Uterine fibroids are benign tumors of the uterine muscle. These are very common in women in their 30’s and 60’s, Fibroids usually do not cause problem Most of the women with fibroid uterus never even know they have them, While most fibroids are asymptomatic, they can grow and can cause :
- Heavy and painful menstruation
- Frequent urination
- Pelvic pressure or pain
There is certain type of fibroids which are known to decrease fertility. The fibroids can distort the uterus and endometrial cavity and interfere with embryo implantation whether natural conception or IVF.
The size and location of the fibroid are very important. The majority of fibroids are very small and located in an area of the uterus such that they will not have any impact on reproductive function. On the basis of their location fibroids can be divided into three categories:
- Subserous: located in the outer wall of uterus
- Intramural: in the muscular layer of the uterine wall
- Submucosal: protruding in the uterine cavity.
About 55% are subserosal, 40% intramural and 5% are submucosalt.
Fibroids that are inside uterine cavity or those more than 4 cm in size that are located with in the wall of uterus can affect fertility. Submucosal fibroids are most likely to affect fertility.
Management of Uterine Fibroids
After evaluating the size and the site of fibroid in the uterus, the decision has to be made about conservative or surgical management by the specialist Le. a gynaecologist or a surgeon. Most of the times we have observed that multiple or large fibroid effects the reproductive function of a female resulting into infertility, IVF failure or spontaneous first trimester pregnancy loss.
Decision should be made very clear in our mind that how we should deal with these. A laparoscopic or open myomectomy should be given an option to the patient depending on the sire. number and location the fibroid.
In case of large intramural fibroid or submucosal fibroid, we clearly tell the patient regarding the chances of IVF failure and if conceived. chances of early pregnancy loss. Subsequently. patient is counseled for nvyomectomy before going for ART programme. Thus diagnosis leads to prognosis.
Patient should not be encouraged to undergo an ART procedure before the removal of such fibroid and once these are removed either by laparoscopy or laparotomy, 4-6 months of the healing period should be given to the patient before they are talten for ART procedures.
In case of fibroids up to 4cm which are not impinging in the endometrial cavity either from the anterior or posterior wall of uterus. ART procedures can be initiated without their removal and proper luteal support should be given if a pregnancy occurs in such cases.
A regular and timely ultrasound evaluation should be made in such cases to check the size or any secondary degeneration of fibroid and to ensure the well being of the foetus.
A complete hysteroscopic evaluation of the uterine cavity is to be done in such cases and before taking them for an ART procedure like IVF. if we chose conservative approach and plan an ART cycle without surgery, usage of GnRH analog really makes the difference, and helps in fibroid size constriction and hence increases the chances of success.
We commonly see such fibroid uterus in upto 15-20% of infertility cases and ensure that before the patient is taken up for the ART procedure a proper counselling of the couple is done regarding the diagnosis and prognosis. The couple is very clearly made understood why there is a need for surgical intervention and why it should not be done wherever not required. We as a team takes the decision for the management in such cases and their after either direct ART procedure is worked out or a surgical management is done prior to ART.
A careful and timely decision always plays a crucial role in successful infertility treatment what is practiced here.