submucous fibroids are postulated to cause menometrorrhagia , preterm delivery , postpartum hemorrhage , and puerperal infection . in their submucosal location , myomas can be treated exclusively using surgical procedures and they may be accessible by operative hysteroscopy : the standard minimally invasive surgical approach . though a large number of reports have been published on laparoscopic and laparotomic myomectomy , the studies available regarding hysteroscopic myomectomy are few in number by comparison . a few retrospective studies published in 1990s have demonstrated successful reproductive outcome after hysteroscopic removal of submucous myomas in infertile women . the aim of this retrospective study was to evaluate the subsequent fertility and outcome of pregnancy after hysteroscopic myomectomy according to ( a ) the characteristics of submucous fibroids and ( b ) association with intramural fibroids . the study was conducted during a period of 6 years from 2004 march to 2010 march . this was a retrospective cohort study . in order to assess the other associated causes of infertility , patients were evaluated by follicular study , hormonal assessment , semen analysis , and laparoscopy . the details of subsequent fertility were obtained from hospital records and direct information from patients . all infertile patients with submucous fibroids confirmed on three - dimensional ( 3d ) ultrasound . only those patients who had a follow - up of at least 12 months from the day of surgery were included . submucous fibroids were classified based on european society of gynaecological endoscopy into type 0-whole of fibroid inside the uterine cavity . of these , 37 patients who were subfertile and fulfilled our criteria were included . in infertile patients , the duration of infertility ranged from 12 to 108 months , the mean duration being 42 months . pre - operative treatment with leuprolide 3.75 mg once a month for 2 months were given in two cases when the size of fibroid was 4 cm . all myomectomies were performed under general anesthesia . in all 37 patients , resectoscope ( 26 fr , karl storz , tuttlingen , germany ) with a bipolar wire loop the intrauterine pressure was controlled by hamou hysteromat , karl storz , tuttlingen , germany . resection was carried out under video control from fundus to os using cutting current . for each patient , intra- and postoperative complications such as hemorrhage , perforation , or intravasation of fluid medium into circulation was recorded . all these patients had a postoperative sonogram at the end of 3 months to evaluate the completion of the procedure . postoperative estrogen and progesterone was given in four patients , when the affected endometrial surface was too broad . fertility was analyzed according to the type of fibroids , size , number of myomas , associated intramural fibroids , associated factors contributing to infertility , and time to conception using spss software . analysis was performed using chi - square test and chi - square test modified by yates . all infertile patients with submucous fibroids confirmed on three - dimensional ( 3d ) ultrasound . duration of infertility more than or equal to 12 months . only those patients who had a follow - up of at least 12 months from the day of surgery were included . submucous fibroids were classified based on european society of gynaecological endoscopy into type 0-whole of fibroid inside the uterine cavity . a total of 48 patients had undergone hysteroscopic myomectomy during the study period . of these , 37 patients who were subfertile and fulfilled our criteria were included . in infertile patients , the duration of infertility ranged from 12 to 108 months , the mean duration being 42 months . pre - operative treatment with leuprolide 3.75 mg once a month for 2 months were given in two cases when the size of fibroid was 4 cm . all myomectomies were performed under general anesthesia . in all 37 patients , resectoscope ( 26 fr , karl storz , tuttlingen , germany ) with a bipolar wire loop the intrauterine pressure was controlled by hamou hysteromat , karl storz , tuttlingen , germany . for each patient , intra- and postoperative complications such as hemorrhage , perforation , or intravasation of fluid medium into circulation was recorded . all these patients had a postoperative sonogram at the end of 3 months to evaluate the completion of the procedure . postoperative estrogen and progesterone was given in four patients , when the affected endometrial surface was too broad . fertility was analyzed according to the type of fibroids , size , number of myomas , associated intramural fibroids , associated factors contributing to infertility , and time to conception using spss software . analysis was performed using chi - square test and chi - square test modified by yates . the mean patient age was 32 years ( range : 24 to 40 years ) . the mean duration of infertility was 42 months ( range : 12 to 108 months ) . the most common symptoms were menorrhagia which was present in seven patients and dysmenorrhea / pelvic pain in five patients . of the 37 patients , the average time taken for the procedure was 54 mins ( range : 20 - 180 ) including associated laparoscopy and the treatment of intraoperative complications . the average duration of hospital stay was 40 h. removal of subserous myoma was performed in 14 cases . all cases of intramural fibroids found close to endometrium or distorting endometrium as previously diagnosed by 3d or four - dimensional ultrasound and intramural fibroids more than 4 cm were resected by simultaneous laparoscopy performed in nine cases . two of the patients with intramural myoma had undergone hysteroscopic myomectomy as part of pre in vitro fertilization ( ivf ) workup and intramural myomectomy was not performed in them . the size of intramural fibroids was 3 and 2.5 cm in these cases . there were two complications in this series ( 5.4% ) . one patient had intraoperative hemorrhage which was controlled with intrauterine foleys for 8 h and one pint of blood transfusion . a total of 11 patients conceived after hysteroscopic myomectomy , that is , 29.7% . of the 37 patients , endometriotic cystectomy or fulguration of deposits was done for them , three had polycystic ovaries which were punctured , two had associated male factor infertility , and three had tubal pathology . in contrast , in those with submucous fibroids with no other identifiable cause , 40% conceived . the value , though substantially higher than those with multifactorial infertility , was not statistically significant [ table 1 ] . pregnancy outcome in patients according to associated infertility factors in our study population , 33.3% of patients with type 0 submucous fibroids conceived , while 25% of those with type 1 conceived . pregnancy outcome according to the type of myomas of the 37 , 28 patients had only one , six had two submucous fibroids , and three patients had three submucous myomas . none of the patients with three or more submucous fibroids conceived . of those with only one submucous fibroid , 32.1% conceived , while in those with two or more submucous myomas , only 22% conceived . thus , conception varied inversely with the number of myomas , though this was not found to be statistically significant [ table 3 ] . pregnancy outcome according to number and size of submucous fibroids the mean number of myomas removed was 1.343 ( range : 1 - 3 ) . in those with size less than 3 cm , 24.3% and those with fibroids mor than 3 cm , -50% conceived [ table 3 ] . thus , it was found that removal of submucous fibroids more than 3 cm has a beneficial effect on fertility , though this was not statistically significant . eight out of the 26 patients with submucous myoma alone conceived , while among those with associated intramural fibroids , three patients conceived . the conception rate was higher in those without associated intramural myoma-30.7% when compared to those with associated intramural myoma-27.6% and this was found to be statistically significant p = 0.045 . nine of the 11 patients with an intramural myoma had undergone a intramural myomectomy . in the remaining two patients , the size of intramural myoma was less than 4 cm and had undergone hysteroscopy as part of pre ivf workup and intramural myomectomy was not performed in them . of the nine patients operated , there were three pregnancies , that is , 33.3% . but due to the small size of the sample ( n = 2 ) , a comparison was not possible between the two groups . the miscarriage rate was found to be much higher in patients with associated intramural myoma-33.3% versus those with no associated intramural myoma-12.5% . however , this was not found to be statistically significant tab . the mean time taken to conceive was increased significantly in those with intramural fibroids than those without intramural fibroid [ table 4 ] . fertility according to the presence of associated intramural fibroids of the 37 patients analyzed , 23 had primary infertility and 14 had secondary infertility . eight ( 34.7% ) of those with primary infertility conceived , while three ( 21.42% ) of those with secondary infertility conceived . endometriotic cystectomy or fulguration of deposits was done for them , three had polycystic ovaries which were punctured , two had associated male factor infertility , and three had tubal pathology . in