What are fibroids?

Uterine fibroids, also known as leiomyomas, are non-cancerous tumors of the womb or uterus. These tumors start in the myometrium(muscle) of the uterus. They occur in nearly half of all women over the age of 30 and this too may be underestimated as fibroids have been found in 77 per cent of uteri removed for reasons other than fibroids.

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What causes fibroids?

Fibroids only occur after puberty and shrink after menopause. The female sex hormones such as oestrogen and progesterone are most likely involved in tumour growth. However, other growth factors as well as some genetic factors may also be involved. Though the causes are not known , women who have never had children, or are obese are particularly at risk.

It is difficult to know if fibroids run in families as they are so common. Women who have used the combined oral contraceptive pill or other drugs as contraceptive agents are protected against developing fibroids.

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Are Fibroids Cancerous?

Fibroids are non cancerous. Cancer of fibroids (leiomyosarcoma) is very rare and begin as cancers Benign tumours do not transform to malignant ones.
• Fibroids occur in more than 25% of women over 30 years of age.
• Commonest cause for hysterectomy in women under 50 years.
• Growth of fibroids depends on oestrogen and progesterone.
• Benign fibroids do not become cancerous.

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Symptoms Of Fibroids

• Heavy Periods (Menorrhagia) - Heavy periods occur in 30 per cent of women having fibroids .Tiredness, weakness and emotional changes may occur secondary to the anaemia which results from the excessive blood loss.
• Bowel and Bladder Symptoms - Pressure caused by the fibroids may result in bowel and bladder symptoms Rarely complete blockage of urine may occur requiring a catheter to be passed.
• Lump or Bloating - Discovery of a lump in the abdomen and / or distension of the abdomen may be the fi rst change noticed. The distention may be partly due to the fibroid, which is fi rm to feel, or bowel that is pushed and distended, which feels soft.
• Sexual Discomfort or Difficulty - If the fibroid (s) expand the uterus and take up considerable space within the pelvis full vaginal penetration may be prevented. This may reduce enjoyment for the female and male.
• Pain - Menstrual. Period pain(dysmenorrhoea) may be due to stretching of the uterus, or the response of trying to expel the fibroid , creating ‘labour like’ pains.
- Pressure on neighbouring organs. Back pain, or pain in the lower abdomen, may result from pressure on the spine, pelvic bones, nerves or tissue , bowel and bladder.

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Complications Of Fibroids

• Degeneration - Occasionally the blood supply to the fibroid is blocked and it undergoes degeneration resulting in swelling and release of chemicals which can cause severe pain.
• Twisting - The fibroid may grow outside the uterus and is connected to the uterus by a narrow stalk, may twist on itself and cause severe pain and tenderness.
• Infection - Rarely fibroids become infected, which usually occurs when they are protruding in the vagina or after childbirth.
• Cancer - They are very rare ,a cancerous fibroid is called ‘sarcoma’.. There may be no symptoms to distinguish a sarcoma from a simple fibroid. Sometimes a rapid increase in size may raise the suspicion of the presence of a sarcoma.

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Types of Fibroids, Symptoms & Progression

Even though 25 per cent of women above the age of 30 years have fibroids, only about half experience symptoms. Fibroids may be either single or multiple and may vary from being as small as a pea to as large as a football. Their site in the womb may also vary. They may be present within the cavity of the uterus (submucosal), within the muscle of the uterus (intramural), or in the outer layer and protrude from the uterus (subserosal).

• Submucosal fibroids - Submucosal fibroids protrude inwards into the cavity of the uterus and are commonly associated with heavy bleeding and may cause infertility.
• Intramural fibroids - Intramural fibroids begin as little lumps in the muscle of the uterus that grow, making the uterus larger and distort its shape. This type of fibroid may play a role in heavy periods and pressure symptoms.
• Subserosal fibroids - Subserosal fibroids grow and protrude from the outer surface of the uterus, vary greatly in size, and may be multiple.

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Fibroids and Infertility

Fibroids may reduce the chances of becoming pregnant in a variety of ways:
• By causing heavy periods and subsequent anaemia resulting in ill health and tiredness.
• Very large fibroids may bulge into the vagina and cause pain or discomfort during intercourse.
• Fibroids in the fundus of the uterus occasionally block the tubes preventing formation of embryos.
• Fibroids inside the cavity of the uterus may prevent implantation of the embryo.
• Multiple fibroids in the wall of the uterus reduce IVF success rates, perhaps by affecting the lining of the uterus andthe implantation of the embryo.
• Most fibroids do not need to be removed before attempting to become pregnant unless the fibroid is causing infertility.

