Pro & Con: Should intramural myomas be removed in infertile patients? (Opinion).

YES

Infertility occurs in about 5%-10% of women with myomas. If myomectomy is not performed, treatments such as clomiphene or gonadotropins may be less effective. Potentially, you could open yourself up to litigation if a patient with a myoma goes for a long time in your care without conceiving, then undergoes a myomectomy and conceives.

There are other issues as well. Myomectomy relieves symptoms about 80% of the time. The recurrence rate is only about 27% over 10 years, usually in women who are treated for a large number of fibroids.

There are no data regarding the expectant management of infertile women with myomas or their monthly fecundity or eventual fertility. When these patients are managed conservatively coming into their mid-30s, they face increasing infertility as they age. They eventually end up having a myomectomy, and all you've done is postpone the surgery and pay the price in fertility.

The term pregnancy rate following myomectomy ranges from 40% to 60%. Importantly, these pregnancies occur mostly within 1 year of myomectomy.

We know that implantation rates are reduced by distortion of the uterine cavity caused by myomas. Pregnancy rates are reduced among in vitro fertilization patients with myomas. Data show that clinical pregnancy rates are 53% in patients without myomas and 37% in those with myomas. Delivery rates are higher in patients who do not have myomas: 48% versus 33% in those with myomas. Other data show that pregnancy rates are reduced with intramural myomas as well as with submucosal myomas.

Spontaneous abortion rates seem to be higher in women with myomas for reasons that are not understood. Spontaneous abortion rates improve following removal of myomas.