You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Uterine leiomyomas in the infertile patient: preoperative localization with MR imaging versus US and hysterosalpingography.
Abstract 1:
Eleven women with a history of infertility and uterine leiomyomas underwent magnetic resonance ( MR ) imaging of the pelvis prior to myomectomy .  Nine also underwent preoperative pelvic ultrasonography ( US )  , and ten underwent hysterosalpingography .  All studies were interpreted prospect ively by independent observers . With each imaging modality , the location ( one of 11 anatomic segments ) , size , and appearance of detected uterine leiomyomas were determined and compared with surgical and histologic findings . Among the nine patients who underwent both MR and US  , the sensitivity ( 85 % ) and accuracy ( 94 % ) of MR imaging for abnormal segments was significantly better than that of US ( sensitivity = 69 % , P = .015 ; accuracy = 87 % , P = .043 ) . For the ten patients who underwent both MR and hysterosalpingography , the sensitivity ( 91 % ) and accuracy ( 96 % ) of MR imaging was better than that of hysterosalpingography ( sensitivity = 18 % , P = .0005 ; accuracy = 72 % , P = .0005 ) . The specificities of the three modalities did not significantly differ ( 100 % , 97 % , and 98 % for MR , US , and hysterosalpingography , respectively ) . These data suggest that MR imaging is superior to US or hysterosalpingography for preoperatively locating uterine leiomyomas


Title 2:
The effect on IVF outcome of small intramural fibroids not compressing the uterine cavity as determined by a prospective matched control study.
Abstract 2:
BACKGROUND Several studies have reported that the presence of intramural fibroids affects conception following IVF . We attempted to corroborate or refute the conclusions relating to IVF and leiomyomas of the aforementioned studies . METHODS Women with small intramural leiomyomata ( < or = 5 cm ) discovered on initial pelvic sonographic studies performed in preparation for IVF were prospect ively matched by age , with the next patient of the same age undergoing IVF who did not demonstrate fibroids ( controls ) . RESULTS Though no significant differences were found in outcome when comparing these two groups , there was a distinct trend for lower live delivery rates and higher miscarriage rates . CONCLUSIONS These data support the conclusions of the only other prospect i ve matched control study evaluating similar factors , i.e. that small intramural fibroids can negatively affect IVF outcome . Nevertheless , we think that a multicentre study should be conducted first before evaluating whether myomectomy improves outcome or not


Title 3:
Transabdominal Sonohysterography, Transvaginal Sonography, and Hysteroscopy in the Evaluation of Submucous Myomas
Abstract 3:
Objective To assess the usefulness of transabdominal sonohysterography in the diagnosis and evaluation of submucous myomas . Methods Fifty-two premenopausal women hospitalized for hysterectomy for benign gynecologic indications under-went preoperative conventional transvaginal sonography , transabdominal sonohysterography , and hysteroscopy .  The results of the three techniques in terms of diagnosis , size , intracavitary growth , and location of the submucous myomas were compared with those revealed by direct inspection of the surgical specimens . Results Conventional transvaginal sonography for the diagnosis of submucous myomas had a sensitivity of 90 % and a specificity of 98 % ; the predictive values of abnormal and normal scans were 90 and 98 % , respectively . Transabdominal sonohysterography had sensitivity , specificity , and predictive values of 100 % , as did hysteroscopy . In all cases , the sonographic techniques measured tumor size more accurately than did hysteroscopy . The transabdominal sonohysterography measurements differed from direct evaluation by no more than 2 mm , and the hysteroscopic measurements were significantly different from those of the surgical specimens . The sonohysterographic evaluation of intrauterine growth was significantly more precise than that of the other techniques , differing from direct measurements by no more than 5–10 % . Conventional transvaginal sonography failed to localize three of 11 myomas ; hysteroscopy and  transabdominal sonohysterography provided the exact location in all cases . Conclusion Transabdominal sonohysterography is the most accurate technique for detecting submucous myomas and evaluating their size , intracavitary growth , and location


Title 4:
Doppler ultrasound examination of uterine arteries on the day of oocyte retrieval in patients with uterine fibroids undergoing IVF.
Abstract 4:
BACKGROUND There is no consensus as to whether uterine fibroids have any adverse effects on the outcomes of assisted reproduction treatment . This prospect i ve 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 st and ard 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


Title 5:
A prospective controlled study of the effect of intramural uterine fibroids on the outcome of assisted conception.
Abstract 5:
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 prospect ively studied . METHODS Data were prospect ively 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


