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 American Journal of  Medical Science and 
Innovation (AJMSI)

Fibroids and Subfertility: A Systematic Review of  Latest Evidence from international 
Societies   

Alina Shirazi1*, Tokunbo Adeoye1, Seema Bagtharia1, Jitendra Jadhav1, Sumi Garg2, Humna Mian Faiz Rasul3, Fatima Shah4

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.3992
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: November 03, 2024

Accepted: December 08, 2024

Published: March 04, 2025

Uterine fibroids (leiomyomas) are benign tumors of  the uterus, commonly present among 
women of  reproductive age, affecting fertility outcomes. This systematic review aims to 
gather the current evidence regarding the association between fibroids and subfertility. 
Additionally, this review aims to analyze national recommendations to conclude the best 
uterine fibroid treatment, while highlighting the optimal method of  enhancing pregnancy 
rates.  A thorough literature search was conducted to retrieve standard of  practice guidelines 
across PubMed, Google Scholar, and MEDLINE databases. Further guidelines were also 
searched through relevant websites of  obstetrics and gynecology associations. Hence, seven 
international clinical guidelines were retrieved. The findings state that fibroids can affect 
fertility through several mechanisms, such as modification of  the uterine environment, 
and distortion of  fallopian tubes and uterine cavity, leading to potential implantation and 
placentation failure. In addition, various fibroid management approaches, including medical 
treatments like surgical and minimally invasive interventions in women desiring future 
fertility, are investigated. Latest studies suggest that the amount, size, and location of  
fibroids impact fertility outcomes. All guidelines recommend that during the selection of  
a treatment method, personalized patient requirements like the preference for childbirth in 
the future should be taken into consideration. The number, size, and location of  fibroids are 
critical elements to take into consideration. Globally, fibroid management with inexplicable 
infertility in women has limited empirical and standardized guidelines. Therefore, further 
research is crucial to understand the fundamental mechanisms and to establish effective 
management strategies for women with fibroids facing subfertility.

Keywords
Fertility, Fibroids, Guidelines, 
Infertility, Leiomyomas, Uterine 
Fibroids

1  Department of  Obstetrics and Gynaecology, Basildon Hospital, South and Mid-Essex Foundation Trust, Basildon, Essex, UK
2 Department of  Obstetrics and Gynaecology, Colchester Hospital, UK 
3  Sir Syed Medical College, Karachi, Pakistan
4  Bedford Hospital, NHS Trust, Bedford, UK
* Corresponding author’s e-mail: alinashirazimrcog@gmail.com

INTRODUCTION
Uterine myomas (leiomyomata, fibroids) are known to 
be the most common type of  reproductive tract tumors, 
showing a cumulative incidence rate of  70% among 
women of  reproductive age (Baird et al., 2003; Cramer 
& Patel, 1990). Due to fibroids, a woman’s quality 
of  life is impacted along with fertility and obstetrical 
results. They are developed through the fibroblasts of  
myometrium and the cells of  smooth muscle, categorized 
as submucosal, intramural, or sub-serosal, reliant on 
their position (Michos et al., 2023). The stimulation of  
estrogen has a positive association with the development 
of  fibroids, resulting in fibroid reduction as menopause 
initiates (Goerke et al., 2014; Toprak et al., 2019).
Usually, leiomyomas are one the main issue that arises in 
women of  reproductive age, which can pose detrimental 
effects on fertility outcomes or exhibit symptoms like 
bleeding, pressure, abnormal uterine bleeding, or pelvic 
pain (Drayer & Catherino, 2015; Khaund & Lumsden, 
2008). Uterine myomas, also known as benign monoclonal 
tumors, are typically common among women of  African 
lineage (Khaund & Lumsden, 2008; Mahdi, 2019). At an 
early age, African descent women usually give birth with 
a substantially adverse burden of  myoma as compared to 
Caucasian women with symptomatic myomas (Peddada 
et al., 2008).
Throughout the years, several research groups and 

