Fibroid Characteristics Research Articles

Association of uterine fibroids with birthweight and gestational age

PurposeTo determine if fibroids or their characteristics are associated with birthweight and/or gestational age, and to assess the impact of race or ethnicity. MethodsRight from the Start (2000–2012) is a prospective cohort that enrolled women from the southern US in early pregnancy. Transvaginal ultrasounds were used to measure fibroid characteristics and confirm gestational age. Date of birth and birthweight were obtained from vital or medical records. We assessed whether fibroid presence, number, type, and volume were associated with birthweight and/or gestational age using multivariate analysis of covariance, accounting for a priori confounders. ResultsAmong 3926 women, 416 had one or more fibroids. Mean infant birthweight and gestational age were similar among women with and without fibroids. When adjusting for race or ethnicity, all associations were attenuated. Overall, women with and without fibroids had infants of similar birthweight (−20 grams, 95% confidence interval [CI] −77, 36) and gestational age (0.4 days, 95% CI −0.9, 1.8). Women with three or more fibroids were more likely to have lighter infants (−201 grams, 95% CI −345, −58). ConclusionsRace or ethnicity substantially confounds the associations. The clinical belief that uterine fibroids impair fetal growth is supported only by a significant decrease in birthweight for women with multiple fibroids.

Ulipristal acetate versus gonadotropin-releasing hormone agonists prior to laparoscopic myomectomy (MYOMEX trial): Long term results of a double-blind randomized controlled trial

ObjectiveThe aim of this study was to compare the effect of ulipristal acetate (UPA) and gonadotropin-releasing hormone agonists (GnRHa) before laparoscopic myomectomy on long term secondary outcomes of the MYOMEX-trial, regarding quality of life, ultrasound characteristics, hemoglobin levels 6 weeks post-operative, sexual function and menstrual bleeding control. A cost-analysis was also performed. Short-term primary and secondary outcomes are reported elsewhere. Study designA double-blind, randomized, controlled, non-inferiority trial in nine hospitals in the Netherlands. Participants were randomized in a 1:1 ratio (block size of four, stratified per hospital) to either UPA or GnRHa pre-treatment. Additional placebo injections containing saline, respectively daily placebo tablets were given to both groups to ensure double-blinding. Surgery was performed within a month after the last tablet. Women were followed up until six months post-surgery. ResultsA total of 55 participants were randomized: 30 to the UPA- and 25 to the GnRHa-group between May 2015 and July 2017. Uterine volume at six weeks post-operative did not differ significantly between both pre-treatment groups with 170.1 cm3 (106.8–243.5; N = 29) vs. 152.8 cm3 (92.3–205.6; N = 23) for the UPA- and GnRHa-group respectively (p = 0.423). Hemoglobin levels six weeks post-operatively recovered back to baseline and were not significantly different between groups with 7.7 mmol/L for the UPA- vs. 8.1 mmol/L for the GnRHa-group (p = 0.157; mean difference -0.4 (CI -0.9, 0.2). Menstrual bleeding pattern, quality of life, effects on general and sexual health showed a significant improvement compared to baseline in both groups without any differences between the treatment groups. Symptom severity scores also decreased significantly at 6 week post-operatively compared to baseline, but did not differ between the treatment groups. Fibroid characteristics at baseline (e.g. mean diameter of largest fibroid) appeared not to be a confounding factor. An exploratory cost analysis showed no significant differences in absenteeism costs, total healthcare and societal costs, after adjustment for confounding factors. ConclusionPre-treatment prior to laparoscopic myomectomy with UPA compared to GnRHa has similar effects on bleeding pattern, menopausal symptoms, sexual functioning, symptom severity and quality of life from baseline up to six months post-operative. Due to the small sample size, these findings should be interpreted with caution. Also, no firm conclusions on costs could be made.

Influence of Ethnicity on Clinical Presentation and Quality of Life in Women With Uterine Fibroids: Results From a Prospective Observational Registry.

