Abdominal myomectomy for infertility: a comprehensive review

To obtain estimates of the effect of abdominal myomectomy on infertility, information from studies published in the English language literature between 1982 and 1996 was retrieved. Articles were identified through hand and computerized searches using Medline. A total of 27 trials, all published in peer-reviewed journals, was identified, of which four were excluded from the analysis because of methodological limitations. All studies were non-comparative and only nine were prospective. The sample size was generally limited, the mean number of patients included being 49 and the mean number of infertile subjects 26. All patients were followed for at least 12 months after surgery in 12 studies. The combined estimate of pregnancy rates across prospective studies based on a total of 138 observed subjects was 57% [95% confidence interval (CI), 48-65%]. Time to conception varied from a mean of 8 to 20 months. Survival analysis was used in only three studies, with cumulative rates ranging from 57 to 67% at 1 year, and 63% at 5 years. The overall conception rate among seven prospective studies in which only women with otherwise unexplained infertility were recruited was 61% (95% CI, 51-70%) compared with 38% (95% CI, 20-59%) in two prospective studies that included patients with causes of infertility in addition to myomas (chi2(1) = 4.25, P = 0.04; mean difference = 23%, 95% CI, 1-43%; OR = 2.47, 95% CI, 1.03-5.94). The conception rate ranged from 58 to 65% in the three studies of women with only intramural and/or subserous fibroids and were respectively 53 and 70% in the two that considered only patients with submucous myomas. Data on recurrence after myomectomy were reported in 13 articles, with rates varying from 4 to 47%. According to the available evidence, slightly less than two-thirds of women with uterine leiomyomas and otherwise unexplained infertility conceived after myomectomy. However, comparison with expectant management is needed before drawing definitive conclusions on the effectiveness of this time-honoured conservative surgical procedure.