Myomectomy And Infertility

MYOMECTOMY REFERS TO THE SURGICAL REMOVAL OF UTERINE LEIOMYOMAS, OTHERWISE KNOWN AS fibroids. A uterine fibroid is a benign tumour that grows from the muscle tissue that makes up the wall of the uterus. These fibroids are not normally removed unless they cause pain or pressure, excessive bleeding or interfere with fertility. In fact, if none of these symptoms are present, it is possible that a patient would never know that the fibroids exist.

There are four main types of fibroids: intramural are the most common, and located within the wall of the uterus; subserosal are located underneath the mucosal surface of the uterus; submucosal fibroids are located in the muscle beneath the endometrium of the uterus; and cervical fibroids are located in the wall of the cervix. With regard to fertility, studies have been carried out comparing the pregnancy rates in women undergoing IVF between those fibroids and those without. The studies have shown that submucosal intramural and subserosal fibroids appear to interface with fertility, in decreasing order of importance.

The presence of these fibroids may also cause dysfunctional uterine contractility and interfere with sperm and ovum transport, making it difficult to achieve fertilisation. The proximity of fibroids to be area where the embryo attaches can make it difficult for a woman to conceive or to miscarry if her fertilized eggs manage to implant (or attach to the endometrium). Fibroids tend to grow quite large during pregnancy, often 3 to 10 times in volume and can interfere with growth of the baby or cause problems for the delivery.

There was a time when a hysterectomy (the complete removal of the uterus) would be the only way to remove fibroids. However, as surgical techniques have advanced, doctors developed myomectomy, where preservation of the uterus – and subsequently fertility – would be achieved. The first hysterectomy to remove fibroids was performed in the late 1980s before doctors were able to develop a way to remove fibroids while simultaneously maintaining the integrity of the uterus.

Myomectomy can now be performed using laparotomy (where the uterus is accessed via a wide incision in the abdomen); laparoscopy (also known as minimally invasive surgery), where operations in the abdomen are performed through small incisions or puncture holes; or hysteroscopy, where access to submucous fibroids is gained through the cervix. Laparoscopic myomectomies are regarded as the best treatment to remove fibroids in women who want to maintain their fertility. The hysteroscopic option is regarded as the best treatment for women with excessive uterine bleeding infertility and repeated miscarriages.

Most fibroids can now be managed endoscopically, utilising laparoscopy or hysteroscopy. However, it should be noted that laparoscopic myomectomies require specialised (“laparoscopic”- deleted) skills. The surgeon should have undergone advanced training and is qualified to carry out these difficult surgeries (often referred to as Level 3 surgeries in the training centers). Ability to carry out laparoscopic culturing is essential, as this may affect the ability of the uterus to maintain its integrity, should a patient become pregnant at a later stage. Sub-standard culturing can result in the uterus rupturing in late pregnancy or during labour. This can be life threatening with excessive bleeding. It should be noted that a myomectomy will not prevent further fibroids from growing. If a patient is susceptible, it may be likely that further fibroids will develop. Should a patient have no attachment to her uterus – i.e. she is menopausal or is no longer considering pregnancy, then a full hysterectomy may be more suitable.