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About Uterine Fibroids
 What are Fibroids?
Fibroids are benign uterine tumors originating from the uterine muscle (myometrium). They begin as small seedlings in women with genetic predisposition and increase in size during the reproductive life and especially during pregnancy. A small percentage of fibroid tumors, usually those that grow rapidly, may become cancerous.
Size, Location, and Symptoms
Fibroid tumors may be very small or as large as the head of a newborn. They may be located outside of the uterus (subserosal), in the wall of the uterus (intramural), in the uterine cavity (submucosal or intracavitary), or anywhere in between. The symptoms vary depending upon size and location of the fibroids. Some women may be totally asymptomatic. Others may have pelvic pain and pelvic pressure symptoms as well as symptoms from the urinary or gastrointestinal systems. With submucosal or intracavitary fibroids, heavy menstrual bleeding, clotting, and/or hemorrhaging may be present.
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Subserosal fibroid |
Intramural fibroid |
Large subserosal fibroid |
Effect on Fertility
Submucosal or intracavitary fibroids prevent normal embryo implantation and result in infertility. Intramural fibroids may also decrease fertility and should be removed to improve chances for pregnancy. In women of reproductive age, fibroids larger than 5 cm not only prevent pregnancy but may also increase the risk of a miscarriage, premature delivery, or other pregnancy complications.
Diagnostic Tests
Uterine fibroids can be detected with pelvic ultrasound, computerized tomography (CT) scans, and magnetic resonance imaging (MRI). Submucosal or intracavitary fibroids can be evaluated using hysteroscopy, hysterosalpingogram, or sonohysterogram. Laparoscopy allows visualization of the size and location of intramural and subserosal fibroids.
Treatment
Surgical excision is the only way to permanently remove fibroids. Fibroids that rapidly increase in size are suspect of being cancerous and should be removed without delay. Treatment of other fibroids depends on their size, location, and associated symptoms. Small and asymptomatic fibroids in a woman who is approaching menopause may be observed without specific treatment; they will begin to decrease in size after menopause sets in. Symptomatic fibroids in a woman who wants to preserve her uterus for future childbearing should be removed by myomectomy, leaving the uterus in place and its anatomy restored. In a woman who has completed her family, fibroids may be removed along with the uterus (hysterectomy).
Medical Treatment
Fibroids are estrogen-dependent tumors; they decrease in size with a decrease in the estrogen levels. Medications such as GnRH agonists or GnRH antagonists (GnRH analogs) decrease the size of the fibroids by suppressing estrogen levels. However, within six months after the end of treatment with GnRH analogs, the fibroids grow back to their original size.
Myomectomy Through Laparotomy
Laparotomy is a traditional approach to myomectomy and is still being used if the fibroids are multiple, large, vascular, difficult to resect, or are attached to other organs. However, laparotomy may result in the development of pelvic and abdominal adhesions which can compromise fertility.
Laparoscopic Myomectomy
Laparoscopic myomectomy is a much more difficult procedure - an equivalent of performing surgery with chopsticks. It requires advanced laparoscopic skills - not only to remove the fibroids without damage to the uterus - but to reconstruct the uterus so it can carry the pregnancy. Laparoscopic myomectomy is facilitated by pretreatment with GnRH analogs which decrease blood supply to the uterus and the size of the fibroids, thereby facilitating the laparoscopic procedure.
Modifications of Laparoscopic Myomectomy
Laparoscopic myomectomy, reconstruction of the uterus, and removal of fibroid tumors through small incisions are technically difficult and require advanced surgical skills. Several modifications to laparoscopic myomectomy have been recently advocated. Using various energy sources, the laparoscopist can destroy fibroid tumors without removing them from the uterus. This can be achieved with very low temperatures (cryo-myolysis), lasers (laser-myolysis), or electromagnetic waves. Another method not requiring laparoscopy and used by interventional radiologists is based on embolization of the arteries providing blood supply to the fibroids. However, none of these methods have been tested extensively and several patients required emergency hysterectomy after myolysis because of uterine necrosis and life-threatening sepsis.
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Submucosal (intracavitary) fibroid protruding into the uterine cavity |
Uterus containing multiple fibroids |
Uterus after laparoscopic myomectomy |
Our Approach to the Management of Uterine Fibroids
The principle of our approach is to preserve the uterus and a woman's reproductive function and to remove fibroids by the least invasive method. At OBFC, for more than 10 years now, we perform 90% of myomectomies through laparoscopy while only about 10% require laparotomy. To facilitate the laparoscopic surgery, we pretreat most of our patients with GnRH analogs for 3-4 months. After the fibroids are removed, the uterus is reconstructed laparoscopically which allows our patients to conceive, have normal pregnancies, and in most cases normal deliveries. If the fibroids are multiple, which would make reconstruction of the uterus difficult, or if they are not accessible to laparoscopic resection, we may perform laparotomy and myomectomy and use adhesion-preventing methods to preserve the patient's fertility. We remove intracavitary or submucous fibroids hysteroscopically under laparoscopic control.
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Approach One - (COH/AIH) Approach Two - (IVF/ET) 
Symptoms/Diagnosis Management of Infertility Management of Chronic Pelvic Pain 
SUCCESS RATE 
Dr. Dmowski Dr. Rana Dr. Ding Nurses Facilities Accrediation / Affiliations 