This study sought to evaluate ethnic variations in the clinical presentation of women with uterine fibroids. A total of 996 premenopausal women with symptomatic uterine fibroids were enrolled in a prospective, non-interventional, observational registry at 19 clinical sites across Canada (CAPTURE Registry). Patient-reported outcomes were assessed using Uterine Fibroid Symptom and Health-Related Quality of Life Symptom Severity questionnaires and the Aberdeen Menorrhagia Severity Scale (Ruta score). Linear and logistic regression models, adjusted for patient and fibroid characteristics, were used to examine differences among ethnicities for continuous and binary outcomes of interest. Black women were 4.9 years younger (P<0.001), were more likely to be nulligravid (P=0.046), had a 41% longer duration of symptoms before enrolment (P=0.01), had a 49% larger fibroid volume (P=0.01), and were more likely to be anemic (P<0.001) compared with White women. Black women reported lower health-related quality of life scores (-5.19 points; 95% CI -9.90 to -0.48, P=0.03) compared with White women. East Asian women were 2.0 years younger (P=0.01), were more likely to be nulligravid (P<0.001), had a 53% longer duration of symptoms (P=0.01), had 67% larger fibroid volume (P=0.01), and were more likely to be anemic (P=0.003) compared with White women. East Asian women had lower symptom severity scores (-5.95 points; 95% CI -11.16 to -0.75, P=0.02). Non-White women preferred uterine-preserving treatment options (P<0.001). Black and East Asian women have an increased burden of disease compared with White women and prefer uterine preservation. There is a discrepancy between disease burden and patient-reported outcomes that may reflect ethnocultural differences in disease experience.

Predictors of uterine fibroid volume reduction under ulipristal acetate: a prospective MRI study.

Can patient and/or uterine fibroid characteristics predict the volume reduction of fibroids under ulipristal acetate (UPA) treatment? This was a monocentric observational prospective cohort study of women with symptomatic fibroids who were willing to undergo surgery after a 3-month treatment of daily 5mg doses of UPA. Patients underwent magnetic resonance imaging before and after treatment, and the volumes of the three largest fibroids were assessed. The reduction in volume was assessed qualitatively: fibroids decreasing in volume were considered to be 'responsive' to treatment, and fibroids that were stable or increased in volume were considered to be 'non-responsive'. Comparisons were made of patient (age and body mass index) and fibroid (initial volume, number and location) characteristics between fibroids that were responsive and non-responsive to UPA treatment. Fifty-three women were included in the final analysis and 116 fibroids were measured. The initial number and initial volume of the fibroids were statistically associated with the response to UPA treatment (adjusted odds ratio [OR] 0.645, 95% confidence interval [CI] 0.461-0.903, P = 0.0115 for number of fibroids, and adjusted OR 1.447, 95% CI 1.063-1.970, P = 0.0195 for initial volume, with a log-linear relationship). Submucosal fibroids had a higher response rate to treatment (i.e. a decrease in volume) than intramural fibroids (21/25 [84.0%] versus 15/28 [53.6%]; P = 0.0490; adjusted OR 4.478, 95% CI 1.007-19.918). The location, initial volume and number of fibroids may allow prediction of the outcome of a single 3-month treatment course of daily 5 mg doses of UPA in terms of reduction in volume before surgery.

Implementing robotic assisted myomectomy in surgical practice \u2013 a retrospective cohort study

