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