Fibroids and Infertility

Efficacy of Tranexamic Acid in Reducing Myomectomy-Associated Blood Loss among Patients with Uterine Myomas at Federal Teaching Hospital Abakaliki: A Randomized Control Trial

Background

Myomectomy can be associated with life-threatening conditions such as bleeding. Excessive bleeding usually necessitates blood transfusion. Interventions to reduce bleeding during myomectomy will help reduce the need for blood transfusion with its associated complications. Tranexamic acid has been used to reduce bleeding in other surgical procedures, and its usage during myomectomy merits evaluation.

Objective

To assess the efficacy of tranexamic acid in reducing myomectomy-associated blood loss.

Materials and Methods

This is a prospective double-blinded randomized trial conducted on women who had abdominal myomectomy. Patients were randomized into two groups. The study group received perioperative intravenous tranexamic acid (TXA) while the control group received a placebo. Intraoperative blood loss was calculated by measuring the volume in the suction apparatus and weighing the surgical swabs. In addition, blood collected postoperatively from the wound drains and drapes were measured. Haemoglobin concentrations were determined preoperatively and on second postoperative day for all cases. Any adverse effect was noted in both groups. The data was processed using Epi Info software (7.2.1, CDC, Atlanta, Georgia). The relationships between categorical data were analyzed using X2 and Student's t-test to determine relationships between continuous variables, with a P value of 0.05 considered statistically significant, and correlation coefficients were calculated using Pearson's formula, and probability of 0.05 was set for statistical significance.

Results

Symptomatic uterine myomas constituted 17.3% of all gynaecological admissions and 21.3% of gynaecological operations at Federal Teaching Hospital Abakaliki. The mean intraoperative blood loss among patients that had perioperative tranexamic acid infusion was 413.6 ± 165.6 ml, while that of patients with placebo infusion was 713.6 ± 236.3 ml. Perioperative tranexamic acid infusion therefore reduced mean intraoperative blood loss by 300 ml, and this was statistically significant (SMD = -0.212, 95% CI: -403.932 to -196.067, P < 0.0001). Perioperative tranexamic acid reduced mean total blood loss by a value of 532.3 ml, and this is statistically significant (SMD = 30.622, 95% CI: 393.308 to 670.624, P < 0.0001). Tranexamic acid also improved postoperative haemoglobin concentration by 1.8 g/dl compared with placebo, and this is statistically significant (SMD = -0.122, 95% CI: 1.182 to 2.473, P < 0.0001). Tranexamic acid infusion decreased hospital stay by about 2 days, and this difference was statistically significant (SMD = -3.929, 95% CI: -3.018 to -0.983, P = 0.0003). There was no adverse drug reaction in the course of the study.

Conclusion

The use of tranexamic acid during myomectomy reduced intraoperative and postoperative blood loss. It is also associated with decreased hospital stay. This trial is registered with NCT04560465.

AI Tools for Assessing Human Fertility Using Risk Factors: A State-of-the-Art Review

Infertility has massively disrupted social and marital life, resulting in stressful emotional well-being. Early diagnosis is the utmost need for faster adaption to respond to these changes, which makes possible via AI tools. Our main objective is to comprehend the role of AI in fertility detection since we have primarily worked to find biomarkers and related risk factors associated with infertility. This paper aims to vividly analyse the role of AI as an effective method in screening, predicting for infertility and related risk factors. Three scientific repositories: PubMed, Web of Science, and Scopus, are used to gather relevant articles via technical terms: (human infertility OR human fertility) AND risk factors AND (machine learning OR artificial intelligence OR intelligent system). In this way, we systematically reviewed 42 articles and performed a meta-analysis. The significant findings and recommendations are discussed. These include the rising importance of data augmentation, feature extraction, explainability, and the need to revisit the meaning of an effective system for fertility analysis. Additionally, the paper outlines various mitigation actions that can be employed to tackle infertility and its related risk factors. These insights contribute to a better understanding of the role of AI in fertility analysis and the potential for improving reproductive health outcomes.

