Jurnal ok myom 6.doc

Submucous myomas and their implications in the pregnancy rates of patients with otherwise unexplained primary infertility undergoing hysteroscopic myomectomy: a randomized matched control study Tarek Shokeir, M.D., Muhammed El-Shafei, M.D., Hamed Yousef, M.D., Abdel-Fattah Allam, M.D., and Ehab Sadek, M.D. Department of Obstetrics and Gynecology, Fertility Care Unit, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt Objective: To determine whether hysteroscopic myomect
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  Submucous myomas and their implications in the pregnancy rates of patients with otherwise   unexplained primary infertility undergoing   hysteroscopic myomectomy: a randomized matched   control study Tarek Shokeir, M.D., Muhammed El-Shafei, M.D., Hamed Yousef, M.D., Abdel-Fattah Allam, M.D.,   and Ehab Sadek, M.D. Department of Obstetris and ! neolo# , Fertilit $are %nit, Mansoura %ni&ersit Hospital, Mansoura Fault of Mediine,Mansoura, E# pt Objective: To determine 'hether h sterosopi m ometom for submuous fibroids in 'omen 'ith une(plained    primar infertilit ahie&ed better pre#nan rates than no inter&ention. Design: )rospeti&e randomi*ed mathed ontrol trial. Setting: Tertiar uni&ersit fertilit are unit. Patient(s: From +anuar  to Februar //0, a total of 1 'omen 'ith une(plained primar infertilit and   'ith ultrasono#raphiall dia#nosed submuous m omas as the sole ause for fertilit failure 'ere reruited. !ntervention(s: 2omen 'ere randoml alloated to one of t'o pretreatment #roups mathed b a#e. H stero-   sopi m ometom 'as performed in the stud #roup 3n /4. Dia#nosti h sterosop and m oma biops   'as performed in the ontrol #roup 3n /54. 6o fertilit therap 'as #i&en for either #roup. #ain Outcome #easure(s: $linial pre#nan rates aordin# to patient and m oma harateristis. $esult(s: The baseline harateristis of both patients and submuous m omas 'ere omparable. Amon# patients 'ith omplete follo'-up, a total of 5 371.084 pre#nanies oured907 305.784 in the stud #roupand  3:.84 in the ontrol #roup. 2omen in the stud #roup had a better possibilit of beomin# pre#nantafter h sterosopi m ometom 'ith a relati&e risk of . 318 onfidene inter&al, .1;.4. 6o differene in pre#-   nan rates 'as obser&ed aordin# to si*e, number, and loation of m omas in both #roups. Ho'e&er,fertilit rates appeared to inrease after h sterosopi m ometom of t pe / and t pe < m omas 3) % /./14. <nontrast,   for the sub#roup of patients 'ith t pe << m omas, no differene in fertilit rates 'ere noted. &onclusion(s: H sterosopi m ometom for submuous fibroids in 'omen 'ith une(plained primar infertil-it is effeti&e in ahie&in# a better pre#nan rate. 2e think that a multienter stud should be onduted  before   e&aluatin# the impat of submuous m oma harateristis on fertilit outome. 3Fertil Steril = //>7?@7;.// b Amerian Soiet for Beproduti&e Mediine.4 'ey ords: Submuous m oma, h sterosopi m ometom , infertilit There are man reports in the literature onernin#infertilit and submuous fibroids, and none of themontain a on-   firmed onlusion. )h siians 'ho ha&efemale patients   'ith uterine submuous m omas 'ho 'antto beome pre#-   nant fae a linial Cuandar re#ardin# the best mana#ement of suh fibroids. The main ar#umenta#ainst onser&ati&e   h sterosopi m ometom is thelak of definite e&idene of a ausal assoiation bet'eensubmuous fibroids and infer-   tilit 3;54. $onerns remainabout potential ad&erse onse-   Cuenes, suh as morbidit ,ompliations, and intrauterine $eceived December )* +,,-. revised #arch /0* +,,). accepted #arch/)*+,,). published online #ay 1* +,,)232S2 has nothing to disclose2 #245S2 has nothing to disclose2 6272 hasnothing to disclose2 859282 has nothing to disclose2 42S2 has nothingto disclose2 $eprint reuests: 3are; 82 Sho;eir* #2D2* Department of Obstetricsand   <ynecology* 9ertility &are =nit* #ansoura =niversity 6ospital*#an5   soura 9aculty of #edicine* #ansoura* 4gypt (34>: ? +, 1,+@@///-.   