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Daniels J, Middleton LJ, Cheed V, McKinnon W, Sirkeci F, Manyonda I, Belli AM, Lumsden MA, Moss J, Wu O, McPherson K, On Behalf Of The Femme Trial Collaborative Group. Uterine artery embolization or myomectomy for women with uterine fibroids: Four-year follow-up of a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol X 2021; 13:100139. [PMID: 34877531 PMCID: PMC8633559 DOI: 10.1016/j.eurox.2021.100139] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To examine the quality of life experienced by women with symptomatic uterine fibroids who had been treated with UAE in comparison to myomectomy. We report the four-year follow-up of the FEMME randomised trial. Two-year follow-up data has been previously reported. Study Design Premenopausal women who had symptomatic uterine fibroids amenable to myomectomy or uterine artery embolization were recruited from 29 UK hospitals. Women were excluded if they had significant adenomyosis, any malignancy, pelvic inflammatory disease or had had a previous open myomectomy or uterine artery embolization. Participants were randomised to myomectomy or embolization in a 1:1 ratio using a minimisation algorithm. Myomectomy could be open abdominal, laparoscopic or hysteroscopic, according to clinician preference. Embolization of the uterine arteries was performed according to local practice, under fluoroscopic guidance. The primary outcome measure was the Uterine Fibroid Symptom Quality of Life questionnaire, adjusted for baseline score and reported here at four years post-randomisation. Subsequent procedures for fibroids, pregnancy and outcome were amongst secondary outcomes. Trial registration ISRCTN70772394 https://doi.org/10.1186/ISRCTN70772394 Results 254 women were randomized, 127 to myomectomy (105 underwent myomectomy) and 127 to uterine artery embolization (98 underwent embolization). At four years, 67 (53%) and 81 (64%) completed UFS-QoL quality of life scores. Mean difference in the UFS-QoL at 4 years was 5.0 points (95% CI −1.4 to 11.5; p = 0.13) in favour of myomectomy. There were 15 pregnancies in the UAE group and 7 in the myomectomy group, with a cumulative pregnancy rate to four years of 15% and 6% respectively (hazard ratio: 0.48; 95% CI 0.18–1.28). The cumulative repeat procedure rate to four years was 24% in the UAE group and 13% in the myomectomy group (hazard ratio: 0.53; 95% CI 0.27–1.05). Conclusions Myomectomy resulted in greater improvement in quality of life compared with uterine artery embolization, although by four years, this difference was not statistically significant. Missing data may limit the generalisability of this result. The numbers of women becoming pregnant were too small draw a conclusion on the effect of the procedures on fertility.
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Affiliation(s)
- Jane Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham NG7 2RD, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - William McKinnon
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham B15 2TT, UK
| | - Fusun Sirkeci
- Department of Obstetrics and Gynaecology, Whipps Cross Hospital, London E11 1NR, UK
| | - Isaac Manyonda
- Department of Gynaecology, St George's Hospital and Medical School, London SW17 0QT, UK
| | - Anna-Maria Belli
- Department of Radiology, St George's Hospital and Medical School, London SW17 0QT, UK
| | | | - Jonathan Moss
- School of Medicine, University of Glasgow, Glasgow G31 2ER, UK
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow G12 8RZ, UK
| | - Klim McPherson
- Department of Primary Care, University of Oxford, OX3 9DU, UK
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Abstract
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.
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Affiliation(s)
- Mostafa Metwally
- Sheffield Teaching HospitalsThe Jessop Wing and Royal Hallamshire HospitalSheffieldUKS10 2JF
| | - Grace Raybould
- University of SheffieldDepartment of Oncology & Metabolism, Academic Unit of Reproductive and Developmental MedicineSheffieldUK
| | - Ying C Cheong
- University of SouthamptonHuman Development and Health Academic Unit, Faculty of MedicineLevel F, Princess Anne HospitalCoxford RoadSouthamptonUKSO16 5YA
| | - Andrew W Horne
- University of EdinburghMRC Centre for Reproductive HealthQueen's Medical Research Institute47 Little France CrescentEdinburghUKEH16 4TJ
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Ali M, Al-Hendy A. Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids. Biol Reprod 2018; 97:337-352. [PMID: 29025038 PMCID: PMC5803778 DOI: 10.1093/biolre/iox094] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/23/2017] [Indexed: 12/15/2022] Open
Abstract
Uterine fibroids (UFs, AKA leiomyoma) are the most important benign neoplastic threat to women's health, with costs up to hundreds of billions of health care dollars worldwide. Uterine fibroids caused morbidities exert a tremendous health toll, impacting the quality of life of women of all ethnicities, especially women of color. Clinical presentations include heavy vaginal bleeding, pelvic pain, bulk symptoms, subfertility, and obstetric complications. Current management strategies heavily lean toward surgical procedures; nonetheless, the choice of treatment is generally subject to patient's age and her desire to preserve future fertility. Women with UF who desire to maintain future fertility potential face a dilemma because of the limited treatment choices that are currently available to help them achieve that goal. Recently, ulipristal acetate the first of the promising family of oral selective progesterone receptor modulators has been approved for UF treatment in Europe, Canada, and several other countries and is under review for possible approval in the USA. In this review article, we discuss recent advances in the management options against UF with a bend toward oral effective long-term treatment alternatives who are particularly suited for those seeking to preserve their future fertility potential. We also explore the transformative concept of primary and secondary UF prevention using these new anti-UF agents. We envision a remarkable shift in the management of UF in future years from surgical/invasive treatment to orally administrated options; clearly, this potential shift will require additional intense clinical research.
