Submucous myomas and their implications in the

pregnancy rates of patients with otherwise

unexplained primary infertility undergoing
hysteroscopic myomectomy: a randomized
matched control study
Tarek Shokeir, M.D., Muhammed El-Shafei, M.D., Hamed Yousef, M.D., Abdel-Fattah Allam,
M.D., and Ehab Sadek, M.D.
Department of Obstetrics and Gynecology, Fertility Care Unit, Mansoura University Hospital, Mansoura Faculty of Medicine,
Mansoura, Egypt

Objective: To determine whether hysteroscopic myomectomy for submucous fibroids in women with
unexplained primary infertility achieved better pregnancy rates than no intervention.
Design: Prospective randomized matched control trial.
Setting: Tertiary university fertility care unit.
Patient(s): From January 1999 to February 2006, a total of 215 women with unexplained primary infertility
and with ultrasonographically diagnosed submucous myomas as the sole cause for fertility failure were
recruited. Intervention(s): Women were randomly allocated to one of two pretreatment groups matched by
age. Hystero- scopic myomectomy was performed in the study group (n 101). Diagnostic hysteroscopy and
myoma biopsy was performed in the control group (n 103). No fertility therapy was given for either group.
Main Outcome Measure(s): Clinical pregnancy rates according to patient and myoma characteristics.
Result(s): The baseline characteristics of both patients and submucous myomas were comparable. Among
patients with complete follow-up, a total of 93 (45.6%) pregnancies occured64 (63.4%) in the study group
and 29 (28.2%) in the control group. Women in the study group had a better possibility of becoming pregnant
after hysteroscopic myomectomy with a relative risk of 2.1 (95% confidence interval, 1.52.9). No difference in
preg- nancy rates was observed according to size, number, and location of myomas in both groups. However,
fertility rates appeared to increase after hysteroscopic myomectomy of type 0 and type I myomas (P < 0.05). In
contrast, for the subgroup of patients with type II myomas, no difference in fertility rates were noted.
Conclusion(s): Hysteroscopic myomectomy for submucous fibroids in women with unexplained primary infertility is effective in achieving a better pregnancy rate. We think that a multicenter study should be conducted
before evaluating the impact of submucous myoma characteristics on fertility outcome. (Fertil Steril
2010;94:7249.
2010 by American Society for Reproductive Medicine.)
Key Words: Submucous myoma, hysteroscopic myomectomy, infertility

There are many reports in the literature concerning

infertility and submucous fibroids, and none of them
contain a con- firmed conclusion. Physicians who have
female patients with uterine submucous myomas who want
to become preg- nant face a clinical quandary regarding the
best management of such fibroids. The main argument
against conservative hysteroscopic myomectomy is the
lack of definite evidence of a causal association between
submucous fibroids and infer- tility (13). Concerns remain
about potential adverse conse- quences, such as morbidity,
complications, and intrauterine
Received December 9, 2008; revised March 16, 2009; accepted March
19,
2009; published online May 5, 2009.
T.S. has nothing to disclose. M.E-S. has nothing to disclose. H.Y. has
nothing to disclose. A-F.A. has nothing to disclose. E.S. has nothing
to disclose.
Reprint requests: Tarek A. Shokeir, M.D., Department of Obstetrics
and Gynecology, Fertility Care Unit, Mansoura University Hospital,
Man- soura Faculty of Medicine, Mansoura, Egypt (TEL: 20 50
2331118; FAX: 20 50 2319922; E-mail: tarekshokeir@hotmail.com).

adhesion formations in some cases. However, indirect

evidence suggests that the pregnancy rate in women with
otherwise un- explained primary infertility is fairly good,
and more than half of patients become pregnant after
hysteroscopic surgery (4).
Most publications addressing submucous myomas
report a high pregnancy wastage rate, frequently
exceeding 70%. However, the role of the submucous
myoma in this regard and indications for myomectomy
remain controversial (5, 6). We have recently published an
observational prospective study of 26 women11 with
primary infertility and 15 with recur- rent pregnancy loss,
with a submucous myoma as the only ex- planation for the
diagnosisand reported improved reproductive outcomes
after hysteroscopic myomectomy. Af- ter a mean
postoperative follow-up period of 40 months, 81% of
women with unexplained primary infertility and 63% of
those with recurrent pregnancy loss achieved a live birth
(7).
Hysteroscopic removal of such myomas is now the
accepted treatment, despite the lack of good prospective,

