Bumps in the Road: Fibroids and Fertility Explained

Fibroids are common, but when do they actually impact fertility? In this episode of Taco Bout Fertility Tuesday, Dr. Mark Amols dives into everything you need to know about fibroids—their types, how they’re diagnosed, their effect on fertility, and the latest treatment options. Whether you're trying to conceive or just curious about how fibroids can affect your health, this episode has you covered. Plus, don’t miss the shoutout to Dr. Piere Johnson, the ‘Fibroid Slayer,’ who will be sharing his expertise on Sperm Meets Egg Live! Grab a taco and join us for this informative discussion!

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Transcript

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Today we talk about fibroids, when they matter, when they don't, and how they can affect fertility. I'm, Dr. Mark Amols, and this is Taco about Fertility Tuesday. Fibroids are like unexpected guests in your uterus. Most are harmless, but some overstay their welcome and cause some trouble. Now, fibroids are very common. Matter of fact, by age 40, about 40% of women will have fibroids. If you could see them, they look like tumors and look like they're scary, but they're actually benign. And sometimes they can cause some issues. In today's podcast, we're going to talk about what fibroids are, how we diagnose them, their impact on fertility, and what treatments are available. So grab yourself a taco or two and let's talk about fibroids. Fibroids themselves are a smooth muscle and part connective tissue. Now, smooth muscle is the muscle that goes around things like the bowel or your stomach. And then there's what's called skeletal muscle. That's the muscle you have that allows you to move your arms. And then you have cardiac muscle, which allows your heart to beat. And cardiac muscle and skeletal muscle are very similar, but smooth muscle is very different. It's not linear like skeletal muscle. It goes in different directions which allows it to kind of squeeze down and such as, like your bladder. So smooth muscle already is somewhat not disorganized, but think of it just not as linear as, like, skeletal muscle is. And so what's interesting is that a fibroid is when that smooth muscle develops into a benign tumor of smooth muscle and is very disorganized, but it'still actually normal tissue. What is very common to this would be like a wart. A wart on your skin is the same tissue as your skin, but it's organized in a manner that makes it not normal and looks like a piece of tissue coming out of your skin. But just like fibroids, warts in certain areas can cause problems. I'm not talking about vanity. I'm talking about, like, a planter's wart that's on the bottom of your foot. If you step on your foot and you have a planner sport, there's a very good chance you're going to have discomfort because it's going to feel like there's a rock in your shoe. So even though it's benign, it creates problems. Fibroids are the same smooth muscle as the uterus, but again, disorganized. And when they are pushing on other organs, such as the bladder it can make you feel like you have to urinate more. If it's pushing on the bowel, you may feel like you have to go to the restroom more. And if it's pushing into the cavity of the uterus, then it may affect your chances to get pregnant. Now for the most part, most fibroraids don't cause any issue. Matter of fact, most people don't even know they have them because they're not getting ultrasounds all the time. But when you go through fertility you get lots of ultrasounds. So people see your uterus and start noticing these things. Now sometimes some fibroids start off not being an issue and then later grow and become an issue. And what causes them to grow is estrogen. So when you're going through fertility, estrogen can eventually make them grow larger and larger. Most women find out they have fibroids later in life and they are so close to menopause they don't do anything about them. And once they go in into menopause the estrogen levels drop and the fibrays start to shrink on their own and they don't cause any issues. There are three main types of submucosal, intramural and some cosal. Lets start with subseroosal. Subs Cosal are fibroids on the outside of the uterus. So they can either be what's called peduncula, where are hanging off the outside of the uterus like an appendage, or they can be in the muscle and then bulging out of the uterus, making it look like it has a head on the uterus. Intramural fibroids are ones that are contained in the muscle. So they're not going outside of the uterus, they're not going towards the inside of the cavity, they're staying within the muscle. The last category is subucosal. This is one that's distorting the uterine cavity. So it doesn't mean it has to all be in the cavity. It may all be in there like a stalk again hanging in there. It could be partially in the cavity, it could be mainly in the cavity. But if it's breaking into the cavity we consider it submicosal. If it stays within the muscle we call it intramural. If its subsosal we consider it when it's