So Who Really Needs Infertility Surgery?

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

 

References:

  • 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.

13 responses to “So Who Really Needs Infertility Surgery?”

  1. Anonymous says:

    Hello Dr.Licciardi,

    What is your suggestion on using “Fertility Blend” as a supplement while trying to conceive naturally. We have been TTC naturally for quite sometime now, we have had all the tests done at a fertility clinic and all results are normal. We do want to give it some more try before going in for IUI or IVF.

    Thanks.

  2. John says:

    Is infertility or infertility problems and fibroids are connected to each other?

  3. Jenny says:

    I look forward to reading your post on polyps. This is an interesting insight into infertility surgery. Its always a tough call to make in a situation where the woman has a small fibroid as it could be harmless in terms of conception..but who can be sure? Thanks for sharing.

  4. keith says:

    Nice post,and very well explained with examples. i have always been in favor of natural ways to cure various problems which prevent couples to conceive. Great post!

  5. SaintDimas says:

    This comment has been removed by the author.

  6. Crystal says:

    Very interested to read your opinion on polyp resection, as I’m dealing with a 17mm x 17mm polyp…about to have the hysteroscopy w/ a possible lap depending on hsg results due to history of stage III endo.

    There is a possibility it’s a fibroid, of course. While I don’t know if it was a factor, or if it was even there at the time, I gave birth at 25 weeks during my last pregnancy. In my case, I definitely want the thing in a jar. 🙂

  7. Anonymous says:

    hello dr Licciardi.
    I did found your blog when I was seaching info about fsh levels. I live in sweden and we did get a good dr to help us after 1 year of trying to conceive a baby. he is expert on womens health down there;)
    i did take 2 fsh tests… one in janyari day 2 .fsh 9.2 and one in may day 3.. i hade normal prolaktin 16 and progesteron 35 day 21. my husbands spermtest was normal too..
    i have read much about fsh levels on te internet mostly written by dr in uk and usa..
    what du you think about a fsh lever of 9.4 day 3? is it inpossible to get pregnant by our selvs?we have tried over a year and nothing is happend.. our dr said that fsh is normal but many dr here in sweden does not know so much about fsh or they dont care som much about it..
    i have normal cycle 28 and have ovulation day 14 every month. i did eat birthcontrol pills for 13 years…
    my dr says that he can give me clomid this autumn if nothing happend… do you think that will help me if i already have my own ovulation
    thank you for a helpful site.
    //heidi from sweden

  8. Anonymous says:

    Hi Dr Licciardi

    Thank you for your wonderful blog!

    I’m currently contemplating a first IVF cycle and I really wanted to know if I am wasting my time – am I going to have a better chance of pregnancy with IVF than going it alone???

    TTC for 3 years, all bloods normal, hycosy clear, uterine biopsy showed borderline NK cells, karyotype normal, I ovulate every month confirmed by charting, normal periods every 28-32 days. My husband has 400m sperm, 11% morph, 2% DNA frag, all else normal including karyotype.
    We have had one MC in the last three years. I’m 36 yo in Australia.

    I’m really just finding it hard to get my head around the fact that we have such good results but cannot acheive pregnany.

  9. Sally says:

    Getting pregnant naturally is very possible. I got pregnant naturally at ages 39 and 41 and now have two beautiful sons. Don’t know about Fertility Blend, but FertilAid has many success stories. Here’s my fertility success story

  10. kavitha says:

    Very useful information…Thank you Dr.

  11. moni kumari says:

    Thanks for your nice posting!!keep it up!!
    I’ve been using OVULATION TEST KIT for a long time and I still get butterflies when that little smiley shows his face. 🙂 I got one from the internet by searching on Google HOME CHECK Ovulation Kit it was great!

  12. JM says:

    Hi Dr,

    I have been reading your blog for a long time, and have found myself on a crossroad so have called your office to schedule a second opinion phone call (since I live in FL) and your nurse advised that you do not do them anymore :(…. I will really appreciate your advise.

    I am 31 years old, DH is 32. We have been together forever and never being pregnant. I had a septum that was corrected through laparoscopy a year ago, where Dr. found stage 3 endometriosis. After that, no pregnancy, so we did 4 IUIs with no results, and then moved on with IVF. Now we have 2 failed IVF with 0 embryos to transfer on day 5 on neither. If you see the IVF pictures, my eggs are not the best looking. We have a good/fair fertilization and I estimulate really good (20 and 18 egss). Did ICSI the first time but not the second. The issue is that embryos do not develop well enough to get to 8 cells on day 3. Only few of them get to this stage, and start arresting after that. My Dr. does not assure if it is an egg or sperm isuue (although DH’s sperm rocks) and suggested that we move to DE or try with another sperm to crosscheck.

    Both IVF cycles were antagonist protocol, and my AMH levels are not the best for my age but not bad. Should we give it another shot with lupron long protocol, and expect a twist on the results, or should we give up and move to a donor cycle? What is your opinion , is our case egg quality or sperm? Thanks in advance for your time!

  13. mk sharma says:

    Nice Posting! Keep it up!!Main Problems Faced by Women Trying to Conceive.First you must determine the length of your menstrual cycle from ovulation calendar, which commences on the first day of bleeding or spotting and ends on the day before your next period starts.
    I’ve been using OVULATION TEST KIT for a long time and I still get butterflies when that little smiley shows his face. 🙂 I got one from the internet by searching on Google HOME CHECK OVULATION KIT it was great!

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