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Affiliation(s)
- Mohamed Ali
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA.,Clinical Pharmacy department, Faculty of pharmacy, Ain Shams University, Cairo, Egypt
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
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Hartmann KE, Velez Edwards DR, Savitz DA, Jonsson-Funk ML, Wu P, Sundermann AC, Baird DD. THE AUTHORS REPLY. Am J Epidemiol 2018; 187:1133-1134. [PMID: 29547991 DOI: 10.1093/aje/kwy033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/13/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Katherine E Hartmann
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN
| | - Digna R Velez Edwards
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN
| | - David A Savitz
- Department of Epidemiology, Brown School of Public Health, Brown University, Providence, RI
- Department of Obstetrics and Gynecology, Brown Alpert Medical School, Brown University, Providence, RI
| | - Michele L Jonsson-Funk
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Pingsheng Wu
- Department of Biostatistics, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
| | - Alexandra C Sundermann
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
- Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN
| | - Donna D Baird
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
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Toth B, Würfel W, Bohlmann M, Zschocke J, Rudnik-Schöneborn S, Nawroth F, Schleußner E, Rogenhofer N, Wischmann T, von Wolff M, Hancke K, von Otte S, Kuon R, Feil K, Tempfer C. Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry Number 015/050). Geburtshilfe Frauenheilkd 2018; 78:364-381. [PMID: 29720743 PMCID: PMC5925690 DOI: 10.1055/a-0586-4568] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 03/05/2018] [Accepted: 03/06/2018] [Indexed: 12/13/2022] Open
Abstract
Purpose Official guideline of the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (ÖGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). The aim of this guideline was to standardize the diagnosis and treatment of couples with recurrent miscarriage (RM). Recommendations were based on the current literature and the views of the involved committee members. Methods Based on the current literature, the committee members developed the statements and recommendations of this guideline in a formalized process which included DELPHI rounds and a formal consensus meeting. Recommendations Recommendations for the diagnosis and treatment of patients with RM were compiled based on the international literature. Specific established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders were taken into consideration.
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Affiliation(s)
- Bettina Toth
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | | | | | - Johannes Zschocke
- Zentrum für Medizinische Genetik, Universität Innsbruck, Innsbruck, Austria
| | | | | | | | - Nina Rogenhofer
- Klinikum der Universität München - Frauenklinik Maistraße, München, Germany
| | - Tewes Wischmann
- Institut für Medizinische Psychologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Michael von Wolff
- Universitätsklinik für Frauenheilkunde, Inselspital Bern, Bern, Switzerland
| | - Katharina Hancke
- Klinik für Frauenheilkunde, Universitätsklinikum Ulm, Ulm, Germany
| | - Sören von Otte
- Kinderwunschzentrum, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Ruben Kuon
- Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Katharina Feil
- Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin, Universität Innsbruck, Innsbruck, Austria
| | - Clemens Tempfer
- Universitätsfrauenklinik, Ruhr-Universität Bochum, Bochum, Germany
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Hartmann KE, Velez Edwards DR, Savitz DA, Jonsson-Funk ML, Wu P, Sundermann AC, Baird DD. Prospective Cohort Study of Uterine Fibroids and Miscarriage Risk. Am J Epidemiol 2017; 186:1140-1148. [PMID: 28591761 DOI: 10.1093/aje/kwx062] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 01/05/2017] [Indexed: 12/14/2022] Open
Abstract
We sought to determine the relationship of fibroids to pregnancy loss in a prospective cohort in which fibroid status was uniformly documented in early pregnancy. Participants had an intake interview, transvaginal ultrasonography, computer-assisted telephone interview, and follow-up assessment of outcomes. We recruited diverse participants for the Right From the Start study from 8 metropolitan areas in 3 states in the United States during 2000-2012. Participants were at least 18 years of age, trying to become pregnant or at less than 12 weeks' gestation, not using fertility treatments, fluent in English or Spanish, and available for telephone interviews. Miscarriage was defined as loss before 20 weeks' gestation. Fibroid presence, number, type, and volume were assessed using standardized ultrasonography methods. We used proportional hazards models to estimate associations. Among 5,512 participants, 10.4% had at least 1 fibroid, and 10.8% experienced a miscarriage. Twenty-three percent had experienced a prior miscarriage and 52% prior births. Presence of fibroids was associated with miscarriage in models without adjustments. Adjusting for key confounders indicated no increase in risk (adjusted hazard ratio = 0.83, 95% confidence interval: 0.63, 1.08). No characteristic of fibroids was associated with risk. Prior evidence attributing miscarriage to fibroids is potentially biased. These findings imply that surgical removal of fibroids to reduce risk of miscarriage deserves careful scrutiny.
