A Case of Primary infertility and Uterine Fibroids

Emobileclinic Patient’s corner

We had so many cases of fibroids this week, so will talk on one of them. One of Emobileclinic patient had 11 fibroids masses removed from her uterus during the week. She was 35years old nulliparous woman with primary infertility. She had no evidence of pelvic infection and was of relatively normal weight and stature. She had presented with inability to conceive and abdominal swelling. Her menses was normal.

Uterine fibroids are the commonest tumour in the body, composing mainly of smooth muscles fibers and variable amount of connective tissue. They are benign tumours of the uterus found in both fertile and infertile women, but is found more to be more common in nulliparous and relatively infertile females. It occurs in 20-30% of women over the age 30 years. It is also 3-9 times more common in the blacks compared to Whites, Hispanic and Asian women. Uterine fibroids account for 6.58% to 13.4% of all gynecological admission in many center in Nigeria.

Fibroids are usually multiple with varying sizes. They are described by their location with respect to the uterus as submucous, intramural, subserous, intraligamentary or parasitic. The aetiology of uterine fibroids is unknown but estrogen is suspected to play some role. The higher numbers of oestrogen receptors in leimyomata than in normal myometrium, its development during the reproductive years and regression after menopause are supportive of oestrogen influence. Obesity, early menarche and pelvic inflammatory disease have all being implicated.

Most cases of uterine fibroids are asymptomatic, being discovered when evaluating for other gynaecological conditions such as infertility as in this case. Symptomatology of Uterine fibroids includes vaginal bleeding in form of menorrhagia and irregular menses. Others are secondary dysmenorrhoea, chronic pelvic pains, recurrent abortion, pressure symptoms and fibroid complicating pregnancy.

The diagnosis of uterine fibroids in this patient was made based on history, physical examination and ultrasonographic findings. It was further confirmed by histological finding. IVU and HSG were done to outline the ureters and the uterus with its tube respectively. HSG was particularly important in this patient because of the infertility. The report was that of non-demonstration of the tube possibly from under filling or blockage on account of the fibroids. A common cause of non-demonstration of the tubes in this environment is tubal blockage from pelvic infections. Intra-operative findings in this patient revealed a clean pelvic with no evidence of adhesion as well as grossly normal fallopian tube and ovaries. Premenstrual endometrial biopsy was done to confirm ovulatory changes in view of the infertility. Seminal fluids analysis was done on the husband which turned out to be normal.

The management of uterine fibroids depend on the age of the patient, the reproductive desires as well as the symptoms of the fibroids. Despite the fact that several studies have not causally linked fibroids to infertility, myomectomy is still usually performed when uterine fibroid is found in association with infertility. Possible mechanisms by which uterine fibroids cause infertility include; distortion of endometrial cavity, impairment of blood supply to endometrium, dysfunctional uterine contractility amongst others.

Myomectomy is essentially a fertility enhancing procedure and crude pregnancy rate after myomectomy for infertility in many studies ranges between 38-65%, majority conceiving within 6 months of the procedure. So myomectomy had been done for our patient.

Why some women reported infertility after myomectomy?

Adhesion formation is a significant tissue in patients whom the aim of surgery is for enhancement of fertility and if careful measures are not put in place, myomectomy itself may decrease fertility probably as a result of adhesion formation. (This is the part you need to shine your eye when choosing your doctor). The following measures are taken to minimize adhesion for our patient; minimal and anterior placed uterine incision, gentle handling of tissues, use of absorbable non-reactive suture in the serosa and performing a thorough pelvic cavity lavage at the end of the surgery.

Other methods of treating uterine fibroids include hysteroscopic resection of the submucous fibroids, hysterectomy, myolysis, bilateral uterine artery ligation via vaginal route and uterine artery embolisation. All these are unsuitable for women desirous of having children because these modalities of treatment are associated with risk of possible worsening of infertility, interference with placental blood flow and possible uterine rupture in future pregnancy.

Medical treatments for fibroids include the use of nonsteroidal anti-inflammatory drugs, levonorgestrel releasing IUCD, oral contraceptive pills, danazol, gesterone and GnRH analogues. These are effective in controlling menorrhagia and dysfunctional uterine bleeding.

Vaginal delivery after myomectomy is safe because the scar heals better and there is less risk of uterine rupture as compared to caesarean section scar. Some authorities however believe that elective cesarean section should be performed if endometrial cavity was opened. We counseled our patient and told her to present early in event of a pregnancy and told her the need for hospital delivery.