Abstract
Fibroids have long been labelled by clinicians as a factor resulting in adverse reproductive outcomes, from conception to parturition. However, despite the widespread belief that fibroids are a detriment to reproduction, there have been surprisingly few high-quality studies addressing these issues and even fewer that have examined the value of intervention via treatment trials. This chapter will discuss the role of fibroids in hindering fertility, early pregnancy, and late pregnancy. In this, we will examine the existing data, the quality of that data, and attempt to draw conclusions consistent with the best available evidence to aid in the clinical approach to these tumours.
Fibroids have long been labelled by clinicians as a factor resulting in adverse reproductive outcomes, from conception to parturition. However, despite the widespread belief that fibroids are a detriment to reproduction, there have been surprisingly few high-quality studies addressing these issues and even fewer that have examined the value of intervention via treatment trials. This chapter will discuss the role of fibroids in hindering fertility, early pregnancy, and late pregnancy. In this, we will examine the existing data, the quality of that data, and attempt to draw conclusions consistent with the best available evidence to aid in the clinical approach to these tumours.
6.1 Issues with Existing Data
The primary problem with studying the disease ‘uterine fibroids’ is that leiomyomas are quite heterogeneous in their characteristics from patient to patient and even within the same patient. Fibroids vary in the number present per patient, the size, the location within the uterus, the location in relation to the uterine cavity, and histology/biochemistry. To further complicate the issue, the description of these factors is varied and inconsistent throughout the literature.
An additional problem confronting researchers is the large number of confounding variables when comparing women with fibroids to those without. Women with fibroids are often older, have an increased body mass index, are more likely of African descent, are more likely to suffer from diabetes pre-pregnancy as well as gestational diabetes, and more likely to have pre-pregnancy hypertension as well as hypertensive disorders during pregnancy. They are less likely to smoke cigarettes, but are more likely to consume alcohol.
6.2 Classification
Fibroids may be present just below the serosal surface of the uterus (subserosal), within the wall of the uterus (intramural), or extending into the uterine cavity (submucosal). The ability to differentiate a submucosal from an intramural location may be particularly critical, but is often exceedingly difficult due to the nature of available diagnostic tests. Unfortunately, non-uniformity of criteria for this classification adds considerable confusion to the literature. Furthermore, many published studies inadequately classify women with fibroids or omit this parameter altogether.
To classify a fibroid as submucosal, some authors require the fibroid to be within 4 mm of the endometrium, while some just subjectively determine that a tumour is ‘abutting’ or ‘impinging upon’ the endometrium. Others may rely upon operative report descriptions or specific tests used to determine if the cavity is invaded. For intramural fibroids, many authors rely upon measurements of 4 or 10 mm from the endometrium, while others simply determine the location subjectively. Some use ‘depth of the fibroid into the myometrium’ of 70–100% to classify a fibroid as a submucosal, but call the fibroids intramural in location if the depth is 30–70% into the myometrium. Even subserosal location definitions vary, with some authors using >50% outside the muscularis and others requiring ‘most’ of the fibroid outside the myometrium.
Recently, Munro and colleagues put forth a sub-classification system to ensure uniformity for practitioners and authors when speaking about fibroids and their location (Figure 6.1). Unfortunately, many authors have ignored this system, further promoting heterogeneity within the literature.
6.3 Diagnostic Methodology
When an attempt is made to determine the type(s) of fibroids present in a patient, the most common pre-operative tests are the hysterosalpingogram (HSG) and transvaginal ultrasonography (TVUS). Both of these techniques have limited accuracy due to significant limitations.
HSGs may have sensitivities as low as 50% and positive predictive values as low as 28.6% for intrauterine lesions [2]. Furthermore, specificity may be as low as 20% [3]. Thus, if evaluation of the uterine cavity is limited to hysterosalpingography, imprecise fibroid localization is highly likely.
TVUS was once thought to be an accurate tool for diagnosis of submucosal fibroids, with initial studies showing sensitivity and specificity of 100% and 94%, respectively, with positive predictive values of 81% and negative predictive values of 100% when compared with hysteroscopy as the ‘gold standard’ [4]. However, current studies have failed to duplicate this high level of accuracy, with sensitivities as low as 69% and positive predictive values as low as 47% [5].
