Reproductive issues in women with uterine leiomyomas (fibroids)
- Togas Tulandi, MD, MHCM
Togas Tulandi, MD, MHCM
- Professor of Obstetrics and Gynecology
- Milton Leong Chair in Reproductive Medicine
- McGill University, Canada
The management of women with uterine leiomyomas depends upon several factors, including the patient's age and symptoms, her obstetrical history and future childbearing plans, and the size and location of the leiomyomas. A general approach to counseling women with leiomyomas about reproductive issues will be reviewed here. Effects of fibroids during pregnancy and other fibroid-related issues are discussed in detail separately (see individual topic reviews). (See "Pregnancy in women with uterine leiomyomas (fibroids)".)
A uterine leiomyoma in an asymptomatic woman is usually an incidental finding. Although some of these tumors will naturally regress, others will continue to grow and new leiomyomas may develop. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)", section on 'Natural history'.)
Use of low dose estrogen-progestin contraceptives does not cause leiomyomas to grow; therefore, administration of these drugs is not contraindicated in women with leiomyomas who wish to use this method of contraception. One possible exception is girls with exposure to estrogen-progestive contraceptives between the ages of 13 and 16 years . In adolescents, the advantages of estrogen-progestin contraceptives need to be weighed against this potential risk. (See "Epidemiology, clinical manifestations, diagnosis, and natural history of uterine leiomyomas (fibroids)", section on 'Hormonal contraception'.)
We suggest that women with leiomyomas not postpone pregnancy for a prolonged period of time, if possible. Our rationale is that fertility naturally declines with age, especially after age 35 years, and leiomyomas may impair fertility and adversely affect pregnancy outcome (see 'Infertility and miscarriage' below).
There are no well-designed studies that provide high-quality data on whether leiomyomas adversely affect pregnancy outcome. Instead, the available information consists largely of observational case series and case reports that are limited by different patient populations; different criteria regarding the size, location, and number of leiomyomas; small numbers of adverse events; ascertainment bias in selecting study participants; and inadequate adjustment of confounders.
- Marshall LM, Spiegelman D, Goldman MB, et al. A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertil Steril 1998; 70:432.
- Stout MJ, Odibo AO, Graseck AS, et al. Leiomyomas at routine second-trimester ultrasound examination and adverse obstetric outcomes. Obstet Gynecol 2010; 116:1056.
- Buttram VC Jr, Reiter RC. Uterine leiomyomata: etiology, symptomatology, and management. Fertil Steril 1981; 36:433.
- Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol 2008; 198:357.
- Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril 2009; 91:1215.
- Orisaka M, Kurokawa T, Shukunami K, et al. A comparison of uterine peristalsis in women with normal uteri and uterine leiomyoma by cine magnetic resonance imaging. Eur J Obstet Gynecol Reprod Biol 2007; 135:111.
- Casini ML, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility. Gynecol Endocrinol 2006; 22:106.
- Gardner RL, Shaw RW. Cornual fibroids: a conservative approach to restoring tubal patency using a gonadotropin-releasing hormone agonist (goserelin) with successful pregnancy. Fertil Steril 1989; 52:332.
- Donnez J, Tomaszewski J, Vázquez F, et al. Ulipristal acetate versus leuprolide acetate for uterine fibroids. N Engl J Med 2012; 366:421.
- Donnez J, Tatarchuk TF, Bouchard P, et al. Ulipristal acetate versus placebo for fibroid treatment before surgery. N Engl J Med 2012; 366:409.
- Tulandi T. Treatment of uterine fibroids--is surgery obsolete? N Engl J Med 2007; 356:411.
- Goldberg J, Pereira L. Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy. Curr Opin Obstet Gynecol 2006; 18:402.
- Walker WJ, McDowell SJ. Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies. Am J Obstet Gynecol 2006; 195:1266.
- Pron G, Mocarski E, Bennett J, et al. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol 2005; 105:67.
- Vilos GA, Allaire C, Laberge PY, et al. The management of uterine leiomyomas. J Obstet Gynaecol Can 2015; 37:157.
- Iverson RE Jr, Chelmow D, Strohbehn K, et al. Relative morbidity of abdominal hysterectomy and myomectomy for management of uterine leiomyomas. Obstet Gynecol 1996; 88:415.
- American College of Obstetricians and Gynecologists. Surgical alternatives to hysterectomy in the management of leiomyomas. ACOG practice bulletin 16. ACOG 2000; Washington, DC.
- Stotland NE, Lipschitz LS, Caughey AB. Delivery strategies for women with a previous classic cesarean delivery: a decision analysis. Am J Obstet Gynecol 2002; 187:1203.
- Dubuisson JB, Fauconnier A, Deffarges JV, et al. Pregnancy outcome and deliveries following laparoscopic myomectomy. Hum Reprod 2000; 15:869.
- Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol 2004; 104:393.
- Marchionni M, Fambrini M, Zambelli V, et al. Reproductive performance before and after abdominal myomectomy: a retrospective analysis. Fertil Steril 2004; 82:154.
- Saleh S, Issa A. Reproductive outcome after abdominal myomectomy. J Obstet Gynaecol 2000; 20:282.
- Gavai M, Berkes E, Lazar L, et al. Factors affecting reproductive outcome following abdominal myomectomy. J Assist Reprod Genet 2007; 24:525.
- Dubuisson JB, Fauconnier A, Fourchotte V, et al. Laparoscopic myomectomy: predicting the risk of conversion to an open procedure. Hum Reprod 2001; 16:1726.
- Hockstein S. Spontaneous uterine rupture in the early third trimester after laparoscopically assisted myomectomy. A case report. J Reprod Med 2000; 45:139.
- Seracchioli R, Manuzzi L, Vianello F, et al. Obstetric and delivery outcome of pregnancies achieved after laparoscopic myomectomy. Fertil Steril 2006; 86:159.
- Goldfarb HA. Myoma coagulation (myolysis). Obstet Gynecol Clin North Am 2000; 27:421.
- Lichtinger M, Hallson L, Calvo P, Adeboyejo G. Laparoscopic uterine artery occlusion for symptomatic leiomyomas. J Am Assoc Gynecol Laparosc 2002; 9:191.
- Cowan BD. Myomectomy and MRI-directed cryotherapy. Semin Reprod Med 2004; 22:143.
- Chudnoff SG, Berman JM, Levine DJ, et al. Outpatient procedure for the treatment and relief of symptomatic uterine myomas. Obstet Gynecol 2013; 121:1075.
- ASYMPTOMATIC LEIOMYOMAS
- PRECONCEPTIONAL PLANNING
- INFERTILITY AND MISCARRIAGE
- Preparing for in vitro fertilization
- OPTIONS FOR TREATMENT OF LEIOMYOMAS
- Medical therapy
- Myomectomy versus embolization
- Route of myomectomy
- - Hysteroscopic myomectomy
- - Abdominal myomectomy
- - Laparoscopic myomectomy
- Miscellaneous techniques
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS