Fertility after fibroids
Uterine fibroids are smooth muscle tumors of the uterus occurring in up to 80 per cent of black women. However, only in two to three per cent of women are fibroids thought to be responsible for their infertility.
The precise impact of uterine fibroids, on reproductive function and infertility, is unknown. The need to treat fibroids that are distorting the uterine cavity is widely accepted, but fibroids in other locations and their sizes continue to present a clinical problem regarding what is the best treatment options or if any treatment is needed. Women who are asymptomatic and have no other reason for their infertility should be treated expectantly for three to 12 months depending on their age.
Usually, only those fibroids that distort the endometrial cavity affect fertility. However, large fibroids that compress and block the fallopian tubes or where they cause abnormal uterine contraction patterns may also affect fertility.
Surgery to treat fibroids can also affect fertility in several ways. If the endometrial cavity is entered during the surgery, there is a possibility of post-operative scarring formation within the uterine cavity. Because of bleeding that may occur during a myomectomy, there is a high likelihood of abdominal adhesion formation, which could cover the ovaries and prevent the release of the eggs or block the ends of the fallopian tubes. Therefore, it is important that only expert surgeons who are familiar with techniques to minimise blood loss and prevent adhesion formation perform myomectomies on reproductive age women.
Traditionally, abdominal myomectomy has been advocated to treat fibroids for the reproductive population; other methods are now available such as laparoscopy and hysteroscopic myomectomy. Fibroids that are within the uterine cavity and measuring less than five-mm should be removed via the hysteroscopic route. Multiple large intramural fibroids that are distorting the uterine cavity should be removed via the open abdominal route. Laparoscopic surgery is used to remove large (greater than five-cm) submucosal fibroid usually less than five fibroids.
There is no role for medical therapy as a stand-alone treatment for fibroids in the infertile patient. If used, the medication is only a temporary fix; used mostly to decrease the size of large fibroids to make their ultimate surgical removal easier.
There are other options for the treatment of uterine fibroids, but these alternatives are not recommended for women who desire fertility. Some of these options are: uterine artery embolization (UAE) and Magnetic Resonance-guided Focused Ultrasound Surgery.
Treatment of fibroids should be individualised, and symptomatology may be a critical factor in whether or not a fibroid should be removed. Myomectomy remains the gold standard for treatment.
• Dr Vernon Davidson is the Director of the Fertility Management Unit at the University of the West Indies, Mona. Email: firstname.lastname@example.org