If you’re planning to undergo a form of assisted reproduction to conceive, such as in vitro fertilization (IVF) and you've been diagnosed with uterine fibroids, your chances of success may improve if you have the fibroids removed first. That's the conclusion of a study on the impact of certain fibroids on assisted reproductive technology (ART) outcomes.1
The findings were published in the journal Fertility and Sterility.
Thus far, the impact of uterine fibroids on the success of ART has been "controversial", wrote Eric Surrey, MD, medical director at the Colorado Center for Reproductive Medicine and his fellow investigators.
While some earlier studies have suggested that fibroids have a detrimental impact on ART cycles—specifically, implantation, pregnancy, and live birth rates—other research has suggested they have no impact, Surrey's team noted.
Thus, for this analysis, Surrey and his colleagues wanted to determine if myomectomy—surgery to remove fibroids—has any effect on ART results.
Common Benign Tumors
Uterine fibroids are the most common, non-cancerous tumors found in women of child-bearing age. They appear as tumors or lumps made of muscle cells and other tissue that grow in the wall of the uterus. They have no known cause and few treatment options. It's estimated that about one-fourth of all women in the United States alone have fibroids. Common symptoms include heavy periods, pelvic pain or a feeling of "fullness" in the pelvis, infertility, and a higher risk of miscarriage.2
Surrey explained that there is not always a standard treatment approach for women with fibroids. "Decisions in our practice are made on a case-by-case basis," he told Priority Healthcare. "However, we do recommend resection of all submucosal fibroids, as well as those intramural fibroids which impinge upon or directly abut the endometrial cavity prior to ART."
Submucosal fibroids are those that develop from within the uterine wall and grow into the uterine cavity. By contrast, intramural fibroids grow primarily within the uterine wall.
Fibroids that distort or impinge on the uterine cavity carry several risks to a potential pregnancy, such as implantation failure, increased likelihood of miscarriage, and in cases involving larger fibroids, premature labor, and abnormal fetal presentation, Surrey explained.
Fibroids' Impact on ART
For their retrospective analysis, Surrey's group collected data on patients who underwent IVF and embryo transfer with their own or donated eggs over a 2-year period at their fertility clinic in Englewood, Colorado. Patients were divided into two groups: those diagnosed with fibroids that distorted or impinged on the uterine cavity and those without the lesions.
"Outcomes were compared with contemporaneous groups of patients without such lesions given the problematic nature of including control groups of patients with leiomyomata [fibroids] allowed to cycle despite the presence of a potentially compromised uterine environment," the research team wrote in explaining their methodology.
The women diagnosed with fibroids had undergone myomectomy using either hysteroscopy or laparotomy, depending on the size and location of the fibroid tumor prior to undergoing ART.
All women had subsequently undergone standard ART treatment cycles consisting of ovarian hyperstimulation, followed by egg retrieval, and then fertilization using IVF or IVF combined with intracytoplasmic sperm injection (ICSI), in which one sperm is collected and injected into the egg to improve fertilization success.3
Resulting embryos were then transferred to each woman to begin pregnancy.
Fibroid Removal Shows Benefits
When all the patient information had been analyzed, Surrey and his colleagues learned that those patients who had their fibroids removed had similar ART outcomes compared with those who had never been diagnosed with fibroids. "No significant differences were noted within either set of treatment groups with regard to number of [eggs] retrieved, fertilization rate, day 3 embryo quality score, and number of embryos transferred or cryopreserved," they wrote.
ART outcomes using ICSI, assisted hatching, and the incidence of day 3 versus day 5 embryo transfer were similar between the groups, as well. The patients were additionally subdivided into groups that included those who used their own eggs versus donor eggs. Those women using donor eggs had more eggs for assisted reproduction, but fewer embryos transferred, as expected, the investigators wrote.
"We have demonstrated that patients who undergo pre-cycle myomectomy for uterine leiomyomata that are considered clinically significant have ART cycle outcomes that are similar to controls with regard to ongoing pregnancy, implantation, and early pregnancy loss," wrote Surrey's team.
Take-Home Message
Based on the findings, Surrey says he would recommend removal of all fibroids that impinge on the uterine cavity, but those that abut the cavity should be evaluated case-by-case. For example, "the risk of removing an extremely small intramural fibroid that is adjacent to the cavity, but can only be resected by laparotomy may outweigh the benefit," he explained.
While this was one of the largest clinical trials to evaluate the impact of myomectomy on ART outcome, "an appropriately designed prospective randomized trial would clearly provide definitive answers," the researchers added.
The study team plans to re-address this issue in the future with a larger number of patients, Surrey said.
In the meantime, based on the findings, it is "critical" for doctors to conduct a uterine examination prior to the start of an ART cycle to look for fibroids, they stressed. "The ART cycle outcome appears to be enhanced by judicious resection of those lesions that are most likely to exert a negative effect."
1. Surrey ES, Minjarez DA, Stevens JM, Schoolcraft WB. Effect of myomectomy on the outcome of assisted reproductive technologies. Fertil Steril 2005 May;83(5):1473-9.
2. National Institute of Child Health & Human Development. National Institutes of Health (NIH). Fast Facts About Uterine Fibroids. Available at: http://www.nichd.nih.gov/publications/pubs/fibroids/sub1.htm#what. Accessed June 1, 2005.
3. Al-Hasani S, Ludwig M, Palermo I et al. Intracytoplasmic injection of round and elongated spermatids from azoospermic patients: results and review. Hum Reprod 1999 Sep;14 Suppl 1:97-107.
John Martin is a long-time health journalist and an editor for Priority Healthcare. His credits include overseeing health news coverage for the website of Fox Television's The Health Network, and articles for the New York Post and other consumer and trade publications.
