Uterine myomas (e.g., leiomyomata, fibroids) are the most common tumor of the reproductive tract, with a cumulative incidence of 70% in women of reproductive age. Fibroids vary greatly in their size, number, and location within the uterus. All factors could negatively impact a woman’s fertility. Regardless of their location, size, or number, uterine fibroids are found in about 5%-10% of women with infertility. For approximately 1.0%-2.4% of women with infertility, uterine fibroids are the only abnormal findings.
The adverse effects of uterine myomas include both a reduction in fertility and an association with early pregnancy complications. Uterine myomas are associated with a variety of clinical complications including menorrhagia, pelvic pressure, as well as pregnancy complications, and adverse obstetric outcomes such as preterm labor and delivery, placenta previa, intrauterine growth retardation, increased rates of cesarean section, and postpartum hemorrhage.
Risk Factors for the Development of Uterine Myomas
Early menstruation, nulliparity, caffeine and alcohol intake, obesity, and high blood pressure have been found to increase the risk of uterine fibroids. Epidemiological evidence indicates that the prevalence of uterine myomas increases as a woman gets older. At the same time, ART statistics suggest that women are delaying childbearing, which increases their risk of both age-related and fibroid-related impacts on fertility.
Impact of Location of Uterine Myomas and IVF Outcome
Existing studies described uterine fibroids so far. Still, none takes into account all the parameters that determine the heterogeneity of these tumors. Traditionally, based on uterine fibroids location in relationship to the endometrial cavity, they are classified as submucosal, intramural, or subserosal.
As for the effect of uterine myomas on the chance of a woman to get pregnant and keep her pregnancy to term, it is prudent to refer to spontaneous pregnancies to have a broad idea of the pathophysiology of the issue. Existing studies examine the clinical frequency of pregnancy, the frequency of spontaneous abortions, current pregnancy, the frequency of live births, the frequency of implantations and the frequency of premature births in women with and without uterine fibroids, as well as in women who have undergone myomectomy. The location/effect relationship of uterine myomas versus pregnancy outcome was mapped clearly.
Fertility outcomes are decreased in women with submucosal fibroids, and removal seems to confer benefit. Subserous fibroids do not affect fertility outcomes, and removal is not beneficial. Women with intramural fibroids appeared to have reduced fertility, but the results of the therapy are unclear.
The decision to do a myomectomy before an IVF cycle is not an easy one. Fertility specialist will always be asked with the patient’s question: “Do you think it is essential, Dr.?” To reply this question, fertility specialist has to have clear-cut evidence that this woman will more likely face less of a chance to get pregnant following an IVF cycle unless she has a myomectomy. Or, if she gets pregnant, she will probably lose her baby.
Such patients consider IVF as the salvage for their long-standing misery as they believe it is a “once and for all” means to them to fulfill their dream of having a baby. Such patients may not welcome myomectomy before IVF, as this is not “a surgery” with all its risks and fears, it is a failure, or at least a delay in the “time to pregnancy” path. A good number of such patients are in their late 30s. In the back of their minds, they know that they do not have the luxury of waiting, as their fertile days will soon perish.
What about the Effect of Previous Myomectomy on the Success of the IVF Cycles?
Some studies advise against myomectomy before enrolling a patient for IVF, while other ones show evidence that myomectomy will promote the possibility of a positive outcome of these cycles. Another angle that should be considered is the fact that myomectomy is considered a major surgery. As with any major surgical procedure, myomectomy carries risks, such as bleeding, infection, and damage to other organs. Furthermore, myomectomy is associated with adhesion formation, although this may be argued that it is not a concern for women who are planning to pursue ART.
While surgical myomectomy is a traditional treatment for uterine fibroids, in the past few years, non-surgical approaches have gained popularity. Several alternative approaches, such as uterine artery embolization and laparoscopic cryo-myolysis, have recently been investigated. However, due to safety concerns, women who wish to maintain fertility are generally excluded from studies of these treatments. Thus, pregnancy outcome data for these procedures are scarce, and in addition, the safety of the procedures must be assessed before reproductive results can be discussed.
Cases with uterine myomas who are seeking fertility through ART should be handled on an individualized basis. Since pregnancy-related concerns depend on the location and size of the leiomyoma, the importance of an in-depth discussion of a management plan between patients and a doctor cannot be overemphasized.
In counseling patients with fertility specialist’s final decision, the age of the patient and her ovarian reserve should be taken into consideration given the time lapse that will have to be imposed before pursuing another ART cycle. It has been concluded from several studies that subserosal fibroids with a size of less than 7 cm and intramural fibroids with a diameter of less than 4–5 cm that do not affect the endometrium, apparently, have little effect on the results of IVF. Large intramural and subserosal fibroids are a clinical dilemma, and more research is needed to clarify the final treatment plan.
Myomectomy should be considered in women affected with submucosal and/or intramural fibroids, encroaching on the cavity, who are pursuing fertility treatments, particularly in cases of previously failed IVF/ICSI cycles. High resolution 2D transvaginal sonography may serve as an initial screening tool for the assessment of uterine myomas in this respect. In cases with deep implanted intramural fibroids and submucous fibroids, 3D SHG is an essential, more accurate diagnostic tool.
In addition, hysteroscopy should be considered an invaluable additional tool in the proper assessment of the uterine cavity of IVF patients with uterine myomas. This tool is valuable in studying the endometrium overlying those myomas that compromise the uterine cavity such as submucous fibroids, or in cases with intramural fibroids impacted deep enough to encroach on the uterine cavity.
In addition, evaluation of the endometrium and uterine cavity before enrolling the patient in a new or repeat ART cycle should be considered. Hysteroscopic myomectomy should be considered the gold standard for the treatment of submucous fibroids. In another but important note, myomectomy has long been considered the standard treatment for various symptoms associated with uterine fibroids, such as pelvic pressure, pain, or menorrhagia.
Alternative treatments, such as uterine artery embolization, laparoscopic myolysis, or MRI-guided focused ultrasound, should not be used regularly until their safety and effectiveness have been more fully evaluated.