Fibroids and Fertility
Part 1: The Effect of Fibroids on Fertility
Fibroid presence, size or location does not impact time to pregnancy
We enrolled a cohort study of women in early pregnancy. Participants retrospectively reported their time to conception. Fibroid characteristics were determined by first-trimester ultrasound. We used discrete time hazard models to estimate the effects of uterine fibroids on time to pregnancy. RESULTS: In this population of 3000 women, 11% (324) with one or more fibroids, we found no association between fibroid presence, type, location, segment or size on time to pregnancy. CONCLUSIONS: These results suggest that fibroids have little effect on time to pregnancy in this cohort of women. The study excluded women who had been treated for infertility, and this may have resulted in underestimation of the association. However, differences between our study and previous studies in specialty clinics may be, in part, attributable to differences between our community-recruited population of women and women receiving fertility care, as well as difference in fibroid size or type in women having myomectomies to treat infertility.
http://www.ncbi.nlm.nih.gov/pubmed/22811308
No evidence that intramural fibroids affect pregnancy or live birth rate
Ten studies reported the effects of intramural fibroids on assisted conception treatment including one study reporting the effect of myomectomy for these fibroids. Combined analysis of the included studies, after taking into account possible confounding factors, showed no evidence of a significant effect for intramural fibroids on clinical pregnancy rate, live birth rate or miscarriage rate. There was also no evidence for a significant effect for myomectomy on the clinical pregnancy rate or the miscarriage rate. These findings highlight the current deficiency in the literature and suggest that evidence is insufficient to draw any conclusions regarding the effect of intramural fibroids on reproductive outcomes.
http://www.ncbi.nlm.nih.gov/pubmed/21549642
When outside the endometrial cavity, fibroids do not affect implantation or miscarriage rate
To compare in vitro fertilization outcome, a total of 1035 cases from our oocyte donation database were included, comprising patients with ultrasonographically documented fibroids not affecting the endometrial cavity, including those with one fibroid less than 5 cm; two fibroids less than 5 cm; three or more fibroids less than 5 cm; one fibroid 5 cm or greater; and two control groups: women with previous myomectomy; and women without uterine pathology treated on the same dates. RESULTS: Term pregnancy rates after oocyte donation were 36.9, 34.1, 39.0, 36.4, 39.2, and 42.6% among the established groups. Similarly, no correlation between implantation and miscarriage with fibroid number and size was found. CONCLUSIONS: Fibroids have no effect on oocyte donation outcome when the size and number of fibroids are analyzed.
http://jcem.endojournals.org/content/93/9/3490.long
Intramural and subserosal fibroids increase miscarriage, unrelated to oocyte quality
PURPOSE: To evaluate the effect of intramural or subserosal fibroids in the uterine fundus or corpus on pregnancy outcome following transfer of embryos formed from donated oocytes methods. RESULTS: There was no difference in pregnancy rates in those with or without fibroids. However, there was a significantly higher miscarriage rate in the former group. CONCLUSION: Women with fibroids are generally older. Thus conclusions about the effect on miscarriage rates are complicated by the effect of the aging oocyte on miscarriages. This study eliminated the oocyte factor by using only younger donated oocytes.
http://www.ncbi.nlm.nih.gov/pubmed/15672960
Intramural and submucosal fibroids reduce implantation 32%, increase miscarriage 112%
To evaluate the influence of inner myometrium fibroids (myomas) on the outcome of IVF cycles, a retrospective age matched controlled study was performed. The study group included IVF/intracytoplasmic sperm injection cycles in patients with one or more intramural and/or submucosal fibroids, while the control group consisted of cycles in patients without fibroids. The two groups were similar for mean oestradiol concentration at human chorionic gonadotrophin administration, mean number of transferred embryos and clinical pregnancy rate (34.9 versus 41.1%). Conversely, the implantation rate was significantly lower in the study group (18.0%) than in the control group (26.5%), whereas the rate of miscarriage demonstrated an opposite trend (40 versus 18.9%). Further research should be aimed at classifying fibroids on the basis of their location, especially when they are positioned in the junctional zone of the myometrium. Whether this classification will be superior in predicting the impact of fibroids on the reproductive outcome should be elaborated in a large multicentric study.
