Myom ve infertilite

Dr. Engin Oralİstanbul Üniversitesi

Cerrahpaşa Tıp FakültesiKadın Hastalıkları ve Doğum ABD

Myom ve fertilite Sorular

• Myom infertiliteye yol açar mi – İmplantasyon– abortus

• Myom varlığı IVF sonuçlarını etkiler mi

• Myomektomi fertilite üzerine etkili mi

• Hangi yöntem (L/S vs L/P) fertilite icin daha iyi

Myom-Risk Faktörleri

• Kanıtlanmış– Seks, ırk– Yaş– Parite– Erken menarş– Sigara içmek

• Muhtemel– OK– Diyet– Aile anamnezi– Alkol– P iceren enjectabl– Obesite– Hipertansiyon– Uterus enfeksiyonu– PKOS

Stewart EA, 2009, UpToDate,

Myom-infertilityincidence

• It has been estimated that uterine myomas are associated with infertility in 5% to 10% of cases. However, when all other causes of infertility are excluded, myomas may be responsible for only 2% to 3% of infertility cases

Mechanisms by which myomas cause reduced fertility have been suggested

1. Displacement of the cervix that may reduce exposure to sperm

2. Enlargement or deformity of the uterine cavity that may interfere with sperm migration and transport

3. Obstruction of the proximal fallopian tubes

4. Altered tubo-ovarian anatomy, interfering with ovum capture

5. Increased or disordered uterine contractility that may hinder sperm or embryo transport or nidation

6. Distortion or disruption of the endometrium and implantation due to atrophy or venous ectasia over or opposite a submucous myoma

7. Impaired endometrial blood flow

8. Endometrial inflammation or secretion of vasoactive substances

Fertilization

implantation

Summary of Potential Mechanisms by Which Uterine Fibroids May Have an Effect on Embryo Implantation

Andrew W. Horne, , 2007

Submucosal uterine leiomyomas have a global effecton molecular determinants of endometrial receptivity

Beth W. Rackow, and Hugh S. Taylor, In press F& S

Myom da yönetim

• Yaş

• Semptomlar

• Obstetrik geçmiş

• Fertilite planı

• Büyüklüğü

• Yeri

Yerleşim

• Submüköz– Tip 0: Saf submüköz– Tip I: İntramural kısım %50’den az– Tip II: İntramural kısım %50’den fazla

• İntramural: Kaviteyi bozmayan ve %50’den azı seroza dışına çıkan

• Subseröz: %50’den fazlası seroza dışına taşan

Location of Fibroids Affects Success of ART Cycles

Fibroids # of Patients Pregnancy Rates

None 318 30.1%

Subserosal 33 34.1%

Intramural 46 16.4%*

Submucosal 9 10.0%*

Eldar-Geva et al., 1998

Effects of the position of fibroids on fertility

Casini ML, 2006

N: 181

Klatsky PC, 2008

Fibroids and reproductive outcomes: a systematicliterature review from conception to delivery

Klatsky PC, 2008

OR 1.82(1.43-2.30) OR: 1.34(1.04, 1.65)

Donnez J and Jadoul P, 2002

Donnez J and Jadoul P, 2002

PR /After myomectomy

L/S 49%L/T 48 %H/S 45 %

Asymptomatic uterine fibroids

• For the younger woman who wishes to conceive now, whose fibroids are less than 12–14 weeks in size and slow growing, she should be encouraged to try to conceive, and observed carefully for complications that may be attributable to the fibroids.

• The younger woman who wishes to conceive now, whose fibroids are larger than 14 weeks in size but slow growing, should also be encouraged to try to conceive and observed carefully. However, if the fibroids are growing rapidly and/or she fails to conceive within 6 months, she should be counselled for myomectomy

• The younger woman wishing to conceive in the future, whose fibroids are less than 12–14 weeks in size and slow growing, should be kept under surveillance with regular (at least annual) ultrasound scans to assess fibroid behaviour.

• If the fibroids are already more than 14 weeks in size and slow growing, she can be kept under surveillance although she should be discouraged from leaving it too long to conceive. She should also be informed of treatment options including myomectomy and the less-invasiveprocedures referred to above.

Hema Divakar, 2008

Asymptomatic uterine fibroids

• In summary, most women with asymptomatic fibroids can be encouraged to try to conceive without any intervention being undertaken for the fibroids, and the vast majority will indeed conceive.

• There are special circumstances where a case can be made for intervention, especially where the fibroids are submucous, intramural and distorting the cavity, and/or rapidly growing. Evidence does not support routine myomectomy before assisted reproductive technology in women with asymptomatic fibroids that do not distort the endometrial cavity significantly or cause abnormal uterine bleeding, but resection of submucous fibroids improves fertility rates.

Hema Divakar, 2008

Myomas and Assisted Reproduction Techniques

• Five meta-analyses have aimed to assess the impact of fibroids on IVF cycles.– Pritts EA. Fibroids and infertility: a systematic review of the evidence.