societies either national or international, have led studies 
to investigate the link between leiomyomas and fertility, 
with contradictory outcomes concerning the influence 
on fertility (Khaund & Lumsden, 2008; Mukhopadhaya 
et al., 2007; Pritts, 2001). Uterine fibroid management 
is highly debated among women with subfertility, with 
different recommendations for non-surgical procedures 
like, medical intervention and observation, and surgical 
procedures like, myomectomy. Furthermore, concerns 
have been raised regarding the probability of  success and 
intervention protocols with the application of  assisted 
reproductive technologies (ART), like in-vitro fertilization 
(IVF) in cases of  leiomyomas. There is a critical need 
for a comprehensive systematic review evaluating the 
current evidence on fibroids and subfertility, keeping in 
consideration the complexity of  the problem and the 
constant modifications of  clinical guidelines. Hence, 
this review aims to investigate the effects of  fibroids on 
fertility outcomes, while assessing and presenting findings 
established on recent international guidelines.

MATERIALS AND METHODS
This systematic review is executed based on the 
methodology permitting the Preferred Reporting Items 
for Systematic Reviews and Meta-Analysis (PRISMA) 
statements (Moher et al., 2009).



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Inclusion Criteria
Guidelines were included if  they met the following criteria: 
(1) Clinical guidelines associated with uterine fibroids 
with fertility, subfertility, assessing fertility outcomes and 
treatment strategies (2) Guidelines published/authorized 
by one or more nationally or internationally recognized 
medical associations linked to obstetrics/gynecology 
or interventional radiology, who classify as quality 
improvement guidelines or practice standards (3) Recent 
studies published in the last few years, ranging from 2012 
to 2024 (4) Guidelines available in English.

Exclusion Criteria
Guidelines were excluded if: (1) Guidelines were non-
current and outdated (2) Guidelines related to non-
uterine fibroids (3) Not available in English.

Search Strategy
Several electronic databases including PubMed, 
MEDLINE and Google Scholar were searched from 2012 
to 2024 for relevant clinical guidelines regarding uterine 
fibroid treatments, reporting its clinical fertility outcomes 
which meets the inclusion criteria. To further search 
guidelines undiscovered through search strategy, the 
included guidelines’ reference lists were searched manually. 
Guidelines were specifically limited to the availability 
in English language. Varying on the database, different 
combinations of  MeSH terms were employed. The search 

terms included “Fibroids”, “Fertility”, “Guidelines”, 
“Leiomyomas”, “Infertility”, “Uterine Fibroids”.

Data Extraction and Management
Screening of  the abstracts and titles were performed by 
two reviewers. The titles and abstracts of  the screened 
clinical guidelines were reviewed to ensure compliance 
with inclusion criteria. Data extraction was performed 
employing the general data extraction methods 
comprising study attributes such as title, publication year, 
treatment approaches, and outcome measures.

Quality Assessment
In this review, the GRADE system (Grading of  
Recommendations, Assessment, Development, and 
Evaluation) was employed to evaluate the quality of  
guidelines (Brignardello-Petersen & Guyatt, 2024).

RESULTS AND DISCUSSIONS
Initially, 44 studies were overall identified and screened 
through comprehensive database searches. After 
implementing the inclusion and exclusion criteria, 7 articles 
were chosen for a thorough analysis, which included 
clinical guidelines available from 2012 to 2024. Figure 
1 shows the identified databases and screened studies 
included in this systematic review, meeting the inclusion 
and exclusion criteria. The PRISMA flow diagram was 
created using PRISMA2020 (Haddaway et al., 2022).

Figure 1: PRISMA Flow Diagram detailing the process of  study selection

This review follows the guidelines from the British Fibroid 
Society (BFS) (Trust, 2021), European Medical Journal 
of  Reproductive Medicine (EMJ) (Mahdi, 2019), Royal 
Australian and New Zealand College of  Obstetricians 
and Gynecologists (RANZCOG) (Australia, 2020), the 
American Society for Reproductive Medicine (ASRM) 
(Penzias et al., 2017), Society of  Obstetricians and 
Gynecologists of  Canada (SOGC) (Vilos et al., 2015), 

the French College of  Gynecologists and Obstetricians 
(CNGOF) (Marret et al., 2012), and American Association 
of  Gynecologic Laparoscopists (AAGL) (Laparoscopists, 
2012). All the guidelines support the statement that 
the effect of  fibroids on fertility is associated to the 
endometrial cavity alteration and the fibroids position 
in the uterus. However, the type of  treatments such 
as surgical treatments including, minimally invasive 



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gynecologic surgeries (MIGS), myomectomy, Magnetic 
Resonance-guided Focused Ultrasound (MRgFUS), 
and Uterine Artery Embolization (UAE) or medical 
treatments needed is dependent upon the particular 
boards.