BackgroundTo compare surgical outcomes of patients with leiomyomas after robotic-assisted laparoscopic myomectomy (RALM), laparoscopic myomectomy (LsM), or laparotomic myomectomy (LtM) and to construct a useful algorithm for the best modus operandi for uterine leiomyomas.MethodsDesign: A retrospective chart review. Data included patient (age and BMI) and fibroid characteristics (number, measurements of the primary fibroid, type, and location), operating time, blood loss, hospitalization length, complications during and after surgery, and complications during posttreatment pregnancies. Comparisons were based on chi-square and two-sample t tests. Setting: University teaching hospital. Patients: Between 1 January 2009 and 31 December 2016, 51 RALMs, 84 LsMs, and 52 LtMs were performed at our institution. Interventions: Three different approaches of myomectomy were performed: robotic-assisted laparoscopy (RALM), laparoscopy (LsM), and laparotomy (LtM).ResultsThere was no significant difference in the distribution of the location and the type of myoma between the three groups. The mean size of the largest myoma removed by LsM, RALM, and LtM was 60.9, 70.8, and 92.6 mm (p < 0.05), respectively. Surgical outcomes between the three modalities were comparable except for increased mean blood loss and postoperative bleeding and longer hospital stay for patients with LtM and for longer operation time when performing RALM.ConclusionRALM should replace open surgery if feasible and should not replace traditional laparoscopy unless other benefits are proven.

Comparison between single-site and multiport robot-assisted myomectomy

Minimizing the number of port incisions during minimally invasive surgery is associated with improved outcomes and patient satisfaction. We designed this work to study the perioperative outcomes of robotic single-site myomectomy (RSSM) in comparison to robotic multiport myomectomy (RMM) in a certain subset of patients. The design of the study is a multicenter retrospective analysis (Canadian Task Force classification III). The setting was three university hospitals. Eighty patients with symptomatic uterine fibroids undergoing robot-assisted single-site myomectomy were selected for the study. These 80 consecutive RSSM patients were matched at the uterine fibroid tumor burden level with 95 consecutive RMM patients performed at the same institutions, by the same surgeons, within a similar time frame. The main outcome measures were estimated blood loss (EBL), operative time, overnight admission, and post-operative complications. Of the 175 women, 95 (54.2%) underwent RMM and 80 (45.7%) underwent RSSM. Single-site vs. multiport patient demographics differed significantly in mean age (39.1 vs. 35.6, p < 0.001), and BMI (25.3 vs. 27.5, p < 0.04). Pre-operative MRI fibroid characteristics were matched between the two cohorts. Fibroid size on imaging (5.8cm vs. 5.9cm, p = 0.4) and the number of fibroids removed (2.5 vs. 2.3, p = 0.08) were similar between the two groups. After adjustment for multiple covariates with regression models, single-site myomectomy and multiport myomectomy has comparable EBL (83.3mL vs. 109.2mL, p = 0.34), operative time (162.4min vs. 162.4min, p = 0.99), overnight admission (OR = 1.54, p = 0.44) and a post-operative complication (OR = 1.3, p = 0.78). In selected patients, robotic single-site myomectomy is equivalent to its multiport counterpart. Both surgical approaches are associated with low rates of intra-operative and post-operative complications.

Factors influencing the difficulty of laparoscopic myomectomy: the development of a surgical rating tool

Objective To obtain expert consensus on the patient and fibroid characteristics that affect the complexity of laparoscopic myomectomy (LM) and to use these factors to create a grading tool for objective evaluation of LM procedures.Study design Modified Delphi Methodology Study (Canadian Task Force III). Setting included a series of online surveys via SurveyMonkey (SurveyMonkey Inc., San Mateo, California, USA). Participants were Canadian minimally invasive gynecologic surgeons (MIGS) who perform LM. A list consisting of patient, uterine and procedural characteristics was disseminated to Canadian MIGS. Opportunity to include additional factors was provided. Consensus was predefined as Cronbach’s α of ≥0.80. A second Delphi survey was then done to assign weight value for each item in the grading tool.Results Twenty-seven surgeons from across Canada participated. Most (23/27, 85%) were MIGS fellowship trained, and performed more than 6 LM per year (18/27, 66.7%). Consensus was achieved in the first round of the survey (Cronbach’s α = 0.93). Sixteen of 27 factors met the criteria for inclusion (>80% respondents agreed or strongly agreed) and were included in the final rating tool. Factors that met the criteria for inclusion were grouped as patient factors (including body mass index), uterine factors (including number of fibroids, size of largest fibroid), and surgical factors (including ease of developing the cleavage plane).Conclusions Using the Delphi methodology to obtain expert consensus on the factors influencing the difficulty of LM, we have developed an objective grading tool to evaluate the degree of technical complexity of LM.

