CONSERVATIVE MYOMECTOMY AND REPRODUCTIVE FUNCTION: CURRENT DATA AND A PERSONALIZED APPROACH (A NARRATIVE REVIEW)
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Abstract
Objective – to review current evidence on the impact of conservative myomectomy on reproductive function, endometrial status, ovarian reserve, and fibroid recurrence, and to substantiate a personalized approach to the management of women with reproductive plans.
Materials and methods. A narrative review of publications indexed in PubMed, Scopus, and eLibrary was performed. Clinical guidelines, systematic reviews, meta-analyses, and prospective and retrospective studies on uterine fibroids, myomectomy, and reproductive outcomes were included. Priority was given to studies published within the last 5-7 years, while earlier landmark publications were also considered.
Results. The reproductive impact of uterine fibroids cannot be assessed solely by fibroid size and anatomical localization. Intramural fibroids, especially those adjacent to the endometrium, represent the most clinically challenging group, as prognosis depends on morphological characteristics, endometrial status, patient age, and reproductive history. The overall fibroid burden may be more informative than the size of an individual fibroid. Quantitative parameters reflecting the relative volume of fibroids within the uterus appear promising for patient stratification, although their routine clinical value requires further validation. These data support a personalized, multifactorial approach to determining indications for conservative myomectomy.
Conclusion. Conservative myomectomy remains an important option in women with uterine fibroids and reproductive plans. Surgery is best justified for submucosal and cavity-distorting fibroids, whereas intramural fibroids require individualized assessment.
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References
1. Practice Committee of American Society for Reproductive Medicine in collaboration with Society of Reproductive Surgeons. Myomas and reproductive function. Fertil Steril. 2008; 90(5 Suppl): S125-S130. doi: 10.1016/j.fertnstert.2008.09.012
2. Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017; 124(10): 1501-1512. doi: 10.1111/1471-0528.14640
3. Bezhenar VF, Linde VA, Arakelyan BV, Sadykhova EE, Reznik MV, Tarasenkova VA. Uterine fibroids and fertility: a modern view of the problem. A literature review. Journal of Obstetrics and Women’s Diseases. 2022; 71(2): 79-86. Russian (Беженарь В.Ф., Линдэ В.А., Аракелян Б.В., Садыхова Э.Э., Резник М.В., Тарасенкова В.А. Миома матки и фертильность: современный взгляд на проблему (обзор литературы) //Журнал акушерства и женских болезней. 2022. Т. 71, № 2. С. 79-86.) doi: 10.17816/JOWD78831
4. Donnez J, Taylor HS, Marcellin L, Dolmans MM. Uterine fibroid-related infertility: mechanisms and management. Fertil Steril. 2024; 122(1): 31-39. doi: 10.1016/j.fertnstert.2024.02.049
5. Practice Committee of the American Society for Reproductive Medicine. Removal of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline. Fertil Steril. 2017; 108(3): 416-425. doi: 10.1016/j.fertnstert.2017.06.034
6. Don EE, Mijatovic V, van Eekelen R, Huirne JAF. The effect of myomectomy on reproductive outcomes in patients with uterine fibroids: a retrospective cohort study. Reprod Biomed Online. 2022; 45(5): 970-978. doi: 10.1016/j.rbmo.2022.05.025
7. Yan L, Yu Q, Zhang Y-N, Guo Z, Li Z, Niu J, Ma J. Effect of type 3 intramural fibroids on in vitro fertilization-intracytoplasmic sperm injection outcomes : a retrospective cohort study. Fertil Steril. 2018; 109(5): 817-822.e2. doi: 10.1016/j.fertnstert.2018.01.007
8. Favilli A, Etrusco A, Chiantera V, Laganà AS, Cicinelli E, Gerli S, Vitagliano A. Impact of FIGO type 3 uterine fibroids on in vitro fertilization outcomes: a systematic review and meta-analysis. Int J Gynaecol Obstet. 2023; 163(2): 528-539. doi: 10.1002/ijgo.14838
