This document discusses types of fibroids and their impact on fertility. It describes 3 main types of fibroids - submucosal, intramural, and subserosal - and provides details on their classification systems. The document also summarizes several mechanisms by which fibroids can affect fertility, including effects on fertilization and implantation. It reviews findings on the relationship between fibroid characteristics like location, size, and number and fertility outcomes like pregnancy rates. The document concludes by outlining treatment options for fibroids impacting fertility, including expectant management, medical therapies, and various surgical approaches.

1. Benha University Hospital, EgyptAboubakr elnashar

2. Types of fibroids
(The European Society of Hysteroscopy, 1993)
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 (Sessile or pedunculated)
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3. Submucous: 0, 1, 2
Intramural: 3, 4:
Type 3: totally intramural but abut (touch) the endometrium
Type 4: entirely within the myometrium, with no extension to the endometrial
surface or to the serosa.
Subserous: 5, 6, 7
8: cervical, b lig, parasitic.
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4. 20- 40% of women of reproductive age
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5. FIBROIDS & INFERTILITY
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6. Incidence:
Associated with infertility:
5- 10%.
Only cause of infertility:
2- 3%
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7. Mechanisms:
1. Effect on fertilization
Interference with sperm or ovum transport.
a. Enlargement& deformity of uterine cavity
b.Uterine contractility (Vollenhoven et al, 1990).
c. Distortion of the cervix
d. Distortion or obstruction of tubal ostia.
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8. 2. Effect on implantation
Implantation failure or gestation discontinuation
(Buttram & Reiter, 1981)
a.Alteration of the endometrial contour
b.Persistence of intrauterine blood or clots
c. Focal endometrial vascular disturbance
d.Endometrial inflammation
e.Secretion of vasoactive substances
f. Enhanced endometrial androgen environment
None of these putative mechanisms has been
confirmed to be the etiologic factor.
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9. Effect on fertilization Effect on implantation
Anatomic distortion of the cervix Altered endometrial development
Altered uterine contractility Prevention of efflux of discharge or blood
Deformity of the endometrial cavity Distortion of the shape of the
endometrium
Obstruction of tubal ostia
Mechanisms By Which Fibroids Affect Reproductive
Function
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10. Aboubakr elnashar

11. Fibroids & IVF
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12. IVF provides a good model to assess the
effect of fibroid on IR by excluding other
factors such as tubal or male
(Donnez & Jadoul, 2002).
IVF cannot assess the effect of fibroid on
sperm migration & ovum transport.
Type
Size
Number
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13. PR/ET
%
Fibroid
(n)
9Submucou
s
(27)
16Intramural
(44)
27Subserous
(158)
30Control
(2413)
1.Type of fibroid:
Bajekal & Li (2000)
PR with IVF
SM: Most detrimental effect
IM: Modest impact
SS: Least impact on PR.
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14. PR/ET%Fibroid (n)
9Distorted cavity(65)
34Not distorted cavity (487)
40Control(1636)
Donnez & Jadoul (2002).
No difference in implantation or PR unless the
uterine cavity itself was distorted by the myomas
distorting intramural fibroids: adverse pregnancy
outcomes in women undergoing IVF
(Sunkara et al, 2010)
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15. Intramural fibroid halves the chances of ongoing
pregnancy following IVF(Hart et al, 2001)
Metwally M, Farquhar, 2011 (SR &MA)
No evidence of a significant effect for intramural
fibroids on CPR, LBR
or miscarriage rate
No evidence for a significant effect for myomectomy
on CPR or the miscarriage rate
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16. 2. Size of fibroid: intramural
No statistically significant difference in IR or pregnancy
outcome
•<3 cm (Rice et al, 1988, Rosati et al, 1989)
•< 4 cm (Oliveira et al, 2004 )
• < 5 cm (Li et al, 1999; Somigliana et al, 2011.)
•<7 cm (Ramzy et al, 1998; Jun et al, 2001; Olivera et al, 2003)
PR/ET (%)
Ramzy et al, 1998 Jun et al, 2001 Olivera et al,2003
483134<7 cm
454139Control Aboubakr elnashar

