Hysteroscopic resection of type 3 fibroids improve pregnancy outcomes in infertile women: a case-control study

doi:10.21203/rs.3.rs-1447396/v1

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Hysteroscopic resection of type 3 fibroids improve pregnancy outcomes in infertile women: a case-control study

https://doi.org/10.21203/rs.3.rs-1447396/v1

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Background: Evaluate the effect of hysteroscopic resection of type 3 fibroids on pregnancy outcomes in infertile women.

Methods: Patients who underwent IVF-ICSI in our unit were divided into type 3 fibroids group and hysteroscopic myomectomy group according to whether or not they underwent ultrasound-guided hysteroscopic myomectomy. The control group in our study was selected from patients who were treated with IVF only because of fallopian tube factors. According to the age of the type 3 fibroids group and hysteroscopic myomectomy group, random sampling was carried out in patients between 25 to 47 years to determine a control group. The outcomes measured included average transfer times to live birth, cumulative clinical pregnancy rate, and cumulative live birth rate.

Results: A total 386 cycles were enrolled in our study, including 125 cycles with type 3 fibroids, 122 cycles with hysteroscopic myomectomy, and 139 cycles of control patients. Average transfer times to live birth were significantly higher in the type 3 fibroids group than the other two groups. The frequency of cumulative live births in the type 3 fibroids group was significantly lower than control group. Compared with the control group, hysteroscopic myomectomy patients had no statistically significant differences in the rates of cumulative clinical pregnancy rate and cumulative live birth rate.

Conclusions: Type 3 fibroids reduced the cumulative live birth rate of IVF patients. Ultrasound-guided hysteroscopic myomectomy can be used as a treatment for type 3 fibroids, to improve pregnancy outcomes in infertile women.

fibroid

hysteroscopy

in vitro fertilization

pregnancy

live birth

Uterine fibroids (also termed leiomyomas or myomas) are the most common tumors of the female reproductive tract. In recent years, fibroids attract attention for their impact on female fertility and pregnancy outcomes, the cumulative incidence in women of reproductive age is 20–50% [1]. Uterine fibroids may be solely responsible for impaired fertility outcomes in 2–3% of cases [2]. The location of fibroids, size, and number influence a woman's fertility and the outcome of pregnancy in unascertained ways [3]. These negative effects may be due to distortion of the endometrial cavity, which causes abnormal endometrial receptivity and hormonal milieu, and altered endometrial development [4].

The International Federation of Gynecology and Obstetrics (FIGO) developed staging scheme based on fibroid location including submucosal (SM), intramural (IM), subserosal (SS), and transmural lesions [5,6]. According to the FIGO fibroid classification system, IM fibroids include types 3, 4, and 5. Type 3 lesions are totally extra-cavitary but abut the endometrium [5]. By the use of transvaginal ultrasound (TVS), this result was reported to distort the uterine endometrium, but hysteroscopy revealed no alterations in the endometrial cavity. IM fibroids affects the outcome of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment but the conclusions of the current research results were still controversial [7]. Yan et al. explain that type 3 fibroids decrease the rates of implantation, clinical pregnancy and live birth in patients undergoing IVF, but do not significantly increase the clinical miscarriage rate in a retrospective study [8]. Their findings showed that type 3 fibroids exert a negative impact on women with a single fibroid diameter (SD) or total fibroid diameter (TD) > 2.0 cm [8].