9. Bai X, Lin J, Chen Y, Ma C. The impact of FIGO type 3 fibroids on in-vitro fertilization outcomes: a nested retrospective case-control study. Eur J Obstet Gynecol Reprod Biol. 2020; 247: 176-180. doi: 10.1016/j.ejogrb.2019.12.018
10. Balulescu L, Brasoveanu S, Pirtea M, Grigoras D, Secoșan C, Olaru F, et al. The impact of laparoscopic myomectomy on pregnancy outcomes: a systematic review. J Pers Med. 2024; 14(4): 340. doi: 10.3390/jpm14040340
11. Somigliana E, Reschini M, Bonanni V, Busnelli A, Piani LL, Vercellini P. Fibroids and natural fertility: a systematic review and meta-analysis. Reprod Biomed Online. 2021; 43(1): 100-110. doi: 10.1016/j.rbmo.2021.03.013
12. Don EE, Mijatovic V, Huirne JAF. Infertility in patients with uterine fibroids: a debate about the hypothetical mechanisms. Hum Reprod. 2023; 38(11): 2045-2054. doi: 10.1093/humrep/dead194
13. Bulletti C, de Ziegler D, Polli V, Flamigni C. The role of leiomyomas in infertility. J Am Assoc Gynecol Laparosc. 1999; 6: 441-445. doi: 10.1016/S1074-3804(99)80008-5
14. Campo S, Campo V, Gambadauro P. Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous or intramural myomas. Eur J Obstet Gynecol Reprod Biol. 2003; 110: 215-219. doi: 10.1016/S0301-2115(03)00159-3
15. Metwally M, Raybould G, Cheong YC, Horne AW. Surgical treatment of fibroids for subfertility. Cochrane Database Syst Rev. 2020; 1(1): CD003857. doi: 10.1002/14651858.CD003857.pub4
16. Rackow BW, Taylor HS. Submucosal uterine leiomyomas have a global effect on molecular determinants of endometrial receptivity. Fertil Steril. 2010; 93(6): 2027-2034. doi: 10.1016/j.fertnstert.2008.03.029
17. Sinclair DC, Mastroyannis A, Taylor HS. Leiomyoma simultaneously impair endometrial BMP-2-mediated decidualization and anticoagulant expression through secretion of TGF-β3. J Clin Endocrinol Metab. 2011; 96(2): 412-421. doi: 10.1210/jc.2010-1450
18. Sotnikova NYu, Malyshkina AI, Voronin DN, Nagornyy SN, Voskresenskaya DL. Differentiation of macrophages in myoma tissue depending on MRI pattern. Russian journal of immunology. 2021; 24(1): 69-76. Russian (Сотникова Н.Ю., Малышкина А.И., Воронин Д.Н., Нагорный С.Н., Воскресенская Д.Л. Дифференцировка макрофагов в ткани миоматозного узла в зависимости от МРТ-картины //Российский иммунологический журнал. 2021. Т. 24, № 1. С. 69-76.) doi: 10.46235/1028-7221-243-MDI
19. Ng EHY, Ho PC. Doppler ultrasound examination of uterine arteries on the day of oocyte retrieval in patients with uterine fibroids undergoing IVF. Hum Reprod. 2002; 17(3): 765-770. doi: 10.1093/humrep/17.3.765
20. Yoshino O, T Hayashi, Osuga Y, Orisaka M, Asada H, Okuda S, et al. Decreased pregnancy rate is linked to abnormal uterine peristalsis caused by intramural fibroids. Hum Reprod. 2010; 25(10): 2475-2479. doi: 10.1093/humrep/deq222
21. Munro MG, Critchley HOD, Fraser IS. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018; 143(3): 393-408. doi: 10.1002/ijgo.12666
22. Choi YJ, Lee HK, Kim SK. Doppler ultrasound investigation of female infertility. Obstet Gynecol Sci. 2023; 66(2): 58-68. doi: 10.5468/ogs.22131
23. Ferrari S, Salmeri N, He X, Schimberni M, Sangiorgi V, Bartiromo L, et al. Thinking in context: fibroids-to-uterine volume ratio in pre-surgical fertility evaluation for intramural fibroids. Eur J Obstet Gynecol Reprod Biol. 2024; 301: 194-200. doi: 10.1016/j.ejogrb.2024.08.024
24. Dubinskaya ED, Kolesnikova SN, Aleshkina EV, Gasparov AS. Current concepts of uterine peristalsis (literature review). Obstetrics and Gynecology: News, Opinions, Training. 2024; 12(Suppl): 116-123. Russian (Дубинская Е.Д., Колесникова С.Н., Алешкина Е.В., Гаспаров А.C. Современные представления о перистальтике матки (обзор литературы) //Акушерство и гинекология: новости, мнения, обучение. 2024. Т. 12. Спецвыпуск. С. 116-123.) doi: 10.33029/2303-9698-2024-12-suppl-116-123
25. Devyatova EA, Tsaturova KA, Vartanyan EV. Role of assessment of endometrial wave activity in predicting successful implantation. Russian Journal of Human Reproduction. 2016; 22(4): 47-51. Russian (Девятова Е.А., Цатурова К.А., Вартанян Э.В. Роль оценки перистальтики эндометрия в прогнозировании успеха имплантации //Проблемы репродукции. 2016. Т. 22, № 4. С. 47-51.) doi: 10.17116/repro201622447-51
