Uterine fibroids, myomas or other malformations, and how they can affect my fertility?

Elias Tsakos MD, FRCOG
Medical Director , Embryoclinic
From this video you will find out:
  • What are uterine fibroids and how common are they?
  • What are the symptoms of myomas (a.k.a. uterine fibroids)?
  • How fibroids might affect fertility and pregnancy?
  • How are fibroids (myomas) treated?
  • What are congenital uterine anomalies?
  • How can minimally invasive surgical options help with treating uterine factors?

Uterine fibroids, myomas or other malformations, and how they can affect my fertility?

During this session, Dr Elias Tsakos, FRCOG, Medical Director of Embryoclinic – Assisted Reproduction Clinic in Thessaloniki discussed whether uterine fibroids, myomas, and other benign tumours can interfere with fertility and how to treat them to achieve a positive outcome.

The uterus plays a crucial role in implantation and pregnancy, yet it is often overlooked when investigating reproductive issues.

Uterine Fibroids

Fibroids, also known as leiomyomas or myomas, are usually benign tumours, although approximately 1 in 500 myomas can be malignant. They are typically round and can be found in various areas of the uterus, including the uterine cavities, myometrium, or the external part. In some cases, fibroids may be located near the ovaries or present as ovarian cysts. Fibroids are quite common, with around 80% of women having small fibroids, and approximately 50% of women experiencing symptoms. Even women who have completed their families or entered menopause can be affected by fibroids, emphasizing the need for awareness and appropriate management. Treatment may be required for about 30% of women with fibroids, and up to 60% of those may require additional treatment.

Uterine Anomalies

These congenital malformations are relatively common, especially among women with fertility issues. Detecting uterine anomalies is crucial before starting any fertility treatment. Scanning alone may not be sufficient for a confident diagnosis, so additional imaging techniques such as saline or foam hysterosalpingograms (HSG) or standard X-rays are important. The prevalence of uterine anomalies is higher in women with fertility challenges or miscarriages, highlighting the importance of thorough investigation before proceeding with fertility treatments like in vitro fertilization (IVF).

Effects on Fertility & Treatment Considerations

Fibroids can manifest through pain, infertility, heavy bleeding, or pressure symptoms on various organs. While some fibroids may be asymptomatic, they can still impact fertility. The size and location of fibroids determine the management approach. For instance, a small fibroid (around two to two and a half centimetres) within the uterine wall, without distorting the cavity, poses a decision-making challenge for infertility cases. Should it be removed or closely monitored? This decision requires individual consideration. In general, a conservative approach is preferred, but factors such as fibroids within the uterine cavity, rapid growth, symptoms, failed IVFs, or miscarriages may necessitate intervention. Individual counselling is crucial in such cases, along with specialized ultrasound scans (e.g., 3D or Doppler studies), MRI scans, hysteroscopy, and occasionally laparoscopy to assess the fibroids thoroughly.

In conclusion, managing uterine conditions requires a comprehensive understanding of fibroids and congenital anomalies. Their impact on fertility varies, and treatment decisions should be tailored to each patient.

Fibroids and congenital uterine anomalies are well-known factors that can negatively impact fertility. The team at Embryoclinic has researched the effect of robotic and laparoscopic management of fibroids on fertility. Similarly, studies have shown that congenital uterine anomalies can also affect fertility. It is crucial to address these issues and not proceed with in vitro fertilization (IVF) until the uterine cavity and wall have been confirmed as normal. Further investigations, such as 3D ultrasound and MRI scans, should be conducted to ensure that patients do not experience repeated failed IVFs or miscarriages due to undetected uterine anomalies.

Treatment Options

There are various treatment options for fibroids and uterine anomalies. These include watchful waiting, non-invasive medical treatments, minimally invasive options such as laparoscopy and robotic surgery, radiofrequency ablation, traditional surgery, and vascular embolization. However, it is important to note that certain options are not recommended for women seeking fertility. Individualization and consultation with a specialized team of doctors in fertility and surgery are crucial in determining the best course of action.

