Fertility Following Myomectomy FRANCIS M. INGERSOLL, M.D. MYOMECTOMY is an operation frequently indicated in both the maitied and the single woman who desires to preserve her child-bearing function. The influence on the subsequent fertility of a series of 139 myomectomy patients is the subject of this paper. This operation is not new, nor are our results startlingly different from those previously reported by others. We were chiefly interested in: whether the removal of fibroids influenced the fertility of our patients, how soon after the operation conception occulted, and what happened to the unmaitied patient who had a myomectomy. We found that 50% of our married patients did conceive postoperatively (of these, 85% conceived within two years), and that 66% of our single patients who later married were able to conceive. Leiomyomas and Sterility The mechanism by which a leiomyoma interferes with conception is dependent upon its location, size, and blood supply. Most myomas are of no significance and neither interfere with conception nor affect the successful outcome of a pregnancy. However, nidation is mechanically prevented by the submucous fibroid which distorts the endometrial cavity, and over which the endometrium is thin or ulcerated. Likewise, very large multiple leiomyomata may prevent the successful passage of the sperm upward either by increasing the distance the sperm must travel, or by partial obliteration of the cornual portion of the fallopian tube. Distortion of the tubes and malposition of the ovaries in the patient with large intraligamentous fibroids may render the female infertile. Cervical fibroids may compress the cervical canal; when large, they alter the position of the cervix in relation to the vagina and the seminal pool. Cervical myomas may aggravate a retroversion, resulting in fixation of the uterus and hyperemia of the endometrium. The coexistence of leiomyomata and endometrial pathology in the form of From the Departments of Gynecology, Harvard Medical School and the Massachusetts General Hospital (Vincent Memorial), Boston, Mass. This paper was presented at the 19th Annual Meeting of the American Society for the Study of Sterility, New York, N. Y., April 19-21, 1963. 596
VoL. 14, No.6, 1963 FERTILITY FoLLOWING MYOMECTOMY 597 polyps and hyperplasia is high. 5 Also, leiomyomas may complicate a pregnancy, resulting in abortion. 3 The submucous fibroid (Fig. 1) may interfere with the expansion of the products of conception, and multiple intramural fibroids (Fig. 2) may increase rapidly in size, mechanically interfering with Fig. 1 (left). Submucous leiomyomas. Fig. 2 (right). Intramural leiomyomas. the pregnancy. Torsion of pedunculated fibroids and degeneration due to interference with the blood supply may also cause abortion by increasing uterine irritability and initiating contractions. Indications for Myomectomy In our series the indications for operation were usually a combination of infertility and the symptoms caused by the myomas. The submucous myoma large enough to interfere with conception either caused excessive menstruation resulting in anemia, or intermenstrual bleeding which made a dilatation and curettage necessary in order to rule out malignant disease. Occasionally the myomas were large enough to cause pelvic pain and pressure-necessitating surgical relief. At times the myomas were asymptomatic, but as they were laterally placed, removal was mandatory since a malignant ovarian tumor could not be ruled out. Rarely, rapid increase in size of a myoma made operation necessary because of the possibility of sarcomatous degeneration. However, since most myomas are small, incidental, and asymptomatic, the discovery of a leiomyoma at the time of physical examination on a sterility patient does not mean that an operation is indicated or that the order of the study should be changed. All other possible causes of failure of conception must be eliminated by thorough investigation of both husband and wife. A myomectomy is done only after completion of the sterility study and a trial at conception in the group with asymptomatic myomas.
598 INGERSOLL FERTILITY & STERILITY MATERIALS AND METHODS All 139 patients reported here were on private service, and similar preoperative study, evaluation methods, and technical procedures were employed by the three physicians"' cooperating in a 20-year study. The range of our patients' ages is shown below. Age 21-25 26-30 31-35 36-40 41-45 46 As expected, the vast majority of the patients were between the ages of 26 and 40. Only an occasional patient over 40 years of age had a conservative operation for leiomyomas, and only five of these for infertility. Of the 139 patients, 70 were married and 69 single. Our interest is primarily focused on the 56 married women who desired children ( 14 of our married patients were widowed, divorced, or using contraceptives). The reproductive histories of these 56 women reveal that 39 had never conceived and 17 had conceived prior to operation. We have, therefore, two groups of patients: those who have been infertile, and those who have had previous pregnancies. In support of the widespread belief that myomas do produce a relative infertility is the fact that 20 of the 39 patients who had never previously conceived did so after myomectomy with essentially no other treatment. In further support of the theory that myomas do adversely affect fertility is the observation that pregnancy follows operation with surprising rapidity. Of the 20 patients who had been infertile, 11 conceived within the first year following operation, 7 in the second year, and the other 2, five and seven years later. Finn and Muller4 noted that 66% of their patients who conceived delivered within two years of the operation. Table 1 records the figures for the time interval from myomectomy to conception in all 28 of our patients who did conceive. Regardless of age, 24 of the 28 women conceived within two years of the operation. This causeand-effect relationship is hard to ignore. Case Report. L. M. (MGH 118-76-89), age 30, married three years and childless, illustrates the successful result that follows myomectomy. Physical examination failed to show any significant gynecologic pathology; the uterus was only slightly enlarged. A Rubin test demonstrated the tubes to be No. 9 40 43 35 10 2 *Dr. Thomas H. Green, Jr., Dr. Howard -Ulfelder, and the author.
