Uterine fibroids are the commonest benign tumor of the female genital tract. They affect a significant proportion of reproductive aged women and while some women are asymptomatic, fibroids can cause excessive menstrual bleeding, pelvic pressure, and adversely affect reproductive outcomes. Myomectomy is the most suitable surgical option for women who desire preservation of their fertility potential. However, only a selected group of women of childbearing age will benefit from a myomectomy. Furthermore, the consequences of myomectomy on reproductive function have remained controversial. The purpose of this paper is to review the main surgical approaches for myomectomy - hysteroscopic resection, laparoscopic myomectomy and open myomectomy (by laparotomy) - and discuss evidence-based indications for myomectomy in women with fibroids, especially with regards to its impact on reproductive outcomes. A critical review of the literature pertaining to the surgical approaches of myomectomy and the indications for myomectomy was performed, focusing on their impact on fertility and reproductive outcomes. Myomectomy is useful for the treatment of symptomatic fibroids and in selected women with infertility. Symptomatic submucosal fibroids are classically treated by hysteroscopic resection. Symptomatic intramural and subserosal fibroids may be treated by myomectomy, either by laparotomy or laparoscopy depending on their number and size. Prophylactic myomectomy is not recommended for preventing obstetrical complications or the risk of leiomyosarcoma. Although fibroids can have a negative effect on fertility, only the removal of submucosal fibroids has been consistently shown to improve spontaneous fertility or outcomes of assisted reproduction technology.