Title 6:
Effects of the position of fibroids on fertility
Abstract 6:
This prospect i ve , controlled study was performed in order to evaluate whether the location of uterine fibroids may influence reproductive function in women and whether removal of the fibroid prior to conception may improve pregnancy rate and pregnancy maintenance . We examined 181 women affected by uterine fibroids who had been trying to conceive for at least 1 year without success . The main outcome measures were the pregnancy rate and the miscarriage rate . Among the patients who underwent myomectomy  , the pregnancy rates obtained were 43.3 % in cases of submucosal , 56.5 % in cases of intramural , 40.0 % in cases of submucosal – intramural and 35.5 % in cases of intramural – subserosal uterine fibroids , respectively . Among the patients who did not undergo surgical treatment , the pregnancy rates obtained were 27.2 % in women with submucosal , 41.0 % in women with intramural , 15.0 % in women with submucosal – intramural and 21.43 % in women with intramural – subserosal uterine fibroids , respectively . Although the results were not statistically significant in the group of women with intramural and intramural – subserosal fibroids , this study confirms the important role of the position of the uterine fibroid in infertility as well as the importance of fibroids removal before the achievement of a pregnancy , to improve both the chances of fertilization and pregnancy maintenance


Title 7:
Sonohysterography for screening in recurrent pregnancy loss.
Abstract 7:
OBJECTIVE To evaluate the role of sonohysterography for screening of the uterine cavity in patients with recurrent pregnancy loss . DESIGN Prospect i ve evaluation of sonohysterography , including comparison with available hysterosalpingography and hysteroscopy . SETTING University referral center . PATIENT(S ) Thirty-four reproductive-aged women with at least two consecutive pregnancy losses . INTERVENTION(S ) Sonohysterography was performed on all patients , using saline instilled through an endocervically placed balloon catheter with concurrent vaginal sonography . RESULT ( S ) Seventeen of 34 sonohysterograms ( 50.0 % ) demonstrated intrauterine abnormalities . Eighteen of 34 cases have undergone hysteroscopy or , in 1 case , laparoscopy . All confirmed the positive or negative sonohysterographic finding , result ing in a sensitivity and specificity of 100 % . Additionally , 100 % ( 12/12 ) of the defects were diagnosed accurately at sonohysterography when confirmed by surgery . Twenty-seven of 34 patients also had a hysterosalpingogram that demonstrated a 90.0 % sensitivity and 20.0 % specificity based on hysteroscopic findings , yet only 5 of 11 ( 45.5 % ) defects were diagnosed accurately at hysterosalpingography when compared with surgery . CONCLUSION ( S ) Sonohysterography is a highly sensitive , specific , and accurate screening tool for the evaluation of uterine cavitary defects associated with recurrent pregnancy loss and offers several advantages over hysterosalpingography


Title 8:
Second look after laparoscopic myomectomy.
Abstract 8:
The goal of this study was to assess the risk of adhesions after  laparoscopic myomectomy .  To this end our enquiry was based on observations with a prospect i ve collection of data . Between October 26 , 1990 and October 1 , 1996 , 45 patients underwent a second look after laparoscopic myomectomy . Seventy-two myomectomy sites were checked . The overall rate of postoperative adhesion was 35.6 % per patient . The rate of adhesions per myomectomy site was 16.7 % . The factors which influenced the occurrence of an adhesion on the myomectomy site were posterior location of the myoma and the existence of sutures . The rate of adhesions on the adnexa after laparoscopic myomectomy was 24.4 % . The factors which influenced the occurrence of adnexal adhesions were another surgical procedure carried out at the same time , the existence of adhesions prior to the operation and posterior location of the myoma . The rate of adhesions after laparoscopic myomectomy is low and the adhesions rarely involved the adnexa . We recommend that a second-look laparoscopy be carried out systematic ally after laparoscopic myomectomy in patients desiring pregnancy
RESULT ( S ) Women with subserosal fibroids had no differences in their fertility outcomes compared with infertile controls with no myomas , and myomectomy did not change these outcomes compared with women with fibroids in situ .
Women with intramural fibroids appear to have decreased fertility and increased pregnancy loss compared with women without such tumors , but study quality is poor .
Myomectomy does not significantly increase the clinical pregnancy and live birth rates , but the data are scarce .
Fibroids with a submucosal component led to decreased clinical pregnancy and implantation rates compared with infertile control subjects .
Removal of submucous myomas appears likely to improve fertility .
CONCLUSION ( S ) Fertility outcomes are decreased in women with submucosal fibroids , and removal seems to confer benefit .
Subserosal fibroids do not affect fertility outcomes , and removal does not confer benefit .
Intramural fibroids appear to decrease fertility , but the results of therapy are unclear .