Transethnic and race-stratified genome-wide association study of fibroid characteristics in African American and European American women

To identify, through genome-wide association studies, genetic loci that associate with differences in fibroid size and number in a population of African American and European American women. Cross-sectional study. Not applicable. Using BioVU, a clinical population from the Vanderbilt University Medical Center, and the Coronary Artery Risk Development in Young Adults cohort, a prospective cohort, we identified 1520 women (609 African American and 911 European American) with documented fibroid characteristics. None. Outcome measurements include volume of largest fibroid, largest fibroid dimension, and number of fibroids (single vs. multiple). In race-stratified analyses we achieved genome-wide significance at a variant located between MAT2B and TENM2 (rs57542984, β = 0.13; 95% confidence interval 0.09, 0.17) for analyses of largest fibroid dimension in African Americans. The strongest signal for transethnic analyses was at a variant on 1q31.1 located between PLA2G4A and BRINP3 (rs6605005, β = 0.24; 95% confidence interval 0.15, 0.33) for fibroid volume. Results from MetaXcan identified an association between predicted expression of the gene ER degradation enhancing alpha-mannosidase like protein 2 (EDEM2) in the thyroid and number of fibroids (Z score = -4.51). This study identified many novel associations between genetic loci and fibroid size and number in both race-stratified and transethnic analyses. Future studies are necessary to further validate our study findings and to better understand the mechanisms underlying these associations.

Fibroid surgery and improvement in bladder symptoms: The FAB study.

Uterine fibroids are the most common tumor of the female reproductive tract [Baird et al Am J Obstet Gynecol. 188:100-107, 2003] and bladder symptoms are more prevalent in these women [Pron et al Fertil Steril. 79:112-119, 2003; Volkers et al Am J Obstet Gynecol. 196:519.e1-e11, 2007] However, the effect of various fibroid debulking surgeries on different types of urinary incontinence symptoms is poorly understood. Our primary objective was to determine whether surgical debulking of uterine fibroids affects urinary symptoms. Secondary objectives were: to define the baseline prevalence of bladder symptoms in women undergoing fibroid surgery; to explore links between fibroid characteristics, size of debulked fibroids, type of surgery, and postoperative changes in bladder function. Prospective cohort study (2011-2016) of women undergoing vaginal or abdominal myomectomy or hysterectomy. Baseline demographics were obtained. All women underwent a detailed pelvic ultrasound preoperatively. The Urinary Distress Inventory (UDI) questionnaire of the validated Pelvic Floor Distress Inventory (PFDI) was administered before and 6 weeks after surgery. Score changes were assessed using Wilcoxon signed rank test. Sixty-one women completed the study. At baseline, regardless of fibroid characteristics, 96.6% of women had various bothersome urinary symptoms including storage, voiding, and incontinence. Following surgical fibroid debulking, median improvement in the UDI total score was clinically and statistically significant at 39.9 (P < 0.001). All urinary subscale scores were also significantly improved. 11/17 women (64.7%) and 11/18 women (61.1%) were cured of moderately to severely bothersome symptoms of urge and stress urinary incontinence respectively. Urinary symptoms are common in women undergoing surgery for uterine fibroids. Fibroid debulking may be offered as treatment for bladder symptoms in symptomatic women.

Lower Urinary Tract and Pelvic Floor Symptoms and their Correlation with Fibroid Characteristics [39M

