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 Table of Contents  
RESEARCH ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 53-60

Minimal invasive laparoscopic myomectomy with endometrial preservation and fertility enhancement


1 Department of Advanced Laparoscopy Surgery, University Hospital for Gynaecology, Pius-Hospital, Oldenburg, Senior Board of Director of ESGE, Germany
2 Department of Advanced Laparoscopy Surgery, Dubai London Clinic and Specialty Hospital, Jumeira, UAE; Department of Gem Advanced Minimal Access Surgery Training Centre, University Hospital for Gynecology, Oldenburg, Germany
3 Department of Obs/Gyn Dubai London Specialty Hospital, Jumeira, Dubai, UAE

Date of Web Publication9-Sep-2015

Correspondence Address:
Rajesh Devassy
Dubai London Clinic and Specialty Hospital, Jumeira, Dubai

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Source of Support: Nil., Conflict of Interest: There are no conflicts of interest.


DOI: 10.4103/2348-2907.164846

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  Abstract 


Objective: To evaluate the uterine scar and endometrial viability after laparoscopic myomectomy by two-dimensional (2D) ultrasound (US). To examine reproductive performance after surgery. Study Design: We performed a prospective, single-case, nonrandomized study in patients at the Dubai London Hospital: 107 patients with symptomatic fibroids who underwent laparoscopic myomectomy between January 2012 and May 2013. Methods: A total of 107 who underwent lap myomectomy were identified. An inclusion/exclusion criteria applied of which - 76 fulfilled the same. Their endometrial lining and uterine scar evaluated with the 2D US. Doppler study of the uterine artery and endometrial region performed alongside. The reproductive performance of these patients was then followed up over a 2 year period. Outcome: The endometrial sparing technique seems to be fertility sparing without the use of traction and minimal coagulation intraoperatively. The myometrial scar and endometrial lining can be followed up with 2D US, and the multiple suturing technique helps in improving scar integrity and ensures the absence of hematomas while preserving the endometrial thickness. The low resistance index (RI) of the ipsilateral uterine artery in a fibroid uterus shows an increase after surgery and goes back to normal between day 30-day 60. The subendometrial region had some increase but could not be quantified adequately due to lack of a method for the same. The RI of the uterine artery and the measurement of subendometrial color voxels still can be used as a measure of fertility prognosis and uterine receptivity after myomectomy. Limitations: This is a cohort investigation on a limited number of patients and does not compare the different number/size of myoma prior to removal in the US follow-up. Endometrial Doppler studies cannot be used as a prognostic tool of endometrial viability especially due to the lack of an accepted standard criteria to evaluate and measure the subendometrial perfusion.

Keywords: Doppler, endometrial lining, endometrium, fibroids, laparoscopic myomectomy, reproductive outcome, sub endometrial plexus, uterine scar


How to cite this article:
De Wilde R, Devassy R, Gopalakrishnan S. Minimal invasive laparoscopic myomectomy with endometrial preservation and fertility enhancement. IVF Lite 2015;2:53-60

How to cite this URL:
De Wilde R, Devassy R, Gopalakrishnan S. Minimal invasive laparoscopic myomectomy with endometrial preservation and fertility enhancement. IVF Lite [serial online] 2015 [cited 2023 Jan 30];2:53-60. Available from: http://www.ivflite.org/text.asp?2015/2/2/53/164846


  Introduction Top


Myoma or fibroids, as they are commonly called, are a benign growth of smooth muscle in the wall of the uterus. Description of uterine myomas: A uterine myoma (myomauteri) is a solid tumor made of fibrous tissue, hence it is often called a "fibroid" tumor.

