Investigation of The Effect of Myomectomy on Anti-Mullerian Hormone Level in Women with Uterine Leiomyoma: A Prospective Quasi-Experimental Study.

Uterine fibroids affect up to 80% of women of reproductive age. This condition, particularly the submucosal or intramural types, adversely affect fertility and pregnancy ( 1 , 2 ). When these fibroids cause symptoms such as menorrhagia, severe dysmenorrhea, urinary frequency or bulking symptoms, infertility and repeated miscarriages, dyspareunia, and sexual disorders, surgical treatment is often suggested ( 3 , 4 ). Advanced age, race, heredity, hormonal imbalance, high-body mass index (BMI), vascular endothelial growth factor (VEGF), and lifestyle also increases the myoma risk ( 5 , 6 ). Current treatments for leiomyomas include administration of oral contraceptives, progesterone receptor modulators, and gonadotropin hormone-releasing hormone (GnRH) agonists, as well as procedures such as uterine artery embolization (UAE) ( 7 ). Other common treatments for this disorder are radiofrequency ablation ( 8 ), hysteroscopy, open and laparoscopic myomectomy and hysterectomy ( 9 ), as well as presurgical GnRH agonist injection ( 10 ). During laparotomic and laparoscopic myomectomy procedures, there is a possibility that ovarian reserve may be impacted due to certain incidents, including the interruption of collat eral vasculature that supplies the ovaries through cautery, sutures, or temporary occlusion with a tourniquet, as well as bleeding that may result in reduced blood supply to the ovary ( 11 , 12 ). Therefore, it is necessary to use certain methods to reduce the bleeding. Several methods have already been proposed, including intramyometrial injection of vasopressin, intravascular injection of oxytocin, the use of tourniquet, intramyometrial infusion of bupivacaine and epinephrine, and complete removal of the myoma using morcellation ( 13 - 16 ). In extreme cases of bleeding, closing or ligating both uterine arteries is recommended ( 17 ). As mentioned earlier, several studies suggest that un dergoing myomectomy may impact a woman’s ovar ian reserve, however, the small sample size, short-term follow-up, and/or unspecified surgical routes and details limit the scope of these studies. Therefore, it is essential to pay more attention to this issue when examining ovarian reserve and measuring anti-Müllerian hormone (AMH) level prior to performing myomectomy surgery. The aim of the current study is to investigate the changes in AMH before and after myomectomy. Then we evaluate the relationship between these changes with open myomectomy compared to laparoscopic myomectomy. Finally, we compare the rate of postsurgical complications between open and minimally invasive surgeries.

In this study, a total of 93 patients undergoing laparotomic and laparoscopic myomectomy were enrolled. The mean age, BMI, and size of myomas of the patients were 36.76 ± 5.47 (range 18-45 years), 26.56 ± 2.38 kg/m2, and 6.74 ± 1.48 cm, respectively. The most common type of myoma was intramural myoma (45.2%), and 77 (82.8%) patients had a single myoma. The highest number of myomas was observed in one patient with 10 myomas. Four teen (15.1%) patients had underlying diseases [5 cases of hypothyroidism, 1case of hypertension, 7 cases of diabetes mellitus (DM), and 1 case of hyperlipidemia] ( Table 1 ). Among the patients, 61 (65.5%) underwent laparos copy and 32 (34.5%) underwent laparotomy. The rate of postsurgical complications was as follows: fever rate was 12.3 and 6.1% in the laparotomy group and in the lapa roscopy group, respectively. Pain rate [visual analogue scale (VAS) score>7] was higher in the laparotomy group compared to the laparoscopy group (21 vs. 7.3%). SSI rate was 0.9 and 6.3% in the laparoscopy and laparotomy groups, respectively. Also, 3 (3.2%) patients required a blood transfusion during the surgery. Baseline and myoma characteristics among the study participants SD; Standard deviation, BMI; Body mass index, and HLP; Hyperlipidemia. In the laparoscopy group, the AMH levels were 1.23 ± 0.9 and 1.18 ± 0.64 before and 6 months after surgery, respectively (P=0.045). In the laparotomy group, the corresponding figures were 2.76 ± 1.18 and 1.54 ± 1.1, respectively (P=0.028). The reduction of AMH showed a significant difference in both groups (P<0.001). How ever, this reduction was less pronounced in the lapa roscopy group than in the laparotomy group ( Table 2 ). The most common clinical symptoms in the studied patients were AUB (33.3%), followed by abdominal pain (25.8%), dysmenorrhea (26.9%), and infertility (15.1%). The mean change in AMH level was 1.4 ± 0.96 ng/ml ( Fig .2 ). It has been suggested previously that the AMH range varies depending on