Myomectomy: a retrospective study to examine reproductive performance before and after surgery.

The aim of this retrospective study was to establish the impact of myomectomy on pregnancy outcome with particular reference to its effect on the incidence of pregnancy loss. Myomectomy was performed using microsurgical procedures upon 51 women who had intramural or subserosal fibroids and wished to conceive. Overall, the conception rate following myomectomy was 57%. Multiple regression analysis showed that age was the only factor which influenced conception rate: /=36 years, 30% (6/20; P < 0.005). The pregnancy loss rate prior to myomectomy was 60% (24/40), which was reduced to 24% (8/33) after myomectomy (P < 0.001). There was no instance of premature labour or scar rupture among 25 live births. This retrospective study suggests that myomectomy for intramural and subserosal fibroids may significantly improve the reproductive performance of women presenting with infertility or pregnancy loss.     

Doppler ultrasound examination of uterine arteries on the day of oocyte retrieval in patients with uterine fibroids undergoing IVF

BACKGROUND: There is no consensus as to whether uterine fibroids have any adverse effects on the outcomes of assisted reproduction treatment. This prospective study compared implantation/pregnancy rates of women with and without fibroids undergoing IVF-embryo transfer and measured uterine blood flow indices of the fibroid group. METHODS: Patients who had fibroids that, during transvaginal scanning, were found to be not distorting the endometrial lining were placed in the fibroid group, while patients with normal uteri were controls. Those with previous myomectomy or pedunculated subserosal fibroids only were excluded. All received a standard ovarian stimulation regimen. Doppler ultrasound examinations of uterine arteries were carried out in the fibroid group prior to oocyte retrieval. RESULTS: Similar implantation/pregnancy rates, multiple pregnancy rates and pregnancy outcomes were noted in both groups. In the fibroid group, significantly lower pulsatility index (PI) and resistance index (RI) of the right uterine artery and the average of right and left uterine arteries were found in those failing to conceive than in those patients who subsequently conceived (P < 0.001). CONCLUSION: The presence of fibroids not distorting the endometrial lining does not adversely affect implantation and pregnancy rates during IVF-embryo transfer. Significantly lower uterine artery PI and RI were found in non-pregnant women with fibroids than in their pregnant counterparts.     

Can myomectomy be suggested for perimenopausal women before administering hormone replacement therapy?

OBJECTIVES: The aim of this study was to evaluate whether abdominal myomectomy could be a choice for patients with symptomatic fibroids above the age of 48 years, who wish to get hormonal replacement therapy and desire to retain their uterus. METHODS: We performed 504 abdominal myomectomies between 1990 and 2004. The mean age was 33+/-4.09 years, 9 (1.8%; 9/504) patients were above 48 years and 6 (1.19%; 6/504) of them requested hormonal replacement therapy (HRT) after the enucleation of fibroids. Data of these nine cases were compared to a matched control group of patients who had hysterectomy in the same year in 3 months to those who underwent abdominal myomectomy with same indications for surgery, same location, size and number of fibroids. The main aim of our study was to compare perioperative morbidity, duration of hospital stay between myomectomy and hysterectomy groups and determine the recurrence of fibroids and/or symptoms in 1 year with HRT in the myomectomy group. RESULTS: The perioperative morbidity did not differ between the compared groups. In the myomectomy group with 1-year HRT we did not observe the recurrence of fibroids and symptoms. CONCLUSION: Our data suggest that abdominal myomectomy may be a satisfactory option for perimenopausal women with symptomatic fibroids who wish to retain their uterus and get HRT.     

Successful myomectomy during pregnancy

BACKGROUND: Although leiomyomas usually remain asymptomatic during pregnancy, they may complicate its course. In this study, pregnancy outcome observed when myomectomy was performed during pregnancy in carefully selected patients is presented. METHODS: A prospective cohort study of 13 women who underwent myomectomy during pregnancy between January 1994 and December 2001. Surgical management of leiomyoma was required on the basis of characteristics of the myoma and symptoms. RESULTS: Among a total of 15,579 women registered at the authors' prenatal clinic, 622 consecutive pregnant women had sonographically identified myoma; hence, the incidence was 3.9% (95% CI 3.6-4.3%). The vast majority of these women was asymptomatic during pregnancy or managed conservatively (97.4%; 95% CI 96-98%). Among 622 pregnant patients with leiomyoma, 13 presented with complications during pregnancy that required surgical intervention (2.1%; 95% CI 0.9-3.2%), due to increase in lesion size causing discomfort and/or severe abdominal pain not responding to conservative management with analgesic and non-steroidal anti-inflammatory drug medication. In 92% of these cases, successful myomectomy was performed and the pregnancy progressed to term without further complications. CONCLUSIONS: These data provide reassurance for pregnant women with uterine myoma. Surgical management of uterine leiomyoma during pregnancy may be successfully performed in carefully selected patients.     

