The influence of uterine fibroids on fertility in women planning to become pregnant

Q1: How do/can fibroids influence fertility?

When considering how uterine fibroids influence fertility, it's important to understand that uterine fibroids are very common. Uterine fibroids are the most common pelvic tumor in women, and they're non-cancerous tumors that are developed from the muscle cells of the uterus. The lifetime risk, before the age of 50, of a woman having fibroids varies by race and ethnicity, but in general, about 80% of Black women and 70% of Caucasian women will have at least one uterine fibroid diagnosed before the age of 50.

It's also important to understand when considering fertility that the prevalence of uterine fibroids increases as someone gets older. So uterine fibroids are much less common in younger women in their 20s as they are in women in their upper 30s and 40s. That's important to understand when looking at fertility because we also know that with age, fertility decreases. Thus, uterine fibroids also can impact fertility. There's also this age-related factor, which makes it difficult to really look at fibroids as far as being a causative agent for infertility.

We do know that approximately 10% of women with infertility will be diagnosed with uterine fibroids during their evaluation, and there's multiple ways that uterine fibroids impact fertility. In general, it's going to depend on the location of the uterine fibroids, the size and the bulk or the number of uterine fibroids that a woman has.  But when we look at the ways that uterine fibroids can impact fertility, what they can do is they distort the uterine cavity. This is the most common for submucosal fibroids or fibroids that have a component that's present inside the uterine cavity. Fibroids that are submucosal or intramural fibroids  are in the muscle of the uterus and have an intracavitary component. They're well-known to distort the uterine cavity and that can impact implantation of an embryo. There's also thought that it can impact an ongoing pregnancy.

There's speculation that uterine fibroids can impact the blood flow to a pregnancy as well and they may impact fertility. Depending on the size of the uterine fibroid, they may block the fallopian tubes. And so, if you have a uterine fibroid that's in the corner of the uterus, that could cause a tubal factor type of infertility where there's occlusion of the fallopian tube. But in general, the most concern we have for uterine fibroids is how those fibroids impact the uterine lining and implantation of an embryo, and it's thought that those are most likely due to submucosal fibroids, or some intramural fibroids that may be particularly large, or that have a component that's inside the cavity.

Q2. Several studies have attempted to clarify the influence of fibroids on fertility, however, there have been various, sometimes contradictory findings and a lack of well-designed trials. Why is this?

One of the challenges in counseling patients regarding uterine fibroids is that there's really a lack of  high-quality studies assessing uterine fibroids and fertility. And we all know that the gold standard research study is a randomized control trial, as they provide the highest level of evidence, but those are very difficult to conduct especially for women with uterine fibroids, as many women will decline randomization.

It's difficult to design a study where there's one treatment that can be beneficial versus no treatment. That's one challenge. Because of that, the study designs that we've had to date have mostly been retrospective, and there's been some observational studies. But even those studies, unfortunately, are complicated by the fact that fibroids themselves are very heterogeneous. It's a very heterogeneous condition. There's a lot of difference between the size of the uterine fibroids, the location and the bulk of the fibroid, and then there's also going to be the issue with age. If you have a woman who's older with uterine fibroids, obviously her age is also going to impact her fertility. We know that women with uterine fibroids tend to be older and that also impacts fertility. So that's going to have an impact on any research as well.

What we do know from some of the research to date is that it's well-known that submucosal fibroids impair fertility, that's well established. We do know that subserosal fibroids or the fibroids on the surface of the uterus do not impact uterine fibroids. The question that really hasn't been answered because there hasn't been adequate research and there's just not enough data of high quality is, whether intramural fibroids or fibroids inside the uterine muscle, whether they impact fertility.

Many women who have intramural uterine fibroids are asymptomatic. They don't have symptoms at all. So, the question is whether a woman should undergo an invasive procedure to remove that fibroid and if it’s going to help or not? That's one of the questions that we just don't have enough adequate research on because there are some limitations in the literature.

