Can intramural fibroids be removed

Some authors have expressed reluctance to support treatment of intramural myomas in subfertile women. Cited reasons include lack of sufficient evidence and poorly designed trials, insufficient studies supporting or refuting the clinical benefits of treatment of non—cavity-distorting intramural myomas, and the inherent surgical complications and required expertise in the treatment of intramural myomas.

Myomectomy has been the mainstay treatment of symptomatic leiomyomas in women seeking uterine-conserving therapy and conservation and improvement in reproductive outcomes.

Careful palpation helps the surgeon to target hard-to-reach intramural fibroids during the open procedure. In a prospective study evaluating LUS, surgeons performed the laparotomic procedure on women diagnosed preoperatively with symptomatic myomas LUS permitted the detection of 46 residual myomas, In a retrospective study of consecutive cases, Hanafi 19 evaluated those factors that were associated with recurrence of myomas that were at least 2 cm in greatest diameter and that formed after open myomectomy.

One of the limitations of the study was the lack of reporting on the locations of the myomas detected at follow-up. Radosa et al 20 also reported on myoma recurrence rate after laparoscopic myomectomy. Of the women who were initially studied, were lost to follow-up and were followed postoperatively to Two factors significantly increased the risk for recurrence of symptoms: age between 30 and 40 years and presence of multiple myomas at surgery.

Increased risk of recurrence may also have been due to the surgeons not excising all myomas that were present at baseline. For example, in a randomized trial, Brucker et al 21 reported excision of only Uterine artery embolization UAE is an established minimally invasive, percutaneous, image-guided interventional technique involving the occlusion of one or both uterine arteries supplying blood to target myomas, including intramurals and intramurals abutting the endometrium, but not pedunculated myomas.

Magnetic resonance-guided focused ultrasound MRgFUS describes an approved device Exablate; Insightec, Tirat Carmel, Israel and method for noninvasive, nonsurgical ablation of leiomyomas, including intramurals, by focused ultrasound waves, which are guided to the target tissue by real-time three-dimensional MRI.

Given the contraindications and costs, MRgFUS is an option to a limited subset of symptomatic patients. Of the study subjects, only Of the subjects followed to 12 months, a subset of 63 subjects had intramural myomas but no submucous myomas. The growing body of evidence reported in the literature supports the need to diagnose intramural myomas and manage them, in order to reduce the recurrence of symptoms and the need for further intervention.

Patients with symptomatic intramural myomas should be carefully evaluated and appropriately treated. The authors received third-party editorial support, which was funded by Halt Medical, Inc.

National Center for Biotechnology Information , U. Int J Womens Health. Published online May Author information Copyright and License information Disclaimer.

This work is published and licensed by Dove Medical Press Limited. By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Abstract A debate among gynecologic and reproductive surgeons is whether or not there is a clinical need to treat all intramural myomas.

Keywords: intramural myomas, myoma therapies, uterine artery embolization, myomectomy, radiofrequency volumetric thermal ablation, magnetic resonance-guided focused ultrasound. Overview of uterine myomas Uterine myomas have been classified according to their general uterine position: submucous, intramural, and subserosal.

Open in a separate window. Figure 1. FIGO leiomyoma subclassification system. Intramural myomas Intramural myomas are the most prevalent of all the leiomyomas. Uterine artery embolization Uterine artery embolization UAE is an established minimally invasive, percutaneous, image-guided interventional technique involving the occlusion of one or both uterine arteries supplying blood to target myomas, including intramurals and intramurals abutting the endometrium, but not pedunculated myomas.

Magnetic resonance-guided focused ultrasound Magnetic resonance-guided focused ultrasound MRgFUS describes an approved device Exablate; Insightec, Tirat Carmel, Israel and method for noninvasive, nonsurgical ablation of leiomyomas, including intramurals, by focused ultrasound waves, which are guided to the target tissue by real-time three-dimensional MRI.

Conclusion The growing body of evidence reported in the literature supports the need to diagnose intramural myomas and manage them, in order to reduce the recurrence of symptoms and the need for further intervention.

Acknowledgments The authors received third-party editorial support, which was funded by Halt Medical, Inc. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. Int J Gynaecol Obstet. Fibroids are typically diagnosed by ultrasound. The first step might be an exam by your doctor, where he or she would feel an enlarged uterus and suspect fibroids.

