Fibroids

The biggest concern in pregnancy is whether the fibroid will increase the chance or preterm birth or miscarriage. In some cases, fibroids can outgrow their blood supply and cause severe pain. Hospitalization might be needed. Also, fibroids can change the baby’s position in the uterus. This can increase the risk for miscarriage, preterm delivery, and cesarean section.

TYPES OF FIBROIDS

1. Subserosal

Are in the outer wall of the uterus (55%)

2. Intramural

Are found in the muscular layers of the uterine wall (40%)

3. Submucosal

Protrude into the uterine cavity (5%)

Fibroids can also be connected to the uterus by a stalk (pedunculated), or attached to nearby ligaments or organs, such as the bladder and bowel. Fibroids are rarely found outside the pelvic cavity.

 

Fibroids are found in 20% of women of reproductive age, but are more common in African-American women (50%-80%). The exact cause of uterine fibroids is unclear, but there is evidence that it may be a combination of genetic, hormonal, and environmental factors.

Approximately 5% – 10% of infertile women have fibroids. Their size and location determines whether fibroids affect fertility. Examples include fibroids that are inside the uterine cavity (submucosal) or very large (>5 cm in diameter) within the wall of the uterus (intramural).

Most women with fibroids will not be infertile. Women with fibroids and their partners should be thoroughly evaluated to find other problems with fertility before fibroids are treated. A fertility specialist can help assess if fibroids might be hampering conception.

THERE ARE SEVERAL WAYS UTERINE FIBROIDS CAN REDUCE FERTILITY

• Changes in the shape of the cervix can affect the number of sperm that can enter the uterus.
• Fallopian tubes can be blocked by fibroids.
• They can impact the size of the lining of the uterine cavity.
• Blood flow to the uterine cavity can be affected.

This can decrease the ability of an embryo to stick (implant) to the uterine wall or to develop.

FIBROIDS DURING PREGNANCY

Fibroids are found in 2% to 12% of pregnant women, but not all fibroids get larger or cause problems in a pregnancy. If a fibroid grows, it usually does so in the first 12 weeks of pregnancy. If a woman conceives after having a fibroid removed, she should discuss this with the obstetrician who will deliver the baby. A cesarean section may be recommended.

TREATMENT OF UTERINE FIBROIDS

Fibroids usually do not require treatment because most patients with fibroids do not have symptoms. Women with fibroids should have regular checkups to determine if the fibroids are changing in size, to track worsening symptoms, and if planning to get pregnant.

Since some fibroids are affected by estrogen levels, medical management of uterine fibroids may help temporarily but will not improve fertility. Medications that are used may be associated with undesirable side effects. These medicines include gonadotropin- releasing hormone (GnRH) analogs (possible side effects are: hot flashes, vaginal dryness, mood changes, osteoporosis), birth control pills (possible side effects are: breast tenderness, blood clots), progestins (possible side effects are: bloating, abnormal bleeding), and adrogens (unwanted hair growth). Alternative approaches such as herbal and homeopathic therapies have not been shown to improve symptoms caused by fibroids.

Surgery is considered when fibroids cause significant symptoms and should not be considered to treat infertility until after a thorough evaluation of other factors that could be causing infertility. The only surgical option available to women who desire to get pregnant in the future is a myomectomy or surgical removal of the fibroids. In most cases, the size and location of the fibroids will determine the appropriate surgical technique.

The type of myomectomy performed depends on the location and size of the fibroids. All myomectomies carry the risk of scarring and adhesions which can affect future fertility. Each also carries the risk of excessive bleeding, which may require a hysterectomy.

Abdominal myomectomy (Laparotomy)

With this method, the surgeon makes an incision in the abdominal wall. It is most commonly used to remove tumors on the outer surface of the uterus and surrounding organs. This surgery usually requires a 48 to 72 hour hospital stay and 4-6 weeks’ recovery.

Laparoscopic myomectomy

During operative laparoscopy, the doctor places a laparoscope into the abdomen through a small incision near the navel and then uses surgical instruments placed through small 5-10 mm incisions to remove the fibroids. Women can be sent home from the hospital the same day or within 24 hours. Recovery time is usually two to seven days.

Robotic-assisted myomectomy

During a robotic procedure, a doctor places a telescope into the abdomen at or above the navel. Up to five other small incisions are made to hold the instruments to remove the fibroids. Women are typically sent home from the hospital the same day or within 24 hours. Recovery time is usually between a few days and a week.

At Gondra Center for Reproductive Care & Advanced Gynecology most of the fibroids that require an abdominal approach are remove by Dr. Gondra laparoscopically with the assistance of robotic technology, Da Vinci. When the fibroids can be removed through hysteroscopy Dr. Gondra always chooses this approach first regardless of the size of the fibroid (see below)

Hysteroscopic myomectomy

During this procedure, the doctor inserts a telescope through the cervix and fills the uterus with fluid to expand the walls. Surgical instruments are then inserted through a channel in the hysteroscope to remove submucous fibroids. Generally, women are sent home the same day as surgery and can return to their normal activities within a few days after the procedure. Serious complications are uncommon and include damage or scarring to the inside cavity of the uterus, electrolyte imbalance (changes in the minerals in the blood system), puncturing the uterus and bleeding.

RISK OF RECURRENCE

The risk of recurrence is about 30% over 10 years. Patients with multiple fibroids are more likely to experience recurrence as compared to patients with solitary fibroids.