a) Sub-serosal fibroids
b) Intra-mural fibroids
c ) Sub-mucousal fibroids
d) Intra-uterine fibroids
e, f) Pedunculated fibroids
What is known is that female ovarian hormones; estrogens, progesterone along with several locally produced growth factors play an essential role in the development and growth of fibroids. Most fibroids are devoid of genetic re-arrangements at the cellular level, with approximately 20% of the fibroids showing multiple gene mutations. Most of the fibroids in the same uterus contain different chromosomal changes suggesting that each fibroid develops independently. Fibroids do have ethnic and hereditary predisposition, and are more common in African – American women.
An individual may be symptomatic or asymptomatic, depending upon the numbers, size and location of the fibroid(s). Usual symptoms are pelvic pressure, pain, heavy menstrual bleeding, irregular uterine bleeding and painful sexual activity. Many fibroids are discovered during routine gynecological exam.
Most women with uterine fibroids are fertile, but in some women, fibroids may lead to infertility or repeat miscarriages. This effect may be related to distortion of the uterine cavity due to fibroids or local changes in the uterine environment. Frequently, uterine fibroids and pelvic endometriosis including adenomyosis may coexist.
Once fibroids are suspected, a systematic diagnostic approach is initiated. This consists of clinical examination, a transvaginal ultrasound and at times, an MRI of the pelvis. These tests provide comprehensive information about uterine fibroids.
The next step is to evaluate the uterine cavity and the fallopian tubes with saline sonohysterogram (SSHG) or hysterosalpingogram (HSG). Based on these and other diagnostic tests, fibroids are described as follows:
1. Intra-cavitary- inside the uterine cavity
2. Sub-mucosal- pushing on the lining of the uterus (the endometrium)
3. Intra-mural- in the body of the uterus
4. Sub-serosal- outside the uterine cavity
5. Pedunculated- hanging from the uterus on a ‘stalk’
Uterine fibroid treatment is always individualized to meet a woman’s unique circumstances and needs. One treatment doesn’t fit everyone. This individual focused approach takes into consideration a patient’s symptoms of heavy menstrual bleeding, dysmenorrhea (painful periods) or anemia. Many patients with fibroids may have a history of infertility or repeat miscarriages. Once diagnosis is established and patient’s desire/needs have been fully discussed, all available options are presented.
For women who are not interested in having more children, traditional treatment is a hysterectomy. But now with minimally invasive surgical treatment, a conservative approach is more common. However, for a woman with uterine fibroids who does want to have children, or is interested in maintaining her childbearing capability/option, usual treatment consists of a conservative approach focused on removal of fibroids (myomectomy) with minimally invasive laparoscopic method, with or without robotics. Recently, pretreatment with medicines that cause ovarian hormone suppression has been advocated and utilized prior to uterine sparing myomectomies. Pre-treatment with these pharmaceutical agents lead to a decrease in the size of the fibroid and a decrease in blood loss during surgery.
At times, a laparotomy may be needed for those patients whose fibroids may not be amenable to laparoscopic method. The fibroids in the uterine cavity (intra-cavitary or sub-mucosal), are treated by Hysteroscopic surgical procedures. Fibroids which are intramural (in the wall of the uterus), sub-serosal or pedunculated may require laparoscopy or laparotomy. Other less invasive methods for the treatment of fibroids is uterine artery embolization (UAE) which blocks blood flow to the fibroids and results in a decrease in its size. With UAE fibroids don’t disappear, but due to lack of blood, they tend to get smaller. This approach may not be well suited for younger women who are still planning to have children. The uterine artery embolization has a possible inadvertent negative effect on ovarian blood supply, that may lead to decreased ovarian reserve .Another technique in use for non-surgical treatment of fibroids is Magnetic Resonance Guided Focused Ultrasound Surgery (MRgFUS) which directs energy beams, raising temperature sufficiently to cause cell damage in the fibroids.
When it comes to the direct effects on Fertility, it is known that fibroids affecting shape of the uterine cavity can negatively impact In vitro Fertilization/Embryo Transfer (IVF/ET) success. Although it’s reported in literature that intra-cavitary and sub-mucosal fibroids treatment prior to IVF improves IVF success, it’s less clear if intra-mural or sub-serosal fibroids have a similar adverse effect on success of IVF. But if on subsequent uterine cavity re-evaluation, an intra-mural fibroid is sub-mucosal in location, it will require its removal to improve odds of a successful pregnancy. This further emphasizes need for a thorough evaluation of the uterine cavity before proceeding with IVF and embryo transfer.
When fibroids are suspected as a cause of infertility or miscarriages, a thorough evaluation is warranted, with treatment if indicated, prior to the start of Assisted Reproductive Technology (ART) cycles. Your Obstetrician and Gynecologist working with your REI, is the best resource for your evaluation, counseling and treatment.