At initial presentation 4 years prior, the patient was a candidate for several therapies including all medical treatment options as well as surgical treatments. A thorough discussion of all medical and surgical treatment options was done at that time. All medical options were reviewed including combined estrogen-progestin contraceptives (available by pill, patch, or vaginal ring), progestin-only hormonal therapies (available by pill, depot injection, intrauterine insert, or implant), as well as options like gonadotropin receptor hormone agonists. Additional medical treatments for fibroids include androgenic steroids such as danazol and gestrinone, and while they may have beneficial effects on fibroid symptoms, we do not typically prescribe these medications because of frequent side effects like weight gain, acne, hirsutism, and impact on mood. In addition, we reviewed surgical treatment options as well as procedural treatments such as uterine artery embolization. Given her nulliparity, young age, and desire for future fertility, the patient was not a candidate for hysterectomy or traditional uterine artery embolization. Based on PUS findings on initial consultation, we determined that the patient was a good candidate for hysteroscopic myomectomy. A laparoscopic myomectomy was less ideal given the location and small size of many of the fibroids, especially since deep fibroids with a submucosal presentation and small intramural fibroids are not always visible on laparoscopic survey. The patient declined treatment at that time and elected to maintain expectant management of her fibroids and bleeding. She was strongly advised to undergo hysteroscopic myomectomy before she conceived to normalize her uterine cavity and to minimize the risk of pregnancy complications such as pregnancy loss [7].

The patient subsequently represented to our minimally invasive gynecology clinic to discuss fibroid treatment options given the significantly increased fibroid burden, worsening symptoms, and severe blood loss anemia. She was strongly advised to undergo surgical intervention. In our experience, once patients have become transfusion dependent, the role for medical therapy alone is limited. Medical therapies, however, can be used for interim treatment of bleeding as a bridge to surgery. In this case, the patient was started on progestin therapy by her gynecologist with oral medroxyprogesterone 10 mg daily. We increased the dosing to 10 mg twice a day to further stabilize the endometrium and inhibit bleeding. Oral progestin was administered in conjunction with iron infusions to address her severe iron-deficiency and blood-loss anemia. With a combination of blood transfusions, iron infusions, and oral medroxyprogesterone, her hematocrit was increased from 18 to 32.9%. Other preoperative methods to inhibit uterine bleeding and allow for improvement in blood count include GnRH agonists; however, for myomectomy patients we do not advise this treatment since it may compromise the pseudo-capsule dissection planes for the fertility-sparing myomectomy surgery. Autologous blood transfusions are another option, but we do not use it widely in our practice. Our preference is to optimize preoperative hematocrit with IV iron infusions if appropriate, decrease preoperative blood loss, and minimize intraoperative blood loss.

For patients desiring future fertility, we do not typically advise uterine artery embolizations (UAE) for fibroid treatment given the theoretical risk to future pregnancy and placental complications. There have been small case series of pregnancies following UAE ; however, the numbers are small, and the embolization material is not uniform across studies and therefore may not be completely generalizable. A case-control study examining UAE for fibroid treatment by Dobrokhotova et al. does not show an increase in adverse outcomes after UAE. Although it is one of the larger studies, it only includes 59 pregnancies after UAE [8]. There are several additional reports of successful pregnancies after UAE treatment for postpartum hemorrhage, but whether this data can be extrapolated to fibroid patients who undergo UAE is yet to be determined [9]. In addition, some data suggest that UAE may cause temporary ovarian failure [10, 11]. Most patients, however, eventually recover normal ovarian function [12, 13]. In our practice, we offer UAEs to patients with symptomatic fibroids who have completed childbearing. We do not typically recommend UAEs to reproductive-aged women who have not completed their family planning. Instead, we prioritize alternative treatments to UAE in order to maintain the uterine blood supply. This recommendation may change as we are able to follow more pregnancies after UAE [14]. Similarly we do not recommend the various other methods of minimally invasive ablation techniques including radiofrequency myolysis or magnetic resonance-guided focused ultrasound for women seeking future fertility as the data to support its safe use in this population is lacking.

We occasionally utilize a preoperative UAE for patients undergoing myomectomy with extreme fibroid presentations or significant fibroid burden, which may place the patient at high risk for an unplanned hysterectomy. Significant fibroid burden may reflect numerous, sizeable, or anatomically challenging fibroids such as large cervical fibroids compressing the bladder. See Fig. 19.2 above. Although these cases may be better served with hysterectomy, this may not be an option for nulliparous patients trying to reproduce. In these extreme cases, we coordinate with the interventional radiology service to utilize temporary occluding agents, typically gel foam at our institution, for reversibility of the embolization effect. For this very select patient population we coordinate to have the gel foam UAE performed on the day prior to the myomectomy. Again this is for individuals where every heroic effort is made to accomplish a fertility-sparing surgery while avoiding excessive blood loss and unplanned hysterectomy [15].

