If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some cases) big uterine friend(s). Like a bad house guest, they can be a big pain in the rear end. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun. And unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Furthermore, fibroids are the cause for about 2% of infertility cases. Simply stated, you are not the only person who RSVPed yes to the fibroid gala. They work their magic (or rather interfere with the magic) usually by interfering with implantation, distorting the uterus, or blocking off one or both of the tubes. They can take up prime real estate, and this can lead to miscarriage and pre-term delivery.
Depending on the block they chose to call their home (a.k.a. their location in the uterus), their impact on fertility and pregnancy may be more pronounced. Fibroids that are located within or partly within the uterine cavity (medically termed submucosal) almost always need to be evicted before pregnancy. Additionally, these are the ones that are most likely to cause true infertility. Intramural fibroids (those located in the muscle) can go both ways; how they are going to lean is really anyone’s guess. As a general rule, the bigger, the bigger pain for you and everything fertility related. They can press on important things (like tubes or the cavity) and cause problems that need to be dealt with. Last, those hanging out outside the uterus (subserosal) have almost no effect on fertility or pregnancy. Don’t even give them a second thought.
While fibroids can be treated medically or surgically, when it comes to fertility, medical options are no bueno. Most, if not all, medical options will prevent ovulation and implantation, which will prevent pregnancy, so that’s not going to work. Surgical options are really the only ones on the table, and even these “dishes” are limited.
So here is what is on the menu—myomectomy (myoma means fibroid and ectomy means removal). Myomectomies can be performed through an open bikini-cut incision, a camera (laparoscope), a robot, or vaginally. The approach depends on the size of the fibroid(s), the location of the fibroid(s), and the number of fibroid(s). It also depends on your surgeon’s experience and preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.
Surgery will almost definitely bring the bothersome bleeding, pain, and pressure to a halt. However, it can increase your chance for scar tissue (both within the uterus and the pelvis) and other surgical complications. Surgery, no matter who does it, is the real deal. For this reason, you want to avoid going under the knife unless it is absolutely necessary. It will also in many cases, particularly when there are many fibroids, require that you to have a C-Section. The uterus is a muscle, and after surgery, it will be forever changed, scarred, and sometimes weakened. You want to make sure that you treat your muscle with tons of TLC—labor, contractions, and hours of pushing is not anyone’s definition of TLC.
And while we are talking about surgery, we recommend that you always ask your surgeon for their notes from the surgery (a.k.a. the operative report). This is super helpful to anyone else—your OB/GYN or your fertility doctor—who decides to date your uterus in the future. Knowing who has been there and what they have done will help us guide your treatment.
Two big questions come to patients’ minds and ours when considering fibroids and fertility. Are they causing my infertility, and should I treat them before I do fertility treatment? First things first, fibroids are very rarely the sole cause of infertility. If you think of a pizza pie, they are even smaller than the smallest slice (think more of like a baby bite). Usually, fibroids plus something else are keeping you on the fertility sidelines. So even if your fertility doctor diagnoses you with fibroids, they are usually not alone in making this baby thing difficult. For this reason, we always recommend completing the entire fertility work-up before pointing the finger at the fibroid.
The second question is way more complicated. When do you treat a fibroid? This question about fibroids is more controversial than religion and politics at a family dinner! However, while getting us all to agree on when to treat is nearly impossible, we can almost all agree that fibroids, which are on the outermost layer of the uterus, are outside the realm of what we need to treat. They are not causing infertility and don’t need to be treated before a fertility treatment. Exceptions to this are if they are very large causing pain and pressure of the bladder.
On the flip side, fibroids that are in the uterus (submucosal) of women who are experiencing infertility or recurrent miscarriages need to come out before any fertility treatment is started. The fibroid is like a roadblock, blocking any and all traffic. They need to come out before any cars try to pass. The trickiest ones are the ones in the muscle (intramural). It’s like our Congress—no one can really agree on what is right. For most there is a split down the aisle for which to treat and when. The line in the sand usually comes down to how big it is, where it is, and if you had previous fibroid surgery. Fibroid surgery is not something you want to double down on!
Unfortunately, of all the partners you will have, your fibroid is the least likely to leave you. Only menopause and a hysterectomy will break you two up. However, there are ways to temporize them and to temporarily remove them so that you can “attempt to see other people.” Take our advice. Tell them, “It’s not you. It’s me. I just really want to have a baby and don’t want you hanging around.” While they may reappear one day, hopefully, they will leave you alone long enough for a pregnancy to take place.