Myomectomy: a retrospective study to examine reproductive performance before and after surgery

Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy

OBJECTIVE

To assess the risks and outcome of pregnancies and deliveries after laparoscopic myomectomy (LM).

DESIGN

Retrospective study.

SETTING

Center of Reconstructive Pelvic Endosurgery, Reproductive Medicine Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.

PATIENT(S)

A total of 514 patients of fertile age that underwent LM at the Center were selected.

INTERVENTION(S)

All the surgical procedures were performed using the same technique employing a vertical uterine incision and avoiding the use of electrosurgery.

MAIN OUTCOME MEASURE(S)

Number and outcome of pregnancies achieved after surgery, abortion rate, preterm delivery, gestational age, malpresentation, spontaneous or cesarean delivery, and postpartum hemorrhage. We also paid particular attention to the occurrence of uterine rupture.

RESULT(S)

A total of 158 pregnancies were achieved. There were 43 (27.2%) spontaneous abortions, 4 (2.6%) ectopic pregnancies, and 1 (0.6%) therapeutic abortion. Only 27 patients (25.5%) had vaginal deliveries, whereas 79 (74.5%) underwent cesarean section. No instances of uterine rupture were recorded.

CONCLUSION(S)

Our preliminary results confirmed that LM, performed by an expert surgeon, can restore reproductive capacity, allowing patients to have a successful pregnancy.

The effect of small intramural uterine fibroids on the cumulative outcome of assisted conception

BACKGROUND

This study aimed to evaluate the effect of small intramural fibroids on the cumulative pregnancy, ongoing pregnancy, live birth and implantation rates after three IVF/ICSI attempts.

METHODS

The first three treatment cycles of women enrolled for IVF/ICSI over a 12-month period were analysed. Only patients with small (<or=5 cm) intramural fibroids not encroaching upon the endometrial cavity were included in the fibroid group. Cox's hazards regression was used to estimate the hazard ratio (HR) associated with the presence of intramural fibroids.

RESULTS

During the study period, 322 women without fibroids (control group) and 112 women with fibroids (study group) underwent 606 IVF/ICSI cycles. The pregnancy, ongoing pregnancy and live birth rates in the study group were 23.6, 18.8 and 14.8% compared with 32.9, 28.5 and 24% in the control group, respectively (P<0.05). Cox regression analysis showed that the pregnancy rate at each cycle was reduced by 39% (HR=0.61, 95% CI=0.39-0.95, P=0.029) in the study group compared with the control group. The cumulative ongoing pregnancy rate was reduced by 43% (HR=0.57, 95% CI=0.35-0.91, P=0.018), and the cumulative live birth rate was reduced by 47% (HR=0.53, 95% CI=0.32-0.87, P=0.013) in the study group. After adjusting for confounding variables, the presence of fibroids was found to significantly reduce the ongoing pregnancy rate at each cycle of IVF/ICSI by 40% (HR=0.60, 95% CI=0.36-0.99, P=0.048) and the live birth rate at each cycle by 45% (HR=0.55, 95% CI=0.32-0.95, P=0.03).

CONCLUSION

Small intramural fibroids are associated with a significant reduction in the cumulative pregnancy, ongoing pregnancy and live birth rates after three IVF/ICSI cycles.

Reproductive outcome after laparoscopic myomectomy for intramural myomas in infertile women with or without associated infertility factors

Aims:   To evaluate reproductive outcome after laparoscopic myomectomy for intramural myomas in infertile women with or without associated infertility factors. Methods:   A retrospective study was carried out in 30 infertile women with intramural myomas measuring ≥50 mm in diameter and treated using laparoscopy. Results:   The overall rate of spontaneous intrauterine pregnancy was 50.0% (15 patients). Of 13 patients with infertility factors associated with the uterine myomas, three (23.1%) became pregnant, whereas 12 of 17 patients (70.6%) with no other associated infertility factor became pregnant. No uterine ruptures were observed. All pregnancies were spontaneous and 13 occurred within 1 year of the operation. In the 10 patients who gave birth by Cesarean section, no adhesions were found on the myomectomy scar. Conclusions:   On the basis of these results, laparoscopic surgery for myomas appears to offer comparable results to laparotomy. In infertile patients with intramural myoma, pregnancy rates are affected by the presence of other infertility factors associated with the uterine myomas. (Reprod Med Biol 2006; 5: 31-35).