Leiomyomas on Fertility Outcomes
Due to uterine leiomyomas, clear anatomic disruption 
of  the normal uterine cavity can occur. The endometrial 

cavity can be affected specifically by submucosal 
leiomyomas, potentially influencing embryo development 
and implantation. However, leiomyomas can occur in 
other positions like, in sub-serosal site or in myometrium 
(Donnez & Jadoul, 2002). Leiomyomas can augment into 
large masses before the occurrence of  symptoms such as, 
pelvic pain or pressure although, it may plausibly disturb 
pregnancy management and fertility (Penzias et al., 2017). 
Figure 2 shows the postulated mechanisms of  fibroids.

Figure 2: Postulated mechanisms through which fibroids results in subfertility

This figure shows the postulated theories of  mechanisms 
that can result in fibroids causing subfertility (Khaund & 
Lumsden, 2008).
Although, there are several fibroid categories (Lasmar et 
al., 2005; Stamatellos & Bontis, 2007), the International 
Federation of  Gynecology and Obstetrics (FIGO) 
targeted a comprehensive categorization, suggesting the 
division of  leiomyomas into eight types, 0 to 8 (Munro 

et al., 2011). Figure 3 shows the FIGO Classification 
System for Uterine Leiomyoma. In accordance with 
this classification system, reliant on the percentage of  
protruding fibroid from the endometrial cavity sub-
mucosal myomas are subcategorized into 0, 1, and 2. 
Moreover, the intramural myoma are subcategorized 
into 3, 4, and 5 whereas, the sub-serosal myomas are 
subcategorized into 6, 7, and 8.



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Figure 3: FIGO Revised Classification System 2023 for Uterine Leiomyoma

This model summarizes the FIGO classification system 
for uterine leiomyoma (fibroids) based on its location 
(Munro et al., 2011). This classification system was 
established for clinical and research purposes (Gomez 
et al., 2021), however, in clinical application, there is 
substantial deviation in agreement (Laughlin-Tommaso 
et al., 2017).

Medical Management in Fibroids
For the clinical management of  fibroids, the 
recommendations of  the guidelines promote 
gonadotropin-releasing hormone (GnRH) analogues 
as a pre-operative intervention and suggest careful 
application regarding ulipristal acetate (UPA). Table 
1 shows the summary of  the interventions associated 
with medical management of  fibroids according to 
various international societies. If  the other treatments 
are unsuccessful, BFS permits restricted use of  UPA 
for intermittent intervention of  moderate to severe 
symptoms of  fibroids due to the risk of  severe liver injury 
(Trust, 2021). On the other hand, the ASRM does not 
approve UPA in the United States for the treatment of  
fibroids, especially in infertile women, due to its significant 
adverse effects (Penzias et al., 2017). The EMJ notes that 
UPA can reduce fibroid size by inducing apoptosis in 
leiomyoma cells, but its use is limited to three months, 
with effects lasting up to six months (Mahdi, 2019). 
According to RANZCOG, usage of  UPA is restricted in 

infertile women with leiomyomas due to the associated 
risk of  substantial adverse effects (Australia, 2020). In 
contrast, GnRH analogues are widely suggested by the 
ASRM, RANZCOG, CNGOF, BFS, and AAGL as pre-
operative therapies to reduce uterine volume and manage 
anemia, facilitating less invasive surgeries (Australia, 
2020; Laparoscopists, 2012; Marret et al., 2012; Penzias 
et al., 2017; Trust, 2021). However, the EMJ does not 
discuss GnRH analogs in their guidelines (Mahdi, 2019). 
Similarly, CNGOF and AAGL do not discuss UPA in 
their guidelines (Laparoscopists, 2012; Marret et al., 2012). 
Although, SOGC has discussed both UPA and GnRH 
analogues, there is no role of  their medical management 
as a stand-alone treatment (Vilos et al., 2015).

