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Understanding Infertility Uterine Fibroids

Uterine Fibroids

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Uterine fibroids, or uterine myomas, are benign growths within the uterus. They are the most common female pelvic tumors, accounting for 35-50% of all hysterectomies performed in the U.S. each year. They vary in size and can be as small as a pea or as big as a melon. By age 50, 80% of African American and 70% of Caucasian women will develop fibroids. They cause symptoms in less than 50% of the cases. Their most common symptoms are abnormal bleeding, pelvic pain and infertility.

The cause of uterine fibroids is typically unknown, but what we do know is that they stem from the smooth muscle of the uterus and are heavily influenced by estrogen levels. These benign growths tend to appear during a woman’s reproductive years, typically receding post-menopause when hormonal activity in the ovaries dwindles.

Having given birth to at least two children full-term seems to diminish the risk of fibroids. Additionally, lower rates of fibroids have been observed in women with a low Body Mass Index (BMI), smokers, and those who maintain regular exercise routines, all of which correlate with reduced estrogen levels.

Conversely, women who are obese, and thus have elevated estrogen levels, tend to exhibit a higher incidence of fibroids. Notably, fibroid tumors are 2-3 times more common in African American women compared to other racial groups.

  • Pelvic examination: The fibroid uterus is typically enlarged and may have a “bumpy” surface if multiple fibroids are present.
  • Ultrasound: The pear-shaped uterus is outlined in white. The fibroid has a darker shade and is outlined in yellow.
  • Sonohysterogram or Saline Infusion Sonography: The pear-shaped uterus is outlined in white. The saline filling the cavity is the black area within the uterus. The fibroid, outlined in yellow, is pushing into the uterine cavity.
  • Hysterosalpingogram(HSG or tubal x-rays): The lighter shade represents a fibroid protruding into the uterine cavity.
  • MRI: Three fibroids (white arrows) are distorting the uterine cavity (red arrow).
  • Direct visualization: Utilizing surgical procedures such as Laparoscopy and Hysteroscopy
Intracavitary Fibroids

Intracavitary fibroids are a type of uterine fibroids that grow within the cavity of the uterus. They originate from the muscle layer of the uterus, but as they develop, they expand into the uterine cavity. Intracavitary fibroids can lead to symptoms such as heavy menstrual bleeding, prolonged periods, and irregular menstrual cycles due to their location within the uterine cavity. They may also cause fertility issues or complications during pregnancy. 

Submucosal Fibroids

Submucosal fibroids develop just underneath the mucosal surface of the uterus, which is the inner lining of the uterus. These fibroids can grow into the uterine cavity, distorting it and potentially causing significant symptoms.Given their location, submucosal fibroids can interfere with the normal function of the uterus, leading to problems such as heavy or prolonged menstrual bleeding, increased frequency of urination due to pressure on the bladder, pelvic pain or pressure, fertility issues, and potentially miscarriages or complications during pregnancy.

Intramural or Interstitial Fibroids 

Intramural, or interstitial, fibroids are a type of uterine fibroid that develop within the muscular wall of the uterus. They are the most common type of fibroids. These fibroids can expand, making the uterus appear larger, and they may cause discomfort or a feeling of pressure or heaviness in the lower abdomen. Depending on their size and location, intramural fibroids may also lead to symptoms such as prolonged and heavy menstrual periods, lower back pain, pain during intercourse, and an increased need to urinate.

Subserosal and Pedunculated Fibroids 

Subserosal and pedunculated fibroids are a type of uterine fibroids that develop on the outer wall of the uterus and do not affect the uterine cavity. They can cause the uterus to appear larger and may grow in size, but often they don’t result in the same menstrual irregularities that other types of fibroids can cause and are not associated with infertility. However, when they become large, they may put pressure on other organs, potentially causing symptoms such as pelvic pain, back pain, or a sensation of fullness or pressure in the lower abdomen.

The primary goals of uterine fibroid treatment is to enhance fertility in women who want to conceive and to help manage symptoms of pain and bleeding in women to whom pregnancy is not a concern. Women who have no immediate fertility considerations require only periodic evaluation by pelvic examinations and ultrasounds to monitor for changes in the size of the fibroid.

Treatment Options
  • Surgery to remove fibroids (Myomectomy)
  • Medical treatment
  • Uterine Artery Embolization (UAE)
  • MRI Guided High Frequency Ultrasound Therapy
What should you do if you have uterine fibroids and want to conceive?

It’s important to note that not all uterine fibroids cause infertility. If our fertility specialists determine that your fibroids are affecting your fertility, we may recommend surgery (myomectomy). The surgery is not without risks and the decision to operate will depend on the type, size and number of the fibroids, their proximity to the uterine cavity and on whether other or not symptoms are present (pain and bleeding). Fibroid surgery is sometimes recommended if a woman has failed previous fertility treatment or if there is no other explanation for her infertility.

Here are some rules of thumb:
  • For infertile women with intracavitary or submucosal fibroids which distort the uterine cavity, myomectomy surgery is likely to improve fertility.
  • Women with intramural fibroids appear to have decreased fertility and increased pregnancy loss, but it is not clear whether myomectomy will improve their fertility outcome. Generally speaking, if the fibroids are over 4 centimeters in size, myomectomy is often recommended.
  • Subserosal fibroids have no obvious fertility implications and surgery to remove them has not been shown to be beneficial. Surgery may be recommended for large fibroids or if they are causing pain or pelvic pressure.
What to do if you have fibroids and you do not want to conceive?

