Fibroids, Polyps and Uterine Surgery Before IVF

Fibroids need surgery before IVF when they distort the uterine cavity. Submucous fibroids, which project into the cavity, should be removed unless they are extremely small, and intramural fibroids should be removed when they indent the cavity, unless they are very small. Purely subserosal fibroids, on the uterus's outer surface, do not need removal for fertility. Endometrial polyps, intrauterine adhesions and a uterine septum are also corrected before IVF.

The uterus is where an embryo implants and grows, so any abnormality of the cavity can undermine an IVF cycle that is otherwise well run. Dr. Shelly Singh, Senior Director Obstetrics & Gynaecology, Fortis La Femme, New Delhi, India, set out which uterine abnormalities need correcting before IVF, which can safely be left alone, and how each operation is done. Her recurring question is a practical one: will this abnormality interfere with implantation? The wider pathway, from the first tests to cost, is covered in the complete guide to pre-IVF workups and corrective surgeries.

Which fibroids need surgery before IVF?

Fibroids (benign growths of the uterine muscle) are among the commonest problems in infertility, but their effect on fertility depends far more on where they sit than on how large they are.

The three positions that matter

• Submucous fibroids project into the uterine cavity. These are the fibroids that interfere with implantation, and they definitely need to be enucleated (shelled out) and removed. A submucous fibroid can also grow on a stalk inside the cavity, forming a submucous fibroid polyp, which likewise has to be removed.
• Intramural fibroids lie within the muscle wall. Some sit entirely in the wall; others extend partly into the cavity and partly towards the outer surface. A small intramural fibroid confined to the wall may not need removal, but a reasonably large one that impinges on the cavity should be removed.
• Subserosal fibroids lie on the outer surface of the uterus and have nothing to do with the cavity. Purely from the point of view of fertility, they do not need removal.

Position matters in one further way. Even a small fibroid can cause infertility if it sits at the cornual end of the uterus, where the tube joins it, and blocks the tube. Such a fibroid needs removal whatever its size.

The FIGO classification

FIGO, the international federation of obstetric and gynaecological societies, classifies fibroids into numbered types according to their position: type 0 is a pedunculated fibroid (one on a stalk) entirely within the cavity, types 1 and 2 are submucous fibroids with a progressively larger part in the wall, types 3 and 4 are intramural, types 5 to 7 are subserosal, and type 8 covers fibroids in other sites, such as the cervix. Dr. Singh uses this classification to decide which fibroids to remove: those inside the cavity, and large intramural fibroids extending into it, definitely need removal, while purely subserosal ones do not.

What size of fibroid needs to be removed?

There is no single size taken as the benchmark for removal. Dr. Singh's rule is that a small fibroid needs removal if it is causing a problem, for example a cornual blockage, and that submucous fibroids and fibroid polyps will definitely need removal. At the other end of the scale, a fibroid that enlarges the uterus to roughly the size of a 12 to 14 week pregnancy is a very large fibroid that definitely requires removal.

Fibroids may also need treatment for reasons unrelated to fertility. Very large fibroids that cause pain, or pressure on the bladder or bowel, are an indication for surgery in their own right.

Hysteroscopic and laparoscopic myomectomy

Two minimally invasive approaches are now used to remove fibroids, and the choice follows the fibroid's position:

• Hysteroscopic myomectomy: a hysteroscope, a thin telescope passed through the cervix, is used to remove fibroids that sit essentially inside the cavity, such as pedunculated and submucous fibroids. There is no abdominal incision.
• Laparoscopic myomectomy: fibroids lying towards the outer surface of the uterus, and mainly intramural fibroids, are removed through keyhole incisions in the abdomen.
• Combined hysteroscopy and laparoscopy: some patients need both, so that all the fibroids are removed completely.

Once a fibroid has been shelled out of the uterus laparoscopically, it can be morcellated, broken into smaller pieces, and removed through the small incisions.

How long to wait before conceiving after a myomectomy

Dr. Singh advises contraception for at least three to four months after a myomectomy, with no conception in that window. The uterus has been sutured, and although surgeons try hard not to open the cavity while removing fibroids, it sometimes happens when a large fibroid indents the cavity. After a hysteroscopic myomectomy the cavity has, by definition, been operated on. These areas are weak points on the uterus, and they need three to four months to heal before a pregnancy places strain on them.

Can fibroids be treated with medicines instead?

