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Deger U, Altinbas E, Karabay M, Karatas Y, Deniz Z, Buyuker C, Yildirim Kopuk S, Tiras B, Cakiroglu Y. Effects of Non-Cavity-Distorting Intramural Fibroids on IVF Outcomes in Patients with Recurrent IVF Failure: Does Myomectomy Change IVF Outcomes ? J Obstet Gynaecol India 2023; 73:322-328. [PMID: 37701080 PMCID: PMC10492715 DOI: 10.1007/s13224-023-01750-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 03/10/2023] [Indexed: 09/14/2023] Open
Abstract
Background Uterine fibroids are the most common benign smooth muscle tumors of the uterus. However, there is no consensus on whether myomectomy improves IVF success in women with non-cavity-distorting intramural fibroids. The aim of this study was to compare the IVF and pregnancy outcomes of women who had non-cavity-distorting intramural fibroids and underwent myomectomy vs women who had intramural fibroids, but did not undergo myomectomy. Methods A retrospective cohort study at Acibadem Maslak Hospital, IVF Center, between 2019 and 2020. Data of 128 women aged between 25 and 43 years who have at least 2 intramural non-cavity-distorting fibroids of 2-6 cm in size were used. All patients had at least two IVF failure. The intervention group comprised women who decided to proceed to myomectomy before IVF (Group 1, n = 56). The control group was established women with intramural fibroids who reject myomectomy (Group 2, n = 71). Results In regard to IVF result parameters and perinatal outcomes, there was no statistically significant difference between the two groups. Between study groups, there were no statistically significant differences in the perinatal outcomes. Myomectomy surgery did not increase miscarriage and biochemical pregnancy rate (odds ratio (OR) 0.9; 95% confidence interval (CI) 2.8-3.7). Conclusion Myomectomy does not impact on pregnancy or live birth rates substantially, according to the results of this study.
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Affiliation(s)
- Ugur Deger
- Department of Obstetrics and Gynecology, Memorial Hospital, Diyarbakır, Turkey
| | - Ekin Altinbas
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Melis Karabay
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Yagmur Karatas
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Zeynep Deniz
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Ceyda Buyuker
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
| | - Sule Yildirim Kopuk
- Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey
| | - Bulent Tiras
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
- Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey
| | - Yigit Cakiroglu
- School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey
- Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey
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Sefah N, Ndebele S, Prince L, Korasare E, Agbleke M, Nkansah A, Thompson H, Al-Hendy A, Agbleke AA. Uterine fibroids - Causes, impact, treatment, and lens to the African perspective. Front Pharmacol 2023; 13:1045783. [PMID: 36703761 PMCID: PMC9871264 DOI: 10.3389/fphar.2022.1045783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/12/2022] [Indexed: 01/12/2023] Open
Abstract
Leiomyomas, or uterine fibroids as they are commonly known, are mostly seen in women of reproductive age. However, they can go undetected in most women, and approximately 25% of women show clinical symptoms. Although fibroids are a global burden impacting 80% of premenopausal women, they are more prevalent among Black women than among women of other races. Based on clinical diagnosis, the estimated cumulative incidence of fibroids in women ≤50 years old is significantly higher for black (>80%) versus white women (∼70%). The cause of leiomyomas is not clearly known, but studies have shown evidence of factors that drive the development or exacerbation of the disease. Evidence has linked risk factors such as lifestyle, age, environment, family history of uterine fibroids, and vitamin D deficiencies to an increased risk of uterine fibroids, which impact women of African descent at higher rates. Treatments may be invasive, such as hysterectomy and myomectomy, or non-invasive, such as hormonal or non-hormonal therapies. These treatments are costly and tend to burden women who have the disease. Sub-Saharan Africa is known to have the largest population of black women, yet the majority of uterine fibroid studies do not include populations from the continent. Furthermore, the prevalence of the disease on the continent is not well determined. To effectively treat the disease, its drivers need to be understood, especially with regard to racial preferences. This paper aims to review the existing literature and build a case for conducting future research on African women.
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Affiliation(s)
| | | | | | | | | | | | | | - Ayman Al-Hendy
- University of Chicago, Chicago, United States,*Correspondence: Ayman Al-Hendy, ; Andrews Akwasi Agbleke,
| | - Andrews Akwasi Agbleke
- Sena Institute of Technology, Penyi, Ghana,*Correspondence: Ayman Al-Hendy, ; Andrews Akwasi Agbleke,
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Dudova KA, Makulova MV, Taits AN, Vorobtsova IN. The Estimation Of The Quantity And Quality Of Oocytes And Embryos In The IVF Protocols In Women With Uterine Fibroids With And Without Surgical Treatment. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Myoma periodically leads to infertility by causing impaired blood flow, aseptic inflammation in the endometrium, increased uterine contractility, impaired sperm migration with cerviсal myoma nodes and obstruction of the proximal fallopian tubes. Objective — The estimation of the quantity and quality of oocytes and embryos in the IVF (in vitro fertilization) protocols in women with uterine fibroids with and without surgical treatment. Material and Methods — The retrospective study included 37 IVF cycles from 37 patients that had infertility combined with myoma. The Group 1 patients were subjected to the IVF procedure without previous treatment of the myoma, while the Group 2 patients were subjected to IVF after myomectomy. Results — The total quantity of oocytes and the percentage of mature (MII) oocytes obtained during the ovarian puncture of the patients in the compared groups were slightly higher in the group without surgical treatment (p>0.05). Any significant differences in the frequency of formation of high-quality embryos (р=0.43) and good-quality embryos (р=0.22) between the groups were not obtained. The number of embryos suitable for embryo transfer to the uterine cavity and/or cryopreservation in the women with myomectomy was 9% higher than the one in the group without surgical treatment. Conclusion — Surgical treatment of uterine fibroids does not significantly affect the quantity and quality of oocytes and embryos obtained in the IVF procedure.