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Abstract
AbstractUterine fibroids affect a wide cross-section of the population, with prevalence, symptom severity, and overall disease burden generally higher among black women, likely due to both genetic and environmental factors. Potential symptoms of uterine fibroids include painful and excessive uterine bleeding, interference with everyday life and self-image, and impaired fertility. Because of the high estimated prevalence and costs associated with treatments, the direct and indirect costs of uterine fibroids are substantial for both the health care system and the individual patient. Special patient populations—such as black women, women seeking to retain fertility, and women with asymptomatic fibroids—have particular treatment needs that require a variety of diagnostic methods and treatment options. Despite the widespread occurrence of uterine fibroids and newer treatment options, little high-quality data are available to formulate evidence-based guidelines that address these unmet patient needs. Specific areas in need of attention include improving diagnostic techniques, increasing patient access to early treatment, and identifying best practices for this diverse patient population.
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Affiliation(s)
- Ayman Al-Hendy
- Division of Translational Research, Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Evan Robert Myers
- Division of Clinical and Epidemiological Research, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth Stewart
- Department of Obstetrics and Gynecology and Surgery, Mayo Clinic, Rochester, Minnesota
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Sundermann AC, Velez Edwards DR, Bray MJ, Jones SH, Latham SM, Hartmann KE. Leiomyomas in Pregnancy and Spontaneous Abortion: A Systematic Review and Meta-analysis. Obstet Gynecol 2017; 130:1065-1072. [PMID: 29016496 PMCID: PMC5656535 DOI: 10.1097/aog.0000000000002313] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To systematically review studies reporting the risk of spontaneous abortion among pregnant women of typical reproductive potential with and without uterine leiomyomas. DATA SOURCES We searched PubMed, EMBASE, Web of Science, and ClinicalTrials.gov for publications from January 1970 to December 2016. METHODS OF STUDY SELECTION We excluded studies that did not use imaging to uniformly document leiomyoma status of all participants, did not have a comparison group without leiomyomas, or primarily included women seeking care for recurrent miscarriage, infertility care, or assisted reproductive technologies. TABULATION, INTEGRATION, AND RESULTS Two authors independently reviewed eligibility, extracted data, and assigned overall quality ratings based on predetermined criteria. Of 1,469 articles identified, nine were eligible. Five enrolled general obstetric populations and four included women undergoing amniocentesis. In five studies in general obstetric populations that included 21,829 pregnancies (1,394 women with leiomyomas and 20,435 without), only one adjusted for potential confounders. This meta-analysis revealed no increase in risk of spontaneous abortion among those with leiomyomas compared with those without (11.5% compared with 8.0%; risk ratio 1.16, 95% CI 0.80-1.52). When bias from confounding was estimated for nonadjusted studies, the aggregate calculated risk ratio was 0.83 (95% CI 0.68-0.98). CONCLUSION Leiomyoma presence was not associated with increased risk of spontaneous abortion in an analysis of more than 20,000 pregnant women. Failure of prior studies to adjust for confounders may have led to the common clinical belief that leiomyomas are a risk factor for spontaneous abortion.
