O-229 To remove or not to remove - debate continues
Authors: Nayar K.D 
Published: June 2022

Abstract
Fibroids and Fertility - To remove or not to remove debate continues
Uterine fibroids (leiomyomas or myomas) are the most common benign pelvic tumors in reproductive age women. Fibroids are increasingly found in women seeking infertility treatment because of longer reproductive timeline & current trend to postpone childbearing.
Fibroids adversely affect the female fertility by distortion of uterine cavity, thinning of endometrium, reduced blood supply in endometrium & myometrium, increased contractility of uterus and hormonal changes. Fibroids also exert global effect on endometrial receptivity through molecular signaling.
Women with submucosal myomas experience significantly lower implantation, clinical pregnancy, ongoing pregnancy, and live birth rates, and higher miscarriage rates. The need and effect of myomectomy on submucous myoma is acknowledged in literature. Subserosal fibroids, do not affect fertility and removal is not advisable prior to IVF.
There is heterogenicity in the studies reporting the effect of intramural fibroids on fertility. Some have reported an association between intramural fibroids and reduced chance of pregnancy and increased rates of early pregnancy loss. The effect of fibroids which are in close proximity to the endometrium & are 100% intramural (FIGO type 3 and 4) on fertility has been investigated by many researchers. The endometrial cavity may not be distorted by these fibroids, yet they can affect fertility because of their proximity to the uterine cavity. Studies have shown that both size of the fibroid and distance of fibroid from endometrial cavity are important factors, which determine the effect of intramural fibroids on fertility. The production of transforming growth factor beta-3b (TGF- b3), is increased as size of the fibroid increases and impairs the endometrial receptivity. Fibroids causing menorrhagia are likely to affect endometrial receptivity.
In women with infertility, an effort should be made to adequately evaluate and classify fibroids, particularly those impinging on the endometrial cavity, using transvaginal ultrasound, hysteroscopy, hysterosonography, or magnetic resonance imaging. (Evidence III-A)
Submucosal fibroids are managed hysteroscopically. The fibroid size should be &lt; 5 cm, although larger fibroids have been managed hysteroscopically, but repeat procedures are often necessary. ( III-B). In women with otherwise unexplained infertility, submucosal fibroids should be removed in order to improve conception and pregnancy rates. ( II-2A).
Removal of subserosal fibroids is not recommended. (III-D).
Whether to surgically remove intramural fibroids not distorting the endometrial lining (FIGO types 3–4) for improving fertility in asymptomatic infertile patients has been a subject of debate since long. The studies favoring myomectomy indicate that It is better to perform myomectomy prior to ART cycle women with reduced ovarian reserve, advanced maternal age, recurrent pregnancy loss or previous failed IVF cycles. Decision for a particular approach for myomectomy - via a laparotomy, laparoscopy or hysteroscopy should be based on the size and location of  fibroid and experience of surgeon.
There is fair evidence to recommend against myomectomy in women with intramural fibroids more than 3–4 cm before ART cycle (hysteroscopically confirmed intact endometrium) and otherwise unexplained infertility, regardless of their size (II-2D). Surgery in patients with intramural fibroids presenting with infertility, should be considered to be a risky procedure, not only because of the limited evidence of the efficacy of myomectomy on reproductive outcomes but also because of the potential for several surgery-related complications. We need to investigate other modalities such as uterine artery embolization and magnetic resonance-guided focused ultrasound.
The observed lack of consensus regarding recommendations for myomectomy in case of infertile patients with intramural fibroid is mainly because of heterogenicity of the studies. The decision to perform myomectomy on intramural fibroids should be individualized (III-C)