Evaluation and Management of Uterine Fibroids Before ART
For women with fibroids desiring pregnancy through ART, submucosal fibroids should be removed hysteroscopically before treatment, while intramural fibroids distorting the cavity warrant myomectomy; subserosal fibroids require no intervention. 1
Pre-ART Fibroid Assessment
All infertile women should undergo comprehensive fibroid evaluation using transvaginal ultrasound combined with either hysteroscopy, hysterosonography, or MRI to precisely identify fibroid presence, location, size, and degree of cavity involvement. 2, 3 Hysterosalpingogram is inadequate for fibroid classification and should not be used. 2
The assessment must specifically document:
- Fibroid location (submucosal, intramural, subserosal)
- Size and number of fibroids
- Degree of cavity distortion
- Thickness of residual myometrium to serosa 2
Treatment Recommendations by Fibroid Type
Submucosal Fibroids
Remove all submucosal fibroids hysteroscopically before initiating ART, regardless of size, to improve conception and pregnancy rates. 2, 3 These fibroids significantly reduce implantation rates (4.3% vs 15.7% in controls) and pregnancy rates (10% vs 30.1% in controls). 4, 5
- Hysteroscopic myomectomy is the treatment of choice for fibroids <5 cm 2
- Larger fibroids may require repeat procedures 2
- Preoperative assessment should include evaluation of cavity invasion degree and myometrial thickness 1, 2
Intramural Fibroids
For intramural fibroids distorting the endometrial cavity: perform myomectomy before ART. 2, 6 These fibroids reduce implantation rates (6.4% vs 15.7%) and pregnancy rates (16.4% vs 30.1%). 4, 5
For intramural fibroids NOT distorting the cavity: there is fair evidence to recommend against routine myomectomy. 2 The evidence remains controversial—some studies show reduced pregnancy rates 4, 5, while others found no significant difference with small-to-moderate fibroids. 7 Given surgical risks including adhesion formation, uterine rupture in pregnancy, and potential fertility impairment, avoid myomectomy unless fibroids are >4 cm, which may require increased ART cycles for success. 7
Subserosal Fibroids
Do not remove subserosal fibroids—they do not impact ART outcomes. 2, 3 Pregnancy rates (34.1%) and implantation rates (15.1%) with subserosal fibroids are equivalent to controls. 4, 5
Surgical Approach When Myomectomy Is Indicated
When abdominal myomectomy is necessary, use an anterior uterine incision to minimize postoperative adhesion formation. 2 Laparoscopic myomectomy offers equivalent cumulative pregnancy rates to minilaparotomy but with faster recovery, less postoperative pain, and reduced febrile morbidity. 2 However, laparoscopic approach requires appropriate patient selection based on fibroid number, size, location, and surgeon expertise. 2
Medical Management Has No Role Pre-ART
Medical therapies (GnRH agonists, GnRH antagonists, oral contraceptives, progestin-containing IUDs, ulipristal acetate) suppress ovulation, reduce estrogen production, or disrupt endometrial development—all counterproductive when attempting conception. 1, 2 These agents have no role as standalone treatment in the infertile population preparing for ART. 2
Avoid Uterine Artery Embolization
Women seeking future pregnancy should not be offered uterine artery embolization. 2 This procedure results in lower pregnancy rates, higher miscarriage rates, more adverse pregnancy outcomes compared to myomectomy, and is associated with loss of ovarian reserve, especially in older patients. 2, 8
Common Pitfalls
- Performing unnecessary myomectomy on non-cavity-distorting intramural fibroids, which introduces surgical risks without proven benefit 2
- Using hysterosalpingogram for fibroid evaluation—it cannot adequately classify fibroids 2
- Removing subserosal fibroids, which provides no fertility benefit 2, 3
- Initiating medical management that delays ART and suppresses fertility 2