In 5.4–77% of females, fibroids are diagnosed in their reproductive years.[1] Although the pathogenesis is not completely understood, we do know that myomas are hormone dependent and are derived from individual myoma cells and not from a metastatic process. Myomas are the most common benign solid tumors of the female genital tract. Although often asymptomatic, they may cause menorrhagia, metrorrhagia, infertility, pain, pressure symptoms hemorrhage, and repeated abortions.[2]

Fibroids and fertility

Fibroids are the only abnormality detected in 1–2.4% of women with fertility issues.[1] The anatomical location of the fibroid is an important factor, with their importance in decreasing order as follows: Submucous, intramural and subserosal fibroids. Those located near the tubal ostia also pose a problem. Next is the size of the fibroid-those >4 cm tend to hamper fertility.[3]

These myomas can also contribute to implantation failure or early miscarriage due to focal endometrial vascular disturbances and inflammation, secretion of vasoactive substances, or an enhanced endometrial androgen environment.[4],[5]

Fibroids and reproductive outcome

Fibroids may produce complications in pregnancy with miscarriage being the most common. The location of the fibroid in relation to the placenta appears to be very important than size as noted by Muram et al., 1980; Rosati et al., 1989.[6],[7] Of significance here is a report by Li et al., 1999[8] where they observed a first trimester miscarriage rate of 40% and second trimester miscarriage of 17% with intramural and subserosal fibroids. Apart from miscarriage myomas cause abdominal pain due to degeneration, preterm labor, abruption, intrauterine growth retardation, obstructed labor, and postpartum hemorrhage.

The ultrastructure of the host myometrium of the fibroid uteri was studied to understand the mechanism of miscarriage and they found that the sarcolemmal dense bands of most myometrial myocytes were found to be significantly longer than that of normal myometria with a decrease in the number of caveolae thus making the host myometria abnormal. This abnormality affects the calcium metabolism in these tissues which triggers of abnormal contractions leading to pregnancy wastage or infertility.[9]

Fibroids and assisted conception

Reports from retrospective studies show that pregnancy outcome after assisted conception followed the same trend as the spontaneous conception that is, in descending order of importance - submucous, intramural, and subserosal fibroids. The pregnancy rate per embryo transfer in submucous, intramural, and subserosal fibroids were 9, 16, and 37%, respectively, compared with an average of 30% in control subjects.[10],[11] From the said data it can be safely said that patients going through IVF should always have a submucosal fibroid removed, intramural fibroids possibly depending on the number, size, and location of the same. Women with subserosal fibroids can be reassured as it is unlikely to have an adverse impact on implantation rate and live birth rate. It should be remembered that the results based on IVF studies evaluate the effect of fibroids on embryo implantation failure especially when the diameter is more than 4 cm. The hurdles to the tubal transfer of oocytes and embryos are overcome with this process.[12],[13] Recent studies show a positive relation to the size of fibroid and implantation rates (Sudik et al., 1999). In case of large fibroids more than 5 cm it is necessary to individualized treatment plan based on reproductive history, size, and extension of fibroid involvement on the endometrium and uterine cavity.

Myomectomy

The role of growing myomas in the reproductive years has been a subject of debate for years and is an accepted indication for myomectomy. Semm and Mettler[14] published their first paper on laparoscopy myomectomy in 1980. In the 1990's – surgeons started laparoscopic myomectomy for intramural fibroids. At present laparoscopic myomectomy in infertile patients is one of the most common procedures. The procedure is not without its risks and an intramural laparoscopic myomectomy has to be done with surgeon of good experience or else there may be breach of endometrial cavity, application of excessive tissue coagulation, difficulties in tissue approximation or use of unsuitable suture size with the risk of hematoma, indentations, and uterine fistulas eventually leading to uterine rupture. Minimally, invasive myomectomy as opposed to laparotomy (open abdominal) myomectomy results in has resulted in remarkable advantages for the patient in medical, social, and economic terms, with less postoperative pain and shorter recovery time[15] (Mais et al.[16]; Seracchiolli. [17,18] The consideration while undertaking a decision on myomectomy are location and size of the fibroid, and whether or not it is impinging on the endometrium and distorting the uterine cavity. Doubts and debates about the reproductive outcome after myomectomy continues with authors like Stovall et al.[19] saying that the procedure compromises assisted conception, but these studies are not without its limitations. The reports mostly have combined intramural and subserosal fibroids as one group, but it is commonly understood that the impact from an intramural fibroid on the reproductive outcome is different than that of subserosal fibroids. The rates of conception after myomectomy has ranged between 25% and 70%. The presence of other factors contributing to fertility issues has a greater impact on the conception rate.[20]

