terectomy specimens, which did not show coagulative ne-crosis.

How can one explain the difference between our seriesand the series of Jones and colleagues? As mentioned in ourarticle (1), our patients were systematically treated preoper-atively by GnRH, so that the endometrium was very thin andthe patient was not bleeding at the time of the ELITTprocedure.

In conclusion, the Jones et al. letter confirms the amen-orrhea rates of our study, which were the highest rates ofamenorrhea ever published in the literature after endometrialablation. We strongly advocate the ELITT procedure whenthe patient is not bleeding.

J. Donnez, M.D.Brussels, BelgiumFebruary 24, 2001

References1. Donnez J, Polet R, Rabinovitz R, Ak M, Squifflet J, Nisolle M. Endo-

metrial laser intrauterine thermo-therapy: the first series of 100 patientsobserved for one year. Fertil Steril 2000;74:791–6.

2. Donnez J, Polet R, Mathieu PE, Nisolle M, Casanas-Roux F. Endome-trial laser interstitial hyperthermy: a potential modality for endometrialablation. Obstet Gynecol 1996;87:459–64.

3. Donnez J, Polet R, Squifflet J, Rabinovitz R, Levy U, Ak M, et al.Endometrial laser intrauterine thermo-therapy (ELITT): a revolutionarynew approach to the elimination of menorrhagia. Curr Opin ObstetGynecol 1999;11:363–70.

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Validity of comparisons?To the Editor:

We read with interest the paper by Osada et al. (1) on theevaluation and treatment of proximal tubal obstruction witha combination of selective salpingography and balloon tu-boplasty in a one-stop outpatient setting. We felt though thatthe way that the information was presented could be mis-leading.

Selective salpingography is primarily a diagnostic instru-ment. Therefore, its results need to be compared with theresults of other diagnostic methods, rather than with treat-ment techniques, like balloon tuboplasty. Comparing it withlaparoscopy and dye, which would be regarded by many asthe gold standard, Woolcott et al. (2), in a randomizedprospective controlled study, found selective salpingographyto be superior in the diagnosis of proximal tubal obstruction.

After this diagnosis is confirmed, a therapeutic procedurecan be employed. Osada et al. (1) used balloon tuboplastyunder hysteroscopic control and achieved a 66% (88 of 133women) recanalization rate. Lang and Dunaway (3) used aflexible platinum tip guidewire under fluoroscopic guidanceand achieved an 86.7% (145 of 187 women) recanalizationrate. In both studies a selective salpingography immediately

before had confirmed proximal tubal obstruction. We feelthat balloon tuboplasty should be compared with tubal cath-eterization for a meaningful comparison of therapeutic pro-cedures. Thus, “balloon tuboplasty is more effective treat-ment than selective salpingography” is a statement that canlead to confusion.

It was also interesting to note that from the 178 womenwho failed hysteroscopic selective salpingography, 133 pro-ceeded to balloon tuboplasty, because in 47 women (26.4%of the total of women who had failed hysteroscopic selectivesalpingography), the tubal ostia could not be identified. Thiscontradicts the view of Osada et al. (1) that direct visualiza-tion through the hysteroscope makes this approach techni-cally simpler than the radiographically guided procedures.

The availability of different alternatives in dealing with aproblem can only benefit our patients. It is important thoughto be precise in our definitions, which in turn would allowmeaningful comparisons between the results of these tech-niques.

Spyros Papaioannou, M.R.C.O.G.Masoud Afnan, F.R.C.O.G.Bolarinde Ola, M.R.C.O.G.Aravinthan Coomarasamy, M.B., Ch.B.Nahed Hammadieh, M.R.C.O.G.Khaldoon Sharif, M.R.C.O.G.Birmingham, United KingdomNovember 8, 2000

References1. Osada H, Fujii TK, Tsunoda I, Tsubata K, Satoh K, Palter S. Outpatient

evaluation and treatment of tubal obstruction with selective salpingog-raphy and balloon tuboplasty. Fertil Steril 2000;73:1032–6.

2. Woolcott R, Fisher S, Thomas J, Kable W. A randomized, prospective,controlled study of laparoscopic dye studies and selective salpingogra-phy as diagnostic test of fallopian tube patency. Fertil Steril 1999;72:879–84.

3. Lang E, Dunaway HH. Recanalization of obstructed fallopian tube byselective salpinography and transvaginal bougie dilatation: outcome andcost analysis. Fertil Steril 1996;66:210–5.

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Reply of the Authors:

We appreciate the comments of Drs. Papaioannou andcolleagues regarding our paper, “Outpatient evaluation andtreatment of tubal obstruction with selective salpingographyand balloon tuboplasty.” We are sorry that they may havebeen confused about the information presented regardingdiagnostic versus treatment techniques. They comment thatselective salpingography (SS) is primarily a diagnostic, nottherapeutic, procedure. However, it is established that inmany cases of tubal obstruction, patency may be achievedwith SS. Some of these cases represent false obstructions,whereas others represent mucus plugs and fine adhesions. Infact, our paper is the first comparison of the efficacy of thesetools for establishing tubal patency and lends support to theirposition. The fact that 35.7% of our patients with tubal

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