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    Optimal approaches to fibroid management

    Consider fibroid location and the patient’s pregnancy plans

     

    Nonsurgical treatments

    A number of less-invasive treatment approaches are available, such as uterine artery embolization (UAE) and MRI-guided thermal ablation. In addition, patients may desire medical management exclusively. However, very little data are available regarding the effects of these strategies on fertility and reproductive outcomes.

    Studies on the effects of UAE on fertility and outcomes are mostly small, observational reviews with low-quality data. While results are inconsistent, an increased incidence of infertility, preterm birth, cesarean section, and postpartum hemorrhage has been reported.19-21 Only one prospective trial comparing myomectomy to UAE has been conducted and demonstrated a lower delivery rate and high miscarriage rate in patients treated with UAE.22

    Until higher-quality data are available to clarify these associations, UAE should be avoided in patients wishing to preserve fertility. Magnetic-resonance-guided focused ultrasound surgery (MRgFUS) is a thermal ablation technique that directs ultrasonic energy to a fibroid, resulting in tissue necrosis with limited surrounding damage. Only 35 pregnancies have been reported following MRgFUS. Thus, the experience is currently too small to draw conclusions regarding the safety of pregnancy following this method.23

    Several medical treatments have been shown to reduce the size of fibroids. These include gonadotropin-releasing hormone agonists, danazol, and mifepristone. Although these therapies may reduce myoma volume by 50%, all must be discontinued before pregnancy and the uterus usually returns to pretreatment size upon stopping treatment.24 Thus, there is no evidence that fertility improves with medical management and these strategies may delay the initiation of more efficacious approaches.

    Fibroids and pregnancy

    Fibroids are significantly associated with multiple morbidities in pregnancy, although significant misconceptions about this continue. The most common is that pregnancy will result in fibroid growth and an increased risk of adverse symptoms. Data show that the course of fibroid growth during pregnancy is variable. Approximately 85% patients experience no significant growth during pregnancy and those fibroids that do grow are rarely clinically significant.25,26 However, pelvic pain is significantly more common in patients with fibroids (12.6% vs. 0.1%, P<0.001) and is the most common fibroid-related pregnancy complication.

    The association of fibroids with more serious untoward pregnancy outcomes has been evaluated in many studies. While most studies are observational and limited by small numbers of adverse events, consistent associations exist in the literature for some poor outcomes in pregnancy27 (Table 1). Fibroids are associated with an increased risk of preterm birth, placental abruption, and postpartum hemorrhage. Placentation overlying large fibroids increased the risk for these morbidities. Fibroids are also associated with an increased incidence of malpresentation and cesarean delivery.

    Next: Technologies to determine fertility

    Most women with fibroids do not experience fibroid-related complications during pregnancy.28 Furthermore, performing a myomectomy for a patient without symptoms in the preconception period also exposes her to a number of additional risks: surgical risk of myomectomy and future cesarean sections, pelvic and intrauterine adhesion formation, and uterine rupture. Thus, it is not advisable to perform preconception myomectomy for the prevention of pregnancy complications. However, if a patient experiences a pregnancy complication that is suspected to be related to her fibroids, myomectomy is a logical approach.

    Summary

    The evidence upon which to base recommendations for contemporary fibroid management is challenging to interpret. Furthermore, each patient’s individual presentation provides additional nuances that complicate clinical decision making. However, it is clear that imaging techniques that accurately define a fibroid’s relationship to the endometrial cavity are essential when determining the optimal course of action.

    There is little doubt that cavity-distorting myomas are associated with infertility and miscarriage and that removing these fibroids improves outcomes. Whether the same conclusions can be drawn about truly intramural myomas is debatable, but large myomas are most likely to be associated with poor outcomes.

    While fibroids do increase the incidence of certain untoward obstetric outcomes, the vast majority of pregnancies are uncomplicated despite the presence of fibroids. Thus, prophylactic myomectomy is not indicated to prevent poor pregnancy outcomes but rather only to prevent their recurrence.

    References

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    2. Munro MG, Critchley HO, Broder MS, Fraser IS. The FIGO Classification System (“PALM-COEIN”) for causes of abnormal uterine bleeding in non-gravid women in the reproductive years, including guidelines for clinical investigation. Int J Gynaecol Obstet. 2011;113:3-13.

    3. Cepni I, Ocal P, Erkan S, et al. Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies. Aust N Z J Obstet Gynaecol. 2005;45(1):30-35.

    4. Bingol B, Gunenc Z, Gedikbasi A, Guner H, Tasdemir S, Tiras B. Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy. J Obstet Gynecol. 2011;31(1):54-58.

    5. Dueholm M, Lundorf E, Hansen ES , Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvagianal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol. 2002;186:409-415.

