Fibroids are a common problem for women in my practice. While I’m not a fertility specialist, doing general gynecology and basic infertility requires that I know enough to advise my patient about what to do if she knows she has a fibroid or I find one and she wants to get pregnant.
Who gets fibroids?
Different studies have given different numbers. The older you are, the more likely you are to have them. Other factors associated with fibroids include never having been pregnant (nulliparity), obesity, cigarette smoking, prolonged menstrual cycles and African-American ethnicity (almost three-times as likely as white women).
What are fibroids and where are they?
Fibroids are benign tumors. Only rarely will they become malignant. They can be located just under the lining of the uterine cavity (submucosal), deep in the muscle of the uterus (intramural) or near the outside of the uterus (subserosal). They can also be on stalks inside the uterine cavity (polypoid) or outside the uterus (pedunculated). They can be single or multiple, big or small. Some cause symptoms and some don’t. I know that was complicated, but it’s all about location.
What symptoms would I have if I have fibroids?
If you have fibroids, you may have heavy periods. You may have pressure on your bladder or your back, depending on the location of the fibroids. Some women have extremely painful periods, with pain going down their legs, either in the back or in the front. Some women feel like they are constipated because of where their fibroids are located. I often think about fibroids after just talking to a woman before we even go into the exam room.
What about getting pregnant?
Not everyone with fibroids has problems getting pregnant. About 2% of women with unexplained infertility have fibroids as the only cause found. There are several theories as to why fibroids may cause infertility. Usually that means we don’t really know.
Are there particular fibroids that cause more problems?
It seems that the fibroids that are just under the lining of the uterine cavity (submucus) cause the most problems. The ones on the outside (subserosal and pedunculated) don’t seem to be a problem unless they are really large or change your normal anatomy a lot. The ones in the muscle (intramural) may or may not be a problem. Size is not as important as location, location, location.
What about treating the fibroids if I’m having trouble getting pregnant?
There are several ways to remove fibroids. Some increase the chances of getting pregnant, some do not. The only one that does, in my research, is to go through the cervix with a hysteroscope and remove any fibroids that are just under the lining of the cavity. This is called a hysteroscopic myomectomy. You need to see a doctor who does a lot of these if you are planning a pregnancy.
Removal of those fibroids that are in the muscle does not statistically change pregnancy rates. If this requires abdominal surgery, there is a risk of scar tissue (adhesions), which causes further issues with getting pregnant. Laparoscopic surgery causes somewhat less scarring.
Are there other treatments?
Uterine artery embolization (UAE) and magnetic resonance-focused ultrasound (MRI-FUS) are the most commonly utilized alternatives to surgical treatment for uterine fibroids. These are not offered everywhere. They require special equipment and training. There may be more complications after these treatments, including an increased rate of miscarriage, higher risk of cesarean section, and a higher risk of post-partum hemorrhage. There is no higher risk of preterm delivery, intrauterine growth restriction or abnormal presentation of the baby (breech, etc).
So what should I do if I have fibroids and I want to get pregnant?
You should talk to your gynecologist. You may need to be referred to a “reproductive endocrinologist” who is a specialist in fertility and fertility issues. Do not rush to have surgery until all other issues have been explored. Make sure there are no other issues that may be causing infertility. If you do have surgery, make sure you discuss the risks of surgery on pregnancy with your doctor.