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Affiliation(s)
- Alexandra C. Sundermann
- Vanderbilt Epidemiology Center, Institute of Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 800, Nashville, TN 37203-1738
| | - Digna R. Velez Edwards
- Vanderbilt Epidemiology Center, Institute of Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 800, Nashville, TN 37203-1738
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, 1100 Medical Center North, Nashville, TN, 37232
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, 2219 Garland Avenue, Nashville, TN 37232
| | - Michael J. Bray
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, 2219 Garland Avenue, Nashville, TN 37232
| | - Sarah H. Jones
- Vanderbilt Epidemiology Center, Institute of Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 800, Nashville, TN 37203-1738
| | - Sanura M. Latham
- Evidence-Based Practice Center, Vanderbilt University Medical Center, 2525 West End Avenue, TN 37203
| | - Katherine E. Hartmann
- Vanderbilt Epidemiology Center, Institute of Medicine and Public Health, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 800, Nashville, TN 37203-1738
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, 1100 Medical Center North, Nashville, TN, 37232
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Uterine Fibroids in the Setting of Infertility: When to Treat, How to Treat? CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0192-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Flyckt R, Soto E, Nutter B, Falcone T. Comparison of Long-Term Fertility and Bleeding Outcomes after Robotic-Assisted, Laparoscopic, and Abdominal Myomectomy. Obstet Gynecol Int 2016; 2016:2789201. [PMID: 28163718 PMCID: PMC5259613 DOI: 10.1155/2016/2789201] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 11/10/2016] [Accepted: 11/24/2016] [Indexed: 11/23/2022] Open
Abstract
Background/Aims. To compare long-term fertility and bleeding outcomes of women who underwent robotic-assisted, laparoscopic, and abdominal myomectomy at our institution over a 15-year period. Methods. This was a retrospective cohort study of myomectomy patients 18-39 years old that had surgery between January 1995 and December 2009 at our institution. Long-term follow-up on fertility and bleeding outcomes was collected from the patient directly. The uterine fibroid symptom and quality of life survey was also administered to assess current bleeding patterns. Baseline characteristics were compared across groups. Univariable comparisons of fertility and bleeding outcomes based on surgical approach were made using analysis of variance, Kruskal-Wallis analysis of ranks, and Chi-square tests as appropriate. Results. 134/374 (36%) subjects agreed to participate in the study. 81 subjects underwent an open procedure versus 28 and 25 subjects in the laparoscopic and robotic groups, respectively. Median follow-up after surgery was 8 years. 50% of patients desired pregnancy following surgery and, of those, 60% achieved spontaneous pregnancy; the spontaneous pregnancy rate did not differ between groups. Additionally, UFS-QOL scores and/or subscores did not differ between groups. Conclusion. There is no significant difference in long-term bleeding or fertility outcomes in robotic-assisted, laparoscopic, or abdominal myomectomy.
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Affiliation(s)
- Rebecca Flyckt
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Enrique Soto
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Nutter
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tommaso Falcone
- Obstetrics, Gynecology, and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update 2016; 22:665-686. [PMID: 27466209 PMCID: PMC5853598 DOI: 10.1093/humupd/dmw023] [Citation(s) in RCA: 356] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 05/12/2016] [Accepted: 05/27/2016] [Indexed: 12/24/2022] Open
Abstract
Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms and obstetric complications.Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by patient's age and desire to preserve fertility or avoid 'radical' surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.There are only a few randomized trials comparing various therapies for fibroids. Further investigations are required as there is a lack of concrete evidence of effectiveness and areas of uncertainty surrounding correct management according to symptoms. The economic impact of uterine fibroid management is significant and it is imperative that new treatments be developed to provide alternatives to surgical intervention.There is growing evidence of the crucial role of progesterone pathways in the pathophysiology of uterine fibroids due to the use of selective progesterone receptor modulators (SPRMs) such as ulipristal acetate (UPA). The efficacy of long-term intermittent use of UPA was recently demonstrated by randomized controlled studies.The need for alternatives to surgical intervention is very real, especially for women seeking to preserve their fertility. These options now exist, with SPRMs which are proven to treat fibroid symptoms effectively. Gynecologists now have new tools in their armamentarium, opening up novel strategies for the management of uterine fibroids.
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Affiliation(s)
- Jacques Donnez
- Professor EM, Catholic University of Louvain, Director, Société de Recherche pour l'Infertilité (SRI), 143 Avenue Grandchamp, B-1150 Brussels, Belgium
| | - Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium; Pôle de Gynécologie, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200 Brussels, Belgium
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Viner AC, Menezes MQ. An Overview of the Aetiology, Epidemiology, Symptomatology and Management of Uterine Fibroids. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
A debate among gynecologic and reproductive surgeons is whether or not there is a clinical need to treat all intramural myomas. Considerations include myoma size and number, ability to access them, whether or not they compromise the endometrium, and treatment effect on gynecologic, reproductive, and obstetric outcomes. We conducted a detailed study regarding intramural myomas, their prevalence in subject populations, the imaging methods used to detect them, their growth rate, their suspected adverse effects on gynecologic, fertility, and obstetric outcomes, and the effectiveness of various treatment methods. The growing body of evidence reported in the literature supports the need to manage intramural myomas and to treat them appropriately.
