Ep 285: Fibroids: Friend or Foe?

Fertility Docs Uncensored is hosted by Dr. Carrie Bedient from the Fertility Center of Las Vegas, Dr. Susan Hudson from Texas Fertility Center, and Dr. Abby Eblen from Nashville Fertility Center. In this episode, “Fibroids, Friend or Foe?” the docs dive into one of the most common—and often confusing—topics in reproductive medicine: uterine fibroids and their impact on fertility. They break down the different types of fibroids—submucosal, intramural, and subserosal—and explain why location is often more important than size when it comes to whether a fibroid should be removed. Fibroids that distort the uterine lining can interfere with embryo implantation by causing inflammation or friction, making pregnancy more difficult. The docs explain the surgical options for fibroid removal, including hysteroscopy (removal through the cervix), laparoscopy, and laparotomy (which address fibroids from outside the uterus). They also discuss fluid management during hysteroscopy to ensure patient safety. Beyond fertility concerns, fibroids may need to be removed if they’re causing significant bleeding or pelvic pressure. Finally, they touch on recovery and why patients may need to wait several months after surgery before attempting pregnancy. If fibroids are part of your fertility journey, this episode is a must-listen.  This episode was sponsored by ReceptivaDx and Reproductive Science Center of the Bay Area. 

Transcript

Susan Hudson (00:00)

You're listening to the Fertility Docs Uncensored podcast, featuring insight on all things fertility from some of the top rated doctors around America. Whether you're struggling to conceive or just planning for your future family, we're here to guide you every step of the way.

Susan Hudson MD (00:21)

This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test used to help detect inflammatory conditions on the uterine lining, most commonly associated with endometriosis and may be the cause of failed implantation or recurrent pregnancy loss. Take advantage by learning more about this condition at receptivadx.com and how you can get tested and treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx, because the journey is worth it.

Carrie Bedient MD (00:51)

Hello and welcome to another episode of Fertility Docs Uncensored. I am Dr. Carrie Bedient from the Fertility Center of Las Vegas, joined by my two unique, upbeat, uber-excellent co-hosts, Dr. Abby Eblen from Nashville Fertility Center and Dr. Susan Hudson from Texas Fertility Center.

Abby Eblen MD (01:01)

Thanks.

Hi everybody.

Susan Hudson MD (01:08)

Uber happy to be here.

Carrie Bedient MD (01:09)

I am so ultra glad that you are.

How are you girls doing?

Susan Hudson MD (01:13)

We are good.

Abby Eblen MD (01:13)

We are great!

Carrie Bedient MD (01:14)

I need help from the two of you because I am very used to living in dry environments where there are no mosquitoes. And I don't know what the hell has happened this year, but I am getting eaten alive and this needs to stop. I have the little light things that you plug in and it's that blue light and it attracts the bugs and that's kind of working, but I'm still getting eaten alive. Tell me your secrets.

Abby Eblen MD (01:30)

Zip, zip, zip, zip, zip, zip.

Gotcha. So first of all, I have a medical question for you and you don't have to answer. What's your blood type? I'm just curious.

Carrie Bedient MD (01:39)

O positive.

Abby Eblen MD (01:41)

Me too. So apparently we're favorites for the mosquitoes. I know living in the deep South with humid air, there are mosquitoes everywhere. And when I walk outside at night, it's like, they're everywhere. And it's kind of like, yeah, yeah. Yeah. My kids would laugh at me.

Carrie Bedient MD (01:54)

Wait, wait, how was that? okay good.

Susan Hudson MD (01:57)

The best thing is she did it twice.

Carrie Bedient MD (02:01)

With your hand movements.

Abby Eblen MD (02:04)

I mean for doing that too, but yeah, so they swarm me anytime it starts to get past about four o'clock. So I've got you the answer. Skin So Soft from Avon is the best stuff out there. So Deet works great too, but who wants to smell like Deet all the time? Those chemicals are probably not good for your skin. And so if they kill the mosquitoes, they're probably not good for you either. But Skin So Soft is great. You can order it on Amazon.

You can put it on bath oil in the shower and it works fabulously. I even went on a mission trip to Guatemala in the middle of rainy season and I avoided the mosquitoes. Now, it's kind of like when I try and put on sunscreen. If I put on sunscreen and I miss one dot in one place, then I have this ultra red, horribly burned patch. It's the same way with the mosquitoes. I put it on the soles of my feet, in between my toes, behind my ears, under my arms.