Surgical Management of  Fibroids to Improve 
Fertility
Myomectomy, a surgical procedure to remove uterine 
fibroids, is considered an option for improving pregnancy 
rates in certain cases, though recommendations vary 
across medical guidelines (Casini et al., 2006). Table 2 
shows the summary of  the interventions associated 
with surgical management of  fibroids in enhancing 
fertility outcomes according to various international 
societies. The BFS suggests hysteroscopic resection for 
submucosal fibroids and open abdominal or laparoscopic 
surgery for intramural and sub-serosal fibroids (Trust, 
2021). EMJ suggests hysteroscopic or laparoscopic 



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Table 1: Summary of  the Medical Management of  Fibroids.
Medical
Management

BFS EMJ RANZCOG ASRM SOGC CNGOF AAGL
U

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myomectomy for submucosal fibroids and hysteroscopic 
myomectomy for fibroids situated in the FIGO 0 and 
FIGO-1 cavity (Mahdi, 2019). ASRM recommends 
myomectomy for women with distorted cavity fibroids 
(intramural with submucosal components or submucosal 
fibroids). However, it is generally advised against the 
procedure for non-cavity distorting fibroids in women 
experiencing no symptoms (Penzias et al., 2017). On the 
other hand, in cases where severe distortion of  pelvic 
architecture complicates oocyte retrieval, myomectomy 
may still be considered. RANZCOG supports the use 
of  hysteroscopic myomectomy to enhance fertility 
outcomes, particularly for submucosal fibroids, though 
it acknowledges the need for further research (Australia, 
2020). Studies suggest that up to 50% of  women suffering 

from infertility associated with fibroids become pregnant 
following myomectomy, with the most significant 
improvement observed in women with submucosal 
fibroids (Jeldu et al., 2021). Although, SOGC suggests 
myomectomy as an effective treatment option for 
enhancing fertility, further investigation is stated (Vilos et 
al., 2015). Moreover, CNGOF recommends hysteroscopic 
myomectomy in sub-mucosal fibroids ranging less than 4 
cm. Whereas, laparoscopic myomectomy is recommended 
for symptomatic fibroids, taking in consideration its 
amount and size for enhancing fertility (Marret et al., 
2012). AAGL recommends abdominal myomectomy 
when hysteroscopic myomectomy may widely damage 
the endometrial surface or in the presence of  3 or more 
sub-mucous fibroids (Laparoscopists, 2012).

Table 2: Summary of  the Surgical Management of  Fibroids to Improve Fertility.
Surgical Management

Societies Myomectomy (Hysteroscopic/Laparoscopic/Abdominal)
BFS Myomectomy enhances 50% of  fertility in women with fibroid-associated infertility

Hysteroscopic suggested for sub-mucosal fibroids (<5cm and >50% intramural)
Open abdominal or laparoscopic suggested for intramural and sub-serosal fibroids

EMJ Myomectomy enhances 50% of  fertility in women with fibroid-associated infertility
Hysteroscopic or laparoscopic suggested for submucosal fibroids
Hysteroscopic suggested for fibroids situated in the FIGO 0-1 cavity

RANZCOG Hysteroscopic may enhance fertility in sub-mucosal fibroids
Myomectomy may be suggested for women undergoing ART with sub-mucosal fibroids

ASRM Hysteroscopic, laparoscopic or open may enhance fertility in asymptomatic women with 
cavity-distorted fibroids
Not suggested in infertile, asymptomatic women with non-cavity distorted fibroids 

SOGC Myomectomy suggested for enhancing fertility
CNGOF Hysteroscopic suggested for sub-mucosal fibroids (<4 cm)

Laparoscopic suggested for symptomatic fibroids
AAGL Abdominal suggested for 3 or more sub-mucosal fibroids or when hysteroscopic may 

