How to manage a 2 cm uterine fibroid (leiomyoma) in an infertile woman?

Management of a 2 cm Uterine Fibroid in an Infertile Woman

For a 2 cm uterine fibroid in an infertile woman, surgical myomectomy is recommended if the fibroid is submucosal or intramural, while no intervention is needed if it is subserosal, as the location rather than size determines impact on fertility. 1

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
• 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
• Submucosal fibroids have the most detrimental effect on fertility with the lowest pregnancy rates (10%) and implantation rates (4.3%) 1

Diagnostic Evaluation

• Transvaginal ultrasound should be performed to accurately classify the fibroid as subserosal, intramural, or submucosal 1
• Additional imaging such as hysteroscopy, hysterosonography, or MRI may be needed to better characterize the relationship of the fibroid to the endometrial cavity 2
• Hysterosalpingogram is not appropriate for evaluating and classifying fibroids 2

Management Recommendations Based on Fibroid Type

For Submucosal Fibroids:

• Hysteroscopic myomectomy is the treatment of choice for submucosal fibroids to improve conception and pregnancy rates 1, 2
• The procedure is associated with shorter hospitalization and faster recovery compared to other surgical approaches 1
• Retrospective studies show pregnancy rates of 85% after hysteroscopic myomectomy with live birth rates of 65% 1

For Intramural Fibroids:

• Evidence regarding removal of intramural fibroids is less clear, but surgical treatment should be considered before assisted reproductive technology (ART) treatment 1
• Laparoscopic or open myomectomy are options with similar pregnancy and live birth rates 1
• Laparoscopic approach offers advantages of shorter hospital stays, less postoperative pain, and faster recovery 2

For Subserosal Fibroids:

• Removal is not recommended as they do not significantly impact fertility 2
• Observation is appropriate as pregnancy and implantation rates are not influenced by the presence of subserosal fibroids 1

Medical Management Options

• Medical therapy alone is not recommended for fibroid-related infertility as most medications suppress ovulation or disrupt endometrial development 2
• GnRH agonists or antagonists may be used short-term to reduce fibroid size before surgery 1
• 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 1

Alternative Treatments and Cautions

• Uterine Artery Embolization (UAE) is generally not recommended for women seeking future pregnancy due to lower pregnancy rates and higher miscarriage rates compared to myomectomy 2
• MR-guided Focused Ultrasound (MRgFUS) has limited evidence for fertility enhancement 1
• Endometrial ablation is contraindicated in women desiring pregnancy due to high risk of pregnancy complications 1
• Hysterectomy is not appropriate for women desiring fertility 1

Surgical Considerations

• If abdominal myomectomy is performed, an anterior uterine incision should be used to minimize postoperative adhesions 2
• The choice between laparoscopic, hysteroscopic, or open myomectomy should be based on the location, size, and number of fibroids 2
• Surgical outcomes show pregnancy rates of 54-59.5% after myomectomy in women with no other apparent cause of infertility 1

Follow-up and Timing of Conception

• Conception should typically be delayed 3-6 months after myomectomy to allow for complete healing of the uterine wall 3
• Regular monitoring is recommended as fibroids may recur, particularly in women with multiple fibroids 4