Full text of DOI:10.1093/humrep/17.11.2967

Human Reproduction Vol.17, No.11 pp. 2967–2971, 2002
Operative morbidity and reproductive outcome in
secondary myomectomy: a prospective cohort study
J.Frederick1, M.Hardie, M.Reid, H.Fletcher, S.Wynter and C.Frederick
Department of Obstetrics, Gynaecology and Child Health, University Hospital of the West Indies, Kingston 7, Jamaica, W.I.
1To whom correspondence should be addressed. E-mail: jfrederick@jamweb.net
BACKGROUND: This prospective study was designed to evaluate the operative morbidity and reproductive
outcome in patients who had secondary myomectomy for recurrent symptomatic uterine fibroids. METHODS: A
total of 58 women were subjected to a secondary myomectomy via the abdominal route. The operative morbidity
such as blood loss, presence of adhesions and febrile index were estimated and the pregnancy outcome over a 2–4
year period of follow-up. RESULTS: The mean age and standard deviation (⍨ SD) of the women was 35 (⍨ 2.4)
years. Nineteen patients (33%) had a postoperative temperature ≥100°F and the estimated blood loss ranged from
159–2500 ml (median 700 ml). Seven patients (12%) required blood transfusion and one had a hysterectomy due
to haemorrhage. Nine women (15.5%) became pregnant but only five (56%) had live births. Those with successful
pregnancies tended to be younger with a mean age of 31.8 (⍨ 2.6) years versus 35 (⍨ 1.8) years, (P ⍧ 0.08, non-
significant) and had fewer uterine leiomyomata; median with range values, 2 (1–6) versus 7 (6–15). The variables
which best predicted the postoperative likelihood of pregnancy were; age, presence of tubal adhesions and the
number of uterine fibroids. CONCLUSION: This prospective study showed a high operative morbidity and a poor
fertility outcome after a repeat myomectomy. The factors affecting successful outcome in a logistic regression model
were age, tubal adhesions and number of uterine fibroids.
Key words: operative morbidity/pregnancy outcome/secondary myomectomy/uterine fibroids
Introduction
1956; Babaknia et al., 1978; Dubuisson and Chapron, 1996;
Sudik et al., 1996) and up to 75% of these pregnancies will
take place in the first year after surgery. These findings support
the theory that fibroids have some association with infertility.
Notwithstanding this, 50% of patients still remain infertile
5 years after primary myomectomy. Thus patients with recur-
rence of their symptomatic fibroids in their mid-thirties and
who have not fulfilled their reproductive ambition are faced
with a real dilemma.
Therefore the aim of this cohort study was to find a treatment
modality to alleviate the symptoms of women with recurrence
of their fibroids while conserving their reproductive potential.
The principle was to perform a repeat myomectomy and assess:
(i) the possible morbidity associated with the procedure, such
as febrile index or blood loss, (ii) to assess the presence of
adhesions caused by the first myomectomy, (iii) to evaluate
the natural pregnancy outcome after the procedure and (iv) to
improve the anatomy of the uterus in order to enhance
implantation if assisted reproduction has to be employed.
In Jamaica, where 90% of the population is of African descent,
uterine fibroids are very common (Frederick et al., 1994).
Black women are three to nine times more likely to have
fibroids than white women (Buttram and Reiter, 1981). A
Jamaican woman undergoing primary myomectomy in her late
twenties is not uncommon. Clinical reports on women with
uterine fibroids who have had primary myomectomy have
indicated that recurrence rates are between 15–45% within a
5–10 year period (Brown et al., 1956; Candiani et al., 1991).