724

Fertility and Sterility Vol. 94, No. 2, July 2010

Copyright 2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

0015-0282/$36.00
doi:10.1016/j.fertnstert.2009.03.075

randomized control trials and the small size of many

reported series. A majority of these trials are retrospective
or case con- trol studies that compare the reproductive
outcome before and after hysteroscopic myomectomy (1
4). Furthermore, to our knowledge, no prospective
controlled data exist re- garding fertility outcome after
hysteroscopic myomectomy among this select patient
group, according to the characteris- tics of the submucous
myomas.

polyps).
After a detailed history and thorough clinical examination,
all of the patients received a complete infertility workup

Because of the considerable controversy that surrounds

the topic of submucous myomas and unexplained primary
infertility, we designed this prospective, randomized, agematched control trial to discover whether hysteroscopic myomectomy in women with otherwise unexplained infertility
affects pregnancy rates.
MATERIALS AND METHODS
From January 1999 to February 2006, 352 patients fulfilling
the inclusion criteria of unexplained primary infertility with
sub- mucous myoma discovered on initial pelvic
sonographic stud- ies as the sole cause for a diagnosis
were selected. Patients (aged 2135 years) were informed
of the study design and were recruited for the trial. Two
hundred and fifteen (61%) of them agreed to participate and
informed consent was obtained. The study was approved by
the hospitals ethics committee.
The sonographic diagnosis of submucous myomas has
been described elsewhere (8). In all patients, a baseline
diagnosis was made using ultrasonography performed with
a multifre- quency endovaginal transducer (Sonace Medical
Corporation, Seoul, Korea). The size, number (single or
multiple), and loca- tion of the fibroid in the uterus was
recorded based on height (fun- dus, corpus, lower segment,
or cervical). If >3 months elapsed between the initial
baseline sonogram and the occurrence of pregnancy, the
myoma was reevaluated every 3 months to deter- mine any
significant changes in the myoma characteristics.
Inclusion criteria were women with R12 months of
primary infertility (duration of infertility ranged 12120
months), regular menstruation, a sonographic diagnosis of
submucous myoma, and candidacy for hysteroscopic
myomectomy. The indication for myomectomy was a
submucous myoma in com- bination with a history of
unexplained primary infertility if the lesion was thought to
be the only contributing factor to infertil- ity. No patients
were experiencing menorrhagia in our study.
Women older than 35 years were excluded from the
study to avoid the inclusion of subjects with age-related
subfertility. Also excluded from the study were women
with pelvic le- sions, such as endometriosis, that could
adversely affect fer- tility. Cases with associated interstitial
fibroids, submucous myomas >5 cm in diameter and/or a
uterine cavity >10 cm in length were also excluded. All
patients had never had pre- vious surgery for leiomyomata
or other uterine surgery, and no other uterine cavity
abnormalities existed (e.g., uterine septum or endometrial
Fertility and Sterility

including semen analysis, assessment of ovulation by

midlu- teal serum progesterone level, assessment of
ovarian reserve by cycle day 3 serum FSH level,
postcoital test (PCT), and hysterosalpingography (HSG).
The initial suggestion of diag- nosing submucous myoma
was made by HSG for most of the cases within 1 year.
Laparoscopy was performed primarly for all patients to
assess the pelvis for causes of infertility. Those with
pelvic lesions were excluded from the study.

or myomas >3 cm in diameter, the patient was scheduled

for operative hysteroscopic examination under general
anesthesia. Electrosurgical resection was done during the
early proliferative phase of the subsequent menstrual cycle