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Affiliation(s)
- Kristina A. Dudova
- St. Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Maria V. Makulova
- St. Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Anna N. Taits
- St. Petersburg State Pediatric Medical University, Saint Petersburg, Russia
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Intramural myomas more than 3-4 centimeters should be surgically removed before in vitro fertilization. Fertil Steril 2021; 116:945-958. [PMID: 34579828 DOI: 10.1016/j.fertnstert.2021.08.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/29/2022]
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5
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Rikhraj K, Tan J, Taskin O, Albert AY, Yong P, Bedaiwy MA. The Impact of Noncavity-Distorting Intramural Fibroids on Live Birth Rate in In Vitro Fertilization Cycles: A Systematic Review and Meta-Analysis. J Womens Health (Larchmt) 2020; 29:210-219. [DOI: 10.1089/jwh.2019.7813] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Kiran Rikhraj
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver General Hospital, Vancouver BC, Canada
| | - Justin Tan
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Omur Taskin
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Arianne Y. Albert
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Paul Yong
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
| | - Mohamed A. Bedaiwy
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of British Columbia, BC Women's Hospital, Vancouver, BC, Canada
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The Impact of Noncavity-Distorting Intramural Fibroids on the Efficacy of In Vitro Fertilization-Embryo Transfer: An Updated Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8924703. [PMID: 30255100 PMCID: PMC6142781 DOI: 10.1155/2018/8924703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/16/2018] [Indexed: 12/01/2022]
Abstract
Aim To address the impact of noncavity-distorting intramural fibroids on the efficacy of in vitro fertilization-embryo transfer (IVF-ET) outcomes. Methods The PubMed, Web of Science, Embase, Cochrane Library, and China National Knowledge Infrastructure were searched systematically. A meta-analysis was performed based on comparative or cohort studies that explored the impact of noncavity-distorting intramural fibroids on the efficacy of IVF-ET treatment. The IVE-ET outcomes of study group (women with noncavity-distorting intramural fibroids) and control group (women without fibroids) were compared, including live birth rate (LBR), clinical pregnancy rate (cPR), implantation rate (IR) , miscarriage rate (MR), and ectopic pregnancy rate (ePR). Results A total of 28 studies involving 9189 IVF cycles were included. Our meta-analysis showed a significant reduction of LBR in the study group compared to control group (RR = 0.82, 95% CI: 0.73-0.92, and P = 0.005). In addition, it indicated that study group had a significant reduction in cPR (RR = 0.86, 95% CI: 0.80-0.93, P = 0.0001) and IR (RR = 0.90, 95% CI: 0813-1.00, P = 0.04) and have a significantly increase in MR (RR = 1.27, 95% CI: 1.08-1.50, and P = 0.004) compared with control group. Conclusions The present evidence suggests that noncavity-distorting intramural fibroids would significantly reduce the IR, cRP, and LBR and significantly increase the MR after IVF treatment, but it would not significantly increase the ePR.
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7
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Tanos V, Berry K. Benign and malignant pathology of the uterus. Best Pract Res Clin Obstet Gynaecol 2018; 46:12-30. [DOI: 10.1016/j.bpobgyn.2017.10.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 10/08/2017] [Accepted: 10/09/2017] [Indexed: 01/11/2023]
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8
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Effect of intramural fibroid on uterine and endometrial vascularity in infertile women scheduled for in-vitro fertilization. Arch Gynecol Obstet 2017; 297:539-545. [DOI: 10.1007/s00404-017-4607-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
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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: 17] [Impact Index Per Article: 2.4] [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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Vlahos NF, Theodoridis TD, Partsinevelos GA. Myomas and Adenomyosis: Impact on Reproductive Outcome. BIOMED RESEARCH INTERNATIONAL 2017; 2017:5926470. [PMID: 29234680 PMCID: PMC5694987 DOI: 10.1155/2017/5926470] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/19/2017] [Accepted: 08/30/2017] [Indexed: 12/26/2022]
Abstract
Among uterine structural abnormalities, myomas and adenomyosis represent two distinct, though frequently coexistent entities, with a remarkable prevalence in women of reproductive age. Various mechanisms have been proposed to explain the impact of each of them on reproductive outcome. In respect to myomas, current evidence implies that submucosal ones have an adverse effect on conception and early pregnancy. A similar effect yet is not quite clear and has been suggested for intramural myomas. Still, it seems reasonable that intramural myomas greater than 4 cm in diameter may negatively impair reproductive outcome. On the contrary, subserosal myomas do not seem to have a significant impact, if any, on reproduction. The presence of submucosal and/or large intramural myomas has also been linked to adverse pregnancy outcomes. In particular increased risk for miscarriage, fetal malpresentation, placenta previa, preterm birth, placenta abruption, postpartum hemorrhage, and cesarean section has been reported. With regard to adenomyosis, besides the tentative coexistence of adenomyosis and infertility, to date a causal relationship among these conditions has not been fully confirmed. Preterm birth and preterm premature rupture of membranes, uterine rupture, postpartum hemorrhage due to uterine atony, and ectopic pregnancy have all been reported in association with adenomyosis. Further research on the impact of adenomyosis on reproductive outcome is welcome.
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Affiliation(s)
- Nikos F. Vlahos
- 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, National and Kapodistrian University of Athens, School of Medicine, 76 Vasilissis Sofias Av., 11528 Athens, Greece
| | - Theodoros D. Theodoridis
- 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Faculty of Health Sciences, School of Medicine, Ring Road, Municipality of Pavlos Melas, Area of N. Efkarpia, 56403 Thessaloniki, Greece
| | - George A. Partsinevelos
- Assisted Reproduction-IVF Unit, MITERA Hospital, 6 Erithrou Stavrou Str., Marousi, 15123 Athens, Greece
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11
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Moon JW, Kim CH, Kim JB, Kim SH, Chae HD, Kang BM. Alterations in uterine hemodynamics caused by uterine fibroids and their impact on in vitro fertilization outcomes. Clin Exp Reprod Med 2015; 42:163-8. [PMID: 26816875 PMCID: PMC4724601 DOI: 10.5653/cerm.2015.42.4.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 11/06/2015] [Accepted: 11/20/2015] [Indexed: 11/21/2022] Open
Abstract
Objective To investigate the impact of fibroids on the blood flow of the uterine and subendometrial arteries and in vitro fertilization (IVF) outcomes. Methods In this study, we analyzed 86 IVF/intracytoplasmic sperm injection (ICSI) cycles in which a gonadotropin-releasing hormone antagonist protocol was used for controlled ovarian stimulation between January 2008 and March 2009. The subjects comprised 86 infertile women with (fibroid group, n=43) or without (control group, n=43) uterine fibroids. Results Patient characteristics were similar between the fibroid and control groups. The IVF/ICSI outcomes in patients with fibroids were similar to those of patients in the control group. The resistance index (RI) and pulsatile index (PI) of the uterine and subendometrial arteries on the day of embryo transfer were also comparable between the two groups. IVF outcomes and uterine hemodynamics in patients with multiple (≥2) fibroids were similar to those of patients with a single fibroid. However, clinical pregnancy and implantation rates were significantly lower in patients with fibroids who experienced uterine cavity distortion than in patients with fibroids who had a normal uterine cavity (both p<0.05). The RI and PI of the subendometrial artery were significantly higher on the day of embryo transfer in patients with fibroids who experienced uterine cavity distortion than in patients with fibroids who had a normal uterine cavity (both p<0.05). Conclusion Fibroids which distorting the uterine cavity might impair the subendometrial artery blood flow clinical pregnancy rate and embryo implantation rate in infertile patients undergoing IVF. Otherwise, IVF outcomes were not influenced by the presence of uterine fibroids.