Every nook and cranny you can think of, because if you miss one, they're going to bite you there. It's just like not putting sunscreen on certain spots. And the of your feet, too. Those really hurt.

Carrie Bedient MD (03:02)

In between your toes?

Susan Hudson MD (03:07)

You know what, last night I got one like on the little skinny part on the back of your ankle and let me tell you, that hurts like you know what? That's a terrible place to get bitten by a mosquito. It was, owie.

Abby Eblen MD (03:14)

It works. Yes.

Carrie Bedient MD (03:20)

I don't mean to sound judgmental here, but isn't the only rash that shows up on your palms or soles of your feet from syphilis?

Abby Eblen MD (03:27)

Syphilis.

Yeah, but it's not a rash. It's not a rash. It's just a whelp. It's an ugly whelp. And I don't know why it hurts more, I think, because it's just tougher tissue, but it really hurts. 

Susan Hudson MD (03:35)

You're the one asking for advice, Carrie. I said you're the one asking for advice.

Carrie Bedient MD (03:39)

What?

Abby Eblen MD (03:42)

You're asking for advice and you're saying that Susan has syphilis? Wow, that's kind of hard. okay. ⁓ me, okay.

Carrie Bedient MD (03:45)

No, I was saying you have syphilis. You're the one with...You're the one with the stuff between your toes.

Abby Eblen MD (03:54)

That's where they bite. They find any little spot that they can put their little sucker in and get blood out.

Carrie Bedient MD (03:57)

Okay.

Susan Hudson MD (03:59)

I'll give you some advice for helping clear out mosquitoes. One, obviously make sure you don't have any standing stagnant water. Okay. That's good. Make sure you don't have any leaves or compost stuff that's accessible because they breed in there. Apparently mosquitoes and I don't know if this is completely true, but I've been told that they can actually lay eggs that can be dormant for years. And then one rainstorm will let them hatch. Crazy, crazy. And I don't know, do y'all have public utilities or do you have septic tanks? Okay, all right. So listeners, there's things you can put in your septic tanks.

Abby Eblen MD (04:31)

I didn't know that.

Susan Hudson MD (04:47)

I have a septic tank and so they actually can breed in your septic tank so you drop these little pellets that help prevent them. Plants that help keep them away. You want things like rosemary, lavender. 

We have Dynatraps, which are contraptions to attract and destroy. And they don't produce any chemicals or anything like that. We have small ones and we have gigantic ones.

Abby Eblen MD (05:18)

Don't they have like water, those Dynatraps have water or something, they attract the mosquitoes and...

Susan Hudson MD (05:22)

There's some of them that do, but a lot of the newer designs don't have water. It's all by the light that is, it's a blue light. However, the light produces a smell that they're attracted to. And it also attracts other, flying critters like moths and stuff. ⁓ Those are some pieces of advice that will help. And of course the citronella candles and stuff like that.

Abby Eblen MD (05:30)

Yeah, I have one of the loaded ones, yeah. and make a zap.

Ooh, my neighbor had these citronella things that were, citronella, didn't think it really worked that well, but she bought these things, I think she got them on Amazon, and they look like a lantern, and you light them. Like we ate outside at her house, and it's like it just burns from the end just slowly, and it burns all the way around, and it produces citronella, but you don't really smell it. It really kept the mosquitoes away when we sat outside. So just wow.

Carrie Bedient MD (06:08)

Thank you very much for your expertise. I am ultra-uberly appreciative.

Abby Eblen MD (06:13)

Just be glad you don't have chiggers. Susan gave me some good advice about chiggers a couple weeks ago when I had some bites. I did put antibiotic ointment on it and I don't know why, but it worked. It really did. It had been driving me crazy for days and then it just stopped. Another episode.

Susan Hudson MD (06:23)

It's crazy!

We'll talk about triggers on another day.

Carrie Bedient MD (06:29)

Alright, so do we have any questions today?

