Women’s experiences of birth and birth options counselling after laparoscopic or open myomectomy

Abstract There is emerging evidence that vaginal birth after open and laparoscopic myomectomy may be safe in many pregnancies, however, there are no studies examining the perspectives of women who have given birth post myomectomy and their preferences regarding mode of birth. We performed a retrospective questionnaire survey of women who had an open or laparoscopic myomectomy followed by a pregnancy within 3 maternity units in a single NHS trust in the UK over a 5-year period. Our results revealed only 53% felt actively involved in the decision making for their birth plan and 90% had not been offered a specific birth options counselling clinic. Of those who had either a successful trial of labour after myomectomy (TOLAM) or elective caesarean section (ELCS) in the index pregnancy, 95% indicated satisfaction with their mode of birth however, 80% would prefer vaginal birth in a future pregnancy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this study is the first to explore the subjective experiences of women who had given birth post laparoscopic or open myomectomy and has highlighted the inadequate involvement of these women in the decision-making process. IMPACT STATEMENT What is already known on this subject? Fibroids are the commonest female solid tumours in women of childbearing age with surgical management including open and laparoscopic excision techniques. However, the management of a subsequent pregnancy and birth remains controversial with no robust guidance on which women may be suitable for vaginal birth. What do the results of this study add? We present the first study to our knowledge which explores women’s experiences of birth and birth options counselling after open and laparoscopic myomectomy. What are the implications of these findings for clinical practice and/or further research? We provide a rationale for using birth options clinics to facilitate an informed decision-making process and highlight the current inadequate guidance for clinicians on how to advise women having a pregnancy following a myomectomy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this needs to be carried out in a way which promotes the preferences of the women affected by this research.


Introduction
Fibroids (leiomyomas) are the commonest female solid tumours in women of childbearing age, with an incidence between 217-3745 cases per 100,000 woman years (Stewart et al. 2017) and significant symptoms experienced in 50% including heavy menstrual bleeding, pressure effects on bladder and bowel and subfertility.Myomectomy, the surgical removal of fibroids, may be performed by an open abdominal procedure, laparoscopically (which may include morcellation of the fibroid tissue) or by trans-cervical resection of fibroid, TCRF.(TCRF is not considered within the scope of this study).
Post myomectomy the management of subsequent pregnancy and birth remains controversial.There is no consensus amongst specialists as to the optimum interval to pregnancy and mode of birth (Weibel et al. 2014).The scarred uterus post myomectomy is often compared to the uterus after a single previous lower segment caesarean section (LSCS), provided there is no breach of the endometrial cavity.This is not reflected in the counselling given to women, however, with inconsistency between the guidelines used for birth CONTACT Thomas C. Grainger thomas.grainger@nhs.netThe Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK Supplemental data for this article can be accessed online at https://doi.org/10.1080/01443615.2023.2205516.
options after caesarean section, and the advice given after myomectomy.Many women who have a previous LSCS opt for VBAC (vaginal birth after caesarean) with dedicated birthoptions clinics widely available.There have been studies seeking the opinion of women on how they would prefer to give birth post caesarean (Attanasio, Kozhimannil and Kjerulff 2019); unfortunately, such studies do not exist for women after myomectomy.Post myomectomy many women are advised to undergo elective caesarean section (ELCS), despite additional complications that can arise from caesarean in this group (Gimovsky et al. 2020).In the context of emerging evidence to support the safety of trial of labour after myomectomy (TOLAM) (Gambacorti-Passerini et al. 2018) and the essential caveat of informed decision-making we felt that it was the opportune time to explore the perspectives of women who have given birth post myomectomy.
The aim of this study was to explore the subjective experience of women who have given birth post laparoscopic and open myomectomy, to gain insight into their experiences of and satisfaction with birth options counselling and to evaluate their preferred mode of birth after myomectomy in the index and subsequent pregnancies.

Study design
A retrospective questionnaire survey of women who had undergone an open or laparoscopic myomectomy between 2010 and 2018 with subsequent a birth over a 5-year period (2015)(2016)(2017)(2018)(2019).

Inclusion criteria
Women who had undergone an open or laparoscopic myomectomy within Barts Health NHS Trust and had a subsequent registered birth in any of the 3 maternity units within the trust over a 5-year period.

