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Hello and Welcome Back,

Today we will talk about trying to figure out who needs infertility surgery and who does not. Some cases are obvious, and some are very borderline.

This blog will discuss the case of the fibroid uterus, another blog will follow concerning other problems.

I’ll start with a little story. Cathy was a 40-year-old woman who had been trying to become pregnant for years. Before I examined her she said that doctors have told her she has a fibroid, but she did not think it was causing her any problems.

When I got to her exam, I found a huge fibroid growing all the way to her navel. On ultrasound she had a fibroid larger than a grapefruit distorting her entire uterus making it impossible to become pregnant. In addition, she was anemic because the fibroid was causing her to have super heavy periods. Upon further questioning, she revealed that she had been told about this problem years ago, but figured she would just try on her own just in case.

So here is a woman who absolutely needed surgery to become pregnant, and for some reason did not want get it done. I gently explained her that she could not get pregnant without an operation, and she told me she was really going to consider it this time, but never returned.

I can’t explain her behavior; maybe fear, or maybe a family member was giving her advice. But the point here is that from my end, this was easy advice to give, it was clear, she needed surgery. Very few cases are as clear as this. In fact in most cases of infertility surgery, non-surgery is a real option.
Lets go through a few more scenarios.Here is another easy fibroid case, the case of the submucus myoma (myoma=fibroid). Submucus means right in the cavity itself, it grows among the glands that are necessary to hold an embryo.
A submucus myoma even as small as a half of an inch can be a problem because it can disrupt the uterine lining (the endometrium), interfering with implantation. Plus they can cause heavy bleeding.
While pregnancy is possible with these myomas, we usually recommend removal because the surgery is relatively easy and the results are favorable. Rarely, scar tissue can be a complication and sometimes the cases need to be repeated if it’s hard to get every little bit out at the first case.
Most doctors recommend the removal of submucus myomas, even if small.
Here is another easy one. What if you have one 3 centimeter (cm) (3 cms is a bit bigger than one inch) fibroid that is not growing near the lining, and it’s your only fibroid.
In this case, you do not need surgery.
Every doctor has his or her own size cutoff, but for almost all of us, 3 cm is just too small to operate.
Yes they can grow during pregnancy, but many do not.
Most doctors do not recommend surgery for 3 cm fibroids, as long as they are not in the cavity (submucus).
Now it’s going to be a bit harder.
What if you have 3 fibroids that are 3 cm each?
Or one fibroid that is 6 cms, or 7 fibroids all less than 2 cms?
These are the cases where the real answers are hard to come by.
Maybe you need surgery, maybe you don’t. And what does need mean?
Does it mean you can’t get pregnant without surgery? Does it mean you could get pregnant but then have an early miscarriage? Or does it mean that all will be well until the 28thweek of pregnancy when you prematurely deliver?
This is all impossible to predict. Every fibroid is different and every uterus is different. In addition, there are so many causes (not all known) of infertility, miscarriage and premature delivery that blaming the fibroids on bad outcomes is at times futile.
Many doctors have just a firm size cutoff, which could vary from 4, 5, 6, or 7 cms depending on the doctor. Some doctors, don’t use a cutoff, they use many multiple factors including size, location and history. Either way, we never really know, except in the most obvious cases, if the surgery we did made the difference.

I realize this can be a difficult part, and here is where the broken record comes in, get different opinions.
In the case of fibroids, opinions from high-risk obstetricians are very helpful. These are the doctors who take care of women with problem pregnancies, and they have a good understanding of the possible risks associated with fibroids.
I have found that these types of doctors are more comfortable with taking care of women with fibroids, but see that your doctors say.Next time we will talk about other conditions such as polyps and endometriosis.Of course any real opinions of you condition and options will have to come from your doctors. Dr. Licciardi



  • Fibroids:
    • American Association of Gynecologic Laparoscopists (AAGL): Advancing Minimally Invasive Gynecology Worldwide. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol. 2012 Mar-Apr;19(2):152-71.
    • Giatras K, Berkeley AS, Noyes N, Licciardi F, Lolis D, Grifo JA. Fertility after hysteroscopic resection of submucous myomas. J Am Assoc Gynecol Laparosc 1999 May;6(2):155-8.
    • 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 Apr;198(4):357-66.
    • Munro MG. Uterine leiomyomas, current concepts: pathogenesis, impact on reproductive health, and medical, procedural, and surgical management. Obstet Gynecol Clin North Am. 2011 Dec;38(4):703-31.
  • Endometriosis:
    • Marcoux S, Maheux R, Berube S, et al. Canadian Collaboration Group on Endometriosis. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Eng J Med. 1997; 377:212-22.
    • Jacobson TZ, Duffy JMN, Barlow D, Koninckx PR, Garry R. Laparoscopic surgery for pelvic pain associated with endometriosis. Cochrane Database of Systematic Reviews: 4, 2009.
    • Fayez JA, Vogel MF. Comparison of Different Treatment Methods of Endometriomas by Laparoscopy. Obstet Gynecol. 1991; 78: 660.
    • Gruppo Italiano per lo Studio dell’Endometriosi. Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial. Hum Reprod. 1999; 14(5): 1332.
    • Vercellini P, Chapron, C, Di Giorgi, O, Consonni, C, Frontino, G, Crosignani, PG. Coagulation or excision of ovarian endometriomas. Am J Obstet Gynecol 2003; 188(3):606-10.
  • Polyps:
    • American Association of Gynecologic Laparoscopists. AAGL practice report: practice guidelines for the diagnosis and management of endometrial polyps. J Minim Invasive Gynecol. 2012 Jan-Feb;19(1):3-10.
    • Rackow BW, Jorgensen E, Taylor HS. Endometrial polyps affect uterine receptivity. Fertil Steril. 2011 Jun 30;95(8):2690-2.
    • Bosteels J, Weyers S, Puttemans P, Panayotidis C, Van Herendael B, Gomel V, Mol BW, Mathieu C, D’Hooghe T. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update. 2010 Jan-Feb;16(1):1-11.
    • Varasteh NN, Neuwirth RS, Levin B, Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol. 1999 Aug;94(2):168-71.