Sonohysterogram, hysteroscopy, and magnetic resonance imaging (MRI) are the most accurate techniques available to localize the fibroid outside of pathologic evaluation of the extirpated uterus. This is particularly true when differentiating between submucosal and intramural fibroids. In 1993, Fukuda found that when attempting to classify fibroids as intramural or submucosal, sonohysterogram misdiagnosed only 1 of 22 of these myomas [6]. In a second study, sonohysterography and hysteroscopy had sensitivity, specificity, and predictive values of 100% [7].
MRI, while expensive and time-consuming, is likely the most accurate of all. In a study comparing sonography, hysteroscopy, and MRI in 106 women scheduled for hysterectomy – with the gold standard being pathologic examination – MRI proved to perform the best, with 100% sensitivity and 91% specificity [8]. The value of MRI, however, may extend beyond mere classification of fibroids. The junctional zone of myometrium is ontogenetically, structurally, and hormonally different from the outer myometrium and MRI alone can successfully distinguish these histologic interfaces. This may prove to be of value as investigations become more precise in their research questions and hypotheses [9].
6.4 Fibroids and Infertility
Since 2001, when the first systematic review and meta-analysis was published addressing the issue of uterine fibroids and infertility, there have been nine additional systematic reviews/meta-analyses [10]. To date, there are 31 total studies with control groups: 10 prospective (with 2 randomized) and 21 retrospective. There are only seven treatment trials, and one of those was recently redacted [11].
6.4.1 What Effect Does Fibroid Location Have upon Fertility Status?
For submucosal fibroids, the data combined from only a few studies show a decrease in clinical pregnancy rate, but no differences in implantation or ongoing pregnancy/delivery rates. However, due to the limited amount of data the robustness of these findings is questionable [5] (Table 6.1).
Table 6.1 Effect on fertility of submucosal fibroids
The role of intramural myomas is of intense interest and has long been controversial. We examined the existing data in 2012 and it suggested that women have significantly lower rates of implantation and ongoing pregnancy/delivery rates in the presence of these myomas (Table 6.2).
Table 6.2 Effect on fertility of intramural fibroids
In an attempt to improve the quality of those meta-analytic data, our group performed subset analyses. When only those studies that used ultrasound and hysteroscopy in all subjects are included, the differences above disappear (Table 6.3).
Table 6.3 Effect on fertility of intramural fibroids: results from studies that used ultrasound and hysteroscopy in all subjects
Recently, an analysis was performed on data from a randomized controlled trial addressing intramural fibroids. The initial study included 900 couples, and different treatment regimens were evaluated for fertility outcomes. Of those couples, 11% were found to have intramural fibroids without intracavitary involvement. Once adjusted for confounders, there were no differences in conception, clinical pregnancy, pregnancy loss, or live birth rates in women with intramural fibroids compared to control subjects without fibroids [12].
Although it is possible that intramural fibroids without intracavitary involvement may affect fertility, the best evidence thus far does not support this theory.
For fibroids that are primarily subserosal in location, the studies consistently report no differences in clinical pregnancy rates, implantation rates, or ongoing/live birth rates. These data did include studies evaluating women undergoing assisted reproductive techniques as well as those attempting spontaneous conception [13] (Table 6.4).
Table 6.4 Effect on fertility of subserosal fibroids
6.4.2 Does Fibroid Size Affect Fertility?
An important clinical question is whether there is a particular size of fibroid that results in decreased fertility. Once that size is identified, the follow-up question would be whether or not surgical removal of the fibroid will enhance fertility.
To better understand the relationship between size and fertility, we attempted to perform a systematic review of the studies addressing this issue. Due to the heterogeneity of studies, we were unable to perform a meta-analysis. Below is a summary of the studies addressing outcomes from comparing women that have smaller fibroids with those without fibroids. There appear to be no differences in clinical pregnancy rates, implantation rates, or ongoing pregnancy/delivery rates (Table 6.5) [14–20].
Table 6.5 The effect of fibroid size on fertility: studies comparing outcomes in women with small fibroids versus no fibroids
When addressing fibroids that are larger, the data are more conflicting. If all data are included, no matter the diagnostic criteria for classification, there is some variability in study findings (Table 6.6) [21–26].
Table 6.6 The effect of fibroid size on fertility: studies of outcomes in women with larger fibroids (CPR, clinical pregnancy rate; DR, delivery rate; IR, implantation rate; ROC, receiver operating characteristic; SAB, spontaneous abortion)
However, if only those studies that utilize adequate methods of diagnosing the location (hysteroscopy and ultrasound, or sonohysterography) are examined, then the number is limited to three investigations. All are retrospective, and in one, the cohort of women suffering from larger fibroids is older than those with smaller fibroids (Table 6.7) [22, 24, 25].
