Fibroids

1

Fibroids reproductive function
Prof. Aboubakr Elnashar
Benha University Hospital Delta (Mansura) Benha
Fertility Centers E-mail elnashar53_at_hotmail.com
2

• Types of fibroids
• (The European Society of Hysteroscopy, 1993)
• Submucos (SM) Fibroid distorting the uterine
  cavity.
• Type 0 pedunculated without intramural extension
• Type I Sessile with intramural extension lt50
• Type II Sessile with intramural extension gt50
• 2. Intramural (IM) Fibroid not distorting the
  cavity with lt50 protrusion into serosal
  surface
• 3. Subserosal (SS) gt50 protrudes out of the
  serosal surface

3
(No Transcript)
4
20 to 40 of women of reproductive age
Incidence
5
Effects of fibroid on reproduction
Fertility IVF Pregnancy
6

• FIBROIDS INFERTILITY
• Incidence
• Fibroids are associated with infertility in 5 to
  10.
• When all other causes of infertility are
  excluded, fibroids are responsible for only 2
  to 3 of infertility cases

7

• Mechanisms
• 1. Interference with sperm or ovum transport.
• Enlargement and deformity of the uterine cavity
• Uterine contractility (Vollenhoven et al, 1990).
• Distortion of the cervix
• d. Distortion or obstruction of the tubal ostia.

8
(No Transcript)
9

• 2. Implantation failure or gestation
  discontinuation (Buttram Reiter, 1981)
• Alteration of the endometrial contour
• Persistence of intrauterine blood or clots
• Focal endometrial vascular disturbance
• Endometrial inflammation
• Secretion of vasoactive substances
• Enhanced endometrial androgen environment
• However, none of these putative mechanisms has
  been confirmed to be the etiologic factor.

10
Fibroids IVF IVF provides a good model to
assess the effect of fibroid on implantation rate
by excluding other factors such as tubal or male
(Donnez Jadoul, 2002). IVF cannot assess the
effect of fibroid on sperm migration ovum
transport.
11

• Type of fibroid
• Pregnancy rates with IVF
• Bajekal Li (2000)

SM fibroid has the most detrimental effect, IM a
modest impact SS has the least impact on PR.
12

• Donnez Jadoul (2002).
• No difference in implantation or pregnancy rates
  unless the uterine cavity itself was distorted by
  the myomas

13

• 2. Size of fibroid
• lt3 cm (Rice et al, 1988, Rosati et al, 1989)
• lt 5 cm (Li et al, 1999)
• lt7 cm (Ramzy et al, 1998 Jun et al, 2001)

No statistically significant difference in
implantation rate or pregnancy outcome
14

• Olivera et al, (2003)

15
3. Number of fibroids (Feliciani et al, 2003)
16
(No Transcript)
17
4. Distance from the endometrium (Aboulghar et
al, 2004) gt 5 mm no effect
18
FIBROID PREGNANCY Incidence 1.4 to 8.6 of
pregnancies
19

• Effect of pregnancy on size of fibroid
• 80 of fibroids remain the same size or become
  smaller (Muram et al, 1980 Lev-Toaf et al, 1987)
  
• 20 increase in size
• Growth is usually seen only in the first
  trimester, and many fibroids, particularly large
  ones, often get smaller late in pregnancy

20
Effect of fibroid on pregnancy 1. Increased risk
of spontaneous abortion increase uterine
contractions and growth or degeneration of
myomas. However, none of these potential
mechanisms has been clearly established as the
basis for pregnancy wastage.
21
Miscarriage rate 1. Type Bajekal Li (2000)
22
2. Size Olivera et al, (2003)
23
3. Number Feliciani et al, (2003) gt3 fibroids
are associated with increased risk of abortion
24
2. Premature labor in 15 to 20 3. Intrauterine
growth restriction in 10 4. Malpresentation in
20
25

• 5. Location of the myomas is important. Those
  located adjacent to the placental site were
  associated with an increased risk of
• Bleeding,
• Abruption, and
• Premature rupture of membranes

26
(No Transcript)
27
PATIENT EVALUATION
28

• Ultrasound
• Confirm diagnosis
• Locate the myomas.
• TAS may be required for uteri greater than 12
  weeks' size as these will be beyond the reach of
  the TVS.

