Myomectomy or conservative management of uterine fibroids: effects on reproductive potential

AIM: The aim of this study was to analyze reproductive function, pregnancy and labor in women after laparoscopic myomectomy and in women with unoperated myoma.

MATERIALS AND METHODS: The main group consisted of 60 patients aged 25-46 years with a scar on the uterus who had laparoscopic myomectomy. Inclusion criteria were full-term pregnancy, uterine scar after laparoscopic myomectomy for subserosal or intramural uterine myoma (3-10 cm), and myomatous nodules (one to three). The comparison group included 30 women aged 25-46 years who were not surgically treated. Inclusion criteria were full-term pregnancy, subserosal or intramural uterine myoma (3-10 cm), and myomatous nodules (one to three). All patients in the main group underwent laparoscopic myomectomy. In all cases, the myomatous nodule was removed intracapsularly, leaving the leiomyoma pseudocapsule, which, with a deep arrangement of the transmural myomatous nodules, avoided opening the uterine cavity; myomatous nodule morcellation being used. With a deep intramural arrangement of the leiomyoma, the myometrial defect was sutured layer by layer with the application of several rows of endosutures.

RESULTS: Six months after myomectomy, the patients underwent MRI of their pelvic organs with contrast. In 95% of cases, the uterine scar had no anatomical insolvency. In assessing the anamnesis, gynecological diseases occurred two times more often in women in the main group: 22 (36.7%) patients resorted to the use of the in vitro fertilization method for pregnancy, while among the patients in the comparison group, there were only two (6.7%) of them (χ² = 12.8; р < 0.001). In the main group, moderate preeclampsia and gestational diabetes mellitus were twice as common. In the main group, all patients were delivered by caesarean section, of which 83.3% were planned and 16.7% were emergency. In the comparison group, 73.3% of patients were delivered through the natural birth canal and 26.7% by caesarean section (χ² = 149, p < 0.0001). The most unfavorable signs predisposing to obstetric complications and operative delivery were the presence of multiple nodules (OR = 5.96 (1.09-32.72), p < 0.05), the location of the nodule or scar in the uterine bottom (OR = 2.52 (1.00-6.33), p < 0.05), and their combination with IVF (OR = 9.09 (2.42-34.07), р < 0.01).

CONCLUSIONS: In 95% of women, the scar on the uterus after myomectomy was consistent, but all these pregnant women were delivered by cesarean section, mainly for combined indications. However, they carried out the pregnancy safely, with a good outcome for the fetus. In women with uterine myoma and its conservative management, there was a lower rate of aggravated gynecological history and obstetric complications, and 73.3% of them were delivered through the natural birth canal. Despite the increased risk of caesarean section, the presence of uterine fibroids, even of a large size (more than 4 cm), should not be considered as a contraindication to vaginal delivery.