Fibroid and Fertility
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5th Jun 2012, 09:24 PM #1
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Fibroid and Fertility
What are fibroids?
Fibroids of the uterus, also known as leiomyomas or just myomas, are benign (non-cancerous) growths of smooth muscle usually within the normal smooth muscle walls of the uterus. A woman may have a single fibroid or multiple fibroids and they may be located on the exterior or interior uterine surfaces or within the wall of the uterus.
These benign tumors are very common and in the majority of women cause very few problems. Sometimes they can be associated with heavy menstrual flow, severe cramping, pelvic pressure and bladder or bowel problems. If these symptoms become severe and disruptive to a woman's quality of life, surgery to remove the fibroids (myomectomy) may be recommended. If the woman is no longer interested in childbearing, hysterectomy is another option. Recently developed less invasive techniques such as uterine artery embolization and electrical ablation are being offered in some hospitals.
Fibroids and Pregnancy
During pregnancy, fibroids can cause problems in some patients, depending on their size and location. As these benign tumors are dependent on estrogen to grow, the high levels of estrogen during pregnancy can, in some cases, lead to rapid growth. If the fibroid is on the outer surface of the uterus, this may present little problem, if any, with regards to conception and carrying the pregnancy. If the fibroid is located within the uterus muscle wall or nearer the uterine cavity where the fetus is growing, a patient may be at higher risk for miscarriage of the pregnancy. In rare cases, the fibroid may grow so rapidly during pregnancy that it outgrows its blood supply and the center of the tumor undergoes a process of degeneration, which can be painful. Also uncommon but of significance is the fact that some fibroids may block the lower portion of the uterus and not allow the baby's head to descend for birth. Cesarean delivery may be necessary in this case. It is important to keep in mind that the majority of patients with fibroids experience no problems whatsoever during pregnancy.
Fibroids and Fertility
The issues for women with fibroids who are attempting to conceive are much less certain. It is unclear as to the exact mechanism for how fibroids may prevent embryo implantation; it does appear that fibroids that enlarge or distort the uterine cavity do diminish the chances that an embryo will implant in the uterine lining. If the fibroid does not distort the lining, in most cases it does not appear that the fibroids cause implantation failure.
Data from a large study by Buttram and colleagues reported that of over 1,200 women undergoing myomectomy surgery for fibroid tumors, 27% complained of infertility and 3% had a history of miscarriage but of these women, only 76 women had no other cause for their infertility. When these women underwent myomectomy to remove the fibroids, the conception rate was significantly improved and 40% of the women conceived, suggesting but not proving that the fibroids contributed to their infertility. Other more recent studies have reported pregnancy rates in the range of 35-60% following either abdominally or hysteroscopic (trans-vaginal) myomectomy.
As with any potential fertility factor, the age of the woman must be considered when evaluating results from myomectomy studies. For instance, Buttram's study reported decreased pregnancy rates following myomectomy when the patients were 36 years old or older. Likewise, the size of the uterus prior to surgery may predict the likelihood of success of the procedure. Women with very large fibroids and with uterine measurements greater than the size of a three-month pregnant uterus had a diminished chance of successful conception after myomectomy.
Location of the fibroid and impact of the fibroid (or fibroids) on the uterine cavity appear to be important factors. A 1995 study by Farhi and colleagues suggested that when the fibroid distorts the endometrial (uterine) lining, the chance that any one embryo will implant at the time of in vitro fertilization is reduced to about one third the implantation rate seen when women have fibroids that do not distort the cavity. In this group of women with non-distorting fibroids, the embryo implantation rate was the same as the women who were undergoing IVF with no fibroids present.
5th Jun 2012, 09:25 PM #2
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Re: Fibroid and Fertility
Detection of Fibroids
Pelvic Examination and Routine Pelvic Ultrasound
If the fibroid tumor or tumors are very large, they may be felt on pelvic examination. Smaller fibroids may be difficult to diagnose on examination alone. Pelvic ultrasound is usually the best way to see a fibroid. In order to evaluate the potential effect on the uterine cavity, the ultrasound should be performed shortly before ovulation, when the endometrial lining is at its thickest and any fibroid within the cavity or impinging on the cavity may best be seen against the background of the pre-ovulatory endometrium. If a fibroid within the uterine cavity is suspected, it may be confirmed on hysterosonogram or hysteroscopy.
