Surgical removal of fibroids does not improve fertility outcomes

Fibroids are the most common benign tumours of the female genital tract and commonly affect women of reproductive age. Fibroids occur in different parts of the womb and can vary in size and shape. Fibroids can lead to a variety of symptoms including heavy periods, pain, difficulty to conceive, or problems with pregnancy such as miscarriage and premature labour. In women wishing to preserve their fertility, it is possible to remove the fibroid while preserving the womb, an operation known as myomectomy. This procedure can be performed by open surgery, laparoscopic surgery (a key-hole through the abdomen) or hysteroscopic surgery (a key-hole through the neck of the womb) depending on the site and size of the fibroid. This review included three studies with 474 participants and aimed to answer two questions. Firstly, whether myomectomy led to an improvement in fertility; and secondly, if the procedure is beneficial, what is the ideal surgical approach. Only one study was found that examined the effect of myomectomy on fertility and it found no significant benefit. However, there are some concerns regarding how the data were analysed and therefore the evidence cannot be considered to be conclusive until further studies are available. Regarding the choice of the surgical approach to the myomectomy, only two studies were identified. They compared open versus laparoscopic myomectomy and found no difference in fertility outcomes. Therefore, again more studies are needed before a strong conclusion can be reached.

Authors' conclusions: 

There is currently insufficient evidence from randomised controlled trials to evaluate the role of myomectomy to improve fertility. Regarding the surgical approach to myomectomy, current evidence from two randomised controlled trials suggests there is no significant difference between the laparoscopic and open approach regarding fertility performance. This evidence needs to be viewed with caution due to the small number of studies. Finally, there is currently no evidence from randomised controlled trials regarding the effect of hysteroscopic myomectomy on fertility outcomes.

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Background: 

Fibroids are the most common benign tumours of the female genital tract and are associated with numerous clinical problems including a possible negative impact on fertility. In women requesting preservation of fertility, fibroids can be surgically removed (myomectomy) by laparotomy, laparoscopically or hysteroscopically depending on the size, site and type of fibroid. Myomectomy is however a procedure that is not without risk and can result in serious complications. It is therefore essential to determine whether such a procedure can result in an improvement in fertility and, if so, to then determine the ideal surgical approach.

Objectives: 

To examine the effect of myomectomy on fertility outcomes and to compare different surgical approaches.

Search strategy: 

We searched the Cochrane Menstrual Disorders and Subfertility Group (MDSG) Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, CINAHL, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and ongoing clinical trials registered online. The final search was in June 2012.

Selection criteria: 

Randomised controlled trials examining the effect of myomectomy compared to no intervention or where different surgical approaches are compared regarding the effect on fertility outcomes in a group of infertile women suffering from uterine fibroids.

Data collection and analysis: 

Data collection and analysis were conducted in accordance with the procedure suggested in the Cochrane Handbook for Systematic Reviews of Interventions.

Main results: 

One study examined the effect of myomectomy on reproductive outcomes and showed no evidence for a significant effect on the clinical pregnancy rate for intramural (OR 1.88, 95% CI 0.57 to 6.14), submucous (OR 2.04, 95% CI 0.62 to 6.66), combined intramural and subserous (OR 2.00, 95% CI 0.40 to 10.09) and combined intramural submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57). Similarly, there was no evidence for a significant effect of myomectomy for any of the described types of fibroids on the miscarriage rate (intramural fibroids OR 0.89 (95% CI 0.14 to 5.48), submucous fibroids OR 0.63 (95% CI 0.09 to 4.40), combined intramural and subserous fibroids OR 0.25 (95% CI 0.01 to 4.73) and combined intramural submucous fibroids OR 0.50 (95% CI 0.03 to 7.99).

Two studies compared open versus laparoscopic myomectomy and found no evidence for a significant effect on the live birth rate (OR 0.80, 95% CI 0.42 to 1.50), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04), miscarriage rate (OR 1.31, 95% CI 0.40 to 4.27), preterm labour rate (OR 0.68, 95% CI 0.11 to 4.43) and caesarean section rate (OR 0.59, 95% CI 0.13 to 2.72).

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