Title: Fertility-enhancing hysteroscopic surgery: multi-center retrospective cohort study of
reproductive outcome.
Version: 3 Date: 27 Mar 2023
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research
question(s) (brief or other article types: is there a clear objective)?
No - there are major issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with technical rigor to allow
confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
No - there are issues with the statistics in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically
sound? If not, can revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: I read carefully the article ""Fertility-enhancing hysteroscopic
surgery; multi-center retrospective cohort study of reproductive outcome"". Despite I appreciate
the efforts of the authors in designing and conducting this retrospective analysis, there are
numerous and important methodological biases that do not allow to draw a firm conclusion on
the topic.
REQUESTED REVISIONS:
I recommend to take into account the following suggestions:
- The text needs to be edited by a native speaker, in order to improve grammar and style.
- Abstract: the first sentence, “Hysteroscopy to treat uterine septum and some fibroids are the
only feasible way to improve the reproductive outcome”, is simply false. Assisted Reproduction
Technology is aimed also to improve reproductive outcome and enhance fertility potential.
- Introduction: authors should refer to the Global Congress on Hysteroscopy Scientific
Committee Consensus Statement about the management of asymptomatic submucous myomas
in women of reproductive age (PMID: 30012468).
- Introduction: there is no reason to refer to endometrial polyps, since the authors did not enroll
women with this type of disease in their study.
- Methods: the authors declared that the women were followed-up for a minimum of 6 months.
It is crystal clear that in case of so short follow-up it is not possible to draw any firm conclusion
about term pregnancy rate.
- Methods/Results: the authors declared that they enrolled 165 women. Considering 5 years
of recruitment (from September 2016 to October 2021) and two recruiting centers, the mean
number of enrolled patients per year is 16.5, which is extremely low.
- Methods: diagnostic laparoscopy is not the gold standard anymore for the diagnosis of
endometriosis, according to the least ESHRE guidelines (PMID: 35350465). Indeed, a simple
diagnostic laparoscopy can miss the retroperitoneal lesions, if present.
- Methods: authors declared that they excluded endometriosis in the population with uterine
septum, but they did not declare the same in the population with myomas. Why?
- Methods: what about the rate of adenomyosis in the two populations (women with uterine
septum and women with myomas)?
- Methods: in the population with myomas, authors declared that they included women with
myomas up to 6 cm. I have serious doubts that they managed 6 cm fibroids by hysteroscopy in
one surgical session (one step approach).
- Methods: the authors declared that they used “30 degrees hysteroscopic loop for the polyps/
fibroids”. Nevertheless, the study is about fibroids, not polyps, so it is not clear why they
included women with uterine polyps.
- Methods: the authors should classify uterine myomas according to the FIGO classification
(PALM-COEIN) system (PMID: 21345435).
- Methods: authors should report the ovarian reserve (AMH or AFC) of the patients; conversely
it is impossible to stratify the reproductive potential of the enrolled population.
- Methods: authors should clearly declare what they considered primary outcome, and secondary
outcomes.
- Methods: what about the sample size calculation? This should have been done based on the
primary outcome, conversely the study may be considered underpowered to detect significant
differences.
- Results: the authors should report the rate of partial (class U2a) and complete septum (class
U2b) according to the ESHRE/ESGE classification (PMID: 23771171)
- Results: the authors need to report the total complication rate and the number of each
complication.
- Discussion: authors should add further elements to discuss, at least briefly, how hysteroscopic
septum resection does not increase the rate of preterm delivery (PMID: 32196404), uterine
rupture (PMID: 33331203) and placental abnormalities (PMID: 36614977) in case of subsequent
pregnancy."