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doi:10.1111/jog.12548
J. Obstet. Gynaecol. Res. Vol. 41, No. 3: 474–477, March 2015
Is ‘cold loop’ hysteroscopic myomectomy a better option for reproduction in women with diffuse uterine leiomyomatosis? A case report of successful repeated pregnancies Ivano Mazzon1, Alessandro Favilli2, Mario Grasso1, Daniela Morricone1, Gian Carlo Di Renzo2 and Sandro Gerli2 1 ‘Arbor Vitae’ Centre, Clinica Nuova Villa Claudia, Rome, and 2Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
Abstract Diffuse uterine leiomyomatosis (DUL) is a rare clinical entity with important reproductive consequences. To date, only four pregnancies have been reported after hysteroscopic myomectomy. Here we describe the case of a 28-year-old infertile woman with diffuse uterine leiomyomatosis, who presented infertility and metrorrhagia lasting for 2 years. A countless number of subserous, intramural and submucous myomas were ultrasonographically revealed. Diagnostic hysteroscopy described a uterine cavity completely subverted by the presence of myomas. A two-step ‘cold loop’ hysteroscopic myomectomy was performed following the technique previously described. One month after the treatment, there were no submucous myomas. A regular uterine cavity free of synechiae was endoscopically confirmed. After the treatment, the patient carried to term three consecutive, uneventful pregnancies. This is the first report of repeated successful pregnancies following the ‘cold loop’ hysteroscopic technique in DUL. We believe that ‘cold loop’ resectoscopic myomectomy may provide new advantageous perspectives for women with DUL seeking pregnancy. Key words: cesarean section, cold loop myomectomy, diffuse uterine leiomyomatosis, fertility, hysteroscopic myomectomy.
Introduction Diffuse uterine leiomyomatosis (DUL) is a rare pathological condition characterized by the presence of innumerable myomas in the context of myometrium. In extreme cases, it is very difficult to identify intact areas of healthy tissue where there are no myomas.1–4 Hysterectomy is the most frequently used surgical procedure for its treatment regardless of age as the condition is the cause of severe menometrorrhagia.5
Infertility is often present and the management of this condition is complex for patients who wish to have children. Considering the number of myomas to be removed, traditional myomectomy may be nonresolutive and damaging to healthy myometrial tissue in these patients, with a possible risk of severe complications during subsequent pregnancies.6 Several authors have recently proposed hysteroscopic myomectomy as a treatment for DUL, in the presence of submucous myomas, reporting excellent reproductive outcomes. Four pregnancies have been
Received: February 18 2014. Accepted: July 27 2014. Reprint request to: Dr Sandro Gerli, Department of Obstetrics and Gynecology, University of Perugia, Ospedale S.M. della Misericordia, 06156 Perugia, Italy. Email: [email protected]
474
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Pregnancy in diffuse uterine myomatosis
described and all of them have been performed with classic resectoscopic slicing.3,4 ‘Cold loop’ hysteroscopic myomectomy was first realized by Mazzon, developed with the purpose of making this procedure safe and efficient, and aimed at giving more attention to the anatomical and physiological integrity of the endometrium and myometrium.7 Recently, the technique has been described and a significantly lower prevalence of intrauterine adhesions can be obtained in respect to the classical electrical procedure.8 We describe the case of an infertile woman with DUL treated with a ‘cold loop’ resectoscopic myomectomy. After the procedure, the patient had three consecutive, uneventful pregnancies.
Case Report A 28-year-old woman with infertility and metrorrhagia lasting 2 years was referred to our Endoscopic Centre. The first gynecological evaluation showed that her uterus was enlarged to the size of 12 weeks’ gestation. A countless number of subserous, intramural and submucous myomas, the majority measuring between 10 and 30 mm, partially protruding into the uterine cavity, was ultrasonographically revealed. Only one 40-mm subserous, intramural myoma of the anterior wall was detected (Fig. 1). The ovaries were normal. Diagnostic hysteroscopy confirmed the ultrasonographic finding, describing a uterine cavity completely deformed by the presence of myomas (Fig. 2). The patient was anemic with hemoglobin at 9 g/dL. After 3 months’ treatment with gonadotrophin-
Figure 1 Ultrasonographic aspect of diffuse dissemination of uterine leiomyomas.
