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Meta-Analysis
. 2020 Jan 29;1(1):CD003857.
doi: 10.1002/14651858.CD003857.pub4.

Surgical treatment of fibroids for subfertility

Mostafa Metwally  1 , Grace Raybould  2 , Ying C Cheong  3 , Andrew W Horne  4
Affiliations
Meta-Analysis

Surgical treatment of fibroids for subfertility

Mostafa Metwally et al. Cochrane Database Syst Rev. .

Abstract

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 methods: We searched the Cochrane Gynaecology and Fertility Group (CGFG) Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, Epistemonikos database, World Health Organization (WHO) International Clinical Trials Registry Platform search portal, Database of Abstracts of Reviews of Effects (DARE), LILACS, conference abstracts on the ISI Web of Knowledge, OpenSigle for grey literature from Europe, and reference list of relevant papers. The final search was in February 2019.

Selection criteria: Randomised controlled trials (RCTs) 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: This review included four RCTs with 442 participants. The evidence was very low-quality with the main limitations being due to serious imprecision, inconsistency and indirectness. Myomectomy versus no intervention One study examined the effect of myomectomy compared to no intervention on reproductive outcomes. We are uncertain whether myomectomy improves clinical pregnancy rate for intramural (odds ratio (OR) 1.88, 95% confidence interval (CI) 0.57 to 6.14; 45 participants; one study; very low-quality evidence), submucous (OR 2.04, 95% CI 0.62 to 6.66; 52 participants; one study; very low-quality evidence), intramural/subserous (OR 2.00, 95% CI 0.40 to 10.09; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 3.24, 95% CI 0.72 to 14.57; 42 participants; one study; very low-quality evidence). Similarly, we are uncertain whether myomectomy reduces miscarriage rate for intramural fibroids (OR 1.33, 95% CI 0.26 to 6.78; 45 participants; one study; very low-quality evidence), submucous fibroids (OR 1.27, 95% CI 0.27 to 5.97; 52 participants; one study; very low-quality evidence), intramural/subserous fibroids (OR 0.80, 95% CI 0.10 to 6.54; 31 participants; one study; very low-quality evidence) or intramural/submucous fibroids (OR 2.00, 95% CI 0.32 to 12.33; 42 participants; one study; very low-quality evidence). This study did not report on live birth, preterm delivery, ongoing pregnancy or caesarean section rate. Laparoscopic myomectomy versus myomectomy by laparotomy or mini-laparotomy Two studies compared laparoscopic myomectomy to myomectomy at laparotomy or mini-laparotomy. We are uncertain whether laparoscopic myomectomy compared to laparotomy or mini-laparotomy improves live birth rate (OR 0.80, 95% CI 0.42 to 1.50; 177 participants; two studies; I2 = 0%; very low-quality evidence), preterm delivery rate (OR 0.70, 95% CI 0.11 to 4.29; participants = 177; two studies; I2 = 0%, very low-quality evidence), clinical pregnancy rate (OR 0.96, 95% CI 0.52 to 1.78; 177 participants; two studies; I2 = 0%, very low-quality evidence), ongoing pregnancy rate (OR 1.61, 95% CI 0.26 to 10.04; 115 participants; one study; very low-quality evidence), miscarriage rate (OR 1.25, 95% CI 0.40 to 3.89; participants = 177; two studies; I2 = 0%, very low-quality evidence), or caesarean section rate (OR 0.69, 95% CI 0.34 to 1.39; participants = 177; two studies; I2 = 21%, very low-quality evidence). Monopolar resectoscope versus bipolar resectoscope One study evaluated the use of two electrosurgical systems during hysteroscopic myomectomy. We are uncertain whether bipolar resectoscope use compared to monopolar resectoscope use improves live birth/ongoing pregnancy rate (OR 0.86, 95% CI 0.30 to 2.50; 68 participants; one study, very low-quality evidence), clinical pregnancy rate (OR 0.88, 95% CI 0.33 to 2.36; 68 participants; one study; very low-quality evidence), or miscarriage rate (OR 1.00, 95% CI 0.19 to 5.34; participants = 68; one study; very low-quality evidence). This study did not report on preterm delivery or caesarean section rate.

Authors' conclusions: There is limited evidence to determine the role of myomectomy for infertility in women with fibroids as only one trial compared myomectomy with no myomectomy. If the decision is made to have a myomectomy, the current evidence does not indicate a superior method (laparoscopy, laparotomy or different electrosurgical systems) to improve rates of live birth, preterm delivery, clinical pregnancy, ongoing pregnancy, miscarriage, or caesarean section. Furthermore, the existing evidence needs to be viewed with caution due to the small number of events, minimal number of studies and very low-quality evidence.

