Fibroids and infertility: a systematic review of the evidence

Approaches to improve the diagnosis and management of infertility

BACKGROUND Recent advances in our understanding of the causes of infertility and of assisted reproductive technology (ART) have led to the development of complex diagnostic tools, prognostic models and treatment options. The Third Evian Annual Reproduction (EVAR) Workshop Meeting was held on 26-27 April 2008 to evaluate evidence supporting current approaches to the diagnosis and management of infertility and to identify areas for future research efforts. METHODS Specialist reproductive medicine clinicians and scientists delivered presentations based on published literature and ongoing research on patient work-up, ovarian stimulation and embryo quality assessment during ART. This report is based on the expert presentations and subsequent group discussions and was supplemented with publications from literature searches and the authors' knowledge. RESULTS It was agreed that single embryo transfer (SET) should be used with increasing frequency in cycles of ART. Continued improvements in cryopreservation techniques, which improve pregnancy rates using supernumerary frozen embryos, are expected to augment the global uptake of SET. Adaptation and personalization of fertility therapy may help to optimize efficacy and safety outcomes for individual patients. Prognostic modelling and personalized management strategies based on individual patient characteristics may prove to represent real progress towards improved treatment. However, at present, there is limited good-quality evidence to support the use of these individualized approaches. CONCLUSIONS Greater quality control and standardization of clinical and laboratory evaluations are required to optimize ART practices and improve individual patient outcomes. Well-designed, good-quality studies are required to drive improvements to the diagnosis and management of ART processes.

Role of hysteroscopy prior to assisted reproductive techniques

BACKGROUND

There have been numerous advances in the area of assisted reproduction. Among the various reasons of implantation failure, intrauterine lesions play an important role.

OBJECTIVE

The aim of the present study is to evaluate the role of hysteroscopy prior to any assisted reproductive technique.

MATERIALS AND METHODS

It is a retrospective study of 292 women who attended our infertility clinic over a period of 18 months, who had a variable number of failed IVF cycles previously.

RESULTS

Out of the 292 women studied, in 74 women, that is 25%, intrauterine pathology was detected, which when rectified by hysteroscopy, gave a considerable increase in pregnancy rate.

CONCLUSION

According to this study it can be concluded that evaluating the uterine cavity is an important step before any assisted reproductive procedures.

Submucosal uterine leiomyomas have a global effect on molecular determinants of endometrial receptivity

OBJECTIVE

To evaluate the effect of uterine leiomyomas on the endometrium using molecular markers of endometrial receptivity: HOXA10, HOXA11, LIF, and BTEB1.

DESIGN

Case-control study.

SETTING

University medical center.

PATIENT(S)

Thirty reproductive-aged women with submucosal, intramural, or no uterine myomas who underwent hysteroscopy or hysterectomy.

INTERVENTION(S)

Proliferative phase endometrial sampling was performed at the time of surgery. In uteri with a submucosal myoma, directed endometrial biopsies were obtained over the myoma and over normal myometrium.

MAIN OUTCOME MEASURE(S)

Endometrial HOXA10 expression was evaluated as a primary endpoint using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and immunohistochemistry. HOXA11, BTEB1, and LIF were evaluated using real-time RT-PCR.

RESULT(S)

Endometrial HOXA10 and HOXA11 messenger RNA (mRNA) expression were significantly decreased in uteri with submucosal myomas compared with controls and with uteri with intramural myomas. A similar trend was seen in BTEB1 mRNA expression; however, no difference was found in LIF mRNA expression. Immunohistochemistry localized the decrease in endometrial HOXA10 protein expression to stroma. In the presence of a submucosal myoma, there were no regional differences in gene expression.

CONCLUSION(S)

The molecular mechanism by which submucosal myomas adversely affect reproduction includes a global decrease in endometrial HOX gene expression, not simply a focal change over the myoma. This may explain the reproductive dysfunction observed with submucosal myomas.

