Intramural myomas more than 3–4 centimeters should be surgically removed before in vitro fertilization
2021; Elsevier BV; Volume: 116; Issue: 4 Linguagem: Inglês
10.1016/j.fertnstert.2021.08.016
ISSN1556-5653
AutoresMarie‐Madeleine Dolmans, Keith Isaacson, Wenjia Zhang, Stephan Gordts, Malcolm G. Munro, Elizabeth A. Stewart, Mathilde Bourdon, Piétro Santulli, Jacques Donnez,
Tópico(s)Gynecological conditions and treatments
ResumoDIALOG: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/33200 DIALOG: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/33200 Myomas can cause infertility depending on their size and site (1Donnez J. Dolmans M.M. Uterine fibroid management: from the present to the future.Hum Reprod Update. 2016; 22: 665-686Crossref PubMed Scopus (249) Google Scholar, 2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). The International Federation of Gynecology and Obstetrics (FIGO) classification takes into account the degree of intramural extension and distortion of the uterine cavity (3Munro M.G. Critchley H.O. Broder M.S. Fraser I.S. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age.Int J Gynaecol Obstet. 2011; 113: 3-13Crossref PubMed Scopus (402) Google Scholar). There are numerous mechanisms (Fig. 1) linking uterine fibroids and infertility (2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar): uterine cavity distortion (myoma types 0, 1, 2, 2–5); impaired endometrial and myometrial blood supply; greater uterine contractility; hormonal, paracrine, and molecular modifications; defective endometrial receptivity and gene expression, role of transforming growth factor beta-3 (TGF-β3) and HOXA-10; and a thicker capsule. The first mechanism is clearly discernible and has been widely documented (4Pritts E.A. Parker W.H. Olive D.L. Fibroids and infertility: an updated systematic review of the evidence.Fertil Steril. 2009; 91: 1215-1223Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar). Because this Fertile Battle is focusing on intramural myomas, we will investigate intramural myoma-related infertility (2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5Donnez J. Uterine fibroids and progestogen treatment: lack of evidence of its efficacy: a review.J Clin Med. 2020; 9: 3948Crossref Scopus (0) Google Scholar). The presence of myomas close to the uterine cavity (type 3) impedes endometrial blood flow (6Forssman L. Distribution of blood flow in myomatous uteri as measured by locally injected 133Xenon.Acta Obstet Gynecol Scand. 1976; 55: 101-104Crossref PubMed Scopus (45) Google Scholar, 7Sladkevicius P. Valentin L. Marsál K. Transvaginal Doppler examination of uteri with myomas.J Clin Ultrasound. 1996; 24: 135-140Crossref PubMed Scopus (34) Google Scholar). Indeed, studies using magnetic resonance imaging have reported diminished blood flow in fibroids and their surrounding myometrium (6Forssman L. Distribution of blood flow in myomatous uteri as measured by locally injected 133Xenon.Acta Obstet Gynecol Scand. 1976; 55: 101-104Crossref PubMed Scopus (45) Google Scholar). Transvaginal ultrasound (7Sladkevicius P. Valentin L. Marsál K. Transvaginal Doppler examination of uteri with myomas.J Clin Ultrasound. 1996; 24: 135-140Crossref PubMed Scopus (34) Google Scholar) has shown that uterine fibroids possess lower resistance and uterine artery pulsatility indices. A prospective study by Nieuwenhuis et al. (8Nieuwenhuis L.L. Keizer A.L. Stoelinga B. Twisk J. Hehenkamp W. Brölmann H. et al.Fibroid vascularisation assessed with three-dimensional power Doppler ultrasound is a predictor for uterine fibroid growth: a prospective cohort study.BJOG. 2018; 125: 577-584Crossref PubMed Scopus (9) Google Scholar) demonstrated that blood supply alterations interfere with myoma growth because volume is typically greater in highly vascularized fibroids. Intramural fibroids may alter uterine peristalsis and, hence, blastocyst implantation (9Orisaka M. Kurokawa T. Shukunami K. Orisaka S. Fukuda M.T. Shinagawa A. 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: 111-115Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 10Miura S. Khan K.N. Kitajima M. Hiraki K. Moriyama S. Masuzaki H. et al.Differential infiltration of macrophages and prostaglandin production by different uterine leiomyomas.Hum Reprod. 2006; 21: 2545-2554Crossref PubMed Scopus (59) Google Scholar, 11Yoshino 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.Hum Reprod. 