PubMed Disclaimer

Conflict of interest statement

MM, GR, and YC declare no known conflicts of interest. AH has received grant funding from the MRC, NIHR, CSO, Wellbeing of Women, Roche Diagnostics, Astra Zeneca and Ferring, and is Chair of RCOG Academic Board, ESHRE National Representative for the UK, WES Ambassador, SEUD Board Member, Past Chair of ESHRE Special Interest Group Endometriosis, Member of NICE and ESHRE Endometriosis Guideline Groups, Trustee and Medical Advisor to Endometriosis UK, Medical Advisor to Pelvic Pain Support Network, and Deputy Editor in chief of Human Reproduction Open. AH's institution has received consultancy fees from Roche Diagnostics, AbbVie, Nordic Pharma and Ferring for work carried out on their behalf.

Figures

1
1
Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) flowchart.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison 1: Myomectomy versus no intervention, Outcome 1.3: Clinical pregnancy rate.
4
4
Forest plot of comparison 2: Laparoscopic myomectomy versus myomectomy at laparotomy or mini‐laparotomy, Outcome 2.1: Live birth rate.
5
5
Forest plot of comparison 2: Laparoscopic myomectomy versus myomectomy at laparotomy or mini‐laparotomy, Outcome 2.2: Preterm delivery rate.
6
6
Forest plot of comparison 3: Monopolar versus bipolar resectoscope use in hysteroscopic myomectomy, Outcome 3.1 Live birth rate/Ongoing pregnancy rate.
1.1
1.1. Analysis
Comparison 1 Myomectomy versus no intervention, Outcome 1 Clinical pregnancy rate.
1.2
1.2. Analysis
Comparison 1 Myomectomy versus no intervention, Outcome 2 Miscarriage rate.
2.1
2.1. Analysis
Comparison 2 Laparoscopic myomectomy versus myomectomy by laparotomy or mini laparotomy, Outcome 1 Live birth rate.
2.2
2.2. Analysis
Comparison 2 Laparoscopic myomectomy versus myomectomy by laparotomy or mini laparotomy, Outcome 2 Preterm delivery rate.
2.3
2.3. Analysis
Comparison 2 Laparoscopic myomectomy versus myomectomy by laparotomy or mini laparotomy, Outcome 3 Clinical pregnancy rate.
2.4
2.4. Analysis
Comparison 2 Laparoscopic myomectomy versus myomectomy by laparotomy or mini laparotomy, Outcome 4 Ongoing pregnancy rate.
2.5
2.5. Analysis
Comparison 2 Laparoscopic myomectomy versus myomectomy by laparotomy or mini laparotomy, Outcome 5 Miscarriage rate.
2.6
2.6. Analysis
Comparison 2 Laparoscopic myomectomy versus myomectomy by laparotomy or mini laparotomy, Outcome 6 Caesarean section rate.
3.1
3.1. Analysis
Comparison 3 Monopolar versus bipolar resectoscope use in hysteroscopic myomectomy, Outcome 1 Live birth rate/ongoing pregnancy rate.
3.2
3.2. Analysis
Comparison 3 Monopolar versus bipolar resectoscope use in hysteroscopic myomectomy, Outcome 2 Clinical pregnancy rate.
3.3
3.3. Analysis
Comparison 3 Monopolar versus bipolar resectoscope use in hysteroscopic myomectomy, Outcome 3 Miscarriage rate.
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References

References to studies included in this review

Casini 2006 {published data only}
    1. Casini ML, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility. Gynecological Endocrinology 2006;22(2):106‐9. - PubMed
Palomba 2007 {published data only}
    1. Palomba S, Zupi E, Falbo A, Russo T, Marconi D, Tolino A, et al. A multicenter randomized, controlled study comparing laparoscopic versus minilaparotomic myomectomy: reproductive outcomes. Fertility and Sterility 2007;88(4):933–41. - PubMed
Roy 2017 {published data only}
    1. Roy KK, Metta S, Kansal Y, Kumar S, Singhal S, Vanamail P. A prospective randomized study comparing unipolar versus bipolar hysteroscopic myomectomy in infertile women. Journal of Human Reproductive Sciences 2017;10(3):185‐93. - PMC - PubMed
Seracchioli 2000 {published data only}
    1. Seracchioli R, Rossi S, Govoni F, Rossi E, Venturoli S, Bulletti C, et al. Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal delivery. Human Reproduction 2000;15(12):2663‐8. - PubMed

