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Minimally Invasive Therapy. 2011;20:338345

ORIGINAL ARTICLE

Laparoscopic myomectomy in patients with uterine myomas associatedwith infertility

ANDREAS HACKETHAL1, ANNE WESTERMANN1, GARRI TCHARTCHIAN2,FRANK OEHMKE1, HANS-RUDOLF TINNEBERG1, KARSTEN MUENSTEDT1,BERND BOJAHR2

1Department of Obstetrics and Gynecology, Justus-Liebig-University of Giessen, Giessen, Germany, and

2Clinic for

Minimally Invasive Surgery, Berlin, Germany

Abstract

Although myomectomy is widely accepted in women of childbearing age who wish to retain their fertility, the extent to which

myomas affect fertility and whether their removal improves this remain unclear. This study aimed to elucidate the favourable

surgical approach in women with uterine myomas and infertility. This retrospective, follow-up study was carried out in three

centres in Germany. Data on women who had undergone myomectomy via laparoscopy, laparotomy or conversion to

laparotomy in 200004 were collected and analysed. Fertility outcome after myomectomy was assessed by follow-up postal

questionnaire in a subgroup of women with myoma-associated infertility. Data on 159 women with otherwise unexplained

infertility were included (mean age 35 years (range 1747), mean number of myomas 2.4 (range 18) and mean myoma size

6.1 cm (range 0.520)). Women who underwent laparoscopy had fewer complications. 39.6% (63/159) of women completed

the questionnaire, which showed that the pregnancy rate after myomectomy was 46% in this group. No uterine rupture

occurred. Laparoscopy is associated with fewer postoperative complications and since no preoperative or intraoperative factors

seem to inuence the fertility outcome in women with uterine myomas, it is the treatment of choice in these patients.

Key words:Uterine myoma,broids, laparoscopic myomectomy, fertility, delivery mode, uterine rupture, subsequent pregnancy

Introduction

Around a third of women of childbearing age have

uterine myomas. These cause bleeding disorders and

pain, including dysmenorrhoea and pelvic pressure

pain, and may also result in infertility. Approximately

510% of infertile women have uterine myomas

commonly multiple myomas. Uterine myomas may

interfere with gamete transport by distorting the uter-

ine cavity and obstructing the tubal ostia, and they canbring about changes in the endometrium which affect

embryo implantation and growth (1).

Table I shows the effect and inuence of uterine

myomas and myomectomy on fertility and pregnancy.

The best treatment for preserving or enhancing fer-

tility in women with uterine myomas remains unclear.

Although systematic reviews by Pritts and Klatsky

concluded that only those myomas with submucosal

or intracavitary components are associated with

reduced fertility, various surgical and non-surgical

methods of treating myomas and increasing the rate

of natural and assisted conception in affected women

have been suggested (25). These include laparot-

omy, laparoscopy, hysteroscopy, gonadotrophin

releasing hormone agonist (GnRH) analogues and

uterine artery embolisation (611). Verkaufs study

of myomectomy in the treatment of recurrent abor-tion and infertility reported that approximately half of

affected women who had not previously become

pregnant conceived after this procedure (12). Con-

troversy also exists over the tensile strength of the

uterotomy scar during a subsequent pregnancy, since

there is a risk of uterine rupture, especially during

labour contractions.

Correspondence: A. Hackethal, Universittsfrauenklinik Giessen, Klinikstrasse 32, D-35392 Giessen. Fax: +49 641 99 45139.

E-mail: [email protected]

ISSN 1364-5706 print/ISSN 1365-2931 online 2011 Informa Healthcare

DOI: 10.3109/13645706.2010.541922

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There are additional areas of uncertainty in relation

to improving the likelihood of conception after myo-

mectomy. These include the following: The lack ofdata on which to base decisions on whether laparos-

copy or laparotomy is the best surgical approach to

follow; patient parameters such as the number and

size ofbroids, age and co-factors; and suture tech-

niques and layers. We conducted this study to clarify

some of these uncertainties so that the optimal treat-

ment for these patients can be determined.

Material and methods

Subjects

In this study, all patients who had undergone myo-

mectomy at the Department of Obstetrics and Gynae-

cology of the Justus-Liebig-University, Giessen, the

Asklepios Clinic, Lich or the Clinic for Minimally

Invasive Surgery, Berlin, Germany, between 1 January

2000 and 31 December in 2004 were identied

from patient records. Patients who had undergone

submucous myomectomy by hysteroscopic proce-

dures were excluded from the analysis. The group

of women with primary or secondary infertility inwhich myoma was the only apparent cause was subject

to further evaluation (Figure 1). Their medical history

and information on the surgical procedure and

their postoperative course were recorded for further

evaluation.