A hysterosonogram is sometimes also called a saline sonogram, a water sonogram or a sonohysterogram. It involves performing a pelvic sonogram at the same time that a small amount of sterile fluid is placed into the uterus through a small tube placed into the cervix. If there is a fibroid in the cavity or impinging on the cavity, it should be clearly visible on this type of ultrasound.
A hysteroscopy is a minor surgical procedure that involves placing a lighted telescopic instrument (hysteroscope) through the uterine cervix and visualizing any abnormalities within the wall of the uterine cavity. If a fibroid is seen, it can sometimes be removed at the same procedure.
Magnetic Resonance Imaging (MRI)
If a patient has large, multiple fibroids, MRI can help to delineate the fibroids, even small ones, which may be of help in insuring all are removed at a subsequent myomectomy. Also, MRI can help to distinguish fibroids from the one other uterine abnormality that it can sometimes be confused with, adenomyosis. While fibroids can be removed surgically, adenomyosis cannot, so if there is any doubt about this on routine pelvic ultrasound, MRI is the best method to distinguish the two conditions.
Removal of Fibroids
Most women undergoing surgery for uterine fibroids are doing so because they are having symptoms such as heavy or prolonged uterine bleeding, severe menstrual cramping, or uncomfortable sensations of pelvic pressure. If a patient is not having symptoms and is not trying to conceive, it is usually not necessary to remove the fibroids, as they are virtually always benign.
If a woman is having fertility problems and has fibroids distorting the uterine lining, it may be necessary to consider myomectomy.
Myomectomy is surgery to remove the fibroid, preserving as much of the normal uterine muscle as possible. If the fibroids are mostly within the wall of the uterus, the surgery is usually done by laparotomy, that is, performing an open abdominal incision and cutting into the uterus from the external surface. This surgical procedure can be performed by most all gynecologists. Risks to the procedure are minimal but may include bleeding and damage to the normal uterine muscle. Many patients will have pelvic scar tissue forming as a result of the open abdominal incision and the uterine incisions. Most patients that have a myomectomy will need to have a Cesarean section with any subsequent pregnancy.
If the fibroid is mostly situated within the uterine cavity, the best approach is usually through a hysteroscope, a thin lighted telescope used to visualize the fibroid. Electrosurgical loops can be used to remove the fibroid or vaporize it within the uterus. Gynecologic surgeons must have specialized training to perform this type of surgery. Risks of the procedure again are minimal but may include puncturing the uterine wall, bleeding and fluid overload (special fluids are used to fill the uterine cavity during the procedure so the fibroid can be visualized and this fluid can be absorbed rapidly into the bloodstream). Following resection, there is some risk of intrauterine scarring. Recovery is rapid and there are no incisions.
Some surgeons have advocated removal of fibroids through a "belly button surgery" called a laparoscopy. This minimally-invasive surgery requires special training and equipment. It is still somewhat controversial as to whether women who desire future fertility should undergo this surgical approach, as there is some question as to whether there may be an increased risk of rupture of the uterus during a subsequent pregnancy. Gynecologic surgeons must be specially trained to perform laparoscopic myomectomy. Risks may include bleeding, injury to the intestines or other pelvic tissues. Scar tissue formation after surgery is usually less than with open surgery and recovery time is much quicker as the abdominal incisions are minimal.
Uterine Artery Embolization
This relatively new technique involves placing specially guided catheters into the arteries of the leg (at the groin) which are then threaded up, under X-ray visualization, into the arteries that supply blood to the uterus and the fibroids. Special beads are then injected into the uterine artery and they work to occlude the blood supply to the fibroids. This procedure is still under active research investigation but is becoming more widely available. This procedure should only be performed by radiologists with highly specialized training and experience with the procedure. Risks include bleeding, damage to the arteries, infection and a small possibility of blood clots. It is usually associated with pain requiring overnight hospitalization for pain management and many patients experience flu-like symptoms of fever and tiredness as the fibroids start to die. Because of newness of this procedure, long-term effects are not yet known and it is not a recommended procedure for women wishing to preserve their fertility.
Fibroids are very common benign growths within the muscle of the uterus and in the vast majority of women do not cause significant health problems. A few women who desire pregnancy may need to have the fibroid or fibroids removed prior to attempting pregnancy if the fibroid(s) are located in such a manner as to distort or impinge upon the uterine cavity. Various surgical approaches may be considered, depending on fibroid location.