This document provides information about Dr. Kaberi Banerjee, a medical director and chairperson in Delhi, India. It outlines her qualifications and experience in obstetrics, gynecology, and reproductive medicine. The document then discusses myomas (fibroids) and their relationship to infertility, outlining various diagnostic and treatment options for fibroids including hysteroscopic myomectomy, abdominal myomectomy, laparoscopic myomectomy, morcellation, medical management, uterine artery embolization, MRI-guided focused ultrasound, and vaginal occlusion of uterine arteries.

1. Dr. Kaberi Banerjee
Medical Director- Advanced Fertility and Gynae Centre, New Delhi
Chairperson Delhi State Chapter ISAR
• MBBS and MD in Obstetrics & Gynecology (AIIMS, New Delhi)
• FRCOG, London, UK
• Commonwealth Fellow in Reproductive Medicine, London UK.
• More than 8000 IVF, ICSI, Donor and Surrogacy Cases
• Awards:
• Bharat Jyoti Award in 2008 . Global Healthcare Excellence Award 2014
• India Today Excellence Award in Field of Medicine 2015
• BL Jhaveri National Award in Medicine 2015
• Pricewaterhouse Coopers Award for Leading IVF Centre SE Asia 2017
• Economic Times Award for Distinguished Work in IVF in 2019
• Publications:
• 2006- Published in Fertil Steril – Meta-ananlysis of role of Aspirin in ART
• 2008- Presented in FIGO – Original work in Embryo Transfer Methods
• 2017- Oral Presentation in Aspire Kualalumpur on Acceptance of donor gametes in Indian couples
• 2017 – Oral Paper accepted in Embryology Conference, Chicago on Retrograde Ejaculation.
• 2017- Paper accepted in International Journal of HIV
• More than 20 articles published in National and International Journals of repute
• Invited Author in various Fertility Articles.
• Conferences
• Organizing Chairperson CUPART and Co Organizer Embryology Allied Chicago.

2. Myoma in Infertility
Dilemmas in Management
Dr Kaberi Banerjee
New Delhi

3. Fibroid
• Most common tumor of
reproductive tract
• Affecting 20–50 %
women of reproductive
age
• Fibroids - present in 5-
30% of infertile patients

4. Risk Factors of Fibroids

5. Fibroid causes Infertility

7. Dilemmas in Fibroid Management
• How do you diagnose?
• When do you need to intervene?
• How do you intervene?

8. Diagnosis
• Pelvic/ Abdominal Examination
• Ultrasound – Gold Standard, Saline Infusion,
3D
• Hysteroscopy – Cavity Assesment, Biopsy

9. MRI
• Number
• Size
• Relationship with Cavity
• Doubt re malignancy
• Expensive !

11. Dilemmas in Fibroid Management
(Method)
• Hysteroscopy/Laparoscopy/ Laparotomy
• Morsellation
• Medical Options
• Other Options

12. Management
• Depends on
– Age
– Symptomatic
– Desire to retain uterus
– Future fertility
• Treatment selection depends
on fibroid –
– Location
– Size
– Number
• Previous Surgeries
• Technical Expertise
• Facilities

13. Hysteroscopic Myomectomy
 Least invasive surgical
approach
 Indications of
hysteroscopic approach -
• Depending on location -
– Type 0
– Type I
– Type II
• Difficult to resect
completely
• Often associated with need
for repeated procedures
• Depending on size –
– Recommended in fibroids <
3 cm

14. Hysteroscopic Myomectomy
• Decision to be taken in (2 stage procedure)
– SM Fibroids > 3 cm
– Type II fibroids
• Complication
– Intrauterine adhesions - 7.5%
– Perforation
– Bleeding If >3 cm
– Fluid intravastion
• Prevention of post op adhesions
– Estrogen therapy for 4 to 8 weeks

