Fibroids are the most common tumor in women of reproductive age, and found in up to 50% of our patients. Despite that high prevalence, there is a paucity of data on how best to treat fibroids. Many fibroids are asymptomatic, but some cause significant bleeding and pain. In fact, nearly 250,000 American women have hysterectomies because of fibroids each year. Obviously, that would not be the treatment of choice in women seeking to preserve their fertility. Surgical removal of fibroids should not be undertaken without consideration of whether we can improve our patient’s chance of conception and delivering a child.
Large fibroids can be palpated on physical exam, but determining their location relative to the uterine cavity requires further study. Ultrasound , MRI, and Hysteroscopy are excellent options to diagnosis leiomyomas. Hysteroscopy carries significant cost and surgical risks and therefore is best left for treatment. MRI is an excellent diagnostic tool, but is often prohibitively expensive to evaluate all women with fibroids. Ultrasound remains the gynecologist’s greatest screening tool for fibroids. A sonohystogram, where saline is infued into the uterine cavity, is highly sensitive and specific to further classify fibroid location in cost effective manner.
Once diagnosed, treatment depends upon the reproductive wishes of our patients. Leiomyomas can impair fertility and pregnancy in four ways. First, they can block sperm and Embryo transport. Second, they can create an inhospitable environment for Implantation. Third, fibroids can lead to loss of pregnancy. Finally, they can cause poor outcomes in the third trimester of pregnancy from fetal malpresentation, failure to progress, post partum hemorrhage, placental abruption, abnormal placentation leading to IUGR, fibroid infarction and degeneration and preterm delivery. Treatment decisions should address each of the different phases of fertility in relation to the risks of Myomectomy.
As in the real estate market, it’s all about the location, location, location of the fibroid. They can have a direct mechanical effect on the Uterus and tubes. Laterally located fibroids, can lead to occlusion of one or more tubal ostia impairing sperm and embryo transport. Fibroids within the lower uterine segment or along the cervical canal can impair sperm transport into the uterus, alter Cervical Mucus, cause cervical stenosis, or lead to arrest of descent in labor. Large fibroid uteri can also be associated with dyspareunia, which may inhibit coital frequency leading to decreased fecundity, or fetal malposition necessitating a cesarean section.
Fibroids that are predominately in the uterine cavity (pedunculated variety) are significantly associated with decreased implantation, menorrhagia, and metrorrhagia. Therefore, most gynecologists and reproductive endocrinologists recommend surgical removal via a hysteroscope. The fibroids that have both submucosal and intramural portions are more difficult to resect via the hysteroscope, but there is compelling evidence that they are associated with decreased implantation and pregnancy rates as well. Histologic examination of the Endometrium overlaying the fibroids and the contralateral endometrial wall reveal endometrial atrophy. Endometrium immediately adjacent to the fibroid is associated with hyperplasia. These changes in endometrial histology are associated with decreased implantation of embryos and abnormal placentation leading to pregnancy loss. Therefore, removal of these fibroids is recommended. However, decisions to do surgery must take into account the risk to the patient as well as the skill level of the surgeon and the potential improvement in pregnancy chances.
Treatment of intramural fibroids and intramural fibroids with a subserosal portion presents a controversial clinical problem. There are some studies, which suggest these fibroids decrease pregnancy rates regardless of location and size, while other studies find no difference. No concrete recommendations can be made, and physicians should discuss the risks of surgery and potential decrease in fecundity with patients to decide how to proceed.
However, the effect these intramural fibroids have on the shape of the endometrial cavity appears to have greater relevance. Multiple studies have found that in women with leiomyomas that distort the intrauterine cavity, there are lower implantation rates and pregnancy rates compared to women with normal uterine contours. Therefore, we recommend removal of fibroids that significantly distort the cavity. These patients present difficult management decisions because myomectomy requires an abdominal approach, which is associated with an increased morbidity more than hysteroscopic approaches.
Leiomyomas, which are predominately subserosal, have not been shown to have any negative effects on fertility and fecundity. However, removal should be considered, if there is concern about torsion, or degeneration during pregnancy, which could lead to pain, preterm delivery, and unnecessary hospitalization.
In respect to fibroids, size does matter. Most studies agree that fibroids without submucosal portions larger than 7 cm are associated with lower pregnancy rates. In addition, these larger fibroids can lead to fetal malpresentation and impair progression of labor. They also are at greater risk of degeneration during pregnancy leading to management dilemmas, hospitalizations, and poor obstetrical outcomes. Other studies suggest the negative fertility effects occur when fibroids are larger 5 cm, and still greater controversy exists for 2-5 cm leiomyomata. The majority of studies suggest these smaller fibroids do not impair fertility or lead to problems during pregnancy. However, one of the few prospective large studies found that fibroids less than 5 cm do have a negative effect. Treatment options should be discussed with our patients as we weigh the negative impact of fibroids on fertility versus the risks of myomectomy, although large intramural fibroids (>7cm) should probably be removed prior to attempting pregnancy.
The gold standard of fibroid therapy remains myomectomy for women desiring future childbearing. A hysteroscopic approach can be attempted with smaller predominately submucosal leiomyomata. There remain risks with fluid overload, intrauterine scarring, and perforation, but these are less morbid than an abdominal approach. An abdominal approach to myomectomy remains the best approach to removing intramural fibroids. Whether this is by laparotomy, Laparoscopy, or robotically assisted laparoscopy should be determined by the surgeon’s expertise and level of comfort. Laparoscopic suturing and closure the uterine defect are of the utmost importance to prevent uterine dehiscence and rupture during pregnancy when attempting these via the laparoscope. Unfortunately, laparotomy is associated with substantially increased adhesions formation, blood loss, infection, longer hospitalization, and prolonged recovery.
Other modalities like artery embolization, cryomyolysis, and high-intensity focused ultrasound are contraindicated in patients desiring future fertility and should not be recommended to our patients. Medical therapies may shrink the fibroid, but only succeed in delaying fertility therapy.
Despite these recommendations, there remain no randomized trials examining fertility outcomes when comparing myomectomy to expectant management of fibroids. However, using patients as their own control pre- and post-myomectomy most studies demonstrate a significant improvement in fecundity and obstetrical outcomes.