Impact of fibroids on reproductive function

There is debate regarding whether fibroids cause infertility or if they are simply an association. However, it is possible that fibroids are responsible for 2-3% of cases of infertility. The mechanisms by which these benign tumours could cause impaired reproductive function, both in terms of difficulty conceiving and early pregnancy loss, remain unclear. Myomectomy facilitates removal of a fibroid with preservation of reproductive potential. The procedure is associated with significant risks but, overall, some studies have suggested that this surgical option increases pregnancy rates significantly in women with fibroid-associated infertility. Miscarriage rates in women with fibroids and those who have undergone myomectomy vary considerably. It appears that miscarriage rates fall after myomectomy, although the overall rates of pregnancy loss remain higher than those seen in the general population. Fibroids affect 0.1-3.9% of pregnancies, and a number of complications encountered antenatally and post partum are thought to be directly related to the presence of these benign tumours. A number of contraceptive options exist for women with fibroids, with the choice depending on patient preference and both fibroid and patient characteristics.

Fibroids and reproductive outcomes: a systematic literature review from conception to delivery

We examined the published relationship between uterine fibroids and reproductive outcomes. Submucosal fibroids had the strongest association with lower ongoing pregnancy rates, odds ratio, 0.5; 95% confidence interval, 0.3-0.8, primarily through decreased implantation. Cumulative pregnancy rates appeared slightly lower in patients with intramural fibroids 36.9% vs 41.1%, which may reflect biases in the literature; however, patients with intramural fibroids also experienced more miscarriages, 20.4% vs 12.9%. Adverse obstetric outcomes are rare and may reflect age or other differences in fibroid populations. Increased risk of malpresentation (odds ratio, 2.9; 2.6-3.2), cesarean (odds ratio, 3.7; 3.5-3.9), and preterm delivery (odds ratio, 1.5; 1.3-1.7) are reported; however, the incidence of labor dystocia was low (7.5%). There was no conclusive evidence that intramural or subserosal fibroids adversely affect fecundity. More prospective, controlled trials are needed to assess the effects of myomectomy. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids.

Asymptomatic uterine fibroids

It is estimated that at least 50% of fibroids are asymptomatic, but this figure is likely to be an underestimate as it is based on women in whom fibroids are found incidentally during another procedure (e.g. cervical screening), and there is little, if any, data from population studies on the true incidence of fibroids. If a prevalence of 50% by 50 years of age is accepted, a large number of women have asymptomatic fibroids. Working on the cliché, 'if it ain't broken, don't fix it', it may seem surprising that there should be a chapter dedicated to the issue of asymptomatic fibroids, since the simplistic approach might be to leave the asymptomatic fibroids well alone. However, asymptomatic fibroids may become symptomatic in the future, so it may be wiser to treat fibroids before they grow to a size when they become symptomatic, or treatment becomes more challenging, especially in young women who may desire fertility at a later stage, and in view of the fact that many women are starting their families in their mid-thirties when they have a 30% chance of having a fibroid(s). Despite their common occurrence, fibroids are still poorly understood. It is not known why they form in the first place, what determines their number and ultimate size, the best treatment approaches, or the factors that determine which women develop symptoms. Even when women present with disorders such as infertility, pelvic pain and abnormal bleeding, it is not always possible to be certain that a given myoma is not simply an innocent bystander rather than the cause of the symptom. This chapter addresses the challenging issue of what to do when fibroids are diagnosed incidentally. Firstly, there is the need to ascertain that the pelvic mass palpated is indeed a fibroid, and not an early, more sinister tumour, especially if conservative management is adopted. In addition, there is the issue of size, position and potential for becoming symptomatic at a later date. With the availability of uterine-preserving and largely non-invasive treatment modalities, should more asymptomatic, younger women be offered treatment if it is deemed that their fibroids may cause problems as they grow? Where treatment is not offered, is it necessary to follow-up such women, and if so, with what modality of surveillance and how frequently?