Pregnancy With Uterine Fibroids: Obstetric Outcome at a Tertiary Care Hospital of Central India

BACKGROUND

Uterine fibroids are the most frequent benign tumor of the female reproductive system, with a significantly lower frequency in pregnancy. This could be due to the fact that uterine fibroids are linked to infertility and low implantation rates following in vitro fertilization (IVF). The goal of this study was to look at the obstetrics outcomes of uterine fibroids and their consequences in a tertiary hospital.

MATERIALS AND METHODS

The current study was a observational cohort study that evaluated the cases of pregnancy with fibroid. Study was undertaken at the Department of Obstetrics and Gynecology (OBGY) at a medical college in central India and it was conducted over a period of nine months from 1st November 2021 to 31st July 2022. All pregnant women who had an ultrasonography (USG)-documented uterine fibroid diagnosed prenatally or antenatally were enrolled. All demographic information, laboratory and USG results were noted and their mode of delivery, obstetric complications, if any, and neonatal outcomes were evaluated.

RESULTS

A total of 110 cases were enrolled as per inclusion and exclusion criteria. The majority of patients (42.73%) were in the 26- to 30-year-old age group. In this study, the majority of cases were carried to term (80.9%). The most prevalent mode of delivery was caesarean section (61.82%). Major complications during pregnancy were threatened preterm labor (21.82%), and blood transfusion (20.00%), whereas postpartum hemorrhage (PPH) occurred in 9.09% cases, and 47 patients (42.72%) were asymptomatic throughout pregnancy. Major neonatal outcomes in our study were neonatal intensive care unit (NICU) hospitalization (20%), required neonatal resuscitation (14.55%), and neonatal mortality occurring in 1.82% cases. Gestational age at termination of pregnancy, when compared with different characteristics of fibroid, like type (p value 0.663), location (p value 0.552) and number of fibroid (p value 0.112), did not show any significant association. Similarly, maternal complications also did not show significant association (p value >0.05) with different characters of fibroid.  Conclusion: Pregnancies with fibroid are high-risk pregnancies that are linked to difficulties throughout the antepartum, intrapartum, and postpartum periods, as well as increased chances of cesarean delivery and PPH.

Intrauterine Fetal Demise Associated with Vascular Malperfusion and Multiple Uterine Leiomyomata: A Report of Two Cases

BACKGROUND

Uterine leiomyomata have been loosely associated with intrauterine fetal demise (IUFD), largely attributed to fetal growth restriction from cavitary distortion. We present two cases of IUFD in patients with non-distorting leiomyomata and pathologic placental findings of maternal vascular malperfusion (MVM) and fetal vascular malperfusion (FVM).

CASE REPORT

Case 1 details a 28w3d IUFD associated with large leiomyomata (largest 11.9 × 7.6 × 9.7 cm), post-partum deep vein thrombosis, and severe pre-eclampsia histologic features. Case 2 details a 25w2d IUFD associated with smaller leiomyomata (largest 3.1 × 3.0 × 3.3 cm). Both placentas demonstrated MVM, including parenchymal thrombi and accelerated villous maturity, and FVM, including avascular stem villi.

DISCUSSION

As the placentas in both cases demonstrated findings consistent with altered placental perfusion, we posit that leiomyomata in these cases may have been associated with both maternal and fetal vascular malperfusion, ultimately contributing to fetal demise.