Q3. What are the current treatments, both surgical and nonsurgical, for patients with fibroids who may want to become pregnant?

I think if there's a patient, a woman with uterine fibroids who's interested in fertility, she may be a patient who is diagnosed with symptomatic fibroids, who wants to preserve her fertility, or she may be a patient who's an infertility patient who during her fertility evaluation discovers she has fibroids. It is important to determine whether treatment is appropriate for that patient, and as we just discussed, there's not a lot of answers in the literature for some patients. I think the most important thing to do first before deciding on a treatment is  to determine the best type of treatment. At Johns Hopkins, for many of our patients with uterine fibroids, they'll undergo a pelvic MRI because the pelvic MRI can provide the most detailed information regarding the size and exact location of the uterine fibroids.

We then have a multidisciplinary conference every two weeks where we review the MRIs with a group of minimally invasive surgeons, interventional radiologists, and fertility specialist where we can really decide the best treatment for the individual patient. In deciding on a patient, it's important to make the right decision and have the most information. So as far as treatments that are available, for women who are wanting to preserve their fertility or planning to get pregnant very soon, the most common options are going to be surgical.

The least invasive surgical treatment would be a hysteroscopic myomectomy where we would do a hysteroscopy and remove the uterine fibroids by either shaving the pieces of the submucosal fibroid or we can remove it with a hysteroscopic morcellator. There are various techniques. But for the submucosal fibroids that are inside the uterine cavity, hysteroscopic myomectomy is very minimally invasive. It's an outpatient procedure. It's very safe and it's something that we will typically offer to patients who have submucosal fibroids.

For patients who have symptomatic uterine fibroids and may have bulk symptoms, or have numerous uterine fibroids, we typically would recommend either a laparoscopic robotic-assisted myomectomy, sometimes just a laparoscopic myomectomy, or for women who have the most severe, a very large fibroid uterus, let's say greater than 20 centimeters, they may actually need to undergo an exploratory laparotomy or abdominal myomectomy. For patients who have symptomatic subserosal fibroids and large intramural fibroids that need to be removed, it really depends on the size, location, and bulk of the uterine fibroids. And that's where the pelvic MRI becomes very useful.

I would say that for the majority of my patients that have a large amount of fibroids, are still able to undergo a robotic-assisted laparoscopic hysterectomy which oftentimes can be an outpatient procedure just because we've had this improvement in technology with robotic and laparoscopic surgery. But surgery can be very beneficial as far as removing the bulk of the uterine fibroids. And so that is typically our treatments that we would recommend for those who want future fertility or who are imminently trying to get pregnant.

There are medical treatments as well or non-surgical treatments such as GnRH analogs that can shrink the size of the uterine fibroids. Unfortunately, the uterine fibroids are still there and typically will still impact fertility. So that's not something that we do often for those that are actively trying to get pregnant. The same for uterine artery embolization or uterine fibroids embolization. We will not recommend that for patients who want to have future fertility because the fibroids will still be in that location and they're typically in a location that's impairing fertility.

Q4. How long do patients have to wait after a fibroid treatment to try to get pregnant?

The length of time that a patient needs to wait after having fibroids removed for surgical treatment typically depends on the type of surgery the patient undergoes as well as the size of the fibroids and the extent of the surgery. For a patient who's undergoing a hysteroscopic myomectomy, they typically only must wait a month or two. Once they're assessed that there's no residual fibroid that's left, then they can try to conceive.

For patients who need to undergo abdominal myomectomy or laparoscopic myomectomy, those are much more extensive procedures. Typically, surgeons will recommend a patient wait three to six months to try to conceive. It's also important for the surgeon to discuss with the patient the extent of the myomectomy and whether that patient, when she does become pregnant, will require a c-section because typically if the uterine cavity is entered or if there are multiple incisions on the uterus during the myomectomy surgery, surgeons will recommend a c-section for that patient when she does become pregnant to decrease the risk of uterine rupture. And typically, that will be documented in the operative note, but the surgeon will also counsel the patient regarding this.