15. Pregnancy outcome
• Post-surgery pregnancy rates ranging from 16.7% to
76.9% with a mean of 50%

16. Intramural Fibroid ?

18. The effect of intramural fibroids without uterine cavity
involvement on the outcome of IVF treatment: a systematic
review and meta-analysis.
• CONCLUSION:
• The presence of non-cavity-distorting intramural
fibroids is associated with adverse pregnancy
outcomes in women undergoing IVF treatment.
• Sunkara et al, Hum Reprod. 2010 Feb;25(2):418-29

20. Pre- Treatment?

22. Abdominal Myomectomy
• Indication –
– Large (> 3 cm) Type II
submucosal fibroids
– Type II fibroids with < 1
cm between external
surface of fibroid and
uterine serosa
– Type III, IV, V (If > 3 cm)

23. Laparoscopy vs Laparotomy (Open)
• Laparoscopy - Beneficial
– Less severe post-
operative morbidity
– Faster recovery
– Same reproductive
outcomes
– No difference in
recurrence risk

24. Laparoscopic myomectomy
• Contraindications
– Presence of an
intramural myoma >10–
12cm in size
– Multiple myomas (≥4) in
different sites of the
uterus, requiring
numerous incisions

27. Morsellation- Risks
• Injuries to surrounding structures
• Parasitic Leiomyoma
• Upstaging Sarcoma
• Missing diagnosis

28. Morcellation – Reducing Risks
• Careful removal of fragments
• Good lavage
• Trendelenburg – anti- Trendelenburg
• Power Morcellation in Bag

30. Medical Management of Fibroids

31. Why do we need Medical Options
• Cost ($2 billion dollars/year)
• Morbidity
• Delay Surgery
• Pre- operative preparation
• Prevent re- growth

34. Medical Therapy
GnRH Agonist
• Used pre-operatively to
postpone surgery in
severely anemic patient or
to reduce uterine volume
•  fibroid volume by 35-65%
in 3 months
•  risk of recurrence
• Not used for long periods
because of their side effects
(hot flushes and bone loss)
Curr Opin Obstet Gynecol.2004
SPRMs
• Benefit in bleeding control
and reduce fibroid volume
• ≥50% fibroid volume
reduction in 4 courses
• Allow less invasive surgery
or even complete avoidance
of surgery
• Less S/E as maintains
estrogen levels
• Pregnancy studies needed
Curr Opin Obstet Gynecol 2015b

36. Fibroid Shrinkage after Medical
Treatment

37. Other Options

38. UAE
• Percutaneous ablation of the
fibromatous uterus
• Induce ischemic necrosis of
fibroids
• Myometrium revascularizes
• Advantages
– Simultaneously many fibroids
targeted
– Shorter hospital stay
– Earlier resumption of normal
activities
– Highly effective for treating
symptoms (reduction in
bleeding and fibroid size)

39. UAE
• Risk
– Reoperation (15–20% after successful embolization
and up to 50% in cases of incomplete infarction)
– Abdominal pain due to ischemic necrosis of fibroids
– Risk of infection
– Loss of ovarian function
– Relative contraindication in women desirous of
future fertility
• Transient and permanent amenorrhea lead to endometrial
damage
• My cause abnormal placentation and/ or reduced ovarian
function or failure
• Reserved for poor surgical candidates

40. MRI-guided focused ultrasound surgery
(MRgFUS)
• Application of MRI-directed beams of
ultrasound capable of heating an area of
fibroid tissue to up to 70 °C and causing
destruction through coagulative necrosis
• Minimal thermal effects to surrounding
tissue
• Future fertility may be compromised

41. Vaginal occlusion of uterine arteries
• Procedure
– Occlusion of the uterine
arteries with a clamp-
like device
– Remains in place for 6 h
leads to myoma
ischemia
• Not recommended for
women wishing to
conceive in future

43. Indication of Myomectomy in
Infertility

48. Suggested Reading

50. Mas et al , IJWH, 2017