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Laparoscopic Myomectomy

Laparoscopic Myomectomy. Limits, Effectivity and Efficasy in ART Yücel Karaman MD. Prof. IVF and Endoscopic Surgery Center Brussel’s Women’s Health & Infertility Center www.istanbulivf.com. Uterin myomas are the most common benign uterine tumor found in women Crammer et all 1995

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Laparoscopic Myomectomy

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  1. Laparoscopic Myomectomy Limits, Effectivity and Efficasy in ART Yücel Karaman MD. Prof. IVF and Endoscopic Surgery CenterBrussel’s Women’s Health & Infertility Center www.istanbulivf.com

  2. Uterin myomas are the most common benign uterine tumor found in women • Crammer et all 1995 • They are estimated to occur in 20-50% of women >30years • Genetic predisposition seems to contribute to the development of myomas (black women) 3-9 times more than white women • Wallach et all 1992

  3. Symtoms of Myomas • Usually asymtomatic • Most common symptoms • Mass effect of the enlarged uterus on adjacent pelvic organs • Abnormal uterine bleeding • Severity of symptoms depends on the size, position, and number of fibroids.

  4. Diagnosis • Transvaginal ultrasound and/or hydrosonography • Hysteroscopy

  5. Causes of Reduced Implantation • Impared gamet transport • Distortion of the endometrial cavity • Impairment of blood supply of the endometrium • Atrophy and ulcerations of the endometrium • Aberant Endometrial Growth Factor expression Eldar – Geva et all 1998Buttram V.C. Et all 1981

  6. Myomas • Submucosal Myomas • Intramural • Subserosal

  7. Submucosal Myomas • Improved pergnancy outcome after myomectomy Pritts 2001

  8. Subserosal Myomas • Have no influence on pregnancy outcome compared to control group Elder – Geva - 1998

  9. Effects of Myomas on Fertility in patients undergoing assisted reproduction • The aim is to evaluate the current data to understand the impact of intramural leimyomata on pregnancy outcome in ART without cavitary distortion. Benecke et all 2005

  10. Patients Selection • Pregnancy date on IVF • Intramural myomas with no cavitary distortion • Control group with no myomata 150 Articles were reviewedBenecke et all 2005

  11. End points of the study • Pregnancy rate per transfer • Implantation rate per transfer • Ongoing Pregnancy rate/transfer

  12. Results Benecke 2005

  13. Uterine corporal myomata not encroaching the cavity and <7cm in mean diameter do not affect the implantation or miscarriage rate in IVF/ICSI Uterine myomata and outcome of ART (39 patients) Ramzy et all 1998

  14. Effects of Myomas on Fertility in patients undergoing assisted reproduction Results of Meta Analysis showed that : • There was a significant negative impact on implantation rate in the intramural myomata groups versus the control groups:16,4 vs 27,7% - OR 0,62 (0,48-0,8) • The delivery rate per transfer cycle was also significantly lower 31,2 vs 40,9 % - OR 0,69 (0,50-0,95) Benecke et all Gyn/Obs. İnvest March - 2005

  15. Intramural Myomas Based on this results • Intramural myomata affect pregnancy outcome in ART • Must be taken into consideration particularly in previous failed ART cycles Benecke - 2005

  16. Conclusion of this meta analysis • This study showed that; • Patients with intramural fibroids have a lower implantation rate per cycle • The studies did not shed new light on the size of intramural myomata that could affect the outcome • In previous failed IVF cycles, myomectomy should be considered. Benecke et all Gyn/Obst Invest March - 2005

  17. What is not clear from the article? • The size of intramural myomata without intracavitary involvement varied and no final conclusion could be drawn based on the article • Although the studies did not correlate pregnancy rates with the size of the myomata as well as their position and distance from uterine cavity.

  18. In a recent review by PRITTS “There was doubt on the approach towards the intramural myomata and removal of the myomata was not recommended” Pritts et all - 2001

  19. But; • Prospective data by HART et all • Retrospective studies reviewed by Benecke et all Concluded that;They lean more towards a surgical removal of myomata, especially 1. if located close to uterine cavity2. the size ≥ 2cm in diameter Hart et all 2001 Benecke et all 2005

  20. Impact of subserosal and intramural myomas(without endometrial cavity distortion) on the outcome of in IVF-ICSI (245 Patients) • If myoma ≤4cm, IVF-ICSI outcomes is similar to those without myomas • However they recomended surgery, if myoma ≥4cm Oliveira et all 2004

  21. Removal of myomata • Implantation rate significantly • Ongoing pregnancy rate This approach must be considered especially in patients with previous failed IVF with intramural myoma.

  22. Which method should be used to remove intramural myomata? • Laparoscopic surgery • Laparotomic microsurgery • Robotic Laparoscopic Surgery

  23. Laparoscopic Myomectomy

  24. Intra-ligamenter myomectomy

  25. Sesil subseros myoma

  26. Intramural myomectomy

  27. Intra-corporeal Sutur

  28. Morcelator

  29. Morcelation

  30. Laparoscopic Myomectomy Y. Karaman 2006

  31. (Laparoscopic Myomectomy) Pregnancy Rates • 27 patients form pregnancy • 1 patient uterine rupture 34th week • 20 patients (71%) Normal vaginal delivery • 8 patients (29%) C/S Dubisson et all 1998

  32. CONCLUSION • Intramural myomata without intracavitary involvement have an impact on pregnancy outcome in ART and surgical removal must be considered especially in patients with previous failed ART cycles. • Intramural myomata with intracavitary involvement has to be removed. • Myomectomy can be performed easily by laparoscopic surgery in the hand of the well trained surgeons. • We await in anticipation a prospective randomized controlled trails that assess the effect of the size and position of intramural myoma on fertility in ART

  33. CONCLUSION • But, prospective randomized studies are difficult to conduct because of physician training and preferences, patient preferences, and women’s understandable reluctance to be randomized to a major surgical procedure.

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