Surgical treatment of fibroids for subfertility

Uterine Leiomyomas and Infertility: A Comparison of National and International Guidelines

Uterine leiomyomas are the most common benign tumors of the female genital track, causing various symptoms and problems, including a possible impact on fertility. The relationship between fibroids and infertility has long been a debate among gynecologists. Management of fibroids in women with otherwise unexplained infertility worldwide lacks standardized, evidence-based guidelines. Therefore, a review of guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynecologists, the American College of Obstetricians and Gynecologists, the Society of Obstetricians and Gynecologists of Canada, the Collège National des Gynécologues et Obstétriciens Français, and the American Society of Reproductive Medicine was conducted. There is agreement among all guidelines that the effect of fibroids on fertility is related to their position in the uterus and the alteration of the endometrial cavity. However, whether surgical intervention (laparotomy, laparoscopy, or hysteroscopy) is required varies among committees. More specifically, for submucous myomas, all guidelines agree that surgical intervention is needed. On the other hand, regarding intramural myomas, there is no consensus on what the approach may be. Novel treatments such as uterine artery embolization (UAE) and magnetic resonance-guided focused ultrasound surgery (MRgFUS) should only be used in clinical trial settings. Nevertheless, all guidelines agree that medical management of fibroids further delays efforts to conceive and has no role as a stand-alone treatment of fibroids; though, the use of GnRH analogues preoperatively can be useful to improve anemia and/or reduce fibroid volume. There is a need for updated international protocols to be introduced, in order to help clinicians dealing with fibroids and infertility to better suggest the optimal treatment.

Physiologic Events of Embryo Implantation and Decidualization in Human and Non-Human Primates

Reproduction is a fundamental process for the preservation of the human species. This process requires a sequence of orchestrated events that are necessary for a successful pregnancy. Two of the most critical steps in the establishment of human pregnancy are implantation and decidualization, which are required for maternal interactions with the developing embryo. This review primarily highlights the physiological aspects of these two events and the adverse pregnancy outcomes from defective implantation and decidualization. The focus of this review is to provide a general concept of the mechanisms involved during the window of implantation, description of components involved in the process and possible pathologies that could disrupt the embryo implantation and decidualization and specifically as it applies to women and non-human primates.

Surgical treatment of fibroids for subfertility

BACKGROUND

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.

OBJECTIVES

To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Epistemonikos database, World Health Organization (WHO) International Clinical Trials Registry Platform search portal, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and reference list of relevant papers. The final search was in February 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

This review included four RCTs with 442 participants. The evidence was very low-quality with the main limitations being due to serious imprecision, inconsistency and indirectness. Myomectomy versus no intervention One study examined the effect of myomectomy compared to no intervention on reproductive outcomes. We are uncertain whether myomectomy improves clinical pregnancy rate for intramural (odds ratio (OR) 1.88, 95% confidence interval (CI) 0.57 to 6.14; 45 participants; one study; very low-quality evidence), submucous (OR 2.04, 95% CI 0.62 to 6.66; 52 participants; one study; very low-quality evidence), intramural/subserous (OR 2.00, 95% CI 0.40 to 10.09; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57; 42 participants; one study; very low-quality evidence). Similarly, we are uncertain whether myomectomy reduces miscarriage rate for intramural fibroids (OR 1.33, 95% CI 0.26 to 6.78; 45 participants; one study; very low-quality evidence), submucous fibroids (OR 1.27, 95% CI 0.27 to 5.97; 52 participants; one study; very low-quality evidence), intramural/subserous fibroids (OR 0.80, 95% CI 0.10 to 6.54; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 2.00, 95% CI 0.32 to 12.33; 42 participants; one study; very low-quality evidence). This study did not report on live birth, preterm delivery, ongoing pregnancy or caesarean section rate. Laparoscopic myomectomy versus myomectomy by laparotomy or mini-laparotomy Two studies compared laparoscopic myomectomy to myomectomy at laparotomy or mini-laparotomy. We are uncertain whether laparoscopic myomectomy compared to laparotomy or mini-laparotomy improves live birth rate (OR 0.80, 95% CI 0.42 to 1.50; 177 participants; two studies; I² = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I² = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I² = 0%, very low-quality evidence), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04; 115 participants; one study; very low-quality evidence), miscarriage rate (OR 1.25, 95% CI 0.40 to 3.89; participants = 177; two studies; I² = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I² = 21%, very low-quality evidence). Monopolar resectoscope versus bipolar resectoscope One study evaluated the use of two electrosurgical systems during hysteroscopic myomectomy. We are uncertain whether bipolar resectoscope use compared to monopolar resectoscope use improves live birth/ongoing pregnancy rate (OR 0.86, 95% CI 0.30 to 2.50; 68 participants; one study, very low-quality evidence), clinical pregnancy rate (OR 0.88, 95% CI 0.33 to 2.36; 68 participants; one study; very low-quality evidence), or miscarriage rate (OR 1.00, 95% CI 0.19 to 5.34; participants = 68; one study; very low-quality evidence). This study did not report on preterm delivery or caesarean section rate.