Q1: How do/can fibroids influence fertility?

When considering how uterine fibroids influence fertility, it's important to understand that uterine fibroids are very common. Uterine fibroids are the most common pelvic tumor in women, and they're non-cancerous tumors that are developed from the muscle cells of the uterus. The lifetime risk, before the age of 50, of a woman having fibroids varies by race and ethnicity, but in general, about 80% of Black women and 70% of Caucasian women will have at least one uterine fibroid diagnosed before the age of 50.

It's also important to understand when considering fertility that the prevalence of uterine fibroids increases as someone gets older. So uterine fibroids are much less common in younger women in their 20s as they are in women in their upper 30s and 40s. That's important to understand when looking at fertility because we also know that with age, fertility decreases. Thus, uterine fibroids also can impact fertility. There's also this age-related factor, which makes it difficult to really look at fibroids as far as being a causative agent for infertility.

We do know that approximately 10% of women with infertility will be diagnosed with uterine fibroids during their evaluation, and there's multiple ways that uterine fibroids impact fertility. In general, it's going to depend on the location of the uterine fibroids, the size and the bulk or the number of uterine fibroids that a woman has.  But when we look at the ways that uterine fibroids can impact fertility, what they can do is they distort the uterine cavity. This is the most common for submucosal fibroids or fibroids that have a component that's present inside the uterine cavity. Fibroids that are submucosal or intramural fibroids  are in the muscle of the uterus and have an intracavitary component. They're well-known to distort the uterine cavity and that can impact implantation of an embryo. There's also thought that it can impact an ongoing pregnancy.

There's speculation that uterine fibroids can impact the blood flow to a pregnancy as well and they may impact fertility. Depending on the size of the uterine fibroid, they may block the fallopian tubes. And so, if you have a uterine fibroid that's in the corner of the uterus, that could cause a tubal factor type of infertility where there's occlusion of the fallopian tube. But in general, the most concern we have for uterine fibroids is how those fibroids impact the uterine lining and implantation of an embryo, and it's thought that those are most likely due to submucosal fibroids, or some intramural fibroids that may be particularly large, or that have a component that's inside the cavity.

Q2. Several studies have attempted to clarify the influence of fibroids on fertility, however, there have been various, sometimes contradictory findings and a lack of well-designed trials. Why is this?

One of the challenges in counseling patients regarding uterine fibroids is that there's really a lack of  high-quality studies assessing uterine fibroids and fertility. And we all know that the gold standard research study is a randomized control trial, as they provide the highest level of evidence, but those are very difficult to conduct especially for women with uterine fibroids, as many women will decline randomization.

It's difficult to design a study where there's one treatment that can be beneficial versus no treatment. That's one challenge. Because of that, the study designs that we've had to date have mostly been retrospective, and there's been some observational studies. But even those studies, unfortunately, are complicated by the fact that fibroids themselves are very heterogeneous. It's a very heterogeneous condition. There's a lot of difference between the size of the uterine fibroids, the location and the bulk of the fibroid, and then there's also going to be the issue with age. If you have a woman who's older with uterine fibroids, obviously her age is also going to impact her fertility. We know that women with uterine fibroids tend to be older and that also impacts fertility. So that's going to have an impact on any research as well.

What we do know from some of the research to date is that it's well-known that submucosal fibroids impair fertility, that's well established. We do know that subserosal fibroids or the fibroids on the surface of the uterus do not impact uterine fibroids. The question that really hasn't been answered because there hasn't been adequate research and there's just not enough data of high quality is, whether intramural fibroids or fibroids inside the uterine muscle, whether they impact fertility.

Many women who have intramural uterine fibroids are asymptomatic. They don't have symptoms at all. So, the question is whether a woman should undergo an invasive procedure to remove that fibroid and if it’s going to help or not? That's one of the questions that we just don't have enough adequate research on because there are some limitations in the literature.

