Int J Gynaecol Obstet 15: 397-399, 1978

Myomectomy in Infertile Jamaican Women Bijoy S. Sengupta1, Hugh H. Wynter1, Lennox Matadial1, and Abraham Halfen 2 1

Department of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston 7, Jamaica Servicio de Planificación Familiar, Caracas, Venezuela

2

ABSTRACT Sengupta, B. S., Wynter, H. H., Matadial, L. and Halfen, A. (Dept. of Obstetrics and Gynaecology, University of the West Indies, Mona, Kingston 7, Jamaica, and Servicio de Planificación Familiar, Caracas, Venezuela). Myomectomy in infertile Jamaican Women. Int J Gynaecol Obstet 15: 397-399, 1978 One hundred nineteen Jamaican women who underwent myomectomy from 1964 to 1969 were followed up for 5 to 9 years. Infertility was the most common presenting complaint. Preoperative hysterosalpingograms were performed on 61 patients and were abnormal for the majority of these patients. Surgery revealed submucous fibroids in 41 patients and pelvic inflammatory disease in 51 patients. The pregnancy rate following myomectomy was 18.5%, but successful outcomes occurred in only 9.2% of the cases. Pregnancy was unsuccessful for all patients who underwent both myomectomy and tuboplasty. Twenty-three patients had a recurrence of myoma, and 13 of these underwent subsequent hysterectomy.

INTRODUCTION Uterine leiomyomas are the most common tumors of the female genital tract, particularly in Jamaican women. In nulliparous women, these tumors are often treated by myomectomy. This retrospective study examines the postoperative reproductive performance of 119 myomectomy patients. MATERIALS AND METHODS This report is based on the records of 119 patients who underwent abdominal myomectomy from 1964 to 1969 at the University Hospital of the West Indies, Jamaica. The patients were followed up through December 1974. No patient was followed up for fewer than 5 years following surgery, and many patients received follow-up care for more than 9 years. RESULTS The patients studied ranged from 22 to 46 years of age. Most of the patients (107) were between 25 and 39 years old, and only five patients were over 40. Only 50 of the 119 patients were married.

Indications for myomectomy are shown in Table I. Infertility was the most common presenting complaint (71.4%), and it was the only indication for surgery in 10.9% of the patients. The majority of patients presented with a combination of complaints. Menorrhagia was present in 47 patients (39.5%) and dysmenorrhea in 36 others (30.3%). Pressure symptoms were uncommon, and only one patient had symptoms related to the urinary tract. Seventy-five (63%) of the patients studied were nulliparous. Of the remaining 44 (37%) who had secondary infertility, 21 had had a total of 41 live births previously. Thirty-eight of the patients had one or two abortions before this surgery. Hysterosalpingograms (HSGs) were ordered for 33 nulliparous patients and for 28 previously parous patients prior to surgery. Radiologic evidence of pelvic inflammation such as blocked tubes and hydrosalpinges was shown in 17 (51.5%) of the 33 nulliparous patients. Fourteen (50%) of the previously parous patients showed evidence of pelvic infection. HSG indicated filling defects of the uterine cavity in 12 cases (19.7%), and surgery revealed submucous fibroids in each of these cases. Miscarriages and resulting infections may be associated with submucous fibroids, thus explaining the higher percentage of parous patients examined by HSG in our study. Pelvic inflammatory disease (PID) was diagnosed by HSG in 17 nulliparas and was discovered in another 18 nulliparous patients at surgery. A total of 35 (46.7%) nulliparous patients had both PID and fibroids.

Tabl» I. Presenting complaints of 119 myomectomy patients Complaint Primary infertility Secondary infertility Menorrhagia Dysmenorrhea Abdominal pain a Abdominal swelling a

No.

%

49 36 47 36 36 23

41.1 30.3 39.5 30.3 30.3 19.3

Other than dysmenorrhea.

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398 B. S. Sengupta et al.

