Fibroids and Fertility
Fibroids are very common in women. Fibroids are medically known as leiomyomas and are smooth muscle benign tumors of the uterus. As women grow older, the incidence of fibroids increases. Fibroids may impact a woman's fertility and may increase complications during pregnancy.
Whether a fibroid affects pregnancy is controversial. Many factors must be considered before treatment for fibroids can be considered.
Location, size, menstrual bleeding pattern and age are a few of the factors that your physician and you must consider.
Treatment Options for Fibroid Tumors
There are many options available for the treatment of fibroids. The following discussion is a general outline of those options. However, depending on your particular medical situation, your SRM physician will help you determine which option is best for you.
Myomectomy is a surgical procedure that requires general anesthesia. Simply put, your physician surgically removes the fibroids in your uterus and reconstructs the uterus after their removal. You may required to stay in hospital. Myomectomy can be removed through small incisions using specialized instrumentation called laparoscopy or it can be removed through a bigger incision called laparotomy.
Whether laparoscopy or laparotomy is performed will depend on your personal medical situation and your physician's recommendation. The major difference between the two methods is recovery time with laparoscopy having a faster recovery.
Fibroids can be located in several locations in the uterus. When they involve the inside of the uterus, called the endometrial cavity, research shows that these submucosal fibroids can reduce reproductive potential up to 70%. Fortunately, most of these fibroids can be removed using a hysteroscope. (a camera that is inserted through your cervix) If fibroids involve the muscle portion of the uterus (intramural, subserosal), the removal of the fibroids will depend on several factors, i.e. your age, how much it involves the uterus, proximity to the endometrial cavity and size of the fibroid. Fibroids that are pedunculated and involve the outside of the uterus are typically left alone unless the size of the fibroid is enormous.
Leuprolide acetate (Lupron® injection or Lupron Depot®) is a hormone-like medication taken as a daily or monthly injection. The drug works by blocking or suppressing the release of hormones from the pituitary gland, namely Follicle Stimulating hormone (FSH) and Luteinizing Hormone (LH). If the ovaries do not see the FSH and LH, then the ovaries temporarily become dormant, and do not release any of their normal hormones (i.e.- estrogens and androgens), and the normal follicular development that results in ovulation also does not occur.
Because the estrogen levels are reduced by the GnRH agonist (Synarel® or Lupron®), processes that are estrogen dependent such as fibroid tumors tend to decrease in size after 3-6 months of use. In many cases, fibroid tumors treated with leuprolide acetate therapy shrink in size to almost half the original volume. As soon as the therapy is discontinued, however, the fibroids return to their normal size.
Therapy usually lasts between 3 and 6 months. For a period of time after stopping the treatment - often up to one or two months after treatment stops, most women do not have return of their monthly menstrual periods. However, menstruation does return similar to the way it was before therapy.
Leuprolide acetate seems to be safe. There is no evidence of increased congenital anomalies in pregnancies that occur following leuprolide acetate therapy, nor does it appear to have any adverse effects on fertility. Currently, no major adverse side effects in humans have been documented.
Side effects of leuprolide acetate therapy include the following:
- Temporary discontinuation of menstrual periods
- Hot flashes
- Temporary mild worsening of the disease (e.g. fibroid tumor) early in treatment
- Local skin reaction or bruising around injection site
- Bone loss, which is usually reversible, has been shown to occur after a 6 month course of therapy
- Head aches, vaginal dryness, mood swings
In a patient with fibroids, GnRH agonist is indicated in two situations:
- shrinking a fibroid to allow a myomectomy to be technically easier. This will depend on your physician's recommendation.
- If you are anemic from heavy and/or irregular menstrual flow due to the fibroid, GnRH agonist will stop your flow quickly to allow your blood stores to return to normal prior to surgical removal.
Consult with your SRM physician as specific recommendations to your medical situation may vary.
Uterine Artery Embolization
Uterine artery embolization (UAE)is a radiologic technique recently developed for the treatment of fibroids. Performed by interventional radiologists. UAE is a procedure in which the radiologist blocks the blood supply to the fibroid resulting in the shrinkage of fibroids. UAE has been used successively for fibroids responsible for excessive and/or irregular menstruation.
The main advantage is that UAE is a relatively non-invasive procedure as compared to surgical removal of fibroids. However, UAE does not necessarily result in complete removal of the fibroid and post-procedure pain due to fibroid cell death may require hospitalization.
UAE use in fertility however is not very studied at this time. There have been reported cases of spontaneous pregnancies doing well following this procedure. However, because blood supply is reduced to the fibroid, there exists concerns in its use for women still wanting to retain their fertility potential as it may reduce blood supply to the uterus as well.. At this time, UAE is not recommended as a therapy for fibroids in women with infertility issues.
This procedure involves the removal of the uterus. In the treatment of fibroids, hysterectomy can be an option in women no longer considering getting pregnant in the future. Discuss this option with your SRM physician as it may pertain to your medical situation and your reproductive goals.