http://www.ncbi.nlm.nih.gov/pubmed/15901454
Submucosal fibroids reduce pregnancy rate 50%; intramural increase miscarriage 58%
Submucosal fibroids had the strongest association with lower ongoing pregnancy rates, odds ratio: 0.5, primarily through decreased implantation. Cumulative pregnancy rates appeared slightly lower in patients with intramural fibroids 36.9% vs 41.1%, which may reflect biases in the literature; however, patients with intramural fibroids also experienced more miscarriages, 20.4% vs 12.9%. Adverse obstetric outcomes are rare and may reflect age or other differences in fibroid populations. Increased risk of malpresentation (odds ratio, 2.9), cesarean (odds ratio, 3.7), and preterm delivery (odds ratio, 1.5) are reported; however, the incidence of labor dystocia was low (7.5%). There was no conclusive evidence that intramural or subserosal fibroids adversely affect fecundity. More prospective, controlled trials are needed to assess the effects of myomectomy. Good maternal and neonatal outcomes are expected in pregnancies with uterine fibroids.
http://www.ncbi.nlm.nih.gov/pubmed/18395031
Fibroids larger than 5 cm associated with early delivery and blood transfusions
Compared to women with no fibroids or small fibroids (≤5 cm), women with large fibroids (>5 cm) delivered at a significantly earlier gestational age (38.6 vs. 38.4 vs. 36.5 weeks). Short cervix, preterm premature rupture of membranes, and preterm delivery were also significantly more frequent in the large fibroid group, and were associated with number of fibroids >5 cm in diameter. Blood loss at delivery was significantly higher in the large fibroid group (486.8 vs. 535.6 vs. 645.1 mL), as was need for postpartum blood transfusion (1.1 vs. 0.0 vs. 12.2%). CONCLUSION(S): Women with large uterine fibroids in pregnancy are at significantly increased risk for delivery at an earlier gestational age compared to women with small or no fibroids, as well as obstetric complications including excess blood loss and increased frequency of postpartum blood transfusion.
http://www.ncbi.nlm.nih.gov/pubmed/22100166
Fibroids increase risk of miscarriage in second trimester and other complications
We observed 65 pregnant patients with uterine fibroids and 165 pregnant patients without fibroids. RESULTS: The frequency of threatened miscarriage, risk of miscarriage in the second trimester, preterm births, premature rupture of membranes and abnormal fetal presentation was significantly higher in patients with uterine fibroids compared to patients without fibroids. It was not demonstrated that fibroids grow during follow-up even, there was a trend toward reduction in size as pregnancy progressed and until its completion. No significant differences in the frequency of cesarean section between groups. Uterine atony was more frequent in patients with fibroids than in patients without fibroids. There were no differences in perinatal outcomes between the groups. CONCLUSIONS: Uterine fibroids increase the risk of complications during pregnancy and childbirth. Could not be demonstrated an increased risk of caesarean section.
https://sites.google.com/site/miscarriageresearch/fibroids-and-fertility
Fibroids increase the risk of premature delivery by 190%
The main objective was to compare the incidence of complications of pregnancy and delivery in two groups of women: group 1 (women with uterine fibroids) and group 2 (women without fibroids). RESULTS: Degeneration of fibroids occurred in 15% of cases. The incidence of threatened miscarriage (51.3% versus 18.8%; odds ratio: 2.7), threaten premature delivery (26.3% versus 10%; odds ratio: 2.6), premature delivery (22.5% versus 7.9%; odds ratio: 2.9), tocolytic treatment (48.8% versus 20.0%; odds ratio: 2.4) and Caesarean section (40% versus 13.8%; odds ratio: 3.1) were significantly increased in the women with fibroids than in the women without. We also noticed a moderate increase of the incidence of miscarriage (11.3% versus 5%), breech presentation (11.3% versus 5%); however, the difference was not statistically significant in two groups. CONCLUSION: We concluded that pregnancy in women with uterine fibroids is a high-risk pregnancy and needs a particular follow-up.
