What are the treatment options for a woman with uterine fibroids (myoma) experiencing infertility?

Treatment of Infertility in Women with Uterine Fibroids

Women with submucosal or intramural fibroids experiencing infertility should undergo surgical removal before attempting assisted reproductive technology, while subserosal fibroids do not require treatment as they do not impair fertility outcomes.

Impact of Fibroid Location on Fertility

The location of fibroids is the single most critical factor determining their effect on reproductive outcomes:

• Submucosal fibroids have the most devastating impact on fertility, with pregnancy rates of only 10% and implantation rates of 4.3% in assisted reproductive technology (ART) cycles 1
• Intramural fibroids significantly reduce pregnancy rates to 16.4% and implantation rates to 6.4% compared to women without fibroids (30.1% and 15.7% respectively), even when the uterine cavity appears normal on ultrasound 1, 2
• Subserosal fibroids do not interfere with fertility, showing pregnancy rates of 34.1% and implantation rates of 15.1%, which are comparable to women without fibroids 1, 2

Diagnostic Evaluation

Transvaginal ultrasound is the initial imaging modality of choice, achieving 90-99% sensitivity for detecting fibroids overall and 90% sensitivity with 98% specificity for submucosal fibroids specifically 1, 3

• Combined transabdominal and transvaginal ultrasound provides the most comprehensive initial assessment 1, 3
• MRI should be obtained when surgical planning is needed, as it can alter management in up to 28% of patients by providing superior mapping of fibroid location, size, and number 3, 2

Treatment Algorithm Based on Fibroid Type

For Submucosal Fibroids (Highest Priority)

Hysteroscopic myomectomy is the definitive treatment and should be performed before attempting conception or ART 1, 2:

• This approach achieves pregnancy rates of 85% with live birth rates of 65% in retrospective studies 1, 2
• The procedure offers shorter hospitalization and faster recovery compared to other surgical approaches 1, 2
• Historical data shows 54-59.5% pregnancy rates after myomectomy in women with no other identifiable infertility factors 1

For Intramural Fibroids

Surgical or medical treatment should be considered before proceeding to ART, though the evidence is less definitive than for submucosal fibroids 1, 2:

• Laparoscopic or open myomectomy are both acceptable options with similar pregnancy and live birth rates 2
• The combined miscarriage rate after myomectomy is 14%, comparable to the general population 2, 4
• Preoperative medical therapy with GnRH agonists/antagonists for 2-3 months can reduce fibroid size and facilitate minimally invasive approaches 2, 4
• Ulipristal acetate has shown a 41% reduction in fibroid volume with pregnancy rates similar to controls without fibroids 2

For Subserosal Fibroids

No treatment is necessary as these fibroids do not impair fertility outcomes 1, 2

Preoperative Optimization

When surgery is indicated, optimize the patient before the procedure:

• Correct anemia with iron supplementation while initiating medical therapy to control bleeding 4
• Consider 2-3 months of GnRH agonists/antagonists or ulipristal acetate to shrink fibroids, though be aware this can cause fibroid migration 4
• Repeat imaging after medical therapy to reassess fibroid location before surgery 4

Treatments to Avoid in Fertility Patients

Several interventions are either contraindicated or not recommended:

• Hysterectomy causes permanent, irreversible infertility and is never appropriate 1, 2
• Endometrial ablation is contraindicated due to high risk of pregnancy complications 1, 2
• Uterine artery embolization is not first-line for fertility patients, with increased risks of miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) compared to myomectomy 2
• MR-guided focused ultrasound has insufficient evidence for fertility enhancement 2

Critical Pitfalls to Avoid

The most common error is treating all fibroids the same regardless of location. Remember that subserosal fibroids do not require intervention, while submucosal and intramural fibroids significantly impair implantation through mechanisms involving endometrial changes, altered vascularization, and impaired secretion of growth or angiogenic factors 1. Another pitfall is proceeding directly to ART without addressing problematic fibroids—pregnancy and implantation rates remain significantly compromised even with advanced reproductive technologies when intramural or submucosal fibroids are present 1.