17. Small intramural fibroids
significant reduction in the cumulative
pregnancy, ongoing pregnancy and LBR after
three IVF/ICSI cycles
(Khalaf et al, 2006)
fibroids >4cm required an increased number of
cycles to obtain an ongoing pregnancy.
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18. 3. Number of fibroids (3-5 cm):
(Feliciani et al, 2003)
PR (%)Number of
fibroids
37<3
28>3
41Control
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19. Aboubakr elnashar

20. 4. Distance from the endometrium
(Aboulghar et al, 2004)
> 5 mm: No effect
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21. Aboubakr elnashar

22. • Ultrasound:
Confirm diagnosis
Locate the myomas.
• TAS:
uteri >12 w
{Beyond the reach of the TVS}.
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23. •TVS:
Accurate in excluding endometrial
hyperplasia
Inaccurate in dd SM fibroids & polyps (A).
•TVS or SIS Vs hysteroscopy
More accurate in location of fibroids (A).
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24. •SIS:
If the location is unclear in AUB
-When the relationship between the myoma
and the uterine cavity is unclear
-100% sensitive& specific
-SIS Vs office hysteroscopy:
•easier
•less uncomfortable
•less expensive
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25. Aboubakr elnashar

26. •Endometrial biopsy:
Irregular or intermenstrual bleeding.
Abnormal endometrial thickening on TVS
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27. •MRI:
Uncommon presentations.
Uncertain location after TVS & SIS
when the number of lesions >5, MRI
exceeds ultrasound’s technical limitation in
precise fibroid mapping and characterization.
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28. MRI (T2) scan
Multiple leiomyomas
extending up to L4. Two
leiomyomas were present,
one fundal subserosal with
broad attachment to the body
and a left posterior wall fibroid
extending into the broad
ligament. Also a 7.5-cm
pedunculated component was
found extending from the
right body
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29. Differentiation of an adenomyoma from a
fibroid
Adenomyoma:
absence of a lesion margin
presence of lacunae
When doubts persist: MRI
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30.  Bromley et al (2000)
2 or more of the followings:
1. Mottled heterogeneous myometrial texture:
All cases.
2. Globular uterus: 95% of cases.
3. Small myometrial lucent areas: 82%.
4. “Shaggy” indistinct endometrial strips: 82%.
The most predictive:
ill-defined heterogeneous echotexture within the
myometrium
(Brosen et al, 2004)
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31. • Standard infertility evaluation:
HSG
-If the uterine cavity is normal: no advantage in
performing hysteroscopy
tt plan should be recommended after the couple
has been fully evaluated
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32. Aboubakr elnashar

33. In some women, no treatment is better than
treatment
(Fletcher & Frederick, 2005)
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34. Aboubakr elnashar

35. I. Expectant Management
• Indications:
1.Infertile patients without any identifiable
etiology except uterine myomas
2. Asymptomatic fibroid
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36. II. Medical Treatment
Not effective in improving infertility
•Progestin therapy, including oral
contraceptive pills
•Androgens (gestrinone or danazol)
• Mifepristone
•GnRH analogs
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37. ulipristal acetate (UPA)
One medical treatment of uterine leiomyoma is a selective
progesterone modulator, ulipristal. It is associated with rapid
decrease in uterine bleeding, reduction in myoma size and
minimal menopausal symptoms
an oral selective progesterone-receptor modulator (SPRM):
reduction in pain, bleeding, and size of fibroids.
(Daniell, 2014)
UPA provides more prolonged volume reduction after
treatment is discontinued, as compared with the rapid
regrowth observed in GnRH agonist treatments.
Employing UPA, some benign endometrial changes have
been described and resolved 6 months after treatment.
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38. Correction of 1,25-dihydroxyvitamin D3 (Vitamin
D) insufficiency has been proposed as an emerging
therapeutic option for uterine fibroids.
Epidemiological investigations reveal an
association between low vitamin D reserve and
presence of fibroids.
The link between vitamin D deficiency and ovarian
hormones upon fibroids might be the canonical Wnt
(wingless-type)/ β-catenin signaling pathway that
have been shown to be of importance mediating the
estrogen/progesterone-dependent tumorigenesis of
fibroids.
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39. Other anti-uterine fibroid agent still under
investigation is Epigallocatechin gallate (EGCG) –
green tea extract that has been shown to inhibit
fibroid cell proliferation in vitro.
Finally, growth factor receptor antagonist under
laboratory investigation, such as AG 1478 and
TKS050 have been shown to control fibroid cell
proliferation in vitro and they might serve as future
therapeutic options.
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40. Aboubakr elnashar