Рrediction of infertility in patients with uterine leiomyoma

Infertility is an important socio-economic problem due to the fact that planned childbearing occurs much later than three decades ago. In recent years, more attention has been paid to the role of uterine leiomyoma in the development of infertility. Uterine leiomyoma is a benign monoclonal, well-demarcated encapsulated tumor originating from the smooth muscle cells of the cervix or body of the uterus. Uterine leiomyoma is the most common uterine tumor in the reproductive age group, affecting 20-50 % of women. With conceptual changes in marriage and childbearing, the number of women over 35 with leiomyoma who want to have children has also increased significantly. The need to treat submucosal fibroids is widely recognized, but fibroids of other locations and sizes remain a clinical mystery. The purpose of the literature review was to determine the role of uterine fibroids in predicting infertility. It has been established that the incidence of uterine leiomyoma in women of reproductive age is on average about 40 %, infertility associated with this pathology occurs in 5-10 % of women. In 10 % of cases of infertility, uterine leiomyoma is the only established cause of infertility. Uterine leiomyoma is common among women of reproductive age, and as women continue to delay childbearing, an increasing number of patients will require fertility-preserving treatment options. Leiomyoma affects not only fertility but also obstetric outcomes. Women with intramural fibroids without cavity deformity have a 21 % reduction in live birth rates after in vitro fertilization compared with controls without fibroids. Despite advances in fundamental understanding of the biology of leiomyomas, the role of different fibroid variants remains a matter of discussion. The question of the negative impact of submucosal nodes on infertility today is not in doubt, and the effect of subserous and intramural nodes requires further study.

Concurrent gestational trophoblastic neoplasia and large uterine fibroid in a nullipara – Case report

Introduction

The management of a large uterine fibroid concurrent with gestational trophoblastic disease (GTD) in a nullipara is complicated, challenging yet should focus on conserving fertility. We would like to share our experience.

Case description

A 28-year-old G1P0A0 of 10–11 weeks’ gestation presented with a profuse vaginal bleeding with a history of passing swollen, grape-like tissues from the vagina. Since 7 months prior, a large uterine fibroid >10 cm had been diagnosed on ultrasound. Patient was diagnosed with GTD with β-human chorionic gonadotropin (hCG) levels exceeding 1,000,000 mIU/mL. No pulmonary metastases were detected. She underwent a vacuum curettage for her complete hydatidiform mole.Six days later, she underwent an elective myomectomy. Her nulliparity precluded hysterectomy. Post-discharge, her β-hCG levels plateaued and were consistently high over 3 consecutive measurements. A diagnosis of gestational trophoblastic neoplasia (GTN) was established. Patient is currently undergoing a methotrexate-folinic acid rescue chemotherapy regimen due to her having a low risk, stage 1 GTN.

Discussion

Uterine fibroid may reach exceptional sizes. There is so far no link between GTD and uterine fibroids but their concurrent presence is extremely rare. The definitive management for a large fibroid is hysterectomy but considering the patient's nulliparity, a myomectomy was appropriate. GTD's definitive management is vacuum curettage.Periodical β-hCG measurement should follow discharge. Plateauing β-hCG levels indicated GTN and due to her low-risk GTN, she required a single-agent methotrexate chemotherapy. Most patients with low-risk GTN make a complete recovery.

Conclusion

Fertility after myomectomy and GTN generally has an excellent prognosis.

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Uterine fibroids and gestational trophoblastic disease are rarely encountered together.

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Managing fibroids and gestational trophoblastic disease in a nullipara should focus on conserving fertility.

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Fertility after myomectomy is generally excellent.

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Fertility after chemotherapy for gestational trophoblastic disease is generally excellent.

Arterial spin labeling assessment of myometrial perfusion changes in patients with uterine fibroid and its impact on fertility

Background

Fibroids are the most common uterine tumor in the reproductive age group. These tumors although benign, their relation to infertility is still controversial. The purpose of this study is to assess the fibroid impact on fertility using arterial spin labeling (ASL) technique.

Results

This prospective study included 40 cases (30 female patients having uterine fibroid and 10 age- and sex-matched control cases). The 30 patients were divided according to their fertility into 2 subgroups: fertile (n = 15) and infertile (n = 15). All cases underwent pelvic magnetic resonance imaging (MRI) examination with ASL technique. The perfusion values were measured in the uterine walls, fibroids, and in the gluteus maximus muscle as control. ASL demonstrated non-significant difference in the perfusion between anterior and posterior uterine walls in the control cases and revealed significant difference in the perfusion between fibroid positive and fibroid negative uterine walls in patients with uterine fibroid (p value < 0.04). Perfusion values of the fertile and infertile subgroups showed no statistically significant difference.