Susan Hudson MD (06:33)

We do have a question today and our question today is inspired by our main topic. We're going to talk about fibroids and IVF for our topic today, but our question is, hi, I've been listening to your podcast for a year while going through my fertility journey. Thank you for all the wonderful content. 36 year old female with four attempted IUIs and one FET so far. Husband did not have great sperm count or morphology. They have 3 subserosal uterine fibroids, one being 6 cm, mild-moderate psoriasis. I recently had a missed miscarriage last month of a PGT-tested euploid embryo. It was measuring 5 weeks. It was a blighted ovum in my first FET. What's the main reason for euploid embryo miscarriage? Up until this point, I've been told that the type of fibroid does not affect fertility but now my RE says I may need a myomectomy. We have six euploid embryos left. What do you think my chances are of a live birth?

Carrie Bedient MD (07:36)

Excellent question. What do you think, Abby?

Abby Eblen MD (07:37)

Well, she said her fibroids are subserosal and we'll talk about this probably more in just a minute, but location, location, location, it's like real estate, it's really important. Size and location, but location's probably, I would say, the most important. And we know if fibroids are far away from the cavity, which subserosal means they're really as far away as they can possibly be from the cavity, and sometimes even people, I've seen people with really large fibroids, didn't even know they had them, and they were so far away from the cavity that they really didn't have any symptoms, they didn't have...They they didn't have bleeding. so typically, subserosal fibroids are not ones we usually go after in and of themselves unless they just happen to be humongous. So if there three small subserosal fibroids, I really don't think that there's a reason that you need to have any surgical treatment for those before IVF.

Susan Hudson (08:21)

Exciting news from Fertility Docs Uncensored! Our long-awaited book, The IVF Blueprint, is now available. on Amazon. Go now to pre-order your copy to learn everything you need to know about IVF, egg freezing, and embryo transfer. Did you know that you can cram decades of experience, science, and heartfelt advice into a book, and then the whole thing hinges on what happens in week one? Yep, week one is basically the prom queen election of publishing. So if you've ever thought, "Huh, I should check out The IVF Blueprint by the Fertility Docs Uncensored crew." Now is your moment to shine. Buying it early tells bookstores, "Hey, stock this." It tells publishers people care about this. And most importantly, it helps get real information into the hands of people staring down fertility treatments with more questions than answers. The book's called The IVF Blueprint. It's for folks considering IVF, already in the thick of it, or just trying to figure out what the heck their doctor is talking about. Help us help more people and maybe confuse a few algorithms while you're at it.

Carrie Bedient MD (09:25)

What do think, Susan?

Susan Hudson MD (09:25)

I agree with that, I don't really make a habit of removing fibroids that aren't interfering with the lining of the cavity. And I have to say that is something that I think has evolved quite a bit in the last 10 years. 10 years ago, we would go after almost anything that was abnormal. Whereas realistically, I don't think it's going to change your chances of pregnancy that much and it is going to significantly your risk of needing to have a c-section and as high as c-section rates are nowadays anything we can do to minimize that as long as it's safe I think is worthwhile. Now the main reason you wrote to us was because of this miscarriage and want to have an idea of your chances with your six remaining euploid embryos. So one as hard as a miscarriage is that actually is a good sign that implantation could occur.

Abby Eblen MD (09:52)

Yeah.

Susan Hudson MD (10:15)

Your best chances of getting pregnant are in the few months following a miscarriage. And I think one of the most insightful things to pay attention to is your history of psoriasis. So you're an autoimmune person. And I would probably use some sort of steroid protocol. There's a million different ways that we could skin that cat but your physician probably has some sort of autoimmune steroid protocol they could do for you and making sure your psoriasis is in the best condition in stability that it can be with medications that are pregnancy friendly. I think that's gonna be the most important thing. Now, of course, making sure the lining of your uterus looks good. If you have not had a saline ultrasound and mainly only had an HSG, I think further evaluation of your cavity is very reasonable. Dotting I's and crossing T's, making sure that there's not anything obvious that's being missed, but not every chromosomal normal embryo is going to result in a baby. And even though we know that you had chromosomal normality based on your PGT results, realize number one PGT results are correct 98 plus percent of the time. So there's a very small but there is a small margin that you could have had an abnormal embryo or the embryo may have been developing abnormally. Maybe there was something critical that although things started off good, that things didn't completely develop in a normal way that you are going to end up with the healthy normal baby you guys are hoping for.

Carrie Bedient MD (11:44)

Agreed on all counts.

