Fertility after laparoscopic myomectomy of large intramural myomas: preliminary results

Fertility outcome following laparoscopic myomectomy was evaluated.A prospective clinical study was carried out between October1990 and October 1993 in 21 infertile patients who underwentlaparoscopic myomectomy for a myoma measuring 3>;5 cm indiameter. The overall rate of intrauterine pregnancy was 333%(seven patients). Out of 12 patients with infertility factorsassociated with uterine myomas, three (25.0%) became pregnant,whereas four (44.4%) out of nine patients with no other associatedinfertility factor became pregnant. No uterine rupture was observed.Out of the seven pregnancies, four were spontaneous and beganwithin 1 year of the operation. The other three were achievedafter in-vitro fertilization in patients with associated infertilityfactors. In the four patients who gave birth by Caesarean section,no adhesions were found on the myomectomy scar. From these preliminaryresults, laparoscopic surgery for myomas seems to offer comparableresults with those obtained by laparotomy.     

Operative morbidity and reproductive outcome in secondary myomectomy: a prospective cohort study

BACKGROUND: This prospective study was designed to evaluate the operative morbidity and reproductive outcome in patients who had secondary myomectomy for recurrent symptomatic uterine fibroids. METHODS: A total of 58 women were subjected to a secondary myomectomy via the abdominal route. The operative morbidity such as blood loss, presence of adhesions and febrile index were estimated and the pregnancy outcome over a 2-4 year period of follow-up. RESULTS: The mean age and standard deviation (+/- SD) of the women was 35 (+/- 2.4) years. Nineteen patients (33%) had a postoperative temperature vertical line 100 degrees F and the estimated blood loss ranged from 159-2500 ml (median 700 ml). Seven patients (12%) required blood transfusion and one had a hysterectomy due to haemorrhage. Nine women (15.5%) became pregnant but only five (56%) had live births. Those with successful pregnancies tended to be younger with a mean age of 31.8 (+/- 2.6) years versus 35 (+/- 1.8) years, (P = 0.08, non-significant) and had fewer uterine leiomyomata; median with range values, 2 (1-6) versus 7 (6-15). The variables which best predicted the postoperative likelihood of pregnancy were; age, presence of tubal adhesions and the number of uterine fibroids. CONCLUSION: This prospective study showed a high operative morbidity and a poor fertility outcome after a repeat myomectomy. The factors affecting successful outcome in a logistic regression model were age, tubal adhesions and number of uterine fibroids.     

Autoantibodies and antisperm antibodies in sera and follicular fluids of infertile patients; relation to reproductive outcome after in-vitro fertilization

Immune reactions have effects at various concentrations in thereproductive process and autoantibodies may have an impact onfertility and the outcome of assisted conception. We measuredthe prevalence of and relation between antibodies to smoothmuscle, nuclear, phospholipid and sperm antigens, and concentrationsof immunoglobulins G, M and A and complement components C3 andC4, in the sera and follicular fluids of women with unexplainedinfertility (n = 30), endometriosis (n = 20), tubal infertility(n = 50) and the sera of 20 normal non-pregnant women. We assessedfertilization and successful pregnancy rates in relation toantibody status of infertile women after in vitro fertilization.All antibodies had a higher prevalence in infertile women comparedwith controls and this was significant for smooth muscle antibodyin endometriosis (P < 0.05); anticardiolipin antibody intubal infertility P < 0.05); and antisperm antibody in alltypes of infertility (P < 0.001). There was no relation betweenpresence of specific antibodies in serum or between serum andfollicular fluids. Total biochemical pregnancy rate was higherwith endometriosis (P = 0.05) but clinical pregnancy and livebirth rates did not differ between groups or in relation toantibody status. Significant differences in immunoglobulin andcomplement components occurred in women with and without successfulbiochemical pregnancy.     

Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy

The purpose of this study was to compare, in infertile patients, the efficacy of laparoscopic myomectomy versus abdominal myomectomy, in restoring fertility and to evaluate the obstetric outcomes. Between January 1993 and January 1998, 131 patients of reproductive age, with anamnesis of infertility, underwent myomectomy because of the presence of at least one large myoma (diameter greater than or = 5 cm). Patients were randomly selected for treatment by laparotomy (n = 65) or laparoscopy (n = 66). The two groups were homogeneous for number, size and position of large myomata. Significant differences were found in the post-operative outcome: febrile morbidity (> 38 degrees C) was more frequent in the abdominal than in the laparoscopic group (26.2 versus 12.1%; P < 0.05). Laparotomy caused a more pronounced haemoglobin drop (2.17 +/- 1.57 versus 1.33 +/- 1.23; P < 0.001); three patients received a blood transfusion after laparotomy and none after laparoscopy. The post-operative hospital stay was shorter in the laparoscopic group (142.80 +/- 34.60 versus 75.61 +/- 37.09 h; P < 0.001). No significant differences were found between the two groups as concerns pregnancy rate (55.9% after laparotomy, 53.6% after laparoscopy), abortion rate (12.1 versus 20%), preterm delivery (7.4 versus 5%) and the use of Caesarean section (77.8 versus 65%). No case of uterine rupture during pregnancy or labour was observed.     

Myomectomy: a retrospective study to examine reproductive performance before and after surgery.

The aim of this retrospective study was to establish the impact of myomectomy on pregnancy outcome with particular reference to its effect on the incidence of pregnancy loss. Myomectomy was performed using microsurgical procedures upon 51 women who had intramural or subserosal fibroids and wished to conceive. Overall, the conception rate following myomectomy was 57%. Multiple regression analysis showed that age was the only factor which influenced conception rate: /=36 years, 30% (6/20; P < 0.005). The pregnancy loss rate prior to myomectomy was 60% (24/40), which was reduced to 24% (8/33) after myomectomy (P < 0.001). There was no instance of premature labour or scar rupture among 25 live births. This retrospective study suggests that myomectomy for intramural and subserosal fibroids may significantly improve the reproductive performance of women presenting with infertility or pregnancy loss.     

Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study

Frequency of recurrence of fibroids after myomectomy has beenevaluated in 145 women (median age 38 years, range 21–52)who underwent myomectomy. After surgery all women returned forfollow-up visit every 12 months after surgery. Transvaginalultrasound examination was performed routinely in every patientat 24 and 60 months and at 12, 36 and 48 months if there wereany abnormal pelvic findings or suspicious symptomatology. Atotal of 39 (27%) women gave birth after myomectomy. For thewhole series, the cumulative probability of recurrence (CPR)increased constantly during the study period reaching 51% in5 years. The 5-year CPR decreased with parity after myomectomy,being 55% for women with no childbirth after surgery and 42%(based on 13 recurrences, P < 0.01) for those who gave birth.     

Long-term results of laparoscopic myomectomy: recurrence rate in comparison with abdominal myomectomy

Laparoscopic myomectomy is still a debated procedure and there are conflicting opinions regarding the recurrence rate. Laparoscopic myomectomy may present a higher risk of recurrence compared with abdominal myomectomy. The aim of this investigation was to analyse the recurrence rate of myomas after surgery. From January 1991 to June 1998, 165 myomectomies were performed for symptomatic myomas measuring at least 3 cm in diameter and numbering seven or less per patient. During the first 3 years of this survey, 81 patients were randomized for abdominal or laparoscopic myomectomy. Transvaginal ultrasound examination was performed within 15-30 days of surgery and every 6 months for a post-operative period of 40 months. The two groups had similar pre-operative clinical features and the number and volume of myomas did not differ between the two groups. At the end of the study the group of abdominal myomectomies showed nine recurrences (23%) against 11 (27%) of the laparoscopic group. In order to evaluate the recurrence rate in relation to several risk factors, laparoscopic myomectomies were performed from 1991 in 84 patients who agreed to follow-up (and were not in the randomized group). Of these, 78 patients were evaluated with transvaginal ultrasound for a mean interval of 26 months and 17 (21.78%) recurrences were found. Most recurrences (75%) were seen at ultrasound between 10 and 30 months after surgery. The patient's age, pre- and post-operative gravidity and parity had no influence on recurrence. Neither the number of myomas removed nor the depth of penetration or size were positively associated with the risk of recurrence. However, an associated risk factor was pre-operative gonadotrophin-releasing hormone agonist treatment (P < 0.02). None of the women with recurrence required additional surgery. We conclude that laparoscopic myomectomy is a reliable procedure. The recurrence rate is similar to that seen after abdominal myomectomy.     