PID was present in 16 (36.4%) of the previously parous patients. Fourteen of these cases were diagnosed by HSG before surgery. Of the two previously undiagnosed cases, one did not have a preoperative HSG and the other's HSG appeared normal, but surgery revealed multiple pelvic adhesions. A total of 51 cases (42.9%) of PID were diagnosed. When salpingostomy was performed, the technique used was cuff-salpingostomy with reperitonealization of the denuded area. Submucous fibroids were found in the 12 patients previously diagnosed by HSG. The remaining 29 patients with submucous fibroids did not have a preoperative HSG. Four previously nulliparous patients had a total of seven pregnancies after surgery. Two of these patients previously treated for both PID and fibroids had unsuccessful extrauterine pregnancies. Successful pregnancies occurred only in the two patients (2.6%) previously treated for fibroids alone. Brief histories of the four patients who became pregnant are as follows: Patient E. B. was sterile for 66 months prior to treatment. Her preoperative HSG revealed bilateral blockage of the Fallopian tubes. Bilateral salpingolysis was performed and three large myomas were removed. She had PID. Two unsuccessful ectopic pregnancies followed at 12 and 18 months after surgery. Patient M. B. was sterile for 24 months prior to treatment. Her preoperative HSG revealed bilateral hydrosalpinix, and a bilateral salpingostomy was performed. She had PID. An unsuccessful ectopic pregnancy followed 34 months after surgery. Patient L. P. was sterile for 36 months prior to treatment. Her preoperative HSG appeared normal, and surgery revealed two large fibroids the size of a 16 weeks' cyesis. She had no PID. Two pregnancies delivered abdominally at term followed at 67 and 104 months after myomectomy. Patient H. T. was sterile for 156 months prior to treatment. Her preoperative HSG appeared normal and surgery revealed fibroids but no PID. A normal pregnancy, delivered vaginally at term, followed 12 months after myomectomy. A second pregnancy 10 years after surgery was terminated because of thyrotoxicosis. Among the 44 previously parous patients, a mean of 83.6 months had elapsed between the last pregnancy and treatment leading to diagnosis of myoma. Eleven of these patients (25%) became pregnant after myomectomy. Nine of these had 11 successful pregnancies, 5 of which required cesarean section. No patient with past PID had a successful pregnancy. The interval between the myomectomy and subsequent pregnancy ranged from 10 to 60 months (mean, 27.9 months). Int J Gynaecol Obstet 15

The overall pregnancy rate for both groups of patients following myomectomy was 12.6% (15 patients). Fourteen live births resulted from 22 pregnancies. When tubal surgery was performed in addition to myomectomy, the pregnancy rate dropped to 4.2%, and there were no live births. Myoma recurred in 23 patients (19.3%) who were followed for a minimum of 5 years. Eight of these patients had no further treatment, three patients had a repeat myomectomy, and one patient had two repeat myomectomies followed by a hysterectomy. Thirteen of the 23 patients underwent hysterectomy in the follow-up period. No patient who underwent repeat myomectomy became pregnant. DISCUSSION Uterine myomas are benign tumours which frequently disturb the lives of many women. Treatment usually is initiated when uterine physiology is sufficiently disturbed to endanger the patient's health or when the condition prevents childbearing. Treatment by myomectomy is preferred because this procedure preserves menstrual function and the possibility of future pregnancy. For this reason, myomectomy rarely is p e r f o r m e d in postmenopausal patients. Rubin (7) reports that only 12 of the 481 patients undergoing myomectomy in his study were postmenopausal women. There were no postmenopausal patients in our study. Only seven of our patients were younger than 25 years of age, and we found that in our patients symptomatic myomas occurred most often between the ages of 25 and 39. It is uncommon for patients with uterine fibroids to have abdominal pain directly caused by the tumor (4). Abdominal pain other than dysmenorrhea was evidenced in 30.3% of our patients, and it is tempting to point to the high incidence of PID as a cause of this pain. There was a high percentage of fetal wastage among the previous pregnancies of the patients studied. Approximately half of the previously parous patients had aborted, and about one quarter of these patients had aborted more than once. There was a high correlation between the preoperative HSG findings and findings evidenced at surgery. Approximately 43% of the patients had both operative and HSG evidence of PID, and about 51% had a preoperative HSG showing no peritoneal spill of the contrast medium. Failure of peritoneal spill during HSG cannot unequivocally be attributed to PID since a fibroid obstruction of the uterotubal junction may exist. Surgery revealed submucous fibroids in every patient whose HSG showed filling defects of the uterine cavity. HSG

