What We Know about the Long-Term Risks of Hysterectomy for Benign Indication-A Systematic Review

Obianuju Sandra Madueke-Laveaux, Amro Elsharoud, Ayman Al-Hendy, Obianuju Sandra Madueke-Laveaux, Amro Elsharoud, Ayman Al-Hendy

Abstract

Hysterectomy is the most common treatment option in women with uterine fibroids, providing definitive relief from the associated burdensome symptoms. As with all surgical interventions, hysterectomy is associated with risk of complications, short-term morbidities, and mortality, all of which have been described previously. However, information on the potential long-term risks of hysterectomy is only recently becoming available. A systematic literature review was performed to identify studies published between 2005 and December 2020 evaluating the long-term impact of hysterectomy on patient outcomes. A total of 29 relevant studies were identified. A review of the articles showed that hysterectomy may increase the risk of cardiovascular events, certain cancers, the need for further surgery, early ovarian failure and menopause, depression, and other outcomes. It is important to acknowledge that the available studies examine possible associations and hypotheses rather than causality, and there is a need to establish higher quality studies to truly evaluate the long-term consequences of hysterectomy. However, it is of value to consider these findings when discussing the benefits and risks of all treatment options with patients with uterine fibroids to allow for preference-based choices to be made in a shared decision-making process. This is key to ensuring that patients receive the treatment that best meets their individual needs.

Keywords: adverse events; complications; long-term consequences of hysterectomy; patient engagement; uterine fibroid management; uterine fibroids.

Conflict of interest statement

Obianuju Sandra Madueke-Laveaux is a consultant for CooperSurgical, Inc. Ayman Al-Hendy has provided consulting services to AbbVie, Bayer, Myovant, Novartis, and ObsEva, and he is grant funded by the National Institute of Health for fibroid-related research (R01 ES 028615-01, R01 HD 087417, R01 HD 094378, R01 HD 094380, 5U54 MD 007602-32, R01 HD 100367). In addition, he holds a patent for Methods for novel diagnostics and therapeutics for uterine sarcoma (US Pat No. 9,790,562 B2). Amro Elsharoud declares no conflict of interest.

Figures

Figure 1
Figure 1
Cumulative incidence curves for cardiovascular and metabolic conditions in women who underwent hysterectomy with ovarian conservation at 35 years or younger compared with age-matched referent women (stratified analyses). The hazard ratios (HRs) and corresponding 95% confidence intervals were calculated using Cox proportional hazards models with age as the time scale and adjusted using inverse probability weights. Reprinted from Menopause, Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: a cohort study, 25: 483–492, ©2018, with permission from Wolters Kluwer Health, Inc. [34].
Figure 2
Figure 2
Age-specific rates of first urinary incontinence operation in women in the exposed and unexposed cohorts. Age-specific rates are shown with 95% CIs. Age intervals show attained age during follow-up period. Reprinted from The Lancet, 370, Altman et al., Hysterectomy and risk of stress-urinary-incontinence surgery: nationwide cohort study, 1494–1499, ©2007, with permission from Elsevier [47].

References

    1. Pérez-Lopez F.R., Ornat L., Ceausu I., Depypere H., Erel C.T., Lambrinoudaki I., Schenck-Gustafsson K., Simoncini T., Tremollieres F., Rees M. EMAS position statement: Management of uterine fibroids. Maturitas. 2014;79:106–116. doi: 10.1016/j.maturitas.2014.06.002.
    1. Zimmermann A., Bernuit D., Gerlinger C., Schaefers M., Geppert K. Prevalence, symptoms and management of uterine fibroids: An international internet-based survey of 21,746 women. BMC Women’s Health. 2012;12:6. doi: 10.1186/1472-6874-12-6.
    1. Maruo T., Ohara N., Wang J., Matsuo H. Sex steroidal regulation of uterine leiomyoma growth and apoptosis. Hum. Reprod. Update. 2004;10:207–220. doi: 10.1093/humupd/dmh019.
    1. Stewart E.A., Cookson C.L., Gandolfo R.A., Schulze-Rath R. Epidemiology of uterine fibroids: A systematic review. BJOG. 2017;124:1501–1512. doi: 10.1111/1471-0528.14640.
