Fibroids and Fertility

Carla Dionne was 28 and pregnant with her second child when she suffered a miscarriage at two months. In a workup to determine the cause, her gynecologist discovered she had fibroids, benign tumors of the uterus made up of abnormal connective tissue and smooth muscle cells. Assuming these growths were to blame, he suggested a hysterectomy (removal of the uterus), saying it was the only cure for fibroids. Dionne was devastated. She and her husband hoped to have more children, but the doctor didn’t offer an alternative. “I just walked away in tears,” she recalls.

Dionne, now 48, decided against the hysterectomy and nine months later was pregnant again. She gave birth to a healthy boy in 1986, and another boy in 1991, without ever having had her fibroids removed. Nonetheless, between the ages of 28 and 40, she recalls, “I had 16 hysterectomy recommendations.”

With new options available for treating fibroids that don’t involve removing the uterus, you might expect gynecologists to take a more measured approach today, but that’s not always the case. “Women with fibroids are getting the same advice I did 20 years ago,” says Dionne, executive director of the non-profit National Uterine Fibroids Foundation in Colorado Springs, Colorado. “Even women in their 20s and 30s who haven’t had children yet.” And there’s still little known about why fibroids occur, how they might be prevented, and what their effect on fertility and pregnancy is. “Biologically speaking, we have no clue what causes fibroids,” says Carla Dionne. “Prevention is critical, and the whole issue of fertility is huge.”

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 are considered medically appropriate. Certainly, there’s reason to question a hysterectomy in a woman of childbearing age whose fibroids aren’t causing problems. And these days, thanks to in vitro fertilization (IVF) and other reproductive technologies, childbearing age can extend well into the forties.

That said, women with fibroids who hope to conceive still face challenges getting good medical care. Is it better to leave the fibroids alone and try to get pregnant with them? Does treating fibroids first have an impact on the ability to conceive and carry a pregnancy to term? Although few studies address these questions, the available data suggests that 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. “Before we send the message that all women with fibroids should have them removed, we need to stop and think about the consequences, particularly in women who haven’t tried to get pregnant on their own first,” says Alison Jacoby, M.D., director of the Comprehensive Fibroid Center at the University of California, San Francisco.

Dr. Jacoby’s fibroid program is one of several around the country that have sprung up to study new treatments and decode the genetics of these tumors, which affect 1.6 million women a year and up to 40 percent of all women during their reproductive lives. “Our long-term goal is to find the genes that predispose women to fibroids and, eventually, customize treatment,” says Elizabeth Annella Stewart, M.D., clinical director of the Center for Uterine Fibroids in the departments of obstetrics and gynecology, and pathology at Brigham and Women's Hospital in Boston.

Fertility May Depend on Fibroid Location

When it comes to deciding how to treat fibroids, the most important factors are a woman’s fertility status and where in her reproductive real estate the tumors reside. 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. 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.

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, conducted by Elizabeth Pritts, M.D., now an assistant professor of obstetrics and gynecology at the University of Wisconsin School of Medicine in Madison, 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,” says David Olive, M.D., professor of obstetrics and gynecology at the University of Wisconsin School of Medicine. He and Dr. Pritts, who happens to be his wife, evaluated more recent studies and reached the same conclusions.

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.

Does Size Matter?

Whether a fibroid’s girth has an impact on fertility is poorly understood. “We don’t have a lot of good evidence to guide us,” says Dr. Stewart. “We do have some information that the larger the fibroid is, the more it’s associated with an increased risk of pregnancy complications.”

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. 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, says Dr. Jacoby, “this practice isn’t based on any good evidence from research studies. I have a patient who has a 20 cm fibroid (think grapefruit), and aside from being a little uncomfortable, she’s had a very uneventful pregnancy. I saw her before she became pregnant, when the fibroid was 8 cm large, and advised her not to have surgery.” The few studies that have addressed the topic showed no significant association between a fibroid’s size and fertility, notes Dr. Pritts’ analysis.