Fibroids and infertility: an updated systematic review of the evidence.

OBJECTIVE: To investigate the effect of fibroids on fertility and of myomectomy in improving outcomes.
DESIGN: Systematic literature review and meta-analysis of existing controlled studies.
SETTING: Private center for Reproductive endocrinology and infertility. PATIENT(S): Women with fibroids and infertility. INTERVENTION(S): A systematic literature review, raw data extraction and data analysis. MAIN OUTCOME MEASURE(S): Clinical pregnancy rate, spontaneous abortion rate, ongoing pregnancy/live birth rate, implantation rate, and preterm delivery rate in women with and without fibroids, and in women who underwent myomectomy. RESULT(S): Women with subserosal fibroids had no differences in their fertility outcomes compared with infertile controls with no myomas, and myomectomy did not change these outcomes compared with women with fibroids in situ. Women with intramural fibroids appear to have decreased fertility and increased pregnancy loss compared with women without such tumors, but study quality is poor. Myomectomy does not significantly increase the clinical pregnancy and live birth rates, but the data are scarce. Fibroids with a submucosal component led to decreased clinical pregnancy and implantation rates compared with infertile control subjects. Removal of submucous myomas appears likely to improve fertility. CONCLUSION(S): Fertility outcomes are decreased in women with submucosal fibroids, and removal seems to confer benefit. Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit. Intramural fibroids appear to decrease fertility, but the results of therapy are unclear. More high-quality studies need to be directed toward the value of myomectomy for intramural fibroids, focusing on issues such as size, number, and proximity to the endometrium.