    1. Baird D.D., Dunson D.B., Hill M.C., Cousins D., Schectman J.M. High cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. Am. J. Obstet. Gynecol. 2003;188:100–107. doi: 10.1067/mob.2003.99.
    1. Laughlin S.K., Stewart E.A. Uterine leiomyomas: Individualizing the approach to a heterogeneous condition. Pt 1Obstet. Gynecol. 2011;117:396–403. doi: 10.1097/AOG.0b013e31820780e3.
    1. Al-Hendy A., Myers E.R., Stewart E. Uterine Fibroids: Burden and Unmet Medical Need. Semin. Reprod. Med. 2017;35:473–480. doi: 10.1055/s-0037-1607264.
    1. Fortin C., Flyckt R., Falcone T. Alternatives to hysterectomy: The burden of fibroids and the quality of life. Best Pract. Res. Clin. Obstet. Gynaecol. 2018;46:31–42. doi: 10.1016/j.bpobgyn.2017.10.001.
    1. Wise L.A., Laughlin-Tommaso S.K. Epidemiology of uterine fibroids: From menarche to menopause. Clin. Obstet. Gynecol. 2016;59:2–24. doi: 10.1097/GRF.0000000000000164.
    1. Ghant M.S., Sengoba K.S., Recht H., Cameron K.A., Lawson A.K., Marsh E.E. Beyond the physical: A qualitative assessment of the burden of symptomatic uterine fibroids on women’s emotional and psychosocial health. J. Psychosom. Res. 2015;78:499–503. doi: 10.1016/j.jpsychores.2014.12.016.
    1. Borah B.J., Nicholson W.K., Bradley L., Stewart E.A. The impact of uterine leiomyomas: A national survey of affected women. Am. J. Obstet. Gynecol. 2013;209:319.e1–319.e20. doi: 10.1016/j.ajog.2013.07.017.
    1. Hasselrot K., Lindeberg M., Konings P., Kopp Kallner H. Investigating the loss of work productivity due to symptomatic leiomyoma. PLoS ONE. 2018;13:e0197958. doi: 10.1371/journal.pone.0197958.
    1. Donnez J., Dolmans M.M. Uterine fibroid management: From the present to the future. Hum. Reprod. Update. 2016;22:665–686. doi: 10.1093/humupd/dmw023.
    1. Williams A.R. Uterine fibroids—What’s new? F1000Research. 2017;6:2109. doi: 10.12688/f1000research.12172.1.
    1. Barrett M.L., Weiss A.J., Stocks C., Steiner C.A., Myers E.R. Procedures to Treat Benign Uterine Fibroids in Hospital Inpatient and Hospital-Based Ambulatory Surgery Settings, 2013: Statistical Brief #200. Agency for Healthcare Research and Quality (US); Rockville, MD, USA: 2016. [(accessed on 6 July 2021)]. Available online:
    1. Marsh E.E., Al-Hendy A., Kappus D., Galitsky A., Stewart E.A., Kerolous M. Burden, prevalence, and treatment of uterine fibroids: A survey of U.S. women. J. Women’s Health. 2018;27:1359–1367. doi: 10.1089/jwh.2018.7076.
    1. Nicholson W.K., Wegienka G., Zhang S., Wallace K., Stewart E., Laughlin-Tommaso S., Thomas L., Jacoby V.L., Marsh E.E., Wise L., et al. Short-term health-related quality of life after hysterectomy compared with myomectomy for symptomatic leiomyomas. Obstet. Gynecol. 2019;134:261–269. doi: 10.1097/AOG.0000000000003354.
    1. Clarke-Pearson D.L., Geller E.J. Complications of hysterectomy. Obstet. Gynecol. 2013;121:654–673. doi: 10.1097/AOG.0b013e3182841594.
    1. Goksever Çelik H., Çelik E., Turan G., Seçkin K.D., Gedikbaşi A. Risk factors for surgical site infection after hysterectomy. J. Infect. Dev. Ctries. 2017;11:355–360. doi: 10.3855/jidc.9053.
    1. Wiser A., Holcroft C.A., Tulandi T., Abenhaim H.A. Abdominal versus laparoscopic hysterectomies for benign diseases: Evaluation of morbidity and mortality among 465,798 cases. Gynecol. Surg. 2013;10:117–122. doi: 10.1007/s10397-013-0781-9.
