Myoma and Infertility: What next?

What’s Next…?
Myoma & Infertility
Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (OBGY)
MRCOG (London)
Consultant, Genome: The Fertility Centre, Kolkata
Secretary, Website and Bulletin Committee, Bengal
Obstetric and Gynaecological Society (BOGS)- 2017-18
Managing Committee Member, BOGS- 2017-18
Member, Quiz Committee, FOGSI East Zone, 2018-19
Member, Food and Drug Committee, FOGSI, 2018-19
Peer Reviewer, BMJ Case Reports

Introduction
• Leiomyoma/ myoma/ fibromyoma/ fibroid uterus
• Is a benign tumor of uterus, essentially composed of smooth muscle
tissue and a variable amount of fibrous connective tissue.
• These occur when a single uterine smooth muscle cell
replicates until a cluster of cells form a mass that is distinct from
the normal muscular tissues.
• It is the most common tumor of uterus, and is found in 20% of
women in reproductive age group.

Incidence of Fibroid in
India
STANDARD TREATMENT GUIDELINE OBSTETRICS & GYNAECOLOGY; Ministry of Health & Family Welfare Govt. of India
 Nearly 20-30% women in reproductive age group have
fibroid uterus.
 At any given time, nearly 15-25 million Indian women have
fibroid uterus.

Pathophysiology
 Exact etiology not known
Monoclonal origin ( arising from
single cell)
Genetic basis definite**
Various growth factors like TGFβ ,
EGF, IGF-1, IGF- 2, BFGF
 Epidemiological risk factors :-
• Increased risk age 35 to 45 years , nulliparous
or low parity , Black women, strong family
history, obesity, early Menarche, Diabetes,
hypertension.
• Decreased risk ↑↑ parity, exercise, ↑↑intake of
green vegetables, Prog.only contraceptives,
cigarette smoking
 Genetic basis:
Responsible for 40% cases of
fibroids
• Translocation between Chromo. 12 & 14,
• Trisomy 12
• Rearrangement of short arm of Chromo 6
• Rearrangement of long arm of Ch. 10,
• Deletion of Ch.3 or Ch.7
 Estrogen although not proved for
causing myoma definitely implicated
in its growth.
• Not detected before puberty & regresses after
menopause.
• May increase during pregnancy
• Estrogen receptors are in higher concent.ns
• Common fifth decade due to anovulatory cycles with
high or unopposed estrogen.

Progesterone & Estrogen Receptors [ER &
PR]
• Progesterone & estrogen are key growth factors in the pathogenesis of
fibroids.
• Fibroid cells express functional progesterone and estrogen receptor.
• ER binding was twice and PR binding was three times higher in fibroid
as in myometrium.
Fernimdez-Montoli et al. GnRH-a and fibroid steroid receptors Fertility and Sterility;
E
RPR

6
Progesterone
plays a vital role in promoting uterine fibroid growth
1. Human Reproduction Vol.21, No.9 pp. 2408–2416, 2006
2. Curr Opin Obstet Gynecol 2009;21:318-24
3. Eur J Obstet Gynecol Reprod Biol 2012 Aug 14
4. n engl j med 366;5
Newer pathology as authenticated by

Progesterone link with fibroid growth
Progesterone has dual actions on fibroid growth
Stimulates growth by up-regulation of Epidermal growth factor
(EGF) & B-cell Lymphoma (Bcl 2) a key protein in the inhibition of
apoptosis.
Down regulates tumour necrosis factor- alpha (TNF)
expression.
J. Julie Kim, Progesterone Action in Endometrial Cancer, Endometriosis, Uterine Fibroids, and Breast Cancer
1
2

Role of progesterone in pathogenesis of uterine fibroids
(UF)
SPRMs for fertility preservation in leiomyoma, 2017, Vol. 97, No. 3

Extracellular matrix in uterine
leiomyoma pathogenesis
Extracellular matrix (ECM)
accumulation and remodeling
are thought to be crucial for
fibrotic diseases such as
uterine leiomyoma
ECM accumulation is affected by growth factors (TGF-β, activin-A and PDGF,
cytokines (TNF-α), steroid hormones (estrogen and progesterone) and microRNAs
(miR-29 family, miR-200c and miR-93/106b)
Among these, TGF-βs (1 and 3) and activin-A have been suggested as key players
in the accumulation of excessive ECM (fibrosis) in leiomyoma.

