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Value of Myomectomy in the Treatment of Infertility
FERTILITY AND STERILITY
Vol. 59, No. 6, June 1993
Copyright '" 1993 The American Fertility Society
Printed on acid-free paper in U.S.A.
Value of Myomectomy in the Treatment of Infertility
To the Editor: Verkaufs (1) review on myomectomy is comprehensive, excellent, and up-to-date. However, I cannot agree on one point in the abdominal myomectomy technique. Verkauf says that, subsequently spiraled arterioles that meet in the midline ofthe uterus. It is ideal, although not always possible, to make the uterine incision in the midline anteriorly." However, according to Farrer-Brown et al. (2) and Saeki and Kotaki (3), the arteries that meet in the midline of the uterus are not spiral arterioles but arcuate anterior branches of the uterine arteries. Moreover, they (2, 3) demonstrated that the arteries and arterioles in the myometrium, such as arcuate arteries, radial arteries, and spiral arterioles, run not vertically but almost transversely, as shown in Fig. 1. Consequently, the ideal incision in the myometrium is not the vertical one on the midline but the transverse one on the site nearest to the myoma, because the vertical incision in the myometrium often cuts the transversely running arteries and arterioles, but the transverse incision causes the least injury to these transversely running vessels. Moreover, sutures in the transverse incision, lying perpendicular to the transverse direction, are very useful for hemostasis of bleeding from the transversely running vessels. Like Verkauf, most textbooks and references on gynecological surgery have recommended the anterior vertical incision in myomectomy as the optimal uterine incision technique. However, theoretical surgery based on the anatomy of uterine arteries demonstrates that the most reasonable operative technique to minimize blood loss in myomectomy is transverse parallel-vessels incision in the myometrium. Such a transverse incision had been recommended historically in only a few :t:eferences (3-5). Incidentally, to lessen blood loss during myomectomy, a variety of methods have been reported (1). One proposed method was to pass a rubber catheter through an avascular portion of the broad ligament on either side of the cervix. However, this method often increases blood loss, because it is apt to close only veins but not arteries. My method is to use a
Vol. 59, No.6, June 1993
.
rI',,-----1
... ______ ............
I I I
Figure 1 Scheme of arterial vasculature of the uterus. 1, uterine arteries; 2, ascending branches of uterine arteries; 3, arcuate arteries; 4, radial arteries; 5, spiral arterioles; UC, uterine cavity.
piece of gauze, instead of a rubber catheter. This Ushaped gauze is not tied, just held with a hemostat forceps, and lifted upward by an assistant. This procedure is effective not only in preventing bleeding during myomectomy but also in raising the uterus to facilitate myomectomy. The above mentioned two procedures are simple but the most effective methods to minimize intraoperative bleeding and postoperative hematoma and infection.
Masao Igarashi, M.D. Department of Obstetrics and Gynecology Gunma University School of Medicine Maebashi, Gunmaken, Japan November 24, 1992
Letters-to-the-editor
1331
REFERENCES 1. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril1992;58:1-15. 2. Farrer-Brown G, Beilby JOW, Tahbit MH. The blood supply of the uterus. 1. Arterial vasculature. J Obstet Gynaecol Br Commonw 1970;77:673-81. 3. Saeki M, Kotaki S. Vasculature of uterine myoma for myomectomy. Acta Obstet Gynecol Jpn 1974;26:335-42. 4. Louros NC. Conservative myomectomy. Postgrad Med 1964;35:52-6. 5. Parsons L, Ulfelder H. An atlas of pelvic operations. 2nd ed. Philadelphia: WB Saunders, 1968:70-1.
