Generally, it is a well-known medical fact that most women will have fibroids during their lifetime.
Fibroids affect around 30 percent of all women by 35 years and 20 to 80 percent by 50 years. They usually develop between the ages of 16 to 50 years. The estrogen levels are higher during this reproductive period. Women of this age would have already completed a family in the past. However, today, many women have children later in life. It is common to start a family in the thirties or even forties rather than in the twenties. It makes understanding the potential relationship between fibroids and infertility significant.
Several authors confirm that many women will have fibroids that will not hurt their chances of having children. The fibroids may stay small or occur in areas that do not affect the reproductive system. However, certain fibroids will profoundly affect the ability to conceive, stay pregnant, and carry a baby to term.
Based on their anatomical locations in the body, fibroids may prevent sperm and egg from meeting for conception. Fibroids can hamper the ability of an embryo to implant. They often grow in places or sizes that make it challenging for a pregnancy to continue. Fibroids may even affect the health and welfare of the fetus.
How do Fibroids affect fertility?
Below are some of the ways fibroids affect fertility:
- Fibroids that change the shape of the cervix can affect the number of sperm entering the uterus.
- Fibroids that block the Fallopian tubes can make implantation difficult or impossible.
- Fibroids that change the shape of the uterus may decrease the number of places an embryo can successfully implant or reduce uterine space needed for embryo development.
- Fibroids that weaken the lining of the uterine cavity or decrease the blood supply to a growing embryo can cause miscarriage.
Fibroid Prevalence in Nigeria
Estimating the overall incidence of fibroids in the population depends on the community under investigation and the sensitivity and specificity of the methods used to detect fibroids. In this case study, ultrasonography estimated a prevalence of 6.83% in asymptomatic Nigerian women. This value is close to what has been reported in other parts of South-West Nigeria: 7.6% and 8.35% were recorded for Ife and Ilesha (both in Osun state), respectively (Oguniyi & Fasuba, 1990; Sankaran & Manyonda, 2008); 3.2% for Sagamu, Ogun State (Akinyemi et al., 2004). However, higher values have been reported for other parts of the country, especially the eastern region: 13.6% was recorded in Ebonyi State (Obuna et al., 2008); 19.75% was reported for Irrua, Edo State; 25.9% obtained in Enugu (Ozumba et al., 2011).
What are the causes of Fibroids?
Giving birth to less than two children
The more children one has, the less likely one is to develop fibroids. It is unclear to researchers why this is, and it is essential to note that this does not mean women should have more children to avoid fibroids. Since fibroids occur even in women with three or four children.
Alcohol consumption
According to The Black Women’s Health Study, there is a link between uterine fibroids and black women taking alcohol, especially beer. To avoid the risk of Fibroids, we encourage reduced intake of alcohol, especially beer, to once per week or less.
Inadequate Fruits intake
In a study of dietary habits, researchers found that two servings of fruit a day ( these two servings equal about 250 grams), especially citrus fruits, was associated with a lowered risk of uterine fibroids. If you don’t eat enough fruits and vegetables, you might be increasing your chances of developing fibroids. Please note that the best fruits to this effect are fruits grown in your genetic environment and must be in moderation. Hence apples and overseas grapes are not recommended.
Early Menstruation
Fibroids are sensitive to hormones, particularly estrogen. This explains why women who begin menstruating before age 11 are more likely to develop fibroids than women who started menstruating after age 13.
Vitamin D Deficiency
Vitamin D is a fat-soluble vitamin in certain foods, particularly dairy foods. The exposure of our skin to sunlight enables our bodies to produce vitamin D. Research has shown that vitamin D can diminish the growth of cells and regulate the immune system. Vitamin D also limits the production of fibrous tissue by fibroid cells. Make sure you are getting an adequate amount of vitamin D.