Methods
Women were identified through the business intelligence unit at Barts Health NHS Trust London.Barts Health includes 3 maternity units on different geographical sites.The participants were sent a written invitation to participate.Informed consent was obtained and questionnaires were either sent to the patients by post or undertaken via telephone by TG, JR or ZM.
The survey questionnaire was based on previous studies assessing attitudes towards birth experiences (Feeley and Thomson 2016).Basic demographic data regarding age, parity and ethnicity were collected.Participants were questioned about their indication for and route of myomectomy, mode of birth post myomectomy, recall of advice regarding interval to pregnancy, actual interval to pregnancy, recall regarding advice given on mode of birth post myomectomy, whether they had performed their own research on the topic, their experience of mode of birth decision making, satisfaction with the process of decision making and satisfaction with their actual mode of birth.When designing the questionnaire, the use of Likert scales was considered, but felt to be inappropriate for our study owing to the inherent assumption of normalised distribution and tendency towards false usage of parametric analysis (Bishop and Herron 2015).Instead, a study design using a mixture of open and closed questions were used in order to gain a wide range of responses.Questions about patient satisfaction were limited to a yes/no format, as we were comparing two discrete variables.By using white space questions instead of scales, our aim was to focus on the content of women's responses, rather than aggregated analysis, aiming to follow principles of interpretive phenomenology.This was felt to be the most appropriate approach given that birth is an emotion-laden time during which women may experience similar events with very different perspectives from one individual to another (Smith and Osborn 2015).
An initial focus group was held with senior clinicians to seek opinion on the suitability of the questions and the questionnaire was piloted on 5 women (not included in final analysis) who had a previous myomectomy for feedback on whether the language used was understandable to our target cohort.

Data analysis
Data was stored and analysed on Microsoft Excel and SPSS.The first analyses examined the demographics of the TOLAM and ELCS groups (Table 3).The unpaired t-test was used to compare the age of the two groups.Due to the skewed distribution of the parity measurements, the Mann-Whitney test was used to compare this measure between groups (Sundjaja, Shrestha and Krishan 2022).Subsequent analyses examined associations with mode of delivery.All variables in these analyses were categorical in nature, so the associations between variables were performed using the Chi-square test (Ugoni and Walker 1995), or Fisher's exact test where the number of subjects in some categories was low (Kim 2017).A P value of <0.05 was deemed statistically significant.Qualitative data were analysed thematically by AMD using data familiarisation, coding, theme identification and refinement (Clarke and Braun 2014) following discussion between AMD, TG and FO.

Ethical approval
The study was registered with the trust Clinical Effectiveness unit and IRAS ID 286841.

Results
Of the 94 women who met the inclusion criteria, 46 responded (48% response rate).

Surgery and indications
Of the 46 respondents, 18 (39%) had an open myomectomy and 25 (54%) had a laparoscopic myomectomy.3 patients were converted from laparoscopic to open myomectomy thus for analysis were added to the open group.The indications for surgery are summarised in Table 1.

Mode of birth
The planned modes of birth post myomectomy are shown in Figure 1.The reasons for EMCS were not explored but there were no cases of uterine rupture.There were no statistical differences between methods of myomectomy and modes of birth.In 65% of women planned for TOLAM, they successfully went on to have a vaginal birth.

Demographics
Demographics are summarised in Table 2. Barts health NHS trust covers a wide area of London, with between 21% (City of London) and 80% (Newham) of the population comprising of individuals from Black and Minority Ethnicities (BAME) (Care Quality Comission 2014).In our study, this figure was 74%.Women who were nulliparous at the time of myomectomy made up 74%, and the mean age of participants was 42.
Comparison is made between the TOLAM and ELCS groups in Table 3.There were no significant differences between the TOLAM and ELCS groups in terms of parity (p ¼ 0.16) or age (p ¼ 0.25).

Advice, counselling and sources of information
Of the 46 women surveyed, 21 (46%) recalled being given advice about how long to wait after myomectomy before getting pregnant whilst the other 25 (54%) could not recall being advised on this.Of the women who did recall being given advice the advice ranged from 6-18 months with a mean of 8.4 months and 6 months the most frequently advised interval.
Time to pregnancy in this group of women ranged from 6-18 months.Most women were pregnant by 12 months (22 women; 48%) and 14% of women were pregnant at a shorter time interval than advised.In the group who were not given or who could not recall the advice given, the time to pregnancy ranged from 4-84 months with the most common time to pregnancy at 12 months.
35% of the women had conducted their own research regarding mode of birth post myomectomy in the interval between their myomectomy and their pregnancy.The commonest source of information was the internet (72%) with 50% combining their own research with information from clinicians.
Women who did their own research were more likely to have a vaginal birth 44% vs 27% however these numbers were too small to reach statistical significance (p ¼ 0.54).This is presented in table S1.
18 women did their own investigation into mode of birth after myomectomy prior to conceiving, with 9 using the  internet as their primary source of information, 5 relying on health professionals and 4 using both the internet and health professionals.These findings are summarised in Figure 2.