Laparoscopic myomectomy and subsequent pregnancy: results in 54 patients

The laparoscopic approach to myomectomy has raised questions about the risk of uterine rupture in patients who become pregnant following surgery. It has been suggested that the rupture outside labour in pregnancies following laparoscopic myomectomy can be due to the difficulty of suturing or to the presence of a haematoma or to the wide use of radio frequencies. In this paper we describe the pregnancy outcome of 54 patients submitted to laparoscopic myomectomy at our Institution and prospectively followed during subsequent pregnancies. A total of 202 patients underwent laparoscopic myomectomy. A total of 65 pregnancies occurred in 54 patients who became pregnant following surgery. Data were collected about complications of pregnancy, mode of delivery, gestational age at delivery and birthweight of the neonates. No cases of uterine rupture occurred. Twenty-one pregnancies followed an IVF procedure. Nine patients conceived twice and one three times. Four multiple pregnancies occurred. Eight pregnancies resulted in a first trimester miscarriage and another in an interstitial pregnancy requiring laparotomic removal of the cornual gestational sac. Of the remaining 56 pregnancies, 51 (91%) were uneventful. In two cases a cerclage was performed at 16 weeks. In two cases pregnancy-induced hypertension developed. Two pregnancies ended with a preterm labour (26-36 weeks). A Caesarean section was performed in 45 cases (54/57, 80%). In terms of the safety of laparoscopic myomectomy in patients who become pregnant following surgery, our results were encouraging. However, further studies are needed to provide reliable data on the risk factors and the true incidence of uterine rupture.     

Laparoscopic myomectomy: predicting the risk of conversion to an open procedure

BACKGROUND: Laparoscopic myomectomy (LM) has some advantages over laparotomy; however, it is reputed to be technically difficult, and the risk of conversion to laparotomy might be an obstacle in using this procedure. The aim of this study was to identify the pre-operative factors affecting the risk of conversion to an open procedure (either laparoscopic assisted myomectomy or laparotomy), and to develop a simple prediction model based on available pre-operative data with the use of multiple logistic regression. METHODS: A total of 426 women presenting with a subserous or intramural myoma measuring 20 mm or more underwent LM between March 1989 and October 1999. Of these patients, 378 had successful LM. Forty eight patients [11.3%, 95% confidence interval (CI) 8.3--14.3] had a conversion to an open procedure. A total of 265 women had adequate pre-operative ultrasonography (US) and were used for the analysis. RESULTS: The best prediction model included four pre-operative factors that were found to be independently related to the risk of conversion: size > or = 50 mm at US (adjusted OR = 10.3; 95% CI = 2.8--37.9), intramural type (adjusted OR = 4.3; 95% CI = 1.3--14.5), anterior location (adjusted OR = 3.4; 95% CI = 1.3-9.0) and pre-operative use of gonadotrophin-releasing hormone (GnRH) agonists (adjusted OR = 5.4; 95% CI = 2.0--14.2). The regression coefficients were then scaled and rounded to integers to provide an estimate of the risk for conversion. For a given patient with selected characteristics the predicted risk varied from 0--73%. CONCLUSIONS: This prediction model provides a useful tool that enables multiple criteria to be taken into account simultaneously to help select cases for LM. GnRH agonists should been used only in selected cases. US evaluation is essential before performing LM.     