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Affiliation(s)
- Jei-Won Moon
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Chung-Hoon Kim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Jun-Bum Kim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Sung-Hoon Kim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Hee-Dong Chae
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
| | - Byung-Moon Kang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
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Ahdad-Yata N, Fernandez H, Nazac A, Lesavre M, Pourcelot AG, Capmas P. [Fertility after hysteroscopic resection of submucosal myoma in infertile women]. ACTA ACUST UNITED AC 2015; 45:563-70. [PMID: 26321611 DOI: 10.1016/j.jgyn.2015.06.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 06/12/2015] [Accepted: 06/18/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Myoma is the most frequent benign uterine tumor and might have a negative impact on fertility. In 5 to 10% of cases, infertility is associated with myoma and in 1 to 3% myoma is the only infertility factor. Even if effect of myomectomy on fertility is controversial, benefit of hysteroscopic myomectomy for submucosal myoma on fertility has already been shown. The aim of this study is to evaluate fertility of infertile women less than 46years old after hysteroscopic resection of submucosal myoma. MATERIAL AND METHODS This retrospective unicentric study took place in the gynecologic unit of a teaching hospital. All infertile women with a hysteroscopic myomectomy for submucosal myoma between March 2009 and May 2013 were included. A phone questionnaire was conducted to evaluate pregnancy rate, eventual medical assistance, time between submucisal resection and pregnancy and issue of pregnancies. RESULTS Seventy-one infertile women with a hysteroscopic resection of submucosal myoma were included. Pregnancy rate was 33.8% with 50% of live births, 41.6% of miscarriages and 8.4% of late fetal losses with a mean follow-up of 28.7months. Mean time between hysteroscopic resection and pregnancy was 9.9months. A medical assistance was necessary for 6 women (25% of pregnancy). CONCLUSION This study reports hysteroscopic resection of submucosal myoma for infertile women. The rate of pregnancy after treatment is 33.8%.
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Affiliation(s)
- N Ahdad-Yata
- Service de gynécologie obstétrique, hôpital Bicêtre, GHU Sud, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - H Fernandez
- Service de gynécologie obstétrique, hôpital Bicêtre, GHU Sud, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; U1018 CESP-Inserm, Centre de recherché en épidémiologie et santé des populations, 82, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; Faculté de médecine, université Paris Sud, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
| | - A Nazac
- Service de gynécologie obstétrique, hôpital Bicêtre, GHU Sud, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; Laboratoire de physique des interfaces et des couches minces, école polytechnique, 91128 Palaiseau, France
| | - M Lesavre
- Service de gynécologie obstétrique, hôpital Bicêtre, GHU Sud, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; Faculté de médecine, université Paris Sud, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France
| | - A-G Pourcelot
- Service de gynécologie obstétrique, hôpital Bicêtre, GHU Sud, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - P Capmas
- Service de gynécologie obstétrique, hôpital Bicêtre, GHU Sud, AP-HP, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; U1018 CESP-Inserm, Centre de recherché en épidémiologie et santé des populations, 82, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France; Faculté de médecine, université Paris Sud, 63, rue Gabriel-Péri, 94270 Le Kremlin-Bicêtre, France.
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Guven S, Kart C, Unsal MA, Odaci E. Intramural leoimyoma without endometrial cavity distortion may negatively affect the ICSI - ET outcome. Reprod Biol Endocrinol 2013; 11:102. [PMID: 24168009 PMCID: PMC4231457 DOI: 10.1186/1477-7827-11-102] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 10/17/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the impact of intramural fibroids on the intracytoplasmic sperm injection-embryo transfer (ICSI-ET) cycle outcome, when there is no compression of the endometrial cavity. METHODS In this retrospective, matched control study, the ICSI-ET outcome of sixty-two patients (Group I) with intramural fibroid (mean diameter <7 cm) and normal endometrial cavity demonstrated by office hysteroscopy was compared with matched-control group of patients (n = 301) with no fibroid (Group II). The diagnosis of fibroids was done by transvaginal ultrasonography. RESULTS The mean age in fibroid group was 32.66 +/- 5.30 while this figure was 32.95 +/- 3.98 in control group. The clinical pregnancy rate was significantly lower in the fibroid group although fibroids not distorting the uterine cavity (25.8% vs. 39.9%, p = 0.04). In fibroid group the implantation rate was significantly lower than control group (20.97 +/- 37.93 vs.32.89 +/- 43.18%, p = 0.04). However, spontaneous abortion rate was higher in fibroid group but it did not reach the significant level (12.5% vs. 9.2%, p > 0.05). CONCLUSION Women having intramural leiomyomas not encroaching on the uterine cavity have unfavorable ICSI/ET outcomes comparable to those of women without such leiomyomas. Therefore, myomectomy may be a good option for such patients with intramural fibroids even they do not have any endometrial distortion.
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Affiliation(s)
- Suleyman Guven
- Department of Obstetrics and Gynecology, Farabi ART Center, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Cavit Kart
- Department of Obstetrics and Gynecology, Farabi ART Center, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Mesut A Unsal
- Department of Obstetrics and Gynecology, Farabi ART Center, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Ersan Odaci
- Department of Obstetrics and Gynecology, Farabi ART Center, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
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Edwards TL, Hartmann KE, Velez Edwards DR. Variants in BET1L and TNRC6B associate with increasing fibroid volume and fibroid type among European Americans. Hum Genet 2013; 132:1361-9. [PMID: 23892540 DOI: 10.1007/s00439-013-1340-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 07/14/2013] [Indexed: 12/18/2022]
Abstract
Uterine fibroids (UFs) affect 77 % of women by menopause and account for $9.4 billion in yearly healthcare costs. We recently replicated findings from the first UF genome-wide association study (GWAS), conducted in the Japanese. Here we tested these GWAS-discovered SNPs for association with UF characteristics to further assess whether risk varies by sub-phenotypes of UFs. Women were enrolled in Right from the Start (RFTS) and the BioVU DNA repository (BioVU). UF status was determined by pelvic imaging. We tested the top GWAS-associated SNPs for association with UF characteristics (RFTS: type, number, volume; BioVU: type) using covariate adjusted logistic and linear regression. We also combined association results of UF type using meta-analysis. 456 European American (EA) cases and 1,549 controls were examined. Trinucleotide repeat containing 6B (TNRC6B) rs12484776 associated with volume in RFTS (β = 0.40, 95 % CI 0.05-0.75, p = 0.024). RFTS analyses evaluating stratified quartiles of volume showed the strongest OR at rs12484776 for the largest volume (16.6-179.1 cc, odds ratio (OR) = 2.19, 95 % confidence interval (CI) 1.07-4.46, p = 0.031). Meta-analysis showed a strong association at blocked early in transport 1 homolog (BET1L) rs2280543 for intramural UFs (meta-OR = 0.51, standard error (SE) = 0.14, Q = 0.590, I = 0, p = 2.48 × 10(-6)), which is stronger than the overall association with UF risk. This study is the first to evaluate these SNPs for association with UF characteristics and suggests these genes associate with increasing UF volume and protection from intramural UF in EAs.
