Myomectomy at the Chelsea Hospital for Women

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

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

Are the anticipated benefits of myomectomy achieved in women of reproductive age? A 5-year review of the results at a UK tertiary hospital

Fibroids are the most common benign tumours of the pelvis in women, with a prevalence estimated at 20-50%. They are more common towards the end of the reproductive years. There is a racial preponderance, being more common in black than white women. This may relate to the aetiology, which is still poorly understood. Generally, fibroids do not cause symptoms but some sufferers do complain about pressure symptoms, abnormal vaginal bleeding and infertility. For these reasons, myomectomy is often resorted to after failure of medical interventions on the premise that it brings about improvement/cure of symptoms and enhancement of fertility. However, the evidence for these indications for surgery is hazy. An analysis of the 109 medical records of symptomatic patients who had myomectomy over a 5-year period at a tertiary centre revealed the following. Single-symptom presentation in 41 (38%), menorrhagia in 20 (18%) being the most common. Only 52 (48%) patients had medical treatment of one form or another before myomectomy. Additional operative findings included pelvic adhesions, evidence of PID and endometriosis. Thirty-four (31%) had an estimated blood loss 500 ml and 23 of these patients needed blood transfusion. There were four cases of unscheduled hysterectomies due to uncontrollable bleeding. Pyrexia was the most common (38%) postoperative complication followed by superficial wound infection in 5%. We observed improvement of symptoms, assessed over a range of 2-24 months, in 34 cases (68%) in patients without fertility symptoms who accounted for 50 of these women. The symptomatic benefit was less (36%) in the 'infertility group'. Following an observation period of over 12-36 months, 17 patients in the 'infertility group' were lost to follow-up. Two (14%) of the 14 patients who attempted in vitro fertilisation (IVF) were successful. In the non-IVF group, 13 (46%) of the 28 achieved natural conception. These results suggest that symptomatic improvement and fertility enhancement may be possible in some patients with fibroids. In view of the risks and potential failure of treatment associated with myomectomy these results, yet again, support the fact that patients should be properly counselled before embarking on myomectomy and we strongly advocate local data to form the basis of the advice given during the consultation rather than what obtains in the literature.

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

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

Hysterectomy and myomectomy by laparotomy

Hysterectomy provides definitive treatment for uterine fibroids. Surgery should be offered to women whose fibroids are symptomatic; it is not indicated on the basis of uterine size alone. Myomectomy is an option for those wishing to preserve uterine function. The prospects for successful pregnancy following myomectomy are encouraging, although there is a significant risk of the later recurrence of fibroids. Laparotomy remains the most appropriate surgical approach for large fibroids, although vaginal, rather than abdominal, hysterectomy may be suitable for some women whose uteri do not exceed a 12-14 week gestation size. There is some evidence that the morbidity of abdominal procedures increases with very large uteri. Uterine shrinkage with GnRH analogues may facilitate vaginal hysterectomy and be useful prior to abdominal hysterectomy or myomectomy for very large fibroids, although cost-effectiveness for its use with abdominal procedures has not been demonstrated.

Laparoscopic myomectomy in African-American women

STUDY OBJECTIVE

To evaluate the effectiveness of laparoscopic myomectomy in an ethnic group with a statistically increased frequency of uterine leiomyomata.

DESIGN

Retrospective chart review.

SETTING

Private practice of one surgeon, and Department of Obstetrics and Gynecology, Rush Medical College, Chicago, Illinois.

PATIENTS

Forty-one consecutive African-American women who underwent laparoscopic myomectomy and were followed for 12 to 26 months.

INTERVENTIONS

The women received a modified protocol for gonadotropin-releasing hormone agonist treatment before laparoscopic surgery. Laparoscopic myomectomies were performed under general anesthesia using energy sources of monopolar and bipolar electrosurgery and ultrasonic coagulation-cutting (harmonic scalpel).

MEASUREMENTS AND MAIN RESULTS

Seventy percent (70%, 29 women) of procedures were completed on an outpatient basis. Twelve patients were hospitalized for an average of 1.3 days. No significant operative or postoperative complications occurred, and none of the women required blood transfusions or readmission. The conversion rate was zero. Forty patients (91%) reported complete resolution or significant reduction of their symptoms.