Obstetric Complications of Fibroids

The effect of uterine fibroids on fecundity and pregnancy outcome is difficult to determine with any degree of accuracy; this is due, in large part, to the lack of adequate large clinical trials. In general, the literature tends to underestimate the prevalence of fibroids in pregnancy and overestimate the complications that are attributed to them. In contrast to popular opinion, most fibroids do not exhibit a significant change in volume during pregnancy, although those that do increase in size tend to do so primarily in the first trimester. Although most pregnancies are unaffected by the presence of uterine fibroids, large submucosal and retro-placental fibroids seem to impart a greater risk for complications, including pain (degeneration), vaginal bleeding, placental abruption, IUGR, and preterm labor and birth. Preconception myomectomy to improve reproductive outcome can be considered on an individual basis, but likely has a place only in women who have recurrent pregnancy loss, large submucosal fibroids, and no other identifiable cause for recurrent miscarriage. Antepartum myomectomy should be reserved for women who have subserosal or pedunculated fibroids and intractable fibroid pain that are unresponsive to medical therapy and who are in the first or second trimester of pregnancy. Myomectomy at the time of cesarean delivery is associated with significant morbidity (hemorrhage) and should be pursued with caution and only in select patients.

Myomas and Assisted Reproductive Technologies: When and How to Act?

The effect of myomas on reproductive outcome has been the subject of many studies; however, a definitive answer is still missing. Therefore, the authors have tried to outline some guidelines for the management of women who have uterine myomas and desire to conceive. The location and size of the myomas are the two parameters that influence the success of a future pregnancy. Subserosal myomas seem to have little, if any,effect on reproductive outcome, especially if they are up to 5 to 7 cm in diameter. Intramural myomas that do not encroach upon the endometrium also can be considered to be relatively harmless to reproduction, if they are smaller than 4 to 5 cm in diameter. This is the ambiguous gray zone of the subject, and where research should be focused before a consensus can be established. Myomas that compress the uterine cavity with an intramural portion (submucous myoma type II) and submucous myomas significantly reduce pregnancy rates, and should be removed before assisted reproductive techniques are used. Hysteroscopic myomectomy is the gold standard for the treatment of submucous myomas. For other myomas, abdominal myomectomy, or laparoscopic myomectomy--when the experience of the surgeon and the facilities are sufficient--are the best alternatives. In most of the literature, the pregnancy rates were increased and the miscarriage rates were decreased after surgery with these two techniques. Other alternative treatment modalities, such as CUV, laparoscopic myolysis, or MRI-guided focused ultrasound, are to be monitored and evaluated thoroughly before they are applied as routine procedures.

MRI Evaluation of the Uterine Structure after Myomectomy

Myomectomy is a good indication for women with uterine leiomyoma who desire to preserve their child-bearing potential. However, there are still no reports about how long it takes the uterus to reach a stable state after myomectomy. We evaluated the changes in uterine structure during the recovery process after myomectomy by MR images. MR images were used to analyze the time-dependent changes in the length of the uterine cavity, the volume of the uterus, recovery of the junctional zone, prevalence of modification of the endometrium, and uterine structure in the region of the enucleated myoma. The cavity length and the volume of the uterus, and the myometrium were stabilized at six weeks after the myomectomy. With regard to the endometrium, 12 weeks were required for it to achieve a stable state after myomectomy. However, even at 12 weeks postoperatively, 14.2% of the cases showed an unusual view near the uterine incision on MR images. We concluded that the recovery process is complete at 12 weeks after the operation if there are no clear findings of hematoma or edema formation in the myometrium on MR images.

Effects of the position of fibroids on fertility

This prospective, controlled study was performed in order to evaluate whether the location of uterine fibroids may influence reproductive function in women and whether removal of the fibroid prior to conception may improve pregnancy rate and pregnancy maintenance. We examined 181 women affected by uterine fibroids who had been trying to conceive for at least 1 year without success. The main outcome measures were the pregnancy rate and the miscarriage rate. Among the patients who underwent myomectomy, the pregnancy rates obtained were 43.3% in cases of submucosal, 56.5% in cases of intramural, 40.0% in cases of submucosal-intramural and 35.5% in cases of intramural-subserosal uterine fibroids, respectively. Among the patients who did not undergo surgical treatment, the pregnancy rates obtained were 27.2% in women with submucosal, 41.0% in women with intramural, 15.0% in women with submucosal-intramural and 21.43% in women with intramural-subserosal uterine fibroids, respectively. Although the results were not statistically significant in the group of women with intramural and intramural-subserosal fibroids, this study confirms the important role of the position of the uterine fibroid in infertility as well as the importance of fibroids removal before the achievement of a pregnancy, to improve both the chances of fertilization and pregnancy maintenance.

