Infertility and Fibroids – informed decision making
The association between fibroids and infertility has been controversial. With advances in infertility management like fertility drugs, ART (Assisted Reproductive Technologies like IVF, ICSI) and advanced surgical techniques like hysteroscopic and laparoscopic myomectomy (removal of the fibroid) there is considerable interest in the commonly asked questions: Do fibroids really cause infertility and which fibroids would require myomectomy?
Fibroids are bundles of smooth muscle cells in the uterus forming benign tumours. Depending on their location they affect fertility in different ways. Those which are inside the cavity of the uterus are called polypoid/submucous fibroids depending on whether they hang with a stalk or not. Intramural fibroids lie totally within the walls of the uterus. Those arising from the outer surface of the uterus are subserous fibroids.
An estimated 20-30% women have fibroids during their reproductive years, more with increasing age. The current trend of delaying childbearing increases the chances of having fibroids. Most fibroids are detected because of the symptoms they may cause: excessive menstruation, pelvic pain and sensation of weight, pressure on the urinary system or rectum. All such fibroids will require treatment irrespective of their size, number and location. More fibroids, however, are asymptomatic, with no symptoms other than infertility or repeated abortions, and are picked up on routine ultrasound. Since the most essential information is whether there is distortion of the uterine cavity and the inability of simple ultrasound to give this information, hysteroscopy is a key diagnostic tool and the gold standard.
An excellent review was published in the April 2008 issue of the American Journal of Obstetrics and Gynaecology. Briefly, the data confirms that submucous fibroids are associated with a 20% decrease in pregnancy rate as compared to infertile women with no fibroids. Most infertility specialists therefore recommend removal of these fibroids to enhance pregnancy rates. Though actual scientific evidence to support this strategy is limited, hysteroscopic myomectomy is an important treatment modality to improve pregnancy rates and should be considered, especially as the safety of this procedure is well established.
Intramural fibroids may decrease pregnancy rates slightly but this should be viewed with caution since most journals tend to publish papers showing positive effects. Currently, routine removal of intramural fibroid for optimizing pregnancy rate is not justified unless it is larger than 7 cms or there has been a previous IVF failure. And certainly removal of subserous fibroids does not enhance fertility.
This is about fibroids in those women who have realized, after one year of trying to conceive, that they are infertile. The crucial question concerns those who have not attempted to conceive as yet or have tried for less than a year and have been incidentally diagnosed as fibroids. They desire a future pregnancy and wish to be ‘fit’ for it. This review confirms that pregnancy with fibroids is associated with increased rates of preterm delivery, caesarean section and haemorrhage. Simultaneously most women with asymptomatic fibroids conceive easily and remain well enough throughout pregnancy and labour, very often achieving normal delivery even with large fibroids. The risks such women may be exposed to are not high enough to justify the costs of hospitalization and surgery, however easy and safe it may be.
So the bottom line is that certain fibroids will require removal in infertile women, not in those whose infertility status is not as yet known.