    1. Tabibian N., Swehli E., Boyd A., Umbreen A., Tabibian J.H. Abdominal adhesions: A practical review of an often overlooked entity. Ann. Med. Surg. 2017;15:9–13. doi: 10.1016/j.amsu.2017.01.021.
    1. American College of Obstetricians and Gynecologists Committee on Gynecologic Practice American College of Obstetricians and Gynecologists Committee on Gynecologic Practice, Committee Opinion No 701: Choosing the route of hysterectomy for benign disease. Obstet. Gynecol. 2017;129:e155–e159. doi: 10.1097/AOG.0000000000002112.
    1. Food and Drug Administration Quantitative Assessment of the Prevalence of Unsuspected Uterine Sarcoma in Women Undergoing Treatment of Uterine Fibroids Summary and Key Findings. [(accessed on 1 December 2020)]; Available online: .
    1. Multinu F., Casarin J., Hanson K.T., Angioni S., Mariani A., Habermann E.B., Laughlin-Tommaso S.K. Practice patterns and complications of benign hysterectomy following the FDA statement warning against the use of power morcellation. JAMA Surg. 2018;153:e180141. doi: 10.1001/jamasurg.2018.0141.
    1. Stentz N.C., Cooney L.G., Sammel M., Shah D.K. Changes in myomectomy practice after the U.S. Food and Drug Administration safety communication on power morcellation. Obstet. Gynecol. 2017;129:1007–1013. doi: 10.1097/AOG.0000000000002035.
    1. Harris J.A., Swenson C.W., Uppal S., Kamdar N., Mahnert N., As-Sanie S., Morgan D.M. Practice patterns and postoperative complications before and after US Food and Drug Administration safety communication on power morcellation. Am. J. Obstet. Gynecol. 2016;214:98.e1–98.e13. doi: 10.1016/j.ajog.2015.08.047.
    1. Desai V.B., Wright J.D., Lin H., Gross C.P., Sallah Y.H., Schwartz P.E., Xu X. Laparoscopic hysterectomy route, resource use, and outcomes: Change after power morcellation warning. Obstet. Gynecol. 2019;134:227–238. doi: 10.1097/AOG.0000000000003375.
    1. Casiano E.R., Trabuco E.C., Bharucha A.E., Weaver A.L., Schleck C.D., Melton L.J., 3rd, Gebhart J.B. Risk of oophorectomy after hysterectomy. Obstet. Gynecol. 2013;121:1069–1074. doi: 10.1097/AOG.0b013e31828e89df.
    1. Parker W.H., Jacoby V., Shoupe D., Rocca W. Effect of bilateral oophorectomy on women’s long-term health. Women’s Health. 2009;5:565–576. doi: 10.2217/WHE.09.42.
    1. Page M.J., McKenzie J.E., Bossuyt P.M., Boutron I., Hoffmann T.C., Mulrow C.D., Shamseer L. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71.
    1. Wilson L.F., Pandeya N., Byles J., Mishra G.D. Hysterectomy status and all-cause mortality in a 21-year Australian population-based cohort study. Am. J. Obstet. Gynecol. 2019;220:83.e1–83.e11. doi: 10.1016/j.ajog.2018.10.002.
    1. Iversen L., Hannaford P.C., Elliott A.M., Lee A.J. Long term effects of hysterectomy on mortality: Nested cohort study. BMJ. 2005;330:1482. doi: 10.1136/bmj.38483.669178.8F.
    1. Howard B.V., Kuller L., Langer R., Manson J.E., Allen C., Assaf A., Cochrane B.B., Larson J.C., Lasser N., Rainford M., et al. Risk of cardiovascular disease by hysterectomy status, with and without oophorectomy: The Women’s Health Initiative Observational Study. Circulation. 2005;111:1462–1470. doi: 10.1161/01.CIR.0000159344.21672.FD.
    1. Laughlin-Tommaso S.K., Khan Z., Weaver A.L., Smith C.Y., Rocca W.A., Stewart E.A. Cardiovascular and metabolic morbidity after hysterectomy with ovarian conservation: A cohort study. Menopause. 2018;25:483–492. doi: 10.1097/GME.0000000000001043.
