Impact of Uterine Myomas on IVF Outcome

Jason G. Bromer; Aydin Arici

Disclosures

Expert Rev of Obstet Gynecol. 2008;3(4):515-521. 

In This Article

Abstract and Introduction

Abstract

Many studies have provided evidence that uterine myomas have a significant effect on IVF outcomes and there is a large body of evidence that treatment of uterine myomas increases fertility and pregnancy rates, and decreases the rate of pregnancy loss. The evidence supports treatment of all very large myomas (>7cm) and any cavity-deforming submucosal myomas. Thus, sonohysterography should be considered an invaluable tool in the management of IVF patients with fibroids. While subserosal myomas that are smaller than 7cm in size and intramural myomas of less than 4-5cm in diameter appear to have little effect on IVF outcomes, larger intramural and subserosal myomas present a clinical dilemma and more studies are needed to clarify a definitive plan for management.

Introduction

Uterine fibroids affect 20-50% of women of reproductive age; and since the prevalence of fibroids increases with age, they are the most common benign tumor in this population of women. Fibroids frequently present symptomatically, causing pelvic pressure and pain, abnormal bleeding and dysfunction in adjacent organs, such as the bladder and bowel; however, many patients remain asymptomatic.[1,2,3,4]

Fibroids are present in approximately 5-10% of patients presenting with infertility; however, they are found to be the sole factor identified in only 1-2.4% of infertile patients. Fibroids have also been further implicated in recurrent pregnancy loss.[2,3,4] The mechanisms by which myomas affect reproductive function have been investigated extensively and a number of theories have been proposed ( Table 1 ). Anatomically, fibroids distort the uterus and endometrial cavity, obstruct the tubal ostia or cervical canal, or displace the cervix itself, all of which can impede sperm migration and fertilization.

Furthermore, implantation of the embryo may be impacted by alterations in uterine function due to impaired uterine contractility or damage to the endometrium. Moreover, fibroids can lead to changes in vasculature, persistence of intrauterine blood clots or lasting inflammation, all of which can result in an altered biochemical environment at the site of implantation.[1,2]

In addition to the biological plausibility of these mechanisms of action, a large amount of data also suggest that fibroids have an impact on fertility. Many retrospective studies have evaluated the efficacy of treatment of uterine fibroids on reproductive outcomes. The largest body of literature exists for the evaluation of submucosal fibroids, which includes all fibroids that distort the endometrial cavity. These fibroids have been further subclassified by the European Society of Gynecologic Endoscopy based on the degree of myometrial invasion as either Type 0, I or II, corresponding to 0, less than 50 or more than 50% invasion, respectively.

Fertility has been shown to improve after hysteroscopic or abdominal myomectomy for submucosal myomas.[5,6,7] In addition, abdominal myomectomy for intramural and subserosal fibroids has also been demonstrated to significantly improve outcomes in patients with either infertility or recurrent pregnancy loss.[8,9,10,11]

Thus, it appears to be generally accepted that submucosal, and possibly intramural and subserosal fibroids decrease fertility, and that their removal improves pregnancy rates. Nonetheless, the effect of uterine fibroids and their management in the setting of IVF has only recently been investigated more extensively. This review will summarize the available evidence related to uterine fibroids and IVF outcomes, in an attempt to address the following questions:

  • Do uterine myomas affect the success rate of IVF?

  • Does treatment of uterine myomas improve reproductive outcome?

  • What is the optimal plan of management for myomas in the setting of IVF?

 

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