By Antonio R. Gargiulo, MD
Brigham & Women’s Hospital
Even in the age of highly effective assisted reproduction, the uterus remains an essential and irreplaceable component of successful fertility treatment. Common benign gynecologic condition such as uterine fibroids (present in over 30% of women over 35 years old) can threaten the integrity of the uterus during the reproductive years. Uterine fibroids are benign solid tumors of the muscle layer of the uterus (the myometrium) but can also affect the funct
ional inner layer of the uterus (endometrium) where embryo implantation occurs. It is not rare for these tumors to be diagnosed in women experiencing infertility or pregnancy loss. Two basic questions arise under these circumstances. Are fibroids a cause of infertility or pregnancy loss? Is surgery indicated? The answer to both questions is often a complex one to give, and the surgical care for these conditions is highly personalized.
We do not know why fibroids appear in some women and not in others, but we do know that at the origin of each fibroid there is a uterine muscle cell that has lost its proliferative control and replicates without inhibition. Some women have only one fibroid, some have too many to count, most have just a few. In terms of their size, fibroids may weigh from a gram or less to over a thousand grams. A normal uterus weighs 60 grams. Therefore, large fibroids are likely to have a profound clinical impact even when they are far from the uterine cavity, whereas small fibroids tend to impact reproduction when they are adjacent to or within the uterine cavity. Due to the above variability, one can argue that no two patients with uterine fibroids have an identical problem. This is exactly why researchers still struggle to identify patients who will definitely benefit from fibroid surgery. The conscientious gynecologist will start from the logical assumption that because fibroids are so frequent in women their role as a cause of infertility must be overall minor. However, there are several situations in which the surgical removal of the fibroids is indicated. For example, when uterine fibroids cause symptoms (such as pelv
ic pain, abnormal urination or abnormal uterine bleeding) they need to be treated. Fibroids that cause no symptoms are often found during the diagnostic or treatment phases of fertility care and the role of surgery is more controversial for these tumors. There is evidence to suggest that all fibroids with involvement of the endometrium and certain fibroids with exclusive involvement of the myometrium (namely those with a size above 4 cm) are a possible cause of infertility and pregnancy loss. Moreover, there are studies suggesting that fibroids with a size above 5 cm carry a significant risk of poor obstetrical outcome (preterm rupture of membranes in particular). In summary, the scientific data on the negative impact of some uterine fibroids on embryo implantation, placenta formation and function and final obstetrical outcome is solid. Surprisingly, no high quality clinical study to date that has demonstrated that, when surgery is performed in these cases, the chance to have a healthy baby is actually improved. That does not mean that surgery should not be offered. However, the lack of definitive outcome data leaves space for discussion about the best way to proceed when surgery is considered as an attempt to improve the woman’s chance to conceive and carry a pregnancy.
In women who want to preserve their ability to carry a child the only treatment option is a myomectomy (the removal of fibroids with reconstruction of the uterus). No medical treatment of fibroids are currently available, and interventional radiology treatments, such as uterine embolization and focused ultrasound, remain highly investigational. Given the above, a clear understanding of the surgical risks of myomectomy is paramount in the decision of whether to proceed with treatment at all. Clearly, surgical risks depend much more on the specific skills of the surgical team than on the pathology at hand. Minimally invasive surgical treatment of uterine fibroids (hysteroscopic and laparoscopic) presents many advantages over conventional open surgery and represents the best standard of care for all but the most challenging myomectomy cases. Of course, there is athreshold of technical challenge above which open myomectomy is necessary. The Center for Uterine Fibroids at Brigham and Women’s Hospital has been a world pioneer in the use of computer-assisted (robotic) laparoscopy to raise the threshold for open surgery. Our robotic program , now in its eight year, has spared hundred of young women the traumatic experience of open surgery. Less than 5% of women referred to our center will end up needing open surgery for treatment of their uterine fibroids. Cases that are not suitable for minimally invasive approach are identified in advance, through pre-operative screening with high definition magnetic resonance imaging. While the availability of a minimally invasive approach does not change the rational basis for choosing when to intervene, it can certainly make the process more manageable for most women, due to the speedy recovery and much lower incidence of surgical complications.
Power morcellation is the technique used to extract these fibroids from the abdominal cavity (once they are removed from within the uterus) through a small hole, in small strips. Power morcellation has received a
lot of attention from the lay press in recent months because of its alleged role in spreading previously undiagnosed uterine cancer in rare patients undergoing hysterectomy (not myomectomy). As a response to these concerns, our hospital (together with several others in the country) has moved away from open power morcellation,
and only allows morcellation of uterine tissue in a contained environment.
In conclusion, 1) uterine fibroids are highly prevalent among women of reproductive age and many fibroids will not impact a woman’s ability to become pregnant and to deliver a healthy child, 2) women of reproductive age with symptomatic uterine fibroids should undergo myomectomy, 3) women with asymptomatic fibroids who are planning to conceive or are experiencing reproductive difficulties (infertility, pregnancy loss, repeated implantation failure in assisted reproduction cycles) should be counseled by an expert reproductive endocrinologist on whether surgery is a reasonable option; 4) women with asymptomatic fibroids with a history of poor obstetrical outcome (placental abnormalities, preterm labor, preterm rupture of membranes) should be counseled by an expert maternal-fetal medicine specialist on whether surgery is a reasonable option; 5) treatment for fibroids in reproductive age is surgical (myomectomy); 6) myomectomy should be performed with minimally invasive technique unless this is judged to be unsafe by an expert reproductive surgeon (an infertility specialist practicing advanced minimally invasive surgery), in which case an open myomectomy should be performed; 7) power morcellation of uterine fibroids should be performed in a contained environment, where the risk of any tumor spread is virtually eliminated.
Patients should remain fully engaged in this complex decision-making process, helping their fertility expert make the best decisions for their personalized care.
Dr. Gargiulo is at Brigham & Women’s Hospital Center for Infertility and Reproductive Surgery, Center for Uterine Fibroids and the Boston Center for Endometriosis. He is the medical director of the Center for Robotic Surgery at Brigham and Women’s Health Care, and assistant professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School.