Previous research shows myomectomy successfully used to relieve symptoms and improve health-related quality of life [9]. Hysteroscopy visualize the uterine and endocervical cavities directly. Recent innovations in endoscopic techniques have increased the accessibility of diagnostic and therapeutic procedures. Hysteroscopy has many advantages that are incomparable with traditional treatment methods. The procedure lasts only a few minutes, with minimal discomfort, is well tolerated by almost all women, and can resolve problems that often underlie reproductive incapacity [10]. When considering hysteroscopic treatment, the location of a fibroid is important. Resection of submucosal fibroids > 2 cm can effectively improve women fertility [11]. The effect of hysteroscopic surgery is also very impressive. Compared with laparotomy and open myomectomy, conception rates of 55% and live birth rates of 80% can be achieved after hysteroscopic myomectomy [12]. The Practice Committee of the American Society for Reproductive Medicine (ASRM) issued guidelines stating that myomectomy may be considered to optimize pregnancy outcome for women with asymptomatic myomas [13]. There is fair evidence that hysteroscopic myomectomy for asymptomatic cavity-distorting myomas improves clinical pregnancy rate [13]. But few studies have looked at the effect of surgical removal of type 3 fibroids on pregnancy outcomes. Hysteroscopic myomectomy is an effective treatment for type 3 fibroids. In a retrospective cohort study Capmas P et al. identified that hysteroscopic resection is a potential alternative to traditional surgery for type 3 myoma; however this procedure must be performed by skilled surgeons because of its difficult nature; moreover, it takes 6–8 weeks for the endometrium to recover [14]. But, there has been no separate study of pregnancy outcomes in infertile women after hysteroscopic resection for type 3 fibroids to date.

Therefore, we performed a single-center, retrospective, case-control study to evaluate the effect of hysteroscopic resection of type 3 fibroids on pregnancy outcomes in infertile women.

Study design

This retrospective case-control study was conducted at the Center for Reproductive Medicine, Tianjin Central Hospital of Gynecology Obstetrics from January 1, 2014 to June 30, 2021, through the analysis of our electronic records. The inclusion criteria for the type 3 fibroids group and the hysteroscopic myomectomy group were as follows: 1) age ≤ 40 years at the time of commencement of IVF-ICSI treatment; 2) diagnosis of type 3 fibroids by means of TVS on two separate occasions or accepted for hysteroscopic resection for type 3 fibroids; 3) SD or TD > 2.0 cm. The following exclusion criteria were used: 1) oocyte donor treatment cycles; 2) presence of chromosomal abnormalities (included chromosome polymorphism); 3) history of other uterine surgery (included endometrial polyps, cesarean etc.); 4) presence of intracavitary lesions, including SM fibroids; 5) single fibroid > 5.0 cm; 6) unclear ultrasound description of fibroids; 7) preimplantation genetic testing was performed; 8) cervical fibroids, and 9) congenital or acquired uterine malformations.

Patients were divided into type 3 fibroids group (Non-surgery group) and hysteroscopic myomectomy group (Surgery group) according to whether or not they underwent hysteroscopic myomectomy. The control group in our study was selected from patients who were treated with IVF only because of fallopian tube factors. According to the age of Non-surgery group and surgery group, random sampling was carried out in patients between 25 to 47 years to determine a control group. The Non-surgery group and surgery group patients were assessed for the treatment of hysteroscopic myomectomy, according to each patient’s condition and their personal wishes. All patients underwent controlled ovarian stimulation (COS) using a routine protocol (long, short, GnRH antagonist protocol, or other protocol, including ultralong protocol, mini-stimulation protocol, natural protocol, etc.) at our center. One experienced surgeon (who had performed more than 500 operative hysteroscopies per year for more than 10 years as a resident) performed all of the procedures.

Surgeries

Operative hysteroscopy was performed using a 26Fr hysteroscope equipped with a 30-degree lens (Endoskope; Karl Storz GmbH and Co., Tuttlingen, Germany). Saline solution (0.9%) was used as the distention medium with a fluid management system. Hysteroscopic resection for type 3 myoma began with an incision of the endometrium in front of the type 3 myoma with bipolar energy. Under ultrasound guidance, the uterine mucosa and myometrium were cut longitudinally with needle electrodes to reveal type 3 fibroids. Intravenous infusion of oxytocin causes fibroids to bulge, and the fibroids are gradually removed under ultrasound monitoring with ring electrodes. Resection was performed with postoperative ultrasound until there were no residual fibroids. Patients underwent hysteroscopic myomectomy after oocyte retrieval, or underwent COS after the surgery. Patients could then return to our center for transfer after a rest period of 2 menstrual cycles after surgery and after TSV to ensure that there was no recurrence of fibroids before each transfer cycle. More than one ultrasonography was performed to observe the change in the myoma of type 3 fibroids before transfer. All TVS and hysteroscopic myomectomy were, respectively, performed by the same professional clinicians.