We contacted these women between November

2005 and March 2006 and asked them to complete

a questionnaire which included items on their post-

operative course and subsequent fertility. The preg-

nancy rate after myomectomy was correlated with the

patients age, previous pregnancies, myoma number,

the size and location of the largest myoma, intrao-

perative and postoperative data and the type of sur-gical approach in order to assess the inuence of

these factors on the probability of conception after

myomectomy.

Classication of myomas

Myomas were classied according to the operative

notel as follows:

. Intramural if more than 50% developed in the

uterine wall. Subserous if more than 50% of the myoma was

covered by the serosal layer. Pedunculated if more than 80% developed

within the abdominal cavity

Laparoscopy procedure

All myomectomies were performed under gene-

ral anaesthesia. In laparoscopic myomectomy, a

710 mm laparoscope was inserted through a sub-

umbilical trocar. Additional working trocars (5 mm)

were then inserted one suprapubic trocar was

Eligible patients with myomectomy between 1/2000 and12/2004 in examined centres (n= 316)

Patients with infertility(n= 159)

Total (n= 159)LSK (n= 64)LAP (n= 51)Conv (n= 44)

Total (n= 63)LSK (n= 29)LAP (n= 20)Conv (n= 14)

Patients responding toquestionnaire (n= 63)

Figure 1. Flow diagram of study population.

Table I. Effect and inuence of uterine myomas and myomectomy on fertility and pregnancy*.

Before myomectomy After myomectomy

Fertility impaired by Interference and alterations in endometrium Location of uterotomy

Size, number and location of myomas Surgical complications

Distortion of the uterine cavity Adhesions

Inuence of pregnancy Abortion Uterine dehiscence

Intrauterine growth restriction Risk of uterine rupture

Placental abnormalities

Malpresentation

Preterm delivery

*Adapted from Somiglianna 2007.

Laparoscopic myomectomy in infertility 347

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positioned in the midline and two lateral trocars were

positioned in the left and right lower abdomen lateral

to the supercial epigastric artery. Before opening

the uterine wall above the myoma pseudocapsule

with a monopolar hook, a vasoactive agent POR 8

(ornithine-8-vasopressin, Sandoz, Holzkirchen,Germany) or Glycylpressin (terlipressin, Ferring,

Kiel, Germany) was injected. A myoma screw was

then inserted into the myoma and it was enucleated

using constant traction combined with blunt

dissection. A bipolar energy source was used reluc-

tantly to reduce tissue necrosis and preserve the

myometrium.

After all visible myomas had been enucleated, the

uterotomy was closed. Up to three layers of sutures

were used, depending on the type of incision. Deep

and supercial myometrial incisions were closed

using interrupted absorbable Vicryl 2-0 sutures

(polyglactin 910, Ethicon, Norderstedt, Germany)and the uterine serosa was closed with continous

PDS 2-0 or 3-0 sutures (polydioxinone, Ethicon,

Norderstedt, Germany). Pedunculated myomas were

removed by electrocoagulation of the pedicle.

Myomas were then morcellated using either a

15 mm or 20 mm electrical morcellator which

was inserted in place of the left 5 mm working

trocar. The abdominal fascia of ports 10 mm

was closed with interrupted Vicryl sutures 2-0.

The skin wound was closed with intracutaneous

Monocryl or Dermabond topical skin adhesive

(poliglecaprone 25 and Dermabond, Ethicon,

Norderstedt, Germany).

Laparotomy

Laparotomy was performed under general anaes-

thesia through a transverse lower abdominal incision

following the Pfannenstiel Querschnitt technique.

The procedure followed for myomectomy was the

same as that given above for laparoscopy. In closing

the abdominal wall, the peritoneum was not approx-

imated. The fascia was closed with a continuous

suture (PDS 0) and after subcutaneous adaptation,

if appropriate, intracutaneous continuous adaptationwith Monocryl was performed.

Conversion to laparotomy

Conversion after diagnostic laparoscopy or as

a result of complications was dened as myomec-

tomy performed by laparotomy after an inten-

ded laparoscopic surgical approach. It followed

the same surgical procedures as described for

laparotomy.

