Uterine fibroids & infertility: which fibroids should be removed?—a narrative review

Background and Objective: Although fibroids are frequent in the infertile population, their high heterogeneity and methodological problems hinder efforts to reach high-quality evidence on their impact on and surgery’s role in infertility. Methods: We have searched PubMed from 1980 to September 1st, 2022 for publications in English, using various combinations of keywords “fertility”, “infertility”, “fibroid”, “myoma uteri”, “myomectomy”, and “surgery”. There were no limitations regarding study type. Since this is a narrative review, we have only included publications that we believed were solid and relevant to our questions of interest. Key Content and Findings: Submucous (SM) and intramuscular (IM) fibroids that distort the uterine cavity are likely to affect fertility adversely and surgical removal of these is recommended. On the contrary, subserosal (SS) fibroids are not thought to have an impact on fertility, therefore removal of these solely for fertility purposes is not recommended. The effect of non-cavity distorting IM fibroids on fertility is still debated, however, the evidence is inclined to suggest that their presence may lower a woman’s chance of achieving a live birth. However, whether their surgical removal restores or improves this is a gray area and usually not recommended. However, it can be an option for women with large fibroids, a history of miscarriages, or failed in vitro fertilization (IVF) attempts.The route of myomectomy is also an underinvestigated area. SM and IM fibroids that distort endometrial cavity are best managed hysteroscopically, if not larger than 5 cm. For other fibroids, laparoscopy and laparotomy seem to yield similar reproductive results, but laparoscopy may be preferred for quicker recovery and reduced postoperative pain. Conclusions: Finally, it should be remembered that the majority of data on the relationship between fertility, fibroids and their surgical correction are based on heterogenous, observational studies, providing low-quality evidence, and should be treated with caution.