Medical treatment of submucous myomas with GnRHa will stop bleeding, improve existing anaemia and usually will shrink those myomas bigger than 4 cm. Further shrinking of a submucous fibroid will retract it from the JZ and endometrial margin and may improve the chance of implantation. When used preoperatively GnRHa will shorten the operative time and decrease the risk of bleeding. and hence their use is recommended in cases of large submucous myomas [14]. In one study, 39 consecutive patients with submucous myomas graded as Type 0 or Type 1, with a myoma size range of 10–35 mm were randomized to either direct surgery or 2 months of GnRHa prior to hysteroscopic resection. Patients treated with GnRHa had significantly shorter operative times (15.9 ± 3.1 min vs. 21.3 ± 4.0 min) and significantly reduced fluid absorption (378 ± 137 mL vs. 566 ± 199 mL) compared to the control arm. Operative difficulty and overall surgeon satisfaction were significantly better in the GnRHa group [14].

Progestogens and danazol can also resolve preoperative anaemia, reduce endometrial thickness, vascularization of fibroids and assist in surgical scheduling. Letrozol (non steroidal aromatase inhibitor) given 5 mg/day, orally for 3 months [15] and nomegestrol acetate (very potent progestogen) day 1–14, 5 mg daily, lead to rapid thinning of the endometrium and provide an easier operative field [16].

In order to ease insertion of the resectoscope and avoid difficult cervical dilatation, especially in a non-gravid woman, mifepristone and asoprisnil can be used for cervical priming. Any route of administration, orally or sublingual or vaginally can be used and with equal results. However, many times the cervix becomes extremely soft causing problems with maintaining fluid distension during the procedure as a result of fluid leakage from a soft cervix.

Disadvantages of Hormonal therapy are the high cost, menopausal symptoms and high recurrence rate. Preoperative use may also render small fibroids less visible [17], increase the risk of uterine perforation due to reduced myometrial thickness [18] and increase the risk of the ‘sinking’ phenomenon due to decreased elasticity of the myometrium and /or oestrogen deficiency [19].

Submucous myomas are better operated on hysteroscopically [20]. There are several hysteroscopic techniques involving different equipment, energy modalities and instruments. Combination of all these techniques is also feasible and mainly depends on the surgeon’s experience, operating room set up, energy sources and equipment availability. The location but more important the size of the fibroid will judge the selection of the equipment, instrument and technique to be used for surgery. What is mandatory for hysteroscopic excision for a submucous myoma is constant intracavitary pressure providing a safe operative field, clear vision and comfortable surgery. Surgery will be directed according to the age of the patient, severity of symptoms, myoma characteristics, duration of infertility and recurrent failure of ART [14, 20].

Small myomas: A “See and treat” hysteroscopy approach has been proposed in women of reproductive age when a small incidental submucous myoma is found. The procedure is simple with few risks The high potential of a small myoma to grow and have a negative impact on spontaneous conception make this an attractive approach [15]. Small submucous fibroids 1–1.5 cm can be removed by cold scissors technique. Usually concomitant use of ultrasound can direct the surgeon to the myoma location while dissection of the overriding endometrium will assist in identifying the whitish tissue of the myoma. Further dissection to the sides of the myoma within the cleavage plane using the tip of the scissors will separate and eventually detach the myoma from its fovea. Progressive movements with the tip of the hysteroscope will lead to the base of the myoma. In case of a feeding vessel or adhesions it is better to use electrical energy, like a 5Fr bipolar needle, ball, twizzle or resectoscope in order to secure haemostasis. A hysteroscopic tenaculum can then be used to extract the myoma from the endometrial cavity [21]. The remaining cavity disappears after a few weeks and a second look hysteroscopy diagnoses a smooth cavity covered by healthy endometrium.

Large myomas: Hysteroscopic treatment of submucous fibroids is the method of preference unless the myoma is too large or too numerous [20]. A randomized matched control study of 215 women with submucous fibroids as sole reason for infertility demonstrated that hysteroscopic myomectomy is effective and increases pregnancy rates. Fertility rates appeared to increase after hysteroscopic myomectomy of G 0 and G I myoma (0.05) but in G II myoma no difference in fertility rates were noted [22].

