The uterus must be normally formed and free of large obstructions, such as endometriosis, fibroids and polyps for a successful pregnancy outcome. Some women are born with an abnormally shaped uterus such as the bicornuate uterus, which is the most common malformation. A woman may also have a septate uterus that is abnormally divided by a "wall".

Surgery to correct these defects is effective in many women .

When the uterus is severely malformed it cannot accommodate a growing fetus. In these cases, a surrogate may be the only option for having a genetically related child. There are two types of surrogacy: 1) gestational where the surrogate carries the couple's embryo created from an IVF cycle and 2) traditional where the surrogate uses her own eggs, fertilized by the father, usually in an IUI cycle.

Fibroids (leiomyoma)

A uterine fibroid (known as a lei omyoma) is a benign (non cancerous) growth composed of smooth muscle and connective tissue. Fibroids rarely become cancerous ( less than 0.1%). The are found in over 50% of women between the ages of 30 and 50 although they may cause symptoms in only about 25%

Women with fibroids typically have a number of symptoms including:

• The most common symptoms include heavy bleeding during menstruation. Large fibroids can also cause pressure and pain in the abdomen or lower back that some say feels like menstrual cramps.
• As the fibroids grow larger, some women feel them as hard lumps in the lower abdomen.
• Unusually large fibroids may press against the bladder and urinary tract and cause frequent urination or the urge to urinate, particularly during the night when a women is lying down.
• Abnormal pain during intercourse (called dyspareunia)
• Fibroid pressure against the rectum can cause constipation. Fibroids can degenerate during pregnancy causing pain and may cause premature labor.

Fibroids are Classified According to their Location

• Intramural fibroids-- grow within the middle and thickest layer of the muscular pare of the uterus. They are the most common fibroids.
• Subserosal fibroids- out from the thinner outer fibrous layer of the (called the serosa)Subserosal can be stalk-like (pedunculated). These are the second most common fibroids.
• Submucosal fibroids grow from the uterine wall toward and into the inner lining of them uterus (the endometrium). Submucous fibroids can cause bleeding and have been implicated in some of the causes of spontaneous miscarriages.

Fibroids can decrease fertility by interfering with several reproductive processes:

• Alter the endometrial contour (uterine lining) and interfere with embryo implantation
• Enlarge the uterine cavity, or alter its contractility, interfering with sperm transport
• Persistent blood clots and may interfere with embryo implantation
• Fibroids can obstruct the openings to the fallopian tubes
• Increased risk of miscarriage 
• Increased risk of premature labor

Uterine Fibroids Etiology (Causes)

Proteins called growth factors may be responsible for some of the abnormalities leading to muscle over growth and fibroids. Scientists have identified chromosomes carrying a total of genes that may have an effect on fibroid growth. Some experts report that uterine fibroids ar inherited from paternal genes (the father's side).

The diagnosis and location of fibroids can sometimes be detected by a pelvic exam but a more precise diagnosis is established using ultrasound, the hysterosalpingogram, and/or the sonohysterogram.  A hysterosalpingogram can detect fibroids that are in the uterine cavity. A sonohysterogram is performed by injecting saline into the uterine cavity and performing ultrasound examinations. The fluid creates a “contrast” making the fibroids easier to identify.

Surgery may not be necessary if the fibroids are very small or are located outside the uterine cavity.  Large fibroids can usually be removed laparoscopically or sometimes using the hysteroscope. 

Myomectomy

A myomectomy is a surgical procedure where individual large fibroids are removed through an abdominal incision. Dependent on their location and numbers many fibroids can usually be removed laparoscopically (laparoscopic myomectomy), which dramatically reduces recovery time and pain. With  laparoscopic myomectomy there is little on no hospital stay and one can resume normal activities in as little as three days.  

Fibroids which are located inside the uterine cavity, can by removed through the cervix and vagina using the hysteroscope (hysteroscopic myomectomy). This is an outpatient procedure and requires no hospital stay.

Fibroids can sometimes be temporarily treated with Lupron, which is a GnRH agonist medication.  Lupron has the following actions:

• Decreasing bleeding which is often encountered during the myomectomy
• Decreasing the size of the uterus for easier manipulation
• Creating a menopause like state that often shrinks the fibroids by 50%. The effect is temporary and the fibroids will re grow once medication has been discontinued.

INSIGHTEC

Insightec is an FDA approved noninvasive treatment to shrink uterine fibroids. The patient
receives intravenous sedation while they are lying down in an MRI chamber, which is used to localize and direct ultrasound heat energy  to treat the fibroids.

After a session of three to four hours of treatment, the patient is discharged home and can return to work the next day. This method of treatment has minimal or no side effects, and offers many advantages to patients who can now receive relief of symptoms without the risks of surgery.

In severe cases, where the couple does not desire children, hysterectomy may be the treatment of first choice.

See "Pelvic Pain" page for a discussion of the causes of, and treatments for, pelvic pain.