What is the recommended conservative surgical management for a reproductive‑age woman with symptomatic uterine fibroids who wishes to preserve her uterus and future fertility?

Conservative Surgical Management for Uterine Fibroids

For reproductive-age women with symptomatic uterine fibroids who wish to preserve fertility, myomectomy is the recommended conservative surgical approach, with the specific technique—hysteroscopic, laparoscopic, or open—determined by fibroid location, size, and number. 1

Surgical Approach Selection Algorithm

Hysteroscopic Myomectomy

• Indicated as first-line conservative surgical therapy for pedunculated submucosal fibroids ≤5 cm in diameter. 1
• Provides the shortest hospital stay (same-day discharge or overnight observation), fastest postoperative recovery (1–2 weeks to usual activities), and quality-of-life outcomes comparable to other approaches by 2–3 months. 1
• Not advisable as sole treatment when substantial intramural or subserosal fibroid burden exists, or when co-existing adenomyosis is present, because benefit is limited. 1
• Potential complications include uterine perforation, fluid overload, need for transfusion, bowel/bladder injury, endomyometritis, and possible re-intervention. 1

Laparoscopic Myomectomy

• Recommended for subserosal or intramural fibroids when the overall fibroid burden is limited. 1
• Associated with shorter hospital stay (1–2 days), quicker return to daily activities (2–3 weeks), and lower wound-infection rates compared with open surgery. 1
• Technically demanding procedure requiring highly experienced endoscopic surgeons. 1
• Does not reduce adhesion formation at the operative site but decreases new adhesions elsewhere in the pelvis. 1

Open (Abdominal) Myomectomy

• Preferred for multiple fibroids or very large uteri (≥16 weeks' gestation size) where minimally invasive techniques are not feasible. 1
• Offers durable improvement in quality of life maintained for up to 10 years. 1
• Disadvantages include higher incidence of postoperative adhesions, longer recovery time (3–4 weeks), and increased wound-infection rates. 1

Pre-operative Optimization

Anemia Correction

• Correcting pre-operative anemia reduces the likelihood of peri-operative blood transfusion and should be completed before elective surgery. 1, 2
• Selective progesterone receptor modulators and GnRH analogues are effective at correcting anemia and should be considered preoperatively in anemic patients. 2
• Autologous blood storage should be considered for patients identified as high-risk for bleeding. 1

High-Risk Patient Identification

• Women with uterine size ≥16 weeks' gestation have markedly higher risk of intra-operative transfusion and require enhanced pre-operative preparation. 1
• Patients with posterior uterine fibroid location are at increased risk for major intra-operative hemorrhage and should be evaluated carefully before surgery. 1

Pre-operative Imaging

• Pelvic ultrasound serves as first-line modality to differentiate fibroids from other pelvic masses. 1
• Endovaginal sonography with saline infusion enhances detection of fibroid proximity to the endometrial cavity. 1
• Surgical planning should be based on mapping the location, size, and number of fibroids with appropriate imaging. 1, 2

Intra-operative Hemostatic Techniques

• Application of tourniquets to vascular pedicles effectively reduces intra-operative blood loss. 1
• Intramyometrial injection of vasopressin is recommended to diminish hemorrhage during fibroid enucleation. 1
• Use of vasopressin, bupivacaine and epinephrine, misoprostol, peri-cervical tourniquet, or gelatin-thrombin matrix reduce blood loss and should be considered. 2
• When vasopressin is administered, surgeons must verify that postoperative myometrial incisional bleeding does not occur after the vasopressin effect has dissipated. 1
• Intra-operative blood-scavenging systems can decrease net surgical blood loss. 1

Critical Technical Considerations

Incision Placement

• Incisions should be confined to the anterior uterine surface to avoid injury to bowel and adnexal structures. 1
• Posterior uterine incisions should be avoided when possible because they are associated with higher risk of severe bleeding. 1

Adhesion Prevention

• Myomectomy carries substantial risk of postoperative adhesion formation at incision sites and creation of new adhesions from peritoneal trauma. 1
• These adhesions may lead to reduced subsequent fertility or cause bowel obstruction. 1
• Minimizing surgical trauma and applying adhesion-prevention barriers—such as oxidized regenerated cellulose, polytetrafluoroethylene, or hyaluronic-acid-carboxymethylcellulose combinations—are recommended to mitigate adhesion formation. 1

Specimen Removal

• When morcellation is necessary, patients should be informed about possible risks and complications, including the fact that in rare cases fibroids may contain unexpected malignancy and that laparoscopic power morcellation may spread cancer, potentially worsening prognosis. 2

Post-operative Management and Fertility Considerations

Timing of Conception Attempts

• Patients should wait 2–3 months after myomectomy before attempting conception to allow adequate healing of the uterine incision and to lower the risk of uterine rupture in subsequent pregnancy. 1

Pregnancy Risks

• Both laparoscopic and open myomectomy carry a measurable risk of uterine rupture in later pregnancies. 1

Realistic Fertility Expectations

• Large prospective registries show no statistically significant difference in subsequent fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy. 1
• Among women who attempt conception after myomectomy, fewer than 50% achieve pregnancy within three years, and fewer than half of those pregnancies result in live birth. 1
• Clinicians must not assume that myomectomy will automatically improve fertility; high-quality evidence demonstrating increased live-birth rates is lacking. 1
• Retrospective data suggest pregnancy rates around 85% and live-birth rates near 65% following hysteroscopic myomectomy. 1
• The miscarriage rate after myomectomy is about 14%, comparable to the general obstetric population. 1

Quality-of-Life Outcomes

• Symptom relief and quality-of-life scores become comparable across all surgical approaches by 2–3 months post-operatively. 1
• The improvement in quality of life is sustained for up to 10 years regardless of surgical technique used. 1

Fibroid Recurrence

• Approximately 50% of patients experience fibroid recurrence following surgical removal. 1
• Myomectomy carries the potential for further intervention. 2

Critical Pitfalls to Avoid

• Endometrial ablation should never be performed in women desiring future fertility, as it markedly increases the risk of pregnancy complications. 1, 3
• Recommending hysterectomy as initial treatment for patients who wish to preserve fertility is contraindicated. 1
• Performing myomectomy during operative delivery is especially hazardous because of heightened uterine vascularity in pregnancy. 1
• Hysteroscopic myomectomy is not appropriate for patients with substantial intramural/subserosal burden or adenomyosis. 1
• Women with asymptomatic fibroids should be reassured that there is no evidence to substantiate major concern about malignancy and that hysterectomy is not indicated. 2