Thursday, January 08, 2004

Abdominals not cut, Myo not panacea for fertility problems


I was worried about my abdominal muscles being damaged during myo (which have yet to undergo) and I asked the surgeon about it. She told me that they do not cut the abdominal muscles, instead they just push them to the sides, and I imagine they brace them there.

They do cut through some connective tissue and the abdominal fascia, a membrane that holds your internal organs together, but they stitch the fascia closed at the end of the procedure (I'm not sure if they reconnect the connective tissue -- I haven't seen mention of that anywhere) What Your Doctor May Not Tell You About Fibroids includes a detailed description of the procedure that you may with to refer to.


The ability of myomectomy to improve fertility is not definative at this point in time (this is confirmed in What Your Doctor May Not Tell You About Fibroids by Dr Michael Brody, an ob/gyn and former RAND medical researcher). There have been annectodal stories of success by patients and doctors but current research has had flaws that limit its usefulness in determining the appropriateness of this procedure to treat infertility, especially if other factors exist that may be contributing to the infertility (male factor, blocked tubes, endocrine issues, etc.) This is partly why I have been reluctant to undergo this procedure for my largely asymptomatic fibroid, we have a known male factor.

Gynecologic Myomectomy
"Myomectomy is also performed frequently in patients with infertility with the presence of fibroids (Vercillini, 1998). Studies supporting myomectomy as a fertility-enhancing procedure are uncontrolled and do not use life-table analysis; nonetheless, a number of authors recommend offering myomectomy to women who are infertile after other causes of infertility have been eliminated (Hutchins, 1995;
Nachtigal, 1989; Verkauf, 1996).

Several papers suggest that patients with fibroids who are undergoing assisted reproductive technology procedures may have lower success rates compared to patients without fibroids. Stovall et al (1998) noted decreased fertility rates in patients with any myomas undergoing in vitro fertilization or zygote intrafallopian transfer. Eldar-Geva and coworkers (1998) noted decreased success in patients with intramural and submucosal myomas but not in those with subserosal myomas. Ramzy et al (1998) noted no change in fertility, but this study specifically excluded anyone with large, submucous, or intramural myomas that distorted the endometrial cavity. Importantly, note that no randomized studies document that removal of these myomas
improves success rates."

Myomectomy* (68.29) (CPT Codes 56309 [laparoscopy with removal of leiomyomata], 58140 [abdominal approach], or 58145 [vaginal approach]

Leiomyomata (218.0-218.9) in infertility patients (628.3), asa probable factor in failure to conceive or in recurrent pregnancy loss

Confirmation of Indication:
In the presence of failure to conceive or recurrent pregnancy loss:
1. Presence of leiomyomata of sufficient size or specific location to be a probable factor
2. No more likely explanation exists for failure to conceive or recurrent pregnancy loss

Actions Prior to Procedure:
1. Evaluate other causes of male and female infertility or recurrent pregnancy loss
2. Evaluate the endometrial cavity and fallopian tubes, e.g. hysterosalpingogram
3. Document discussion that complexity of disease process may require hysterectomy

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