Uterine fibroids are the most common female pelvic tumours
occurring in about 15–30% of women in the reproductive age
group (Zaloudek and Norris, 1987). Surgical intervention is
often indicated when symptoms such as menorrhagia, congest-
ive dysmenorrhoea, urinary frequency, infertility and recurrent
pregnancy losses occur (Buttram and Reiter, 1981). The
majority of studies on uterine fibroids have focused on primary
myomectomy or interruption of blood supply by the abdominal
approach (Berkeley et al., 1983; Frederick et al., 1994; Fletcher
et al., 1996), laparoscopic removal (Hasson et al., 1992),
hysteroscopic resection (Hallez, 1995), the vaginal approach
(Magos et al., 1994), myolysis (Dubuisson et al., 1995) and
arterial embolization (Spies et al., 2002).
Materials and methods
This prospective cohort study analysed a total number of 58 women
who had secondary myomectomy because of recurrence of their
uterine fibroids and associated symptoms, at the University Hospital
Fertility after primary myomectomy using different tech-
niques has been reported to be between 20–50% (Brown et al.,
© European Society of Human Reproduction and Embryology
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J.Frederick et al.
Table I. Patients’ characteristics
Clinical characteristics
All patients
NPP n ϭ 48
PP n ϭ 9
SPP n ϭ 5
n ϭ 58
Age (years)
35.4 Ϯ 2.4
0 (0–2)
35.8 Ϯ 2.1
0 (0–1)
33.2 Ϯ 2.7
0 (0–2)
31.8 Ϯ 2.6
0 (0–0)
aParity
aSize of uterus (weeks)
aSize of largest fibroid (cm)
aNumber of leiomyoma
aPre-operative haemoglobin
aPre-operative haematocrit
aPre-operative white cell count
aSystolic pressure mmHG
aDiastolic pressure mmHG
16 (12–36)
7 (4–18)
10 (1–31)
11.8 Ϯ 1.0
36.0 Ϯ 2.8
58 Ϯ 0.9
16 (12–28)
7 (4–18)
16 (14–24)
7 (6–10)
6 (1–15)
11.7 Ϯ 1.0
35.1 Ϯ 3.0
6.0 Ϯ 0.9
105.1 Ϯ 14.6
62.2 Ϯ 8.3
16 (14–16)
6 (6–9)
2 (1–6)
11.3 Ϯ 0.5
33.2 Ϯ 1.3
5.7 Ϯ 0.9
106.8 Ϯ 15.5
62.0 Ϯ 8.4
10 (1–31)
11.9 Ϯ 1.0
36.2 Ϯ 2.8
5.8 Ϯ 0.9
115.1 Ϯ 17.8
69.3 Ϯ 14.3
113.5 Ϯ 17.5
67.7 Ϯ 14.1
NPP ϭ never pregnant post secondary myomectomy; PP ϭ pregnancy post secondary myomectomy; SPP ϭ
successful pregnancy post secondary myomectomy.
aValues are medians with minimum and maximum values. One patient had a total hysterectomy post
secondary myomectomy because of uncontrollable haemorrhage and was therefore not included in the NPP
group.
and recurrent abortions), clinical uterine size, haemoglobin level,
haematocrit and white cell count, (ii) intra-operative; the number of
fibroids, number of incisions (anterior and or posterior), blood loss,
presence of adhesions, cavity breached, and tubal occlusion, (iii)
post-operative; a full blood count to determine the haemoglobin,
haematocrit, white cell count difference, the highest temperature after
the first 24 h post-operatively (to determine the febrile morbidity).
The size of the largest leiomyoma was confirmed from the pathological
report. Patients in the study were seen at monthly intervals for
2 months and 6 monthly intervals thereafter and were instructed to
report in the event of a pregnancy. The number of patients who
became pregnant and the outcome of the pregnancies such as
miscarriages and the mode of delivery were recorded.
Table II. Indications for surgery
Indications
All patients
NPP
n ϭ 58
PP
n ϭ 48
SPP
n ϭ 5
Menorrhagia
42
41
17
44
7
35
34
14
36
4
6
6
3
7
3
3
4
1
4
1
Primary infertility
Secondary infertility
Pelvic pain
Recurrent miscarriages
NPP ϭ never pregnant post secondary myomectomy; PP ϭ pregnancy post
secondary myomectomy; SPP ϭ successful pregnancy post secondary
myomectomy.
