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ORIGINAL RESEARCH |
From the Division of Reproductive Endocrinology, Department of Obstetrics & Gynecology, St. Luke’s-Roosevelt Hospital Center, University Hospital of Columbia University, College of Physicians & Surgeons, New York, New York; and the Division of Biostatistics, Columbia University School of Public Health, New York, New York.
Address reprint requests to: Martin D. Keltz, MD Department of Obstetrics and Gynecology St. Luke’s-Roosevelt Hospital Center 1000 10th Avenue New York, NY 10019
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Abstract |
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Methods: Women with diagnoses of infertility who had hysteroscopic evaluations by a single surgeon between 1975 and 1996 were sent a routine follow-up questionnaire regarding their reproductive histories. All 92 subjects who were located responded to the questionnaire, and 78 met inclusion criteria: age under 45 years, at least 12 months of infertility, and at least 18 months of follow-up with attempts to conceive, including in vitro fertilization in women with bilateral tubal occlusion.
Results: Of the 78 subjects, 36 had myomectomies, 23 had polypectomies, and 19 had normal cavities. Among the three groups, there were no significant differences in age, type of infertility, length of infertility, or follow-up after the procedure. Polypectomy subjects had significantly higher pregnancy and live birth rates than women with normal cavities. Women who had myomectomies larger than 2 cm had significantly higher pregnancy and live birth rates, achieving statistical significance at a myoma size of 3 cm or greater for live births. Spontaneous abortion rates among first pregnancies after myomectomy, polypectomy, or normal study were similar: 31.5%, 27.7%, and 37.5%, respectively.
Conclusion: Both hysteroscopic polypectomy and hysteroscopic myomectomy appeared to enhance fertility compared with infertile women with normal cavities. Despite concern that hysteroscopic resection of a large myoma might ablate a large surface area of the endometrial cavity, the reproductive benefit appears greater than the risk.
Although there are many factors that might contribute to infertility and recurrent pregnancy loss, uterine cavity-filling defects, including leiomyomata and polyps, are fairly common findings. The rate of cavitary defects associated with infertility has traditionally been 5–10%1 and 15–50%,2,3 in association with habitual abortion. However, a number of hysteroscopic studies suggest the association might be higher; one hysteroscopic study of infertile women found endometrial polyps in 24% and submucosal myomas in 7.8% of subjects.4
How submucosal myomas and polyps contribute to infertility and pregnancy loss is uncertain. It has been postulated that myomas decrease or block normal vascular supply to the trophoblastic tissue of an implanting embryo.5 Polyps might affect the endometrial environment by bleeding or presenting an abnormal site for implantation. The effect of polyps on infertility, however, has had little study.
Leiomyomas associated with infertility have long been treated with abdominal myomectomy, with studies showing high pregnancy rates after surgery.6 With the advent of operative hysteroscopy, intracavitary myomas can be removed without laparotomy. The advantages of hysteroscopic myomectomy include reduced hospitalization and expense, reduced pain and recovery time, and elimination of risk of pelvic adhesions that often accompany abdominal myomectomy.7 One possible risk of hysteroscopic myomectomy is scarring the uterine cavity at the site of resection. Hysteroscopic polypectomy can be done easily and, if on a stalk, should not result in endometrial scarring.
Only a few uncontrolled series have evaluated reproductive outcomes after hysteroscopic myomectomy, reporting pregnancy rates ranging from 31% to 77%.8–11 Little data exist on the effect of polypectomy.12,13 Our study was designed to compare cumulative reproductive outcomes over time in infertile women who have had hysteroscopic myomectomies or polypectomies or have documented normal cavities at hysteroscopy.
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Materials and Methods |
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All located subjects returned questionnaires with complete responses. Inclusion criteria were at least 12 months of primary or secondary infertility before hysteroscopy (which excluded nine subjects); age of 45 or younger at the time of hysteroscopy (which excluded three subjects); follow-up of at least 12 months after surgery (which excluded one subject). We were interested only in those attempting to conceive after the procedure, which excluded one subject with bilateral tubal occlusion who had not had in vitro fertilization (IVF), leaving 78 subjects to be evaluated.
Subjects had diagnostic hysteroscopies in the office with CO2 or Dextran 70 distention, using a paracervical block when necessary. In some cases of suspected cavitary abnormalities, diagnostic hysteroscopy was initially done in the hospital operating room. Those diagnosed with normal endometrial cavities did not have operative hysteroscopy. All subjects with polyps or myomas at diagnostic hysteroscopy had resections in the operating room. Women with cavities that sounded to greater than 10 cm or had greater than 4-cm diameter of endometrial surface replaced by a myoma were excluded from hysteroscopic resection. A hysteroscope within a 26 F resectoscope was used with 70 W of cutting power to morcellate submucosal leiomyomata, and the standard 4-mm resectoscope loop was used to calculate myoma size to the nearest half centimeter. A resectoscope, or more commonly ovum forceps, was used to remove polyps. For distention, glycine 1.5% solution or Dextran 70 was used. After myomectomy, an inflatable silastic balloon was used to tamponade the endometrial cavity for 24 hours. Women were given conjugated estrogens orally, 2.5 mg daily for 7–10 days after myomectomy.7
The 78 subjects were categorized into three groups, myomectomy (36), polypectomy (23), and normal diagnostic study (19). Their follow-up data were compared with respect to time to first clinical pregnancy and first live birth, and spontaneous abortion rates in first pregnancies. Cox proportional hazard models were used with adjustment for age at procedure to evaluate cumulative clinical first pregnancy and live birth rates over time between the three groups. The myomectomy group was subdivided into myomas greater than 2 cm and less than or equal to 2 cm and compared, along with polyps, to the normal group. Analysis of variance was used to compare age and time of infertility before and after the procedure. 
