A myomectomy is a surgical procedure that removes uterine fibroids or leimyomas.  There are several approaches and techniques for dealing with leiomyomas.  The size an location of the fibroid can affect the type of surgery that is performed.  Usually some form of imaging such as a pelvic ultrasound, saline contrast ultrasound, or MRI of the pelvis is used to determine the size and location of the fibroid.  In many cases, there are multiple fibroids that affect the uterus and cause infertility.  It is generally accepted that fibroids within the endometrial cavity of the uterus will affect pregnancy.  Fibroids distorting the cavity of the uterus will also cause infertility.  In cases with multiple fibroids, the normal muscle tone of the uterus can be affected even if the fibroids do not affect the cavity of the uterus.  Fibroids are also common causes for painful menstrual cycles, known as dysmenorrhea, and heavy menstrual cycles or abnormal bleeding, known as menorrhagia.  The physician will review the size and location of the fibroids and recommend the appropriate type of surgery.

Uterine Leiomyoma (fibroids)

Abdominal Myomectomy for Uterine Fibroids

The most common method for surgically treating leiomyomas, or fibroids, in the muscle wall of the uterus is the laparotomy or minilaparotomy with excision of the tumor(s).  This procedure is known as an abdominal myomectomy.  The incision is similar to that made to perform a cesarean section, though usually much smaller.  Incisions are made on the uterus where the fibroids are located.  The normal muscle is separated from the fibroid using gentle traction and an electrosurgical device.  Care must be taken to minimize bleeding because the normal uterine muscle is highly vascularized and will bleed easily when disrupted.  Surgeons attempt to remove as many of the fibroids through the anterior aspect of the uterus (side closest to the bladder).  This is done to reduce the risk of the fallopian tubes and intestines scaring to the incision and interfering with fertility.  This risk is increased with incisions made to the posterior aspect of the uterus, but can be minimized with careful surgical technique.  The incisions are also closed using a special suturing technique that will reduce the risk of adhesion (scar tissue) formation.  After incisions are made in the uterus from procedures like a myomectomy, patients will need to deliver future pregnancies with a planned cesarean section to reduce the risk of uterine rupture during labor.

Fibroid following a myomectomy.
Note the well defined border and solid appearance.
Click the image for larger view.

The majority of myomectomies can be performed in an outpatient surgical center and do not require hospitalization unless mandated by insurance.   Our surgeons have been performing outpatient myomectomies for over 20 years.  A specialized approach to making the incisions, controlling bleeding, and managing post operative pain result in an approach that is quite different than the approach by many other doctors.

Once an abdominal incision is made, the abdominal muscles are separated (not cut), and the abdomen is entered.  Once the fibroid(s) have been located, the surgeon carefully determines a surgical approach to minimize damage to the uterus and to reduce the subsequent risk of scar tissue formation.  The surgeon then separates the uterine muscle from the hard and rubbery fibroid.  In most cases the fibroid “shell out” from the surrounding tissue.  Care must be taken to minimize the damage to the surrounding muscle and blood vessels.  The uterine muscle is sewn in layers to provide strength and restore the normal architecture to the uterus as best as possible.  The surgical time can range from one hour for a single uterine fibroid to 3 or more hours for multiple uterine fibroids.  In most cases, blood loss is less than 200 mL (less than a cup).

Patients are sent home the same day to begin the recovery process.  It is normal to experience pain after the procedure, however most patients are able to walk around the house and provide care for themselves.  The recovery is very comparable to a cesarean section.  While some patients may take longer to recover, most patients are resuming normal activities by 2 weeks.  Patients should refrain from driving and intercourse until cleared by their surgeon.

Following surgery, the uterine tissue undergoes remodeling and healing.  After this process the uterus can take on a normal appearance and function.  In many cases it is difficult to tell a woman has had a myomectomy if the procedure was completed by an experienced surgeon.  Depending on the amount of normal muscle that is disrupted by the surgery or displaced by the fibroid, the physician may recommend that labor be avoided in favor of a cesarean section.  As the muscle heals scar tissue can form.  This scar is prone to rupture during labor.  Not all myomectomies require subsequent cesarean section for delivery so be certain you understand your situation after the surgery and patients should follow the instructions provided by their surgeon.

