Uterine fibroids (leiomyomas or myomas) are common non-cancerous growths that develop in the muscular wall of the uterus. These growths are frequently diagnosed during reproductive years and can cause symptoms ranging from heavy bleeding to pelvic pain. When fibroids cause symptoms or contribute to difficulty conceiving, a myomectomy may be performed. This surgical procedure removes the fibroids while carefully preserving the uterus, making it the preferred option for those who wish to become pregnant. A primary concern for anyone considering this surgery is the potential impact the operation itself could have on their future ability to conceive.
Defining Fibroids and Myomectomy
Fibroids are classified based on their location within the uterine structure, which determines the symptoms they cause and the surgical method used for removal. Submucosal fibroids develop just beneath the uterine lining and project into the uterine cavity. Intramural fibroids grow within the thick, muscular wall of the uterus and are the most common type. Subserosal fibroids are situated on the outside surface of the uterus.
The location of the fibroid is a major factor in deciding the type of myomectomy needed. The procedure is defined as the surgical removal of the fibroids, leaving the rest of the uterine structure intact. This approach distinguishes it from a hysterectomy, which involves removing the entire uterus. The goal of a myomectomy is to alleviate symptoms and improve the chances of a successful pregnancy.
How Fibroids Impair Fertility
The presence of fibroids can interfere with the reproductive process. Submucosal fibroids, even small ones, can significantly distort the shape of the uterine cavity, interfering with the ability of a fertilized egg to successfully implant.
Large intramural fibroids, especially those exceeding six centimeters, may also compromise fertility by changing the overall shape of the uterus. Fibroids situated near the fallopian tubes can potentially block the path of the egg or sperm, preventing fertilization. Furthermore, fibroids may alter the local uterine environment, disrupting blood flow to the endometrium and proteins necessary for healthy implantation. Myomectomy is often performed to remove these obstacles, aiming to restore the natural conditions required for conception.
Surgical Technique and Fertility Risk
While myomectomy is generally performed to improve fertility, the procedure carries a risk of causing infertility. This risk is primarily associated with the formation of scar tissue, known as adhesions, and the depth of the incision made into the uterine wall. Adhesions are fibrous bands that can form between organs following surgery, potentially obstructing the passage of eggs or sperm if they involve the fallopian tubes or ovaries.
The surgical approach plays a large role in adhesion risk. Traditional open abdominal myomectomy (laparotomy) historically carries a higher chance of adhesion formation than minimally invasive techniques like laparoscopy. When a fibroid is deeply embedded, a full-thickness incision through the uterine wall is required and repaired with multiple layers of sutures. This uterine reconstruction leaves a scar that, in rare cases, can weaken the integrity of the uterus. The formation of this internal scar tissue, especially when the uterine cavity has been entered, is the main factor that can compromise future fertility, though surgeons use meticulous techniques and adhesion barriers to minimize this complication.
Managing Pregnancy After Myomectomy
Following a myomectomy, the uterus requires a specific period to heal completely before attempting conception. Physicians typically recommend a waiting period of three to six months to ensure the uterine scar is fully mature and strong. This healing time is necessary to minimize the risk of complications during pregnancy.
The most significant risk during a subsequent pregnancy is uterine rupture, a rare but serious complication where the uterine scar tears. The estimated risk of uterine rupture following a myomectomy is approximately one percent. This risk is highest during labor, especially for patients who required deep, full-thickness incisions into the uterine muscle. Therefore, a scheduled Cesarean section is often recommended for delivery, particularly if surgical records confirm the uterine cavity was breached. This planned delivery is a precautionary measure to prevent the forces of labor from compromising the integrity of the healed uterine wall.