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Affiliation(s)
- Mayra J Thompson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bruce R Carr
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Abstract
The precise impact of fibroids, which are the most common benign gynaecological tumours in women, on reproductive function and infertility is unknown. The need to treat submucosal fibroids is widely accepted, but fibroids in other locations and sizes continue to present a clinical conundrum. This article examines the mechanisms by which fibroids affect implantation and fertility, and stratifies their impact on basis of size, location and nature. It also explores the evidence base of the available treatment modalities in specific relation to improving fertility outcomes. Traditionally, a myomectomy has been advocated to treat fibroids for the reproductive population; however, as well as evaluating the benefits of surgery including endoscopic, this article explores alternative therapies including medical and radiological interventions.
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Unplanned pregnancy after ultrasound-guided percutaneous microwave ablation of uterine fibroids: A follow-up study. Sci Rep 2016; 6:18924. [PMID: 26733265 PMCID: PMC4702107 DOI: 10.1038/srep18924] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 11/25/2015] [Indexed: 11/08/2022] Open
Abstract
A follow-up study was performed with 169 women of childbearing age who underwent ultrasound-guided percutaneous microwave ablation (UPMWA) therapy for symptomatic uterine fibroids in the Chinese PLA General Hospital from June 2007 to December 2014. This study aimed to observe the incidence of unplanned pregnancies in these women after UPMWA treatment in order to evaluate its effect on natural conception. Ten unplanned pregnancies in nine women were occurred. Of the nine patients, six did not want the pregnancy and chose for induced abortion to end the pregnancy at an early stage. Three chose to continue with the pregnancy and gave birth to a healthy term infant delivered by cesarean section (of these three patients, two had been previously diagnosed as infertility). None of the patients had any serious obstetric complications. After UPMWA treatment for uterine fibroids, patients may conceive naturally, the impact of the procedure on fertility and pregnancy outcomes is worthy of further prospective study in larger sample.
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Abstract
BACKGROUND Laparoscopic surgery has led to great clinical improvements in many fields of surgery; however, it requires the use of trocars, which may lead to complications as well as postoperative pain. The complications include intra-abdominal vascular and visceral injury, trocar site bleeding, herniation and infection. Many of these are extremely rare, such as vascular and visceral injury, but may be life-threatening; therefore, it is important to determine how these types of complications may be prevented. It is hypothesised that trocar-related complications and pain may be attributable to certain types of trocars. This systematic review was designed to improve patient safety by determining which, if any, specific trocar types are less likely to result in complications and postoperative pain. OBJECTIVES To analyse the rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy, regardless of the condition. SEARCH METHODS Two experienced librarians conducted a comprehensive search for randomised controlled trials (RCTs) in the Menstrual Disorders and Subfertility Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, CDSR and DARE (up to 26 May 2015). We checked trial registers and reference lists from trial and review articles, and approached content experts. SELECTION CRITERIA RCTs that compared rates of trocar-related complications and postoperative pain for different trocar types used in people undergoing laparoscopy. The primary outcomes were major trocar-related complications, such as mortality, conversion due to any trocar-related adverse event, visceral injury, vascular injury and other injuries that required intensive care unit (ICU) management or a subsequent surgical, endoscopic or radiological intervention. Secondary outcomes were minor trocar-related complications and postoperative pain. We excluded trials that studied non-conventional laparoscopic incisions. DATA COLLECTION AND ANALYSIS Two review authors independently conducted the study selection, risk of bias assessment and data extraction. We used GRADE to assess the overall quality of the evidence. We performed sensitivity analyses and investigation of heterogeneity, where possible. MAIN RESULTS We included seven RCTs (654 participants). One RCT studied four different trocar types, while the remaining six RCTs studied two different types. The following trocar types were examined: radially expanding versus cutting (six studies; 604 participants), conical blunt-tipped versus cutting (two studies; 72 participants), radially expanding versus conical blunt-tipped (one study; 28 participants) and single-bladed versus pyramidal-bladed (one study; 28 participants). The evidence was very low quality: limitations were insufficient power, very serious imprecision and incomplete outcome data. Primary outcomesFour of the included studies reported on visceral and vascular injury (571 participants), which are two of our primary outcomes. These RCTs examined 473 participants where radially expanding versus cutting trocars were used. We found no evidence of a difference in the incidence of visceral (Peto odds ratio (OR) 0.95, 95% confidence interval (CI) 0.06 to 15.32) and vascular injury (Peto OR 0.14, 95% CI 0.0 to 7.16), both very low quality evidence. However, the incidence of these types of injuries were extremely low (i.e. two cases of visceral and one case of vascular injury for all of the included studies). There were no cases of either visceral or vascular injury for any of the other trocar type comparisons. No studies reported on any other primary outcomes, such as mortality, conversion to laparotomy, intensive care admission or any re-intervention. Secondary outcomesFor trocar site bleeding, the use of radially expanding trocars was associated with a lower risk of trocar site bleeding compared to cutting trocars (Peto OR 0.28, 95% CI 0.14 to 0.54, five studies, 553 participants, very low quality evidence). This suggests that if the risk of trocar site bleeding with the use of cutting trocars is assumed to be 11.5%, the risk with the use of radially expanding trocars would be 3.5%. There was insufficient evidence to reach a conclusion regarding other trocar types, their related complications and postoperative pain, as no studies reported data suitable for analysis. AUTHORS' CONCLUSIONS Data were lacking on the incidence of major trocar-related complications, such as visceral or vascular injury, when comparing different trocar types with one another. However, caution is urged when interpreting these results because the incidence of serious complications following the use of a trocar was extremely low. There was very low quality evidence for minor trocar-related complications suggesting that the use of radially expanding trocars compared to cutting trocars leads to reduced incidence of trocar site bleeding. These secondary outcomes are viewed to be of less clinical importance.Large, well-conducted observational studies are necessary to answer the questions addressed in this review because serious complications, such as visceral or vascular injury, are extremely rare. However, for other outcomes, such as trocar site herniation, bleeding or infection, large observational studies may be needed as well. In order to answer these questions, it is advisable to establish an international network for recording these types of complications following laparoscopic surgery.
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Affiliation(s)
| | - Hilko A Swank
- Academic Medical CentreDepartment of SurgeryG4‐144P.O. Box 22660AmsterdamNetherlands1100 DD
| | - Monique E Wessels
- Dutch Association of Medical SpecialistsDepartment of Quality in HealthcareMercatorlaan 1200UtrechtNetherlands3528 BL
| | - Ben Willem J Mol
- The University of AdelaideDiscipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research InstituteLevel 3, Medical School South BuildingFrome RoadAdelaideSouth AustraliaAustraliaSA 5005
| | - Sidney M Rubinstein
- VU University AmsterdamDepartment of Health Sciences, Faculty of Earth and Life Sciencesde Boelelaan 1085Room U422AmsterdamNetherlands1081 HV
| | - Frank Willem Jansen
- Leiden University Medical CenterDepartment of Obstetrics and GynaecologyPO Box 9600LeidenNetherlands2300 RC
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Tsuji I, Fujinami N, Kotani Y, Tobiume T, Aoki M, Murakami K, Kanto A, Takaya H, Ukita M, Shimaoka M, Nakai H, Suzuki A, Mandai M. Reproductive Outcome of Infertile Patients with Fibroids Based on the Patient and Fibroid Characteristics; Optimal and Personalized Management. Gynecol Obstet Invest 2015; 81:325-32. [DOI: 10.1159/000441788] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022]
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Pier BD, Bates GW. Potential causes of subfertility in patients with intramural fibroids. FERTILITY RESEARCH AND PRACTICE 2015; 1:12. [PMID: 28620517 PMCID: PMC5424315 DOI: 10.1186/s40738-015-0005-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/19/2015] [Indexed: 08/30/2023]
Abstract
BACKGROUND Intramural leiomyomas have been long debated as a potential cause of infertility and pregnancy loss. FINDINGS Previous research has linked intramural fibroids to defective implantation, as well as to abnormal peristaltic events of the uterine smooth muscle. Previous reports describe the effects of intramural fibroids on normal human fertility and early pregnancy loss, specifically in regards to implantation failure. CONCLUSION A thorough understanding of prior research may direct new research focus, leading to better understanding of leiomyoma-associated infertility.