http://www.ncbi.nlm.nih.gov/pubmed/19576703
Part 2: Removing Fibroids May Improve Fertility
Removing fibroids boosts IVF success by 120%
The present study was undertaken to establish the impact of surgical removal of fibroids on fertility and infertility of patients undergoing assisted reproductive technology procedures. Patients who underwent surgical removal of fibroids before in vitro fertilization (Group A) had a cumulative success rate of 33% for one to three procedures and delivery rate of 25%. Patients who underwent in vitro fertilization without previous surgery (Group B) had a 15% clinical pregnancy rate and 12% delivery rate. Miscarriage rates were 7% and 4% in Groups A and B, respectively. This study confirms the beneficial effect of surgical removal of fibroids before undergoing ART procedures.
http://www.ncbi.nlm.nih.gov/pubmed/15731301
Removing submucosal fibroids increases pregnancy rate 59%; submucosal-intramural, 167%
We examined 181 women affected by uterine fibroids who had been trying to conceive for at least 1 year without success. The main outcome measures were the pregnancy rate and the miscarriage rate. Among the patients who underwent myomectomy, the pregnancy rates obtained were 43.3% in cases of submucosal, 56.5% in cases of intramural, 40.0% in cases of submucosal-intramural and 35.5% in cases of intramural-subserosal uterine fibroids, respectively. Among the patients who did not undergo surgical treatment, the pregnancy rates obtained were 27.2% in women with submucosal, 41.0% in women with intramural, 15.0% in women with submucosal-intramural and 21.43% in women with intramural-subserosal uterine fibroids, respectively. Although the results were not statistically significant in the group of women with intramural and intramural-subserosal fibroids, this study confirms the important role of the position of the uterine fibroid in infertility as well as the importance of fibroids removal before the achievement of a pregnancy, to improve both the chances of fertilization and pregnancy maintenance.
http://www.ncbi.nlm.nih.gov/pubmed/16603437
Submucosal fibroids reduce fertility 70% over infertile controls; equivalent after surgery
Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous fibroids demonstrated lower pregnancy rates (odds ratio: 0.30) and implantation rates (odds ratio 0.28) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous fibroids were considered separately, pregnancy was increased after myomectomy compared with infertile controls (odds ratio: 1.72) and delivery rates were now equivalent to infertile women without fibroids (odds ratio: 0.98). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.
http://www.ncbi.nlm.nih.gov/pubmed/11496160?dopt=Abstract
Removal improves take home baby rate by 357% in those with submucosal fibroids
This was a retrospective clinical analysis of 186 patients who underwent hysteroscopic myomectomy by monopolar electrode loop. The mean follow-up period was 36.5 months. RESULTS: There was a significant difference in reduction of number of miscarriages and increase in term deliveries while the number of preterm deliveries remained almost the same. Fifty-eight out of 82 infertile patients (70.7%) conceived after hysteroscopic myomectomy. The take home baby rate was increased from 16.2 to 74%. There was an increased incidence (35.6%) of cesarean section recorded in mode of delivery. CONCLUSION: Hysteroscopic myomectomy is a safe and effective method for improving the obstetric outcome in women with infertility and recurrent abortions and associated submucous fibroids.
http://www.ncbi.nlm.nih.gov/pubmed/20512650
Removing submucosal fibroids smaller than 4 cm boosts pregnancy rate 90%
We identified 30 relevant publications. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (relative risk = 1.9; 95% CI: 1.0-3.7). CONCLUSIONS: Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps or fibroids indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.
http://humupd.oxfordjournals.org/content/16/1/1.long
Removing submucosal fibroids eliminates 2nd trimester losses and doubles live birth rate
Two study groups of women with recurrent miscarriage were subsequently examined: women with cavity-distorting fibroids who underwent surgery and women with fibroids not distorting the cavity who did not undergo any intervention. The latter was compared with a control group of women with unexplained recurrent miscarriage. RESULTS: The prevalence of fibroids was found to be 8.2%. Women with intracavitary distortion and undergoing myomectomy significantly reduced their mid-trimester miscarriage rates in subsequent pregnancies from 21.7 to 0%. This translated to an increase in the live birth rate from 23.3 to 52.0%. Women with fibroids not distorting the cavity behaved similarly to women with unexplained recurrent miscarriage achieving a 70.4% live birth rate in their subsequent pregnancies without any intervention. CONCLUSIONS:Fibroids are associated with increased mid-trimester losses amongst women with recurrent miscarriage. Resection of fibroids distorting the uterine cavity can eliminate the mid-trimester losses and double the live birth rate in subsequent pregnancies. Women with fibroids not distorting the uterine cavity can achieve high live birth rates without intervention.
