Introduction:

Uterine fibroids are the most common benign tumors in reproductive-aged women, and a frequent cause of infertility, miscarriage, or adverse pregnancy outcomes. Myomectomy remains the uterus-preserving treatment of choice in women desiring pregnancy, but risks increase with extensive procedures, especially when the endometrial cavity is entered and reconstructed. There is limited literature on successful term pregnancies following extensive myomectomy with cavity reconstruction and conception within less than a year.

Case Description:

We present a case of a 34 year old G0P0000 who presented to Sinai Medical Group reporting a long standing history of abnormal uterine bleeding as well as primary infertility. Her menstrual history was remarkable for menorrhagia resulting in symptomatic anemia and necessitating blood transfusions in the past. She additionally reported dysmenorrhea, dyspareunia, and constant sensation of pelvic pressure exacerbated during menses. She had previously failed a trial of hormonal therapy. She had been actively trying to conceive for 3 years prior to presentation. 

Transvaginal ultrasound revealed a uterus measuring 9.5 x 19.4 cm. MRI of the pelvis was fairly consistent, revealing a uterus measuring 18.7 x 13.9 x 11.8 cm and 2 large uterine masses measuring 9.1 x 8.5 x 9.8 cm and 10.1 x 6.9 x 9.5 cm. At least four additional smaller fibroids were identified. After a discussion of risks and benefits, she elected to proceed with abdominal myomectomy.

She underwent uncomplicated abdominal myomectomy via Pfannestiel incision. Intraabdominal survey revealed an enlarged uterus with a prominent anterior fibroid. It was noted to have breached the endometrial cavity, requiring reconstruction of the cavity following removal. Several smaller fibroids were excised. She did well and was discharged home on postoperative day 2 after meeting all appropriate milestones. 

8 months post operatively, she conceived naturally. Her pregnancy was complicated by mild anemia (starting hemoglobin 9.9 in the first trimester). She had regular prenatal care; routine labs and fetal anatomy surveys were unremarkable. She underwent a scheduled primary cesarean section at 37 weeks and 5 days. A viable female infant was born, weighing 4200 grams with APGAR scores of 8,8. Delivery was complicated by postpartum hemorrhage. She completed her postoperative milestones and was discharged home on postoperative day 3 in stable condition.

Conclusion:

Extensive myomectomy, including procedures involving the endometrial cavity, can preserve or restore fertility, with successful pregnancy achievable in selected cases. Comprehensive patient counseling, individualized delivery planning, and further research to clarify optimal timing of conception and antenatal management are essential to optimize reproductive outcomes.

Discussion:

This report adds to the limited body of evidence that fertility and favorable obstetric outcomes are possible after extensive myomectomy with endometrial cavity entry and reconstruction. Reported risks after extensive myomectomy include uterine rupture, abnormal placentation, intrauterine adhesions, infertility, and miscarriage. Many guidelines recommend delaying conception at least 12-18 months post-myomectomy to allow adequate uterine healing, though this is not strongly evidence-based. Patients undergoing extensive myomectomy should be counseled on both risks and potential for successful pregnancy. Delivery planning should be individualized.