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Uterine Fibroids
BradleyS.Hurst
9
Background
The identication of uterine broids during evaluation for infertility or in preparation for assisted
reproductive technology can present a perplexing
problem for patients and their providers, especially when broids are asymptomatic. The concern is well-deserved, since unnecessary surgery
for broids exposes the patient to risks, has a
high potential to result in adhesion formation,
may require future cesarean delivery, and may
reduce fertility if adhesions compromise the
tubo-ovarian relationship or distort the uterine
cavity. However, failure to treat broids could
impair spontaneous conception, compromise outcomes of fertility treatments, or increase the risk
of miscarriage and pregnancy-related complications. The goal of this chapter will be to provide
rational treatment options for women with uterine broids, based on the best available data.
A uterine broid is a monoclonal growth of
brovascular cells that arise from the myometrium. Estrogen and progesterone receptors are
present in broids, and both hormones stimulate
broid proliferation. Fibroids are surrounded by
a dense vascular pseudocapsule, and larger
B. S. Hurst (*)
Carolinas Medical Center, Department of Obstetrics
and Gynecology, Reproductive Endocrinology and
Infertility, Charlotte, NC, USA
e-mail: brad.hurst@atriumhealth.com
masses usually have a greater vascular supply
[1]. Factors within the pseudocapsule stimulate
broid growth, including a local overexpression
of aromatase, which converts androgens to estrogens [2]. Estrogen stimulates growth factors in
the pseudocapsule, including EGF, IGF-1, bFGF,
GH, TGF-β, PDGF, endothelin A, and VEGF [3].
Vitamin D deciency appears to stimulate broid
growth [4].
The prevalence of broids peaks during the
fourth decade because of the cumulative effects of
estrogen, progesterone, and growth factors on
myoma growth during the reproductive years [5].
Fibroids are more numerous and larger in AfricanAmericans. Ultrasound studies have found a
cumulative incidence of broids in approximately
80% of African-American women by age 50 [6].
However, broids are common in all ethnicities,
including a cumulative incidence of 70% in
Caucasian women. There is great interest in identifying dietary and environmental factors that
contribute to broid growth. There is increasing
evidence that hypertension, a family history of
broids, time since last birth, food additives, and
soybean milk consumption increase the risk of
uterine broids [7]. Oral contraceptives, depot
medroxyprogesterone acetate, smoking, and
increased parity reduce the risk of broids.
The broid deforms the surrounding tissues as it
grows. A broid that develops in the myometrial
wall is considered an “intramural” myoma
(Fig. 9.1). A broid that protrudes into the
© Springer Nature Switzerland AG 2019
L. A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
https://doi.org/10.1007/978-3-030-16699-1_9
137
138
Fig. 9.1 Saline infusion
sonohysterography with
intramural broid
endometrial mucosa is a “submucous” myoma.
Fibroids that protrude the serosal surface of the
uterus are called “subserosal” myomas (Fig.9.2).
Other terms sometimes used to describe the location of broids include “sessile,” a type of submucous myoma that is located in the myometrium but
also distorts the endometrium (Fig.9.3). A “pedunculated” broid is located primarily outside of the
uterus, connected to the uterus by a brovascular
stalk (Fig.9.4). In this chapter, the terms broid,
myoma, and leiomyoma are used interchangeably.
In 2011, the International Federation of
Gynecology and Obstetrics (FIGO) published a
classication system further describing the location of broids [8], and clinical studies often
refer to this classication. There are eight broid
types. Submucous broids are divided into Type
0 (completely intracavitary), Type 1 (>50% intracavitary), and Type 2 (≥ 50% intramural)
(Fig.9.5). A Type 3 broid is intramural but contacts the endometrium, Type 4 is intramural and
entirely within the endometrium, and Type 5 is
intramural and distorts the serosa but is ≤50%
subserosal. A Type 6 broid is partly intramural
but >50% subserosal, and a Type 7 broid is subserosal pedunculated. A Type 8 broid is not
attached to the uterus and may include other locations such as the cervix or could be a parasitic
broid. Finally, a “Hybrid 2–5” broid distorts
B. S. Hurst
Fig. 9.2 Transvaginal ultrasound demonstrating subsero-
sal broid
the endometrium and the serosa but is <50% submucosal and <50% subserosal.
Symptoms attributed to broids are deter-
mined by the size and the location of the
9 Uterine Fibroids
Fig. 9.3 Transvaginal
ultrasound
demonstrating several
uterine broids,
including one submucous
myoma with deection
of the endometrial cavity
Fig. 9.4 Transvaginal
ultrasound
demonstrating
pedunculated broid
139
masses. Most intramural, subserosal, and
pedunculated broids are asymptomatic.
