Infertility Treatments > Surgical > Myomectomy

Technically known as leiomyomas, fibroids are benign (99+% of the time) muscle tumors that grow in the uterus. No one knows what causes fibroids, but there certainly is good evidence that there is a genetic predisposition. If your mother or sister has them, you are more likely to. Fibroids may be very small or extremely large, ranging in size from pea size to as big as a grapefruit or larger. They can also be solitary or numerous.  Thye can also be defined as pedunculated, sub-serosal, intra-myometrial, sub-mucosal, or intra-cavitary.  Pedunculated firoids are those that literally hang from a stalk from the surface of the uterus.  Sub-serosal and intra-myometrial typically do not distort the uterine cavity.  Sub-mucosal fibroids distort the uterine cavity, and intra-cavitqry are within the uterine cavity.

Most fibroids do not cause difficulty conceiving. However, there are exceptions. A large fibroid that distorts pelvic anatomy so that the fallopian tubes cannot function properly can certainly be significant. Also, any fibroid that distorts the uterine cavity can be a problem.

If a fibroid distorts the uterine cavity enough that the distortion can be seen on SIS, X-ray, or hysteroscopy, it has probably compromised the blood supply to the endometrium that overlies it. If this blood supply is compromised, this tissue cannot function properly and undergo all of the changes that it should, and it may not be able to allow implantation. Fibroids can also be pedunculated, or hanging into the uterine cavity from a stalk. The uterus does not like having anything in it with the exception of a fetus. Fibroids in the uterine cavity can result in much the same effect that occurs with an IUD - they irritate the uterus enough that it will not allow implantation to occur. Fibroids that distort the uterine cavity may be associated with bleeding at times other than the normal period. Consideration should be given to removing any fibroid within the uterine cavity or that distorts the uterine cavity.

There are now several techniques available for treating fibroids, but the gold standard still remains surgical removal.   Most sub-mucosal and intra-cavitary fibroids can be removed via hysteroscopy, a minor outpatient surgcal procedure in whcihc a small telescope like instrument is placed through the cervix, the fibroid visualized and removed. 

Pedunculated and sub-serosal fiboids can often be removed via laparascopy.  Laparoscopic removal has the advantage of a much shorter post-operative recovery with less pain than a major surgical procedure (laparotomy).  However, there are limitations as to which fibroids should be removed laparoscopically.  The biggest risk of myomectomy is uterine rupture during subsequent pregnancy.  For this reason, great care is taken at the time of myomectomy to reapproximate the remaining muscle of the uterus that surrounded the firboids.  This requires that the muscle be very carefully sutured.  There is no question that suturing of large defects can be most adequately perfomed at the time of laparotomy.  Therefore, if a significant defect in the muscle of the uterus results from removal of the fibroid, laparotomy is the approach of choice.

Depo-Lupron can be used to medically shrink fibroids.  This is, however, temporary and upon discontinuation of the lupron the fibroids will return to their previous size.  The only time that lupon is of real value is in individuals who are anemic, or who need to postpone surgery for one reason or another.  Lupron in these circumstances allows us to delay surgery without further bleeding or growth of the fiboids.  Fibroids do shrink as a result of treatment with Lupron, but this change in size is, most of the time, not enough to justify the cost and side-effects of lupron use.

Embolization is a technique that has gained recent favor for treating fibroids.  In an embolization procedure, the blood vessels that supply the fibroid are occluded.  Without adequate blood supply, the fibroids shrink or regress completely.  This is not, however, an option for women who wish to preserve their child-bearing potential.  There have been case reports of uterine rupture during pregnancy in women who have had embolization. 

The risks of myomectomy include bleeding, infection, formation of scar tissue, and uterine rupture during pregnancy.  Bleeding is very rarely an issue in the hands of an experienced surgeon.  The same is true for infection.  There are many steps taken during this surgical procedure to prevent scarring.  This includes meticulous surgical technique, copious irrigation, and the use of adhesion barriers.  With appropriate technique, uterine rupture is an extremely rare event.  If removal of the fibroid(s) does result in entry into the uterine cavity, the subsequent delivery should be by cearean section.  Otherwise, normal vaignal delivery can be anticipated.  Once removed, fibroids do not recur.  Other fibroids may grow, but removal is definitive treatment.

© 2005 Jarrett Fertility Group