For smaller fibroids, the only way to diagnose them is often with ultrasound. Some doctors may choose to also do an MRI of the pelvis as a way to see exactly where the fibroids are. It depends on symptoms and size. For example, if a woman has fibroids inside the uterine cavity, we may do a hysteroscopic myomectomy, in which we look inside the uterus with a camera. If a woman has severe symptoms, and if the fibroids are in the muscle or outside of the uterus, surgery may be the best option.

In that case, robotic-assisted laparoscopic myomectomy is more common. This is a minimally invasive procedure that involves making four to five small incisions in the abdomen. We then use small instruments attached to robotic arms to remove the fibroids through these very small openings.

In severe cases, a woman would have an open myomectomy, which is also called abdominal myomectomy. This surgery requires an incision either in the bikini area or a vertical incision along the abdomen. We then remove the fibroids through this incision. Some nonsurgical management of uterine fibroids may include medicine that can help suppress their growth, such as birth control pills.

There's also a medication called leuprolide acetate, which can help shrink them. Their impact on fertility depends on the location and the size of the fibroids, as well as the type of symptoms a woman has. Types 6 and 7 are SS fibroids. The average thickness of the myometrium at the body of the uterus ranges from 1. Studies show that uterine fibroid causes endometrial vascular disorders and inflammation resulting a non-conducive environment for embryo implantation and thus leading to infertility 9 , The way IM fibroid causes difficulty in conceiving has been discussed extensively in the paper by Pier and Bates The following discussion on the pathophysiology of IM fibroid causing subfertility is extracted from this paper.

Implantation is a complex process. Several factors such as HOXA, glycodelin, leukemia inhibitory factor and glutathione peroxidase 3 are involved in this process.

HOXA is responsible for cellular differentiation while glycodelin is responsible in promoting angiogenesis, suppressing natural killer cells NKc and inhibiting the binding of the spermatozoa to the zone pellucida.

Normally, both factors reduce during follicular phase and increase during implantation. Although studies which showed a reduction trends in HOXA is not conclusive but this reduction causing inability of the embryo to implant is confirmed in animal model 12 - So, we hypothesis that the reduction of both factors is responsible in embryo implantation failure causing infertility.

In women of reproductive age, magnetic resonance imagining MRI has shown three distinct layers in the myometrium. The innermost layer that immediately abuts the endometrium is labelled the JZ This zone may affect fertility by two different mechanisms.

Firstly, the origin of myometrial peristalsis in the JZ Disruption of this zone by fibroids may lead to increased peristalsis This will be discussed in the next section. Secondly, IM fibroids may cause thickening or disruption of the JZ leading to poor reproductive outcome The changes in the thickness of the JZ can be due to the changes in the expression of oestrogen, progesterone, the respective receptors and aromatase 23 - Besides, we noticed that the amount of NKc and macrophage cells in the uterine influence the fertility potential.

Study demonstrated that the NKc were significantly reduced while the macrophage cells were significantly increased in the endometrium closer to the fibroid compared to other area, the amount of both cells were significantly reduced regardless of the area when compared to the fibroid-free patient Since JZ plays an important role in implantation and its disruption may lead to implantation failure, we propose that type 4 fibroid can be further classified into type 4a and 4b as shown in Figure 1.

There are 2 types of uterine contractions. The first is focal and sporadic bulging of the myometrium first described by Togashi et al. The second is the rhythmic and subtle stripping movement in the subendometrial myometrium known as uterine peristalsis UP captured by cine mode magnetic resonance imaging cMRI From menstruation to the mid-ovulatory phase of the menstrual cycle, the uterus contracts from the cervix to the fundus with increasing frequency.

Post-ovulation, the contraction frequency decreases to relatively quiet during implantation. In the luteal phase, the direction of peristalsis is reversed Based on the studies, UP is increased in patients with IM and SM fibroids during the mid-luteal phase and decreased during the peri-ovulatory phase compared to the healthy controls 27 , The relationship between infertility and abnormal UP among patients with IM fibroids was explored by Yoshino et al.

Ninety-five infertile patients with only IM fibroids underwent cMRI during the implantation period luteal phase days 5—9 and were further categorized into two groups low and high uterine peristaltic frequency.

To avoid bias, the authors recruited patients with same numbers and diameter of fibroid but half of them had cavity-encroaching fibroids. They offered infertility treatment like natural cycle, ovulation induction by hormonal therapy and intrauterine insemination in an increasing manner depends on the severity of the infertility.