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Affiliation(s)
- Todd L Edwards
- Vanderbilt Epidemiology Center, Vanderbilt University, 2525 West End Ave., Suite 600 6th Floor, Nashville, TN, 37203, USA
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Pistofidis G, Makrakis E, Balinakos P, Dimitriou E, Bardis N, Anaf V. Report of 7 Uterine Rupture Cases After Laparoscopic Myomectomy: Update of the Literature. J Minim Invasive Gynecol 2012; 19:762-7. [DOI: 10.1016/j.jmig.2012.07.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 07/08/2012] [Accepted: 07/12/2012] [Indexed: 11/30/2022]
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Desai P, Patel P. Fibroids, infertility and laparoscopic myomectomy. JOURNAL OF GYNECOLOGICAL ENDOSCOPY AND SURGERY 2012; 2:36-42. [PMID: 22442534 PMCID: PMC3304294 DOI: 10.4103/0974-1216.85280] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: To review the literature and summarize the available evidence about the relationship of fibroids with infertility and to review the role of laparoscopic myomectomy in infertility. Materials and Methods: Medline, PubMed, and Cochrane Databases were searched for articles published between 1980 and 2010. Results: Fertility outcomes are decreased in women with submucosal fibroids, and myomectomy is of value. Subserosal fibroids do not affect fertility outcomes, and removal may not confer benefit. Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. Although pregnancy rates for women with leiomyomata, managed endoscopically, are similar to those after laparotomy, there is a risk of uterine rupture. The risk is essentially unknown. Finally, the risk of recurrence seems higher after laparoscopic myomectomy compared to laparotomy. Conclusions: Laparoscopic myomectomy, when performed by an experienced surgeon, can be considered a safe technique, with an extremely low failure rate and good results in terms of the outcome of pregnancy.
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Affiliation(s)
- Pankaj Desai
- Department of Obgyn, Medical College and S.S.G. Hospital, Baroda, India
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Johnson G, MacLehose RF, Baird DD, Laughlin-Tommaso SK, Hartmann KE. Uterine leiomyomata and fecundability in the Right from the Start study. Hum Reprod 2012; 27:2991-7. [PMID: 22811308 DOI: 10.1093/humrep/des263] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Previous research suggests the removal of uterine leiomyomata may improve ability to conceive. Most of this previous research was conducted in infertility clinics. We investigated the association between leiomyoma characteristics on time to pregnancy among women enrolled from the general population. METHODS We enrolled a cohort study of women in early pregnancy. Participants retrospectively reported their time to conception. Leiomyomata characteristics were determined by first-trimester ultrasound. We used discrete time hazard models to estimate the effects of uterine leiomyomata on time to pregnancy. RESULTS In this population of 3000 women, 11% (324) with one or more leiomyomata, we found no association between leiomyomata presence, type, location, segment or size on time to pregnancy. CONCLUSIONS These results suggest that leiomyomata have little effect on time to pregnancy in this cohort of women. The study excluded women who had been treated for infertility, and this may have resulted in underestimation of the association. However, differences between our study and previous studies in specialty clinics may be, in part, attributable to differences between our community-recruited population of women and women receiving fertility care, as well as difference in leiomyomata size or type in women having myomectomies to treat infertility.
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Affiliation(s)
- Gayle Johnson
- Division of Biostatistics, University of Minnesota, Minneapolis, MN 55455, USA
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Bendifallah S, Brun JL, Fernandez H. Place de la myomectomie chez une patiente en situation d’infertilité. ACTA ACUST UNITED AC 2011; 40:885-901. [DOI: 10.1016/j.jgyn.2011.09.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Is another meta-analysis on the effects of intramural fibroids on reproductive outcomes needed? Reprod Biomed Online 2011; 23:2-14. [DOI: 10.1016/j.rbmo.2010.08.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 08/12/2010] [Accepted: 08/17/2010] [Indexed: 11/19/2022]
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Roux I, Faivre E, Trichot C, Donnadieu AC, Fernandez H, Deffieux X. Fertilité après myomectomie par laparotomie pour les femmes de plus de 38 ans. ACTA ACUST UNITED AC 2011; 40:123-9. [DOI: 10.1016/j.jgyn.2010.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 09/22/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
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21
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Ramzy AMI. Myomectomy before IVF: Which fibroids need to be removed? MIDDLE EAST FERTILITY SOCIETY JOURNAL 2011. [DOI: 10.1016/j.mefs.2010.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril 2010; 94:324-30. [DOI: 10.1016/j.fertnstert.2009.02.069] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 01/21/2009] [Accepted: 02/25/2009] [Indexed: 10/20/2022]
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Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol BWJ, Mathieu C, D'Hooghe T. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update 2010; 16:1-11. [PMID: 19744944 DOI: 10.1093/humupd/dmp033] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking. METHODS We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied. RESULTS We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0-3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5-0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5-2.0). CONCLUSIONS Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.
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Affiliation(s)
- Jan Bosteels
- Department of Obstetrics and Gynaecology, Imeldahospital, Bonheiden, Belgium.
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Sunkara SK, Khairy M, El-Toukhy T, Khalaf Y, Coomarasamy A. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta-analysis. Hum Reprod 2009; 25:418-29. [DOI: 10.1093/humrep/dep396] [Citation(s) in RCA: 221] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Ezzati M, Norian JM, Segars JH. Management of uterine fibroids in the patient pursuing assisted reproductive technologies. ACTA ACUST UNITED AC 2009; 5:413-21. [PMID: 19586433 DOI: 10.2217/whe.09.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.
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Affiliation(s)
- Mohammad Ezzati
- Department of Obstetrics & Gynecology, Washington Hospital Center, Washington, DC, USA.