AUTHORS' CONCLUSIONS

There is limited evidence to determine the role of myomectomy for infertility in women with fibroids as only one trial compared myomectomy with no myomectomy. If the decision is made to have a myomectomy, the current evidence does not indicate a superior method (laparoscopy, laparotomy or different electrosurgical systems) to improve rates of live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage, or caesarean section. Furthermore, the existing evidence needs to be viewed with caution due to the small number of events, minimal number of studies and very low-quality evidence.

Laparoscopy or laparotomy as the way of entrance in myoma enucleation

PURPOSE

Uterine myomas are the main cause of benign uterine diseases in premenopausal women. Objective of the present paper is to investigate the current best treatment modalities of myomas, depending on age of the patient and her desire to preserve fertility, as well as on clinical presentation of this pathology, such as size, number, and location of fibroids and, furthermore, on surgical experience of the gynecologist.

METHODS

The design of our work is a systematic literature review of existing studies, reviews, and meta-analysis conducted in PubMed and Cochrane Library to identify relevant literature. Commonly, the myomectomy is to be recommended in women desiring to preserve fertility when myomas are associated with symptoms such as excessive bleeding, pelvic discomfort, or palpable abdominally fibroids. The decision of surgical approach for myomectomy should be individualized, depending on size and location, as well as on surgeon's experience. The different modalities of myomectomy, laparoscopic, hysteroscopic, robotic-assisted, or laparotomic are in detail presented in the paper, according to Society of Obstetricians and Gynecologists of Canada (SOGC) clinical practice guidelines and taking into consideration possible concerns of myomectomy such as uterine rupture, development of adhesions, and myomas' recurrence.

Fertility and Pregnancy Outcome after Myoma Enucleation by Minilaparotomy under Microsurgical Conditions in Pronounced Uterus Myomatosus

Introduction: Besides the typical complaints and symptoms, myomas can cause sterility, infertility and complications during pregnancy. Laparoscopic interventions reach their limits with regard to organ preservation and the simultaneous desire to have children in the removal of multiple and larger intramural myoma nodes. The aim of this study is to examine fertility status and pregnancy outcome after myoma removal by minilaparotomy (skin incision maximal 8 cm) in women with pronounced uterus myomatosus. Materials and Methods: This retrospective study makes use of the data from 160 patients with an average age of 34.6 years. Factors analysed include number, size and localisation of the myomas, complaints due to the myoma, pre- and postoperative gravidity, mode of delivery, and complications of birth. Results: Indications for organ-sparing myoma enucleation were the desire to have children (72.5 %), bleeding disorders (60 %) and pressure discomfort (36.5 %). On average 4.95 (SD ± 0.41), maximally 46 myomas were removed. The largest myoma had a diameter of 6.64 cm (SD ± 2.74). 82.5 % of the patients had transmural myomas, in 17.5 % the uterine cavity was inadvertently opened. On average the operating time was 163 minutes (SD ± 45.47), the blood loss 1.59 g/dL (SD ± 0.955). 60.3 % of the patients with the desire to have children became pregnant postoperatively. 75.3 % of the pregnancies were on average carried through to the 38th week (28.4 % vaginal deliveries, 71.6 % Caesarean sections). In the postoperative period there was one case of uterine rupture in the vicinity of a previous scar. Discussion: By means of the microsurgical "mini-laparotomy" even extensive myomatous uterine changes can, in the majority of cases, be operated in an organ-sparing manner with retention of the ability to conceive and to carry a pregnancy through to maturity of the infant. The risk for a postoperative uterine rupture in a subsequent pregnancy and during delivery is minimal.