Fibroids and in-vitro fertilization: which comes first?

PURPOSE OF REVIEW

There is no consensus about the impact of uterine fibroids on fertility. This review explores past and recent studies that investigated the effects of submucosal, intramural, and subserosal fibroids on in-vitro fertilization (IVF) outcomes. We discuss the importance of proper evaluation of the uterus and endometrial cavity, and current options for optimal fibroid management in patients desiring fertility.

RECENT FINDINGS

Several studies have reviewed the data on fibroids and infertility, further exploring this potential relationship. Two recent studies investigated reproductive outcomes before and after myomectomy, and IVF outcomes based on fibroid size and location. Both studies concluded that fibroids can impair reproductive outcomes. Several papers thoroughly reviewed medical and surgical management options for patients with fibroids and desired fertility. Although several medical therapies may reduce fibroid volume or decrease menorrhagia, myomectomy remains the standard of care for future fertility. Recent data identified an increased rate of pregnancy complications after uterine artery embolization compared with laparoscopic myomectomy. A new procedure, magnetic resonance imaging-guided focused ultrasound ablation, shows promise for the management of symptomatic fibroids, and possibly for the management of fibroids prior to pregnancy. As with embolization, more data are needed to evaluate postprocedure fertility and pregnancy outcomes.

SUMMARY

Fibroid location, followed by size, is the most important factor determining the impact of fibroids on IVF outcomes. Any distortion of the endometrial cavity seriously affects IVF outcomes, and myomectomy is indicated in this situation. Myomectomy should also be considered for patients with large fibroids, and for patients with unexplained unsuccessful IVF cycles.

Evaluation of postmyomectomy uterine scar

PURPOSE

To determine preoperative and intraoperative factors that affect the healing pattern of a myomectomy uterine incision and to estimate the incidence and outcome of postmyomectomy hematoma demonstrated with sonography.

METHODS

This observational longitudinal prospective study followed the course of patients diagnosed with at least 1 leiomyomata. Each patent was scheduled for abdominal myomectomy. Preoperative assessments included sonographic measurement of the uterine volume as well as identification of the numbers and sites of the leiomyomata. Detailed operative notes were reported for every patient. Transvaginal sonography was performed for all cases on day 2, day 7, and at 1 month and 3 months postoperatively. The main outcome measure was the occurrence of postoperative hematoma versus preoperative and postoperative factors that possibly affect uterine healing.

RESULTS

We found a statistically significant reduction of the uterine volume on follow-up (P < 0.001) of the 169 women enrolled. Hematoma in the myomectomy bed was observed postoperatively in 40 (24%) 28 (17%) and 12 (7%) patients on day 2, day 7, and 1 month, respectively. A preoperative myoma size greater than 110 cm(3), the use of a tourniquet, and the experience of the surgeon were significantly correlated with formation of uterine scar hematomas.

CONCLUSIONS

The postoperative sonographic diagnosis of wound hematoma may be used as an indicator of wound healing that is usually complete within 3 months. Use of a tourniquet is frequently associated with hematoma formation. Myomectomy should usually be performed by an experienced surgeon without a tourniquet, using microsurgical principles, especially when the sizes of the leiomyomata exceed 110 cm(3).

Recurrent miscarriage

Recurrent miscarriage, the occurrence of three consecutive first-trimester losses of pregnancy, affects 1% of women. The purported causes of recurrent miscarriage include chromosomal abnormalities, thrombophilia, metabolic disorders, anatomical causes and immune factors. At present, the only recommended investigations are testing for lupus anticoagulant and anticardiolipin antibody levels (to diagnose antiphospholipid syndrome, an acquired thrombophilia) and the karyotyping of both parents for chromosomal abnormalities. Women with antiphospholipid syndrome should be offered treatment with aspirin and low molecular weight heparin. Couples with chromosomal abnormalities should be referred to a clinical geneticist with whom the options of prenatal diagnosis, pre-implantation genetic diagnosis, donor gametes and adoption in subsequent pregnancies should be discussed. Couples with unexplained recurrent miscarriage should be offered appropriate emotional support and reassurance that they have a good prognosis for future pregnancies.