• Fibroids in Pregnancy - Fibroids may not only make it diffi cult to get pregnant, but they may cause miscarriage, malnutrition of the foetus, abnormal position of the baby in the uterus, obstruction during labour requiring caesarean section, and bleeding after delivery of the baby.
- Most fibroids do not need to be removed before attempting pregnancy.
- Removal of fibroids before pregnancy may be required if they are large ,cause severe bleeding, grow rapidly, or protrude into the uterine cavity.

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Diagnosis

• Detection and Diagnosis - Clinical Examination: Fibroids are often diagnosed during vaginal examination by the gynaecologist at the time of a routine Pap smear/ general health checkup . Ultrasound: The best and least expensive test to diagnose the presence of fibroids .The addition of Color Doppler measures the blood fl ow and helps to determine the diff erence between fibroids, adenomyosis (endometriosis inside the uterus) and some cancers.
• Computerised tomography - CT is another method of assessing lumps and masses in the pelvis but is not as specific as ultrasound and is inferior in its ability to diff erentiate between the uterus and ovaries.
• Magnetic Resonance Imaging (MRI) - This sophisticated X ray is most the specific imaging for the female pelvis with precision, definition and accuracy . It may be helpful in distinguishing between fibroids and adenomyosis.
• Management Strategy - Management depends upon size of the fibroid, the position of the fibroid in the uterus, the age of the women, the desire to conceive, and the attitude to surgery. Symptoms of heavy bleeding, pain during periods, or pressure on the bladder, bowel and spine usually require treatment. The anemia due to the excessive bleeding can be managed by oral iron or intravenous iron sucrose therapy if oral iron not tolerated .
Fibroids which are growing in size may need treatment, as delay may increase the difficulty of surgery and lead to more extensive surgery. Most often fibroids up to 3 cm need not be treated unless they are in the cavity of the uterus.
In some circumstances it may be considered prudent to remove a fibroid even if it is not causing any symptoms, e.g. a symptom-free 7cm fibroid may be dealt with laparoscopically easily, whilst in a few years time if it doubles in size and causes symptoms the surgery is likely to be more complex.

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Prevention of Fibroids

• Weight control – reduction of obesity
• Early child-bearing
• Lactation
• Oral Contraceptive Pills

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Treatment

No Treatment may be required

- No symptoms
- Small fibroids
- After menopause
If no treatment is given regular ultrasonography should be done to monitor the growth of fibroids.

Treatment may be required

- Symptoms – heavy bleeding, pain
- Large fibroid in young women
- Rapid growth in fibroid
- Infertility related to fibroid
- Suspicion of cancerous fibroid (sarcoma)

Embolization of Fibroids

Embolization is a technique used by interventional radiologists, performed under local anaesthesia through a tiny puncture in the groin and branches of the uterine artery are blocked.
The fibroid shrinks because it is starved of blood. This may prevent it from producing growth factors which may disturb the mentstrual cycle. The shrinkage of the fibroid is slow and may take up to 3 months.

Shrinkage of fibroids before surgery

The shrinkage eff ect of GnRH analogues drugs is sometimes quite dramatic but is only temporary and may not be suffi cient to overcome the ill eff ects the fibroid on fertility. They can regrow in 3 to 6 months so the drug therapy maybe useful for postponement of surgical removal.

Removal of Fibroids (Myomectomy)

Myomectomy, the surgical removal of fibroids while preserving the uterus and its child bearing function is the defi nitive treatment .

Techniques of removal

• Hysteroscopic - Telescope via birth passage
• Laparoscopic - By Small Key Hole Incisions in the abdomen
• Laparo-hysteroscopic - By a combination of Hysteroscopy & Laparoscopy
• Laparotomy - By an incision in the abdomen

What is Hysterectomy?

Hysterectomy (removal of the uterus) is the second most frequent major operation performed on women next only to caesarean section.It is considered as the last option for benign conditions being offered only to women above the age of 45 years and who have completed their child bearing. Over the past several decades new developments have been made in the surgical approaches to hysterectomy The term laparoscopic hysterectomy is used to define various types of hysterectomy with a laparoscopic access to the abdominal cavity.

