The impact of uterine leiomyomas on reproductive outcomes.

Uterine leiomyomas (fibroids, myomas) are a common benign disease of the uterus with a prevalence of 8-18%. Prevalence rates vary with race, and fibroids are most common in African American women. Uterine leiomyomas can also be present during pregnancy, which may occur more frequently than previously suspected, with prevalence rates reported of up to 10%. Recent evidence has emerged to clarify the relationship of uterine fibroids on fertility and obstetrical outcomes. In this paper we review evidence that uterine fibroids, specifically submucosal and intramural myomas, negatively impact fertility and are associated with adverse obstetrical outcomes such as: pain, preterm labor, placental abruption, malpresentation, postpartum hemorrhage, and cesarean section. Myomectomy performed for submucosal and intramural fibroids significantly improves fertility outcome, and current evidence suggests myomectomy is the treatment of choice in women desiring to conceive. For women that do not desire surgery, medical management of myomas is available. Treatment with GnRH agonists may be considered, however newer medications with fewer side effects give practitioners and patients more options. Progesterone antagonists, selective progesterone receptor modulators, and aromatase inhibitors have all shown promise as effective therapies. Non-pharmacologic treatments such as uterine artery embolization and MRI-guided ultrasound have also emerged as effective treatments for uterine fibroids. With such a wide range of new and emerging treatment options, it is important for providers to understand which fibroids are likely to respond optimally to a specific treatment, in order to individualize appropriate and effective management for patients.