In those with a healthy pelvis, hysteroscopic

examination was performed to assess the uterine cavity,
confirm the diag- nosis, and assess the characteristics of
the myoma including its size, number, location, and type.
The classification pro- posed by the European Society
of Hysteroscopy (9) was used in our study for
identifying the type of leiomyoma by the degree of
intramural development. Accordingly, type 0 was
defined as the myoma with development limited to the
uterine cavity (pedunculated myoma), type I was defined
as the myoma with partial intramural development
(endoca- vitary component >50%), and type II was
defined as the myoma with predominantly intramural
development (endo- cavitary component <50%).
Idiopathic primary infertility was diagnosed in
patients with normal ovulatory cycles, semen analysis,
HSG, and PCT in infertile couples for >24 months.
Except for submu- cous fibroids, no concurrent causes of
infertility were identi- fied in any patient.
The study group was composed of 107 women in
whom a myoma was extracted during hysteroscopy in the
early pro- liferative phase of the menstrual cycle.
Alternatively, the con- trol group was composed of 108
women in whom submucous myomas were not extracted
during diagnostic hysteroscopy and myoma biopsy only
was performed.
Randomizati
on
When a patient with a submucous myoma was selected
for myomectomy, she was matched with the next case in
which the other patient was nearly of the same age (within
2 years) and scheduled for no myomectomy. Patients
matched by age were randomized into two groups with the
use of an envelope technique, with assignment determined
by a computer-gener- ated random number table.
Operative
Procedure
The myomectomy was performed by means of a 5.5mm Karl-Storz (Tuttlingen, Germany) continuous flow
office hys- teroscope under local anesthesia using a
paracervical block. The formations were resected by
means of a rigid scissors and forceps and submitted for
histopathologic examination. When resection was not
possible during the diagnostic hys- teroscopy, in cases
with multiple myomas, and in those with residual lesions

Shokeir et al.

Hysteroscopic myomectomy in unexplained

infertility

Vol. 94, No. 2, July 2010

by using a 26-Fr resectoscope with a cutting knife electrode

(Karl-Storz, Tuttlingen, Germany). Glycine 1.5% was used
to distend the uterine cavity. All hysteroscopic
examinations were performed by the same surgeon. No
hormonal or antihor- monal treatment was given before and
after the resection until complete healing had been proven
by a second-look hys- teroscopic examination at the
clinicians office.
For type I and II myomas, the intracavitary dome of the
my- oma was resected to a flat surface that was even with
intrauter- ine cavity. Next, prostaglandin F2 alpha was
intraoperatively injected into the uterine body when
concomitant laparoscopy was performed (10) or into the
uterine cervix transvaginally. The remnant part of the
myoma was then compressed by uter- ine contractions.
Finally, the newly raised myomal dome in the uterine
cavity was resected electrosurgically. Electrosurgical
manipulation was never performed deeply into the
intramural remnant myoma or into the intramyometrial
space. In the case of this procedure failing, a second
resection was planned.
Follow-up
Patients in the study group were seen on the first postoperative day and returned for a follow-up visit approximately
1 month later for assessment and to evaluate the
configuration of the uterine cavity. This was accomplished
with follow-up outpatient hysteroscopic examination under
local anesthesia. The criteria for a second procedure were
the presence of a par- tially resected myoma and/or
regrowth of the excised one.
Women in both groups were advised to engage in natural
intercourse. No fertility therapy was given for either group.
Following hysteroscopic resection and to assess fertility
out- come, women were asked by telephone or regular
visits to complete a health questionnaire. This
questionnaire con- cerned pregnancy data including date
of last normal men- strual period, serum hCG titre, and
ultrasound confirmation of a viable clinical pregnancy. Any
postoperative complica- tions were also recorded.
For outcome analysis, only women with a follow-up of
12 months in both groups were included in the present
study. For women requiring a second resection, followup dates were derived from the time of the second
procedure. Serum hCG level was determined in absence
of menstruation for diagnosis of pregnancy.
Outcome Measures
Clinical pregnancy was the main outcome measure
analyzed to determine the effectiveness of treatment. We
studied the first normally intrauterine pregnancy after the
surgical proce- dure rather than its outcome. The secondary
outcome was to determine whether the different
characteristics of the fibroid influenced the pregnancy rate.