laboratory equipment and age ( 18 ). Comparison of AMH levels between laparoscopy and laparotomy surgery before and after myomectomy Data are presented as mean ± SD. AMH; Anti-Müllerian hormone and *; Paired t test. Additionally, changes in AMH levels varied based on the type, size, and number of myomas, with the most significant reduction observed in patients with larger or multiple myomas ( Table 3 ). There was a direct correlation between the volume of bleeding and the size of myoma with the degree of AMH drop ( Table 4 ). The average size of the myoma had no significant effect on the occurrence of the investigated complications. Also, this study provided further evidence supporting the effects of size and type of myoma on AMH levels. The reduction of AMH in hybrid myomas was more pronounced than in the other myomas. The mean change in AMH level before and after myomectomy was 1.71 ± 0.83 in hybrid myoma compared to that in intramural myoma (0.74 ± 0.2) and subserosal myoma (0.64 ± 0.3, P=0.040). A significant decreasing trend towards the size of myoma on AMH level was observed. Decline in serum AMH level is more frequently seen in myomas larger than 8 cm compared to smaller myomas. AMH change was 2.79 ± 1.71 in myomas larger than 8cm, 0.76 ± 0.5 in myomas of 5-7 cm, and 0.61 ± 0.2 in myomas smaller than 5 cm. Box plot (median, range and 25-75 percentage) of Anti-Müllerian hormone (AMH) level before and 6 months after myomectomy. Mean AMH level before and after myomectomy and mean differences of AMH levels based on myoma characteristics Data are presented as mean ± SD. AMH; Anti-Müllerian hormone, *; Paired t test, **; The repeated measures ANOVA, and ***; Analysis of variance (ANOVA). The Pearson correlation between AMH levels with age, BMI, size and the number of myoma Data are presented as mean ± SD. AMH; Anti-Müllerian hormone, *; Paired t test, **; The repeated measures ANOVA, and ***; Analysis of variance (ANOVA).

The results of our study showed that AMH level significantly decreased following myomectomy. Besides this, there was a significant difference in mean AMH level be fore and 6 months after the surgery for the type and size of myomas. In the laparoscopy group, the mean AMH level was 1.23 ± 0.9 and 1.18 ± 0.64 before and 6 months after surgery, respectively. In the laparotomy group, the corresponding figures were 2.76 ± 1.18 and 1.54 ± 1.1, respectively. AMH level significantly decreased in both groups. However, this reduction was less pronounced in the laparoscopy group compared to the laparotomy group. Myomectomy is known as a primary treatment method for symptomatic myomas ( 19 ). This study was done to in vestigate the possible effects of this procedure on ovarian reserve. The AMH test is the most accurate one to assess ovarian reserve. It is produced by the granulosa cells of growing follicles within the ovaries ( 20 ). Recent studies have shown that AMH is a more sensitive and accurate predictor of ovarian reserve than other possible indicators, such as follicle-stimulating hormone (FSH) ( 21 , 22 ). A study indicates that a decrease in AMH level is linked to the obstruction of blood supply to the ovaries, particularly in cases of internal iliac artery ligation. The authors suggest that the temporary ischemia experienced during myomectomy may also impact the growth of follicles, resulting in a temporary reduction in AMH level until new follicles are recruited ( 23 ). A study conducted by Aharon et al. ( 24 ) revealed that 111 patients who underwent open myomectomy and laparoscopic myomectomy experienced a significant decline in serum AMH levels at 2 weeks post-surgery in laparoto mic myomectomy, but there was no significant difference at 3 and 6 months after the surgery. They suggested that the use of a tourniquet, which temporarily reduces ovarian blood supply, could be responsible for the short-term decline in AMH level ( 24 ). Furthermore, multiple linear regression analysis revealed that open myomectomy was associated with a significant decline in AMH level at 2 weeks after the surgery (open myomectomy vs. minimal ly invasive myomectomy), but there were no significant differences at 3 and 6 months intervals following the surgery. In the laparoscopic myomectomy group, there were no significant differences in mean AMH levels between baseline and postoperative intervals ( 24 ). Furthermore, in another study conducted by Chen et al. ( 25 ) there was no notable difference in serum AMH or FSH levels prior to and at 3 and 6 months following uterine artery occlusion during myomectomy. The ovarian volume, antral follicle count (AFC), and blood flow within the ovarian stroma showed significant alterations in the right ovary. Both ovarian volume and AFC showed a notable