Minimally Invasive Therapy.

2011;20:338345

ORIGINAL ARTICLE

Laparoscopic myomectomy in patients with uterine myomas associated

with infertility
ANDREAS HACKETHAL1, ANNE WESTERMANN1, GARRI TCHARTCHIAN2,
FRANK OEHMKE1, HANS-RUDOLF TINNEBERG1, KARSTEN MUENSTEDT1,
BERND BOJAHR2
1

Department of Obstetrics and Gynecology, Justus-Liebig-University of Giessen, Giessen, Germany, and 2Clinic for
Minimally Invasive Surgery, Berlin, Germany

Abstract
Although myomectomy is widely accepted in women of childbearing age who wish to retain their fertility, the extent to which
myomas affect fertility and whether their removal improves this remain unclear. This study aimed to elucidate the favourable
surgical approach in women with uterine myomas and infertility. This retrospective, follow-up study was carried out in three
centres in Germany. Data on women who had undergone myomectomy via laparoscopy, laparotomy or conversion to
laparotomy in 200004 were collected and analysed. Fertility outcome after myomectomy was assessed by follow-up postal
questionnaire in a subgroup of women with myoma-associated infertility. Data on 159 women with otherwise unexplained
infertility were included (mean age 35 years (range 1747), mean number of myomas 2.4 (range 18) and mean myoma size
6.1 cm (range 0.520)). Women who underwent laparoscopy had fewer complications. 39.6% (63/159) of women completed
the questionnaire, which showed that the pregnancy rate after myomectomy was 46% in this group. No uterine rupture
occurred. Laparoscopy is associated with fewer postoperative complications and since no preoperative or intraoperative factors
seem to inuence the fertility outcome in women with uterine myomas, it is the treatment of choice in these patients.

Key words: Uterine myoma, broids, laparoscopic myomectomy, fertility, delivery mode, uterine rupture, subsequent pregnancy

Introduction
Around a third of women of childbearing age have
uterine myomas. These cause bleeding disorders and
pain, including dysmenorrhoea and pelvic pressure
pain, and may also result in infertility. Approximately
510% of infertile women have uterine myomas
commonly multiple myomas. Uterine myomas may
interfere with gamete transport by distorting the uterine cavity and obstructing the tubal ostia, and they can
bring about changes in the endometrium which affect
embryo implantation and growth (1).
Table I shows the effect and inuence of uterine
myomas and myomectomy on fertility and pregnancy.
The best treatment for preserving or enhancing fertility in women with uterine myomas remains unclear.
Although systematic reviews by Pritts and Klatsky

concluded that only those myomas with submucosal

or intracavitary components are associated with
reduced fertility, various surgical and non-surgical
methods of treating myomas and increasing the rate
of natural and assisted conception in affected women
have been suggested (25). These include laparotomy, laparoscopy, hysteroscopy, gonadotrophin
releasing hormone agonist (GnRH) analogues and
uterine artery embolisation (611). Verkaufs study
of myomectomy in the treatment of recurrent abortion and infertility reported that approximately half of
affected women who had not previously become
pregnant conceived after this procedure (12). Controversy also exists over the tensile strength of the
uterotomy scar during a subsequent pregnancy, since
there is a risk of uterine rupture, especially during
labour contractions.

Correspondence: A. Hackethal, Universittsfrauenklinik Giessen, Klinikstrasse 32, D-35392 Giessen. Fax: +49 641 99 45139.
E-mail: andreas.hackethal@gyn.med.uni-giessen.de
ISSN 1364-5706 print/ISSN 1365-2931 online
2011 Informa Healthcare
DOI: 10.3109/13645706.2010.541922

Laparoscopic myomectomy in infertility

347

Table I. Effect and inuence of uterine myomas and myomectomy on fertility and pregnancy*.

Fertility impaired by

Inuence of pregnancy

Before myomectomy

After myomectomy

Interference and alterations in endometrium

Location of uterotomy

Size, number and location of myomas

Surgical complications

Distortion of the uterine cavity

Adhesions

Abortion

Uterine dehiscence

Intrauterine growth restriction

Risk of uterine rupture

Placental abnormalities
Malpresentation
Preterm delivery
*Adapted from Somiglianna 2007.

There are additional areas of uncertainty in relation

to improving the likelihood of conception after myomectomy. These include the following: The lack of
data on which to base decisions on whether laparoscopy or laparotomy is the best surgical approach to
follow; patient parameters such as the number and
size of broids, age and co-factors; and suture techniques and layers. We conducted this study to clarify
some of these uncertainties so that the optimal treatment for these patients can be determined.