INTRODUCTION: Lower urinary tract symptoms (LUTS) are prevalent in women with uterine fibroids. Research suggests that increased fibroid volume and uterine bulk is associated with more severe LUTS and pelvic floor symptoms, however the correlation between fibroid size/location, adenomyosis, and symptoms has been under-studied. We sought to investigate this correlation using MRI which provides detailed information on fibroid characteristics. METHODS: A retrospective chart review was conducted for patients seen at the Stanford Fibroid Clinic. Patient demographics, medical history and pelvic MRI data were collected on 60 patients with completed Uterine Fibroid Symptom (UFS) and Pelvic Floor Distress Inventory (PFDI) validated symptom surveys. Primary outcome was scaled symptom scores and sub-scores including the Urogenital Distress Inventory (UDI-6). RESULTS: Dominant fibroid volume correlated negatively with urinary frequency (r=-0.307, P=.030), urgency (r=−0.287, P=.043), and pelvic pain or discomfort (r=-0.281, P=.049). Longest fibroid dimension also negatively correlated with UDI-6 (r=-0.304, P=.028). Number of fibroids and uterine volume were not significantly associated with LUTS. However, higher PFDI score was significantly associated with presence of adenomyosis on MRI (mean 82.9 vs 159.6, P=.018) and serosal fibroid location (mean 139.3 vs 69.0, P=.011). Patient BMI correlated positively with UDI-6 (r=0.415, P=.002) and PFDI (r=0.371, P=.005). CONCLUSION: Contrary to common belief, dominant fibroid size was inversely associated with LUTS, suggesting that fibroid dimensions may not predict bulk-related symptom severity. Adenomyosis should be considered in the evaluation of LUTS in women with uterine fibroids. In accordance with current literature, BMI is associated with LUTS including incontinence, urgency, and frequency.

Admixture mapping of uterine fibroid size and number in African American women

To evaluate the relationship between genetic ancestry and uterine fibroid characteristics. Cross-sectional study. Not applicable. A total of 609 African American participants with image- or surgery-confirmed fibroids in a biorepository at Vanderbilt University electronic health record biorepository and the Coronary Artery Risk Development in Young Adults studies were included. None. Outcome measures include fibroid number (single vs. multiple), volume of largest fibroid, and largest fibroid dimension of all fibroid measurements. Global ancestry meta-analyses revealed a significant inverse association between percentage of European ancestry and risk of multiple fibroids (odds ratio: 0.78; 95% confidence interval 0.66, 0.93; P=6.05 × 10-3). Local ancestry meta-analyses revealed five suggestive (P<4.80 × 10-3) admixture mapping peaks in 2q14.3-2q21.1, 3p14.2-3p14.1, 7q32.2-7q33, 10q21.1, 14q24.2-14q24.3, for number of fibroids and one suggestive admixture mapping peak (P<1.97 × 10-3) in 10q24.1-10q24.32 for volume of largest fibroid. Single variant association meta-analyses of the strongest associated region from admixture mapping of fibroid number (10q21.1) revealed a strong association at single nucleotide polymorphism variant rs12219990 (odds ratio: 0.41; 95% confidence interval 0.28, 0.60; P=3.82 × 10-6) that was significant after correction for multiple testing. Increasing African ancestry is associated with multiple fibroids but not with fibroid size. Local ancestry analyses identified several novel genomic regions not previously associated with fibroid number and increasing volume. Future studies are needed to explore the genetic impact that ancestry plays into the development of fibroid characteristics.

Endoscopic treatment of symptomatic fibroids at reproductive age and beyond

Objectives: To evaluate the feasibility of endoscopic treatment of symptomatic uterine fibroids based on patient and fibroid characteristics in reproductive, pre-menopausal and post-menopausal women.Material and methods: The medical records of women with symptomatic uterine fibroids who underwent surgical procedures from 2010 to 2015 were retrospectively reviewed.Results: A total of 819 patients, of which 710 (86.6%) underwent endoscopic procedures. The mean age of women who underwent laparoscopic myomectomy (LM) was 36.77 ± 6.54 and hysteroscopic myomectomy (HSCM) was 43.10 ± 10.26. The mean cumulative diameter of fibroids in the LM was 8.94 ± 3.1 and 3.68 ± 1.64 cm in the HSCM. Furthermore, LM and HCSM were performed when the mean diameter of the largest fibroid was up to 18.50 and 5.5 cm, respectively. The mean age of women in laparoscopic supracervical hysterectomy (LSH) was 46.02 ± 6.13 and total laparoscopic hysterectomy (TLH) was 47.30 ± 8.12. The mean cumulative diameter of fibroids in the LSH was greater than in the TLH, at 8.94 ± 3.1 and 7.63 ± 3.60 cm, respectively.Conclusions: Uterus-preserving procedures are feasible, even if the largest fibroid diameter is more than 10 cm in LM and equal to 5.5 cm in HSCM. For pre- and post-menopausal women, TLH is the definitive treatment modality for uterine fibroids, and LSH represents an alternative to TLH.