Early outcome of myomectomy by laparotomy, minilaparotomy and laparoscopically assisted minilaparotomy. A randomized prospective study

BACKGROUND: To compare in the first 7 days after surgery the outcome of myomectomy performed by three laparotomic approaches: laparotomy (LT), minilaparotomy (MLT) and laparoscopically assisted minilaparotomy (LA-MLT). METHODS: Fifty-one women with 5-15 cm total myoma diameter were randomized blindly using a computer randomization list, to LT (n = 17), MLT (n = 17) or LA-MLT (n = 17). RESULTS: Mean operation length was similar in the three groups. Mean (+/- SEM) time of paralytic ileus (55.0 +/- 4.5 versus 33.4 +/- 3.4 h; P < 0.01) and discharge (141.6 +/- 5.2 versus 81.5 +/- 8.2 h; P < 0.01) was longer in LT than LA-MLT or even MLT. In comparison with LA-MLT, LT induced a greater haemoglobin decline (-3.07 +/- 0.3 versus -1.8 +/- 0.15 mg/dl; P < 0.025), and a greater post-operative stress, as documented by increased prolactin (+15.1 +/- 3.8 versus +0.16 +/- 4.5 ng/ml; P < 0.03) and decreased insulin sensitivity (fasting glucose/insulin; -7.5 +/- 2.6 versus -0.7 +/- 2.1; P < 0.02). Seven days after surgery, abdominal pain (P < 0.05) was higher after LT (3.0 +/- 0.6) than MLT (0.5 +/- 0.2) and LA-MLT (0.9 +/- 0.4). CONCLUSIONS: In selected cases, myomectomy by LA-MLT offers some advantages versus LT and, to a smaller extent, MLT.     

Prevalence of chromosomal abnormalities in 2078 infertile couples referred for assisted reproductive techniques

BACKGROUND: This study analyses the prevalence of karyotype changes and Yq11 microdeletions among couples referred for assisted reproduction techniques. METHODS: Prior to receiving either IVF or ICSI treatment, each partner of 2078 infertile couples was screened for karyotype changes by GTG-banding technique on peripheral lymphocytes. No subject presented with obvious phenotype of chromosomal rearrangement. All the oligo/azoospermic men with normal karyotype were further investigated by PCR for Yq11 microdeletions. RESULTS: Eighty-two out of 2078 couples (3.95%) had one partner carrying a chromosomal change, and 10 out of 202 (4.95%) men showed Yq11 microdeletions. The chromosomal rearrangements were 44 (2.1%) translocations, 23 (1.1%) gonosomal mosaics, six (0.3%) 47,XXY, five (0.24%) marker chromosomes, three (0.14%) inversions and one (0.05%) duplication. Frequency of anomalies in men and women were similar: 42 and 40 cases respectively. CONCLUSIONS: Partners of infertile couples requiring IVF or ICSI treatment appear to be affected by higher frequency of chromosomal rearrangements than the general population. Categories with greater risk were represented by men with sperm cell count <20 x 10(6) sperm/ml, and women with history of pregnancy loss.     

Sperm penetration through cervical mucus in infertile couples in relation to selected cervical factors

One-hundred-and-fourteen women of infertile marriages with negativepost-coital test (PCT) results were studied. The women weredivided into three grou those with anatomical anomalies of thecervix, abnormalities of the cervical mucus and a negative PCIand normal parameters in cervical mucus. Patients were treatedwith mestranol when the physicochemical characteristics of thecervical mucus were impaired. Those with antispermatozoal antibodiesfound by means of the Katsh test were treated with desensitizingtherapy, condoms and homologous artificial insemination (AIH).Among all the patients therapy resulted in 23 pregnancies. Afterapplying these treatments to women, 49 of them (43%) had positivePCT results.     

Investigation of the infertile couple: investigation of the infertile couple in the era of assisted reproductive technology: a time for reappraisal

At present, several of the elements in widespread use in basic infertility testing are in dispute, marked variability exists in the work-up among specialists, and practice patterns are influenced both by modern assisted reproductive technologies (ART) and the increasing age of couples seeking help for infertility. This article is intended to stimulate the debate on a possible (lack of) usefulness of conventional methods of infertility evaluation in relation to both the modern techniques of assisted reproduction and the woman's age.     

