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Author
Information
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.)
Abstract
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.
Introduction
Leiomyomas
are benign monoclonal tumors originating from smooth muscle cells of
myometrium of uterus.[1] Its incidence varies from 35% to 80%
depending upon age and ethnicity.[2] 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.[3] 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.
Case
Report
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.
Discussion
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.[4] Lower fertility rates are seen with submucous
leiomyomas but not with subserosal or intramural leiomyomas.[5]
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,[6]
myomectomy
with tubal reimplantation (more of historical importance) and in
vitro fertilization and embryo transfer, in case the other fallopian
tube is obstructed too.
Acknowledgments
We
thank Dr Rashmi Prasad for taking the operative photograh.
References
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Day Baird D, Dunson DB, et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188:100-107.
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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