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Journal of obstetrics and gynaecology Canada | 2015

The Management of Uterine Fibroids in Women With Otherwise Unexplained Infertility

Belina Carranza-Mamane; Jon Havelock; Robert Hemmings; Anthony P. Cheung; Sony Sierra; Allison Case; Dwyer Cathie; James Graham; Kimberly E. Liu; Ward Murdock; Tannys D.R. Vause; Benjamin Wong; Margaret Burnett

OBJECTIVE To provide recommendations regarding the best management of fibroids in couples who present with infertility. Usual and novel treatment options for fibroids will be reviewed with emphasis on their applicability in women who wish to conceive. OPTIONS Management of fibroids in women wishing to conceive first involves documentation of the presence of the fibroid and determination of likelihood of the fibroid impacting on the ability to conceive. Treatment of fibroids in this instance is primarily surgical, but must be weighed against the evidence of surgical management improving clinical outcomes, and risks specific to surgical management and approach. OUTCOMES The outcomes of primary concern are the improvement in pregnancy rates and outcomes with management of fibroids in women with infertility. EVIDENCE Published literature was retrieved through searches of PubMed, MEDLINE, the Cochrane Library in November 2013 using appropriate controlled vocabulary (e.g., leiomyoma, infertility, uterine artery embolization, fertilization in vitro) and key words (e.g., fibroid, myomectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English and French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to November 2013. Grey (unpublished literature) was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence in this document was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). BENEFITS, HARMS, AND COSTS These recommendations are expected to allow adequate management of women with fibroids and infertility, maximizing their chances of pregnancy by minimizing risks introduced by unnecessary myomectomies. Reducing complications and eliminating unnecessary interventions are also expected to decrease costs to the health care system. Summary Statements 1. Subserosal fibroids do not appear to have an impact on fertility; the effect of intramural fibroids remains unclear. If intramural fibroids do have an impact on fertility, it appears to be small and to be even less significant when the endometrium is not involved. (II-3) 2. Because current medical therapy for fibroids is associated with suppression of ovulation, reduction of estrogen production, or disruption of the target action of estrogen or progesterone at the receptor level, and it has the potential to interfere in endometrial development and implantation, there is no role for medical therapy as a stand-alone treatment for fibroids in the infertile population. (III) 3. Preoperative assessment of submucosal fibroids is essential to the decision on the best approach for treatment. (III) 4. There is little evidence on the use of Foley catheters, estrogen, or intrauterine devices for the prevention of intrauterine adhesions following hysteroscopic myomectomy. (II-3) 5. In the infertile population, cumulative pregnancy rates by the laparoscopic and the minilaparotomy approaches are similar, but the laparoscopic approach is associated with a quicker recovery, less postoperative pain, and less febrile morbidity. (II-2) 6. There are lower pregnancy rates, higher miscarriage rates, and more adverse pregnancy outcomes following uterine artery embolization than after myomectomy. (II-3) Studies also suggest that uterine artery embolization is associated with loss of ovarian reserve, especially in older patients. (III) Recommendations 1. In women with infertility, an effort should be made to adequately evaluate and classify fibroids, particularly those impinging on the endometrial cavity, using transvaginal ultrasound, hysteroscopy, hysterosonography, or magnetic resonance imaging. (III-A) 2. Preoperative assessment of submucosal fibroids should include, in addition to an assessment of fibroid size and location within the uterine cavity, evaluation of the degree of invasion of the cavity and thickness of residual myometrium to the serosa. A combination of hysteroscopy and transvaginal ultrasound or hysterosonography are the modalities of choice. (III-B) 3. Submucosal fibroids are managed hysteroscopically. The fibroid size should be < 5 cm, although larger fibroids have been managed hysteroscopically, but repeat procedures are often necessary. (III-B) 4. A hysterosalpingogram is not an appropriate exam to evaluate and classify fibroids. (III-D)  5. In women with otherwise unexplained infertility, submucosal fibroids should be removed in order to improve conception and pregnancy rates. (II-2A) 6. Removal of subserosal fibroids is not recommended. (III-D) 7. There is fair evidence to recommend against myomectomy in women with intramural fibroids (hysteroscopically confirmed intact endometrium) and otherwise unexplained infertility, regardless of their size. (II-2D) If the patient has no other options, the benefits of myomectomy should be weighed against the risks, and management of intramural fibroids should be individualized. (III-C) 8. If fibroids are removed abdominally, efforts should be made to use an anterior uterine incision to minimize the formation of postoperative adhesions. (II-2A) 9. Widespread use of the laparoscopic approach to myomectomy may be limited by the technical difficulty of this procedure. Patient selection should be individualized based on the number, size, and location of uterine fibroids and the skill of the surgeon. (III-A) 10. Women, fertile or infertile, seeking future pregnancy should not generally be offered uterine artery embolization as a treatment option for uterine fibroids. (II-3E).