Infertility treatment: the viability of the laparoscopic view

Assisted reproductive technology (ART) and laparoscopy are not mutually exclusive, but coexisting and potentially complimentary treatments. For disease conditions contributing to infertility in addition to other concomitant or potential morbidity, laparoscopy represents a more comprehensive approach.

Thrombospondin-1 and thrombospondin-2 mRNA and TSP-1 and TSP-2 protein expression in uterine fibroids and correlation to the genes COL1A1 and COL3A1 and to the collagen cross-link hydroxyproline

Uterine fibroids are composed of altered collagen fibrils and represent an arrested response to injury-initiating fibrosis. In many tissues, TSP-1 is secreted by adult macrophages and monocytes upon wounding and is involved in the activation of transforming growth factor beta. In the absence of TSP-1, the orchestrated process of wound healing is impaired. The authors obtained tissue from the edge and center of fibroids at the time of hysterectomy and compared them with adjacent myometrium. The pattern of TSP-1 and TSP-2 expression was correlated to that of COL1A1 and COL3A1. Collagen and hydroxyproline were increased in fibroids. Thrombospondin-1 was consistently underexpressed in both the edge and center of the fibroids, while COL1A1 and COL3A1 were consistently overexpressed. However, TSP-2 was inconsistently expressed. These findings lead to the conclusion that the underexpression of TSP-1 may contribute to the overall development of uterine fibroids.

Do uterine fibroids affect IVF outcomes?

The effect of myomectomy on implantation and pregnancy rates prior to assisted reproduction treatments is controversial. This study was designed to assess clinical outcomes of IVF cycles in women with uterine fibroids. A retrospective single-centre assessment of clinical outcomes of IVF/intracytoplasmic sperm injection (ICSI) treatments in infertile women in a 4-year span was carried out. All patients underwent detailed transvaginal ultrasound and hysteroscopy to precisely identify presence, location and intracavitary growth of uterine fibroids. Cumulative pregnancy, ongoing pregnancy and live birth rates were considered primary outcome measurements. Fifty-one women with fibroids (97 treatment cycles), 63 patients with previous myomectomy (127 cycles), and 106 infertile women who did not demonstrate fibroids anywhere in the uterus (215 cycles) were considered for the analysis. No significant difference was found for pregnancy and live birth rates between groups. Women with fibroids>4 cm required an increased number of cycles to obtain an ongoing pregnancy, compared with the other groups. The data do not support pre-IVF myomectomy in women with small-to-moderate uterine fibroids, regardless of their location. This represents valuable information in the counselling of women with fibroids before reproductive assisted cycles.

Successful pregnancies in women with diffuse uterine leiomyomatosis after hysteroscopic management

OBJECTIVE

To describe the surgical and reproductive outcomes of early diffuse uterine leiomyomatosis with hysteroscopic myomectomy.

DESIGN

Retrospective report.

SETTING

University hospital.

PATIENT(S)

Five consecutive women of reproductive age with innumerable small-sized (0.5-3 cm) diffuse uterine myomas with profuse menorrhagia.

INTERVENTION(S)

Use of hysteroscopic myomectomy to excise only myomas impinging into the endometrial cavity, while leaving other intramural myomas in place.

MAIN OUTCOME MEASURE(S)

Postoperative synechiae, recurrence, menstrual amount, conception, and pregnancy outcome.

RESULT(S)

A total of 10 hysteroscopic surgeries were performed, among which 1 patient had repeated adhesiolysis for postoperative synechiae, 2 experienced repeated myomectomy because of submucosal myoma recurrence, and 1 underwent a scheduled two-step procedure with gonadotropin-releasing hormone analogue treatment in between. The uterus was successfully preserved and a normal amount of menstruation was restored in all (5/5) patients. All (3/3) patients who wished to conceive had successful conceptions, with four healthy deliveries.