Material and methods

Subjects
In this study, all patients who had undergone myomectomy at the Department of Obstetrics and Gynaecology of the Justus-Liebig-University, Giessen, the
Asklepios Clinic, Lich or the Clinic for Minimally
Invasive Surgery, Berlin, Germany, between 1 January
2000 and 31 December in 2004 were identied
from patient records. Patients who had undergone
Eligible patients with myomectomy between 1/2000 and
12/2004 in examined centres (n = 316)

submucous myomectomy by hysteroscopic procedures were excluded from the analysis. The group
of women with primary or secondary infertility in
which myoma was the only apparent cause was subject
to further evaluation (Figure 1). Their medical history
and information on the surgical procedure and
their postoperative course were recorded for further
evaluation.
We contacted these women between November
2005 and March 2006 and asked them to complete
a questionnaire which included items on their postoperative course and subsequent fertility. The pregnancy rate after myomectomy was correlated with the
patients age, previous pregnancies, myoma number,
the size and location of the largest myoma, intraoperative and postoperative data and the type of surgical approach in order to assess the inuence of
these factors on the probability of conception after
myomectomy.
Classication of myomas
Myomas were classied according to the operative
notel as follows:
.
.

Patients with infertility

(n = 159)

Total (n = 159)
LSK (n = 64)
LAP (n = 51)
Conv (n = 44)

Patients responding to
questionnaire (n = 63)

Total (n = 63)
LSK (n = 29)
LAP (n = 20)
Conv (n = 14)
Figure 1. Flow diagram of study population.

Intramural if more than 50% developed in the

uterine wall
Subserous if more than 50% of the myoma was
covered by the serosal layer
Pedunculated if more than 80% developed
within the abdominal cavity

Laparoscopy procedure
All myomectomies were performed under general anaesthesia. In laparoscopic myomectomy, a
710 mm laparoscope was inserted through a subumbilical trocar. Additional working trocars (5 mm)
were then inserted one suprapubic trocar was

348

A. Hackethal et al.

positioned in the midline and two lateral trocars were

positioned in the left and right lower abdomen lateral
to the supercial epigastric artery. Before opening
the uterine wall above the myoma pseudocapsule
with a monopolar hook, a vasoactive agent POR 8
(ornithine-8-vasopressin,
Sandoz,
Holzkirchen,
Germany) or Glycylpressin (terlipressin, Ferring,
Kiel, Germany) was injected. A myoma screw was
then inserted into the myoma and it was enucleated
using constant traction combined with blunt
dissection. A bipolar energy source was used reluctantly to reduce tissue necrosis and preserve the
myometrium.
After all visible myomas had been enucleated, the
uterotomy was closed. Up to three layers of sutures
were used, depending on the type of incision. Deep
and supercial myometrial incisions were closed
using interrupted absorbable Vicryl 2-0 sutures
(polyglactin 910, Ethicon, Norderstedt, Germany)
and the uterine serosa was closed with continous
PDS 2-0 or 3-0 sutures (polydioxinone, Ethicon,
Norderstedt, Germany). Pedunculated myomas were
removed by electrocoagulation of the pedicle.
Myomas were then morcellated using either a
15 mm or 20 mm electrical morcellator which
was inserted in place of the left 5 mm working
trocar. The abdominal fascia of ports 10 mm
was closed with interrupted Vicryl sutures 2-0.
The skin wound was closed with intracutaneous
Monocryl or Dermabond topical skin adhesive
(poliglecaprone 25 and Dermabond, Ethicon,
Norderstedt, Germany).
Laparotomy
Laparotomy was performed under general anaesthesia through a transverse lower abdominal incision
following the Pfannenstiel Querschnitt technique.
The procedure followed for myomectomy was the
same as that given above for laparoscopy. In closing
the abdominal wall, the peritoneum was not approximated. The fascia was closed with a continuous
suture (PDS 0) and after subcutaneous adaptation,
if appropriate, intracutaneous continuous adaptation
with Monocryl was performed.

Conversion to laparotomy
Conversion after diagnostic laparoscopy or as
a result of complications was dened as myomectomy performed by laparotomy after an intended laparoscopic surgical approach. It followed
the same surgical procedures as described for
laparotomy.