Q3. What are the current treatments, both surgical and nonsurgical, for patients with fibroids who may want to become pregnant?

I think if there's a patient, a woman with uterine fibroids who's interested in fertility, she may be a patient who is diagnosed with symptomatic fibroids, who wants to preserve her fertility, or she may be a patient who's an infertility patient who during her fertility evaluation discovers she has fibroids. It is important to determine whether treatment is appropriate for that patient, and as we just discussed, there's not a lot of answers in the literature for some patients. I think the most important thing to do first before deciding on a treatment is  to determine the best type of treatment. At Johns Hopkins, for many of our patients with uterine fibroids, they'll undergo a pelvic MRI because the pelvic MRI can provide the most detailed information regarding the size and exact location of the uterine fibroids.

We then have a multidisciplinary conference every two weeks where we review the MRIs with a group of minimally invasive surgeons, interventional radiologists, and fertility specialist where we can really decide the best treatment for the individual patient. In deciding on a patient, it's important to make the right decision and have the most information. So as far as treatments that are available, for women who are wanting to preserve their fertility or planning to get pregnant very soon, the most common options are going to be surgical.

The least invasive surgical treatment would be a hysteroscopic myomectomy where we would do a hysteroscopy and remove the uterine fibroids by either shaving the pieces of the submucosal fibroid or we can remove it with a hysteroscopic morcellator. There are various techniques. But for the submucosal fibroids that are inside the uterine cavity, hysteroscopic myomectomy is very minimally invasive. It's an outpatient procedure. It's very safe and it's something that we will typically offer to patients who have submucosal fibroids.

For patients who have symptomatic uterine fibroids and may have bulk symptoms, or have numerous uterine fibroids, we typically would recommend either a laparoscopic robotic-assisted myomectomy, sometimes just a laparoscopic myomectomy, or for women who have the most severe, a very large fibroid uterus, let's say greater than 20 centimeters, they may actually need to undergo an exploratory laparotomy or abdominal myomectomy. For patients who have symptomatic subserosal fibroids and large intramural fibroids that need to be removed, it really depends on the size, location, and bulk of the uterine fibroids. And that's where the pelvic MRI becomes very useful.

I would say that for the majority of my patients that have a large amount of fibroids, are still able to undergo a robotic-assisted laparoscopic hysterectomy which oftentimes can be an outpatient procedure just because we've had this improvement in technology with robotic and laparoscopic surgery. But surgery can be very beneficial as far as removing the bulk of the uterine fibroids. And so that is typically our treatments that we would recommend for those who want future fertility or who are imminently trying to get pregnant.

There are medical treatments as well or non-surgical treatments such as GnRH analogs that can shrink the size of the uterine fibroids. Unfortunately, the uterine fibroids are still there and typically will still impact fertility. So that's not something that we do often for those that are actively trying to get pregnant. The same for uterine artery embolization or uterine fibroids embolization. We will not recommend that for patients who want to have future fertility because the fibroids will still be in that location and they're typically in a location that's impairing fertility.

Q4. How long do patients have to wait after a fibroid treatment to try to get pregnant?

The length of time that a patient needs to wait after having fibroids removed for surgical treatment typically depends on the type of surgery the patient undergoes as well as the size of the fibroids and the extent of the surgery. For a patient who's undergoing a hysteroscopic myomectomy, they typically only must wait a month or two. Once they're assessed that there's no residual fibroid that's left, then they can try to conceive.

For patients who need to undergo abdominal myomectomy or laparoscopic myomectomy, those are much more extensive procedures. Typically, surgeons will recommend a patient wait three to six months to try to conceive. It's also important for the surgeon to discuss with the patient the extent of the myomectomy and whether that patient, when she does become pregnant, will require a c-section because typically if the uterine cavity is entered or if there are multiple incisions on the uterus during the myomectomy surgery, surgeons will recommend a c-section for that patient when she does become pregnant to decrease the risk of uterine rupture. And typically, that will be documented in the operative note, but the surgeon will also counsel the patient regarding this.

