Skip to main content Accessibility help
  • Print publication year: 2018
  • Online publication date: February 2018

20 - Myomectomy

from Section 3 - Infertility



Uterine fibroids (myomas) affect nearly 80 percent of women. Risk factors for myomas include increasing age up to menopause and black race. Although not all myomas are symptomatic, many women suffer from pain, pressure symptoms, infertility, recurrent miscarriage, and abnormal uterine bleeding. Although many patients choose to undergo hysterectomy as definitive treatment for fibroids, others opt for myomectomy to preserve the uterus and fertility options. Myomas can be submucosal, intramural, or subserosal. Further classification into a numeric system 0–8 has been proposed to standardize the description of fibroid location. See Table 20.1 for specific details.

Myomectomy can be performed hysteroscopically, laparoscopically, or through a laparotomy. The indications for performing a myomectomy, how to approach the surgery, ways to optimize safety of the operation, and the risk of fibroid recurrence will be reviewed in this chapter.

Scope of the Problem

Fibroids can affect fertility in several ways. Depending on their location, they can lead to infertility, subfertility, or recurrent pregnancy loss. A meta-analysis looking at the affect of fibroids on fertility reported that women with myomas had lower pregnancy rates, less successful pregnancy implantations, and lower rates of live birth compared to infertile women with no myomas. The data analyzed in this study also showed that women with fibroids had higher spontaneous abortion rates. The authors then looked into the location of the myomas to determine which type of fibroids have the greatest impact on fertility. The meta-analysis showed that women with cavity distorting fibroids had lower rates of implantation, ongoing pregnancy and live-birth, and higher rates of spontaneous abortion compared to infertile women without myomas. The authors then looked into the effect of noncavity distorting myomas on fertility. The analysis of those women with intramural myomas showed the same negative impact on fertility as seen in women with cavity distorting fibroids. However, those women with subserosal myomas alone had no difference in any measure compared to infertile women without fibroids.

Benefits of Myomectomy

On the basis of this evidence, it would seem reasonable to offer women myomectomy for fertility improvement if their fibroids are either submucosal or intramural; the data, however, is limited and shows mixed results. A recent Cochrane Review on fertility improvement with hysteroscopic interventions found only two randomized controlled trials looking at hysteroscopic myomectomy compared with no intervention in subfertile women with submucosal myomas in situ.

