Analyzing Reproductive Performance Before and After Abdominal Myomectomy
Abstract & Commentary
Synopsis: Abdominal myomectomy might improve reproductive outcome in cases of intramural or subserosal fibroids especially if the patient is less than 30 years of age and the myoma is single.
Source: Marchionni M, et al. Fertil Steril. 2004;82: 154-159.
This retrospective case series of 72 patients with intramural and subserosal fibroids from an academic center in Italy was designed to look at various reproductive outcome measures before and after surgery over a 3-year time interval. To be considered subserous, the greatest diameter of the tumor had to lie outside the uterine contour. Intramural fibroids had their greatest diameter outside the uterine cavity. Surgical techniques were similar to those used by contemporary gynecologic surgeons.
Prior to myomectomy, the conception rate was 28%. After surgery, it was 70%. For pregnancy loss, the rates were 69% before and 25% after. The live birth rates were 30% and 75% respectively. The only independent predictors of obstetric outcome were age under 30 years of age and numbers of fibroids removed.
Comment by Frank W. Ling, MD
With apologies to the reproductive endocrinologists/infertility subspecialists among our readership, I am enclosing this article within the context of the generalist reviews because of the reality of clinical practice of obstetrics/gynecology. Apologies should also be offered because it is a retrospective analysis and, given our desire for the best evidence possible, it falls short of our gold standard prospective, randomized trial. We should be aware, however, that in our practices we should apply the best data available, and that’s what this is—the best recent data available.
All of us have faced the clinical dilemmas presented by infertility and fibroids, either separately or together. This article helps us to put some numbers together with the type of fibroids that we are dealing with. It does not tell us whether or when a particular patient should undergo myomectomy, but it does demonstrate that conception rates are better after myomectomy than they were in the same patients prior to the procedure. However, the difficult questions remain. For example, how do we answer Ms. Smith’s questions about her asymptomatic fibroids? How should we deal with the menorrhagia that plagues Ms. Hill? What about Ms. Jones who wants to conceive, but hasn’t tried yet? Then there is Ms. Williams who has been trying to conceive unsuccessfully for the past 6 months. What should be done with her?
Well, as always, the traditional principle still applies: treat each patient individually. It is unrealistic to expect the health of the woman with asymptomatic fibroids can be improved. Even though this article does not address this particular problem, Ms. Smith should probably just be followed. Ms. Hill’s menorrhagia should be managed medically if possible, using NSAIDs and possibly hormonal management, prior to consideration of myomectomy. Ms. Jones’ desire to conceive isn’t necessarily affected by the fibroids—at least not yet. Attempts to conceive with the fibroid(s) in situ can be encouraged. If pregnancy doesn’t occur, then her situation would be similar to that of Ms. Williams who has failed to conceive the past 6 months.
Putting myomectomy into the clinical perspective of infertility carries with it the responsibility to advise that a basic infertility work-up be done. First of all, the patient’s age and reproductive history will go a long way to determine the appropriate options. Certainly a semen analysis to evaluate a patient’s partner is mandatory. Similarly, knowing the ovulatory status of the patient is critical. Whether by way of a history of regular menses, or a luteal phase endometrial biopsy, or a day 21-serum progesterone, knowing that the patient is ovulating is also needed before undergoing myomectomy. Finally, some pre-operative evaluation for tubal patency will help the surgeon better provide informed consent. For example, if there is distal tubal obstruction, the surgery will be significantly different from a simple myomectomy. Furthermore, if proximal obstruction is found on a pre-operative hysterosalpingogram, surgery and its outcomes are clouded even more.
The issues surrounding scheduling a myomectomy may be complex and all the factors mentioned above may be interrelated with the pre- and post-myomectomy conception rates listed in the article. The article is a useful tool to both counsel patients and remind us that surgical removal of fibroids by gynecologic surgeons is a potentially effective treatment for the properly selected patients.
Frank W. Ling, MD, Women’s Health Specialists, PLLC, Memphis, Tennessee, is Associate Editor of OB/GYN Clinical Alert.