Jagtap V*, Valvi D**, Parulekar S V***
(*Third Year resident, **Assistant Professor, ***Professor and Head, Department of Obstetrics and Gynecology, Seth G. S. Medical college and KEM hospital, Mumbai, India.)
Leiomyomas are the commonest tumors of benign origin in females. Usually a leiomyoma does not cause infertility, unless it obstructs the fallopian tubes. We present a case in which the fallopian tube was patent despite the presence of a cornual leiomyoma.
Leiomyomas are benign monoclonal tumors originating from smooth muscle cells of myometrium of uterus. Its incidence varies from 35% to 80% depending upon age and ethnicity. Leiomyomas may be seen in up to 10% of women with infertility. However only up to 2.5% cases of infertility show leiomyoma as the only cause of infertility with all other possible factors ruled out. Usually a leiomyoma does not cause infertility, unless it obstructs the fallopian tubes. This may occur with a large leiomyoma or multiple leiomyomas which alter the normal pelvic anatomy, or a cornual location which causes obstruction of a fallopian tube, the other fallopian tube being obstructed due to any other reason. We present a case of infertility in which in which a fallopian tube was patent despite the presence of a leiomyoma exactly medial to the origin of the tube.
A twenty eight year old woman, married since four years presented for management of primary infertility. She had regular and normal menstrual cycles with no medical or surgical comorbidity. All her pre-operative investigations for fitness for anesthesia, thyroid function test, serum prolactin levels, Pap smear and her husband’s semen analysis were within normal limit. Hence she was posted for diagnostic hystero-laparoscopy with chromopertubation and uterine curettage. Hysteroscopy showed normal findings and on laparoscopy uterus, bilateral ovaries and fallopian tubes were normal. Only incidental finding was a small 1.5×2 cm cornual leiomyoma on left side. On chromopertubation dye spillage was present bilaterally. The patient made an uneventful recovery.
Figure 1. Left cornual leiomyoma (arrows). Remaining pelvic findings are normal.
Leiomyoma may cause infertility due to obstruction of the fallopian tubes, as with large or multiple leiomyomas which alter the pelvic anatomy, or cornual location of the leiomyoma which can obstruct only one fallopian tube. A cornual leiomyoma may also cause tubal ectopic pregnancy. Other causes of infertility due to uterine leiomyomas include distortion of the uterine cavity, inflammation of endometrium, interference with implantation, altered tubal contractility, cervical obstruction or due to obstruction of proximal tubal end. Lower fertility rates are seen with submucous leiomyomas but not with subserosal or intramural leiomyomas.
A cornual leiomyoma can be dignosed with ltrasonography, aided by hysterosalpingography or sonohysterography. Comuterized tomography or magnetic resonance imaging are not necessary. The diagnosis can be confirmed by laparoscopy, and the tubal patency can be tested at that time with chromopertubabtion, as in the case presented. This patient had a cornual leiomyoma and the fallopian tube appeared to arise right from its lateral aspect. The leiomyoma was large enough to obstruct the fallopian tube. However the tube was found to be patent on chromopertubabtion. This highlights the point that the mere presence of a cornual leiomyoma should not lead to the presumption that the fallopian tube on that side would be obstructed. This patient remains at risk of development of a tubal ectopic pregnancy on that side. No active management is required in such a case. She was counseled about the risk of development of an ectopic pregnancy and advised to report if she missed a period and developed lower abdominal pain, fainting, or vaginal bleeding. Other treatment options for cornual leiomyomas include GnRH agonists to reduce size of the fibroid, myomectomy with tubal reimplantation (more of historical importance) and in vitro fertilization and embryo transfer, in case the other fallopian tube is obstructed too.
We thank Dr Rashmi Prasad for taking the operative photograh.
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Jagtap V, Valvi D, Parulekar SV. Cornual Leiomyoma And Patent Tube. JPGO 2016. Volume 3 No. 4. Available from: http://www.jpgo.org/2016/04/cornual-leiomyoma-and-patent-tube.html