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ORIGINAL ARTICLES-G

VOL. 73 ● NUMBER 4 ● July-August  2023
ORIGINAL ARTICLES-G

Effects of Non‑Cavity‑Distorting Intramural Fibroids on IVF Outcomes in Patients with Recurrent IVF Failure: Does Myomectomy Change IVF Outcomes ?

Ugur Deger1 · Ekin Altinbas2 · Melis Karabay2 · Yagmur Karatas2 · Zeynep Deniz2 · Ceyda Buyuker2 · Sule Yildirim Kopuk3 · Bulent Tiras2,3 · Yigit Cakiroglu2,3

Ugur Deger is an Assoc.Prof.Dr., Department of Obstetrics and Gynecology, Memorial Hospital, Diyarbakır, Turkey. Ekin Altinbas, M.D.; Melis Karabay, M.D.; Yagmur Karatas, Med. Student; Zeynep Deniz, Med.Student; Ceyda Buyuker, Med. Student, School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey. Sule Yildirim Kopuk is an Assoc. Prof.Dr., Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey. Bulent Tiras is Prof., School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey and Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey. Yigit Cakiroglu is Prof., School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey and Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey.

Sule Yildirim Kopuk suleyildirim@msn.comAuthors and Affiliations 1 Department of Obstetrics and Gynecology, Memorial Hospital, Diyarbakır, Turkey 2 School of Medicine, Acibadem Mehmet Ali Aydınlar University, Istanbul, Turkey 3 Assisted Reproductive Technologies Unit, Acibadem Maslak Hospital, Istanbul, Turkey

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Background Uterine fibroids are the most common benign smooth muscle tumors of the uterus. However, there is no consensus on whether myomectomy improves IVF success in women with non-cavity-distorting intramural fibroids. The aim of this study was to compare the IVF and pregnancy outcomes of women who had non-cavity-distorting intramural fibroids and underwent myomectomy vs women who had intramural fibroids, but did not undergo myomectomy.

Methods A retrospective cohort study at Acibadem Maslak Hospital, IVF Center, between 2019 and 2020. Data of 128 women aged between 25 and 43 years who have at least 2 intramural non-cavity-distorting fibroids of 2–6 cm in size were used. All patients had at least two IVF failure. The intervention group comprised women who decided to proceed to myomectomy before IVF (Group 1, n = 56). The control group was established women with intramural fibroids who reject myomectomy (Group 2, n = 71).

Results In regard to IVF result parameters and perinatal outcomes, there was no statistically significant difference between the two groups. Between study groups, there were no statistically significant differences in the perinatal outcomes. Myomectomy surgery did not increase miscarriage and biochemical pregnancy rate (odds ratio (OR) 0.9; 95% confidence interval (CI) 2.8–3.7). Conclusion Myomectomy does not impact on pregnancy or live birth rates substantially, according to the results of this study.

Keywords : Intramural fibroids · Non-cavity-distorting · In vitro fertilization · Myomectomy · Perinatal outcome

The most common benign smooth muscle tumors of the uterus are uterine fibroids, also called as leiomyomas. Its incidence is 20–25% in the general population; in histological or ultrasonographic imaging studies, this rate rises to 70–80% [1, 2]. While many fibroids remain asymptomatic, some of them can disrupt the functions of the uterus and become symptomatic. Excessive uterine bleeding and anemia due to disrupted uterine contractions, back pain, defective endometrial receptivity, habitual abortion, preterm delivery and blockage of labor are symptoms of fibroids [3]. It is estimated that 25% of the fibroids are asymptomatic. Their propensity to remain asymptomatic and/or develop symptoms insidiously leaves most fibroids undiagnosed in many women [4, 5].

The location and the size of the fibroid in the uterus are significant determinants of its clinical manifestations. Based on their location, fibroids are mainly categorized as submucosal, intramural, and subserosal [6]. FIGO (Fédération Internationale de Gynécologie et d’Obstétrique) classification system can be used for more specific staging of fibroids according to their location in the uterine wall and distortion of the uterine cavity. Intramural fibroids can be either cavity-distorting or non-distorting. Several previous studies in the literature revealed that the cavity-distorting intramural fibroids are associated with difficulty in conceiving pregnancy and poor IVF (in vitro fertilization) outcomes [7, 8]. However, many intramural fibroids do not have intracavitary component, and the utility of myomectomy in these fibroids still remains unclear [8]. Despite the lack of an intracavitary component, some intramural fibroids have been reported to interfere with uterine functionality by having paracrine molecular effects on the neighboring endometrium, resulting in heavy bleeding or poor implantation, irrespective of size or location [3, 9].