The outcomes measured in our retrospective study included average transfer times to live birth(s), cumulative clinical pregnancy rate, and cumulative live birth rate. Clinical pregnancy rate was defined as the presence of a gestational sac seen on transvaginal ultrasound. Live birth rate was defined as the delivery of a live birth(s) (≥ 28 weeks of gestation) following any embryo transfer cycle. Cumulative clinical pregnancy rate was calculated as the first gestational sac observed and cumulative live birth rate was calculated as live births achieved after all cycles of embryo transfer (cycles using fresh embryos and all frozen-thawed embryos) among both groups. Analysis of the transfer and pregnancy outcomes of the patients in the hysteroscopic myomectomy group started from the first transfer after the operation. Furthermore, we conducted a self-controlled case series study of surgery group to compare transfer and pregnancy outcome before and after operation.

Statistical Analysis

Statistical analysis was performed using SPSS25.0. Student’s t-test, chi-square test, Fisher’s exact test, Kruskal–Wallis test, or Mann–Whitney U test were used to compare the groups according to data distribution. A P-value of < 0.05 was considered to indicate statistical significance. Values are presented as mean ± SD or median (lower quartile, upper quartile) according to data distribution. Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated before and after adjusting for confounding variables, including age, infertility duration, body mass index (BMI), average endometrial thickness in transfer cycle, and average high-quality embryo rate.

Ethics Statement

This study was approved by the Institutional Review Board (IRB) of Tianjin Central Hospital of Gynecology Obstetrics (No: ZY2021010) and performed in accordance with the Helsinki Declaration. Written informed consent was obtained from the participants when they presented for IVF-ICSI treatment.

According to the above inclusion and exclusion criteria, a total 386 cycles of 162 women were enrolled in our study, including 125 cycles of 59 women with type 3 fibroids, 122 cycles of 42 women with hysteroscopic myomectomy, and 139 cycles of 61 control subjects. Among these 59 women with type 3 fibroids, seven suffered from multiple fibroids (five women had combined SS, two women had combined SS and multiple type 3 fibroids), and the average diameter of type 3 fibroids was 2.45 cm. Among these 42 women with hysteroscopic myomectomy, six suffered from multiple type 3 fibroids but these had been removed by surgery (Fig. 1). In addition, there were seven patients who had undergone transfer before and after surgery in the Surgery group.

In the Non-surgery group, there were 10 patients who did not complete the transfer of all embryos after oocyte retrieval before pregnancy; two patients obtained clinical pregnancy after transfer, but they were not followed up to the final pregnancy outcome in our statistical data. In the Surgery group, three patients became pregnant naturally and delivered live births (including analysis of pregnancy outcomes, transfer times to live birth), two patients did not undergo transfer after surgery, eight patients did not transplant all embryos before pregnancy, and three patients progressed to clinical pregnancy after transfer; however, the final pregnancy outcome was included in our statistical data. In the control group, there were eight patients who did not transfer all embryos after oocyte retrieval before pregnancy, four patients obtained a clinical pregnancy after transfer, but they were not followed up to the final pregnancy outcome in our statistical data.

The baseline characteristics of each group are presented in Table 1. There was no statistically significant difference in age, BMI, infertility duration, day 3 serum LH level, day 3 serum E2 level, or day 3 serum testosterone among three groups. Day 3 serum FSH level was significantly lower in control group than the other two groups (P = 0.001) and the number of MII oocytes retrieved was significantly higher in control group. The number of cycles of frozen-thawed embryo transfer were significantly higher in the Surgery group and control group than in the type 3 fibroids group (P = 0.020), and average transfer time to live birth(s) was significantly higher in the Non-surgery group than the other two groups (P = 0.023) as presented in Table 2.