Advantages of Myomectomy and Minimally Invasive Surgery

Myomectomy, specifically through minimally invasive techniques like hysteroscopy or laparoscopy, is superior in terms of fertility outcomes compared to other options. Robotic surgery, a state-of-the-art technology, has shown significant advantages over conventional laparoscopy, especially in Myoma surgery for patients seeking fertility. Our team has conducted an extensive review of the outcomes and benefits of robotic myomectomy, which is currently under review for publication. The results indicate improved pregnancy rates, reduced miscarriage rates, shorter conception time, and higher live birth rates. Hysteroscopic management is also important for treating congenital anomalies and has provided successful results in the last two decades.

Take-Home Messages

Anomalies of the uterus can have a significant impact on fertility and may present various clinical manifestations. They are often an underlying cause of infertility, which can be missed during comprehensive investigations. Surgical treatment, particularly minimally invasive approaches, is the most effective option for fertility patients. These solutions not only improve fertility outcomes, but also enhance the quality of life for patients. It is essential to address uterine anomalies and fibroids to prevent undiagnosed and untreated conditions that can hinder fertility.

- Questions and Answers

I had 1 fibroid that was not considered a concern, so I was advised to ignore it. I underwent 9 transfers, but none resulted in implantation. After 3 years of unsuccessful natural attempts, I developed a submucosal fibroid. Surgery was recommended, and the surgeon performed an abdominal myomectomy to remove both fibroids, which were small (two centimeters and one centimeter). The surgeon mentioned that if I hadn’t experienced implantation failure, he wouldn’t have removed them. However, based on the histology, it was necessary. I had 1 euploid transfer since the fibroid removal, but it resulted in a chemical pregnancy. Could the fibroids be the cause of the implantation failure? Also, I have a controversial diagnosis of full HLA DQA1 match. Should I consider myself as starting anew after the fibroid removal, or did they not impact the failure, meaning things will never work?

I must comment that I find it surprising that you underwent an abdominal myomectomy for fibroids that were only 2 centimetres and 1 centimeter in size. This procedure involves opening up and stitching the uterus, which may lead to complications. Ideally, for submucosal fibroids, hysteroscopic management or sectioning of the submucosal component should have been considered. My suggestion would be to evaluate the uterine cavity once again, starting with a hysteroscopy to ensure it is normal, especially after the abdominal surgery. Additionally, an assessment of the uterine cavity and tubes should be conducted through a hysterosalpingogram (HSG) to check for any potential damage or adhesions caused by the surgery. This will help determine if there are any hydrosalpinx issues or if the uterine cavity is near-normal. Therefore, I recommend a hysteroscopy and HSG before proceeding with another transfer.

I had an HSG performed by an interventional radiologist and an Asherman specialist who stated that a hysteroscopy was not necessary. They performed saline scans, and the results were fine.

I understand that the HSG and saline scans were conducted, but I still strongly suggest a hysteroscopy. It is considered the gold standard for assessing the uterine cavity, providing more accuracy than any imaging technique. Moreover, it can help check the condition of the cervix and perform a small scratching of the uterine cavity if needed. Obtaining histology and microbiome testing can provide valuable information before proceeding with the transfer. Although this is my opinion, please evaluate whether it would be useful for your situation.

Will my myomectomy cause scarring? I had a failed frozen embryo transfer, and I was advised to remove a 6-centimetre subserosal fibroid.

Scarring is inevitable with any surgery. Regarding your case, a 6-centimetre fibroid is quite large, although it is typically benign and may not significantly affect fertility. However, a subserosal fibroid can cause complications during or outside of pregnancy. If you plan to become pregnant, the fibroid might grow and reach 12 centimetres. Therefore, I would recommend surgery, preferably a minimal access approach such as robotic surgery or conventional laparoscopic surgery in the hands of an experienced surgeon. Open abdominal surgery is not recommended for fertility-related issues nowadays. Conventional laparoscopy has evolved greatly and is the preferred option, with robotic surgery reserved for more complex cases.

I just had an egg retrieval cycle where unfortunately I ovulated just before we traveled. Additionally, my right ovary was not visualized through ultrasound, probably due to my multiple fibroids. There’s no submucosal fibroid. I was stimulated for 13 days before the three follicles on the visualized ovary grew to the desired size. I have been advised to consider removing the fibroids to promote better follicle growth and visualization in future IVF cycles. I have low AMH, I am 40. What is your opinion?

