During this event, Dr Kristýna Frühaufová, PhD, Head Physician at GYNEM Fertility Clinic in Czechia, shared practical insights, and advanced treatment options for infertility caused by fibroids.
Fibroids are smooth muscle benign tumours. As shown on the slide, they are quite white, and they are age- and ethnicity-dependent. More fibroids are found at a younger age, especially in Afro-American or Asian women. On the other hand, Europeans tend to have fewer fibroids than other ethnicities. The growth of fibroids is hormonally dependent, so they tend to diminish after menopause. It is said in the literature that almost half of the patients are asymptomatic, so they don’t know about the fact that they have a fibroid located in their uterus. However, if the symptoms are present, the most common ones are heavy bleeding during the menstruation period, pelvic pain, or pressure complaints. The symptoms depend on the location of the fibroids.
In the ways to describe the location, there are 3 different types of fibroids. Ones that are located within the uterine cavity or disturb the lining of the uterine cavity are called submucosal ones. Those are the ones that we may see when we enter the uterine cavity with a hysteroscope. Then, the fibroids located within the wall of the uterus are called intramural ones. They also might present inside the cavity or outside the uterus, depending on their size. The fibroids that are located outside or within the capsule of the uterus are called subserosal ones. There is a special type called pedunculated, which is sort of connected to the uterine wall with a pedicle and feeding vessel.
What is the connection between fibroids and infertility? It’s still unknown. According to Dr Frühaufová, we know that fibroids present a higher risk for pregnancy, especially in early pregnancy. When you have a fibroid located within the uterine cavity, there is a high risk of early pregnancy loss. This risk is about one-third higher than when you don’t have any fibroids at all. Also, pregnancy-related complications may occur later on during the pregnancy. The most common ones are the risk of preterm labour, especially in women with large fibroids, fetal growth restriction (which means that the baby is not fed well within the uterus and is not growing enough), or there might be some complications during labour, such as higher blood loss in women with large uterine fibroids. There might also be an issue with heavy bleeding after birth.
What is the reason fibroids may interfere with fertility? There are several factors. When you have a large fibroid that is the cause of severe pelvic pain, having intercourse might be almost impossible. Another factor is that the location of the fibroid may interfere with the transport of the sperm or the oocyte, or might interfere with the embryo implantation itself. It might play a role or be a mechanical factor in infertility. When you have fibroids, there might be changes in the microbiome, altering the immune response, so it may harm the implantation of the embryo. Additionally, fibroids may disturb the blood flow within the uterine cavity, which may alter the way that the placenta is being formed, leading to either miscarriage or preterm delivery when there is insufficient placentation.
How can we determine if a woman has a fibroid? The first method of choice is to do an ultrasound. You may describe even small fibroids using transvaginal ultrasounds. The bigger fibroids are usually discovered using a combination of transvaginal and transabdominal ultrasound. When there’s doubt about the biological origin, MRI can be used, which will provide more insight into the tissue itself. Alternatively, a direct diagnosis by hysteroscopy or laparoscopy can be performed to look inside either the womb or the abdomen. The first method of choice is still a surgical treatment if we need to treat the fibroids. There are some advances in pharmacological treatment as well, and there are some options, such as, for example, uterine artery embolization. Those are not designed as the first method of choice for women desiring pregnancy.
The first surgical treatment option is hysteroscopy, which is suitable for patients with myomas located inside the uterine cavity. Hysteroscopy is a relatively simple procedure, with the resection of the myoma typically taking about 10 to 20 minutes. Small fibroids can often be removed in a single session. If the fibroid is larger or extends deeper into the uterine wall, two or three consecutive hysteroscopies might be necessary. However, most fibroids within the uterine cavity can be effectively treated this way.
For fibroids located within the uterine wall, laparoscopic, robotic, or laparotomic procedures are usually chosen, depending on the size of the fibroid and the surgeon’s expertise. Larger fibroids, generally those measuring over 4 or 5 cm in diameter, or those causing symptoms, are more likely to be treated surgically. If the patient experiences heavy menstrual bleeding or pelvic pain, surgery becomes a stronger consideration. We also operate on patients with a history of miscarriages. The main drawback of this approach is the necessary waiting period between surgery and attempting pregnancy.
Typically, a period of 6 months is needed to allow the scar on the uterus to heal properly. Pharmacological treatment is mostly used for patients who are waiting for surgery. Currently, a new oral treatment called Relugolix is available. It is a GnRH antagonist in tablet form and can be used for a period of 3 to 6 months. This treatment offers symptomatic relief and appears to help reduce the size of the uterus. However, it is mainly intended for patients awaiting surgery and will not eliminate fibroids. It is considered safe for patients planning pregnancy, though large-scale data is still needed, as it is a relatively new treatment.
As mentioned earlier, there are other options, such as uterine artery embolization or high-intensity focused ultrasound (HIFU). However, these methods do not result in a significant reduction of fibroid volume and carry a high risk of uterine necrosis and rupture during pregnancy. Therefore, these methods are not recommended for patients who wish to conceive. If pregnancy is not being considered at the moment, these methods might offer symptomatic relief.
In general, uterine fibroids, especially those that affect the uterine cavity, are associated with pregnancy-related complications.
If intracavitary or submucosal fibroids are present, they should be removed before IVF. For fibroids located within the uterine wall, the treatment approach depends on the size, location, and symptoms and is discussed with the patient individually. Still, the first choice for treatment remains surgical. If fibroids are removed using laparoscopy, laparotomy, or robotic surgery, the patient should be informed that a waiting period of at least six months is necessary to allow the uterine scar to heal and ensure a safe pregnancy.