Table 1

Baseline characteristics
Item	Control (n = 61)	Non-surgery (n = 59)	Surgery (n = 42)	P value
Age, y	32.85 ± 4.20	34.73 ± 4.69	33.41 ± 4.24	0.062
< 37 years	43(75.4)	44 (76.6)	32 (76.2)	0.983
≥ 37 years	14 (24.6)	15 (25.4)	10 (23.8)
Infertility duration, y	5.05 ± 3.23	5.19 ± 4.02	4.21 ± 2.55	0.325
BMI, kg/m2	23.05 ± 3.05	23.09 ± 3.17	22.43 ± 3.07	0.538
Basal FSH, mIU/L	6.13 ± 1.55	7.46 ± 2.29^a	7.37 ± 2.33^b	0.001
Basal LH, mIU/L	4.51 ± 6.21	4.00 ± 2.46	4.21 ± 1.74	0.499
Basal E₂, ng/L	47.82 ± 21.17	48.94 ± 22.00	47.62 ± 18.32	0.941
Basal testosterone, ng/L	40.10 ± 16.22	36.23 ± 16.89	35.34 ± 17.39	0.309
Note: Values are presented as mean standard deviation or n (%). BMI = body mass index; FSH = follicle stimulating hormone; LH = luteinizing hormone; E₂ = estradiol; ^a shown that there have significantly different between non-surgery group and control group; ^b shown that there have significantly different between surgery group and control group.

Table 2

Ovarian stimulation outcomes in three groups
Item	Control	Non-surgery	Surgery	P value
Gn initial dosage, IU	273.31 ± 67.41	286.84 ± 95.44	293.31 ± 82.89	0.471
Duration of Gn stimulation, d	8.98 ± 2.01	9.39 ± 2.55	8.59 ± 2.25	0.254
Total dosage of Gn per cycle, IU	2438.92 ± 788.71	2807.23 ± 935.16	2654.73 ± 811.35	0.065
Average transfer endometrial thickness, mm	9.67 ± 1.52	9.64 ± 2.17	10.17 ± 1.96	0.944
Oocytes MII retrieved, n	19.92 ± 7.12^a	9.47 ± 6.32^b	12.32 ± 9.19^c	0.000
High-quality embryo rate	39.10 ± 26.10	35.12 ± 29.74	36.40 ± 28.72	0.740
Cycle of transfer				0.020
Fresh embryo transfer cycle	30 (28.0)	43 (44.8)^a	19 (27.9)^b
Frozen-thawed embryo transfer cycle	77 (72.0)	53 (55.2)	49 (72.1)
Protocol of ovary stimulation				0.539
Short protocol	3 (4.9)	4 (6.8)	4 (9.5)
Long protocol	40 (65.6)	33 (55.9)	27 (64.3)
GnRH-A protocol	18 (29.5)	19 (32.2)	10 (23.8)
Natural-cycle protocol	0 (0)	3 (5.1)	1 (2.4)
Endometrium preparation protocol				0.719
Natural-cycle	64 (83.1)	42 (79.2)	38 (76.7)
HRT	13 (16.9)	11 (20.8)	11 (22.4)
Patients undergoing embryo transfer				0.332
Cleavage transfer rate	98(91.6)	88(91.7)	58 (85.3)
Blastocyst transfer rate	9 (8.4)	7 (7.3)	10 (14.7)
Sequential transfer rate	0 (0)	1 (1.1)	0 (0)
High-quality embryo transferred rate	84 (78.5)	65 (67.7)	46 (67.6)	0.153
No. of embryos transferred, n	1.77 ± 0.47	1.74 ± 0.57	1.66 ± 0.51	0.415
Average transfer times to live birth, times	1 (1,2)	2 (1,2)	1 (1,1)^c	0.023
Note: Values are presented as mean standard deviation, n (%) or median (lower quartile, upper quartile). Gn = gonadotropin; GnRH-A = gonadotropin releasing hormone antagonist; HRT = hormone replacement treatment cycle; ^a shown that there have significantly different between non-surgery group and control group; ^b shown that there have significantly different between surgery group and control group; ^c shown that there have significantly different between surgery group and non-surgery group.

