Fibroids (myoma or leiomyoma) are the most common noncancerous origin tumour, arising in the uterus, and are seen in woman of the reproductive age group. The incidents are seen in about 50-70% of the females of the reproductive age group. The symptoms (pain and heavy or irregular bleeding) will be seen in only 20-30% of these people and roughly about 5-10% of infertile females will have an associated finding of fibroids.
Some fibroids can cause infertility especially those that are protruding into the cavity of the uterus (also called submucous fibroids) or those that are in the body of the uterus and are distorting the uterine cavity by pushing the cavity (cavity distorting intramural fibroids). Intramural fibroids less than 3 cm in diameter or those that are > 1 cm away from the endometrial lining are harmless. Large intramural fibroids >3-4 cm in diameter, especially located < 1 cm from the uterine lining may cause infertility and may need to be removed. Sometimes the fibroids are on the outer wall of the uterus, also called subserous fibroids. If the subserous fibroids are asymptomatic and less than 5 cm in size, they are left alone, and patients can be treated with IUI or IVF. However, it is better to remove very large subserous fibroids especially those that may come in the way of the egg retrieval. Besides infertility fibroids can also cause repeated pregnancy losses/miscarriages. Fibroids are diagnosed by the standard vaginal/abdominal 2 D or 3 D Ultrasound. One can also use the MRI machine with contrast , in case of difficulty to differentiate it from other growths such as sarcoma or adenomyosis.
Small fibroids can be left alone or can be treated with an oral medicine called ulipristal or a subcutaneous injection called Goserelin or leuprolide. One can also use focussed ultrasonic beam(non surgical) , making use of either MRI machine(MR Focussed USG ) or 3 D Ultrasound machine . However, this cannot totally melt the fibroid. Additionally, this may damage the abdominal structures and may need multiple sittings. Routinely the fibroids are removed surgically (called Myomectomy) either by opening the abdomen in a traditional way (called laparotomy) or by making use of a laparoscope. In our IVF centres most fibroids are removed laparoscopically. However due to the present COVID 19 pandemic, it is safer to remove them by open laparotomy method using spinal anaesthesia. Sub mucus fibroids are best removed by hysteroscopic technique. In patients who have finished their childbearing function one can use a transfemoral angiography and embolise the uterine artery. As this method can damage the uterus, we cannot use it in women who want children. We can also remove fibroid using robotic surgery. However it has no added advantage and unnecessarily be more costly. Thus treatment, depends upon the location and size of fibroid. There is medical treatment which is effective for a few group of patients, but in maximum symptomatic, submucosal or larger intramural and subserosal fibroids, we might require hysteroscopic or laparoscopic removal. For the next two years, during COVID it is better to remove it by opening the abdomen. Any tumour distorting the cavity or in the uterine cavity has to be removed. Whether to remove any tumour which is present in the body of the uterus not distorting the cavity is still a debatable issue. The pros and cons of the procedure should be well evaluated and also all the factors which could attribute towards failure of a fertility treatment, either IVF or ICSI or any other ART modality should be evaluated and ruled out first ,before contemplating myomectomy.
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