What are the principles of myomectomy—including indications, pre‑operative evaluation, choice of surgical approach, intra‑operative technique, and postoperative management—for a reproductive‑age woman desiring future fertility?

Principles of Myomectomy for Fertility Preservation

For reproductive-age women desiring future fertility, myomectomy should be performed using a surgical approach tailored to fibroid location: hysteroscopic resection for submucosal fibroids <5 cm, laparoscopic myomectomy for accessible subserosal or intramural fibroids, and open myomectomy for multiple fibroids or very large uteri, with all approaches yielding equivalent long-term fertility outcomes. 1

Indications for Myomectomy

Primary Indications

• Symptomatic fibroids causing abnormal uterine bleeding, pelvic pain, or pressure symptoms in women desiring uterine preservation 1, 2
• Submucosal fibroids in women with infertility, as removal of submucosal fibroids has been consistently shown to improve spontaneous fertility and assisted reproduction outcomes 2
• Selected intramural or subserosal fibroids causing symptoms, though their removal for fertility enhancement remains controversial 2

When NOT to Perform Myomectomy

• Prophylactic myomectomy is not recommended for preventing obstetrical complications or leiomyosarcoma risk 2
• Surgery should not be offered based on uterine size alone without symptoms 3
• Patients with significant intramural or subserosal fibroid burden with concomitant adenomyosis are less likely to benefit from hysteroscopic approaches 1

Pre-operative Evaluation and Preparation

Risk Assessment

• Uterine size ≥16 weeks' gestation significantly increases transfusion risk and should prompt enhanced preparation 4
• Posterior uterine location represents a significant risk factor for major intraoperative hemorrhage 4

Pre-operative Optimization

• Correct anemia pre-operatively to reduce transfusion risk 4
• Consider autologous blood storage for high-risk cases 4
• GnRH analogues may facilitate surgery for very large fibroids, though cost-effectiveness for abdominal procedures remains unproven 3

Choice of Surgical Approach

Hysteroscopic Myomectomy

• Indicated for: Pedunculated submucosal fibroids <5 cm diameter 5
• Advantages: Shortest hospitalization, fastest recovery, equivalent quality of life outcomes at 2-3 months compared to abdominal approaches 1, 5
• Technique considerations: "Cold loop" technique represents the best option for G1 and G2 fibroids, allowing safe complete removal in one procedure while respecting healthy myometrium 6
• Risks: Uterine perforation, fluid overload, transfusion need, bowel/bladder injury, endomyometritis, reintervention 1, 5

Laparoscopic Myomectomy

• Indicated for: Subserosal or intramural fibroids in patients with limited fibroid burden 1
• Advantages: Shorter hospital stay, faster return to activities, lower wound infection rates compared to open approach 1, 4
• Technical considerations: Can be safely performed regardless of myoma size, number, and location by experienced surgeons using Lee-Huang point (midpoint between umbilicus and xiphoid) for large uteri 7
• Specimen extraction: Place myoma in Endo bag, bring edges extracorporeally through port site, perform C-shaped incision with scalpel to reduce size, or use in-bag power morcellation 7

Open (Abdominal) Myomectomy

• Indicated for: Multiple fibroids or very large uteri where laparoscopy is not feasible 1
• Advantages: Most appropriate for large fibroids, improved quality of life maintained for up to 10 years 4, 8
• Disadvantages: Greater adhesion formation risk, longer recovery, higher wound infection rates 4
• Technical note: Morbidity increases with very large uteri 3

Comparative Fertility Outcomes

• Large prospective registries demonstrate no significant difference in fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy 1, 5
• Of patients attempting conception post-myomectomy, less than half achieve pregnancy at 3 years, and less than half of these result in live birth 1

Intra-operative Hemostatic Techniques

Blood Loss Prevention

• Apply tourniquets on vascular pedicles to minimize blood loss 4
• Inject vasospastic agents (vasopressin) into myometrium to reduce hemorrhage 4
• Avoid posterior uterine incisions when possible due to increased hemorrhage risk 4

Surgical Technique Principles

• Success depends on proper incision technique, enucleation, hemostatic measures, and suturing techniques 7
• Minimize deep myometrial cuts to preserve uterine integrity 6

Postoperative Management

Recovery Timeline

• Wait 2-3 months before attempting pregnancy to allow adequate uterine incision healing and minimize uterine rupture risk during subsequent pregnancy 4, 8
• Symptom improvement and quality of life become equivalent across all surgical approaches by 2-3 months 1, 8
• Long-term quality of life improvement maintained for up to 10 years regardless of approach 4, 8

Pregnancy Counseling

• Uterine rupture risk exists with both laparoscopic and open myomectomy in subsequent pregnancies 1, 4
• Retrospective data suggest 85% pregnancy rates with 65% live birth rates after hysteroscopic myomectomy, though high-quality prospective evidence is lacking 5
• Miscarriage rates may be substantial (30-50% in some studies) 1

Critical Pitfalls to Avoid

• Never perform endometrial ablation for fibroids in fertility-desiring patients—no supporting literature exists and pregnancy complications are high-risk 1, 5
• Do not assume fertility improvement without proper counseling—high-quality evidence on live birth rates is lacking 5
• Avoid hysteroscopic myomectomy as sole treatment for patients with significant intramural/subserosal burden or adenomyosis 1, 5
• Do not recommend hysterectomy as initial treatment when fertility preservation is desired 1
• Avoid prophylactic myomectomy in asymptomatic patients 2