Technique of myomectomy

The uterus was cannulated when possible to allow correct exposure of the myomas and strong countertractions during enucleation and suturing. To reduce vascularization and blood loss, we injected myomas with diluted ornithine vasopressin and now diluted (20 IU:500 ml) argipressin. The vasoconstrictive agent was injected laparoscopically between the myometrium and the myoma capsule, looking for the cleavage plane, until blanching occurred. Extracapsular approach with an incision was made on the serosa overlying the myoma. The subendometrial plexus and the myometrium identified and careful dissection done. At this stage, extreme caution applied as it is normal after exposure of the myoma to apply traction on the myoma and to expose the cleavage plane. No counter traction given as the endometrium may be pulled into the dissecting field leading to injury. A slow blunt and sharp dissection help prevent damage to the endometrial plexus and endomyometrial interface. Mechanical enucleation was advised whenever possible. Division of the connective tissues surrounding the myoma was obtained with a bipolar scissors or most preferably with the Ultrasonic Cutting and Coagulating System the latter having the advantage of less tissue charring. The only exception to this technique was in the case of unsuspected adenomyosis. In this situation, the cleavage plane does not exist, and excision can only be carried out with a monopolar hook, sharp cutting shears/endo knife, or an ultrasonic energy device, paying attention to use electrosurgery close to the adenomyoma/myoma and not to the myometrium or endometrium. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] show the different phases of the myomectomy (preoperative to postoperative) with endometrial preservation. The myoma was gently enucleated from the surrounding myometrial and endometrial tissue. Hemostasis could be achieved with bipolar/ultrasonic shears coagulation of the vessels feeding the myoma, paying attention to dangerous structures, such as the ureter (in rarely applied cases) or uterine vessels. As the base of the myoma was reached, coagulation of the blood supply was obtained with preferably ultrasound (US) shears or sometimes bipolar forceps. A clear vision of the bed is mandatory to prevent inadvertent injury to the endometrium which is the primary goal in endometrial sparing. Eventually, the careful closure of each myometrial layer done with PDS barbed sutures. We always ensure to endosuture in 2 or 3 layers because it consists of bringing the entire thickness of the edges of the myomectomy site together to prevent the formation of hematomas. This suture also helps in scar integrity during the healing period and reduces suture line tension which ultimately enhances healing by preventing suture necrosis and preserving the myometrial function efficiently rather than having a nonfunctional myometrial scar.
Figure 1: Preoperative hysteroscopic view of myoma involving endometrium

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Figure 2: Myomectomy in progress

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Figure 3: Complete enucleation after dissection showing an intact endometrium

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Figure 4: Postmyomectomy-myometrial suturing in layers

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Figure 5: Interceed/intercoat adhesion barrier routinely used after myomectomy

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Figure 6: Hysteroscopic view postmyomectomy showing the uterine cavity with an intact endometrium

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Study design

A prospective study at the Dubai London Hospital: 107 patients with symptomatic fibroids who underwent laparoscopic myomectomy between January 2012 and May 2013.


  Methods Top


A total of 107 who underwent lap myomectomy were identified. An inclusion/exclusion criteria applied - 76 fulfilled the same. A preoperative two-dimensional (2D) US was performed to evaluate the evolution of the sonographic findings after myomectomy. The endometrial lining and uterine scar evaluated with the 2D US after surgery along with Doppler study of the uterine artery and subendometrial surface. The reproductive performance of these patients was then followed up over a 2 year period.