Related content

Powered by UNSILO
1. Baird, D, Dunson, D, Hill, M, Cousins, D, Schectman, J. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100–107.
2. Munro, M, Critchley, H, Broder, M et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynecol Obstet 2011;113:3–13.
3. Pritts, E, Parker, W, Olive, D. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009;91(4):1215–23.
4. Bosteels, J, Kasius, J, Weyers, S et al. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2015;(2):CD009461.
5. Buttram, V, Reiter, R. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril. 1981;36(4):433.
6. Vilos, G, Allaire, C, Laberge, P et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015;37(2):157–78.
7. Klatsky, P, Tran, N, Caughey, A et al. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008;198(4):357–66.
8. Chen, Y, Lin, H, Chen, S et al. Increased risk of preterm births among women with uterine leiomyoma: a nationwide population-based study. Hum Reprod 2009;24(12):3049–56.
9. Stout, M, Odibo, A, Graseck, A et al. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol 2010;116(5):1056–63.
10. Hulka, J, Peterson, H, Phillips, J et al. Operative hysteroscopy: American Association of Gynecologic Laparoscopists’ 1993 membership survey. J Am Assoc Gynecol Laparosc 1995;2(2):131–2.
11. Ferrero, S, Racca, A, Tafi, E et al. Ulipristal acetate prior to high complexity hysteroscopic myomectomy: a retrospective comparative study. J Minim Invasive Gynecol 2015. [Epub ahead of print]
12. Pundir, J, Pundir, V, Walavalkar, R et al. Robotic-assisted laparoscopic vs. abdominal and laparoscopic myomectomy: systematic review and meta-analysis. J Minim Invasive Gynecol 2013;20(3):335–45.
13. Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication, Available at: Retrieved February 29, 2016.
14. Barron, K, Richard, T, Robinson, P et al. Association of the U.S. Food and Drug Administration morcellation warning with rates of minimally invasive hysterectomy and myomectomy. Obstet Gynecol 2015;126(6):1174–80.
15. Chittawar, B, Franik, S, Pouwer, A et al. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids (review). Cochrane Database Syst Rev 2014;(10):CD004638.
16. LaMorte, A, Lalwani, S, Diamond, M. Morbidity associated with abdominal myomectomy. Obstet Gynecol 1993;82(6):897–900.
17. Lethaby, A, Vollenhoven, B, Sowter, M. Pre-operative GnRH analogue therapy before hysterectomy or myomectomy for uterine fibroids. Cochrane Database Syst Rev 2001;(2):CD000547
18. Conforti, A, Mollo, A, Alviggi, C, et al. Techniques to reduce blood loss during open myomectomy: a qualitative review of literature. Eur J Obstet Gynecol Reprod Biol 2015;192:90–5.
19. Al-Shabibi, N, Chapman, L, Madari, S et al. Prospective randomized trial comparing gonadotrophin-releasing hormone analogues with triple tourniquets at open myomectomy. Br J Obstet Gynaecol 2009;116(5):681–7.
20. Frederick, J, Fletcher, H, Simeon, D et al. Intramyometrial vasopressin as a hemostatic agent during myomectomy. Br J Obstet Gynaecol 1994;101(5):1103–5.
21. Fletcher, H, Frederick, J, Hardie, M et al. A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy. Obstet Gynecol 1996;87(6):1014–18.
22. Wong, A, Cheung, C, Yeung, S et al. Transcervical intralesional vasopressin injection compared with placebo in hysteroscopic myomectomy: a randomized controlled trial. Obstet Gynecol 2014;124(5):897–903.
23. Celik, H, Sapmaz, E. Use of single preoperative dose of misoprostol is efficacious for patients who undergo abdominal myomectomy. Fertil Steril 2003;79(5);1207–10.
24. Abdel-Hafeez, M, Elnaggar, A, Ali, M et al. Rectal misoprostol for myomectomy: a randomized placebo-controlled study. Aust N Z J Obstet Gynaecol 2015;55(4):363–8.
25. Ragab, A, Khaiary, M, Badawy, A. The use of single versus double dose of intra-vaginal prostaglandin e2 “misoprostol” prior to abdominal myomectomy: a randomized controlled clinical trial. J Reprod Infertil 2014;15(3):152–6.
26. Shaaban, M, Ahmed, M, Farhan, R et al. Efficacy of tranexamic acid on myomectomy-associated blood loss in patients with multiple myomas: a randomized controlled clinical trail. Reprod Sci 2015. [Epub ahead of print]
27. Ahmad, G, O'Flynn, H, Hindocha, A, Watson, A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015 (4):CD000475.
28. Tulandi, T, Closon, F, Czuzoj-Shulman, N, Abenhaim, H. Adhesion barrier use after myomectomy and hysterectomy: rates and immediate postoperative complications. Obstet Gynecol 2016;127(1):23–8.
29. Malone, L. Myomectomy: recurrence after removal of solitary and multiple myomas. Obstet Gynecol 1969;34:200–203.
30. Martin-Merino, E, Rodriguez, L, Wallander, M et al. The incidence of hysterectomy, uterus-preserving procedures and recurrent treatment in the management of uterine fibroids. Eur J Obstet Gynecol Reprod Biol 2015;194:147–52.
31. Radosa, M, Owsianowski, Z, Mothes, A et al. Long-term risk of fibroid recurrence after laparoscopic myomectomy. Eur J Obstet Gynecol Reprod Biol 2014;180:35–9.
32. Weibel, H, Jarcevic, R, Gagnon, R, Tulandi, T. Perspectives of obstetricians on labour and delivery after abdominal or laparoscopic myomectomy. J Obstet Gynaecol Can 2014;36(2):128–32.
33. ACOG Committee Opinion #560. Medically indicated late-preterm and early-term deliveries. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice. Obstet Gynecol 2013;121(4):908–10.
34. Gambacorti-Passerini, Z, Gimovsky, A, Locatelli, A, Berghella, V. Trial of labor after myomectomy and uterine rupture: a systematic review. Acta Obstet Gynecol Scand 2016; [Epub ahead of print].