Preprocedural MRI and MRA in planning fibroid embolization.

This pictorial review aims to discuss and illustrate the up-to-date use of preprocedural magnetic resonance imaging (MRI) in selecting patients and planning uterine artery embolization (UAE). The merits of magnetic resonance angiography (MRA) in demonstrating the pelvic vasculature to guide UAE are highlighted. MRI features of fibroids and their main differential diagnoses are presented. Fibroid characteristics, such as location, size, and enhancement, which may impact patient selection and outcome, are presented based on recent literature. Pelvic arterial anatomy relevant to UAE, including vascular variants are illustrated, with conventional angiography and MRA imaging correlation. MRA preprocedural determination of the optimal projection angles for uterine artery catheterization is straightforward and constitutes an important strategy to minimize ionizing radiation exposure during UAE. A reporting template for MRI/MRA preassessement of UAE for fibroid treatment is provided.

Symptomatic Fibroid Management: Systematic Review of the Literature.

Background and Objectives:Symptomatic uterine fibroids are a societal and healthcare burden with no clear consensus among medical professionals as to which procedural treatment is most appropriate for each symptomatic patient. Our purpose was to determine whether recommendations can be made regarding best practice based on review and analysis of the literature since 2006.Database:A systematic search of journal articles relevant to the treatment of symptomatic uterine fibroids was performed within PubMed, clinical society websites, and medical device manufacturers' websites. All clinical trials published in English, representing original research, and reporting clinical outcomes associated with interventions for the management of symptomatic uterine fibroids were considered. Each article was screened and selected based on study type, content, relevance, American College of Obstetricians and Gynecologists score, and internal/external validity. Outcomes of interest were patient baseline characteristics, fibroid characteristics, procedural details, complications, and long-term follow-up. Random-effects meta-analyses were used to test the quantitative data. Assessment of 143 full-length articles through January 2016 produced 45 articles for the quantitative analysis. The weighted combined results from hysterectomy trials were compared with those from uterine-preserving fibroid studies (myomectomy, uterine artery embolization, laparoscopic radiofrequency ablation, and magnetic resonance-guided focused ultrasound).Conclusion:We explored trends that might guide clinicians when counseling patients who need treatment of symptomatic fibroids. We found that fibroid therapy is trending toward uterine-conserving treatments and outcomes are comparable across those treatments. Since minimally invasive options are increasing, it is important for the clinician to provide the patient with evidence-based therapeutic strategies.

Associations between uterine fibroids and obstetric outcomes in twin pregnancies

ObjectiveTo examine potential associations between the presence of fibroids and obstetric outcomes in twin pregnancies. MethodsA prospective cohort study compared obstetric outcomes between individuals with twin pregnancies who did and did not have fibroids. Patients were considered for inclusion if they underwent first-trimester ultrasonography examination, and went on to deliver at the Beijing Obstetrics and Gynecology Hospital between September 1, 2012 and December 31, 2014. Participants were grouped based on the presence or absence of fibroids and baseline demographics, fibroid characteristics, and obstetric outcomes were recorded and compared between the two groups. ResultsIn total, 153 patients with twin pregnancies were recruited; 51 had fibroids and 102 did not. Patients in the fibroid group demonstrated a higher maternal age (P<0.001), higher pre-pregnancy body mass index (P=0.01), and higher rate of assisted reproductive technology use (P=0.04). The presence of fibroids was not associated with any change in obstetric outcomes, and obstetric outcomes were unaffected by the number, size, location, and type of fibroids (all P>0.05). ConclusionFibroids were not a risk factor for any adverse obstetric outcomes among patients with twin pregnancies.