98A: ? +, 1, +@/))++. 45mail: tare;sho; e irBhotmail2co m 2 adhesion formations in some ases. Ho'e&er, indirete&idene su##ests that the pre#nan rate in 'omen 'ithother'ise un-   e(plained primar infertilit is fairl #ood,and more than half    of patients beome pre#nant after h sterosopi sur#er  3 7 4. Most publiations addressin# submuous m omasreport a hi#h pre#nan 'asta#e rate, freCuentl e(eedin# @/8.   Ho'e&er, the role of the submuousm oma in this re#ard   and indiations for m ometom remain ontro&ersial 3 1 , 0 4.   2e ha&e reentl published anobser&ational prospeti&e stud   of 0 'omen9 'ith primar infertilit and 1 'ith reur-   rent pre#nan loss,'ith a submuous m oma as the onl e(-    planation for thedia#nosis9and reported impro&ed   reproduti&e outomesafter h sterosopi m ometom . Af-   ter a mean postoperati&e follo'-up period of 7/ months, :8   of 'omen 'ith une(plained primar infertilit and 058 of those 'ith reurrent pre#nan loss ahie&ed a li&e birth3 @ 4.H sterosopi remo&al of suh m omas is no' theaepted treatment, despite the lak of #ood prospeti&e,  C+ 9ertility and Sterility = Eol2 )D* Fo2 +* Guly +,/,,,/15,+-+HI@02,,&opyright  D +,/, 8merican Society for $eproductive #edicine* Published by 4lsevier !nc2doi:/,2/,/0Hj2fertnstert2+,,)2,@2,C1  9ertility and Sterility = 3 randomi*ed ontrol trials and the small si*e of man reported   series. A maorit of these trials are retrospeti&eor ase on-   trol studies that ompare the reproduti&eoutome before   and after h sterosopi m ometom 3; 7 4 . Furthermore,   to our kno'led#e, no prospeti&eontrolled data e(ist re-   #ardin# fertilit outome after h sterosopi m ometom amon# this selet patient#roup, aordin# to the harateris-   tis of the submuousm omas.eause of the onsiderable ontro&ers that surroundsthe topi of submuous m omas and une(plained primar infertilit , 'e desi#ned this prospeti&e, randomi*ed, a#e-mathed ontrol trial to diso&er 'hether h sterosopi m -ometom in 'omen 'ith other'ise une(plained infertilit affets pre#nan rates. #834$!8>S 8FD #436ODS From +anuar  to Februar //0, 51 patients fulfillin#the   inlusion riteria of une(plained primar infertilit 'ithsub-   muous m oma diso&ered on initial pel&isono#raphi stud-   ies as the sole ause for a dia#nosis'ere seleted. )atients   3a#ed ;51 ears4 'ere informedof the stud desi#n and   'ere reruited for the trial. T'ohundred and fifteen 3084 of    them a#reed to partiipate andinformed onsent 'as obtained.   The stud 'as appro&ed b the hospitalGs ethis ommittee.The sono#raphi dia#nosis of submuous m omas has been   desribed else'here 3:4. <n all patients, a baseline dia#nosis   'as made usin# ultrasono#raph performed 'itha multifre- Cuen endo&a#inal transduer 3Sonae Medial$orporation,   Seoul, orea4. The si*e, number 3sin#le or multiple4, and loa-   tion of the fibroid in the uterus 'asreorded based on hei#ht 3fun-   dus, orpus, lo'er se#ment,or er&ial4. <f J 5 months elapsed    bet'een the initial baseline sono#ram and the ourrene of     pre#nan , them oma 'as ree&aluated e&er 5 months to deter-   mine an si#nifiant han#es in the m oma harateristis.<nlusion riteria 'ere 'omen 'ith B months of  primar   infertilit 3duration of infertilit ran#ed ;/months4,   re#ular menstruation, a sono#raphi dia#nosis of submuous   m oma, and andida for h sterosopim ometom . The   indiation for m ometom 'as asubmuous m oma in om-    bination 'ith a histor of une(plained primar infertilit if the   lesion 'as thou#ht to be the onl ontributin# fator to infertil- it . 