Fibroids & Polyps

Benign (non-cancerous) growths known as uterine fibroids can cause heavy bleeding in the uterus. Another cause of midcycle uterine bleeding can be lesions known as endometrial polyps, which also are benign. Hormonal imbalances, uterine infection or abnormal uterine cell growth also can cause such bleeding.

Fibroids (or leiomyomas) are very common benign smooth muscle tumors. They appear to have a racial predilection, being more common in black women and least common in Asian women. Many cause no symptoms at all. Others can cause pressure symptoms, abnormal bleeding and possibly increase the likelihood of infertility and miscarriage. Still, the mere presence of a fibroid does not mean that it is the cause of infertility. It appears that location is a critical factor. Fibroids are characterized by their location within the uterus: submucosal (inside the uterine cavity), intramural (inside the wall of the uterus), subserosal (outside the wall of the uterus), and pedunculated (on a stalk connected to the uterus).

Fibroids inside the uterine cavity (submucosal) have clearly been shown to have a negative effect on IVF outcomes. They also increase the risk of miscarriage and are associated with an increased incidence of abnormal bleeding. Fibroids inside the wall of the uterus (intramural) that distort the uterine cavity may also have this effect. Other types of fibroids may cause symptoms, but do not appear to routinely impact fertility or embryo implantation.

Fibroids inside the uterine cavity are typically removed during an outpatient surgical procedure performed under an intravenous anesthetic in which the cervix is dilated and a wider hysteroscope is introduced into the uterine cavity. A wire loop (resectoscope) with an energy source is introduced through the hysteroscopy which allows the surgeon to shave the fibroid and remove the tissue through the cervix.

Fibroids inside the wall of the uterus (intramural) usually can not be removed completely in this fashion. They require an abdominal approach employing an incision in the uterus, fibroid removal and subsequent uterine repair. This can be performed either through a small abdominal incision (mini-laparotomy) or, in certain circumstances, through a laparoscope.

If the uterine cavity is entered during this procedure, a subsequent Caesarian section should be electively performed prior to onset of labor to minimize the risk of uterine rupture due to weakening of the uterine wall. Newer radiologic techniques for treating symptomatic fibroids such as uterine artery embolization (UAE) and MR guided ultrasound ablation have not yet been shown to be appropriate for women who wish to conceive.

In a recent study, we reported that ongoing pregnancy rates in women undergoing in vitro fertilization or egg donation cycles after removal of submucosal fibroids or intramural fibroids that were distorting the uterine cavity were the same as those in matched women who had no fibroids at all. Unfortunately, there have been no randomized trials published which directly address this issue.

Clearly the uterine cavity should be thoroughly evaluated prior to in vitro fertilization and abnormalities should be treated if appropriate. The mere presence of a fibroid does not mean that it is the cause of infertility; or that it should be removed. However, those that do create a high risk for compromised outcomes should be dealt with so that unnecessary cycle failure can be avoided.