Management of diffuse uterine leiomyomatosis for fertility preservation: Case series and systematic literature review

Aim

The aim of this study was to evaluate the surgical, reproductive, and perinatal outcomes of patients with diffuse uterine leiomyomatosis desiring fertility preservation.

Methods

Patients diagnosed with diffuse uterine leiomyomatosis based on magnetic resonance imaging at Kindai University Hospital between 2017 and 2024 were included in a case series. A systematic literature review on diffuse uterine leiomyomatosis desiring fertility preservation was carried out.

Results

The case series showed that fertility preservation was desired in 8 of 18 cases, of which 1 was conceived after assisted reproductive technology and underwent cesarean section at 34 weeks of gestation for placenta previa accreta. A systematic literature review identified 31 cases from descriptive observational studies (1–8 cases per study). Although more fibroids (n = 87) were enucleated by extensive myomectomy than by hysteroscopic myomectomy (n = 33) (p < 0.0001), extensive myomectomy was often associated with massive blood loss and blood transfusion. Perinatal complications were more frequent in extensive myomectomy (5/7) compared to hysteroscopic myomectomy (2/12, p = 0.04). Preterm delivery before 36 weeks was more frequent in extensive myomectomy (4/6 cases) than in hysteroscopic myomectomy (1/11 cases, p = 0.03).

Conclusion

Fertility preservation in diffuse uterine leiomyomatosis was previously considered difficult, but it is now recognized to be possible. Hysteroscopic myomectomy is a minimally invasive option. If conception is not achieved, extensive myomectomy may be considered. However, extensive myomectomy is more invasive, with a higher risk of perinatal complications. Large-scale clinical trials are required to establish a management standard for diffuse uterine leiomyomatosis.