Reply: Predictive value of myomectomy

Reply: Predictive value of myomectomy Reply of the Authors: We appreciate Dr. Pritts and Parker’s interest in our manuscript. However, we would like to take issue with several of the points made in their recent letter. The intent of our manuscript was to evaluate in a retrospective case control manner the impact of two different surgical approaches to resection of uterine fibroids on IVF and oocyte donation cycle outcome (1). One group of patients underwent operative hysteroscopy of purely submucosal lesions. The other group underwent laparotomy for lesions, which were noted to impinge upon or distort the endometrial cavity. The determination of which fibroids were most likely to exert a deleterious effect on cycle outcome was based on previously published data. The deleterious effect of submucosal lesions has been well described (2, 3). Although the authors suggest that there is no evidence that intramural fibroids have an impact on IVF outcome, there are indeed several rather large studies that do suggest that intramural lesions have a significant adverse effect (2, 3). In a previous publication, we noted that intramural lesions that did not distort the endometrial cavity resulted in a decrease in implantation rates in patients undergoing IVF (4). In that study, we did not evaluate the spatial relationship between the intramural fibroid and the endometrial cavity but merely noted an absence of distortion at hysteroscopy. These data served as the basis for our inclusion of appropriately selected intramural lesions in the current investigation. Nevertheless, in the Discussion section of the current manuscript, we made every effort to also review those manuscripts that reached conflicting conclusions. Indeed, one of the problems with these studies and other similar trials is the lack of differentiation of the relationship between the intramural lesion and the endometrial cavity. Thus, these trials evaluate a heterogeneous group of lesions. We therefore made a decision with the current investigation to eliminate from consideration those lesions that would be least likely to have an impact. By arbitrarily limiting our study to resection of those intramural lesions that were adjacent (⬍2 mm of normal myometrium) or impinging upon the endometrial cavity and most likely to have a clinical impact, we attempted to take a more conservative approach than that applied by prior investigators. We would agree that it is possible that lesions that distort the endometrial cavity may have a different mechanism of action than those that impinge upon the endometrial cavity, but we are unaware of any data that clearly support this contention. We would concur that ultrasound is not the most accurate way of measuring uterine fibroids. However, the use of alternative approaches is not practical at this stage. As suggested by Pritts and Parker, evaluation of a myomectomy specimen is not helpful to make a determination of whether to proceed with surgery. The accuracy of measurements at surgery may also be somewhat deceptive and potentially

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require unnecessary disruption of the endometrial cavity. The routine use of magnetic resonance imaging (MRI), which may be more accurate, is not a current standard of care. We are unaware of published trials that evaluate the impact of leiomyomata on assisted reproductive technologies (ART) outcome based on prior MRI evaluation. In the current trial, a uniform diagnostic approach of a standardized ultrasound examination and office hysteroscopy was consistently performed on all patients. Other investigators have not typically performed both techniques on all subjects. Pritts and Parker state that there are no previously published studies that prove that myomectomy would improve ART outcome. We would concur and suggest that this is the reason that the current investigation was performed! We are aware of only one other manuscript that evaluated the effect of myomectomy on the outcome of ART (5). This retrospective series also reported no deleterious effect but evaluated women who primarily had subserosal lesions that have generally been shown not to have an impact on the outcome of ART. Therefore, we would suggest that the current manuscript is the first that has specifically addressed the issue of the impact of resection of clinically significant uterine fibroids on the outcome of ART. We would agree, and indeed stated clearly in our manuscript, that the only way to provide definitive answers would be to undertake an appropriately designed prospective randomized trial of patients with uterine leiomyomata of similar size and location that were either resected or observed before IVF. We hope that our initial report will spur this type of investigation. Eric S. Surrey, M.D. Debra A. Minjarez, M.D. John M. Stevens, B.S. William B. Schoolcraft, M.D. Colorado Center for Reproductive Medicine Englewood, Colorado December 15, 2005

REFERENCES 1. Surrey ES, Minjarez DA, Stevens JM, Schoolcraft WB. Effect of myomectomy on the outcome of assisted reproductive technologies. Fertil Steril 2005;83:1473–9. 2. Eldar-Geva T, Meagher S, Healy D, MacLachlan V, Breheny S, Wood C. Effect of intramural, subserosal, and submucosal uterine fibroids on the outcome of assisted reproductive technology treatment. Fertil Steril 1998;70:687–91. 3. Hart R, Khalaf Y, Yeong C-T, Seed P, Taylor A, Braude T. A prospective controlled study of the effect of intramural fibroids on the outcome of assisted conception. Hum Reprod 2001;16:2411–7. 4. Surrey E, Lietz A, Schoolcraft W. Impact of intramural leiomyomata in patients with a normal endometrial cavity on in vitro fertilization– embryo transfer cycle outcome. Fertil Steril 2001;75:405–10. 5. Seoud M, Patterson R, Muasher S, Coddington C. Effect of myomas or prior myomectomy on in vitro fertilization (IVF) performance. J Assist Reprod Genet 1992;9:655– 8.

doi:10.1016/j.fertnstert.2006.01.004

Fertility and Sterility姞 Vol. 85, No. 4, April 2006 Copyright ©2006 American Society for Reproductive Medicine, Published by Elsevier Inc.

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