Uterine Fibroids in the Setting of Infertility: When to Treat, How to Treat?

Purpose of Review We aim to provide insight on the treatment of fibroids in the infertile patient. Specifically, we discuss which fibroids, based on size and location within the uterine wall, have the most impact on fertility outcomes. In addition, we demonstrate which methods are best for treatment of fibroids in the infertile patient, focusing on minimally invasive techniques. Recent Findings Current research demonstrates that, in addition to submucosal fibroids, also intramural fibroids can have a negative impact on fertility via molecular and mechanical disruption of the endometrium and of normal uterine peristalsis. Certain intramural fibroids should be considered for removal or treatment in the infertile patient, depending on size and patient history. We also provide a large body of evidence demonstrating the safety and clinical advantages of minimally invasive techniques, such as hysteroscopy, laparoscopy, and robot-assisted laparoscopy in the treatment of uterine fibroids. Summary All submucosal and many intramural fibroids interfere with uterine function. In the evaluation of the infertile patient, accurate fibroid mapping within the uterus is essential to identify those submucosal and intramural fibroids that are likely to have the most impact of fertility outcomes. The mainstay of treatment is surgery for those fibroids with the most detrimental impact. Nonsurgical alternatives such as magnetic resonance-guided focused ultrasound (MRgFUS) and radiofrequency volumetric thermal ablation (RFVTA) need further validation before their widespread adoption in infertile patients.