Fibroids and Pregnancy: Myomectomy, Fertility and Adhesions

Fibroids and pregnancy are linked in two ways: a fibroid can stop an embryo implanting, and it can complicate a pregnancy once it starts. For a woman who wants a baby, Dr. Suman Lal, Senior Director & Unit Head - Obstetrics And Gynaecology, Robotic Surgery, Gynaecologic Laparoscopy, Pregnancy Management at Max Hospital, Gurugram, India, at the time of this masterclass, treats problem fibroids by removing them (myomectomy), not by embolisation.

This article follows that path: how fibroids affect fertility and pregnancy, the warning signs of a fibroid causing trouble in pregnancy, the four routes to remove a fibroid, how to keep scar tissue from forming afterwards, and how Dr. Lal approaches the conditions that often travel alongside fibroids in the fertility clinic: endometriosis, adenomyosis and polycystic ovary syndrome. The overall framework for choosing a fibroid treatment is in the complete guide to uterine fibroid treatment options.

How fibroids affect fertility

Dr. Lal describes two mechanisms by which fibroids cause infertility. A fibroid can block the fallopian tube, so that egg and sperm cannot meet. And a fibroid can distort the cavity of the uterus, so that an embryo cannot attach to its lining. Fibroids that bulge into the cavity (submucosal fibroids) have the clearest effect on implantation; fibroids within the wall (intramural fibroids) can also reduce fertility when they distort the cavity.

Fibroids are therefore a regular finding in IVF clinics. Their presence does not mean they are the cause of a couple's infertility, and that is where Dr. Lal starts.

Find the cause before treating it

Infertility has several causes, and each needs different medication and treatment. Dr. Lal's first step is to establish which one is at work:

• Blocked fallopian tubes, one of the most common causes.
• Too few eggs, or eggs of inadequate quality, the other most common cause.
• A structural or hormone-driven condition of the uterus or pelvis: fibroids, adenomyosis or endometriosis.

Only once the cause is clear does a fibroid become the target. When it is, the choice lies between removing it and, for a woman who wants to avoid surgery, shrinking it with a GnRH agonist and trying to conceive in the six to nine months the shrinkage lasts. The drugs involved are covered in the guide to treating fibroids without surgery. For the pre-IVF perspective on the same question, Dr. Shelly Singh's article on fibroids and surgery before IVF sets out which fibroids need removing before an embryo transfer.

Fibroids and pregnancy: the risks

A woman who becomes pregnant with a fibroid carries a higher-risk pregnancy. Dr. Lal lists three complications:

1. Miscarriage.
2. Preterm labour.
3. Heavy bleeding after delivery (postpartum haemorrhage), because a uterus distorted by fibroids contracts less effectively once the baby is born.

Warning signs of a fibroid causing trouble in pregnancy

Asked how a high-risk pregnancy with a fibroid can be recognised early, Dr. Lal pointed to four signs, each of which points to a particular cause:

Degeneration happens when a fibroid outgrows its blood supply, which is more likely in pregnancy as the fibroid enlarges; the affected tissue breaks down and becomes painful and tender. Any of these signs calls for an ultrasound to establish whether the fibroid is the source of the problem.

Myomectomy: removing fibroids and keeping the uterus

Myomectomy is the surgical removal of fibroids while preserving the uterus. It is the treatment Dr. Lal recommends when a woman wants a future pregnancy. She performs it by four routes: hysteroscopic, laparoscopic, robotic and, sometimes, open surgery. The route is set by where the fibroid lies, which is why she establishes the position of each fibroid before planning the operation. Approximate costs are on Jivo Healthcare's myomectomy cost page.

Hysteroscopic myomectomy: no cut at all

Hysteroscopy means looking at the uterus from inside, with a thin telescope passed through the vagina and cervix. A small fibroid inside the cavity can be removed this way, through the vaginal route, without any incision. Dr. Lal performs it as a daycare procedure: the woman is admitted in the morning and goes home the same evening, and she describes it as a procedure without blood loss. Because submucosal fibroids are the ones most likely to block implantation and cause heavy bleeding, hysteroscopic removal is often the most direct fertility-enhancing operation available. Costs for hysteroscopic procedures are on the hysteroscopy cost page.