To The Editor: Dr. Verkaufs (1) recent review does a fine job in satisfying the stated objective, "to review, evaluate, and synthesize current published reports assessing the value of abdominal myomectomy in infertile women and those desiring to preserve fertility potential." However, the conclusion that "abdominal myomectomy is an appropriate alternative to hysterectomy . . . for most women who wish to . . . enhance [childbearing potential]" is overstated and not justified by the data presented within the body of the review. It may make intuitive sense to debulk a large uterus before conception or to remove a myoma that is obstructing a fallopian tube. However, the benefit of myomectomy among women with so-called "unexplained" infertility and uterine myomas has not been established. As yet, there are no reports of prospective randomized studies comparing empirical myomectomy to simple observation in this group. There has as yet not been published even a single case control study comparing the incidence and size of myomas among infertile as compared with fertile women. In the absence of such studies, a generalized conclusion that myomectomy is an appropriate modality for the enhancement offertility is not justified. In the final paragraph of the text, there is a statement that demonstrates the faulty reasoning that unfortunately has plagued the infertility literature for many years, "while not proof, the long duration of infertility before surgery, the absence of other factors to explain their not conceiving, and the short time interval subsequent to surgery in which conception occurs suggests myomectomy has value in treatment of patients with leiomyomata and otherwise unexplained infertility." Because unexplained infertility has many spontaneous cures, with as many as 50% of couples with this diagnosis con-
1332
Letters-to-the-editor
ceiving in each year (2), one may consider a model of coin-flipping, with "tails" representing continued infertility and "heads" as representing a successful conception or cure. If one thousand such coins are flipped five times in a row, by pure chance about 30 of them will come up tails in each of the five flips. In this example, this group of 30 coins may be considered to represent a group of patients with unexplained infertility of 5-years duration. If one now "treats" this "population" of 30 "failures" with a treatment that has no impact on the natural history of the disease (e.g., myomectomy, progesterone suppositories, empirical antibiotics), it is easy to see that 50% of the previous failures will now be "cured" (come up heads). If one concludes from this experiment that the "long duration of disease" (coming up tails 5 times in a row) and the rapid recovery of 50% of the population is suggestive that the "treatment" has value, one will be seriously led astray. Myomectomy is an established effective procedure for debulking a large uterus while preserving childbearing potential. However, its benefit in enhancing fertility (in the absence of obvious impingement on tubal ostea or obliteration of the uterine cavity) must be viewed as theoretical at this time.
Richard J. Paulson, M.D. In Vitro Fertilization Program University of Southern California, School of Medicine Women's Hospital Los Angeles, California August 3, 1992
REFERENCES 1. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril1992;58:1-15. 2. Barnea ER, Holford TR, Mcinnes DRA. Long-term prognosis of infertile couples with normal basic investigations: a lifetable analysis. Obstet Gynecol 1985;66:24-6.
Reply of the Author: Bleeding at surgery is at best a nuisance. Dr. Igarashi's insights are thus appreciatively received. Myomata are frequently multiple, and it seems to me that the principle reason for recommending an anterior vertical incision in the midline relates to the goal of removing multiple myomata if required
Fertility and Sterility
Vol. 59, No. 6, June 1993
Copyright '" 1993 The American Fertility Society
Printed on acid-free paper in U.S.A.
Value of Myomectomy in the Treatment of Infertility
To the Editor: Verkaufs (1) review on myomectomy is comprehensive, excellent, and up-to-date. However, I cannot agree on one point in the abdominal myomectomy technique. Verkauf says that, subsequently spiraled arterioles that meet in the midline ofthe uterus. It is ideal, although not always possible, to make the uterine incision in the midline anteriorly." However, according to Farrer-Brown et al. (2) and Saeki and Kotaki (3), the arteries that meet in the midline of the uterus are not spiral arterioles but arcuate anterior branches of the uterine arteries. Moreover, they (2, 3) demonstrated that the arteries and arterioles in the myometrium, such as arcuate arteries, radial arteries, and spiral arterioles, run not vertically but almost transversely, as shown in Fig. 1. Consequently, the ideal incision in the myometrium is not the vertical one on the midline but the transverse one on the site nearest to the myoma, because the vertical incision in the myometrium often cuts the transversely running arteries and arterioles, but the transverse incision causes the least injury to these transversely running vessels. Moreover, sutures in the transverse incision, lying perpendicular to the transverse direction, are very useful for hemostasis of bleeding from the transversely running vessels. Like Verkauf, most textbooks and references on gynecological surgery have recommended the anterior vertical incision in myomectomy as the optimal uterine incision technique. However, theoretical surgery based on the anatomy of uterine arteries demonstrates that the most reasonable operative technique to minimize blood loss in myomectomy is transverse parallel-vessels incision in the myometrium. Such a transverse incision had been recommended historically in only a few :t:eferences (3-5). Incidentally, to lessen blood loss during myomectomy, a variety of methods have been reported (1). One proposed method was to pass a rubber catheter through an avascular portion of the broad ligament on either side of the cervix. However, this method often increases blood loss, because it is apt to close only veins but not arteries. My method is to use a
Vol. 59, No.6, June 1993
.
rI',,-----1
... ______ ............
