The Effect of Intramural Myomas Without an Intracavity Component on In Vitro Fertilization Outcomes in Single Fresh Blastocyst Transfer Cycles

The effect of uterine fibroid region and depth on endometrial stress and strain: a finite element approach

Uterine fibroids are common benign gynecological tumors that are observed in up to 80% of premenopausal women. It is understood that as the fibroid size increases, the surrounding tissues will be subject to greater loads. However, the effect of fibroid region on the uterine structure is not as clear. To better understand the mechanical loading of the endometrium due to the presence of a uterine fibroid, we developed a finite element model of the uterus to examine the effect of both fibroid depth and region in relation to the endometrium. The finite element model of the uterus, endometrium, and a uterine fibroid were created from a 3D segmentation of a patient's magnetic resonance images. This model was then loaded into ANSYS Mechanical 2023 R1, and then deformation, stress, and strain of the endometrium was measured for 24 fibroid positions (8 regions × 3 depths). The highest endometrial loads (deformation, stress, strain) were observed when the fibroid region was superior to the uterus and the depth was deep. Superior regions generated 10-20% higher loads on the endometrium in comparison to other regions, while deep locations had 5-10% higher endometrium loads when compared to superficial depths across almost all regions. A simple uterus model was used to show the effect of fibroid position on loads acting on the endometrium. This can provide insight into mechanisms of abnormal uterine bleeding and infertility and better inform clinical decision making.

Uterine fibroid-related infertility: mechanisms and management

Fibroids are a common pathology and increasingly observed in women seeking medical treatment for infertility. The longer reproductive horizon because of improvements in medical care and current trend for women to postpone childbearing are making fibroid-related infertility increasingly common. This review aimed to critically analyze the association between uterine fibroids and infertility, mechanisms by which uterine fibroids may impair fertility, and management of myoma-related infertility. The association of fibroids with infertility is a source of controversy. As the focus of this review is infertility, it is crucial to analyze the mechanisms by which fertility may be impaired by the presence of fibroids. Current management strategies involve mainly surgical interventions, including myomectomy by hysteroscopy, laparotomy, or laparoscopy, and nonsurgical approaches, such as uterine artery embolization and focused ultrasound performed under radiologic or echographic guidance. The risks and benefits of each option should be discussed with patients, and several factors need to be considered, including the skills of surgeons and availability of different resources in various centers. Concerning the efficacy of oral gonadotropin-releasing hormone antagonists (i.e., elagolix, relugolix, and linzagolix), they were shown to have a rapid impact on heavy menstrual bleeding (HMB) in >70% of women. When used without add-back therapy, these drugs cause a significant reduction in fibroid volume, namely, approximately 50% from baseline to week 24. Further studies are required to determine the best protocol and optimal dosage if a reduction in myoma volume is the main goal, as in case of myoma-related infertility.

Infertility in patients with uterine fibroids: a debate about the hypothetical mechanisms

Fibroids are benign tumours of the myometrium and are the most common gynaecologic abnormality. Although most fibroids are asymptomatic, they can cause symptoms like heavy menstrual bleeding, pelvic pain, sexual dysfunction, pressure complaints, and infertility. The association between fibroids and infertility has been debated for decades. It is generally acknowledged that the closer the fibroid is to the uterine cavity and the endometrium lining, the more unfavourable effect it might have on fertility, reducing the odds for successful implantation and gestation. Based on the limited available literature, we propose and discuss seven hypotheses on the underlying mechanism by which fibroids may reduce fertility. (i) Fibroids can cause sexual dysfunction, as fibroids can cause dyspareunia, pelvic pain, and prolonged and heavy menstrual bleeding, which could interfere with sexual arousal and as a consequence the frequency of intercourse, resulting in a reduced probability of conception. (ii) Mechanical compression by fibroids on theinterstitial part of the fallopian tubes or deformation of uterine cavity could disturb oocyte and sperm transport. (iii) Fibroids can disturb peristalsis of the junctional zone in the myometrium, which could negatively influence oocyte and sperm transport as well as implantation. In addition, fibroids could induce a detrimental environment for implantation in other ways, by: (iv) changing the vagino-uterine microbiome; (v) disturbing the levels of inflammation and autophagy; (vi) inducing molecular changes in the endometrium; and (vii) inducing aberrant angiogenesis and altering the endometrial blood supply. After the discussion of these hypotheses, the implication of the influence of fibroids on early pregnancy loss is discussed. Surgical fibroid treatment is not tailored nor focussed on the pathophysiology of the fibroid; consequently it may be accompanied by recurrence of fibroids and risks of complications. Unravelling the pathogenic mechanisms about how fibroids influence fertility is essential to evolve classic surgical fibroid treatment. Instead of treatment of fibroid-related symptoms, the research should supports development of fibroid-targeted (pharmaceutical) treatment that is compatible with an active wish to become pregnant.