The clinical presentation of uterine
leiomyomas
Adapted from Sabry and Al-Hendy. Innovative oral treatments of uterine leiomyoma. Obstet Gynecol Int. 2012;2012:943635.27
i.Asymptomatic
ii. Abnormal uterine bleeding
a.Menorrhagia
b. Anemia
iii. Pelvic pressure
a. Urinary frequency
b. Urinary incontinence
c. Difficulty with urination
d. Hydronephrosis
e. Constipation
f. Tenesmus
iv. Pelvic mass
v. Pelvic pain
vi. Infertility*
vii. Obstetric complications
viii. Pregnancy related
a. Myoma growth
b. Red degeneration and pain
c. Spontaneous miscarriage
ix. Malignancy
x. Rare associations
a. Ascites
b. Polycythemia
c. Familial syndromes, renal cell
carcinoma
xi. Benign metastasizing

Uterine Fibroid & Fertility
• Uterine fibroids (UF) have a negative impact on female infertility.
• Uterine fibroids are present in 5%–10% of women with infertility
• The only detectable cause of infertility in up to 2.5% of these cases.
• Women with UF who desire to maintain future fertility potential face a
dilemma because of the limited treatment choices that are currently
available to help them achieve that goal.
Surrey ES, Lietz AK, SchoolcraftWB. Impact of intramural leiomyomata in patients with a normal endometrial cavity on in
vitro fertilizationembryo transfer cycle outcome. Fertil Steril 2001; 75(2):405–410.

• The management of symptomatic fibroids has been traditionally surgical
• No medical therapy can completely eliminate fibroids
• However alternative pharmacological treatments have been proposed to control symptoms
• Choice of appropriate therapeutic modality depends on several factors including :
1. Age & Parity
2. Child bearing expectations
3. Extent & Severity of Symptoms
4. Size, number & location of myomas
4. Proximity of menopause
5. Risk of Malignancy
Current Therapies for uterine fibroids:
Are they Satisfactory?

Symptomatic Uterine Fibroids
Medical Therapy Surgical Therapy Other modalities
Non Hormonal
Hormonal
Open /Laparoscopic
Myomectomy & Hysterectomy
Endometrial Ablation &
Hysteroscopic Myomectomy
U A E
(Polyvinyl Particles)
Magnetic Resonance-guided
focused Ultrasound Surgery
(MRgFUS)
& & &

Algorithm for management of Uterine Leiomyomas
SPRMs for fertility preservation in leiomyoma, 2017, Vol. 97, No.
3

Submucous fibroids are
classified by European society
for gynec endoscopy ( ESGE, 1993 ):
Type 0 – No intramural extension
Type I – Intramural extension < 50 %
Type II – Intramural extension > 50 %

FIGO (2011) Classification of ALL fibroids

B. MINIMALLY INVASIVE
PROCEDURE
A. SURGERY PROPER

A. Surgical interventions
•Myomectomy
for patients who want to preserve their fertility
• Laparoscopic myomectomy for subserous fibroids
• Hysteroscopic myomectomy for submucosal fibroids
• Vaginal myomectomy for Pedunculated vaginal
• recur in 50% of patients
•Hysteroscopic endometrial ablation for menorrhagia.

Uterine Fibroid & Fertility
• Current literature call for removal of submucous (type 0) fibroid and
possibly cavity distorting intramural fibroid (types 1–2) to optimize ART
supported pregnancy outcomes.
• While removal of intramural fibroids (noncavity distorting, types 3–5) of
any size and especially if less than 4 cm is still controversial.
MohamedAli et al.; Selective progesterone receptor modulators for fertility preservation in women with symptomatic uterine fibroids
Biology of Reproduction, 2017, 97(3), 337–352

SUB MUCOUS
HYSTEROSCOPIC
MYOMECTOMY
SUBSEROUS AND INTRAMURAL
<4CM
OBSERVE
4-7CM >7CM
LAP
MYOMECTOMY?
Optimum Management

Evidences
Pritts, et al. 2009 Meta-
analysis
Removal of submucous fibroids seems to confer
benefit in terms of pregnancy rates.
T. Shokeir, et al.
2010
RCT Women, with no other factors associated with
infertility, undergoing hysteroscopic myomectomy
had a better possibility of becoming pregnant.
Irrespective of fibroid size, number, and location
in both groups.