The debate around non-cavity-distorting myomas continues in women who undergone IVF procedure [10]. The effects of myomectomy on fertility, the IVF outcomes, and the live birth rates (LBR) are continuing to be discussed by most authorities. Many studies showed that myomectomy increased the success ratio of IVF in patients with submucosal myomas [10, 11]. However, there is no consensus whether myomectomy is associated with better IVF outcomes in women with non-cavity-distorting intramural fibroids. In the present study, we want to compare the IVF and obstetrics outcomes with non-cavity-distorting intramural fibroids who had myomectomy with the women who are offered myomectomy but rejected.

  1. Baird DD, Dunson DB, Hill MC et al. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol. 2003; 188(1). https:// doi. org/ 10. 1067/ mob. 2003. 99.
  2. Cramer SF, Patel A. The frequency of uterine leiomyomas. Am J Clin Pathol. 1990; 94(4). https:// doi. org/ 10. 1093/ ajcp/ 94.4. 435. 
  3. Bulun SE (2013) Uterine fibroids. N Engl J Med. 2013; 369(14). https:// doi. org/ 10. 1056/ NEJMr a1209 993.
  4. Laughlin SK, Schroeder JC, Baird DD. New directions in the epidemiology of uterine fibroids. Semin Reprod Med. 2010; 28(3). https:// doi. org/ 10. 1055/s- 0030- 12514 77.
  5. Evans P, Brunsell S. Uterine fibroid tumors: diagnosis and treatment. Am Fam Physician. 2007;75(10):1503–8.
  6. Cook H, Ezzati M, Segars JH, and McCarthy K (2010) The impact of uterine leiomyomas on reproductive outcomes. Minerva Ginecol 62(3).
  7. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2009; 91(4). https:// doi. org/ 10. 1016/j. fertn stert. 2008. 01. 051.
  8. Wang X, Chen L, Wang H et al. The impact of noncavity-distorting intramural fibroids on the efficacy of in vitro fertilizationembryo transfer: an updated meta-analysis. Biomed Res Int. 2018. https:// doi. org/ 10. 1155/ 2018/ 89247 03.
  9. Sinclair DC, Mastroyannis A, Taylor HS. Leiomyoma simultaneously impair endometrial BMP-2-mediated decidualization and anticoagulant expression through secretion of TGF-beta3. J Clin Endocrinol Metab. 2011; 96(2). https:// doi. org/ 10. 1210/ jc. 2010- 1450.
  10. Saridogan E, Saridogan E. Management of fibroids prior to in vitro fertilization/intracytoplasmic sperm injection: A pragmatic approach. J Turk Ger Gynecol Assoc. 2019;20(1). https:// doi. org/ 10. 4274/ jtgga. galen os. 2018. 2018. 0148. 
  11. Surrey ES, Minjarez DA, Stevens JM et al. Effect of myomectomy on the outcome of assisted reproductive technologies. Fertil Steril. 2005; 83(5). https:// doi. org/ 10. 1016/j. fertn stert. 2004. 11. 045.
  12. Somigliana E, De Benedictis S, Vercellini P et al. Fibroids not encroaching the endometrial cavity and IVF success rate: a prospective study. Hum Reprod. 2011; 26(4). https:// doi. org/ 10. 1093/ humrep/ der015. 
  13. Styer AK, Jin S, Liu D et al. Association of uterine fibroids and pregnancy outcomes after ovarian stimulation-intrauterine insemination for unexplained infertility. Fertil Steril. 2017;107(3). https:// doi. org/ 10. 1016/j. fertn stert. 2016. 12. 012. 
  14. Oliveira FG, Abdelmassih VG, Diamond MP et al. Impact of subserosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection. Fertil Steril. 2004; 81(3). https:// doi. org/ 10. 1016/j. fertn stert. 2003. 08. 034. 
