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Myoma in Infertility Dilemmas in Management
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 2016
• 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.
3. Fibroid
• Most common tumor of
reproductive tract
• Affecting 20–50 %
women of reproductive
age
• Fibroids - present in 5-
30% of infertile patients
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
19. 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
23. 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)
24. Laparoscopy vs Laparotomy (Open)
• Laparoscopy - Beneficial
– Less severe post-
operative morbidity
– Faster recovery
– Same reproductive
outcomes
– No difference in
recurrence risk
25. Laparoscopic myomectomy
• Contraindications
– Presence of an
intramural myoma >10–
12cm in size
– Multiple myomas (≥4) in
different sites of the
uterus, requiring
numerous incisions
32. Why do we need Medical Options
• Cost ($2 billion dollars/year)
• Morbidity
• Delay Surgery
• Pre- operative preparation
• Prevent re- growth
33.
34.
35. 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
39. 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)
40. 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
41. 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
42. 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