References to studies excluded from this review

Bernard 2000 {published data only}
    1. Bernard G, Darai E, Poncelet C, Benifla JL, Madelenat P. Fertility after hysteroscopic myomectomy: effect of intramural myomas associated. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2000;88:85‐90. - PubMed
Bulletti 1999 {published data only}
    1. Bulletti C, Ziegler D, Polli V, Flamigni C. The role of leiomyomas in infertility. Journal of the American Association of Gynaecologic Laparoscopists 1999;6(4):441‐5. - PubMed
Bulletti 2004 {published data only}
    1. Bulletti C, Ziegler D, Levi Setti P, Cicinelli E, Polli V, Stefanetti M. Myomas, pregnancy outcome, and in vitro fertilization. Annals of the New York Academy of Sciences 2004;1034:84‐92. - PubMed
Campo 2003 {published data only}
    1. Campo S, Campo V, Gambadauro P. Reproductive outcome before and after laparoscopic or abdominal myomectomy for subserous intramural myomas. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2003;110:215‐9. - PubMed
Chang 2011 {published data only}
    1. Chang WC, Chou LY, Chang DY, Huang PS, Huang SC, Chen SY, et al. Simultaneous laparoscopic uterine artery ligation and laparoscopic myomectomy for symptomatic uterine myomas with and without in situ morcellation. Human Reproduction 2011;26(7):1735‐40. - PubMed
Chatterjee 2012 {published data only}
    1. Chatterjee S, Chatterjee A, Chowdhury R, Dey S, Ganguly D. Fertility promoting laparoscopic surgery: our experience. Journal of South Asian Federation of Obstetrics and Gynaecology 2012;4:12‐6.
Chong 1988 {published data only}
    1. Chong RK, Thong PH, Tan SL, Thong P, Salmon YM. Myomectomy: Indications, results of surgery and relation to fertility. Singapore Medical Journal 1988;29:35‐7. - PubMed
Darai 1997 {published data only}
    1. Darai E, Dechaud H, Benifla JL, Renolleau C, Panel P, Madelenat P. Fertility after laparoscopic myomectomy: preliminary results. Human Reproduction 1997;12(9):1931‐4. - PubMed
Dubuisson 2000 {published data only}
    1. Dubuisson JB, Fauconnier A, Chapron C, Kreiker G, Norgaard C. Reproductive outcome after laparoscopic myomectomy in infertile women. Journal of Reproductive Medicine 2000;45(1):23‐30. - PubMed
Fauconnier 2000 {published data only}
    1. Fauconnier A, Dubuisson J, Ancel P, Chapron C. Prognostic factors of reproductive outcome after myomectomy in infertile patients. Human Reproduction 2000;15(8):1751‐7. - PubMed
Fernandez 2001 {published data only}
    1. Fernandez H, Sefrioui O, Virelizier C, Gervaise A, Gomel V, Frydman R. Hysteroscopic resection of submucosal myomas in patients with infertility. Human Reproduction 2001;16(7):1489‐92. - PubMed
Gatti 1989 {published data only}
    1. Gatti D, Falsetti L, Viani A, Gastaldi A. Uterine fibromyoma and sterility: role of myomectomy. Acta Europaea Fertilitatis 1989;20(1):11‐3. - PubMed
Gehlbach 1993 {published data only}
    1. Gehlbach DL, Sousa RC, Carpeter SE, Rock JA. Abdominal myomectomy in the treatment of infertility. International Journal of Gynaecology and Obstetrics 1993;40(1):45‐50. - PubMed
Giatras 1999 {published data only}
    1. Giatras K, Berkeley AS, Noyes N, Licciardi F, Lolis D, Grifo JA. Fertility after hysteroscopic resection of submucous myomas. Journal of the American Association of Gynecologic Laparoscopists 1999;6(2):155‐8. - PubMed
Kim 2013 {published data only}
    1. Kim M, Uhm Y, Kim J, Jee B, Kim Y. Obstetric outcomes after uterine myomectomy: Laparoscopic versus laparotomic approach. Obstetrics and Gynecology Science 2013;56:375‐81. - PMC - PubMed
Kramer 2016 {published data only}
    1. Krämer B, Hahn M, Taran F, Kraemer D, Isaacson KB, Brucker SY. Interim analysis of a randomized controlled trial comparing laparoscopic radiofrequency volumetric thermal ablation of uterine fibroids with laparoscopic myomectomy.. International Journal of Gynecology and Obstetrics 2016;133:206‐11. - PubMed
Li 1999 {published data only}
    1. Li TC, Mortimer R, Cooke ID. Myomectomy: a retrospective study to examine reproductive performance before and after surgery. Human Reproduction 1999;14(7):1735‐40. - PubMed
Litta 2014 {published data only}
    1. Litta P, Conte L, Marchi F, Saccardi C, Angioni S. Pregnancy outcome after hysteroscopic myomectomy. Gynecological Endocrinology 2014;30(2):149‐52. - PubMed
Malzoni 2003 {published data only}