A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception.

BACKGROUND: Although uterine fibroids occur in 30% of women and are associated with a degree of subfertility, the effect of intramural fibroids on the outcome of IVF or ICSI treatment has not been prospectively studied. METHODS: Data were prospectively collected on 434 women undergoing IVF/ICSI in the assisted conception unit of an inner London teaching hospital. Patients were assessed for the presence of fibroids by transvaginal ultrasound and hysterosonography or hysteroscopy where appropriate. RESULTS: During the study period, 112 women with (study), and 322 women without (controls), intramural fibroids were treated. Patients were similar regarding the cause and duration of their infertility, number of previous treatments, and basal serum FSH concentration. Women in the study group were on average 2 years older (36.4 versus 34.6 years; P < 0.01). There was no significant difference in the duration of ovarian stimulation or gonadotrophin requirement, number of follicles developed, oocytes collected, embryos available for transfer or replaced. When analysing only women with intramural fibroids of < or =5 cm in size (n = 106) pregnancy, implantation and ongoing pregnancy rates were significantly reduced: 23.3, 11.9 and 15.1 respectively compared with 34.1, 20.2 and 28.3% in the control group (P = 0.016, P = 0.018 and P = 0.003). The mean size of the largest fibroids was 2.3 cm (90% range 2.1-2.5 cm). Logistic regression analysis demonstrated that the presence of intramural fibroids was one of the significant variables affecting the chance of an ongoing pregnancy, even after controlling for the number of embryos available for replacement and increasing age, particularly age > or =40 years, odds ratio 0.46 (CI 0.24-0.88; P = 0.019). CONCLUSION: This study demonstrated that an intramural fibroid halves the chances of an ongoing pregnancy following assisted conception.     

Fibroids, infertility and pregnancy wastage

Uterine fibroids are often found in women of reproductive age. Different types of fibroids may affect reproductive outcome to a different extent, with submucous, intramural and subserosal fibroids being (in decreasing order of importance) a cause of infertility and pregnancy wastage. Fibroids may also produce a number of complications during pregnancy. Women who are scheduled for assisted conception should be advised to have submucous and possibly intramural fibroids removed prior to IVF. Large fibroids (>5 cm), wherever their location, should be considered individually, with the reproductive history being an important consideration. Miscarriage rates are significantly reduced following myomectomy. Open myomectomy should be the route of choice when there are large subserosal or intramural fibroids, multiple fibroids or entry into the uterine cavity is to be expected. Proper assessment of the benefits and risks of surgery for individual patients should be carefully considered before offering a procedure.     

Fluid accumulation within the uterine cavity reduces pregnancy rates in women undergoing IVF

BACKGROUND: The occurrence of fluid accumulation within the uterine cavity was examined in women undergoing IVF to investigate its correlation with tubal disease and impact on the pregnancy outcome. METHODS: A registry of ultrasound procedures spanning 5 years was retrospectively studied. RESULTS: Thirty five out of 746 (4.7%) IVF cycles were identified as having uterine fluid accumulation, and 15 (2.0%) persisted until the day of embryo transfer. Two of the 20 cycles of women with transient fluid accumulation were pregnant, and none of those with fluid retention on the day of embryo transfer conceived. The pregnancy rate was only 5.7% (2/35) in women with uterine fluid accumulation detected during IVF cycles. In contrast, the pregnancy rate was 27.1% (193/711) among women in whose cycles no fluid accumulation was detected (P = 0.0048). Uterine fluid accumulation during IVF cycles was found in 8% (18/225) of women documented with tubal factor compared with 3.3% (17/521) with non-tubal factor (P = 0.005). CONCLUSIONS: Fluid accumulation within the uterine cavity during the IVF transfer treatment could be observed in patients with both tubal and non-tubal factors; however, it mainly occurred in women with tubal infertility. Although it is not a common complication of IVF cycles, excessive uterine fluid is detrimental to embryo implantation.     