Birth options clinics and decision making
Overall, 41 (90%) of the respondents were not given the option of a birth options clinic; 3 (6.5%)were offered and 2 could not confidently recall.In total, 21 (45%) of women felt the decision on mode of birth was made by their health care team and 53% of women felt they were actively involved in the decision making for their birth plan.
Of the women who had a vaginal birth, 73% (11/15) women felt they participated in the decision making, whilst 2 women (13.3%) felt the decision was made by their doctor and 2 did not recall how the decision was made.In the ELCS group only 30% (7/23) of women felt they were involved in the decision making while 69% (16/23) felt they were not actively involved in the decision making.

Satisfaction and future preferences
All 15 (100%) women who had vaginal birth after myomectomy reported being satisfied with their method of birth, compared to 20 of the 23 (87%) women who had ELCS.In the vaginal birth group, 2 of the 15 women reported being dissatisfied with the information given to them prior to birth, compared to 1 of 23 women in the ELCS group.
When we asked women which mode of birth they would prefer if they were to have a further pregnancy, 37 women stated they would prefer a vaginal birth.This number included 23 women in the caesarean section group.4 stated they would prefer a caesarean section and the remaining 5 gave no indication of preference.None of the women in the vaginal birth group wanted to have a caesarean section if they were to have another pregnancy.
In addition to these more rigid questions, we invited patients to give us any other comments about birth after myomectomy that they wished to share with our intended audience.We excluded any comments which related to our maternity services too generally to relate to birth after myomectomy, as well as any comments in specific praise or criticism of named individuals.All other comments that women specifically raised have been included in Figure 3 in an effort Figure 2. Sources of information used by patients to inform mode of birth choice between their myomectomy and their pregnancy.to focus on these women's lived experiences.Patients' experiences and comments were then analysed thematically.Key themes identified were preference (n ¼ 7), choice (n ¼ 6) and respect for expertise (n ¼ 2).Other themes noted were faith, research, and lack of support, but these were mentioned only once each.

Key findings
� Less than half of women were given advice on how long to wait post myomectomy before conceiving.Where given, advice ranged from 6 to 18 months � Of the women given advice regarding how long to wait to conceive post myomectomy most adhered to it with only 14% of women conceiving before the advised time period post myomectomy � 90% of the respondents were not given the option of a specific birth options counselling clinic � Only 53% of women felt they were actively involved in the decision making for their birth plan � Half of women had a planned ELCS and half opted for TOLAM of which 65% had successful vaginal birth.� Women who underwent ELCS were more likely to feel that the decision on mode of birth was predominately made by their doctor (70%) than were women who had vaginal birth (13%).� All women who had a vaginal birth were satisfied with their mode of delivery compared to 87% of those who had a caesarean section.� Most women who had a caesarean would prefer a vaginal birth if they went on to have a further pregnancy � None of the women who had a successful TOLAM would want a caesarean at a subsequent birth

Discussion
Our study, the first of its kind to address the perspectives of women having a pregnancy post myomectomy, demonstrates inadequate involvement of women in the decisionmaking process regarding mode of birth and shows a preference for vaginal birth in the majority of women.

