Department of Obstetrics, Gynaecology and Child Health, University Hospital of the West Indies, Kingston 7, Jamaica, W.I.
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Abstract |
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Key words: operative morbidity/pregnancy outcome/secondary myomectomy/uterine fibroids
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Introduction |
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Uterine fibroids are the most common female pelvic tumours occurring in about 1530% of women in the reproductive age group (Zaloudek and Norris, 1987). Surgical intervention is often indicated when symptoms such as menorrhagia, congestive dysmenorrhoea, urinary frequency, infertility and recurrent pregnancy losses occur (Buttram and Reiter, 1981
). The majority of studies on uterine fibroids have focused on primary myomectomy or interruption of blood supply by the abdominal approach (Berkeley et al., 1983; Frederick et al., 1994
; Fletcher et al., 1996
), laparoscopic removal (Hasson et al., 1992
), hysteroscopic resection (Hallez, 1995
), the vaginal approach (Magos et al., 1994
), myolysis (Dubuisson et al., 1995
) and arterial embolization (Spies et al., 2002
).
Fertility after primary myomectomy using different techniques has been reported to be between 2050% (Brown et al., 1956; Babaknia et al., 1978
; Dubuisson and Chapron, 1996; Sudik et al., 1996
) and up to 75% of these pregnancies will take place in the first year after surgery. These findings support the theory that fibroids have some association with infertility. Notwithstanding this, 50% of patients still remain infertile 5 years after primary myomectomy. Thus patients with recurrence of their symptomatic fibroids in their mid-thirties and who have not fulfilled their reproductive ambition are faced with a real dilemma.
Therefore the aim of this cohort study was to find a treatment modality to alleviate the symptoms of women with recurrence of their fibroids while conserving their reproductive potential. The principle was to perform a repeat myomectomy and assess: (i) the possible morbidity associated with the procedure, such as febrile index or blood loss, (ii) to assess the presence of adhesions caused by the first myomectomy, (iii) to evaluate the natural pregnancy outcome after the procedure and (iv) to improve the anatomy of the uterus in order to enhance implantation if assisted reproduction has to be employed.
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Materials and methods |
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They were all counselled and signed a consent form stating that a hysterectomy would be performed in the event of uncontrollable haemorrhage. Myomectomy was performed using vasopressin as the haemostatic agent and employing the technique previously described (Frederick et al., 1994). All fibroids were enucleated and large blood vessels were clamped and tied. The uterine defects were closed with 10 chromic catgut and the serosal surface closed with 20 chromic catgut (Ethicon, Brussels, Belgium). Pelvic lavage was carried out with warm normal saline solution prior to the application of Interceed® adhesion barrier (Johnson & Johnson, New Brunwick, NJ, USA). A prophylactic antibiotic Cefuroxime 1.5 g, (Glaxo Wellcome, Greenford, UK), was given i.v. prior to the procedure, by the anaesthetist.
Several parameters were determined pre-operatively, intra-operatively and post-operatively. The variables noted were: (i) pre-operative; age, parity, bulk symptoms (menorrhagia, infertility, pelvic pain and recurrent abortions), clinical uterine size, haemoglobin level, haematocrit and white cell count, (ii) intra-operative; the number of fibroids, number of incisions (anterior and or posterior), blood loss, presence of adhesions, cavity breached, and tubal occlusion, (iii) post-operative; a full blood count to determine the haemoglobin, haematocrit, white cell count difference, the highest temperature after the first 24 h post-operatively (to determine the febrile morbidity). The size of the largest leiomyoma was confirmed from the pathological report. Patients in the study were seen at monthly intervals for 2 months and 6 monthly intervals thereafter and were instructed to report in the event of a pregnancy. The number of patients who became pregnant and the outcome of the pregnancies such as miscarriages and the mode of delivery were recorded.
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Results |
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Discussion |
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The median blood loss was 700 ml intra-operatively in this study despite the use of vasopressin as a haemostatic agent compared with 200400 ml in other reported series of primary myomectomy (LaMorte et al., 1993; Fletcher et al., 1996
). Seven patients (12%) required blood transfusions. This compared favourably with other reported series of the primary myomectomies (Smith and Uhlir, 1990
; Frederick et al., 1994
). Only one patient had a hysterectomy as a result of intractable post-operative haemorrhage, however, this is acceptable for such a difficult procedure.
Febrile morbidity in this study was higher, compared with the primary myomectomy and hysterectomy in other reported series. (Gambone et al., 1990; LaMorte et al., 1993
). However, our definition of the fever was a temperature
100°F (excluding the first 24 h) compared with the criteria of
100.4°F used in the above series.
Adnexal adhesions occurred in 59% of the cases in this series and could have been associated with the infertility in this group. This is said to be mainly due to posterior adhesions in patients with posterior incisions on the uterus during myomectomy. (Tulandi et al., 1993; Ugur et al., 1996
). Second look laparoscopy performed 6 weeks post primary myomectomy revealed a high incidence of adhesions particularly adnexal with posterior uterine incisions in two series (Tulandi et al., 1993
; Dubuisson et al., 1998
). They also showed that lysis of adhesions at laparoscopy increased the pregnancy rate post myomectomy.
Most studies have reported pregnancy successes between 2050% post primary myomectomy (Rosenfield 1986; Li et al., 1999
; Solitt and Issa, 2000
) but no studies have been reported on the natural pregnancy outcome in secondary myomectomy. Firstly, this study clearly demonstrates that the natural pregnancy outcome (15%) is significantly lower than most reported series of primary myomectomy. Secondly, there was a high incidence of dense vascular adhesions present during the secondary myomectomies which despite adhesiolysis left the potential for tubal occlusion particularly in posterior incisions (Fauconnier et al., 2000
).
In light of the operative morbidity and poor fertility results reported in this series, assisted reproduction may be a valid alternative form of treatment. One study found no significant difference in the total pregnancy rates between patients with uterine fibroids and all IVF patients (Seoud et al., 1992). Another study reported similar findings and that implantation rate was impaired only in cases in which the fibroids caused intracavitary deformity (Farhi et al., 1995
). In a third series, which excluded multiple large uterine fibroids causing deformity of the cavity, comparable results were found with those with uterine myomas and those without (Ramzy et al., 1998
).
This series has shown that primary myomectomy is associated with adhesions, which can compromise fertility, and a secondary procedure also has a poor fertility outcome. Most of the studies on the effects of uterine fibroids on patients undergoing IVF excluded patients with large leiomyomata and those causing deformity of the uterine cavity. The ultimate aim of our study was to alleviate symptoms and to preserve the reproductive potential, therefore large sizes and site were not part of our exclusion criteria as compared with the three studies reported in assisted reproduction.
The miscarriage rate was 40% in this series but the numbers are too small to compare with other series with reduction rates post primary myomectomy from 6019% (Buttram and Reiter, 1981; Li et al., 1999
). Other modalities of treatment such as GnRH analogues (Friedman et al., 1994
) and uterine artery embolization (Spies et al., 2002
) have been used effectively to improve symptoms but have not addressed the fertility outcome as in this study.
In conclusion, a repeat myomectomy is a difficult procedure with risk of complications and a pregnancy rate that appears to be lower than that of the primary procedure. However, the evolution of assisted reproduction affords women another option of improving their fertility following a repeat myomectomy.
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Acknowledgements |
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Notes |
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References |
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Submitted on March 11, 2002; accepted on July 18, 2002.