26. Yoshino O, Nishii O, Osuga Y, Asada H, Okuda S, Orisaka M, et al. Myomectomy decreases abnormal uterine peristalsis and increases pregnancy rate. J Minim Invasive Gynecol. 2012; 19(1): 63-67. doi: 10.1016/j.jmig.2011.09.010
27. Hasegawa E, Ito H, Hasegawa F, Hatano K, Kazuka M, Usuda S, Isaka K. Expression of leukemia inhibitory factor in the endometrium in abnormal uterine cavities during the implantation window. Fertil Steril. 2012; 97(4): 953-958. doi: 10.1016/j.fertnstert.2012.01.113
28. Fortin CN, Hur C, Radeva M, Falcone T. Effects of myomas and myomectomy on assisted reproductive technology outcomes. J Gynecol Obstet Hum Reprod. 2019; 48(9): 751-755. doi: 10.1016/j.jogoh.2019.05.001
29. Han Y, Yao R, Zhang Y, Yang Z, Luo H, Wang XY, et al. Hysteroscopic resection of type 3 fibroids could improve the pregnancy outcomes in infertile women: a case-control study. BMC Pregnancy Childbirth. 2022; 22(1): 522. doi: 10.1186/s12884-022-04828-3
30. Deger U, Altinbas E, Karabay M, Karatas Y, Deniz Z, Buyuker C, et al. Effects of non-cavity-distorting intramural fibroids on IVF outcomes in patients with recurrent IVF failure: does myomectomy change IVF outcomes? J Obstet Gynaecol India. 2023; 73(4): 322-328. doi: 10.1007/s13224-023-01750-2
31. Verma S, Shanbhag A, Salim S, Potdar N. Myomectomy for intramural fibroids prior to in vitro fertilization/intracytoplasmic sperm injection cycles: a conundrum? Systematic review and meta-analysis. Int J Gynaecol Obstet. 2025 Dec 18. doi: 10.1002/ijgo.70748
32. Alizarad C, Mohamed MH, Shanab WSA. Role of uterine artery Doppler in assessment of unexplained infertility. Egypt J Radiol Nucl Med. 2021; 52: 59. doi: 10.1186/s43055-021-00430-3
33. Ahn H, Cruz-Martinez R, Hernandez-Andrade E. Variation in the uterine arteries Doppler parameters when obtained transvaginally or transabdominally at different sampling locations. J Matern Fetal Neonatal Med. 2022; 35(25): 5709-5716. doi: 10.1080/14767058.2021.1892062
34. Aharon D, Sekhon L, Getrajdman C, Naert M, Hanley W, Kerr A, et al. Association of myomectomy with anti-Müllerian hormone levels and ovarian reserve. Obstet Gynecol. 2022; 140(6): 1000-1007. doi: 10.1097/AOG.0000000000004983
35. Margueritte F, Adam C, Fauconnier A, Gauthier T. Time to conceive after myomectomy: should we advise a minimum time interval? A systematic review. Reprod Biomed Online. 2021; 43(3): 543-552. doi: 10.1016/j.rbmo.2021.05.016
36. Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update. 2016; 22(6): 665-686. doi: 10.1093/humupd/dmw023
37. Kozachenko IF, Smolnikova VYu, Adamyan LV. Results of infertility treatment using ART in patients after myomectomy: risk factors for repeated unsuccessful ART programs. Gynecology. 2020; 22(6): 44-49. Russian (Козаченко И.Ф., Смольникова В.Ю., Адамян Л.В. Результаты лечения бесплодия с использованием методов ВРТ у больных, перенесших миомэктомию: факторы риска повторных неудачных программ ВРТ //Гинекология. 2020. Т. 22, № 6. С. 44-49.) doi: 10.26442/20795696.2020.6.200491
38. Claeys J, Hellendoorn I, Hamerlynck T, Bosteels J, Weyers S. The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis. Gynecol Surg. 2014; 11: 197-206. doi: 10.1007/s10397-014-0842-8
39. Gambacorti-Passerini Z, Gimovsky AC, Locatelli A, Berghella V. Trial of labor after myomectomy and uterine rupture: a systematic review. Acta Obstet Gynecol Scand. 2016; 95(7): 724-734. doi: 10.1111/aogs.12920
40. Rojhani E, Abiad M, Zargarzadeh N, Aghajani F, Lopez MC, Shamshirsaz AA, et al. Placenta accreta spectrum after myomectomy: a systematic review and meta-analysis stratified by surgical approach. Am J Obstet Gynecol. 2026: S0002-9378(26)00065-7. doi: 10.1016/j.ajog.2026.02.003
41. Lee SJ, Ko HS, Na S, Bae JY, Seong WJ, Kim JW, et al. Nationwide population-based cohort study of adverse obstetric outcomes in pregnancies with myoma or following myomectomy: retrospective cohort study. BMC Pregnancy Childbirth. 2020; 20(1): 716. doi: 10.1186/s12884-020-03406-9