Table 6.7 The effect of larger fibroids on fertility: studies using hysteroscopy and/or sonohysterography for diagnosis
If the studies are further limited to those that control for age, there are only two studies evaluable. There are no differences in either clinical pregnancy rates, implantation rates, or ongoing pregnancy rate. However, one study did note that a second in vitro fertilization cycle was necessary for those with larger fibroids to achieve the same success rate (Table 6.8) [22, 24].
Table 6.8 The effect of larger fibroids on fertility: studies of age-matched samples using hysteroscopy and/or sonohysterography for diagnosis (HSC, hysteroscopy; IVF, in vitro fertilization; US, ultrasound)
Thus, from the best available evidence, it is observed that fibroids that are less than 5–6 cm probably do not affect fertility. When looking at women with larger fibroids, there is more ambiguity as to whether or not they produce an adverse effect due to size alone.
6.4.3 Does the Number of Fibroids Affect Fertility?
A number of studies have addressed this issue, and the majority are quite consistent in demonstrating that there is no effect on fertility potential with increasing numbers of fibroids, at least when the number of fibroids is easily countable (Table 6.9) [15, 17, 18, 21–27].
Table 6.9 Effect on fertility of number of fibroids
6.5 Fibroids and Early Pregnancy Loss
It has long been hypothesized that uterine fibroids can increase the risk of early pregnancy loss. Mechanisms that have been postulated include anatomic distortion resulting in abnormal uteroplacental circulation, increased early uterine contractility, adverse mechanical effects, and biochemical impairment of developing pregnancies [28].
The data regarding miscarriages and fibroids have been questionable at best. Most studies are retrospective, location is inconsistently and often suboptimally evaluated, and confounding factors such as age are rarely adjusted for.
We published a meta-analysis in 2009 that suggested an increased risk of spontaneous abortion in the presence of either submucosal or intramural fibroids. Three studies were subsequently published that, when added to the results of the meta-analysis, demonstrated a higher rate of spontaneous abortion for all types of fibroids [5].
More recently, however, Hartmann and colleagues conducted a prospective cohort study of 5,512 participants. All had uniform evaluation and outcome assessment. While an association appeared between fibroids and spontaneous abortion in the crude data, adjustment for confounding factors eliminated this association. Furthermore, fibroid location was not of predictive importance [29] (Table 6.10).
Table 6.10 Relationship between number of fibroids and rate of spontaneous abortion
A recent high-quality meta-analysis found similar results [30]. Five studies comparing women with fibroids to the general population without fibroids found no difference in spontaneous abortion rate between groups. The researchers were careful to include only those studies that documented fibroids or no fibroids with ultrasound, and the study must not have been limited to special populations of women. Confounders were adjusted for in only one study, so in the remaining four studies they approximated adjusted point estimates based upon the single study that did adjust (Table 6.11).
Table 6.11 Relationship between type of fibroid and rate of spontaneous abortion
Size of myomas and number of fibroids have also been evaluated as possible contributors to early pregnancy failure. In the two studies examining size, no effect was seen between small versus large fibroids [29, 31] (Table 6.12). Three studies have evaluated fibroid number. None showed an increased risk of miscarriage in the presence of one or two fibroids, but two studies suggested a higher pregnancy failure rate if more than two fibroids are present. However, the best study [29], which adjusted for confounders, failed to find any difference in spontaneous abortion rates even with more than two fibroids.
Table 6.12 Relationships between size and number of fibroids and rates of early pregnancy failure
Thus, despite the suggestion from early studies that fibroids are associated with an increase in spontaneous abortion, current best available evidence would suggest that this is not the case, regardless of location, size, and number.
6.6 Late Pregnancy Complications
Although the majority of women with fibroids have normal pregnancies, a large number of complications of late pregnancy have been linked to their presence [32]. Many investigators have attempted to determine which complications are more common with fibroid uteri, and if so how much is the risk increased. In examining these studies, however, the evidence evaluating such complications is of varying quality and reliability. Of the 22 studies found by the authors, only 4 are prospective in design. Eighteen used control groups, but only five made use of controls matched for one or more known confounders. Fifteen studies collected data on confounders, and 12 attempted to adjust for these via regression analysis.
