Uterine Fibroids and Infertility

What are Uterine Fibroids and What are Their Common Manifestations?

Uterine fibroids are common benign tumors that arise from the muscle tissue of the uterus; they may be single or multiple. About 25% of all women over the age of 35 have fibroids; among African-American women, fibroids are even more common. With the trend toward delayed childbearing, more and more women are encountering the problems of fibroids during their reproductive years. These tumors may grow into the uterine cavity (submucous fibroids); they may be located in the uterine wall (mural) or protrude outside of the uterine wall (subserous). Submucous fibroids are the type that most commonly causes significant problems; even small tumors located in or bulging into the uterine cavity may cause abnormal bleeding (heavy bleeding, prolonged periods, bleeding between periods), anemia, pain, infertility, or miscarriage. Mural fibroids (located in the uterine wall) and subserous fibroids (protruding outside the uterine wall) may reach a large size before causing symptoms. These symptoms include pressure on the bladder with urinary frequency and urgency, or, less frequently, difficulty in voiding, pressure on the rectum with constipation, lower back and abdominal pain, as well as abnormal bleeding. A large fibroid uterus may also compress the ureter as it enters into the pelvis and lead to hydronephrosis (swelling of kidneys due to urine accumulation because of obstruction of the ureters) because of obstructed urine flow from the kidney.

Do Uterine Fibroids Cause Infertility?

It is generally accepted that fibroids may cause infertility, recurrent pregnancy losses, and premature delivery. In reviewing the literature, Verkauf reported on 94 infertile women with uterine fibroids who had at least one tumor larger than 3cm and no other apparent cause for infertility. Following surgical removal of fibroids (myomectomy), 59.5% of these women conceived, most within a short time. Buttram and Reiter suggested that only tumors 3cm or larger, those in submucous locations of any size, and tumors obstructing the fallopian tubes be considered for myomectomy as possible contributors to infertility. The miscarriage rate in the presence of fibroids is about 40%. Following myomectomy, 80% of patients with a history of repeated miscarriages will have a successful pregnancy.

Effective Treatment for Uterine Fibroids

Myomectomy is the surgical removal of fibroids. When performed by an expert, it is a safe and effective procedure that can be accomplished with minimal blood loss. When the operation is performed with the optimal technique by a highly experienced surgeon, the need for blood transfusions is limited to very few cases. Likewise, in an expert’s hands, a myomectomy is rarely converted during surgery to an unplanned hysterectomy because of uncontrollable bleeding. A gynecologic surgeon who has extensive experience with myomectomy can remove all fibroids regardless of their location. The successful myomectomy should result in the resolution of all symptoms related to fibroids and the reconstruction of a uterus with normal size and shape, capable of withstanding the stresses and demands of a full-term pregnancy.

Myomectomy: The Operation

Depending upon the location of the fibroid(s), myomectomy can be accomplished by either an abdominal or vaginal (using hysteroscopy) approach. When the fibroid causing symptoms is bulging into the uterine cavity (submucous), it is usually possible to remove it by using hysteroscopic technique. This technique involves using an operating “telescope” which is inserted into the uterus through the vagina. Hysteroscopic myomectomy is performed on an outpatient basis; the short recovery period at home is 2-3 days before the resumption of full activity. The major complication associated with hysteroscopic myomectomy is perforation of the uterus. This complication, however, should be rare indeed when the procedure is performed by a surgeon experienced in operating through the hysteroscope.

In the presence of fibroids in the uterine wall (mural) or bulging out of the uterus (subserosal), abdominal myomectomy through an abdominal incision is usually required. In most cases this can be accomplished through a low horizontal incision along the bikini line, resulting in a minimally visible scar. In my experience, following an uncomplicated abdominal myomectomy, discharge from the hospital is usually possible within 2-3 days. There is a variable recovery period at home of 2-6 weeks depending upon individual factors and lifestyle.

A critical part of a successful myomectomy is the optimal reconstruction of the uterus after the fibroids have been removed. The irregular defects created in the uterine wall by the removal of the fibroids must be meticulously repaired so that potential sites of bleeding and/or infection are eliminated. A poorly reconstructed uterus may rupture during a subsequent pregnancy or delivery. In this regard, removing mural fibroids through the laparoscope (telescope inserted through the navel) is not advisable in infertile women because optimal reconstruction of the uterus is not accomplished in this manner. Suboptimal reconstruction may also lead to post-operative bleeding, which may require an emergency hysterectomy and/or blood transfusions. In addition, internal bleeding (with or without infection) may cause pelvic adhesions, tubal occlusion, infertility and/or chronic pelvic pain.