Complications

Intraoperative complications were dened as opening

of the uterine cavity, injury to adjacent organs or

major bleeding (>1000 ml). Postoperative com-

plications were dened as persistent abdominal or

shoulder pain, a fall in the haemoglobin concentration

>2.4 mmol/l, revision surgery, temperature >38.0C,

haematoma at the trocar insertion site or intra-

abdominal nerve injury and ileus. During the study

period, no adhesion prevention barriers or other

agents were used.

Statistical analysis

Data management and statistical analysis were per-

formed using descriptive statistics and cross tabula-

tion bySPSS for Windows, Version 15.0. The x2 and

Students t test were used to analyse results. Forbetween-groups statistical analysis, we used analysis

of variance (ANOVA). A probability value of

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The mean age of women in this subgroup who

conceived after myomectomy did not differ signi-cantly from the mean age of all study subjects. The

overall pregnancy rate was 46% (29/63). In this sub-

group, 44.8% (13/29) women who had undergone

primary laparoscopy became pregnant, compared

with 45% (9/20) who had had laparotomic myomec-

tomy and 50.0% (7/14) of those who had had a

conversion procedure (Table III). The abortion rates

were 4.7% (1/21) after laparoscopy, 26.3% (5/19)

after laparotomy and 9.1% (1/11) after conversion

to laparotomy. All of these were early abortions.

There was no reduction in the rate of abortion as a

result of myomectomy in either group. Interestingly,

no intraoperative factor such as myoma number or

size, number of suture layers or opening of the uterine

cavity inuenced the fertility outcome (Table III).

One nding, which is not statistically signicant but

noteworthy, is the doubled postoperative complica-

tion rate seen in women who subsequently failed to

become pregnant. Analysis by surgical approaches

showed that the complication rate for laparotomy

was 17.6% (9/51) and that for laparoscopy was

3.2% (2/62) (P=0.02) (Table III). After laparotomy

the patients were more likely to deliver by caesarean

section (83.3% compared with 50%). No uterine

ruptures were noted in study subjects.

Discussion

Laparoscopic myomectomy was rst described in

1979 (13). Over the past 25 years, improvements in

instruments and techniques and greater operator

experience have increased the use and consolidated

the success of this procedure. (14,15). In this study we

endeavoured to clarify a number of uncertainties

which still exist in relation to improving the likelihood

of conception after myomectomy, including the lack

of data on which to base decisions on whether lapa-

roscopy or laparotomy is the best surgical approach to

follow; patient parameters such as the number and

size ofbroids, age and co-factors; suture techniques

and layers and delivery modes.

Our results suggest that the likelihood of becoming

pregnant after myomectomy is not inuenced by

factors related to the uterine myomas or intrasurgical

aspects. However, women who failed to become

pregnant after myomectomy were more likely to

have experienced complications during or after sur-

gery. These results conrm previous ndings that

Table II. Surgical approach-dependent broid characterization and perioperative data in the subgroup of infertile women (n = 159).

Laparoscopy (n = 64) Laparotomy (n = 51) Conversion (n = 44)

Number of enucleated myomas (n) 1.4 0.9 (1; 5) 2.94 2.3 (1; 4) 3.1 2.3 (1;8)

Diameter of largest myoma (cm) 5.5 3.7 (0.5; 20.0) 7.1 4.1 (1.5; 20.0) 5.9 2.7 (2.0; 12.0)

Myoma location: (n)

pedunculated 38.1% (24/63) 16% (8/50) 7.1% (3/42)

subseroes 34.9% (22/63) 52% (26/50) 57.1% (24/42)

intramural 27.0% (17/63) 32% (16/50) 35.7% (15/42)

Uterine location: (n)

fundal 24.6% (15/61) 20% (10/50) 13.6% (6/44)

anterior wall 21.3% (13/61) 14% (7/50) 13.6% (6/44)

posterior wall 26.2% (16/61) 14% (7/50) 18.2% (8/44)

different 27.9% (17/61) 52% (26/50) 54.5% (24/44)

Suture layers: (n)

none 19% (12/63) 2% (1/51) 2.3% (1/43)

one 28.6% (18/63) 47.1% (24/51) 44.2% (19/43)

two 46% (29/63) 45.1% (23/51) 27.9% (12/43)

three 6.3% (4/63) 5.9% (3/51) 25.6% (11/43)