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Lucot JP, Coutty N, Lions C. Impact sur la fertilité des traitements conservateurs d’un utérus fibromateux : traitements chirurgicaux et non chirurgicaux. IMAGERIE DE LA FEMME 2009. [DOI: 10.1016/j.femme.2009.06.002] [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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Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009; 91:1215-23. [DOI: 10.1016/j.fertnstert.2008.01.051] [Citation(s) in RCA: 570] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 01/14/2008] [Accepted: 01/14/2008] [Indexed: 11/21/2022]
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Bozdag G, Esinler I, Boynukalin K, Aksu T, Gunalp S, Gurgan T. Single intramural leiomyoma with normal hysteroscopic findings does not affect ICSI–embryo transfer outcome. Reprod Biomed Online 2009; 19:276-80. [DOI: 10.1016/s1472-6483(10)60085-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008; 198:357-66. [PMID: 18395031 DOI: 10.1016/j.ajog.2007.12.039] [Citation(s) in RCA: 266] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2007] [Revised: 11/29/2007] [Accepted: 12/31/2007] [Indexed: 10/22/2022]
Abstract
We examined the published relationship between uterine fibroids and reproductive outcomes. Submucosal fibroids had the strongest association with lower ongoing pregnancy rates, odds ratio, 0.5; 95% confidence interval, 0.3-0.8, primarily through decreased implantation. Cumulative pregnancy rates appeared slightly lower in patients with intramural fibroids 36.9% vs 41.1%, which may reflect biases in the literature; however, patients with intramural fibroids also experienced more miscarriages, 20.4% vs 12.9%. Adverse obstetric outcomes are rare and may reflect age or other differences in fibroid populations. Increased risk of malpresentation (odds ratio, 2.9; 2.6-3.2), cesarean (odds ratio, 3.7; 3.5-3.9), and preterm delivery (odds ratio, 1.5; 1.3-1.7) are reported; however, the incidence of labor dystocia was low (7.5%). There was no conclusive evidence that intramural or subserosal fibroids adversely affect fecundity. More prospective, controlled trials are needed to assess the effects of myomectomy. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids.
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Makris N, Vomvolaki E, Mantzaris G, Kalmantis K, Hatzipappas J, Antsaklis A. Role of a bipolar resectoscope in subfertile women with submucous myomas and menstrual disorders. J Obstet Gynaecol Res 2007; 33:849-54. [DOI: 10.1111/j.1447-0756.2007.00667.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gavai M, Berkes E, Lazar L, Fekete T, Takacs ZF, Urbancsek J, Papp Z. Factors affecting reproductive outcome following abdominal myomectomy. J Assist Reprod Genet 2007; 24:525-31. [PMID: 18008158 PMCID: PMC3455029 DOI: 10.1007/s10815-007-9135-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2006] [Accepted: 04/12/2007] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Fibroids may cause infertility and recurrent pregnancy loss. Studies have analysed the reproductive results after myomectomy according to the size, location and number of fibroids removed, but data are insufficient about comparison of opening the uterine cavity or not during surgery. MATERIALS AND METHODS Two hundred twenty-nine abdominal myomectomies with the indication of infertility and/or recurrent pregnancy loss were analysed retrospectively. The main purpose was to compare postoperative pregnancy, delivery and miscarriage rates according to either the uterine cavity was opened or not during the surgery. As a secondary outcome postoperative pregnancy rates were assessed by location, size and number of fibroids. RESULTS There was no significant difference in reproductive results according to either the uterine cavity was opened or remained closed. Preoperative location, size and number of fibroids did not influence significantly the postoperative pregnancy rates. CONCLUSION Opening the uterine cavity does not impair postoperative pregnancy rates. Preoperative location, size and number of fibroids do not influence postoperative reproductive results.
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Affiliation(s)
- Marta Gavai
- Department of Obstetrics and Gynecology, Semmelweis University, 1088-Budapest, Baross Street 27, Budapest, Hungary.
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Mukhopadhaya N, Pokuah Asante G, Manyonda IT. Uterine fibroids: impact on fertility and pregnancy loss. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.ogrm.2007.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Malartic C, Morel O, Akerman G, Tulpin L, Clément D, Barranger E. La myomectomie par cœlioscopie en 2007: état des lieux. ACTA ACUST UNITED AC 2007; 36:567-76. [PMID: 17597308 DOI: 10.1016/j.jgyn.2007.05.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 04/10/2007] [Accepted: 05/09/2007] [Indexed: 11/30/2022]
Abstract
With fifteen years of development, laparoscopy for myomectomy has proven its advantages. However, this technique remains controversial concerning its feasibility and the quality of uterine scar obtained. Laparoscopic myomectomy (LM) is usually indicated when number of myomas is less than 3 to 4 with a 8 to 9 cm maximal size. Surgical technique is standardized and intervention time becomes acceptable. Risk of conversion ranges between 1 to 3% when technique is realized by trained surgeon. Bleeding is less important compared with laparotomy and immediate postoperative complications are exceptional. Results concerning fertility are positive with more than 50% of infertile patient conceiving after surgery, this rate rising up to 61 to 76% for myomas isolated cause for infertility; these values can be compared with myomectomy realized by laparotomy. Postoperative adhesions seem to be less important after laparoscopy when compared with laparotomy but this point needs to be confirmed. Risk of uterine rupture is estimated between 0 to 1%, but this point needs for larger series evaluation and needs to be compared with pregnancies after laparotomy. Laparoscopic myomectomy is a feasible technique, safe for patients waiting for conception and has proven its interest in case of infertility.
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Affiliation(s)
- C Malartic
- Service de gynécologie-obstétrique, APHP, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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Holub Z. Clinical experience and fertility outcome after uterine artery occlusion and embolization. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s10397-007-0318-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Levens ED, Stegmann BJ, Feinberg EC, Larsen FW. Ultrasonographic characteristics of the endometrium among patients with fibroids undergoing ART. Fertil Steril 2007; 89:1005-7. [PMID: 17662279 PMCID: PMC2394501 DOI: 10.1016/j.fertnstert.2007.03.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 03/29/2007] [Accepted: 03/29/2007] [Indexed: 11/23/2022]
Abstract
A retrospective cohort study examining all completed nondonor first ART cycles was performed to evaluate the ultrasonographic appearance of the endometrial pattern and thickness at time of hCG administration among precycle screened patients with uterine fibroids compared with patients without fibroids. There was no difference in the endometrial thickness (10.3 +/- 2.0 mm vs. 10.0 +/- 2.6 mm) between those with fibroids and controls; however, the rate of nonproliferative endometrial pattern (3.1% vs. 1.0%) and live birth rates (34.4% vs. 43.0%) were significantly different, most notably among those patients with intramural fibroids.
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Affiliation(s)
- Eric D Levens
- Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, Building 10, CRC, Room E1-3140, 10 Center Drive, Bethesda, MD 20892, USA.
