- Email: [email protected]
Hysterosalpingography
fective first endometrial biopsy, and must be performed by a nonparametric test for related samples,3 as we used in our study. Accordingly, we do not feel that the analysis of percentages, as proposed by Dr. Strickland, allows any conclusion on our data. Finally, we emphasize that endometrial biopsy performed by the biopsy suction-curette according to Semm (Wisap, Munich, Germany), which we use is a simple and painless procedure, and it costs less than P radioimmunoassay.
Juan Balasch, M.D. Associate Professor Department of Obstetrics and Gynecology Faculty of Medicine Hospital Clinico y Provincial Barcelona, Spain February 10, 1986 REFERENCES 1. Balasch J, Vanrell JA, Creus M, Marquez M, GonzalezMerlo J: The endometrial biopsy for diagnosis of luteal phase deficiency. Fertil Steril 44:699, 1985 2. Balasch J, Vanrell JA, Marquez M, Rivera F, GonzalezMerlo J: Luteal phase in infertility: problems of evaluation. Int J Fertil 27:60, 1982 3. Siegel S: Nonparametric Statistics for the Behavioral Sciences. New York, McGraw-Hill Book Co., 1946
Hysterosalpingography
putting OSCM into tubes that are occluded; therefore, flushing this material out the distal end of the tubes is not a realistic expectation. These patients are those that specifically should not have OSCM remaining in the tubes for long periods of time, since granuloma formation would make reparative surgery all the more difficult. In our publication 2 we suggest first a watersoluble contrast medium hysterosalpingogram to make sure that the tubes are patent. Once this is completed, and there is documentation that the tubes are essentially normal on'fluoroscopy, then the OSCM can be utilized as a therapeutic modality by flushing 3 to 5 ml of this medium through the tubes. This gives the procedure a certain degree of safety and is better than a "cart before the horse" approach.
Alan H. DeCherney, M.D . John Slade Ely Professor of Obstetrics and Gynecology Yale University School of Medicine New Haven, Connecticut 06510-8063 December 9, 1985 REFERENCES 1. Beyth Y, Navot D, Lax E: A simple improvement in the
technique of hysterosalpingography achieving optimal imaging and avoiding possible complications. Fertil Steril 44:543, 1985 2. DeCherney AH, Kort H , Barney JB, DeVore GR: Increased pregnancy rate with oil-soluble hysterosalpingography dye. Fertil Steril 33:4407, 1980
To the Editor: It is good to see, as demonstrated by the recent article by Beyth et al., entitled, "A simple improvement in the technique of hysterosalpingography achieving optimal imaging and avoiding possible complications," 1 that there is still active interest and controversy surrounding hysterosalpingograms. It is reassuring to see that even the. oldest of techniques remains controversial in this age of rapid advancement and high technology. Beyth et al. described a technique to reduce the granuloma formation following an oil-soluble contrast medium (OSCM) hysterosalpingogram, in that they suggest flushing the uterine cavity with 5 to 10 ml of Hartmann's solution "until no intraluminal contrast media could be visualized either in the uterus or in the tubes." Although this is a good suggestion, it has an inherent flaw, in that one might still wind up 582
Letters-to-the-editor
Reply of the Author: The comments of Dr. DeCherney regarding our paper "A simple improvement in the technique of hysterosalpingography achieving optimal imaging and avoiding possible complications" 1 are to the point. However, I would like to add the following remarks: 1. In our practice we do not use the concentrated OSCM (Lipiodol), but the milder one, Ethiodol. 2. The main risk of OSCM is the formation of granulomas in intact, patent tubes. This phenomenon has been documented, thus placing emphasis on the importance of flushing the tubes with Hartmann's solution. 3. Indeed, occluded tubes cannot be flushed, meaning that the OSCM very often remains in Fertility and Sterility
their lumens. However, as mentioned in our paper, this medium provides a much clearer and sharper image of the tubal mucosa, and this fact may be crucial in the process of decision-making as to the preferred mode of treatment: microsurgery versus in vitro fertilization. Moreover, in instances where the tubes are occluded and surgery is indicated, it should be performed as soon as possible after the hysterosalpingogram, thereby, in all probability, avoiding granuloma formation. 4. Dr. DeCherney's suggestion of using OSCM once the water-soluble contrast medium has dem-
Vol. 45, No. 4, April 1986
onstrated patent tubes does not necessarily prevent granuloma formation.