    1. Ingelsson E., Lundholm C., Johansson A.L., Altman D. Hysterectomy and risk of cardiovascular disease: A population-based cohort study. Eur. Heart J. 2011;32:745–750. doi: 10.1093/eurheartj/ehq477.
    1. Choi H.G., Lee S.W. Hysterectomy does not increase the risk of hemorrhagic or ischemic stroke over a mean follow-up of 6 years: A longitudinal national cohort study. Maturitas. 2018;117:11–16. doi: 10.1016/j.maturitas.2018.08.008.
    1. Yeh J.S., Cheng H.M., Hsu P.F., Sung S.H., Liu W.L., Fang H.L., Chuang S.Y. Hysterectomy in young women associates with higher risk of stroke: A nationwide cohort study. Int. J. Cardiol. 2013;168:2616–2621. doi: 10.1016/j.ijcard.2013.03.042.
    1. Ding D.C., Tsai I.J., Hsu C.Y., Wang J.H., Lin S.Z. Hysterectomy is associated with higher risk of coronary artery disease: A nationwide retrospective cohort study in Taiwan. Medicine. 2018;97:e0421. doi: 10.1097/MD.0000000000010421.
    1. Ding D.C., Tsai I.J., Hsu C.Y., Wang J.H., Lin S.Z., Sung F.C. Risk of hypertension after hysterectomy: A population-based study. BJOG. 2018;125:1717–1724. doi: 10.1111/1471-0528.15389.
    1. Li P.C., Tsai I.J., Hsu C.Y., Wang J.H., Lin S.Z., Ding D.C., Sung F.C. Risk of hyperlipidemia in women with hysterectomy-a retrospective cohort study in Taiwan. Sci. Rep. 2018;8:12956. doi: 10.1038/s41598-018-31347-z.
    1. Altman D., Yin L., Johansson A., Lundholm C., Grönberg H. Risk of renal cell carcinoma after hysterectomy. Arch. Intern. Med. 2010;170:2011–2016. doi: 10.1001/archinternmed.2010.425.
    1. Guenego A., Mesrine S., Dartois L., Leenhardt L., Clavel-Chapelon F., Kvaskoff M., Boutron-Ruault M.C., Bonnet F. Relation between hysterectomy, oophorectomy and the risk of incident differentiated thyroid cancer: The E3N cohort. Clin. Endocrinol. 2019;90:360–368. doi: 10.1111/cen.13899.
    1. Luo J., Hendryx M., Manson J.E., Liang X., Margolis K.L. Hysterectomy, oophorectomy, and risk of thyroid cancer. J. Clin. Endocrinol. Metab. 2016;101:3812–3819. doi: 10.1210/jc.2016-2011.
    1. Falconer H., Yin L., Bellocco R., Altman D. Thyroid cancer after hysterectomy on benign indications: Findings from an observational cohort study in Sweden. Int. J. Cancer. 2017;140:1796–1801. doi: 10.1002/ijc.30606.
    1. Forsgren C., Lundholm C., Johansson A.L., Cnattingius S., Altman D. Hysterectomy for benign indications and risk of pelvic organ fistula disease. Obstet. Gynecol. 2009;114:594–599. doi: 10.1097/AOG.0b013e3181b2a1df.
    1. Altman D., Falconer C., Cnattingius S., Granath F. Pelvic organ prolapse surgery following hysterectomy on benign indications. Am. J. Obstet. Gynecol. 2008;198:572.e1–572.e6. doi: 10.1016/j.ajog.2008.01.012.
    1. Altman D., Granath F., Cnattingius S., Falconer C. Hysterectomy and risk of stress-urinary-incontinence surgery: Nationwide cohort study. Lancet. 2007;370:1494–1499. doi: 10.1016/S0140-6736(07)61635-3.
    1. Li P.C., Huang H.K., Ding D.C. Hysterectomy associated with de novo lower urinary tract symptoms in a Taiwanese population: A nationwide, population-based study. Int. Urogynecol. J. 2019;30:1711–1717. doi: 10.1007/s00192-018-3796-y.
    1. Moorman P.G., Myers E.R., Schildkraut J.M., Iversen E.S., Wang F., Warren N. Effect of hysterectomy with ovarian preservation on ovarian function. Obstet. Gynecol. 2011;118:1271–1279. doi: 10.1097/AOG.0b013e318236fd12.