Values are counts. One patient had a total hysterectomy post secondary
myomectomy because of uncontrollable haemorrhage and was therefore not
included in the NPP group
Results
of the West Indies and Andrews Memorial Hospital Kingston, Jamaica,
from January 1997–December 2000. A protocol sheet was designed
to maintain uniformity for data entry. The subjects under study were
between 30–41 years of age and had undergone further conservative
surgery for relief of their symptoms, particularly preservation of their
reproductive capabilities. The indications for surgery were patients
with symptoms such as menorrhagia, infertility, chronic pelvic pain,
and recurrent miscarriages. Exclusion criteria were patients who had
endometriosis or those who were not desirous of further pregnancies
or patients whose spouses had abnormal semen analyses.
The mean age of the patients was 35.4 (Ϯ 2.4) years (range,
30–41). The mean duration of follow-up was 2 years. The
characteristics of these 57 patients such as age, parity, size of
the uterus, number and size of the largest fibroids, pre-operative
haemoglobin and blood pressure are summarized in Table 1.
The uterine size ranged from 12–36 weeks (median 16 weeks),
the number of fibroids ranged from 1–31 (median 10) and the
median diameter of the largest fibroid was 7 cm (ranged from
4–18 cm) (Table I).
They were all counselled and signed a consent form stating that a
hysterectomy would be performed in the event of uncontrollable
haemorrhage. Myomectomy was performed using vasopressin as the
haemostatic agent and employing the technique previously described
(Frederick et al., 1994). All fibroids were enucleated and large blood
vessels were clamped and tied. The uterine defects were closed with
1–0 chromic catgut and the serosal surface closed with 2–0 chromic
catgut (Ethicon, Brussels, Belgium). Pelvic lavage was carried out
with warm normal saline solution prior to the application of Interceed®
adhesion barrier (Johnson & Johnson, New Brunwick, NJ, USA).
A prophylactic antibiotic Cefuroxime 1.5 g, (Glaxo Wellcome,
Greenford, UK), was given i.v. prior to the procedure, by the
anaesthetist.
In this series over 70% of the patients had the three main
symptoms (menorrhagia, infertility and pelvic pain) associated
with uterine fibroids as indications for surgical interventions.
The majority of the patients (41/58) suffered from primary
infertility compared to those with secondary infertility (17/58)
(Table II).
Operative findings and morbidity.
Secondary myomectomy was successfully performed in 57 out
of the 58 patients in this study as in one case a hysterectomy
had to be performed as a result of postoperative bleeding and
hypovolaemic shock. Abdomino-pelvic adhesions, possibly a
reflection of the previous surgery, were the most significant
finding (Table III). Tubal adhesions were present in 34 (59%)
Several parameters were determined pre-operatively, intra-operat-
ively and post-operatively. The variables noted were: (i) pre-operative;
age, parity, bulk symptoms (menorrhagia, infertility, pelvic pain
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Operative morbidity and reproductive outcome
Table III. Operative findings, morbidity and relative risks of becoming pregnant (values are counts)
Operative findings
All patients
NPP
PP
SPP
RR
and morbidity
n ϭ 58
n ϭ 48
n ϭ 9
n ϭ 5
All bowel adhesions
Large bowel adhesions
Tubal adhesions
Fimbrial occlusions
Vascular adhesions
Endometriosis
30
22
34
14
15
2
28
22
31
11
14
2
2
0
2
2
1
0
6
1
0
1
1
1
0
2
0.26 (0.06, 1.13)
-
0.20 (0.04, 0.87)
0.97 (0.23, 4.10)
-
-
Tubal patency
39
32
1.0 (0.28, 3.57)
Incision on uterus
-anterior only
-posterior only
9
5
44
37
7
5
36
31
-
2.4 Ϯ 1.2
5.4 Ϯ 3.0
5.0 Ϯ 3.9
2
0
7
5
-
1
0
4
2
-
-anterior and posterior
Uterine cavity entered
Hysterectomy
0.73 (0.22, 2.42)
1
-
-
-
-
aChange in haemoglobin
aChange in haemotocrit
aChange in white
