During this event, Dr Elias Tsakos, MD, FRCOG, Medical Director of Embryoclinic in Greece, addressed the impact of uterine fibroids, myomas, and other malformations on fertility. He also explored whether these conditions always require correction and presented the latest treatments and strategies for managing them.
This is one of those borderline cases. I would do 2 things. One is a high-resolution ultrasound scan with 3D and 4D scanning and mapping of the myoma, with particular attention to the flow and characteristics. Is it a myoma or an adenomyoma? Sometimes it’s not easy to distinguish. That’s the first thing I would do. The second is a hysteroscopy to ensure that this is not entering the uterine cavity, producing bulges or abnormalities, and I would definitely take some endometrial biopsies as well, just to be on the safe side.
If that were normal, I would probably not operate on a 3-centimetre myoma. I would observe and maybe keep going with another one or two cycles. From my experience, I have no evidence, but I estimate a 10 to 20% reduction in implantation rates with myomas of this size. This is due to micro changes in the microvasculature of the endometrium and perhaps subtle uterine contractions. When doing the embryo transfer, I might consider some non-steroidal to reduce contractions and prostaglandin release. I would go for a straightforward embryo transfer, possibly facilitated by a small dilation 1 to 2 months prior through hysteroscopy. I would also give a slightly higher dose of progesterone to maintain a relaxed uterine state. I would be fairly optimistic that you will succeed.
There are two areas I would look at in your case. Firstly, are you using own eggs IVF or egg donation? If using own eggs IVF at 46, the chance of success, even with a normal uterus, is no higher than 1 or 2%. Age alone makes pregnancy almost impossible, but if you are producing embryos, I wouldn’t discourage you from trying. I would suggest PGT-A testing on blastocysts to ensure you’re transferring healthy embryos.
As for uterine factors, the septate uterus depends on size, location, and consistency. This should be mapped out by advanced general ultrasound, along with a hysteroscopy. If the septum is larger than five to seven millimetres, I would correct it hysteroscopically. Regarding myomas, as I explained before, even a 3-centimeter myoma not touching the uterine cavity can reduce implantation rates by 10 to 20%. If you have multiple myomas, this could further impact the chances. Given your case, which involves genetic, age, and uterine factors, I would optimize your uterus as much as possible.
Essentially, we start with the diagnosis. We write down the exact symptoms. How painful is painful? How is it managed? Does it interfere with everyday normal life, and sexual function? We need to have some clinical symptom classification.
Secondly, we need a high-resolution ultrasound scan. I keep insisting on that. May I say that most gynaecologists were not trained in scanning? Some of us are trained in scanning, particularly those in the fertility field. Even in the fertility field, we are trained to a certain level. We can recognize the uterus, maybe see a big diaphragm, or identify a fibroid, and we can see an ovarian cyst, and that’s about it. Then there’s advanced gynaecology scanning.
Advanced gynaecology scanning is like pregnancy scanning. As you probably know, different people are scanning every day, every week, every month, to see if the baby is alive and how much it measures. Different people do fetal anomaly scanning at 24 weeks and measure all the fine details. The same applies to advanced gynaecology scanning. It’s a specialized subspecialty, I would say. It’s a specialized skill, learned, and certified, and requires training and high-technology ultrasound machines, which are not usually available for standard scanning.
Many of my patients, come to our clinic after having had a couple of scans at another clinic or in an outpatient scanning department. They may or may not have some films or photographs, and I refer them to advanced gynaecology scanning within my department, and this is what it is.
Advanced gynaecology scanning, and we have published a lot on the subject, my team and I, is superior to an MRI scan because it can identify all those factors. You have bleeding, but you don’t know why you’re bleeding. You may have had a scan or two and still don’t know because you may have an anomaly that has not been picked up. Is it a small polyp? Is it a fibroid? Is it both? Is it hyperplasia? So, before we discuss how to manage uterine bleeding, we need to make an accurate diagnosis.
When I was in my first years of training in the early ’90s, the general surgeons were very pompous and demeaning to us gynaecologists. They kept saying, “Oh, women complain about three things: too much bleeding, too little bleeding, and whatever else.” What is too much bleeding? We didn’t know. This can be measured objectively. We have to define and diagnose menorrhagia or heavy periods correctly. That’s one factor. The second factor, which thankfully is history, is that maybe until 10 or 15 years ago, heavy bleeding was the number one cause of hysterectomy. Hysterectomy was the most common surgery performed on women for heavy bleeding, which, in many cases, was dysfunctional. Even in those days, as a trainee in England, we had endless lists of women lined up for hysterectomy for factors that we now understand much better and can treat much more easily.
I cannot give you a treatment for your heavy period right now. All I can say is that with thorough investigation and assessment, we can identify the reason, and in 98% of cases, we can treat that reason conservatively without sacrificing your uterus.
