Uterine fibroids & fertility
Fibroids are benign tumours of the muscular wall of the uterus and one of the most common gynaecological conditions — up to one in two women will develop a fibroid at some point in life. Many fibroids cause no symptoms at all and are found incidentally on an ultrasound scan.
The question that rightly concerns every woman who wants to conceive is a single one: does my fibroid affect my fertility, and does it need to be removed? The answer depends mainly on its location, not simply on its size.
How common are fibroids and why does their location matter?
Fibroids are classified according to their position in the uterine wall. Submucosal fibroids project into the uterine cavity. Intramural fibroids sit within the muscular wall. Subserosal fibroids grow towards the outer surface of the uterus.
This very classification determines their relationship with fertility. A fibroid that distorts the uterine cavity can hinder embryo implantation, whereas a fibroid growing outwards usually has no effect at all.
Which fibroids genuinely harm fertility?
The clearest evidence concerns fibroids that distort the uterine cavity — chiefly submucosal ones. Women with such fibroids have lower rates of implantation, clinical pregnancy and live birth, as well as higher miscarriage rates.
By contrast, subserosal fibroids do not appear to affect fertility and removing them does not improve outcomes. The size and number of fibroids matter, but the position relative to the cavity remains the decisive factor.
What about intramural fibroids that do not distort the cavity?
Here the data are more debated. Some studies link intramural fibroids that do not distort the cavity with slightly lower pregnancy rates in IVF, especially when they are large or multiple; others find no clear difference.
Because the evidence that removing them improves birth rates is limited, surgery for intramural fibroids without cavity distortion is not decided automatically. The possible benefit is weighed against the risks of the operation, on an individual basis.
When is fibroid removal (myomectomy) recommended?
For fibroids that distort the cavity, myomectomy is considered a reasonable option before trying to conceive or before IVF. Submucosal fibroids are usually removed hysteroscopically, through the vagina, without abdominal incisions.
According to ASRM guidance, in women with cavity-distorting fibroids myomectomy may improve pregnancy rates. The decision is made by weighing the woman’s symptoms, age, ovarian reserve and fertility goals.
What are the risks and the timing of myomectomy?
Myomectomy is a safe operation, but it is not trivial. Depending on the type and location, it carries risks such as bleeding, adhesion formation and, in operations on the muscular wall, weakening of the uterus that may affect a future delivery.
After a myomectomy on the muscular wall, a waiting period before trying to conceive is usually advised, and in some cases a caesarean delivery. The precise timing is individualized.
Should every fibroid be removed before IVF?
No. Removing every fibroid “just to be safe” is not evidence-based and may needlessly delay treatment or add surgical risk. Subserosal fibroids and small intramural fibroids that do not touch the cavity are usually monitored, without surgery.
The correct approach is individualized: assessment with ultrasound or, where needed, with MRI and hysteroscopy, to determine whether the cavity is truly affected, and only then a decision about surgery.
Summary
Not all fibroids are the same for fertility. Location is decisive: fibroids that distort the uterine cavity (chiefly submucosal ones) reduce pregnancy rates and their removal can help; subserosal fibroids do not affect fertility; for intramural fibroids without cavity distortion the evidence is limited and debated. Removing every fibroid “just to be safe” is not justified. The decision is made individually.
⚕ Medically reviewed by Prof. Stratis Kolibianakis · Thessaloniki Medical Association Reg. No. 16340
ARTICLE 21 · FEMALE CONDITIONS & FERTILITY