One of the challenges for patients currently is that most IVF doctors these days are not minimal-access surgeons, meaning they don’t perform surgeries. So, when you have a hammer, you always see nails. Unfortunately, the expertise of a surgeon usually doesn’t coexist in the same room with the fertility specialist. In general, if there is a big fibroid, more than 3, 3 and a half, or 4 centimetres (remember that the normal uterus size diameter is about 4-5 centimetres), for a medium to a big fibroid, multiple fibroids, fibroids within or close to the uterine cavity, or fast-growing fibroids, the indication is surgery. Specifically, you may require robotic surgery, and it might even involve two procedures. In some cases, there are so many fibroids that it is virtually impossible to remove them in one procedure. Performing such a lengthy procedure would take several hours, which is not ideal. Please keep in mind the chance of malignancy. Although it’s not common, it does happen. I encounter it about once a year. Sometimes, even with fibroids that don’t appear suspicious, there could be a malignancy. I recall a recent case of a young lady in her early 40s with a 4 cm myoma. She experienced irregular periods and heavy bleeding, but it didn’t seem serious. However, it turned out to be a sarcoma. She underwent radical surgery and is now considering surrogacy to become a mother. So, let’s not forget the risk of malignancy. Fibroids are considered benign tumours until proven otherwise, so it’s always important to be sceptical about big multiple fibroids or fibroids that grow back after surgery. Also, fibroids with lots of vessels identified through Doppler may raise concerns. Now, looking at your age and the low AMH level, being 40 years old, it’s normal to have a low AMH. However, with a 22-week-sized uterus, I don’t think you should attempt to get pregnant naturally or via IVF. It would be better to address the issues with your uterus first. If the uterus is deemed safe for impregnation, then you can proceed. Otherwise, it would be advisable to consider other options. Fibroids can be a debilitating disease, similar to endometriosis. In cases with serious fibroids, there are three types to consider. The first type is the mild case, where there might be a small fibroid, around 2 cm, located away from the uterine cavity. In such cases, it might be fine to ignore them and proceed with one or multiple embryo transfers. The majority of patients would still have successful pregnancies, even though the fibroids might grow and double in size during pregnancy. However, they usually don’t cause any problems. The second type is the medium case, which is a bit more challenging. It typically involves a fibroid around 3.5 or 4 centimetres, located away from or close to the uterine cavity but not within it. Some specialists may suggest leaving them, while others, usually minimal access surgeons, would recommend removing them. For patients, it might be more convenient to ignore the fibroids, but they need to be aware that the chance of successful IVF may be reduced by 30% to 50% due to the effect of these medium-sized fibroids on implantation. There is also a higher risk of miscarriage. Additionally, if everything goes well, the 3.5 cm fibroid will grow to become 8 or 9 centimetres during pregnancy, which may cause pain, bleeding, and potential complications during delivery. It could even result in a complicated caesarean section if the fibroid obstructs the cervix outlet. Patients must fully understand these risks, although many of them are not adequately informed. Unfortunately, sometimes it’s not just the doctors, but the healthcare system itself that fails to recognize fibroids larger than 4, 5, 6, or 7 centimetres as an indication for surgery. This presents a different challenge altogether. Lastly, we have severe cases with large or growing fibroids. One of the first things I want to rule out in these cases is malignancy. Removing them as soon as possible is better for the patient, as it minimizes scarring. If the uterine cavity was breached during an open myomectomy, does this mean there would be implantation failure? I don’t have a definitive answer for that. The best person to talk to is the surgeon who performed the surgery. To determine the status of the uterine cavity, a standard hysterosalpingogram (HSG) and hysteroscopy can be done. If these tests show normal results, then you can proceed without concerns.

I don’t have any fibroids but have a small endometrial polyp measuring 1 centimetre. Can this affect fertility?

Well, polyps and fibroids are similar in nature. Regardless of whether it’s a polyp or a fibroid, anything within the uterine cavity is not desirable. A 1-centimetre polyp should be removed through hysteroscopy. It’s a straightforward procedure performed by an experienced surgeon using high-tech equipment. This surgery has minimal impact on your everyday life and quality of life. Removing the polyp will definitely improve fertility. It is also advised not to conceive while the polyp is still present because it can increase the chances of failed implantation or miscarriage.