That’s the High-Intensity Focused Ultrasound (HIFU) that I mentioned in the presentation. Generally, this is not the method of choice for women desiring pregnancy, the reason being that it does not significantly reduce the volume of the fibroid. There are lots of studies that describe the reduction of the volume of the uterus but not a significant reduction in the size of the fibroid itself because it’s a different thing if you describe the uterus or if you describe the fibroid. The clinical data hasn’t been too promising on this method, and since it may cause necrosis of the fibroid, it creates tissue that might be insufficient during pregnancy. There is also a risk of uterine rupture, so I wouldn’t go for this method as the first choice for women planning pregnancy, just to be on the safe side.
No, well, Europe is a bit different from the US. Surgeons from the US say that anything that doesn’t heal within six weeks won’t heal at all. But the thing is, we need to make sure that the scar created on the uterus will sustain the pregnancy. After fibroid surgery, there’s around a 0.5 to 1% risk of uterine rupture, especially when the woman is in labour. Not during pregnancy, as the uterus grows steadily and slowly, so the risk is not that high. But when there are contractions, the risk goes up. This is just to make sure that the uterus has healed properly. There shouldn’t be any haematoma within the scar, so six months is usually considered the minimum.
Yes, you can. We even stimulate with any kind of medication, again, taking into account the age, prognosis, and the possible outcome of the stimulation. Of course, we won’t stimulate if we see, for example, that there’s a diminishing ovarian reserve. We know that any hormonal treatment induces the growth of fibroids, but we do have patients undergoing IVF with fibroids using any kind of medication.
Yes, it might be the case. Especially the ones that are sitting on the uterus, they might be quite large. I’ve seen patients with 7 or 8-cm fibroids that are just outside. It depends on the location. Most likely, it will be an issue during labour. But other than that, we have lots of fibroids that we just watch and wait. Of course, these are things that need to be checked. It’s not always necessary to remove them; you can just follow up if the growth is not fast.
As I said, 5 cm is usually like the waterline. It depends on the symptoms, whether the patient has had any miscarriages, etc., and also the age of the patient, because the age factor and the healing process need to be taken into account. If the patient is 42, we would most likely just go ahead with IVF treatment first. There are lots of factors, and it’s hard to make a definitive statement without more details.
I would, just my guess because I haven’t seen the ultrasounds, but most likely the fibroids are not the reason for the implantation failure unless they are located within the uterine cavity. But I don’t think this is an issue. Most likely, it is the adenomyosis that might be a problem. Adenomyosis can mimic uterine fibroids, especially when you have well-defined lesions of adenomyosis within the uterine wall. It might look like a fibroid, but it has a different origin. It is more genetically similar to endometriosis.
We see different genetic mutations in fibroids and adenomyosis, so it’s completely different. In patients with adenomyosis, we see failures, and there is a high risk of miscarriage. There are several reasons for that, starting from immunology, then altered vascularization, insufficient placental formation, and things like that. Adenomyosis can be treated hormonally rather than surgically. We tend to regulate the patients before embryo transfers. So, in adenomyosis, there is a place for hormonal treatment rather than surgery.
There’s no data to say whether we know that the chances are a bit lower, but since fibroids are a very heterogeneous group of patients due to the location, size, etc., especially when you tend to have larger fibroids in older women, that’s also an age factor we have to take into consideration. Most likely, it does affect the success, but then we would have to go by the location and size to divide it into subcategories to make it clear. It’s impossible to do it otherwise.
Yes, you can, but it depends on where the fibroid is located and what kind of suture you have. In my experience, patients where we had to go deep inside the myometrium or where we had to open up the uterine cavity during surgery, were obliged to deliver with a C-section. The more layers of suture you have to put on the uterus, the higher the risk of rupture. So, if you have superficial myomas or if you had myomas removed by hysteroscopy, there’s no big deal having a vaginal delivery. But this should be defined by the surgeon who did the operation. They should inform you about how to deliver.
Yes, pretty much the same. Just again, we have to keep in mind that we may induce the growth of the fibroid, so that’s it. But since there is no hormone treatment, and even in the natural cycle, you’re producing estrogens, there isn’t much to change or alter in the IVF protocols.
Yes, it is. We do see it sometimes during pregnancy that, since the major blood supply goes to the fetus, the fibroid may die or shrink during pregnancy. We do see it in small ones. Sometimes, they even form a small scar or expulsion, which means that the fibroid will come out. It’s quite rare, and I’ve seen a few cases in patients who had fibroids located within the uterine cavity. But as I said, it’s really rare. You need to be aware of that. When there’s necrosis of the fibroid, which is the process of tissue death, this can be painful.
Each country has different products, so this is something that I cannot say. Usually, Lactobacillus species are recommended, as the major Lactobacillus should be located within the uterine cavity if you wish. But it’s hard to tell exactly which product by name, as the brand names are different in each market. Remember that it’s impossible sometimes to provide you with direct medication because of these differences.
Yes, a 2 cm fibroid is quite large. If it’s located inside the uterine cavity or has a small portion inside, it might be an issue. This would need treatment. We usually divide the treatment based on the maximum volume of the fibroid. If more than 50% is located within the uterine cavity, we go for hysteroscopy. If it’s less than 50%, we treat it by laparoscopy.
Fibroids are a huge topic. The treatment of uterine fibroids depends on their location and the patient’s medical history. We have to personalize the treatment, as there’s no one-size-fits-all solution. Case-by-case judgment is essential, and personalized treatment is key.