Myomectomy

was shown to be a valuable diagnostic tool for both nulliparous (primary infertility) and parous (secondary infertility) patients. The pregnancy rate following myomectomy was a disappointment, considering that 71.4% of our patients desired pregnancy. All patients had regular menses. Since only 4% of patients who have a regular menstrual cycle are anovulatory (4), we must assume that the majority of patients were ovulating. It has been estimated that 40% of the women who have a real opportunity to conceive do become pregnant after myomectomy (4). In a series of patients reviewed by Brown et al. (2), 54% of the patients with an opportunity to conceive were delivered of at least one living child after myomectomy. The incidence of PID is high in our population. This study revealed that fertility was improved after myomectomy if surgery revealed no evidence of PID. None of our patients with surgical evidence of PID delivered a viable fetus after myomectomy. Ectopic pregnancies and spontaneous abortions occurred in four patients with both fibroids and PID. The high incidence of ectopic tubal pregnancy may be indirect evidence of infection. In addition, the high incidence of diverticula of the Fallopian tube (6) may increase the possibility of disordered tubal function. In this study, proof of tubal patency and function were inferred in some cases from a recent pregnancy or abortion. Twenty percent of the patients who evidenced PID at surgery did not have a preoperative HSG to confirm tubal patency. A patient's opportunity to conceive after myomectomy cannot be established until her partner's semen is analyzed. In this study, seminal analysis was recorded in only a few cases because of a cultural attitude that infertility is due primarily to an abnormality of the female partner. Reluctance of the male partner to submit semen for analysis is, therefore, a major problem in assessing infertility in Jamaica. Patients who. became pregnant after myomectomy usually delivered vaginally. Three patients had delivered by cesarean section prior to myomectomy, and two of these delivered abdominally after the surgery. Six patients delivered vaginally prior to myomectomy. After myomectomy, five of these were delivered by cesarean section and four were operated on for intrapartum problems. Vaginal delivery has been recommended only if the endometrial cavity was not entered at myomectomy

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and if the patient experienced no postoperative uterine wound infection (1, 3, 5). However, Brown et al. (2) have reported that five out of seven patients whose endometrial cavities were entered subsequently delivered vaginally. Successful vaginal delivery after uterine surgery also has been reported by Davids (3) and Telinde (8). However, most patients who undergo myomectomy usually are approaching the end of their reproductive careers. In such cases, abnormalities during pregnancy or labor usually result in delivery by early cesarean section. The treatment of uterine leiomyomas by myomectomy rather than hysterectomy preserves the uterus for future pregnancy, but entails the definite risk of recurrent myoma which will necessitate hysterectomy. In this study, 19.3% of the patients experienced recurrent myoma during the follow-up period. Browri et al. (2) reported a 32% recurrence rate during a 5-20 year follow-up period.

REFERENCES 1. Brown, A B, Chamberlain, R & Telinde, R W: Myomectomy. Am J Obstet Gynecol 71:159, 1956. 2. Brown, J M, Malkasian, G D & Symmonds, R E: Abdominal myomectomy. Am J Obstet Gynecol 99:126, 1967. 3. Davids, A M: Myomectomy. Am J Obstet Gynecol 63:592, 1952. 4. Jeffcoate, T N A: Principles of Gynaecology, 3rd éd., p. 469. Butterworth & Co., London, 1967. 5. Munnell, E W & Martin, F W: Uterine leiomyomata. Am J Obstet Gynecol 62:109, 1951. 6. Persaud, V: Etiology of tubal ectopic pregnancy. Obstet Gynecol 36:257, 1970. 7. Rubin, I C: Progress in myomectomy. Am J Obstet Gynecol 44:196, 1942. 8. Telinde, R W: Operative Gynaecology, 3rd ed. J. B. Lippincott Co., Philadelphia, 1962.

Address for reprints: Bijoy S. Sengupta Department of Obstetrics and Gynaecology University of the West Indies Mona, Kingston 7 Jamaica West Indies

Int J Gynaecol Obstet 15

Myomectomy in infertile Jamaican women.

Int J Gynaecol Obstet 15: 397-399, 1978 Myomectomy in Infertile Jamaican Women Bijoy S. Sengupta1, Hugh H. Wynter1, Lennox Matadial1, and Abraham Hal...
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