Hysteroscopic myomectomy and ART
Epublication WebSurg.com, Feb 2015;15(02). URL: http://websurg.com/doi/lt03encampo011
Fibroids represent an extremely common benign uterine pathology, the incidence of which increases with age, and approximately 10% of women with infertility problems will present a myoma. The association between uterine myoma and infertility is still controversial. Evidence exists that subserosal myomas do not impair the pregnancy rate in IVF whereas submucous myomas significantly decrease the implantation rate. Unfortunately, the effect of intramural myomas upon reproduction outcomes remains unknown, and until now no adequate diagnostic and therapeutic guidelines have been established. Magnetic resonance imaging (MRI) imaging has redefined the functional anatomy of the uterus. Contrarily to ultrasound, MRI demonstrates that the non-pregnant myometrium is not a homogeneous smooth muscle mass but consists of two different structural and functional entities. The myometrium adjacent to the endometrium is a different hormone-dependent uterine compartment called junctional zone (JZ) myometrium. It is a functionally important entity in reproduction and it is ontogenetically related to the endometrium. Submucosal fibroids originate from this JZ myometrium and differ from subserosal fibroids as they have less cytogenetic abnormalities, less expression of Sex Steroid Hormone receptors, and they are more responsive to GnRH analog treatment and provide fewer recurrences after surgery. Despite the lack of randomized studies, the sharp decline in pregnancy rates in case of submucous myoma is quite convincing and it is based on the existing evidence that myomectomy should be performed prior to ART for junctional zone myomas which protrude into the uterine cavity. We demonstrate the different modern techniques of hysteroscopic myomectomy, the new instrumentation, the tips and tricks, the possible complications and clinical outcome.