Dr Sunita Tandulwadkar
Head of Department of Obstetrics & Gynaecology, Ruby Hall Clinic, Pune
Chief, Ruby Hall IVF
& Endoscopy Centre, Pune
Elected Board Member,
International Society of Gynaecological Endoscopist (ISGE) (2013-2017)
Joint Secretary, IAGE (2015)
Librarian, Indian Society of
Assisted Reproduction (ISAR)
Founder Secretary Maharashtra
Chapter, ISAR
Executive Vice Chairperson
Maharashtra Chapter ISARCo-Chairperson Research Committee
of ISAR
FOGSI Infertility Committee
Chairperson (2011-2013)
Reviewer, Fertility and Sterility
Advisor & Reviewer, Journal of
Human Reproductive Sciences.
MYOMA/FIBROID
What
is a fibroid/myoma?
Fibroids or myomas or leiomyoma are non cancerous smooth muscle cell tumours
arising from the wall of the uterus which are the commonest benign gynecologic
tumour seen in 20-50% women of reproductive age.
What are the different types of fibroids/myomas?
· Submucosal fibroids: Grow into and distort the cavity of the uterus.
· Intramural fibroids: Grow in the
muscle wall of the uterus without distorting the cavity.
· Subserosal fibroids: Grow on the outer most lining of the uterus away
from the cavity.
What are symptoms of fibroid?
Symptoms vary depending
upon size and location of myoma.
· Changes in menstruation pattern:
—Longer, more
frequent, or heavy menstrual periods
—Menstrual pain
(cramps)
—Vaginal bleeding
at times in between menstrual cycles
· Pain
—In the abdomen or
lower back (usually dull, heavy and aching)
—During sex or
menses.
· Pressure
—Difficulty
urinating or frequent urination
—Constipation
—Abdominal cramps
· Enlarged uterus and abdomen
· Recurrent miscarriages
· Infertility
How do fibroids
cause infertility?
- Submucous
myomas may act as intrauterine devices and produce subacute endometritis
leading to failure of implantation.
- Intramural
myomas occurring in the region of the tubal ostia may cause tubal
blockage.
- Compression
and dilatation of adjacent vasculature may cause abnormal endometrial maturation,
which may be inhospitable for embryo maturation.
- Large
intramural, submucous or the combined variety of myomas may cause atrophic
or ulcerated endometrium, which is hostile to nidation.
- Distortion
of the endometrial cavity may increase the travel distance for the sperm.
- Prostaglandins
present in the seminal plasma are believed to increase rhythmic myometrial
contractility possibly facilitating sperm transport. Myomas in some way
interfere with this mechanism and may decrease fertilization rates.
- Changes
in the endometrium mediated by inflammation and factors involved in the
process of fibrosis could also have a detrimental effect. In addition,
fibroids may affect gene expression pattern in the endometrium (such as
HOXA10), disrupting the window of implantation.
- Distort
the uterus- making it enlarged, elongated, alters its contour and surface
area
- This
can impair the migration of sperm/ ovum/ embryo and also negatively impact
implantation
- Dysfunctional and altered uterine
contractility which could hinder gamete and embryo transportation
11. Affect
overlying endometrium, creating endometrial vascular disturbances,
inflammation, thinning, altered biochemical ch again can impair implantation
Most fibroids may not cause any symptoms at all and
may be diagnosed during a routine pelvic examination. Such fibroids that are
small, asymptomatic and diagnosed near menopause don’t require treatment.
However fibroids associated with any of the above symptoms which are severe
enough to disrupt a patients daily activities, those affecting the fertility or
IVF results (Implantation) or repeated miscarriage or those with rapid growth
and uncertainty regarding their origin need to be investigated and treated.
Drug therapy is an option for some women with
fibroids. Although fibroids cannot be eliminated by medications they can
be used to provide symptomatic relief. Surgery often is
needed later. Various combined birth control pills, Gonadotropin-releasing
hormone (GnRH) agonists, Progestin–releasing intrauterine device; NSAIDS have
been used for symptomatic treatment.
·
Hysterectomy is the removal of the uterus. The ovaries may or
may not be removed. Hysterectomy is done when other treatments have not worked
or are not possible or the fibroids are very large. A woman is no longer give
birth to a child after having a hysterectomy.
What is endoscopic
approach and which is better - Endoscopic or open?
Endoscopic approach involves the use of a camera
attached to an endoscope, which is used to visualize the fibroid and surgically
remove it. It can be of two types:
·
Hysteroscopic myomectomy: This
technique is used to remove submucosal fibroids that protrude into the cavity
of the uterus. A resectoscope is
inserted through the hysteroscope. The resectoscope destroys fibroids with
electricity or a laser beam. This is an outpatient surgical procedure and patients can go home the
same day of surgery with minimal side effects. Larger fibroids may require more
than one sitting for removal.
· Laparoscopic approach: This approach involves making
small 0.5-1 cm incisions on abdominal wall through which the surgery is
performed using a camera for visualization. In the hands of
an expert, a laparoscopic approach is definitely preferred and can be used for
almost all patients with fibroids barring few. It is associated with a quicker recovery, less postoperative pain, and
less febrile morbidity. Patients typically go home the
day of or day after their surgery.
To know more about Dr.
Sunita Tandulwadkar, please log onto www.infertilityinindia.com