2010; 25: 2475-2479Crossref PubMed Scopus (93) Google Scholar). Decreased contractility in response to progesterone could favor embryo implantation (12Fanchin R. Picone O. Ayoubi J.M. Marcadet-Fredet S. Kadoch J. Frydman R. Contractilité utérine et reproduction humaine: nouvelles perspectives [Uterine contractility and reproduction: new perspectives].J Gynecol Obstet Biol Reprod (Paris). 2002; 31 (French): 325-332PubMed Google Scholar, 13Fanchin R. Righini C. Schönauer L.M. Olivennes F. Cunha Filho J.S. Frydman R. Vaginal versus oral E(2) administration: effects on endometrial thickness, uterine perfusion, and contractility.Fertil Steril. 2001; 76: 994-998Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar), but if the proximity of intramural myomas impacts uterine peristalsis, it may cause defective blastocyst implantation. Fibroids can affect the expression of genes needed for implantation, like glycodelin and bone morphogenetic protein (BMP) receptor type 2 (14Ikhena D.E. Bulun S.E. Literature review on the role of uterine fibroids in endometrial function.Reprod Sci. 2018; 25: 635-643Crossref PubMed Scopus (19) Google Scholar). Myomas may also be responsible for declining levels of cytokines crucial to implantation, such as leukemia inhibitory factor (LIF) and cell adhesion molecules. Furthermore, the decreased expression of cell adhesion molecule E-cadherin has been reported in the endometrium of subjects with non-cavity-distorting intramural fibroids. Uterine myomas have a considerable influence on both function and gene expression in the endometrium, hampering endometrial receptivity (14Ikhena D.E. Bulun S.E. Literature review on the role of uterine fibroids in endometrial function.Reprod Sci. 2018; 25: 635-643Crossref PubMed Scopus (19) Google Scholar). In 2015, Rackow and Taylor (15Rackow B.W. Taylor H.S. Submucosal uterine leiomyomas have a global effect on molecular determinants of endometrial receptivity.Fertil Steril. 2010; 93: 2027-2034Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar) reported that the endometrial messenger ribonucleic acid expression of HOXA-10 (critical to regulating endometrial receptivity) was consistently lower in the presence of submucosal myomas. HOXA messenger ribonucleic acid and stromal protein expression were also affected in the intramural group compared with controls. In an editorial, Taylor (16Taylor H.S. Fibroids: when should they be removed to improve in vitro fertilization success?.Fertil Steril. 2018; 109: 784-785Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar) proposed that larger fibroids produce greater quantities of TGF-β3, allowing those closest to the uterine cavity to release more TGF-β into endometrial cells, thereby altering BMP-2 and HOXA-10 expression. The amounts of TGF-β reaching the uterine cavity vary by the square of the distance from the cavity (1/x2, where x is the distance between the endometrium and the fibroid) (16Taylor H.S. Fibroids: when should they be removed to improve in vitro fertilization success?.Fertil Steril. 2018; 109: 784-785Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar). The capsule surrounding fibroids is made up of compressed myometrium and contains nerves and neuroendocrine fibers, which may affect muscle contractility (17Tinelli A. Favilli A. Lasmar R.B. Mazzon I. Gerli S. Xue X. et al.The importance of pseudocapsule preservation during hysteroscopic myomectomy.Eur J Obstet Gynecol Reprod Biol. 2019; 243: 179-184Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar). While the need to treat submucosal fibroids is generally acknowledged (4Pritts E.A. Parker W.H. Olive D.L. Fibroids and infertility: an updated systematic review of the evidence.Fertil Steril. 2009; 91: 1215-1223Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar), the debate around non-cavity-distorting uterine fibroids continues (1Donnez J. Dolmans M.M. Uterine fibroid management: from the present to the future.Hum Reprod Update. 2016; 22: 665-686Crossref PubMed Scopus (249) Google Scholar, 2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). In a recent review (2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar), all series published to date were discussed, including two important meta-analyses that are reported here (18Yan L. Yu Q. Zhang Y.N. Guo Z. Li Z. Niu J. et al.Effect of type 3 intramural fibroids on in vitro fertilization-intracytoplasmic sperm injection outcomes: a retrospective cohort study.Fertil Steril. 2018; 109: 817-822.e2Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 19Rikhraj K. Tan J. Taskin O. Albert A.Y. Yong P. Bedaiwy M.A. The impact of noncavity-distorting intramural fibroids on live birth rate in in vitro fertilization cycles: a systematic review and meta-analysis.J Womens Health (Larchmt). 