Fibroids are the most common tumour of the uterus. 1 in 5 women in the general population will have fibroids. It is three times more common in women of African origin. 2 out of 3 African women are likely to have fibroids in their uterus.
Do fibroids stop you from getting pregnant? How do we treat them?
This blog discusses how fibroid can affect your fertility.
What are fibroids?
Uterine fibroids, also called myoma or leiomyoma, are tumours of the uterine wall. They are formed by overgrowth of the muscle of the uterus. They are typically benign (non-cancerous) tumours (the risk of cancer in a fibroid is less than 0.1% i.e less than 1 in 1000).
They vary widely in their number, size and location. Some women can have one small pea size fibroid, while others can have numerous fibroids with some growing as big as size of a melon.
When they remain only in the wall of the uterus, they are called an intramural fibroid.
They can push towards the cavity of the uterus and come close to the lining of the uterus, and are called a submucosal fibroid.
They can push inwards and be completely inside the cavity, called an intracavitary fibroids.
They can push outwards, towards the outer wall of the uterus, called a subserosal fibroid.
Sometimes they can be connected to the uterus by a stalk, called pedunculated fibroid.
They grow under the effect of oestrogen and they tend to shrink after menopause.
Fibroids are benign (non-cancerous) tumours of the muscle of the uterine wall.
What are the symptoms?
Symptoms depend on the location and size of the fibroids. Many women have no symptoms and you diagnose fibroid while doing an ultrasound scan for other reasons.
The main symptom is heavy bleeding during period. In some women, periods can be painful as well. The heavy bleeding can cause anaemia.
Many women with fibroids have no symptoms.
For those with large fibroids, can have abdominal discomfort, backache, abdominal swelling, urinary frequency due to fibroid pressing on the bladder, constipation due to fibroids pressing on bowels and in some there can swelling of the kidneys or ureter due to fibroids pressing on them. This can affect the quality of life.
Main symptoms are heavy periods, pain in abdomen and back, abdominal swelling and pressure symptoms.
3. Can fibroid cause infertility?
Most women with fibroids will conceive naturally and are not infertile. Depending on their location, fibroids can sometimes reduce your chances of getting pregnant.
The submucosal fibroids, incavitary fibroids are mostly associated with infertility.
Subserosal fibroids rarely cause infertility.
Intramural fibroids can sometimes be associated with infertility if they are causing distortion of the cavity.
Most women with fibroids will conceive naturally and are not infertile.
Rather than the size, their location is more important for fertility. A small fibroid inside the uterus can interfere with pregnancy than a large size fibroid outside the uterus.
The exact way in which the fibroid causes infertility is not known. It could be in various ways:
Blocking the cervix, reducing the sperm that goes in the uterus,
Blocking the tubes
Distorting the uterine cavity, interfering with the movement of the sperm or embryo.
By being present in the cavity the submucosal fibroids can reduce the ability of the embryo to implant.
The blood flow could be diverted, leading to inadequate development of the lining of the uterus, which can stop embryos from implanting or cause early miscarriage.
Rather than the size, their location is more important for fertility.
4. How do I know if my fibroid is causing infertility?
Having fibroid in the uterus doesn’t always mean you are infertile. If you are <35 years and not conceived within 12 months or if you are >35 years and not conceived within 6 months of trying, then you should see a fertility specialist to get investigated.
There could be other factors causing infertility, like problems with ovulation, tubal blockage or defects in the sperm.
Having fibroid in the uterus doesn’t always mean you are infertile. There could be other factors causing infertility.
If you have fibroids, then it is important to ensure that the fibroids are not coming inside the cavity or causing distortion of the cavity.
This can be done by:
A Transvaginal ultrasound scan or
Saline sonography, which involves inserting saline inside the uterus while performing the transvaginal scan. It gives a better view of the uterine cavity. It can be performed along with a 3D scan, which increases the accuracy of the diagnosis even more.
Hysteroscopy, which involves direct visualisation of the cavity. This can be done with or without general anaesthetic.
MRI- It is very accurate in mapping out the location of fibroids mainly when you have multiple fibroids.
If you have fibroids, then it is important to ensure that the fibroids are not coming inside the cavity or causing distortion of the cavity.
5. How can I get pregnant naturally if I have fibroids?
If you have been investigated and no obvious cause for infertility is found, you have every chance of falling pregnant naturally, even if you have fibroids.
Whether you need treatment for fibroid depends on how many fibroids you have, their location and what symptoms they are causing to you.
If you have been investigated and no obvious cause for infertility is found, you have every chance of falling pregnant naturally, even if you have fibroids.
Management of fibroid has to be decided on a case-by-case basis.
If you have a small fibroid, which is not, distorting the uterine cavity, not causing any symptoms like heavy period or pain, and, then it doesn’t necessarily need to be treated.
If you have intracavitary or submucosal fibroid, then removing them might increase your chances of getting pregnant. Small submucosal or intracavitary fibroids less than 5 cm can be removed by hysteroscopy. Hysteroscopy is a telescope like instrument attached with a camera. It is inserted through the vagina, into the uterus and fibroids are removed under direct vision.
