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Middleton, WI, United States

Olive D.L.,Wisconsin Fertility Institute
Seminars in Reproductive Medicine | Year: 2011

Uterine fibroids are a major gynecologic disorder among women and commonly found in the infertile couple. Although numerous surgical techniques exist to destroy or remove these tumors, the role of such surgical procedures in the infertile woman has been heavily debated. The primary reason for this is a lack of evidence of a cause-and-effect relationship between fibroids and subfertility. However, review of the evidence suggests that submucous myomas and possibly intramural myomas both serve to decrease female fertility. A second reason for caution is concern over the impact of surgical treatment on fertility enhancement. For submucous myomas, hysteroscopic myomectomy has proven capable of increasing fertility rates, although this statement may not apply to type 2 submucous myomas. No evidence currently exists for a beneficial effect on fertility of surgical intervention for intramural or subserous fibroids. More randomized treatment trials are clearly needed to clarify the role of myomectomy and other procedures in the infertile woman with type 2 submucous and intramural myomas. Copyright © 2011 by Thieme Medical Publishers, Inc.

Pritts E.A.,Wisconsin Fertility Institute | Vanness D.J.,University of Wisconsin - Madison | Berek J.S.,Stanford University | Parker W.,University of California at Los Angeles | And 3 more authors.
Gynecological Surgery | Year: 2015

There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research. © 2015, The Author(s).

Parker W.H.,University of California at Los Angeles | Pritts E.A.,Wisconsin Fertility Institute | Olive D.L.,Wisconsin Fertility Institute
Clinical Obstetrics and Gynecology | Year: 2016

In November 2014, the Food and Drug Administration (FDA) calculated that for every 498 women having surgery for presumed fibroids, one woman would be found to have an occult leiomyosarcoma( LMS). TheFDAissued a safety communication warning against the use of laparoscopic morcellators in the majority of women undergoing myomectomy or hysterectomy for treatment of fibroids. This communication was prompted by concern that if a patient had an occult LMS, the morcellator might spread tumor cells within the peritoneal cavity. We submit that the FDA directive was based on a flawed and misleading analysis. More rigorous evidence estimates the prevalence of LMS among women operated upon for presumed uterine fibroids at approximately one in 2000 women, significantly lower than the FDA's estimate. In addition, there is no reliable evidence that morcellation influences survival or that power-morcellation is inferior to vaginal or mini-lap morcellation with a scalpel. Recent publication shows that open surgery carries more risk for women when compared with minimally invasive surgery. Although the possibility of occult LMS should be considered by women and their gynecologists, we suggest that current morcellation techniques be continued for women who wish to benefit from minimally invasive surgery. Investigation into new and, hopefully, better morcellating devices may make the procedure safer for women. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Pritts E.A.,Wisconsin Fertility Institute | Parker W.H.,University of California at Los Angeles | Brown J.,University of Texas M. D. Anderson Cancer Center | Olive D.L.,Wisconsin Fertility Institute
Journal of Minimally Invasive Gynecology | Year: 2015

There is concern that morcellation of occult leiomyosarcomas during surgery to treat presumed myomas may substantially worsen patient outcome. We reviewed the existing medical literature to better understand whether such a risk was demonstrable and, if so, what the magnitude of that risk might be. We identified 4864 articles initially, of which 60 were evaluated in full. Seventeen were found to have outcomes information and are included in this review. Six studies addressed the question of whether morcellation of occult leiomyosarcomas resulted in inferior outcomes as compared with en bloc uterine and tumor removal. In these 6 studies, results suggested that en bloc removal may result in improved survival and less recurrence; however, the data are highly biased and of poor quality. There is no reliable evidence that morcellation, power or otherwise, substantially results in tumor upstaging. There is no evidence from these 17 studies that power morcellation differs in any way from other types of morcellation or even simple myomectomy insofar as patient outcome. Whether electromechanical morcellation poses a unique danger to the patient with occult leiomyosarcoma is an unanswered question and one clearly in need of more extensive investigation before conclusions are drawn and policies created. © 2015 AAGL.

Olive D.L.,Wisconsin Fertility Institute | Pritts E.A.,Wisconsin Fertility Institute
Seminars in Reproductive Medicine | Year: 2010

Uterine fibroids are commonly seen in women with reproductive disorders such as infertility, spontaneous abortion (SAB), and obstetric complications. Although it is certain that these tumors can occasionally cause such pathophysiology, it is critical to understand the rate of such occurrences, the degree of causality of the fibroids, and our ability to ameliorate the problems via surgical treatment. Evaluation of the available data is hampered by poor quality studies, heterogeneity of the disease, and confounding factors affecting outcomes. Nevertheless, the best available evidence suggests the following: (1) Submucous myomas decrease fertility and increase SAB rates; myomectomy is likely to be of value; (2) intramural myomas may decrease fertility, but the issue is less clear; they do seem to increase rates of miscarriage; there is no solid evidence that myomectomy restores the patient to normal; (3) subserosal myomas do not impair fertility but may enhance the rate of SAB; and (4) fibroids increase the risk of several obstetric complications, including cesarean delivery, malpresentation, postpartum hemorrhage, retained placenta, intrauterine growth retardation, preterm labor, placenta previa, and abruption. Higher quality studies are desperately needed to add confidence to these tenuous conclusions. © 2010 by Thieme Medical Publishers, Inc.

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