All right, let's dive into our topic, which is fibroids and IVF. And so what do you do with them and where do you go with them and how do you diagnose them and all of those types of questions. Let's start with the basics. First of all, Abby, what is a fibroid?

Abby Eblen MD (12:02)

So fibroid is a benign tumor in the uterus. Interestingly enough, it has the same DNA. It's one cell that just continues to grow and grow and grow and grow. 99.9 % of them are completely benign, really, really rare for them to be a cancer. And I think that's one of the reasons why our thinking about removing them has evolved so much, because most of them are benign. Generally, if you're not trying to get pregnant, you would remove a fibroid only if the patient has really heavy bleeding, which is one of the side effects from having fibroids, significant pain, pain with intercourse, back pain, pressure from the fibroid being there. Those would be the reasons to remove a fibroid if you're not trying to get pregnant. If you're trying to get pregnant, fibroids that are in the cavity or distort the cavity. So if you think of like a balloon, if you blow a balloon up and like say you push your fist in the balloon, if that's what the fibroid does to your cavity, it distorts the cavity, then that's typically a fibroid that we want to come out. It's almost like a little rock in your cavity that causes irritation and friction and essentially causes sterile inflammatory reaction that could prevent you from being pregnant.

Carrie Bedient MD (13:04)

So Susan, where can fibroids be located?

Susan Hudson MD (13:07)

So fibroids are generally located in or on the uterus. Sometimes people come to us and they're like, I have a fibroid on my ovary. That's not a fibroid. So it's oftentimes a little confusing, but when we talk about fibroids, we really talk about, as Abby mentioned, how close they are to the endometrium or the lining of the uterus or how far away. So you can have...submucosal fibroids, are ones that are interfering with the lining of the uterus. Now, sometimes the entire fibroid is in the cavity of the uterus and the potential space that's there. Or it might be only partially in there and partially in the muscle of the uterus. We have a whole numbering system, nothing that you need to worry about today. But there is a fancy way for us to tell this from doctors to doctors so we know how to communicate it. Some fibroids are only in the muscle of the uterus and then other fibroids are as we mentioned with our our listener, a subserosal fibroid, which is where it's attached to the outside of the uterus. And so really the ones that we are going to focus on when we're going into an IVF cycle are mainly those interfering with the lining of the uterus or if you have symptoms like Abby mentioned, but specifically for IVF, really causing so much distortion that we may not be able to get to your ovaries, would be another reason we might do surgery to remove a fibroid or some fibroids can actually produce hormones like prolactin. Prolactin is a hormone your brain produces that normally makes women get breast milk after they have babies. But women who have lots and lots and lots of fibroids or really, really large fibroids those can even cause enough prolactin production that may interfere with your implantation chances. And so those would also be ones that may need to be operated on before an embryo transfer.

Abby Eblen MD (15:02)

So the quick question for you, Susan, because I've had patients ask me this before, well, if the fibroid's in the way, why can't you just, it's tissue, why can't you put the needle through the fibroid and get to the ovary if you're trying to do an egg retrieval?

Susan Hudson MD (15:12)

Well, what happens is the uterus gets bigger because the fibroid is taking up more space and it essentially elevates the position of the ovary sometimes so that they're so high up in your belly that it's not safe for us to put a needle from your vagina into the ovary because the distance between those two pieces of anatomy ends up with things like bowel in between because of the pelvic distortion of the uterus and its size. And so it makes it so it may not be a safe procedure for you, or we might have to go through your abdomen or even maybe just not access eggs from that side.

Abby Eblen MD (15:51)

And another thing would add in too about that is fibroids tend to have lots and lots of blood supply. So if you poke a needle into them, they bleed. And that's another concerning thing when you're doing an egg retrieval. We typically try to avoid those as best we can.

Carrie Bedient MD (16:03)

And sometimes it's purely a length issue. Those fibroids are so big, the needle is only so long, even if you go through and through them, you still can't hit the ovary because your needle is going through all these fibroids. The fibroids are really stiff as well. And so sometimes we find out when we go through them that they've bent our needle to all hell. And so you think you're in one place, but in reality, you're another. And that is a very unsafe way to do surgery that we do not want to play with.

Carrie Bedient MD (16:30)

All right, so we know what they are. We know where they can be. As always, size matters. How big can they be and how small can they be?