Data on fibroids were also widely variable. Fifteen studies attempted to categorize fibroids by size, 13 by location, 11 by number, and only 4 calculated total fibroid volume.
6.6.1 Excessive Blood Loss at Delivery
Two retrospective studies have examined the issue of blood loss at delivery, and both showed greater blood loss at delivery in the presence of fibroids [33, 34]. Both used age-matched controls and adjusted for confounders via regression analysis. In both studies, the excessive blood loss was only seen in women with fibroids greater than 5 cm in diameter. In these women with large fibroids, one study found an increased rate of transfusion [34] and also noted a correlation between transfusion rate and total fibroid volume.
6.6.2 Caesarean Section Rate
Fifteen studies have examined the rate of caesarean section in the presence and absence of fibroids, with 13 of the 15 showing an increased rate. Of the 11 studies that adjusted for confounders via regression analysis, all 11 demonstrated an increased rate [33, 35–44]. Additionally, a meta-analysis recently examined this issue, including 10 of these studies. The authors found an increased risk with an odds ratio of 2.60 (95% CI: 2.02–3.18).
Six studies have examined the effect of fibroid size on caesarean section rate, with three showing no effect [35, 37, 39] and three showing that size does matter [33, 38, 44]. Four studies determined the relationship between fibroid number and c-section rate, with two showing an increased rate [35, 43] and two not showing a difference [37, 41]. Total fibroid volume combines both of these variables, and the two studies that calculated the correlation between volume and rate of caesarean section both found a mildly increasing rate with volume increase [38, 42]. Two studies demonstrated no rate change with fibroid location [42, 43], while one claimed a higher c-section rate with fibroids in the lower uterine segment [37].
In summary, it appears that women with fibroids in pregnancy are indeed at increased risk for having a caesarean section, even when adjusting for the many confounding factors that affect this decision. However, it is not clear which women with fibroids are at heightened risk based on the number and characteristics of their tumours.
6.6.3 Malpresentations
Seven studies examined whether the presence of fibroids leads to a higher rate of fetal malpresentation, and five concluded that this was indeed the case. Of the five studies utilizing multivariate regression for correction of confounding variables, all showed an increased risk of malpresentation at delivery [39–41, 43, 44]. Furthermore, a recent meta-analysis showed a significant association between fibroids and malpresentation at term, with an odds ratio of 2.65 (95% CI: 1.0–3.70) [45].
6.6.4 Dysfunctional Labour
It has been theorized that uterine fibroids might cause abnormal labour patterns due to disruption of normal uterine contractility patterns. One population-based study from Israel, with prospective data collection but a retrospective research direction, has examined this issue. The authors found that there was a significant increase in the rate of failing to progress during the first stage of labour in women with fibroids but not in the second stage [40]. Unfortunately, the data were not analysed to correct for confounders. A second study found no difference in length of either first or second stage, but this investigation was limited to women who delivered vaginally [39]. Finally, Coronado and colleagues examined the rate of dysfunctional labour with adjustments for multiple confounders and revealed an increased odds ratio of 1.85 (95% CI: 1.65–2.18) [36]. Thus, the idea of fibroids leading to abnormal labour is plausible, and limited data seem to bolster this hypothesis.
6.6.5 Postpartum Haemorrhage
Five studies have examined aspects of the relationship between uterine fibroids and postpartum haemorrhage, all retrospective in research direction. Two found postpartum haemorrhage to be more common in women with fibroids [39, 43], both utilizing large population-based databases and regression analysis to correct for confounding variables. A third study found no difference, but did find an increase in transfusion rate when postpartum haemorrhage occurred [40]. Size has been claimed to play a role, with one investigation showing a higher rate of postpartum haemorrhage with larger fibroids [43] and a second showing more frequent transfusions when large fibroids (>5 cm) were present [34]. Finally, location may also play a role, with higher rates of haemorrhage seen when fibroids are intramural [43] or low in the uterus or cervix [37], as opposed to other locations. Thus, fibroids seem to enhance the likelihood of severe postpartum haemorrhage, and this is particularly true if the fibroid(s) is large, intramural, or low-lying.
6.6.6 Hysterectomy
Two retrospective studies have examined the rate of caesarean hysterectomy in women with fibroids, one finding an 18-fold increase in the rate (5.3% vs. 0.3% in controls) [46] and the other a 75-fold increase (2.9% vs. 0.04%) [47]. This does appear to be a real complication and worthy of further investigation to help delineate more specific risk factors.