To ensure the stable of the outcomes, the patients who had not achieved a pregnancy outcome by the statistical date were excluded from the analysis of pregnancy outcomes in our study. The main pregnancy outcomes in the three groups are presented in Table 3. After adjusting for confounding factors among the three groups, the frequency of cumulative live birth in the Non-surgery group was significantly lower compared with the control group (55.3% vs. 79.6%), with an OR of 0.316 (95% CI 0.114–0.880; P = 0.032). Compared with the control group, Surgery group patients had no statistically significant differences in the rates of cumulative clinical pregnancy rate and cumulative live birth rate.

Transfer and pregnancy outcomes of seven patients who had transfer before and after operation in the Surgery group are as presented in Table 4. Transfer times to live birth, cumulative pregnancy rate, and cumulative live birth showed no statistically significant difference before and after operation.

Table 3

Binary logistic regression analysis of pregnancy outcomes in three groups
Item	case			Non-surgery versus Control				surgery versus Control				Surgery versus Non-surgery
	Control	Non-surgery	Surgery	Crude OR (95%CI)	P value	Adjusted OR (95%CI)	P value^d	Crude OR (95%CI)	P value	Adjusted OR (95%CI)	P value^d	Crude OR (95%CI)	P value	Adjusted OR (95%CI)	P value^d
Cumulative clinical pregnancy rate	40/49 (81.6)	30/47 (63.8)	18/29 (62.1)	0.363 (0.143–0.921)	0.033	0.607 (0.198–1.863)	0.328	0.405 (0.141–1.167)	0.094	0.238 (0.059–1.103)	0.055	0.927 (0.356–2.416)	0.877	0.388 (0.092–1.645)	0.199
Cumulative live birth rate	39/49 (79.6)	26/47 (55.3)	18/29 (62.1)	0.219 (0.118–0.717)	0.007	0.316 (0.114–0.880)	0.032	0.462 (0.163–1.305)	0.145	0.294 (0.083–1.044)	0.063	1.322 (0.514–3.410)	0.563	0.667 (0.172–2.586)	0.558
Note: Data presented as n (%) and odds ratio (95% confidence interval). CI = confidence interval; OR = odds ratio.
^d Logistic regression analysis was conducted by adjusting for age, infertility duration, body mass index (BMI), average endometrial thickness in transfer cycle and average high-quality embryo rate.

Table 4

Analysis of transplantation and pregnancy outcomes in the hysteroscopic myomectomy group patients who had transfer before and after operation
Item	Before	After	P value
Average transfers to live birth	2 (1,3)	1 (1,1)	0.165
Cumulative clinical pregnancy rate	2/7 (28.6)	3/7 (42.9)	0.500
Cumulative live birth rate	1/7 (14.3)	3/7 (42.9)	0.280
Note: Values are presented as n (%) or median (lower quartile, upper quartile).

Sensitivity analysis

In order to restrict bias in the results, all patients included who had not achieved a pregnancy outcome by the statistical date were analyzed by the regression equation for sensitivity analysis, and predictive the lowest and highest cumulative live birth rate can be obtained. In this part, patients who had not achieved a pregnancy outcome by the statistical date were supposed to have not received live birth(s) or have received live birth(s) respectively to calculate the lowest and highest cumulative live birth rate. The outcomes of sensitivity analyses are presented in Table 5. After adjusting for confounding factors among the three groups, the frequency of highest cumulative live birth rate in the Non-surgery group was significantly lower than control group (64.4% vs. 83.6%), with an OR of 0.305 (95% CI 0.136–0.900; P = 0.040). Compared with the control group, surgery group patients showed no statistically significant differences in highest cumulative live birth rate.

