Intramural fibroid and fertility—to operate or not
Small intramural fibroids in subfertile women pose a clinical challenge. Based on the FIGO classification, types 3 and 4 are intramural fibroids. There are many reasons why intramural fibroids causes infertility but the only measurable cause is uterine peristalsis. It is not known why some patients with intramural fibroids have increased uterine peristalsis. However, studies have shown that increased uterine peristalsis in patients with intramural fibroids have poorer pregnancy outcome. Studies have also shown that intramural fibroid that affects the junctional zone (JZ) have increased frequency of abnormal uterine peristalsis. Due to this reason, we propose that type 4 fibroid should be further classified into type 4a and type 4b. Type 4a fibroid disrupts the JZ and type 4b does not. There appears to be sufficient evidence that intramural fibroid affects fertility but the evidence that myomectomy in such patients will improve pregnancy outcome is not strong. Alternatives to myomectomy in these patients are to shrink the fibroid or decrease the uterine peristalsis using medication. Methods to shrink these intramural fibroids include ulipristal acetate, gonadotrophin releasing hormone (GnRH) agonist, uterine artery embolization (UAE) and high intensity focused ultrasound (HIFU). Atosiban can be used to suppress uterine peristalsis. These methods are discussed. We recommend that future research should be directed at development of an effective and cheap method of measuring uterine peristalsis. Until measurement of uterine peristalsis is easily available, it is difficult to recommend routine myomectomy in subfertile patients with small intramural fibroid and non-invasive methods such as HIFU appears to be a more attractive method to shrink these fibroids to improve fertility, but this need to be assessed in clinical studies.