decrease at 3 months, but then returned to baseline at the 6-month mark postoperatively ( 25 ). Ahmed and Zaghlol ( 26 ) also reported that myomectomy does not affect ovarian reserve and infertility conditions conventionally associate to other factors, such as endometrial factors or even improper oocyte maturation. Diab et al. ( 27 ) also conducted a study on 30 women of reproductive age and found that open myomectomy did not have a significant impact on ovarian reserve parameters. Regarding the underlying variables, both age and the AMH level were drawn as uncorrelated in our study. The reduction of AMH level was observed along with increased age before and after the surgery. Although the difference was not significant, it was more pronounced in older patients. La Marca et al. ( 28 ), Ahmed and Zaghlol ( 26 ), and Kel sey et al. ( 29 ) consistently have reported an inverse correlation between age and AMH levels. In some studies, this correlation is statistically significant. In our study, similar conditions were observed for the relationship between the BMI and AMH levels. However, none of the BMI groups showed a significant difference in AMH levels before and after the surgery. We also compared the changes in AMH levels between laparoscopy and laparotomy. Our data showed that the rate of AMH drop was less pronounced in the laparoscopy group than in the laparotomy group. This finding can be explained by more blood loss in the laparotomy group compared to the laparoscopy group. According to the results of our study, the type and size of myoma(s) may significantly affect AMH level before and after myomectomy. More sutures, bleeding, hypo tension (resulting from both blood loss and anesthesia), prolonged surgery time, and the presence of intramural myomas are factors that may affect the small follicles secreting AMH. Based on various studies, it can be argued that the type of myoma has no impact on ovarian reserve during myomectomy ( 29 , 30 ). The size of myoma, on the other hand, has been reported as an influential factor ( 31 ). However, few studies have investigated these two variables’ effects on myomectomy outcome for serum AMH level. In our study, the significant impacts of these two variables were demonstrated. Wang et al. ( 32 ) also argue that pre- and postsurgical bleeding may be the reason for the decline in serum AMH levels. In our study, the average intraoperative bleeding volume in the studied patients was 327.9 ml. Therefore, the AMH drop after the operation may be partially attributed to this argument. Some items may lead to varying results and interpretations, including surgical approach differences, patients’ demographic characteristics (race, age, BMI, comorbidities), type of AMH measurement (preoperative and post operative), type, size and number of myoma, study design, follow-up duration and analytical approaches. Therefore, it is essential to consider the findings of multiple studies collectively to draw comprehensive conclusions. The strengths of our study were as follows: it was the first prospective trial to compare the effect of type of my oma in reducing AMH level. Also, we assessed blood loss during the surgery. Moreover, an appropriate sample size in this study improves sufficient statistical power to detect meaningful changes in AMH levels, enhances the reliabil ity and generalizability of the findings, and accounts for potential variability among women with uterine leiomyoma undergoing myomectomy. We evaluated the impact of myomectomy on ovarian reserve over a prolonged period, and also investigated the correlation between surgical approach and postoperative ovarian reserve. We considered the location and size of all uterine myomas in evaluating ovarian reserve of the patients (based on FIGO classification). The limitations of the current study included: the AMH level was checked only once after the myomectomy. Also, it is ideal to conduct a similar study with a larger sample size to obtain more accurate data. Based on the current study, the number of infertile women who need to undergo myomectomy and also reserve their ovaries is increasing. Therefore, it is be recommended to freeze embryos before the surgery, when the AMH level is low. Also, it is better to perform laparoscopic surgery because AMH levels drop less pronouncedly in laparoscopy compared to in laparotomy.

The results of this study showed that myomectomy led to a decrease in AMH in women with uterine leiomyoma within 6 months after the operation. In addition, we found that the size of myoma may significantly affect the changes in AMH level. In women with infertility and low AMH level that candidate to open or laparoscopic myomectomy, it can be recommended to freeze embryo before surgery.

