Fibroids and reproduction

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Effect of uterine fibroids on fertility, invito-fertilization and pregnancy

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By: afuntummireku (57 month(s) ago)

An excellent presentation. Thank you.

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Fibroids & reproductive function Prof. Aboubakr Elnashar Benha University Hospital E-mail: elnashar53@hotmail.com

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Types of fibroids (The European Society of Hysteroscopy, 1993) Submucos (SM): Fibroid distorting ut cavity. Type 0: pedunculated without intramural extension Type I: Sessile with intramural extension <50% Type II: Sessile with intramural extension >50% 2. Intramural (IM): Fibroid not distorting the cavity & <50% protrusion into serosal surface 3. Subserosal (SS): >50% protrudes out of the serosal surface

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20- 40% of women of reproductive age Incidence

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Effects of fibroid on reproduction Fertility IVF Pregnancy

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FIBROIDS & INFERTILITY

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Incidence: Associated with infertility: 5- 10%. Only cause of infertility:2- 3%

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

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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 None of these putative mechanisms has been confirmed to be the etiologic factor.

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Fibroids & IVF

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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.

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Type of fibroid: PR with IVF Bajekal & Li (2000) SM: Most detrimental effect IM: Modest impact SS: Least impact on PR.

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

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2. Size of fibroid: No statistically significant difference in implantation rate or pregnancy outcome <3 cm (Rice et al, 1988, Rosati et al, 1989) < 5 cm (Li et al, 1999) <7 cm (Ramzy et al, 1998; Jun et al, 2001; Olivera et al,2003 )

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3. Number of fibroids (3-5 cm): (Feliciani et al, 2003)

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4. Distance from the endometrium (Aboulghar et al, 2004) > 5 mm: No effect

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FIBROID & PREGNANCY

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Incidence: 1.4- 8.6%

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Effect of pregnancy on size of fibroid: 80%: remain the same or become smaller (Muram et al, 1980; Lev-Toaf et al, 1987) 20 %: increase Growth is usually seen only in 1st trimester Many fibroids, particularly large ones, often get smaller late in pregnancy

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Effect of fibroid on pregnancy: 1. Increased risk of spontaneous abortion {Increase uterine contractions& growth or degeneration of myomas}. None of these potential mechanisms has been clearly established as the basis for pregnancy wastage.

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Miscarriage rate: 1. Type Bajekal & Li (2000)

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2. Size Olivera et al, (2003)

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3. Number: Feliciani et al, (2003) >3 fibroids (3-5 cm) are associated with increased risk of abortion

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2. Preterm labor:15- 20% 3. IUGR: 10% 4. Malpresentation: 20%

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5. Increased risk of: Bleeding Abruption PROM: Those located adjacent to the placental site

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PATIENT EVALUATION

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Ultrasound: Confirm diagnosis Locate the myomas. TAS: uteri >12 w {Beyond the reach of the TVS}.

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TVS: Accurate in excluding endometrial hyperplasia Inaccurate in dd SM fibroids & polyps (A). TVS or SIS Vs hysteroscopy More accurate in location of fibroids (A).

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SIS: If the location is unclear in AUB -100% sensitive& specific -SIS Vs office hysteroscopy: easier less uncomfortable less expensive

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Endometrial biopsy: Irregular or intermenstrual bleeding. Abnormal endometrial thickening on TVS

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MRI: Uncommon presentations. Uncertain location after TVS & SIS

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Standard infertility evaluation: HSG -If the uterine cavity is normal, there is no advantage in performing hysteroscopy A treatment plan should be recommended after the couple has been fully evaluated

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MANAGEMENT In some women, no treatment is better than treatment (Fletcher & Frederick, 2005)

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

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

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III. Surgical Treatment Myomectomy: -Indications: To maintain fertility. Distorting the uterine cavity >5cm Multiple (Bajekal & Li, 2000)

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-GnRH analogues for 3 to 4 months prior to myomectomy (Cochrane library, 2001) Reduce both uterine volume & fibroid size. Correct preoperative iron deficiency anemia Reduce blood loss Blood transfusion rates& complication rates are not different. No significant impact on operative time, difficulty or complications.

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-Pregnancy after myomectomy 75% in 1st y PR drops sharply after this time (Dessole et al, 2001). If possible, therefore, myomectomy should be timed when a woman is ready to start a family

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10-75% (mean: 50%) (Donnez & jadoul, 2000). The differences may be attributed to: Age & other infertility factors Factors related to fibroid Technical factors

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Age >35 y& other infertility factors Decreases PR (Ramzy et al, 1998; Li et al, 1999; Zollner et al, 2001)

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2. Factors related to the fibroid Number: More fibroids removed: lower PR (Sudik et al, 1996; Dessolle et al, 2001) No difference (Vercellini et al, 1999; Rossetti et al, 2001)

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b. Size: Removal of fibroid >8 cm: Better PR (Sudik et al, 1996). No difference (Vercellini et al, 1999; Rossetti et al, 2001)

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c. Site: Posterior wall: lower PR (Fauconnier et al, 2000) Distortion of the cavity: Better PR (Dessolle et al, 2001) No influence (Sudik et al, 1996)

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3. Technical factors: The approach depend on: Fibroid: Site, number & size Surgeon: Expertise Patient: preference

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Open myomectomy (Bajekal & Li, 2000) The route of choice: Large SS or IM(>7 cm) Multiple fibroids (>5) When entry into uterine cavity is to be expected

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b. Hysteroscopic myomectomy: The route of choice: SM fibroids. Compared to laparotomy, it is associated with a lower risk of scar rupture & no pelvic adhesion (Bajekal & Li, 2000) Large (>5 cm) type II SM fibroids may be unsuitable for hysteroscopic surgery. A significant benefit of removing SM fibroid >2cm (Varasteh et al, 1999)

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c. Laparoscopic myomectomy: Pedunculated or SS: not candidate for removal {not the cause of infertility or recurrent miscarriage} (Bajekal & Li, 2000). IM: Uterine rupture: 2 reports both at 34 w{inability to effectively close the myometrium laparoscopically} Uterine indentation Uterine fistula Very experienced laparoscopic surgeon

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Results of hysteroscopic& laparoscopic myomectomy are similar to those following abdominal myomectomy (Bajekal & Li, 2000).

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Prevention of adhesion: 1. Surgical technique: anterior incisions 2. Adhesion barriers are effective GnRH analogs prior to surgery will not reduce postoperative adhesions

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-Pregnancy outcome after myomectomy Miscarriage rates Reduced from 41 to 19% (Li et al, 1999; Vercellini et al, 1999)

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2. Uterine scar complications Pathologically adherent placenta Placenta praevia Uterine rupture

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3. Cesarean section: Recommended (Friedman et al, 1996; Seineira et al, 1997) 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}.

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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.

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

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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.

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Fibroid 1. Cavity Distorted Not distorted 2. Size >7 cm <7 cm 3. Number (3-5 cm) >3 <3

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Thank you Prof. Aboubakr Elnashar Benha University Hospital, Egypt Email: elnashar53@hotmail.com