妊娠期子宫肌瘤5例的剔除治疗体会

目的探讨子宫肌瘤剔除术在妊娠期的应用价值及安全性。方法对2003年10月～1005年4月我院实施的妊娠期子宫肌瘤剔除术5例进行回顾分析。结果妊娠10～21周手术3例，其中1例宫颈巨大肌瘤同时行人工流产，2例术后均足月分娩，孕足月剖宫产同时剔除肌瘤2例，均无不良反应。结论妊娠期子宫肌瘤剔除术是解决妊娠合并较大子宫肌瘤尤其是红色变性时的有效方法，只要时机选择恰当，手术方法和技巧正确，可避免严重并发症发生。     

An association of IgG anti-laminin-1 autoantibodies with endometriosis in infertile patients

BACKGROUND: Laminin-1, a multifunctional glycoprotein of the basement membrane, is thought to be important in embryogenesis, embryonic implantation, and placentation. We recently showed that serum IgG anti-laminin-1 autoantibodies (auto-Abs) are associated with recurrent first-trimester miscarriages. The present study assessed the clinical significance of anti-laminin-1 Abs with infertility, accompanied with or without endometriosis. METHODS: Sixty-eight infertile patients who underwent laparoscopy or laparotomy and 39 healthy non-pregnant women were tested for IgG anti-laminin-1 Abs. The association between the Abs and endometriosis was analysed. The presence of laminin-1 mRNA was detected in endometriotic lesions. RESULTS: Twenty infertile patients were positive for anti-laminin-1 Abs. The Ab levels in those patients were significantly higher than those in healthy non-pregnant women (P = 0.0005). The presence of the Abs was significantly associated with endometriosis in those patients (P = 0.0096). The Abs recognized a particular domain, i.e., the laminin-alpha1 chain G domain. mRNA encoding laminin-alpha1, -beta1, and -gamma1 chains was expressed in 90% of endometriotic lesions. CONCLUSIONS: IgG anti-laminin-1 Abs were significantly associated with endometriosis in infertile patients. The Abs might be clinically important in the development of autoimmune-mediated reproductive failures and the assessment of the Abs may provide a novel non-invasive diagnosis of endometriosis.     

Differential efficacy of group and individual/couple psychotherapy with infertile patients

BACKGROUND: The diagnosis of infertility and concurrent medical treatment may inflict an array of negative emotional symptoms in infertile persons. Evidence for the positive effects of psychotherapy on negative affect and also possible influence on conception rates has been discussed in several studies. METHOD: Meta-analyses were conducted in order to evaluate the efficacy of group and individual/couple therapies on (i) the reduction of negative emotional symptoms, and (ii) the possible promotion of pregnancy. RESULTS: Group and individual/couple psychotherapy led to a decrease in feelings of anxiety. Upon termination of psychotherapy, a reduction of depressive symptoms in patients was greater after 6 months. Psychotherapy accompanying IVF treatment yielded similar conception success rates to psychological interventions administered to patients not in specific medical care. CONCLUSION: Results are suggestive of positive effects of psychotherapy for infertile patients. However, these results must be viewed with caution due to methodological and informational bias within the studies analysed.     

Prognostic factors in assessment and management of male infertility.

Evaluation of 304 infertile couples with at least one abnormal semen analysis (sperm density < 20 x 10(6)/ml and/or motility < 50%) and no apparent female factors was performed in a multicentre prospective cohort study. In 73 cases therapeutic donor insemination was performed (TDI group) with a resulting pregnancy rate of 48%. The remaining 231 couples (non-TDI group) had an overall pregnancy rate of 25%. The TDI group had a shorter duration of infertility. The ages of both partners were comparable in TDI and non-TDI groups. In the non-TDI group, univariate analysis resulted in identification of six clinical variables associated with a change in pregnancy rates. The strongest association was noted for length of infertility. There was a weaker association for semen volume, concentration of leukocytes in semen, history of pregnancy in the female partner and laparoscopy. Multiple variable analysis of data from the non-TDI group revealed that independent predictors of pregnancy were 'duration of infertility' and 'history of pregnancy in the female partner'. The multiple variable modelling suggested that (i) an increase in the length of infertility by 1 month prolongs the time to pregnancy by an additional 1.6% (95% confidence interval: 1.5-1.7%); and (ii) a history of past pregnancy in the female partner reduces the time of pregnancy by 51% (95% confidence interval: 47-56%).     