extensively damage endometrial surface



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Minimal Invasive Surgical Options
In context to preservation of  fertility, MRgFUS and UAE 
are both under scrutiny. Table 3 shows the summary of  
the minimally invasive surgical interventions associated 
with medical management of  fibroids to improve 
fertility outcomes according to various international 
societies. BFS and SOGC does not discuss MRgFUS in 
its guidelines in context to fertility. EMJ recognizes the 
potential of  MRgFUS in treating infertility but concurs 
that additional studies are necessary to substantiate its 
effectiveness and safety (Mahdi, 2019). ASRM notes 
that currently, there is lacking evidence to suggest 
MRgFUS for patients aiming to maintain future fertility, 
emphasizing the need for further research (Penzias et al., 
2017). RANZCOG advises MRgFUS, alongside other 
interventions like, radiofrequency ablation (RFA) and 
myolysis must be utilized only within approved clinical 
trials (Australia, 2020). Similarly, according to CNGOF 
and AAGL, MRgFUS must only be utilized within 
approved clinical trials (Laparoscopists, 2012; Marret et 
al., 2012). Regarding UAE, BFS acknowledges a growing 
number of  pregnancies following the procedure but 
asserts that there is still inadequate data to endorse its 
safety for women with leiomyomas, desiring preservation 
of  their fertility (Trust, 2021). The ASRM considers UAE 
unsuitable for patients desiring pregnancy in the future 
as a result of  augmented risks associated with pregnancy 

and possible ovarian reserve declines (Penzias et al., 2017). 
RANZCOG supports this stance, recommending that 
UAE be limited to clinical trials when applied to fibroids 
in women with infertility (Australia, 2020). EMJ reports 
that UAE is associated with lower pregnancy rates and 
longer conception times in women under 35 compared 
to myomectomy, making it a less favorable option for 
those seeking to preserve fertility. Additionally, CNGOF 
and AAGL state UAE as an inadvisable intervention for 
women desiring future pregnancies (Laparoscopists, 2012; 
Marret et al., 2012). Whereas, SOGC may recommend 
UAE only in selective women due to increased pregnancy-
associated risks (Vilos et al., 2015). According to BFS, 
RFA is not suitable for treating all types of  fibroids (Trust, 
2021). EMJ, ASRM and SOGC does not discuss both 
RFA and myolysis in context to fertility. CNGOF states 
that further research is essential for RFA and myolysis 
(Marret et al., 2012). AAGL does not recommend RFA 
for women wanting future pregnancies (Laparoscopists, 
2012). Moreover, it does not discuss myolysis. Overall, 
there is a consensus that all of  the minimally invasive 
surgical procedures require further investigation and 
should currently be considered primarily within the 
framework of  clinical trials. In line with this cautious 
approach, uterine-sparing, minimal invasive procedures 
are being explored as substitutes to myomectomy.

Table 3: Summary of  the Minimal Invasive Surgical Procedures.
Minimally 
Invasive Surgical 
Procedures

BFS EMJ RANZCOG ASRM SOGC CNGOF AAGL

M
Rg

FU
S

N
ot

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isc

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se

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Pr
om

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ng

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le

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f 

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ffi

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it 

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te

 
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n 

(<
35

 a
ge

)

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co

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A

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pr
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nc

y



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M
yo

ly
sis

N
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se

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N
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Quality Assessment Findings
The quality assessment findings show that myomectomy 
is strongly recommended and supported by high-
quality evidence from cohort, observational studies 
and systematic reviews for the treatment for fibroid-
related infertility (Grade 1A or A). Whereas, UAE is 
conditionally suggested for women suffering from 
large-sized fibroids, unable to treatment from surgery 
(Grade 2B or B). Furthermore, the expert opinion 

recommends that myomectomy and UAE as effective 
interventions in accordance with most of  the guidelines. 
No recommendations for the treatment of  small-sized 
asymptomatic fibroids are suggested unless fertility is 
impacted. Table 3 and 4 summarizes quality assessment 
findings using the GRADE system, applicable to fibroids 
and their treatment in infertility according to various 
international guidelines.

Table 4: GRADE System for Fibroids and Infertility Treatment.
Evidence Type BFS EMJ RANZCOG ASRM SOGC CNGOF AAGL

RC
Ts

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

im
pr

ov
es

 
fe

rt
ili

ty
 (G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

fo
r 

su
bm

uc
os

al
 fi

br
oi

ds
 

(G
ra

de
 A

)

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

fo
r f

er
til

ity
 

(G
ra

de
 A

)

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

ef
fe

ct
iv

e 
(G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

im
pr

ov
es

 
fe

rt
ili

ty
 (G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

is 
th

e 
go

ld
 

st
an

da
rd

 (G
ra

de
 1

A
)

H
ig

h 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

re
co

m
m

en
de

d 
(G

ra
de

 1
A

)

