Uterine Fibroids

yvonneFertility, Pelvic Pain, Surgery

​Uterine fibroids (also known as leiomyomas) are extremely common muscle tumors (or growths) that develop from a single muscle cell within the womb.  It is stated in the literature that up to 75% of women develop a fibroid prior to menopause (1).  That being said, not all women require intervention.  The questions that need to be answered include:  Do I really need this fibroid removed?  If it needs to be removed, how can that be accomplished?    

​Recommendations for fibroid removal or myomectomy hinge on size, location, symptoms and the desire for future fertility.  Fibroids may be located anywhere in the uterus.  Tumors located within or close to the uterine cavity may impact bleeding and cramping even if they are small.  Some women may suffer from anemia or low blood counts.  Larger fibroids can cause pressure symptoms and discomfort.  Decisions regarding management in these cases are fairly straightforward since surgery should be able to resolve or significantly improve these symptoms.  The big question is a woman with no symptoms that is attempting to conceive.

​It is well known that any fibroid that distorts or disrupts the uterine cavity has a negative impact on one’s ability to conceive both naturally and with in vitro fertilization (IVF) (2).  In addition, pregnancy complications may be increased including miscarriage, preterm labor/delivery, postpartum bleeding, C-section risk and malpresentation (where the baby is positioned differently in the uterus).  Some controversy exists regarding fibroids that are “close to” but not within the uterine cavity.  According to multiple studies, there is some evidence that fibroids that exist in close proximity to the cavity (where the baby will be developing) do pose a negative impact on success.  A recent study published in March of this year found that fibroids located close to the uterine cavity were associated with reductions in live birth rates in women undergoing IVF (3).  How then do fibroids impact fertility?

​Fibroids that impact the uterine cavity have an obvious mechanical impact but what about fibroids not immediately within the cavity.  What other mechanisms have been proposed?  Impacts on blood flow have been proposed as well as the potential for fibroids to produce substances that may have a significant impact on the receptive nature of the nearby endometrium or uterine lining (4).  Other theories have focused on the impact on the fallopian tube and the possible deleterious effect on the tubal transport of the sperm, egg or embryo.  It is our belief that fibroids causing cavity distortion or larger fibroids in close proximity to the cavity should be removed.  

​Since fibroid size and location are the most important characteristics that dictate how we counsel our patients, we recommend uterine imaging to assist us in our ability to recommend the best course of action.  Saline ultrasound offers excellent visualization of uterine fibroids and furthermore, allows the physician to determine distance from the cavity as well as the best surgical approach for smaller fibroids that may not be directly visible from the outside when performing minimally invasive surgery.

​The technique of myomectomy may be performed in several different ways, depending on fibroid size, number and patient characteristics.  Smaller fibroids located within the uterine cavity may be approached with a hysteroscope (an instrument placed through the cervix) while the patient is under anesthesia.  This technique does not require incisions and most patients return to normal activity the following day.  Larger fibroids or fibroids where all or the majority of the tumor is located outside the cavity are treated either with laparoscopy (small incisions) with approximately 5-7 days out of work or with laparotomy which requires longer recovery times.  By far, the majority of cases can be handled in a minimally invasive way without a hospital stay.  Laparoscopic management requires advanced laparoscopic skills and has been shown to be associated with reductions in post-operative complications and blood loss.  Our experience has been that patients undergoing laparoscopic myomectomy recover faster and return to work sooner with minimal scars.

​Although fibroids are very common, the first step is to determine whether an intervention is necessary.  This is based on symptoms and fertility desires.  Furthermore, your physician, through very basic testing, can determine whether the fibroid(s) are hindering your ability to conceive and carry a child.  If one desires to proceed with myomectomy, most can be accomplished in a minimally invasive way.  We would encourage anyone with symptoms of painful periods, cramping, pelvic pressure or infertility to seek an evaluation for anatomic causes.  There are multiple options available and outcomes after myomectomy are excellent.

 

Christopher W. Lipari, M.D.

Board Certified Reproductive Endocrinologist and Infertility Specialist

Jacksonville Center for Reproductive Medicine 

Advanced Reproductive Specialists

 

 

 

1. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM.  High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence.  Am J Obstet Gynecol 2003; 188: 100-7.

2. Farhi J, Ashkenazi J, Feldberg D, Dicker D, Orvieto R, Ben Rafael Z.  Effect of uterine leiomyomata on the results of in-vitro fertilisation treatment.  Hum Reprod 1995; 10: 2576-8.

3. Yan L, Yuq Zang Y, Guo Z, Lee Z, Niu J, Ma J.  Effect of type 3 intramural fibroids on endometrial fertilization – intracytoplasmic sperm injection outcomes as: a retrospective cohort study. Fertil Steril 2018; 109: 817-22.

4. Rackow B, Taylor HS.  Submucosal uterine leiomyomas have a global effect on molecular determinates of endometrial receptivity.  Fertil Steril 2010; 93: 2027-34.