Effect of inner myometrium fibroid on reproductive outcome after IVF

To evaluate the influence of inner myometrium fibroids (myomas) on the outcome of IVF cycles, a retrospective agematched controlled study was performed at SISMeR Reproductive Medicine Unit. The study group included 129 IVF/intracytoplasmic sperm injection cycles in 75 patients with one or more intramural and/or submucosal fibroids, while the control group consisted of 129 cycles in 127 patients without fibroids. The two groups were similar for mean oestradiol concentration at human chorionic gonadotrophin administration (1205.16 +/- 874 versus 1395 +/- 821 pg/ml), mean number of transferred embryos (2.02 +/- 0.4 versus 2.14 +/- 0.6) and clinical pregnancy rate (34.9 versus 41.1%). Conversely, the implantation rate was significantly lower in the study group (18.0%) than in the control group (26.5%; chi(2) = 4.81, P < 0.05), whereas the rate of spontaneous abortion demonstrated an opposite trend (40 versus 18.9%; chi(2) = 4.34, P < 0.05). Further research should be aimed at classifying fibroids on the basis of their location, especially when they are positioned in the junctional zone of the myometrium. Whether this classification will be superior in predicting the impact of fibroids on the reproductive outcome should be elaborated in a large multicentric study.

Gene therapy of uterine leiomyomas: adenovirus-mediated expression of dominant negative estrogen receptor inhibits tumor growth in nude mice

BACKGROUND

Leiomyomas (fibroids) are common estrogen-dependent uterine tumors with no effective medicinal treatment; hysterectomy is the mainstay of management.

STUDY DESIGN

This study was undertaken to investigate a potential therapy for leiomyoma; we used a mutated dominant-negative estrogen receptor gene delivered via an adenoviral vector (Ad-ER-DN).

RESULTS

Ad-ER-DN transduction, in both human and rat leiomyoma cell lines, induced an increase in both caspase-3 levels and BAX/Bcl-2 ratio with evident apoptosis in the TdT-mediated dUTP nick-end labeling assay. In nude mice, rat leiomyoma cells ex vivo transduced with Ad-ER-DN supported significantly smaller tumors compared with Ad-LacZ-treated cells 5 weeks after implantation. In mice treated by direct intratumor injection into preexisting lesions, Ad-ER-DN caused immediate overall arrest of tumor growth. The Ad-ER-DN-treated tumors demonstrated severely inhibited cell proliferation (BrdU index) and a marked increase in the number of apoptotic cells (TdT-mediated dUTP nick-end labeling index).

CONCLUSION

Dominant-negative estrogen receptor gene therapy may provide a nonsurgical treatment option for women with symptomatic uterine fibroids who want to preserve their uteri.

Uterine myomas: an overview of development, clinical features, and management

OBJECTIVE

To review the biology and the pathophysiology of uterine myomas, focus on options for management, and emphasize principles that will render the decision-making process as logical as possible.

DESIGN

Literature review and synthesis of the authors' experience and philosophy.

RESULTS

Uterine myomas are the most common solid pelvic tumors in women. There is increasing evidence that they have a genetic basis and that their growth is related to genetic predisposition, hormonal influences, and various growth factors. Treatment choices are wide and include pharmacologic, surgical, and radiographically directed intervention. Most myomas can be followed serially with surveillance for development of symptoms or progressive growth.

CONCLUSION

The past century has witnessed development of highly sophisticated diagnostic and therapeutic technology for myomas. The tools currently at our disposal permit greater management flexibility with safe options, which must be tailored to the individual clinical situation.

Reproductive performance before and after abdominal myomectomy: a retrospective analysis

OBJECTIVE

To evaluate the results of abdominal myomectomy for intramural and subserosal fibroids and to identify factors that influence the reproductive outcome after surgery.

DESIGN

Retrospective analysis of a case series.

SETTING

An academic department specializing in gynecologic surgery.

PATIENT(S)

A total of 72 women with intramural and subserosal fibroids submitted to abdominal myomectomy who wished to conceive after surgery.

INTERVENTION(S)

Data were collected on clinical characteristics, surgical features, and obstetric history before and after surgery.