    1. Malzoni M, Rotondi M, Perone C, Labriola D, Ammaturo F, Izzo A, et al. Fertility after laparoscopic myomectomy of large uterine myomas: operative technique and preliminary results. European Journal of Gynaecological Oncology 2003;24(1):79‐82. - PubMed
Narayan 1994 {published data only}
    1. Narayan R, Goswamy K. Treatment of submucous fibroids, and the outcome of assisted conception. Journal of the American Association of Gynecologic Laparoscopists 1994;1(4 pt 1):307‐11. - PubMed
Ribeiro 1999 {published data only}
    1. Ribeiro SC, Reich H, Rosenberg J, Guglielminetti E, Vidali A. Laparoscopic myomectomy and pregnancy outcome in infertile patients. Fertility and Sterility 1999;71(3):571‐4. - PubMed
Rossetti 2001 {published data only}
    1. Rossetti A, Sizzi O, Soranna L, Lanzone A. Fertility outcome: long term results after laparoscopic myomectomy. Gynecological Endocrinology 2001;15:129‐34. - PubMed
Saleh 2018 {published data only}
    1. Saleh HS, Mowafy HE, Hameid AA, Sherif HE, Mahfouz E.M. Does uterine fibroid adversely affect obstetric outcome of pregnancy?. BioMed Research International 2018;2018:1‐5. - PMC - PubMed
Sato 2018 {published data only}
    1. Sato M, Hara S, Suyama F, Beck W, Mukoda Y. Impact of laparoscopic myomectomy on reproductive and obstetric outcomes in patients with intramural myomas. Human Reproduction 2018;33:478‐9.
Seyam 2015 {published data only}
    1. Seyam E, Hassan M, Gad M, Mahmoud H, Ibrahum M. Pregnancy outcome after office microhysteroscopy in women with unexplained infertility. International Journal of Fertility and Sterility 2015;9:168‐75. - PMC - PubMed
Shokeir 2010 {published data only}
    1. Shokeir T, El‐Shafei M, Yousef H, Allam AF, Sadek E. Submucous myomas and their implications in the pregnancy rates of patients with otherwise unexplained primary infertility undergoing hysteroscopic myomectomy: a randomized matched control study. Fertility and Sterility 2010;94(2):724‐9. - PubMed
Spies 2010 {published data only}
    1. Spies J, Bradley L, Guido R, Maxwell L, Levine B, Coyne K. Outcomes from leiomyoma therapies. Obstetrics and Gynecology 2010;116(3):641‐52. - PubMed
Sudik 1996 {published data only}
    1. Sudik R, Husch K, Stellar J, Daume E. Fertility and pregnancy outcome after myomectomy in sterility patients. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1996;65:209‐14. - PubMed
Ubaldi 1995 {published data only}
    1. Ubaldi F, Tournaye H, Camus M, Pas H, Gepts E, Devroey P. Fertility after hysteroscopic myomectomy. Human Reproduction Update 1995;1(1):81‐90. - PubMed
Varasteh 1999 {published data only}
    1. Varasteh NN, Varasteh RS, Neuwirth BL, Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstetrics and Gynecology 1999;94(2):168‐71. - PubMed
Vercellini 1999a {published data only}
    1. Vercellini P, Zaina B, Yaylayan L, Pisacreta A, Giorgio O, Crosignani PG. Hysteroscopic myomectomy: Long term effect on menstrual pattern and fertility. Obstetrics and Gynecology 1999;94(3):341‐7. - PubMed
Vercellini 1999b {published data only}
    1. Vercellini P, Maddalena S, Giorgi O, Pesole A, Ferrari L, Crosignani PG. Determinants of reproductive outcome after abdominal myomectomy for infertility. Fertility and Sterility 1999;72(1):109‐14. - PubMed
Wang 2013 {published data only}
    1. Wang CJ, Yu HT, Wu PJ, Su H, Wu KY, Han CM. Laparoscopic myomectomy instead of hysteroscopic myomectomy for large submucous fibroids. Gynecology and Minimally Invasive Therapy 2013;2:93‐5.
Wang 2016 {published data only}
    1. Wang H, Zhao J, Li X, Li P, Lu C, Tian S, Wang ZH. The indication and curative effect of hysteroscopic and laparoscopic myomectomy for type II submucous myomas. BMC Surgery 2016;16(9):1‐7. - PMC - PubMed
Wen 2018 {published data only}
    1. Wen KC, Sung PL, Chang WH, Horng HC, Chen YJ, Lee WL, et al. A case‐control study to compare the outcome of women treated by two minimally invasive procedures‐ ultraminilaparotomy myomectomy and laparoscopic myomectomy. Taiwanese Journal of Obstetrics and Gynecology 2018;57:264‐9. - PubMed
Yarali 2002 {published data only}
    1. Yarali H, Bukulmez O. The effect of intramural and subserous uterine fibroids on implantation and clinical pregnancy rates in patients having intracytoplasmic sperm injection. Archives of Gynecology and Obstetrics 2002;266:30‐3. - PubMed