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Goldberg J, Pereira L. Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy. Curr Opin Obstet Gynecol 2006; 18:402-6. [PMID: 16794420 DOI: 10.1097/01.gco.0000233934.13684.cb] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW The management of uterine fibroids in patients requiring treatment who desire future fertility remains controversial. Myomectomy has been the most common operative procedure to improve pregnancy rates and outcomes. Uterine fibroid embolization is an increasingly popular, minimally invasive treatment for fibroids. This review aims to provide critical analysis of available data on pregnancy following myomectomy and uterine artery embolization. RECENT FINDINGS Patients with distorted uterine cavities due to submucosal fibroids of more than 2 cm have higher pregnancy rates following hysteroscopic resection. Pregnancy rates following myomectomy, both via laparoscopy and laparotomy, are in the 50-60% range, with most having good outcomes. Pregnancy rates following uterine artery embolization have not been established. Pregnancies following uterine artery embolization had higher rates of preterm delivery (odds ratio 6.2, 95% confidence interval 1.4-27.7) and malpresentation (odds ratio 4.3, 95% confidence interval 1.0-20.5) than pregnancies following laparoscopic myomectomy. SUMMARY Both myomectomy and uterine artery embolization are safe and effective fibroid treatments, which should be discussed with appropriate candidates. Pregnancy complications, most importantly preterm delivery, spontaneous abortion, abnormal placentation and postpartum hemorrhage, are increased following uterine artery embolization compared to myomectomy. Although most pregnancies following uterine artery embolization have good outcomes, myomectomy should be recommended as the treatment of choice over uterine artery embolization in most patients desiring future fertility.
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Affiliation(s)
- Jay Goldberg
- Department of Obstetrics, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
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Abstract
Adenomyosis, the heterotopic presence of endometrial glands and stroma within the myometrium, has traditionally been diagnosed by the pathologist in hysterectomy specimens. However, the recent development of high-quality non-invasive techniques such as transvaginal sonography (TVS), magnetic resonance imaging (MRI) and hysteroscopy has renewed interest in diagnosing adenomyosis in the office prior to any treatment. Hysteroscopy offers the advantage of direct visualization of the uterine cavity, and since nowadays it is performed in the office, it can be offered as a first-line diagnostic tool for evaluation of uterine abnormalities in patients with abnormal uterine bleeding and/or infertility. The available data clearly indicate that high-quality mini-hysteroscopes, saline as a distension medium, and atraumatic insertion technique are essential for the success of office hysteroscopy. The procedure is indicated in any situation in which an intrauterine anomaly is suspected; it is immediately preceded by a physical exam and a TVS to evaluate uterine characteristics, and it is followed by a second TVS to take advantage of the intracavitary fluid for a contrast image of the uterus. Although diagnostic hysteroscopy does not provide pathognomonic signs for adenomyosis, some evidence suggests that irregular endometrium with endometrial defects, altered vascularization, and cystic haemorrhagic lesion are possibly associated with the entity. In addition to the direct visualization of the uterine cavity, the hysteroscopic approach offers the possibility of obtaining endometrial/myometrial biopsies under visual control. Since they can be performed in the office, the combination of TVS, fluid hysteroscopy and contrast sonography is therefore a powerful screening tool for detecting endometrial and myometrial abnormalities in association with adenomyosis.
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Affiliation(s)
- Carlos Roger Molinas
- Centre for Gynaecological Endoscopy (Cendogyn), Centro Médico La Costa, Asunción, Paraguay.
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Khalaf Y, Ross C, El-Toukhy T, Hart R, Seed P, Braude P. The effect of small intramural uterine fibroids on the cumulative outcome of assisted conception. Hum Reprod 2006; 21:2640-4. [PMID: 16790615 DOI: 10.1093/humrep/del218] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the effect of small intramural fibroids on the cumulative pregnancy, ongoing pregnancy, live birth and implantation rates after three IVF/ICSI attempts. METHODS The first three treatment cycles of women enrolled for IVF/ICSI over a 12-month period were analysed. Only patients with small (<or=5 cm) intramural fibroids not encroaching upon the endometrial cavity were included in the fibroid group. Cox's hazards regression was used to estimate the hazard ratio (HR) associated with the presence of intramural fibroids. RESULTS During the study period, 322 women without fibroids (control group) and 112 women with fibroids (study group) underwent 606 IVF/ICSI cycles. The pregnancy, ongoing pregnancy and live birth rates in the study group were 23.6, 18.8 and 14.8% compared with 32.9, 28.5 and 24% in the control group, respectively (P<0.05). Cox regression analysis showed that the pregnancy rate at each cycle was reduced by 39% (HR=0.61, 95% CI=0.39-0.95, P=0.029) in the study group compared with the control group. The cumulative ongoing pregnancy rate was reduced by 43% (HR=0.57, 95% CI=0.35-0.91, P=0.018), and the cumulative live birth rate was reduced by 47% (HR=0.53, 95% CI=0.32-0.87, P=0.013) in the study group. After adjusting for confounding variables, the presence of fibroids was found to significantly reduce the ongoing pregnancy rate at each cycle of IVF/ICSI by 40% (HR=0.60, 95% CI=0.36-0.99, P=0.048) and the live birth rate at each cycle by 45% (HR=0.55, 95% CI=0.32-0.95, P=0.03). CONCLUSION Small intramural fibroids are associated with a significant reduction in the cumulative pregnancy, ongoing pregnancy and live birth rates after three IVF/ICSI cycles.
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Affiliation(s)
- Y Khalaf
- Assisted Conception Unit, Guy's and St. Thomas' Hospital NHS Foundation Trust, Department of Women's Health, King's College London, UK.
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Abstract
The effect of uterine fibroids on fecundity and pregnancy outcome is difficult to determine with any degree of accuracy; this is due, in large part, to the lack of adequate large clinical trials. In general, the literature tends to underestimate the prevalence of fibroids in pregnancy and overestimate the complications that are attributed to them. In contrast to popular opinion, most fibroids do not exhibit a significant change in volume during pregnancy, although those that do increase in size tend to do so primarily in the first trimester. Although most pregnancies are unaffected by the presence of uterine fibroids, large submucosal and retro-placental fibroids seem to impart a greater risk for complications, including pain (degeneration), vaginal bleeding, placental abruption, IUGR, and preterm labor and birth. Preconception myomectomy to improve reproductive outcome can be considered on an individual basis, but likely has a place only in women who have recurrent pregnancy loss, large submucosal fibroids, and no other identifiable cause for recurrent miscarriage. Antepartum myomectomy should be reserved for women who have subserosal or pedunculated fibroids and intractable fibroid pain that are unresponsive to medical therapy and who are in the first or second trimester of pregnancy. Myomectomy at the time of cesarean delivery is associated with significant morbidity (hemorrhage) and should be pursued with caution and only in select patients.