    1. Farquhar C.M., Sadler L., Harvey S.A., Stewart A.W. The association of hysterectomy and menopause: A prospective cohort study. BJOG. 2005;112:956–962. doi: 10.1111/j.1471-0528.2005.00696.x.
    1. Verschoor C.P., Tamim H. Frailty is inversely related to age at menopause and elevated in women who have had a hysterectomy: An analysis of the Canadian longitudinal study on aging. J. Gerontol. A Biol. Sci. Med. Sci. 2019;74:675–682. doi: 10.1093/gerona/gly092.
    1. Farquhar C.M., Sadler L., Stewart A.W. A prospective study of outcomes five years after hysterectomy in premenopausal women. Aust. N. Z. J. Obstet. Gynaecol. 2008;48:510–516. doi: 10.1111/j.1479-828X.2008.00893.x.
    1. Choi H.G., Jung Y.J., Lee S.W. Increased risk of osteoporosis with hysterectomy: A longitudinal follow-up study using a national sample cohort. Am. J. Obstet. Gynecol. 2019;220:573.e1–573.e13. doi: 10.1016/j.ajog.2019.02.018.
    1. Wilson L.F., Pandeya N., Byles J., Mishra G.D. Hot flushes and night sweats symptom profiles over a 17-year period in mid-aged women: The role of hysterectomy with ovarian conservation. Maturitas. 2016;91:1–7. doi: 10.1016/j.maturitas.2016.05.011.
    1. Choi H.G., Rhim C.C., Yoon J.Y., Lee S.W. Association between hysterectomy and depression: A longitudinal follow-up study using a national sample cohort. Menopause. 2020;27:543–549. doi: 10.1097/GME.0000000000001505.
    1. Wilson L., Pandeya N., Byles J., Mishra G. Hysterectomy and incidence of depressive symptoms in midlife women: The Australian Longitudinal Study on Women’s Health. Epidemiol. Psychiatr. Sci. 2018;27:381–392. doi: 10.1017/S2045796016001220.
    1. Laughlin-Tommaso S.K., Satish A., Khan Z., Smith C.Y., Rocca W.A., Stewart E.A. Long-term risk of de novo mental health conditions after hysterectomy with ovarian conservation: A cohort study. Menopause. 2020;27:33–42. doi: 10.1097/GME.0000000000001415.
    1. Phung T.K., Waltoft B.L., Laursen T.M., Settnes A., Kessing L.V., Mortensen P.B., Waldemar G. Hysterectomy, oophorectomy and risk of dementia: A nationwide historical cohort study. Dement. Geriatr. Cogn. Disord. 2010;30:43–50. doi: 10.1159/000314681.
    1. Shen Y.C., Chen W., Tsai I.J., Wang J.H., Lin S.Z., Ding D.C. Association of hysterectomy with bipolar disorder risk: A population-based cohort study. Depress Anxiety. 2019;36:543–551. doi: 10.1002/da.22904.
    1. Wild R.A., Carmina E., Diamanti-Kandarakis E., Dokras A., Escobar-Morreale H.F., Futterweit W., Lobo R., Norman R.J., Talbott E., Dumesic D.A. Assessment of cardiovascular risk and prevention of cardiovascular disease in women with the polycystic ovary syndrome: A consensus statement by the Androgen Excess and Polycystic Ovary Syndrome (AE-PCOS) Society. J. Clin. Endocrinol. Metab. 2010;95:2038–2049. doi: 10.1210/jc.2009-2724.
    1. Dimmitt S.B. Risk of renal cell carcinoma after hysterectomy: Is it all obesity? Arch. Intern. Med. 2011;171:1215–1216. doi: 10.1001/archinternmed.2011.303.
    1. Alkatout I., Mettler L., Peters G., Noé G., Holthaus B., Jonat W., Schollmeyer T. Laparoscopic hysterectomy and prolapse: A multiprocedural concept. JSLS. 2014;18:89–101. doi: 10.4293/108680813X13693422520846.
    1. Hill A.M., Pauls R.N., Crisp C.C. Addressing apical support during hysterectomy for prolapse: A NSQIP review. Int. Urogynecol. J. 2020;31:1349–1355. doi: 10.1007/s00192-020-04281-w.
