| Journal of Clinical Gynecology and Obstetrics, ISSN 1927-1271 print, 1927-128X online, Open Access |
| Article copyright, the authors; Journal compilation copyright, J Clin Gynecol Obstet and Elmer Press Inc |
| Journal website https://jcgo.elmerpub.com |
Letter to the Editor
Volume 15, Number 3, September 2026, pages 126-128
Comment on: Does Office Hysteroscopy Add Value in Polycystic Ovary Syndrome Patients With Normal Transvaginal Ultrasound Findings?
Moazma Irshad 
Gujranwala Medical College, Gujranwala, Pakistan
Manuscript submitted July 18, 2026, accepted July 27, 2026, published online August 24, 2026
Short title: Comment on Office Hysteroscopy in PCOS With Normal TVS
doi: https://doi.org/10.14740/jcgo1742
| To the Editor | ▴Top |
We read with interest the article by Darwish et al evaluating the utility of office hysteroscopy in infertile women with polycystic ovary syndrome (PCOS) who had normal transvaginal sonography (TVS) [1]. The authors should be commended for addressing a clinically relevant question: whether routine hysteroscopy adds meaningful diagnostic value in a subgroup of patients in whom noninvasive imaging appears reassuring.
The study’s conclusion that routine office hysteroscopy is not recommended in women with normal TVS is clinically important, particularly in resource-limited settings and in fertility care pathways where patients may already undergo multiple investigations. Avoiding low-yield invasive procedures can reduce cost, discomfort, anxiety, and unnecessary intervention. The finding that hysteroscopy detected only a small number of structural abnormalities in the PCOS group—thin endometrium in 4%, a tiny polyp in 1%, and a sub-septate uterus in 1%—supports a selective rather than universal approach.
However, several points merit further discussion.
First, the clinical significance of “subtle” hysteroscopic and histopathological findings requires careful interpretation. The authors report vascularity abnormalities, Darwish triad micropolyps, chronic endometritis with micropolyps, disordered proliferative endometrium, and occasional hyperplasia, with some findings occurring more frequently in PCOS. While these observations are biologically plausible given the anovulatory and estrogen-exposed endometrial milieu in PCOS, the study did not demonstrate significant clinical correlations. Without linkage to outcomes such as implantation rate, pregnancy rate, miscarriage, live birth, or response to treatment, it remains difficult to determine whether these findings should alter management.
Second, the inclusion of infertile women with PCOS and normal TVS raises the question of whether infertility duration, prior treatment failure, metabolic profile, and ovulatory status may identify subgroups with higher diagnostic yield. PCOS is heterogeneous, and patients with long-standing oligomenorrhea, obesity, insulin resistance, prolonged unopposed estrogen exposure, or recurrent implantation failure may not carry the same endometrial risk as younger patients with shorter infertility duration and regular withdrawal bleeding. A stratified analysis according to these clinical variables would have strengthened the practical applicability of the conclusion.
Third, the comparator group of unexplained infertility is useful, but the unequal group sizes and cross-sectional design limit causal inference. Larger prospective studies with predefined outcome measures would be valuable. In particular, it would be helpful to know whether detecting and treating chronic endometritis, tiny polyps, or subtle cavity abnormalities in PCOS patients with normal TVS improves fertility outcomes. Diagnostic yield alone does not necessarily justify routine use unless it leads to an intervention that improves patient-centered outcomes.
In summary, Darwish et al provide useful evidence against routine office hysteroscopy in infertile PCOS patients with normal TVS. Their findings support a patient-centered, selective approach. Office hysteroscopy may be best reserved for patients with long-standing infertility, recurrent implantation failure, abnormal uterine bleeding, persistently abnormal endometrial thickness, suspected chronic endometritis, failed assisted reproduction, or risk factors for endometrial hyperplasia. Further prospective studies correlating hysteroscopic and histopathological findings with reproductive outcomes are needed before subtle abnormalities detected in this setting can be considered clinically actionable.
Acknowledgments
None to declare.
Financial Disclosure
The authors received no financial support for the research, authorship, and/or publication of this letter.
Conflict of Interest
The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this letter.
Informed Consent
Not applicable.
