Fibroid Removal Surgery :
In-Vitro Fertilisation (IVF)
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What are the Fibroids?
Fibroids are non-cancerous tumors, which arise from the smooth muscle cells of the uterus. They are solid as opposed to cystic and vary widely in size. Often they are microscopic. They can also grow to the size of a beach ball.
All fibroids originate from the wall of the uterus. The direction in which fibroids grow determines what type they are, and what sorts of symptoms they may cause.
What Are the Symptoms of Fibroids?
Any woman can get fibroids, but some women are more likely candidates than others are. Fibroids most commonly appear during the years in which women produce estrogen and progesterone, in other words, the reproductive years. During the third and fourth decade of life is when most women develop symptoms as a result of their fibroids, but some women continue to have problems even after menopause. Many women assume (and bank on) that their fibroids will disappear after their periods stop. They generally don’t, but usually stop growing, and over time, eventually shrink.
Symptoms from fibroids vary widely, from women who have no symptoms at all, (the majority); to women who feel the fibroid is controlling their life. Typical problems in symptomatic women include:
- Pelvic Pressure
Large fibroids can push on the bladder, rectum, or cause abdominal distention. Many women can feel their own fibroids just by resting their hand on their belly. Many women are unaware of pressure symptoms due to their gradual onset.
Pain can result from degeneration of a large fibroid in which a portion of the fibroid outgrows its blood supply and dies. This is more common during pregnancy when fibroids grow quickly. Heavy menstrual bleeding also causes pain. The uterus contracts (cramps) in an attempt to expel the clots caused by the heavy bleeding.
- Pregnancy Problems
One-third of women with fibroids who become pregnant experiences significant growth, particularly in the first trimester. This is actually when many women first become aware that they have fibroids.
Fibroids can certainly impact on fertility, particularly if their location blocks the fallopian tube or prevents implantation from submucosal fibroids impinging on the uterine cavity. This is a problem which has increased in magnitude due to the number of women who delay pregnancy until their 30’s or 40’s, giving their fibroids extra time to grow.
How are Fibroids Investigated?
Fibroids are often diagnosed and discovered on pelvic examination, where the uterus feels larger than expected with hard round lumps felt arising from the surface. Ultrasound scan can tell where the fibroids are located and give an idea of their size. Sometimes they are detected on laparoscopy (looking into the abdomen with a small telescope) or hysteroscopy (looking into the uterus with a fine telescope). Hysteroscopy is particularly useful for seeing the submucous fibroids and assessing how much of the uterine cavity is involved.
Surgery is the standard treatment for fibroids that are causing pain, heavy or lengthy menstrual bleeding, or other problems. There are many treatment options available depending on the particular patients condition and age:
- Hysteroscopic resection
- Laparoscopic surgery
Hysterectomy is the surgical removal of the uterus (and usually of the cervix as well). It is the most common treatment for fibroids. Three out of every 10 hysterectomies in the United States are performed because of fibroids. Currently, hysterectomy is the only permanent cure for fibroids. However, a woman cannot become pregnant or carry a baby after having a hysterectomy.
Hysterectomy is often considered when the uterus reaches the size it would be at 12 weeks of pregnancy. In the past, many doctors recommended a hysterectomy because they feared that such large fibroids could hide the presence of cancer of the uterus.
Now, however, tests such as ultrasound and MRI can be used to see whether a fibroid is growing rapidly (a sign of cancer). Increased use of these tests has reduced the number of hysterectomies performed for fibroids.
How is a hysterectomy performed?
A hysterectomy is usually performed through an incision in the abdomen. Sometimes the ovaries are removed in addition to the uterus and cervix. The decision to remove the ovaries depends on the woman's age and on whether the ovaries are diseased. (The ovaries are responsible for producing hormones such as estrogen. After menopause, however, the ovaries produce much less estrogen than they did before.)
What is a vaginal hysterectomy?
Sometimes, for smaller fibroids, the uterus can be removed through the vagina. This is known as a vaginal hysterectomy. After a vaginal hysterectomy, the only stitches are inside the vagina. The body absorbs the stitches in four to six weeks.
Occasionally a surgeon will perform a vaginal hysterectomy assisted by laparoscopy. This is called a laparoscopic-assisted vaginal hysterectomy.
What are the risks of a hysterectomy?
Like all operations, a hysterectomy has risks. These include:
- Infection requiring treatment with antibiotics (1 in 5 women)
- Internal bleeding (hemorrhage) requiring a blood transfusion (1 in 15)
- Injury to other pelvic organs such as the bladder, bowel, or ureters (less than 1 in 100)
death (1 in 2,000)
What happens after a hysterectomy?
A woman usually stays in the hospital for two to five days after an abdominal hysterectomy. Full recovery usually takes about six weeks. Women are generally advised to avoid driving and heavy lifting for two to four weeks after surgery. Light exercise may begin after four weeks. Vigorous exercise and sexual intercourse should be avoided for six weeks after surgery.
