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Fibroids and Fertility -- New Trends

Fibroids are benign uterine growths (tumors) that are present in 25-50% of women. The most common occurrence of symptoms come when women reach their thirties and forties. Fortunately, most women with fibroids do not have symptoms and can be safely followed by annual pelvic examination or ultrasound. The most common symptoms for which women seek treatment are abnormal uterine bleeding, pelvic pain and reproductive problems such as infertility and recurrent miscarriages. Women who do have symptoms from fibroids must be carefully examined, usually by an in-office ultrasound, to determine the exact size and location of any fibroid(s) that are present.

Because medically treated fibroids tend to grow back or recur, most fibroids that cause symptoms are managed surgically. Gynecologists have traditionally offered the option of a hysterectomy to women who have completed their childbearing while reserving removal of the fibroid(s) (myomectomy) for those still interested in future fertility. Over the past decade, a growing number of women who are informed about their options are desiring to preserve their fertility potential well into their forties. Fueling this trend has been the growing awareness and success of many fertility treatments such as In Vitro Fertilization and egg donation. As a result of these societal trends and infertility advancements, a much greater percentage of women with symptomatic fibroids are choosing the fertility-sparing myomectomy surgery over hysterectomy.

When myomectomy is chosen, ultrasound evaluation is critical in order to map out the exact size and location of the fibroids. Depending on the size, number and location of fibroids, the best surgical approach for myomectomy can be selected from one of the following three options: 1) Standard laparotomy or abdominal incision (commonly done through a “bikini incision”) is utilized when fibroid tumors are large (more than 8 cm) or numerous (more than 4 fibroids), 2) Hysteroscopy is a procedure where the uterine cavity is viewed with a telescope through the vagina and cervix. This procedure allows the removal of fibroids through the cervix and is ideal for fibroids that are located within the uterine cavity (submucosal fibroids) and, 3) Laparoscopy, a telescopic view of the pelvis through the navel, takes advantage of minimal incisions and a short recovery time. It is most useful for fibroids that are small and few in number. These latter two procedures are also called “endoscopies” and generally require greater skill and training as well as more specifically designed equipment.

What Are The New Trends?

While most myomectomies are still performed by laparotomy, there is a rapidly growing trend towards less invasive approaches which offer the advantages of more cosmetically appealing incisions and significantly reduced recovery periods. Technological advancements in endoscopic instrumentation, equipment and the surgeon’s expertise have lead to an ever-increasing number of informed women choosing the advantages of the new and innovative techniques utilizing hysteroscopy and laparoscopy.

Laparoscopy is most often employed in women that are diagnosed early when their fibroids are small and more suited to laparoscopic removal. New surgical devices called morcellators (an instrument that allows removal of large amounts of tissue through a small incision) have only recently become available. This allows the safe and efficient removal of fibroid tumors much larger than could have been accomplished in the past. Typically three small skin incisions, each less than 1/2 inch, are required and full recovery is expected within a few days similar to other laparoscopic surgeries.

If You Have A Fibroid

The majority of fibroids do not cause symptoms, and therefore can be followed with routine annual pelvic examinations. However, when fibroids begin to cause symptoms, an ultrasound assessment including fibroid size, number and location will help your physician to counsel you about your treatment options. You and your physician can then together decide which option best suits your unique set of symptoms and ultrasound findings.

The new trend, driven by the preferences of a growing number of informed women, is moving toward more conservative and minimally invasive surgery. Now, more than ever, myomectomy is being chosen over hysterectomy by many women and their physicians. Perhaps, in the words of the famous modernist architect Ludwig Mies Van der Rohe — “Less is More”.