Challenging myomectomy of large cervical fibroid - successful fertility outcome: a case report

The cervical fibroids are rare and large cervical fibroids are rarer. Removing large cervical fibroids when a patient desires future fertility is a surgical challenge because of the risks of significant blood loss, bladder and ureteric injury, and unplanned hysterectomy. For women who desire future fertility, myomectomy can improve the chances of pregnancy by restoring normal anatomy. In this article, we describe a successful pregnancy following the restoration of the normal anatomy of the cervix by a challenging myomectomy in a sub-fertile patient with a large cervical fibroid. A 38-year-old nulliparous lady presented to the reproductive endocrinology and infertility (REI) department of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh with primary sub-fertility for five and half years, and dysmenorrhea for 2 years. She was a regularly menstruating woman with average flow and duration. Being a resident of Canada, she was diagnosed there as a case of large cervical fibroid (10×9 cm) by TVS extending up to the posterior wall of the uterus, cervix, and upper vagina impacted in the pouch of Douglas during infertility workup. For this reason, she was advised for in vitro fertilization (IVF) keeping the fibroid in situ. However, due to the failure of embryo transfer with this large cervical fibroid, she was advised for embryo transfer following myomectomy. Hysteroscopic myomectomy was tried first (in February 2019 in Canada) but was unable to be removed. Then Laparotomy was tried (in September 2019 in Canada) but failed again. Being a complicated case, she was counselled there for myomectomy by a multidisciplinary approach with the high risk of injury to the urinary bladder, ureter, bowel, and other pelvic structures. But she refused to do a myomectomy there after knowing the dreadful complications with the fear of injury to the pelvic organs. With this problem, she went to different institutions both in the country and abroad but couldn’t get the proper treatment. Finally, she visited the outpatient department (OPD) of the REI department, BSMMU, Dhaka, Bangladesh with the hope of getting the most appropriate treatment for her and she was reassured, counselled, and managed by a challenging myomectomy (in March 2022) through a combined approach of the vagina and abdominal route without any significant intra and post-operative complications. Her whole post-operative period was uneventful, the anatomy of the cervix was restored and detected by TVS, and trial transfer was done before embryo transfer with easy negotiation to the cervix. Finally, she conceived 1 year after myomectomy with easy frozen embryo transfer. Myomectomy in expert hand even for the large cervical fibroid can restore normal anatomy and can achieve successful pregnancy outcomes.

Effects of autologous stem cell therapy for fertility enhancement among women with premature ovarian insufficiency

Background: Premature ovarian insufficiency (POI) is a condition where the ovary loses its normal reproductive potential earlier than 40 years, compromising fertility. There is no treatment for POI, only ovum or embryo donation. Autologous stem cell ovarian transplant (ASCOT) may be a procedure that creates new eggs in the ovaries of women with POI. The aim of the study was to find out the efficacy of ASCOT in patients suffering from POI.Methods: A total of 50 patients were included according to inclusion and exclusion criteria in this prospective observational study. POI was confirmed with low levels of anti-mullerian hormone (AMH) (<0.5 ng/dl), high level of follicle stimulating hormone (FSH) >25 ng/ml, and or a low number of antral follicle count (AFC) (<3 in each ovary).Results: Results showed that after stem cell therapy, mean AMH values increased by 0.48±0.306 and mean FSH values increased by 2.73±3.98 but the difference was not statistically significant. AFC values significantly decreased by 1.33±0.625 at 1st post-stem-cell cycle. During the second cycle, AMH and AFC increased by 0.110±0.051 and 4.63±1.49, respectively, and FSH decreased by 7.4±2.78. In third cycle, AMH & FSH was significantly increased by 0.820±0.44 & 4.120±0.470 and FSH has been decreased by 2.150±3.625. The increase in AMH & AFC was statistically significant, and the decrease in FSH was not statistically significant compared to baseline values.Conclusions: The study showed that autologous stem cell therapy can have a significant effect on women’s ovarian function and fertility. It showed that ASCOT can increase AMH and AFC, and decrease FSH in patients with POI, with a total pregnancy rate of 4% after the third cycle follow-up.