releasing hormone (GnRH) agonist, the uterus was reduced to about half its volume and hemoglobin levels reached 12 g/dL. A ‘cold loop’ resectoscopic myomectomy following the described technique was performed.8 During the slicing phases of the myoma, monopolar electrical energy at 110 W in pure-cut mode was used, whereas cold loops (mechanical loops of Mazzon) for the enucleation of the intramural portion were adopted to disconnect connective bridges present between the pseudo capsule of the myoma and the myoma itself.8 None of the resections required the use of electric energy in ‘coagulation’ modality for the hemostasis of the blood vessels. Many G0, G1 and G2 submucous myomas spread throughout the uterine cavity were removed. We monitored the intravasation of the sorbitol–mannitol safety limit using EQUIMAT and intrasurgical sodium assay. The procedure lasted 35 min but was not completed because the safety level of distension media was reached (1000 mL) and also to avoid an excessive endocavitary trauma, which would have raised the risk of the occurrence of intrauterine synechiae. The following month the patient underwent a second resectoscopic myomectomy (two-step treatment) to complete the procedure. The operating time was 15 min and at the end of surgery, the uterine cavity was free of myomas, recovering the anatomic normality. No complications were observed during and after surgeries. An ultrasonographic and a hysteroscopic followup were carried out after 1 month: there were no
Figure 2 Hysteroscopic view of uterine cavity completely deformed by the presence of numerous myomas.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
475
I. Mazzon et al.
submucous myomas and a regular uterine cavity free of synechiae was endoscopically confirmed. Numerous intramural and subserous myomas with a diameter varying between 5 and 30 mm, with a 40-mm subserous myoma of the anterior uterine wall, were visualized. Three months later, the patient spontaneously conceived. A threatening abortion was the only adverse symptom recorded during pregnancy. A cesarean delivery was planned at 39 weeks’ gestation, due to intrauterine growth restriction. A healthy newborn of 2200 g was delivered. The placenta was manually removed without any sign of accretism and no sign of post-partum hemorrhagia was detected. During the cesarean section, a 70-mm intramural-subserous, anterior myoma was removed. After 1 year, the patient again spontaneously conceived. The pregnancy was uneventful. A cesarean section was performed at 39 weeks’ gestation with a healthy fetus of 3300 g. No surgical or late complications were observed. A new conception occurred 26 weeks after the previous surgery and a third cesarean section was carried out. A healthy baby of 3300 g was delivered at 39 weeks of pregnancy. No complications were registered. Menstrual periods were regular and no episodes of metrorrhagia were recorded in the interval between pregnancies and up to 8 years after the third cesarean section. Fifteen years after the resectoscopic myomectomy, the patient was 43-years-old and periods became progressively more abundant. An ultrasound scan revealed a uterus approximately three times the normal size; a diagnostic hysteroscopy showed a large number of newly formed submucous myomas. A hysterectomy was performed.
Discussion Diffuse uterine leiomyomatosis represents a rare clinical entity with important implications for genital apparatus. Infertility is a major consequence related to the widespread presence of myomas in the context of the myometrium. A few pregnancies after hysteroscopic myomectomy in DUL have been described;3,4 however, this is the first report with three consecutive, uneventful pregnancies in the same patient after a ‘cold loop’ hysteroscopic removal of submucous myomas. The ‘cold loop’ resectoscopic technique allows the treatment of submucous myomas with a large intramural portion (G1–G2),9 preserving the integrity of myometrial muscular fibres.7 The use of the hysteroscopic
476
cold loop allows deepening into the myometrium without damaging muscular fibers to remove the intramural component of the myoma by disconnecting the connective bridges anchoring the myoma to the myometrium. In this way the risk of thermal loop perforation is virtually eliminated and the prevalence of intrauterine adhesions is significantly reduced.8 In women with DUL, this complication is a major concern after the procedure, as multiple endometrial scars are a possible cause of synechiae and may reduce the reproductive performance of the woman. In order to reduce the prevalence of intrauterine adhesions, several authors proposed to treat only myomas not invading the myometrium (G0) or a partial removal of the G1–G2 myoma.3,4 We consider that to leave the intramural part of G1–G2 myomas makes their treatment incomplete and inappropriate for a pregnancy: indeed, the uterine cavity could be newly deformed by the migration of the residual intramural component of the partially removed myoma. Pregnancies are also reported in patients with DUL after medical treatment with GnRH agonists,10,11 but if we consider a surgical approach, hysteroscopic myomectomy is undoubtedly a less invasive and less traumatic procedure compared to laparoscopic or laparotomic treatment. Nevertheless, necrotic damage and reactive fibrosis caused by the incision of the myometrium may alter its function.12 Similar consequences might be evident after resectoscopic myomectomies performed on submucous G1–G2 myomas using the traditional intramural ‘slicing’ technique, especially when electricity is applied in the ‘coagulation’ modality, whereas monopolar or bipolar ‘pure-cut’ modality minimizes the thermal damage. Necrotic damage and subsequent reactive fibrosis is the basis for the occurrence of postoperative synechiae and severe complications, such as spontaneous uterine rupture during pregnancy.6 Furthermore, it is evident from the literature that the integrity of the uterine cavity may have a significant, positive impact on the pregnancy outcome.12 We strongly agree with Yen et al.3 affirming the importance of an early hysteroscopic follow-up in order to easily lyse the filmy adhesions with the tip of the hysteroscope or by irrigation with distension medium. In our patient, although a 1-month hysteroscopic follow-up was scheduled, a regular uterine cavity free of synechiae was demonstrated; anyway, we did not apply anti-adhesive gel or hormonal therapy as described elsewhere.3,4 Mazzon et al. already demonstrated that the use of electricity exclusively dispensed
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Pregnancy in diffuse uterine myomatosis
as a ‘pure-cut’ modality during the slicing phase of the intracavitary component of the myoma, in combination with the ‘cold loop’ technique for the treatment of the intramural part of the myoma, may play an important role in avoiding the formation of postoperative synechiae.8 Furthermore, we must emphasize that the described treatment guaranteed a long period of wellbeing free from clinical symptoms. This case report shows that ‘cold loop’ hysteroscopic myomectomy in patients with DUL may better restore the uterine cavity compared to electrical resectoscopic myomectomy, providing better results in diffuse leiomyomatosis for those patients who want to preserve their fertility.
Disclosure Ivan Mazzon reports non-financial support from STORZ, Tuttlingen, Germany, outside the submitted work. Alessandro Favilli, Mario Grasso, Daniela Morricone, Gian Carlo Di Renzo and Sandro Gerli report no conflict of interest for the present article.
References 1. Clement PB, Young RH. Diffuse leiomyomatosis of the uterus: A report of four cases. Int J Gynecol Pathol 1987; 6: 322–330.
2. Baschinsky DY, Isa A, Niemann TH, Prior TW, Lucas JG, Frankel WL. Diffuse leiomyomatosis of the uterus: A case report with clonality analysis. Hum Pathol 2000; 31: 1429– 1432. 3. Yen CF, Lee CL, Wang CJ, Soong YK, Arici A. Successful pregnancies in women with diffuse uterine leiomyomatosis after hysteroscopic management. Fertil Steril 2007; 88: 1667– 1673. 4. Shimizu Y, Yomo H, Kita N, Takahashi K. Successful pregnancy after gonadotropin-releasing hormone analogue and hysteroscopic myomectomy in a woman with diffuse uterine leiomyomatosis. Arch Gynecol Obstet 2009; 280: 145–147. 5. Lapan B, Solomon L. Diffuse leiomyomatosis of the uterus precluding myomectomy. Obstet Gynecol 1979; 53: 82S–84S. 6. Gerli S, Baiocchi G, Favilli A, Di Renzo GC. New treatment option for early spontaneous rupture of a postmyomectomy gravid uterus. Fertil Steril 2011; 96: e97–e98. 7. Di Spiezio Sardo A, Mazzon I, Bramante S et al. Hysteroscopic myomectomy: A comprehensive review of surgical techniques. Hum Reprod Update 2008; 14: 101–119. 8. Mazzon I, Favilli A, Cocco P et al. Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study. Fertil Steril 2014; 101: 294–298. 9. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: Results regarding the degree of intramural extension. Obstet Gynecol 1993; 82: 736–740. 10. Fedele L, Bianchi S, Zanconato G, Carinelli S, Berlanda N. Conservative treatment of diffuse uterine leiomyomatosis. Fertil Steril 2004; 82: 450–453. 11. Purohit R, Sharma JG, Singh S. A case of diffuse uterine leiomyomatosis who had two successful pregnancies after medical management. Fertil Steril 2011; 95: 2434.e5–e6. 12. Parker WH, Einarsson J, Istre O, Dubuisson JB. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol 2010; 17: 551–554.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