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Indications for Hysterectomy (Removal Of Uterus)

Benign Disease
- Leiomyomas: For symptomatic fibroids, hysterectomy provides a permanent solution to menorrhagia and the pressure symptoms related to an enlarged uterus.
- Abnormal uterine bleeding not responding to medical management. Endometrial lesions must be excluded preoperatively or by frozen section intraoperatively if indicated.
- Endometriosis: in the presence of severe symptoms with failure of other treatments and when fertility is no longer desired.
- Pelvic organ prolapse: in these cases , hysterectomy should include associated pelvic organ supporting procedures.
- Pelvic pain: A multidisciplinary approach is recommended. When the pain is confined to dysmenorrhea or associated with signifi cant pelvic disease, hysterectomy may offer relief.
Pre - Invasive Disease
- Hysterectomy is usually indicated for endometrial hyperplasia with atypia.
- Cervical intraepithelial neoplasia in itself is not an indication for hysterectomy.
- Simple hysterectomy is an option for treatment of adenocarcinoma in situ of the cervix when invasive disease has been excluded.
Invasive Disease
- Hysterectomy is an accepted treatment or staging procedure for endometrial carcinoma. It may play a role in the staging or treatment of cervical, epithelial ovarian, and fallopian tube carcinoma.

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Types of Hysterectomy

• Total Hysterectomy - Total hysterectomy which involves the removal of the uterus and cervix only; the ovaries and tubes are retained .
• Subtotal Hysterectomy - Subtotal hysterectomy where the body of the uterus is removed, but the cervix, ovaries and tubes remain.
• Total Hysterectomy With Bilateral Salpingo-oopherectomy - Total hysterectomy and bilateral salpingo-oophorectomy in which the uterus, cervix ovaries and tubes are all removed.

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Modes Of Hysterectomy

• Abdominal Hysterectomy - Abdominal hysterectomy is performed through a long abdominal cut which may be either horizontal incision just above the symphisispubis like for a Caesarean section, or vertical in the midline below the umbilicus (naval).
• Vaginal Hysterectomy - Vaginal hysterectomy is performed through the vagina and there are no cuts in the abdomen.
• Laparoscopically assisted vaginal Hysterectomy - Laparoscopically assisted vaginal hysterectomy The tubes and ovaries are separated laparoscopically, the vault is sutured vaginally and uterus removed through the vagina (like a vaginal hysterectomy).
• Total Laparoscopic Hysterectomy - Total Laparoscopic hysterectomy which can be done by multiport or single port depending on the size of the uterus, this involves complete separation of the uterus pedicles laparoscopically.
It is the most advanced and least traumatic mode but requires precise surgical skills, sophisticated endoscopy equipment and for advanced anaesthesia monitoring and management good patient outcome. Total laparoscopic hysterectomy (TLH) is currently accepted as a safe, efficient and acceptable alternative to standard abdominal hysterectomy . It offers a superior view of the anatomy, facilitates meticulous hemostasis, enables the surgeon to perform adhesiolysis effectively, and reduces morbidity associated with large abdominal incisions.

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Pre Operative Preparation

All patients need basic preoperative evaluation ,investigations and preparation.Admission is usually on the day of surgery Antibiotic prophylaxis and prophylaxis against possible thromboembolic episodes is used appropriately.

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Operative Procedure

TLH is performed under general anesthesia with advanced monitoring including spirometry, entropy (depth of anaesthesia), capnography, gas analysis, st analysis, in addition to routine pulse oxymetry and non invasive blood pressure monitoring.

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Surgical Steps

• The 10-mm port is inserted under vision avoiding damage to major vessels and viscera. The pelvis and the abdomen are inspected and any other pathology (endometriotic lesions, adhesions, ovarian pathology etc), if present, is tackled first. The course of the ureters is traced out at the start of the procedure. The size, site and the number of myomas if present are assessed. The surgery is performed through three five mm accessory ports.
• The uterovesical fold of peritoneum is identified and opened from the round ligaments on either side. The bladder is dissected down completely so that the uterine vessels on either side can be clearly seen. A window is created in the broad ligament close to the uterine vessels,the ascending branch of the uterine artery identified near the isthmus and ligated at this level close to the uterus, by transfi xation using 1-0 delayed absorbable suture material. The vasculature of the uterus is thus secured and this is evidenced by the color change in the fundus, which becomes pale.
• Bilateral cornual pedicles are then dessicated and cut either using bipolar diathermy or the harmonic ultracision. The ligated uterine pedicles are cut. The uterosacrals and cardinal ligaments are dessicated and cut.
• The vaginal vault is opened & the specimen is detached completely. If ovaries need to be removed, the infundibulopelvic ligaments are also desiccated and cut . The vaginal vault is then sutured with No. 1 delayed absorbable interrupted fi gure-of-eight sutures.
• The specimen is either delivered vaginally or retrieved by Morcellation. Peritoneal lavage is given with normal saline solution..Skin is sutured with absorbable subcuticular sutures .