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

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.

Myomectomy in infertile women: More harm than good?

Adhesion formation following gynecological surgery remains a challenge. The adoption of minimally invasive surgical approaches, such as conventional or robotic-assisted laparoscopy combined with meticulous microsurgical principles and the application of adhesion-reducing substances, is able to reduce the risk of de novo adhesion formation but do not eliminate it entirely. Myomectomy is the most adhesiogenic surgical procedure and postoperative adhesions can have a significant impact on the ability to conceive. Therefore, when surgery is performed as infertility treatment, attention should be paid to whether the benefits outweigh the risks. Among several factors, the size and the location of fibroids are the most accountable factors in terms of adhesion development and post surgical infertility; therefore, the search for effective strategies against adhesion formation in this setting is of paramount importance. The purpose of this review is to evaluate the incidence and factors of adhesion formation and the best preventive measures current available.

Pregnancy outcomes after ultrasound-guided high-intensity focused ultrasound (USgHIFU) for conservative treatment of uterine fibroids: experience of a single institution

OBJECTIVE

To assess the impact of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation for uterine fibroids on fertility.

MATERIAL AND METHODS

A retrospective observational study was conducted of 560 reproductive-age women with symptomatic uterine fibroids who underwent USgHIFU therapy at Mútua Terrassa University Hospital, Spain, between February 2008 and February 2018. We analyzed pregnancy outcomes including time to conception, pregnancy approach, gestational age, delivery mode, neonatal outcomes and complications during pregnancy and delivery.

RESULTS

After USgHIFU treatment, 71 pregnancies were obtained in 55 patients. Of these, 58 (82%) cases were natural pregnancies and 13 (18%) were in vitro fertilization (IVF) pregnancies. The median time to conception was 12 (range 1-72) months. There were 43 (61%) successful deliveries, including a twin gestation, 22 (31%) spontaneous abortions and 6 (8%) therapeutic abortions. The rate of full-term deliveries was 91% (39/43) and the remaining 9% (4/43) were preterm deliveries. Of the 44 live births, 25 (57%) were born vaginally and 19 (43%) by cesarean section. The complications reported included 3 women with retained placenta (7%), 2 with placenta previa (5%) and 1 with severe preeclampsia (2%). The mean birth weight was 3.1 (range: 1.4-4.3) kg, and except for a baby born with a tetralogy of Fallot, all newborns developed well without complications during postpartum and breastfeeding.

CONCLUSION

Patients undergoing USgHIFU treatment of uterine fibroids can achieve full-term pregnancies with few intrapartum or postpartum complications. More studies are required to compare fertility and perinatal outcomes between patients who underwent or not USgHIFU.

Impact of intramural non-cavity-distorting leiomyoma on placental histopathology and perinatal outcome in singleton live births resulting from in vitro fertilization treatment

PURPOSE

To evaluate the effect of non-cavity-distorting intramural leiomyomas on the placental histopathology pattern and perinatal outcome in singleton live births resulting from in vitro fertilization treatment.

METHODS

The study population included all singleton live births following in vitro fertilization treatment with autologous oocytes during the period from 2009 to 2017. Primary outcomes included anatomical, inflammation, vascular malperfusion, and villous maturation placental features. Secondary outcomes included fetal, maternal, delivery, and perinatal complications.