Q1: How do/can fibroids influence fertility?

When considering how uterine fibroids influence fertility, it's important to understand that uterine fibroids are very common. Uterine fibroids are the most common pelvic tumor in women, and they're non-cancerous tumors that are developed from the muscle cells of the uterus. The lifetime risk, before the age of 50, of a woman having fibroids varies by race and ethnicity, but in general, about 80% of Black women and 70% of Caucasian women will have at least one uterine fibroid diagnosed before the age of 50.

It's also important to understand when considering fertility that the prevalence of uterine fibroids increases as someone gets older. So uterine fibroids are much less common in younger women in their 20s as they are in women in their upper 30s and 40s. That's important to understand when looking at fertility because we also know that with age, fertility decreases. Thus, uterine fibroids also can impact fertility. There's also this age-related factor, which makes it difficult to really look at fibroids as far as being a causative agent for infertility.

We do know that approximately 10% of women with infertility will be diagnosed with uterine fibroids during their evaluation, and there's multiple ways that uterine fibroids impact fertility. In general, it's going to depend on the location of the uterine fibroids, the size and the bulk or the number of uterine fibroids that a woman has.  But when we look at the ways that uterine fibroids can impact fertility, what they can do is they distort the uterine cavity. This is the most common for submucosal fibroids or fibroids that have a component that's present inside the uterine cavity. Fibroids that are submucosal or intramural fibroids  are in the muscle of the uterus and have an intracavitary component. They're well-known to distort the uterine cavity and that can impact implantation of an embryo. There's also thought that it can impact an ongoing pregnancy.

There's speculation that uterine fibroids can impact the blood flow to a pregnancy as well and they may impact fertility. Depending on the size of the uterine fibroid, they may block the fallopian tubes. And so, if you have a uterine fibroid that's in the corner of the uterus, that could cause a tubal factor type of infertility where there's occlusion of the fallopian tube. But in general, the most concern we have for uterine fibroids is how those fibroids impact the uterine lining and implantation of an embryo, and it's thought that those are most likely due to submucosal fibroids, or some intramural fibroids that may be particularly large, or that have a component that's inside the cavity.

Q2. Several studies have attempted to clarify the influence of fibroids on fertility, however, there have been various, sometimes contradictory findings and a lack of well-designed trials. Why is this?

One of the challenges in counseling patients regarding uterine fibroids is that there's really a lack of  high-quality studies assessing uterine fibroids and fertility. And we all know that the gold standard research study is a randomized control trial, as they provide the highest level of evidence, but those are very difficult to conduct especially for women with uterine fibroids, as many women will decline randomization.

It's difficult to design a study where there's one treatment that can be beneficial versus no treatment. That's one challenge. Because of that, the study designs that we've had to date have mostly been retrospective, and there's been some observational studies. But even those studies, unfortunately, are complicated by the fact that fibroids themselves are very heterogeneous. It's a very heterogeneous condition. There's a lot of difference between the size of the uterine fibroids, the location and the bulk of the fibroid, and then there's also going to be the issue with age. If you have a woman who's older with uterine fibroids, obviously her age is also going to impact her fertility. We know that women with uterine fibroids tend to be older and that also impacts fertility. So that's going to have an impact on any research as well.

What we do know from some of the research to date is that it's well-known that submucosal fibroids impair fertility, that's well established. We do know that subserosal fibroids or the fibroids on the surface of the uterus do not impact uterine fibroids. The question that really hasn't been answered because there hasn't been adequate research and there's just not enough data of high quality is, whether intramural fibroids or fibroids inside the uterine muscle, whether they impact fertility.

Many women who have intramural uterine fibroids are asymptomatic. They don't have symptoms at all. So, the question is whether a woman should undergo an invasive procedure to remove that fibroid and if it’s going to help or not? That's one of the questions that we just don't have enough adequate research on because there are some limitations in the literature.

Q3. What are the current treatments, both surgical and nonsurgical, for patients with fibroids who may want to become pregnant?