Conclusion

Arterial spin labeling is an evolving technique that can be used to evaluate the myometrial perfusion changes in patients with uterine fibroid without using contrast media. Uterine fibroids were associated with decreased perfusion but with no statistically significant impact on fertility.

Prognostic value of the location of submucosal uterine leiomyomas in infertility

Submucosal fibroid location and size are predictive factors of impaired fertility. Submucosal fibroids cause infertility through several mechanisms including distortion of the endometrial cavity, increased uterine contractility, local inflammation and remodeling of the endometrial blood supply. This is a monocentric, retrospective, cross-sectional study, conducted in the Department of Obstetrics and Gynecology of 'Sf. Pantelimon' Clinical Emergency Hospital, analyzing patients from a 5-year period (January 2015-December 2019). In the present study, the relationship between different characteristics of the submucosal fibroids (among others, location and dimensions) and fertility (birth rates, early pregnancy loss rates) were investigated. This study identified that submucosal and intramural fibroids are risk factors for reduced birth rate compared with subserosal fibroids (P=0.02, RR=2.58, 95% CI 1.03-6.47; P=0.005, RR=1.18, 95% CI 1.02-1.35, respectively). In addition, G2 leiomyomas are risk factors for low birth rate compared with G0 and G1 fibroids (P=0.01, RR=1.95, 95% CI 1.05-3.60). Moreover, the presence of a subserosal fibroid was associated with an increased early pregnancy loss rate (P=0.01, RR=2.14, 95% CI 1.05-4.35). In conclusion, the location and degree of uterine cavity distortion are important factors that alter the normal development of a pregnancy and the birth rate.

Efficacy of ulipristal acetate in women with fibroid induced menorrhagia: A systematic review and meta-analysis

AIM

To evaluate the efficacy of UPA in women with fibroid induced menorrhagia.

METHODS

Embase, MEDLINE, CAB Abstracts, Cochrane Central Register of Controlled Trials, PsychInfo were searched up to 18th May 2020 and updated on 7th February 2021. Randomised controlled trials evaluating the efficacy of UPA in women with fibroid induced menorrhagia were included in the study.

RESULTS

Two authors independently reviewed and extracted the study data. Statistical heterogeneity was quantified using I² statistics. Publication bias and data asymmetry was assessed by funnel plots. A meta-analysis was conducted where appropriate. Six studies were eligible for inclusion. UPA (5 mg and 10 mg) achieved statistically significant amenorrhoeic outcome when compared to placebo (p<0.00001). Increased adverse events (AE) profile was observed in the higher UPA dose, however, did not reach statistical significance.

CONCLUSIONS

This review demonstrates the efficacy of UPA in achieving amenorrhoea in women with fibroid induced menorrhagia. However, the favourable dose of UPA remains inconclusive when AE profile is taken into account. Evidence remains obscure regarding liver damage and further research is warranted to attain a conclusive outcome.

Obstetrical outcomes are unchanged after hysteroscopic myomectomy in women with submucosal fibroids

BACKGROUND

Previous studies have demonstrated increased rates of poor obstetrical outcomes including preterm delivery, placental abruption, and intrauterine growth restriction in women with uterine leiomyomas. Currently, preconception myomectomy has not been reported to improve pregnancy rates or pregnancy outcomes in women with subserosal leiomyomas, and the data remain inconclusive for intramural fibroids. Pregnancy rates have been found to improve after the removal of submucosal fibroids. However, the effect of preconception myomectomy for submucosal fibroids on birth outcomes has yet to be examined.

OBJECTIVE

This study aimed to determine whether hysteroscopic excision of submucosal leiomyomas affects the rate of preterm delivery, among other obstetrical outcomes.

