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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 9  |  Issue : 4  |  Page : 136-139

Fertility following myomectomy at Aba, Southeastern Nigeria


Department of Obstetrics and Gynaecology, Abia State University Teaching Hospital, Aba, Nigeria

Date of Web Publication14-May-2015

Correspondence Address:
Dr. B Chigbu
Department of Obstetrics and Gynaecology, Abia State University Teaching Hospital, PMB 7004, Aba
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/9783-1230.157045

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  Abstract 

Background: While hysterectomy remains the gold standard treatment for fibroids, it is an unacceptable treatment option for women who wish to conserve their fertility. The actual effects of myomectomy on fertility remain uncertain though. Objective: The objective was to ascertain pregnancy and live birth rates among a small group of women undergoing abdominal myomectomy. Methods: The study population consisted of women of reproductive age intending to conceive soon after undergoing abdominal myomectomy. A total of 40 women who met the inclusion criteria were recruited for the study and followed-up for 4 years. Women who achieved pregnancy within the study period were analyzed in terms of their demographics and intra-operative findings. Results: The mean age of the women was 28 years (range 24-35) married for about 3 years. Majority of the women (50%) had more than 11 fibroid nodules, and the largest nodule was bigger than 5 cm in 35 women (87.5%). Cumulative pregnancy rate was 60% (24/40) while live birth rate was 22/40 (55%) following myomectomy and majority 19/22 achieved this within 2 years of myomectomy. Conclusion: Myomectomy for fibroid-associated infertility increase pregnancy rates such that approximately 60% of women undergoing the procedure subsequently conceive.

Keywords: Fertility, fibroid, myomectomy


How to cite this article:
Chigbu B, Onwere S, Aluka C, Kamanu C, Feyi-Waboso P, Okoro O, Ezirim E, Ndukwe P, Akwuruoha E, Ejikem M, Aharauka C, Ojike U. Fertility following myomectomy at Aba, Southeastern Nigeria. J Med Investig Pract 2014;9:136-9

How to cite this URL:
Chigbu B, Onwere S, Aluka C, Kamanu C, Feyi-Waboso P, Okoro O, Ezirim E, Ndukwe P, Akwuruoha E, Ejikem M, Aharauka C, Ojike U. Fertility following myomectomy at Aba, Southeastern Nigeria. J Med Investig Pract [serial online] 2014 [cited 2019 May 22];9:136-9. Available from: http://www.jomip.org/text.asp?2014/9/4/136/157045


  Introduction Top


While many women with fibroids conceive easily, some have problems conceiving. The role of fibroids as a possible cause of infertility has been the subject of considerable debate. For this reason, physicians who have patients with uterine fibroids who are trying to get pregnant face a clinical dilemma regarding the best management options. Indirect evidence suggests that the location of fibroids like large intramural, submucosal, and subserosal fibroids can affect the ability to conceive naturally and reduce the effectiveness of assisted reproduction cycles. [1],[2] But concerns remain about the potential adverse complications of myomectomy such as adhesion formation and high recurrence rate. [3],[4] There are no published randomized controlled studies with sufficient power to support the theory that myomectomy improves fertility outcome. However, despite the lack of evidence from randomized studies, indirect evidence from observational studies suggests that surgical intervention for uterine fibroids does increase pregnancy rates. [5]

The aim of this study was to review pregnancy and live birth rates among a small group of women undergoing abdominal myomectomy in a single health-care facility in Aba, Southeastern Nigeria. It is hoped that findings in this study would contribute further evidence on the impact of myomectomy on fertility and may be useful when counseling women considering myomectomy for fibroid-associated infertility in our locale.


  Methods Top


The study population consisted of 40 women of reproductive age intending to conceive soon after undergoing abdominal myomectomy (resection of large submucosal lesions with multiple intramural component or intramural lesions that impinge upon or distort the endometrial cavity) in a context of infertility.