I had a subcutaneous fibroid that was partially removed through hysteroscopy. My doctor said I am now ready for embryo transfers, but I’m concerned that there might still be something in the uterine surface that could impact implantation.

It depends. Curettage is a mechanical procedure and is not effective in removing fibroids, polyps, or anything within the uterine cavity. Performing a curettage after a hysteroscopy is a blind procedure. I personally am not a fan of curettage, whether in fertility or women without fertility issues. The gold standard for removing fibroids or polyps within the uterine cavity is operative hysteroscopy. This procedure allows visualization and simultaneous removal using techniques like electrical or mechanical energy. In Marina’s case, it is suggested to perform a high-resolution ultrasound to determine the presence of any remaining tissue. However, this should always be followed by a diagnostic hysteroscopy for a more accurate assessment. Diagnostic hysteroscopy is a quick, safe, and effective tool that provides valuable information about the condition of the endometrium and other factors that may affect IVF success. In conclusion, hysteroscopy, whether diagnostic or operative, is a valuable procedure in fertility investigations and treatments. It provides crucial information about the uterus and cervix and can help identify factors that may reduce the chances of success in IVF or natural fertility. Despite some theories suggesting that interfering with the uterus through hysteroscopy is not advisable, there is no scientific evidence to support this claim. Considering the relative simplicity and affordability of hysteroscopy, it is a beneficial addition to fertility treatments and can provide valuable insights into the health of the uterus, especially in women over the age of 35 who are more likely to have some form of uterine pathology.

Regarding fibroid surgery, specifically robotic fibroid surgery, I wasn’t aware that it was an option when I was treated in the UK. Could you provide information about the cost of robotic surgery?

Although I am based in the UK and trained there, I must admit that the adoption of Da Vinci robotic surgery has been slower compared to other countries. However, in the last 2 to 3 years, there has been a significant shift towards robotic surgery in the UK. As for the cost, it depends on factors such as the type of surgery, patient characteristics, and the duration of the procedure. If you could send us an email with details about your case, we would be able to provide you with specific cost information. Generally, the cost of robotic surgery in Greece is significantly less than in the UK and even more so compared to the US.

Regarding the removal of fibroids, there are 3 fibroids, each measuring 1 centimetre. Should they be removed?

I would be cautious about their location. If the fibroids are not within the uterine cavity or protruding into it, they may not need to be removed. But if any part of a fibroid, even half a centimetre or five millimetres is inside the cavity, it should be removed. Fibroids within the uterine cavity have a high chance of growth within the next few months and can cause complications during pregnancy, particularly bleeding. If the fibroids are far from the cavity, they may not need to be removed, but it’s important to monitor them closely.

I had a transfer of 3 fresh embryos on day 5 from egg donation. My progesterone level on day 5 after the transfer was 57.64 ng/ml, beta HCG level was 10.77. On day 15 after the transfer beta HCG level was less than 5. However, the ultrasound showed an empty sac.

Transferring 3 day-5 embryos from egg donation is not a common practice. Most clinics, including ours, would usually transfer one or, in some cases, two blastocysts. The levels of progesterone and beta HCG can vary and may not provide conclusive information about the success of the pregnancy. I would recommend not relying solely on these values for determining the outcome. Unfortunately, a beta HCG level of less than 5 on day 15 after the transfer indicates a negative result. I’m sorry for the disappointing outcome.
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Picture of Elias Tsakos MD, FRCOG

Elias Tsakos MD, FRCOG

Dr Elias Tsakos, FRCOG, is a Medical Director of Embryoclinic - Assisted Reproduction Clinic in Thessaloniki, Greece. He has received extensive and certified training in the United Kingdom and is a Fellow of the Royal College of Obstetrics & Gynaecology. Dr Tsakos is also a Board Member Representative of the Royal College for Greece and Cyprus and a Board Member of the Hellenic Society of Assisted Reproduction. He is a Member of the British, European and American Fertility Societies (BFS, ESHRE, ASRM). Dr Tsakos has been living and working in Thessaloniki, Greece, since 1999.
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