2. Myoma and infertility
Dr B.Khani

3. Subjects Myoma ,Description and types
Effect on fertility and IVF/ICSI outcome
Myomectomy, When? Whom?
Conclusions

4. Myomas appear to arise from a mutation in a single myometrial cell
Regulated factor : estrogen , progesterone , local growth factors
Myomas are the most common benign tumors of the female genital tract and occur in about 20-50% of women
They are associated with many gynecological problems including heavy menstrual bleeding and infertility.
Yoshino O, et al. Human Reproduction 2010;25(10):2475–9.

5. Types of fibroids .

7. Myoma and infertility
Myomas are present in approximately 5%–10% of women with infertility Fibroids and are estimated to be the sole cause of infertility in less than 3% of cases
Depending on size, number and location in the uterus, myomas have been implicated in both recurrent pregnancy loss and infertility
Farquhar C. BMJ 2009;16:338.

8. The outcomes of women with any location of fibroid, clinical pregnancy, implantation, and ongoing pregnancy/live birth were all significantly lower in women with myomas than in control subjects
The spontaneous abortion rate was significantly greater in women with fibroids
Pritts et al, Fertile Steril.  2009 Apr;91(4):

9. No difference was seen in rate of preterm delivery.
The women with SM fibroids, compared with infertile women without fibroids, demonstrated a significantly lower clinical pregnancy rate, implantation rate, and ongoing pregnancy/live birth rate and a significantly higher spontaneous abortion rate.
No difference was seen in rate of preterm delivery.
Women with no cavitary involvement had a significantly decreased implantation rate and ongoing pregnancy/live birth rate as well as an increased spontaneous abortion rate compared with nonfibroid control subjects.
No significance was seen in preterm delivery rates
Pritts et al, Fertile Steril.  2009 Apr;91(4):

10. Submucosal fibroids had the strongest association with lower ongoing pregnancy rates, through decreased implantation.
Cumulative pregnancy rates appeared slightly lower in patients with intramural fibroids (36.9% vs 41.1%)
Patients with intramural fibroids also experienced more miscarriages, 20.4% vs 12.9%.
There was no conclusive evidence that intramural or subserosal fibroids adversely affect fecundity.

11. Fertility outcomes are decreased in women with submucosal fibroids, and removal seems to confer benefit.
Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit.
Intramural fibroids appear to decrease fertility, but the results of therapy are unclear.
More high-quality studies need to be directed toward the value of myomectomy for intramural fibroids, focusing on issues such as size, number, and proximity to the endometrium.

12. Live birth as an outcome showed a statistically significant 21% relative reduction in women with non-cavity-distorting intramural fibroids compared with women without fibroids
Clinical pregnancy as an outcome showed a statistically significant 15% reduction in women with non-cavity-distorting intramural fibroids, following IVF treatment
Sunkara et al, Hum Reprod, 2010 Feb;25(2):  

13. In asymptomatic patients selected for IVF, small fibroids with a diameter < 50 mm and not encroaching the endometrial cavity do not impact on the rate of success of the procedure. This result should not, however, be used to conclude that all intramural or subserosal lesions are unremarkable.
In fact, current available evidence indicates that at least some lesions may be deleterious.

15. Results suggest that fibroids not encroaching upon the uterine cavity may not have a strong adverse effect on IVF/ICSI outcomes.
Type 3 IM fibroids did not portend a poorer response to IVF/ICSI compared with matched controls.

16. DIAGNOSIS
ultrasound (transabdominal, transvaginal), sonohysterogram, hysterosalpingogram, MRI and CT scans.
Hysterosalpingogram has very low sensitivity (approximately 50%) and specificity (as low as 20%) for the evaluation of uterine cavity involvement [25,26].
Until recently, transvaginal ultrasound had been considered accurate in the evaluation of submucous fibroids, with older studies showing a sensitivity of 100% and specificity of 94% [27].
A more recent study comparing transvaginal ultrasound with MRI, however, reports a sensitivity and specificity of 69% and 83%, respectively [28]. This same study reports a sensitivity and specificity of 100% and 91%, respectively, for MRI, which is currently considered to be the most accurate imaging modality for the diagnosis and characterization of intramural and submucous fibroids. Unfortunately, few studies use MRI preoperatively for diagnosis, thus leading to potential underreporting of intracavitary involvement.

17. A 2003 review reported that saline infusion sonography is equivalent to hysteroscopy for the diagnosis of submucous fibroids, with both techniques being superior to transvaginal ultrasound [29]. The 3D sonohysterography has also been found to be comparable to both standard 2D-sonohysterography and hysteroscopy [30,31].

