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 fi broid-related infertility increasingly common. This review aimed to critically analyze the association between uterine fi broids and infertility, mechanisms by which uterine fi broids may impair fertility, and management of myoma-related infertility. The association of fi broids 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 fi broids. 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 bene fi ts 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 ef fi cacy 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 signi fi cant reduction in fi broid 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. (Fertil Steril (R) 2024;122:31 - 9. (c) 2024 by American Society for Reproductive Medicine.)