    1. Vermeulen C.K.M., Veen J., Adang C., van Leijsen S.A.L., Coolen A.W.M., Bongers M.Y. Pelvic organ prolapse after laparoscopic hysterectomy compared with vaginal hysterectomy: The POP-UP study. Int. Urogynecol. J. 2021;32:841–850. doi: 10.1007/s00192-020-04591-z.
    1. Gabriel I., Kalousdian A., Brito L.G., Abdalian T., Vitonis A.F., Minassian V.A. Pelvic organ prolapse after 3 modes of hysterectomy: Long-term follow-up. Am. J. Obstet. Gynecol. 2021;224:496.e1–496.e10. doi: 10.1016/j.ajog.2020.11.008.
    1. Ng K.L., Ng K.W.R., Thu W.P.P., Kramer M.S., Logan S., Yong E.L. Risk factors and prevalence of urinary incontinence in mid-life Singaporean women: The Integrated Women’s Health Program. Int. Urogynecol. J. 2020;31:1829–1837. doi: 10.1007/s00192-019-04132-3.
    1. Sarmento A.C., Lírio J.F., Medeiros K.S., Marconi C., Costa A.P., Crispim J.C., Gonçalves A.K. Physical methods for the treatment of genitourinary syndrome of menopause: A systematic review. Int. J. Gynaecol. Obstet. 2021;153:200–219. doi: 10.1002/ijgo.13561.
    1. Georgakis M.K., Beskou-Kontou T., Theodoridis I., Skalkidou A., Petridou E.T. Surgical menopause in association with cognitive function and risk of dementia: A systematic review and meta-analysis. Psychoneuroendocrinology. 2019;106:9–19. doi: 10.1016/j.psyneuen.2019.03.013.
    1. Chen Y.C., Oyang Y.J., Lin T.Y., Sun W.Z. Risk assessment of dementia after hysterectomy: Analysis of 14-year data from the National Health Insurance Research Database in Taiwan. J. Chin. Med. Assoc. 2020;83:394–399. doi: 10.1097/JCMA.0000000000000286.
    1. Foster T., Forcina R.C. Why Shared Decision-Making Matters More Than Ever. [(accessed on 6 July 2021)]. Available online: .
    1. Simon J.A., Al-Hendy A., Archer D.F., Barnhart K.T., Bradley L.D., Carr B.R., Dayspring T., Feinberg E.C., Gillispie V., Hurtado S., et al. Elagolix treatment for up to 12 months in women with heavy menstrual bleeding and uterine leiomyomas. Obstet. Gynecol. 2020;135:1313–1326. doi: 10.1097/AOG.0000000000003869.
    1. Al-Hendy A., Lukes A.S., Poindexter A., III, Venturella R., Villarroel C., Wagman R.B., Li Y., McKain L., Stewart E.A. LIBERTY: Long-term extension study demonstrating one-year efficacy and safety of relugolix combination therapy in women with symptomatic uterine fibroids. Fertil. Steril. 2020;114:E1. doi: 10.1016/j.fertnstert.2020.08.027.
    1. Al-Hendy A., Lukes A.S., Venturella R., Li Y., Wagman R.B., Hunsche E., Stewart E.A. Relugolix combination therapy improves uterine fibroid-associated pain during menstrual and non-menstrual days: Results from the LIBERTY Phase 3 program. Fertil. Steril. 2020;114:E232. doi: 10.1016/j.fertnstert.2020.08.649.
    1. Stewart E.A., Taylor H.S., Taylor R.N., Donnez J., Bestel E., Gotteland J.P., Humberstone A., Garner E. Efficacy and safety of linzagolix (LGX) for the treatment of heavy menstrual bleeding (HMB) due to uterine fibroids (UF): Results from two phase 3 randomized clinical trials. Fertil. Steril. 2020;114:E527. doi: 10.1016/j.fertnstert.2020.09.016.
    1. Al-Hendy A., Lukes A.S., Poindexter A., III, Venturella R., Villarroel C., Li Y., McKain L.F., Stewart E.A. Treatment of symptoms of uterine fibroids with relugolix combination therapy: Efficacy and safety results from the Phase 3 LIBERTY 1 clinical trial. Fertil. Steril. 2019;112:E434. doi: 10.1016/j.fertnstert.2019.08.012.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe