**10.1. Endoscopic myomectomy prior to IVF/ICSI**

The impact of uterine myoma on the outcome of IVF/ICSI is a very controversial topic. Many centers are overdoing myomectomy for nearly all myomata regardless size and site considerations. Contrary, other investigators have shown that fibroids don't exert a

deleterious effect. Nevertheless, many studies have provided evidence that uterine myomas have a significant effect on IVF outcomes and there is a large body of evidence that treatment of uterine myomas increases fertility and pregnancy rates, and decreases the rate of pregnancy loss (70). There is no doubt that any cavity-distorting myoma should be removed whether completely submucous or interstitial myoma with submucous encroachment. This highlights the central role of prior hysteroscopy as well as saline infusion solonhysterography (SIS) as previously described (39). Not only does sub mucous myoma cause mechanicl interference with implantation, but it also alters endometrial receptivity (71)

Endoscopy versus IVF: The Way to Go 47




still a subject of debate (75,76).

2010 Dec;94(7):2758-60.

*Obstetrics and Gynecology, Assiut University, Assiut, Egypt* 

option in Australia? Med J Aust 2007; 187:271-3.

Cochrane Database Syst Rev 2008; Issue 3. Art. No.: CD006415.

of infertility: diagnosis and treatment. Clin Ter. 2010;161(1):77-85.

obstruction--are we making progress? Fertil Steril. 1987 Oct;48(4):523-42

**Author details** 

**12. References** 

Atef Darwish


**11.2. Uterine myoma and infertility** 

Uterine myoma may affect fertility according to its size, site and associated pathology. Endoscopic approach has a definite role in its management. HM is the gold standard line of management of submucous myoma of suitable size. LM doesn't seem to be superior to conventional open myomectomy regarding fertility and is characterized by both short and long term drawbacks. Uterine myomata would affect IVF/ICSI outcome whenever disturbing the endometrial cavity or large sized. The impact of other types of myomata on IVF/ICSI deserves further studies. Hysteroscopic myomectomy is indicated for intracavitary myomas and submucous myomas having at least 50% of their volume within the uterine cavity. The management of the subfertile women with small intramural fibroids (<5 cm) is

[1] Pandian Z, Akande VA, Harrild K, Bhattacharya S. Surgery for tubal infertility.

[2] Petrucco OM, Silber SJ, Chamberlain SL, Warnes GM, Davies M. Live birth following day surgery reversal of female sterilisation in women older than 40 years: a realistic

[3] Marana R, Ferrari S, Merola A, Astorri AL, Pompa G, Milardi D, Giampietro A, Lecca A, Marana E. Role of a mini-invasive approach in the diagnosis and treatment of tuboperitoneal infertility as an alternative to IVF . Minerva Ginecol. 2011 Feb;63(1):1-10. [4] Muzii L, Sereni MI, Battista C, Zullo MA, Tambone V, Angioli R Tubo-peritoneal factor

[5] Bateman BG, Nunley WC Jr, Kitchin JD 3rd. Surgical management of distal tubal

[6] Nezhat C, Lewis M, Kotikela S, Veeraswamy A, Saadat L, Hajhosseini B, NezhatC. Robotic versus standard laparoscopy for the treatment of endometriosis.Fertil Steril.

Controversy exists for interstitial and subserous myomata. The evidence supports treatment of all very large myomas (>7 cm) (70). Subserosal myomas that are smaller than 7 cm in size and intramural myomas of less than 4–5 cm in diameter appear to have little effect on IVF outcomes. Larger intramural and subserosal myomas present a clinical dilemma and more studies are needed to clarify a definitive plan for management (70). In a prospective controlled study, the distance between the intramural myomas and the endometrial lining did not appear to affect the IVF outcome. An insignificant tendency towards improvement of IVF outcome is found in myomas at more than 5 mm from endometrial lining (72).

In a recent review of literature (73) on myoma and assisted reproduction technology and spontaneous conception, hysteroscopic sub-mucous myoma resection is found to increase pregnancy rates. Intramural fibroids appear to decrease fertility, but the myomectomy does not improve assisted reproduction technology and spontaneous fertility. More high-quality studies are needed to conclude toward the value of myomectomy for intramural fibroids. Subserosal fibroids do not affect fertility outcomes, and removal does not confer benefit.