Abby Eblen MD (16:39)

They can be humongous, they can be, such that, and think of the fibroid, a lot of times, with the exception maybe of the subserosal fibroid, like Susan said, it really just grows the whole uterus, so the whole uterus just expands. And so when we do exams on women, pelvic exams, the type that we do with our hands where we put two fingers in the vagina and we press on the outside, sometimes fibroids can be so large that...we think about them in terms of the size of a pregnancy. So for example, a 20 week pregnancy would be a pregnancy where we push on the top of the uterus and it's right at the belly button of the patient. And typically that's how we communicate doctor to doctor how big they are, but I mean, they can be bigger than that even. They can be really big and really distort the whole anatomy, push everything up out of the pelvis.

Susan Hudson MD (17:21)

But you can also have teeny teeny tiny ones. Interesting factoid is that in autopsy reports, 80 % of women have fibroids. So most of us are going to get fibroids at some point. The key is how many do you have and when do you potentially develop them? And we've all had people who they may have one troublesome fibroid. Honestly, I don't think that makes us nearly as worried as the person who has literally hundreds of teeny tiny ones because most skilled surgeons are gonna be able to remove one big fibroid without any major complications. It's those women who have, when the ultrasound or MRI report says innumerable fibroid replacing all uterine tissue, those are the ones that we're really having to start thinking outside of the box.

Susan Hudson MD (18:09)

Big news for the Bay Area. Reproductive Science Center of the San Francisco Bay Area is expanding. A brand new state-of-the-art IVF lab is coming soon to Menlo Park, RSC's second in the region. With advanced fertility treatments, a high success rate, and flexible financial options, RSC helps hopeful parents take control of their family building journey. Visit rscbayarea.com to schedule your consultation.

RSC is proud to lead the way in West Coast fertility care.

Carrie Bedient MD (18:39)

If you talk about fibroids and you're thinking about size and you've got a fibroid that is in the wall of the uterus, at what point is it really worth going after versus at what point do you just say, look, I'm going to do more damage going after it than it's doing just by sitting there. And so in the wall, what size are you looking for?

Abby Eblen MD (18:59)

Yeah, I think there's some data that says, and it's like apples and oranges. It's hard to really get a good study because it's hard to compare people and the number of fibroids they have and where they are. But I've heard that five centimeters or seen about five centimeters or greater are typically the fibroids that we start to worry about. In theory, the concern is that the fibroid can zap blood supply from the uterine cavity and just make it harder for implantation. We also worry too that when people get pregnant, if you have a fibroid and the placenta implants near it, there's an increased risk of the placenta tearing away and abrupting, increased risk of pain, growth of a fibroid during pregnancy. So those are all reasons why you might think preemptively about taking it out, even if you're not having severe pain or severe bleeding.

Susan Hudson MD (19:40)

I think that is something that's changing. When we think of that five centimeter fibroid, I think that was something that we thought about in years past. And it's definitely become less of a rule and more of a guideline. And, there is definitely more flexibility in whether or not you go straight to surgery or you try an embryo transfer. Some of it also depends on patient wishes. Having a fibroid surgery is not, it's not an easy surgery. I mean, that's a major surgery. If it's a big fibroid, like what Carrie's talking about, that surgery is going to make you have a C-section. And so I know I have quite a few patients who are like, I have a fibroid, it's big, I'm not really having a problem with it.

It's not interfering with the lining of my uterus and I really want to avoid a C-section if I can. And I'm like, hey, we can try this. We know that it might be a factor, but I've also had plenty of people who've gone on to have no problems at all too.

Abby Eblen MD (20:37)

Well, the other thing to think about too, if you end up having surgery where the fibroid is removed from the outside, meaning they have to either have, do laparoscopic surgery, open laparotomy where a bigger incision is made. The other thing to consider too, which I think is even bigger than having to have a C-section is most people want you to wait about six months before you're able to carry a pregnancy because as your uterus enlarges and stretches, we worry that that incision can break open. So that's the other reason. And I would agree, five centimeters is a starting point. It's not an absolute. It doesn't mean absolutely you need to have it taken out. But I think it's worth having the conversation with your reproductive endocrinologist and also with your OBGYN about what could happen if you leave that in.

