Fibroids are benign tumours, formed by smooth muscle cells of the uterus. These tumours are not malignant (they do not cause cancer) and are very common among young women: about 25% of women in reproductive age have fibroids. Fibroids are even more common in women with fertility problems. However, most fibroids do not cause infertility and can be ignored.
Unfortunately, many doctors believe in removing all fibroids. An unnecessary operation like this might itself cause infertility. So, the big question concerning fibroids is: ‘which fibroids cause fertility problems - and thus need to be removed – and which fibroids can be let alone?’
Fibroids are classified into 3 categories depending on where they grow:
• Submucosal - they grow underneath the endometrium, i.e. in the cavity of the uterus
• Intramural - they grow in the smooth muscle wall of the uterus
• Subserosal - they grow underneath the outer layer of the uterus (peritoneal surface)
Although the cause of fibroids is not quite clear, their growth seems to be controlled by cell growth genes, as it happens with all tumours. Their growth also depends on reproductive hormones such as estrogens and progesterone.
Most fibroids are small and do not cause any symptoms. In most women they are detected by means of clinical examination or ultrasound. Submucosal fibroids can cause heavier bleeding, while large fibroids might cause pressure on the pelvis. Other symptoms include pain, heavy bleeding, bleeding in between 2 periods and anemia.
Fibroids and infertility
A submucosal fibroid that grows inside or might alter the uterine cavity acts as ‘foreign body’ in the uterus and hinders embryo implantation. Some doctors believe that intramural fibroids diminish blood flow to the endometrium, which impedes embryo development. Fibroids growing in the outer layers of the uterus can affect a pregnancy by pressing or blocking the fallopian tubes, thus preventing the sperm from finding the egg. However, this is quite rare.
Most women with fibroids have a perfectly normal pregnancy and give birth to healthy babies without any complications. Women with large fibroids tend to have some problems during pregnancy such as breech presentation (the baby comes with the legs), premature delivery and placenta detachment (the placenta is detached from the uterus wall).
Most fibroids can be detected during a sonogram, but sometimes it takes more tests to make a precise diagnosis (to determine the exact position of the fibroid)
The cavity of the uterus is filled with saline, so that fibroids are easy to detect.
This test can only detect submucosal fibroids that distort the uterine cavity.
Hysteroscopy is a valuable examination in women with fertility problems because it can detect fibroids that grow within the uterine cavity or severely distort it.
• Magnetic Resonance Imaging (MRI)
MRI is rarely used for detecting fibroids. It offers no more than a thorough sonogram and is very expensive.
Most fibroids in women with fertility problems do not need to be treated as they do not affect the patient’s fertility or pregnancy. However, some fibroids must be removed due to their position and size. Following any surgery, adhesions may occur. Adhesions are known to create problems to the function of the fallopian tubes. Consequently, if a surgery is not necessary, it should not be performed as it may cause more problems.
The decision on performing a surgery or not depends on other factors as well: age, medical history (especially miscarriages), symptoms (pain) etc. The doctor’s clinical experience and clinical judgment are of critical importance.
Submucosal fibroids must be removed, because they grow inside the uterine cavity or they cause a distortion to it. Submural fibroids exceeding 3cm in size should also be removed because they cause infertility and miscarriages. They also affect the success of fertility treatments. On the other hand, it seems that subserosal fibroids do not affect fertility or the pregnancy.
Most fibroids are removed by means of laparoscopy. An open surgery is required only in case of large or multiple fibroids (larger than 7-8cm). Laparoscopic removal is less painful, requires shorter post-op recovery time, while less adhesions develop later. However, laparoscopy is more demanding and the doctor must be sufficiently trained and experienced. Normally, the operation is recorded and a DVD is given to the patient for her medical records.