One-stop recurrent miscarriage clinic and hysteroscopy—an urgent combination?

Sir, We read the paper by Habayeb and Konje (2004) and would like to make some critical comments on some details of their concept. The authors described their management to increase the efficacy of investigations in women with recurrent miscarriages. They could reduce either the interval or the number of visits. One main problem with the study is the inclusion of patients after only two miscarriages. It was critically discussed, but we cannot understand how the older publications cited can refute the accepted definition of recurrent miscarriages reviewed in an more recent publication (Li et al., 2002). If we speak about efficacy it is also necessary to think about the costs resulting from the inclusion of patients with only two miscarriages. This subgroup is 40% (!) of all patients with miscarriages in this study. However, the most important point of criticism is the evaluation of the uterine cavity. Hysteroscopy was performed only in a ‘selected group’ of patients (2/189; ∼1% !). What were the selection criteria? There are different studies showing a high incidence of intrauterine pathology after only one (!) first trimester abortion with dilatation and curettage. Fiedler et al. (1993) performed post-abortion hysteroscopy in 147 patients and found intrauterine pathology in 38 (25.9%), mainly intrauterine adhesions. This was confirmed by Römer (1994) with intrauterine adhesions in 18.8% after the first abortion and 47.6% after two or more abortions. Interestingly, intrauterine abnormalities in 38 patients (10.1%), mainly adhesions (26/38), were found during a screening hysteroscopy of 379 asymptomatic patients with primary infertillity and without any risk factor (Nawroth et al., 2003). From these data it is not justifiable to exclude ∼99% of patients with recurrent abortions from intrauterine hysteroscopic evaluation. One can discuss whether hysteroscopy will remain the ‘gold standard’ in the future. Preliminary studies show excellent results in regard to the evaluation of uterine cavity with three-dimensional ultrasound (Kupesic et al., 2002; Hartman et al., 2004). Different studies comparing hysteroscopy with other methods (hysterosalpingography, sonohysterography) have shown no equal efficiency in regard to evaluation of intrauterine pathology. Hysteroscopy is an invasive procedure but we and other authors found only a minimal and tolerable discomfort performing minihysteroscopy with optics <3 mm in diameter without any anaesthesia (De Iaco et al., 2000; Nawroth et al., 2003). Therefore it is unproblematic to include minihysteroscopy in the suggested one-stop evaluation. In conclusion, we appreciate the attempt to rationalize the diagnostic approach to patients with recurrent miscarriages. This will make diagnosis possible, especially for women living a long distance from the specialized centre. But with the knowledge of the above-mentioned data one can assume that the inclusion of routine hysteroscopy (or perhaps in the future 3D sonography) will increase reproductive outcome. It could further decrease the reported 54% of the patients with no cause for recurrent miscarriage in favour of uterine causes which are operable. 1Centre of Reproductive Medicine and Gynecologic Endocrinology, Endokrinologikum Hamburg and 2Department of Obstetrics and Gynaecology, University of Cologne, Germany