Complications
Intraoperative complications were dened as opening
of the uterine cavity, injury to adjacent organs or
major bleeding (>1000 ml). Postoperative complications were dened as persistent abdominal or
shoulder pain, a fall in the haemoglobin concentration
>2.4 mmol/l, revision surgery, temperature >38.0 C,
haematoma at the trocar insertion site or intraabdominal nerve injury and ileus. During the study
period, no adhesion prevention barriers or other
agents were used.
Statistical analysis
Data management and statistical analysis were performed using descriptive statistics and cross tabulation by SPSS for Windows, Version 15.0. The x2 and
Students t test were used to analyse results. For
between-groups statistical analysis, we used analysis
of variance (ANOVA). A probability value of
<0.05 was regarded as statistically signicant.
Ethical approval
Approval for the study was sought from the ethics
committee of the University of Giessen and granted in
all cases. All subjects in the follow up subgroup gave
informed consent.
Results
A total of 159 patients with infertility, which was
unexplained by any factors other than myoma, were
included in the study. At surgery their mean age was
35 (range 1747) years; mean number of myomas was
2.4 (range 18) and mean myoma size was 6.1 cm
(range 0.520 cm). Laparoscopic myomectomy was
associated with a signicantly earlier return to normal
activities (laparoscopy 22.4 15.8 days, laparotomy
36.3 9.9 days, conversion 27.8 13.1 days, ANOVA
F: 5.9, p = 0.05) and a trend towards lower blood loss
(laparoscopy: 120 111.4 ml, laparotomy 266.9
250.1 ml and conversion: 200.8 159.1 ml). Patients
with multiple uterine myomas were more likely than
others to undergo laparotomy (laparotomy: 2.9 2.4,
laparoscopy 1.4 0.9, conversion 3.1 2.3, ANOVA
F: 13.5, p = 0.000).
Data on the broid characterization and perioperative data are summarized in Table II. The hospital
stay was signicantly shorter in the laparoscopy group
(p = 0.000). A questionnaire on the postoperative
course and fertility outcome was sent to all these
women and was completed by 39.6% (63/159).

Laparoscopic myomectomy in infertility

349

Table II. Surgical approach-dependent broid characterization and perioperative data in the subgroup of infertile women (n = 159).
Laparoscopy (n = 64)
Number of enucleated myomas (n)

1.4 0.9 (1; 5)

Diameter of largest myoma (cm)

5.5 3.7 (0.5; 20.0)

Laparotomy (n = 51)

Conversion (n = 44)

2.94 2.3 (1; 4)

3.1 2.3 (1;8)

7.1 4.1 (1.5; 20.0)

5.9 2.7 (2.0; 12.0)

Myoma location: (n)

pedunculated

38.1% (24/63)

16% (8/50)

7.1% (3/42)

subseroes

34.9% (22/63)

52% (26/50)

57.1% (24/42)

intramural

27.0% (17/63)

32% (16/50)

35.7% (15/42)

Uterine location: (n)

fundal

24.6% (15/61)

20% (10/50)

13.6% (6/44)

anterior wall

21.3% (13/61)

14% (7/50)

13.6% (6/44)

posterior wall

26.2% (16/61)

14% (7/50)

18.2% (8/44)

different

27.9% (17/61)

52% (26/50)

54.5% (24/44)

2% (1/51)

2.3% (1/43)

Suture layers: (n)

none

19% (12/63)

one

28.6% (18/63)

47.1% (24/51)

44.2% (19/43)

two

46% (29/63)

45.1% (23/51)

27.9% (12/43)

three
Duration of surgery (min)

6.3% (4/63)

5.9% (3/51)

25.6% (11/43)

107.9 52.2 (20.0; 251.0)

145.7 46.8 (68.0; 310.0)

125.4 49.7 (35.0; 333.0)

Complicationrate: (n)
intraoperative
postoperative
hospital stay (d)

10.9 (7/64)

11.8 (6/51)

40.9 (18/44)

3.2 (2/64)

17.6 (9/51)

6.8 (3/44)

3.5 2.2 (1,11)

8.8 2.0 (5,16)

7.7 2.3 (2,14)

The mean age of women in this subgroup who

conceived after myomectomy did not differ signicantly from the mean age of all study subjects. The
overall pregnancy rate was 46% (29/63). In this subgroup, 44.8% (13/29) women who had undergone
primary laparoscopy became pregnant, compared
with 45% (9/20) who had had laparotomic myomectomy and 50.0% (7/14) of those who had had a
conversion procedure (Table III). The abortion rates
were 4.7% (1/21) after laparoscopy, 26.3% (5/19)
after laparotomy and 9.1% (1/11) after conversion
to laparotomy. All of these were early abortions.
There was no reduction in the rate of abortion as a
result of myomectomy in either group. Interestingly,
no intraoperative factor such as myoma number or
size, number of suture layers or opening of the uterine
cavity inuenced the fertility outcome (Table III).
One nding, which is not statistically signicant but
noteworthy, is the doubled postoperative complication rate seen in women who subsequently failed to
become pregnant. Analysis by surgical approaches
showed that the complication rate for laparotomy
was 17.6% (9/51) and that for laparoscopy was
3.2% (2/62) (P = 0.02) (Table III). After laparotomy
the patients were more likely to deliver by caesarean