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Affiliation(s)
- Bruce D Pier
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, WIC 10390, 1700 6th Avenue South, Birmingham, AL 35294 UK
| | - G Wright Bates
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, WIC 10390, 1700 6th Avenue South, Birmingham, AL 35294 UK
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Hurrell A, Oliver R, Agarwal N, Rouabhi S, Odejinmi F. Evaluation of the selective use of abdomino-pelvic drains at laparoscopic myomectomy: in enhanced recovery, do drains delay discharge home? Eur J Obstet Gynecol Reprod Biol 2015; 185:36-40. [DOI: 10.1016/j.ejogrb.2014.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 11/12/2014] [Accepted: 11/21/2014] [Indexed: 01/05/2023]
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Tikhomirov AL. Successful pregnancy after gigantic uterine fibroids treatment with the help of ulipristal acetate. ACTA ACUST UNITED AC 2015. [DOI: 10.17116/repro201521486-88] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Boosz AS, Reimer P, Matzko M, Römer T, Müller A. The conservative and interventional treatment of fibroids. DEUTSCHES ARZTEBLATT INTERNATIONAL 2014; 111:877-83. [PMID: 25597366 DOI: 10.3238/arztebl.2014.0877] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 09/08/2014] [Accepted: 09/08/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Fibroids are the most common benign tumors in women. One-third of all women of reproductive age undergo treatment for symptomatic fibroids. In recent years, the spectrum of available treatments has been widened by the introduction of new drugs and interventional procedures. METHODS Selective literature review on the treatment of uterine fibroids, including consideration of several Cochrane Reviews. RESULTS Fibroids can be treated with drugs, interventional procedures (uterine artery embolization [UAE] and focused ultrasound treatment [FUS]), and surgery. The evidence regarding the various available treatments is mixed. All methods improve symptoms, but only a few comparative studies have been performed. A meta-analysis revealed that recovery within 15 days is more common after laparoscopic enucleation than after open surgery (odds ratio [OR], 3.2). A minimally invasive hysterectomy, or one performed by the vaginal route, is associated with a shorter hospital stay and a more rapid recovery than open transabdominal hysterectomy. UAE is an alternative to hysterectomy for selected patients. The re-intervention rates after fibroid enucleation, hysterectomy, and UAE are 8.9-9%, 1.8-10.7%, and 7-34.6%, respectively. The main drugs used to treat fibroids are gonadotropin-releasing hormone analogs and selective progesterone receptor modulators. CONCLUSION Multiple treatment options are available and enable individualized therapy for symptomatic fibroids. The most important considerations in the choice of treatment are the question of family planning and, in some cases, the technical limitations of the treatments themselves.
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Affiliation(s)
- Alexander Stephan Boosz
- Städtisches Klinikum Karlsruhe, Department of Gynecology and Obstetrics, Frauenklinik des Evangelischen Krankenhauses Köln Weyertal, Städtisches Klinikum Karlsruhe, Institute of Diagnostic and Interventional Radiology, FUS Center, Dachau Medical Center
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Abstract
Uterine anomalies are one of the most common parental causes of recurrent pregnancy loss, occurring in about 19% of patients. Congenital uterine anomalies are most likely caused by HOX gene mutations, although the mechanism is probably polygenic. There are no known environmental causes other than estrogenic endocrine disruptors such as diethylstilbestrol. Acquired uterine anomalies may result from uterine trauma (adhesions) or benign growths of the myometrium (fibroids) or endometrium (polyps). Although randomized controlled trials are lacking, surgical treatment is recommended for repair of uterine septa, and for removal of severe adhesions and submucosal fibroids, especially if no other causes are identified.
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Affiliation(s)
- Carolyn R Jaslow
- Department of Biology, Rhodes College, 2000 North Parkway, Memphis, TN 38112, USA.
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Bøggild A, Langhoff-Roos J, Sundberg K, Istre O. Placenta percreta after transcervical myomectomy. CASE REPORTS IN PERINATAL MEDICINE 2014. [DOI: 10.1515/crpm-2013-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background: Large uterine fibroids and placenta percreta are often associated with a hysterectomy.
The case: A 31-year-old nulligravida had a transcervical resection of a large fibroid (158 g) in the anterior wall of the uterus. A subsequent spontaneous pregnancy was complicated by placenta percreta. In late pregnancy, she had an elective cesarean section, the percrete area was resected, and she had an abdominal cerclage for hemostasis and support. Subsequently, she had two term pregnancies with normal placentation.
Conclusion: The woman avoided hysterectomy twice, first for gynecological and second for obstetrical reasons – and had three healthy infants. We conclude that the uterus should be preserved whenever possible in young fertile women.