Reduction of postoperative adhesions with an auto-crosslinked hyaluronan gel in gynaecological laparoscopic surgery: a blinded, controlled, randomized, multicentre study

BACKGROUND: Following myomectomy, postoperative adhesions occur in many patients with adverse effects on fertility. This study investigated the applicability, safety and efficacy of an auto-crosslinked hyaluronan gel in preventing adhesion formation after laparoscopic myomectomy. METHODS: Fifty-two patients aged 22-42 years, undergoing surgery at four centres, were randomly allocated to receive either the gel or no adhesion prevention. The incidence and severity of postoperative adhesions were assessed laparoscopically after 12-14 weeks in a blinded, scored fashion. The primary efficacy variable was the presence/absence of postoperative adhesions at second-look. RESULTS: A nonsignificantly higher proportion of patients receiving the gel were free from adhesions (13 of 21; 62%) compared with control patients (9 of 22; 41%), with a statistically significant difference between the severity of uterine adhesions at baseline and at second-look (0.3 +/- 0.9 versus 0.8 +/- 1.0, P < 0.05). In subjects undergoing myomectomy without concomitant surgery, the proportion of adhesion-free patients was 8 of 12 (67%) and 4 of 11 (36%) (not significant) in the gel and control groups, respectively, with a significant difference in the mean severity scores (P < 0.05). In subjects without uterine adhesions before myomectomy, 12 of 18 (67%) and 8 of 20 (40%) patients in the gel and control groups, respectively were adhesion-free (not significant), with a significant difference in the severity of uterine adhesions (P = 0.05). CONCLUSIONS: Our results suggest that the auto-crosslinked hyaluronan gel may have a favourable safety profile and efficacious antiadhesive action following laparoscopic myomectomy.     

Laparoscopic salpingotomy for tubal pregnancy: comparison of linear salpingotomy with and without suturing

BACKGROUND: The study was carried out to clarify the incidence of post-operative tubal adhesions, patency rate and pregnancy outcome after laparoscopic salpingotomy with and without suturing for tubal pregnancy. METHODS: From May 1996 to December 2002, a total of 97 cases of tubal pregnancy were treated in our centre by laparoscopic conservative surgery. The successful salpingotomy cases were randomly assigned to undergo salpingotomy without suturing (group I; n = 43) or with suturing (group II; n = 32). We compared these patients and assessed their surgical and pregnancy outcome by second look laparoscopy (SLL) 3 months after the first operation. RESULTS: Seventy-five cases (77%) were treated successfully by salpingotomy at initial laparoscopic surgery, and the remaining 22 cases were unsuccessful because of bleeding or complete tubal damage. Pelvic findings were assessed at SLL in 21 of 43 cases (49%) in group I and 17 of 32 (53%) in group II. There were no significant differences in gestational age, ectopic site, tubal diameter, tubal condition, intraperitoneal haemorrhage and pre-operative HCG levels between the two groups. Only the operation time was longer in group II than in group I (91 +/- 15 versus 69 +/- 15 min, P < 0.05). The tubal patency rate of the treated side was 90% (19/21) in group I and 94% (16/17) in group II. Also the peritubal adhesions were observed in 33% (7/21) in group I and 29% (5/17) in group II, and were mostly comprised of filmy adhesions. A tubal fistula occurred in two cases in each group. Pregnancy rate was 79% (15/19) in group I and 92% (12/13) in group II, and this did not reveal any significant difference of cumulative pregnancy rate between the groups. CONCLUSION: We recommend laparoscopic linear salpingotomy as a useful method in the management of cases with tubal pregnancy who desire future pregnancy. This preliminary study emphasizes that the procedure involving suturing has no additional benefit over the non-suturing technique during salpingotomy.     