Uterine fibroid characteristics and sonographic pattern among Ghanaian females undergoing pelvic ultrasound scan: a study at 3-major centres.

BackgroundUterine fibroids are the most common benign tumours affecting premenopausal women and are often associated with considerable hospitalization and morbidity.The purpose of this study was to identify the uterine fibroid characteristics and sonographic patterns of uterine fibroids among Ghanaian women undergoing abdomino-pelvic or pelvic ultrasound scan at three major diagnostic centres. The outcome is expected to help in appropriate policy formulation in women care in Ghana.MethodA total of two hundred and forty four (244) women were evaluated between November 2011–February 2012, using identical 2–5 MHz curvilinear probe of Philips HD3 ultrasound machines at three major diagnostic centers in Ghana, using a trans-abdominal pelvic approach.ResultsThe range, mean and standard deviation (SD) of the patients’ ages were 14–54 years, 31.89 years and ± 7.92 respectively. The majority, 57.8 % of the fibroids were intramural with only 4.4 % noted as sub-mucosal. Most (55.6 %) of the fibroids were located in more than one part of the uterus. The most popular (55.6 %) echo pattern of the various fibroid nodules was mixed echogenicity.ConclusionThe sonographic patterns of uterine fibroids among Ghanaian women have been assessed at three major diagnostic centres. The study shows that most Ghanaian women who have fibroids have degenerative fibroid nodules as these nodules demonstrate mixed echo patterns on ultrasound. The findings may aid in appropriate diagnosis and interventions in the country.

Reproductive Outcome of Infertile Patients with Fibroids Based on the Patient and Fibroid Characteristics; Optimal and Personalized Management

Aims: To analyze the detailed clinical course of infertile patients with uterine fibroids and to identify optimal and personalized treatment based on the patient or fibroid characteristics. Methods: Retrospective analysis of a case series was performed on 176 infertile patients with fibroids. The patients were classified into different groups according to different treatments (conservative infertility treatment, myomectomy and non-myomectomy surgery). Patient or fibroid characteristics for different groups were analyzed for a possible correlation with the reproductive outcome. Results: The cumulative pregnancy rates by conservative treatment plateaued in 1 year. Myomectomy improved the reproductive outcome in patients who did not conceive with conservative infertility treatments. The most important determinant of the reproductive outcome in patients by conservative treatment prior to surgery was a past patient history of pregnancy. The most important determinant of the reproductive outcome after myomectomy was patient age. Conclusion: Myomectomy should be considered when infertile patients with fibroids do not conceive within 1 year of conservative infertility treatments. The most important determinant of reproductive outcome after myomectomy is patient age. Therefore, for patients younger than 40, the treatment schedule should be carefully considered so that the patients can sufficiently benefit from myomectomy and assisted reproductive technology.

Identifying patients who can improve fertility with myomectomy

ObjectiveTo identify the characteristics of cases and fibroids that will indicate which patients should undergo myomectomy to improve fertility. Materials and methodsWe recruited patients (n=101) who had undergone myomectomy to improve fertility and received follow-up care for at least six months by the hospital. Medical records were retrospectively reviewed to analyze the pregnancy rates after myomectomy and to identify clinical factors that correlate with pregnancy rates. Cumulative pregnancy rates were analyzed using the Kaplan–Meier method and the Log rank test. The patients were then divided into three groups according to the timing of the myomectomy. The analysis was performed for all patients, for patients in the post-superovulation and/or intrauterine insemination (post-SO/IUI) group and the post-assisted reproductive technology (post-ART) group combined, and for patients in the post-ART group. ResultsSixty-three pregnancies were achieved by 58 patients (57.4%) who underwent myomectomy. The mean time period between surgery and conception was 9.8 months. Most pregnancies (91.5%) were achieved within two years after surgery. Pregnancy rates were higher in patients aged less than 36 years, with no male factors, and without severe endometriosis, in comparison with patients 36 years of age or older (p<0.05), with male factor (p<0.05), and severe endometriosis (p<0.05). In the analysis of the post-ART group, pregnancy rates were higher (p<0.05) in cases where enucleation had penetrated the endometrial cavity in comparison with patients where the cavity was not penetrated; however, fibroid characteristics did not correlate with the post-myomectomy pregnancy rate in the post-SO/IUI plus post-ART group. ConclusionPost-myomectomy pregnancy rates were higher in women who did not have additional infertility factors. These results suggest that the removal of fibroids benefits especially patients who suffer from infertility of an otherwise unknown cause: surgery should be strongly recommended for these patients. Our study also shows the difficulty in identifying fibroids for removal to improve fertility. Further studies are needed to develop new diagnostic techniques for identifying patients who can improve fertility with myomectomy.