AAGL Practice guidelines for sub mucous myomas :Level A
• Removal improves fertility esp for type 0 and type 1 but remains low
as compared to normal uteri
• Cervical preparation can reduce trauma .
• Pre op use of GnRHa corrects anaemia

• Location of myomas
• Number of myomas
• Size of myomas
• Asymptomatic/symptomatic
• Associated adenomyosis/endometriosis
• Distortion of endometrium
• Previous failed IVF cycles
• Previous pregnancy losses
• Available expertise and resources
• Other factors affecting fertility
Before decision making

B. Minimally invasive techniques
 Even women without a desire for future pregnancies might not
wish to lose their uterus for various reasons.
 Some of these therapies include
 Uterine artery embolization (UAE)
 MRgFUS (magnetic resonance-guided focused ultrasound
surgery) and
 Ultrasound-guided ablation (VizAblateTM [Gynesonics,
Redwood City, CA, USA] and Acessa™ [Halt Medical, Inc.,
Brentwood, CA, USA] Procedures).
Aamir T Khan et al1 Uterine fibroids: current perspectives; International Journal of Women’s Health 2014:6

Uterine artery embolization (UAE)
It involves the placement of an
angiographic catheter into the uterine
arteries via a common femoral artery
approach and injection of embolic
agents (in most cases, polyvinyl alcohol
particles or trisacryl gelatin
microspheres) into both uterine arteries
until the flow becomes sluggish

The proposed mechanism of UAE’s
action is by occluding or markedly
reducing uterine blood flow at the
arteriolar level to produce an
irreversible ischemic injury to the
fibroids, causing them to undergo
necrosis and shrink, while the normal
myometrium is able to recover

• The early and medium term (to 5 years) results of uterine artery
embolisation (UAE) are good.
• A 1/3 of women will require a second intervention by 5 years.
• Around 80–90% of patients will be asymptomatic or have
significantly improved symptoms at 1 year
• 40-70% reduction in fibroid volume.

Surgery vs UAE
Gupta JK et al. Cochrane database of systemic reviews. Uterine Artery Embolization for symptomatic fibroids. 2013

Fertility, UAE and myomectomy
• The evidence for fertility and pregnancy outcomes after UAE and
after myomectomy is poor.
• Similarly there is very little literature on the differential effects of
myomectomy and UAE on subsequent fertility in women with
fibroids.

 The effect of UAE on ovarian reserve and pregnancy
outcome is less well established.
 The UAE pregnancies were more likely to be delivered by
cesarean section and to experience postpartum hemorrhage.
 Rates of preterm delivery, IUGR, and malpresentation were
similar in UAE pregnancies and in control pregnancies with
fibroids.

A randomised trial of treating fibroids with either embolisation or
myomectomy to measure the effect on quality of life among women
wishing to avoid hysterectomy (the FEMME study): study protocol for a
randomised controlled trial

MRI-guided Focused Ultrasound Surgery (MRgFUS)
 MRgFUS is a relatively new method of thermal ablation for treating
fibroids.
 It uses high-intensity focused ultrasound that passes through the
anterior abdominal wall and converges into a precise target point within
the fibroid to cause a temperature rise (55°C–90°C) sufficient to induce
coagulative necrosis within a few seconds.
 Concurrent MRI allows accurate tissue targeting and real-time
temperature feedback, thereby achieving controlled localized thermal
ablation

 Advantages - completely non-invasive character and continuous imaging
of fibroids and adjacent structures
 Disadvantages- relatively few patients are eligible – only those with
fibroids located immediately beneath the anterior abdominal wall
without bowel interposition or scars in the region of interest.
 Due to the lack of randomized data, MRgFUS should still be regarded as
an experimental treatment.

Other ablation procedures
(VizAblate™)
VizAblate A new transcervical device (VizAblate™) has recently been
introduced that combines real-time intrauterine sonography
with radiofrequency (RF) ablation for the treatment of fibroids.
The VizAblate System
The VizAblate treatment device

Other ablation procedures
(Acessa™)
Acessa
 A laparoscopic ultrasound-guided radiofrequency
volumetric thermal ablation of uterine myomas in
symptomatic women.
 The key feature to using laparoscopic ultrasound lies in
the inherent and immediate proximity of the
transducer to the target (fibroid), allowing the use of
higher frequencies with significantly increased
resolution

Gn Rh Agonists
MEDICAL TREATMENT
NSAIDs
Oral Contraceptive pills Progesterone Releasing IUDProgesterone Pills
No Medical treatment completely
eliminates Fibroids

Why go for medical treatment ?
• The treatment of Fibroid is classically surgical. However, various medical
options are now available.
• They provide symptomatic control while minimizing risks and
complications.
• Now, the choice of treatment should generally be subject to patient’s age
and her desire to preserve future fertility.
Therapeutic drugs may offer excellent alternative options for many UF
patients, including those who desire more conservative management
approach, women approaching menopause (perimenopause), and
particularly for young UF patients who wants to preserve their future fertility.

