Fibroids
Fibroids are extremely common and up to 50% of women have them and have no problems conceiving or carrying the pregnancy. A submucosal fibroid is a fibroid that is inside the cavity. There is a FIGO classification for fibroids, type 0 is intracavitary, type 1 is a fibroid that is >50% inside the cavity, type 2 fibroid is a fibroid that is < 50% in the cavity. There is consensus amongst the REI physicians that these fibroids can impact implantation of an IVF embryo and can increase the risks of miscarriages and should be removed. The effect of a Type 3 fibroid which is intramural and to the level of the cavity without impingement is less clear and it depends on its size, and should be monitored with frequent ultrasounds for changes. The best evaluation of the uterine cavity is with a saline sonogram or a hysteroscopy which is a direct visualization of the uterine cavity with a telescope after the cavity is distended with fluid.
The management of uterine fibroids in an infertile patient with a history of miscarriages is controversial. If a patient has type 0-2 fibroids, then the standard of care would be surgery. However, in a patient who does not have a type 0-2 submucosal fibroid and has normal saline sonogram and hysteroscopy, surgery is not recommended as the fibroids cannot be removed hysteroscopically. The surgery would be more invasive with abdominal approach and can cause more harm to the uterus without a clear benefit.
Intramural fibroids can grow with time, with age and with hormonal stimulation from fertility treatment and pregnancy, although fertility treatment is not contraindicated. It is also very reasonable to remove fibroids if there is continued history of miscarriages after fertility treatment even after a tested embryo is transferred. However, it is not a deviation from standard of care not to do a myomectomy earlier if previous ultrasounds and saline sonograms do not show a clear indication.