CONCLUSION(S)

Women with early-stage diffuse uterine leiomyomatosis can be treated by hysteroscopic resection, which has the benefits of preserving the uterus successfully, conceding a limited recurrence rate, and yielding satisfactory reproductive outcomes.

The impact of uterine artery embolization on fertility and pregnancy outcome

PURPOSE OF REVIEW

Uterine artery embolization for management of symptomatic fibroids is an effective and increasingly popular treatment option. There are several studies evaluating the effects of uterine artery embolization on later pregnancies; however, the effects on fertility are still largely uncertain. This paper reviews the current literature on the effects of this technique on fertility and pregnancy outcome.

RECENT FINDINGS

Two recent studies have reported pregnancy rates following uterine artery embolization in women seeking pregnancy. A small, third study reported preliminary results in a randomized controlled trial comparing uterine artery embolization with myomectomy in women wishing to preserve fertility.

SUMMARY

The body of medical literature supports use of uterine artery embolization as an effective treatment for symptoms of vaginal bleeding and pelvic pressure from uterine fibroids. Patient selection is critical in determining the appropriateness of this treatment option. Myomectomy remains the standard of care for women with symptomatic fibroids seeking fertility preservation.

Magnetic Resonance Imaging (MRI) Analysis of Fibroid Location in Women Achieving Pregnancy After Uterine Artery Embolization

The purpose of this study was to evaluate the fibroid morphology in a cohort of women achieving pregnancy following treatment with uterine artery embolization (UAE) for symptomatic uterine fibroids. A retrospective review of magnetic resonance imaging (MRI) of the uterus was performed to assess pre-embolization fibroid morphology. Data were collected on fibroid size, type, and number and included analysis of follow-up imaging to assess response. There have been 67 pregnancies in 51 women, with 40 live births. Intramural fibroids were seen in 62.7% of the women (32/48). Of these the fibroids were multiple in 16. A further 12 women had submucosal fibroids, with equal numbers of types 1 and 2. Two of these women had coexistent intramural fibroids. In six women the fibroids could not be individually delineated and formed a complex mass. All subtypes of fibroid were represented in those subgroups of women achieving a live birth versus those who did not. These results demonstrate that the location of uterine fibroids did not adversely affect subsequent pregnancy in the patient population investigated. Although this is only a small qualitative study, it does suggest that all types of fibroids treated with UAE have the potential for future fertility.

Uterine myomas: management

OBJECTIVE

To review the currently available literature regarding the current management alternatives available to women with uterine myomas.

DESIGN

Literature review of 198 articles pertaining to uterine myomas.

RESULT(S)

Many advances have been made in the management of uterine myomas. Watchful waiting; medical therapy; hysteroscopic myomectomy; endometrial ablation; laparoscopic myomectomy; abdominal myomectomy; abdominal, vaginal, and laparoscopic hysterectomy; uterine artery embolization; uterine artery occlusion; and focused ultrasound are now available.

CONCLUSION(S)

Many options are now available to women with uterine myomas. The presently available literature regarding the treatment of myomas is summarized.

Focused ultrasound surgery of intramural leiomyomas may facilitate fertility: A case report

OBJECTIVE

To describe a successful pregnancy after a change in configuration of the endometrial cavity after magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) for leiomyomas.

DESIGN

Case report.

SETTING

University hospital.

PATIENT

A 40-year-old woman with known leiomyomas and a history of secondary infertility.

INTERVENTION

Magnetic resonance imaging-guided focused ultrasound surgery treatment of two intramural myomas, one with a significant submucosal component.

MAIN OUTCOME MEASURE

Change in conformation of the uterine cavity.

RESULT(S)

A viable intrauterine pregnancy, with full-term uneventful labor and vaginal delivery.

CONCLUSION(S)

Magnetic resonance imaging-guided focused ultrasound surgery changed the configuration of the endometrial cavity, and a subsequent pregnancy resulted in a term delivery.