Susan Hudson MD (21:15)

With that being said, please make sure you understand we're talking about those fibroids that we're saying, oh, there's leeway. Those are fibroids not interfering with the lining of the uterus. If they're interfering with the lining of the uterus and they're half a centimeter big, they're coming out. Or it could be five centimeters. It doesn't matter the size. If it's interfering with the lining, that baby needs to be gone.

Abby Eblen MD (21:24)

Correct. It'll come out. Yeah. Yeah.

Carrie Bedient MD (21:36)

So what are potential issues of, as people are making this decision of, okay, I've got a fibroid that's big and I can sort of feel it, but maybe not. Like the people who are on the line, what are the potential implications of having fibroids just in pregnancy? You get pregnant, you make it past the first trimester, what are the implications down the line, potentially?

Susan Hudson MD (21:56)

So I think one thing that we all hate seeing is that fibroid can actually start to necrosis or start to go through cellular changes, which can cause pain and inflammatory reactions. That type of situation can sometimes increase the risk of things like preterm labor. I think that's probably one of the biggest things we're concerned about when we're talking about a fibroid that's in place.

We also worry about the difficulty of delivery. Sometimes if you, may not, your baby may be fine, but if you're needing to have a C-section for another reason, say you're not progressing in labor or whatever the indication may be, if a fibroid's right at the place where we would normally make a incision in your uterus, you might end up with a more risky C-section incision at that point in time.

Abby Eblen MD (22:51)

And I will add to that, because this happened to me a couple of years ago, if you have a very large fibroid and you have an ectopic, it makes it much more challenging to do laparoscopic surgery to take the ectopic out too. So just FYI.

Carrie Bedient MD (23:04)

All right, so those are for the fibroids that are in the muscle of the uterus. What about the... Or pedunculated, meaning they're on a tiny little string that's just hanging out and they're on the outside of the uterus in the pelvic cavity, but not within the uterine cavity. So what about those fibroids that are in the uterine cavity? What are those called and what do we do with them?

Abby Eblen MD (23:27)

So there's submucosal and we want to take them out and we try and take them out hysteroscopically. The challenge really comes if the fibroid is not just, if it's just sitting there in the cavity, completely in the cavity, those are pretty easy fibroids to remove with the instruments that we have now. Fibroids that are buried partially in the wall, and I will tell you, as a reproductive endocrinologist, even if there's a little bit of a fibroid in the wall, the onus is on us to get that fibroid out. And that can be some of the hardest surgery you'll ever do is trying to dig a fibroid out because if the fibroid is partially buried in the wall, you can only see what's pressing into the cavity. And so there's some surgical techniques that we can use in the process of doing it where we take all of our instruments out and wait a minute or wait a few minutes. And sometimes the uterus, because it's a muscle and it squeezes, sometimes it will squeeze the fibroid out further and we can then remove the remainder of it. But there are times when you take the fibroid out and it looks great, it looks beautiful when you finish, you think you've gotten it all, and then you do a saline sonogram or some sort of test on the cavity, and six or eight weeks later you see that maybe there's still a piece of the fibroid that got pushed into the cavity, or sometimes there's even another fibroid behind it that you didn't know about that gets pushed through as well. So sometimes when we do that surgery, and always when I do a surgery on somebody, I always tell them there's always a possibility we may have to go back and do this as a second surgery. We may not get everything with the first surgery.

Susan Hudson MD (24:49)

Doing hysteroscopy for fibroids is one of the surgeries that we do the most commonly that results in us potentially needing to have a second surgery. If we're doing a hysteroscopy and taking care of polyps, those polyps are generally going to be gone. Whereas fibroids tend to occur, people have fibroids, get fibroids, more fibroids. And sometimes even despite our best efforts, even if it looks like everything's come out or if it needs to enucleate, it kind of pops out like a pimple does that it will pop out after we've let the uterus rest and recover, meaning we need to come back and do another procedure.

Carrie Bedient MD (25:27)

Especially when you've got fibroids that are half in the cavity, half out or half in the wall and they're bigger. Those are the ones where for sure you have to plan on it's gonna take a couple of procedures and going back and look multiple times. And it also may be one where we do leave fibroid in there because if it's big enough, you're walking this line between wanting to get it out, but also not wanting to damage the uterus itself. And like we were talking about earlier, it is much easier to get one fibroid out than to have to get out 15 little guys. Well, when you're approaching hysteroscopically, it is hard to dig. And if you can avoid having to go in abdominally, then you want to do that because those abdominal surgeries are the ones that necessitate a C-section.

