toward earlier gestational age at delivery. Although not statistically significant, the index live-birth rate (95% CI) was 38% (20–60) compared with 64% (33–86), and the cumulative live-birth rate (95% CI) was 76% (54–90) compared with 64% (33–86), neither of which suggested a trend toward improvement after metroplasty. The cohort (n5257) study of Rikken et al 2 concludes that, in women with a septate uterus, metroplasty does not increase the live-birth rate compared with expectant management. National and international guidelines are not uniform—the American Society for Reproductive Medicine recommends metroplasty; the Royal College of Obste- tricians and Gynaecologists does not rec- ommend and states, “the procedure must be evaluated in a prospective controlled trial”; the European Society for Human Reproduction and Embryology does not recommend and further states, “septum resection should be evaluated in the con- text of surgical trials.” 3–5 The publication of our results in this well-defined cohort can be used to generate a sample size for a randomized trial to definitively answer whether hysteroscopic metroplasty improves pregnancy outcomes, as opposed to the approach of offering surgery until it is proven to be ineffective. Financial Disclosure: The authors did not report any potential conflicts of interest. Anna Whelan, MD Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Alpert Medical School at Brown University, Providence, Rhode Island Channing Burks, MD Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Case Western Reserve University, Cleveland, Ohio Mary D. Stephenson, MD, MSc Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, Illinois REFERENCES 1. Whelan A, Burks C, Stephenson MD. Pregnancy outcomes in women with a his- tory of recurrent early pregnancy loss and a septate uterus, with and without hys- teroscopic metroplasty. Obstet Gynecol 2020;136:417–9. 2. Rikken JFW, Verhorstert KWJ, Emanuel MH, Bongers MY, Spinder T, Kuchen- becker W, et al. Septum resection in women with a septate uterus: a cohort study. Hum Reprod 2020;35:1578–88. 3. Practice Committee of the American Society for Reproductive Medicine. Uter- ine septum: a guideline. Fertil Steril 2016; 106:530–40. 4. Royal College of Obstetricians and Gy- naecologists. Recurrent miscarriage, investigation and treatment of couples (Green-top Guideline No. 17). London, UK: RCOG; 2011. 5. European Society of Human Reproduction and Embryology. Guideline on the man- agement of recurrent pregnancy loss. Grim- bergen, Belgium: ESHRE; 2017:1–153. Resident and Program Director Confidence in Resident Surgical Preparedness in Obstetrics and Gynecologic Training Programs The members of the Global Commu- nity of Hysteroscopy Scientific Com- mittee have read and subsequently discussed with great interest the article published by Banks et al 1 in the August 2020 issue. The authors, aiming to assess the self-reported readiness of U.S. obstetrics and gynecology resi- dents who perform surgical procedures compared with the perception of their program directors, present a survey of the residents and their program direc- tors in which they query the readiness to independently perform surgical pro- cedures. We were surprised to read that, in their survey, more than 90% of the residents and their program di- rectors were confident in their ability to perform operative hysteroscopy. More- over, 63% of postgraduate year (PGY)- 1 and 92% of PGY-2 respondents felt they could perform an operative hys- teroscopy independently. The first step in solving a problem is recognizing that there is one. In this study, 92.5% (CI 90.8–94.0) of resi- dents and 96.7% (CI 93.3–98.7) of their program directors felt that the PGY-4 residents were surgically prepared to independently perform a laparoscopic hysterectomy. That is opposite to what a previous survey revealed, in which only 18% of first-year fellows could independently perform a laparoscopic hysterectomy. 2 Hysteroscopic surgical skills are needed to safely manage many gyne- cologic conditions. The set of skills required to safely perform complex hysteroscopic procedures such as myomectomies, especially of type 2 large leiomyomas, hysteroscopic lysis of adhesions in cases of Asherman syndrome, septum resection, and re- sectoscopic endometrial ablation are difficult to master. These procedures require a comprehensive understand- ing of the female surgical anatomy, thorough knowledge of the use of hysteroscopic energy sources, patho- physiology of the disease and opera- tive indications, and contraindications and limitations of the different devi- ces, to name only a few requirements. These requirements are almost impos- sible to master as a PGY-1 or PGY-2, considering that residents also have other, nongynecologic skills that they are learning. It is concerning that the authors consider operative hysteroscopy a junior resident procedure. It is surprising to see that the majority of PGY-1 residents felt more confident in safely performing operative hysteroscopy than other con- siderably easier procedures, such as a vacuum-assisted delivery or a cesarean delivery. The biggest problem is that operative hysteroscopy was not defined by the authors. Operative hysteroscopy is more than just removing a polyp. We are troubled to see that the complexity and potential surgical risks for the patient during operative hystero- scopy are underestimated by residents and their program directors, which could pose considerable risk to their patients. We, from the Global Community of Hysteroscopy Scientific Committee, strongly advocate for a comprehensive and structured hysteroscopic teaching curriculum to provide the residents with the exposure needed to safely perform hysteroscopy surgery independently on graduation. Operative hysteroscopy is a complex surgical skill that is not easy to master. It should not be seen as a simple procedure to be performed by the least-trained postgraduate year residents. Financial Disclosure: The authors did not report any potential conflicts of interest. VOL. 136, NO. 6, DECEMBER 2020 Letters to the Editor 1233 © 2020 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.