Background: Uterine leiomyomas (fibroids) are now known to be highly variable in their clinical behavior and biologic basis. However, the approach to leiomyomas and their effect on fertility, miscarriage and pregnancy complications has been based on location alone.Materials and Methods: This talk with bring together published information on the effect of leiomyomas on reproductive performance and newer literature on growth, regression and genetics of uterine fibroids. In addition, we will discuss the effects of treatments for fibroids on reproductive performance.Results: Location within the uterus remains the most predictive clinical factor in determining the impact of uterine fibroids on fertility. Submucosal fibroids have the greatest fertility impairment. Moreover, removal of submucosal fibroids is associated with an improvement in fertility potential. In contrast, intramural fibroids also have a measurable inhibitory effect on fertility potential, but show no attenuation of that impairment with conventional surgical removal. However, it is not clear whether it is biologic differences in the two or the adverse effects of surgical myomectomy which makes a difference.Conclusion: Further work is necessary to understand genotype/phenotype relationships in uterine fibroids. Less invasive treatment options may also benefit women with leiomyomas who desire pregnancy.