outside of the uterus. Now each one of these can be slightly different. So you can have an intramural that's so big that it's distorting the cavity, but it's actually not going into the cavity, it's just pushing everything. Subm mucosals can cause other things like heavy periods, painful periods, large blood clots because of the fact that you have a fibroid in the cavity. Rarely do these cause pressure symptoms like problems with urination and defecation. Usually those are going to be a large intramural or specifically some cosal because they'll be pushing on those anatomical locations. Statistically speaking, the distribution of these fibroids are about 40 to 60% are usually in intramural. About 20 to 40% end up being subsosal. And about 5 to 10% of fibroidss will affect the intrauterine lining, such as the cathe with submucossal. Now as I mentioned, some people may have no symptoms but have fibroids. So the way you diagnose this is usually someone comes in with a problem such as heav menses or some type of pressure symptoms and then these are found. These fibroids can get so large that some women can even look like they're pregnant. And these can be the size of a basketball. So even though they are benign, they can get seriously large. Now the first diagnostic test is going to be an ultrasound. Usually this can be trans abdominally, this can be transvaginally. It's kind of the first line tool because it allows us to really see the fibroids, and we're able to say it very clear. But the problem is, even though it's a non invasive approach, it is limited because it's so dense, those fibroids that if it's very big, we're not able to see them very well. The other thing is we can't see inside the uterus. So you need something like a solo histstogram or something like that to separate the layers to find out how the fibroid is in the cavity. So ultrasound is great to be able to determine if via fibroids, but that's about as far as they go. And if it's a very big fibroid, we really can't see a lot about the fibroids. Now when it comes to the cavity, as I just mentioned, the best thing would be a saline infusion solno histogram and that would fill the uterine cavity to let us know how the fibroid is affecting the cavity. Is it truly affecting it or is it just, abuting it? If it's abuting it and not going into the cavity, it's fine. If it's in the cavity, something needs to be done. One of the main ways that people are now looking at fibroids is they're using mri. This gives a very high resolution imaging, so we can get the details of the fibroid, find out if it's very dense or not. Honestly, anyone with a large fibroid that's going to undergo surgery usually gets an MRI because it allows you for pre surgical planning to make sure you can know if there's any complex portions of it. The downside of MRIs is that they're expensive and not all the time do they get approved. So people don't start there, they go there when they need to, such as when you're going to surgery. Now, another way that we can look inside the uterus instead of using a saline infusion sono histogram is using a hysteroscopy. The downside of the hysteroscopy is, yes, we get to go in the cavity and we can look for sure and know that the fibroid is not pushing in the cavity. But the other problem is we can't see the outside of it. So with a hysteroscopy you're only able to do one thing, and that is determine if the fibroid is in the cavity. Now, if it is in the cavity, you can actually do something about it. You can actually use what's called a morcelator that goes through the camera and is able to cut the fibroid out. Again, these are usually not too large, but I've even removed some that are up to 2, 3 centimeters. So you can remove them all through this camera. But it's important to understand that from a diagnostic standpoint, you only get to see the inside. One of the nice things about a, saline infusion on the histogram is you can actually now see the outside of the uterus too. So now you can know if there's fibroids outside of it. In fertilility, we really just care if it's in the cavity. So a saline infusion, cyno histogram or hysteroscopy is fine for us. The last test you could use, and definitely not the one you would want to jump to first, would be a hterosal pingogram. And this is where we put a contrast into the urine cavity to see if the tubes are open, basically looking for tubal patency. Now, you can in some ways tell if the cavity is being affected because you will see it on the image where the uterine cavity is being deformed, telling you that there's some type of fibroid there. But you don't know it's a fibroid. You just know there's some deformity. That's why it's not a very good test. And honestly's something that usually is found while you're doing the hsg. And then they go, we need to do another test to figure out what's deforming the cavity. Now, if we had to rank these fibroids into which are the most concerning. Without question, submucossal fibroids are the most impactful. They will distort the cavity and they can also prevent implantation and could even prevent you from being