VoL. 14, No. 6, 1963 FERTILITY FOLLOWING MYOMECTOMY 599 TABLE 1. Interval from Myomectomy to Pregnancy Age group11 Time in year a 1 2 3 4 5 6+ 21-25 1 2 3 26-30 8 5 1 14 31-35 4 1 1 2 8 36-40 2 1 3 41+ 15 9 1 1 2 28 patent, a postcoital test that her husband was fertile, and the BBT chart that she ovulated. At D. and C., a mass was found distorting the endometrial canal, and a 4-cm. myoma was removed through a hysterotomy incision. Within 5 months she conceived and had an uneventful pregnancy. In any analysis such as this, the reasons why some patients failed to conceive are important. A review of our records on 28 patients not conceiving revealed obvious and significant additional reasons for infertility in half the cases. These other factors were infertile husbands with low sperm counts, adnexal disease (such as adhesions), endometriosis, and age. Simmons and Taymor 9 have shown that sterility patients frequently have multiple etiologic factors such as we found in these cases. Seventeen of our 56 patients who desired children had previously conceived ( 10 full term deliveries, 6 spontaneous abortions, and 1 ectopic pregnancy). Analysis of this small group discloses that the fertility of these women was not appreciably altered by the myomectomy. Of the 10 who had previously delivered living children, myomas had either complicated their pregnancy or developed subsequently, necessitating a myomectomy. Following operation, 6 of the 10 patients conceived and were delivered in most cases by cesarean section. Case Report. S. M. (MGH 805-370), thirty-three years old, married for seventeen months, successfully completed her first pregnancy in spite of several large myomas. However, these tumors not only failed to diminish appreciably in size postpartum, but in fact began to grow rapidly, and with each menstrual period, bleeding became more profuse, resulting in an anemia. A lower abdominal mass extended half-way to the umbilicus and consisted of nine large fibroids deeply embedded in the uterine wall. After myomectomy the patient's second baby (delivered. by cesarean section) died of a congenital lung condition, following which the patient developed thrombophlebitis and a pulmonary embolus requiring femoral vein ligation. Two years later she delivered a living child, and four years later she had a repeat cesarean
600 INGERSOLL FERTILITY & STERILITY section followed by a hysterectomy because of atony of the uterus. This case report serves to emphasize that the patient with fibroids is usually fertile, that conception follows myomectomy promptly, and that preservation of the uterus permits the patient to complete her family. Four of the 10 patients who had a child prior to myomectomy failed to conceive following the operation. Secondary sterility of 6-15 years' duration was thoroughly investigated and no cause was found other than the myomas, which were removed in the hope of improving the patients' fertility. However, the myomas proved to be incidental since no patient conceived after their removal. Six of the 17 who had conceived before myomectomy had had spontaneous abortions only and no living children. Unfortunately, the removal of the myomas did little to alter this situation since only one patient conceived and delivered. None of our patients falls into the category of the habitual aborter as reported by Brown et au or Munnell and Martin,6 whose strikingly good results after myomectomy suggest that, at least occasionally, the location of a myoma is a factor in abortion. Both Rubin 8 and Davids, 2 in large series of patients, have stressed the role of myomas in abortion, noting the high incidence in the patients with multiple myomas, and the decreased incidence after myomectomy. Although the number of our cases is small and therefore not statistically valid, 45% of the pregnancies prior to myomectomy aborted, whereas only 21% aborted postmyomectomy. The eighth pregnancy in this group of 17 occurred in a patient who had had an ectopic pregnancy prior to the myomectomy. We conclude that the fertility of these women who had previously been pregnant was not modified by the operation. Those who conceived previously and had living children did so again in most instances, and those who previously had difficulty conceiving or carrying to term continued to do so. Sterility and Age The importance of the age factor in sterility is