As Dr Sneha Parghi outlined in our last blog post, fibroids are very common, non-cancerous overgrowths of the uterine muscle (or ‘myometrium’). Many women have fibroids, and will never be aware of them, as they never develop any significant symptoms. Women who do have symptomatic fibroids may experience heavy menstrual bleeding, so-called ‘pressure symptoms’, and / or fertility problems. This article will discuss what management options are available to women who have fibroids and subfertility and / or obstetric complications as a result.
What types of fibroids cause fertility problems?
Broadly speaking, fibroids are divided into three types, based on their location in relation to the uterine cavity:
– Subserosal fibroids poke out from the outside surface of the uterus
– Intramural fibroids are those that are contained within the muscle layer of the uterus (the ‘myometrium’)
– Submucosal fibroids protrude into the uterine cavity
The more a fibroid distorts the shape of the uterine cavity, the more likely it is to lead to subfertility and / or obstetric complications. Hence, subserosal fibroids are very unlikely to impact upon your fertility. Intramural fibroids can, if they are large and / or distort the uterine cavity.
Submucosal fibroids are most likely to affect your fertility: worst case scenario, they can have a negative impact upon the likelihood of:
– An embryo successfully attaching to the lining of the uterus
– Clinical pregnancy (i.e. a pregnancy test being positive)
– Ongoing pregnancy (i.e. submucosal fibroids can increase the likelihood of miscarriage)
– And live birth rate
How fibroids can impact your fertility
Any fibroid that changes the shape of your uterine cavity can impact upon your capacity to fall pregnant. Even if you do manage to conceive, they can cause problems both during pregnancy, during labour, and in the post-partum period.
Submucosal fibroids in particular can:
– Disrupt the capacity of the uterine muscle to contract, which is thought to impact both sperm progression and embryo implantation. This may be especially true in uteruses with multiple large fibroids, with significant distortion of the uterine cavity
– Distort the Fallopian tubes, and impair their function
– Create a detrimental, inflammatory atmosphere, and change the local hormonal environment inside the uterus, that may impair both sperm migration and embryo implantation
Interfering with egg pick-up during IVF
Numerous large fibroids (especially intramural and subserosal) can impair fertility doctors’ capacity to perform egg pick-up, which is a vital part of the in vitro fertilisation (IVF) process. If this is the case, your IVF doctor will tell you as much, and may recommend surgical removal of your fibroids.
Problems during pregnancy
There is an association between fibroids that significantly distort the uterine cavity, and premature birth. Such fibroids can also make it hard for the baby to position itself to be ‘head down’ (or cephalic), leading to so-called ‘fetal malpresentation’: when the baby lies across-ways (transverse lie), or breech (bottom first).
Problems during birth
Having numerous intramural fibroids can impair the uterine muscle’s capacity to contract during labour. Hence, there is an association between having a multi-fibroid uterus, and ‘labour dystocia’ or ‘failure to progress’ during labour – when labour stalls, and the cervix stops opening up.
Problems after birth
Immediately after having a baby, the uterus should contract down tightly, to stop heavy bleeding. Because having multiple large fibroids can impair the capacity of the uterine muscle to contract, post-partum haemorrhage can occur.
When should you seek treatment, if you have fibroids and want to conceive?
If you have fibroids, and want to conceive, there are several things to consider when working out whether or not they need to be treated, and how.
Firstly, your clinician needs to work out what type of fibroids you have, and to what extent they’re distorting the uterine cavity and / or impacting upon your ability to conceive.
If you also have heavy periods and / or pressure symptoms
If you have other symptoms of fibroids, such as heavy menstrual bleeding (HMB) or so-called ‘pressure symptoms’, your fibroids may need removing on those grounds alone. (Pressure symptoms include: tummy swelling, constipation, and needing to urinate frequently). Symptomatology may be a decisive factor in whether or not a fibroid should be removed.
If you have had challenges conceiving
If you are < 35 years old and have tried to conceive for over 12 months without success, or > 35 years old and have tried to conceive for over 6 months without success, investigations should be performed to try to work out where the issue lies. These investigations should include a transvaginal ultrasound, which may show fibroids.
It has been estimated that 5 – 10% of women with infertility are found to have fibroids. However, when all other causes of infertility (e.g. problems with ovulation, Fallopian tube function, and / or sperm function) are ruled out, fibroids are found in only 1 – 2% of the remaining women.
If you have had poor fertility and / or obstetric outcomes in the past
As noted above, submucosal fibroids in particular are associated with impaired pregnancy rates, higher miscarriage rates, and lower live birth rates. If you have already had problems such as these, and have been found to have submucosal fibroids, there may be a case for having them removed, to improve your chances of having a baby in future.
What treatment options aren’t appropriate if you want to conceive
There are numerous ways to manage fibroids, including tablets, injections, nasal sprays, interventional radiology, and various types of surgery. Some of these are not appropriate if you want to conceive in future.
Hormonal suppression: combined oral contraceptive pill (COCP), progesterone intrauterine device (IUD)
While the COCP and progesterone IUD can help manage heavy periods associated with fibroids, they are (obviously) contraception, so defeat the purpose if you are wanting to conceive!