Prenatal Exposures
Although nothing can be done about what you were exposed to while in the uterus, understanding what may lead to your fibroids’ development is still helpful and can help prevent fibroids in future generations. Exposure to diethylstilbestrol (DES), an artificial synthetic form of estrogen given to women from 1938 to 1971 as a treatment for infertility and premature deliveries can cause fibroids. Also, maternal pre-pregnancy diabetes or gestational diabetes can cause fibroids in women. Being part of multiple pregnancies, such as being a twin or triplet also increases the chances of having fibroids.
Hair Relaxers
Hair relaxers may contain phthalates, a group of chemicals considered hormonally disruptive. Detectable levels of phthalates found in urine are associated with uterine fibroid risk. The best thing to do is to avoid using hair relaxers or use them once in a while.
Stress/Life Events
Stressful major life events, such as the loss of a child or spouse, divorce, or the birth of a first child, are associated with fibroids. Stress is thought to lead to changes in hormone levels that encourage the development of fibroids. Take care of yourself by exercising, getting enough sleep, and eating right to better your emotional and physical well-being and help your fibroids.
Genetics
African American women are more likely to develop fibroids than Caucasian women. By age 35, 60% of African American women will have fibroids, compared to 40% of Caucasian women. While you cannot change your genetics, you can focus on the other causes of uterine fibroids that you have control over.
In summary, the most determining factor is an event that can lead to the unopposed action of estrogen in the body.
Two examples to illustrate the management.
Case 1. Mrs. B. F. was a 30-year-old lady who presented to the Medical Arts Center with three years of infertility. Evaluated showed that all was normal apart from the low sperm count and a submucous fibroid of 1.0mm seen at Saline Hysterosonography (HSN). We conclude not to do any hysteroscopy to remove the submucous fibroid. We recommended IVF with ICSI (Intracytoplasmic sperm injection) due to the low sperm. She got pregnant and has since delivered a baby boy.
Case 2. Mrs. SQ is a 43year mother of 4 who presented to the hospital with fatigue and weakness following heavy menstrual bleeding (menorrhagia) during her last menstrual period three days prior. This problem has been present for about four years now. Her periods are regular, every 28 days, and are usually heavy with clots and flooding on the last two days with associated painful periods. Mrs. SQ uses 9 – 10 sanitary pads per day during her period.
She also noticed abdominal swelling, which was progressively increasing in size. It was distressing for her because many people thought she was pregnant. She has been married for 19 years, and her last pregnancy was eight years ago and has never received any treatment for her heavy periods and painful menstruation.
On examination, Mrs. SQ was pale but comfortable at rest. She had an enlarged Abdomen. A smooth, firm mass was felt that extended from her pubic region to her umbilicus. Her blood pressure was reasonable, but her heart rate was fast. A packed cell volume (PCV) showed a low blood level. An ultrasound scan revealed two large uterine fibroids. She was transfused with blood and subsequently scheduled for surgery later.
Discussion
The fibroid is the most common benign uterus tumor (womb). The word ‘a tumor’ evokes fear mainly because it is associated with cancer; however, fibroids are non-cancerous growths that arise from the smooth muscle cells of the uterus, sometimes known as myomas or leiomyomas. It is different from uterine cancer, but this is not to say they are harmless, as they can cause symptoms that can lead to loss of life.
They range in size from a pea to a football, and a woman can have multiple fibroids. It commonly affects women of African or Caribbean descent. Complications that can arise include anemia (low blood level), prevention of pregnancy (infertility), and it can even cause problems in an existing pregnancy, such as placenta abruption (separation of the placenta from the wall of the uterus), miscarriage, among others._
The cause of fibroid is still not precisely known. Still, it is believed that factors such as the family history of a fibroid, hormones, infertility, being over 30, being of African or Caribbean descent, and having a high body weight may influence their formation.
Most women do not know that they have fibroids as it usually does not have symptoms. However, some women have symptoms like heavy menstrual bleeding, bleeding between periods, painful periods, abdominal swelling, pain or discomfort during sex, constipation, lower back pain, and frequent need to urinate.
Physical examination by medical personnel might reveal a pale, exhausted, and weak patient with excessive menstrual bleeding and an abdominal mass.