18. Medical management
 Currently, the only US FDA approved medical treatments for symptomatic fibroids are GnRH analog (leuprolide acetate) and levonorgestrel-containing intrauterine device (Mirena®, Bayer AG, Berlin, Germany) [32]. Leuprolide has been approved for decreasing the size of fibroids, while Mirena is approved for the treatment of heavy menses, not necessarily related to fibroids. Several other medications are currently undergoing clinical trials, many of which appear to have potential for the treatment of uterine myomas. These include ulipristal acetate, proellex, mifepristone, asoprisnil, aromatase inhibitors, pirfenidone and epigallocatechin gallatethan leuprolide acetate.

19. Ulipristal, a selective progesterone-receptor modulator, in particular has shown promise. Recent studies by Donnez et al. have shown a reduction in bleeding and fibroid size with ulipristal versus placebo, as well as non-inferiority compared with leuprolide [33,34]. Additionally, ulipristal was shown to be less likely to cause hot flashes in study subjects than leuprolide acetate.

20. Surgical management
In the setting of infertile patients in whom fibroids are felt to contribute to difficulty conceiving or recurrent miscarriages, surgical removal is the most appropriate option. Any surgical intervention is best optimized by preoperative imaging to determine the precise size and location of the fibroid(s), as reviewed above. This helps to determine which surgical approach is the most appropriate for a particular patient
 The removal of submucous myomas has been shown to increase clinical pregnancy rates in comparison with controls where their fibroids were left in situ [13,37]. However, myomectomy in the setting of intramural fibroids is more controversial, as discussed previously

21. Myomectomy Hysteroscopic myomectomy is choice for SM myoma
IM myomectomy may perform via laparoscopy or laparotomy
Note: Correct repair in the bed of myoma is essential
The best time for myomectomy is 3-6 months before desire pregnancy
Repeated myomectomy is difficult and may lead to unwanted hystrectomy
For SS myoma mostly no surgery unless for very huge myomas

22. Hysteroscopic myomectomy is the preferred surgical
Hysteroscopy
Hysteroscopic myomectomy is the preferred surgical
modality whenever possible. It is appropriate for submucous myomas that are up to 4–5 cm in size. Hysteroscopic resection can be performed on type 0, 1 or 2 myomas although type 2 fibroids often require multiple procedures for complete resection Complications of hysteroscopic myomectomy include uterine perforation, fluid overload, bleeding and intracavitary adhesion formation

23. Many fibroids with a significant intramural component (some type 2s, hybrid myomas; as well as any with no intracavitary involvement (types 3–8) require abdominal removal, whether via laparotomy, traditional laparoscopy or robotic-assisted laparoscopy. An additional classification, created by Lasmar et al., that is specific to hysteroscopic myomectomy exists. This system (STEPW), has been shown to be a better predictor of successful hysteroscopic fibroid removal and surgical complications than the ESGE/FIGO system (Table 1 & Figure 1).

25. Laparotomy
Although a minimally invasive approach is often desirable, at times open myomectomy is necessary.
If there are numerous complicating intra-abdominal adhesions, and/or the surgeon is not confident in his or her laparoscopic skills, then laparotomy should be performed].
In these circumstances, however, the standard risks of open abdominal surgery apply, including the risk of increased blood loss and longer recovery time in comparison with minimally invasive approaches. The advent of laparoscopic morcellators has decreased the need for the open approach, as previously it was required for large myomas to be removed via laparotomy. However, very large myomas (i.e., >20 cm in diameter) or any that are suspected of being malignant still require an open approach].

26. Laparoscopy
In comparison with laparotomy, laparoscopic myomectomy provides improved visualization, decreased blood loss, quicker recovery and decreased postoperative pain.
However, pregnancy outcomes and the risk of fibroid recurrence appear to be similar .
There have been some reports of concern for uterine rupture during pregnancy following laparoscopic myomectomy, although the real risk is unclear as some studies report an increased risk of rupture, while others report a decreased risk.
This concern is partly related to the technical difficulty of performing a multilayer closure .However, the overall incidence of uterine rupture following laparoscopic myomectomy appears to be extremely low, and there is as yet no definitive evidence that this risk does not also exist for laparotomy.

27. Figure 2. Uterine artery embolization
Figure 2. Uterine artery embolization. Polyvinyl particles are injected into the uterine arteries using the transfemoral approach

28. Conclusions
Myoma may interfere with fertility specially SM and IM myoma
Treatment perform via surgery, hystroscopy, laparoscopy or laparotomy
Repair of bed of myoma is crucial and the best time is 3-6 months before desire pregnancy.
The precise characterization of myomas is important in selecting appropriate surgical candidates and subsequently the correct surgical approach.