And so if we can stay away from that, we do, but there's a lot of skill in dealing with fibroids. There's a lot of nuance. Every single case is different. And it's one of those things where you just got to know, where is good enough? You're not looking for perfection here. You want good enough.

Susan Hudson MD (26:28)

And also when we're doing hysteroscopy, so hysteroscopy is where we put a tiny little telescope inside the uterus. We essentially put saline saltwater inside the uterus so we can see and then we generally nowadays use a little shaving device to remove the fibroid. When we are doing that, we're watching how much fluid goes into the uterus and how much comes out.

So a couple of things that are unique to fibroids, we mentioned that fibroids bleed, okay? So that means there's blood vessels. And sometimes through those vessels or through the fallopian tubes, we can lose fluid. And we know that there's certain amounts of fluid that can go into your body safely and your body can accommodate for it without a problem. But there's also limits at what your body likes to accommodate for.

And so sometimes with fibroid surgery, we may get to a point that we're like, we're right there near perfection, but we reach limits where your safety is where the shots get called. And so as we've mentioned in previous episodes, your safety is always our number one priority, pregnancy is number two. And so if we have a safety reason that we need to stop and potentially come back at another time, that is a possibility.

Abby Eblen MD (27:47)

And one other thing I would mention too, some people have had hysteroscopy and had polyps taken out. And like Susan said, from the surgical standpoint, it's easier to take those out, less risk of damage to the lining. And so one of the problems that we have, particularly for digging in really deep to get a fibroid out, we're going through your normal tissue that lines the uterus into the muscle. And when we do that, we create, sometimes can create scar in there. And so, as reproductive endocrinologists, we're really focused on the endometrial lining. We want to keep the endometrial lining as nice a shape as we can. And so there's different tricks and techniques that many of us use and probably Carrie and Susan may do something a little different than I do, but generally I put women on estrogen. I always joke and say, estrogen's like Miracle Grow for your lining. It helps fluff up your lining, helps sort of the normal endometrium overgrow that raw denuded area where we may have removed a fibroid.

So that's a hormonal way to help your lining grow. And I usually do that for a month or so. The other thing that I often do is put a catheter that's the same thing as the one we put in the bladder. It has a little tiny balloon. holds about four to five cc's of fluid, so a small amount. But what it does is it keeps the two sidewalls of the cavity apart so that as the, for lack of a better term, like the scab, or as the tissue starts to grow and and become healthy again, it keeps it from sticking to any other place in the cavity. Because when we operate, we put fluid in, it blows the cavity up so that we can see what we're doing. When we're finished, we remove the fluid, the cavity, the two sidewalls of the cavity are sitting together. So this balloon just mechanically stays in place to keep the two sidewalls apart. So generally, in my experience, that's worked really well with pretty much everybody I've ever operated on as long as we do estrogen and do some sort of mechanical treatment to keep the two sidewalls apart.

Carrie Bedient MD (29:28)

What kind of imaging do you guys like to get when you think there's some sort of fibroid issue going on? So first of all, what imaging are we most likely seeing that says, we gotta look into this further?

Susan Hudson MD (29:41)

So we're generally starting off with a pelvic ultrasound and it's with an internal vaginal probe. So we're using the long probe that's going to go inside the vagina so that we're going to have the best visualization of the uterus. And that's our first step. I think our second step, depending on how much we see and where we see things.

Then we may stepwise go to what's called a saline ultrasound, which is similar, but we put a little catheter in the uterus, instill some saline through that little catheter and take ultrasound images at the same time. That gives us a good idea if we have any interference with the lining or the endometrium of the uterus and the step beyond that, especially if we're having a lot of trouble seeing because we have one of those 20 week size uteruses is in one of those big fibroids, lots of them. Sometimes different people are easier to scan based on the size of their body and different things like that. We may look at doing an MRI to do what we call fibroid mapping to really get a good idea of where those fibroids are, how many of them are there, and which ones may be the pesky little ones that may be causing us issues.

Carrie Bedient MD (30:57)

So we've talked a lot about surgical methods to deal with fibroids. Are there any medical ways to deal with them?

