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While the commonest problem found in the uterus is a fibroid (myoma), this is rarely a cause of infertility, and is usually an incidental finding of little importance. Fibroids are common benign smooth muscle tumors, which arise in the wall of the uterus, and may be single or multiple. About 25% of all women over the age of 35 have fibroids. Most fibroids develop in the wall of the uterus (intramural) or protrude outside of the uterine wall (subserous fibroids), and these can usually be left alone, since neither do they hinder fertility, and nor do they cause problems during pregnancy. In fact, unnecessary surgery to remove the fibroid often causes more harm than good.
This surgery often creates adhesions, which causes the tubes to get blocked. However, if the fibroids are very large, they may need surgical removal, and this procedure is called a myomectomy. Some doctors give an injection of a GnRH analog prior to surgery in order to shrink the fibroid and make surgery technically easier. When performed by an expert, it is a safe and effective procedure that can be accomplished with minimal blood loss. However, sometimes because of uncontrollable bleeding the surgeon may be forced to remove the entire uterus (a procedure called hysterectomy), and this is obviously a disaster for the infertile woman! The standard technique for removing a fibroid is through open surgery (laparatomy). It is now also possible to remove fibroids through the laparoscope, but laparoscopic myomectomy does not allow for optimal reconstruction of the uterus. Submucous fibroids which protrude into the uterine cavity are an uncommon but an important cause of infertility, because they interfere with implantation of the embryo, by acting as a foreign body. These are best removed by an operative hysteroscopy. While surgery can remove the fibroid, it can recur again, and most doctors advise the patient to try to conceive as early as possible after surgery.
Fig 2. Schematic showing a submucous fibroid; and a subserous fibroid compressing the right fallopian tube
© Dr. Aniruddha Malpani and Dr. Anjali Malpani www.drmalpani.com
Credits: How to Have a Baby: Overcoming Infertility