contrast , in those with submucous fibroids with no other identifiable cause , 40% conceived . the value , though substantially higher than those with multifactorial infertility , was not statistically significant [ table 1 ] . pregnancy outcome in patients according to associated infertility factors in our study population , 33.3% of patients with type 0 submucous fibroids conceived , while 25% of those with type 1 conceived . of the 37 , 28 patients had only one , six had two submucous fibroids , and three patients had three submucous myomas . none of the patients with three or more submucous fibroids conceived . of those with only one submucous fibroid , 32.1% conceived , while in those with two or more submucous myomas , only 22% conceived . thus , conception varied inversely with the number of myomas , though this was not found to be statistically significant [ table 3 ] . the mean number of myomas removed was 1.343 ( range : 1 - 3 ) . less than 3 cm , 24.3% and those with fibroids mor than 3 cm , -50% conceived [ table 3 ] . thus , it was found that removal of submucous fibroids more than 3 cm has a beneficial effect on fertility , though this was not statistically significant . eight out of the 26 patients with submucous myoma alone conceived , while among those with associated intramural fibroids , three patients conceived . the conception rate was higher in those without associated intramural myoma-30.7% when compared to those with associated intramural myoma-27.6% and this was found to be statistically significant p = 0.045 . nine of the 11 patients with an intramural myoma had undergone a intramural myomectomy . in the remaining two patients , the size of intramural myoma was less than 4 cm and had undergone hysteroscopy as part of pre ivf workup and intramural myomectomy was not performed in them . of the nine patients operated , there were three pregnancies , that is , 33.3% . but due to the small size of the sample ( n = 2 ) , a comparison was not possible between the two groups . the miscarriage rate was found to be much higher in patients with associated intramural myoma-33.3% versus those with no associated intramural myoma-12.5% . however , this was not found to be statistically significant tab . the mean time taken to conceive was increased significantly in those with intramural fibroids than those without intramural fibroid [ table 4 ] . of the 37 patients analyzed , 23 had primary infertility and 14 had secondary infertility . eight ( 34.7% ) of those with primary infertility conceived , while three ( 21.42% ) of those with secondary infertility conceived . in our experience , the pregnancy rate after hysteroscopic myomectomy in infertile patients was 29.7% . little data are available about fertility after hysteroscopic myomectomy for submucous myoma . in a series of 13 infertile women by corson and brooks , the pregnancy rates after the procedure as reported by various studies have been described in table 5 . summary of studies reporting on the reproductive outcome after hysteroscopic myomectomy many of these series report better results than those achieved in the present study . nevertheless , the current results are similar to those reported in two studies , namely a pregnancy rate of 33.5% in 31 women ( bernard et al . ) and a rate of 28.7% in 14 women ( hucke et al . ) . all these studies thus conclusively prove that submucous fibroids are associated with infertility and their removal considerably improves fertility . the pregnancy rate was 40% when the myoma was the only apparent cause , compared with 22.7% with the presence of additional factors . we found that the results are best with type 0 fibroids-33.3% and the rates drastically fell with increasing intramural extension . the reduction in fertility rates with increasing intramural extension was also reported in a study by ioannis et al . , it was a small study that looked at 25 patients . they found a fertility rate of 57.15% in type 0 , 42.8% in type 1 , and 25% in type 2 fibroids . paradoxically , in the current study , the rate was higher among those with larger myomas ( 30 mm ) . this observation is important ; indeed , the large size of the myoma was in these cases the sole factor for infertility , and reinforced the fact that myomas could be a cause of infertility . similar results were obtained in a myomectomy via laparotomy series ( sudik et al . ) , while another group ( varasteh et al . ) reported similar findings when using hysteroscopy , with a cumulative pregnancy rate of 25% for myomas < 20 mm and 75% for those > 30 mm . these results offer indirect proof that large myomas are a valid cause of infertility , mainly because of the mechanical distortion