Fertility and obstetric outcome after laparoscopic myomectomy of large myomata: a randomized comparison with abdominal myomectomy

The purpose of this study was to compare, in infertile patients, the efficacy of laparoscopic myomectomy versus abdominal myomectomy, in restoring fertility and to evaluate the obstetric outcomes. Between January 1993 and January 1998, 131 patients of reproductive age, with anamnesis of infertility, underwent myomectomy because of the presence of at least one large myoma (diameter greater than or = 5 cm). Patients were randomly selected for treatment by laparotomy (n = 65) or laparoscopy (n = 66). The two groups were homogeneous for number, size and position of large myomata. Significant differences were found in the post-operative outcome: febrile morbidity (> 38 degrees C) was more frequent in the abdominal than in the laparoscopic group (26.2 versus 12.1%; P < 0.05). Laparotomy caused a more pronounced haemoglobin drop (2.17 +/- 1.57 versus 1.33 +/- 1.23; P < 0.001); three patients received a blood transfusion after laparotomy and none after laparoscopy. The post-operative hospital stay was shorter in the laparoscopic group (142.80 +/- 34.60 versus 75.61 +/- 37.09 h; P < 0.001). No significant differences were found between the two groups as concerns pregnancy rate (55.9% after laparotomy, 53.6% after laparoscopy), abortion rate (12.1 versus 20%), preterm delivery (7.4 versus 5%) and the use of Caesarean section (77.8 versus 65%). No case of uterine rupture during pregnancy or labour was observed.     

A case-control study to compare the variability of operating time in laparoscopic and open surgery.

The purpose of this study was to compare the variability of operating times for some of the most common gynaecological procedures performed laparoscopically and by open surgery. The case notes of 60 women randomly selected from a cohort of 600 who had undergone laparoscopic surgery for ectopic pregnancy, ovarian cysts, leiomyoma and hysterectomy were reviewed. These patients were matched with an equal number of women who had been treated by open surgery for similar indications. Additional matching criteria included age (+/-2 years), size of the lesion in cases of ovarian cysts and fibroids (+/-3 cm), the period of amenorrhoea in ectopic pregnancies, and uterine size and pelvic pathology in women undergoing hysterectomy. Comparison of laparoscopy and laparotomy showed that the mean procedure times were similar for the two routes of surgery, with the exception of hysterectomy which took significantly longer if done laparoscopically. The duration of laparoscopic surgery for ectopic pregnancy, ovarian cystectomy and hysterectomy was significantly less predictable than at laparotomy. These data indicate that with the exception of hysterectomy, the average operating time for laparoscopic procedures is comparable to that for laparotomy. In contrast, the variability of duration of laparoscopic surgery tends to be much greater than with laparotomy for all procedures considered.     

Risk factors for clinically diagnosed uterine fibroids in women around menopause

OBJECTIVE: We analysed the risk factors for clinically diagnosed uterine fibroids in women attending menopause clinics in Italy. METHODS: Between 1997 and 2003 we conducted a large cross-sectional study on the characteristics of women around menopause attending a network of first-level outpatient menopause clinics in Italy for general counselling about menopause or treatment of menopausal symptoms. A total of 85,967 non-hysterectomized women not reporting myomectomy entered the study; 2239 had a diagnosis of uterine fibroids. A woman was defined as having uterine fibroids if she had at gynecological examination an enlarged uterus (2 months of gestation or more) and a clinical diagnosis of fibroids. In 769 cases was performed in ultrasound examination which confirmed the diagnosis. RESULTS: In comparison with women with a body mass index (BMI) <22, the multivariate ORs for BMI 26 or more were 1.30 (95% CI, 1.09-1.55) for cases with clinical diagnosis, and 1.29 (95% CI, 1.01-1.45) for women with ultrasonographic diagnosis. In comparison with premenopausal women, the multivariate OR for clinically detected fibroids was 0.63 (95% CI, 0.55-0.72) for post-menopausal ones. The risk of fibroids was lower in parous women than in nulliparous ones, and the risk decreased with number of births regardless the type of diagnosis. CONCLUSION: This study confirms in a large sample that parity is the main protective factor for the development of fibroids. Overweight increases the risk.     

剖宫产同时子宫肌瘤剔除35例临床研究

目的 探讨妊娠合并子宫肌瘤病人在剖宫产同时肌瘤剔除术的可行性，安全性。方法 妊娠合并子宫肌瘤35例，在剖宫产同时行肌瘤剔除术，与35例单纯剖宫产的产妇做对照。结果 手术时间，术后出血量，术后病率，术后住院天数，肌瘤剔除组与单纯剖宫产组比较，差异不显著（均P〉0．05）。结论 剖宫产同时行肌瘤剔除术是可行的，安全的。妊娠合并子宫肌瘤时，应放宽剖宫产指征，同时行子宫肌瘤剔除术。     

Fertility after laparoscopic myomectomy of large intramural myomas: preliminary results

