By fertility experts from Spain.
Dr Harry Karpouzis, Founder & Scientific Director at IVF Pelargos Fertility Group, is answering patients’ questions regarding fibroids, infertility, IVF treatment options and outcomes.
The most common reason is if they are close to the tubes, they can block one of the tubes, if they’re close to the cervix, they can cause problems in the passage of the sperm. The main way is fibroids inside the lining of the womb. Either if this is less than 50% or more than 50% or even touching the endometrium, it may cause problems with infertility because it can affect the blood flow, reduce the blood from so reducing the chances of implantation by occupying some part of the endometrium. Keep in mind as well that surgery, especially not a good surgery which happens quite often, can cause problems by creating local infection inside the lining of the womb. Many times we’ve operated on patients that came back with thin endometrium that is not increasing in size after a lot of fibroids surgeries, so all of those fibroids are associated with infertility.
This is a tricky question and I wouldn’t want to give a specific answer. I don’t like the put label on sizes because I have said many times, the most important thing is to take every couple as an individualized case. So you need to consider a lot of factors to answer that. The most important thing is not size, its position. So even if a fibroid is very small but it protrudes the whole of it or even part of it, it needs to be removed, as it can cause miscarriage, it can decrease the chance of implantation. Regarding fibroids that are 3-4 centimetres in size or 2-4 centimetres in size, and they are outside of the womb but very close to the endometrium, the most recent research says that they need to be removed because they can affect the blood flow in the endometrium. We need to take into consideration as well as other factors, f.e. the age of the woman if she had any previous surgeries, if she had failed IVF attempts or not, so there is no clear answer.
Regarding the fibroids that are outside the lining of the womb, and they are not close to the lining, they are more than 1-2 centimetres from there, so subserosal fibroids, I wouldn’t remove them unless they get too big. If they do get bigger, but they don’t cause problems, if they are subserosal that would depend if the woman is 25-30 and has a normal ovarian reserve, we can remove it but if someone is f.e. 42, possibly we would not want to lose time and get the eggs first.
I am a laparoscopic surgeon as well so I wouldn’t be able to say anything else than that the laparoscopy is preferable. The general benefit of laparoscopy is smaller scars, quicker recovery, so going back to your activities sooner, possibly less bleeding if the surgery is done correctly. So if we can remove fibroids laparoscopically, we should do it that way rather than do it abdominally, especially if we’re planning to do an IVF and we don’t want to lose a lot of time. Selection of the surgeon is very important, you always need to look for a surgeon who has experience in performing such surgeries laparoscopically.
Hysteroscopy should be a procedure of choice. When we’re talking about submucosal fibroids and intramural fibroids that protrude in more than 50% inside the endometrium, in this second case it Leeds to be a good technique because we need to remove the whole fibroid, it needs to be done with a specific technique and not everybody can do it because you can do some harm as well. So fibroids that are protruding more than 50% can be removed by hysteroscopy with the right techniques without affecting the endometrium, which is very important.
Hysteroscopy can also be diagnostics as well if we’re not sure from the ultrasound of what exactly is happening with the fibroid. When you go for the surgery, it is crucial to know where exactly the fibroids are so that you can choose the right technique.
Most of the research says that if we have a submucosal component, especially if there is more than 50%, it needs to be removed. Even if it is less than 50%, again it needs to be removed but we always need to individualize the case. If a patient has a poor ovarian reserve or is older, we don’t want to lose time, so we may act differently.
We need to first know if the pain is coming indeed from the fibroids or not. Because a small fibroid usually does not cause pain unless it is increasing very quickly and degenerates. Regarding the fibroids and if they affect infertility, it depends on their size and position, not if they are painful or not. You should do an ultrasound scan to find out where the fibroid is, whether it has a submucosal element if it protrudes inside the womb, how big it is and then decides if we need to remove it or now. If the fibroid is big, that may be causing the pain, so that is one more reason for removing it. Regarding endometriosis, it is another topic but to check if you have it or not, you need to do a laparoscopy and if it is found we can help. The pain from endometriosis is different, you would feel pain during the period or the sexual intercourse, it’s associated with a cycle, it’s not a permanent pain unless it is in specific places inside the tummy, it’s a completely a different story.
If it was close to the cavity, it can play a role. If it is the only factor that causes infertility or not, it is hard to really say. Also, at the time of laparoscopy, it would be important to know if they’ve found anything else, like blocked tubes, or if they’ve found endometriosis or not, so you need to investigate some other reasons like sperm analysis, your hormonal profile, your age, AMH etc. The fibroid that is close to the cavity can play a role.