This prospective quasi-experimental study was conducted by a surgical team from January 15, 2020, to May 20, 2022, and all consecutive participants who referred to in Beheshti and Al-zahra hospitals, candidate for laparoscopic myomectomy. In this study, 93 patients with uterine leiomyoma and candidates for myomectomy by laparotomy or laparoscopy were selected based on inclusion and exclusion criteria ( Fig .1 ). The sampling method was based on convenience sampling. CONSORT flow diagram of the study population. The sample size was calculated based on a 95% confidence and a power of 80% to see a moderately small effect size equal to 0.3 during the study for AMH. Inclusion criteria were ages of 18-45 years, symptomatic myoma [abnormal uterine bleeding (AUB), infertility, pelvic pressure], and willingness to participate in the study. Exclusion criteria were endometriosis, history of polycystic ovary syndrome (PCOS), change of surgical technique, and failure to visit the patient. Personal and clinical information such as age, BMI, underlying disease(s), surgery history, infertility, menstrual disorders (AUB and painful menstruation), and other complaints were elicited from the participants and recorded. Before surgery, an ultrasound was performed by a sonographer to determine the number, size, type of the myomas and location of the myomas in each patient. Moreover, the duration of the surgery, the amount of in traoperative bleeding, the need for blood transfusion, and postsurgical complications were recorded. Then, 5 ml of venous blood was taken from the patient and sent to the laboratory to determine the AMH level. All specimens were sent to the same laboratory. The decision on laparoscopy or laparotomy was made based on the patient’s characteristics and the size and number of myomas. Patients with myomas smaller than 5 cm or fewer than 3 myomas were considered candidates for laparoscopy. The remaining patients were assigned to the laparotomy group. In the laparoscopy group 4 trocars, including the umbilical, suprapubic, and right and left trocars, were used. The surgery began by injecting diluted vasopressin (20 U in 100 ml normal saline; Exir Pharmaceutical Company, Iran) into the serosa that covers the myoma, with an injection needle through the port. Then, the uterine serosa was cut using a monopolar cutting electrode. A myoma was gripped using a tenaculum and extracted by a combination of traction-counter traction and electrosurgery, as required. After the my omectomy, the uterine defect was closed in 1 to 3 layers using vicryl sutures (Ethicon, Somerville, NJ) based on the type of myoma. Then, the myoma was morcellated and removed via the trocar. If a morcellation device was not available, the myoma was removed by a minilaparotomy using retractor (alexis). A Penrose drain tourni quet measuring three-quarters of an inch was used during the laparotomy procedure. The uterus was brought outside the abdominal incision, and then the tourniquet was secured to the base of the uterus. The tourniquet encircled the uterine and ovarian vessels and encompassed the ovaries. Any detectable leiomyomas were removed after making a uterus incision. If the patient underwent an open myomectomy, the tourniquet was left in place throughout the procedure, but was intermittently released. The ovarian and uterine vessels were preserved. During the procedure, various data were collected, such as the duration of the surgery, the amount of blood loss, the weight of the leiomyomas, and any concomitant procedures, such as adhesiolysis. When the patient was discharged from the hospital, she was asked to refer 2 weeks and then 2 months after the surgery for evaluation of pain, vaginal bleeding and other symptoms. In addition, six months after the surgery, the level of AMH was measured and recorded for each patient. It should be noted that the AMH level, before and after the surgery, was measured in the same laboratory by the same person and the same machine. This study was approved by ethical approval from the Isfahan University of Medical Sciences in Iran (IR.MUI. MED.REC.1401.089). Moreover, all participants provided informed consent prior to enrollment. Data were shown as means ± standard deviation for continuous variables and the frequency as percent for categorical variables. Normality distribution was assessed using the Kolmogorov–Smirnov test. The paired t test was used to compare the levels of AMH before and after the surgery. The independent t test was used to compare the AMH level and its changes between the two groups. The repeated measures ANOVA and analysis of variance (ANOVA) were applied to compare the study groups in terms of any changes in AMH levels during the study. The Pearson coefficient of correlation was used to evaluate relations among variables. Statistical significance was defined as P<0.05, and analysis was performed using SPSS 26 (IBM Corp., Armonk, NY, USA).