Seminars in Reproductive Medicine | 2006

Genetics of recurrent pregnancy loss.

Sony Sierra; Mary D. Stephenson


Human Reproduction | 2006

Reproductive outcomes in recurrent pregnancy loss associated with a parental carrier of a structural chromosome rearrangement

Mary D. Stephenson; Sony Sierra


Journal of obstetrics and gynaecology Canada | 2014

Issues de grossesse à la suite du recours à la procréation assistée

Nanette Okun; Sony Sierra; R. Douglas Wilson; François Audibert; Jo-Ann Brock; Carla Campagnolo; June Carroll; Lola Cartier; David Chitayat; Alain Gagnon; Jo-Ann Johnson; Sylvie Langlois; Lynn Murphy-Kaulbeck; W. Kim MacDonald; Melanie Pastuck; Lih Yeen Tan; Valda Poplak; Helen Robson


Archive | 2010

Déclenchement de l'ovulation en présence du syndrome des ovaires polykystiques Résumé

Tannys D.R. Vause; Anthony P. Cheung; Sony Sierra; Paul Claman; James Graham; Jo-Anne Guillemin; Louise Lapensée; Sabrina Stewart; Benjamin Chee-Man Wong; Comité De Société; Jason K. Min; Ken Cadesky; Ellen M. Greenblatt; Jon Havelock; Jeffrey Roberts


Archive | 2010

Le Transfert sélectif d'un seul embryon à la suite de la fécondation

Jason K. Min; Edward G. Hughes; David Young; Comité Commun; Matt Gysler; Robert Hemmings; Anthony P. Cheung; Gwendolyn J. Goodrow; Jason Min; Vyta Senikas; Benjamin Chee-Man Wong; Sony Sierra; Belina Carranza-Mamane; Allison Case; Cathy Dwyer; James Graham; Jon Havelock; Francis Lee; Kim Liu; Tannys D.R. Vause


Journal of Reproductive Medicine | 2008

Hysterosalpingography in the Investigation of Women Requesting Reversal of Sterilization : Should It Play a Role?

Sony Sierra; Peter F. McComb


Fertility and Sterility | 2006

Preliminary counseling with age-related fertility rates does not influence whether women undergo reversal of sterilization

Yolanda A. Butt; Sony Sierra; Peter F. McComb


Fertility and Sterility | 2005

Does Hysterosalpingography Have a Role in the Investigation of Women Requesting Reversal of Sterilization

Sony Sierra; Peter F. McComb


Fertility and Sterility | 2005

LH and Progesterone Levels Do Not Predict Pregnancy Success in Cryopreserved Embyro Replacement Using Transdermal Estradiol for Endometrial Synchronization

Anthony P. Cheung; J.M. Noble; Sony Sierra; S.J. Wilson

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Anthony P. Cheung

University of British Columbia

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Peter F. McComb

University of British Columbia

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Mary D. Stephenson

University of Illinois at Chicago

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Allison Case

Université de Sherbrooke

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Belina Carranza-Mamane

University of British Columbia

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Sylvie Langlois

University of British Columbia

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Jon Havelock

University of Minnesota

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Alain Gagnon

University of British Columbia

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Cathy Dwyer

University of Saskatchewan

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