Uterine fibroids are the most common tumors in women and their prevalence is higher in patients with infertility. At present, they are classified according to their anatomical location, as no classification system includes additional parameters such as their size or number. There is a general agreement that submucosal fibroids negatively affect fertility, when compared to women without fibroids. Intramural fibroids above a certain size (>4 cm), even without cavity distortion, may also negatively influence fertility. However, the presence of subserosal myomas has little or no effect on fertility. Many possible theories have been proposed to explain how fibroids impair fertility: mechanisms involving alteration of local anatomical location, others involving functional changes of the myometrium and endometrium, and finally endocrine and paracrine molecular mechanisms. Nevertheless, any of the above mentioned mechanisms can cause reduced reproductive potential, thereby leading to impaired gamete transport, reduced ability for embryo implantation, and creation of a hostile environment. The published experience defines the best practice strategy, as not many large, well-designed, and properly powered studies are available. Myomectomy appears to have an effect in fertility improvement in certain cases. Excision of submucosal myomas seems to restore fertility with pregnancy rates after surgery similar to normal controls. Removal of intramural myomas affecting pregnancy outcome seems to be associated with higher pregnancy rates when compared to non-operated controls, although evidence is still nοt sufficient. Treatment of subserosal myomas of reasonable size is not necessary for fertility reasons. The results of endoscopic and open myomectomy are similar; thus, endoscopic treatment is the recommended approach due to its advantages in patient's postoperative course.