Factors Affecting Fertility Following Laparoscopic Myomectomy

Introduction

Tt concept that uterine myomas are responsible for infertility through several mechanisms—including distortion of the uterine cavity, obstruction of the tubal ostia interfering with sperm migration, and alternations in the endometrium affecting embryo implantation—is still controversial. Although it is thought that uterine myomas may contribute to infertility,^1,2 many women with uterine myomas conceive spontaneously. Therefore, myomectomy is indicated only after a complete evaluation of other potential factors for infertility. ³ Laparoscopic myomectomy (LM) has distinct advantages, compared with abdominal myomectomy in that LM reduces blood loss during the operation, shortens hospital stay, produces minimal esthetic damage, and leads to less postoperative adhesive disease.^4–6 To the best of the authors' knowledge, although many researchers have reported pregnancies achieved after LM,^1,2 there has not be adequate discussion about which factors have influence on fertility following LM. This study was performed to assess the factors affecting fertility following LM.

Materials and Methods

A retrospective review of 36 women who wanted children was performed. The women were selected from 79 women who underwent LM in Tohoku University Hospital and Sendai Social Insurance Hospital, both in Miyagi, Japan, between January 2003 and September 2008.

Institutional review board approval was not requested because LM is the standard treatment used in the department of obstetrics and gynecology of Tohoku University Hospital and Sendai Social Insurance Hospital. All the procedures followed were in accordance with the revised Declaration of Helsinki, and patients gave informed consent before the surgery.

Study inclusion criteria were (1) the patient wanted to conceive children; and (2) availability of a detailed description of the laparoscopic operative procedure. Exclusion criteria were: (1) the patient had had prior surgery for any gynecologic disease including myomas and/or endometriosis; (2) the existence of endometriosis and/or severe peritubal adhesion in the pelvic cavity when LM was performed; and (3) the patient had other severe infertility factors including the severe male factor (low sperm count or motility, or other fertility issues) of the partner and/or ovulatory dysfunction and/or tubal occlusion and endometrial cavity problems detected by hysterosalpingogram (HSG) before and 3–6 months after the surgery. All patients were followed-up every 6 months for the first year after the operation, and then given any follow-up as needed.

All operations were performed using the same technique as follows: Four trocars were placed. Pitressin (Parke-Davis, Morris Plains, NJ) was injected into the myometrium to prevent hemorrhage. An incision was performed vertically on the uterine serosa overlying the myoma with a harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Traction on the myoma with countertraction enabled enucleation. Hemostasis was achieved by a double-layer closure of the myometrium with interrupted suturing and closure of the serosa with a baseball suturing, avoiding electrocoagulation as much as possible. Interceed (Johnson & Johnson Medical, Inc., Arlington, TX) was placed on uterine scar to avoid adhesion formation.

Comparisons were made between patients who were able to become pregnant after LM and patients who were unable to do so. Factors compared included age of the patients, gonadotrophin hormone-releasing analogues (GnRHa;Mochida, Tokyo, Japan) pretreatment, number and diameter of resected myomas, type of the largest resected myoma, operation time, amount of hemorrhage, and ability to reach the uterine cavity.

Results

Of 36 women, the pregnancy rate obtained was 39% (14 of 36 patients; total of 14 pregnancies). Characteristics of patients who were able to achieve pregnancy versus those who were unable to do so are shown in Table 1. Ten of 14 patients who were able to achieve postoperative pregnancy were primipara, and 4 were multipara, whereas 17 of 22 patients who were unable to become pregnant were primipara and 5 were multipara. There was no significant difference in parity between the two groups. Within 6 months after the operation, 7 patients became pregnant, and all 14 patients became pregnant within a year. Ten pregnancies (71%) were spontaneous, 1 was achieved after artificial insemination by the husband (AIH), and 3 were achieved after AIH following controlled ovarian hyperstimulation. Four of 14 patients who were able to achieve postoperative pregnancy became pregnant after AIH, whereas 5 of 22 patients who were unable to become pregnant underwent assisted reproductive technology (ART) after LM. There was no significant difference in the rate of use of ART after LM between the two groups. One ectopic pregnancy and no abortions were recorded. The total number of deliveries was 13. Two (15%) were vaginal deliveries. Eleven (85%) elective cesarean sections were performed because of the presence of a uterine scar. No obstetric complications, including uterine rupture and postpartum massive hemorrhage, were recorded.