Statistical Analysis
Subjects were randomized into one of two groups in a 1:1 ratio and matched by age using a restricted randomization. A

descriptive analysis was performed for each variable of

the study, as well as a bivariate analysis between the
dependent and each of the independent variables with
2
contingency tables, with c -test for categorical variables
and Students t test for continuous variables.
The relative risk (RR) of achieving pregnancy was
calcu- lated along with 95% confidence intervals (CIs).
With the report of the pathologist, myomas in the study
group were subdivided into four groups based on their
quartiles (<5 mm, 510 mm, 1120 mm, 2150 mm), and
pregnancy rates were compared between groups.
Furthermore, the type, site, and number of the myomas
were determined and preg- nancy rates were compared
between groups accordingly. Sig- nificance was defined
as P < 0.05.
RESULT
S
In-office hysteroscopic examination was not possible
with seven patients (3.2%), so they were performed in the
operat- ing room under general anesthesia. The cause for
the failures was severe pain because of cervical
conditions in all cases. Concomitant laparoscopic and
hysteroscopic
examinations were performed in
approximately 50 (50%) cases.
Eleven patients were lost from the study, six from the
study group (three lost to follow-up, two pathologic
reports of en- dometrial polyps, and one patient in whom
the myoma was not confirmed), and five from the control
group (one lost to follow-up, two patients in whom the
myoma was not con- firmed, and two pathologic reports
of endometrial polyps). These 11 cases were excluded
from the study, leaving 101 patients in the study group
and 103 in the control group.
Of 101 infertile patients in the study group, 99 had a
com- plete resection in one surgical setting and two
patients (2%) needed a second resection procedure. For
these two patients, the reasons for needing a second
resection were intraopera- tive complication (uterine
perforation treated conservatively) and incomplete
resection of large fundal myoma. The mean number of
myomas removed was 1.4 (range, 14). The mean
diameter of the largest extracted myoma was 20 mm
(range, 1050 mm). No postoperative complication was
noted. After resection, all 101 infertile women had a
sec- ond-look office hysteroscopic examination result
that con- firmed the healthiness of the cavity.
Table 1 summarizes the characteristics of the patients
and submucous fibroids in both groups. The mean time of
follow- up and the duration of infertility were comparable.
Regarding the myoma characteristics, there were no
statistically signif- icant differences between groups,
including the size, number, type, and location of the
myomas. Furthermore, no significant changes in the
myoma characteristics were noted at follow- up
transvaginal sonography (TVS) among the control group.

Overall, among patients with complete follow-up, a total

of 93 (45.6%) pregnancies occured64 (63.4%) in the
study group and 29 (28.2%) in the control. Women in the
study group had a better possibility of becoming
pregnant after

TABLE 1
Baseline patients and submucous myoma characteristics (n [ 204).
Myomectomy
Study (n [ 101)
Age (y), mean SD
Follow-up (mo), mean SD
Duration of infertility (y), %
R3
<3
Myoma size (mm), %
<5
510
1120
>20
Myoma number, %
1
R2
Myoma type, %
0
I
II
Myoma location, %
Fundal
Lower uterine segment
Cervical

No myomectomy
Control (n [ 103)

30.8 4.1
9.4 2.5

30.9 4.4
8.8 2.4

15.0
27.7

14.0
31.0

24.8
31.7
25.7
17.8

32.0
29.1
22.1
20.4

89.1
10.9

90.3
9.7

56.4
27.7
15.8

58.2
28.2
13.4

59.4
41.0
0.0

63.1
36.9
0.0

P value
NS
NS
NS
NS

NS

NS

NS

Note: NS not significant.