477
doi:10.1111/jog.12548
J. Obstet. Gynaecol. Res. Vol. 41, No. 3: 474–477, March 2015
Is ‘cold loop’ hysteroscopic myomectomy a better option for reproduction in women with diffuse uterine leiomyomatosis? A case report of successful repeated pregnancies Ivano Mazzon1, Alessandro Favilli2, Mario Grasso1, Daniela Morricone1, Gian Carlo Di Renzo2 and Sandro Gerli2 1 ‘Arbor Vitae’ Centre, Clinica Nuova Villa Claudia, Rome, and 2Department of Obstetrics and Gynecology, University of Perugia, Perugia, Italy
Abstract Diffuse uterine leiomyomatosis (DUL) is a rare clinical entity with important reproductive consequences. To date, only four pregnancies have been reported after hysteroscopic myomectomy. Here we describe the case of a 28-year-old infertile woman with diffuse uterine leiomyomatosis, who presented infertility and metrorrhagia lasting for 2 years. A countless number of subserous, intramural and submucous myomas were ultrasonographically revealed. Diagnostic hysteroscopy described a uterine cavity completely subverted by the presence of myomas. A two-step ‘cold loop’ hysteroscopic myomectomy was performed following the technique previously described. One month after the treatment, there were no submucous myomas. A regular uterine cavity free of synechiae was endoscopically confirmed. After the treatment, the patient carried to term three consecutive, uneventful pregnancies. This is the first report of repeated successful pregnancies following the ‘cold loop’ hysteroscopic technique in DUL. We believe that ‘cold loop’ resectoscopic myomectomy may provide new advantageous perspectives for women with DUL seeking pregnancy. Key words: cesarean section, cold loop myomectomy, diffuse uterine leiomyomatosis, fertility, hysteroscopic myomectomy.
Introduction Diffuse uterine leiomyomatosis (DUL) is a rare pathological condition characterized by the presence of innumerable myomas in the context of myometrium. In extreme cases, it is very difficult to identify intact areas of healthy tissue where there are no myomas.1–4 Hysterectomy is the most frequently used surgical procedure for its treatment regardless of age as the condition is the cause of severe menometrorrhagia.5
Infertility is often present and the management of this condition is complex for patients who wish to have children. Considering the number of myomas to be removed, traditional myomectomy may be nonresolutive and damaging to healthy myometrial tissue in these patients, with a possible risk of severe complications during subsequent pregnancies.6 Several authors have recently proposed hysteroscopic myomectomy as a treatment for DUL, in the presence of submucous myomas, reporting excellent reproductive outcomes. Four pregnancies have been
Received: February 18 2014. Accepted: July 27 2014. Reprint request to: Dr Sandro Gerli, Department of Obstetrics and Gynecology, University of Perugia, Ospedale S.M. della Misericordia, 06156 Perugia, Italy. Email: [email protected]
474
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Pregnancy in diffuse uterine myomatosis
described and all of them have been performed with classic resectoscopic slicing.3,4 ‘Cold loop’ hysteroscopic myomectomy was first realized by Mazzon, developed with the purpose of making this procedure safe and efficient, and aimed at giving more attention to the anatomical and physiological integrity of the endometrium and myometrium.7 Recently, the technique has been described and a significantly lower prevalence of intrauterine adhesions can be obtained in respect to the classical electrical procedure.8 We describe the case of an infertile woman with DUL treated with a ‘cold loop’ resectoscopic myomectomy. After the procedure, the patient had three consecutive, uneventful pregnancies.
Case Report A 28-year-old woman with infertility and metrorrhagia lasting 2 years was referred to our Endoscopic Centre. The first gynecological evaluation showed that her uterus was enlarged to the size of 12 weeks’ gestation. A countless number of subserous, intramural and submucous myomas, the majority measuring between 10 and 30 mm, partially protruding into the uterine cavity, was ultrasonographically revealed. Only one 40-mm subserous, intramural myoma of the anterior wall was detected (Fig. 1). The ovaries were normal. Diagnostic hysteroscopy confirmed the ultrasonographic finding, describing a uterine cavity completely deformed by the presence of myomas (Fig. 2). The patient was anemic with hemoglobin at 9 g/dL. After 3 months’ treatment with gonadotrophin-
Figure 1 Ultrasonographic aspect of diffuse dissemination of uterine leiomyomas.