Uterine fibroids: a review of health-related quality of life assessment

OBJECTIVE

To summarize the literature describing the impact of uterine fibroids on health-related quality of life (HRQOL), the measures used to assess HRQOL, and related areas for future research.

METHODS

A search of three electronic databases (MEDLINE, Embase, and Current Contents) was performed, and 40 papers were identified referencing leiomyoma or uterine fibroids and (health-related) quality of life (HRQOL). Studies including women with benign gynecological conditions other than uterine fibroids were also reviewed.

RESULTS

The EQ-5D, SF-36, and related generic measures are used to assess HRQOL in women with diverse gynecological conditions, including uterine fibroids. The UFS-QOL, a condition- specific measure, provides scores on symptom severity and six HRQOL dimensions. All instruments consistently demonstrate that HRQOL is considerably impaired in women with symptomatic uterine fibroids and that appropriate treatment can lead to improved QOL.

CONCLUSIONS

The published data on HRQOL associated with uterine fibroids report significantly lower HRQOL scores for women with fibroids than for women without this disorder. Additional research is needed to confirm these findings and provide greater detail describing the specific domains most affected by uterine fibroids. These advances are necessary to effectively compare new treatment modalities vs. standard invasive therapies, such as hysterectomy.

Laparoscopic Myomectomy and Abdominal Myomectomy

Most women develop myomas during their lifetimes; however, 80% are asymptomatic. When symptoms are determined to be caused by myomas, a number of management options exist that include "watchful waiting," medical therapy, surgery, or more recently uterine artery embolization and focused ultrasound. Myomectomy, either abdominal or laparoscopic, is an approach particularly suited for those women who wish future fertility. It seems clear that, in well trained and experienced hands, well-selected patients can have myomectomy performed under laparoscopic direction. Very large myomas are not as suitable for the laparoscopic approach, but are amenable to a uterine conserving procedure via laparotomy that is facilitated by a number of preoperative and intraoperative measures aimed to minimize or replace operative blood loss. These techniques should provide selected women a uterine conserving procedure with reduced morbidity.

Hysteroscopic Treatment of Submucous Myomas

Submucous myomas can cause heavy bleeding, pain, and infertility. Sonohysterography and office hysteroscopy can provide accurate diagnosis. Classification systems have been developed to help predict the difficulty of resection. Patient selection and proper surgical technique are essential to achieve good results and reduce the risk of complications. Hysteroscopic treatment can in many cases provide excellent results and eliminate the need for major surgery.

The second National Institutes of Health International Congress on advances in uterine leiomyoma research: conference summary and future recommendations

OBJECTIVE

To summarize the proceedings of the Advances in Uterine Leiomyoma Research: 2nd NIH International Congress, which was convened on February 24-25, 2005 by the Department of Health and Human Services (DHHS), National Institutes of Health (NIH) in Bethesda, Maryland.

DESIGN

Scientific information was presented at a 2-day conference, which was a collaborative effort of agencies across the DHHS and members of the academic, clinical, and medical communities involved in uterine leiomyoma research.

CONCLUSION(S)

The conference brought together scientists in biomedicine, epidemiology, basic research, therapeutics, and translational medicine and fostered an exchange of scientific information among members of the uterine leiomyoma research and health care communities. This document summarizes this exchange and outlines research needs and recommendations for future research directions.

Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies

OBJECTIVE

This study was undertaken to evaluate the incidence and outcome of pregnancies after uterine artery embolization (UAE) for symptomatic uterine fibroids.

STUDY DESIGN

A retrospective analysis of all pregnancies after UAE by a single interventional radiologist.

RESULTS

Fifty-six completed pregnancies were identified in approximately 1200 women after UAE. One hundred eight patients were attempting to become pregnant and 33 of these became pregnant. Thirty-three (58.9%) of the 56 pregnancies had successful outcomes. Six (18.2%) of these were premature. Seventeen (30.4%) pregnancies miscarried. There were 3 terminations, 2 stillbirths, and 1 ectopic pregnancy. Of the 33 deliveries, 24 (72.7%) were delivered by cesarean section. There were 13 elective sections and the indication for 9 was fibroids. There were 6 cases of postpartum hemorrhage (18.2%).