Inclusion criteria

  • Women below 42 years
  • They had myomectomy using microsurgical techniques for intramural fibroids >3 cm with endometrial involvement but not necessitating a hysteroscopic myomectomy (this was validated with corresponding 2D US findings)
  • They wished to conceive after surgery
  • They had no other significant infertility factors
  • No postoperative fever.


Exclusion criteria

  • Previous uterine surgery (excluding caesarean section) so as to prevent dilution of the study w.r.t to endometrial integrity from the previous surgery
  • Presurgical treatment with gonadotropin-releasing hormone (GnRH) analogues
  • A history of gynecological malignancy.


Exclusion criteria for preoperative GnRH analog treatment were due to reported increased risk of recurrence, a possible delay in the diagnosis of leiomyosarcoma, a risk of massive hemorrhage from degeneration, a greater difficulty in finding the cleavage plane, and a greater extent of hyalinization phenomena.[15] All fibroids were selected through standardized transvaginal/transabdominal US myoma mapping; all patients had intramural fibroids more than 3 cm, and transvaginal US dates were recorded for postsurgical evaluation.

The purpose of this study was Phase 1-to note the evolution of the uterine scar following laparoscopic myomectomy and also note endometrial thickness and integrity with a 2D US and Doppler velocimetry of uterine arteries and the during the Phase 2 of the study the patients were followed up over a 2 year period to note reproductive outcome (spontaneous, as well as with assisted conception). A transvaginal/transabdominal US was performed on day 7, day 30, and day 60 for uterine scar and to measure the endometrial thickness (day 0= surgery). The resistance index (RI) was calculated from the flow velocimetry waveform of the uterine arteries, at the origin of their ascending branch. To study endometrial perfusion, we chose 1 mm as the subendometrial region because the subendometrial region may extend beyond the uterine contour especially in the cornual region if 5 mm was taken. The fibroids were not included when 1 mm was used. To study endometrial perfusion, we chose 1 mm as the subendometrial region because the subendometrial region may extend beyond the uterine contour especially in the cornual region if 5 mm was taken. Following the assessment of the endometrium itself, the subendometrium was examined in the same window which allows the user to generate a variable contour that parallels the originally defined surface contour. The fibroids were not included when 1 mm was used. Due to the lack of standard criteria in the literature in examining the blood flow in the endometrium the presence of color voxels along the endometrial contour was taken as the viable endometrium. At discharge, the patients who were keen on conception were educated about the chances of recurrence and advised conception after 90 days and before 1.5 years.

Postoperative ultrasound findings and its importance

The uterine scar on day 7 appeared as a highly echogenic area having ill-defined heterogenous myometrial texture however there was no hemorrhagic collection noted, due to the meticulous interspersed suturing technique of closing each layers applied. The endometrium had a thickness between 9 and 11 mm. The color voxel index of the endometrium along the subendometrial surface was maintained in all the cases. Day 30 saw the image of the uterine scar gradually shifting with significant involution. Sutures echoes were identified; endometrium continued to maintain a close relation to the myometrial surface with no signs of any breach and by day 60 there was progressive reduction of the uterine scar in myomas measuring between 5 and 7 cm. The larger myomas (>10 cm) were reviewed on day 90 and 180. In all the cases, there was evidence of a shift to normal echogenic myometrial texture while maintaining a good endomyometrial interphase. In patients with over 10 cm myomas showing just regional myometrial mild hypertrophy, with no adenomyotic changes or suture echoes visible which is characteristic of the normal healing process.

The RI is a measure of the resistance to blood flow and is affected by the microvascular bed distal to the site of measurement. An RI of 0 corresponds to continuous flow, an RI of 1 suggests systolic but not diastolic flow, and an RI >1 corresponds to reverse diastolic flow. An increase in RI in the immediate postoperative period reflects neoangiogenesis that occurs in the uterine muscle wall after myomectomy (Malavasi et al. [21,22]).