OCPs
 Breakthrough bleeding
 Increase the size of myoma
Progeins
• often associated with breakthrough bleeding that limit
their use and they may promote proliferation of
fibroids.
LNG IUD
 Leads to more irregular bleeding
 System expulsion, especially in large volume of uterus
GnRH agonists:
 Effects are transient & the myoma usually return to the
pre-therapy size within a few months of
discontinuation*
 Suppresses estradiol, Cause hypoestrinism, 67%
patients report Hot flushes
 Reduced BMD
GnRH antagonists
several reasons prohibit widespread use of the antagonists
generally in symptomatic treatment of UF such as high
price, requirement of daily administration, and lack of
clinical trial-based evidence of their superiority over the
agonist
Selective estrogen receptor modulators (SERM):
clinical trial results were unsatisfactory
*Drug Des Devel Ther. 2014 Feb 20;8:285-92.
Drawbacks of available medical therapies

Summary of medical treatments used in clinical
practice for management of uterine leiomyomas

Pharmacological treatment
Selective progesterone receptor modulators (SPRM)
SPRMs are relatively new class of synthetic steroid ligands with a PR-target
and tissue selective effects of mixed agonist and antagonist activities.
SPRMs are poised to provide additional options in the management choices
against UF and may provide viable alternative to surgery for women seeking
fertility preservation (medical myomectomy).

Comparison of SPRM
SPRMs for fertility
preservation in leiomyoma,
2017, Vol. 97, No. 3

Mifepristone
•Mifepristone has been associated with development of endometrial changes in some reports and
its use in treatment of fibroids is currently restricted to research settings.
Ulipristal acetate
•It induces apoptosis in uterine fibroid cells and inhibits proliferation of cells.
• There was no difference in the control of menstrual bleeding between UA and leuprolide.
However, UA was tolerated better and controlled bleeding more rapidly than leuprolide.
49

Ulipristal Acetate (UPA):
A synthetic steroid derived from 19-
nortestosterone, and has tissue-specific
mixed agonist/antagonist effects with
noted preferential binding in the uterus,
cervix, ovaries, and hypothalamus
UPA is characterized by its superior selectivity for PRs, even higher than P4
itself, and it increases apoptosis and decreases proliferation via numerous
mechanisms including increase in alkaline phosphatase activity, upregulation
of cleaved caspase-3, and downregulation of both tumor necrosis factor alpha
(TNF-α) and Bcl-2 expression

About Ulipristal acetate
• A first-in-class, effective, well-tolerated SPRM specifically designed for
uterine fibroids
• Reversible blockage of progesterone receptors
• It binds progesterone receptors, but not estrogen receptors
• No affinity on mineralocorticoid receptors
• Action only on fibroid cells & not in normal myometrial cells

Mechanism of action of Ulipristal acetate

Reprod Sci. 2014 Sep 16.
Pharmacokinetics

Ulipristal authenticated by
PGL4001 (Ulipristal acetate)
Efficacy Assessment in
Reduction of symptoms due to
uterine Leiomyomata
PEARL
I
PEARL
II
PEARL
III
PEARL
IV
PHASE 3 CLINICAL
TRIAL IN EUROPE

PEARL
I
PEARL
II
PEARL
III
PEARL
IV
Study Ulipristal Acetate
(UPA) vs
Placebo for
Fibroid treatment
before surgery
UPA vs
Leuprolide
Acetate for
Uterine Fibroids
Long term
treatment of
uterine fibroids
with UPA
Efficacy and
safety of repeated
use of UPA in
uterine fibroids
Conclusion Treatment with UPA
for 13 weeks
effectively controlled
excessive bleeding
due to uterine
fibroids and reduced
the size of the
fibroids
Both the 5-mg and
10-mg daily doses of
ulipristal acetate were
non inferior to once
monthly leuprolide
acetate in controlling
uterine bleeding and
were significantly less
likely to cause hot
flashes.
Repeated 3-month
courses of oral UPA 10
mg once daily effectively
control bleeding and pain,
reduce fibroid volume,
and restore QoL over the
long term in many women
with symptomatic fibroids,
providing an effective and
well-tolerated long-term
medical treatment for
fibroids
Repeated 12-week
courses of oral
ulipristal acetate (5
and 10 mg/d)
effectively and safely
control bleeding and
pain, reduce fibroid
volume, and restore
quality of life in
patients with
Phase 3
Clinical Trial