Author Contributions
Moazma Irshad conceptualized the letter, drafted the manuscript, and approved the final version.
Data Availability
The authors declare that data supporting the findings of this study are available within the article.
| Response to the Letter to the Editor | ▴Top |
Dear Editor,
We sincerely thank Ms. Moazma Irshad for her thoughtful comments on our article, “Does Office Hysteroscopy Add Value in Polycystic Ovary Syndrome Patients With Normal Transvaginal Ultrasound Findings?” We appreciate her recognition of the clinical relevance of our work and her constructive observations.
We agree that the clinical significance of subtle hysteroscopic and histopathological abnormalities requires confirmation through prospective studies correlating these findings with reproductive outcomes. Our study was intentionally designed as a cross-sectional diagnostic investigation and was not powered to evaluate implantation, pregnancy, or live birth rates. Prospective longitudinal studies are needed to determine whether the detection and management of subtle hysteroscopic abnormalities translate into improved reproductive outcomes.
We also acknowledge the heterogeneity of polycystic ovary syndrome (PCOS) and agree that subgroup analyses based on metabolic profile, infertility duration, ovulatory status, and previous treatment failures would provide additional clinically relevant insights. These important questions warrant investigation in future prospective multicentric studies, particularly in light of the recently proposed concept of polyendocrine metabolic ovarian syndrome (PMOS), which recognizes the broader metabolic and endocrine spectrum of the disease [1].
We agree that the cross-sectional design precludes causal inference, and this limitation was explicitly acknowledged in our discussion. However, the comparator groups were not unequal, as both the PCOS and unexplained infertility groups comprised 75 women, based on an a priori sample size calculation. The unexplained infertility group was intentionally selected as a hormone-free control to minimize the confounding effects of hormonal disturbances on endometrial morphology and hysteroscopic findings. The primary objective of our study was to compare the diagnostic yield of office hysteroscopy between two well-defined populations rather than to establish causality.
Our principal conclusion remains unchanged: routine office hysteroscopy is not justified in infertile women with PCOS (or PMOS) who have normal transvaginal ultrasound findings. Instead, office hysteroscopy should be reserved for selected patients with appropriate clinical indications, such as abnormal uterine bleeding, recurrent implantation failure, suspected chronic endometritis, failed assisted reproduction, or persistent sonographic abnormalities.
We thank the author once again for the valuable comments, which reinforce the importance of individualized, evidence-based use of office hysteroscopy in infertility practice and highlight areas for future research.
| Reply to the Response of Darwish et al | ▴Top |
Dear Editor,
I thank Dr. Darwish and colleagues for their detailed and thoughtful response to my Letter to the Editor. I appreciate their willingness to engage in this academic discussion and their respectful acknowledgment of my comments.
I acknowledge their clarification regarding the group sizes: both the PCOS and unexplained infertility groups comprised 75 women, based on an a priori sample size calculation. I stand corrected on this point and appreciate the authors for clarifying their study design.
I am glad to note that the authors agree with my main suggestions that prospective longitudinal studies are needed to correlate hysteroscopic findings with reproductive outcomes, and that subgroup analyses based on metabolic profile, infertility duration, and other clinical variables would provide additional clinically relevant insights. I also welcome the authors’ reference to the newly proposed concept of polyendocrine metabolic ovarian syndrome (PMOS), which adds a valuable perspective to the discussion.
I fully support the authors’ conclusion that routine office hysteroscopy is not justified in infertile women with PCOS (or PMOS) who have normal transvaginal ultrasound findings, and I agree that hysteroscopy should be reserved for selected patients with appropriate clinical indications.
I thank the authors once again for their valuable work and for their constructive engagement with my comments.
Yours sincerely,
| References | ▴Top |
- Darwish AMM, Fathalla MM, Fetih AN, Elsaid NM, Darwish D, Abden AA. Does Office Hysteroscopy Add Value in Polycystic Ovary Syndrome Patients With Normal Transvaginal Ultrasound Findings? J Clin Gynecol Obstet. 2026;15(2):62-68.
doi
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, including commercial use, provided the original work is properly cited.
Journal of Clinical Gynecology and Obstetrics is published by Elmer Press Inc.