Table 5

Sensitivity analysis
Item				Non-surgery versus Control				surgery versus Control				Surgery versus Non-surgery
	Control	Non-surgery	Surgery	Crude OR (95%CI)	P value	Adjusted OR (95%CI)	P valued	Crude OR (95%CI)	P value	Adjusted OR (95%CI)	P valued	Crude OR (95%CI)	P value	Adjusted OR (95%CI)	P valued
Cumulative live birth rate lower limit	39/61 (63.9)	26/59 (44.1)	18/42 (42.9)	0.444 (0.214–0.925)	0.030	0.451 (0.199–1.102)	0.050	0.423 (0.189–0.945)	0.036	0.292 (0.113–1.059)	0.043	0.952 (0.428–2.115)	0.904	0.618 (0.230–1.663)	0.341
Cumulative live birth rate upper limit	51/61(83.6)	38/59(64.4)	31/42(73.8)	0.355 (0.150–0.840)	0.019	0.350 (0.136-0.900)	0.040	0.553 (0.210–1.451)	0.229	0.563 (0.187–1.692)	0.332	1.557 (0.652–3.718)	0.318	1.472 (0.481-4.500)	0.498
Note: Data presented as n (%) and odds ratio (95% confidence interval). CI = confidence interval; OR = odds ratio.
^d Logistic regression analysis was conducted by adjusting for age, infertility duration, body mass index (BMI), average endometrial thickness in transfer cycle and average high-quality embryo rate.

Type 3 fibroids are a special subtype of IM fibroids that are most likely to affect pregnancy outcomes of assisted reproductive techniques. They can affect endometrial receptivity, the hormonal milieu, and alter endometrial development that may be underlying causes of primary or secondary infertility [15]. Hysteroscopic resection is a treatment for type 3 fibroids, but there has been no specific study of its efficacy to date. Moreover, we did not know whether hysteroscopic myomectomy could improve fertility and IVF-ICSI outcomes of infertile women with type 3 fibroids. Our study focused on the effectiveness of hysteroscopic resection of type 3 fibroids on pregnancy outcomes in infertile women.

The current study demonstrates that hysteroscopic resection, as a treatment for type 3 fibroids, can improve cumulative live birth rates in patients with type 3 fibroids undergoing IVF-ICSI, and significantly improve the transfer time to live birth for patients after surgery. Although the cumulative live birth rate between Surgery and Non-surgery group were not statistically significant, rates for the Surgery group were higher than Non-surgery group (62.1% vs. 55.3%) and there was a statistical difference between Non-surgery group and control group (55.3% vs. 79.6%). However, there was no statistical difference between the control group and surgery group (62.1% vs. 79.6%). Statistical differences were found in the average transfer times to live birth among the three groups; the Non-surgery group was significantly higher than the other two groups. Hysteroscopic myomectomy can improve the time to live birth to a certain extent, although, before and after hysteroscopic myomectomy, the average transfer times to live births, the cumulative clinical pregnancy rate and cumulative live birth rate were not statistically different. But compared with the two groups, the average transfer times to live birth after operation were less than those of the preoperative group [1(1,1) vs. 2(1,3)]; the cumulative clinical pregnancy rate and the cumulative live birth rate were higher than the preoperative group at 42.9% vs. 28.6% and 42.9% vs. 14.3%. Therefore, in a sense, hysteroscopic resection can improve the clinical pregnancy rate and live birth rate of patients with type 3 fibroids, and shorten the time to live birth. In addition, three postoperative patients were followed up who obtained a spontaneous pregnancy and a live birth.

In our hospital and unit, TVS and hysteroscopy are performed by experienced clinicians, so the reliability of the data can be guaranteed. In this study, the length of time between diagnosis and surgery was quite short. On the other hand we let each patient go through two menstrual cycles before returning since the endometrial recovery time after hysteroscopy is 6–8 weeks [14].