STUDY DESIGN

We performed a retrospective case-control study of women who underwent hysteroscopic resection of leiomyomas (cases) and controls of women who had submucosal fibroids at the time of their first-trimester ultrasounds. Women were included if they delivered a nonanomalous fetus beyond 20 weeks' gestation. A total of 73 cases were identified and matched with 219 controls (case-to-control ratio, 1:3). Subsequently, owing to multiple-gestation pregnancy, 11 patients were excluded from the case population and 4 patients from the control group. The final analysis included 277 women-62 cases and 215 controls. Our primary outcome was preterm delivery before 37 weeks' gestation. Prespecified secondary outcomes of interest were preterm delivery before 34 weeks' gestation, placental abruption, fetal malpresentation, intrauterine growth restriction, and rate of cesarean delivery. Data analysis was performed using univariate and multivariate statistics.

RESULTS

Cases and controls were similar with respect to age, race, body mass index, and mode of delivery. Cases were more likely to be primiparous (66% cases [42 of 62] vs 37% controls [80 of 215]; P=.00) and use assisted reproductive technology to conceive (22.6% cases [14 of 62] vs 7.0% controls [15 of 215]; P<.001). No differences were found in the rate of preterm delivery at <37 weeks' gestation (12.9% cases [8 of 62] vs 13.5% controls [29 of 215]; P=.89), preterm delivery at <34 weeks' gestation (4.84% cases [3 of 62] vs 6.97% controls [15 of 215]; P=.77), or other obstetrical outcomes.

CONCLUSION

Overall, women with submucosal uterine leiomyomas who undergo hysteroscopic removal have similar birth outcomes to those who do not.

Laparoscopic-assisted myomectomy with uterine artery occlusion at a freestanding ambulatory surgery center: a case series

Background

Non-hysteroscopic myomectomy is infrequently performed in a freestanding ambulatory setting, in part due to risks of intraoperative hemorrhage. There are also concerns about increased surgical risks for morbidly obese patients in this setting. The purpose of this study is to report the surgical outcomes of a series of laparoscopic-assisted myomectomy (LAM) cases at a freestanding ambulatory surgery center (ASC), including a comparative analysis of outcomes in morbidly obese patients (BMI > 40 kg/m²).

Methods

A retrospective comparative analysis was performed of 969 women, age 18 years or older, non-pregnant, who underwent LAM by one of two high volume, laparoscopic gynecologic surgical specialists at a freestanding ambulatory surgery center serving the Washington, DC area, between October 2013 and February 2019. Reversible occlusion was performed laparoscopically by placing a latex-based rubber catheter as a tourniquet around the isthmus of the uterus, causing a temporary occlusion of the bilateral uterine arteries. Permanent occlusion was performed laparoscopically via retroperitoneal dissection and uterine artery ligation at the origin of the anterior branch of the internal iliac artery. Minilaparotomy was performed for specimen removal in all cases. No power morcellation was used. Postoperative complications were graded using the Clavien-Dindo Classification system. Outcomes were compared across BMI categories using Pearson Chi-Square.

Results

Average myoma weight and size were 422.7 g and 8.3 cm, respectively. Average estimated blood loss (EBL) was 192.1 mL; intraoperative and grade 3 postoperative complication rates were 1.4% and 1.6%, respectively. While EBL was significantly higher in obese and morbidly obese patients, this difference was not clinically meaningful, with no significant difference in blood transfusion rates. There were no statistically significant intraoperative or postoperative complication rates across BMI categories. There was a low rate of hospital transfers (0.7%) for all patients.

Conclusion

Laparoscopic-assisted myomectomy can be performed safely in a freestanding ambulatory surgery setting, including morbidly obese patients. This is especially important in the age of COVID-19, as elective surgeries have been postponed due to the 2020 pandemic, which may lead to a dramatic and permanent shift of outpatient surgery from the hospital to the ASC setting.

The role of magnetic resonance-guided focused ultrasound in fertility-sparing treatment of uterine fibroids-current perspectives

Uterine fibroids (UFs) are the most common benign tumours of the female reproductive system and the most frequent reason for hysterectomy worldwide. UFs are reported in 20%–70% of women of reproductive age depending on a study group. Although most women with UFs are asymptomatic, over 30% of them will present with different symptoms. Abnormal uterine bleeding, pain, pressure and infertility are the most common. Lesions that cause these kinds of symptoms may require medical intervention.