    6. Kurjak A, Kupesic-Urek S, Miric D. The assessment of benign uterine tumor vascularization by transvaginal color Doppler. Ultrasound Med Biol. 1992;18:645-649.

    7. Ben-nagi J, Miell J, Mavrelos D, Naftalin J, Lee C, Jurkovic D. Endometrial implantation factors in women with submucous uterine fibroids. Reprod BioMed Online. 2010;21(5):610-615.

    8. Donnez J, Jadoul P. What are the implications of myomas on fertility? A need for debate? Hum Reprod. 2002;17:1424-1430.

    9. Cook H, Ezzati M, Segars JH, McCarthy K. The impact of uterine leiomyomas on reproductive outcomes. Minerva Ginecol. 2010;62:225-236.

    10. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review of the evidence. Fertil Steril. 2009;91:1215-1223.

    11. Somigliana E, Vercellini P, Daguati R, Pasin R, De Giorgi O, Crosignani PG. Fibroids and female reproduction: a critical analysis of the evidence. Hum Reprod Update. 2007;13:465-476.

    12. Sunkara KS, Khairy M, El-Toukhy T, Khalaf Y, Coomarasamy A. The effect of intramural fibroids without uterine cavity involvement on the outcome of IVF treatment: a systematic review and meta-analysis. Hum Reprod. 2010;25(2): 418-429.

    13. Oliveira FG, Abdelmassih VG, Diamond MP, Dozortsev D, Melo NR, Abdelmassih R. Impact of subserosal and intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization-intracytoplasmic sperm injection. Fertil Steril. 2004;81:582-587.

    14. Casini ML, Rossi F, Agostini R, Unfer V. Effects of the position of fibroids on fertility. Gynecol Endocrinol. 2006;22(2):106-109.

    15. Donnez J, Jadoul P. What are the implications of myomas on fertility? A need for a debate? Hum Reprod. 2002;17:1424-1430.

    16. Bulletti C, De Ziegler D, Levi Setti P, Cicinelli E, Polli V, Steanetti M. Myomas, pregnancy outcome, and in vitro fertilization. Ann N Y Acad Sci. 2004;1034:84-92.

    17. Bozdag G, Esiner I, Boynukalin K, Aksu T, Gunalp S, Gurgan T. Single intramural leiomyoma with normal hysteroscopic findings does not affect ICSI-embryo transfer outcomes. Reprod Biomed Online. 2009;19:276-280.

    18. Olive DL. The surgical treatment of fibroids for infertility. Semin Reprod Med. 2011;29:113-123.

    19. Goldberg J, Pereira L, Berghella V, Diamond J, Darai E, Seinera P, Seracchioli R. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol. 2004;191(1):18-21.

    20. Torre A, Paillusson B, Fain V, Labauge P, Pelage JP, Fauconnier A. Uterine artery embolization for severe symptomatic fibroids: effects of fertility and symptoms. Hum Reprod. 2014;29:3):490-501.

    21. Homer H, Saridogan E. Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril. 2010; 94(1):324-330.

    22. Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008;31(1):73-85.

    23. Clark NA, Mumford SL , Segars JH. Reproductive impact of MRI-guided focused ultrasound surgery for fibroids: a systematic review of the evidence. Curr Opin Obstet Gynecol. 2014;26:151-161.

    24. Myomas and reproductive Function. The Practice Committee of the American Society for Reproductive Medicine. Fert Steril. 2008;90:S125-30.

    25. Strobelt N, Ghidini A, Cavallone M, Pensabene I, Ceruti P, Vergani P. Natural history of uterine leiomyomas in pregnancy. J Ultrasound Med. 1994;13:399-401.

    26. Ouyang DW, Economy KE , Norwitz ER. Obstetric complications of fibroids. Obstet Gynecol Clin North Am. 2006; 33:153-169.

    27. Klatsky PC, Tran ND, Caughey AB, Fujimoto VY. Fibroids and reproductive outcomes: a systematic literature review from conception to delivery. Am J Obstet Gynecol. 2008;198(4):357.

    28. Segars JH, Parrott EC, Nagel JD, Guo XC, Gao X, Birnbaum LS , Pinn VW, Dixon D. Proceedings from the 3rd National Institutes of Health International Congress on Advances in Uterine Leiomyoma Research: comprehensive review, conference summary and future recommendations. Hum Reprod Update. 2014;20(3):309-333.

    Scott J Morin, MD
    Dr Morin is a Fellow in Reproductive Endocrinology and Infertility at Thomas Jefferson University/Reproductive Medicine Associates of ...
    William D Schlaff, MD
    Dr Schlaff is Professor and Chair of the Department of Obstetrics & Gynecology at Sidney Kimmel Medical College at Thomas Jefferson ...

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