SART Fertility Experts - Fibroids and Fertility

The information and opinions expressed in this podcast do not necessarily reflect those of ASRM and SART. These podcasts are provided as a source of general information and are not a substitute for consultation with a physician. Welcome to SART Fertility Experts, a podcast that brings you discussions on important topics for people trying to build a family.

Our experts are members of SART, the Society for Assisted Reproductive Technology, an organization dedicated to ensuring you receive quality fertility care. Hello, my name is Brooke Rossi and I am a practicing reproductive endocrinologist and infertility specialist in Columbus, Ohio. We will be doing a podcast today on uterine fibroids and fertility.

We have Dr. Elizabeth Stewart with us today. She is a practicing reproductive endocrinologist and infertility specialist at the Mayo Clinic in Rochester, Minnesota. She is a professor in the Department of Obstetrics and Gynecology at the Mayo Clinic School of Medicine.

She is an expert in diseases of the uterus, specifically uterine fibroids. She has contributed greatly to research on uterine fibroids, addressing many aspects of the condition, including genetics, treatment, prevention, and cost. The SART podcast series is thankful to have Dr. Stewart joining us today to discuss uterine fibroids and fertility.

So Dr. Stewart, maybe we can just start by talking about what uterine fibroids are. Okay, so uterine fibroids are gross inside the wall of the uterus. That they can be as small as a penny or they can be as large as a basketball and they tend to cause certain symptoms for women and the most common symptoms are heavy or long menstrual periods, pressure or discomfort because the uterus is enlarged like it can be when a woman is pregnant and there's increasing data that they're also related to painful periods and also maybe pain between periods.

Okay, so I've had patients come to me and say that their doctor has diagnosed them with a mass in their uterus and a lot of people mass equals cancer and so they get really nervous about that. So are fibroids the same thing as cancer or can fibroids become cancer? Well, fibroids are rarely ever cancer. The problem is sometimes when you do see a mass in the uterus you don't know whether it's a typical fibroid or rare cancer but for most reproductive age women, women in their 20s, 30s and 40s, it's much, much, much more likely that it's going to be a fibroid and especially if you're having fibroid related symptoms.

Perfect and so most people who are reproductive age, so women between the ages of maybe 20 and 50, most of them aren't going to have cancer if they're told they have a fibroid. Absolutely, absolutely. Okay, and how common are fibroids? Well, they're extremely common and that's one of the big issues.

The study suggests that white women have up to a 70% chance of having a fibroid within their lifetime and for black women it's more like 80% and so many, many women will have a fibroid during their lifetime and a pretty good percentage of those women will have fibroid symptoms but some women have fibroids, they never cause them any problem and they never have to take any action. Okay and so you did mention that there's a little bit of a racial difference in maybe the rates of fibroids. Are there any other women that are more prone to have fibroids? Do they run in families or anything like that? So there is some data that fibroids do run in families but being of African descent really not only increases your risk of fibroids, it causes you to be more likely to develop fibroids at an earlier age and also is associated with more severe fibroid symptoms.

So black women have multiple risk factors that make fibroids more of a problem for this group. Now for Asian women, Latino women, there's not a lot of research. The current research suggests that fibroids are not more likely in these groups but that research is really based on a small number of women.

So I think we've got more research ongoing to understand global risk. Okay so definitely an area that we need to look more into. How is it that most patients are told they have fibroids? Are they found with any specific type of testing like ultrasound or CT scans or anything like that? So the two most common things that cause a woman to find out she has unsuspected fibroids are either a pelvic exam.

If your doctor's doing a pelvic exam and feels a lumpy or bumpy uterus that sometimes indicates that there may be fibroids because when the fibroids are on the outside of the uterus it feels irregular. Do people ever feel them themselves? Oh absolutely and sometimes they don't even know what it is. They come in and say I've got something over here on my right side or I'm feeling something funny.

But I would say probably the most common thing is an ultrasound. So you may even be getting an ultrasound for an ovarian cyst or during a pregnancy and you may be told oh gee you have a fibroid too. And again many women have asymptomatic fibroids so just knowing it's there doesn't make you need to do something.