Trends in UF treatment change along with patient awareness and the introduction of new methods and techniques. Selecting an appropriate treatment option should be individualised and adjusted to the patient’s expectations as much as possible. This choice will mostly depend on the patient’s age, UF location, the size and number of lesions, severity of symptoms and, most importantly, the patient’s expectations concerning the preservation of fertility. Observations made for the past few years showed an increasing number of pre- and perimenopausal women who wish to preserve their uterus or decline surgery. In line with current trends and demands in medicine, great importance is attached to the development and upgrade of new minimally invasive or noninvasive procedures in UF therapy.

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is not associated with severe destruction of the uterine cavity and walls. For this reason, this method may be considered as a kind of hope in fertility-sparing UF therapy and the data about its use in this indication raises future hope. In this review, we summarise the available data on the use of MR-HIFU as a fertility-sparing method in the treatment of UFs. We also indicate how it could evolve in the future.

According to the available data, MR-HIFU is a relatively safe noninvasive method which seems not to deteriorate fertility compared to the pre-treatment status. MR-HIFU may constitute an alternative solution and be chosen in patients who meet the qualification criteria and deny other methods, which also facilitates the use of other treatment options in case the procedure is ineffective. Further randomised studies are necessary to confirm the above information.

UTERINE FIBROIDS IMPACT ON FERTILITY AND PREGNANCY OUTCOME

The clinical confirmation of the relationship between uterine leiomyoma and female infertility is of interest to scholars. The aim of our research was to study obstetric history and the level of sex hormones in women of reproductive age with leiomyoma. Materials and methods. The main group consisted of 90 women of reproductive age with uterine leiomyoma, the control group - 45 healthy women. Gynaecological and obstetric history, hormone content in peripheral blood and pelvic vessels (estradiol, progesterone) were analysed. Statistical processing of clinical material was performed using Microsoft Excel, Statistica 7.0, and Statistica 8.0 for Windows. Results. The frequency of infertility in the surveyed women with LM was 18.9 %. One in three patients in the main group (33.3 %) did not give birth, which was statistically different from the healthy women group. In this case, 25.6 % of women in the main group did not use any methods of contraception. It was found that 51.11 % of patients with LM had threatened miscarriage in their history, 37.5 % – complicated delivery. Pathological changes in the concentrations of estradiol and progesterone in the preferential blood and blood vessels of women with fibroids have been identified. We have found that the content of sex hormones in the local bloodstream has a reliable relationship with the location of the myomatous node. Conclusion. The obtained results may indicate that leiomyoma contributes to the reduction of fertility. This is evidenced by the fact that women with LM are more likely to have the risk of miscarriage, complicated delivery and delivery by caesarean section, including complicated one. The findings have made a significant contribution to the further development of effective strategies for the prevention and treatment of infertility in women with fibrotic uterine lesions.

The Role of Tumor Necrosis Factor α in the Biology of Uterine Fibroids and the Related Symptoms

Uterine fibroids (UFs) are the most common benign tumors of the female genital tract. The incidence of UFs has been estimated at 25⁻80% depending on selected population. The pathophysiology of UFs remains poorly understood. The transformation of smooth muscle cells of the uterus into abnormal, immortal cells, capable of clonal division, is the main component of all pathways leading to UF tumor formation and tumor necrosis factor α (TNF-α) is believed to be one of the key factors in this field. TNF-α is a cell signaling protein involved in systemic inflammation and is one of the cytokines responsible for the acute phase reaction. This publication presents current data about the role of tumor necrosis factor α in the biology of UFs and the related symptoms. TNF-α is an extremely important cytokine associated with the biology of UFs, UF-related symptoms and complaints. Its concentration has been proven to be elevated in women with clinically symptomatic UFs. The presented data suggest the presence of an "inflammation-like" state in women with UFs where TNF-α is a potent inflammation inducer. The origin of numerous symptoms reported by women with UFs can be traced back to the TNF-α influence. Nevertheless, our knowledge on this subject remains limited and TNF-α dependent pathways in UF pathophysiology should be investigated further.

