The patient wishes future fertility . Due to the type 0 fibroid and multiple type 4 fibroids, some of which about the endometrial cavity, neither observation nor uterine artery embolization (UAE) is recommended. Type 0 fibroids have been shown to decrease fertility by approximately 70% (RR 0.32 CI 0.12–0.85) when compared with infertile controls matched by age. Removal of type 0 fibroids has been shown to return fertility to baseline for infertile age-matched controls (RR 1.13 CI 0.96–1.33) [1]. Although rare, UAE has been associated with spontaneous abortion, placenta accreta, and preterm delivery, and at our institution, it is not recommended for women wishing future fertility [2].

Due to the large size of the uterus and insufficient room for placement of endoscopic ports, neither the laparoscopic nor robotic approach is felt to be technically feasible. In addition, identifying and removing smaller type 4 fibroids without the benefit of palpation at the time of surgery is felt to be difficult.

High-intensity focused ultrasound is felt to be inappropriate due to the overall size of the uterus and presence of the intracavitary fibroid. Fertility data, with likelihood of conception following treatment, is not available, and only minimal pregnancy outcome data are available, and, thus, we have not recommended this modality for women wishing to conceive.

Therefore, abdominal myomectomy is considered the procedure of choice with the best outcome (Figs. 6.1, 6.2, and 6.3).

Correction of the patient’s preoperative anemia was addressed initially. Although we have used either GnRH or erythropoietin in the past, we find that, for women with chronic blood loss anemia, intravenously administered iron infusions are remarkably effective in returning hemoglobin levels to near normal. Intravenous iron avoids the side effects of GnRH agonists (hot flashes, insomnia, vaginal dryness, headaches) and expense of either GnRH agonists or erythropoietin B. Iron sucrose and iron gluconate can be given in a maximal single dose of 200  mg over a minimum infusion time of 30 min.

In order to reduce intraoperative blood loss, we administer preoperative cytotec, 400 μm placed vaginally 3 h before surgery and tranexamic acid 10 mg/kg given IV at the time of the skin incision.

We perform all of our abdominal myomectomies through low transverse incision. In this case, we would extend the fascial incision cephalad at the lateral borders of the rectus muscles in order to avoid transection of the ilioinguinal nerve. Midline separation of the fascia away from rectus muscles to the level of the umbilicus also allows for more space to exteriorize the uterus.