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Recovery

Perioperative pain is managed judiciously so as to keep the patient pain free and comfortable. The urinary catheter is removed as early as possible and oral liquids started after peristalsis is established, usually within six hours. The patient is discharged the following day and called for follow-up after seven days.

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Discussion

Given adequate training in laparoscopic surgery and with proper technique, TLH can be performed successfully in most women.

Eventhough laparoscopic hysterectomy has been the subject of many controversial comments especially when it comes to large uterus and previous cesarean sections . In skilled hands, these patients could benefit from the advantages related to minimally invasive approach such as minimal blood loss, short hospital stay, prompt recovery, obtaining a satisfactory result. Compared with abdominal hysterectomy there is compelling evidence indicating that defi nitely provides specific benefits.

Total Laparoscopic Hysterectomy should be considered instead of laparotomy in all patients needing hysterectomy off ers minimal postoperative discomfort, shorter hospital stay, rapid convalescence, and early return to normal activity

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Myths about hysterectomy?

• Hysterectomy and menopause
If the ovaries are not removed, they continue to function and provide the oestrogen that skin, hair, bones, breasts and blood vessels need. If the ovaries are removed, hormone replacement therapy (HRT) can provide the necessary oestrogen. It should however be mentioned that hysterectomy may be responsible in some women for an earlier decline in ovarian function with the development of menopausal symptoms, such as hot flushes and night sweat, up to 2 years earlier than the average age of menopause.
• Sex life deteriorates after hysterectomy
Ninety per cent of women who have a hysterectomy find that sex is as good, if not better, than before the operation.
• Hysterectomy causes weight gain
If there is a tendency to gain weight before hysterectomy, that tendency will persist after surgery. It is important to remember that activity level and energy requirements will be reduced during recovery after surgery, and diet should be adjusted accordingly until normal activity is resumed.
• Pap smears need to be performed after hysterectomy
Unless the cervix has been retained, or there was an abnormal cervical smear test in the past, there is no need to continue Pap smears.

Infertility

Inability to have children is infertility after one year of regular unprotected coitus. Either Male or Female or both factors may be responsible for Infertility. About 15% of couples suffer from infertility. In a country like ours, infertility is not only a medical problem but a social one too. Today, advances in reproductive medicine have helped many couples become parents with Assisted Reproductive Techniques (ART). In July, 1978, Louise Brown, the world’s first baby was born by In-vitro Fertilization Technique (IVF). It changed management of infertile couples and brought hope and happiness to many childless couples. The problem of male infertility was conquered in 1992, with the world’s first baby being born with Intra-cytoplasmic Sperm injection (ICSI).

There are many different ways in which fertility treatment can be offered to patients and today with advances in ART, almost 80% of the patients can be helped with some form of Assisted Reproduction.

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Male Factors

In approximately 40% of the couples, male factor is the sole contributory cause of infertility. Hence a proper semen analysis is very important.Extended sperm function tests may be needed depending on the initial evaluation. A Testicular Biopsy may be needed in cases of azoospermia. Today, in cases of obstructive azoospermia, sperm can be retrieved directly from the testes and pregnancies achieved with ICSI suing PESA or TESA sperms.

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Female Factors

Approximately 40 % of patients are infertile due to female factors. The common causes of female factor infertility will need tests for proper evaluation. Hormonal profile, Uterine and tubal factor evaluation, Monitoring of a natural cycle for ovulation and ultrasonography for checking for other pelvic pathology along with basic routine hematology tests are needed for the evaluation of female factors.

