Management of Uterine Fibroids in Infertile Women

Impact of Fibroids on Fertility Based on Location

Subserosal fibroids do not appear to significantly impact fertility, with pregnancy rates (34.1%) and implantation rates (15.1%) similar to women without fibroids (30.1% and 15.7% respectively) 1, 2
Intramural fibroids significantly reduce pregnancy rates (16.4%) and implantation rates (6.4%) compared to women without fibroids, even when there is no distortion of the uterine cavity 1, 2
Submucosal fibroids have the most detrimental effect on fertility with the lowest pregnancy rates (10%) and implantation rates (4.3%) 1, 2

Transvaginal ultrasound should be performed to accurately classify the fibroid as subserosal, intramural, or submucosal 3

Hysteroscopic myomectomy is the treatment of choice for submucosal fibroids to improve conception and pregnancy rates 3
The procedure is associated with shorter hospitalization and faster recovery compared to other surgical approaches 3
Retrospective studies show pregnancy rates of 85% after hysteroscopic myomectomy with live birth rates of 65% 3
Evidence regarding removal of intramural fibroids is less clear, but surgical treatment should be considered before assisted reproductive technology (ART) treatment 1, 2
Laparoscopic or open myomectomy are options with similar pregnancy and live birth rates 4

GnRH agonists or antagonists may be used short-term to reduce fibroid size before surgery 5
Recent studies of ulipristal acetate in patients with submucosal fibroids undergoing IVF showed a 41% reduction in fibroid volume with pregnancy rates similar to controls without fibroids 4

MR-guided Focused Ultrasound (MRgFUS) has limited evidence for fertility enhancement 4
Endometrial ablation is contraindicated in women desiring pregnancy due to high risk of pregnancy complications 3
Hysterectomy is not appropriate for women desiring fertility 3

Surgical outcomes show pregnancy rates of 54-59.5% after myomectomy in women with no other apparent cause of infertility 1

The American College of Radiology recommends laparoscopic or open myomectomy as the primary treatment for women with large fibroids who desire fertility, with similar pregnancy and live birth rates in randomized controlled trials 6, 7
Open myomectomy is preferred over laparoscopic approaches for very large uteri (such as 20-week size) or multiple fibroids, offering better access and outcomes 8
The combined miscarriage rate after myomectomy (14%) is comparable to the general population, with laparoscopic myomectomy offering advantages of shorter hospital stays, less postoperative pain, and faster recovery compared to open myomectomy 6, 8
Medical management, such as ulipristal acetate, can be considered as a temporary measure before surgery, with a 41% reduction in fibroid volume and pregnancy rates similar to controls without fibroids 6, 7
Most medical therapies, like GnRH agonists/antagonists, suppress fertility and are primarily used for short-term fibroid size reduction before surgery, with a recommended duration of 2-3 months before surgery 8

Uterine Artery Embolization (UAE) is generally not recommended as first-line treatment for women desiring fertility, with increased risks of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) after UAE compared to myomectomy 9
Current evidence suggests myomectomy is superior to UAE for women planning future pregnancy, with myomectomy offering better pregnancy outcomes and lower risks of complications 9
MR-Guided Focused Ultrasound (MRgFUS) has limited evidence for fertility enhancement, with only case reports and a terminated randomized controlled trial investigating MRgFUS for fertility 6

Hysterectomy is never appropriate for women desiring fertility as it causes permanent and irreversible infertility, and endometrial ablation is contraindicated in women desiring pregnancy due to high risk of pregnancy complications 6, 10