blood cell count
2.6 Ϯ 1.8
6.0 Ϯ 5.2
5.0 Ϯ 3.8
3.3 Ϯ 3.7
9.2 Ϯ 11.3
4.8 Ϯ 3.2
1.8 Ϯ 1.4
5.0 Ϯ 3.3
5.1 Ϯ 4.0
#Blood loss
700
(159,2500)
7
19
700
(159,2500)
7
17
600
(200,1000)
0
2
500
(200,700)
0
0
-
-
-
Transfusion required
Febrile morbidity
#Days in hospital
4 (1, 8)
4 (1, 8)
4 (4, 4)
4 (4, 4)
NPP ϭ never pregnant post secondary myomectomy; PP ϭ pregnancy post secondary myomectomy; SPP ϭ
successful pregnancy post secondary myomectomy; RR ϭ unadjusted relative risk with 95% confidence
interval for becoming pregnant by operative findings.
aValues are means Ϯ SD; # Values are medians with minimum and maximum values. One patient had a
total hysterectomy post secondary myomectomy because of uncontrollable haemorrhage and was therefore
not included in the NPP group.
patients, 30 (52%) and 22 (38%) patients had small and large
number of uterine fibroids, breaching of uterine cavity, type
of uterine incision, tubal adhesions, tubal patency and fimbrial
adhesions) should be incorporated into a final regression model
with age as a covariate and a subsequent pregnancy as the
response variable. The results indicated that the absence of
the variables such as uterine size, breaching of uterine cavity,
type of uterine incision, tubal patency and fimbrial adhesions
from the full model which included these variables along with
age, number of uterine fibroids and the presence of tubal
adhesions as predictors did not significantly reduce the log
likelihood (χ2 ϭ 2.1, df : 5; P ϭ 0.8, non-significant). On the
other hand, the omission of either the variable, number of
uterine fibroid or presence of tubal adhesions, from the reduced
model significantly reduced the log likelihood. Thus the model
which was the best predictor of positive pregnancy outcome
from the data included the predictors, age OR 0.62 (95 %
CI: 0.37, 1.02), presence of tubal adhesions OR 0.07 (95%
CI: 0.01, 0.72), and number of uterine fibroids OR 0.81 (95%
CI: 0.64,1.03) (Table IV).
bowel adhesions respectively. However, 39 (67%) patients had
normal tubal patency despite the presence of adhesions. The
cavity was breached in 37 (63%) patients to enucleate
submucous fibroids that contributed to a high incidence of
menorrhagia and infertility. Febrile morbidity occurred in 19
patients despite the administration of prophylactic antibiotics.
Seventeen had a temperature of 100°F whilst two had a
temperature of 102°F. The average intra-operative blood loss
for all patients in the study ranged from 150–2500 ml (median
700 ml) but only seven (12%) of the patients received intra-
operative and/or post-operative blood transfusions (Table III).
Pregnancy outcome
Nine women became pregnant following secondary myomec-
tomy. Out of the nine women who became pregnant, five
(56%) carried the pregnancy to term and delivered a live
infant. Compared with those women who became pregnant
but had miscarriages, the patients with successful pregnancies
tended to be younger [31.8 Ϯ 2.6 year versus 35 Ϯ 1.8 year
(mean Ϯ SD), P ϭ 0.08, non-significant] and had fewer uterine
leiomyomata; median with minimum and maximum values 2
(1–6) versus 7 (6–15). The relationship between the various
predictors and subsequent pregnancy was explored with a series
of logistic regression models. In these models a subsequent
pregnancy outcome was coded as 1 while a code of zero was
used if the women did not become pregnant post secondary
myomectomy. Likelihood ratio tests were used to determine
which of the following combination of variables (uterine size,
Discussion
This is the first study, to our knowledge, addressing both
alleviation of symptoms and conserving the reproductive
potential in women with recurrence of fibroids by performing
a repeat myomectomy. The mean age of women in this study
was 35 Ϯ 2.4 years, with recurrence of symptomatic fibroids
which justified the need for a conservative treatment particu-
larly in those who were childless.
