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Fibroid Treatments Demystified, Part IV: Myomectomy

 

Myomectomy, a widely practiced method of removing subserosal or intramural uterine fibroids, is an alternative to hysterectomy for fibroid patients seeking uterine preservation.

How Myomectomy Works

In myomectomy, a surgeon removes one or more fibroids by cutting them out of the uterine wall. While incisions are made in its tissue, the uterus itself ultimately stays in place. Depending on the type and location of the fibroids, myomectomy may be performed laparoscopically (accessing the uterine cavity through abdominal incisions) or hysteroscopically (accessing the uterine cavity by way of the vagina).
The method used for performing myomectomy dictates the recovery and hospitalization time. Post-operative hospital stays currently range from 0-2 days, and recovery time ranges from 4-6 weeks.

Treatment Outcomes

Myomectomy patients typically see an enduring reduction in symptoms: in a recently published study, the research team of Pitter et al. reported that 62.9% of the myomectomy patients in their study population were free of symptoms at three years post-procedure.

Once a fibroid is completely removed, it will not grow back. That is not to say, however, that new fibroids won’t develop, potentially triggering the return of symptoms. A study by Yoo et. al assessed the probability of fibroid recurrence in laparoscopic myomectomy patients over an 8-year follow-up period. The researchers observed that the cumulative probability increased steadily from 11.7% at 1 year post-procedure to 84.4% at the 8 year mark. Factors influencing fibroid recurrence were found to be patient age, number of fibroids, pre-operative uterine size, and childbirth following the procedure. Another team of researchers, Obed et al., added family history of fibroids and multiple symptoms as to that list of factors, and concluded from their own study that “there is a high recurrence of uterine fibroids following myomectomy”.

Risks associated with myomectomy include post-surgical adhesions and both intra- and post-operative bleeding. Dubuisson et al. observed adhesions, or scars produced as incisions in the uterine tissue heal, in 35.6% of patients during “second-look” laparoscopy; this result that has been corroborated by additional studies. Cases of uterine rupture during pregnancy following a laparoscopic myomectomy have also been reported.

Since a myomectomy does not involve removal of the uterus, it is possible to preserve the patient’s fertility. Research largely suggests that myomectomy is an appropriate procedure for fibroid patients who desire pregnancy. That said, certain complications associated with myomectomy, such as adhesions, can, themselves, impair fertility – a fact that should be taken into account when considering the fertility-sparing aspects of the procedure.

One technique for removing larger fibroids through small ports in laparoscopic myomectomy, called power morcellation, has recently been the subject of major controversy. In power morcellation, a tool called a morcellator is used to dissect large fibroids, so that the dead tissue may be more easily extracted without expanding the abdominal incisions. In April 2014, the Federal Drug Administration (FDA) released a safety communication notice discouraging use of power morcellation, citing concerns that the technique could spread cancerous cells within the abdominal cavity if it came in contact with cancerous tissue. While uterine fibroids (also called leiomyomas) are almost always benign, the rare fibroid (about 1 in 1,000) that is malignant may not be detected as such in advance of surgery. Several manufacturers of the power morcellator have since pulled the device from the market, and power morcellation is now rarely used in laparoscopic myomectomies.

 

 

SOURCES:

Pitter, M.C. et al. “Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy”, Obstetrics & Gynecology, Apr 19, 2015. ePub. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417601/. Retrieved July 2, 2015

Yoo, E. et al. “Predictors of leiomyoma recurrence after laparoscopic myomectomy.” Journal of Minimally Invasive Gynecology, Nov-Dec 2007; Vol. 14(6):690-7

Obed et al. “Uterine fibroids: risk of recurrence after myomectomy in a Nigerian population.” Archives of Gynecology and Obstetrics, Feb 2011; Vol. 283(2):311-5

Dubuisson J.B., et al. “Second look after laparascopic myomectomy”, Human Reproduction. 1998; Vol. 13:2102–6

“FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids”, FDA News Release, Apr 17,2014. Web: http://www.fda.gov/newsEvents/Newsroom/PressAnnouncements/ucm393689.htm. Retrieved July 2, 2015.

 

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How Fibroids Affect Fertility

For women of childbearing age who are diagnosed with Uterine Fibroids, a common concern is how fibroids will impact their fertility. Fortunately, the incidence of infertility occurring as a direct result of fibroids is low. While research has shown that that approximately 5-10% of infertile women have one or more fibroids, the fibroids can only be identified as the single cause of infertility in 2-3% of those cases.

When fibroids do impact a woman’s fertility, they can do so in several possible ways: namely, by impacting the movement of the egg, embryo, or sperm through the woman’s reproductive organs. As fibroids grow in size, they can change the shape of the uterus, push surrounding reproductive organs, and create blockages. Changes in the uterine muscle that are caused by an intramural fibroid can inhibit the movement or implantation of an embryo. If a fibroid blocks the fallopian tubes, it could prevent eggs from moving freely during ovulation. If its positioning results in movement of the cervix, sperm may not be able to successfully move through the cervix to reach the uterus. In any one of these scenarios, the presence of a fibroid can impact a woman’s fertility.

To some extent, the size of the fibroid can make a difference; it is known that fibroids larger than 5 centimeters are more likely to affect the success of in-vitro fertilization (IVF). In addition to creating blockages and displacement of reproductive organs, a fibroid can impair fertility by causing inflammation in the uterine wall and thereby discouraging implantation of an embryo. Moreover, the position of a fibroid could restrict blood flow to the uterine cavity where an embryo would implant.

The bottom line is fibroids can affect fertility and may decrease the chances of success for women undergoing IVF. That said, the mere presence of fibroids does not preclude a woman from becoming pregnant, and if infertility is a problem, it is unlikely that fibroids are the sole cause.

Sources:

  1. American Society for Reproductive Medicine, “Fibroids and Fertility Fact Sheet”, Resources, ReproductiveFacts.org: 2011. Retrieved March 16, 2015, from http://www.reproductivefacts.org/FACTSHEET_Fibroids_and_Fertility/
  2. “Fibroid Tumors.” [Video]. American Society for Reproductive Medicine, 21 Feb. 2012. Retrieved March 14, 2015, from https://www.youtube.com/watch?v=eSJ-ztQ97Og

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