If you’re not looking to conceive, the goal of care is to minimize complications such as anemia and pain. However, most fibroids cause no symptoms and can be left alone. Fibroids are estrogen dependent and will shrink with menopause when the ovaries stop producing significant amounts of estrogen. Currently, there are no medicines that can permanently shrink fibroids.

If our fertility specialists determine that surgery is necessary to remove your uterine fibroids, we will likely perform one of the following procedures:

  • Hysteroscopic myomectomy
  • Laparoscopic myomectomy
  • Robotic computer assisted laparoscopic myomectomy
  • Laparotomy (major abdominal surgery) myomectomy
What are the surgical risks of myomectomy?
  • Infection
  • Bleeding
  • Blood transfusions
  • Post operative adhesions and infertility
  • Uterine rupture during pregnancy
  • Risk of cesarean section delivery
Hysteroscopic Myomectomy

This procedure is often utilized for fibroid tumors which are located within the uterine cavity (intracavitary or submucosal). During hysteroscopy, a thin fiberoptic tube (the hysteroscope) is equipped with a video camera and is guided through the vagina into the uterine cavity. The cavity is distended with fluid to give the surgeon a good view of the fibroid. A special tool, called the resectoscope, is equipped with a cutting loop which shaves the fibroid into small pieces. The fibroid fragments are removed and the uterine cavity is restored back to normal.

Laparoscopic Myomectomy

For fibroid tumors located within the wall of the uterus (intramural or submucosal)), minimally invasive outpatient Laparoscopic surgery is often advised. A thin fiber-optic tube, equipped with an HD camera, is inserted into the abdomen, through a small incision in the belly button. An image of the uterus is then projected on a monitor screen. The fibroid appears as a bulge in the uterus. Special tools, inserted into the abdomen through two or three additional small incisions, help the surgeon complete the procedure.

Laparoscopic myomectomy is most suitable for fibroids measuring less than 6 centimeters. Some surgeons prefer to treat their patients with Lupron preoperatively. Lupron causes a temporary and reversible medical menopause and takes 6-12 weeks to complete. It causes the fibroid to shrink in size, making it easier to remove. The treatment also decreases the blood supply to the fibroid, reducing the risk of bleeding during surgery.

Robotic Laparoscopic Myomectomy

Robotic laparoscopic surgery is now routinely utilized to remove larger fibroids than was previously possible with traditional laparoscopy. The surgeon controls the robotic arms from a console station, utilizing high-definition 3D camera. Four small incisions are made in the abdomen through which a camera and specialized surgical tools are inserted into abdominal cavity. The robot is wheeled into the operative field and is docked into position. An incision is made into the uterus and the fibroid is carefully dissected and removed from the abdomen. The uterine incision is closed completing the surgery.

Laparotomy Myomectomy

The procedure is performed through a major abdominal incision (laparotomy). It is indicated for the very large fibroids. Laparoscopic approach may be difficult when the fibroids extend high to the level of the umbilicus. Laparotomy surgery is more painful than laparoscopy and requires 4-6 weeks of recuperation. Complications from myomectomy include bleeding, scar tissue formation and infection. When pregnancy occurs after myomectomy surgery, a Caesarian Section delivery is often necessary to prevent rupture of the uterus during labor.

Fibroids need estrogen to sustain their growth, so fibroids often shrink with menopause because the ovaries no longer produce significant amounts of estrogen. When a surgical approach is not appropriate, certain medications can be used to suppress uterine fibroids. 

  • Lupron, Synarel: These medications suppress pituitary hormones vital to ovarian function, resulting in a temporary, reversible chemical “menopause”. Without estrogen, the fibroids shrink in size. Unfortunately the treatment is associated with side effects, such as, hot flashes and significant bone loss and can not be given for more than 6 months. The benefit from this therapy is therefore only temporary, because fibroid tumors grow back to their pretreatment size shortly after the medicine is discontinued. This treatment is given preoperatively to shrink the size of the fibroids, making it easier for the surgeon to remove them with minimally invasive laparoscopic surgery.
  • Mifepristone: Anti-progesterone medication
  • Asoprisnil: This medication belongs to a new class of compounds known as Selective Progesterone Receptor Modulators or SPRM and is currently being evaluated for treatment of fibroids in patients who do not desire children. The main advantage of this drug, over other medical therapies, is its ability to bring about cessation of menses with decrease in fibroid size, eliminating bone loss and hot flashes associated with other anti-fibroid medications.
  • Uterine Artery Embolization (UAE): UAE is a minimally invasive radiological treatment for symptomatic fibroids. It is an alternative to hysterectomy and myomectomy. In this procedure, a catheter is inserted into the femoral artery and advanced into the uterine artery. Small particles are injected into the uterine artery to block the blood supply to the fibroid. This results in significant reduction in the size of the fibroid and decreased pain and bleeding. The treatment is not currently recommended for infertile women with uterine fibroids. There is about 5% risk of menopause with this treatment, but this occurs most commonly in women over the age of 45.
  • MRI Guided High Frequency Ultrasound Therapy: This therapy is another noninvasive treatment for uterine fibroids. It can take more than 3 hours to complete. It may be associated with mild to moderate pain in 65% of patients and severe pain in another 15%. The procedure is not ideal for patients with fibroids over 10cm in size, fibroids located under the bladder or in patients with abdominal scar tissue, or patients who desire future childbearing.

Fibroids rarely become cancerous. In fact, cancer is thought to occur in no more than one tenth of 1% of all fibroids. Uterine fibroids are not to be confused with leiomyosarcomas, which are malignant uterine tumors occurring most commonly in postmenopausal women.