Medical treatment can shrink fibroids, but it has clear limits where fertility is concerned. Dr. Singh described the options she uses when required: oral gonadotrophin-releasing hormone (GnRH) antagonists, now prescribed to shrink fibroids, and injectable GnRH analogues. These reduce the size of the uterus and of most fibroids. The limitation is that submucous fibroids, the main culprits in infertility, often do not respond to medical management, which is why they are removed surgically.

Endometrial polyps: removal before IVF

An endometrial polyp is an overgrowth of the uterine lining that projects into the cavity. A large polyp can fill the cavity, leaving no healthy surface on which a pregnancy can implant. Polyps are removed hysteroscopically, and the tissue is sent for biopsy to establish what kind of polyp it is. Dr. Singh's position is that a polyp occupying the cavity of a woman preparing for IVF should be removed.

Asherman syndrome: treating intrauterine adhesions before IVF

Asherman syndrome is the presence of intrauterine adhesions, bands of scar tissue that cause the walls of the uterus to stick together. It develops when the basal layer of the endometrium is damaged.

Causes and diagnosis

The commonest cause is an overly vigorous curettage, for example a dilatation and curettage (D&C) after a miscarriage or an abortion, which destroys the normal endometrium so that the walls adhere and form dense adhesions. Infections can do the same; Dr. Singh singled out tuberculosis, which she noted is common in India and in many African countries.

The main symptom is a change in periods: menstrual flow becomes scanty or stops altogether. The diagnosis is made on HSG, or on a good three-dimensional ultrasound with Doppler, which shows whether the cavity is stuck together; hysteroscopy then divides the adhesions.

Treatment: adhesiolysis and regeneration of the lining

The adhesions are divided under direct vision through a hysteroscope, a procedure called hysteroscopic adhesiolysis. Afterwards, Dr. Singh either places a Foley catheter in the cavity for a period, to keep the walls apart, or gives oestrogen and progesterone so that the endometrium regenerates.

Her regimen is oestrogen throughout the cycle with progesterone added for the last 14 days, continued for about three months. A transvaginal ultrasound measures endometrial thickness before treatment and again after those three months to assess how well the lining has regenerated. Where the scarring is not severe and the adhesions have not permanently damaged the endometrium, the lining usually starts to improve after about six weeks.

What can be achieved, and what cannot

Before IVF, the goal is a good, plush endometrial lining, and where the lining is not adequate, medicines can improve it. Dr. Singh described a recent patient with intrauterine adhesions after a suction evacuation and curettage for a missed miscarriage, performed elsewhere. The cavity was full of adhesions, the walls were stuck together, and in places the endometrium was less than 1 mm thick and completely scarred. She performed an adhesiolysis and then treated the patient with oestrogen and progesterone to regenerate the lining.

The response, she cautioned, varies from patient to patient. Where the scarring is very severe, it may not be possible to regenerate an adequate endometrium at all.

Uterine anomalies: which need correction before IVF?

Congenital uterine anomalies arise from the way the uterus forms before birth. Dr. Singh's answer to whether all of them need correction for fertility was a clear no. Most can be left alone; a few cannot.

For a bicornuate uterus that needs surgery, the Strassman procedure (metroplasty) unites the two horns into a single cavity. A rudimentary horn containing functioning endometrium can cause pelvic pain and endometriosis, which is the reason for removing it.

Uterine anomalies are sometimes associated with abnormalities of the kidneys, the heart and the vertebrae, so these operations can be technically demanding and the associated conditions need to be identified first. Dr. Singh's emphasis was on careful selection: choosing which anomalies genuinely need surgery and which are better left alone. The septate uterus is the anomaly she said definitely requires correction.

Where uterine surgery fits in the pre-IVF plan

Uterine surgery is one half of corrective surgery before IVF. The other half concerns the ovaries, the pelvis and the fallopian tubes, covered in Endometriosis and tubal surgery before IVF. Most of the abnormalities in this article are first suspected on the transvaginal ultrasound described in Pre-IVF tests: ovarian reserve, tubal patency and semen analysis. Indicative costs for these procedures are on the myomectomy cost page and the hysteroscopy cost page. Questions that attending doctors put to Dr. Singh on these operations, including what size of fibroid must be removed, how long to wait after a myomectomy and how long the endometrium takes to regenerate, are answered in the Live Discussion from this masterclass.