The importance of uterine blood flow assessment by Doppler lies in the fact that there is evidence of a clear association between abnormal uterine artery velocity and fertility. A significantly lower pulsatility index (PI)/RI was noted in women with fibroids compared to normal uteri (Tinelli et al.[23]). In 2002, it was noted that the reduction in PI and RI was accompanied by decreased blood flow to the endometrium due drainage of blood to the fibroids.[24]


  Results Top


Of the 107 patients who were operated for myomectomy - 24% had pelvic pain, abnormal uterine bleeding in 23%, fertility based issues in 40%, and a rapidly growing fibroid in 13%. The mean age was 35.2 ± 3.6 years (33–38 years) with a mean parity of 1.3 ± 0.7.

In the 76 patients who have fulfilled both the inclusion and exclusion criteria – the uterine scar after myomectomy had a diameter 62 % less than that of the previous fibroid on day 7; 81% on day 30; and almost disappeared by day 90. The progressive reduction in the size of the uterine scar on US was significant (P < 0.005).

The endometrium persistently measured above 5–7 mm with it varying according to the phase of the cycle; adequate vascular perfusion to the endometrium was also recorded and there seemed to be no collection or anechoic shadows between the myometrium and endometrial surface.

There was an increase of the RI value of the ipsilateral uterine arteries from 0.52 of the preoperative day (range: 0.59–0.73) to 0.83 (range: 0.74–0.92) in all the patients on day 7 after surgery, then the RI decreased to 0.70 (range: 0.59–0.73) on day 30 in 87.5% of the patients (66/76), then the RI decreased to 0.61 (range: 0.50–0.66) in 98% (75/76) on the 60th postoperative day. There was no end-diastolic flow in one of the patients. This difference in the initial velocity rise and then decrease is normal, but the difference in above range during comparisons is significant (P < 0.05).

The RI values in contralateral uterine artery remained the same pre- and post-operatively. Small anechoic areas <5 mm noted on day 7 in <3% of patients which were nonexistent on follow-up day 30; some linear hyperechoic points along the sutures were seen – with an absorption time of 50–60 days during US evaluation. No fluid-filled areas noted. The color voxel index and endometrial thickness along the endometrial surface in all patients except 2 (98%) was maintained. Of these 2 women 1 patient with a decreased perfusion in the endometrial surface and absent end diastolic flow was lost for follow-up after 8 months after being referred to fertility center.

Among the 76–51 patients had fertility issues (67%) of which - 29 (57%) conceived after myomectomy spontaneously and 8 conceived with assisted conception leading to a cumulative pregnancy rate of 72%, that is, 37 pregnancies in all. The pregnancy rates after myomectomy were higher in women with greater color voxels along the subendometrial region. There were 6 patients who reported first trimester pregnancy loss. There was no second/third trimester pregnancy losses recorded. It was also noted that women aged 40 years and less had a higher chance of conception. The results of the reproductive outcome of our study is compared to other studies in [Table 1] and [Table 2] to show that the outcome of this technique of myomectomy has results which are superior to regular laparoscopic myomectomy.
Table 1: Outcome of assisted conception treatment in women with fibroids

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Table 2: Laparoscopic myomectomy: Reproductive outcome in infertile women

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  Discussion Top


Laparoscopic myomectomy is now an accepted surgical procedure, but the doubts still persist due to reported cases of poor healing, fibrotic scar, uterine rupture, and fertility challenges. Poor vascularization and tissue necrosis due to the widespread use of electrosurgery affects scar strength which could be attributed to the adopted technique. A widely accepted diagnostic tool for healing after myomectomy is not in place, hence US is used to resolve the problem. The advantage of US lies in the fact that it allows us to visualize all the layers of the uterus, so as to detect any change in the echotexture of the endometrium and myometrium. The added advantage is the importance of the vascular study involving the uterus and the scar which can be used as a prognostic tool in patients wishing to conceive.