29
TVS is accurate in excluding endometrial
hyperplasia but is often unable to distinguish SM
fibroids polyps (A). TVS and SIS are both more
accurate in diagnosing the location of fibroids
than hysteroscopy (A).
30

• SIS
• -If the location of the myoma is unclear in
  patients with abnormal bleeding or
• in those who are not trying to conceive
• - Almost 100 sensitive and specific in
  identifying intrauterine lesions
• easier,
• less uncomfortable, and
• less expensive than office hysteroscopy

31
(No Transcript)
32

• Endometrial biopsy
• If there is
• irregular or intermenstrual bleeding or
• abnormal endometrial thickening on TVS
• If cycles are regular and the woman has moliminal
  symptoms, it may be assumed that she is
  ovulatory.
• A mid-luteal serum progesterone of 3 ng/ml or
  more supports this clinical impression.
• In such cases, endometrial biopsy is rarely
  indicated because the risk of hyperplasia or
  malignancy is remote

33

• MRI
• Not commonly indicated.
• May be indicated in
• uncommon presentations.
• uncertain location of fibroid after TVS SIS

34

• Standard infertility evaluation
• HSG
• -Assess the uterine cavity.
• -If the uterine cavity is normal, there is no
  advantage in performing hysteroscopy
• -Inject the contrast with a device attached to
  the cervix rather than an instrument which has an
  intrauterine component which may obscure
  intrauterine pathology.
• A treatment plan should be recommended after the
  couple has been fully evaluated

35
(No Transcript)
36
MANAGEMENT
37

• I. Expectant Management
• Indications
• Infertile patients without any identifiable
  etiology except uterine myomas
• 2. Asymptomatic fibroid

38

• II. Medical Treatment
• is not effective in improving infertility
• Progestin therapy, including oral contraceptive
  pills
• Androgens (gestrinone or danazol)
• Mifepristone
• GnRH analogs

39

• III. Surgical Treatment
• Myomectomy
• -Indication
• Women who wish to maintain potential fertility.
• SM or IM fibroid distorting the uterine cavity
• Fibroids gt5cm
• Multiple fibroids (Bajekal Li, 2000)

40
Myomectomy fertility outcome 75 of conceptions
following myomectomy occur in the first year
(Dessole et al, 2001), with PR drops sharply
after this time. If possible, therefore, the
surgery should be timed to take place when a
woman is ready to start a family
41

• PR after myomectomy varies between 10 75 with
  mean of 50
• (Donnez jadoul, 2000).
• The differences may be attributed to
• Age other infertility factors
• Factors related to fibroid
• Technical factors

42

• Age other infertility factors
• Age gt35 an association with other infertility
  factors decreases PR (Ramzy et al, 1998 Li et
  al, 1999 Zollner et al, 2001)

43

• 2. Factors related to the fibroid
• Number
• A lower PR when more fibroids were removed
  (Sudik et al, 1996 Dessolle et al, 2001),
• Others noted no difference (Vercellini et al,
  1999 Rossetti et al, 2001)

