Do all fibroids need removal?

Dr Richa Sharma, Dr Amit Basnotra
Fibroids are the part of womb only and its effects can be variable depending upon number, size, location and also by the age of the female.Its a sort of space occupying lesion as it may replace birth place of prospective baby in some cases so where all problem actually arise and that’s how you may land up to your treating Doctor
In layman’s term it is called as ‘Rasoli'(in Hindi). This is a very common problem faced by all age group of females but it doesn’t mean all will get operated. Whether it is to be removed or not will be decided as per the clinical status of the patient.Blanked Treatment doesnot apply all and it needs individualized approach with patience on part of patient and doctor both as knife cannot be a solution to all troubles most of the time.Needs a thorough and systematic approach !!
Effect of Fibroids on Fertility-
Fibroids are found in 1-2.4% of women with unexplained infertility
There are conflicting data aboutalmost all aspects of the role of fibroids on-
* Implantation
* Pregnancy rates
* Miscarriage rates
* Pregnancy outcome.
-But definitely if they are bigger in size and distorting the womb and especially in cases with previous multiple pregnancy losses or multiple IVF failures then the removal of fibroids cannot be ignored
-More so even if the patient insists not to get operated we have duty to explain the underlying risk of degenerative changes which can happen during pregnancy which is a crisis.
Look since is neither zero nor 100%, it gives you some middle figures . What proves beneficial for a particular patient definitely should be evidence based but with clinical acumen.
Why Fibroids removal important ?
-IVF-ET is expensive and somewhat risky. If a woman is trying naturallyto conceive, the only thing lost is time by not treating fibroids. However, ifthe presence of a fibroid in a given woman will reduce the chance of conception following IVF-ET, the decision for surgery should be consideredearlier than for a couple not requiring IVF-ET.
The data certainly support hysteroscopic removal of submucosal fibroids > 2 cm.
Intramural fibroids distorting the uterine cavity or those<7cm probably warrant surgical intervention.
Risks –
Nevertheless, because majorsurgery is necessary and permanent damage precluding future pregnancies
is possible, patients must be properly informed as to potential risks andbenefits
Role in IVF-ET-
Although there seems to be a possible trend for lower implantationrates with smaller intramural fibroids not compressing the uterine cavity,there seems to be an acceptable pregnancy rate with these fibroids present to warrant at least two or three ETs before considering surgery. This philosophyis also based on the fact that there are no studies to date showingthat surgery under these conditions improves outcome
Role in previous miscarriage(s) and how many ?
Since the data strongly suggest that certain fibroids increase miscarriagerates, we would recommend surgery if there was at least one previous miscarriage,as long as it was not found to be of genetic origin. Previously, wemay have used a minimum size to suggest surgery, but, based on recentdata, even the size may not be a factor.39 Of course, patients must beinformed that one cannot prove that the fibroid was the cause, or thatremoving it would necessarily help. The final decision should be up to thepatient.
When Does Surrogacy Helps and Prevailing Laws Of Land ?
In very bad cases we often come across in our clinic are those with primary infertility with multiple fibroids distorting womb with no space left for baby to grow and are having symptoms like heavy bleeding , painful periods etc besides secondary symptoms, no extent of surgery may be proving beneficial then in such cases they are given the option of surrogacy( with self or donor eggs as per situation).
But now Surrogacy also can be Altruistic only(Please refer to latest updates on ART Bill, 2019 On Regulation Of Surrogacy Tabled in Rajya Sabha) with limitations in age group.