41. III. Surgical Treatment
Myomectomy:
-Indications: To maintain fertility.
1. Distorting the uterine cavity
 Submucous
regardless of the size or the presence of symptoms
(Gambadauro,2012).
 Intramural
distorting the cavity reduce the chances of conception,
not distorting the cavity: controversial results.
{uterine wall is no more than 2 cm in thickness}: all the
intramural fibroids ≥ 5 cm have some submucous
component: deserve surgical consideration.
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42.  Subserosal
No indication
2. Intramural:
>5-7cm
≥3(3-5 cm)
(Bajekal & Li, 2000)
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43.  Myomectomy of of submucous fibroids:
significant increase in PR (from 27.2% to 43.3%)
and a decrease in miscarriage rate (from 50%
tom38.5%).
 (Pritts et al, 2009, SR)
 Insufficient evidence from RCT to evaluate the
role of myomectomy to improve fertility
(Metwally M et al. Cochrane Database Syst Rev 2012).
 The data do not support pre-IVF myomectomy in
women with small to moderate uterine fibroids,
regardless of their location
(Vimercati et al, 2007)
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44. -GnRHa for 3 to 4 months prior to
myomectomy
(Cochrane library, 2001)
Reduce both uterine volume & fibroid size.
Correct preoperative iron deficiency anemia
Reduce blood loss
Blood transfusion rates& complication rates
are not different.
No significant impact on operative time,
difficulty or complications.
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45. Aboubakr elnashar

46. -Pregnancy after myomectomy
75% in 1st y
PR drops sharply after this time (Dessole et al, 2001).
If possible, therefore, myomectomy should be
timed when a woman is ready to start a
family
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47. 10-75% (mean: 50%)
(Donnez & jadoul, 2000).
The differences may be attributed to:
1. Age & other infertility factors
2. Factors related to fibroid
3.Technical factors
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48. 1. Age >35 y& other infertility factors
Decreases PR
(Ramzy et al, 1998; Li et al, 1999; Zollner et al, 2001)
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49. 2. Factors related to the fibroid
a.Number:
More fibroids removed: lower PR
(Sudik et al, 1996; Dessolle et al, 2001)
No difference
(Vercellini et al, 1999; Rossetti et al, 2001)
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50. b. Size:
Removal of fibroid >8 cm: Better PR
(Sudik et al, 1996).
No difference
(Vercellini et al, 1999; Rossetti et al, 2001)
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51. C. Site:
Posterior wall: lower PR
(Fauconnier et al, 2000)
Distortion of the cavity: Better PR
(Dessolle et al, 2001)
No influence
(Sudik et al, 1996)
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52. 3. Technical factors:
The approach depend on:
Fibroid: Site, number & size
Surgeon: Expertise
Patient: preference
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53. Open myomectomy
(Bajekal & Li, 2000)
The route of choice:
Large SS or IM(>7 cm)
Multiple fibroids (>5)
When entry into uterine cavity is to be
expected
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54. b. Hysteroscopic myomectomy:
The route of choice:
SM fibroids.
Compared to laparotomy, it is associated with a lower
risk of scar rupture & no pelvic adhesion
(Bajekal & Li, 2000)
Large (>5 cm) type II SM fibroids may be unsuitable
for hysteroscopic surgery.
A significant benefit of removing SM fibroid >2cm
(Varasteh et al, 1999)
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55. effect of hysteroscopic myomectomy on fertility outcomes. (Metwally M et al. Cochrane
Database Syst Rev 2012).
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56. European Society for Gynaecological Endoscopy (ESGE) and
STEPW classifications(size, topography, extension,
penetration, wall)
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57. Aboubakr elnashar