Fertility outcome following laparoscopic myomectomy was evaluated.A prospective clinical study was carried out between October1990 and October 1993 in 21 infertile patients who underwentlaparoscopic myomectomy for a myoma measuring 3>;5 cm indiameter. The overall rate of intrauterine pregnancy was 333%(seven patients). Out of 12 patients with infertility factorsassociated with uterine myomas, three (25.0%) became pregnant,whereas four (44.4%) out of nine patients with no other associatedinfertility factor became pregnant. No uterine rupture was observed.Out of the seven pregnancies, four were spontaneous and beganwithin 1 year of the operation. The other three were achievedafter in-vitro fertilization in patients with associated infertilityfactors. In the four patients who gave birth by Caesarean section,no adhesions were found on the myomectomy scar. From these preliminaryresults, laparoscopic surgery for myomas seems to offer comparableresults with those obtained by laparotomy.     

Pregnancy following laparoscopic myomectomy: preliminary results.

The objective of this study was to assess the outcome of pregnancy in a series of women who underwent laparoscopic myomectomy. A total of 115 women underwent laparoscopic myomectomy for pressure and pain (76.5%), abnormal bleeding (52.2%) and/or infertility (29.6%). Follow up data were obtained either by reviewing the patient's chart or returned questionnaire. Of the 115 women, there were 42 pregnancies in 31 patients. Two women were lost to follow-up. Of the remaining 40 pregnancies, six ended with vaginal delivery at term. Caesareans were performed in 22 cases, including 21 at term and one at 26 weeks gestation. Two pregnancies were associated with a normal delivery, but the mode of delivery is unknown. Eight resulted in first trimester pregnancy loss, one was an ectopic pregnancy, and one patient underwent elective termination. Spontaneous uterine rupture was not noted during pregnancy or at term in any of the cases. Average length of follow-up from the date of surgery was 43 months, with a range of 9-99 months. Our series did not confirm the hypothesis that laparoscopic myomectomy is associated with an increased risk for uterine dehiscence during pregnancy. However, a larger series is needed to make a conclusive judgement.     

The effect of fibroids without cavity involvement on ART outcomes independent of ovarian age

BACKGROUND: The effect of fibroids that do not distort the endometrial cavity on pregnancy rate (PR) and implantation rate (IR) is controversial. Use of oocyte donor-derived embryos offers an ideal patient population to study the effect of fibroids in patients utilizing assisted reproductive technologies (ARTs). METHODS: We conducted a retrospective cohort study of patients undergoing oocyte donor recipient (ODR) IVF cycles at two tertiary care fertility centres. We examined medical records for the presence of non-cavity-distorting fibroids and evaluated subsequent PR and IR. RESULTS: Three hundred and sixty-nine patients, 94 with fibroids, underwent oocyte donor recipient transfer cycles with fresh embryos. There was no statistical difference in IR (36 versus 38%) or clinical PR (47 versus 54%) between patients with or without fibroids. Neither the location (subserosal versus intramural) and the presence of multiple myomas nor the size of the myomas affected outcomes. Fibroids were more likely to be present in patients with increasing recipient age. CONCLUSIONS: Clinical PR and IR are not affected by the presence of non-cavity-distorting leiomyomata. This evidence does not support myomectomy before ART in patients with asymptomatic fibroids that do not significantly distort the endometrial cavity or cause abnormal uterine bleeding.     

Embolization versus myomectomy versus hysterectomy: which is best, when?

Uterine fibroids are the commonest tumour affecting the female reproductive tract. In many instances they are asymptomatic, but in some women there does appear to be an association with heavy menstrual blood loss and, possibly, subfertility. Classically, treatment has been surgical with hysterectomy the most common approach for women who have completed their fertility and myomectomy for those who wish to conceive. The surgery can be carried out laparoscopically, vaginally and abdominally, although all routes are associated with an appreciable rate of morbidity. Myomectomy can also be achieved hysteroscopically. Hysterectomy is associated with a high rate of satisfaction and is likely to relieve menstrual problems in virtually all women. The success of myomectomy is less certain since no randomized trials against expectant management have ever been carried out. In addition, myomectomy may lead to adhesion formation within the abdominal cavity, which may impair fertility further. Since myomectomy is not the ideal answer, other treatments for fibroids are being sought. Medical treatment may be useful in specific instances and for the short-term, but does not lead to a cure. Consequently, other modalities are being developed, one of which is uterine artery embolization. This procedure involves occluding the vessels using either foam or coils. The normal myometrium rapidly develops a new blood supply from collateral circulations, whereas the fibroids do not. The procedure leads to fibroid shrinkage of approximately 30-50% and appears to lead to relief of fibroid-associated symptoms, although it is too early to determine the effect on fertility. However, it is associated with significant complications and requires further evaluation before being accepted as a useful alternative to surgical therapy in the management of women with uterine fibroids.     

