Myom ve infertilite

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Myom ve infertilite
Dr. Engin OralIstanbul Üniversitesi Cerrahpasa
Tip FakültesiKadin Hastaliklari ve Dogum ABD
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Myom ve fertilite Sorular

• Myom infertiliteye yol açar mi
• Implantasyon
• abortus
• Myom varligi IVF sonuçlarini etkiler mi
• Myomektomi fertilite üzerine etkili mi
• Hangi yöntem (L/S vs L/P) fertilite icin daha
  iyi

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Myom-Risk Faktörleri

• Kanitlanmis
• Seks, irk
• Yas
• Parite
• Erken menars
• Sigara içmek

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

Stewart EA, 2009, UpToDate,
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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

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Fibroid-Infertility
Somigliana E, 2007
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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
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Summary of Potential Mechanisms by Which Uterine
Fibroids May Have an Effect on Embryo Implantation
Andrew W. Horne, , 2007
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Submucosal uterine leiomyomas have a global
effecton molecular determinants of endometrial
receptivity
Beth W. Rackow, and Hugh S. Taylor, In press F
S
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Myom da yönetim

• Yas
• Semptomlar
• Obstetrik geçmis
• Fertilite plani
• Büyüklügü
• Yeri

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(No Transcript)
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Yerlesim

• Submüköz
• Tip 0 Saf submüköz
• Tip I Intramural kisim 50den az
• Tip II Intramural kisim 50den fazla
• Intramural Kaviteyi bozmayan ve 50den azi
  seroza disina çikan
• Subseröz 50den fazlasi seroza disina tasan

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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
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Effects of the position of fibroids on fertility
N 181
Casini ML, 2006
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Klatsky PC, 2008
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Fibroids and reproductive outcomes a
systematicliterature review from conception to
delivery
OR 1.82 (1.43-2.30) OR 1.34 (1.04, 1.65)
Klatsky PC, 2008
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Donnez J and Jadoul P, 2002
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PR /After myomectomy
L/S 49 L/T 48 H/S 45
Donnez J and Jadoul P, 2002
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Asymptomatic uterine fibroids

• For the younger woman who wishes to conceive now,
  whose fibroids are less than 1214 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 1214 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
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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
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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
  20015648391
• Donnez J, Jadoul P. What are the implications of
  myomas on fertility? A need for a debate? Hum
  Reprod 200217142430
• 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 20055922530.
• 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 20071346576.

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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
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Fibroids and infertility an updated systematic
review of the evidence
Elizabeth A. Pritts, William H. Parker, and
David L. Olive, 2009
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Fibroids and infertility an updated systematic
review of the evidence
Elizabeth A. Pritts, William H. Parker, and
David L. Olive, 2009
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Fibroids and infertility an updated systematic
review of the evidence
Elizabeth A. Pritts, William H. Parker, and
David L. Olive, 2009
25
Fibroids and infertility an updated systematic
review of the evidence
Elizabeth A. Pritts, William H. Parker, and
David L. Olive, 2009
26
Fibroids and infertility an updated systematic
review of the evidence
Elizabeth A. Pritts, William H. Parker, and
David L. Olive, 2009
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Fibroids and infertility an updated systematic
review of the evidence
Elizabeth A. Pritts, William H. Parker, and
David L. Olive, 2009
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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.

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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
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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
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Proposed flow chart for the management of women
seeking conception in the presence of uterine
myomas
Edgardo Somigliana, 2008
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Cerrahi
Bekle veya ART
Yas Yerlesim Sayi Çap Diger infertilite nedenleri
lt 38 Intramural gt1 3 cm Yok
38 Subseröz 1 lt3cm Var
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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
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• 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).

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• 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).

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Medical therapy

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

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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