Leiomyomas Leiomyomas, also called myomas or fibroids, are benign monoclonal uterine myometrial tumors that affect 25% to 45% of reproductive-age women, particularly African Americans (241). The mechanisms by which fibroids cause infertility are unknown, but may involve altered uterine contractility, impaired gamete transport, or endometrial dysfunction (242). Among women with infertility and uterine leiomyomas, pregnancy rates are primarily affected by leiomyoma location (236,242). Subserosal fibroids do not appear to affect fertility or obstetric outcomes, while intramural (regardless of cavity distortion) and submucosal myomas are associated with lower implantation and live birth rates (236,242,243). It remains unclear whether the size of intramural fibroids determines pregnancy rates and obstetric outcomes, because lower or unchanged pregnancy rates have been reported among patients with fibroids of varying sizes including >2cm, >4cm, or 4–8 cm when compared to patients without fibroids (242).
Myomectomy In women desiring fertility who require treatment for fibroids, myomectomy is the preferred approach, and uterine artery embolization is relatively contraindicated (242). Removal of cavity-distorting intramural and submucous myomas is generally recommended prior to proceeding with infertility treatment. The utility of surgical removal of non-cavity-distorting intramural fibroids is presently unknown (236,242, 243).
Myomectomy can be performed hysteroscopically, via laparotomy, laparoscopically (alone or with robotic assistance), or vaginally (237,241,244–246). Hysteroscopic removal is generally preferred for small submucous fibroids without intramural involvement, while use of the other methods generally depends on patient preference, operator skill, or the presence of other pelvic pathology (237,241,244,245). The utility of pretreatment with GnRH agonists prior to surgery is debatable. GnRH agonists may shrink larger fibroids (5 to 6 cm) enough to allow hysteroscopic resection and may decrease the risk of intraoperative blood loss and postoperative anemia. Fluid overload and uterine perforation are the most common complications of hysteroscopic myomectomy, while bleeding and adjacent organ injury are more often associated with alternative approaches (237,241). Fibroids that are located low on the uterus and posteriorly are less amenable to laparoscopic resection. Transmyometrial approaches raise concern for uterine rupture during pregnancy, although this risk appears to be very low (241).