Mode of birth
In our study, the commonest mode of birth after myomectomy was caesarean section.In line with current literature we found comparable rates of vaginal birth, ELCS and EMCS between patients having undergone laparoscopic and open myomectomies (Fukuda et al. 2013).One of the key concerns when considering the safety of the scarred uterus in labour is that of the uncommon, but potentially catastrophic uterine rupture.Many clinicians consider an intra-operative breach of uterine cavity at myomectomy as an absolute contra-indication to vaginal birth similar to that of previous classical CS in view of the full thickness nature of the defect and subsequent reduced integrity (RCOG 2015).The uterine rupture rates for VBAC are significantly higher than that of the general population; 68/10000 after 1 CS, 92/10000 after 2 CS (Landon et al. 2006) compared with 1/10000 in the unscarred uterus (Al-Zirqi et al. 2010).However, the overall rate is frequently considered low enough to warrant a risk benefit discussion with many women opting for VBAC and a 72-75% success rate (RCOG 2015).Many clinicians equate the uterus post myomectomy to that of the uterus post 2 CS in view of the multiple scars.As such there is often more hesitancy to pursue this mode of birth in part due to the potential complexity of rapid abdominal entry if EMCS is required and the increased risks of hysterectomy and blood transfusion (Tahseen and Griffiths 2010).However, in well selected and appropriately supervised cases VBAC for 2 previous CS has success rates of over 71.1% (Tahseen and Griffiths 2010) and evidence from a recent retrospective study revealed a 90% vaginal birth success rate in women opting for TOLAM (Gambacorti-Passerini et al. 2018).
There were no cases of uterine rupture in this series but as per other small data sets (Gambacorti-Passerini et al. 2018) it is underpowered to comment.A systematic review including 756 births post myomectomy found that most cases of uterine rupture occurred before 36 weeks and the overall rate in labour was 0.47% (Gambacorti-Passerini et al. 2016).Subsequent studies have also failed to detect a uterine rupture rate post myomectomy significantly higher than that of the background population (Mara et al. 2016, King et al. 2018).Although the risk of rupture is believed to be higher following breach of uterine cavity at myomectomy there is currently insufficient evidence to support this (Odejinmi et al. 2020).Gimovsky et al. (2020) compared 367 post myomectomy patients undergoing ELCS for singleton, term pregnancies with 33,635 controls and found post myomectomy patients had 180% increased risk of blood transfusion, were 713% more likely to sustain bowel injury and 243% more likely to undergo caesarean hysterectomy (Gimovsky et al. 2020).Thus, routinely advising ELCS at 37-39 weeks following myomectomy is neither supported by current data nor avoids the possibility of pre-labour uterine rupture.

Interval to pregnancy
There is no current consensus as to optimum interval between myomectomy and pregnancy.In this study the most common interval advised was 6 months, but a wide range of advice (6-18months) was given and the majority of women did not receive any advice at all.Literature examining the safe interval between myomectomy and pregnancy has mostly been based on small scale, retrospective studies with a recent systematic review failing to find any consensus on the safest interval; suggestions ranged from 2 weeks to 12 months and included no safe interval at all (Milazzo et al. 2017).More recently, a nationwide population study found that uterine rupture rate was significantly higher for deliveries occurring within 12 months of myomectomy than for any interval greater than 12 months (Lee et al. 2020).Our findings demonstrate the difference between advice given and conception time and the lack of consensus as reported in literature.

Patient preference
Although our findings demonstrate a preference for vaginal birth in the majority of women post myomectomy, there is currently no published guidance on the optimal mode of birth for this cohort.It is well established that physician and patient accepted risk thresholds may differ (Devereaux et al. 2001).Patients may adopt a 'trade-offs' model of decision making when faced with risk versus benefit scenarios as demonstrated in the context of patient choice on salpingectomy versus salpingotomy for ectopic pregnancy (van Mello et al. 2010).Whilst knowledge of patient preference is key, an informed patient decision must be precluded by a discussion regarding the safety of birth mode post myomectomy.

Decision making process
Women who underwent ELCS were more likely to feel that the decision on mode of birth was predominately made by their doctor (70%) than were women who had vaginal birth (13%).Furthermore, when asked what type of birth women would want if they were to undergo a further pregnancy, those surveyed were more likely to prefer a vaginal birth (80%) to an ELCS (8.6%).It may be the case that patients in our study who underwent CS had factors considered to increase risk of adverse pregnancy outcomes such as endometrial cavity breach or multiple incisions at myomectomy and the advanced mean maternal age of our cohort is notable.However, in such cases an individualised risk assessment and discussion is paramount.It is unclear whether the surgeon advised ELCS because they always do after myomectomy or whether there was a particular reason in that case.
For women having a pregnancy after LSCS, these discussions often happen in dedicated birth options clinics.Across our women surveyed, only 3 were seen in a dedicated birth options clinic to discuss mode of birth.Decision regarding mode of birth post myomectomy requires counselling to enable comprehension of the associated risks and should be an informed choice (Odejinmi et al. 2020).With the increasing sub-specialisation in workload of the obstetrician and surgical gynaecologist, these discussions may require combined input.We therefore suggest that multi-disciplinary birth options clinics are an underutilised tool in antenatal care for women having had prior myomectomy.
Interestingly, 72% of women in our study used the internet to guide their choice with 50% of women using this as their primary information source.Women who did their own research were more likely to have a successful TOLAM, however this did not reach statistical significance.One woman wanted to highlight to us that there is insufficient information available to patients undergoing pregnancy after myomectomy.This is consistent with the literature, which has demonstrated there is a lack of suitable online material on the subject.Hirsch et al showed that a 'google' search on the topic of fibroids does not result in any high quality, accurate, patient-focused websites and that 18% of available resources are outdated and inaccurate (Hirsch et al. 2020).Patient decision aids are routinely used in VBAC counselling often in the form of information leaflets outlining key points and predictors of success (Schoorel et al. 2014) but have yet to be developed in the context of myomectomy.It has been identified that the key components of VBAC counselling include shared decision making; correct information; sufficient preparation and a culture of supporting VBAC (Nilsson et al. 2017) However, there is distinct heterogeneity amongst current available fibroid management guidelines (Amoah et al. 2021) and as yet no guideline on birth after myomectomy.

