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Friday, 14 February 2014

Fibroids and Infertility

Bulk of the uterus is made of muscle fibres that run crisscross. These have the ability to relax and expand in the event of a growing pregnancy and the contractions of these muscles causes delivery of the baby. During menstruation the muscles contract (which is perceived as period cramps). Imperceptible contractions also occur at other times (especially around the time of ovulation) that aim at helping the sperms to move up towards the Fallopian tubes. This aids the sperms to reach the  tubes, where the fertilisation of egg can occur and later lead to a pregnancy.

Fibroids are harmless (non-cancerous) growths in the muscle wall of the uterus. These can be single or multiple, vary in size and may not be symptomatic. Depending on the location, fibroids are of three types: those that grow in the muscle wall (intramural), those that are growing towards and into the cavity of the uterus (submucous), and those that are growing outwards or on the surface of the uterus (subserosal). 

Various studies have quoted the overall incidence of fibroids between 5 and 21%. More than 80% of African American women and about 70% of caucasian women may develop fibroids by the time they are 50 yrs old. Indian women seem to be at a lower risk. Fibroids that impinge the cavity may interfere in implantation and thus cause infertility. Also those growing near the openings of the fallopian tubes may cause blockage. They may also cause interference with the contraction patterns in the uterine muscles. 

There is insufficient evidence pertaining to the role of operative intervention in improving fertility. As subserosal fibroids are the most innocuous, they may be left alone. Appropriate investigations such as 3-D ultrasound by an experienced radiologist may assist in deciding the best management. It is crucial to thoroughly counsel patient regarding the lack of sufficient evidence supporting surgery as well as potential complications such as emergency hysterectomy and blood transfusion. The patient should also understand that there is the possibility of scar tissue in the wall and in the cavity of the uterus which in turn may have an adverse effect on fertility. In short the evidence to decide the right management is lacking and the discretion of the doctor and patient wishes after thorough counselling should dictate the action to be taken. 

                    

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