COMMENTARY

Effects of Fibroids on Women's Fertility

Peter Kovacs, MD, PhD

Disclosures

April 29, 2009

Fibroids and Infertility: An Updated Systematic Review of the Evidence

Pritts EA, Parker WH, Olive DL
Fertil Steril. 2009;91:1215-1223. Epub 2008 Mar 12.

Background

Fibroids are common benign tumors of uterine origin that may develop as variably sized solitary tumors or as aggregated clusters. They occur predominantly in premenopausal women, and their growth appears to be hormone (estradiol, progesterone) dependent. They may grow towards the uterine cavity (submucous) or towards the abdominal cavity (subserosal), or they may be located within the uterine wall (intramural). Fibroids may be asymptomatic or could be associated with a variety of complaints. Symptoms, such as menometrorrhagia, pressure, urinary frequency, constipation, and pain, are associated with size, number, and location of the fibroids.

It has long been suspected that fibroids that distort the uterine cavity are associated with infertility and miscarriages. The association between fibroids and reproductive failure (infertility, pregnancy loss) has been studied by several groups. The majority of these studies are affected by the same problems: small sample size, no or inappropriate controls, and a retrospective design. The use of a meta-analysis may remedy the shortcomings of individual studies. In addition, few studies have addressed the benefits of treatment in a well-designed manner. To further complicate the issue, several treatment options -- medical, surgical, radiologic -- are available, but their effects would need to be assessed separately.

Summary

This analysis is based on the results of 23 studies and is an update of a previous review.[1] Fibroids in general, regardless of location, were associated with a 15% reduction in pregnancy rates, a 30% reduction in live birth rates, and a 67% increase in miscarriage rates when compared with controls without fibroids. The effect was especially pronounced when submucous fibroids were analyzed (64% reduction in pregnancy rates, 69% reduction in live birth rates, and 67% increase in miscarriage rate). The effect of intramural fibroids was significant but less pronounced (22% decrease in live birth rates, 89% increase in miscarriage rates). Subserous fibroids did not affect pregnancy rates or pregnancy outcome. The analysis did not demonstrate a consistent effect on pregnancy rates and outcomes.

Myomectomy was associated with improved pregnancy outcome when submucosal myomas were evaluated. The pregnancy rate was significantly higher after myomectomy when compared with women with fibroids left in place. On the basis of a small number of cases, the removal of intramural fibroids was not associated with improved pregnancy outcome.

Viewpoint

Although fibroids are one of the most common benign tumors that affect reproductive-age women, studies are few and have been poorly designed to assess their effect on reproduction. A cause-and-effect relationship seems obvious between submucosal fibroids and reproductive failure. This association is supported by this current review as well. In these cases, myomectomy does improve outcome. The association between intramural fibroids and lower pregnancy rates seems to be supported as well, but the effect of treatment is not obvious. In these cases, treatment needs to be individualized on the basis of the outcome of previous pregnancies, the number of previous surgeries, comorbidities, and the number and size of fibroids when treatment is offered. In the future, studies will have to evaluate the benefits of treatment of intramural myomas.

Abstract

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