2020; 29: 210-219Crossref PubMed Scopus (6) Google Scholar). Data from Yan et al. (18Yan L. Yu Q. Zhang Y.N. Guo Z. Li Z. Niu J. et al.Effect of type 3 intramural fibroids on in vitro fertilization-intracytoplasmic sperm injection outcomes: a retrospective cohort study.Fertil Steril. 2018; 109: 817-822.e2Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar) strongly indicated that type 3 fibroids have a negative impact on clinical pregnancy and live birth rates, especially if their individual diameter exceeds 2 cm. Rikhraj et al. (19Rikhraj K. Tan J. Taskin O. Albert A.Y. Yong P. Bedaiwy M.A. The impact of noncavity-distorting intramural fibroids on live birth rate in in vitro fertilization cycles: a systematic review and meta-analysis.J Womens Health (Larchmt). 2020; 29: 210-219Crossref PubMed Scopus (6) Google Scholar) reviewed 15 quantitative studies out of 139 identified records. They concluded that patients with non-cavity-distorting intramural fibroids undergoing in vitro fertilization (IVF) have a 44% lower chance of a live birth and 32% lower odds of a clinical pregnancy than unaffected women. In conclusion, all published studies and meta-analyses reviewed by Donnez and Dolmans (2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar) concur that non-cavity-distorting intramural myomas do indeed have a deleterious impact on IVF outcomes. Two factors have emerged as key: fibroid size (the larger, the more TGF-β3 secretion) and proximity to the uterine cavity. In other words, a type 3 myoma of 2 cm or more will have a detrimental effect close to the endometrial lining. If a fibroid is intramural but not in contact with the underlying endometrium (types 4 and 5), 3 cm is usually considered the cutoff (2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). A number of investigators recommend surgical removal of intramural fibroids (16Taylor H.S. Fibroids: when should they be removed to improve in vitro fertilization success?.Fertil Steril. 2018; 109: 784-785Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar), but we should perhaps be asking ourselves another crucial question (1Donnez J. Dolmans M.M. Uterine fibroid management: from the present to the future.Hum Reprod Update. 2016; 22: 665-686Crossref PubMed Scopus (249) Google Scholar, 2Donnez J. Dolmans M.M. Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review.Reprod Biomed Online. 2020; 41: 431-442Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar). If the negative impact of myomas is linked to size and proximity to the uterine cavity, why not try a medical approach to reduce their size and force them further into the myometrium? Submucosal (types 0–2) fibroids distorting the endometrial cavity can impact pregnancy and assisted reproductive technology (ART) outcomes (20Farhi J. Ashkenazi J. Feldberg D. Dicker D. Orvieto R. Ben Rafael Z. Effect of uterine leiomyomata on the results of in-vitro fertilization treatment.Hum Reprod. 1995; 10: 2576-2578Crossref PubMed Google Scholar, 21Practice Committee of the American Society for Reproductive MedicineRemoval of myomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: a guideline.Fertil Steril. 2017; 108: 416-425Abstract Full Text Full Text PDF PubMed Google Scholar). A 2009 systematic review demonstrated that the presence of fibroids decreased fertility overall, with the largest impact seen in the submucosal group with a 70% reduction in clinical pregnancy rates. In the intramural group, a reduction in both live birth (RR, 0.70) and clinical pregnancy (relative risk [RR], 0.81) rates was seen (4Pritts E.A. Parker W.H. Olive D.L. Fibroids and infertility: an updated systematic review of the evidence.Fertil Steril. 2009; 91: 1215-1223Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar). Women who underwent hysteroscopic resection of submucosal fibroids had improved clinical pregnancy rates compared with those who did not undergo hysteroscopic myomectomy (4Pritts E.A. Parker W.H. Olive D.L. Fibroids and infertility: an updated systematic review of the evidence.Fertil Steril. 2009; 91: 1215-1223Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar). Recommendations for myomectomy are less clear for asymptomatic women with infertility who have intramural fibroids that do not distort the endometrial lining (types 3–4) (4Pritts E.A. Parker W.H. Olive D.L. Fibroids and infertility: an updated systematic review of the evidence.Fertil Steril. 2009; 91: 1215-1223Abstract Full Text Full Text PDF PubMed Scopus (479) Google Scholar, 22Zepiridis L.I. Grimbizis G.F. Tarlatzis B.C. Infertility and uterine fibroids.Best Pract Res Clin Obstet Gynaecol. 