getting pregnant altogether because they can be creating inflammation and that can also prevent implantation. The next impactful will be intramural fibroids. They have some moderate impact because if they're large, such as like for in the mirrors are greater, they can get close to the cavity and start distorting the cavity. Now, they're not going to create that inflammatory response that you would see with a submicosal fibroid. But by distorting the cavity they may cause some problems. And there's questions about that. We know for sure some mucosals will cause fertility problems. Intramural is a little bit different, especially if they abut the cavity. The last category would be subsroscal fibroids. And these really rarely affect fertility. They can end up being very large. And because they have all that space in your pelvis and the abdomen, they can just kind of move around and they can create issues for sure and you can have discomfort, but rarely do they cause fertility problems. Now, whats interesting is weve talked about them being in the cavity. That can cause problems. And thats true. But how else can fibrotes cause problems? Well, they can actually block things. So if theyre intramural or subsosal and theyre around the fallopian tubes, they could block the floping tubes and prevent you from being able to get pregnant by blocking the sperm from getting to the egg. The other area that is being studied but is not considered a proven effect of fibroids is the indirect effects that may come from fibroids, such as inflammation if it's altering the uterine contractility. All this stuff is being studied. And as of now, we don't believe those things prevent you from getting pregnant. But we may learn in the future there may be bigger issues. I myself have had patients with very large fibroids that I wouldn't have thought that would affect them getting pregnant. And interesting Enough. Even though we kept failing transfers, we finally said, let's just get it removed at this point. And they did. And they, am having success. Now, that's anecdotal. That's not actual science. So I can't say that's what did it, but that's why this is being studied. So now you know you have a fibroid, and the question is, what are your options? And so we're going to go through each of those. The first one would be watching and waiting. So if you have something that's asymptomatic, it's not causing you any problems, and it's just a small fibroid. If you can just watch it, and if it never becomes a problem, you never have to worry about it. Like I mentioned, women who are close to menopause may find they have one. They don'to anything because it's not going to matter soon. Now, as I mentioned, it may grow and eventually become a problem, but you can watch that and eventually do something. One of the concerns in the past was if they got too large, your surgery went from a simple laparoscopic surgery to now a large myomectomy where you actually had to go and do like a C6 to remove it. Nowadays with robotic surgery, they can actually remove those large fibroids, even to a laparoscopic incision. The second, less invasive option is then going to be medical management. And this is where you take medications to either shrink the fibroids or to control the bleeding that comes from the fibroids. So this would be the situation where maybe you don't want to do something right now. So you say, hey, I'm going to take someone like Lupron to shut down my hormones or put in like an IUD that has a meirena IUD making progesterone, and that will cause the bleeding to be very minimal. So you can either then postpone your surgery or potentially getting close to menopause, don't have to do anything until you get there. From, this point, we get to the surgical options, and there are basically two major surgical options. And there is one minor surgical option. Let's start with the minor options. So the minor surargical option is going to be things like radio frequency ablation. And this is where they can actually take a wire, put it through the uterus to the fibroid, and can actually burn, heat up the fibroid, where they make it become almost liquefied. Now, it doesn't get rid of it completely, but it does get rid of a lot of those symptoms. Now, it's something, let's say, like a submucossal. You couldn't use that. That's going to be for your intramural fibroids. There's also a thing called uterine artery embolization. This is where you actually take small beads where you go through the arteries all the way down to the uterine artery and you embolize it, basically blocking the blood vessels to the uterus, which will cause the uterus to shrink, the fibroids will shrink, and then that way it may help with a lot of your symptoms. Now, as you could imagine, some of these don't sound very safe if you want to get pregnant again, and that's correct, doing something like a urterinary embolization and then trying to get pregnant is not the safest thing because you're cutting off the blood supply. There are some studies looking at radiolation, and those may be fine. The same thing with another one called MRI guided focus