In our observation, the size of the uterine scar has steadily decreased from day 7 to day 30, while the reduction was slow and gradual after that, and this can be explained by the edema and inflammatory changes which is the first stage of the healing process. The edema and the minimal amount of blood at the site of surgery disappear rapidly with the replacement of collagen fibers as part of the regeneration process which lasts from 48 h up to 6 weeks. Fiber organization occurs at random by day 4 after surgery. From day 30 to 60 (and in case of large myomas - day 90) there was a gradual reduction in scar size and this was because the scar was in the final phase of healing called the remodeling phase, which lasts from 3 weeks to 12 months when final aggregation, orientation and arrangement of collagen fibers occur. Healing of the injured muscle by the regenerative response rather than the fibrotic response does not fully restore muscle to its prior state but fully restores myometrial function. The two processes of healing and fibrosis compete with each other and impair complete regeneration (Malavasi et al., 2011b).[25],[26],[27]

The parameter of importance that was noted in the Doppler study was RI. There was a rise in RI on the 7th postoperative day in comparison with preoperative values due to increased neoangiogenesis during the inflammatory phase. This indicates that the healing process is right on the path. This gradually decreases on day 30 and day 60. The RI is a measure of the resistance to blood flow and is affected by the microvascular bed distal to the site of measurement. The A RI of 0 corresponds to continuous flow while an RI of 1 suggests systolic but not diastolic flow and an RI >1 corresponds to reverse diastolic flow. An increase in RI in the immediate postoperative period reflects neoangiogenesis that occurs in the uterine muscle wall after myomectomy. On complete healing the RI returns to normal after approximately 30–60 days.[28]

To study endometrial perfusion, we chose 1 mm as the subendometrial region because the subendometrial region may extend beyond the uterine contour especially in the cornual region if 5 mm was taken. The spiral artery Doppler flow in the endometrium showed no major difference in the pre- and post-operative period. This, however, cannot be generalized to the endometrial sparing technique of myomectomy. The importance of Uterine and Endometrial blood flow assessment by Doppler lies in the fact that there is evidence of a clear association between abnormal uterine artery velocity and fertility. A significantly lower PI/RI was noted in women with fibroids compared to normal uteri. Absent endometrial or subendometrial flow detected by color or power Doppler in 2D US is associated with no pregnancy[29] (Battaglia et al.[30]) or much reduced pregnancy rate (Chen et al.[31]; Maugey-Laulom et al.[32]). A study in 2002 by Ng and Ho.[33] Observed that the reduction in PI and RI was accompanied by decreased blood flow to the endometrium due drainage of blood to the fibroids. The implantation rate is decreased when the uterine artery PI is >3.5 at the time of hCG administration, oocyte retrieval or embryo transfer. Since there are no substantial differences in the pre- and post-operative period endometrial Doppler study it can be assumed that there has been no breach of the endometrium with the adopted technique of laparoscopic endometrial sparing myomectomy adopted. Endometrial Doppler studies cannot be used as a prognostic tool of endometrial viability after myomectomy especially due to the lack of an accepted standard criteria to evaluate and measure the subendometrial perfusion.


  Conclusion Top


The dissection technique that involves preservation of the endometrium, the endomyometrial interphase, and subendometrial plexus improve uterine receptivity and fertility outcome which otherwise can be compromised.[37]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Dr. Rajesh Devassy is one of the UAE's best known advanced Laparoscopic Surgeon. An expert in advanced Endoscopic Surgery and Laparoscopic Pelvic Reconstructive and Oncological Surgery. He has performed over 37,000 Laparoscopic Surgeries of which more than 28,000 are advanced Laparoscopic Gynaecological procedures with over 15 years experience in Practise and Teaching in India, Germany and the UAE. Member of the European, Indian and American Gynaecological Endoscopy Association. Dr. Devassy is the Course Director and Principal Faculty Member of Gem Advanced Minimal Access Surgery Training Centre. Clinic of Gynaecology, Obstetrics and Gynaecological Oncology, University Hospital for Gynaecology, Pius-Hospital, Oldenburg.


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