MAIN OUTCOME MEASURE(S)

Conception rate, pregnancy loss, and live birth rate before and after surgery, as well as postoperative probability of conception according to selected clinical and fibroid characteristics.

RESULT(S)

Conception rate was 28% before myomectomy and 70% after surgery. The corresponding figures were 69% and 25% for pregnancy loss and 30% and 75% for live birth rate, respectively. Age <30 years and number of fibroids removed were the only significant and independent predictors of obstetric outcome by multivariate analysis.

CONCLUSION(S)

Our results suggest that abdominal myomectomy might improve reproductive outcome in patients with intramural and subserosal fibroids. The reproductive performance was particularly good when the patients were younger than 30 years and had a single myoma to remove.

Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas

OBJECTIVES

To analyze the reproductive outcome before and after myomectomy in patients with subserous or intramural myomas, and to assess the factors influencing pregnancy rate after myomectomy.

STUDY DESIGN

Out of 128 patients submitted to myomectomy, we considered eligible for this study only the 41 patients wishing to conceive after surgery and who did not present any plausible infertility factor, apart from the removed myomas. We have evaluated the pregnancy outcome prior to and following myomectomy, and analyzed the correlation between conception rate after surgery and patient's age at the time of the surgery, type of surgery, number and size of the myomas, location of the largest fibroid and previous pregnancies.

RESULTS

Nineteen patients had been submitted to abdominal (group A) and 22 to laparoscopic myomectomy (group B). Prior to surgery, 28 pregnancies had occurred in 14 of the 41 patients, with a miscarriage rate of 57.1%. Following surgery 29 pregnancies occurred in 25 patients (60.9%), pregnancy rate being similar in both groups. The postoperative delivery rate was 86.2% whereas the miscarriage rate was reduced to 13.8% (P<0.001). Overall, 60% of deliveries were vaginal. No cases of ectopic pregnancy or uterine rupture occurred. Those patients who conceived after surgery were significantly younger (32.36+/-4.06 years versus 35.88+/-3.57 years; P=0.0073), and their removed myomas were significantly larger (5.80+/-2.69 cm versus 4.28+/-1.54 cm; P=0.0274). Furthermore, a multivariate analysis shows that, apart from age and diameter, the probability of conceiving after myomectomy is higher in case of intramural myomas (intramural versus subserosal: OR 12.382, 95% CI: 1.61-95.22) or laparoscopic surgery (laparoscopy versus laparotomy: OR 14.062, 95% CI: 1.40-141.15).

CONCLUSIONS

Our results suggest that myomectomy significantly improves pregnancy outcome in patients with subserous or intramural fibroids, probably removing a plausible cause of altered uterine contractility or blood supply. The main determinants of pregnancy rate after surgery are patient age, diameter and intramural localization of the myomas and type of surgery.

An analysis of the pattern of pregnancy loss in women with recurrent miscarriage

OBJECTIVE

To describe the pattern of pregnancy loss in women with a history of recurrent miscarriage (RM).

DESIGN

Retrospective, observational study.

SETTING

A tertiary referral center for RM.

PATIENT(S)

Five hundred thirty-eight subjects with RM.

INTERVENTION(S)

Women with antiphospholipid syndrome were treated with clexane and aspirin; some patients with uterine anomalies underwent corrective surgery, and some cases of retarded endometrium were treated with hMG.

MAIN OUTCOME MEASURE(S)

Pregnancy outcome, including the stage of pregnancy at which pregnancy loss occurred.

RESULT(S)

In women with a prothrombotic state, the miscarriage rate before the detection of fetal heart activity (early loss) in the untreated group (50%) was significantly higher than in the treatment group (17.5%). In women with a uterine anomaly, the early loss rate and the later loss rate (after detection of fetal heart activity) were both increased. Women with retarded endometrium, women with >/=6 losses, and older women (>/=41 years) are more likely to have a further early loss but not a later loss.

CONCLUSION(S)

An understanding of the patterns of pregnancy loss provides further insight into the mechanism of the reproductive failure, which has implications for treatment.

What are the implications of myomas on fertility? A need for a debate?