CONCLUSION

Compared with the general obstetric population, there is a significant increase in delivery by cesarean section and an increase in preterm delivery, postpartum hemorrhage, miscarriage, and lower pregnancy rates. When taking into account the demographics of the study population, these results can be partly explained. There were no other obstetric risk identified.

Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy

PURPOSE OF REVIEW

The management of uterine fibroids in patients requiring treatment who desire future fertility remains controversial. Myomectomy has been the most common operative procedure to improve pregnancy rates and outcomes. Uterine fibroid embolization is an increasingly popular, minimally invasive treatment for fibroids. This review aims to provide critical analysis of available data on pregnancy following myomectomy and uterine artery embolization.

RECENT FINDINGS

Patients with distorted uterine cavities due to submucosal fibroids of more than 2 cm have higher pregnancy rates following hysteroscopic resection. Pregnancy rates following myomectomy, both via laparoscopy and laparotomy, are in the 50-60% range, with most having good outcomes. Pregnancy rates following uterine artery embolization have not been established. Pregnancies following uterine artery embolization had higher rates of preterm delivery (odds ratio 6.2, 95% confidence interval 1.4-27.7) and malpresentation (odds ratio 4.3, 95% confidence interval 1.0-20.5) than pregnancies following laparoscopic myomectomy.

SUMMARY

Both myomectomy and uterine artery embolization are safe and effective fibroid treatments, which should be discussed with appropriate candidates. Pregnancy complications, most importantly preterm delivery, spontaneous abortion, abnormal placentation and postpartum hemorrhage, are increased following uterine artery embolization compared to myomectomy. Although most pregnancies following uterine artery embolization have good outcomes, myomectomy should be recommended as the treatment of choice over uterine artery embolization in most patients desiring future fertility.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are benign tumours of the uterus occurring in up to 77% of women. Fibroids have been noted to occur more frequently in women with infertility. Retrospective studies have suggested the benefit of surgically removing fibroids to increase the fertility efficacy of both natural conception and assisted conception. There are a variety of methods to surgically remove fibroids including laparotomy, laparoscopy and hysteroscopy. The relative advantages and disadvantages of these modalities in terms of fertility efficacy and side effects are unknown.

OBJECTIVES

To determine the efficacy and safety of the removal of uterine fibroids in subfertile women by laparotomy, laparoscopy or hysteroscopy when compared with expectant management or each other. The review will include also new surgical approaches as and when they are trialed.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Review Group Specialised register of controlled trials, MEDLINE (PUBMED) 1985 to 2004, EMBASE (1985 to 2004), CINAHL (1985 to 2004) and National Research Register.

SELECTION CRITERIA

Randomised controlled trials (RCTs) in which fibroids were removed via surgery for the treatment of infertility

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data.

MAIN RESULTS

Only one randomized controlled study was included (131 women) and this was probably underpowered. There was no evidence of a difference in outcome in terms of clinical pregnancy rate and live birth rate when fibroids were removed via laparotomy or laparoscopy for infertility. There were some non fertility benefits of removal via laparoscopy including shorter hospital stay, less febrile illness and a smaller drop in pre-operative haemoglobin concentration when compared to laparotomy. There were no randomised controlled studies comparing hysteroscopic removal or no intervention with other surgical modalities.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that there is no difference in fertility efficacy outcome if fibroids are removed via laparotomy when compared to laparoscopy. There is no good randomised controlled evidence to support hysteroscopic removal of fibroids compared to other surgical modalities for fertility efficacy.

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.