However, large broids may cause bulk symptoms such as abdominal pressure, bloating, or
distention. A myoma that presses against the
bladder may cause urinary frequency, urgency,
or nocturia. A broid that compresses the rectum may cause constipation, diarrhea, or alternating symptoms. Infarction of a broid may
cause severe acute pain, and the inammation
caused by degenerating myoma may cause
adhesions. Fibroids located in the posterior cul-
de-sac may cause dyspareunia. Occasionally,
broids are associated with chronic, intermittent, or cyclic pain.
Submucous myomas often cause abnormal
uterine bleeding (Fig.9.6). Symptoms of submucous broids include menorrhagia, dysmenorrhea, clotting, and intermenstrual bleeding [9].
When bleeding is severe, anemia may occur.
With the high prevalence of broids and the multitude of symptoms that may be attributed to
broids, it is not surprising that broids are the
leading indication for hysterectomy. However,
140
B. S. Hurst
Leiomyoma
subclassification
system
3
2-5
6
5
Fig. 9.5 International Federation of Gynecology and Obstetrics (FIGO) published a classication system further
describing the location of broids [8]. (Reprinted with permission from Munro etal. [8])
4
0
1
2
7
SM - Submucosal
O - Other
Hybrid
leiomyomas
(impact both
endometrium and
serosa)
0Pedunculated intracavitary
1
<50% intramural
≥50% intramural
2
3
Contacts endometrium; 100% intramural
4
Intramural
Subserosal ≥ 50% intramural
5
6
Subserosal <50% intramural
7
Subserosal pedunculated
8
Other (specify e.g. cervical, parasitic)
Two numbers are listed separated by a hyphen. By convention, the first
refers to the relationship with the endometrium while the second refers
to the relationship to the serosa. One example is below
2–5
Submucosal and subserosal, each with less
than half the diameter in the endometrial
and peritoneal cavities, respectively.
broids increases with age, fertility declines with
age, and many women with broids conceive
spontaneously.
The location of broids is important in determining the impact on fertility. In some circumstances, broids impair fertility by mechanically
distorting the uterine cavity, altering the endometrium and impairing embryo implantation and
growth. Other obvious causes of broid-related
infertility may include mechanical obstruction of
the tubal ostia.
Submucous myomas directly impair fertility
and cause adverse reproductive outcomes by several potential mechanisms [9]. These broids
alter the vascular supply and development of the
endometrium with intramural myomas or alter
growth factors and inammatory substances that
Fig. 9.6 Three-dimensional mapping of a submucosal
broid
may impair implantation or fetal growth. The
mechanical distortion of the endometrial cavity
almost certainly has a direct effect on fertility. In
general, greater endometrial distortion more
other treatment options must be considered for
women who are interested in childbearing.
clearly results in compromised fertility.
Myomectomy improves fertility in these cases.
Intramural broids reduce fertility when they
are 4cm or larger, and myomectomy appears to
Fibroids andFertility
restore fertility [10]. Additionally, FIGO Type 3
intramural broids 2cm or larger that touch the
It is difcult to determine the direct impact of
broids on fertility, since the incidence of uterine
endometrium impair fertility [11]. Another study
found that fertility was reduced in women who
9 Uterine Fibroids
Fig. 9.7 Transvaginal
ultrasound
demonstrating multiple
intramural broids; the
entire endometrium is
difcult to visualize
141
had two or more intramural broids, or for intramural broids that are 3 cm or larger [12].
However, there is no clear evidence that myomectomy enhances fertility in women with intramural myomas [13, 14]. Subserosal broids do
not impair fertility [15].
Many women have multiple broids, and the
different size, location, number, and relative relationship to the endometrium increase the difculty in establishing the effect of broids on
fertility, as no two individuals are directly comparable (Fig. 9.7). As such, the relative usefulness of myomectomy in these situations cannot
be established with certainty.
Fibroids andIVF
Studies of the impact of broids in IVF cycles are
helpful to establish the impact, since many factors impacting fertility are either controlled, such
as male infertility, or directly evaluated, such as
the impact of age on cycle outcome. Submucosal
broids have long been recognized to reduce IVF
pregnancy and birth rates [16, 17]. Furthermore,
hysteroscopic myomectomy improves pregnancy
rates, with outcomes comparable to women with
a normal uterine cavity [18].