6.6.7 Retained Placenta
Three retrospective analyses have addressed the issue of retained placenta rate in the presence of fibroids. Two studies found no relationship [34, 42]. The third study [40] found a significant increase in retained placenta rate (1.2% vs. 0.5% in controls), but this disappeared when adjusted for confounders using multivariate analysis. There is no evidence that fibroids in pregnancy increase the chances of retained placenta after delivery.
6.6.8 Chorioamnionitis and Endomyometritis
Only one research group has examined the rate of chorioamnionitis in pregnancies with and without fibroids [39]. In this 10-year retrospective evaluation, there was no difference in the chorioamnionitis rate between groups. The same team also examined the rate of endomyometritis [39]. There was a non-significant trend towards more infection in the fibroid patients compared to controls (5.5% vs. 3.6%). However, even this trend disappeared when the rates were adjusted for mode of delivery.
6.6.9 Intrauterine Growth Restriction and Small for Gestational Age Newborns
Seven studies have investigated intrauterine growth restriction (IUGR) in women with fibroids. Six of these found no difference in the risk between women with fibroids and controls [33, 34, 41, 42, 46, 47], while one study that did show a difference (6.8% with fibroids vs. 1.9% for controls) made no adjustment for confounders [40]. Thus, there is little evidence that fibroid uteri predispose to IUGR. Seven studies have examined birth weight: five show no difference due to the presence of fibroids [34–36, 46, 48] while the two demonstrating a difference found the decrease to be on average only 14–177g [49, 50]. It has been suggested by data from Knight et al. that large, retroplacental fibroids are more likely to result in poor fetal growth [50], but this issue has not been thoroughly examined.
6.6.10 Preterm Labour
Three studies have attempted to determine the relationship between preterm labour (PTL) and the presence of fibroids. All three are of relatively poor quality in that none adjusted for potential confounders. One study found no difference between women with fibroids and those without [33], one found a substantial increase in PTL in the presence of fibroids (16.3% vs. 9.7% in controls) [45], and the third uncovered an increase only when fibroids were larger than 3 cm [46]. It remains unclear whether or not there is an association between PTL and fibroid uteri.
6.6.11 Preterm Delivery
Twelve studies have addressed this issue. Ten have investigated whether preterm delivery (PTD) is more common in women with fibroids, with six showing an increased risk [34, 35, 39, 41, 49, 51] and four showing no difference between women with fibroids and those without [42–44, 48]. However, five of the six that adjusted the risk ratio for known confounders found an increase, lending greater credence to the theory that fibroids do influence PTD [35, 39, 41, 43, 49, 51]. If there is an increased risk, it is also unclear whether or not the fibroid number changes that risk, with one study saying the risk is higher with multiple myomas [37] and one claiming no difference [39]. Finally, a single study suggests location (anterior vs. posterior) does not matter [48]. In summary, it remains unclear whether or not fibroids increase PTD risk, but the best available evidence would suggest that they do.
6.6.12 Placenta Praevia
Eight studies have investigated the occurrence rate of placenta praevia in the presence of fibroids, with six being cohort studies and two being matched case–control studies. Of these, four show no difference in the rate of placenta praevia in fibroid uteri vs. control uteri [34, 35, 42, 43], while four studies show an increased occurrence rate [39–41, 44]. Four of the investigations adjust for confounders, with three claiming an increased risk of praevia [39, 41, 44] and the fourth showing a trend (adjusted OR = 1.1, 95% CI: 1.0–1.3) [43].
A recent meta-analysis has also investigated this relationship [52]. The authors found no correlation between fibroids and placenta praevia in the studies that used crude analysis, while including only the studies with odds ratios adjusted for confounders led to an increase in placenta praevia when fibroids are present (OR = 2.21, CI: 1.48–2.94). They also found that when only large fibroids of 5 cm or more are considered, the association is still present (OR = 3.53, 95% CI: 1.02–6.05).
In summary, the data regarding the predilection of placenta praevia occurring when fibroids are present is varied, but the best evidence would suggest that a relationship does indeed exist, with the possibility that larger fibroids contribute more to the formation of this pathology.