In this study, we used a series of matching and exclusion criteria to keep interference factors to a minimum. As it is known that COS protocols can affect IVF success [8], there was no statistically significant difference in ovarian stimulation protocols among the three groups. As previously reported in the literature [8], type 3 fibroids with SD or TD > 2.0 cm can significantly decrease the live birth rate after IVF-ICSI, so we choose patients with SD or TD fibroids > 2.0 cm and single fibroids < 5.0 cm as the research subjects. In order to select the appropriate research population and exclude the influence of other infertility factors, we selected patients who were treated with IVF only because of fallopian tube factors as the control group. Age was used as the screening index, so the ovarian function of the control group was better than the other two groups. Because of this, the number of MII oocytes retrieved and the Day 3 serum FSH values of control group were significantly different from those of the other two groups.

The principal limitation of this study was the small number of patients, which led to a low statistical power. However, there are not many women with type 3 myoma who undergo hysteroscopic myomectomy. Sensitivity analysis suggests that the estimated value of the included study was basically within the confidence interval of the total effect size, that is to say, the result was stable. Selection bias in data analysis is inevitable in a retrospective study. In addition, some patients underwent surgery after COS, and the stimulation of COS on fibroids cannot be ruled out. Therefore, large cases of randomized controlled long-term observational research are suggested in the future.

To the best of our knowledge, this is the first independent study to address the impact of hysteroscopic resection of type 3 fibroids on the pregnancy outcomes of infertile women. Furthermore, this study shows the necessity of a clinical consultation with infertile patients with type 3 fibroids with SD or TD > 2.0 cm regarding the need for hysteroscopic myomectomy. One of the important advantages of the present study was the use of multiple matching criteria and randomization principles to minimize the clinical heterogeneity of the included patients.

Type 3 fibroids reduce the cumulative live birth rate of IVF patients. Ultrasound-guided hysteroscopic myomectomy can be used as a treatment for type 3 fibroids, and can improve the cumulative pregnancy rate, cumulative live birth rate, and the time to reach live birth of infertile patients with type 3 fibroids.

FIGO: the International Federation of Gynecology and Obstetrics; IVF: in vitro fertilization; ICSI: intracytoplasmic sperm injection; SM: submucosal; IM: intramural; SS: subserosal; TVS: transvaginal ultrasound; SD: fibroid diameter; TD: total diameter; ASRM: Practice Committee of the American Society for Reproductive Medicine; COS: controlled ovarian stimulation; ORs: odds ratios; CIs: confidence intervals; BMI: body mass index; IRB: Institutional Review Board; FSH = follicle stimulating hormone; LH:luteinizing hormone; E2: estradiol; HRT: hormone replacement treatment cycle; Gn: gonadotropin; GnRH: gonadotropin releasing hormone

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of the Reproductive Center of Tianjin Central Hospital of Gynecology Obstetrics (No: ZY2021010) and performed in accordance with the Helsinki Declaration. All participating patients were informed that their clinical data may be used for academic research in the future before entering the IVF cycle and signed written informed consents.

Consent for publication

Not applicable.

Availability of data and materials

The data used or analyzed during the current study are included within the article. The datasets are not publicly available due to the hospital policy and personal privacy. However, the datasets are available from the corresponding author on reasonable request.

Competing interests

No author has any potential confict of interest.

Funding

No funding was received.

Authors’ contributions

YH contributed to design research and write the manuscript. RY collected the data and drafted the manuscript. YFZ contributed to design research. ZY drafted the manuscript. HL performed the research. XW contributed to analysis the data. AD contributed to editing the manuscript. YSZ and YJZ critically revised the drafts of the manuscript. All authors reviewed the manuscript.

Acknowledgements

The authors thank all the doctors, nurses, and embryologists in the Reproductive Medicine Center of Tianjin Central Hospital of Gynecology Obstetrics for their help in collecting data.

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23 Mar, 2022
Editor assigned by journal
23 Mar, 2022
Editor invited by journal
23 Mar, 2022
Submission checks completed at journal
23 Mar, 2022
First submitted to journal
13 Mar, 2022

You are reading this latest preprint version

Hysteroscopic resection of type 3 fibroids improve pregnancy outcomes in infertile women: a case-control study

Status:

Version 1

Abstract

Figures

Introduction

Methods

Study design

Surgeries

Statistical Analysis

Ethics Statement

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1