Bleeding During Myomectomy

There are numerous surgical techniques for performing a myomectomy. However, the important goal common to all is minimizing blood loss and other complications. It is of utmost importance to prevent significant blood loss during and after surgery, as this may result in post-operative complications such as anemia, fever, infection, and the requirement for blood transfusion. In published series, the incidence of blood loss during myomectomy requiring blood transfusion varies up to 24% of all myomectomies. However, meticulous technique in the hands of an experienced surgeon is associated with a much lower transfusion rate of 2 to 5%. Bleeding and/or infection are important problems because they may lead to pelvic adhesions which, in turn, may cause pain or bowel obstruction in the short or long term. Of primary concern in the infertile woman with fibroids, of course, is the fact that these adhesions may lead to failure of the operation to restore fertility by inducing a new cause of infertility, namely, adhesions covering the ovaries and or blocking the tubes.

What is the Role of Hormonal Treatment?

Some physicians advocate hormone treatment with GnRH agonists, such as Lupron, in preparation for myomectomy. This treatment postpones the operation for 2-4 months. During this time the fibroids decrease in size and the bleeding is markedly reduced. Although some surgeons feel that this makes the operation easier and diminishes blood loss, many other experienced surgeons find this very expensive treatment unnecessary with few exceptions. However, it is generally agreed that if a woman is very anemic, hormone treatment along with iron supplements is indicated as it promotes recovery from the anemia prior to surgery. Concern has been raised that GnRH treatment may shrink small fibroids which could, therefore, be missed at surgery only to enlarge again and cause problems later.

What Kind of Imaging Tests May Be Helpful Prior to Myomectomy?

The role of imaging studies in women with fibroids is to: a) confirm the clinically suspected diagnosis of fibroids, b) exclude other causes of uterine enlargement or pelvic masses such as adenomyosis, uterine malignancy, and benign or malignant ovarian masses, c) identify normal ovaries in the presence of an enlarged uterus, d) examine the kidneys and urinary tract for obstruction due to the pelvic mass, e) assess the fallopian tubes for patency and f) determine precisely the number, size, and location of the fibroids. The latter is particularly important for a successful myomectomy because it helps the surgeon determine ahead of time what kind of operation is required. The type of imaging test depends on the individual findings in a given woman and the availability of certain equipment/techniques. The tests commonly used are pelvic ultrasound (both transabdominal and vaginal) and x-rays of the kidneys and urinary tract (IVP). Newer imaging modalities that may be used in selected cases include MRI and Sonohysterography. MRI helps define the size and location of fibroids in a giant uterus and also detects adenomyosis as an additional diagnosis or as the sole diagnosis (instead of fibroids). Sonohysterography is an ultrasound study performed after the instillation of saline into the uterine cavity. It helps define the location and presence of submucous or intracavity fibroids.

The Role of Other Surgical Techniques for Myomectomy in the Infertile Patient

Fibroids can also be treated by other surgical techniques, namely, laparoscopic myomectomy, laparoscopic coagulation with laser or bipolar needles, and laparoscopic freezing (cryo myolysis). These techniques are not recommended for women with infertility. Laparoscopic myomectomy does not allow for optimal reconstruction of the uterus. This is very important for the woman desiring pregnancy because the poorly-repaired uterus is prone to the rare but potentially catastrophic complication of uterine rupture during pregnancy. This could threaten the life of the mother and fetus. Suboptimal repair of the uterus is also associated with complications of bleeding and adhesion formation. Laparoscopic coagulation and freezing techniques are relatively new and are considered only for women for whom fertility and childbearing are not issues.

Pregnancy and Delivery After Myomectomy

Pregnancy and delivery after myomectomy are usually uneventful. In rare cases, uterine rupture may occur during pregnancy or delivery; this complication may result in severe hemorrhage, fetal loss, and even maternal death. Because of the potential for catastrophic results, it is recommended that women have cesarean deliveries in the following circumstances: 1) when the myomectomy involved full-thickness incision of the uterine wall or multiple deep uterine incisions or 2) when myomectomy was complicated by an infection which may have weakened the uterine wall or 3) when there is doubt regarding the adequacy or extent of the uterine repair.

Questions to Ask Before Choosing a Surgeon for Myomectomy

1. How often do you perform myomectomy?
2. How many years have you performed myomectomy and how many myomectomies have you performed?
3. What was the outcome of these myomectomies: How often was the operation converted into hysterectomy?
4. In what percentage of cases were blood transfusions required?
5. How long do your patients stay in the hospital after surgery?

These questions are important because they help pinpoint the experience and “track record” of a doctor. An experienced, confident surgeon will not find these questions threatening and should be readily forthcoming with these facts and figures. On the other hand, if a physician’s surgical skill is limited primarily to hysterectomy, these questions will reveal inexperience or poor results with myomectomy. For further reassurance, consider speaking with other women who have undergone myomectomy by the surgeon under consideration. consideration.

Conclusions

Uterine fibroids, alone or in combination with other conditions, may lead to infertility, miscarriages, and premature deliveries. In carefully selected cases, myomectomy is an important step in resolving the problems of infertility and/or repeated pregnancy loss. It is important to stress that myomectomy is a demanding surgical procedure with serious potential for complications. However, in optimal circumstances, a successful myomectomy is a rewarding operation that can restore health and fertility. Becoming familiar with the facts and carefully choosing an experienced, caring surgeon will increase the likelihood of achieving the desired goal.