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Investigations for infertile couple

Male Investigations
- Semen analysis and culture
- Routine basic hematology
- Testicular biopsy if Azoospermia

Female Investigations
- Routine basic hematology
- Baseline hormonal evaluation – on day 2/3 of period
- Natural Cycle Follicular monitoring by TVS
- Hysterosalpingography (HSG) or Hysteroscopy with laparoscopy and chromopertubation for uterine and tubal testing
- Ultrasound of the pelvis (USG): This is done to evaluate and identify any abnormality in the pelvis. In certain cases we may also need 3-D USG

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Infertility Treatment Options

• Simple forms of Fertility Management
- Ovulation Induction
- Ovulation induction with Planned Relations
- Ovulation induction with Intra-Uterine Insemination (IUI)
- Donor insemination

• Assisted Reproductive Techniques (ART)
- In-vitro Fertilization (IVF)
- IVF with Intra-Cytoplasmic Sperm Injection (ICSI)
- IVF with ICSI with Surgical Sperm retrieval (TESA or PESA)
- IVF with Ovum Donation
- IVF with Embryo Donation
- IVF with surrogacy

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In-Vitro Fertilization (IVF) & Intra Cytoplasmic Sperm Injection (ICSI)

What is in vitro fertilization (IVF)? - For many couples who have exhausted traditional clinical and surgical treatments for infertility, Assisted Reproductive technologies (ART) may offer the best hope for pregnancy. Through these procedures, women with otherwise untreatable infertility have given birth to healthy babies. IVF or In-vitro Fertilization means fertilization outside the body.In ICSI (Intra Cytoplasmic Sperm Injection), the sperm is directly injected into the egg.

IVF-ICSI – Indications - Absent or blocked fallopian tubes ( Previous tubal pregnancy or infections, STD, or Tuberculosis)
- Endometriosis
- Low sperm count or motility
- Absent sperm count due to obsturction
- Patients where all other treatments such as ovulation induction with intra uterine insemination have failed
- Unexplained infertility
- Advanced age
- Poor ovarian reserve
- Patients who want to become pregnant by the procedure of egg donation
- Patients who want to become pregnant by the procedure of embryo donation
- Patients who need surrogacy services for achieving pregnancy

Often husbands of patients undergoing treatment cycles may not be around at the time of the IVF treatment (due to the nature of their jobs eg:expats, staying and coming from abroad, sailors etc). In these cases the sperms are obtained earlier and frozen sperms are used for the fertilization procedure. Occasionally, in cases of male factor infertility, donor sperm is required and this can also be provided from a registered sperm bank.

Egg Donation
- Most ART centers will offer a comprehensive donor egg program. There are many circumstances where the female partner is unable to produce eggs or the egg quality is very poor. These patients can qualify for egg donor –recipient program.In egg donation, eggs are borrowed from a young woman (less than 31 yrs of age) called the donor, with her consent. These eggs are then fertilized with the sperms of the husband of the recipient woman and the resultant embryo is inserted into the womb of the recipient. The success rate of this procedure is in the region of 30 to 40%.
Surgical Sperm Retrieval
- In cases of azoospermia it is important ot evaluate if there is sperm production in the testes and if present, we can use these sperms by the technique of PESA (Percutaneous Epididymal Sperm Aspiration) or TESA (Testicular Sperm Aspiration). Hence, it is important that the testicular biopsy must be done at the unit where ART services are available so that if present the sperm can be frozen immediately for use in later cycle.

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Complications

There are only two main side-effects of IVF-ICSI treatment and they are both temporary.

• Ovarian hyperstimuationSyndrome(OHSS). This is usually seen in patients with Polycystic ovaries and is due to a hormonal stimulation. It occurs in about 0.5-2% of cases. The management is mainly by prevention. This is achieved by using low dose stimulation protocols. If it still occurs, the manangment is intensive monitoring and adequate hydration. In some cases, ascetic fluid tapping may be needed.

• Multiple Pregnancies – currently the rate of multiple pregnancy is about 20-25%. Most of them are twins, but some are high order multiple as triplets and quadruplets. This also occurs due to multiple embryo transfers. We have now started decreasing the number of embryos transferred to 2. With improving laboratory conditions and better culture systems, we are hopeful that we will soon transfer only one embryo and hence be able to decrease this incidence to less than 5%

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Success Rates

Most ART units should be able to offer success rates of about 40% in young patients. Average success rates are between 30-40% depending on the age of the patients, the cause of infertility and presence of other pelvic pathology.

With the availability of Assisted Reproduction in the form of IVF / ICSI many couples are able to achieve pregnancy and fulfill their dream of parenthood. It is a true miracle of medical science to see couples get pregnancies and see these babies grow. Since 1978, 3 million babies have been born with ART and the number is only increasing.