section (83.3% compared with 50%). No uterine

ruptures were noted in study subjects.
Discussion
Laparoscopic myomectomy was rst described in
1979 (13). Over the past 25 years, improvements in
instruments and techniques and greater operator
experience have increased the use and consolidated
the success of this procedure. (14,15). In this study we
endeavoured to clarify a number of uncertainties
which still exist in relation to improving the likelihood
of conception after myomectomy, including the lack
of data on which to base decisions on whether laparoscopy or laparotomy is the best surgical approach to
follow; patient parameters such as the number and
size of broids, age and co-factors; suture techniques
and layers and delivery modes.
Our results suggest that the likelihood of becoming
pregnant after myomectomy is not inuenced by
factors related to the uterine myomas or intrasurgical
aspects. However, women who failed to become
pregnant after myomectomy were more likely to
have experienced complications during or after surgery. These results conrm previous ndings that

350

A. Hackethal et al.

Table III. Characteristics of subjects and perisurgical factors in relation to fertility outcome in the subgroup of 63 women who completed the
follow up postal questionnaire.

Age, mean SD years

Women who became pregnant

(n = 29, unless otherwise stated)

Women who did not become pregnant

(n = 34, unless otherwise stated)

34.0 4.0

34.9 5.2

Surgical approach, no (%)

Laparoscopy

13 (44.8)

16 (47.1)

Laparotomy

9 (31.0)

11 (32.4)

Conversion

7 (24.1)

7 (20.6)

Number of myomas, mean SD

2.3 1.8

1.9 1.6

Size of myomas, mean SD (cm)

5.1 3.2

5.5 3.0

Type of myoma, no (%)

Subserous/pedunculated
Intramural

8 (27.6)

10 (30.3)

15 (51.7)

15 (45.5)

Subserous/intramural
Location of myoma, no (%)

6 (20.7)
n = 28

8 (24.2)
n = 32

Fundal

4 (14.3)

5 (15.6)

Anterior wall

7 (25.0)

5 (15.6)

Posterior wall
Different location
Layers of suture, mean SD

5 (17.9)

9 (28.1)

12 (42.9)

13 (40.6)

1.5 0.8

1.7 0.9

117.3 40.9

126.9 55.1

Intraoperative complications, no (%)

5 (17.2)

8 (23.5)

Opening of uterine cavity, no (%)

4 (13.8)

6 (17.6)

Postoperative complications, no (%)

3 (10.3)

7 (20.6)

Operation time, mean SD min

laparoscopic myomectomy is associated with a lower

requirement for postoperative analgesia, reduced
blood loss and faster postoperative recovery than
laparotomy (16,17). Since the women who underwent
laparoscopic myomectomy had fewer complications
than those in the laparotomy group, this surgical
approach is recommended for women with uterine
myomas associated with infertility.
A vast variety of factors inuence the decision for
the surgical approach, wound healing process and
subsequent fertility. Most studies either focus on
the uterine pathology or on surgical aspects. The
strength of this study is the evaluation of different
pre- intra- and postoperative factors and their inuence on fertility outcome.
One weakness of our study might be the limited
number of subjects who participated in the follow-up.
However, the group was large enough to give sufcient statistical power to our analysis and was also
fairly evenly balanced between women who had
undergone laparoscopy and laparotomy. Another
weakness might be the specialist nature of the hospitals, which might mean that the data would not be

generalisable. Two of the three institutions in the

study are centres of excellence for endoscopic surgery
and the positive outcome for laparoscopy might be
biased as a result. The mean time between surgery
and recall was 3 years and 11 months. Therefore the
rate of postoperative complications might be modied
by subsequent complications after the questionnaire.
In earlier work, we analysed quality assurance data
in Hesse, Germany and showed that over 36% of
myomectomies are performed by laparoscopy (18). In
the present study, the laparoscopy rate in the subgroup of women with infertility was 67.9% (108/159),
however, the subsequent conversion to laparotomy
was quite high at 27.7% (44/159). Unfortunately, the
data did not allow us to differentiate between conversions performed because of complications and
conversions after a diagnostic laparoscopy. In the
latter case, particularly, laparoscopy-assisted myomectomy, might have benets in evaluating the peritoneum for endometriosis.
In cases of infertility or sterility and uterine myomas, the indications for myomectomy depend on a
number of factors. These include the patients age, the