When can you try to get pregnant?  The uterus recovers within 2 to 3 months of the surgery.  The surgeons at California IVF Fertility Center recommend patients do not attempt pregnancy for at least 2-3 months to give the uterus and abdomen time to heal.  When patients are undergoing fertility treatments, the treatment process can usually start after 2 months so the soonest pregnancy will generally occur will be 3 months after the surgery.  Patients with multiple uterine fibroids will be at a higher risk of having the fibroids return and may wish to discuss more aggressive treatment such as IVF.

Hysteroscopic Myomectomy for Intrauterine Fibroids

When uterine fibroids occur in the cavity of the uterus, the procedure used to remove the fibroid is known as an operative hysteroscopy, or hysteroscopic myomectomy.  A camera is placed through the uterus to visualize the inside of the uterus.  Instruments are then passed through the hollow portion of the scope to remove the fibroid.  There are several instruments that can be used to remove fibroids from the uterus.  One of the older surgical techniques involves using an electrical wire loop to shave pieces off the fibroid.  These pieces are then removed from the uterine cavity.  The surgeon must be very careful to not go too deep with the electrical loop or cause too much damage to the uterus.  The risk of post operative scar tissue is slightly higher when the muscle wall of the uterus is damaged.

An alternative to the operative resectoscope is the hysteroscopic morcellator.  This is a specialized instrument designed to grind, or morecellate, the fibroid and evacuate it using suction.  The devices are designed in such a way that damage to the normal uterine muscle is greatly reduced.  Because the devices are usally combined with a fluid management system to control the inflow and outflow of water, the surgeon can accurately measure fluid volumes and minimize the risk of fluid overload.  The outgoing fluid carries away the fragments of the fibroid so the surgical times can be greatly reduced.   Most patients are candidates for this newer technique.

Hysteroscopy can only be used for fibroids that are inside the cavity of the uterus.  When the fibroids are in the muscle wall of the uterus, they may be able to be removed hysteroscopically.  As the fibroid is removed, the uterine muscle contracts and pushes the fibroid more into the cavity of the uterus.  The majority of the fibroid will need to be in the cavity for this approach to work.  If the majority of the fibroid is in the muscle wall, an abdominal myomectomy will be needed.  In some cases, patients may need operative hysteroscopy to remove fibroids in the cavity of the uterus and an abdominal myomectomy to remove fibroids in the muscle wall of the uterus.

Adenomyosis and Adenomyomas

Adenomyosis is a condition in which the glandular tissue that normally lines the inside of the uterus (endometrium) invades into the muscle of the uterus.  These glands go through changes during the menstrual cycle like the normal endometrial tissue.  The body attempts to remove the tissue from the muscle and scar tissue can result.  The normal soft muscle tissue begins to become hard and rubbery with less and less normal blood flow to support a pregnancy.  Because the glandular tissue is interwoven with the normal muscle tissue, it can not be removed surgically.  When the adenomyosis tissue becomes more hardened and forms a larger mass, it may be referred to as an adenomyoma.  Adenomyomas can appear to be fibroids on an ultrasound.  Adenomyomas and uterine fibroids can exist together in the same uterus.  Adenomyomas can be debulked by removing a portion of the uterine wall or muscle along with the mass.  Care must be taken not to damage or destroy too much of the uterine muscle or cavity of the uterus.  Adenomyosis can significantly reduce the chances of pregnancy.  When adenomyosis is encountered during surgery, the surgeon may attempt to minimize the effect of the adenomyosis though in many cases the prognosis for a successful pregnancy is low.  Adenomyosis can be very difficult to identify or diagnose outside of surgery and in many cases it has gone undetected for years before it is discovered.  There are some medical treatment strategies that have been used with limited success.  Women with adenomyosis should have a consultation with a fertility specialist as soon as possible.  The longer adenomyosis is present, the worse the prognosis can become.