2016; 34: 66-73Crossref PubMed Google Scholar, 23Sunkara S.K. 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.Hum Reprod. 2010; 25: 418-429Crossref PubMed Scopus (195) Google Scholar). We strongly believe that women with type 3 myomas (intramural abutting the endometrial cavity) ranging from 2 to 4 cm in diameter should have these fibroids removed hysteroscopically in patients with recurrent implantation failure and unexplained infertility. Our opinion is supported by science and logic presented in the following. Uterine peristalsis is initiated by the inner myometrium and changes throughout the menstrual cycle in a hormonally mediated manner (24Brosens J.J. de Souza N.M. Barker F.G. Uterine junctional zone: function and disease.Lancet. 1995; 346: 558-560Abstract Full Text PDF PubMed Scopus (155) Google Scholar, 25De Ziegler D. Bulletti C. Fanchin R. Epiney M. Brioschi P.A. Contractility of the nonpregnant uterus: the follicular phase.Ann N Y Acad Sci. 2001; 943: 172-184Crossref PubMed Google Scholar). During the estrogen-dominant follicular phase, there is a progressive increase in uterine contractility peaking in the preovulatory period (25De Ziegler D. Bulletti C. Fanchin R. Epiney M. Brioschi P.A. Contractility of the nonpregnant uterus: the follicular phase.Ann N Y Acad Sci. 2001; 943: 172-184Crossref PubMed Google Scholar, 26Eskes T.K. Hein P.R. Kars-Villanueva E.B. Braaksma J.T. Janssens J. Kollerie A. The influence of steroids on the motility of the non-pregnant human uterus in vivo.Arch Int Pharmacodyn Ther. 1969; 182: 409PubMed Google Scholar, 27Abramowicz J.S. Archer D.F. Uterine endometrial peristalsis--a transvaginal ultrasound study.Fertil Steril. 1990; 54: 451-454Abstract Full Text PDF PubMed Google Scholar, 28de Vries K. Lyons E.A. Ballard G. Levi C.S. Lindsay D.J. Contractions of the inner third of the myometrium.Am J Obstet Gynecol. 1990; 162: 679-682Abstract Full Text PDF PubMed Scopus (211) Google Scholar). In the periovulatory period, the predominant uterine peristalsis propagates from the cervix to the fundus, which can facilitate fertilization by assisting sperm transportation (25De Ziegler D. Bulletti C. Fanchin R. Epiney M. Brioschi P.A. Contractility of the nonpregnant uterus: the follicular phase.Ann N Y Acad Sci. 2001; 943: 172-184Crossref PubMed Google Scholar, 28de Vries K. Lyons E.A. Ballard G. Levi C.S. Lindsay D.J. Contractions of the inner third of the myometrium.Am J Obstet Gynecol. 1990; 162: 679-682Abstract Full Text PDF PubMed Scopus (211) Google Scholar, 29Ijland M.M. Evers J.L. Dunselman G.A.J. Volovics L. Hoogland H.J. Relation between endometrial wavelike activity and fecundability in spontaneous cycles.Fertil Steril. 1997; 67: 492-496Abstract Full Text PDF PubMed Scopus (107) Google Scholar, 30Kunz G. Beil D. Deininger H. Wildt L. Leyendecker G. The dynamics of rapid sperm transport through the female genital tract: evidence from vaginal sonography of uterine peristalsis and hysterosalpingoscintigraphy.Hum Reprod. 1996; 11: 627-632Crossref PubMed Google Scholar). After ovulation, the progesterone-dominant luteal phase shows relative uterine quiescence to facilitate fundal implantation. If no pregnancy occurs, the early follicular phase demonstrates an antegrade wave from the fundus to the cervix, emptying uterine contents and establishing hemostasis (25De Ziegler D. Bulletti C. Fanchin R. Epiney M. Brioschi P.A. Contractility of the nonpregnant uterus: the follicular phase.Ann N Y Acad Sci. 2001; 943: 172-184Crossref PubMed Google Scholar, 31Martinez-Gaudio M. Yoshida T. Bengtsson L.P. Propagated and nonpropagated myometrial contractions in normal menstrual cycles.Am J Obstet Gynecol. 1973; 115: 107-111Abstract Full Text PDF PubMed Google Scholar). Both submucosal and intramural fibroids cause abnormal uterine peristalsis (9Orisaka M. Kurokawa T. Shukunami K. Orisaka S. Fukuda M.T. Shinagawa A. 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: 111-115Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 11Yoshino 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.Hum Reprod. 2010; 25: 2475-2479Crossref PubMed Scopus (93) Google Scholar, 32Nishino M. Togashi K. Nakai A. Hayakawa K. Kanao S. Iwasaku K. et al.Uterine contractions evaluated on cine MR imaging in patients with uterine leiomyomas.Eur J Radiol. 