ultrasound. Where you lay on the table, the MRI maps out where the fibroid is. And then using focus ultrasound, try to shrink the fibroids through heating them up. The other minimally invasive procedure is what's called uterine ablation. A now this doesnn't help the fibroids, but if you have heavy periods, it could burn the inside of the lining of your uterus, which could then theoretically stop you from having heavy periods. But again, it does not treat pressure symptoms on the fibroids that would only be helping the heaviness of your periods. And then it takes us to the major surgical options. The least invasive of them is what I talked about, robotic assisted laparoscopy. This is what, using a robot, they can go through, ah, a laparoscopy, which is a small incision on your abdomen, and they can remove all the fibroids. It's basically like doing it with their hands, but instead they're doing it with a robot through a small incision. It takes a lot of time and a lot of skill, but it allows the surgeon to do the surgery through a very small incision and allow you to have a much lighter recovery time. The next procedure is called a abdominal myomectomy. This is where you actually make an incision on the abdomen, like a C section incision, and then you remove the fibroids manually by cutting each one out. This used to be the kind of gold standard if you wanted to remove, let's say, 20 or 30 fibroids. But now specialized surgeons who can do this Robotically can do this all through a small incision. The benefit of doing a myomectomy over, let's say some of those other procedures is that you can still get pregnant. You're preserving the uterus. Now some people may want to preserve the uterus to be able to get pregnant, some may just want to keep it. Matter of fact, there are ah, some data that shows that some women have what we call uterine orgasms, meaning their uterus is part of their orgasm. And so they don't want to remove their uterus because they want to be able to keep that uterine org acid that they have. And that then takes us to the very last treatment, which is a hysterectomy. People who have fibroids who are obviously not trying to get pregnant can have a hysterectomy where you remove the uterus and then you don't have to ever worry about coming back. But one con is you can't get pregnant. At least carry the pregnancy. You still keep your ovaries, but you won't be able to carry it. And that's the point. All these other procedures, there's always the possibility of it coming back. And that's because fibroids can come back. Not the same one, but they can keep growing. Whatever cause it to grow may start again. We actually know that certain cultures have more fibroids. For example, African American women definitely have more fibroids compared to let's say Caucasians. And there's some studies looking at the genetics to figure out what it is in those families that cause these women to keep havse fibroids. In the end, if you have a fibroid, the things you have to think about is do you have to keep your uterus if you want to get pregnant? If you don't care about pregnancy, then you don't have to worry about that. And then the question is how is it affecting you? And then based how is's affecting you that you would then decide with the surgeon what is the best treatment for you. Well, what's good to know is there's options out there and each option is made for a specific situation and for that patient. I have no doubt that in the next few years we'going even have more treatments available, some even less invasive and some even better. Until then, these are the current treatments that you can do. So remember, not all fibroids cause fertility issues. Location matters the most. And not everyone who has fibroids is worried about getting pregnant. Sometimes it has to do with their quality of life and some of the symptoms'dealing with. If you suspect you have fibroids or have some type of heavy periods or pressure symptoms, talk to your doctor and explore the diagnostic testing that you can do to determine if you have that. And if you really like this podcast and you want to know more about fibroids, I'd recommend tuning in tomorrow to our show Spermmeat egg live with Dr. Pierre Johnson. This guy is the fibroid Slayer. He removes humongous fibroids from people all through a laparoscopic port. Its pretty amazing. This guy is actually a really great guy to listen to. He's from Chicago and I think you'going to enjoy what he has to say. This guy is the Bruce Lee of removing fibroids. No fibre can defeat his fibroid slayer technique. As always, I greatly appreciate everyone listening to this and I hope you enjoyed this podcast. And again check out Sperme Egg. I think you're going toa love it. If you love this show please tell everyone about it and as always give us a five starer review on your favorite medium. Help us build this so that way we can educate more people so they can be an advocate for themselves when undergoing things like treatment. And the most important thing is to keep coming back. I look forward to talking to you again next week on Taco Bel Fertility Tuesday.