For women who have fertility requirements but are asymptomatic, how large and in what location do fibroids require surgical treatment? Uterine fibroids are the most common benign gynecologic tumors. There is a basic consensus that there is no indication that surgery is necessary for women without fertility requirements and without symptoms, no matter how large the fibroids are. The symptoms themselves provide information on treatment options and there is no evidence to support the routine treatment of asymptomatic uterine fibroids [1]. Women with fertility requirements and definite symptoms also need to be treated separately depending on the severity of symptoms: (1) If symptoms are mild, patients are advised to actively try to conceive for 6 months. If there is no pregnancy, an evaluation related to infertility is performed. If no other associated infertility factors are found, myomectomy or other uterus-preserving treatments may be considered, but the physician needs to be consulted about the impact of these treatments on fertility. (2) If symptoms are more severe, an infertility-related evaluation should be performed and myomectomy or other uterus-preserving treatment modalities should be considered, again requiring consultation with the physician about the impact of these treatments on fertility [1]. (3) For women who require pregnancy with a combination of symptomatic interstitial or subplasmacytic myomas, surgical resection is the best option [2-6]. Open surgery has a greater impact on fertility, with 3-4% being converted to total hysterectomy intraoperatively due to surgical difficulties, and pelvic and abdominal adhesions also frequently occur [7]. What size and location of fibroids require surgical treatment for women with fertility requirements who are asymptomatic? Especially in those with a history of “bad” pregnancies and deliveries (habitual abortion, fetal malformation, intrauterine death, postpartum hemorrhage, etc.). After a review of the literature, unfortunately, we are unable to answer this question. However, based on the available evidence, we can probably summarize these conclusions: submucosal fibroids have the greatest impact on fertility and should be removed hysteroscopically if possible, especially in women with unexplained infertility or those preparing for assisted reproduction. Bipolar electric instruments and anti-adhesion adhesive are the best options. Interstitial fibroids also have a negative impact on fertility, but it is not possible to give cut-off values for the size and number of fibroids. Importantly, removal of interstitial myomas does not improve pregnancy outcomes. (However, in my personal opinion, surgical treatment of interstitial myomas >4 cm in diameter may be considered in asymptomatic patients with a previous history of adverse pregnancy and delivery that cannot be explained by other factors). Little is known about the effect of submural myomas on pregnancy outcome, but there does not seem to be an adverse effect and surgery is certainly not beneficial. The results of open and laparoscopic myoma removal are comparable, but adhesions resulting from open surgery are more common. The following is the literature on which these conclusions are based. A systematic review in 2001 found that myoma location and myomectomy had no effect on fertility, but that submucosal myomas decreased pregnancy rates and bedfellows, and that hysteroscopic myomectomy may be beneficial for fertility outcomes [6]. The same authors published an article with the same title 8 years later and their conclusions did not change much. A systematic review in 2009 found that interstitial myomas may reduce fertility and lead to increased miscarriage rates, but the quality of the study was poor. Myxoma resection did not significantly increase clinical pregnancy and live birth rates, but there are very few relevant data. The submucosal component of leiomyomas leads to decreased clinical pregnancy rates and birth rates compared to a control infertile population, and resection of leiomyomas appears to improve fertility [8]. A Cochrane meta-analysis in 2012 collectively gave a negative answer: there is a lack of sufficient evidence to confirm that myoma removal improves fertility. There are only two RCTs on the effect of myomectomy on fertility, and they found the same value of laparoscopic myomectomy as of open myomectomy. However, because the studies are so small, they need to be cited with caution. Finally, there is also no evidence from RCTs that hysteroscopic myomectomy improves fertility [5]. The 2012 updated French guidelines state: (1) For asymptomatic but deformed submucosal myomas, hysteroscopic resection of myomas improves pregnancy, preferably with a bipolar system and anti-adhesion adhesive. For asymptomatic interstitial and submucosal fibroids, there is no evidence that the number or size of fibroids can increase the risk of infertility. (2) In infertile patients seeking spontaneous pregnancy, submucosal myomas affect pregnancy rates, and hysteroscopic removal of FIGO type 0 or I myomas may improve spontaneous pregnancy rates in these patients. (3) Interstitial myomas also have an impact on fertility, but there is no cut-off for myoma size that can be used as a reference to indicate which myomas require surgical treatment. Surgical removal of asymptomatic interstitial myomas does not affect subsequent spontaneous pregnancy rates (this is true for women who are infertile or fertile). It is possible that removal of a certain size of myoma (5-7 cm) will improve pregnancy rates, with comparable results for open and laparoscopic surgery. (4) In infertile women undergoing assisted reproduction, both submucosal and intermucosal myomas can have an impact on fertility (pregnancy rate, implantation, live birth rate and miscarriage rate). The outcome of assisted reproduction is poorer if the fibroids are larger than 4 cm in size. Subplasmacytic myomas do not affect the outcome of assisted reproduction. Hysteroscopic surgical treatment improves the pregnancy rate in patients with submucosal myomas undergoing assisted reproduction. However, resection of interstitial myomas did not improve pregnancy rates in these patients [2]. The evidence for hysteroscopic myomectomy on fertility was again analyzed in a 2013 Cochrane meta-analysis, in which the authors concluded that hysteroscopic myomectomy may increase clinical pregnancy rates in patients with unexplained infertility and combined submucosal myomas, but the evidence is inconclusive [9]. The 2014 EMAS position statement (equivalent to a guideline) concluded that it remains inconclusive whether myomas cause infertility. Interstitial myomas may be a high risk factor for infertility and increase pregnancy complications including miscarriage. Submucosal myomas alter the volume of the uterine cavity and may interfere with implantation and increase the risk of pregnancy. The impact of the presence or absence of multiple myomas and the size of myomas on fertility is not known [4]. Notably, myoma resection does not reduce the risk associated with interstitial myomas and therefore surgical treatment is not currently recommended for asymptomatic interstitial fibroids [7, 8].