It is hard to answer this question. Usually, if you have an ultrasound scan and you properly measure the fibroid, you have the dimension of the fibroid. If the burgery has happened 3-4 months after the scan, they might have increased in size. By any means, subserosal fibroids of 1,3 and 4 don’t really affect the endometrium, sometimes they don’t even affect infertility. Fibroids of 5,7 and 10 is a different case, they are quite big, they can affect the contractility of the womb sometimes, such fibroids have to be removed and they play a role in IVF success or spontaneous pregnancy.
There is a research that says that fibroids have a genetic predisposition, so sometimes a family history plays a role, sometimes even diet plays a role. We know that in obese patients fibroids are more common, also we know that red meat and reduced diet of vegetables and fruit may increase the frequency of fibroids. Healthy lifestyle, a balanced diet may play a role. Also, we know that fibroids depend on the hormones, on the estrogens so it is better to avoid food that contains it, and you can find f.e. phytoestrogens, so you should avoid it if you have a fibroid and you’re afraid it will be increasing.
As I’ve mentioned before, it can reduce the implantation either by occupying the part of the endometrium, and the fibroids that are inside or close to the womb can affect the blood flow to the endometrium. If they are close to the tubes they can block them. Also, submucosal fibroids that protrude inside of the womb can increase the risk of miscarriage.
If you want to remove them, you’ll need to have an operation. It depends on the location of those fibroids, you can do it either with hysteroscopy which is a minimally invasive procedure, you don’t open the tummy, it’s going through the cervix from down below. If it is inside, it can be done laparoscopically, which again is a minimally invasive procedure. If you need to remove them or not, that depends on the size and position if we’re talking about fertility. If you’re not talking about fertility and you don’t have symptoms, maybe you don’t need to remove them. There are some other medical treatments as well but they are not for fertility, we usually use them before the surgery when we need to shrink the size of f.e. submucosal fibroid which we then can remove, as sometimes if the size is very big, we cannot remove it at once, we need some more steps. I usually don’t use GnRH analogues before laparoscopy. GnRH or esmya, things like that have a point if you want to avoid the surgery and reduce the symptoms of fibroids by shrinking its size. On very rare occasion, we have embolization but sometimes, it can affect fertility as well, especially if it’s done with an older technique.
Usually, if they are not close to the endometrium and they are subserosal, outside of the endometrium, more than 2 centimetres from that, they do not cause miscarriage. If the size is increased too much, then sometimes before IVF, they may need removal.
In order to check if you have endometriosis, you need to suspect that you have it, like painful periods, painful intercourse, or no obvious reason for infertility. If you have any symptoms like this, you can do a laparoscopy and that way you’ll find out if you have endometriosis.
Regarding the fibroids, it depends on where they are located, as not all of them need to be removed. I see that you’ve mentioned you haven’t got a period for several years, so it would be important to check why and check your AMH level, you need to check your hormones if you are in a premenopausal state f.e. or not, perhaps the reason that you do not have periods is associated with PCOS or anything like that. Hashimoto disease by itself if the thyroid hormones are okay shouldn’t cause any periods for that long period. But if you Hashimoto disease has gone into hypothyroidism or the opposite and your thyroid hormones are completely deranged then it can affect your infertility, so that needs to be fixed.
Miscarriage, unlikely. If we’re 100% sure that they are not close to the endometrium, possibly not but if there is no other reason for infertility and you have failed IVF before without really knowing why then the fibroid of 6 cm may need to be removed. If there are other reasons for infertility f.e. the quality of the eggs etc. and you don’t want to lose time you can avoid it.
I would say that between 2-4 cm it is average size fibroids, anything more than 5-6 cm is considered to be big, even though I don’t like the labels, we always need to consider a lot of factors, not only the size.
It is possible to do it straight away if you want. If you know for sure that you’ll go for egg donation, the question is why you need to do the laparoscopy due to endometriosis because sometimes GnRH and things like this can suppress the disease without the need of laparoscopy. If you had done laparoscopy and they have treated endometriosis and you’re 100% sure you’re going for egg donation, you can start right away, in the next cycle if you want.
If the cavity has been breached and the surgery has been done with laparoscopy and you have removed a big fibroid, it would take about 6 months depending on the case.
The adenomyosis scan gives us the suspicion of adenomyosis, so out of the experience we know how the adenomyosis looks like and you realize it is adenomyosis when you see histology, and usually, the adenomyosis cannot be removed. In many cases, adenomyosis can be associated with endometriosis as well, so we always need to make sure that this is not the case because those are different things.