But if somebody tells you you have a fibroid and you go oh yeah maybe that's why I have nine days of my period every month or maybe that's why I can't fit into my clothes anymore. I've had to change the size of my pants in the last year. It prompts you to kind of say gee maybe this is related to something I'm experiencing.

Okay and it sounds like I mean you've mentioned over the course of our talk so far some different symptoms that people have. They may have heavy bleeding. They may have that their waist may start to increase in size.

Some pain. Any other big common symptoms that people have? What do patients come to you and complain about the most? Well I think by the time people come to me they've already had an assessment of their symptoms and they're likely linked to fibroids. But sometimes women are told by their primary care provider that they're anemic and again anemia in older people is associated with colon cancers and other things and nobody may even think gee are her periods heavy could she have fibroids.

Exactly. Sometimes you have bowel or bladder problems because there's a specific fibroid pressing on your bladder. I had one woman who came in who was on her way to hip surgery before someone realized she had an enormous fibroid pressing on her right hip and so the anatomy of the uterus really can affect specific symptoms.

So the fibroids can be in any part of the uterus and they can be large so they can press on either the bladder or they can press on the bowel or they can press on nerves creating all different types of symptoms it sounds like. Back pain, sciatic pain. Now a lot of those symptoms like back pain and sciatic pain are common and fibroids are common so you might have back pain and fibroids but the fibroids may not be causing the back pain.

But I think particularly in a young woman who has heavy menstrual bleeding, prolonged periods, anemia, specific bowel or bladder dysfunction trying to say are fibroids related to this problem can be important. Okay how do the fibroids change over time? Do they always grow and get worse? Do they stay about the same? Yeah so that's actually interesting because many gynecologists don't even know this but studies suggest that about a third of fibroids will stay the same size for a prolonged period of time. About a third will shrink and about a third will grow.

Now gynecologists see the third to grow the others may not ever even walk into their office so that misperception is based in reality. But the other important thing is that many studies are showing that even when women seek information they may not get good feedback. For example since fibroids run in families if you ask your mom is having nine days of your period okay she may say sure that's what's always been the same for me and your sister.

And so that many women may have fibroids and fibroid symptoms for a prolonged period of time and not bring it to someone's attention. Okay we hope you're finding this episode of SART Fertility Experts helpful. Remember for more information on this and related topics visit www.sart.org and click on the tab labeled patients.

And now back to SART Fertility Experts. A lot of our listeners may be women that are interested in getting pregnant and may also have been told that they have fibroids. So I think the two questions I have that I wanted to discuss are how do fibroids affect pregnancy and then also how does the pregnancy affect fibroids? Okay so I think that's a complex question and there's actually some new research that may be changing what we're thinking about fibroids in pregnancy.

Many women with fibroids get pregnant and carry pregnancies without any trouble. But there is some data to suggest that if the inside of the uterus is distorted by what we call a submucosal fibroid, many women will have trouble getting pregnant or maybe an increased risk of miscarriage. And a submucosal fibroid is a fibroid that's a little bit coming into the inside of the the cavity.

Sometimes a little bit and sometimes it's sitting in the middle of the uterus like a golf ball. So that and the good news is that those fibroids are much easier to remove through minimally invasive surgery. So I think if a woman is getting pregnant or having trouble getting pregnant and one of those fibroids is found, then removing it is rather straightforward.

So can those fibroids affect fertility then also? They can and so again usually part of an infertility evaluation is to look at the uterus. You don't want to leave out the other steps and not assess is a woman ovulating and does her partner have sperm because focusing just on the fibroids prematurely can lead you in absolutely the wrong direction. Right because what you're saying is many of those women probably may get pregnant easily be told that they have fibroids and they didn't even know they had them.

Exactly. So we have to be careful about over diagnosing them and treating them maybe prematurely. And that's one of the areas the new research is going in.

One big study that looked at the association between fibroids and miscarriage found that neither the size nor the position of the fibroid affected miscarriage. The real risk factor was increasing age. We know increasing age is increased are associated with an increased risk of miscarriage and we know that fibroids are associated with increasing age up until menopause.

