The relationship between uterine fibroids and infertility

Due to uterine fibroids being a potential cause of infertility, treatment options like myomectomy should be discussed individually with the patient, according to an article published in Diagnostics that evaluated the relationship.

“Other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery,” wrote the authors, who noted that fibroids could be the sole cause of infertility in 2% to 3% of women.

Fibroids have been linked to both recurrent pregnancy loss and infertility, depending on their location in the uterus.

Because pregnancy and live birth rates appear to be low in women with submucosal fibroids, their resection improves pregnancy rates. Conversely, subserosal fibroids do not impact fertility outcomes, so their removal does not offer any benefit, according to the authors.

On the other hand, intramural fibroids appear to reduce fertility; however, treatment recommendations remain unclear.

The differential diagnosis of uterine masses is critical, as adenomyosis, endometrial polyps, and solid tumors of the adnexa are 3 of the most commonly misdiagnosed pathologies.

Moreover, distinguishing adenomyosis from myoma can be challenging—especially when both pathologies coexist—for which color Doppler ultrasound might be useful.

For ambiguous ultrasound findings, magnetic resonance imaging (MRI) provides additional information with 100% specificity, 97% accuracy, and a sensitivity ranging from 86% to 92%. MRI is indicated in cases of huge fibroids or multiple fibroids, when the shadow makes evaluation hopeless.

“A hysteroscopy should be performed for an even more detailed investigation or to confirm the potential involvement of the uterine cavity,” wrote the authors.

Surgery, medication, and interventional radiology are 3 treatment options to improve symptoms by reducing the size of the fibroids, controlling abnormal uterine bleeding, or even curing the fibroids.

The key question is when should a clinician treat a fibroid in women with infertility? The authors say this depends on the existing clinical symptoms, plus the size and location of the fibroids.

In cases of fibroids and infertility, surgical therapy should be favored over medicinal therapy, according to the authors.

Hysteroscopic myomectomy is the current gold standard for surgical treatment of submucosal fibroids, while uterine fibroids classified as 2 by the International Federation of Gynecology and Obstetrics (FIGO) are more difficult to resect and thus may require a 2-stage treatment, particularly if the fibroids are larger than 3 cm.

Complications during surgical intervention are rare and mostly caused by the difficulty of the procedure. Among the most common problems associated with hysteroscopic myomectomy are uterine perforation, bleeding, infection, and venous intravasation.

Intramural and subserosal fibroids (FIGO 3 fibroids and above) are best removed by laparoscopy or laparotomy, with laparoscopic surgery the preferred choice in the absence of contraindications.

The authors advocate that submucosal fibroids be removed before assisted reproductive technology (ART) or in cases of habitual abortions. Likewise, for intramural fibroids greater than or equal to 5 cm, surgery should be performed before ART or for habitual abortion. But for intramural fibroids <5 cm, reported surgical outcomes vary from no difference to significantly reduced cumulative pregnancy rates.

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility.

Fibroids may be the sole cause of infertility in 2–3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility.

Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit.

Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear.

Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.

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Reference

Freytag D, Günther V, Maass N, et al. Uterine fibroids and infertility. Diagnostics (Basel). Published online August 12, 2021. doi:10.3390/diagnostics11081455