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Affiliation(s)
- David W Ouyang
- Department of Obstetrics, Gynecology & Reproductive Biology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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Kolankaya A, Arici A. Myomas and Assisted Reproductive Technologies: When and How to Act? Obstet Gynecol Clin North Am 2006; 33:145-52. [PMID: 16504812 DOI: 10.1016/j.ogc.2005.12.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effect of myomas on reproductive outcome has been the subject of many studies; however, a definitive answer is still missing. Therefore, the authors have tried to outline some guidelines for the management of women who have uterine myomas and desire to conceive. The location and size of the myomas are the two parameters that influence the success of a future pregnancy. Subserosal myomas seem to have little, if any,effect on reproductive outcome, especially if they are up to 5 to 7 cm in diameter. Intramural myomas that do not encroach upon the endometrium also can be considered to be relatively harmless to reproduction, if they are smaller than 4 to 5 cm in diameter. This is the ambiguous gray zone of the subject, and where research should be focused before a consensus can be established. Myomas that compress the uterine cavity with an intramural portion (submucous myoma type II) and submucous myomas significantly reduce pregnancy rates, and should be removed before assisted reproductive techniques are used. Hysteroscopic myomectomy is the gold standard for the treatment of submucous myomas. For other myomas, abdominal myomectomy, or laparoscopic myomectomy--when the experience of the surgeon and the facilities are sufficient--are the best alternatives. In most of the literature, the pregnancy rates were increased and the miscarriage rates were decreased after surgery with these two techniques. Other alternative treatment modalities, such as CUV, laparoscopic myolysis, or MRI-guided focused ultrasound, are to be monitored and evaluated thoroughly before they are applied as routine procedures.
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Affiliation(s)
- Aytug Kolankaya
- Infertility and IVF Unit, Department of Obstetrics and Gynecology, Anadolu Health Center, Affiliated with Johns Hopkins Medicine, Anadolu Saglik Merkezi, Anadolu Cad. No: 1, Cayirova, Gebze, 41400 Kocaeli, Turkey.
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Abstract
Uterine myomas are the most common solid pelvic tumors in women and the primary indication for hysterectomy. Most of the myomas are asymptomatic. The most common symptoms associated with uterine myomas are abnormal uterine bleeding and pelvic discomfort mostly caused by the mass effect. Vaginal bleeding may lead to iron deficiency anemia. Uterine myomas have a significant role in reproductive dysfunction, although a causal relationship between infertility and intramural or subserosal myomas not disturbing the uterine cavity has not been established clearly. Nevertheless myomas, especially the tumors distorting the uterine cavity, are associated with infertility and spontaneous miscarriage. In addition, the myomas may be the potential cause for numerous obstetric complications, especially if they are located adjacent to placenta. The transformation of myomas to leiomyosarcomas is a very rare event. Leiomyosarcomas may be suspected in postmenopausal women with rapidly growing symptomatic solid pelvic mass. Despite the high prevalence of these tumors, there is paucity of data available regarding the natural clinical history of myomas.
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Affiliation(s)
- Orhan Bukulmez
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9032, USA.
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Frishman GN, Jurema MW. Myomas and myomectomy. J Minim Invasive Gynecol 2005; 12:443-56; quiz 457-8. [PMID: 16213434 DOI: 10.1016/j.jmig.2005.05.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2005] [Accepted: 05/13/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Gary N Frishman
- Department of Obstetrics and Gynecology, Women & Infants' Hospital, Brown Medical School, Providence, Rhode Island 02905, USA.
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Christiansen OB, Nybo Andersen AM, Bosch E, Daya S, Delves PJ, Hviid TV, Kutteh WH, Laird SM, Li TC, van der Ven K. Evidence-based investigations and treatments of recurrent pregnancy loss. Fertil Steril 2005; 83:821-39. [PMID: 15820784 DOI: 10.1016/j.fertnstert.2004.12.018] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2004] [Revised: 12/14/2004] [Accepted: 12/14/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To give an overview of currently used investigations and treatments offered to women with recurrent pregnancy loss (RPL) and, from an evidence-based point of view, to evaluate the usefulness of these interventions. DESIGN Ten experts on epidemiologic, genetic, anatomic, endocrinologic, thrombophilic, immunologic, and immunogenetic aspects of RPL discussed methodologic problems threatening the validity of research in RPL during and after an international workshop on the evidence-based management of RPL. CONCLUSION(S) Most RPL patients have several risk factors for miscarriage, and an extensive investigation for all major factors should always be undertaken. There is an urgent need for agreement concerning the thresholds for detecting what is normal and abnormal, irrespective of whether laboratory tests or uterine abnormalities are concerned. A series of lifestyle factors should be reported in future studies of RPL because they might modify the effect of laboratory or anatomic risk factors. More and larger randomized controlled trials, including trials of surgical procedures, are urgently needed, and to achieve this objective multiple centers have to collaborate. Current meta-analyses evaluating the efficacy of treatments of RPL are generally pooling very heterogeneous patient populations and treatments. It is recommended that future meta-analyses look at subsets of patients and treatment protocols that are more combinable.
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Affiliation(s)
- Ole B Christiansen
- Fertility Clinic 4071, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark.
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Abstract
PURPOSE OF REVIEW There is no consensus about the impact of uterine fibroids on fertility. This review explores past and recent studies that investigated the effects of submucosal, intramural, and subserosal fibroids on in-vitro fertilization (IVF) outcomes. We discuss the importance of proper evaluation of the uterus and endometrial cavity, and current options for optimal fibroid management in patients desiring fertility. RECENT FINDINGS Several studies have reviewed the data on fibroids and infertility, further exploring this potential relationship. Two recent studies investigated reproductive outcomes before and after myomectomy, and IVF outcomes based on fibroid size and location. Both studies concluded that fibroids can impair reproductive outcomes. Several papers thoroughly reviewed medical and surgical management options for patients with fibroids and desired fertility. Although several medical therapies may reduce fibroid volume or decrease menorrhagia, myomectomy remains the standard of care for future fertility. Recent data identified an increased rate of pregnancy complications after uterine artery embolization compared with laparoscopic myomectomy. A new procedure, magnetic resonance imaging-guided focused ultrasound ablation, shows promise for the management of symptomatic fibroids, and possibly for the management of fibroids prior to pregnancy. As with embolization, more data are needed to evaluate postprocedure fertility and pregnancy outcomes. SUMMARY Fibroid location, followed by size, is the most important factor determining the impact of fibroids on IVF outcomes. Any distortion of the endometrial cavity seriously affects IVF outcomes, and myomectomy is indicated in this situation. Myomectomy should also be considered for patients with large fibroids, and for patients with unexplained unsuccessful IVF cycles.