References to ongoing studies

NCT03143114 {unpublished data only}
    1. NCT03143114. Effect of myomectomy for intramural myoma on fertility outcomes in infertile women [Effect of myomectomy for intramural myoma on fertility outcomes in infertile women: a randomized clinical trial]. clinicaltrials.gov/ct2/show/NCT03143114 (first received 8 May 2017).
NCT03796130 {unpublished data only}
    1. NCT03796130. Does myomectomy for intramural fibroid improve ART outcome? (MIFART) [Does myomectomy for intramural fibroid improve ART outcome? A randomized controlled trial]. clinicaltrials.gov/ct2/show/NCT03796130 (first received 8 January 2019).

Additional references

Chamberlain 2003
    1. Chamberlain G. The master of myomectomy. Journal of the Royal Society of Medicine 2003;96(6):302‐4. - PMC - PubMed
Dubuisso 2000
    1. Dubuisso JB, Fauconnier A, Babaki‐Fard K, Chapron C. Laparoscopic myomectomy: a current view. Human Reproduction Update 2000;6(6):588‐94. - PubMed
Emanuel 1997
    1. Emanuel M, Hart A, Wamsteker K, Lammes F. An analysis of fluid loss during transcervical resection of submucous myomas. Fertility and Sterility 1997;68:881‐6. - PubMed
Farquhar 2009
    1. Farquhar C. Do uterine fibroids cause infertility and should they be removed to increase fertility?. BMJ 2009;16:338. - PubMed
GRADEpro GDT 2015 [Computer program]
    1. GRADEpro GDT. GRADEpro Guideline Development Tool [Software]. MxMaster University: Evidence Prime, Inc.. McMaster University: Evidence Prime, Inc., 2015.
Gupta 2014
    1. Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database of Systematic Reviews 2014, Issue 12. [DOI: 10.1002/14651858.CD005073.pub4] - DOI - PMC - PubMed
Hall 2015
    1. Hall T, Lee S, Boruta D, Goodman A. Medical device safety and surgical dissemination of unrecognized uterine malignancy: morcellation in minimally invasive gynecologic surgery. Oncologist 2015;20(11):1274‐82. - PMC - PubMed
Hallez 1995
    1. Hallez JP. Single‐stage total hysteroscopic myomectomies: indications, techniques, and results. Fertility and Sterility 1995;63:703‐8. - PubMed
Higgins 2011
    1. Higgins JP, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Inagaki 2003
    1. Inagaki N, Ung L, Otani T, Wilkinson D, Lopata A. Uterine cavity matrix metalloproteinases and cytokines in patients with leiomyoma, adenomyosis or endometrial polyp. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2003;111:197‐203. - PubMed
Kadam 2010
    1. Kadam P, Bhalerao S. Sample size calculation. International Journal of Ayurveda Research 2010;1(1):55‐7. - PMC - PubMed
Klatsky 2008
    1. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic review from conception to delivery. American Journal of Obstetrics and Gynecology 2008;198(4):357–66. - PubMed
Kroon 2011
    1. Kroon B, Johnson N, Chapman M, Yazdani A, Hart R, Australasian CREI Consensus Expert Panel on Trial evidence (ACCEPT) group. Fibroids in infertility‐‐consensus statement from ACCEPT (Australasian CREI Consensus Expert Panel on Trial evidence). The Australian & New Zealand Journal of Obstetrics & Gynaecology 2011;51(4):289‐95. - PubMed
Litta 2014a
    1. Liita P, Conte L, Marchi F, Saccardi C, Angioni S. Pregnancy outcome after hysteroscopic myomectomy. Gynecological Endocrinology 2014;30:149‐52. - PubMed