In order to evaluate the relationship between leiomyomas and infertility, which remains a subject of debate, we have tried to evaluate the impact of myomas on fertility and pregnancy outcome in different conditions where myomas are implicated. Medline research was conducted of publications appearing between January 1988 and August 2001 on the subjects of myomas and myomectomy and their impact on fertility and pregnancy outcome in infertile women. A total of 106 manuscripts were consulted. The incidence of myomas in infertile women without any obvious cause of infertility is estimated to be 1-2.4%. The relationship between leiomyomas and infertility remains a subject of debate. The question is: do myomas influence fertility? We are obliged to conclude that the question remains. The absence of an answer to this crucial question is probably due to the fact that we have not yet conducted the appropriate prospective studies required to obtain any clear results.

A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception

BACKGROUND

Although uterine fibroids occur in 30% of women and are associated with a degree of subfertility, the effect of intramural fibroids on the outcome of IVF or ICSI treatment has not been prospectively studied.

METHODS

Data were prospectively collected on 434 women undergoing IVF/ICSI in the assisted conception unit of an inner London teaching hospital. Patients were assessed for the presence of fibroids by transvaginal ultrasound and hysterosonography or hysteroscopy where appropriate.

RESULTS

During the study period, 112 women with (study), and 322 women without (controls), intramural fibroids were treated. Patients were similar regarding the cause and duration of their infertility, number of previous treatments, and basal serum FSH concentration. Women in the study group were on average 2 years older (36.4 versus 34.6 years; P < 0.01). There was no significant difference in the duration of ovarian stimulation or gonadotrophin requirement, number of follicles developed, oocytes collected, embryos available for transfer or replaced. When analysing only women with intramural fibroids of < or =5 cm in size (n = 106) pregnancy, implantation and ongoing pregnancy rates were significantly reduced: 23.3, 11.9 and 15.1 respectively compared with 34.1, 20.2 and 28.3% in the control group (P = 0.016, P = 0.018 and P = 0.003). The mean size of the largest fibroids was 2.3 cm (90% range 2.1-2.5 cm). Logistic regression analysis demonstrated that the presence of intramural fibroids was one of the significant variables affecting the chance of an ongoing pregnancy, even after controlling for the number of embryos available for replacement and increasing age, particularly age > or =40 years, odds ratio 0.46 (CI 0.24-0.88; P = 0.019).

CONCLUSION

This study demonstrated that an intramural fibroid halves the chances of an ongoing pregnancy following assisted conception.

Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy

Abdominal myomectomy and hysterectomy remain the traditional treatment of large symptomatic uterine myomas. The preoperative indications for abdominal myomectomy or hysterectomy must be clearly evaluated and delineated avoid unnecessary intervention. There appears to be an increasing trend toward expectant management for asymptomatic uterine myomas. Women should consider the options of myomectomy and hysterectomy when their symptoms are severe enough to warrant intervention and the benefits of intervention outweigh the risks. The advantages and disadvantages of preoperative medical also must be addressed before intervention. The factors influencing the choice of therapy seem to be strongly dependent on both the patient and physician preferences. A clinical approach to abdominal myomectomy in patients with infertility and repetitive miscarriage has been presented in this chapter. The rapid development and use of minimally invasive innovations and adjunctive medical therapies has provided clinicians with a wealth of alternatives. A practical and cost-effective approach based on the data currently available have been presented; however, there remains a paucity of prospective randomized data to evaluate and compare the effectiveness and safety of these alternative treatments to abdominal myomectomy and hysterectomy. Future studies should help define the optimal candidates for traditional surgical treatment with abdominal myomectomy and hysterectomy.

[Myoma and infertility: analysis of the literature]

The influence of myomas on reproduction has been clearly demonstrated, however their effects on fertility remain debated. The aim of this review, between January 1988 and December 2000, was to clarify the relation between myoma and fertility, and to assess pregnancy rates after myomectomy in infertile patients. Spontaneously, 54 publications were selected and 40 eligible. No study compared pregnancy rates with or without myomas. Pregnancy rates after myomectomy varied between 9.6% and 76.9%, with descriptive series. In medically assisted procreation, five publications were eligible. Myoma presence was associated with decreased pregnancy rates. Hysteroscopic sub-mucous myoma resection increased pregnancy rates. Relation between myoma and sterility is probable, however no proof was obtained. Myomectomy efficacy has not been statistically proven, but spontaneously almost 60% of patients became pregnant 24 months after surgery. Decreased pregnancy rates are observed when other infertility factors are associated. Concerning myomectomy in medically assisted procreation, conflicting results are available. Prospective randomised studies are needed.

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.