Postoperation, these women were followed-up for 4 years. Questions were asked about subsequent fertility and outcome, and any assisted conception treatments. Information retrieved from hospital records included the indications for surgery, the location and size of the fibroids, and co-morbidities. Infertility was defined as the absence of pregnancy after 12 months attempt at pregnancy. For each patient operated in a context of infertility, a preoperative workup was made including age, duration of infertility (primary or secondary), and study of ovarian function (serial follicular tracking, serum follicle stimulating hormone; luteinizing hormone levels and prolactin), partner's semen analysis, and examination of the uterine cavity and  Fallopian tube More Detailss patency by hysterosalpingography.

Meticulous surgical techniques were used and included gentle tissue handling, constant irrigation of the tissue with a physiological saline solution and meticulous hemostasis with the aid of the uterine artery tourniquet. The fibroid capsule was identified, and then enucleation was carried out within the cleavage plane. As the fibroids were enucleated, the vessels surrounding the fibroid were carefully identified, clamped and tied. Depending on the depth and size of the fibroid, the uterine defect was closed in one or two layers with Vicryl 1-0 and the serosa was approximated with Vicryl 2-0. Afterward, copious abdominopelvic lavage was performed using warm normal saline solution and 600 mg of hydrocortisone acetate was instilled into the peritoneal cavity prior to abdominal closure with a view to reduce adhesion formation. Measurement of the weight of the fibroids was done, and histological examination performed at the Pathology Department of our center.

Ethical approval for the conduct of the study was obtained from the Abia State University Teaching Hospital IRB. Statistical analysis was with the aid of Epi Info version 7 (Centers for Disease Control and Prevention, Atlanta, Georgia (USA, 2012). Student's t-test was used to compare the mean values of two or more independent variables, and Chi-square analysis was used to compare categorical variables. The P < 0.05 were considered significant.


  Results Top


As illustrated in [Table 1], the mean age of the women was 28 years (range 24-35) married for about 3 years. Thirty-two women (80%) had primary infertility whilst 20% had recurrent miscarriages. The male partners of 6 (10%) women had abnormal sperm parameters. Majority of the women (50%) had more than 11 fibroid nodules, and the largest nodule was bigger than 5 cm in 35 women (87.5%); [Table 2] and [Table 3], [Figure 1] and [Figure 2]. Cumulative pregnancy rate was 60% (24/40) while live birth rate was 22/40 (55%) following myomectomy and majority 19/22 achieved this within 2 years of myomectomy [Table 4]. Pregnancy was by assisted reproduction in 4 women. Comorbidities were observed, and they included pelvic adhesions in 2 patients, ovarian cyst in 3 women.
Figure 1: An example of the nature of fibroids in the majority of the women

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Figure 2: The fibroid nodules were often >5 cm

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Table 1: Characteristics of 40 women who underwent myomectomy and wished to conceive


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Table 2: Pregnancies after myomectomy by age


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Table 3: Characteristics of fibroids in the 40 women


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Table 4: Fertility outcomes after myomectomy in the 40 women


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  Discussion Top


When uterine myoma is discovered during the workup for infertility, myomectomy remains an alternative surgical treatment despite the controversies. Pregnancy rate after myomectomy was 60% in this study and age had no significant impact on the pregnancy rate [Table 5]. Majority of the women had multiple fibroids (numbering between 10 and 20), and the size of the fibroids was often more than 5 cm yet there was no significant difference in the pregnancy rates amongst the women with large or small fibroids. The characteristics of fibroids in this series differ from what has been reported by authors in western literature. African women usually have multiple and very large uterine fibroids. [6] This might be due to delay in seeking medical attention or the cultural aversion of our women to surgery. Many of the women in our study delayed surgery for either fear of death or fear that myomectomy could shut out their hopes of getting pregnant.
Table 5: Pregnancy rates after myomectomy


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A review of some studies [7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] on fertility outcomes following myomectomy reveal remarkable but inconsistent results as illustrated below:

A number of factors were reported to influence the reproductive outcome following myomectomy. This includes the presence of concomitant infertility factors. In a meta-analysis by Vercellini et al., [10] the conception rate following myomectomy in women with otherwise unexplained infertility (61%) was higher than in those with other infertility factors (38%). Other factors include size and number of the fibroid, [7],[8] age, and miscarriage history. [7],[8],[10] It is observed that pregnancy rate is more in women with <5 fibroids compared to more than 5 fibroids. [7],[8],[9],[10],[11] Age more than 30 years, infertility more than 3 years, and multiple fibroids also appeared to negatively affect pregnancy rate following myomectomy. [16],[17],[18],[19],[20],[21]

The focus of our study was not on the determinants of reproductive outcome following myomectomy. However, despite the giant nature of the fibroids in our series, pregnancy rate was comparable with observations elsewhere and maternal age had no significant impact on the pregnancy rate. This might be attributed to appropriate surgical care. Majority of the fibroids were removed through a single vertical anterior wall incision on the uterus. Studies have shown that uterine incision during myomectomy influences adhesion formation with posterior uterine incisions causing more adnexal adhesions than anterior or fundal incisions. [23] However, it is unclear if the pregnancy rate following myomectomy is influenced by the site of uterine incision.

The procedure of myomectomy whether performed abdominally, laparoscopically, hysteroscopically or vaginally is associated with risks such as intra-operative hemorrhage, the risk of converting to emergency hysterectomy with consequent loss of fertility, disfigurement of the uterine cavity and risk of uterine rupture in future pregnancy or labor. [4] Myomectomy is also associated with the risk of postoperative adhesion formation, [23] which may result in further compromise of reproductive capacity, intestinal obstruction, chronic pelvic pain, and increased risk of ectopic pregnancy if conception is achieved. [4] Furthermore, myomas have the potential to recur such that 20-25% of women who undergo myomectomy require a secondary procedure. [3],[24] None of these complications were observed among the women enrolled in our study.

In our series of 22 live births following myomectomy, there were no cases of placental abruption, preterm rupture of membranes, premature labor, and intrauterine growth restriction. There was also no case of uterine rupture. However, an apparently high proportion of babies were born by cesarean section possibly because of the need to optimize the chance of delivering a live infant.


  Conclusion Top


It is concluded that abdominal myomectomy may improve pregnancy rates and reproductive outcome even in the presence of multiple and enlarged myomas. However, women should be counseled carefully before surgery regarding the determinants of outcome.

Limitations of the study

This study was a single-center prospective cohort study of a small sample of women undergoing abdominal myomectomy for fibroid associated infertility. There is a need for a multicenter population-based study in our locale.

 
  References Top

1.
Poncelet C, Benifla JL, Batallan A, Daraï E, Madelenat P. Myoma and infertility: Analysis of the literature. Gynecol Obstet Fertil 2001;29:413-21.  Back to cited text no. 1
    
2.
Hart R, Khalaf Y, Yeong CT, Seed P, Taylor A, Braude P. A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception. Hum Reprod 2001;16:2411-7.  Back to cited text no. 2
    
3.
Nezhat FR, Roemisch M, Nezhat CH, Seidman DS, Nezhat CR. Recurrence rate after laparoscopic myomectomy. J Am Assoc Gynecol Laparosc 1998;5:237-40.  Back to cited text no. 3
    
4.
Manyonda I, Sinthamoney E, Belli AM. Controversies and challenges in the modern management of uterine fibroids. BJOG 2004;111:95-102.  Back to cited text no. 4
    
5.
Khaund A, Lumsden MA. Impact of fibroids on reproductive function. Best Pract Res Clin Obstet Gynaecol 2008;22:749-60.  Back to cited text no. 5
    
6.
Okezie O, Ezegwui HU. Management of uterine fibroids in Enugu, Nigeria. J Obstet Gynaecol 2006;26:363-5.  Back to cited text no. 6
    
7.
Machupalli S, Norkus EP, Mukherjee TK, Reily KD. Abdominal myomectomy increases fertility outcome. Gynecol Obstet 2013;3:144.  Back to cited text no. 7
    
8.
Li TC, Mortimer R, Cooke ID. Myomectomy: A retrospective study to examine reproductive performance before and after surgery. Hum Reprod 1999;14:1735-40.  Back to cited text no. 8
    
9.
Rossetti A, Sizzi O, Soranna L, Mancuso S, Lanzone A. Fertility outcome: Long-term results after laparoscopic myomectomy. Gynecol Endocrinol 2001;15:129-34.  Back to cited text no. 9
    
10.
Vercellini P, Maddalena S, De Giorgi O, Pesole A, Ferrari L, Crosignani PG. Determinants of reproductive outcome after abdominal myomectomy for infertility. Fertil Steril 1999;72:109-14.  Back to cited text no. 10
    
11.
Garcia CR, Tureck RW. Submucosal leiomyomas and infertility. Fertil Steril 1984;42:16-9.  Back to cited text no. 11
[PUBMED]    
12.
Rosenfeld DL. Abdominal myomectomy for otherwise unexplained infertility. Fertil Steril 1986;46:328-30.  Back to cited text no. 12
[PUBMED]    
13.
Starks GC. CO2 laser myomectomy in an infertile population. J Reprod Med 1988;33:184-6.  Back to cited text no. 13
    
14.
Kably Ambe A, Anaya Coeto H, Garza Rios P, Delgado Urdapilleta J. Abdominal myomectomy and subsequent fertility. Ginecol Obstet Mex 1990;58:274-6.  Back to cited text no. 14
    
15.
Goldenberg M, Sivan E, Sharabi Z, Bider D, Rabinovici J, Seidman DS. Outcome of hysteroscopic resection of submucous myomas for infertility. Fertil Steril 1995;64:714-6.  Back to cited text no. 15
    
16.
Sudik R, Hüsch K, Steller J, Daume E. Fertility and pregnancy outcome after myomectomy in sterility patients. Eur J Obstet Gynecol Reprod Biol 1996;65:209-14.  Back to cited text no. 16
    
17.
Daraï E, Dechaud H, Benifla JL, Renolleau C, Panel P, Madelenat P. Fertility after laparoscopic myomectomy: Preliminary results. Hum Reprod 1997;12:1931-4.  Back to cited text no. 17
    
18.
Berkeley AS, DeCherney AH, Polan ML. Abdominal myomectomy and subsequent fertility. Surg Gynecol Obstet 1983;156:319-22.  Back to cited text no. 18
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19.
Dubuisson JB, Chapron C. Laparoscopic myomectomy and myolysis. Baillieres Clin Obstet Gynaecol 1995;9:717-28.  Back to cited text no. 19
    
20.
Gatti D, Falsetti L, Viani A, Gastaldi A. Uterine fibromyoma and sterility: Role of myomectomy. Acta Eur Fertil 1989;20:11-3.  Back to cited text no. 20
    
21.
Gehlbach DL, Sousa RC, Carpenter SE, Rock JA. Abdominal myomectomy in the treatment of infertility. Int J Gynaecol Obstet 1993;40:45-50.  Back to cited text no. 21
    
22.
Smith DC, Uhlir JK. Myomectomy as a reproductive procedure. Am J Obstet Gynecol 1990;162:1476-9.  Back to cited text no. 22
    
23.
Kemfang Ngowa JD, Kasia JM, Zibi HN, Neng HT. High incidence of adnexal adhesions formation after abdominal myomectomy among African women. J Pharm Biomed Sci 2012;18:1-4. Available from: http://www.jpbms.info. [Last accessed on 2014 Jul 14 th ).  Back to cited text no. 23
    
24.
Frederick J, Hardie M, Reid M, Fletcher H, Wynter S, Frederick C. Operative morbidity and reproductive outcome in secondary myomectomy: A prospective cohort study. Hum Reprod 2002;17:2967-71.  Back to cited text no. 24
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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