Fibroids, infertility and laparoscopic myomectomy

Objective:

To review the literature and summarize the available evidence about the relationship of fibroids with infertility and to review the role of laparoscopic myomectomy in infertility.

Materials and Methods:

Medline, PubMed, and Cochrane Databases were searched for articles published between 1980 and 2010.

Results:

Fertility outcomes are decreased in women with submucosal fibroids, and myomectomy is of value. Subserosal fibroids do not affect fertility outcomes, and removal may not confer benefit. Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. Although pregnancy rates for women with leiomyomata, managed endoscopically, are similar to those after laparotomy, there is a risk of uterine rupture. The risk is essentially unknown. Finally, the risk of recurrence seems higher after laparoscopic myomectomy compared to laparotomy.

Conclusions:

Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique, with an extremely low failure rate and good results in terms of the outcome of pregnancy.

A national survey of endoscopic practice among gynaecologists in Canada

OBJECTIVE

To assess the current status of endoscopic gynaecological surgery in Canada, as well as the attitudes, perceptions, and educational preferences regarding endoscopy among Canadian obstetrician-gynaecologists.

METHODS

An electronic online survey was sent to 630 obstetrician-gynaecologists in Canada through the Society of Obstetricians and Gynaecologists of Canada electronic mailing list. Survey respondents were asked about demographic variables, level of training and current practice of endoscopic procedures, reasons for and barriers to performing endoscopy, and interest in continuing surgical education in laparoscopy and hysteroscopy.

RESULTS

A total of 178 responses (28.3%) were collected and 152 (85.4%) analyzed. The majority of respondents were general obstetrician-gynaecologists (78.0%). More gynaecologic surgeons performed abdominal (92.7%) and vaginal hysterectomies (89.7%) than laparoscopic (68.4%) and robotic hysterectomies (2.2%). Even though 93.2% of respondents selected the endoscopic approach as the preferred approach to surgery for their patients, 38.7% of respondents did not feel that they had adequate training during residency to perform endoscopy. Lack of operating room resources and lack of time and opportunity for further training were frequently selected as major barriers to performing endoscopy. Participants identified weekend continuing medical education courses and trained endoscopic surgeon outreach as preferred methods of acquiring endoscopic skills.

CONCLUSION

This survey provides a contemporary assessment of the current endoscopic practice patterns of Canadian obstetrician-gynaecologists, and it helps to identify some potentially modifiable factors hindering the practice of endoscopy and some possible solutions to overcoming these barriers.

Clinical 24 month experience of the first MRgFUS unit for treatment of uterine fibroids in Australia

AIM

To describe and evaluate treatment of uterine fibroids using Magnetic Resonance Guided Focused Ultrasound (MRgFUS) during its first 24 months of use at The Royal Women's Hospital Melbourne.

METHODS

One hundred Victorian women were treated with MRgFUS using the ExAblate 2000 system. Treatment outcomes based on fibroid volume shrinkage measured at 4 and 12 months post-treatment and symptom severity score assessment (Symptom Severity Score Quality of Life - SSS-QOL) pre- and post- (4-6 weeks, 4, 6 and 12 months) treatment.

RESULTS

Mean non-perfused volume of the treated fibroids were 67% ± 25% (n = 100) immediately post-treatment. At 4 months post-treatment, the treated fibroids demonstrated an average volume reduction of 29% ± 32% (n = 74) and at 12 months 38% ± 45% (n = 32). Mean symptom severity scores (SSS-QOL) improved by 51% from 59 ± 21 (n = 97) at baseline to 29 ± 17 (n = 36) by 12 months.

CONCLUSION

From our experience, we believe there is a role for MRgFUS in the treatment of uterine fibroids in selected women.