If you have big fibroids, which are giving you pressure symptoms and heavy bleeding, then you would be advised to have surgery. Surgery to remove fibroids can be done by laparoscopy (key hole surgery), or open surgery (myomectomy). During the surgery the surgeon will try to remove the fibroids only from the uterus.
Fibroid surgery can be associated with complications like bleeding, scarring inside the uterus and in worst scenario, the surgeon might have to remove your uterus to save your life if the bleeding is excessive. So the decision to remove fibroids for improving your fertility should be taken only after carefully balancing the risks and benefits from the surgery.
It is usually recommended to wait for 3-6 months after fibroid surgery before you start trying for pregnancy. This allows time for the uterus to heal from the surgery.improving your fertility should be taken only after carefully balancing the risks and benefits from the surgery.
Management of fibroid has to be decided case-by-case basis after carefully balancing the risks and benefits from the surgery.
6. How can I get rid of fibroids without surgery?
The medicines that are used to treat heavy periods due to fibroid are hormonal pills, injections or coils. They are contraceptive in nature as they stop ovulation. Hence they cannot be used when you are trying for pregnancy.
Surgery remains are main treatment option for fibroid in women trying to conceive.
Esmya (Ulipristal acetate) – This drug was initially used to shrink fibroids but now been banned in the UK due to risk of severe liver injury.
Uterine artery embolization- also known as uterine fibroid embolization – The idea of this treatment is to block the arteries feeding the fibroids by injecting tiny particles into the arteries under X-Ray guidance. When the blood supply is cut off, the fibroids degenerate and shrink in size.
However, during the procedure there is risk of damage to the blood supply to the ovaries and uterine lining, which can make falling pregnant difficult, increased risk of miscarriage and need for caesarean section. Hence, this treatment is not recommended for women considering pregnancy, although there are some reports of successful pregnancies after uterine artery embolization.
If you undergo UAE, you should not try for pregnancy for at least 6 months after the procedure.
MRI guided focussed ultrasound for fibroids- this is a new treatment where ultrasound is used under MRI guidance to heat up and destroy fibroids. This is still quite new and not available everywhere. More research is needed before it can be used for women trying for pregnancy.
7. What fertility treatment can I have if I have fibroid?
Having fibroid doesn’t mean that you will need fertility treatment. The decision for fertility treatment should be made based on the results of fertility investigations, your age and duration of infertility e.g., if you have blocked tubes or there are sperm problem, then you would need IVF.
Having fibroid doesn’t automatically mean that you will need fertility treatment.
If your fibroids are big and obscuring the view of the ovaries during transvaginal scans, then to improve the visibility and help in egg collection, you might be advised to have myomectomy before IVF.
Submucous or intracavitary fibroids are usually removed before undertaking any fertility treatment to improve the success.
Big fibroids obscuring visibility during transvaginal scans or submucosal fibroids should be removed before IVF.
8. What food to avoid if you have fibroids?
There is no magic diet that can cure fibroids. Eating healthy balanced diet rich in fibre and vitamins is advisable. Do regular exercise along with balanced diet to avoid gaining weight.
There is no magic diet to cure fibroids.
9. Is pregnancy with fibroids high risk?
Most women with fibroids will have an uneventful pregnancy and have a normal delivery. However, in some pregnancies, there can be complications. There are increased risk of :
Miscarriage
Sometimes the fibroids can increase in size and become painful during pregnancy, which is treated conservatively with pain relief, rest and hydration.
Preterm labour
There is risk of growth restriction for the baby in the womb
Placental abruption – when the placenta separates from the wall of the uterus leading to bleeding during pregnancy
Increased need for caesarean section, specially those after myomectomy as it might weaken the wall of the uterus.
Change in baby’s position and need for caesarean section
Increased risk bleeding after delivery
Most women with fibroids will have an uneventful pregnancy and have normal delivery.
The blood flow to the fibroids increases to a great extent during pregnancy. Removing fibroid during pregnancy can cause massive catastrophic bleeding and hence surgical treatment of fibroid is avoided while you are pregnant.
10. Summary
Fibroids are benign (non-cancerous) tumours of the uterine wall.
Many women have no symptoms; main symptoms are heavy bleeding, anaemia, pressure symptoms.
Most women with fibroids will conceive naturally and are not infertile.
Submucosal fibroids, intracavitary fibroids are mostly associated with infertility. Removal of intracavitary or submucosal fibroid, might increase chances of getting pregnant.
Subserosal/intramural fibroids are removed if they are distorting the cavity or giving pressure symptoms.
Fibroid surgery can be associated with complications, decision to remove fibroids solely for improving your fertility should be taken after carefully balancing the risks and benefits from the surgery.
Having fibroid doesn’t mean that you will need fertility treatment.
Most women with fibroids will have an uneventful pregnancy and have normal delivery. Some will have complications.
Written by: Dr Anupa Nandi