2969

J.Frederick et al.
ity of the cavity, comparable results were found with those
with uterine myomas and those without (Ramzy et al., 1998).
This series has shown that primary myomectomy is associ-
ated with adhesions, which can compromise fertility, and a
secondary procedure also has a poor fertility outcome. Most
of the studies on the effects of uterine fibroids on patients
undergoing IVF excluded patients with large leiomyomata and
those causing deformity of the uterine cavity. The ultimate
aim of our study was to alleviate symptoms and to preserve
the reproductive potential, therefore large sizes and site were
not part of our exclusion criteria as compared with the three
studies reported in assisted reproduction.
The miscarriage rate was 40% in this series but the numbers
are too small to compare with other series with reduction rates
post primary myomectomy from 60–19% (Buttram and Reiter,
1981; Li et al., 1999). Other modalities of treatment such as
GnRH analogues (Friedman et al., 1994) and uterine artery
embolization (Spies et al., 2002) have been used effectively
to improve symptoms but have not addressed the fertility
outcome as in this study.
Table IV. Odds ratio with 95% confidence interval of predictors of getting
pregnant following a second myomectomy.
Predictors
Odds ratio
95% CI
Age
0.62
0.07
0.81
0.37, 1.02
0.01, 0.72
0.64, 1.03
Tubal adhesion
Number of fibroids
Log likelihood ϭ –14.2; LR χ2 df (3) ϭ 17.19, P Ͻ 0.006
The median blood loss was 700 ml intra-operatively in this
study despite the use of vasopressin as a haemostatic agent
compared with 200–400 ml in other reported series of primary
myomectomy (LaMorte et al., 1993; Fletcher et al., 1996).
Seven patients (12%) required blood transfusions. This com-
pared favourably with other reported series of the primary
myomectomies (Smith and Uhlir, 1990; Frederick et al., 1994).
Only one patient had a hysterectomy as a result of intractable
post-operative haemorrhage, however, this is acceptable for
such a difficult procedure.
Febrile morbidity in this study was higher, compared with
the primary myomectomy and hysterectomy in other reported
series. (Gambone et al., 1990; LaMorte et al., 1993). However,
our definition of the fever was a temperature ജ 100°F
(excluding the first 24 h) compared with the criteria of
ജ100.4°F used in the above series.
In conclusion, a repeat myomectomy is a difficult procedure
with risk of complications and a pregnancy rate that appears
to be lower than that of the primary procedure. However, the
evolution of assisted reproduction affords women another
option of improving their fertility following a repeat
myomectomy.
Adnexal adhesions occurred in 59% of the cases in this
series and could have been associated with the infertility in
this group. This is said to be mainly due to posterior adhesions
in patients with posterior incisions on the uterus during
myomectomy. (Tulandi et al., 1993; Ugur et al., 1996).
Second look laparoscopy performed 6 weeks post primary
myomectomy revealed a high incidence of adhesions particu-
larly adnexal with posterior uterine incisions in two series
(Tulandi et al., 1993; Dubuisson et al., 1998). They also
showed that lysis of adhesions at laparoscopy increased the
pregnancy rate post myomectomy.
Acknowledgements
We would like to thank Dr. W.Gardner, Dr. S.Shah, Y.McDonald,
D.Bailey, D.Jones, V.Gabbadon, E.Rhoden, O.Charles, R.Shaw,
G.Campbell, R.Kerr and S.Livingston for their help in this study.
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Submitted on March 11, 2002; accepted on July 18, 2002
2971