C
oh

or
t S

tu
di

es

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

t f
or

 
m

yo
m

ec
to

m
y 

(G
ra

de
 

2B
)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

t f
or

 
m

yo
m

ec
to

m
y 

(G
ra

de
 

B) M
od

er
at

e 
qu

al
ity

; 
M

yo
m

ec
to

m
y 

fo
r 

fe
rt

ili
ty

 (G
ra

de
 B

)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 m

yo
m

ec
to

m
y 

(G
ra

de
 2

B)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 m

yo
m

ec
to

m
y 

(G
ra

de
 2

B)

M
od

er
at

e 
qu

al
ity

; 
Be

ne
fit

s o
f 

su
rg

er
y 

(G
ra

de
 2

B)

M
od

er
at

e 
qu

al
ity

; 
Be

ne
fit

s o
f 

su
rg

er
y 

(G
ra

de
 2

B)

C
as

e-
co

nt
ro

l S
tu

di
es

M
od

er
at

e 
qu

al
ity

; 
Be

ne
fit

s o
f 

su
rg

er
y 

(G
ra

de
 2

B)

Lo
w

 q
ua

lit
y:

 C
as

e-
co

nt
ro

l e
vi

de
nc

e 
(G

ra
de

 C
)

Lo
w

 q
ua

lit
y;

 L
im

ite
d 

ev
id

en
ce

 (G
ra

de
 3

C
)

Lo
w

 q
ua

lit
y;

 L
im

ite
d 

da
ta

 (G
ra

de
 3

C
)

Lo
w

 q
ua

lit
y;

 C
as

e-
co

nt
ro

l e
vi

de
nc

e 
(G

ra
de

 3
C

)

Lo
w

 q
ua

lit
y;

 L
im

ite
d 

ev
id

en
ce

 (G
ra

de
 3

C
)

Lo
w

 q
ua

lit
y;

 L
im

ite
d 

ev
id

en
ce

 (G
ra

de
 3

C
)

Sy
st

em
at

ic
 R

ev
ie

w
s

H
ig

h 
qu

al
ity

; 
St

ro
ng

 e
vi

de
nc

e 
fo

r m
yo

m
ec

to
m

y 
(G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; 
Su

pp
or

ts
 

m
yo

m
ec

to
m

y 
(G

ra
de

 A
)

H
ig

h 
qu

al
ity

; 
St

ro
ng

 e
vi

de
nc

e 
fo

r m
yo

m
ec

to
m

y 
(G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; 
Su

pp
or

ts
 

m
yo

m
ec

to
m

y 
(G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; F
av

or
 

m
yo

m
ec

to
m

y 
(G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; 
St

ro
ng

 e
vi

de
nc

e 
fo

r m
yo

m
ec

to
m

y 
(G

ra
de

 1
A

)

H
ig

h 
qu

al
ity

; U
A

E
 

an
d 

m
yo

m
ec

to
m

y 
(G

ra
de

 1
A

)

E
xp

er
t o

pi
ni

on

M
od

er
at

e 
qu

al
ity

; 
A

gr
ee

m
en

t o
n 

m
yo

m
ec

to
m

y 
(G

ra
de

 2
A

)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 su

rg
er

y 
(G

ra
de

 B
)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 su

rg
er

y 
(G

ra
de

 2
A

)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 su

rg
er

y 
(G

ra
de

 2
A

)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 su

rg
er

y 
(G

ra
de

 2
A

)

M
od

er
at

e 
qu

al
ity

; 
Su

pp
or

ts
 su

rg
er

y 
(G

ra
de

 2
A

)

M
od

er
at

e 
qu

al
ity

: 
Su

pp
or

ts
 su

rg
er

y 
(G

ra
de

 2
A

)



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Am. J. Med. Sci. Innov. 4(1) 74-83, 2025

Table 5: Recommendations of  Fibroid-treatments Across Various Guidelines.
Evidence Type BFS EMJ RANZCOG ASRM SOGC CNGOF AAGL