44
b. Size PR were better after removal of fibroid
with a volume of gt100 ml (gt8 cm diameter) (Sudik
et al, 1996). Others found no difference
(Vercellini et al, 1999 Rossetti et al, 2001)
45
c. Site No influence of myoma location (Sudik
et al, 1996) A lower PR with posterior wall
fibroid (Fauconnier et al, 2000) A better PR when
there was distortion of the cavity (Dessolle et
al, 2001)
46
3. Technical factors The approach depend on
The site, number size of fibroid, The
expertise of the surgeon The patient
preference
47
Open myomectomy (Bajekal Li, 2000) The route of
choice for large SS or IM fibroids (gt7 cm),
when multiple fibroids (gt5) when entry into
uterine cavity is to be expected
48
b. Hysteroscopic myomectomy The route of choice
for SM fibroids. Compared to laparotomy, it is
associated with a lower risk of scar rupture no
pelvic adhesion (Bajekal Li, 2000) Large (gt5
cm) type II SM fibroids may be unsuitable for
hysteroscopic surgery. A significant benefit of
removing SM fibroid gt2cm (Varasteh et al, 1999)
49
(No Transcript)
50
c. Laparoscopic myomectomy Pedunculated or SS
fibroids are not candidate for removal because
they are not the cause of infertility or
recurrent miscarriage (Bajekal Li, 2000). IM
fibroids Uterine rupture 2 reports both at 34
weeks inability to effectively close the
myometrium laparoscopically Uterine
indentation Uterine fistula Very experienced
laparoscopic surgeon
51
(No Transcript)
52
Results of hysteroscopic and laparoscopic
myomectomy are similar to those following
abdominal myomectomy (Bajekal Li, 2000).
53

• GnRH analogues for 3 to 4 months prior to
  myomectomy (Cochrane library, 2001)
• Reduce both uterine volume fibroid size.
• Correct preoperative iron deficiency anemia , if
  present
• No significant impact on operative time or
  complications. Myomectomy is not either easier or
  more difficult than surgery without such
  treatment.
• 3. Reduce blood loss, though transfusion rates
  and complication rates are not different.
• Beneficial in patients with a 14- to 18-week-size
  uterus who would require abdominal hysterectomy
  if not treated with analog but have an 80 chance
  of successfully undergoing vaginal hysterectomy
  with pre-treatment.

54

• Prevention of adhesion
• 1. Surgical technique anterior incisions should
  be used whenever possible.
• 2. Adhesion barriers are effective
• GnRH analogs prior to surgery will not reduce
  postoperative adhesions

55

• Myomectomy pregnancy outcome
• Miscarriage rates are significantly reduced from
  41 to 19 (Li et al, 1999 Vercellini et al,
  1999)

56
2. Uterine scar complications Pathologically
adherent placenta Placenta praevia Uterine
rupture
57
3. Cesarean section CS is recommended (Friedman
et al, 1996 Seineira et al, 1997) it is not
routine (Daria et al, 1997, Ribeiro et al, 1999
Dubuisson et al, 2000). No uterine ruptures after
myomectomy in 212 deliveries, 83 of which were
vaginal. No difference between open
laparoscopic myomectomy in the incidence of C S (
60 Vs 78) (Seracchioli et al, 2000)
58
Myomectomy is rarely indicated, but case reports
suggest that myomectomy can be performed safely
in pregnancy when necessary
59

• IV. Other techniques
• Uterine artery embolization (UAE)
• Myolysis
• Should be avoided in women who desire pregnancy
  fertilization delivery rates are a matter of
  speculation (Donnez jadoul, 2000).
• Until more information is available, these
  approaches should not be considered standard
  treatment for women who wish to maintain their
  fertility.

60

• CONCLUSIONS
• Myomas are the cause of infertility in a
  relatively small percentage of patients.
• Medical therapy of myomas is not effective in
  improving infertility, and surgical therapy
  should be recommended after complete evaluation
  of other potential factors.

61

• If myomas are thought to be unrelated to
  reproductive dysfunction or if they are
  asymptomatic, no treatment is indicated.
• Patients with recurrent miscarriages or pregnancy
  complications due to myomas should be treated
  after thorough evaluation of all other potential
  factors has been completed.

62
Fibroid 1. Cavity Distorted

Not distorted 2. Size gt7 cm

lt7 cm 3. Number gt3
lt3
63
Thank you
WWW.obgyn.net
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt Delta (Mansura)
Benha Fertility Centers Email
elnashar53_at_hotmail.com