CONCLUSIONS

Outpatient laparoscopic myomectomy is safe and effective in African-American women with symptomatic uterine leiomyomata of 20 weeks' size or less.

Pregnancy following regression of uterine submucosal leiomyoma with GnRH therapy; a case report

A patient with a history of two spontaneous abortions, at the 16th and 20th week, respectively, and one intra-uterine fetal death at the 26th week of gestation was investigated. The sole abnormal condition that could be evidenced was a submucosal leiomyoma of 56 mm in diameter in the uterine fundus. Administration of gonadotropin/releasing hormone analog (GnRHa) for 10 months resulted in complete disappearance of myoma. Direct intraperitoneal insemination following induction of ovulation resulted in pregnancy. In a patient harboring uterine leiomyomas, adversely affecting conception and pregnancy outcome, GnRHa treatment may be an initial approach allowing to avoid pelvic surgery. As the beneficial effect of GnRHa might be temporary, assisted reproduction procedures might anticipate conception.

Risk of recurrence after myomectomy

The risk of recurrence of uterine myomas was analyzed in 622 patients who underwent myomectomy between 1970 and 1984 at the First Department of Obstetrics and Gynecology of the University of Milan. The cumulative 10-year recurrence rate was 27%, and this increased steadily up to the end of the observation period. Differences were not observed in frequency of recurrence by age at diagnoses or by the site of the myomas at surgery. Patients with a single myoma tended to experience a lower rate, but this finding was not statistically significant. Women who gave birth to a child after myomectomy had a 10-year recurrence rate of 15%, against 30% for those who did not; this difference was statistically significant.

Recurrent uterine myomata in three sisters--an uncommon occurrence

Three sisters who developed recurrent uterine myomata from a very young age are presented. Despite repeated attempts at myomectomy, all three cases had hysterectomies ultimately. Complications encountered during surgery were severe hemorrhage, inadvertent injury to bladder and bowel in two patients and a rare complication of colonic-uteric-cutaneous fistula occurring post-operatively in one patient. Histology of the final hysterectomy specimens in two cases showed low grade leiomyosarcoma and cellular myoma, respectively.

Submucosal leiomyomas and infertility

Seventeen patients with primary (59%) or secondary (41%) infertility and evidence of at least 1 large (greater than or equal to 5 cm) submucosal leiomyoma underwent abdominal myomectomy . In all patients, no other cause of infertility could be found. Following surgery, 2 of the 17 patients elected to use contraception. Thirteen of the 15 patients wishing to establish a pregnancy had 10 or more months of sexual exposure. The overall pregnancy rate was 47%, and 53% of those patients attempting to establish a pregnancy conceived. The corrected pregnancy rate for those with adequate sexual exposure for at least 10 months was 61.5%. Of those women who attained a pregnancy, 63% did so within 11 months after surgery. Only one patient conceived after more than 3 years (38 months). These results suggest that submucosal leiomyomas are a possible cause of infertility and are highly amenable to surgical treatment and subsequent restoration of fertility.

Management of uterine fibroids at the University of Benin Teaching Hospital

One hundred and eighty cases of uterine fibroids out of the two hundred treated in a gynaecological unit in a 7-year period are reviewed. The incidence of uterine fibroids among gynaecological conditions was 3.2% and it accounted for 3.6% of the operations. The peak age incidence was at 31-40 years (46%). Twenty per cent of those affected were grand multiparae. The commonest clinical features were abdominal swelling, infertility, abdominal pain, menorrhagia and dysmenorrhoea. Most of the patients were treated surgically with myomectomy (68%), mainly on account of the low parity and age. There was increased morbidity among those who had hysterectomy; 2 deaths occurred in this group. We have advocated liberal use of myomectomy , with its preservation of menstrual and reproductive function.

Pregnancy success following abdominal myomectomy for infertility

There were 46 patients with primary infertility (34 patients) or secondary infertility (12 patients) with no other detectable cause except myomas. After myomectomy, 38% of the patients with primary infertility had full-term pregnancies and 50% of those with secondary infertility. Preoperative distortion of the endometrial cavity was not impressively correlated with the postoperative prognosis.