Shokeir. Hysteroscopic myomectomy in unexplained infertility. Fertil Steril 2010.

myomectomy with an RR of 2.1 (95% CI, 1.52.9). The

mean delay (SD) between myomectomy and the
conception was
3.8 2.1 months among the study group compared with
7.5 2.6 months in the control (P < 0.05). Nearly 80%
of the women conceived spontaneously after 6 months of
unpro- tected intercourse.
Fertility outcome according to myoma characteristics
in women undergoing myomectomy for whom follow-up
was complete compared with the control group is shown in
Table 2. Pregnancy rates did not differ significantly
according to the size, number, and location of the myoma
(P > 0.05). However, according to the type of the fibroid,
the myomec- tomy group was associated with
significantly higher preg- nancy rates in patients with
type 0 and type I myomas compared with controls (P <
0.001). Alternatively, no statis- tically significant difference
in pregnancy rate was observed with type II myomas (P >
0.05; Table 2).

DISCUSSION
To our knowledge there are no randomized, control trials
ex- amining fertility outcome after hysteroscopic
myomectomy in patients with unexplained primary
infertility. Retrospec- tive and case control studies

demonstrated that submucous myomas

with decreased pregnancy and

are

associated

implantation rates in patients who attempt to conceive

spon- taneously or who are undergoing IVF (46, 11). Our
data sup- port these findings; the pregnancy rate was
relatively high in women with prolonged duration of
infertility (63.4%). Preg- nancies were achieved after a
relatively short delay in con- ception (3.8 2.1 months
[mean SD]), and the rate of spontaneous conception
was remarkably high (81.8%) after 6 months of
unprotected intercourse. The proportion of preg- nant
patients in the study group was nearly twice that of the
control.
Literature data suggest that an improved uterine
contour may result in an improved pregnancy rate in
women with un- explained infertility (14). Varasteh et al.

(12) reported a cor- relation of 65.2% between

hysteroscopic myomectomy and the accumulated rate of
pregnancies, but polyps and submu- cous myomas were
mixed and the study was retrospective and not
randomized, so their conclusions raise some ques- tions.
In another retrospective series, 11 of 31 infertile women
(35.5%) in whom hysteroscopic myomectomy was
performed conceived within a 12-month period (13).
No prospective data exist regarding fertility outcome
after hysteroscopic myomectomy according to the
characteristics of submucous myomas. To our
knowledge, only Bernard et al. (14) have reported
retrospectively on subsequent fertility and outcome of
pregnancies after hysteroscopic

TABLE 2
Pregnancy rates according to the characteristics of submucous myomas.
Pregnancy rates

Myoma characteristic
Size (mm), %
<5
510
1120
>20
Number, %
1
R2
Type, %
0
I
II
Location, %
Fundal
Lower uterine segment

Myomectomy

No myomectomy

Study (n [ 101)

Control (n [ 103)

68.0
56.2
61.5
61.1

69.6
53.3
58.3
61.5

44.4
36.4

40.9
30.0

57.9
35.7
31.3

33.3
17.2
29.0

50.0
41.5

53.8
42.1

P value
NS

NS

Note: NS not significant.

Shokeir. Hysteroscopic myomectomy in unexplained infertility. Fertil Steril 2010.

myomectomy according to the characteristics of the submucous myomas and also the association with intramural fibroids. They found no difference in pregnancy and delivery
rates according to the size and location of submucous myomas. The authors suggest that fertility after hysteroscopic
myomectomy depends mainly on the number of submucous
myomas resected and the association with intramural fibroids. However, their analyses included mixed patients of
variable age groups and different types of infertility. In
the present prospective study, the data suggest that
restoration of reproductive ability among patients with
unexplained primary infertility is found to be unrelated to
myoma size, number, and location, although it is wellknown that such morphologic factors of submucous
myomas are important for the occurrence of repeated
pregnancy losses (1519). In contrast, Varasteh et al. (12)
in his retrospective study in- cluded a control group of
infertile women with a normal uter- ine cavity at
hysteroscopy, and showed a significant benefit of removing
submucous myomas of >2 cm in size. Fernandez et al.
(13), again using a retrospective series, also described
better pregnancy rates after removal of larger myomas,
although the difference was not statistically significant, suggesting a space-occupying lesion mechanism for infertility.
In the current study, submucous myoma type in relation
to pregnancy rate has been evaluated. In this trial, fertility
rates appear to increase after hysteroscopic myomectomy
of type 0 and type I myomas (P < 0.05). However, for the
subgroup of patients with type II myomas, no difference in
fertility was observed compared with controls. These results

