What They Are
Fibroids are benign uterine growths (or tumors), made up of abnormal connective tissue and smooth muscle cells. There are three major types of fibroids, identified by location: Intramural fibroids are embedded in the muscle wall of the uterus; subserosal fibroids grow on the outside of the uterus; and submucosal fibroids develop in the muscle wall but also extend into the uterine cavity. These growths are common and usually harmless, but can sometimes threaten fertility.
Who Gets It
Fibroids affect up to 40 percent of all women during their reproductive lives.
Most fibroids have no symptoms. Some can cause heavy and painful menstrual periods. Certain types can cause premature delivery or miscarriage.
How They're Diagnosed/Detected
The diagnostic method of choice is a sonohysterogram, performed by inserting an ultrasound probe into the vagina, along with a saline solution to enable the doctor to better visualize the inside of the uterus.
How It Affects Fertility (And Pregnancy)
Only certain types of fibroids are serious threats to fertility and pregnancy and should be removed, while others can—and probably should—be left alone, because surgery itself can compromise fertility.
If a woman has no known fertility problems and is diagnosed with intramural or subserosal fibroids that aren’t causing symptoms (such as pain or pressure on the bladder) – she may be able to avoid treatment altogether. A 2001 analysis of 11 studies of fibroids and fertility involving thousands of women found that patients with these types of tumors had pregnancy and implantation rates similar to those of women without fibroids. There’s no convincing evidence that subserosal or intramural fibroids substantially reduce fertility, or that their removal will enhance pregnancy rates.
Submucosal fibroids, which usually cause excessive bleeding even when small, have a different outlook. Not only do they interfere with implantation, they’re associated with an increased rate of miscarriage and premature delivery. Studies consistently show that surgically removing these fibroids significantly improves a woman’s chances of conceiving and carrying a pregnancy to term—to the level of women without fibroids.
If you opt not to treat, be aware that during pregnancy fibroids grow along with the fetus and can cause pain or pressure on organs, sometimes requiring an extended period of bed rest. Fibroids can also affect a pregnancy by preventing the fetus from descending head first, raising the risk of a cesarean section. While it’s often recommended that submucosal fibroids be removed regardless of size, the size of intramural and subserosal fibroids can be a factor when deciding on treatment.Treatment
Despite better treatment options that are now available, too many gynecologists still recommend hysterectomies (the removal of the uterus), even to women in their prime reproductive years who have not yet had children. Currently fibroid diagnoses account for the majority—60 percent—of the approximately 700,000 hysterectomies performed annually in this country. But according to a 2000 study in Obstetrics & Gynecology, only 21 percent of these surgeries are considered medically appropriate.
Many gynecologists advise women with intramural or subserosal fibroids larger than 6 cm (a little over two inches) to have them removed before trying to conceive. But experts caution that this practice isn’t based on any good evidence from research studies. The few studies that have addressed the topic showed no significant association between a fibroid’s size and a woman’s fertility. The best option for women with fibroids who want to preserve their fertility is myomectomy, a surgical procedure to remove the fibroids—not the uterus—through an incision in the abdomen. This surgery is also the best choice for women with many fibroids (15 to 20, for example) which are 7 cm or larger, or in a sensitive location, such as on top of a fallopian tube.
Myomectomies are major surgery, and require a hospital stay of several days, and a recovery time of several weeks. Depending on how many fibroids there are, and their size, some women may be able to choose a less invasive operation. Fibroids confined to the inside of the uterus, for instance, can be removed through the vagina with the aid of a hysteroscope, a telescope that goes into the uterus through the vagina and cervix. Women who have this procedure can go home the same day and return to normal activities in about 24 hours. Another advantage: the hysteroscope does not leave scars in the uterus, an important factor in fertility preservation.
Laparoscopy, in which fibroids are removed through small incisions in the navel, can be a good choice for women with only a few fibroids that are on the outside of the uterus and that aren’t larger than 6 cm. After a laparoscopy women can leave the hospital the same day, but will need about three days to recover. The biggest concern with laparoscopy is that the uterus must be sewn back together with multiple layers of stitches to prevent it from rupturing during pregnancy, requiring a highly skilled and experienced gynecologist.
Treatments to Avoid
You may be tempted by some of the new, minimally-invasive procedures for shrinking or removing fibroid tumors, but beware: They haven’t been proven safe for women who want to preserve their fertility and get pregnant some day. Exablate, for instance, the latest technique to receive FDA approval for the treatment of fibroids, uses magnetic resonance imaging to locate the exact position of the tumor, then directs heat at it through highly-focused ultrasound waves, destroying the tissue. But it’s too early to know the longterm effects of this procedure on pregnancy.
Uterine artery embolization (UAE), which is becoming more popular, uses polyvinyl particles to cut off the blood supply to fibroids, causing them to shrink. This procedure, however, can also decrease blood supply to the ovaries, resulting in premature menopause in some women. Myolysis, another technique, also cuts off blood supply to fibroids, in this case via an electrical current. But, as with the previous methods, the effect on pregnancy is unknown. Finally, medications to shut down the ovaries’ production of estrogen can shrink fibroids, but they also prevent pregnancy (and, the fibroids grow after treatment is stopped). One hope for the future: Scientists are currently conducting clinical trials of a new drug that shrinks fibroids by shutting down progesterone production, and so far that drug doesn’t appear to interfere with getting or staying pregnant.
For women with fibroids who are experiencing otherwise unexplained fertility problems, the best course of action unclear. It can be difficult to determine whether the fibroids have anything to do with the difficulty getting or staying pregnant. Experts advise that you and your partner first undergo a complete infertility evaluation before you zero in on the fibroids as the root cause.
Couples in which the man or woman already has an infertility diagnosis and who are contemplating IVF (in vitro fertilization) may not require fibroid treatment. Women with subserosal tumors, for instance, appear to be as likely as those without them to become pregnant and deliver a baby after IVF.
Pregnancy rates for women with and without intramural fibroids are similar too, but studies suggest that the chances of the embryo implanting is about 19 percent lower in the fibroid group. If implantation occurs, however, women have similar delivery rates. This suggests that intramural fibroids should come out prior to undergoing an assisted technology. A lot of IVF programs won’t even treat women until after their fibroids are removed. Women who have had fibroid surgery can attempt getting pregnant about three months afterwards. And while the pregnancy will not be considered high-risk, the delivery will be monitored closely to make sure the uterus doesn’t rupture. Some physicians prefer not to have women who’ve undergone uterine surgery even attempt labor, and recommend scheduling a cesarean section instead.
For now, although there is still controversy over the best way to treat fibroids and maintain fertility, the best chance for success is for women to thoroughly research the issue on their own and get more than one medical opinion if necessary.
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