Duration of surgery (min) 107.9 52.2 (20.0; 251.0) 145.7 46.8 (68.0; 310.0) 125.4 49.7 (35.0; 333.0)

Complicationrate: (n)

intraoperative 10.9 (7/64) 11.8 (6/51) 40.9 (18/44)

postoperative 3.2 (2/64) 17.6 (9/51) 6.8 (3/44)

hospital stay (d) 3.5 2.2 (1,11) 8.8 2.0 (5,16) 7.7 2.3 (2,14)


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laparoscopic myomectomy is associated with a lower

requirement for postoperative analgesia, reduced

blood loss and faster postoperative recovery than

laparotomy (16,17). Since the women who underwent

laparoscopic myomectomy had fewer complications

than those in the laparotomy group, this surgical

approach is recommended for women with uterine

myomas associated with infertility.

A vast variety of factors inuence the decision for

the surgical approach, wound healing process and

subsequent fertility. Most studies either focus on

the uterine pathology or on surgical aspects. The

strength of this study is the evaluation of different

pre- intra- and postoperative factors and their inu-

ence on fertility outcome.

One weakness of our study might be the limited

number of subjects who participated in the follow-up.

However, the group was large enough to give suf-

cient statistical power to our analysis and was also

fairly evenly balanced between women who had

undergone laparoscopy and laparotomy. Another

weakness might be the specialist nature of the hospi-

tals, which might mean that the data would not be

generalisable. Two of the three institutions in the

study are centres of excellence for endoscopic surgery

and the positive outcome for laparoscopy might be

biased as a result. The mean time between surgery

and recall was 3 years and 11 months. Therefore the

rate of postoperative complications might be modied

by subsequent complications after the questionnaire.

In earlier work, we analysed quality assurance data

in Hesse, Germany and showed that over 36% of

myomectomies are performed by laparoscopy (18). In

the present study, the laparoscopy rate in the sub-

group of women with infertility was 67.9% (108/159),

however, the subsequent conversion to laparotomy

was quite high at 27.7% (44/159). Unfortunately, the

data did not allow us to differentiate between con-

versions performed because of complications and

conversions after a diagnostic laparoscopy. In the

latter case, particularly, laparoscopy-assisted myo-

mectomy, might have benets in evaluating the peri-

toneum for endometriosis.

In cases of infertility or sterility and uterine myo-

mas, the indications for myomectomy depend on a

number of factors. These include the patients age, the

Table III. Characteristics of subjects and perisurgical factors in relation to fertility outcome in the subgroup of 63 women who completed the

follow up postal questionnaire.

Women who became pregnant(n = 29, unless otherwise stated)

Women who did not become pregnant(n = 34, unless otherwise stated)

Age, mean SD years 34.0 4.0 34.9 5.2

Surgical approach, no (%)

Laparoscopy 13 (44.8) 16 (47.1)

Laparotomy 9 (31.0) 11 (32.4)

Conversion 7 (24.1) 7 (20.6)

Number of myomas, mean SD 2.3 1.8 1.9 1.6

Size of myomas, mean SD (cm) 5.1 3.2 5.5 3.0

Type of myoma, no (%)

Subserous/pedunculated 8 (27.6) 10 (30.3)

Intramural 15 (51.7) 15 (45.5)

Subserous/intramural 6 (20.7) 8 (24.2)

Location of myoma, no (%) n = 28 n = 32

Fundal 4 (14.3) 5 (15.6)

Anterior wall 7 (25.0) 5 (15.6)

Posterior wall 5 (17.9) 9 (28.1)

Different location 12 (42.9) 13 (40.6)

Layers of suture, mean SD 1.5 0.8 1.7 0.9

Operation time, mean SD min 117.3 40.9 126.9 55.1

Intraoperative complications, no (%) 5 (17.2) 8 (23.5)

Opening of uterine cavity, no (%) 4 (13.8) 6 (17.6)

Postoperative complications, no (%) 3 (10.3) 7 (20.6)

350 A. Hackethal et al.

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size of the myomas, their number and location within

the uterus, concomitant myoma-related symptoms

and any additional infertility factors (19). The

presence of additional factors which may affect

conception adversely should be given adequate

weight when deciding between different treatmentoptions. For example, the in vitro fertilisation study

by Oliveira et al. reported that intramural myomas

>4 cm were associated with signicantly lower preg-

nancy rates (20).