58. C. Laparoscopic myomectomy:
 Pedunculated or SS: not candidate for removal {not
the cause of infertility or recurrent miscarriage}
(Bajekal & Li, 2000).
 IM:
depending on:
size, position of the fibroid
skills of the surgeon, suturing skills
instruments available
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59. Aboubakr elnashar

60. Live birth (%)PR (%)Route (n)
7960Laparotomy (465)
8055Hysteroscopy (198)
7647Laparoscopy (191)
No significant difference between the
laparoscopic and open approach regarding
fertility performance.
(Metwally M et al. Cochrane Database Syst Rev 2012).
Results of hysteroscopic& laparoscopic
myomectomy are similar to those following
abdominal myomectomy (Bajekal & Li, 2000).
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61. • Prevention of adhesion:
1. Surgical technique: anterior incisions
2. Adhesion barriers are effective
GnRH analogs prior to surgery will not reduce
postoperative adhesions
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62. -Pregnancy outcome after
myomectomy
1.Miscarriage rates
Reduced from 41 to 19%
(Li et al, 1999; Vercellini et al, 1999)
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63. 2. Uterine scar complications
Pathologically adherent placenta
Placenta praevia
Uterine rupture
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64. 3. Cesarean section:
Recommended (Friedman et al, 1996; Seineira et al, 1997)
Not routine
(Daria et al, 1997, Ribeiro et al, 1999; Dubuisson et al, 2000).
{No uterine ruptures after myomectomy in 212 deliveries, 83% of which were
vaginal}.
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65. Uterine Artery Embolization (UAE)
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66. IV. Other techniques
1.Uterine artery embolization (UAE)
2.Myolysis
Should be avoided in women who desire
pregnancy {fertilization & delivery rates are a
matter of speculation} (Donnez & jadoul, 2000).
Until more information is available, these
approaches should not be considered
standard treatment for women who wish to
maintain their fertility.
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67. Kim& Baer, Up To Date, April. 2013
National Guideline Clearinghouse American College of Radiology May 2012
Uterine fibroid embolization (UFE)
Indicated
premenopausal women with symptomatic fibroid
Desire to retain their uterus.
Not recommend in:
1. Plans for future pregnancy (Grade 2 C)
2. Postmenopausal women
3. Pedunculated or submucosal fibroids >6 cm
4. Fibroid >24 w or multiple fibroids > 10 cm
5. Eextensive adenomyosis,
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68. Kim& Baer, Up To Date, April. 2013
 Occlusion of uterine vessels either via
laparoscopy or a vaginally-placed clamp has
been proposed as an alternative to uterine artery
embolization (UAE)
UAE is preferable to laparoscopic uterine artery
occlusion and less invasive.
Transvaginal occlusion of the uterine arteries
was associated with the need of ureteric stent
due to clamping of the ureters in some cases
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69. Magnetic Resonance-Guided Focused
Ultrasound
(FUS)
Kim& Baer, Up To Date, April. 2013
NICE interventional procedure guidance 413, Nov.
2011
UFE is indicated for premenopausal women with
symptomatic fibroid and have the desire to
retain their uterus. It is not recommend:
 Fibroid resectable with a hysteroscope
 Heavily calcified fibroid
 Fibroid >10 cm (Not absolute)
 When intervening bowel or bladder could be
damaged by treatment
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71. CONCLUSIONS
•Myomas are the cause of infertility in a
relatively small percentage of patients.
•Medical therapy of myomas is not effective in
improving infertility
•Surgical therapy should be recommended
after complete evaluation of other potential
factors.
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72. •If myomas are thought to be unrelated to
reproductive dysfunction or if they are
asymptomatic, no treatment is indicated.
•Patients with recurrent miscarriages or
pregnancy complications due to myomas
should be treated after thorough evaluation of
all other potential factors has been completed.
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73. CAVITY
Distorted
Not distorted
SIZE
≥5 cm ≤5 cm
NUMBER(3-5cm)
≥3 ≤3
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74. Proposed flow chart for the management of
women seeking conception in the presence of
uterine myomas
Edgardo Somigliana, 2008Aboubakr elnashar

