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Fibroids and infertility
 

Fibroids and infertility

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    Fibroids and infertility Fibroids and infertility Presentation Transcript

    • FIBROIDS AND INFERTILITYCURRENT EVIDENCE Dr SATHYA
    •  Fibroids are benign tumours of the uterus occurring in up to 77% of women. Fibroids have been noted to occur more frequently in women with infertility.  Retrospective studies have suggested the benefit of surgically removing fibroids to increase the fertility efficacy of both natural conception and assisted conception.
    •  There are a variety of methods to surgically remove fibroids including laparotomy, laparoscopy and hysteroscopy.  The relative advantages and disadvantages of these modalities in terms of fertility efficacy and side effects are unknown.
    • Cochrane review on surgical management of fibroids and infertility  Objectives  To determine the efficacy and safety of the removal of uterine fibroids in subfertile women by laparotomy, laparoscopy or hysteroscopy when compared with expectant management or each other.
    •  Selection criteria  Randomised controlled trials (RCTs) in which fibroids were removed via surgery for the treatment of infertility
    •  Main results  Only one randomized controlled study was included (131 women) and this was probably underpowered.  There was no evidence of a difference in outcome in terms of clinical pregnancy rate and live birth rate when fibroids were removed via laparotomy or laparoscopy for infertility.
    •  There were some non fertility benefits of removal via laparoscopy including shorter hospital stay, less febrile illness and a smaller drop in preoperative haemoglobin concentration when compared to laparotomy.  There were no randomised controlled studies comparing hysteroscopic removal or no intervention with other surgical modalities.
    • CONCLUSIONS OF COCHRANE  There is limited evidence to suggest that there is no difference in fertility efficacy outcome if fibroids are removed via laparotomy when compared to laparoscopy.  There is no good randomised controlled evidence to support hysteroscopic removal of fibroids compared to other surgical modalities for fertility efficacy.
    • COCHRANE REVIEWS  Of 38 subfertility reviews currently or previously published on the Cochrane Library from the Menstrual Disorders and Subfertility Group, 12 reviews concluded that there was evidence of effectiveness of the interventions studied.  Implications: Very little good evidence is available for infertility and we are still dependent on substandard studies and expert opnion’s on deciding optimal management for a patient.
    • Types of fibroids
    • TYPES OF FIBROIDS 1. Submucos (SM): Fibroid distorting ut cavity.  Type 0: pedunculated without intramural extension  Type I: Sessile with intramural extension <50%  Type II: Sessile with intramural extension >50%  2. Intramural (IM): Fibroid not distorting the cavity & <50% protrusion into serosal surface  3. Subserosal (SS): >50% protrudes out of the serosal surface
    •  Associated with infertility: 5- 10%.  Only cause of infertility:2- 3%  IVF provides a good model to assess the effect of fibroid on implantation rate by excluding other factors such as tubal or male (Donnez & Jadoul, 2002).  IVF cannot assess the effect of fibroid on sperm migration & ovum transport.
    • Type of fibroid and IVF preg rate  SM: Most detrimental effect 9%  IM: Modest impact 16%  SS: Least impact on PR. 27%  Control 30%
    • • Donnez & Jadoul (2002).  No difference in implantation or PR unless the     uterine cavity itself was distorted by the myomas Fibroid preg rate% DISTORTED CAVITY 9% NOT DISTORTED CAVITY 34% CONTROL 40%
    • Size of fibroid  No statistically significant difference in implantation rate or pregnancy outcome • <3 cm (Rice et al, 1988, Rosati et al, 1989) • < 5 cm (Li et al, 1999) • <7 cm (Ramzy et al, 1998; Jun et al, 2001; Olivera et al,2003 )
    • 1998  2000 2003  <7CM 34  CONTROL 39 31 41 48 45
    • Number of fibroids (3-5 cm):  Feliciani 2003     No. of fibroids <3 >3 Control PR% 37 28 41
    • Distance from the endometrium (Aboulghar et al, 2004)  >5mm- no adverse effect.
    • Management of uterine fibroidscurrent evidence  Paucity of “good evidence”  Expectant management- no studies which followed up the natural history of the disease in women who chose to have no intervention.  Pharmaceutical management GnRH analogues-7RCT-Reduction in size  6 RCTs- improvement in Hb levels, Not enough evidence on blood loss during surgery or subsequent fertility.
    •  Progestin -1 small RCT showed weak evidence of reduction in fibroid size with use of lynestenol.  Mifepristone- 1 non - randomised controlled trial showed benefit in terms of reduction in fibroid size and menstrual blood loss.  Estrogen receptor modulators- Raloxifene- 3 small non RCTs showed reduction in fibroid size and two studies found an increase!
    • Uterine artery embolisation  23 TRIALS  6 RCTs  Evidence of moderate strength(consistent effects but weak design)- shorter procedure duration and shorter hospital stay compared to hysterectomy or myomectomy.  Weak evidence(either no significant differences or inconsistent direction of effect) o symptom relief and complications.
    • MR- Focussed ultrsound  No RCTs  Only 1 carefully conducted prospective series  71%- improvement in quality of life  16%- severe pain during procedure  13% reduction in fibroid size.  11% worsened symptoms  28% required further treatment.
    • Surgery vs no interventionfertility  1 clinical trial.  substantial benefit following removal of submucus fibroids.  Not enough evidence for intramural fibroids.  Not enough evidence regarding risk to subsequent pregnancy following myomectomy.Reported incidence one in 314.
    • Conclusions  There is a remarkable lack of high quality evidence     supporting the effectiveness of most interventions in fibroid management. Expectant management is poorly studied. Selection bias is an important weakness in trying to compare outcomes of different interventions in non randomised studies. However, lack of evidence is not equivalent to no benefit or harm. Given how common and concerning fibroids are to women and their health care providers, an increased emphasis on high quality research is imperative. Women deserve better information to guide their choices.