The effect of medium and large intramural
myomas on IVF outcomes is unclear, and some
studies have shown little clinical effect. When
IVF outcomes are generally poor, IVF live birth
rates were not improved by myomectomy in one
small retrospective study: IVF “ongoing” pregnancy rates were 17% after myomectomy
(n=47), 21% with untreated broids (n=11),
and 19% in normal controls [17]. However, 50%
of women with broids experienced a spontaneous abortion, compared to 34% after myomectomy, suggesting that broids compromise
pregnancy outcomes. A study of 46 IVF cases
with intramural and subserosal broids showed
that outcomes were similar to controls, but broid
size was not assessed [19]. Other investigators
found that myomas, 73% of which were subserosal, had no effect on conception in 39 women
[20]. A study of 119 women with asymptomatic
intramural or subserosal broid found that myomas smaller than 5cm did not compromise IVF
pregnancy or birth rates when matched to controls [21]. The outcome was not changed when
the group was limited to those with intramural
myomas.
Contrary to these reports, increasing evidence
suggests that some intramural broids are associated with lower ART live birth rates. A retrospec-
142
B. S. Hurst
tive study found a signicant decrease in IVF live
birth rates in women under age 40 years with
intramural broids (49% and 58%, respectively)
[22]. In 2005, a meta-analysis showed a signicantly lower implantation rate with intramural
broids compared to controls, 16.4 vs. 27.7%,
respectively (OR 0.62, 0.48–0.8), and a signicantly lower birth rate per embryo transfer with
broids compared to controls, 31.2% and 40.9%
(OR 0.69, 0.50–0.95) [23]. In a retrospective
study of 91 IVF cycles in women with intramural
or subserosal broids, Stovall etal. found a signicantly lower pregnancy rate with broids
(37%) compared to matched controls (53%) [24].
The broids size ranged from 8 to 54mm, with a
mean diameter of 29mm, and 95% were intramural. The implantation rate was 14% with
broids, signicantly lower than the 20% implantation rate in controls without broids. Another
study found that women with intramural broids
had signicantly lower pregnancy rates compared to women without broids, 16% and 34%,
respectively, p < 0.05 [16]. Implantation rates
were more than 50% lower with intramural
broids compared to the controls (p < 0.005),
even though the mean diameter of the broids
was 24mm. A meta-analysis assessed 19 observational studies comprising 6087 IVF cycles and
found a signicantly lower IVF live birth
(RR=0.79, 95% CI 0.70–0.88, p<0.0001) and
clinical pregnancy rate (RR=0.85, 95% CI 0.77–
0.94, p = 0.002) in women with intramural
broids compared to those without broids [25].
The authors concluded that non-cavity-distorting
intramural broids are associated with adverse
pregnancy outcomes in women undergoing IVF.
Oliveira etal. found a signicantly lower pregnancy rate with IVF only when intramural
broids were 4cm or larger [10].
Recent studies have identied characteristics
that impair ART live birth rates. A case-control
study of 151 women with FIGO Type 3 intramural broids found that broids 2cm or larger that
touch the endometrium impair IVF pregnancy
and live birth rates, but smaller broids do not
compromise outcomes [11]. Finally, one casecontrolled study women undergoing IVF found
that the live birth rate was reduced in women who
had two or more intramural broids (OR 0.47;
95% CI 0.26–0.83) or if intramural broids that
are 3cm or larger (OR 0.41; 95% CI 0.19–0.89)
[12]. There was no difference in pregnancy outcomes in those with one intramural broid <3cm.
Subserosal broids do not impair fertility [15].
Egg donation provides an opportunity to study
the effect of implantation while minimizing the
effect of confounding factors of maternal age and
male fertility. There is evidence that egg donation
outcomes are lower in African-American women
compared to other populations, although the populations are too small to conclude that broids
are the primary explanation for this effect [26]. It
is possible that uterine broids could provide a
possible explanation for this observation.
Uterine broids may increase the difculty of
the oocyte retrieval or embryo transfer and either
may lower IVF outcomes. A broid may raise the
ovary out of the pelvis, especially large masses. If
this occurs, it may be necessary to perform laparoscopic oocyte retrieval or ultrasound-directed
transabdominal retrieval. A broid may increase
the difculty of the embryo transfer in one of several ways: distorting the position of the cervix in
a way that it is difcult or impossible to expose
the cervix with a speculum, by markedly altering
the endocervical course or causing endocervical
stenosis (Fig. 9.8). Finally, a large broid may
make visualization of embryo transfer difcult or
impossible when an abdominal ultrasoundguided procedure is performed. This can be critical since increasing difculty or tortuosity of the
endocervix makes it difcult to visualize the
transfer catheter to conrm optimal placement.