2005; 53: 142-146Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar). In a large retrospective cohort in 2018, Yan et al. (18Yan L. Yu Q. Zhang Y.N. Guo Z. Li Z. Niu J. et al.Effect of type 3 intramural fibroids on in vitro fertilization-intracytoplasmic sperm injection outcomes: a retrospective cohort study.Fertil Steril. 2018; 109: 817-822.e2Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar) sought to explore the impact of type 3 intramural fibroids on ART success given the small numbers of women with type 3 intramural fibroids in their 2014 cohort. A total of 453 control subjects without fibroids were matched with 151 women with type 3 intramural fibroids undergoing IVF-intracytoplasmic sperm injection, 23 of whom had more than one of fibroids such as multiple intramural or subserosal fibroids. There was a decrease in the fibroid vs. control group regarding the implantation, clinical pregnancy, and live birth rates (22.7% vs. 34.4%, P=.001; 27.8% vs. 43.9%, P=.003; and 21.2% vs. 34.4%, P=.013, respectively) (18Yan L. Yu Q. Zhang Y.N. Guo Z. Li Z. Niu J. et al.Effect of type 3 intramural fibroids on in vitro fertilization-intracytoplasmic sperm injection outcomes: a retrospective cohort study.Fertil Steril. 2018; 109: 817-822.e2Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar). Using the receiver operating characteristic curves, the investigators noted that a size greater than 2.0 cm for type 3 fibroids was associated with a trend in lower birth rates. Given that the data overwhelmingly supports removing type 3 myomas to enhance embryo implantation, the only question is the best method of removal with the options being laparotomic, laparoscopic, and hysteroscopic. It has been well documented that laparoscopic surgery, vs. laparotomy, is associated with a faster recovery and lower risk of blood loss and infection and has no higher risk of uterine dehiscence in pregnancy. It has also been demonstrated that removal of the entire myoma and not a fraction of the myoma is associated with the best long-term outcomes (33Tavcar J. Morris S.N. Loring M. Isaacson K. A different perspective : evidence to support complete resection as the goal for the treatment of submucosal myomas.J Minim Invasive Gynecol. 2020; 27: 787-788Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar). We believe that the preferred method of myomectomy for type 3 myomas between 2 and 4 cm is hysteroscopic and not laparoscopic for the following reasons:•Fibroids are monoclonal and are derived from a single cell. They displace normal myometrium and do not invade normal myometrium. When a type 2 or 3 myoma is removed hysteroscopically using a bipolar loop electrode, the surgery is contained within the pseudocapsule, and no normal myometrium is damaged. When this same procedure is performed laparoscopically, the normal myometrium is cut to reach the myoma. This damaged myometrium requires difficult suturing when repaired in multiple layers. There is higher blood loss and longer operating room time associated with the laparoscopic method. Likewise, the recommendation for pregnancy after operation is 3–6 months following a laparoscopic approach and 6–8 weeks following a hysteroscopic approach.•Because the normal myometrium is interrupted with a laparoscopic approach, most patients will undergo a cesarean section for delivery to minimize the risk of dehiscence during labor. This is not the recommendation after a hysteroscopic resection. There are no case reports in the recent literature describing uterine dehiscence after a hysteroscopic myomectomy.•There is very little scar tissue formed with a hysteroscopic myomectomy if the opposing endometrium is not traumatized. There are often intrapelvic adhesions after a laparoscopic myomectomy that can lead to pain and infertility. Hysteroscopic type 3 myomectomies can be safely accomplished with a bipolar resectoscope and transabdominal ultrasound guidance. Tissue shavers with side opening blades are not designed for this type of dissection. Because there are no abdominal incisions with the hysteroscopic approach, the patient can return to normal activities in 24 hours as opposed to the typical 2–4 weeks with a laparoscopic approach. Removal of intramural myomas should be considered in women with infertility seeking ART. The size and location of intramural fibroids likely contribute to the success of ART, and special consideration should be given to counseling women regarding myomectomy for type 3 fibroids with a size of 2 cm or larger. Hysteroscopic myomectomy using a bipolar resectoscope is the preferred approach for type 3 myomectomies and, thus, should be considered as a first-line therapy.
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