What is the best treatment for women with 20-week sized uterine fibroids who desire fertility?

Best Treatment for Women with 20-Week Fibroids Desiring Fertility

Laparoscopic or open myomectomy is the most appropriate first-line treatment for women with 20-week sized uterine fibroids who desire fertility. 1

Treatment Options Based on Evidence

First-Line Treatment: Myomectomy

• Laparoscopic or open myomectomy is recommended as the primary treatment for women with large fibroids who desire fertility 1
• Open myomectomy is preferred over laparoscopic approaches for very large uteri (such as 20-week size) or multiple fibroids 1
• Both approaches demonstrate similar pregnancy and live birth rates in randomized controlled trials 1
• The combined miscarriage rate after myomectomy (14%) is comparable to the general population 1
• Laparoscopic myomectomy offers advantages of shorter hospital stays, less postoperative pain, and faster recovery compared to open myomectomy 1, 2

Fibroid Location Considerations

• Submucosal fibroids have the most detrimental effect on fertility with the lowest pregnancy rates (10%) and implantation rates (4.3%) 3
• For submucosal fibroids, hysteroscopic myomectomy should be performed if present along with the larger fibroids 3
• Intramural fibroids significantly reduce pregnancy rates (16.4%) compared to women without fibroids 3
• Subserosal fibroids have minimal impact on fertility but may contribute to bulk symptoms in large 20-week sized uteri 3

Alternative Options

Medical Management

• Medical management can be considered as a temporary measure before surgery 1
• Ulipristal acetate has shown a 41% reduction in fibroid volume with pregnancy rates similar to controls without fibroids 1, 3
• Most medical therapies (like GnRH agonists/antagonists) suppress fertility and are primarily used for short-term fibroid size reduction before surgery 1

Uterine Artery Embolization (UAE)

• UAE is generally not recommended as first-line treatment for women desiring fertility 1
• Studies show increased risks of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) after UAE compared to myomectomy 1
• Current evidence suggests myomectomy is superior to UAE for women planning future pregnancy 1

MR-Guided Focused Ultrasound (MRgFUS)

• Evidence for MRgFUS for fertility enhancement is limited to case reports 1
• A randomized controlled trial investigating MRgFUS for fertility was terminated due to lack of enrollment 1

Treatment Algorithm

1. Confirm diagnosis and fibroid characteristics with imaging (MRI preferred for precise mapping)
2. Rule out other causes of infertility with complete infertility workup 1
3. Primary treatment: Laparoscopic or open myomectomy based on:
   • For 20-week sized fibroids: Open myomectomy is typically preferred 1
   • For multiple fibroids: Open approach offers better access 1
4. Consider pre-surgical medical therapy to reduce fibroid size and surgical complexity:
   • GnRH agonists/antagonists for 2-3 months before surgery 1
5. Post-myomectomy recommendations:
   • Wait at least 2-3 months before attempting pregnancy to allow uterine healing 4
   • Monitor for return of normal menstrual function 4

Important Caveats

• Hysterectomy is never appropriate for women desiring fertility as it causes permanent and irreversible infertility 1
• Endometrial ablation is contraindicated in women desiring pregnancy due to high risk of pregnancy complications 1, 3
• For very large fibroids (20-week size), the surgical approach requires expertise in complex myomectomy techniques 2
• Pregnancy rates after myomectomy range from 54-59.5% in women with no other apparent cause of infertility 3
• The risk of fibroid recurrence after myomectomy is approximately 15-30% within 5 years 5