RESULTS

A total of 1119 live births were included in the final analysis and were allocated to the group of pregnancies with non-cavity-distorting intramural myomas (n = 101) and without myomas (n = 1018). After the adjustment for confounding factors, the non-cavity-distorting intramural myomas were found to be significantly associated with assisted placental delivery (OR 2.4; 95% CI 1.5-3.9), furcate cord insertion (OR 3.6; 95% CI 1.4-9.3), circumvallate membranes insertion (OR 5.2; 95% CI 1.4-19.3), chronic deciduitis (OR 8.2; 95% CI 1.6-42.2), focal intramural fibrin deposition (OR 25.1; 95% CI 2.1-306.2), subchorionic thrombi (OR 3.6; 95% CI 1.7-7.6), maternal vasculopathy (OR 2.5; 95% CI 1.2-5.5), and chorangioma (OR 5.9; 95% CI 1.4-25.2) as well as with the failure of labor progress (OR 2.4; 95% CI 1.3-4.4) and induction (OR 3.2; 95% CI 1.2-9.0).

CONCLUSION

Intramural non-cavity-distorting myomas have a significant impact on the placental histopathology with a higher incidence of dysfunctional labor.

Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review

Uterine fibroids may cause infertility, depending on their size and location according to the International Federation of Gynecology and Obstetrics classification. In this review, infertility relating to intramural myomas is evaluated. The mechanisms linking uterine fibroids and infertility are numerous: uterine cavity distortion (fibroids types 0, 1, 2, 2-5); impaired endometrial and myometrial blood supply; increased uterine contractility; hormonal, paracrine and molecular changes; impaired endometrial receptivity in gene expression (decrease in homeobox 10 [HOXA-10] expression); and thicker capsule. The negative effect of intramural myoma is related to myoma size and proximity of the uterine cavity. Therefore, a medical approach could be proposed to reduce the size of the myoma and push it back deep into the myometrium. The relevant medical treatments, including selective progesterone receptor modulator and gonadotrophin releasing hormone antagonist are reviewed. Even if the mystery surrounding intramural myomas remains, the development of new algorithms for intramural myoma-related infertility, and evaluation of the place of medical treatment as a primary approach are urgently needed. An algorithm, taking into account the mechanisms linking uterine fibroids and infertility, is proposed.

The Impact of Noncavity-Distorting Intramural Fibroids on the Efficacy of In Vitro Fertilization-Embryo Transfer: An Updated Meta-Analysis

Aim

To address the impact of noncavity-distorting intramural fibroids on the efficacy of in vitro fertilization-embryo transfer (IVF-ET) outcomes.

Methods

The PubMed, Web of Science, Embase, Cochrane Library, and China National Knowledge Infrastructure were searched systematically. A meta-analysis was performed based on comparative or cohort studies that explored the impact of noncavity-distorting intramural fibroids on the efficacy of IVF-ET treatment. The IVE-ET outcomes of study group (women with noncavity-distorting intramural fibroids) and control group (women without fibroids) were compared, including live birth rate (LBR), clinical pregnancy rate (cPR), implantation rate (IR) , miscarriage rate (MR), and ectopic pregnancy rate (ePR).

Results

A total of 28 studies involving 9189 IVF cycles were included. Our meta-analysis showed a significant reduction of LBR in the study group compared to control group (RR = 0.82, 95% CI: 0.73-0.92, and P = 0.005). In addition, it indicated that study group had a significant reduction in cPR (RR = 0.86, 95% CI: 0.80-0.93, P = 0.0001) and IR (RR = 0.90, 95% CI: 0813-1.00, P = 0.04) and have a significantly increase in MR (RR = 1.27, 95% CI: 1.08-1.50, and P = 0.004) compared with control group.

Conclusions

The present evidence suggests that noncavity-distorting intramural fibroids would significantly reduce the IR, cRP, and LBR and significantly increase the MR after IVF treatment, but it would not significantly increase the ePR.