6o patients'ere e(perienin# menorrha#ia in our stud .2omen older than 51 ears 'ere e(luded from thestud   to a&oid the inlusion of subets 'ith a#e-relatedsubfertilit .   Also e(luded from the stud 'ere 'omen'ith pel&i le- sions, suh as endometriosis, that ouldad&ersel affet fer-   tilit . $ases 'ith assoiated interstitialfibroids, submuous   m omas J 1 m in diameter andIor auterine a&it J / m in len#th 'ere also e(luded. All patients had ne&er had pre-   &ious sur#er for leiom omataor other uterine sur#er , and   no other uterine a&it abnormalities e(isted 3e.#., uterine septum or endometrial pol ps4.After a detailed histor and thorou#h linial e(amination,all of the patients reei&ed a omplete infertilit 'orkup  Sho;eir et al2 6ysteroscopic myomectomy in unexplained Eol2 )D* Fo2 +* Guly +,/, 4 inludin# semen anal sis, assessment of o&ulation b midlu-   teal serum pro#esterone le&el, assessment of o&arian reser&e    b  le da 5 serum FSH le&el, postoital test 3)$T4, and   h sterosalpin#o#raph 3HS!4.The initial su##estion of dia#-   nosin# submuous m oma'as made b HS! for most of the ases 'ithin  ear.Japarosop 'as performed primarl for    all patients toassess the pel&is for auses of infertilit . Those   'ith pel&i lesions 'ere e(luded from the stud .<n those 'ith a health pel&is, h sterosopie(amination 'as performed to assess the uterine a&it ,onfirm the dia#-   nosis, and assess the harateristis of the m oma inludin#   its si*e, number, loation, and t pe.The lassifiation pro-    posed b the European Soiet of H sterosop 34 'as   used in our stud for identif in# the t pe of leiom oma b   the de#ree of intramural de&elopment. Aordin#l , t pe   / 'asdefined as the m oma 'ith de&elopment limited to theuterine a&it 3pedunulated m oma4, t pe < 'as definedas the m oma 'ith partial intramural de&elopment3endoa-   &itar omponent J 1/84, and t pe << 'asdefined as the m oma 'ith predominantl intramuralde&elopment 3endo-   a&itar omponent % 1/84.<diopathi primar infertilit 'as dia#nosed in patients   'ith normal o&ulator  les, semen anal sis,HS!, and   )$T in infertile ouples for J 7 months.E(ept for submu-   ous fibroids, no onurrent auses of infertilit 'ere identi- fied in an patient.The stud #roup 'as omposed of /@ 'omen in'hom   a m oma 'as e(trated durin# h sterosop in theearl pro-   liferati&e phase of the menstrual  le.Alternati&el , the on-   trol #roup 'as omposed of /:'omen in 'hom submuous   m omas 'ere not e(trateddurin# dia#nosti h sterosop   and m oma biops onl 'as performed. $andomization 2hen a patient 'ith a submuous m oma 'as seletedfor    m ometom , she 'as mathed 'ith the ne(t ase in'hih   the other patient 'as nearl of the same a#e 3'ithin ears4   and sheduled for no m ometom . )atientsmathed b a#e 'ere randomi*ed into t'o #roups 'ith theuse of an en&elope   tehniCue, 'ith assi#nment determined b a omputer-#ener-   ated random number table. OperativeProcedure The m ometom 'as performed b means of a 1.1-mm   arl-Stor* 3Tuttlin#en, !erman 4 ontinuous flo'offie h s-   terosope under loal anesthesia usin# a paraer&ial blok.   The formations 'ere reseted b means of a ri#id sissors   and foreps and submitted for histopatholo#i e(amination. 2hen resetion 'as not possible durin# the dia#nosti h s-   terosop , in ases'ith multiple m omas, and in those 'ith   residual lesionsor m omas J 5 m in diameter, the patient 'as sheduledfor operati&e h sterosopi e(amination under    #eneralanesthesia. Eletrosur#ial resetion 'as done durin#   theearl proliferati&e phase of the subseCuent menstrual  le
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