**2. Uterine fibroids**

Submucosal fibroids can affect embryo implantation due to different mechanisms, resulting in subsequent increased uterine contractility, abnormal endometrial vascularity, chronic endometrial inflammatory response and changes in local cytokines profile.

Fibroids which distort the endometrial cavity are associated with lower implantation and pregnancy rates among women who tried a natural pregnancy as well as among those who are undergoing IVF treatment [2].

#### **2.1 Diagnosis**

Uterine fibroids investigation among women with RIF can be done through the following methods:


the above-mentioned guideline states that the routine hysteroscopy among RIF patients with normal basal transvaginal ultrasound scan is not recommended (recommendation strength: strong; evidence level: high) [1, 4]. Hysteroscopy must be considered before a new treatment cycle if the basal transvaginal ultrasound scan shows uterine pathology.


## **2.2 Treatment**

Regarding the management of submucosal fibroids in women with RIF, one advocates their surgical removal, regardless the size, since evidence shows that their removal can improve clinical pregnancy rates [2, 3].

Prior to the surgery, the size and number of fibroids and the depth of intramural extension should be carefully assessed. Resection of a solitary submucous fibroid less than 5 cm in diameter and with little intramural extension should not pose significant difficulties. However, a submucous fibroid more than 5 cm in diameter or more than 50% embedded in the intramural part of the uterus may require removal in two stages. In the case of multiple submucosal fibroids, there is an increased risk of intrauterine adhesion formation after the procedure. Some surgeons advocate the removal of the anterior wall and posterior wall fibroids on separate occasions to reduce the risk of intrauterine adhesions [2, 3].

Unlike what happens to fibroids that distort the uterine cavity, there is no consensus regarding the removal of intramural fibroids in women with RIF. Some authors suggest adverse effects of intramural fibroids on implantation and pregnancy rates in women undergoing to IVF, particularly those larger than 4 cm, while other authors could not demonstrate such association [2].

The meta-analysis papers on the topic agree that women with intramural fibroids seem to have decreased implantation rates compared to those without intramural fibroids. However, the myomectomy did not seem to significantly increase clinical pregnancy and live births rates [3]. Therefore, the pros and cons of the myomectomy must be individually assessed. The patients must be aware of the possible complications caused by the procedure such as bladder and bowel injury, hemorrhage, risk of blood transfusion and hysterectomy that occurs in 1% of cases. Other consequences would be the formation of pelvic adhesions leading to infertility due to peritoneal tube factor, and the risk of uterine rupture in subsequent pregnancies. However, one must acknowledge that intramural fibroids can cause not only implantation failure but also some obstetric complications, such as increased risk of premature delivery, premature placental abruption, intrauterine growth restriction, abnormal fetal presentation and intrapartum hemorrhage. The decision-making must be individualized, and it is strongly recommended that an experienced surgeon takes part in the definition of the treatment [2].

In RIF cases with no determinant factors, the surgical removal of large or multiples fibroids is a choice [5]. After all explanations, the decision about the procedure to be taken - expectant conduct or myomectomy – is shared with the patient.