What did women want to tell us?
The most common themes noted by women when asked what they wanted to tell us about the experience of birth after myomectomy were preference and choice.Women wanted to tell us of their preference for vaginal birth and wanted to highlight their perceived lack of choice.Whilst these were the most common themes identified from our open questions, however, it is notable that there were only 12 responses to our closing open question out of 46 survey respondents, so the dominant themes in our study benefit may not be representative of the wider population.
Future studies looking at birth after myomectomy should address the concerns of women spoken to in this study.One woman pointed out that the decision on her mode of birth was made at the time of myomectomy by her gynaecologist and so she entered her pregnancy with the expectation of having an ELCS 'I was told at my myomectomy that I must have Caesarean'.Deciding the mode of future births at the time of myomectomy may be appropriate moving forward, but further evidence is needed to provide specific guidance on what intra-operative events should influence decision making about future births.
One participant highlighted that although pregnancy post myomectomy is considered high-risk she did not feel this was reflected in the antenatal care schedule she received 'Expecting mothers who have had myomectomy should be more supported than I was because we are high risk.'For women having birth after Caesarean section, there is specific guidance on the schedule of antenatal care, including suggested timing of birth options counselling (RCOG 2015).A similar approach could be considered for women post myomectomy.

Limitations
Limitations of this study include: (1) small sample size (due to the infrequency at which myomectomy followed by registered pregnancy occurs) and subsequent lack of statistical significance in most outcomes, (2) retrospective design, (3) lack of knowledge as to the inherent risk factors that may have informed the advice given (4) lack of knowledge as to the bias of the doctors who were undertaking the discussions with the patients.However, this study highlights the need to start these conversations and to develop appropriate guidance.Current challenges to counselling include the lack of: (1) a standardised fibroid classification system in the context of pregnancy as opposed to abnormal uterine bleeding; (2) prospective data on TOLAM; (3) details regarding factors associated with failure of TOLAM in published series and (4) knowledge of the clinicians' perspectives and what factors influence the advice they give regarding delivery post myomectomy.

Future research
There remains many unanswered questions regarding the factors affecting safety of pregnancy post myomectomy and optimal interval to conception.Prospective national databases for fibroid reporting with standardised classifications, intra-operative technique logging with long-term follow-up and recording of subsequent pregnancies and outcomes is the logical step to obtain this information.As pregnancy post myomectomy is uncommon, multi-centre data is required to allow a meaningful analysis of any relationships between mode of myomectomy, location and depth of uterine incisions, time to and outcomes of subsequent pregnancies.In the absence of clear nationalised guidance on clinician decision making for mode of birth after myomectomy, further work should also look to explore the perspectives of obstetricians and gynaecologists to understand the rationale behind their decision making with respect to this topic.It is important to identify whether these decisions are being made based on recommendations from the gynaecologist who performed the initial myomectomy or based on the obstetrician's preference.
Only with large-scale data can reliable national and international guidance on pregnancy post myomectomy be developed.

Conclusion
In view of emerging evidence to support the safety of vaginal birth after myomectomy, we have presented the first study examining the perspective of the women for whom these decisions have previously been made.Despite the limitations of this study, we have demonstrated inadequate involvement of women in the decision-making process regarding mode of birth post open and laparoscopic myomectomy.Addressing this issue has the potential to improve patient satisfaction and avoid unnecessary caesarean sections.
This survey has also highlighted that vaginal birth is desirable for a high proportion of women after myomectomy and that an individualised risk assessment and discussion is required to facilitate this.Whilst birth options clinics would provide an appropriate forum for such evidence-based discussion this must be supported by further evidence and guidance on the safe interval between myomectomy and pregnancy, as well as risk factors for adverse outcomes in vaginal birth.

Table 3 .
Comparison of demographics between TOLAM and ELCS.