Fertility after laparoscopic myomectomy: preliminary results

We report the limits, complications, subsequent fertility and outcome of pregnancies after laparoscopic myomectomy. From January 1990 to October 1995, 143 patients underwent a first laparoscopic approach to myomectomy. A total of 41 patients (28.7%) had a laparoconversion (12 cases for a number of myomata >5, 15 cases for myoma diameter >7 cm, 12 cases for peroperative haemorrhage and two cases for adenomyosis). Seventy patients (49%) wished to conceive: 26 had undergone laparoconversion and 44 laparoscopic myomectomy. A total of 19 pregnancies were obtained in 17 patients after laparoscopic myomectomy (38.6%): eight vaginal deliveries, three Caesarean sections, four miscarriages, two abortions, one ectopic pregnancy and one therapeutic abortion. The pregnancy rate in patients with unexplained infertility and with multifactorial infertility was 48.2% and 20% respectively. The mean delay to conception was 11.3 months. No uterine rupture was noted. Pelvic adhesions were found in the four patients who underwent second- look procedure. Our preliminary results indicate that laparoscopic myomectomy is a useful technique.      

Recurrence of fibroids after myomectomy: a transvaginal ultrasonographic study

Frequency of recurrence of fibroids after myomectomy has beenevaluated in 145 women (median age 38 years, range 21–52)who underwent myomectomy. After surgery all women returned forfollow-up visit every 12 months after surgery. Transvaginalultrasound examination was performed routinely in every patientat 24 and 60 months and at 12, 36 and 48 months if there wereany abnormal pelvic findings or suspicious symptomatology. Atotal of 39 (27%) women gave birth after myomectomy. For thewhole series, the cumulative probability of recurrence (CPR)increased constantly during the study period reaching 51% in5 years. The 5-year CPR decreased with parity after myomectomy,being 55% for women with no childbirth after surgery and 42%(based on 13 recurrences, P < 0.01) for those who gave birth.     

Comparative analysis of pregnancy rates after the transfer of early dividing embryos versus slower dividing embryos

BACKGROUND: We compared retrospectively the pregnancy outcome in two subgroups of ICSI patients, using early division (26 h post injection) to the 2-cell stage as a criterion for embryo quality and viability (ability to produce a pregnancy). METHODS AND RESULTS: In the early dividing embryo (EDE) group, at least one of the transferred embryos was early dividing. In the late dividing embryo (LDE) group, no early dividing embryo was transferred. Additionally, tubal and uterine transfer in the two groups was also evaluated. Clinical pregnancy rates in the EDE group were significantly increased when compared with that in the LDE group (41.3 versus 20.0%). This was also true for ongoing pregnancy rates (33.3 versus 16.3%). The tubal transfer route showed increased (but not significant) ongoing pregnancy rates when compared with uterine transfer in both EDE (38.5 versus 25.0%) and LDE (22.7 versus 8.3%) groups respectively. In uterine transfer cycles, however, clinical pregnancy rates for EDE were significantly increased compared to LDE (37.5 and 11.1% respectively). The baby rate (number of live babies/embryos transferred) was also significantly increased in the EDE group and the tubal transfer group. Statistical analysis of pregnancy outcome, adjusted for the total number of embryos transferred (expressed as percentage risk difference - %RD), resulted significantly in favour of EDE compared to LDE (RD = 18%, P = 0.02). When adjusted for the combined factors: total number of embryos transferred, EDE and LDE, the pregnancy outcome result was significantly in favour of tubal transfer compared to uterine transfer (RD = 15%, P = 0.05). Pregnancy results of the LDE group only were significantly better in the tube compared to the uterus (RD = 19%, P = 0.04) but not significantly so for the EDE group (RD = 10%, P = 0.4). CONCLUSION: Early division is associated with embryo quality and a very easy and successful embryo transfer selection method. Our results also suggest that when EDE are available, both tubal and uterine embryo transfer can be considered. When only LDE are available, however, tubal transfer should be the preferred transfer route.