Fibroids and Fertility

Fibroids or leiomyomas are benign smooth muscle tumours of the uterus. These tumours are very common and approximately one out of every five women over the age of 30 years has a fibroid. Uterine fibroids tend to be more frequent in African/African American women and less frequent in women from other ethnic groups (i.e. Asian). Often fibroids cause no symptoms and are found during a routine gynaecological examination such as an annual exam. At that time an enlarged or irregularly shaped uterus is noted and later this finding is confirmed by ultrasound. Sometimes fibroids are found during an infertility evaluation when tests such as a pelvic ultrasound, hysterosonogram or hysterosalpingogram are ordered.

Fibroids are classified according to their location in three types:

(1) Subserosal - when the fibroid grows under the outer layer or serosa of the uterus;

(2) Intramural - when the fibroid grows within the muscular wall of the uterus (myometrium), and

(3) Sub mucosal or intracavitary - when the fibroid grows just under the lining of the uterine cavity (mucosa) or it occupies the inside of the uterine cavity. Sub mucosal or intracavitary fibroids can change the shape of the uterine cavity.

Large intramural fibroids may alter the blood flow to the uterine lining and may also alter the shape of the uterine cavity. Subserosal fibroids usually don't alter the shape of the uterine cavity, but when large can cause discomfort.

Most fibroids are usually small, asymptomatic, and don't require treatment. These benign tumours only need close gynaecological observation to document changes in size or the early onset of symptoms. Common symptoms associated to fibroids are back pain, abdominal pressure or discomfort, urinary frequency, rectal pressure or discomfort, and periods that can be painful, heavy and prolonged.

Fibroids are associated with infertility in 5 to 10% of cases. Nevertheless, when all other causes of infertility are excluded fibroids may account for only 2 to 3% of infertility cases. Fibroids may cause reduced fertility or infertility by:

1. Creating an abnormal uterine cavity. An enlarged or elongated cavity could interfere with the sperm transport, and a cavity with an abnormal contour could prevent normal implantation.

2. Fibroids can result in a markedly distorted uterus and cervix. The distortion could result in decreased access to the cervix by the ejaculated sperm preventing its effective transport to the uterus.

3. The uterine segments of the fallopian tubes could be obstructed or distorted by fibroids.

When infertile women present with uterine fibroids every effort should be made to exclude any other possible causes of infertility. A standard infertility evaluation should take place and an assessment of the uterine cavity should be performed by hysterosalpingogram (HSG) or "fluid" ultrasound (hysterosonogram). Only then a decision should be made regarding the management of the fibroids.

Treatment of Fibroids

Most uterine fibroids don't need to be removed except in select cases. The medical literature suggests that removal can be beneficial when the uterine cavity is distorted by the fibroids. In addition, some reports suggest that their removal may also be indicated when they are 5 centimetres or more in diameter and are located within the wall of the uterus (intramural). Otherwise, expectant management is recommended when the uterine cavity is normal, the fibroids are small, or when they are located on the surface of the uterus.

Myomectomy
Fibroids are removed in a surgical procedure called a "myomectomy". Three types of myomectomy can be performed: abdominal myomectomy, laparoscopic myomectomy, and hysteroscopy myomectomy. The abdominal myomectomy requires an abdominal incision usually of the "bikini" type, and through the incision the fibroids are removed from the uterus. This abdominal approach is the best procedure when fibroids are large, numerous, and or located deep within the muscle of the uterus. 

Fibroids can also be removed by laparoscopy, and this type of myomectomy is best when fibroids are few in number, superficial in location and small in size. Hysteroscopy myomectomy is recommended when most of the fibroid is located within the cavity of the uterus. Through the uterine cervix an operative hysteroscopy is inserted and the myomectomy is then performed. Endoscopic scissors, laser or electrocautery are employed to perform this type of myomectomy.

A myomectomy is a relatively safe procedure that results in few serious complications. Postoperative adhesion formation is a common complication and good surgical technique combined with adhesion-prevention barriers should be routinely used at myomectomy.

There are other options for the treatment of uterine fibroids, but these alternatives are not recommended for women who desire fertility. Some of these options are:

1. Uterine artery embolization (UAE) - results in the obstruction of blood flow to the fibroids, which then causes them to shrink. This procedure is quite successful in reducing tumour size and decreasing symptoms. Pregnancies have been reported after UAE but the safety of this procedure in women who want to get pregnant has not been established.

2. Medical therapies with agents such as GnRH agonists, progestational agents, and RU486 (mifepristone). These agents can decrease uterine size and symptoms, but once the treatment is discontinued the fibroids can grow back to their initial size. The use of these drugs is not effective in promoting fertility and is not recommended when women are attempting pregnancy.

3. New techniques are being developed for the treatment of uterine fibroids. One of these new techniques is laparoscopic myolysis in which a needle is used to apply electric current directly to fibroids. The goal is to disrupt the blood flow of fibroids and cause them to shrink over time. A similar laparoscopic procedure uses super cooled cryoprobes to destroy the fibroids. Another technique uses magnetic resonance imaging (MRI) to target a high intensity ultrasound waves to destroy the fibroids. Again, the safety of these procedures in women who want to get pregnant has not been established.

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