Between the group of patients who were able to become pregnant after LM and the group of patients who were unable to do so, there was no significant difference in the rate of GnRHa pretreatment prior to surgery (5/14 versus 6/22 cases), the number of resected nodes (mean±SD, 1.6±0.9 versus 1.4±0.7), the maximum diameter of myomas (6.1±1.7 cm versus 5.4±1.6 cm), type of the largest resected myoma, submucous (0/14 versus 4/22 cases), intramural (10/14 versus 15/22 cases), subserous (4/14 versus 3/22 cases), operation time (237.1±75.0 minutes versus 242.3±69.0 minutes), the amount of hemorrhage during the operation (136.4±200.6 mL versus 115.5±164.3 mL), the rate of reaching uterine cavity during the operation (2/14 versus 6/22 cases). However, there was a significant difference in the mean age of patients (31.9±4.0 versus 35.6±3.4, p <0.05).

Discussion

This study showed that the age of the patient was the only factor correlated with fertility after LM. GnRHa pretreatment, number and diameter of resected myomas, type of the largest resected myoma, operation time, amount of hemorrhage, and reaching uterine cavity during LM did correlate in this study.

One limit of the present study was that the number of recuited cases was relatively small, although current available cases were sufficient to document that the age of the patients was the only factor correlated with fertility after LM.

It is to be assumed that factors affecting fertility following LM have been discussed by only 2 independent researchers^7,8 and one researcher discussed fertility following laparoscopic or abdominal myomectomy. ⁹ Fauconnier et al. reported that size of myoma, deforming effect on the uterine cavity, and age of the patient played no role, and that myoma responsible for menometrorrhagia was the cause of infertility in their study. ⁷ Kumakiri et al. reported that pregnancy after LM correlated positively with the diameter of the largest myoma and negatively with age of the patient at the time of LM and the number of enucleated myomas. ⁸ Campo et al. reported that the main determinants of pregnancy rate after surgery are the age of the patient, and the diameter and intramural localization of the myomas, although their study included both abdominal and laparoscopic myomectomy. ⁹ The data in the current study concerning age of the patients are consistent with the data in Kumakiri's and Campo's studies.^8,9 The current study and Fauconnier's study ⁷ showed that diameter, location, and number of myomas have no significant influence on fertility following LM, whereas Kumakiri's study ⁸ showed that pregnancy after LM correlated positively with diameter of the largest myoma and negatively with the number of enucleated myomas, and Campo's study ⁹ showed that diameter and intramural localization of myomas were the main determinants of pregnancy rate after laparoscopic or abdominal myomectomy. The influence of myomas on fertility is poorly understood. It is known that submucous and intramural myomas that distort the endometrial cavity have been associated with infertility. ¹⁰ However, the effect of intramural and subserosal myomas that do not distort the endometrial cavity is controversial. Some studies reported that clinical pregnancy rates and implantation rates of ART were not affected by the presence of subserosal and intramural myomas that do not distort the endometrial cavity,^11,12 whereas other studies reported that the presence of non–cavity-distorting intramural myomas was associated with adverse pregnancy outcomes in women undergoing in vitro fertilization (IVF). ¹³ Further study is needed to determine which factors concerning enucleated myomas affect fertility following LM.

Some researchers pointed out that there were not any differences in the postoperative pregnancy rates between a group of patients given GnRHa pre-treatment and another group of patients in whom such therapy was not administered. ¹⁴ The results of the current study were consistent with those reports. Because of a higher recurrent rate of myomas after LM, increased difficulty of myomectomy, and an infertile period prolonged by GnRHa treatment itself, it may not be useful for GnRHa pre-treatment to be used routinely.

Conclusions

In conclusion, age of the patient was the only factor that correlated with fertility after LM in the current study. LM should be performed as early as possible when patients who want to conceive children have indications for the surgery.