The impact of fibroid characteristics on pregnancy outcome

The objective of the study was to assess the influence of different characteristics of fibroids on pregnancy outcome. We identified women with fibroids 4 cm or greater in size on ultrasonography at the dating scan between January 2002 and December 2012. The size (4-7 cm, 7-10 cm, >10 cm), number (multiple/single), location (lower uterus/body of uterus), and type (intramural, combination of intramural/subserosal, subserosal) were ascertained. Medical records were reviewed to obtain pregnancy outcomes (preterm delivery, birthweight, mode of delivery, estimated blood loss, postpartum hemorrhage, and admission for fibroid-related pain). A total of 121 patients with 179 pregnancies were identified. Preterm delivery was more likely in those with multiple fibroids compared with single fibroids (18% vs 6%; P = .05). The location of the fibroid had an important effect on the mode of delivery with a higher cesarean section rate for fibroids in the lower part of uterus than in the body of the uterus (86% vs 40%; P = .01), a higher rate of postpartum hemorrhage (22% vs 11%; P = .03), and greater estimated blood loss (830 mL [SD, 551] vs 573 mL [SD, 383]; P = .03). Increasing size of fibroid was associated with greater rates of hemorrhage (11% vs 13% vs 36%; P = .04), increased estimated blood loss (567 mL [SD, 365] vs 643 mL [SD, 365] vs 961 mL [SD, 764]; P = .01), and higher rates of admissions for fibroid-related pain (5% vs 23% vs 21%; P = .01). Different fibroid characteristics affect pregnancy outcome in varying ways. This information can be used to aid counseling women antenatally and in risk-stratifying patients.

3 T MRI uterine peristalsis: Comparison of symptomatic fibroid patients versus controls

To compare uterine peristalsis between symptomatic fibroid patients and normal subjects and to determine the possible effect of fibroid characteristics on uterine peristalsis at high-field magnetic resonance imaging (MRI). The present study included 20 symptomatic fibroid patients (age range 39-53 years) and 20 normal subjects (age range 19-46 years). MRI images were obtained during the peri-ovulatory phase using 3 T MRI using a sagittal T2 turbo spin-echo sequence and a half-Fourier acquisition single-shot turbo spin-echo sequence for display on cine mode. Two radiologists independently evaluated the images for the presence of uterine peristalsis by confidence level. In cases where peristalsis was present, the images were also evaluated for peristalsis frequency and direction. For fibroid patients, uterine and index fibroid volume, fibroid burden and index fibroid location were also recorded. Uterine peristalsis was significantly decreased in symptomatic fibroid patients compared with normal controls (p < 0.01). Peristalsis frequency in fibroid patients was also lower than in normal subjects. Direction of peristalsis was cervix-to-fundus for the majority of fibroid patients and controls. There was no significant relationship between fibroid characteristics, such as uterine volume, index fibroid volume, index fibroid location, and fibroid number in fibroid patients with, and fibroid patients without peristalsis. In women with symptomatic fibroids, the presence of uterine peristalsis is significantly decreased compared to normal controls on 3 T cine MRI. The presence of fibroids appears to disturb the normal conduction of uterine peristalsis and may interfere with fluid (e.g., menses, sperm) transport.