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Myomectomy in Subfertility

Surgery procedures for myoma uteri (leiomyoma or fibroid) in subfertility cases are thought to increase the chances of a successful pregnancy, especially in patients with submucous myoma. However, currently, there is still debate about the best surgical method to treat subfertility due to myoma.

Myomectomy in Subfertility
Myoma
Source: https://dr-raadalsaffar.org/portfolio/laparoscopic-myomectomy-case-1


What is Myoma?

Myoma is a benign monoclonal tumor of the uterine muscle. Often found in women of reproductive age. Myoma masses can experience growth or regression so that asymptomatic cases can usually be observed without intervention. However, certain types of myoma can cause subfertility and require intervention if the patient wants a pregnancy. 

Myoma Types and Their Effect on Fertility

The type of myoma based on its anatomical location is an important factor in evaluating the effect of myoma on fertility. Myomas that distort the uterine cavity (submucosal myomas) are a type of myoma that can cause difficulty getting pregnant and increase the risk of miscarriage or abortion. In contrast, a systematic review of observational studies shows that subserous myomas do not have a significant effect on fertility. Intramural myomas that distort (protrude) into the uterine cavity are thought to interfere with fertility. However, the impact of intramural myoma in general on fertility is currently controversial.

How to treat myoma? Myoma managements are:

  1. expectative management, 
  2. drug therapy 
  3. non-sectional procedures (endometrial ablation, uterine artery embolization) 
  4. And surgery (myomectomy or hysterectomy).


Myoma Surgery

Surgery is the main therapy for myoma. The indications for surgery for myomas are abnormal uterine bleeding, infertility, or recurrent miscarriage. Myomectomy is the procedure of choice for women who still want a pregnancy because it can conserve the uterus. Myomectomy can be done in three ways, namely:
  1. Hysteroscopic myomectomy
  2. Laparoscopic myomectomy
  3. Laparotomy myomectomy

Hysteroscopic myomectomy is the recommended minimally invasive procedure for submucous myomas. It is most commonly associated with a chance of improving fertility. Why? Because submucosal myomas are indeed the most common type of myoma, causing subfertility. Laparoscopic or laparotomy myomectomy is usually performed to remove intramural or subserous myomas. So, the role of these two procedures in women with subfertility is controversial.

Hysteroscopic Myomectomy

Hysteroscopic myomectomy procedure is recommended for patients with submucosal myomas accompanied by subfertility without any other cause. The reasons for choosing this procedure are its minimally invasive nature and the possible benefits of eliminating submucosal myomas. Submucosal myoma often causes subfertility.

A study by Casini et al. compared myomectomy (hysteroscopy and laparotomy) with the expectative management of 181 women with myoma and subfertility. It reported an increase in pregnancy rates in the group undergoing myomectomy. Significant improvement was especially seen in patients with submucous myomas. However, this study did not differentiate separately hysteroscopic and the laparotomy myomectomy results. So that further studies are still needed.

Laparoscopic Myomectomy

Early, Laparoscopic myomectomy was performed for subserous myomas. Now, also in cases of intramural myomas. 

Two studies compared laparoscopic and laparotomy myomectomy. They showed no significant effect on pregnancy rates, live birth rates, and miscarriage rates.

Another study studied 144 patients who underwent laparoscopic myomectomy for large myomas (size 5 cm or more). It stated that Laparoscopic myomectomy could aid conception. However, the study sample was limited, and the study did not include myomas that were less than 5 cm in size. Further study is still needed.


Laparotomy Myomectomy

The choice of laparotomy technique is determined by the number, size, and location of myomas. Patients with multiple or large myomas (especially subserous and intramural myoma types) may require laparotomy myomectomy. Size parameters may vary between surgeons. However, as with laparoscopic myomectomy, the role of laparotomy myomectomy on fertility has not been determined.

The Effect of Surgical Outcomes on Reproduction

Myomectomy is the choice of patients who still want a pregnancy because this procedure can conserve the uterus. However, myomectomy's role in fertility is still uncertain, and the results of existing studies are still not conclusive. Available data suggest that submucosal myomas most commonly cause fertility problems and that surgery may improve fertility. On the other hand, the data suggest that subserous myomas do not significantly affect fertility, and intramural myomas have a debatable effect.

Hysteroscopic myomectomy procedure may be recommended for patients with symptomatic submucosal myoma (there are abnormal bleeding or fertility problems) and want pregnant. The study by Casini et al. showed that myomectomy provides a significant increase in pregnancy rates in cases of submucous myoma. Although this study did not differentiate the results of hysteroscopic myomectomy from laparotomy myomectomy separately, hysteroscopic myomectomy is preferred for submucosal myomas because it is minimally invasive and can maintain the integrity of the myometrium for subsequent pregnancies.

Laparoscopic myomectomy and laparotomy myomectomy are generally performed for cases of intramural and subserous myomas. Because these two types of myoma on fertility are still uncertain, the role of these two myomectomies on fertility is still being debated.

Currently, the latest clinical evidence cannot confirm which myomectomy procedure is superior (laparoscopy, laparotomy, or hysteroscopy) for increasing pregnancy and live birth rates. Further studies on the effect of each of these procedures on fertility are needed.

Conclusion
Submucosal myomas are the most common type of myoma, causing subfertility and the likelihood of an increased chance of pregnancy after myomectomy. The hysteroscopic myomectomy is recommended for women with symptomatic submucous myomas because of their minimally invasive nature. However, there is not enough clinical evidence to confirm the effectiveness of myoma surgery on fertility. The latest clinical evidence also cannot confirm which myomectomy procedure is the most superior.

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