So maybe the fibroids are just innocent bystanders in some pregnancy and miscarriage related issues. Exactly. If a woman conceived easily and had a fibroid, does that fibroid change during pregnancy? Does it grow or cause her any symptoms? Sometimes they can grow but again some fibroids are stable through pregnancy.

There's also a number of pregnancy complications that are associated with fibroids. So generally women with fibroids may be monitored more carefully during pregnancy. But one of the good things is there is some data to suggest that after pregnancy as the uterus grows from being capable of carrying an eight pound baby to going back to the size of a pair, that sometimes gets rid of small fibroids.

So the best thing women can do to decrease their risk of future fibroids is to have a successful pregnancy. Okay and we'll talk about different surgical or different treatments for fibroids in a minute but I think one of the big questions that our listeners may want to know is do their fibroids need to be removed before they do their infertility treatment or IVF? Or maybe a better question is which types of patients do we know may have a better result by having their fibroids removed before they do their infertility treatment? Yeah so I think that's a really tough one and I know that there's not a lot of data. I think in the United States still most fertility specialists would recommend removing those fibroids that are sitting on the inside of the uterus before proceeding to fertility treatment.

But in the U.S. we're much more aggressive about removing fibroids prior to fertility treatment and that may be a bias of our funding system that in other countries where IVF and fibroid surgery are both paid for by the health system, many more women will go to fertility treatment without fibroid surgery. Here where many people are paying out of pocket for fertility care there does seem to be a bias to using your insurance to remove the fibroids to optimize your fertility care. But there's not a lot of good data on that.

Okay so that's definitely a hard question to answer for some of our patients and they should probably speak with their fertility specialist about their specific cases. Let's talk a little bit about how fibroids are treated. Do they always have to be surgically removed and what are those surgical options and are there any other options besides surgery that exist? So we're lucky that there are now more alternatives to hysterectomy and I think everybody should have an alternative to hysterectomy.

So I think if you're told there's no other option that's the time to to seek a second opinion. And that there are both medical and surgical or interventional alternatives to hysterectomy for fibroids. Some women will do fine with medications like a hormone releasing IUD or birth control pills.

There are some medications you can take just during the heavy days of your period to decrease bleeding. So for the woman that has heavy bleeding alone medical care can be an option. There are a couple of surgical alternatives to hysterectomy where the fibroids are removed called a myomectomy.

And that can sometimes be done with telescopes or sometimes through a bigger incision. And there's also a couple of interventional techniques where you can use a laser fiber during laparoscopy. Or you can use little pellets that are delivered through a catheter.

So more like you're having a cardiac catheterization called a uterine artery embolization. Or there are a couple of techniques that use sound waves to destroy fibroids. So there are a number of alternatives to hysterectomy and some of them simple enough that you're only out of work for a couple of days.

And when what options would be available to women who want to have more children? Yeah so again most people find that removing the fibroid surgically through a myomectomy is probably the optimal option because we've used it for a hundred of years. But that being said techniques like uterine artery embolization and focused ultrasound and radiofrequency ablation all have women who've successfully gone on and had pregnancies and deliveries. Great okay.

Now as somebody who's worked in this field for many years where do you see the field of fibroid research going? Any new research you're excited about or treatment options that are on the horizon? Well I think that's what's really exciting is that there are some treatment options that are becoming available. There are some drugs that are available outside the U.S. that block the hormone progesterone that appear to be effective medical therapy for fibroids. They're not available here yet but hopefully in the next couple of years they will be.

They're called progesterone receptor modulators. And then there's another class of drugs called oral GnRH antagonists. And there are several clinical trials ongoing that are showing exciting results for these medications.

Great thank you so much. And again this is the SART podcast series and we had Dr. Elizabeth Stewart with us from the Mayo Clinic in Rochester Minnesota. Thank you so much Dr. Stewart for talking with us today about fibroids and fertility.

Thanks for the opportunity to speak. Thank you for listening to SART Fertility Experts, your resource for information on IVF. If you found this podcast useful please like us on your favorite social media platform and tell your friends about us.

For more family building resources visit www.sart.org patient-information or www.reproductivefacts.org