Fibroids and Fertility: Which Fibroids Need Surgery Before IVF?

A lot of times when an HSG is done without sedation, the patient tenses up so much that there is a tubal spasm, which can appear as a bilateral proximal tubal blockage. One good approach is to give the patient an anti-spasmodic before the procedure, or do it with a little sedation, which removes many of these false positives. But if it still appears to be a genuine proximal blockage in both tubes, it's better to go directly for a diagnostic hysterolaparoscopy with chromopertubation, since that lets you directly visualise the tubes — and most patients also find repeating an HSG very painful.

Success rates of IVF in good centres are now around 60%. Cost depends on the kind of IVF procedure required — sometimes an ICSI procedure, sometimes donor eggs are needed — but it would typically start around 3 to 4 lakh rupees, roughly $3,200 to $4,500 per cycle.

There isn't a specific size used as a strict benchmark — even small fibroids can require removal if they are causing a cornual blockage, and submucous fibroids or polyps will usually require removal regardless of size. But anything bigger than roughly the equivalent of a 12–14 week pregnant uterus is a very large fibroid that definitely requires removal. On medical management: GnRH antagonists such as elagolix are used to help shrink fibroids, as are GnRH analogues/injections like leuprolide, which reduce the size of the uterus. However, submucous fibroids — the main culprits behind infertility — often will not respond well to medical management.

We need a good, plush endometrial lining, and if it isn't good we have medicines that can improve it. For example, in a recent case of severe intrauterine adhesions from a missed abortion managed elsewhere, the endometrial thickness was under 1mm in places and completely scarred. We did adhesiolysis and then gave a combination of estrogen and progesterone — estrogen helps regenerate the endometrium. It takes about 3 months for regeneration, though outcomes depend on how bad the scarring is; in some patients with very severe scarring we may not be able to regenerate a good lining at all.

We generally say at least 3 to 4 months of contraception should be used, and conception should not happen within that window.

Submucosal fibroids that impinge on the uterine cavity need surgical removal before IVF, since they interfere directly with implantation, while purely subserosal fibroids on the outer uterine surface generally do not need removal for fertility purposes alone.

Intramural fibroids may need removal if they also impinge on the uterine cavity or are large, though smaller ones confined to the muscle layer often do not require surgery for fertility purposes.

Submucosal and pedunculated fibroids inside the cavity are typically removed hysteroscopically, while fibroids closer to the outer surface or mainly intramural fibroids are removed laparoscopically, sometimes requiring a combination of both approaches, after which larger fibroids are morcellated for extraction.

Surgery, especially where the uterine cavity was opened, leaves weak areas on the uterine wall that need adequate time to heal, which is why contraception is recommended for several months after a myomectomy.