Surgery for women wanting children
Fibroids in women wanting children
Fibroids – non-cancerous muscle lesions of the womb – are common. Nearly 40% of women will experience them at some point in their lives. For women having difficulty starting a family, it is often very unclear whether fibroids are the cause of this difficulty.
Not all fibroids cause problems, not all fibroids affect a woman’s chances of becoming pregnant and not all fibroids need to be treated.
Where do fibroids occur?
A distinction is made between fibroids in three different locations:
- on the outside of the womb (subserosal fibroids),
- in the muscle wall of the womb (intramural fibroids)
- in the womb cavity (submucosal fibroids)
Depending on their position and size, fibroids may or may not give rise to physical symptoms. Fibroids in the wall of the womb and in the cavity of the womb in particular often lead to increased menstrual bleeding (hypermenorrhoea).
Which types of fibroid cause fertility problems?
- Subserosal fibroids (fibroids on the outside of the womb) have almost no effect on fertility. Whether they need to be removed before getting pregnant depends solely on the symptoms experienced and on their size. They generally need to be removed only if they are very large (more than 7–8 cm in diameter).
- Intramural fibroids (fibroids in the muscle wall of the womb) can affect fertility and implantation of the embryo. It is now, however, clear that this depends on the size of the fibroid. Up to about 3–4 cm in size, intramural fibroids do not affect fertility.
- Submucosal fibroids (fibroids which grow into the cavity of the womb) are likely to interfere with implantation of the embryo regardless of their size.
Which types of fibroids need to be removed?
If the sole issue is difficulty having children and a women is known to have fibroids, intramural fibroids larger than 3–4 cm in size should be surgically removed. This cannot always be carried out successfully using a standard laparoscopy, particularly where the fibroid is deep in the wall.
In this case, fibroids of this type are usually removed via an abdominal incision.
The da Vinci surgical technique is often an excellent option for this type of fibroid. It avoids the abdominal incision which would otherwise be required.
By contrast, fibroids in the cavity of the womb are removed using hysteroscopy. This is an outpatient procedure. It can be helpful to give a hormone treatment to down regulate the lining of the womb for this procedure.
Unless they are too large to be accessed using this technique, fibroids on the outside of the womb are usually easy to remove using a laparoscopy. Here too, the da Vinci® surgical robot offers advantages.
What other options are available for treating fibroids in women who would like to have children?
A range of new techniques for treating fibroids have been introduced over the last few years, but they are of only limited use in women who would like to have children.
Drug treatment using ulipristal acetate
This drug (Esmya®) significantly shrinks fibroids and will stop menstruation for the duration of treatment. It is only licensed for use for hormonal preparation over a 3-month period before planned surgery to remove fibroids. Used alone, it does not improve a woman’s chances of getting pregnant.
Uterine fibroid embolisation
In this procedure, which is carried out using x-ray visualisation, a catheter is advanced into the blood vessels supplying the fibroid and the blood vessels are then blocked. The area of abdominal tissue to which the blood supply has been blocked then slowly dies off. This technique is contraindicated in women who would still like to have children and also involves exposing the pelvic organs to some radiation.
Ultrasound (high intensity focused ultrasound; HIFU)
This new technique, which is being heavily promoted at present, involves destroying the fibroid using ultrasound, resulting in tissue dying off in the abdominal cavity. An MRI scan using a contrast medium is always required beforehand. This method is not suitable for use where there are a large number of fibroids or where there are pedunculated fibroids. The procedure is often carried out with the patient lying on their front in an MRI scanner tube and can take several hours. Long-term pain relief is often required following this procedure. The effect of this technique on fertility and subsequent pregnancies is not yet fully clear. This procedure is not covered by statutory health insurance policies.
Do fibroids grow during pregnancy?
A common reason for removing a fibroid is concern that it will grow rapidly during and could lead to complications with pregnancy. It is not possible to predict this and on its own this is not, therefore, a good reason for removing a fibroid. Fibroids which grow during the first trimester of pregnancy often shrink back down during the third trimester.
Removal of fibroids using the da Vinci® system
A new type of minimally invasive myomectomy, the da Vinci® myomectomy, combines the benefits of open and laparoscopic surgery. Using the da Vinci® surgical system, the latest in robot-assisted technology, uterine fibroids can be removed via small incisions with unmatched precision and control. Here are just some of the potential advantages of da Vinci® myomectomy over conventional open abdominal surgery:
- chance of getting pregnant in future
- significantly less pain
- lower blood loss
- fewer complications
- less scarring
- shorter hospital stay
- quicker resumption of normal daily activities
The da Vinci® myomectomy is performed using the da Vinci® surgical system, which enables the surgeon, irrespective of the size and position of the fibroids, to perform a minimally invasive, but nonetheless remarkably precise, extensive repair to the wall of the womb. The da Vinci® system offers a unique degree of controllability, facilitating extremely precise and meticulous repair of the wall of the womb and helping to prevent tearing of the womb in the event of future pregnancy.
Endometriose / Adenomyose
In endometriosis, tissue which normally grows in the lining of the womb is found growing outside the womb. This tissue can attach itself to the ovaries, fallopian tubes, gut or other parts of the womb. Sometimes this tissue even grows outside the pelvis.
During menstruation, this tissue thickens just like the normal tissue in the womb. This swelling and bleeding can lead to inflammation of neighbouring tissues, resulting in pain and cramps. Persistent irritation can eventually lead to scarring. These areas of scarring are known as adhesions. These adhesions can cause organs to grow together, resulting in additional pain or other symptoms. Adhesions can also reduce a woman’s chances of getting pregnant or result in complications during pregnancy. In other words, adhesions caused by endometriosis can lead to infertility.
Endometriosis is one of the most common conditions suffered by women.1 Symptoms generally occur between the ages of 30 and 50, but can arise in any menstruating woman. The precise cause of endometriosis is unclear – there are a number of theories. Unfortunately, endometriosis cannot be cured at present, but a range of treatment options are available for the pain it causes and potential infertility.
Common symptoms of endometriosis
One or more of the following symptoms may occur in endometriosis:
- cramps and painful periods
- pelvic pain
- pain during sex
- infertility – difficulty getting pregnant (endometriosis)
Stages of endometriosis
Endometriosis can be divided into the following stages: minimal (I), mild (II), moderate (III) or severe (IV). Staging depends on the number, size and location of the endometrial lesions. Other staging factors include the extent of adhesions and pelvic organ involvement. The stage of your disease does not necessarily correlate with the pain you experience. Even mild endometriosis can cause severe pain.
The da Vinci® endometriosis resection
The da Vinci® endometriosis resection allows your surgeon to remove deep penetrating or widespread endometrial tissue without removing the womb. In contrast to conventional open or laparoscopic surgery, the da Vinci® endometriosis resection offers the additional benefits of computer and robot-assisted technology aimed at minimising the risks of endometriosis reoccurring.
The da Vinci® endometriosis resection offers women a range of potential benefits compared to conventional techniques:
- less blood loss1
- lower conversion rate compared to open surgery1
- lower complication rate1
- shorter hospital stay1
- small incisions, resulting in minimal scarring
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