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4/1/2014

Fertility-Sparing Fibroid Treatments

Although the presence of fibroids does not usually impair fertility or affect an ongoing pregnancy, some patients with fibroids may face several pregnancy-related risks. Fibroid location plays an important role in these risks.  Submucosal fibroids can lead to spontaneous abortion or subfertility, presumably from physical disruption of the uterine cavity or interference with implantation. Intramural fibroids may decrease the success rates of in-vitro fertilization. Subserosal fibroids do not appear to have a significant impact on fertility. Preterm delivery and malpresentation may be increased by fibroids. Fibroids may cause pelvic or abdominal pain during pregnancy in the setting of large size, rapid growth, or degeneration.

Patients with asymptomatic fibroids do not require evaluation or treatment before attempting conception unless they have had a previous miscarriage or unexplained infertility. Patients with fibroids contemplating pregnancy should be screened for related symptoms. Heavy menstrual bleeding and bulk symptoms such as pelvic pain or pressure, urinary frequency, or difficulty evacuating stool are most common. Treatment is indicated for significant fibroid related symptoms, with consideration for the impact of various treatments on pregnancy. Pelvic ultrasound or MRI and assessment of the uterine cavity by sonohysterography or hysteroscopy may be indicated to determine fibroid location and size.

Several therapies are available that preserve fertility. Medications including hormonal contraception, non-steroidal anti-inflammatories, tranexamic acid, gonadotropin-releasing hormone antagonists with hormonal add-back therapy, and levonorgestrel intrauterine devices are fertility-sparing treatments to address primarily bleeding and dysmenorrhea symptoms associated with uterine fibroids. If these are ineffective or if the primary symptoms are bulk-related, removal of fibroids can be pursued. Removal of Type 0, Type 1, and some Type 2 submucosal fibroidscan usually be accomplished by hysteroscopic myomectomy which minimizes disruption of myometrial integrity. Intramural or subserosal fibroids (some Type 2 and types 3-7) may be removed by both laparoscopic and abdominal approaches. The surgeon should pay particular attention to ensuring adequate closure of the myometrial defect, particularly with a laparoscopic approach. Cesarean delivery is frequently recommended after abdominal or laparoscopic myomectomy, especially if the removal of the myomas required repair of significant myometrial defects or entry into the endometrial cavity. The risk of uterine rupture during labor, however, is similar to that for 1 prior cesarean section, or about 1%.

Uterine artery embolization has been used prior to pregnancy to decrease fibroid volume; however, little is known about the effect on fetal growth, placentation and ovarian function. Magnetic resonance guided focused ultrasound ablation and ultrasound-guided radiofrequency ablation are also available, but similarly, little data exists on subsequent pregnancy outcomes. For patients with symptomatic fibroids planning for future pregnancy, the current evidence favors myomectomy over other approaches.

Further reading:

American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Management of Symptomatic Uterine Leiomyomas: ACOG Practice Bulletin, Number 228. Obstet Gynecol. 2021 Jun 1;137(6):e100-e115. 

Claeys J, Hellendoorn I, Hamerlynck T, et al. The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis. Gynecol Surg. 2014;11:197–206.

Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med. 2015 Apr 23;372(17):1646-55. doi: 10.1056/NEJMcp1411029. PMID: 25901428.

Initial Approval:  November 2015; Reviewed May 2016; Reaffirmed November 2017; Minor Revision May 2019, Minor revision November 2020, Revised May 2022, Revised and renamed March 2024.

Originally titled “Management of Women with Multiple Fibroids who are Attempting Pregnancy”.  Retitled March 2024

 

 

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