British Fibroid Trust Woman2Woman Fibroid Support Fibroids: Patient Guide
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Fibroids-Infertility-Pregnancy Outcome
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This is a hot subject for all women whose fertility has been compromised because of the presence of fibroids.

Fundamental questions being asked include:
  • I do have fibroids but no symptoms, do these asymptomatic fibroids affect my ability to conceive and the pregnancy outcome?
  • How do symptomatic fibroids affect my conception?
  • How do different types of fibroids influence the outcome of my pregnancy?
  • What is the affect of the size of symptomatic fibroids on fertility?
  • Can womb-sparing operation such as myomectomy improve fertility outcome?
  • How do non-surgical treatments of fibroids affect my fertility?
We present you a summary of the findings so far in the following tables:

Key Points: Non-symptomatic Fibroids
Most women with asymptomatic (i.e. No symptoms) fibroids CAN conceive spontaneously [Klatsky et al].
No benefit in abdominal surgery to remove fibroids before pregnancies in cases of asymptomatic fibroids [Klatsky et al].
Myomectomy to remove asymptomatic fibroids at the time of cesarean delivery is associated with significant haemorrhage and should be performed with caution and only in selected patients except for the pedinculated fibroids. [Turan et al].
Large asymptomatic fibroids > 10cm increase the rates of premature deliveries and cesarean deliveries, as well as the increase in postpartum bleeding and infections such as endometritis. [Turan et al].
Women with asymptomatic fibroids have an increase in caesarean delivery, probably due to malpresentation.
There are slightly higher increased risks of hysterectomy and post partum haemorrhage where the large fibroids are located near the placenta.
No apparent difference for neonatal outcomes from pregnancies between women with asymptomatic fibroids compared with control groups.
In labour, women with large asymptomatic fibroids in cephalic presentation can still have a successful vaginal delivery.
Surgery remains the best suited for women with symptomatic fibroids who desire preservation of fertility.
There is no confirmed evidence that myomectomy can enhance fertility in women with asymptomatic fibroids.

Key points: Fibroids & Infertility Relationship
Fibroids are frequently found in women with a history of infertility [Khaund & Lumsden].
Theories for fibroid-infertility causal relationship include:
- Dysfunctional uterine contractility may interfere with the normal sperm, egg and embryo transport and can cause nidation.
- Fibroids distorting the uterine cavity may interfere with implantation and maintenance of an early pregnancy.
- Fibroids obstructing the tubal ostia may impair the sperm and embryo transport.
- Potential disruption of blood supply to the endometrium by the fibroids may have a negative impact on the normal process of nidation.
- Local inflammation by ulceration of submucosal fibroids may create a hostile environment for sperm, therefore reducing reproductive potential.

Key Points: Fertility and Different Types of Fibroids
Intramural - Has small detrimental effect on ongoing pregnancy rates.
- Causes moderate decrease in implantation rate.
- There is conflicting evidence on the effect of intramural fibroids on fertility.
- When the intramural fibroid is asymptomatic or does not distort the uterine cavity, myomectomy is not recommended before pursuing IVF.
- Intramural fibroids which distort the endometrial cavity have a negative effect on the outcomes of ART in terms of implantation, pregnancy, miscarriage and delivery rates [Khaund & Lumsden].
Subserosal - No effect on fecundity.
- No obvious fertility problem.
Submucosal - Compared with other types of fibroids, submucosal fibroids interfere most with reproductive capacity [Khaund & Lumsden].
- May cause a lower ongoing pregnancy rates [Klatsky et al].
- Submucosal fibroids which distort the endometrial cavity have a negative effect on the outcomes of ART in terms of implantation, pregnancy, miscarriage and delivery rates [Khaund & Lumsden].
- Removal of fibroids enhances rate of conception and live births [Pritts et al].
- Has no effect on fertility and spontaneous abortion [Pritts et al].

Key points: Myomectomy and Fertility
Myomectomy for fibroids associated infertility increased the pregnancy rate with approximately 50% of women conceived after this operation [Khaund & Lumsden]. For submucosal, hysteroscopic resection may be an option and for intramural and subserosal fibroids, open abdominal or lapraroscopic may be called for.
No difference in fertility and obstetric outcomes in infertile women affected by large fibroids who received laparoscopic or minilapraroscopic myomectomy [Malzoni et al].
Hysteroscopic myomectomy for submucosal fibroids in women with unexplained primary infertility is effective in achieving a better pregnancy rate [Shokeir et al].
Although, vaginal delivery can be safe after hysteroscopic myomectomy and uterine rupture has never been reported, many specialists believe that a conservative approach by caesarean delivery is best [Varasteh et al and Klasky et al].