  15. Qu X, Cheng Z, Yang W et al. Controlled clinical trial assessing the effect of laparoscopic uterine arterial occlusion on ovarian reserve. J Minim Invasive Gynecol. 2010; 17(1). https:// doi. org/ 10. 1016/j. jmig. 2009. 10. 001.
  16. Browne H, McCarthy-Keith D, Stegmann B et al. Ovarian response in women undergoing ovarian stimulation after myomectomy. Fertil Steril. 2008; 90(5). https:// doi. org/ 10. 1016/j. fertn stert. 2008. 04. 008.
  17. Ramzy AM, Sattar M, Amin Y et al. Uterine myomata and outcome of assisted reproduction. Hum Reprod. 1998; 13(1). https:// doi. org/ 10. 1093/ humrep/ 13.1. 198. 
  18. Jun SH, Ginsburg ES, Racowsky C et al. Uterine leiomyomas and their effect on in vitro fertilization outcome: a retrospective study. J Assist Reprod Genet. 2001;18(3). https:// doi. org/ 10. 1023/a: 10094 03819 377.
  19. Khalaf Y, Ross C, El-Toukhy T et al. The effect of small intramural uterine fibroids on the cumulative outcome of assisted conception. Hum Reprod. 2006; 21(10). https:// doi. org/ 10. 1093/ humrep/ del218. 
  20. Surrey ES, Lietz AK, Schoolcraft WB. Impact of intramural leiomyomata in patients with a normal endometrial cavity on in vitro fertilization-embryo transfer cycle outcome. Fertil Steril. 2001; 75(2). https:// doi. org/ 10. 1016/ s0015- 0282(00) 01714-3.
  21. Christopoulos G, Vlismas A, Salim R et al. Fibroids that do not distort the uterine cavity and IVF success rates: an observational study using extensive matching criteria. BJOG. 2017; 124(4). https:// doi. org/ 10. 1111/ 1471- 0528. 14362. 
  22. Behbehani S, Polesello S, Hasson J et al. The Effect of intramural myomas without an intracavity component on in vitro fertilization outcomes in single fresh Blastocyst transfer cycles. J Minim Invasive Gynecol. 2018;25(7). https:// doi. org/ 10. 1016/j. jmig. 2018. 03. 005. 
  23. Guven S, Kart C, Unsal MA et al. Intramural leoimyoma without endometrial cavity distortion may negatively affect the ICSI-ET outcome. Reprod Biol Endocrinol. 2013;11. https:// doi. org/ 10. 1186/ 1477- 7827- 11- 102. 
  24. Casini ML, Rossi F, Agostini R et al. Effects of the position of fibroids on fertility. Gynecol Endocrinol. 2006; 22(2). https:// doi. org/ 10. 1080/ 09513 59060 06046 73.
  25. 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(2). https:// doi. org/ 10. 1016/ s0301- 2115(03) 00159-3.
  26. Bulletti C, Dez D, Levi Setti P et al. Myomas, pregnancy outcome, and in vitro fertilization. Ann N Y Acad Sci. 2004;1034.https:// doi. org/ 10. 1196/ annals. 1335. 010.
  27. Dolmans MM, Isaacson K, Zhang W et al. Intramural myomas more than 3–4 centimeters should be surgically removed before in vitro fertilization. Fertil Steril. 2021; 116(4). https:// doi. org/ 10. 1016/j. fertn stert. 2021. 08. 016. 
  28. Rikhraj K, Tan J, Taskin O et al. The impact of noncavity-distorting intramural fibroids on live birth rate in in vitro fertilization fycles: A systematic review and meta-analysis. J Womens Health (Larchmt). 2020; 29(2). https:// doi. org/ 10. 1089/ jwh. 2019. 7813.
  29. Sunkara SK, Khairy M, El-Toukhy T et al. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta-analysis. Hum Reprod. 2010;25(2). https:// doi. org/ 10. 1093/ humrep/ dep396. 
  30. Klatsky PC, Lane DE, Ryan IP et al. The effect of fibroids without cavity involvement on ART outcomes independent of ovarian age. Hum Reprod. 2007; 22(2). https:// doi. org/ 10. 1093/ humrep/ del370.
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