Conservative Surgical Management of Uterine Myomas

Uterine fibroids are a major gynecologic problem in American women, and several alternatives have been developed. Conservative treatment, with the goal of treating the fibroid but retaining the uterus, is a frequent choice among women who require therapy during their early to middle reproductive years. A variety of conservative surgical approaches exist; each has advantages and disadvantages for the clinician and the patient. Some are well-established techniques, whereas others are still in the investigational stage. None has been evaluated adequately for its effects on future fertility. To this end, it is imperative that investigators continue to evaluate these surgical procedures so that the clinician can provide accurate and comprehensive information when faced with a patient who desires one or more of these approaches. Furthermore, it is critical for the practitioner to stay informed about these procedures so that patients can be given a full complement of options.

Clinical Features of Myomas

Uterine myomas are the most common solid pelvic tumors in women and the primary indication for hysterectomy. Most of the myomas are asymptomatic. The most common symptoms associated with uterine myomas are abnormal uterine bleeding and pelvic discomfort mostly caused by the mass effect. Vaginal bleeding may lead to iron deficiency anemia. Uterine myomas have a significant role in reproductive dysfunction, although a causal relationship between infertility and intramural or subserosal myomas not disturbing the uterine cavity has not been established clearly. Nevertheless myomas, especially the tumors distorting the uterine cavity, are associated with infertility and spontaneous miscarriage. In addition, the myomas may be the potential cause for numerous obstetric complications, especially if they are located adjacent to placenta. The transformation of myomas to leiomyosarcomas is a very rare event. Leiomyosarcomas may be suspected in postmenopausal women with rapidly growing symptomatic solid pelvic mass. Despite the high prevalence of these tumors, there is paucity of data available regarding the natural clinical history of myomas.

Uterine Artery Embolization and Infertility

As the acceptance of uterine artery embolization as a treatment option for uterine fibroids grows among patients and physicians, it appears that new questions are being asked about the patient selection criteria used for this procedure. In particular, patients with infertility issues or concerns about preserving fertility after fibroid treatment are often being evaluated for uterine artery embolization. This article was prepared to summarize the available literature regarding fertility preservation after both myomectomy and uterine artery embolization and to provide the reader with an algorithm for evaluating these patients and making literature-based treatment decisions.

Effect of myomectomy on the outcome of assisted reproductive technologies

OBJECTIVE

To evaluate the impact of myomectomy on in vitro fertilization-embryo transfer (IVF-ET) and oocyte donation cycle outcome.

DESIGN

Retrospective case-controlled study of consecutive fresh IVF-ET and oocyte donation patients during a 2-year interval.

SETTING

Private assisted reproductive technology (ART) center.

PATIENT(S)

Patients with submucosal leiomyomata resected hysteroscopically (group A: 15 oocyte donor recipients; group 1 = 31 IVF-ET patients) and those with intramural components or strictly intramural leiomyomata that distorted or impinged upon the endometrial cavity resected at laparotomy (group B = 26 oocyte donor recipients; group 2 = 29 IVF-ET patients).

INTERVENTION(S)

Precycle hysteroscopic or abdominal myomectomy and subsequent fresh IVF-ET or oocyte donation.

MAIN OUTCOME MEASURE(S)

Results of controlled ovarian hyperstimulation as well as ongoing pregnancy and implantation rates were evaluated in comparison with contemporaneous patient groups without such lesions (group C = 552 oocyte donor recipients; group 3: 896 IVF-ET patients).

RESULT(S)

As would be expected, the mean number and size of leiomyomata were significantly larger in patients who underwent abdominal myomectomy. However, neither ongoing pregnancy nor implantation rates were significantly different in comparison with controls among either oocyte donor recipients (group A: 86.7%, 57.8%; group B: 84.6%, 55.2%; group C 77%, 49.1%). The findings were similar for those undergoing IVF-ET in comparison with controls (group 1: 61%, 24%; group 2: 52%, 26%; group 3: 53%, 23%).

CONCLUSION(S)

Precycle resection of appropriately selected clinically significant leiomyomata results in IVF-ET or oocyte donation cycle outcomes that are similar to controls.