I think if there's a patient, a woman with uterine fibroids who's interested in fertility, she may be a patient who is diagnosed with symptomatic fibroids, who wants to preserve her fertility, or she may be a patient who's an infertility patient who during her fertility evaluation discovers she has fibroids. It is important to determine whether treatment is appropriate for that patient, and as we just discussed, there's not a lot of answers in the literature for some patients. I think the most important thing to do first before deciding on a treatment is  to determine the best type of treatment. At Johns Hopkins, for many of our patients with uterine fibroids, they'll undergo a pelvic MRI because the pelvic MRI can provide the most detailed information regarding the size and exact location of the uterine fibroids.

We then have a multidisciplinary conference every two weeks where we review the MRIs with a group of minimally invasive surgeons, interventional radiologists, and fertility specialist where we can really decide the best treatment for the individual patient. In deciding on a patient, it's important to make the right decision and have the most information. So as far as treatments that are available, for women who are wanting to preserve their fertility or planning to get pregnant very soon, the most common options are going to be surgical.

The least invasive surgical treatment would be a hysteroscopic myomectomy where we would do a hysteroscopy and remove the uterine fibroids by either shaving the pieces of the submucosal fibroid or we can remove it with a hysteroscopic morcellator. There are various techniques. But for the submucosal fibroids that are inside the uterine cavity, hysteroscopic myomectomy is very minimally invasive. It's an outpatient procedure. It's very safe and it's something that we will typically offer to patients who have submucosal fibroids.

For patients who have symptomatic uterine fibroids and may have bulk symptoms, or have numerous uterine fibroids, we typically would recommend either a laparoscopic robotic-assisted myomectomy, sometimes just a laparoscopic myomectomy, or for women who have the most severe, a very large fibroid uterus, let's say greater than 20 centimeters, they may actually need to undergo an exploratory laparotomy or abdominal myomectomy. For patients who have symptomatic subserosal fibroids and large intramural fibroids that need to be removed, it really depends on the size, location, and bulk of the uterine fibroids. And that's where the pelvic MRI becomes very useful.

I would say that for the majority of my patients that have a large amount of fibroids, are still able to undergo a robotic-assisted laparoscopic hysterectomy which oftentimes can be an outpatient procedure just because we've had this improvement in technology with robotic and laparoscopic surgery. But surgery can be very beneficial as far as removing the bulk of the uterine fibroids. And so that is typically our treatments that we would recommend for those who want future fertility or who are imminently trying to get pregnant.

There are medical treatments as well or non-surgical treatments such as GnRH analogs that can shrink the size of the uterine fibroids. Unfortunately, the uterine fibroids are still there and typically will still impact fertility. So that's not something that we do often for those that are actively trying to get pregnant. The same for uterine artery embolization or uterine fibroids embolization. We will not recommend that for patients who want to have future fertility because the fibroids will still be in that location and they're typically in a location that's impairing fertility.

Q4. How long do patients have to wait after a fibroid treatment to try to get pregnant?

The length of time that a patient needs to wait after having fibroids removed for surgical treatment typically depends on the type of surgery the patient undergoes as well as the size of the fibroids and the extent of the surgery. For a patient who's undergoing a hysteroscopic myomectomy, they typically only must wait a month or two. Once they're assessed that there's no residual fibroid that's left, then they can try to conceive.

For patients who need to undergo abdominal myomectomy or laparoscopic myomectomy, those are much more extensive procedures. Typically, surgeons will recommend a patient wait three to six months to try to conceive. It's also important for the surgeon to discuss with the patient the extent of the myomectomy and whether that patient, when she does become pregnant, will require a c-section because typically if the uterine cavity is entered or if there are multiple incisions on the uterus during the myomectomy surgery, surgeons will recommend a c-section for that patient when she does become pregnant to decrease the risk of uterine rupture. And typically, that will be documented in the operative note, but the surgeon will also counsel the patient regarding this.