75. Summary Statements
1. Subserosal fibroids do not appear to have an
impact on fertility; the effect of intramural
fibroids remains unclear. If intramural fibroids do
have an impact on fertility, it appears to be small
and to be even less significant when the
endometrium is not involved. (II3)
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76. 2. Because current medical therapy for fibroids is
associated with suppression of ovulation, reduction
of estrogen production, or disruption of the target
action of estrogen or progesterone at the receptor
level, and it has the potential to interfere in
endometrial development and implantation, there is
no role for medical therapy as a standalone
treatment for fibroids in the infertile population. (III)
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77. 3. Preoperative assessment of submucosal fibroids
is essential to the decision on the best approach for
treatment. (III)
4. There is little evidence on the use of Foley
catheters, estrogen, or intrauterine devices for the
prevention of intrauterine adhesions following
hysteroscopic myomectomy. (II3)
5. In the infertile population, cumulative pregnancy
rates by the laparoscopic and the minilaparotomy
approaches are similar, but the laparoscopic
approach is associated with a quicker recovery, less
postoperative pain, and less febrile morbidity. (II2)
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78. 6. There are lower pregnancy rates, higher
miscarriage rates, and more adverse
pregnancy outcomes following uterine artery
embolization than after myomectomy. (II3)
7. Studies also suggest that uterine artery
embolization is associated with loss of ovarian
reserve, especially in older patients. (III)
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79. Recommendations
1. 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. (IIIA)
2. Preoperative assessment of submucosal fibroids
should include, in addition to an assessment of
fibroid size and location within the uterine cavity,
evaluation of the degree of invasion of the cavity
and thickness of residual myometrium to the serosa.
A combination of hysteroscopy and transvaginal
ultrasound or hysterosonography are the modalities
of choice. (IIIB) Aboubakr elnashar

80. 3. Submucosal fibroids are managed
hysteroscopically. The fibroid size should be < 5 cm,
although larger fibroids have been managed
hysteroscopically, but repeat procedures are often
necessary. (IIIB)
4. A hysterosalpingogram is not an appropriate
exam to evaluate and classify fibroids. (IIID)
5. In women with otherwise unexplained infertility,
submucosal fibroids should be removed in order to
improve conception and pregnancy rates.
(II2A)
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81. 6. Removal of subserosal fibroids is not
recommended. (IIID)
7. There is fair evidence to recommend against
myomectomy in women with intramural fibroids
(hysteroscopically confirmed intact endometrium)
and otherwise unexplained infertility, regardless of
their size. (II2D)
If the patient has no other options, the benefits of
myomectomy should be weighed against the risks,
and management of intramural fibroids should be
individualized. (IIIC)
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82. 8. If fibroids are removed abdominally, efforts
should be made to use an anterior uterine incision
to minimize the formation of postoperative
adhesions. (II2A)
9. Widespread use of the laparoscopic approach to
myomectomy may be limited by the technical
difficulty of this procedure. Patient selection should
be individualized based on the number, size, and
location of uterine fibroids and the skill of the
surgeon. (IIIA)
10. Women, fertile or infertile, seeking future
pregnancy should not generally be offered uterine
artery embolization as a treatment option for uterine
fibroids. (II3E).
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