Limits, Effectivity and Efficasy in ARTLimits, Effectivity and Efficasy in ART

Yücel KaramanYücel Karaman MD. Prof. MD. Prof.IVF and Endoscopic Surgery CenterIVF and Endoscopic Surgery CenterBrussel’s Women’s Health & Infertility CenterBrussel’s Women’s Health & Infertility Centerwww.istanbulivf.comwww.istanbulivf.com

Laparoscopic MyomectomyLaparoscopic Myomectomy

• Uterin myomas are the most common benign uterine tumor found in women

» Crammer et all 1995

• They are estimated to occur in 20-50% of women >30years

• Genetic predisposition seems to contribute to the development of myomas (black women) 3-9 times more than white women

» Wallach et all 1992

Symtoms of Myomas

• Usually asymtomatic• Most common symptoms

• Mass effect of the enlarged uterus on adjacent pelvic organs

• Abnormal uterine bleeding• Severity of symptoms depends on the size,

position, and number of fibroids.

Diagnosis

• Transvaginal ultrasound and/or hydrosonography

• Hysteroscopy

Causes of Reduced Implantation

• Impared gamet transport• Distortion of the endometrial cavity• Impairment of blood supply of the endometrium• Atrophy and ulcerations of the endometrium• Aberant Endometrial Growth Factor expression

Eldar – Geva et all 1998Buttram V.C. Et all 1981

Myomas

• Submucosal Myomas

• Intramural

• Subserosal

Submucosal Myomas

• Improved pergnancy outcome after myomectomy

Pritts 2001

Subserosal Myomas

• Have no influence on pregnancy outcome compared to control group

Elder – Geva - 1998

Effects of Myomas on Fertility in patients undergoing assisted

reproduction

• The aim is to evaluate the current data to understand the impact of intramural leimyomata on pregnancy outcome in ART without cavitary distortion.

Benecke et all 2005

Patients Selection

• Pregnancy date on IVF• Intramural myomas with no cavitary

distortion• Control group with no myomata

150 Articles were reviewedBenecke et all 2005

End points of the study

• Pregnancy rate per transfer

• Implantation rate per transfer

• Ongoing Pregnancy rate/transfer

Results

Myoma Group

Control Group

Odds ratio (95% CI)

Implantation Rate 12.1%(143/1181)

20.96(676/3224)

0.64(0.52-080)

Pregnancy ratePer transfer

30.47(160/525)

40.45 (661/1634)

0.72(0.57-090)

Ongoing Pregnancy

rate/transfer

26.75%(103/385)

34.94%(537/1537)

0.65(0.50-0.85)

Benecke 2005

• Uterine corporal myomata not encroaching the cavity and <7cm in mean diameter do not affect the implantation or miscarriage rate in IVF/ICSI

Uterine myomata and outcome of ART Uterine myomata and outcome of ART (39 patients) Ramzy et all 1998(39 patients) Ramzy et all 1998

Effects of Myomas on Fertility in patients undergoing assisted

reproductionResults of Meta Analysis showed that :

• There was a significant negative impact on implantation rate in the intramural myomata groups versus the control groups:16,4 vs 27,7% - OR 0,62 (0,48-0,8)

• The delivery rate per transfer cycle was also significantly lower 31,2 vs 40,9 % - OR 0,69 (0,50-0,95)

Benecke et all Gyn/Obs. İnvest March - 2005

Intramural Myomas

Based on this results• Intramural myomata affect pregnancy

outcome in ART

• Must be taken into consideration particularly in previous failed ART cycles

Benecke - 2005

Conclusion of this meta analysis

• This study showed that;• Patients with intramural fibroids have a lower

implantation rate per cycle

• The studies did not shed new light on the size of intramural myomata that could affect the outcome

• In previous failed IVF cycles, myomectomy should be considered.

Benecke et all Gyn/Obst Invest March - 2005

What is not clear from the article?

1. The size of intramural myomata without intracavitary involvement varied and no final conclusion could be drawn based on the article

2. Although the studies did not correlate pregnancy rates with the size of the myomata as well as their position and distance from uterine cavity.

In a recent review by PRITTS

“There was doubt on the approach towards the intramural myomata and removal of the myomata was not recommended”

Pritts et all - 2001

But;• Prospective data by HART et all

• Retrospective studies reviewed by Benecke et all Concluded that;They lean more towards a surgical removal of myomata, especially 1. if located close to uterine cavity2. the size ≥ 2cm in diameter

Hart et all 2001

Benecke et all 2005

Impact of subserosal and intramural myomas(without endometrial cavity

distortion) on the outcome of in IVF-ICSI (245 Patients)

• If myoma ≤4cm, IVF-ICSI outcomes is similar to those without myomas

• However they recomended surgery, if myoma ≥4cm

Oliveira et all 2004

Removal of myomata

• Implantation rate significantly • Ongoing pregnancy rate

This approach must be considered especially in patients with previous failed IVF with intramural myoma.

Which method should be used to remove intramural myomata?

• Laparoscopic surgery• Laparotomic microsurgery• Robotic Laparoscopic Surgery

Laparoscopic Myomectomy

Intra-ligamenter myomectomy

Sesil subseros myoma

Intramural myomectomy

Intra-corporeal Sutur

Morcelator

Morcelation

Laparoscopic Myomectomy

All Patients 196

Patients want to be pregnant

112

Pregnancy 73

Miss carriage 13

Delivery (27 VD, 33C/S) 60

Uterine Rupture 0

Y. Karaman 2006Y. Karaman 2006

(Laparoscopic Myomectomy) Pregnancy Rates

• 27 patients form pregnancy

• 1 patient uterine rupture 34th week

• 20 patients (71%) Normal vaginal delivery

• 8 patients (29%) C/S

Dubisson et all 1998 Dubisson et all 1998

CONCLUSION• Intramural myomata without intracavitary

involvement have an impact on pregnancy outcome in ART and surgical removal must be considered especially in patients with previous failed ART cycles.

• Intramural myomata with intracavitary involvement has to be removed.

• Myomectomy can be performed easily by laparoscopic surgery in the hand of the well trained surgeons.

• We await in anticipation a prospective randomized controlled trails that assess the effect of the size and position of intramural myoma on fertility in ART

CONCLUSION

• But, prospective randomized studies are difficult to conduct because of physician training and preferences, patient preferences, and women’s understandable reluctance to be randomized to a major surgical procedure.