Uterine fibroids are benign tumors that occur in most women and have been associated with infertility. While some retrospective studies suggest surgically removing fibroids may increase fertility, there is limited high-quality evidence from randomized controlled trials to support the efficacy of different surgical or non-surgical treatment options. A Cochrane review found only one small randomized trial comparing laparotomy and laparoscopy for fibroid removal, and no evidence comparing hysteroscopic removal to other methods. Overall, there is a lack of good evidence available to guide optimal management of fibroids and infertility.

1. FIBROIDS AND INFERTILITYCURRENT EVIDENCE
Dr SATHYA

2.  Fibroids are benign tumours of the uterus
occurring in up to 77% of women. Fibroids have
been noted to occur more frequently in women
with infertility.
 Retrospective studies have suggested the benefit
of surgically removing fibroids to increase the
fertility efficacy of both natural conception and
assisted conception.

3.  There are a variety of methods to surgically
remove fibroids including laparotomy,
laparoscopy and hysteroscopy.
 The relative advantages and disadvantages of
these modalities in terms of fertility efficacy and
side effects are unknown.

4. Cochrane review on surgical
management of fibroids and infertility
 Objectives
 To determine the efficacy and safety of the
removal of uterine fibroids in subfertile women by
laparotomy, laparoscopy or hysteroscopy when
compared with expectant management or each
other.

5.  Selection criteria
 Randomised controlled trials (RCTs) in which
fibroids were removed via surgery for the
treatment of infertility

6.  Main results
 Only one randomized controlled study was
included (131 women) and this was probably
underpowered.
 There was no evidence of a difference in
outcome in terms of clinical pregnancy rate and
live birth rate when fibroids were removed via
laparotomy or laparoscopy for infertility.

7.  There were some non fertility benefits of
removal via laparoscopy including shorter hospital
stay, less febrile illness and a smaller drop in preoperative haemoglobin concentration when
compared to laparotomy.

There were no randomised controlled studies
comparing hysteroscopic removal or no
intervention with other surgical modalities.

8. CONCLUSIONS OF
COCHRANE
 There is limited evidence to suggest that there is
no difference in fertility efficacy outcome if fibroids
are removed via laparotomy when compared to
laparoscopy.
 There is no good randomised controlled
evidence to support hysteroscopic removal of
fibroids compared to other surgical modalities for
fertility efficacy.

9. COCHRANE REVIEWS
 Of 38 subfertility reviews currently or previously
published on the Cochrane Library from the
Menstrual Disorders and Subfertility Group, 12
reviews concluded that there was evidence of
effectiveness of the interventions studied.
 Implications: Very little good evidence is
available for infertility and we are still
dependent on substandard studies and expert
opnion’s on deciding optimal management for
a patient.

10. Types of fibroids

11. TYPES OF FIBROIDS
1. Submucos (SM): Fibroid distorting ut cavity.
 Type 0: pedunculated without intramural extension
 Type I: Sessile with intramural extension <50%
 Type II: Sessile with intramural extension >50%
 2. Intramural (IM): Fibroid not distorting the cavity & <50%
protrusion into serosal surface
 3. Subserosal (SS): >50% protrudes out of the serosal
surface

12.  Associated with infertility: 5- 10%.
 Only cause of infertility:2- 3%
 IVF provides a good model to assess the effect of
fibroid on implantation rate by excluding other factors
such as tubal or male (Donnez & Jadoul, 2002).
 IVF cannot assess the effect of fibroid on sperm
migration & ovum transport.

13. Type of fibroid and IVF preg rate
 SM: Most detrimental effect 9%
 IM: Modest impact 16%
 SS: Least impact on PR. 27%
 Control 30%

14. • Donnez & Jadoul (2002).
 No difference in implantation or PR unless the




uterine cavity itself was distorted by the myomas
Fibroid
preg rate%
DISTORTED CAVITY
9%
NOT DISTORTED CAVITY 34%
CONTROL
40%

15. Size of fibroid
 No statistically significant difference in
implantation rate or pregnancy outcome
• <3 cm (Rice et al, 1988, Rosati et
al, 1989)
•
< 5 cm (Li et al, 1999)
• <7 cm
(Ramzy et al, 1998; Jun et al, 2001;
Olivera et al,2003 )

16. 1998

2000
2003
 <7CM
34
 CONTROL
39
31
41
48
45

17. Number of fibroids (3-5 cm):
 Feliciani 2003




No. of fibroids
<3
>3
Control
PR%
37
28
41

18. Distance from the endometrium
(Aboulghar et al, 2004)
 >5mm- no adverse effect.

19. Management of uterine fibroidscurrent evidence
 Paucity of “good evidence”
 Expectant management- no studies which
followed up the natural history of the disease in
women who chose to have no intervention.
 Pharmaceutical management GnRH analogues-7RCT-Reduction in size
 6 RCTs- improvement in Hb levels, Not enough
evidence on blood loss during surgery or
subsequent fertility.

20.  Progestin -1 small RCT showed weak evidence
of reduction in fibroid size with use of lynestenol.
 Mifepristone- 1 non - randomised controlled trial
showed benefit in terms of reduction in fibroid
size and menstrual blood loss.
 Estrogen receptor modulators- Raloxifene- 3
small non RCTs showed reduction in fibroid size
and two studies found an increase!

21. Uterine artery embolisation
 23 TRIALS
 6 RCTs
 Evidence of moderate strength(consistent effects
but weak design)- shorter procedure duration and
shorter hospital stay compared to hysterectomy
or myomectomy.
 Weak evidence(either no significant differences or
inconsistent direction of effect) o symptom relief
and complications.

22. MR- Focussed ultrsound
 No RCTs
 Only 1 carefully conducted prospective series
 71%- improvement in quality of life
 16%- severe pain during procedure
 13% reduction in fibroid size.
 11% worsened symptoms
 28% required further treatment.

23. Surgery vs no interventionfertility
 1 clinical trial.
 substantial benefit following removal of
submucus fibroids.
 Not enough evidence for intramural fibroids.
 Not enough evidence regarding risk to
subsequent pregnancy following
myomectomy.Reported incidence one in 314.

24. Conclusions
 There is a remarkable lack of high quality evidence




supporting the effectiveness of most interventions in
fibroid management.
Expectant management is poorly studied.
Selection bias is an important weakness in trying to
compare outcomes of different interventions in non
randomised studies.
However, lack of evidence is not equivalent to no
benefit or harm.
Given how common and concerning fibroids are to
women and their health care providers, an increased
emphasis on high quality research is imperative.
Women deserve better information to guide their
choices.