Successful spontaneous pregnancy following surgical removal of a post uterine artery embolized necrotic fibroid capsule: a case report

Uterine artery embolization has been shown to be an effective treatment in controlling symptomatic uterine fibroids. Reports suggest that significant complications associated with the procedure are rare. However, data pertaining to preservation of fertility after embolization are scarce, and some authors do not advocate this procedure for women considering future pregnancy. We present a case of a post-embolization uterine cavity abnormality which was repaired surgically, followed by successful pregnancy outcome.

Hysteroscopic management in submucous fibroids to improve fertility

OBJECTIVE

To evaluate prospectively the reproductive performance following hysteroscopic myomectomy in women with submucous fibroids and wishing a pregnancy.

STUDY DESIGN

Twenty-nine consecutive women wishing a pregnancy with a previously diagnosed submucous fibroid as a sole cause for reproductive failure were treated by hysteroscopic myomectomy. Fourteen women suffered from primary infertility and 15 women had previous pregnancies with a poor obstetric outcome. The myomas were intracavitary (n = 25) and intramural class 1 (n = 4). None of the patients had type 2 or multiple submucousal fibroids. Myoma size was not larger than 5 cm (the mean was 13.3 mm). Before myomectomy, the outcome reproductive data were recorded prospectively. Following myomectomy, the cumulative rate of first pregnancies, live birth rate and the hysteroscopic anatomical results were assessed and compared with that before surgery.

RESULTS

The mean duration of follow-up before and after myomectomy was comparable. Twenty-one women (72.4%) experienced 30 pregnancies after myomectomy. Thirteen women gave birth to 16 live infants. Compared with previous pregnancies, the rate of deliveries increased from 3.8% to 63.2% and the abortion rate decreased from 61.6% to 26.3%. No complications occurred during myomectomy. The hysteroscopic anatomical results were good in the majority of cases.

CONCLUSIONS

This prospective study demonstrates that hysteroscopic myomectomy at present is the method of choice to improve the cumulative pregnancy rate as well as the live birth rate in selected women with submucous myomas and a history of reproductive failure.

Submucous myomas: A new presurgical classification to evaluate the viability of hysteroscopic surgical treatment—Preliminary report

STUDY OBJECTIVE

To develop a new preoperative classification of submucous myomas for evaluating the viability and the degree of difficulty of hysteroscopic myomectomy.

DESIGN

Retrospective study (Canadian Task Force classification II-3)

SETTING

University teaching hospitals.

PATIENTS

Fifty-five patients who underwent hysteroscopic resection of submucous myomas.

INTERVENTION

The possibility of total resection of the myoma, the operating time, the fluid deficit, and the frequency of any complications were considered. The myomas were classified according to the Classification of the European Society for Gynaecological Endoscopy (ESGE) and by our group's new classification (NC), which considers not only the degree of penetration of the myoma into the myometrium, but also adds in such parameters as the distance of the base of the myoma from the uterine wall, the size of the nodule (cm), and the topography of the uterine cavity. The Fisher's exact test, the Student's t test, and the analysis of variance test were used in the statistical analysis. A p value less than .05 in the two-tailed test was considered significant.

MEASUREMENTS AND MAIN RESULTS

In 57 myomas, hysteroscopic surgery was considered complete. There was no significant difference among the three ESGE levels (0, 1, and 2). Using the NC, the difference between the numbers of complete surgeries was significant (p <.001) for the two levels (groups I and II). The difference between the operating times was significant for the two classifications. With respect to the fluid deficit, only the NC showed significant differences between the levels (p = .02).

CONCLUSIONS

We believe that the NC gives more clues as to the difficulties of a hysteroscopic myomectomy than the standard ESGE classification. It should be stressed that the number of hysteroscopic myomectomies used in this analysis was low, and it would be interesting to evaluate the performance of the classification in a larger number of patients.