Laparoscopic-Assisted Myomectomy with Bilateral Uterine Artery Occlusion/Ligation

STUDY OBJECTIVE

Conventional laparoscopic myomectomy (CLM) and robotic-assisted myomectomy (RAM) are limited in the number and size of myomas that can be removed, whereas abdominal myomectomy (AM) is associated with increased complications and morbidity. Here we evaluated the surgical outcomes of these myomectomy techniques compared with those of laparoscopic-assisted myomectomy (LAM), a hybrid approach that combines laparoscopy and minilaparotomy with bilateral uterine artery occlusion or ligation to control blood loss.

DESIGN

Retrospective chart review (Canadian Task Force classification II-1).

SETTING

Suburban community hospital.

PATIENTS

Women age ≥18 years with nonmalignant indications.

INTERVENTION

A total of 1313 consecutive CLMs, RAMs, AMs, and LAMs performed between January 2011 and December 2013.

MEASUREMENTS AND MAIN RESULTS

Our review included 163 CLMs (12%), 156 RAMs (12%), 686 AMs (52%), and 308 LAMs (23%). Although the average number, size, and total weight of leiomyomas removed were comparable in the LAM and AM groups (9.1, 8.13 cm, and 391 g, respectively, vs 9.0, 7.5 cm, and 424 g; p < .0001), the number and weight of myomas were significantly greater in those 2 groups compared with the CLM and RAM groups (2.9 and 217 g, respectively, and 2.9 and 269 g; p < .0001). The intraoperative complication rate was highest in the RAM group, and the postoperative complication rate was highest in the AM group, both of which were approximately 3 times greater than the rates in the LAM group. There was no statistically significant difference in postoperative complication rates between the CLM and LAM groups.

CONCLUSION

LAM with uterine artery occlusion/ligation is a viable approach for removing large tumor loads while minimizing blood loss and precluding the need for power morcellation.

Chronic Inflammation May Enhance Leiomyoma Development by the Involvement of Progenitor Cells

Although the etiology of leiomyoma is unclear, a progenitor/undifferentiated cell population has been described whose dysregulation may be involved in the onset of uterine conditions. Moreover, inflammation is involved in the development of several tumors. The aim of this work was to understand if progenitor cells sustain a chronic inflammatory microenvironment that enhances leiomyoma development. Cells from 12 human leiomyoma and 12 normal myometrium samples of the same patients were in vitro isolated and exhaustively characterized (morphology, proliferation, cytofluorometry, differentiation, RT-PCR, immunofluorescence, immunohistochemistry, and Western blotting assays). Selected cytokines (ELISA) and inflammation-related genes (RT-PCR) were analyzed to identify healthy myometrium progenitor cells (MPCs) and leiomyoma progenitor cells (LPCs). Results show that (i) MPCs and LPCs share stemness features, such as immunophenotype and multidifferentiation assay, (ii) LPCs have a significantly shorter doubling time and a significantly higher expression of stemness genes (p < 0.05), and (iii) LPCs secreted significantly higher levels (p < 0.05) of cytokines related to chronic inflammation and significantly lower amounts (p < 0.05) of cytokines related to acute inflammation. Despite the limited sample size, comparisons between leiomyoma and normal myometrium tissue from each patient allowed normalization of patient-specific differences. The evidenced cytokine expression pattern related to chronic inflammation in LPCs may play a role in the increased risk of adverse obstetric outcomes (infertility, spontaneous miscarriage, and preterm birth) in women affected by leiomyomas. These women should be recognized as “high risk” and subjected to specialized management both before and during pregnancy.

Uterine Fibroids: Burden and Unmet Medical Need

Uterine 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.