Abby Eblen MD (31:04)

So there's a medicine called Lupron, as we all know, we use it for many different reasons, and it will shrink fibroids down, but generally it tends to shrink fibroids down right before you go into do surgery, so it helps decrease the blood supply, decreases bleeding. There's some other more experimental techniques that are used with sound waves that may be beneficial. Just there's not a lot of data in pregnancy on those other treatments, and so it's a little bit scary for us to recommend that full force for women that are trying to get pregnant.

Susan Hudson MD (31:32)

When we're also talking about more quote, non-invasive, but kind of invasive treatments, Abby was talking about the ultrasound, the focused ultrasound sound wave surgeries on fibroids. That's been around for quite a while. Sometimes people will discuss with not fertility doctors having embolization of their uterus.

So essentially, intentionally putting little clots that cut off blood supply to the uterus, that is a really, really, really not great idea if we're planning on pregnancy. Your uterus needs lots of blood supply to help a developing baby. And so if you have any inclination that you want to carry a pregnancy, do not do uterine artery embolization.

Carrie Bedient MD (32:24)

Now there's also ablation procedures and this is more for people who are having crazy bleeding from their fibroids and they just want to get rid of that lining and then later on are doing IVF for the same reason that Susan was talking about. We're very protective of that lining. It can be potentially very effective for the bleeding but it tends to cause really big problems for endometrium and those are some of the hardest surgeries I've seen and in most cases, it's you go and you look and you abandon ship. And so if you have any idea or any thought that you might want a pregnancy in the future, your options are a lot more limited to the direct surgical ones, but it's because the potential side effects of these other ones with respect to pregnancy are no good at all. Now, there's always reports of somebody who had something done and then got pregnant on their own, but    the goal is not to go running into traffic directly. And so if you know that that's on your list of things to do, try and avoid some of the problems. And if you've already done it and then have changed your mind or life has changed your mind, we'll work with what we got. But it's always nice to not have to dig yourself out of a hole if you can avoid it. All right, any other fibroid related thoughts that we should go?

Abby Eblen MD (33:34)

I have one other thing. So when you go in to do fibroid surgery as a surgeon, like Susan said, we can have MRIs that will guide us in terms of where the fibroids are. Some of the fibroids you just can't find. They're little tiny ones or they're in the wall of the muscle. So basically when I do fibroid surgery, back in the day when I did open surgery, I would say we're gonna get the big ones and we're also gonna get the ones that distort your cavity. But rest assured, I'm not gonna probably get all of them. And so I always tell that because I think with surgery, it's important to give patients adequate expectations. And you will never see a more panicked woman than who comes in for her first ultrasound after she's healed up from surgery and the ultrasonographer says, you've got a two centimeter fibroid here. And she's like, what? just had surgery. And so it's really just you want to get out the big ones and you want to get the ones that distort the cavity. You really can't and wouldn't want to get out all that little ones because you'd be slicing up the uterus in a bunch of different places.

We really try and get, if we can, one big incision and get them all out or get as many out as we can with that one incision. if you're prone to fibroids, unfortunately, you're going to probably still make some more and have some little ones after your big surgery is over with. But we just hope we get rid of the ones that really count.

Carrie Bedient MD (34:40)

Exactly. All right. Well, this was a lovely episode to go through something that so many of our patients encounter on a very, very regular basis. So to our audience, thank you so much for listening. Please subscribe to Apple Podcasts to have next Tuesday's episode pop up automatically for you. Be sure to subscribe to YouTube. That really helps us spread reliable information and help as many people as possible.

Susan Hudson MD (35:02)

Visit fertilitydocsuncensored.com to submit questions and sign up for our email list. Keep an eye out for our book being released September 23rd. Check out our Instagram and TikTok for quick hints of fertility tips between weekly episodes.

Abby Eblen MD (35:16)

Great, and as always, this podcast is intended for entertainment. It's not a substitute for medical advice from your own physician. Bye.

Susan Hudson MD (35:23)

Bye.

Carrie Bedient  MD (35:24)

This podcast is sponsored by ReceptivaDx. ReceptivaDx is a powerful test that can help detect inflammatory conditions on the uterine lining that might be preventing you from becoming pregnant or staying pregnant. If you have experienced implantation failure or recurrent pregnancy loss, ask your doctor about ReceptivaDx testing. If found, uterine inflammation can be treated, providing a new pathway to achieving a successful pregnancy. ReceptivaDx because the journey is worth it.