I do not have the answer. But it may not be related to melanin. It may be related to genetic factors or familial factors. It is a fact of life that it is very common. And that’s my biggest fear when I see women of African origin in their mid to late 40s coming to my clinic. When I ask them, “Have you had a scan before?” and they say, “No,” I am always very worried that I will find fibroids. Invariably, I do, sometimes massive fibroids.
If there is a message to take home now, it is a little bit of a policy matter. For example, in Greece, in big cities like Athens, Thessaloniki, or even smaller cities, invariably, all women will have a scan—a pelvic scan, a uterus scan—as a routine a few times in their lives. Some of them, perhaps with more education and a higher social status, may even have annual scans.
At the end of the day, someone who is 50 years old in Greece is very unlikely not to have had at least two or three scans in their lifetime. So, if they had fibroids, they had the opportunity to monitor them.
As you know, this is not the case in most of Western Europe, where I am very familiar with the services, which are mostly publicly funded and state-regulated. It’s very unlikely for a 50-year-old woman with no symptoms to have had a scan. Be aware of that.
I think it is safe, though a little risky politically, to say that even if you’re a healthy woman in your mid-30s, even if you have friends in their mid-30s with no infertility or other factors, it’s not over the top to arrange for a pelvic scan. At least to rule out big fibroids, polyps, or ovarian cysts, if not every year, then a few times in their lifetimes.
If it’s millimeters and not centimeters, then definitely it’s too small to be an issue, especially since it’s located in that area.
On the other hand, after trying to conceive for 8 years with so many unsuccessful transfers and 1 miscarriage, you still have a complex fertility case. I would look a little bit more carefully, perhaps, into the genetics. I don’t know many details about your cycles, but as far as the uterus is concerned, I would definitely reassure you that one fibroid with those characteristics is of no significance. However, please consider having an advanced gynecological ultrasound scan, plus or minus a hysteroscopy. Since you’ve had so many unsuccessful attempts, it may be of value to exclude endometriosis one way or another, as that could be associated with it.
The more complex the case becomes, the more wary we are of factors that may not be obvious. Endometriosis, for example, has a chance of affecting up to 50% of women with infertility, whether we see something on the scan or not. I would urge you to look into other factors.
Difficult again to answer. I would be very sceptical about having repeat hysteroscopies over and over again.
Perhaps I would guess that maybe there are more polyps than 2 or 3. Sometimes, for some reason, they’re not removed completely or how we remove them could be an issue. Some people are a little sceptical about using diathermy, going a little deeper due to fear of adhesions. Some use scissors, which may cause a little more bleeding but might be better for the endometrium.
Sometimes, in fear of producing Asherman syndrome, we don’t remove all the polyps or we don’t remove them completely from the base. I cannot fully answer that. Sometimes polyps may not be exactly polyps; they could be hyperplastic polyps or infectious polyps. This means there may be a background disease that needs treatment. If it’s hyperplasia, it might require hormonal treatment, either with a tablet or an intrauterine device. If they’re infected with polyps, they may need treatment with antibiotics.
In general, you’re a bit of a tricky case. I would be careful about doing too many hysteroscopies, but on the other hand, I wouldn’t feel comfortable doing transfers unless the uterus is very close to normal.
Probably not is the answer. However, I would still stress the importance of a good assessment. An advanced gynaecological ultrasound scan, advanced pelvic ultrasound scan to exclude anomalies in the uterus, endometrium, ovaries, and tubes, plus or minus Hysterosalpingo-Contrast Sonography (HyCoSy), plus or minus hysteroscopy. I think we need to be more meticulous in assessing the endometrium.
It’s like a farmer who needs to pay attention equally to the seed (sperm and egg) and the soil (uterus). Unfortunately, over the last 20 years, with the massive progress of IVF and laboratory techniques, we have focused so much on gametes and embryos that we tend to ignore the importance of the uterus.
I think the uterus is equally important, if not more so. Issues with the uterus can lead not just to failure but to miscarriages, which can be devastating, especially later miscarriages in the second trimester. It can also cause fetal complications like premature labour associated with septums and other issues.
If you ask me, I would say we need to focus more on the uterus. It’s a common problem among doctors, and why? In the earlier years, IVF doctors had to be surgeons as well, performing laparoscopic egg collections. However, the new generation of doctors are not trained in surgery as there’s no time or resources.
If you’re an IVF doctor, you might not give the uterus the attention it needs, often using basic two-dimensional scans that don’t reveal what a specialized machine can show. Fertility surgeons are often excluded from decision-making, but they could provide valuable input on the ability of that precious uterus to sustain a pregnancy and ensure a normal birth.
To be honest, I don’t think so. It’s not associated because every stimulation is opposed, not unopposed, by progesterone invariably. I don’t think that would be a serious issue.