‘GnRH agonists’ (e.g. goserelin / nafarelin)
These medications, available as a nasal spray (nafarelin) or a monthly injection (goserelin) work well to shrink fibroids, and manage heavy periods. However, they also bring on a temporary menopause, by turning off your ovaries. Again: pretty counterproductive if you are trying to fall pregnant!
In some cases, GnRH agonists may be suggested as a temporary measure prior to surgery: taking them will shrink the fibroids and help with your symptoms temporarily. However, due to their side-effects, GnRH agonists can only be used for six months.
Uterine artery embolisation (UAE)
UAE is an interventional radiology procedure, in which a dye (‘contrast’) is injected into your bloodstream, and Xrays used to visualise the blood supply to the fibroids. These blood vessels are then blocked using tiny particles of plastic. The affected fibroids then slowly shrink, and the symptoms they cause improve.
However, UAE cannot be safely recommended to women who want to conceive in future. Studies suggest that UAE (compared to an operation to remove your fibroids) can lead to:
– Lower pregnancy rates
– Higher miscarriage rates
– More adverse pregnancy outcomes (such as premature birth, an abnormally adherent placenta, and postpartum haemorrhage)
– Loss of ovarian reserve (especially in older patients)
Hence, women who want to conceive in future shouldn’t be offered UAE.
Magnetic resonance-guided focused ultrasound (MRgFUS)
MRgFUS involves focusing many high frequency ultrasound beams on the target fibroid(s). Doing so over-heats the fibroids, causing them to stop growing. Further studies are needed before offering MRgFUS to women with fibroids and otherwise unexplained infertility.
While an operation to permanently remove the uterus (a ‘hysterectomy’) is curative of any problems caused by fibroids, it clearly defeats the purpose if you are wanting to fall pregnant in future!
Treatment options that may be appropriate if you want to conceive
There are several treatment options that may be appropriate for you, if you have fibroids and want to conceive. Discussing the pros and cons of each option, and choosing between them, can be quite a nuanced discussion between you and your gynaecological surgeon.
When considering which option is most appropriate for you, think about the following factors:
– What type of fibroids you have (submucosal, intramural and / or subserosal)
– How many fibroids you have
– The extent to which they are distorting the uterine cavity
– Your story so far, in terms of conceiving, carrying, and birthing a baby
– Your age, and how long you have been trying to conceive
– If you have any additional symptoms (e.g. heavy periods and / or pressure symptoms)
As noted above, many medicines used to treat fibroids aren’t appropriate if you are trying to conceive. Hence, the main management options available to you are surgical.
Hysteroscopic myomectomy is an operation which is performed under a general anaesthetic, and can be used to remove submucosal fibroids (that impinge on the uterine cavity). Once you are asleep, you won’t be able to feel or remember anything. A very slim (5mm) long camera will be used to go up through the vagina and cervix, to look at the lining of the uterus, and to visualise the fibroid(s). The fibroid(s) will then be shaved off, like scooping icecream out of a tub, while the surgeon is watching using the video camera. Doing so normalises the shape of the uterine cavity, thereby improving fertility and obstetric outcomes.
Hence, in women with otherwise unexplained infertility or poor obstetric outcomes, submucosal fibroids can be removed in order to improve conception and pregnancy rates
Laparoscopic myomectomy is keyhole surgery to remove fibroids, and is appropriate for subserosal and some intramural fibroids. However, this approach must be considered carefully for women whose main issue is fertility, as (a) intramural fibroids are less likely to be associated with subfertilty than submucosal fibroids and (b) laparoscopic myomectomy causes scarring of the uterine wall, which can have an impact upon subsequent pregnancies, labours, and births.
Frequently asked questions (FAQs)
I know I have fibroids, but haven’t yet started trying to conceive. Do I need to do anything about my fibroids?
You won’t know if your fibroids are going to impact upon your fertility until you start trying to conceive! So our general advice would always be to start trying to conceive naturally. If you don’t have any luck (after twelve months of trying if < 35 years old, or six months of trying if > 35 years old), see your GP and gynaecologist for some investigations. If you are then found to have fibroids, and they are thought to be the only factor affecting your chances of conceiving and carrying a baby, a myomectomy may be indicated (see above).
You should not have an operation to remove your fibroids ‘just ‘coz’, before you develop symptoms or start trying to conceive. This is because, while very safe, no operation is without risk. Any potential benefit from the surgical removal of your fibroid(s) may be negated by the detrimental effect of the surgery on uterine integrity. Hence, it’s important that myomectomy is only undertaken when there is evidence suggesting that doing so will improve your fertility and / or obstetric outcomes.
I have fibroids. Does that mean I’ll definitely have fertility problems?
No! Just because you have fibroids, it doesn’t mean that you’ll definitely run into problems conceiving. Approximately 5 – 10% of women with infertility have fibroids, and most women with fibroids are fertile. You never know until you try!
I had a miscarriage, and was found to have fibroids. What should I do?
Unfortunately, miscarriages are very common. If you have had a miscarriage, and have been found to have submucosal fibroids (that distort the shape of the uterine cavity), there may be a role for hysteroscopic myomectomy. Please see your GP, and discuss this with your gynaecological surgeon.
Does removing fibroids guarantee that I’ll be able to have a baby?
Sadly, no. While there is reasonable evidence to suggest that removing problematic submucosal fibroids may improve your chances of conceiving and carrying a baby, there is no guarantee that this will be the case.