If a patient with innumerable fibroids does not have plans for future childbearing and opts to have fibroid surgery, then we would strongly recommend hysterectomy , especially if one has become dependent on transfusions of blood products. For patients who select uterine-sparing fibroid surgery, we counsel them about the risk of future fibroid growth after myomectomy with recurrent symptoms and need for further intervention that can be greater than 20% at 5 years and 30% at 7 years [16, 17]. We also discuss the mode of incision, which is best determined by the location and number of fibroids present. Patients with submucosal fibroids are best served with a hysteroscopic approach, which is what we offered this patient on initial presentation. However, when the patient represented with an increased fibroid burden manifesting with innumerable fibroids riddled throughout the uterus, a hysteroscopic approach was no longer appropriate.

Patients with fibroids in multiple different locations requesting fertility-sparing myomectomy require careful surgical planning to balance both fibroid treatment and reproductive goals. Some patients may benefit from a hybrid approach where a hysteroscopic myomectomy is performed to resect the submucosal fibroids and a concomitant laparoscopic or abdominal myomectomy is done to remove the intramural and/or subserosal fibroids. This may offer optimal preservation of the myometrium and endometrial cavity in select patients. Alternatively, a partial myomectomy may be appropriate for those prioritizing fertility while addressing fibroid-related symptoms: either with a hysteroscopic myomectomy for removal of only submucosal fibroids to normalize the endometrial cavity and avoid a myometrial incision altogether or with a partial laparoscopic myomectomy for removal of only the largest fibroids to avoid numerous myometrial incisions and minimize adhesion risks. Both these options leave residual smaller intramural/subserosal fibroids behind, posing the potential for increased risk of needing additional fibroid treatment at a future date. Partial myomectomies, or procedures with planned residual disease, may be better suited for women planning to conceive in the near future, but may be less ideal for those planning to have multiple children over the span of many years. If patients desire future fertility, but do not have an immediate timeline, the risk of leaving residual pathology and developing symptoms in the interim before conception may not be insignificant. Because our patient had many deeply intramural fibroids and several large submucosal fibroids, and was not planning immediate conception we advised an abdominal myomectomy for complete removal of all fibroids present.

Patients like this require careful preoperative evaluation and planning and the importance of thorough counseling cannot be overemphasized. At times this requires the preoperative discussion regarding possible purposeful retention of pathology because of the presenting fibroid anatomy. If, for example, there is an intimate relationship between a fibroid and the blood supply to the uterus or ovaries, the risk of unplanned hysterectomy or oophorectomy increases with removal of such fibroids. This is illustrated well in Fig. 19.3, which shows a fibroid that intimately involves the utero-ovarian ligament . Resection of this fibroid would risk the cornua, ostia, and some of the vascular supply to the ipsilateral ovary. This risk must be understood by the patient, and the provider must understand the patient’s preference for either total removal of all possible pathology or minimizing the risks to future fertility. We did remove the utero-ovarian ligament fibroid for this patient while conserving her adnexae and utero-ovarian ligament blood supply.

Myomectomies can be technically challenging due to the anatomical location, number, size, and vascularity of the fibroid. Good surgical technique and an intimate knowledge of pelvic anatomy and fibroid anatomy are essential to minimize blood loss and optimize outcomes during fibroid surgery. Differentiating between a leiomyoma, an adenomyoma, and adenomyosis is critical since the surgical approach for adenomyomas and adenomyosis is vastly different from a traditional leiomyoma that has a pseudo-capsule plane . Although we do not routinely order preoperative MRIs, an MRI may offer a higher sensitivity for detecting adenomyosis and adenomyomas which may offer the patient more detailed preoperative counseling, which can facilitate with preoperative counseling and help set appropriate postoperative expectations. Concurrent adenomyosis or adenomyoma can be difficult to differentiate intraoperatively from degenerating fibroids and all of these abnormalities can pose technical difficulties. Anatomical planes can be difficult to identify among degenerated fibroids or may not exist among adenomyomas or uteri with adenomyosis, thereby increasing the chance of greater blood loss, incomplete treatment, ongoing symptoms, and unintentional removal of excess myometrium.