Uterine fibroids are the most common pelvic tumors in women affecting approximately 70% of women over 30 years of age.
The most common age group being 30 – 40 years.
Fibroids are present in 5-10% of infertile patients and maybe the sole cause of infertility in 1.2-4.2%.
Fibroids are commonly asymptomatic but may present with symptoms depending on location and size.
More than 50% of fibroids are small and asymptomatic.
Symptoms are divided in 3 categories:
- Abnormal uterine bleeding- most common symptom. Presents as heavy or prolonged bleeding or both.
- Pain or pressure symptoms- related to size of fibroids.
- Impaired reproductive function- depends mainly on location, size and number of fibroids. Cause of infertility with fibroids- fibroids cause distortion of uterine cavity, obstruct the fallopian tubes which impairs gamete transport and they alter the endometrial receptivity for implantation.
Types of fibroids: mainly 3 types
- Submucosal: present in uterine cavity
- Intramural: present in wall of uterus
- Subserosal: out of the uterus Diagnosis is made on ultrasound of pelvis.
Asymptomatic fibroids need follow-up, no intervention.
Symptomatic fibroids need treatment which can be medical treatment or surgical treatment.
It is given to improve the symptoms or preoperatively or prior to starting ART.
It consists of
GnRH agonist: given for a period of 3 to 6 months to reduce the size of fibroids.
Ulipristal acetate: approved for treatment of fibroids. It reduces the size of fibroids when taken for 3 months (not all cases).
Infertile patients and those undergoing IVF-ET with fibroids which distort the endometrial cavity or encroach the endometrium need myomectomy (surgical procedure to remove fibroids).
Hysteroscopic myomectomy: advised in patients with fibroid in cavity(submucosal). A camera with operative instrument is introduced through the vagina in the uterine cavity to remove the fibroid.
This procedure may be accompanied with laparoscopic myomectomy (laparoscopy- camera with operative instrument is introduced in the abdomen through a small incision near the umbilicus) in cases of large multiple fibroids at different locations.
Open myomectomy is also an option in multiple large fibroids.
Care is taken not to open the uterine cavity and to prevent adhesions later.
Removing fibroids improves the pregnancy rates by 25 to 42%
Location of fibroids is also critical for ART outcomes. Fibroids distorting the cavity should be removed.
Not all fibroids need surgery or medical treatment. Treatment is decided based on patient complaints and individualized accordingly.