Uterine fibroids, also known as myomas, are common, non-cancerous growths that develop in the muscular wall of the uterus. Up to 80% of women develop them by age 50. When these growths cause symptoms like heavy bleeding or pelvic pressure, or interfere with conception, surgical removal (Myomectomy) is often recommended. While fibroids can cause infertility, a concern is whether the removal procedure itself poses a risk to a woman’s ability to conceive in the future.
The Link Between Fibroids and Fertility
Fibroids do not always impair the ability to become pregnant; their location determines if they impede fertility. Submucosal fibroids, which bulge into the uterine cavity, are the most likely to cause infertility by interfering with embryo implantation. Their presence can distort the inner lining of the uterus, potentially lowering the rate of successful implantation by as much as 70%.
Large intramural fibroids, which grow within the uterine wall, can also affect fertility if they significantly change the shape of the uterine cavity. This distortion can disrupt the movement of sperm or interfere with the function of the fallopian tubes. Conversely, subserosal fibroids, which grow on the outside surface of the uterus, rarely affect fertility. Removing fibroids that distort the uterine cavity is often necessary to improve the chances of pregnancy.
Surgical Options for Fibroid Removal
The Myomectomy method is based on the fibroids’ location, size, and number, and the patient’s desire for future pregnancy. Submucosal fibroids projecting into the uterine cavity are often removed via Hysteroscopic Myomectomy. This procedure inserts a thin instrument through the vagina and cervix, requiring no external abdominal incision or trauma to the uterine wall.
Fibroids within the uterine wall or on the outer surface are generally removed using either Laparoscopic or Abdominal Myomectomy. Laparoscopic and robotic-assisted approaches are minimally invasive, using small abdominal incisions, which leads to less pain and shorter recovery. Abdominal Myomectomy, the most invasive method, involves a larger incision and is reserved for numerous, large, or deeply embedded fibroids. The surgical type directly impacts recovery, scarring potential, and subsequent conception planning.
Assessing the Risk of Infertility Post-Removal
The risk of infertility after Myomectomy stems from the healing process of the uterus and surrounding pelvic organs. When incisions are made deep into the uterine muscle, particularly during abdominal or laparoscopic procedures for intramural fibroids, the resulting scar tissue creates a weak spot in the uterine wall. This scarring increases the risk of uterine rupture during a future pregnancy or labor. The incidence of uterine rupture following Myomectomy is estimated to be between 1% and 3.7% of subsequent pregnancies, necessitating careful monitoring and often a planned Cesarean section.
The formation of adhesions is another risk, as Myomectomy is considered one of the most adhesion-forming procedures in the pelvis. Adhesions are bands of internal scar tissue that form outside the uterus, connecting organs that should remain separate. These adhesions can wrap around the fallopian tubes or ovaries, distorting the pelvic anatomy and physically blocking the path for the egg and sperm, which can lead to infertility.
The extent of the surgery is proportional to the risk of complications; removing multiple, large, or deeply embedded fibroids increases the likelihood of both uterine scarring and adhesion formation. Incisions on the posterior (back) wall of the uterus carry a higher risk of adhesion formation involving the fallopian tubes, potentially impairing fertility more severely than an anterior incision. The surgeon’s skill and technique are important factors in minimizing tissue trauma and reducing the formation of internal scars.
Improving Fertility Outcomes After Surgery
For women whose fibroids were the primary barrier to conception, Myomectomy often improves fertility prospects. Pregnancy rates following the procedure are reported to be between 40% and 60% within one to two years for patients with otherwise unexplained infertility. This outcome is true for those who had submucosal fibroids removed, as the procedure restores the uterine cavity’s normal shape.
Following surgery, the uterus requires time to heal before it can safely withstand the stresses of pregnancy. The recommended waiting period varies based on the procedure’s invasiveness. A shorter waiting period may increase the risk of complications such as uterine rupture or miscarriage.
Recommended Waiting Periods
- Hysteroscopic Myomectomy (no uterine wall incision): One to three months.
- Laparoscopic or robotic-assisted procedures: Three to six months.
- Open abdominal Myomectomy (due to deeper incision): Six to twelve months.
Due to the risk of uterine rupture from the deep surgical scar, women who have undergone a Myomectomy involving an incision through the full thickness of the uterine wall are advised to have a planned Cesarean section. This precaution prevents the strain of labor contractions from causing the uterine scar to tear. Ultimately, while the surgery carries risks that must be managed, the removal of problematic fibroids often leads to successful pregnancy for those with fibroid-related infertility.