Successful pregnancy following extensive myomectomy for diffuse uterine leiomyomatosis

Diffuse uterine leiomyomatosis (DUL) is a rare condition characterized by innumerable leiomyomas (fibroids) diffusely replacing the myometrium, often leading to severe infertility due to distortion of the uterine cavity. Although assisted reproductive technologies are commonly attempted, implantation failure is frequent and effective treatment strategies remain unclear. Extensive myomectomy, involving the removal of numerous fibroids with uterine reconstruction, has been proposed as a fertility-preserving option; however, it is associated with substantial surgical morbidity and potential obstetric risks, including uterine rupture and abnormal placentation. Reports describing successful live birth following this approach with detailed perinatal management are limited.

A 29-year-old nulligravid woman with DUL was referred for infertility after repeated implantation failure despite multiple cycles of assisted reproductive treatment. An initial myomectomy at 32 years of age removed 25 fibroids but did not result in pregnancy, and disease progression was observed. At 34 years of age, she underwent extensive myomectomy, during which 148 fibroids were removed through a longitudinal uterine incision. After postoperative recovery, pregnancy was achieved following embryo transfer, although the first pregnancy ended in miscarriage. A subsequent pregnancy was established at 35 years of age and closely monitored using serial ultrasonography and magnetic resonance imaging (MRI). Imaging findings suggested myometrial thinning and abnormal placentation. The patient was managed with hospitalization due to the risk of uterine rupture. An elective cesarean section was performed at 36 weeks of gestation after preoperative autologous blood preparation. A healthy male infant weighing 3,261 g was delivered. Although partial placental retention and significant bleeding occurred, hemostasis was achieved without allogeneic transfusion. The postoperative course was uneventful, and no recurrence of diffuse uterine leiomyomatosis was observed during follow-up.

This case suggests that extensive myomectomy may represent a feasible fertility-preserving option for carefully selected patients with DUL, although successful pregnancy cannot be guaranteed and careful reproductive and obstetric management remains essential. MRI and repeated hysteroscopic evaluations were useful for assessing uterine cavity involvement and guiding fertility-preserving treatment. Careful antenatal surveillance and planned delivery are essential to manage the risks of uterine rupture and abnormal placentation. Individualized treatment strategies are required to optimize reproductive outcomes in this rare condition.