Yoram Beyth, M.D . Associate Professor of Gynecology Hebrew University Hadassah Medical Center, Jerusalem, Israel February 6, 1985 REFERENCE 1. Beyth Y, Navot D, Lax E: A simple improvement in the technique of hysterosalpingography achieving optimal imaging and avoiding possible complications. Fertil Steril 44:543, 1985
Letters-to-the-editor
583
Juan Balasch, M.D. Associate Professor Department of Obstetrics and Gynecology Faculty of Medicine Hospital Clinico y Provincial Barcelona, Spain February 10, 1986 REFERENCES 1. Balasch J, Vanrell JA, Creus M, Marquez M, GonzalezMerlo J: The endometrial biopsy for diagnosis of luteal phase deficiency. Fertil Steril 44:699, 1985 2. Balasch J, Vanrell JA, Marquez M, Rivera F, GonzalezMerlo J: Luteal phase in infertility: problems of evaluation. Int J Fertil 27:60, 1982 3. Siegel S: Nonparametric Statistics for the Behavioral Sciences. New York, McGraw-Hill Book Co., 1946
Hysterosalpingography
putting OSCM into tubes that are occluded; therefore, flushing this material out the distal end of the tubes is not a realistic expectation. These patients are those that specifically should not have OSCM remaining in the tubes for long periods of time, since granuloma formation would make reparative surgery all the more difficult. In our publication 2 we suggest first a watersoluble contrast medium hysterosalpingogram to make sure that the tubes are patent. Once this is completed, and there is documentation that the tubes are essentially normal on'fluoroscopy, then the OSCM can be utilized as a therapeutic modality by flushing 3 to 5 ml of this medium through the tubes. This gives the procedure a certain degree of safety and is better than a "cart before the horse" approach.
Alan H. DeCherney, M.D . John Slade Ely Professor of Obstetrics and Gynecology Yale University School of Medicine New Haven, Connecticut 06510-8063 December 9, 1985 REFERENCES 1. Beyth Y, Navot D, Lax E: A simple improvement in the
technique of hysterosalpingography achieving optimal imaging and avoiding possible complications. Fertil Steril 44:543, 1985 2. DeCherney AH, Kort H , Barney JB, DeVore GR: Increased pregnancy rate with oil-soluble hysterosalpingography dye. Fertil Steril 33:4407, 1980
To the Editor: It is good to see, as demonstrated by the recent article by Beyth et al., entitled, "A simple improvement in the technique of hysterosalpingography achieving optimal imaging and avoiding possible complications," 1 that there is still active interest and controversy surrounding hysterosalpingograms. It is reassuring to see that even the. oldest of techniques remains controversial in this age of rapid advancement and high technology. Beyth et al. described a technique to reduce the granuloma formation following an oil-soluble contrast medium (OSCM) hysterosalpingogram, in that they suggest flushing the uterine cavity with 5 to 10 ml of Hartmann's solution "until no intraluminal contrast media could be visualized either in the uterus or in the tubes." Although this is a good suggestion, it has an inherent flaw, in that one might still wind up 582
Letters-to-the-editor
Reply of the Author: The comments of Dr. DeCherney regarding our paper "A simple improvement in the technique of hysterosalpingography achieving optimal imaging and avoiding possible complications" 1 are to the point. However, I would like to add the following remarks: 1. In our practice we do not use the concentrated OSCM (Lipiodol), but the milder one, Ethiodol. 2. The main risk of OSCM is the formation of granulomas in intact, patent tubes. This phenomenon has been documented, thus placing emphasis on the importance of flushing the tubes with Hartmann's solution. 3. Indeed, occluded tubes cannot be flushed, meaning that the OSCM very often remains in Fertility and Sterility
their lumens. However, as mentioned in our paper, this medium provides a much clearer and sharper image of the tubal mucosa, and this fact may be crucial in the process of decision-making as to the preferred mode of treatment: microsurgery versus in vitro fertilization. Moreover, in instances where the tubes are occluded and surgery is indicated, it should be performed as soon as possible after the hysterosalpingogram, thereby, in all probability, avoiding granuloma formation. 4. Dr. DeCherney's suggestion of using OSCM once the water-soluble contrast medium has dem-
Vol. 45, No. 4, April 1986
onstrated patent tubes does not necessarily prevent granuloma formation.
Yoram Beyth, M.D . Associate Professor of Gynecology Hebrew University Hadassah Medical Center, Jerusalem, Israel February 6, 1985 REFERENCE 1. Beyth Y, Navot D, Lax E: A simple improvement in the technique of hysterosalpingography achieving optimal imaging and avoiding possible complications. Fertil Steril 44:543, 1985
Letters-to-the-editor
583