Introduction

Uterine leiomyomata or fibroids are benign tumors of the uterine smooth muscle and extracellular matrix and are extremely common in women of reproductive age. Fibroids are considered to be solely responsible for impaired fertility in 2–3% of cases of infertility.^1,2  Using sensitive imaging techniques, cumulative incidence is as high as 70 percent among white women and more than 80 percent among African -American women by age 50.³ Although the efficacy of myomectomy per se on restoring fertility has never been proven by a randomized clinical trial, fibroids are held responsible for infertility in various studies.⁴

Case Report

A 22 year old female presented with anemia associated with menorrhagia. She was married for last 15 months with no issues. On investigation, she was found to have a Hb of 4 gm%. USG showed a large uterine fibroid measuring 15 cm x 17 cm. Clinically uterus was palpable just below the Xiphisternum (28 weeks size). Anemia was corrected with packed cell transfusions. After she became hemodynamically stable and fit for surgery, she was operated for large uterine fibroid.

Operative procedure

When fibroids are very large or are intramural, they are best removed via the abdominal route. Even large fibroids can usually be removed through an incision below the bikini line. If fibroids are huge better access may be obtained though a vertical incision. The aim is to remove every fibroid from the largest to the tiniest, repair the uterus and restore it as near as possible to normal shape and size. Using the minimum number of incisions in the uterus, the fibroids are easily shelled out of their capsules.

It is important to open the cavity of the uterus in order to be able to remove any submucous fibroids that could be distorting the uterine cavity. In this case, we took a fennestial incision, a large fibroid with uterus was delivered through the wound. The fibroid was occupying most of the fundus and posterior wall of the uterus. A V-shaped incision was taken in the seromusculature  posteriorly on the uterine fundus.  A large fibroid approximately 15 x 14 cm was shelled out without damaging the uterine cavity. After hemostasis, uterine wound was closed in layers by 2.0 vicryl sutures. Abdominal wound was closed in layers. The patient recovered well.

Follow up

The patient was followed up on monthly basis. The patient was allowed to have regular marital relations after 6 weeks. The patient conceived after 4 months of corrective surgery. She completed her full 36 weeks confinement period (Fig.1). At 36 weeks, she started complaining of pain with reduced fetal movements as there was no further progress of labour after 24 hours, LSCS was performed and a live female baby was delivered. The myomectomy scar was inspected and a thinning was noted in the area but there was no dehiscence. The post-operative period was uneventful and the patient was discharged after 1 week.

Discussion

The study most commonly cited to give an epidemiological estimate of the impact of fibroids on infertility, is the review published by Buttram and Reiter.⁵ The authors, in their 10 years of experience, found uterine fibroids to be the sole cause of infertility in only 2.4% of the cases . They concluded that fibroids alone are an infrequent cause of infertility. Donnez and Jadoul performed a literature review on both prospective and retrospective studies published between 1988 and 2001.⁶ The pregnancy rate in patients undergoing hysteroscopic and laparoscopic / abdominal myomectomy was 45 and 49%, respectively

In a large observational study of  91 patients, Fauconnier et al found a cumulative probability of conception after myomectomy to be lower when uterine sutures were required.⁷ They postulated adhesions to be responsible for lowered fertility. It is possible that apart from peritoneal adhesions, intrauterine adhesions may also occur, secondary to ischemia of myoma bed or direct endometrial injury.

Damage to endometrium is considered to be a significant factor in the causation of intrauterine adhesions. However, we did not find that formation of intrauterine adhesions to be minimal. In a retrospective analysis, Gupta et al.found a

30% incidence of intrauterine adhesions in cases of abdominal myomectomy where the uterine cavity was breached.⁸

In our case, the endometrial cavity was not breached hence the early pregnancy was possible. Also the closure of uterine seromuscular layer by 2.0 vicryl prevented the early dehiscence as V-shaped flap was raised to remove the myoma. The pregnancy could reach full term thereby resulting in healthy mother and healthy baby.

Conclusion

Myomectomy is a commonly performed surgery in women of reproductive age group desiring fertility. Myomectomy in itself represents a possible cause for intrauterine adhesions irrespective of nature, type, and location of fibroid and whether or not the uterine cavity was opened during surgery. Cavity saving myomectomy avoids the chances of intrauterine adhesions resulting in high fertility rates.