and the dystrophy that they cause . the pregnancy rate was significantly higher in those without associated intramural fibroids than those with intramural fibroids in our study even after their correction . comparing those patients in whom intramural fibroids were left alone with those in whom they were corrected however , the sample size was too small ( n = 2 ) to make any statistical inference . in the current study , 75% of the pregnancies occurred during the 1 year , with a mean surgery to conception time span of 4 months . this short delay of conception has also been observed by others ( rosenfeld ; goldenberg et al . ) . it is , therefore , strongly recommended that patients attempt to conceive soon after the procedure . . they also found a statistically significant negative correlation of intramural myomas with term delivery rate and early conception after hysteroscopic myomectomy . the rate of miscarriage was found to be higher in patients with associated intramural fibroid when compared with those without intramural fibroid- 33.3% versus 12.5% . however , the difference was not statistically significant . this result is in accordance with those of matsunaga and shiota which suggests that myomas increase the risk of miscarriage . the difference could not be due to cavity distortion as that was corrected by laparohysteroscopy . therefore , the results reinforce the hypothesis that other mechanisms may contribute like endometrial atrophy , hyperplasia , vascular factors , and inflammation . in fertile women , expression of molecular markers of endometrial receptivity hoxa11 , leukemia - inhibiting factor , and basic transcriptional element - binding protein 1 rises during luteal phase with the peak occurring during implantation window . in a study by shokrazadeh and alizadeh , endometrial levels of hoxa11 , lif , and bteb1 m rna were significantly reduced in infertile patients with uterine fibroid as compared with healthy fertile controls at the time of implantation . other causes implicated are adhesion molecules , epidermal growth factor , insulin like growth factor , and transforming growth factor present in fibroids . several groups ( fahri et al . ; eldar - geva et al . ; stovall et al . ; have suggested that submucosal leiomyomas and fibroids distorting the endometrial cavity were associated with a reduction in the efficacy of assisted reproduction technique cycles due to reduced implantation and delivery rates ( pritts et al . ) ( home and crithchley ) and that myomectomy should be completed prior to ivf cycles . our results were also analyzed according to the type of infertility . in the present study , completely intracavitary myomas and absence of other contributing factors seem to be the best prognostic factors for further fertility . removal of large myomas ( more than 3 cm ) has a much more beneficial effect on fertility than small ones . the mechanisms by which leiomyomas interfere with fertility are unclear , but presence of intramural myomas was found to impair delivery rate and fertility in our study . since in the majority of patients in this series , intramural myomas which cause cavity distortion and large intramural myomas had been removed previously or by simultaneous laparoscopy , an independent assessment of their effect on fertility and pregnancy outcome was not possible . however , based on this study , removal of associated intramural myomas seems to be a wise option in patients undergoing hysteroscopic myomectomy who are desirous of childbearing .
background : submucosal myomas are associated with infertility and may be treated by hysteroscopic resection.objective:the aim of this retrospective study was to analyze 37 subfertile patients who unnderwent hysteroscopic myomectomy in a tertiary care center with particular regard to their postprocedure reproductive outcome.materials and methods : the entire patient group ( n = 37 ) underwent the procedure between march 2004 and march 2010 . 
 the submucosal myomas were type 0 ( n = 27 ) , type 1 ( n = 8) , and type 2 ( n = 2 ) . 
 the mean myoma size was 2.1 cm ; mean duration of the procedure was 54 mins and mean follow - up was 26  10 months . 
 22 patients had one or more associated infertility factors.results:the complication rate was 5.4% . 
 11 patients ( 29.7% ) conceived after the procedure . 
 the pregnancy rate was better when myoma was the exclusive etiology of infertility ( 40% ) , when the myoma was completely intracavitary ( 33.3% ) , when the lesion was  30 mm in size ( 50% ) , and there were no associated intramural fibroids.conclusion:hysteroscopic myomectomy is a safe procedure to enhance fertility especially in cases with unexplained infertility .