PEARL
I
PEARL
II
PEARL
III
PEARL
IV
Study Ulipristal Acetate
(UPA) vs
Placebo for
Fibroid treatment
before surgery
UPA vs
Leuprolide
Acetate for
Uterine Fibroids
Long term
treatment of
uterine fibroids
with UPA
Efficacy and
safety of repeated
use of UPA in
uterine fibroids
Conclusion Treatment with UPA
for 13 weeks
effectively controlled
excessive bleeding
due to uterine
fibroids and reduced
the size of the
fibroids
Both the 5-mg and
10-mg daily doses of
ulipristal acetate were
non inferior to once
monthly leuprolide
acetate in controlling
uterine bleeding and
were significantly less
likely to cause hot
flashes.
Repeated 3-month
courses of oral UPA 10
mg once daily effectively
control bleeding and pain,
reduce fibroid volume,
and restore QoL over the
long term in many women
with symptomatic fibroids,
providing an effective and
well-tolerated long-term
medical treatment for
fibroids
Repeated 12-week
courses of oral ulipristal
acetate (5 and 10 mg/d)
effectively and safely
control bleeding and
pain, reduce fibroid
volume, and restore
quality of life in patients
with symptomatic
fibroids
Phase 3
Clinical Trial

VENUS II study
Quality of life with Ulipristal acetate (UPA) treatment of symptomatic uterine fibroids (UF)
CONCLUSIONS: UPA 10 mg and 5 mg significantly improved quality of life .
Significant improvement in all UFS-QoL subscales demonstrates that UPA treatment improves a woman’s ability
to lead a normal life.
VENUS I Study
The Second US-Based Phase 3 Study of Ulipristal acetate (UPA) for the treatment of Symptomatic
Uterine Fibroids (UF)
CONCLUSIONS: Numerically greater responses in efficacy were observed with UPA 10 mg vs 5 mg, though
the safety profiles were similar.
Both UPA 10 mg and 5 mg were generally well tolerated
Latest ASRM 2017 Highlights

Ulipristal acetate (UPA) treatment of symptomatic uterine fibroids (UF): VENUS II subgroup analyses by
race and BMI
CONCLUSIONS: UPA 10 mg and 5 mg showed higher responses than PBO in the proportion of women
achieving amenorrhea, regardless of race and BMI.
Both doses of UPA also led to increased QoL, with improvements in physical and social activities compared with
placebo in all subgroups evaluated.
Numerically greater responses were observed with UPA 10 mg vs 5 mg.

• Ulipristal Acetate: A New Hope in the Conservative Management
of Uterine Fibroid
UPA, 10mg, once daily dose is
effective in decreasing
menstrual blood loss, reducing
fibroid volume and pain in
women with symptomatic
uterine fibroid.
Nalini, et al. International Journal of Contemporary Medical Research Volume 4 | Issue 9 | September 2017 | ICV: 77.83
Indian
Study….
1

• Ulipristal acetate (UPA) for fibroids–IVF outcomes
following treatment with UPA after IVF failure:
series of 2 case reports
Kale AR. Int J Reprod Contracept Obstet Gynecol. 2017 Jul;6(7):3177-3181
Indian
Study….
2
UPA seems to be a novel and promising
option, especially for infertile women
who refuse to undergo surgery inspite of
the fibroids distorting the cavity, and for
those with fibroids who shall undergo
IVF

Nalini, et al. International Journal of Contemporary Medical Research Volume 4 | Issue 9 | September 2017 | ICV: 77.83

Retrospective analysis of a series of 52 patients included
Among 52 patients, 21 wished to conceive upon completion of treatment
Among the 21 who attempted to get pregnant, 15 succeeded (71%) totaling 18 pregnancies
Among the 18 pregnancies, 12 resulted in birth of 13 healthy babies & 6 ended in miscarriage
No regrowth of fibroids observed during pregnancy
This confirms the long-term effect after ulipristal therapy
Fertil Steril 2014;102:1404–9 65

