IVF outcome and intramural fibroids not compressing the uterine cavity.

We read with interest the paper by Check and colleagues (Check et al., 2002). In their study, the authors focus on the highly interesting question of the possible influence of intramural myoma on the outcome of IVF. We think it is appropriate to discuss two points critically, which should be considered in the nomenclature and diagnosis of intramural myoma in future multicentre studies. Myoma compressing the uterine cavity with an intramural portion 50% are termed submucous myoma type II (Wamsteker and de Blok, 1993; Wamsteker et al., 1993). Intramural myoma per se do not compress the uterine cavity. Thus, the nomenclature ‘small intramural fibroids not compressing the uterine cavity’ is not correct. Therefore, making the distinction between intramural myoma and submucous myoma type II is decisive in the diagnosis in view of the inclusion criteria of the study. The authors determined the type of myoma by hysterosalpingography and transvaginal sonography. In the light of numerous studies, these methods alone do not seem efficient enough for the above-mentioned differential diagnosis. Hysterosonography offers a discerning diagnostic supplement to transvaginal sonography resulting in increased sensitivity (Schwarzler et al., 1998; Becker et al., 2002). Hysteroscopy, and—using the remaining intracavitary fluid—a subsequent hysterosonography, present another option for an exact diagnosis of possible myoma compressions of the uterine cavity (Cheng and Lin, 2002). With the aid of minioptics, a diagnostic hysteroscopy can be performed without anaesthesia. In contrast to indirect sonographical and radiological methods, hysteroscopy offers a direct visualization of the uterine cavity. The subsequent hysterosonography achieves results comparable with those of a hysterosalpingography while avoiding radiation (Lindheim and Sauer, 1998). To answer the question posed by the authors’ demands an exact exclusion of intracavity myoma. To achieve this, it is, in our opinion, necessary to perform a hysteroscopy and/or a transvaginal hysterosonography.