releasing hormone (GnRH) agonist, the uterus was reduced to about half its volume and hemoglobin levels reached 12 g/dL. A ‘cold loop’ resectoscopic myomectomy following the described technique was performed.8 During the slicing phases of the myoma, monopolar electrical energy at 110 W in pure-cut mode was used, whereas cold loops (mechanical loops of Mazzon) for the enucleation of the intramural portion were adopted to disconnect connective bridges present between the pseudo capsule of the myoma and the myoma itself.8 None of the resections required the use of electric energy in ‘coagulation’ modality for the hemostasis of the blood vessels. Many G0, G1 and G2 submucous myomas spread throughout the uterine cavity were removed. We monitored the intravasation of the sorbitol–mannitol safety limit using EQUIMAT and intrasurgical sodium assay. The procedure lasted 35 min but was not completed because the safety level of distension media was reached (1000 mL) and also to avoid an excessive endocavitary trauma, which would have raised the risk of the occurrence of intrauterine synechiae. The following month the patient underwent a second resectoscopic myomectomy (two-step treatment) to complete the procedure. The operating time was 15 min and at the end of surgery, the uterine cavity was free of myomas, recovering the anatomic normality. No complications were observed during and after surgeries. An ultrasonographic and a hysteroscopic followup were carried out after 1 month: there were no
Figure 2 Hysteroscopic view of uterine cavity completely deformed by the presence of numerous myomas.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
475
I. Mazzon et al.
submucous myomas and a regular uterine cavity free of synechiae was endoscopically confirmed. Numerous intramural and subserous myomas with a diameter varying between 5 and 30 mm, with a 40-mm subserous myoma of the anterior uterine wall, were visualized. Three months later, the patient spontaneously conceived. A threatening abortion was the only adverse symptom recorded during pregnancy. A cesarean delivery was planned at 39 weeks’ gestation, due to intrauterine growth restriction. A healthy newborn of 2200 g was delivered. The placenta was manually removed without any sign of accretism and no sign of post-partum hemorrhagia was detected. During the cesarean section, a 70-mm intramural-subserous, anterior myoma was removed. After 1 year, the patient again spontaneously conceived. The pregnancy was uneventful. A cesarean section was performed at 39 weeks’ gestation with a healthy fetus of 3300 g. No surgical or late complications were observed. A new conception occurred 26 weeks after the previous surgery and a third cesarean section was carried out. A healthy baby of 3300 g was delivered at 39 weeks of pregnancy. No complications were registered. Menstrual periods were regular and no episodes of metrorrhagia were recorded in the interval between pregnancies and up to 8 years after the third cesarean section. Fifteen years after the resectoscopic myomectomy, the patient was 43-years-old and periods became progressively more abundant. An ultrasound scan revealed a uterus approximately three times the normal size; a diagnostic hysteroscopy showed a large number of newly formed submucous myomas. A hysterectomy was performed.
Discussion Diffuse uterine leiomyomatosis represents a rare clinical entity with important implications for genital apparatus. Infertility is a major consequence related to the widespread presence of myomas in the context of the myometrium. A few pregnancies after hysteroscopic myomectomy in DUL have been described;3,4 however, this is the first report with three consecutive, uneventful pregnancies in the same patient after a ‘cold loop’ hysteroscopic removal of submucous myomas. The ‘cold loop’ resectoscopic technique allows the treatment of submucous myomas with a large intramural portion (G1–G2),9 preserving the integrity of myometrial muscular fibres.7 The use of the hysteroscopic
476
cold loop allows deepening into the myometrium without damaging muscular fibers to remove the intramural component of the myoma by disconnecting the connective bridges anchoring the myoma to the myometrium. In this way the risk of thermal loop perforation is virtually eliminated and the prevalence of intrauterine adhesions is significantly reduced.8 In women with DUL, this complication is a major concern after the procedure, as multiple endometrial scars are a possible cause of synechiae and may reduce the reproductive performance of the woman. In order to reduce the prevalence of intrauterine adhesions, several authors proposed to treat only myomas not invading the myometrium (G0) or a partial removal of the G1–G2 myoma.3,4 We consider that to leave the intramural part of G1–G2 myomas makes