After a vaginal hysterectomy, a woman may stay in the hospital for two to four days and recover fully in three to four weeks. She can expect to have a light-brown vaginal discharge for about six weeks after surgery. Women are usually advised not to have sexual intercourse for six weeks after a vaginal hysterectomy. Intercourse should only resume after the surgeon has examined her vagina to assure that it has completely healed.
Myomectomy is the removal of fibroids without removing the uterus. This operation preserves a woman's ability to bear children. However, a successful pregnancy is not guaranteed. Only 4 or 5 out of 10 women become pregnant and give birth after a myomectomy.
Heavy bleeding can occur when the fibroids are removed. A woman is more likely to need a blood transfusion after a myomectomy than after a hysterectomy. She is also at higher risk for problems such as infection and blood clots in the legs.
Fibroids may grow back after a myomectomy, and another operation may be needed later to remove them. The risk of regrowth is related to the number, not the size, of fibroids removed. If more than three fibroids are removed, the risk of regrowth is about 50-50.
How is a myomectomy performed?
Like a hysterectomy, a myomectomy is usually performed through an incision in the abdomen. The risks and recovery time are about the same as for a hysterectomy. Sometimes a myomectomy can be performed with the assistance of a laparoscope or hysteroscope.
Why can it be difficult to become pregnant after a myomectomy?
When the uterus heals after surgery, scarring can occur. Scars may cover the ovaries or block one or both of the fallopian tubes (the tubes through which eggs travel from the ovaries to the uterus). Scarring can make it impossible for the tubes to pick up the eggs after their release from the ovaries (ovulation).
A woman who becomes pregnant after a myomectomy may be advised by her doctor to have a cesarean section without going into labor. This is because the surgery can weaken the wall of the uterus. The doctor may be concerned that labor contractions could tear or rupture the wall
A thin telescope or hysteroscope is inserted through the cervix. As it allows the surgeon to see inside the uterus, the fibroids can be removed using a laser, electrical knife or wire. It does not require any incision.
The procedure is performed under general or local anesthesia.
Under this procedure the fibroids are made to shrink as the blood supply is cut off. Using an X-ray image, a small catheter is threaded through a tiny incision in the groin into the main arteries that supply blood to the uterus. Small particles of plastic are inserted through the catheter to block these blood vessels. Because smaller arteries continue to be connected to the uterus, there is no damage caused. This is all done under local or general anesthesia. The procedure takes an hour.It is necessary to lie flat on the back for 6-7 hours after the surgery to stop the bleeding from the incision. It would take a week to recover completely during which some patients have fever.
Under this form of surgery a pencil-thin surgical telescope called laparoscope is inserted through one or more tiny incisions in the abdomen to remove the fibroids.
Laparoscopic myomectomy is used for small and easy to reach fibroids and an incision in the uterus is made to remove them.
Laparoscopic myolysis is a procedure used for bigger or difficult to reach fibroids. A laser or electric needle is used to destroy or shrink them.
Certain drugs called Gonadotropin releasing hormone agonists (GnRH agonists) can also be used to treat fibroids.They indirectly block production of estrogen which shrinks the fibroids. Once the size of the
fibroids is reduced to one thirds,it is easier to remove them through vaginal hysterectomy or laparoscopic surgery ,rather than abdominal surgery which is more complicated. It can also be used for women close to menopause as fibroids shrink naturally after menopause. It is available as Lupron (leuprolide),Synarel (nafarelin) and Zoladex (goserelin)
Disadvantages and side effects of these drugs are:
If these drugs are consumed for more than 6 months, it causes bone loss leading to osteoporosis or joint pain.
Once the drug consumption stops, the fibroids grow back.
Most women stop having menstrual periods during the period of drug consumption.
This drug has a similar effect as menopause, hence causes all problems that are seen during menopause such as Hot flashes,vaginal dryness ,irregular vaginal bleeding ,mood swings and low sex drive 2.To reduce heavy bleeding due to fibroids, Progestogen or Androgens are also given as synthetic hormones. But they do not shrink the fibroids. Sometimes GnRH agonist is prescribed in combination with a low dose of estrogen or progestogen, which reduces the side effects of GnRH agonists.
Can I take birth control pills if I have fibroids?
Birth control pills contain estrogen. Higher levels of this hormone may help fibroids to grow, although exactly how this might happen is not understood. Some doctors are concerned that taking birth control pills may cause fibroids to grow. Most birth control pills prescribed today contain low doses of estrogen that are unlikely to help fibroids grow. However, if a woman who has fibroids starts taking birth control pills, she should see her doctor after three to six months for an examination to find out whether her fibroids have grown.
Can Fibroids Lead To Cancer?
In most women, fibroids do not lead to cancer. Rarely, however, fibroids can turn into a cancer called a leiomyosarcoma. This happens to an estimated 1 in 1,000 women who have fibroids. Some cancerous tumors may develop directly from normal tissue in the uterus. The average age of women with leiomyosarcoma is 55.
Warning signs of cancer may include:
If a woman has either of these problems, she should see a doctor right away.
- Rapid growth of the fibroids or the uterus
- Vaginal bleeding after a woman has passed menopause.
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