The aims of hysteroscopic myomectomy are to preserve fertility by minimising damage to the endometrium, have an acceptable tolerability with a low incidence of recurrence, and finally have a minimal complication rate. Conventionally fibroid size should not exceed in Type 1, 5–6 cm and in Type 2, 4–5 cm in order to be removed hysteroscopically [23]. Effort should be made to complete excision of the fibroid in one step although several settings may be needed. In the past, resected fibroids were left in the cavity and were expected to be expelled spontaneously during the first menses after surgery. However this can lead to frequent side effects such as colicky pains and intrauterine infections and hence this approach should be avoided [24]. Two step surgery and excision of only the intracavitary portion, usually is reserved for difficult cases of large fibroids or when fluid deficit exceeds safety margin. Migration of the intramural part into the cavity occurs after 20–30 days and the procedure can then be completed.

The operating hysteroscope contains a working element for electrosurgical thermal loops and vaporizing electrodes. Passage of the electrical energy from the thermal loop to the tissues determines the cutting or coagulation action of the resectoscope. Repeated and progressive passages of the cutting loop, achieves excision of the myoma by slicing. Excision begins from the top, progressing in a uniform way towards the base. Hydromassage by inducing rapid changes in the intrauterine pressure provokes uterine contractions and help migration the intramyometrial component of the fibroid into the cavity [25]. Pharmacological enucleation aided techniques can also be used to induce uterine contractions by laparoscopic uterine injection of PGF-2a [26], or Carboprost (methyl analogue of PGF) intracervically [27]. Hallez 1995, reported hysteroscopic partial myomectomy and then finger massage of the uterus to help expulsion of the intramural part into the cavity [28, 29]. Also the Lin fibroid grasper can be used to pull the fibroid further into the cavity [19].

Once the cleavage plane is identified a loop can be used for blunt dissection of the fibroid from its capsule. Chips are removed manually using the loop. Safety and efficacy of bipolar surgery as compared to monopolar resection is due to the use of normal saline instead of glycine or manitol, reduced risk for electrolyte imbalance, reduced risk of electrical burns and better operating control reducing the risk for perforation. The use of smaller hysteroscope diameters minimises cervical dilatation and uterine wall damage, minimises the need of anaesthesia and makes the procedure feasible in the outpatient setting [30].

Intrauterine morcellators, resectoscopes with automatic chip aspiration or the Integrated Bigatti Shaver (by Storz) are also effective instruments for fibroids up to 2 cm, and even for Type 0 and Type 2 fibroids [31–33].

Vaporisation of the fibroid using cylindrical or spherical electrodes dragged along the surface of the fibroid until the nodule is reduced in size can also be used. Vaporisation leaves no chips but also no tissue for histopathology. It is however faster and associated with less blood loss and fluid imbalance [34, 35].

Complications of fibroid resection: The rate of operative complications with the monopolar resectoscope is 0.3–28 % most frequently due to fluid overload and uterine perforation. Uterine perforation is related to the depth of myoma extension into the myometrium and its position [26]. Bleeding, cervical trauma, intrauterine adhesions and very rarely air embolism can also happen during hysteroscopic myomectomy. The risk factors for fluid overload are the intramural extension of the fibroid, the size of the fibroid, the length of the operation and the total inflow volume. Excessive intravasation and transperitoneal absorption can cause severe fluid overload, pulmonary oedema, hyponatriemia, heart failure and cerebral oedema. When fluid intravasation exceeds the 750 ml, the surgeon should prepare to terminate the procedure [35] and when balance exceeds 1,000 ml the procedure must be stopped [36]. Bipolar resection with saline may also cause fluid overload but larger deficits are allowed. Excessive intravasation >1,500 ml risks can however lead to cardiac overload [26, 37].

Uterine Synechiae after bipolar hysteroscopic resection of submucosal myomas was investigated in a retrospective study, when 30 women with primary infertility and 23 women with secondary infertility underwent a second look hysteroscopy 2 months after myoma resection. Intrauterine adhesions were found in 7.5 % of cases. A myoma size of >3.5 cm and age <35 were significantly associated with increased pregnancy rate [38]. The size and penetrance of the myoma, the extent of the endometrial injury and operating time are considered major risk factors for adhesion formation. The highest risk for postoperative intrauterine adhesions is hysteroscopic surgery for opposing myomas. To minimise the risk of adhesions, every effort should be made to minimise endometrial injury and consideration should be given to the use of anti adhesions measures. The use of second look hysteroscopy performed a few months following the primary procedure is useful to diagnose and treat newly formed adhesions.