Laparoscopic and robotic myomectomy

For a woman who wants another baby, Dr. Lal removes fibroids by minimally invasive surgery, through small holes in the abdomen, either laparoscopically or robotically. The benefits she lists are minimal blood loss, less pain and a quick recovery.

The technique has a price, and it is paid in training. Laparoscopic and robotic myomectomy require intensive training and surgical skill: each fibroid must be shelled out and the wall of the uterus repaired in layers strong enough to carry a later pregnancy. Large fibroids, and fibroids growing inwards, in Dr. Lal's view need an expert surgeon, new technology and a good team.

At Max Hospital, Gurgaon, she operates with a team of anaesthetist, surgeons, junior staff and technicians, and performs robotic myomectomy with the da Vinci surgical system. She sits at the console and controls the instruments with both hands through hand controls, while the robotic arms work inside the patient. Her team has performed both laparoscopic and robotic myomectomies. For a detailed account of how the robot changes a multiple-fibroid myomectomy, see Dr. Deepika Aggarwal's guide to robotic surgery for fibroids.

Open myomectomy

Open surgery, through an abdominal incision, remains an option that Dr. Lal uses in some cases. Very large or very numerous fibroids are the usual reasons an open approach is chosen.

Preventing adhesions after myomectomy

Adhesions are bands of scar tissue that can bind the uterus to the bowel or other organs after surgery. A doctor in the discussion asked whether physical therapy is the only way to reduce them. Dr. Lal's answer reframes the problem: adhesion formation is the rule after any surgery. Some women form fewer, some more. The decisive factor is how the operation is done.

Her technique-based approach has five elements:

1. Accurate apposition. Bring the cut edges of the uterine wall together precisely.
2. No blood left behind. Do not leave blood pooled inside the abdomen.
3. Clean tissues. Clean the surrounding tissue before closing.
4. A drain when bleeding is heavier, so that blood drains out rather than collecting.
5. The omentum as a barrier. The omentum is a fatty apron of tissue that hangs from the stomach; it can be placed over the repaired area so that the bowel does not stick there. Otherwise, anti-adhesive products can be used.

Her own later operations bear this out. When women who had a myomectomy done this way return for a caesarean section, she finds few adhesions.

What does not help is equally clear: in Dr. Lal's view, no drug, medicine or dietary advice can really reduce adhesions. Sterilisation of instruments, by contrast, is very important: a woman who develops an infection after surgery forms more adhesions.

Endometriosis and adenomyosis alongside fibroids

Dr. Lal groups fibroids, endometriosis and adenomyosis together as benign, hormone-driven growths, and all three appear among the causes of infertility she screens for. Endometriosis is tissue similar to the lining of the uterus growing outside it, often on the ovaries; adenomyosis is the same tissue growing into the muscle wall of the uterus.

On endometriosis, Dr. Lal is direct: a complete cure is mostly not possible. What changes the outcome is early detection and timely, adequate treatment. Where an endometrioma, an endometriosis cyst on the ovary, is found, she prefers to perform a cystectomy that removes all the endometriotic tissue and then help the woman conceive, so that a later recurrence does not affect the pregnancy. Many medications are available, but the first operation matters most: if it is not done properly, recurrence is more likely. A fuller treatment of the condition is in Dr. Tripti Sharan's guide to endometriosis diagnosis and management.

Polycystic ovary syndrome: lifestyle first

Polycystic ovary syndrome (PCOS) is a hormonal condition marked by irregular ovulation, raised male hormones and multiple small follicles in the ovaries. Dr. Lal calls it fundamentally a lifestyle disease, so the most important treatment is a change in lifestyle: less stress, a better diet, regular exercise and meditation. Beyond that, she treats the specific problem:

• Delayed periods: hormonal pills.
• Acne and hair loss: targeted medication.
• Difficulty conceiving: ovulation induction, with specialist fertility support.

Doctors' questions on infertility medication, endometriosis and PCOS, with Dr. Lal's full answers, are on the Live Discussion page. Costs for fertility treatment are on the IVF cost page.