Myoma and myomectomy: Poor evidence concern in pregnancy

AIM

Summarize the results of the many, but often underpowered, studies on pregnancy complicated by myoma or myomectomy.

METHODS

Survey of the electronic PubMed database for the last two decades was conducted. We selected reviews, meta-analyses, case series, case reports, clinical studies only with statistical analysis, and guidelines from scientific societies.

RESULTS

Delaying childbearing leads to an increased incidence of pregnancy complicated by fibroids or previous myomectomy. Approximately 10-30% of pregnant women with myomas develop complications during gestation, at delivery and in puerperium. Submucosal, retroplacental, large and multiple myomas have a greater risk of complications. Cervical myomas, although rare, need careful management. The location and size of the fibroids should be assessed from the first trimester. Despite the increased risk of cesarean section, fibroids are not a contraindication to labor, unless they obstruct the birth canal or other obstetric conditions coexist. Myomectomy during pregnancy, in selected cases, is feasible and safe. Myomectomy cannot be considered a prophylactic measure prior to conception, but has to be individualized. Uterine rupture after myomectomy generally occurs in the third trimester or during labor and some associated risk factors have been identified. There is no consensus on the optimal interval between myomectomy and conception.

CONCLUSIONS

Pregnancy in patients with fibroids or previous myomectomy should be considered as high risk, requiring a maternal-fetal medicine specialist. To date available literature is inconsistent on evidence-based management. Further research is needed for definitive recommendations.

Biomechanics of the human uterus

The appropriate biomechanical function of the uterus is required for the execution of human reproduction. These functions range from aiding the transport of the embryo to the implantation site, to remodeling its tissue walls to host the placenta, to protecting the fetus during gestation, to contracting forcefully for a safe parturition and postpartum, to remodeling back to its nonpregnant condition to renew the cycle of menstruation. To serve these remarkably diverse functions, the uterus is optimally geared with evolving and contractile muscle and tissue layers that are cued by chemical, hormonal, electrical, and mechanical signals. The relationship between these highly active biological signaling mechanisms and uterine biomechanical function is not completely understood for normal reproductive processes and pathological conditions such as adenomyosis, endometriosis, infertility and preterm labor. Animal studies have illuminated the rich structural function of the uterus, particularly in pregnancy. In humans, medical imaging techniques in ultrasound and magnetic resonance have been combined with computational engineering techniques to characterize the uterus in vivo, and advanced experimental techniques have explored uterine function using ex vivo tissue samples. The collective evidence presented in this review gives an overall perspective on uterine biomechanics related to both its nonpregnant and pregnant function, highlighting open research topics in the field. Additionally, uterine disease and infertility are discussed in the context of tissue injury and repair processes and the role of computational modeling in uncovering etiologies of disease. WIREs Syst Biol Med 2017, 9:e1388. doi: 10.1002/wsbm.1388 For further resources related to this article, please visit the WIREs website.

Successful Pregnancy after Treatment with Chinese Herbal Medicine in a 43-Year-Old Woman with Diminished Ovarian Reserve and Multiple Uterus Fibrosis: A Case Report

Objective: To highlight a natural approach to coexisting oligomenorrhea, subfertility, luteal phase insufficiency and multiple fibroids cohesively when in vitro fertilisation (IVF) has failed. Case Presentation: A 43-year-old woman with diminished ovarian reserve and multiple uterine fibroids had previously been advised to discontinue IVF treatment. According to Chinese Medicine diagnosis, herbal formulae were prescribed for improving age-related ovarian insufficiency as well as to control the growth of fibroids. After 4 months of treatment, the patient’s menstrual cycle became regular and plasma progesterone one week after ovulation increased from 10.9 nmol/L to 44.9 nmol/L. After 6 months, she achieved a natural conception, resulting in a live birth of a healthy infant at an estimated gestational age of 40 weeks. Conclusions: The successful treatment with Chinese Herbal Medicine for this case highlights a natural therapy to manage infertility due to ovarian insufficiency and multiple fibroids after unsuccessful IVF outcome.