Key Points: Effect of UAE & UAO On Fertility Outcome
Although, both UAE and UAO procedures preserve the uterus and ovarian supply, as of today, there is insufficient data to predict the percentage of women achieving pregnancy after these procedures. There are growing reports on pregnancy post embolisation technique [Holub].
Risk of miscarriages seems to increase after UAE pregnancies.
The UAE pregnancies are likely to be delivered by caesarean section and to experience PPH (post partum haemorrhage) [Homer & Saridogan].
In a recent report [Firouznia et al], 23 out of 102 women who underwent UAE were seeking to become pregnant and 14 out of 23 got pregnant (14 spontaneous, 1 by zygote intrafallopian transfer). Two miscarriages occurred and the remaining 13 pregnancies went to term, uncomplicated and ended in elective caesarean delivery.
Despite a growing number of pregnancies reported after UAE procedure, still, there is not sufficient data to endorse UAE as a safe method for women with fibroid who want to preserve their fertility [Firouznia et al].
Generally, women who became pregnant after uterine artery occlusion (UAO) had an increased risk for pre-term (premature) birth and for caesarean delivery [Holub et al].

Concluding Remarks
  • The exact impact on fibroids is highly variable and is related to size, position of fibroid, patient's age and many other factors. However, there is an overall tendency for fibroids to make women less fertile, but this is not absolute in all cases
  • There is limited evidence to support the notion that removal of intracavity fibroids (submucous type) is likely to improve fertility outcome.
  • There is insufficient evidence to support the notion that removal of intramural fibroids by open myomectomy or laparoscopic surgery has a beneficial improvement in fertility outcomes.
  • There is modertate level evidence to support the notion that subserosal fibroids have no detrimental effect on fertility outcome. Hence, in most cases of non-tubal obstructing subserosal fibroids, their removal is not mandatory in women who seek improved fertility outcome.
Reference Sources
Aradhana Khaund, Mary Ann Lumsden
Impact of fibroids on reproductive function
Best Practice & Research Clinical Obstetrics and Gynaecology 20: 749-760
Elizabeth A Pritts, William H Parker, David L Olive
Fibroids and infertility: an updated systematic review of the evidence
Fertility and Sterility: 91(4), 1215-1223.
Hayden Homer, and Ertan Saridogan.
Uterine artery embolization for fibroids is associated with an increased risk of miscarriage.
Fertil Steril 2009; In Press
Jared C. Robins, Sandra A. Carson.
Female Fertility: What Every Urologist Must Understand.
Urol Clin N Am 35 (2008) 173–181
Kavous Firouznia, Hossein Ghanaati, Mina Sanaati, Amir H. Jalali, Madjid Shakiba
Pregnancy After Uterine Artery Embolization for Symptomatic Fibroids: A Series of 15 Pregnancies.
AJR (June 2009):192, 1-5.
Miro Kasum
Fertility following myomectomy.
Acta Clin Croat; 48: 137-143
Peter C Klatsky, Nam D Tran, Aaron B Caughey, Victor Y Fujimoto
Fibroids and reproductive outcomes: a systematic literature review from conception to delivery
American Journal of Obstetrics & Gynecology :357-366
Volkan Turan, Mete Ergenoglu, Ozgu¨r Yeniel, Murat Ulukusx
Assessment of Pregnancy Outcomes with Uterine Leiomyomas Larger Than 10 cm; Antepartum and Postpartum Complications
J Pediatr Adolesc Gynecol: 23(1), 57-58.
Zdenek Holub
Clinical experience and fertility outcome after uterine artery occlusion and embolization
Gynecol Surg 5:7-14
Author: Dr Nicki On, PhD, MRPharmS.
The information on this page has been peer-reviewed by
Dr Rajesh Varma, MA, PhD, MRCOG. Dept of Obstetrics and Gynaecology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 7EH, UK.
And awaiting inputs from Prof Charles Miller, MD, FACOG. Dept of Obstetrics and Gynaecology, University of Chicago and University of Illinois at Chicago, USA.
 
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Copyright © 2009 by Dr Nicki On for the British Fibroid Trust.
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This page was last modified on Friday 4 December 2009 01:32 am.

 
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