Abdominal myomectomy for otherwise unexplained infertility

FERTILITY AND STERILITY Copyright 1986 The American Fertility Society

Vol. 46, No.2, August 1986 Printed in U.SA.

Abdominal myomectomy for otherwise unexplained infertility

David L. Rosenfeld, M.D. * Division of Human Reproduction, Department of Obstetrics and Gynecology, North Shore University Hospital, Cornell University Medical College, Manhasset, New York

Despite the high prevalence of myomata in the female population, myomectomy is an operation infrequently performed solely for the correction of female infertility.1-2 Many women with myomata readily conceive and carry to term. Nevertheless, after myomectomy for otherwise unexplained infertility, pregnancy rates of more than 50% have been reported. Garcia and Tureck recently reported a collected pregnancy rate of61.5% in 17 previously infertile patients after removal of a submucosal leiomyoma of at least 5 cm. 3 However, in those infertile patients who have subserosal or intramural fibroids only, the indications for myomectomy are less clear. Herein are presented the results of abdominal myomectomy in 23 patients with otherwise unexplained infertility and.subserosal or intramural fibroids. MATERIALS AND METHODS

During the interval from 1977 to 1984, the author performed 23 abdominal myomectomies in women with otherwise unexplained infertility. Of eight patients with secondary infertility, six had a history of previous pregnancy loss, and two had prior term births. The patients ranged in age

Received December 9, 1985; revised and accepted March 26, 1986. *Reprint requests: David L. Rosenfeld, M.D., Division of Human Reproduction, Department of Obstetrics and Gynecology, North Shore University Hospital, Cornell University Medical College, 300 Community Drive, Manhasset, New York 11030.

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from 26 to 42 years old (mean age, 34.2 years). The duration of infertility ranged from 1 to 16 years (mean, 5.2 years) within this group. All but one patient had been infertile more than 2 years. Prior to surgery, all patients had undergone postcoital testing, semen analysis of the partner,' basal body temperature monitoring, endometrial biopsy, and hysterosalpingography and/or laparoscopy/hysteroscopy. No abnormalities other than the fibroids were noted. The fibroids ranged in size from 3 to 14 cm. Eight patients had solitary fibroids, and 15 patients had multiple fibroids. None of these fibroids were submucosal in location. One patient had undergone a prior multiple myomectomy at another institution. Three of the 23 patients (13%) had complaints of menorrhagia. Sixteen patients had prior hysterosalpingograms. Fourteen of these were normal, and only 2 demonstrated distortion of the endometrial cavity because of extracavitary compression. The technique of myomectomy was similar to that previously described. 1 Tourniquets or vasoconstrictive agents were not used. Fifteen of the myomectomies were done through a single uterine incision, 6 through two incisions, and 3 through three incisions. Multilayered closure with interrupted 3-0 Vicryl sutures were utilized for the uterine incisions. Uterine suspensions were done in 10 of the 23 patients. In the initial 11 patients in this series, dexamethasone (20 mg) and promethazine (25 mg) were instilled within the peritoneal cavity before abdominal closure. In the latter 12 patients 200 Fertility and Sterility

Table 1. Pregnancy Rate as a Function ofAge and Duration of Infertility at the Time of Myomectomy No. of

No. of

patients

pregnancies

%

2 13

4

2 8 3 2

100 62 75 50

13 7 3

11 2 2

85 29 67

Age (yrs) < 30 30-34 35-39 > 40 Years infertile <5 5-10 > 10

4

ml of 10% dextran 70 (Hyskon Division, Pharmacia, Piscataway, NJ) were utilized instead. All patients were treated with prophylactic antibiotics (doxycycline); and systemic dexamethasone, 20 mg, and promethazine, 25 mg, were given 6 and 3 hours preoperatively and every 4 hours postoperatively for nine doses. There was no additional treatment after surgery to enhance fertility. RESULTS

All patients were advised to try to conceive 3 months after the myomectomy. All had at least 1 year of exposure. Fifteen of the 23 patients (65.2%) conceived (10 of 15 with primary infertility and 5 of 8 with secondary infertility), and 13 had childr.en (56.5%). One patient had an ectopic pregnancy. The pregnancy rates after myomectomy as a function of the age of the patient, the duration of infertility, the size of the largest fibroid, and the number of fibroids removed are listed in Tables 1 and 2. Of the 10 patients who had a uterine suspension 8 conceived (80%), and 7 of 13 (53.8%) patients without suspensions conceived. Eleven of 15 patients (73.3%) with single uterine incisions conceived, and 4 of 8 patients (50%) with two or more incisions conceived. There were no differences in pregnancy rates whether the dexamethasone/promethazine regimen (7 of 11, 64%) or 10% dextran 70 (8 of 12,67%) was used. All but 1 of the 15 patients conceiving did so within 1 year of surgery. The other patient conceived 20 months after her myomectomy. One patient, after two term deliveries, underwent a hysterectomy for recurrent fibroids. There were no operative complications and no postoperative infections in this series. No blood transfusions were required. Vol. 46, No.2, August 1986