I I I
Figure 1 Scheme of arterial vasculature of the uterus. 1, uterine arteries; 2, ascending branches of uterine arteries; 3, arcuate arteries; 4, radial arteries; 5, spiral arterioles; UC, uterine cavity.
piece of gauze, instead of a rubber catheter. This Ushaped gauze is not tied, just held with a hemostat forceps, and lifted upward by an assistant. This procedure is effective not only in preventing bleeding during myomectomy but also in raising the uterus to facilitate myomectomy. The above mentioned two procedures are simple but the most effective methods to minimize intraoperative bleeding and postoperative hematoma and infection.
Masao Igarashi, M.D. Department of Obstetrics and Gynecology Gunma University School of Medicine Maebashi, Gunmaken, Japan November 24, 1992
Letters-to-the-editor
1331
REFERENCES 1. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril1992;58:1-15. 2. Farrer-Brown G, Beilby JOW, Tahbit MH. The blood supply of the uterus. 1. Arterial vasculature. J Obstet Gynaecol Br Commonw 1970;77:673-81. 3. Saeki M, Kotaki S. Vasculature of uterine myoma for myomectomy. Acta Obstet Gynecol Jpn 1974;26:335-42. 4. Louros NC. Conservative myomectomy. Postgrad Med 1964;35:52-6. 5. Parsons L, Ulfelder H. An atlas of pelvic operations. 2nd ed. Philadelphia: WB Saunders, 1968:70-1.
To The Editor: Dr. Verkaufs (1) recent review does a fine job in satisfying the stated objective, "to review, evaluate, and synthesize current published reports assessing the value of abdominal myomectomy in infertile women and those desiring to preserve fertility potential." However, the conclusion that "abdominal myomectomy is an appropriate alternative to hysterectomy . . . for most women who wish to . . . enhance [childbearing potential]" is overstated and not justified by the data presented within the body of the review. It may make intuitive sense to debulk a large uterus before conception or to remove a myoma that is obstructing a fallopian tube. However, the benefit of myomectomy among women with so-called "unexplained" infertility and uterine myomas has not been established. As yet, there are no reports of prospective randomized studies comparing empirical myomectomy to simple observation in this group. There has as yet not been published even a single case control study comparing the incidence and size of myomas among infertile as compared with fertile women. In the absence of such studies, a generalized conclusion that myomectomy is an appropriate modality for the enhancement offertility is not justified. In the final paragraph of the text, there is a statement that demonstrates the faulty reasoning that unfortunately has plagued the infertility literature for many years, "while not proof, the long duration of infertility before surgery, the absence of other factors to explain their not conceiving, and the short time interval subsequent to surgery in which conception occurs suggests myomectomy has value in treatment of patients with leiomyomata and otherwise unexplained infertility." Because unexplained infertility has many spontaneous cures, with as many as 50% of couples with this diagnosis con-
1332
Letters-to-the-editor
ceiving in each year (2), one may consider a model of coin-flipping, with "tails" representing continued infertility and "heads" as representing a successful conception or cure. If one thousand such coins are flipped five times in a row, by pure chance about 30 of them will come up tails in each of the five flips. In this example, this group of 30 coins may be considered to represent a group of patients with unexplained infertility of 5-years duration. If one now "treats" this "population" of 30 "failures" with a treatment that has no impact on the natural history of the disease (e.g., myomectomy, progesterone suppositories, empirical antibiotics), it is easy to see that 50% of the previous failures will now be "cured" (come up heads). If one concludes from this experiment that the "long duration of disease" (coming up tails 5 times in a row) and the rapid recovery of 50% of the population is suggestive that the "treatment" has value, one will be seriously led astray. Myomectomy is an established effective procedure for debulking a large uterus while preserving childbearing potential. However, its benefit in enhancing fertility (in the absence of obvious impingement on tubal ostea or obliteration of the uterine cavity) must be viewed as theoretical at this time.
Richard J. Paulson, M.D. In Vitro Fertilization Program University of Southern California, School of Medicine Women's Hospital Los Angeles, California August 3, 1992
REFERENCES 1. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril1992;58:1-15. 2. Barnea ER, Holford TR, Mcinnes DRA. Long-term prognosis of infertile couples with normal basic investigations: a lifetable analysis. Obstet Gynecol 1985;66:24-6.
Reply of the Author: Bleeding at surgery is at best a nuisance. Dr. Igarashi's insights are thus appreciatively received. Myomata are frequently multiple, and it seems to me that the principle reason for recommending an anterior vertical incision in the midline relates to the goal of removing multiple myomata if required
Fertility and Sterility