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Affiliation(s)
- Amalie Bøggild
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens Langhoff-Roos
- Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karin Sundberg
- Department of Fetal Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olav Istre
- Aleris-Hamlet Hospitalet, Denmark, and University of Southern Denmark, Odense, Denmark
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Successful pregnancy after treatment with ulipristal acetate for uterine fibroids. Case Rep Obstet Gynecol 2014; 2014:314587. [PMID: 25143845 PMCID: PMC4131110 DOI: 10.1155/2014/314587] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/09/2014] [Accepted: 07/10/2014] [Indexed: 11/17/2022] Open
Abstract
This case report presents a clinical pregnancy after ulipristal acetate (UA) to decrease uterine fibroid size. A 37-year-old patient, gravida 1, abortus 1, with uterine fibroids was treated with 5 mg of UA daily for 13 weeks starting eight months after a multiple laparotomic myomectomy. Fibroid shrinkage and restoration of the morphology of endometrial cavity were evaluated in order to allow a subsequent pregnancy. A decrease of the uterine fibroids and a normal morphology of the endometrial cavity were noted by transvaginal ultrasound after treatment. An endometrial biopsy excluded histologic endometrial changes. Three months after the end of UA the patient reported amenorrhea for 5 weeks and a clinical pregnancy was confirmed with transvaginal ultrasound. She underwent a subsequent uneventful pregnancy. Thus, the spontaneous pregnancy after UA to reduce fibroid size may support the potential clinical utility of this selective progesterone receptor modulator in the management of women with pregnancy desire and uterine fibroids after a prior myomectomy. Patients who refuse a new surgical procedure and/or those who are going to undergo assisted reproductive techniques would benefit from UA. It effectively shrinks fibroids, avoids risks of a new surgical procedure, and allows an immediate attempt at conception after the end of treatment.
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Bohlmann MK, Hoellen F, Hunold P, David M. High-Intensity Focused Ultrasound Ablation of Uterine Fibroids - Potential Impact on Fertility and Pregnancy Outcome. Geburtshilfe Frauenheilkd 2014; 74:139-145. [PMID: 24741124 DOI: 10.1055/s-0033-1360311] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/11/2013] [Accepted: 12/21/2013] [Indexed: 10/25/2022] Open
Abstract
Laparoscopic myomectomy is regarded as the gold standard for women with symptomatic fibroids who wish to become pregnant. High-intensity focused ultrasound (HIFU or MRgFUS) ablation of uterine fibroids is also being discussed as a non-surgical, minimally invasive, therapeutic option. This review examines the available data on the impact of HIFU/MRgFUS on fertility and pregnancy, focusing particularly on potential direct side-effects of this type of intervention on ovaries, fallopian tubes and uterus and potential late effects on pregnancy and birth, based on the current literature. All pregnancies after HIFU/MRgFUS published to date (around 100 cases) were evaluated. The published case series suggest that HIFU/MRgFUS ablation has no impact on the rate of miscarriages or other obstetrical outcome parameters. Because no prospective studies exist which permit firm conclusions to be drawn on the impact of HIFU/MRgFUS on fertility and pregnancy outcome in women with symptomatic fibroids, this approach is currently only recommended for women with suspected fertility problems due to uterine fibroids who either decline surgery or who have an unacceptably high surgical risk.
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Affiliation(s)
- M K Bohlmann
- Department of Obstetrics and Gynaecology, University Hospital Schleswig-Holstein - Campus Lübeck, Lübeck
| | - F Hoellen
- Department of Obstetrics and Gynaecology, University Hospital Schleswig-Holstein - Campus Lübeck, Lübeck
| | - P Hunold
- Clinic for Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein - Campus Lübeck, Lübeck
| | - M David
- Klinik für Gynäkologie, Charité Campus Virchow-Klinikum, Berlin
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Zapardiel I, Diestro MD, Aletti G. Conservative treatment of early stage ovarian cancer: oncological and fertility outcomes. Eur J Surg Oncol 2013; 40:387-93. [PMID: 24368049 DOI: 10.1016/j.ejso.2013.11.028] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 11/29/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Ovarian cancer may appear in young women during their reproductive age. As a result of late childbearing nowadays, fertility preservation has become a major issue in young women with gynecological cancer. The aim of this review is to update the current knowledge on conservative treatment and fertility preservation of women affected of early stage epithelial ovarian cancer. MATERIAL AND METHODS A web-based search in Medline and CancerLit databases on conservative treatment for early stage ovarian cancer has been carried out. All relevant information has been collected and analyzed. RESULTS Less than 40% of ovarian cancers are diagnosed at early stages. Conservative treatment may be considered in young patients with a relapse rate that ranges from 9% to 29%, and a 5-year survival ranging from 83% to 100%. Recurrences in the controlateral ovary has been reported to be less than 5%, with most of these patients being alive after savage treatments. Moreover, it has been reported good fertility outcomes after conservative treatment with a successful conception rate that ranges from 60% to 100%, with an abortion rate under 30% in all series reported. CONCLUSIONS Conservative treatment for early epithelial ovarian cancers could be a safe option for women younger than 40 years who wish to preserve their childbearing potential. We need a strict case selection such as FIGO stage I grade 1 and 2, although grade 3 cases could be considered.
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Affiliation(s)
- I Zapardiel
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain.
| | - M D Diestro
- Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | - G Aletti
- Gynecology Department, European Institute of Oncology, Milan, Italy
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