Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Submucous fibroids should be removed in infertile women
- Adam Magos, Pietro Gambadauro, Ioannis Tsibanakos, Amalia Georgakaki, Ioannis Kakaidis, Fady Moiety (19 January 2009)
-
improved fertility after myomectomy
- koneru gangadhara rao (22 January 2009)
-
Uterine Fibroids and fertility retaining intervention
- Klim McPherson, Anna- Maria Belli, Mary Ann Lumsden, Isaac Manyonda and Jon Moss (16 February 2009)
|
|
|||
|
Adam Magos, Consultant Gynaecologist Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, England, Pietro Gambadauro, Ioannis Tsibanakos, Amalia Georgakaki, Ioannis Kakaidis, Fady Moiety
Send response to journal:
|
Having a particular interest in the management of uterine fibroids, we looked forward to reading Professor Farquhar’s interpretation of the data regarding the relationship between fibroids and infertility (1). We agree with much of what she has written but cannot help but feel that she presents an unnecessarily negative, alarmist and to some extent misleading view of the potential benefits of excising submucous fibroids in women who have difficulty with their fertility. The conclusion that there is insufficient evidence to support the routine removal of fibroids before infertility treatment seems to be largely based on the only prospective randomized trial so far published on the topic (2). While Professor Farquhar points out the statistical errors in this study, she does not mention the fact that (a) the study was grossly under powered (it only had a 40% power to detect a 20% improvement in pregnancy rates after myomectomy for submucous fibroids compared with no treatment), (b) the published manuscript included not only statistical errors but also very important and misleading typographic errors in the discussion which unfortunately Professor Farquhar perpetuates by quoting verbatim (“SM (submucosal) fibroids are not a major cause of infertility” at the end of the discussion must actually refer to subserosal fibroids), and related to this (c) the authors compounded this (typographically) erroneous conclusion by misquoting a study whose subject was actually laparoscopic myomectomy for intramural and subserous fibroids and not the treatment of submucous fibroids (3). Although Professor Farquhar alludes to the fact that “the fibroids in this study were small and not numerous”, this does not make it clear just how limited the inclusion criteria were for this study which only looked at a relatively uncommon cohort, women with a maximum of two fibroids no larger than 4 cm in diameter. Considering all these weaknesses, it does not seem to us good science to use this particular report as the basis for any treatment recommendations especially when there are numerous other studies which conclude that fertility and obstetric outcome are improved when submucous fibroids are removed (4). Neither do we think it fair to make a blanket statement that myomectomy is associated with “haemorrhage, adhesions and rarely hysterectomy, as well as uterine rupture during pregnancy”. Yes, these are recognised risks with open and laparoscopic myomectomy, but the chance of any of these complications occurring with hysteroscopic myomectomy for a submucous fibroid must be as close to zero as possible (5). It is important to distinguish the type of myomectomy when talking about treatment complications as in this regard hysteroscopic myomectomy and the other routes of surgery are very different. Finally, and on a lesser point, we were surprised that Professor Farquhar quoted a study published 16 years ago which seems to have considerably underestimated the true prevalence of fibroids (6). In 2003, Day Baird et al showed in an ultrasound based survey that the cumulative incidence of uterine fibroids is >80% in black women and almost 70% in white women by the age of 50 (7). Uterine fibroids are therefore much more prevalent than we had previously appreciated. So, fibroids are very common, virtually all the evidence points to the fact that submucous fibroids in particular compromise fertility and their excision improves fertility, and we also know that hysteroscopic myomectomy is a relatively safe procedure. In our view, women with submucuous fibroids and subfertility should be offered hysteroscopic myomectomy (if appropriate) sooner rather than later and certainly before embarking on expensive and stressful fertility treatments. There may be some uncertainty with such a protocol, but not much. 1. Farquhar C. Practice Uncertainties Page. Do uterine fibroids cause infertility and should they be removed to increase fertility? BMJ 2009;338:b126 2. Casini ML, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility. Gynecol Endocrinol 2006;22:106-9. 3. Dessolle L, Soriano D, Poncelet C. Determinants of pregnancy rate and obstetric outcome after laparoscopic myomectomy for fertility. Fertil Steril 2001;76:370–374. 4. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fert Steril 2008;early electronic publication (11 Mar). 5. Di Spiezio Sardo A, Mazzon I, Bramante S, Bettocchi S, Bifulco G, Guida M, Nappi N. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Hum Reprod Update 2008;14:101-19. 6. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992;58:1-15. 7. Day Baird D, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003;188:100-7. Competing interests: None declared |
|||
|
|
|||
|
koneru gangadhara rao, professor,nri medical college,chinakakani,vijayawada ap .india vijayawada-10
Send response to journal:
|
patients may have recurrent abortions and infertility with posterior wall submucus fibroids due to failure of implantation. Intramural fundal myomas obstructing tubal orifice and cervical fibroids cause infertility. Treatment by myomectomy by lap or hysteroscopy will definitely increase the pregnancy rate. 25% of cases of patients with fibroids will have pid, so pid must be treated before myomectomy. small fibroids in selected cases can be taken care of by uterine artery embolisation or laparoscopic myolysis Competing interests: Fertility-Fibroids |
|||
|
|
|||
|
Klim McPherson, Visiting professor of public health epidemiology Oxford University OX3 9DU, Anna- Maria Belli, Mary Ann Lumsden, Isaac Manyonda and Jon Moss
Send response to journal:
|
Cynthia Farquar and Adam Magos discuss an increasingly relevant clinical concern. Women are increasingly delaying pregnancy to pursue their career and many regard hysterectomy for fibroids as too radical. If fibroids do significantly impair fertility then increaing numbers of women will be wanting to conceive at time when natural fertility is depleting and fibroids becoming rapidly more common. Currently myomectomy may be the treatment of choice for some, but less still is known about embolisation and it effects on fertility. If embolisation is associated with less morbidity, is less invasive and can be shown to be equal or better than myomectomy at preserving reproductive function then women may be benefit. Either way the question is important for understanding the effects of each on quality of life. Colleagues from Glasgow and St Georges and I are proposing a randomised study comparing myomectomy with embolisation head to head for women with troublesome fibroids requiring removal. Only this way can such questions be properly answered and we are seeking collaboration in such a trial among gynaecologists and intervention radiologist in the UK. Interested clinicians can contact us directly. Competing interests: None declared |
|||