http://humrep.oxfordjournals.org/content/26/12/3274.long
Removing 3+ cm fibroids improves pregnancy rate over infertile controls
Of the 78 women with diagnoses of infertility, 36 had myomectomies, 23 had polypectomies, and 19 had normal cavities. Among the three groups, there were no significant differences in age, type of infertility, length of infertility, or follow-up after the procedure. Polypectomy subjects had significantly higher pregnancy and live birth rates than women with normal cavities. Women who had myomectomies larger than 2 cm had significantly higher pregnancy and live birth rates, achieving statistical significance at a myoma size of 3 cm or greater for live births. Spontaneous abortion rates among first pregnancies after myomectomy, polypectomy, or normal study were similar: 31.5%, 27.7%, and 37.5%, respectively. CONCLUSION: Both hysteroscopic polypectomy and hysteroscopic myomectomy appeared to enhance fertility compared with infertile women with normal cavities. Despite concern that hysteroscopic resection of a large myoma might ablate a large surface area of the endometrial cavity, the reproductive benefit appears greater than the risk.
http://www.ncbi.nlm.nih.gov/pubmed/10432121
Part 3: Removing Fibroids May Not Improve Fertility
Myomectomy improves fertility in type 0 and type I submucosal fibroids, but not type II
Women were randomly allocated to one of two pretreatment groups matched by age. Hysteroscopic myomectomy was performed in the study group (n = 101). Diagnostic hysteroscopy and myoma biopsy was performed in the control group (n = 103). No fertility therapy was given for either group. RESULT(S): The baseline characteristics of both patients and submucous myomas were comparable. Among patients with complete follow-up, a total of 93 (45.6%) pregnancies occurred (63.4%) in the study group and 29 (28.2%) in the control group. Women in the study group had a better possibility of becoming pregnant after hysteroscopic myomectomy with a relative risk of 2.1. No difference in pregnancy rates was observed according to size, number, and location of myomas in both groups. However, fertility rates appeared to increase after hysteroscopic myomectomy of type 0 and type I fibroids. In contrast, for the subgroup of patients with type II myomas, no difference in fertility rates were noted. CONCLUSION(S): Hysteroscopic myomectomy for submucous fibroids in women with unexplained primary infertility is effective in achieving a better pregnancy rate. We think that a multicenter study should be conducted before evaluating the impact of submucous fibroid characteristics on fertility outcome.
http://www.ncbi.nlm.nih.gov/pubmed/19406399
As of 2012, there is insufficient evidence to conclude myomectomy improves fertility
One study examined the effect of myomectomy on reproductive outcomes and showed no evidence for a significant effect on the clinical pregnancy rate for intramural, submucous, combined intramural and subserous and combined intramural submucous fibroids. Similarly, there was no evidence for a significant effect of myomectomy for any of the described types of fibroids on the miscarriage rate (intramural fibroids, submucous fibroids, combined intramural and subserous fibroids and combined intramural submucous fibroids). Two studies compared open versus laparoscopic myomectomy and found no evidence for a significant effect on the live birth rate, clinical pregnancy rate, ongoing pregnancy rate, miscarriage rate, preterm labour rate and caesarean section rate. AUTHORS' CONCLUSIONS: There is currently insufficient evidence from randomised controlled trials to evaluate the role of myomectomy to improve fertility. Regarding the surgical approach to myomectomy, current evidence from two randomised controlled trials suggests there is no significant difference between the laparoscopic and open approach regarding fertility performance. This evidence needs to be viewed with caution due to the small number of studies. Finally, there is currently no evidence from randomised controlled trials regarding the effect of hysteroscopic myomectomy on fertility outcomes.