Laparoscopic myomectomy in infertility

size of the myomas, their number and location within
the uterus, concomitant myoma-related symptoms
and any additional infertility factors (19). The
presence of additional factors which may affect
conception adversely should be given adequate
weight when deciding between different treatment
options. For example, the in vitro fertilisation study
by Oliveira et al. reported that intramural myomas
>4 cm were associated with signicantly lower pregnancy rates (20).
There are few reported data on pregnancy after
myomectomy. The pregnancy rates after laparoscopic
myomectomy are comparable with rates after laparotomic myomectomy (21,22). Our results show pregnancy rates of 44.8%50.0% in the laparoscopy and
laparotomy groups respectively after myomectomy.
These conrm pregnancy rates in other studies ranging from 33.3% to 64% within one year of myomectomy (5,2224).
There is no general agreement in the published
reports over the best surgical approach to myomectomy in patients with infertility. Various studies have
attempted to clearly show the benet of one approach
over the other. However, a recent meta-analysis concludes that the rate of major complications, pregnancy
and recurrence were comparable in the laparoscopic
and laparotomic groups (25). Besides individual
surgeons experience and preferences, the factors
inuencing the decision include the number of myomas, myoma size, localisation and previous surgery.
Since the characteristics of myomas should not determine whether or not laparoscopy is suitable in the
hands of experienced surgeons, the accepted main
determinants of the pregnancy rate after myomectomy are patients age, diameter and intramural localisation of the myomas and type of surgery (14,22).
Our results suggest that none of the patient characteristics or factors related to myomas described here
have any inuence on subsequent pregnancy rates.
It is generally believed that a good fertility outcome
after myomectomy is associated with atraumatic tissue handling, minimization of coagulation, adequate
wound adaptation and reducing adhesion formation.
Questions concerning the number of suture layers
used to close a uterotomy have not been answered
satisfactorily because of a lack of trials comparing
myoma size and suture technique. This retrospective
analysis showed a large range from 0.520 cm of
myoma size. Concerns have been raised over adequate wound closure during laparoscopy, as this
demands skilled and experienced surgeons. In our
series, the rate and number of suture layers used in
laparoscopy was comparable with those employed in
laparotomy. This suggests that the difference of
myoma size between the laparoscopy and laparotomy

351

groups did not lead to a divergent uterine wound

management but was more inuenced by the
surgeons preference and rationality.
In this study, no differences were identied
between women who became pregnant after myomectomy and those who did not (Table III). Other studies
have also been unable to nd evidence of a difference
in outcome in terms of pregnancy and live birth rates
when myomectomy for infertility is performed via
laparotomy or laparoscopy (17). Gavai et al. concluded that no differences affecting fertility exist in
relation to whether or not the uterine cavity is
opened and the number and size and localisation of
myomas (26).
In a previous study, multivariate analysis showed
that patients undergoing laparoscopic procedures had
a higher possibility of conceiving, possibly because of
a reduced occurrence of adhesions (27). Surgery often
results in the formation of intra-abdominal adhesions.
After myomectomy, the risk of pelvic adhesions,
which further compromise fertility, has to be taken
into account. It has been suggested that the use of
adhesion formation reduction agents such as icodextrin, hyaluronic acid or oxidized regenerated cellulose
adhesion barrier might increase fertility rates by up to
78% (28,29). However, during the study period, no
adhesion barriers were used.
There are few data on modes of delivery in pregnant
women who have undergone myomectomy. As the
experience and self-condence of surgeons increases
there may be a shift from always performing a caesarean section in these women to advocating spontaneous delivery in some. Some authors suggest that
vaginal delivery is possible in 42.9% to 80.6% of
women who become pregnant after laparoscopy.
(3033). The present study has conrmed the feasibility of vaginal delivery after laparoscopic myomectomy with rates of 50% (6/12) after laparoscopy and
conversion procedures (3/6).
The occurrence of uterine ruptures has been
reported from the rst trimester of pregnancy to the
end (34,35). Besides spontaneous ruptures, these
might occur after any kind of uterotomy (3638).
Uterine rupture after myomectomy is rare; it has an
incidence of 1% and a reported range of 0.24% after
laparoscopic myomectomy to 5.3% after abdominal
myomectomy (32,33,39). In this study, no uterine
ruptures occurred. Prospective randomized trials
should be initiated to conrm the ndings of this
study.
In conclusion, the retrospective analysis shows that
laparoscopic myomectomy is associated with fewer
complications and with the same subsequent pregnancy rates as laparotomic myomectomy. It appears
to be the preferred surgical approach to myomectomy

352

A. Hackethal et al.

for skilled surgeons, regardless of myoma number,

size and localisation.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
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