Fibroid and Infertility

by Dr Agilan Arjunan, Fertility Specialist & Gynaecologist, KL Fertility Centre (Malaysia)

According to medical history, in the periods of Hippocrates in 460-375 BC , fibroid was known as ‘uterine stone’. The first surgery for fibroid was done for the American President Abraham Lincoln’s cousin in 1809. The term fibroid was introduced in 1860.

Many women had been diagnosed with uterine fibroid. For some the fibroid is not medically important but for some women, fibroid can cause infertility.

What is uterine fibroid?

A woman’s womb or uterus is made up of muscles known as ‘myometrium’ . This ‘myometrium’  is composed of many strands of muscle fibres.

Fibroids arise from genetic alteration in a single muscle fibre. This causes the muscles to overgrow and form a fibroid. Circulating female hormone called oestrogen can cause growth of the fibroid.

However, fibroids can also grow in low oestrogen environment , possibly due to conversion of male hormone called androgens into oestrogen. Yes, females have male hormones too!

The problem with fibroid is , it can be a silent killer. Woman may have fibroids without ever knowing about it!  This is because not all the fibroids cause symptoms. Whether the fibroid causes a problem depends on the size and location of the fibroid.

General problems with Fibroid

a) Heavy Period flow

Generally , fibroids that are located close to the inner layer of the womb (endometrium) , and which distort or displace the womb cavity may cause heavy periods. If untreated , it can lead to anaemia.

b) Pelvic Pain 

Larger fibroids ( more than 4-5cm) may also cause pain and if large enough. Sometimes, the core of the fibroid can become soft leading to severe pain . This is called ‘red degeneration ‘ of fibroid.

A large fibroid can lead to compression of urinary bladder and bowel which leads to difficulty in passing out urine or faeces .

How does fibroids steal your fertility ?

a) Cervical displacement 

After sexual intercourse, sperm is deposited in the vagina. It will find its way through the neck of the womb (cervix) into the womb. Large fibroids can displace the cervix and reduces its exposure to the sperm.

b) Interfere with sperm migration 

The sperms that enter the womb need to swim a long distance to meet the female egg. A fibroid that distorts the womb cavity can interfere with sperm migration and transport.

c) Obstruction of Fallopian tube

Once the sperm swims through the entire length of the womb, it now need to enter a tube called Fallopian tube. This is where the sperm will finally meet the egg. Fibroid that are located close to the entrance of the tube can obstruct the entrance. The poor sperm is unable to enter the tube.

d) Interfere with egg uptake after ovulation

The egg, on the other hand, once released from the ovary , will find its way and will be picked up by the Fallopian tube. The fibroid located close to the tube can actually change the anatomical relationship between the ovary and the Fallopian tube. This can interfere with the uptake of the egg into the tube.

e) Affect implantation of embryo

Embryo is formed after the a sperm managed to fertilise an egg. The embryo will then have to swim back into the womb cavity. Fibroid located close to the “endometrial lining” can distort the lining. . When the embryo finally reaches its destination, it may be difficult to get implanted in the womb cavity and grow to become a baby. So , even after the embryo is formed successfully, the woman is not pregnant until the embryo implants .

Treatment options.

Generally treatment for fibroids will depend on your symptoms, size and location of the fibroid.

1. Do nothing

Even if you have been diagnosed to have fibroid , it does not always means you need treatment. So , do not be surprised if your doctor tells you to ‘just wait and see’. Fibroids which are small and does not cause any symptoms can be left alone.

2. Non-Surgical Treatment of Fibroids

a) Gonadotrophin Releasing Hormone (GnRH)

Fibroid growth is dependent of female hormone oestrogen and progesterone. The production of these hormones from the ovary is controlled by our own GnRH in our brain. Synthetic form of GnRH stops the production of our own GnRH which stops the production of oestrogen and fibroid growth. This medication has shown to reduce the size of fibroid by up to 50% . This is a temporary solutions and it comes with side effects.

GnRH makes a woman menopausal as long as they are using it. If used for more than 6 months , it can cause bone loss. For this reasons , usage of GnRH is limited to about 6 months or as a preoperative measure to shrink the fibroid prior to surgery.

b) Ullipristal Acetate

This oral tablet has been used to control heavy menstrual bleeding due to fibroid. It is as efficacious as GnRH. It belongs to a group of medicines known as Selective Progesterone Receptor Modulator (SPRM). However, just like GnRH , it is not used as a long term solution.

c) Magnetic Resonance (MRI) Guided Focused Ultrasound

In this treatment option, your fibroid is slowly ‘killed’ by heating it using a pulsed ultrasonic waves. This will cause cell death. This is done with the guidance of MRI to help the doctor see the fibroid in 3D. Throughout the procedure you are awake but pain killers will be given to keep you relaxed. The procedure generally takes about few hours.

 

About Agilan

A fertility specialist who believes " If there is hope in the future , there will be power in the present" .
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