Uterine fibroids are benign (non-cancerous) tumors of the muscle layer of the womb. They are the most common tumors found in women. By the time of menopause 60-70% of women would be diagnosed with fibroids.
The good thing is that fibroids are rarely cancerous and only 1% of fibroids can undergo malignant change. Fibroids are usually found in or around the body of the uterus but sometimes in the cervix.
Many have asked what causes fibroids, to this day, no clear cause has been identified, and many associations however have been found. Fibroids have been found to be associated with black race, infertility, obesity and some genetic abnormalities. Childbearing seems to be protective of fibroids.
There are three main types of fibroids based on where they are located in the womb. The womb has three main layers, the outer serosal wall, the middle muscular layer and the mucosal layer covering the inner cavity of the womb, where a baby normally grows:
- Subserosal are in the outer wall of the womb (55%)
- Intramural are found in the muscular layers of the uterine wall (40%)
- Submucosal protrude into the uterine cavity (5%)
Fibroids can also be connected to the uterus by a stalk (pedunculated) or attached to nearby ligaments or organs, such as the bladder and bowel. Fibroids are rarely found outside the pelvic cavity.
Fibroids present with a variety of symptoms including infertility. Other symptoms caused by fibroids include heavy and painful menses, lower abdominal pain, abdominal distention, pressure symptoms like constipation and the urge to urinate frequently
This article will discuss how, and when fibroids may affect your fertility, when they should be treated and the outlook for pregnancy if you have fibroids.
Many people have fibroids, yet are not even aware until a pelvic ultrasound scan is done for one reason or the other, this is because fibroids are mostly symptom free and do not cause any problems. Thus most women with fibroids will get pregnant and have babies naturally without any adverse outcomes.
For some women, unfortunately this will not be the case. Studies have shown 5-10% of infertile women have fibroids. Fibroids may be the sole cause of infertility in only 1-3% of these patients. This therefore means that most people with fibroids will have no fertility challenges. The size, number and location of the fibroids might not necessarily affect your fertility. Some patients with huge fibroids will get pregnant without any assistance, conversely, some patients with very small fibroids could have fertility challenges.
Fibroids affect fertility in a variety of ways. Firstly, some women with fibroids have abnormal menses, in fact menstrual abnormalities are the commonest symptom of fibroids, some may bleed for days to weeks on end, and some bleed at unexpected times.
This makes it difficult for the woman to track her cycles and calculate her fertile periods plus the obvious challenges that come with having sex whilst bleeding. This could result in marital disharmony. Without sex at appropriate times conception is unlikely to be achieved,
Secondly fibroids, especially those located near the fallopian tubes can lead to blockage making it difficult or impossible for the sperm to reach the egg for fertilization or for the fertilized egg to reach the uterus and implant.
Changes in the shape of the cervix due to fibroids can also affect the number of sperm that enter the uterus. These cervical fibroids could also lead to painful sex limiting the frequency of sex and thus conception. Fibroid being very hard most likely will prevent implantation when the embryo implants on a fibroid in the uterine cavity.
Lastly, blood flow to the uterine cavity can be distorted in the presence of fibroids. This can decrease the receptivity of the womb to a baby.
So, the question then is, which requires fibroids require treatment for fertility purposes. As earlier mentioned, people with uterine fibroids are able to become pregnant without any treatments for this reason a fibroid should have been deemed to be affecting fertility only after a basic fertility evaluation has revealed no other cause of infertility. The haste to have surgery to remove fibroids (myomectomy) could actually be counterproductive even though the myomectomy may increase your chances of pregnancy, there is the risk of recurrence of fibroids a few years after removal.
A basic fertility evaluation should include an assessment of the semen of the partner, a test for patency of the fallopian tubes, and a test of ovulation. Only after these tests reveal no other fertility problem should removal of fibroids be undertaken. Typically, fibroids that are greater than 4cm in diameter and are in the uterine cavity or close to the cavity are recommended to be removed for fertility purposes. Having said this other previously mentioned symptoms may be severe enough to warrant removal purely to improve the quality of life of the woman, most importantly abnormal menses resulting in excessive blood loss.
Various options are available for the removal or treatment of fibroids, surgery, medical therapy, uterine artery embolization etc. But for fertility purposes, surgical removal of the fibroids is the recommended option. This can be done by various approaches depending on the site of the fibroid, location, size and skill of the surgeon
The impact of fibroids on Assisted Conception or In Vitro Fertilization (IVF) has been a subject of much debate, whether to remove or not to remove before IVF has been a contentious amongst fertility specialists over the years. Most agree that any fibroids found in the uterine cavity (where the embryos or babies are placed after IVF have to be removed before the procedure.
With respect to fibroids outside the uterine cavity questions are inevitably raised by physicians and couples about the possible detrimental impact of these fibroids on the planned IVF procedure. For many doctors the rule of four pertains.
Any fibroid that is greater than 4cm in diameter in the endometrial cavity, is within 4cm of the endometrial cavity or a total of 4 fibroids or more warrant removal before the IVF procedure. At Accra Fertility center the author tends to agree to the latter that not all fibroids should be removed IVF procedure. Decision is made on case by case basis relative to the uterine cavity.
Post-removal women are counseled to avoid getting pregnant for at least 4-6 months, this is to allow for complete healing of the womb muscle. Pregnancy earlier than this could lead to complications, most serious of which is uterine rupture.
In summary, uterine fibroids are common and can affect fertility in many ways. They can affect whether sperm and egg meet, can affect whether an embryo can implant, they can affect whether a pregnancy can continue and can affect the growth and positioning of the baby. Many fibroids also has no effect on fertility.
However, treatment should be decided on a case-by-case basis, not routine removal. If you suspect you have fibroids and have been trying to conceive for 12 months or more you might want to consider booking an appointment with a fertility specialist. For most fibroids no treatment is needed, if required surgery is usually the best approach.
