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Impact of fibroids on reproductive function

https://doi.org/10.1016/j.bpobgyn.2008.01.009Get rights and content

There is debate regarding whether fibroids cause infertility or if they are simply an association. However, it is possible that fibroids are responsible for 2–3% of cases of infertility. The mechanisms by which these benign tumours could cause impaired reproductive function, both in terms of difficulty conceiving and early pregnancy loss, remain unclear. Myomectomy facilitates removal of a fibroid with preservation of reproductive potential. The procedure is associated with significant risks but, overall, some studies have suggested that this surgical option increases pregnancy rates significantly in women with fibroid-associated infertility. Miscarriage rates in women with fibroids and those who have undergone myomectomy vary considerably. It appears that miscarriage rates fall after myomectomy, although the overall rates of pregnancy loss remain higher than those seen in the general population. Fibroids affect 0.1–3.9% of pregnancies, and a number of complications encountered antenatally and post partum are thought to be directly related to the presence of these benign tumours. A number of contraceptive options exist for women with fibroids, with the choice depending on patient preference and both fibroid and patient characteristics.

Section snippets

Do fibroids cause infertility?

Fibroids are known to occur more frequently in women with a history of infertility. Whilst these benign tumours are associated with subfertility in 5–10% of cases, when all other causes of reproductive dysfunction are excluded, fibroids may be responsible for only 2–3% of cases.1 Despite the existence of many studies assessing the correlation between uterine myomas and infertility, the mechanisms by which fibroids have a detrimental effect on reproductive function remain largely unknown.

Fibroids and outcomes of assisted reproductive technology

The effect of uterine fibroids on fertility in association with the use of assisted reproductive technology (ART) has been the subject of many published articles. Studies of women undergoing ART such as in-vitro fertilization (IVF) and intra-cytoplasmic sperm injection (ICSI) have the advantage of being able to exclude other fertility variables such as abnormal pelvic anatomy, tubal disease and sperm function, all of which are known to have an influence on reproductive outcome.

Although the

Fertility following myomectomy

Whilst hysterectomy remains the gold standard treatment for fibroids, in terms of eliminating fibroid-associated symptoms immediately and guaranteeing no recurrence of symptoms, it is an unacceptable treatment option for women who wish to conserve their fertility. Myomectomy, which involves removal of fibroid(s) with conservation of normal myometrial tissue and thus fertility, remains the alternative surgical treatment option for women who wish to conceive in the future, although the actual

Do fibroids cause miscarriage?

Fibroids have the potential to cause a number of problems in pregnancy, including miscarriage and pregnancy wastage. A number of studies have shown that spontaneous miscarriage rates in the first and second trimesters of pregnancy are higher in women with fibroids. Some believe that the rates of miscarriage are likely to be higher if implantation occurs over a submucosal myoma. It has been shown that fibroids in close proximity to the placenta are more likely to be associated with bleeding in

Fibroids and their impact on antenatal complications of pregnancy and labour

The prevalence of uterine fibroids in pregnant women ranges from 0.1 to 3.9%.32, 33 It is likely, however, that this will increase with time as women continue to delay having a family until later in life, and the use of antenatal uterine imaging increases. Despite the frequency with which fibroids are encountered in pregnancy, there is still considerable controversy regarding their effects on the antenatal period, labour and post partum. During pregnancy, these benign tumours have been linked

Postpartum sequelae of fibroids

During the puerperium, the blood supply to the uterus is greatly reduced from that occurring throughout pregnancy. This may result in ischaemic degeneration of uterine fibroids. The latter provides an ideal culture medium for anaerobic organisms which commonly invade the uterine cavity during the postpartum period. This, in turn, may result in endometritis. In its mild form, such infection may be treated with antibiotics, but rarely, hysterectomy may be required for more florid infections

Contraceptive options in the presence of fibroids

A woman's exposure to oestrogens and progesterones is influenced by her use of hormonal contraception, which, in turn, has the potential to influence the natural course of fibroids, the growth of which is known to be partly hormone dependent. A number of contraceptive options are available for women with uterine myomas and these include the combined oral contraceptive pill (COCP), the progesterone-only pill (POP), injectable depo medroxy progesterone acetate (DMPA) and the

Fibroids, infertility and uterine artery embolization

Uterine artery embolization (UAE) is a minimally invasive radiological technique which has been used for the treatment of symptomatic fibroids for just over a decade. Since its introduction in 199552, the safety and efficacy of this procedure have been evaluated in a number of studies worldwide.53, 54, 55, 56 The procedure appears to be safe, and current literature suggests that it is effective in reducing menstrual blood loss, uterine volume and pelvic pain in the majority of women with

Summary

Current evidence for the relationship between fibroids and infertility remains inconclusive. However, studies investigating the link between fibroids and outcomes after the use of ART support the concept that both submucosal and intramural fibroids which distort the endometrial cavity have a negative effect on the outcomes of ART in terms of implantation, pregnancy, miscarriage and delivery rates. The effect of intramural and subserosal fibroids, in the absence of endometrial cavity distortion,

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