Reply of the authors

Abstract

To begin with, we would like to thank Dr. Parker and collegues for the important considerations concerning our study, focused on such a controversial subject. Our main goal was to assess whether uterine leiomyomas (subserosal or intramural, without distortion of the endometrial cavity) <7 cm (mean diameter) had any impact on IVF-intracytoplasmic sperm injection (ICSI) outcomes. To answer this question, we compared the IVF-ICSI outcomes of patients with such uterine fibroids to patients without any fibroids. Both groups were submitted to a transvaginal ultrasound scan before starting the treatment. The patients were retrospectively matched by age and number of retrieved oocytes to control for other variables (1Oliveira F.G. Abdelmassih V. Diamond M.P. Dozortsev D. Melo N. Abdelmassih R. Impact of subserosal and intramural uterine fibroids that do not distort endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection.Fertil Steril. 2004; 81: 582-587Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar). On the basis of our results, we suggested that patients with leiomyomas <4cm (mean diameter) probably would not benefit from myomectomy before ICSI because they had outcomes similar to those of patients without such fibroids. The appropriate counseling and the correct management of patients with fibroids with a mean diameter of 4–7 cm was not clear because they had lower pregnancy rates, lower implantation rates, and, obviously, lower live birth rates than patients with fibroids <4 cm and their respective controls (data not shown). When this group of patients was compared with the respective control group, the small number of patients did not allow us to make conclusions with statistical significance, even though the observed differences were big enough to concern us. On the other hand, we observed statistically significantly lower pregnancy rates, and obviously a lower live birth rate (data not shown) as the mean diameter of the fibroids increased in the whole group of patients with leiomyomas. All in all, we need to differentiate the concepts of statistical significance and practical importance. According to Erb (2Erb H.N. A statistical approach for calculating the minimum number of animals needed in research.ILAR News J. 1990; 32: 11-16Crossref Google Scholar), “Statistical significance refers to the probability that random chance alone is responsible for the observed difference between treatment groups. In contrast, practical importance refers to the usefulness of the observed difference (i.e. is the difference big enough to matter?)” Thus, we believe that our findings were “big enough to matter,” even though in part they did not reach statistical significance. Regarding the benefits of myomectomy for that particulargroup of patients, we never defended the surgical treatment for such patients. However, if it is true that bigger fibroids correlate with poorer outcomes, it seems reasonable to consider it as part of the treatment in some cases. We urge, as other investigators do, a multicenter, collaborative, prospective, randomized controlled study, with enough patients and controls to learn the best counseling and management options. Uterine fibroids—impact on IVF and outcome of IVF pregnanciesFertility and SterilityVol. 82Issue 3PreviewThe conclusions of Oliveira et al. (1) in the article regarding the influence of large intramural fibroids on fertility misrepresent the data presented. We applaud the authors for undertaking a much-needed investigation of this subject and for writing an excellent report. However, they state that the outcome with large fibroids was worse than with smaller fibroids and suggest that it might be reasonable to remove such fibroids before IVF/intracytoplasmic sperm injection. Full-Text PDF