their treatment incomplete and inappropriate for a pregnancy: indeed, the uterine cavity could be newly deformed by the migration of the residual intramural component of the partially removed myoma. Pregnancies are also reported in patients with DUL after medical treatment with GnRH agonists,10,11 but if we consider a surgical approach, hysteroscopic myomectomy is undoubtedly a less invasive and less traumatic procedure compared to laparoscopic or laparotomic treatment. Nevertheless, necrotic damage and reactive fibrosis caused by the incision of the myometrium may alter its function.12 Similar consequences might be evident after resectoscopic myomectomies performed on submucous G1–G2 myomas using the traditional intramural ‘slicing’ technique, especially when electricity is applied in the ‘coagulation’ modality, whereas monopolar or bipolar ‘pure-cut’ modality minimizes the thermal damage. Necrotic damage and subsequent reactive fibrosis is the basis for the occurrence of postoperative synechiae and severe complications, such as spontaneous uterine rupture during pregnancy.6 Furthermore, it is evident from the literature that the integrity of the uterine cavity may have a significant, positive impact on the pregnancy outcome.12 We strongly agree with Yen et al.3 affirming the importance of an early hysteroscopic follow-up in order to easily lyse the filmy adhesions with the tip of the hysteroscope or by irrigation with distension medium. In our patient, although a 1-month hysteroscopic follow-up was scheduled, a regular uterine cavity free of synechiae was demonstrated; anyway, we did not apply anti-adhesive gel or hormonal therapy as described elsewhere.3,4 Mazzon et al. already demonstrated that the use of electricity exclusively dispensed
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Pregnancy in diffuse uterine myomatosis
as a ‘pure-cut’ modality during the slicing phase of the intracavitary component of the myoma, in combination with the ‘cold loop’ technique for the treatment of the intramural part of the myoma, may play an important role in avoiding the formation of postoperative synechiae.8 Furthermore, we must emphasize that the described treatment guaranteed a long period of wellbeing free from clinical symptoms. This case report shows that ‘cold loop’ hysteroscopic myomectomy in patients with DUL may better restore the uterine cavity compared to electrical resectoscopic myomectomy, providing better results in diffuse leiomyomatosis for those patients who want to preserve their fertility.
Disclosure Ivan Mazzon reports non-financial support from STORZ, Tuttlingen, Germany, outside the submitted work. Alessandro Favilli, Mario Grasso, Daniela Morricone, Gian Carlo Di Renzo and Sandro Gerli report no conflict of interest for the present article.
References 1. Clement PB, Young RH. Diffuse leiomyomatosis of the uterus: A report of four cases. Int J Gynecol Pathol 1987; 6: 322–330.
2. Baschinsky DY, Isa A, Niemann TH, Prior TW, Lucas JG, Frankel WL. Diffuse leiomyomatosis of the uterus: A case report with clonality analysis. Hum Pathol 2000; 31: 1429– 1432. 3. Yen CF, Lee CL, Wang CJ, Soong YK, Arici A. Successful pregnancies in women with diffuse uterine leiomyomatosis after hysteroscopic management. Fertil Steril 2007; 88: 1667– 1673. 4. Shimizu Y, Yomo H, Kita N, Takahashi K. Successful pregnancy after gonadotropin-releasing hormone analogue and hysteroscopic myomectomy in a woman with diffuse uterine leiomyomatosis. Arch Gynecol Obstet 2009; 280: 145–147. 5. Lapan B, Solomon L. Diffuse leiomyomatosis of the uterus precluding myomectomy. Obstet Gynecol 1979; 53: 82S–84S. 6. Gerli S, Baiocchi G, Favilli A, Di Renzo GC. New treatment option for early spontaneous rupture of a postmyomectomy gravid uterus. Fertil Steril 2011; 96: e97–e98. 7. Di Spiezio Sardo A, Mazzon I, Bramante S et al. Hysteroscopic myomectomy: A comprehensive review of surgical techniques. Hum Reprod Update 2008; 14: 101–119. 8. Mazzon I, Favilli A, Cocco P et al. Does cold loop hysteroscopic myomectomy reduce intrauterine adhesions? A retrospective study. Fertil Steril 2014; 101: 294–298. 9. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: Results regarding the degree of intramural extension. Obstet Gynecol 1993; 82: 736–740. 10. Fedele L, Bianchi S, Zanconato G, Carinelli S, Berlanda N. Conservative treatment of diffuse uterine leiomyomatosis. Fertil Steril 2004; 82: 450–453. 11. Purohit R, Sharma JG, Singh S. A case of diffuse uterine leiomyomatosis who had two successful pregnancies after medical management. Fertil Steril 2011; 95: 2434.e5–e6. 12. Parker WH, Einarsson J, Istre O, Dubuisson JB. Risk factors for uterine rupture after laparoscopic myomectomy. J Minim Invasive Gynecol 2010; 17: 551–554.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
477