66
Fertil Steril 2014;102:1404–9
Endometrium of sufficient quality for blastocyst implantation
Median time to achieve pregnancy after the end of treatment was 10 months
No maternal complications related to myoma. All babies were healthy
No regrowth of fibroids during pregnancy

NICE Recommendations (2016)
<3 cm
1. LNG-IUS
2. Tranexaemic acid/ Mefenamic Acid/
COC
3. Norethisterone Day5-25
Not resolved
Endometrial Ablation
≥3 cm
• Hb <10.2 g/dl- UPA up to 4 courses
(total 20 months)
• Hb ≥ 10.2 g/dl- Consider UPA (Total 20
months)
Not resolved
Myomectomy/ UAE
GnRH Ago→ Hysterectomy

Before Myomectomy
• Both GnRH or LA can be used

Ulipristal acetate does not disturb the surgical planes in patients
who had to undergo myomectomy for removal of Uterine Fibroids
Clinical benefits of Ulipristal introduced before scheduled surgery

Clinical benefits of Ulipristal introduced
before scheduled surgery
Correction of
patient’s anemia
Reduction of
intraoperative
blood loss
Facilitation of
myomectomy
instead of
hysterectomy

Before UAE
• GnRH agonist MUST be stopped
• UPA is safe
74

Pregnancy &
Breast feeding
Genital Bleeding of
unknown etiology
Uterine, Cervical,
Ovarian,
Breast Cancer
Hypersensitivity to
active substance
75
Absolute & Relative Contraindications

Contraception
Renal impairment
Hepatic impairment
Asthma patients
Endometrial Changes
Concomitant Drugs
Bleeding pattern
76
Special Warnings and Precautions

System Organ Very common Common Uncommon
Reproductive & Breast Amenorrhea
Endometrial thickness
Pelvic pain, Hot flushes,
Breast tenderness & ovarian
cyst
Breast swelling & breast
discomfort
CNS Headache Dizziness
ENT Nasopharyngitis Vertigo
GIT Abdominal pain & Nausea Dyspepsia, Dry mouth,
Constip
Psychiatric Disorder Anxiety, Emotional
disorder
Skin Acne Alopecia, Dry skin
General Disorder Hot flushes Oedema, Fatigue
Renal Incontinence
Musculoskeletal Pain Back pain
Investigations ⇑ Blood Cholesterol ⇑ Trigly and ⇑ Wt
Adverse Drug Reactions

•Limitations of SPRMs
•Endometrial changes unique to progesterone receptor modulators (PRM) are
described and referred to as PRM-associated endometrial changes (PAEC). It is
therefore not always possible to identity patients taking PRM on histology alone and
it is therefore important to inform the pathologist when sending a hysterectomy
or an endometrial biopsy specimen.
• PAEC were evaluated in women taking short courses of SPRMs (asoprisnil, ulipristal
acetate and telapristone acetate) and no hyperplasia, premalignant or malignant
lesions were identified in these specimens.
• Although nonphysiological changes were seen frequently in the ulipristal group,
these changes had resolved 6 months after treatment demonstrating reversibility
of these changes and safety in this respect of their short-term use. 78

Ulipristal Acetate……To Conclude
Repeated 12 week course of oral ulipristal acetate (5 mg) effectively &
safely control bleeding & pain.
Reduce fibroid volume & restores quality of life.
Symptomatic improvement & fibroid volume shrinkage can be largely
maintained during off-treatment periods.
Allows the re-establishment of the morphology of endometrial cavity
thereby would allow an immediate attempt at conception at the end of
fibroid treatment.*
*International journal of Reproduction, contraception, Obstetrics & gynaecology 2017 jul; 6(7); 3177-

Summary
 Uterine fibroids are associated with significant morbidity to nearly 40% of
women during their reproductive years and sometimes even after
menopause.
 There is considerable interest in discovering any etiological clues
 With more and more patients demanding a nonsurgical approach to their
symptoms, there is a developing market for selective estrogen and
especially progesterone receptor modulators.
 Minimally invasive management of fibroids has been even further enriched
by the development and introduction of novel techniques (ie, MRgFUS,
VizAblate™, and Acessa™).

Myoma and Infertility: What next?

Myoma and Infertility: What next?

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