clearly illustrated by the fact that our patients under 31 years of age had little trouble conceiving ( 17 out of 22 did so). In contrast, the 18 patients 36 or over at the time of myomectomy had a disappointing result-only three ( 17%) conceived. No patient in our group over 39 at the time of myomectomy had a child (Table 2). Munnell and Martin 6 have suggested that since successful pregnancy is so infrequent in the older age group that no patient past 42 be considered for this conservative operation. We feel, however, that the decision regarding operation on patients in their 40's should depend upon the physiological age of the patient, her wishes in this matter, and the surgeon's conviction
VoL. 14, No. 6, 1963 FERTILITY FoLLOWING MYOMECTOMY 601 TABLE 2. Myomectomy and the Age Factor No. failin!! to Age groups Total No. No. conceiving conceive %conceived 21-25 4 3 1 75% 26-30 18 14 4 77% 31-35 16 8 8 50% 36-40 13 3 10 23% 41+ 5 0 5 0 TOTAL 56 28 28 50% about preserving the child-bearing function in each individual patient. And it should not be forgotten that for some of those who never conceive it is extremely important to have been able to try. Our oldest successful patient had her first child at 39, after 16 years of infertility. Case Report. I. S. (MGH 82-80-37) had an ectopic pregnancy at age 37, requiring a right salpingo-oophorectomy and at the time of operation also had eight broids of various sizes removed from a grossly distorted uterus. Two years later she delivered her only child without mishap. The surgeon was pleased with this happy result since at the time of the patient's ectopic pregnancy, hysterectomy had been seriously considered because of the many years of sterility and the number and location of the myomas. Fertility of Unmarried Patients Of particular interest are the patients who had a myomectomy while single, and who subsequently married. The number of patients in this group who conceived is great-14 of the 21, and 13 had living children. Of the 7 who married and did not conceive, only 3 tried for children and failed; the other 4 used contraceptives. Obviously the myomectomy preserved the uterus until these fertile women married and had their families, a convincing argument for the operation. Subsequent Hysterectomies Of the total group of 139 patients, 14 ( 10%) have had a recurrence of the myomas, requiring hysterectomy. Four additional patients had a hysterectomy for one of the following reasons: carcinoma of the cervix, prolapse, placenta previa with accreta, and atony of the uterus. Similar recurrence rates have been recorded by others 4 7 and it is of interest to learn how closely our experience has followed theirs.
602 INGERSOLL FERTILITY & STERILITY CONCLUSIONS ( 1. ) In a series of 139 myomectomies, 56 patients desired children and 28 (50%) conceived. ( 2.) Twenty-four of the 28 who conceived did so within two years of the operation. ( 3.) Conception occurred in 17 of the 22 patients 30 years of age or less at the time of operation, but in only 3 of 18 patients 36 years old or more. ( 4.) Twenty-one of the single patients subsequently married and 14 of them conceived. ( 5.) Hysterectomy because of recurrent myomas was necessary in 10% of the cases. 226 Marlborough St. Boston, MasiJ:. REFERENCES 1. BROWN, A. B., CHAMBERLAIN, R., and TELrnnE, R. W. Myomectomy. Am.]. Obst. & Gynec. 71:159, 1956. 2. DAVIDS, A. M. Myomectomy, surgical technique and results in a series of 1,150 cases. Am. ]. Obst. & Gynec. 63:592, 1952. 3. DAVIDS, A. M. The management of fibromyomas in infertility and abortion. Clin. Obst. & Gynec. 2:(3) 837, 1959. 4. FINN, W. F., and MULLER, P. F. Abdominal myomectomy: special reference to subsequent pregnancy and to the reappearance of fibromyomas of the uterus. Am. ]. Obst. & Gynec. 60:109, 1950. 5. IsRAEL, S. L. Diagnosis and Treatment of Menstrual Disorders and Sterility (Mazer and Israel). 4th Ed. Hoeber, New York, 1959. 6. MUNNELL, E. W., and MARTIN, F. W. Abdominal myomectomy advantages and disadvantages. Am. ]. Obst. & Gynec. 62:109, 1951. 7. MussEY, R. D., RANDALL, L. M., and DoYLE, L. W. Pregnancy following myomectomy. Am. ]. Obst. & Gynec. 49:508, 1945. 8. RUBIN, I. C. Uterine fibromyomas and sterility. Clin. Obst. & Gynec. 1 (2) :501, 1958. 9. SIMMONS, F. A., and TAYMOR, M. L. Failure of conception in 100 completely studied couples. Fertil. & Steril. 6:320, 1955.