6.6.13 Placental Abruption
Twelve studies have evaluated the issue of placental abruption and its relationship to fibroids in the pregnant uterus. Of these, five studies have shown a significant increase in the incidence of abruption (odds ratios 2.1–3.7) [36, 40, 41, 46, 47], while seven studies failed to show any difference between fibroid uteri and controls [33–35, 39, 42–44]. Of interest is the fact that three of the negative studies used matched controls and had little power to detect small differences. Additionally, a meta-analysis recently investigated this relationship, including nine of these studies [53]. Among all the studies included, there was a significant increase in the rate of abruption (OR = 2.63, 95% CI: 1.38–3.88). When including only the studies with adjustments for confounders, the significance in the difference was maintained (OR = 2.29, 95% CI: 1.62–2.96).
If abruption is more common in fibroid uteri, it is of value to understand which fibroid characteristics are responsible for this adverse occurrence. Three studies examined fibroid number and found no effect [35, 39, 43]. Two studies have investigated fibroid size and risk of abruption, with one showing no effect [43] and the other noting that myomas greater than 200 cm3 volume increased the rate of abruption [47]. Myoma location within the uterus has been culled out twice, with one study showing no effect by location [43] and another claiming that submucosal myomas significantly increase the risk [47]. Finally, two studies specifically examined the effect of fibroids when located retroplacentally [46, 47], with both finding this location to drastically elevate the risk of abruption. In fact, Rice and colleagues found abruption occurred in 8 of 14 women with retroplacental fibroids, while it occurred in only 2 of 79 women with fibroids in other locations [46]. This specificity of effect may be responsible for variation in study results, as the relationship between fibroid and placenta is not identified in most reports.
In summary, there is a likely relationship between fibroids in the pregnant uterus and the chance of abruption, but it may be limited to fibroids near to or superimposed upon the placental implantation site.
6.6.14 Premature Rupture of Membranes
Seven studies have investigated whether or not fibroids influence the rate of premature rupture of membranes (PROM). Five of the seven showed no difference in risk, with four of the five using regression analysis to correct for confounding variables [33, 39, 43, 44, 47]. Of the two studies that did find a difference, one failed to correct for confounders [40] and the other showed a small increase in the risk (adjusted OR = 1.79, 95% CI: 1.2–2.68) [36]. Similarly, when fibroid characteristics were analysed, there was no increased risk of PROM with increasing fibroid size [39, 43], number [39, 43], or location [43]. Thus, it is highly unlikely that fibroids play a role in promoting PROM in the pregnant uterus.
6.6.15 Preterm Premature Rupture of Membranes
Preterm premature rupture of membranes (PPROM) and its association with uterine fibroids has been evaluated in six studies. Three found no difference in the risk compared to normal uteri [33, 42, 51], but two of the three found absolute differences that did not reach statistical significance, possibly due to inadequately powered comparisons [33, 51]. In fact, one ‘negative’ study showed the rate of PPROM to be twice as high in women with large fibroids (8.89%) compared to women with only small fibroids (4.02%) or no fibroids (4.3%) [33]. Alternatively, three studies found the risk of PPROM to be elevated when fibroids are present [34, 35, 41], with two using matched controls and the other being a population-based cohort study. While the overall risk was not large (adjusted OR = 1.3, 95% CI: 1.0–1.7) [41], all three found larger fibroids to increase the risk of PPROM when compared to small fibroids or no myomas. It appears that this question remains open and deserves future high-quality investigation.
6.7 Treatment of Fibroids for Reproductive Enhancement
6.7.1 Myomectomy
While it is not clear that fibroids are in fact detrimental to fertility and maintenance of early pregnancy, myomectomies are commonly carried out as a means of enhancing fertility potential. Nearly a decade ago, we evaluated the evidence to support such interventions [13].
Submucosal myomas are the fibroids generally believed to be the most damaging to fertility and early pregnancy. However, despite widespread use of myomectomy to remove these tumours in an attempt to enhance fertility, there are few data to evaluate the efficacy. In women who have undergone myomectomy, there is an increased clinical pregnancy rate when compared to women with submucosal myomas in situ (Table 6.13). Furthermore, when compared to other infertile women without fibroids, women with submucosal myomas removed via myomectomy have similar pregnancy rates, suggesting that once the fibroids are removed they respond to infertility treatments like all other women (Table 6.14). Despite the poor and limited quality of data, it appears as if there is likely to be benefit from removal of submucosal myomas in fertility promotion.
Table 6.13 Relationship between myomectomy of submucosal fibroids and pregnancy outcome: comparison with fibroids in situ
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