Reviewer’s report
Title: 
Ex-Vivo Forces Associated with Intrauterine Device Placement and
Perforation: A Biomechanical Evaluation of Hysterectomy Specimens
Version: 
0 
Date: 
30 Dec 2020
Reviewer's report:
Thank you for the opportunity to review this interesting manuscript. Though
rare, uterine perforation during IUD insertion is of serious concern for clinicians.
The authors hypothesized the uterine sound as a major cause of uterine
perforation. However, the methodology used does not seem ideal to test this
hypothesis as it deviates from the usual practice. In clinical practice, uterine
sounding is done prior to IUD insertion. In this study, the sounding is done last,
after 6 forceful attempts with the IUDs (3 times with LNG IUS followed by 3
times with CU IUD). Could this weaken the uterine myometrium at the time of
uterine sounding and potentially contribute to the 100% perforation? Please
clarify if there a unique justification for the reversed step employed in this study.
Line 174-183
The authors mentioned possible objectives of uterine sound and alternatives to
achieve these objectives. These are however for unique cases that may not be
encountered routinely. In routine practice, clinicians use the uterine sound to
measure the depth of the uterine cavity and prepare the IUDs accordingly. It
would be very helpful for the reader if the authors address possible (safer)
alternatives to achieve this goal without using the uterine sound. 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
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