are in accor-

NS
<0.001
<0.001
NS
NS

dance with those published by Ioannis et al. (20), who

re- ported that hysteroscopic myomectomy was associated
with an increase in pregnancy rate in patients with type
0 and type I myomas, whereas in patients with type II
fertility rates did not increase in contrast with those with
type II myomas who received expectant management.
Actually, the interpre- tation of these data concerning the
submucous myoma type in relation to pregnancy rate is
difficult. The difference cannot be due simply to uterine
cavity abnormality. In our series, the absence of cavity
distortion was systematically verified by a hysteroscopic
examination performed in the clinicians office 1 month
after resection. Therefore, these results possibly reinforce
the hypothesis that other mechanisms associated with
leiomyomas might contribute to the infertility (13).
The implications of different submucous myoma

characteris- tics in the pregnancy rates in patients with

unexplained infertil- ity are difficult to be organized.
Possibly, in another study we should eliminate women
whose fibroids are beyond a certain character. For example,
the mean size for the study presented here was 20 mm. If
we kept the sizes the same, for our fertility care unit to have
approximately the right number of patients to show any
significant differences it would take about 6 more years.
Hopefully this study will encourage a multicenter cooperative study to evaluate sooner than this whether
submucous myomas of a certain character negatively affect
pregnancy rates.
Our results suggest that in addition to the presence of
submucous myomas in women with otherwise unexplained
primary infertility, other physiopathologic pathways might

be involved, such as an impairment of implantation subsequent to endometrial alterations. We think that the extent of
endometrial alterations subsequent to the resection depends
on the size, number, type and location of submucous
myomas resected. This suggestion is supported with
evidence from several studies evaluating the effect of
myoma uteri on the pregnancy rate after assisted
reproductive technique (ART). Use of ART provides a
unique setting because factors such as mechanical factors,
greater distance for the gametes to travel, position of the
cervix, or menometrorrhagia can be ex- cluded as possible
causes for infertility associated with this condition. Stovall
et al. (19) showed that even after patients with submucosal
fibroids are excluded, the presence of fibroids reduces the
efficacy of ART. Eldar-Geva et al. (18) compared 106
ART cycles in patients with uterine fibroids with 318 ART
cycles in age-matched patients without uterine fibroids and
concluded that implantation and pregnancy rates were
significantly lower in patients with intramural or submucosal myomas, even in those with no deformation of the
uterine cavity. Therefore, if women with unexplained primary infertility have a better chance of conception after
hys- teroscopic myomectomy and if the main factors in
treatment success are patient age and duration of infertility
as stated by other authors (16), this conservative surgery
should not be postponed for too long.
A recent systematic review and metaanalysis (4) has been
suggested that different types of fibroids may affect
reproduc- tive outcome to a different extent, and removal of
submucous fibroids may be indicated in infertile women
in whom no other factor has been identified. Our
prospective data support these guidelines and provide some
information on the repro- ductive potentials of selected
women who have undergone hysteroscopic myomectomy
for submucous myomas. If we combine the data from our
first prospective control study with data from previously
published ones, we then consider it worthwhile to perform
a hysteroscopic myomectomy in an infertile woman with
otherwise unexplained infertility whose only known
problem is the presence of a submucous myoma.
Although vaginal delivery can be safe after hysteroscopic
myomectomy, and uterine rupture has never been reported
following this procedure, the obstetric management should
be extremely careful (2). Many investigators believe that
cesarean section as a mode of delivery is the best whenever
managing type I or type II submucous myomas
hysteroscopi- cally (12, 16).
In conclusion, pregnancy rates seem to be relatively good
after hysteroscopic myomectomy in women with otherwise
unexplained primary infertility. Ideally, to evaluate the
efficacy of this technique and the fertility outcome after
hys-

teroscopic myomectomy according to the characteristics of

submucous myomas, randomized prospective studies
should be undertaken in multiple centers, accounting for
a larger number of women with this type of abnormality.

