Reassurance is the Appropriate Approach
For a patient with an incidentally discovered 2cm subserosal fibroid who is concerned about pregnancy, reassurance is the correct counseling approach, as subserosal fibroids of this size do not significantly impact fertility or pregnancy outcomes and surgical intervention carries unnecessary risks. 1
Evidence Supporting Reassurance
Minimal Impact on Fertility
- Subserosal fibroids do not significantly affect fertility, with pregnancy rates (34.1%) and implantation rates (15.1%) nearly identical to women without fibroids (30.1% and 15.7% respectively) 1
- Subserosal fibroids project outward from the uterus and typically cause minimal to no bleeding symptoms 1
Risks of Unnecessary Surgery
- Myomectomy carries significant risks including uterine perforation, need for blood transfusion, bowel or bladder injury, and need for reintervention 1
- Case reports have documented uterine rupture during subsequent pregnancy following laparoscopic and open myomectomy 1
- The surgical risks outweigh any theoretical benefit for an asymptomatic 2cm subserosal fibroid 1
Which Fibroids Actually Require Intervention
Fibroids That Impact Fertility
- Submucosal fibroids have the most detrimental effect on fertility with pregnancy rates of only 10% and should be removed to improve conception 1
- Intramural fibroids >4 cm may negatively influence fertility and warrant consideration for removal before assisted reproductive technology 1
- Symptomatic fibroids causing heavy bleeding, bulk symptoms, or pain would require treatment 1
Size and Location Matter
- Large submucosal and retroplacental fibroids impart greater risk for complications including pain, vaginal bleeding, placental abruption, IUGR, and preterm labor 2
- Multiple fibroids are associated with higher rates of preterm delivery (18% vs 6% for single fibroids) 3
- Fibroids in the lower uterus increase cesarean section rates (86% vs 40%) and postpartum hemorrhage risk 3
Appropriate Monitoring Strategy
When to Monitor
- Proceed with attempting conception without surgical intervention 1
- Rapid growth of fibroids can occasionally indicate malignant transformation, though this is rare 1
- Most fibroids do not exhibit significant volume change during pregnancy, and those that do increase primarily in the first trimester 2
Common Pitfall to Avoid
Do not recommend preconception myomectomy for small subserosal fibroids. Preconception myomectomy to improve reproductive outcome should only be considered in women with recurrent pregnancy loss, large submucosal fibroids, and no other identifiable cause for recurrent miscarriage 2. A 2cm subserosal fibroid does not meet these criteria.