Litta 2014b
    1. Liita P, Leggieri C, Conte L, Dalla Toffola A, Multinu F, Angioni S. Monopolar versus bipolar device: Safety, feasibility, limits and perioperative complications in performing hysteroscopic myomectomy. Clinical and Experiemental Obstetrics & Gynecology 2014;41:335‐338. - PubMed
Makris 2007
    1. Makris N, Vomvolaki E, Mantzaris G, Kalmantis K, Hatzipappas J, Antsaklis A. Role of bipolar rectoscope in subfertile women with submucous myomas and menstrual disorders. Journal of Obstetrics and Gynaecology Research 2007;33:849‐54. - PubMed
Metwally 2011
    1. Metwally M, Farquhar CM, Li TC. Is another meta‐analysis on the effects of intramural fibroids on reproductive outcomes needed?. Reproductive Biomedicine Online 2011;23(1):2‐14. - PubMed
Metwally 2015
    1. Metwally M, Li TC. Reproductive Surgery in Assisted Conception. Springer, 2015.
Office for National Statistics 2019
    1. Office for National Statistics. Birth characteristics in England and Wales: 2017. Office for National Statistics 2019.
Pritts 2009
    1. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertility and Sterility 2009;91(4):1215‐23. - PubMed
Sardo 2008
    1. Sardo ADS, Mazzon I, Bramante S, Bettocchi S, Bifulco G, Guida M. Hysteroscopic myomectomy: a comprehensive review of surgical techniques. Human Reproduction Update 2008;14:101‐19. - PubMed
Somigliana 2007
    1. Somigliana E, Vercellini P, Daguati R, Pasin R, Giorgi O, Crosignani PG. Fibroids and female reproduction: a critical analysis of the evidence. Human Reproduction Update 2007;13(5):456‐76. - PubMed
Sunkara 2010
    1. Sunkara SK, Khairy M, El‐Toukhy T, Khalaf Y, Coomarasamy A. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta‐analysis. Human Reproduction 2010;25(2):418‐29. - PubMed
Wechter 2011
    1. Wechter M, Stewart E, Myers E, Kho R, Wu J. Leiomyoma‐related hospitalization and surgery: Prevalence and predicted growth based on population trends. American Journal of Obstetrics and Gynecology 2011;205:492.e1‐492.e5. - PMC - PubMed
Yoshino 2010
    1. Yoshino O, Hayashi T, Osuga Y, Orisaka M, Asada H, Okuda S, et al. Decreased pregnancy rate is linked to abnormal uterine peristalsis caused by intramural fibroids. Human Reproduction 2010;25(10):2475‐9. - PubMed
Yoshino 2012
    1. Yoshino O, Nishii O, Osuga Y, Asada H, Okuda S, Orisaka M, et al. Myomectomy decreases abnormal uterine peristalsis and increases pregnancy rate. Journal of Minimally Invasive Gynecology 2012;19(1):63‐7. - PubMed

References to other published versions of this review

Griffiths 2002
    1. Griffiths AN, D'Angelo A, Amso NN. Surgical treatment of fibroids for subfertility. Cochrane Database of Systematic Reviews 2002, Issue 3. [DOI: 10.1002/14651858.CD003857] - DOI - PubMed
Griffiths 2006
    1. Griffiths AN, D'Angelo A, Amso NN. Surgical treatment of fibroids for subfertility. Cochrane Database of Systematic Reviews 2006, Issue 3. [DOI: 10.1002/14651858.CD003857.pub2] - DOI - PubMed
Metwally 2012
    1. Metwally M, Cheong YC, Horne AW. Surgical treatment of fibroids for subfertility. Cochrane Database of Systematic Reviews 2012, Issue 11. [DOI: 10.1002/14651858.CD003857.pub3] - DOI - PubMed