Assessing Patients in Our Publication on Endometrial Thickness

in women with Asherman’s syndrome. We agree that the finding of very thin endometrium in women with upper cervical occlusion is intriguing, but it does appear to be a genuine phenomenon since the same observation has been made by others. Our contribution was to measure endometrial thickness using ultrasound, not assess the ultrasound-determined extent of adhesions, in a carefully assessed group of Asherman’s syndrome patients for the first time. We agree that the ultrasound methodology for assessment of the extent of intrauterine adhesions may not have been ideal by modern standards, but our transvaginal ultrasound data have been collected over nearly two decades, albeit using the same 2D technique. Like Drs Knopman and Copperman, we now use 3D ultrasound for this assessment. Nevertheless, sonographic imaging was not our sole criterion for the classification of patients into different groupings, including the group in which we were mainly interested, the women who solely had uterine outlet occlusion at the level of the internal os (without any intra-cavitary adhesions). These gradings were determined by careful diagnostic hysteroscopy in all cases (as noted in our publication). Hence, we can refute the statement by Drs Knopman and Copperman that ‘one must wonder if the authors under-diagnosed the extent of disease as a result of their limited screening modality (2D TVUS), thereby affecting the validity of their results’.