Obstet Gynecol Surv 2001;56:483–91– Donnez J, Jadoul P. What are the implications of myomas on

fertility? A need for a debate? Hum Reprod 2002;17:1424–30– Benecke C, Kruger TF, Siebert TI, Van der Merwe JP, Steyn DW.

Effect of fibroids on fertility in patients undergoing assisted reproduction. A structured literature review. Gynecol Obstet Invest 2005;59:225–30.

– Somigliana E, Vercellini P, Daguati R, Pasin R, De Giorgi O, Somigliana E, Vercellini P, Daguati R, Pasin R, De Giorgi O, Crosignani PG. Fibroids and female reproduction: a critical analysis ofthe evidence. Hum Reprod Update 2007;13:465–76.

Of 347 studies initially evaluated, 23 were included in the data analysis . One randomized controlled treatment trial was identified , nine prospective studies were included(one matched, eight cohort) , and the remainder were retrospective.

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Fibroids and infertility: an updated systematic review of the evidence

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Fibroids and infertility: an updated systematic review of the evidence

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Fibroids and infertility: an updated systematic review of the evidence

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Fibroids and infertility: an updated systematic review of the evidence

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Fibroids and infertility: an updated systematic review of the evidence

Elizabeth A. Pritts, William H. Parker, and David L. Olive, 2009

Fibroids and infertility: an updated systematic review of the evidence

Myomas and reproductive functionThe Practice Committee of the American Society for Reproductive

Medicine-2008

• The effects of myomas on reproductive function outcome are not well defined. Overall, evidence suggests that myomas are the primary cause of infertility in a relatively small proportion of women.

• Myomas that distort the uterine cavity and larger intramural myomas may have adverse effects on fertility.

• Medical treatment for myomas does not improve infertility.• In infertile women and those with recurrent pregnancy loss, myomectomy

should be considered only after a thorough evaluation has been completed.• Myomectomy is a relatively safe surgical procedure associated with few

serious complications. However, postoperative adhesions are common after abdominal myomectomy and pose a significant potential threat to subsequent fertility.

• UAE, myolysis, and MRI-guided ultrasonic treatment should not be recommended for women with myomas seeking to maintain or improve their fertility because their safety and effectiveness in such women has not been established.

Submucous myomas and their implications in thepregnancy rates of patients with otherwise unexplained primary infertility

undergoing hysteroscopic myomectomy: a randomized matchedcontrol study

Tarek Shokeir, 2009

Tarek Shokeir, 2009

Submucous myomas and their implications in thepregnancy rates of patients with otherwise unexplained primary infertility

undergoing hysteroscopic myomectomy: a randomized matchedcontrol study

Proposed flow chart for the management of women seeking conception in the presence of

uterine myomas

Edgardo Somigliana, 2008

Yaş

Yerleşim

Sayı

ÇapDiğer infertilitenedenleri

CerrahiBekle veya ART

< 38

Intramural

>1

≥ 3 cm

Yok

≥38

Subseröz

1

<3cm

Var

RECOMMENDATIONSUpToDate

• We suggest women with asymptomatic leiomyomas not postpone pregnancy, if possible, since leiomyomas, combined with advanced maternal age, may impair fertility and adversely impact pregnancy (Grade 2C).

• In women planning pregnancy, we suggest not performing prophylactic myomectomy to prevent pregnancy complications (Grade 2C).

Togas Tulandi, MD, 2009

• The relationship between leiomyomas and infertility is controversial. Couples should complete a full infertility evaluation before addressing the role of leiomyomas in their infertility

• In women with asymptomatic leiomyomas who are infertile or have a history of recurrent pregnancy loss:

• For those with a myoma that is submucosal or has an intracavitary component, we suggest myomectomy (Grade 2C).

• For women with a myoma that is subserosal, we suggest against myomectomy (Grade 2C).

• For women with intramural fibroids that do not distort the uterine cavity, other sources of infertility should be addressed prior to a myomectomy. The decision to perform a myomectomy should be made based on patient preference and clinical factors (eg, obstructing of a fallopian tube or the cervical canal or failure of other infertility treatments).

• We suggest myomectomy for women planning to undergo in vitro fertilization who have a submucosal fibroid or an intramural fibroid that deforms the uterine cavity (Grade 2C).

• We suggest surgical myomectomy over medical therapy or embolization for women planning future pregnancies (Grade 2C).

Medical therapy

Several other nonsurgical treatments exist for uterine fibroids (gonadotropin-releasing hormone agonists, danazol, raloxifene, mifepristone, aromatase inhibitors, and the levonorgestrel-containing intrauterin system), but none has been shown to be of value in the patient desiring future fertility

Laparoscopic versus open myomectomyA meta-analysis of randomizedcontrolled trials

• Six studies and 576 patients were studied• laparoscopic myomectomy was associated with

– less hemoglobin drop, – reduced operative blood loss,– more patients fully recuperated at day 15,– diminished postoperative pain, and fewer overall

complications – but longer operation time.

• However, major complications, pregnancy and recurrence were comparable in the two groups.

Chu Jin, 2009