The moderately increased risk of complications may suggest preventive surgery, but the decision must be made by evaluating several factors
Months ago I was diagnosed with uterine fibroid and I consulted some doctors, who offered me various therapies. I am very anxious because I would like to try to get pregnant soon. What is the best way to solve the problem without jeopardizing my ability to have a child in the next few months, or even in the next few years?
He answers Paul Vercellinidirector of the Gynecology Unit, Ospedale Maggiore Policlinico, Milan
Fibroids are benign tumors of the myometriumi.e. the muscle tissue it forms the uterine wall. They are very frequent nodular lesions in the reproductive period and their growth is stimulated by the hormones produced by the ovaries. The associated symptoms depend not only on their number and size, but largely on their location in relation to the uterine cavity. In general the more the fibroid develops towards the inside of the uterus, the more it causes abundant menstruation and miscarriages. Fibroids that form on the outside of the uterine wall tend to cause little discomfort, unless they are very large. When you combine the search for pregnancy and heavy menstrual flow or feeling of pelvic weight, the simple answer: fibroids must be surgically removed and if possible endoscopically, i.e. avoiding the incision of the abdominal wall.
Other minimally invasive techniques such as focused ultrasound, radiofrequency thermal ablation and uterine artery embolization should be considered with caution: the data available to evaluate potential benefits and harms in women attempting to conceive are currently limited. Some drug therapies (GnRH agonists and antagonists) reduce the size of fibroids but inhibit ovulation, thus preventing pregnancy. Furthermore, the chances of conception do not increase when they are stopped after use for a few months. GnRH analogues can then be employed only in the preoperative phaseto correct an anemic state and facilitate surgery.
The answer, on the other hand, is more difficult in the (frequent) cases of women with medium-sized asymptomatic fibroids that do not affect the uterine cavity. On the one hand, the association between fibroids and a moderately increased risk of some pregnancy complications (first trimester pain, miscarriage, untimely rupture of membranes, preterm birth, haemorrhage during delivery) could suggest preventive surgery; on the other hand, the choice to remove asymptomatic fibroids subjects the patient to inconveniences and risks in the absence of definitive evidence of efficacy and substantially delays the search for offspring: it takes at least six months after surgery to ensure good healing of the uterine wall and often requires us the cesarean section with each subsequent pregnancy.
The choice may prove to be even more complex in the case of in vitro fertilization pathways (Fivet)but the indication of the main scientific Societies of Reproductive Medicine of remove fibroids affecting the full thickness of the uterine wall and abstain from surgery for fibroids that grow exclusively outside the uterus. The gynecologist will then also have to consider the number of these lesions and their size. The decision must be shared with the woman after detailed information on the pros and consboth of myomectomy (the operation to remove uterine fibroids) and of surgical abstention, taking into account the patient’s priorities and preferences, as it is necessary to do whenever the available evidence does not clearly indicate a better choice than the other.
April 1, 2023 (change April 1, 2023 | 06:55 am)
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