Altered luteinizing hormone pulsatility in infertile patients with idiopathic oligoasthenozoospermia

In a previous study, we demonstrated that oligoasthenozoospermic(OAZ) patients had two types of testosterone response to humanchorionic gonadotrophin (HCG) administration: group 1 (OAZ-1)had an altered, monophasic (no first peak) response, and group2 (OAZ-2) had a normal biphasic response. The objective of thepresent work was to study the luteinizing hormone (LH) pulsatilityin OAZ-1 compared with both OAZ-2 and men of proven fertility(PF), in order partly to determine the possible aetiology ofthe blunted acute testosterone response to HCG in these patients.LH pulsatility was measured in 10 PF, 10 OAZ-1 and 10 OAZ-2patients, in blood samples taken every 5 min for 6 h in PF,and for 4 h in OAZ patients. LH values were determined by atime-resolved immunofluorometric assay. Frequency and amplitudeof the LH pulses were determined by a computer program. LH pulsefrequency, expressed as pulses/4 h, was significantly lowerin OAZ-1 (1.5 ± 0.97) than in PF (2.4 ± 0.63)and OAZ-2 (2.4 ± 0.84) patients. In six OAZ-1 and twoOAZ-2 patients, LH pulsatility was diminished, as they showedless than two pulses/4 h. No statistically significant differencesin LH pulse amplitude were found. These results, together witha higher number of OAZ-1 cases found with decreased LH pulsatility,suggest that, at least in a subset of these men, quantitativeand/or qualitative alterations of LH secretion might have occurred.     

Genetic risk factors in infertile men with severe oligozoospermia and azoospermia.

BACKGROUND: Male infertility due to severe oligozoospermia and azoospermia has been associated with a number of genetic risk factors. METHODS: In this study 150 men from couples requesting ICSI were investigated for genetic abnormalities, such as constitutive chromosome abnormalities, microdeletions of the Y chromosome (AZF region) and mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. RESULTS: Genetic analysis identified 16/150 (10.6%) abnormal karyotypes, 8/150 (5.3%) AZFc deletions and 14/150 (9.3%) CFTR gene mutations. An abnormal karyotype was found both in men with oligozoospermia and azoospermia: 9 men had a sex-chromosomal aneuploidy, 6 translocations were identified and one marker chromosome was found. Y chromosomal microdeletions were mainly associated with male infertility, due to testicular insufficiency. All deletions identified comprised the AZFc region, containing the Deleted in Azoospermia (DAZ) gene. CFTR gene mutations were commonly seen in men with congenital absence of the vas deferens, but also in 16% of men with azoospermia without any apparent abnormality of the vas deferens. CONCLUSIONS: A genetic abnormality was identified in 36/150 (24%) men with extreme oligozoospermia and azoospermia. Application of ICSI in these couples can result in offspring with an enhanced risk of unbalanced chromosome complement, male infertility due to the transmission of a Y-chromosomal microdeletion, and cystic fibrosis if both partners are CFTR gene mutation carriers. Genetic testing and counselling is clearly indicated for these couples before ICSI is considered.     

Lack of the T54A polymorphism of the DAZL gene in infertile Italian patients

The Thr54Ala polymorphism of the deleted-in-azoospermia-like (DAZL) protein has been associated with susceptibility to spermatogenic failure in the Taiwanese population. We used single-strand conformation polymorphism and restriction fragment analyses to investigate the presence of the A-->G transition in exon 3 of the DAZL gene in 95 infertile Italian patients. The patients had oligozoospermia or non-obstructive azoospermia with different degrees of testicular cytological picture. The allele carrying T54A polymorphism was not present in this group of patients nor in 63 controls, indicating that the frequency of this putative mutation is <1% in Italy. Since the Italian population usually shows allelic frequencies similar to the other Caucasian populations, we suggest that the T54A allele might play a role in infertility only in Taiwanese or Asiatic individuals.