Fibroids and Infertility – All Fibroids Are Not Created Equal

Fibroids can cause infertility when strategically located in the cervix, beneath the endometrial lining of the uterus or where they block the fallopian tubes. Fibroids are benign smooth muscle tumors mostly arising from the wall of the uterus. The grow slowly and take years to reach a considerable size. At least 40% of women have fibroids in the uterus. The majority of them do not have any complaints.

Fibroids cause symptoms-excessive vaginal bleeding, pressure symptoms, infertility or recurrent pregnancy loss by virtue of their position in the uterus. Asymptomatic fibroids require only periodic observation. Fibroids causing symptoms should be investigated.

Imaging of fibroids. Ultrasound can determine the number, size and location of fibroids. MRI is a more accurate modality. It can also define the location of the fibroid in relation to the cavity of the uterus and the outer surface. This information is valuable in determining the optimal treatment modality. Hysterosalpingogram performed for investigation of tubal patency, may show a filling defect inside the uterus or show blocked fallopian tubes. Saline sonography is an excellent method to delineate the relation of fibroids to the cavity. Small amount of fluid are injected into the uterus while observing the cavity with transvaginal ultrasound. The fluid appears black and can define the surface of the myoma.

Other tests for fibroids include lab tests to estimate blood loss and sampling of the lining of the uterus.

Treatment of infertility associated fibroids. Submucus fibroids. These are fibroids beneath the endometrium. They can be removed using a hysteroscope. The instrument is introduced through the cervix and the fibroid is chipped using an electrical loop.Large fibroids may require multiple sessions to remove. Intramural fibroids. Fibroids large enough to reach close to the outer surface of the uterus are better removed by cutting through the outer surface of the uterus. This can be done through a large abdominal incision-open myomectomy or through minimal access surgery-laparoscopic myomectomy. Robots are sometimes used to help surgeons close the defect in the abdominal wall.

Newer methods for treatment of fibroids as uterine artery embolization-blocking the blood vessels reaching the myoma without surgery or focused ultrasound treatment-where ultrasound waves are concentrated on the fibroid leading to reduction in its size. These methods were not tried in infertile women and are not recommended for women seeking future pregnancy. Uterine artery embolization requires x ray exposure and can reduce the egg reserve in the ovary.

Effect of fibroids on IVF success. Its generally agreed that submucus myoma-fibroids distorting the cavity of the uterus reduce IVF success and should be removed before transferring embryos into the uterus. Also its generally believed that fibroids at the outer surface of the uterus has no effect. on IVF success. The effect of fibroids within the wall of the uterus and not distorting the cavity on IVF success is controversial. Its suspected that large fibroids > 4cm may reduce IVF success. Evaluation and judgment of a reproductive endocrinologist is essential in these cases.