Title: Risk Factors of Uterine Perforation when Using Contraceptive Intrauterine Devices
Version: 0 Date: 29 Jan 2024
Reviewer:  Mojtaba Akbari
Reviewer's report:
Dear Authors,
I have had the opportunity to review your manuscript. I commend you on the thoroughness of
your research and the clarity of your writing. Your work addresses an important topic, and it
is evident that you have put considerable effort into this project. I have some feedback that I
believe will enhance the overall quality of your manuscript. Please find my comments below,
which I hope you will find helpful in refining your work.
1. The introduction mentions the complications associated with IUD use but does not explicitly
highlight the current gaps or limitations in existing research regarding uterine perforation,
malposition, and expulsion. Consider adding a sentence that emphasizes the need for further
understanding or investigation in these areas.
2. The study design is well-described, but it would be helpful to explicitly mention the type of
retrospective study (e.g., case-control, cohort, retrospective cohort and so on) to provide more
clarity.
3. Provide more details on the criteria used for selecting patients in both groups. For instance,
how were patients with retained IUDs identified and included in the study?
4. Considering that the information was retrospectively extracted and reviewed, how was written
informed consent obtained from the study subjects?
5. Attention is needed for a comprehensive review of the results by an analytical statistician
or epidemiologist. The findings should undergo thorough revision, with a specific emphasis on
significant revisions to the tables.
6. Provide more details on the statistical methods used, including the significance level (alpha)
and, power analysis.
7. The data reporting method as well as the method of checking the normality of quantitative
variables should be included in the statistical analysis.
8. The number of participants in each group should be mentioned in the column header.
9. The mean age difference between the case and control groups is statistically significant (p-
value=0.01). It's crucial to discuss the potential implications of this age difference on the study
outcomes and whether it might introduce bias.
10. Clarify the statement about breastfeeding being a risk factor for uterine perforation. If
breastfeeding is a known risk factor, provide supporting evidence or references. Additionally,
discuss the potential biological mechanisms behind this association.
11. Consider providing confidence intervals for key findings.
12. All tables need to have a clear and concise legend caption to accompany them, including
how to report the data, abbreviations, and statistical tests.
13. Compare your findings with existing literature more explicitly. Discuss similarities and
differences with previous studies, providing context for readers to understand the novelty of
your results.
14. Strengthen the discussion on study limitations. Consider potential sources of bias.
15. Explicitly state the generalizability of your findings due to the limited sample size and
emphasize the need for future studies with larger and more diverse populations.
16. Provide concise recommendations based on the study's findings. What steps can be taken to
reduce the risk of uterine perforation during IUD insertion?