This demonstrates that abnormal UP is a likely cause of infertility. So, one can postulate that type 3 and type 4a fibroids may have more UP than type 4b fibroids leading to more subfertility.

This needs to be further evaluated by clinical studies. There are several methods of measuring UP namely intrauterine pressure measurement, transvaginal ultrasound and cMRI. Each method has its own advantages and disadvantages Measuring UP accurately and inexpensively will assist in determining which patients with IM fibroid will benefit from treatment. Leiomyoma is covered by a thin layer which can be identified easily during myomectomy, known as fibroid pseudocapsule PC.

This layer contains bundle of smooth muscle cells and neurotransmitters. Besides, it is highly vascular to supply blood to the myoma and allows neovascularization to occur This statement is proven in studies showing an upregulation of endogolin and CD34 marker of neovascularization in the PC compared to the fibroid and surrounding myometrium 32 , Thickness of the PC varies with the type and location of the fibroid which may alter the expression of modulators.

The thickness also increases as the fibroid approaches to the cervix resulting an increase in the expression of enkephalin and oxytocin which will alter the UP and affect fertility The altered UP may also be contributed by the high levels of neurotensin, neuropeptide tyrosine, and protein gene product 9.

The presence of PC and the associated cytokines, growth factors and hormones may be responsible for the abnormal UP which may result in pregnancy complications like premature uterine contraction resulting in preterm delivery in women with large IM fibroids Although these neurotransmitters produced by PCs induce UP, they are important in promoting inflammation and proper wound healing. So, it is mandatory to perform intracapsular myomectomy without excising the PC to reduce intraoperative blood loss, enhance better uterine healing and correct musculature anatomical restoring to preserve the uterine functionality for reproductive purpose 37 - Uterine fibroid does not present in pre-puberty and rarely post-menopausal with low incidence in multiparity and late menarche This implies that fibroid development depends on the hormonal status.

Ovarian steroids, oestrogen E2 and progesterone P4 are responsible for the formation and growth of the fibroid Fibroids are known as E2-dependent tumour since E2 is the primary growth promoter of fibroids 43 , High level of E2 decreases the tumour suppressor protein p53 in the fibroid cells and regulates its growth factors and signalling pathways, stimulating cellular proliferation and fibroid growth Previous studies have shown that the growth of fibroid is solely dependent on E2 and inhibited by P4 However, recent studies concluded that P4 plays an equally important role as E2 in fibroid growth and maintenance 47 , Besides, P4 will stimulate the signalling pathways by increasing the proliferating cell nuclear antigen causing proliferation and anti-apoptotic B-cell lymphoma protein 2 while decreasing the cleaved caspase 3 causing anti-apoptosis 43 , As a result, the fibroid cells will continue to proliferate without apoptosis 41 , Ishikawa et al.

This showed that both E2 and P4 are mandatory for fibroid growth and maintenance, the absence of either one will not stimulate cellular proliferation.

They also found high PR expression in any groups treated with E2, demonstrating the essential of E2 in PR upregulation. Besides promoting fibroid growth, E2 and P4 are involved in uterine peristalsis.

A study has demonstrated a significant higher peristalsis rate in E2 perfusion but lower in P4 perfusion This is because the endometrial oxytocin and oxytocin receptor which are responsible UP are up-regulated by E2 High E2 level stimulates the JZ and subsequently induces rapid uterine contraction whereas P4 antagonizes the effect of E2 and suppresses the uterine contractility.

In short, hormonal factors are involved in fibroid development. Medications which suppress E2 such as GnRH agonists, selective oestrogen receptor modulators and aromatase inhibitors and medications which suppress P4 like PR modulators will be beneficial in fibroid treatment. The summary of the causes of IM fibroids affect fertility are well described in Figure 2.

SM fibroids type 1 and 2 fibroids are proven to affect fertility and hysteroscopic resection-helps to improve the reproductive outcomes.

SS fibroids type 5, 6, 7 fibroids do not affect fertility, as they do not protrude into the endometrial cavity 3. However, the effect of NCD IM fibroids such as type 3 and 4 fibroids on fertility remains controversial with studies yielding conflicting results. Here, we will review on 10 retrospective studies and 5 prospective studies which show the impact of NCD IM fibroids on fertility outcomes. The participants of these studies consisted of women who were undergoing assisted reproductive treatment ART IVF and ICSI as they were believed to be more sensitive to study on the implantation process 50 , Yan et al.

In Khalaf et al. Besides, Eldar-Geva et al.