2 tests of association were used to compare rates of pregnancy loss after the procedure and different types of infertility in the three groups. Student t test was used to compare the size of myomas in subjects who did or did not conceive. Statistical significance was defined as 
= .05, two-sided level.
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Discussion |
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The time to live birth after polypectomy and myomectomy of myomas greater than 2 cm was also shorter than in women with normal cavities. That difference, although similar to the pregnancy rates, was not statistically significant, likely owing to smaller numbers of subjects achieving live births. As myoma sizes increased, a significantly shorter time to live birth was noted between myomas larger than 3 cm that were resected and normal cavities. There was no difference in the spontaneous abortion rate after polypectomy or myomectomy or for normal cavities. Those findings suggest that once a hysteroscopic polypectomy or myomectomy has been done in an infertile woman, the ability to carry an implanted pregnancy to term will be equivalent to that of infertile women with normal cavities who subsequently conceive.
The cumulative pregnancy rate in this study after hysteroscopic myomectomy of 55.3% was consistent with earlier studies, with follow-up pregnancy rates ranging from 31% to 67%.8,11 Two previous studies found cumulative pregnancy rates after polypectomy lower than in our study, 23%12 and 32%.13 Our study had a fairly high cumulative pregnancy rate after polypectomy of 78.1%, but it is unclear why the cumulative pregnancy rate was so low in the other studies. The expected 3-year cummulative pregnancy rate is over 60% in unexplained infertility,14 so it seems likely the subjects in those studies had additional factors causing infertility.
Our study included control women with normal endometrial cavities at hysteroscopy to compare with those undergoing hysteroscopic myomectomy and polypectomy. While a randomized controlled trial to assess the reproductive effects of hysteroscopic myomectomy and polypectomy would provide a more convincing assessment of their advantages, doing hysteroscopies and leaving myomas and polyps alone would be hard to justify because they often cause menorrhagia, they require histologic diagnosis, and they likely contribute to infertility. Further study would be useful to confirm that cavitary myomas and polyps are not purely coincidental with infertility, and this study suggests that those lesions might be causal in infertility.
This study covered a 21-year period. The procedure done by the operator did not significantly change since its introduction in 1976,7 but there have been many changes in the evaluation and treatment of infertility during that time. The advent of ovulation induction and assisted reproduction might hasten time to conception in unexplained infertility and cure tuboperitoneal infertility. Therefore, women with tubal obstructions who did not have IVF were excluded. There were no significant differences among the three groups in the year or decade of their procedures, nor were there differences in percentages of subjects who had ovulation induction or assisted reproduction.
The concern that large myoma resections might damage the uterine cavity was not confirmed, and larger resections not only increased the conception rate, but also the live birth rate. The finding that polypectomy considerably improved pregnancy rates was unexpected. Further study should determine whether polypectomy is beneficial regardless of polyp size.
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Footnotes |
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Received November 17, 1998. Received in revised form January 25, 1999. Accepted February 10, 1999.
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References |
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2. Stray-Pedersen B, Stray-Pedersen S. Etiologic factors and subsequent reproductive performance in 195 couples with a prior history of habitual abortion. Am J Obstet Gynecol 1984;148:140–6.[Medline]
3. Keltz MD, Olive DL, Kim AD, Arici A. Sonohysterography for screening in recurrent pregnancy loss. Fertil Steril 1997;67:670–4.[Medline]
4. Valle FR. Hysteroscopy in the evaluation of female infertility. Am J Obstet Gynecol 1980;37:425–31.
5. Garcia CR, Tureck RW. Submucosal leiomyomas and infertility. Fertil Steril 1984;42:16–9.[Medline]
6. Verkauf BS. Myomectomy for fertility enhancement and preservation. Fertil Steril 1992;58:1–15.[Medline]
7. Neuwirth RS, Amin HK. Excision of submucous fibroids with hysteroscopic control. Am J Obstet Gynecol 1976;126:95–9.[Medline]
8. Brooks PG, Loffer FD, Serden SP. Resectoscopic removal of symptomatic intrauterine lesions. J Reprod Med 1989;34:435–7.
9. Hallez JP. Single-stage total hysteroscopic myomectomies: Indications, techniques, and results. Fertil Steril 1995;63:703–8.[Medline]
10. Valle RF. Hysteroscopic removal of submucous leiomyomas. J Gynecol Surg 1990;6:89–96.[Medline]
11. Donnez J, Gillerot S, Bourgonjon D, Clerckx F, Nisolle M. Neodymium: YAG I laser hysteroscopy in large submucous fibroids. Fertil Steril 1990;54:999–1003.[Medline]
12. Youfang W, Meiling H, Caijuan L, Aida S, Xiuyun G, Yinggai Z. The value of hysteroscopy in the diagnosis of infertility and habitual abortion. Chin Med Sci J 1992;7:226–9.[Medline]
13. Valle RF. Therapeutic hysteroscopy in infertility. Int J Fertil 1984; 29:143–8.[Medline]
14. Collins JA, So Y, Wilson EH, Wrixon W, Casper RF. Clinical factors affecting pregnancy rates among infertile couples. Can Med Assoc J 1984;130:269–73.[Abstract]
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2 cm; solid square, dashed line = myomas < 2 cm; solid line = normal cavity. Polyps and myomas 