There are few reported data on pregnancy after

myomectomy. The pregnancy rates after laparoscopic

myomectomy are comparable with rates after laparo-

tomic myomectomy (21,22). Our results show preg-

nancy rates of 44.8%50.0% in the laparoscopy and

laparotomy groups respectively after myomectomy.

These conrm pregnancy rates in other studies rang-

ing from 33.3% to 64% within one year of myomec-

tomy (5,22

24).There is no general agreement in the published

reports over the best surgical approach to myomec-

tomy in patients with infertility. Various studies have

attempted to clearly show the benet of one approach

over the other. However, a recent meta-analysis con-

cludes that the rate of major complications, pregnancy

and recurrence were comparable in the laparoscopic

and laparotomic groups (25). Besides individual

surgeons experience and preferences, the factors

inuencing the decision include the number of myo-

mas, myoma size, localisation and previous surgery.

Since the characteristics of myomas should not deter-

mine whether or not laparoscopy is suitable in thehands of experienced surgeons, the accepted main

determinants of the pregnancy rate after myomec-

tomy are patients age, diameter and intramural loca-

lisation of the myomas and type of surgery (14,22).

Our results suggest that none of the patient charac-

teristics or factors related to myomas described here

have any inuence on subsequent pregnancy rates.

It is generally believed that a good fertility outcome

after myomectomy is associated with atraumatic tis-

sue handling, minimization of coagulation, adequate

wound adaptation and reducing adhesion formation.

Questions concerning the number of suture layers

used to close a uterotomy have not been answered

satisfactorily because of a lack of trials comparing

myoma size and suture technique. This retrospective

analysis showed a large range from 0.520 cm of

myoma size. Concerns have been raised over ade-

quate wound closure during laparoscopy, as this

demands skilled and experienced surgeons. In our

series, the rate and number of suture layers used in

laparoscopy was comparable with those employed in

laparotomy. This suggests that the difference of

myoma size between the laparoscopy and laparotomy

groups did not lead to a divergent uterine wound

management but was more inuenced by the

surgeons preference and rationality.

In this study, no differences were identied

between women who became pregnant after myomec-

tomy and those who did not (Table III). Other studieshave also been unable to nd evidence of a difference

in outcome in terms of pregnancy and live birth rates

when myomectomy for infertility is performed via

laparotomy or laparoscopy (17). Gavai et al. con-

cluded that no differences affecting fertility exist in

relation to whether or not the uterine cavity is

opened and the number and size and localisation of

myomas (26).

In a previous study, multivariate analysis showed

that patients undergoing laparoscopic procedures had

a higher possibility of conceiving, possibly because of

a reduced occurrence of adhesions (27). Surgery often

results in the formation of intra-abdominal adhesions.After myomectomy, the risk of pelvic adhesions,

which further compromise fertility, has to be taken

into account. It has been suggested that the use of

adhesion formation reduction agents such as icodex-

trin, hyaluronic acid or oxidized regenerated cellulose

adhesion barrier might increase fertility rates by up to

78% (28,29). However, during the study period, no

adhesion barriers were used.

There are few data on modes of delivery in pregnant

women who have undergone myomectomy. As the

experience and self-condence of surgeons increases

there may be a shift from always performing a cae-

sarean section in these women to advocating sponta-neous delivery in some. Some authors suggest that

vaginal delivery is possible in 42.9% to 80.6% of

women who become pregnant after laparoscopy.

(3033). The present study has conrmed the feasi-

bility of vaginal delivery after laparoscopic myomec-

tomy with rates of 50% (6/12) after laparoscopy and

conversion procedures (3/6).

The occurrence of uterine ruptures has been

reported from the rst trimester of pregnancy to the

end (34,35). Besides spontaneous ruptures, these

might occur after any kind of uterotomy (3638).

Uterine rupture after myomectomy is rare; it has an

incidence of 1% and a reported range of 0.24% after

laparoscopic myomectomy to 5.3% after abdominal

myomectomy (32,33,39). In this study, no uterine

ruptures occurred. Prospective randomized trials

should be initiated to conrm the ndings of this

study.

In conclusion, the retrospective analysis shows that

laparoscopic myomectomy is associated with fewer

complications and with the same subsequent preg-

nancy rates as laparotomic myomectomy. It appears

to be the preferred surgical approach to myomectomy


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for skilled surgeons, regardless of myoma number,

size and localisation.

Declaration of interest: The authors report no

conicts of interest. The authors alone are responsible

for the content and writing of the paper.

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