disease, whereas deeply infiltrating endometriosis is associated with pelvic pain. Fertil Steril 55:759, 1991 Fallon J: Endometriosis. Evidence of tubal origin in the distribution of lesions. Arch Surg 62:412, 1951 Redwine DB: The distribution of endometriosis in the pelvis by age groups and fertility. Fertil Steril 47:173, 1987 Thomas EJ, Cooke ID: Impact of gestrinone on the course of asymptomatic endometriosis. Br Med J 294:272, 1987 American Fertility Society: Classification of endometriosis. Fertil Steril 32:633, 1979
Reply of the Authors: In 716 women with endometriosis (1987 to 1991), the fossa ovaricae (F) were involved in 235 (32.8%) women, the utero sacrals and pouch of Douglas (U) in 494 (69%), the vesico uterine fold (V) in 175 (24.4%), and the ovaries (0) in 319 (44.6%). Combined localizations were as follows: F + U 21.8%, U + V 18.4%, V + 0 11.6%, F + V 10.3%, F + 0 14%, and U + 0 29.6%. Subtle, typical, deep (~6 mm), and cystic endometriosis were found (respectively) in the F in 44.1 %, 71.5%, 0%, and 0%; in the U in 38.4%, 74.0%, 19.9%, and 3%; in the V in 34.9%, 82.8%, 1.7%, and 0%; and in the 0 in 39.9%, 12.3%, 0%, and 66.9%.
Fertility and Sterility