Uterine Fibroids Blog — An Expert Speaks Out

Michelle with her sons

I first saw Michelle when she was 35 in 2005.  She had her first myomectomy at the age of 26 and her second at the age of 33.  She was sent to me by her Ob-Gyn after an ER visit for severe bleeding.

I did an ultrasound on the first visit, and there was fluid in the uterus which outlined a large submucous fibroid. The bulk of the fibroid was in the wall rather than inside the cavity of the uterus.  Because of the location I felt hysteroscopic treatment was inadviseable.  Although we were concerned because she already had two abdominal myomectomies (elsewhere), I did her third myomectomy.

I did an ultrasound in September, 2006 showing a healthy 10 week prgnancy.  Michelle delivered her first son by cesarean in 2007. Her OB noticed some scar tissue inside her uterus at the time.  I later did an office hysteroscopy to clear this and a small amount of retained placental tissue and treat the scar tissue.  In October, 2010, she returned with another healthy early pregnancy.

Comment:  Michelle came in today with her 4 year old son, her 4 month old baby, and a picture of them taken when he was just born.  Even if you have had prior surgery don’t give up hope without seeing an expert in the treatment of fibroids.

Aisha was 38 when I saw her in 2007 with a long history of infertility and fibroids making her look 5 months pregnant.  She underwent a myomectomy in which 31 fibroids were removed.  She had a normal pregnancy and delivered a healthy boy by cesarean.   She recently came in with her 16-month old son.

When I originally saw her her uterus was the size of a 20 week pregnancy. An MRI showed multiple fibroids.  She underwent a myomectomy to remove the fibroids. 

Her uterus, before the removal of fibroids, and the fibroids that were removed are shown below.

Now, four years after her myomectomy and successful pregnancy her uterus is normal size.

Comment:  Some of my most satisfying moments as a gynecologist are seeing women who thought there was no hope for having children come in with their babies.  — Paul Indman, M.D.

Should I have my fibroids removed before I try to get pregnant?  That is one of the most difficult questions I have to answer!  Here is what we know:

1. Submucous fibroids, or intramural fibroids that indent the endometrial cavity (inside of the uterus) significantly decrease the chances of conception, and increase the miscarriage rate. Large intramural fibroids (in the wall of the uterus) can have a submucous portion that distorts the cavity and should be considered included in this group.  Fibroids that are mostly in the endometrial cavity can usually be removed by outpatient hysteroscopic myomectomy (hysteroscopic resection).  This should only be done by a gynecologist with extensive experience in hysteroscopic surgery to reduce the risk of  scar tissue formation.  Although it may be possible to remove some submucous fibroids that are mostly in the wall hysteroscopically, if they are large they should be removed by abdominal, laparoscopic, or robotic myomectomy.
2. Intramural fibroids that do not indent the cavity appear to decrease fertility and increase miscarriage rates, but studies are inconclusive. Even if this is the case, studies are lacking to show that removing these fibroids increases the chance of successful pregnancy.
3. There is no evidence that subserous fibroids interfere with conception or increase the miscarriage rate.

Fibroids in Pregnancy

Although we used to think that pregnancy causes fibroids to increase in size, ultrasound studies show that they usually do not grow.  They often feel larger because the whole uterus is larger.

Some of the problems fibroids can cause are:

1. Pain, which can be severe enough to require hospitalization.  Sometimes a fibroid may infarct or cause pain because of decreased blood flow.
2. Increased risk of placenta problems such as abruption (premature separation of the placenta).
3. Increased risk of prematurity.
4. Increased risk of cesarean section.
5. Increased risk for post-partum hemorrhage.

The risks of serious complication are low.  Most women with fibroids go through pregnancy without any problems.

Treatment recommendation for fibroids before attempting pregnancy

There is no way I or any other physician can make specific recommendations without evaluating you individually!  These are general recommendations, and should not be followed without advice from your own physician.

If fibroids are causing symptoms such as heavy bleeding, pain or pressure it is usually reasonable to remove them.  If the fibroids are not causing symptoms, the following are general recommendations.

1.  Most submucous fibroids should be removed.  Hysteroscopic myomectomy, when done by an expert, is the treatment of choice in most situations.

2. Intramural fibroids that distort the endometrial cavity should usually be removed before attempting pregnancy.

3.  Intramural myomas that do not distort the endometrial cavity and are not causing symptoms usually do not need to be removed before attempting pregnancy.  There is no evidence that removing them improves pregnancy outcomes.

4.  Subserous myomas, unless large enough to cause symptoms, do not need to be removed prior to pregnancy.

Is myomectomy risky? This obviously depends on the skill of the surgeon.  The risk of needing to do a hysterectomy at the time should be less than 1 in 100.  I have never had to do an unplanned hysterectomy in a woman of reproductive age when I had planned to do a myomectomy.  While adhesions can develop, there are a techniques to minimize them.  All in all, myomectomy should not lower, and in many cases will improve the chances for a successful pregnancy.  Be aware that if many or deep fibroids are removed (except by hysteroscopic myomectomy) a cesarean delivery will often be recommended.

What about other treatments, such as embolization (UAE or UFE)?  Embolization blocks the blood vessels to the fibroids and/or uterus.  Although new blood vessels my take over to supply the uterus, the effect on pregnancy is unknown.  While there have been successful pregnancies after embolization, it also can decrease ovarian reserve or menopause as well as causing intrauterine adhesions (Asherman’s syndrome).  Therefore I, and most experts in fertility, would only recommend embolization as a last resort in women desiring pregnancy.