Page 8 - World Journal of Laparoscopic Surgery

Bamgbopa Tajudeen Kehinde

Women in the study group were on average 2 years older (36.4 nor implantation rates were significantly different in comparison
versus 34.6 years; P < 0.01). There was no significant difference with controls among either oocyte donor recipients (group A:
in the duration of ovarian stimulation or gonadotrophin 86.7%, 57.8%; group B: 84.6%, 55.2%; group C: 77%, 49.1%).

requirement,number of follicles developed, oocytes collected, The findings were similar for those undergoing IVF-ET in

and embryos availablefor transfer or replaced. When analyzing comparison with controls (group 1: 61%, 24%; group 2: 52%,

only women with intramural fibroids of 5 cm in size (n = 106) 26%; group 3: 53%, 23%). This study showed that precycle

pregnancy, implantation and ongoing pregnancy rates were resection of appropriately selected clinically significant

significantly reduced: 23.3, 11.9and 15.1 respectively compared leiomyomata results in IVF-ET or oocyte donation cycle

with 34.1, 20.2 and 28.3% inthe control group (P = 0.016, P = outcomes that are similar to controls. 29

0.018 and P = 0.003). Themean size of the largest fibroids was Kolankaya and Arici concluded in their review that myomas

2.3 cm (90% range 2.1 to 2.5cm). Logistic regression analysis that compress the uterine cavity with an intramural portion and

demonstrated that the presence of intramural fibroids was one submucous myomas significantly reduce pregnancy rates, and

of the significant variables affecting the chance of an ongoing should be removed before assisted reproductive techniques

pregnancy, even after controlling for the number of embryos are used and that hysteroscopic myomectomy is the gold

available for replacement and increasing age, particularly age standard for the treatment of submucous myomas. 30

40 years, odds ratio 0.46 (CI 0.24–0.88;P = 0.019). This study In reviewing surgical technique employed at hysteroscopy,

demonstrated that an intramural fibroid halves the chances of 2 publications were examined:

an ongoing pregnancy following assisted conception. 26 Attilio et al in a review of surgical techniques, confirmed
Racknow and Arici, in a review in 2005 concluded that fibroid that myomas that compress the uterine cavity with an intramural
location, followed by size, is the most important factor portion and submucous myomas significantly reduce pregnancy
determining the impact of fibroids on IVF outcomes. Any rates, and should be removed before assisted reproductive
distortion of the endometrial cavity seriously affects IVF techniques are used and that hysteroscopic myomectomy is
outcomes, and myomectomy is indicated in this situation. the gold standard for the treatment of submucous myomas.
Myomectomy should also be considered for patients with large The choice of the technique mostly depends on the intramural
fibroids, and for patients with unexplained unsuccessful IVF extension of the fibroid, as well as on personal experience and
cycles. 27 available equipment. ‘Resectoscopic slicing’ still represents the
Somigliana et al in their analysis concluded that available ‘gold standard’ technique for treating fibroids G0, even if several
evidence also suggests that submucosal, intramural and other effective techniques including ablation by neodymium-
subserosal fibroids interfere with fertility in decreasing order of yttrium-aluminum-garnet laser, morcellation and office
importance. Physicians are advised to pursue a comprehensive myomectomy have been proposed. At present, the ‘cold loop’
and personalized approach clearly exposing the pros and cons technique seems to represent the best option as it allows a safe
of myomectomy to the patient, including the risks associated and complete removal of such fibroids in just one surgical
with fibroids during pregnancy on one hand, and those procedure, while respecting the surrounding healthy
associated with surgery. 28 myometrium. 31
Surrey and colleagues, in a prospective case-controlled Touboul and colleagues tried to determine the rate of uterine
study evaluated the impact of myomectomy on in vitro synechiae after bipolar hysteroscopic myomectomy in patients
32
fertilization-embryo transfer (IVF-ET) and oocyte donation cycle suffering from infertility. In a retrospective case series study,
outcome. Patients were grouped with submucosal leiomyomata a group of 53 patients with primary (n = 30) and secondary
resected hysteroscopically (group A: 15 oocyte donor (n = 23) infertility who underwent bipolar hysteroscopic
recipients; group 1 = 31 IVF-ET patients) and those with resection of myomas between 2001 and 2006, and an outpatient
intramural components or strictly intramural leiomyomata that hysteroscopy was performed 2 months after the fibroid
distorted or impinged upon the endometrial cavity resected at resection. The formation of uterine Synechiae and pregnancy
laparotomy (group B = 26 oocyte donor recipients; group 2 = 29 rates were collected from the patients’ clinical notes. The
IVF-ET patients). Precycle hysteroscopic or abdominal submucosal myomas were intracavitary class 0 (n = 12),
myomectomy were performed with subsequent fresh IVF-ET or intramural class 1 (n = 19), and intramural class 2 (n = 22). The
oocyte donation. Results of controlled ovarian hyperstimulation mean age of the women was 35.0 +/– 4.8 years. The mean myoma
as well as ongoing pregnancy and implantation rates were size was 25 +/– 11 mm. Postoperative office hysteroscopies
evaluated in comparison with contemporaneous patient groups revealed synechiae in four (7.5%) of 53 patients. Sixteen (32.7%)
without such lesions (group C = 552 oocyte donor recipients; of the 49 patients not lost to follow-up conceived, and 12 (24.5%)
group 3: 896 IVF-ET patients). The mean number and size of of them delivered at term. Myoma size >/=3.5 cm and age <35
leiomyomata were significantly larger in patients who underwent years were associated with a significantly higher pregnancy
abdominal myomectomy. However, neither ongoing pregnancy rate in univariate and multivariate analysis. They concluded
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