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Affiliation(s)
- Beth W Rackow
- Section of Reproductive Endocrinology and Infertility, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut 06520-8063, USA
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Benecke C, Kruger TF, Siebert TI, Van der Merwe JP, Steyn DW. Effect of fibroids on fertility in patients undergoing assisted reproduction. A structured literature review. Gynecol Obstet Invest 2005; 59:225-30. [PMID: 15775685 DOI: 10.1159/000084513] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the current data to understand the impact of intramural leiomyomata on pregnancy outcome in assisted reproduction. PATIENTS AND METHODS In this review, articles were found by means of computerized Medline and Cochrane Library search using the key words uterine myomata, leiomyomata, fibroids, implantation, pregnancy, infertility and in vitro fertilization. Limitations were English, human, 1990-2002. Inclusion criteria were pregnancy data on in vitro fertilization, intramural myomata with no cavitary distortion and control groups without myomas for each patient with a myoma. RESULTS There was a significant negative impact on implantation rate in the intramural myomata groups versus the control groups, 16.4 vs. 27.7% OR 0.62 (0.48-0.8). The delivery rate per transfer cycle was also significantly lower (myomata vs. control), 31.2 vs. 40.9% OR 0.69 (0.50-0.95). CONCLUSION Our study supports the notion that patients with intramural fibroids have a lower implantation rate per cycle. The studies did not shed new light on the size of intramural myomata that could affect the outcome. In previous failed in vitro fertilization cycles, microsurgical removal of myomata must be considered.
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Affiliation(s)
- C Benecke
- Reproductive Biology Unit, Stellenbosch University and Tygerberg Hospital, Tygerberg, South Africa
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Ng EHY, Chan CCW, Tang OS, Yeung WSB, Ho PC. Endometrial and subendometrial blood flow measured by three-dimensional power Doppler ultrasound in patients with small intramural uterine fibroids during IVF treatment. Hum Reprod 2005; 20:501-6. [PMID: 15576392 DOI: 10.1093/humrep/deh594] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The impact of intramural fibroids on the success of IVF treatment is controversial and the mechanisms leading to poor treatment outcomes remain unknown. We compared endometrial and subendometrial blood flow between women with and without intramural fibroids during IVF treatment. METHODS Three-dimensional (3D) ultrasound examination with power Doppler was performed on the day of oocyte retrieval in 50 patients with intramural fibroids not distorting the uterine cavity and in 50 matched controls to measure endometrial thickness, uterine pulsatility index (PI)/resistance index (RI), endometrial volume and vascularization index (VI)/flow index (FI)/vascularization flow index (VFI) of endometrial and subendometrial regions. Smokers, patients with serum estradiol concentrations > or =20,000 pmol/l on the day of HCG and previous history of myomectomy were excluded. RESULTS Endometrial thickness and pattern, averaged uterine PI and RI and endometrial and subendometrial VI/FI/VFI were similar between the fibroid group and the control group. There was no correlation between the total volume of fibroids and endometrial and subendometrial 3D power Doppler flow indices in the fibroid group. CONCLUSION Endometrial and subendometrial 3D power Doppler flow indices were similar in patients with and without small intramural fibroids.
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Affiliation(s)
- Ernest Hung Yu Ng
- Department of Obstetrics and Gynaecology, The University of Hong Kong, Hong Kong Special Administrative Region, People's Republic of China.
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Hurst BS, Matthews ML, Marshburn PB. Laparoscopic myomectomy for symptomatic uterine myomas. Fertil Steril 2005; 83:1-23. [PMID: 15652881 DOI: 10.1016/j.fertnstert.2004.09.011] [Citation(s) in RCA: 192] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2004] [Revised: 09/03/2004] [Accepted: 09/03/2004] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the safety, efficacy, and techniques of laparoscopic myomectomy as treatment for symptomatic uterine myomas. DESIGN Medline literature review and cross-reference of published data. RESULTS Results from randomized trials and clinical series have shown that laparoscopic myomectomy provides the advantages of shorter hospitalization, faster recovery, fewer adhesions, and less blood loss than abdominal myomectomy when performed by skilled surgeons. Improvements in surgical instruments and techniques allows for safe removal and multilayer myometrial repair of multiple large intramural myomas. Randomized trials support the use of absorbable adhesion barriers to reduce adhesions, but there is no apparent benefit of presurgical use of GnRH agonists. Pregnancy outcomes have been good, and the risk of uterine rupture is very low when the myometrium is repaired appropriately. CONCLUSION(S) Advances in surgical instruments and techniques are expanding the role of laparoscopic myomectomy in well-selected individuals. Meticulous repair of the myometrium is essential for women considering pregnancy after laparoscopic myomectomy to minimize the risk of uterine rupture. Laparoscopic myomectomy is an appropriate alternative to abdominal myomectomy, hysterectomy, and uterine artery embolization for some women.
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Affiliation(s)
- Bradley S Hurst
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina, USA.
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Gianaroli L, Gordts S, D'Angelo A, Magli MC, Brosens I, Cetera C, Campo R, Ferraretti AP. Effect of inner myometrium fibroid on reproductive outcome after IVF. Reprod Biomed Online 2005; 10:473-7. [PMID: 15901454 DOI: 10.1016/s1472-6483(10)60823-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
To evaluate the influence of inner myometrium fibroids (myomas) on the outcome of IVF cycles, a retrospective agematched controlled study was performed at SISMeR Reproductive Medicine Unit. The study group included 129 IVF/intracytoplasmic sperm injection cycles in 75 patients with one or more intramural and/or submucosal fibroids, while the control group consisted of 129 cycles in 127 patients without fibroids. The two groups were similar for mean oestradiol concentration at human chorionic gonadotrophin administration (1205.16 +/- 874 versus 1395 +/- 821 pg/ml), mean number of transferred embryos (2.02 +/- 0.4 versus 2.14 +/- 0.6) and clinical pregnancy rate (34.9 versus 41.1%). Conversely, the implantation rate was significantly lower in the study group (18.0%) than in the control group (26.5%; chi(2) = 4.81, P < 0.05), whereas the rate of spontaneous abortion demonstrated an opposite trend (40 versus 18.9%; chi(2) = 4.34, P < 0.05). Further research should be aimed at classifying fibroids on the basis of their location, especially when they are positioned in the junctional zone of the myometrium. Whether this classification will be superior in predicting the impact of fibroids on the reproductive outcome should be elaborated in a large multicentric study.
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Affiliation(s)
- Luca Gianaroli
- SISMeR Reproductive Medicine Unit, Via Mazzini, 12 40138 Bologna, Italy
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