In Reply:

In Reply: Thank you for your kind attention to our article in the August 2024 issue.1 You confirm that these study results cannot be extrapolated to the general population because they included only studies in women undergoing assisted reproductive technology (ART). Indeed, 12 of the 13 studies in our analysis were conducted in patients undergoing in vitro fertilization treatment. We were careful to include this information in our study. We appreciate your input and agree with you. We also concur with your reference that medical or surgical interventions that are not grounded in evidence are not appropriate. Since 2007, standard practice patterns of gynecologists worldwide have changed to encourage removal of intramural leiomyomas larger than 5 cm for women with infertility.2,3 The data presented in our study do not support this intervention for women with infertility. There are some emerging data addressing spontaneous fecundability in women with leiomyomas compared with those without, with varying results. In a study from the Danish National Birth Cohort and the Danish National Patient Registry, it appears that women with leiomyomas have a lower fecundability rate. These data come from a prospectively collected database with health information for an entire population over their lifetimes.4 Different results were seen in the Right from the Start study. Women who became pregnant naturally were enrolled in early pregnancy and evaluated for presence or absence of leiomyomas.5 When queried about time to conception, there were no reported differences between the groups. Women who did not conceive or who were undergoing fertility treatment were not included in this study. However, this still gives us valuable information for the association between leiomyoma and pregnancy in women once they become pregnant spontaneously. Consistent with this finding are two studies addressing treatment of women undergoing transfers from donor egg–created embryos during ART cycles. When comparing subgroups with and without intramural leiomyomas, the clinical pregnancy rates and live birth rates were not different.6,7 Because women using donor eggs arguably do not have infertility, we may be able to use these data as a surrogate for becoming pregnant spontaneously. The true association between leiomyoma and natural fecundity is unclear. We do not attempt to address this issue in our meta-analysis.