Fibroids do not often cause symptoms, and as such, they are diagnosed during routine physical examinations in conjunction with imaging studies to determine the size and location of the fibroid; these investigations include abdominopelvic ultrasounds, X-rays, MRIs, and some additional tests such as total blood count to determine the blood level.
The treatment of fibroid depends on whether the patient has symptoms or not, the patient’s desires (for example, conception), size, the location of the fibroid, and the patient’s age. Most fibroids stop growing or even shrink as the woman approaches menopause. As a consequence, it can be managed by ‘watchful waiting.` In this case, the woman’s symptoms are carefully monitored. Active treatment may be necessary for women whose fibroids are large or causing significant symptoms. Generally, treatment options are with medications or surgery, depending on the extent of the disease. We use Anti-hormonal agents that oppose the actions of estrogen and progesterone. Surgical removal of the fibroid is also known as myomectomy. It involves the removal of the fibroid but leaving the uterus intact to enable a future pregnancy. Myomectomy is done in three ways: hysteroscopy, Laparoscopy, and laparotomy. Hysteroscopy involves inserting a lighted tube with a camera into the vagina to gain access to the uterus. Laparoscopy is a small cut on the abdomen, while laparotomy involves a large incision. The approach for a myomectomy depends on the size, location, and number of fibroids.
In some cases where the affected woman has completed her family size, the surgeon will perform a procedure known as a hysterectomy, which involves removing the entire uterus. A newer technique known as uterine artery embolization consists of blocking off the blood supply to the uterus, thereby shrinking them. It is without a large abdominal incision.
PICTURE OF A HYSTEROSCOPY MACHINE AT THE MEDICAL ART CENTER
The fibroid is a frequently diagnosed gynecological tumor affecting women, and the treatment depends on the age, symptoms, extent of the disease, and desire for future childbearing.
The evidence regarding the effect of fibroids on infertility and reproductive outcomes is weak and mostly inconclusive. Appropriate evaluation and classification of fibroids, particularly those involving or suspected of affecting the endometrial cavity, is essential in infertile women. To improve conception rates, submucosal fibroids (FIGO L0-L2) should be treated hysteroscopically (or laparoscopic for large L2). Many studies also feel that submucous fibroid below 1.0mm should be left alone with no consequences on conception. The management of intramural fibroids should be individualized on a case-to-case basis, whereas subserosal fibroid is unlikely to impact fertility significantly. Women who wish to maintain or improve their fertility should avoid conventional conservative treatment measures due to the lack of data on their safety and effectiveness.
What are Medical Treatments for Fibroids?
The treatment of fibroid depends on whether the patient has symptoms or not, the patient’s desires (for example, conception), size, the location of the fibroid, and the patient’s age. In some cases where the affected woman has completed her family size, the surgeon will perform a procedure known as a hysterectomy, which involves removing the entire uterus. A newer technique known as uterine artery embolization consists of blocking off the blood supply to the uterus, thereby shrinking them. It is without a large abdominal incision.
The best treatment for fibroids is LHRH analogs such as Lupron or Zoladex. Studies have shown that when the LHRH analog is given monthly as a subcutaneous injection over three months, there could be up to 50-75% shrinkage in the fibroid size. An attempt at conception can also follow.
Other alternative therapy (Gestational Surrogacy
If the fibroid has spread all over the uterus, it may be difficult for the uterus to carry a baby. Consequently, newer techniques have been employed to assist in meeting the UN human rights charter on the right to have a baby. In such a situation, the couple can use gestational surrogacy to conceive.
In gestational surrogacy, the wife is stimulated to make eggs. The follicles that contain the eggs are aspiration, as in IVF. The husband’s sperm is used to fertilize the eggs. The subsequent embryos so formed can develop in the laboratory for at least three days. The embryos are then transferred to a Gestational host to carry for nine months.
Check our blog resource for more details about this topic. In the USA, 750,000 babies are born every year using gestational surrogacy. Also, about 25,000 babies have been born in India using this method. About 300 babies have been born with gestational surrogacy in Nigeria.