REFERENCES

1.

Practice Committee of the American Society for Reproductive

Medicine. Myomas and reproductive function. Fertil Steril
2004;82(Suppl 1): S1116.

2.

Levy BS. Modern management of uterine fibroids. Acta Obstet

Gynecol Scand 2008;87:81223.
3. Pritts EA. Fibroids and infertility: a systematic review of the
evidence.
Obstet Gynecol Surv 2001;56:48391.

4.

Elizabeth AP, William HP, David LO. Fibroids and infertility: an

updated systematic review of the evidence. Fertil Steril 2009;91:1553
5.
5. Kolankaya A, Arici A. Myomas and assisted reproductive
technologies:
when and how to act? Obstet Gynecol Clin North Am 2006;33:14552.

6.

Taylor E, Gomel V. The uterus and infertility. Fertil Steril

2008;89:116.

7.

Shokeir TA. Hysteroscopic management in submucous fibroids

to improve fertility. Arch Gynecol Obstet 2005;273:504.

8.

Soares SR, Barbosa dos Reis MM, Camargos AF. Diagnostic

accuracy of sonohysterography, transvaginal sonography, and
hysterosalpingography in patients with uterine cavity disease. Fertil
Steril 2000;73:40611.

9.

Wamsteker K, deKruif J. Transcervical hysteroscopic resection

of sub- mucous fibroids for abnormal uterine bleeding: results
regarding the degree of intramural extension. Obstet Gynecol
1993;82:73640.
10. Murakami T, Shimizu T, Katahaira A, Terada Y, Yokomizo R,
Sawada R.
Intraoperative injection of prostaglandin F2 alpha in a patient
undergoing hysteroscopic myomectomy. Fertil Steril 2003;79:1439
41.
11. Ramzy AM, Sattar M, Amin Y, Mansour RT, Serour GI,
Aboulghar MA.
Uterine myomata and outcome of assisted reproduction. Hum Reprod
1998;13:198202.

12.

Varasteh NN, Neuwirth RS, Levin B, Keltz MD. Pregnancy

rates after hysteroscopic polypectomy and myomectomy in infertile
women. Obstet Gynecol 1999;94:16871.

13.

Fernandez H, Sefrioni O, Virelizier C, Gervaise A, Gomel V,

Frydman R. Hysteroscopic resection of submucousal myomas in
patients with infer- tility. Hum Reprod 2001;16:148992.

14.

Bernard G, Darai E, Poncelet C, benifla JL, Madelenat P.

Fertility after hysteroscopic myomectomy: effect of intramural
myomas. Eur J Obstet Gynecol reprod Biol 2000;88:8590.

15.

Bettocchi S, Siristatidis C, Pontrelli G, Sardo A, Ceci O, Nappi L,

et al.
The destiny of myomas: should we treat small submucous myomas in
women of reproductive age? Fertil Steril 2008;90:90510.
16. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and
reproductive outcomes: a systematic literature review from conception to
delivery. Am J Obstet Gynecol 2008;198:35766.

17.

Cravello L, Agostini A, Beerli M, Roger V, Bretelle F, Blanc B.

Results of hysteroscopic myomectomy. Gynecol Obstet Fertil
2004;32:8258.

18.

Elder-Giva T, Meagher S, Healy DL, Maclachan V, Breheny S,

Wood C. Effect of intramural, subserosal, and submucousal uterine

fibroids on the outcome of assisted reproductive technology

treatment. Fertil Steril 1998;70:68791.

19.

Stovall DW, Parrish SB, Van Voorhis BJ, Hahn SJ, Sparks
AET, Syrop CH. Uterine leiomyomas reduce the efficacy of assisted
reproduc- tion cycles. Hum Reprod 1998;13:1927.

20.

Ioannis S, Aristotelis A, Antonios T, Panagiotis S, John B.

Fertility rates after hysteroscopic treatment of submucous myomas
depending on their type. J Gynecol Surg 2006;3:20610.