Some fibroids may be removed using laparoscopy or a robotic assisted laparoscopy procedure.  The surgeon makes several small incisions and instruments are used to remove the fibroids.  Fibroids located on the outside of the uterus are better suited for these techniques.  Often, fibroids located on the outside of the uterus do not require surgery and do not have a significant impact on fertility.  As the techniques have advanced, surgeons are able to remove fibroids from within the muscle of the uterus and repair the muscle through laparoscopic and robotic techniques.  Devices called morcellators will grind the fibroids into small pieces and remove the pieces through instruments.  Concerns have been raised about the potential to spread sarcomas, or cancerous uterine fibroids, when morcellators are used.  Special holding bags are often used for morcellation of fibroids during laparoscopic or robotic myomectomy procedures.

The advantages of laparoscopic and robotic myomectomy surgery include shorter recovery time for the patient due to smaller incisions.  Robotic procedures often require more incision sites which can have an effect on post operative pain.  Many studies comparing laparoscopic and robotic surgeries for uterine fibroids compare the technique to abdominal myomectomies where patients have been hospitalized for several days.  When compared to the technique used by California IVF fertility specialists, the recovery does not appear to be significantly different.

Some of the major drawbacks to laparoscopic and robotic procedures include longer operating times, higher cost, and a limited ability to identify fibroids within the muscle wall of the uterus.  During the abdominal surgery procedure, the surgeon is able to use his hand to identify additional fibroids located in the muscle wall of the uterus.  Removing fibroids that distort the cavity of the uterus is the main goal of the procedure.  Using metal instruments to remove the fibroids can limit the surgeons ability to feel the uterus and remove all of the fibroids.  Our center frequently sees patients who had a recent robotic or laparoscopic procedure that failed to remove fibroids that significantly affected a patient’s fertility potential.  Some surgeons are able to use intraoperative imaging techniques to aid in the identification of fibroids during surgery.  Until these techniques are further refined, patients should use caution when considering a surgery with robotic or laparoscopic techniques.

Uterine Artery Embolization – UAE

Uterine artery embolization is frequently discussed with patients by interventional radiologists.  During this procedure, a catheter is placed through the vessels in the groin region and passed into the arteries in the uterus.  The catheter is used to place microscopic beads, or other substances, are used to block arteries that supply blood to the tissue around the fibroids.  The fibroids don’t contain vessels so the blockage of the blood vessels will also damage the surrounding muscle tissue of the uterus.  Care must be taken with infertility patents.  The damaged muscle becomes more hardened and less vascular.  This can interfere with a woman’s subsequent ability to carry a pregnancy.  Currently most guidelines and physicians advise against UAE, or uterine artery embolization in patients desiring to carry a pregnancy in the future.  For patients finished with their child bearing, the UAE may be a good option to consider for symptomatic relief from fibroids.

Lupron for Fibroids

Lupron, or leuprolide acetate, is an injectable medication that will cause a temporary state similar to menopause.  While using this medication, the ovaries will not produce eggs and estrogen levels will become very low.  The fibroids generally require estrogen to thrive.  While on Lupron, the fibroids often shrink and many of the symptoms such as heavy bleeding or painful cycles can improve.  Unfortunately, the effects of Lupron are temporary and the fibroids will typically return to normal size after the medication is stopped.  Patients are sometimes given Lupron before surgery to shrink the size of the fibroids.  This can actually interfere with how easily the fibroids separate from the surrounding muscle and can caused some fibroids to become too small to detect.  At California IVF Fertility Center our surgeons prefer patients avoid the use of Lupron before surgery unless absolutely needed.

Hysterectomy

A hysterectomy is generally considered a last resort option for women desiring to have children.  With the exception of adenomyosis or recurring fibroids, most patients can avoid a hysterectomy.  Women finished with their child bearing years and not wanting to undergo more conservative surgery such as an abdominal myomectomy, laparoscopic myomectomy, or robotic myomectomy, a hysterectomy may be an appropriate choice.

No Treatment

When fibroids do not cause pain, abnormal bleeding, or do not interfere with fertility, surgical treatment is not necessary.  Fibroids are rarely cancerous.  They can remain in the uterus for years without any significant health risks.  If they become a problem later in life, an appropriate form of treatment can be identified at that time.  Generally when women go through menopause, the fibroids will shrink.  Each individual case will be different and women should discuss their options with a doctor experienced in managing fibroid.  Our fertility doctors at California IVF are expert surgeons but also know how to manage fibroids that don’t require surgery.

The surgeons at California IVF are highly skilled and experienced with myomectomy procedures.