St
ro

ng
 re

co
m

m
en

da
tio

n

G
ra

de
 1

A
; M

yo
m

ec
to

m
y 

fo
r fi

br
oi

d-
as

so
ci

at
ed

 
in

fe
rt

ili
ty

G
ra

de
 A

; M
yo

m
ec

to
m

y 
fo

r s
ub

m
uc

os
al

 fi
br

oi
ds

G
ra

de
 A

; M
yo

m
ec

to
m

y 
fo

r f
er

til
ity

G
ra

de
 1

A
; M

yo
m

ec
to

m
y 

fo
r i

nf
er

til
ity

G
ra

de
 1

A
; M

yo
m

ec
to

m
y 

is 
st

an
da

rd
 tr

ea
tm

en
t

G
ra

de
 1

A
; M

yo
m

ec
to

m
y 

is 
th

e 
op

tim
al

 st
an

da
rd

G
ra

de
 1

A
; R

ec
om

m
en

ds
 

m
yo

m
ec

to
m

y

W
ea

k 
re

co
m

m
en

da
tio

n

G
ra

de
 2

B;
 U

A
E

 fo
r 

la
rg

e 
fib

ro
id

s

G
ra

de
 B

; U
A

E
 fo

r 
la

rg
e 

fib
ro

id
s

G
ra

de
 B

; U
A

E
 fo

r 
la

rg
e 

fib
ro

id
s

G
ra

de
 2

B;
 U

A
E

 fo
r 

la
rg

er
 fi

br
oi

ds

G
ra

de
 2

B;
 U

A
E

 fo
r 

la
rg

e 
fib

ro
id

s

G
ra

de
 2

B;
 U

A
E

 fo
r 

la
rg

e 
fib

ro
id

s

G
ra

de
 2

B;
 U

A
E

 
as

 fe
rt

ili
ty

-s
pa

rin
g 

tre
at

m
en

t

N
o 

re
co

m
m

en
da

tio
n

G
ra

de
 B

; N
o 

tre
at

m
en

t f
or

 
as

ym
pt

om
at

ic
 sm

al
l 

fib
ro

id
s

G
ra

de
 C

; N
o 

tre
at

m
en

t f
or

 sm
al

l 
fib

ro
id

s w
ith

ou
t 

sy
m

pt
om

s

G
ra

de
 3

C
; N

o 
tre

at
m

en
t f

or
 

as
ym

pt
om

at
ic

 fi
br

oi
ds

G
ra

de
 3

C
; N

o 
tre

at
m

en
t f

or
 sm

al
l 

fib
ro

id
s

G
ra

de
 3

C
; N

o 
tre

at
m

en
t f

or
 sm

al
l 

fib
ro

id
s

G
ra

de
 3

C
; N

o 
tre

at
m

en
t f

or
 

as
ym

pt
om

at
ic

 fi
br

oi
ds

G
ra

de
 3

C
; N

o 
tre

at
m

en
t f

or
 sm

al
l 

fib
ro

id
s

CONCLUSION
This systematic review reports an agreement over 
significant guidelines concerning the effect of  fibroids 
on fertility, emphasizing the negative impacts of  
submucosal fibroids that can modify the normal uterus 
lining. According to the reviewed guidelines, specifically 
of  ASRM and RANZCOG, the results demonstrate that 
sub-serosal fibroids do not have negative fertility effects, 
whereas fertility is negatively affected through intramural 
fibroids impacting the cavity of  the uterus. Furthermore, 
myomas can substantially diminish the rates of  conception 
and clinical fertility, regardless of  their position.
The main discussion revolves around improving the 
potential of  conception among infertile women with 
fibroids and the adequacy of  its surgery management. 
To enhance both the chances of  IVF and spontaneous 
pregnancy, the surgical treatment must be personalized 
to attain an ideal uterine cavity. The surgeon must decide 
the type of  surgical intervention; either a minimally 
invasive procedure or myomectomy is required, keeping 
in consideration the site and size of  the fibroid. Even 
though the fibroid position may be closely associated 
with clinical results, the effect of  the amount and size of  
fibroids on fertility stays uncertain.
Current minimal invasive procedures consisting of  
MRgFUS, myolysis, RFA, and UAE are potentially effective 
treatments. However, further research regarding these 
procedures is required for comprehensive assessment. 
Due to a lack of  empirical evidence, recent guidelines 
except ASRM, do not endorse these procedures for 

application other than in clinical trials. The high frequency 
of  leiomyomas and their prospective detrimental effects 
on fertility highlight the establishment of  empirical-based 
procedures and further research is critical.

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