DISCUSSION

Because of the ubiquitous nature of myomata among women of reproductive age, the mere presence of a myomata does not necessarily constitute a reason for impaired reproductive function. 2 Nevertheless, Rubin previously noted that 40% of married women with myomata of appreciable size are infertile. 4 Despite the frequency with which myomectomy is performed as a primary procedure for infertility, several reports,I-3, 5 including the present series, demonstrated significant pregnancy rates after abdominal myomectomy in women with otherwise unexplained infertility. The way in which fibroids impair fertility is not fully understood. It has been speculated that fibroids interfere with sperm transport, impinge on the tubal lumina, distort the course of the fallopian tube, compress the cervical canal, or alter the position of the cervix, thereby interfering with sperm capture in the posterior fornix. 6 Fibroids may also distort the endometrial cavity and disrupt uterine physiology, thereby inter.fering with implantation. 2 ,6 Abnormalities of the myometrial venous patterns because of compression and obstruction of venous. plexi by fibroids have been demonstrated radiographically.7 Histologic abnormalities of the endometrium associated with fibroids are often seen. 8 Nevertheless, the indications for myomectomy in a patient with otherwise unexplained infertility remain vague. In the present series of 23 patients, menorrhagia was an infrequent complaint (13%). Only 2 of 16 patients who underwent preTable 2. .Pregnancy Rate as a Function of Both the Size of the Largest Fibroid and Number ofFibroids Removed at the Time of Myomectomy No. of

Total Solitary Multiple Size (em) <5 5-10 > 10 Size (em) <5 Solitary Multiple 5-10 Solitary Multiple >10 Solitary Multiple

No. of

patients

pregnancies

%

8 15

5 10

62 68

8 9 6

5 6 4

63 67 67

2 6

0 5

0 83

5 4

4 2

80 50

1 5

1 3

100 60

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operative hysterosalpingography had any evidence of distortion of the endometrial cavity. Of those 14 patients with normal hysterosalpingograms, 10 conceived after myomectomy. This is similar to the findings reported by Babaknia et al. 5 where only 9 of 42 patients tested with hysterosalpingography preoperatively had distortion of the endometrial cavity. They likewise noted no relationship between the preoperative distortion of the endometrial cavity and the postoperative results. Babaknia et al. 5 previously reported no success after myomectomy in patients older than 35 years. In the present series (Table 1), five of the eight patients older than 35 years and two of four patients older than 40 years conceived after myomectomy. As in the previous report,5 patients with a shorter duration of infertility were more likely to conceive after myomectomy (Table 1). Of patients with less than 5 years of infertility, 84.6% conceived after myomectomy, whereas 40% of patients with more than 5 years conceived. Nevertheless, two of three patients with more than 10 years of infertility conceived after myomectomy. Buttram and Reiter! previously reported no conceptions following myomectomy in patients with uteri larger than 10 weeks. In the present series (Table 2), the size of the uterus did not influence the pregnancy rate. Four of six patients with fibroids > 10 cm successfully conceived. There was also little difference in the pregnancy rate whether the fibroids were solitary or multiple (Table 2). Of interest, however, is the lack of pregnancy in the two patients with a solitary small « 5 cm) fibroid (Table 2). The technique of myomectomy utilized by the author was similar to that described by Buttram and Reiter.! Tourniquets or vasoconstrictive agents were not used. No blood transfusions were required. The number of uterine scars were minimized. Free grafts were not used. Patients having uterine suspensions with the myomectomies had a higher pregnancy rate (80%) than those not having suspensions (54%). There were no specific criteria for performing the suspensions. Pregnancy rates were the same whether the intraoperative/intraperitoneal dexamethasone/promethazine or 10% dextran 70 regimen was used to prevent adhesions. In the present series, as in others, most of those patients conceiving did so within the first year. 3 , 5

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Only one patient in this series has required a subsequent hysterectomy. The duration of followup, however, is too short to draw valid conclusions from this. Previous reports!,5 of myomectomy have shown recurrence rates of 10% to 45%. In conclusion, despite the absence of specific criteria, myomectomy should be considered in the patient with otherwise unexplained infertility of more than 2 years' duration. The myoma need not necessarily be submucosal in location. Distortion on hysterosalpingography is not essential. The operation is not contraindicated in patients who are older (> 35 years) or who have longer duration of infertility (> 5 years). The patient need not complain of menorrhagia. The size or the number of fibroids need not deter the surgeon from performing myomectomy. The surgeon should adhere to the general principles of reproductive microsurgery. SUMMARY

Twenty-three patients with otherwise unexplained infertility underwent abdominal myo~ mectomy for the removal of subserous or intramural myomata. None were submucosal in location. Fifteen of these patients (65.2%) conceived. There were 18 term births in 13 patients. All but 1 patient conceived within the first year. The age of the patient, duration of infertility, size and number of the fibroids, hysterosalpingography, or presence of menorrhagia did not necessarily predict success. REFERENCES 1. Buttram VC Jr, Reiter RC: Uterine leiomyomata: etiology, symptomalogy, and management. Fertil Steril 36: 433, 1981 2. Stevenson CS: Myomectomy for improvement offertility. Fertil Steril 15:367, 1964 3. Garcia CoR, Tureck RW: Submucosalleiomyomas and infertility. Fertil Steril 42:16, 1984 5. Babaknia A, Rock JA, Jones HW Jr: Pregnancy success following abdominal myomectomy for infertility. Fertil Steril 30:644, 1978 6. Hunt JE, Wallach EE: Uterine factors in infertility-an overview. Clin Obstet Gynecol 17:44, 1974 7. Farrer-Brown G, Beilby JOW, Tarbit MH: The vascular patterns in myomatous uteri. J Obstet Gynaecol Br Commonw 77:967, 1970 8. Deligdish L, Lowenthal M: Endometrial changes associated with myomata uterus. J Clin Pathol 23:676, 1970

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