Management of uterine fibroids in the patient pursuing assisted reproductive technologies

Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Herbal preparations for uterine fibroids

BACKGROUND

Uterine fibroids are the most common non-malignant growths in women of childbearing age. They are associated with heavy menstrual bleeding and subfertility. Herbal preparations are commonly used as alternatives to surgical procedures.

OBJECTIVES

To assess the benefits and risks of herbal preparations for uterine fibroids.

SEARCH STRATEGY

Authors searched following electronic databases: the Trials Registers of the Cochrane Menstrual Disorders and Subfertility Group and the Cochrane Complementary Medicine Field, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, the Chinese Biomedical Database, the Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS), AMED, and LILACS. The searches ended on 31st December 2008.

SELECTION CRITERIA

Randomised controlled trials comparing herbal preparations with no intervention, placebo, medical treatment or surgical procedures in women with uterine fibroids. We also included trials of herbal preparations with or without conventional therapy.

DATA COLLECTION AND ANALYSIS

Two review authors collected data independently. We assessed trial risk of bias according to our methodological criteria . We presented dichotomous data as risk ratios (RR) and continuous outcomes as mean difference (MD), both with 95% confidence intervals (CI).

MAIN RESULTS

We included two randomised trials (involved 150 women) with clear description of randomisation methods. The methodological risk of bias of the trials varied. There were variations in the tested herbal preparations, and the treatment duration was six months. The outcomes available were not the primary outcomes selected for this review, such as symptom relief or the need for surgical treatment; trials mainly reported outcomes in terms of shrinkage of the fibroids.Compared with mifepristone, Huoxue Sanjie decoction showed no significant difference in the disappearance of uterine fibroids, number of patients with shrinking of uterine fibroids or average volume of uterine fibroids, but less effective than mifepristone on reducing average size of uterus (mean difference 23.23 cm(3),95% confidence interval 17.85 to 28.61). There was no significant difference between Nona Roguy herbal product and GnRH agonist in average volume of uterine fibroids or size of uterus. No serious adverse effects from herbal preparations was reported.

AUTHORS' CONCLUSIONS

Current evidence does not support or refute the use of herbal preparations for treatment of uterine fibroids due to insufficient studies of large sample and high quality. Further high quality trials evaluating clinically relevant outcomes are warranted.

Basic infertility including polycystic ovary syndrome

Infertility in women has many possible causes and must be approached systematically. The most common cause of medically treatable infertility is the polycystic ovary syndrome (PCOS). This syndrome is common in young women and is the cause of anovulatory infertility in 70% of cases. It is therefore an important condition to screen and manage in primary care medical settings. In the past 10 years, insulin sensitization with weight loss or metformin has been shown to be a safe and effective treatment for PCOS infertility that eliminates the risk of multiple pregnancy and may reduce the risk of early pregnancy loss as compared with ovulation-inductor drugs. The authors believe metformin should be considered as first-line therapy because it has the advantage to allow for normal single ovulation, for reduced early pregnancy loss, and, most importantly, lifestyle modifications and weight loss before pregnancy. Losing weight not only improves fertility but also reduces adverse pregnancy outcomes associated with obesity.

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.

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.

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.

Factors affecting reproductive outcome following abdominal myomectomy

PURPOSE

Fibroids may cause infertility and recurrent pregnancy loss. Studies have analysed the reproductive results after myomectomy according to the size, location and number of fibroids removed, but data are insufficient about comparison of opening the uterine cavity or not during surgery.

MATERIALS AND METHODS

Two hundred twenty-nine abdominal myomectomies with the indication of infertility and/or recurrent pregnancy loss were analysed retrospectively. The main purpose was to compare postoperative pregnancy, delivery and miscarriage rates according to either the uterine cavity was opened or not during the surgery. As a secondary outcome postoperative pregnancy rates were assessed by location, size and number of fibroids.

RESULTS

There was no significant difference in reproductive results according to either the uterine cavity was opened or remained closed. Preoperative location, size and number of fibroids did not influence significantly the postoperative pregnancy rates.

CONCLUSION

Opening the uterine cavity does not impair postoperative pregnancy rates. Preoperative location, size and number of fibroids do not influence postoperative reproductive results.