Myomas andObstetrical Outcomes
While the impact of broids on fertility is still
debated, obstetrical outcomes appear to be compromised by uterine broids in some [9] but not
all studies. A population-based retrospective
study by Sheiner et al. [27] found that women
with broids had a 3.5-fold increased incidence
of intrauterine growth restriction (6.8% vs.
1.9%), a 4-fold increase in placental abruption
(2.8% vs. 0.7%), a 5-fold higher incidence of
9 Uterine Fibroids
Fig. 9.8 Transvaginal
ultrasound
demonstrating large
broid in the lower
uterus and cervix
143
transverse lie or breech presentation (16.9% vs.
2.4%), a 5 times higher cesarean section rate
(57.7% vs. 10.8%), 70% higher risk of premature
rupture of membranes (9.6% vs. 5.5%), and were
3 times more likely to receive transfusion (4.2%
vs. 1.4%). All of these outcomes were signicant,
with p<0.001. Adjusting for maternal age, parity, gestational age, and malpresentation, pregnancies with broids still had a 6.7 times higher
risk of cesarean delivery, with 95% CI 5.5–8.1,
p<0.01). Placental abruption and preterm deliveries remained signicantly more common with
broids. The size and locations of the broids
were not assessed in this study, but other investigators have found that broids adjacent to the
placenta increase the risk of bleeding and premature rupture of membranes [28].
A retrospective study in 2012 supports the
hypothesis that broids have a detrimental
impact on pregnancy, especially when the
broids are large [29]. The mean gestation age at
delivery for women with broids larger than
5cm was 36.5weeks, signicantly earlier than
women with smaller broids or no broids.
Other signicant effects included shortened cervix, premature preterm rupture of membranes,
preterm delivery, blood loss during delivery, and
the need for postpartum transfusion. Considering
these and other publications, authors of a literature review concluded that pregnancy outcomes
are compromised in women who have intramural
broids [30].
Uterine broids tend to enlarge during pregnancy, regardless of size and maternal age [31].
Although the growth or degeneration of a broid
is not linear throughout the course of pregnancy,
there is remarkable growth during the early pregnancy. This was demonstrated in a prospective
case-controlled study of women with broids
undergoing IVF, in which broids were serially
measured by ultrasound in 25 women who conceived and in 25 who failed to become pregnant
[32]. A signicant 34% increase in the mean
diameter of broids was found in early pregnancy, compared to a 2% increase in those who
failed to conceive. There was no correlation
between ovarian response to stimulation and
broid growth. Therefore, the growth was attributed solely to pregnancy-associated factors. The
observation that broids grow in diameter by
approximately 30–35% during the early pregnancy is concerning, as it is possible that an
asymptomatic or seemingly “innocent” broid
near the endometrium could enlarge and lead to
unexpected problems during pregnancy.
Approximately 70% of broids grow by a volume of 10% or more between the rst and second
and second and third trimesters [31]. However,
there is limited evidence that treatment improves
outcomes.
144
B. S. Hurst
Myomectomy could be justied in some circumstances to reduce the risk of adverse pregnancy outcomes [33]. Unfortunately, the benet
of myomectomy for intramural broids has not
been denitively proven. The most compelling
evidence for intramural myomas appears to be
cases with large broids, 4 cm or larger, and
tumors close to the uterine cavity. It is important
to clarify this issue since myomectomy for intramural broids has a risk of morbidity and adhesion formation, and surgery should not be
considered unless the benets outweigh the risks.
Some studies have questioned the relationship
between uterine broids and miscarriage and
poor pregnancy outcomes. A study of over 500
women with uterine broids found no increase in
risk of miscarriage after adjusting for confounding factors (adjusted hazard ratio = 0.83, 95%
condence interval: 0.63, 1.08) [34]. Furthermore,
a meta-analysis that utilized ve studies that
included 1394 women with broids and 20,435
without found no increase in risk of spontaneous
abortion (risk ratio 0.83, 95% CI 0.68–0.98) [35].
No characteristic of broids was associated with
risk in these studies.
Despite the contradictory literature, myoma
size, location, and number are key factors when
considering treatments such as myomectomy.
However, size, location, and number are not separable for an individual patient, and the provider
must weigh the cumulative impact of all three
factors when deciding if how and when to treat an
infertile woman with uterine broids.
Diagnosis ofUterine Fibroids
A focused history and physical examination may
provide suspicion of uterine broids. Symptoms
related to broids may include menorrhagia, dysmenorrhea, menstrual clotting, intermenstrual
bleeding, pelvic pain, pressure, progressive constipation or alternating constipation and diarrhea,
abdominal distention, or urinary frequency.
However, other conditions can cause any of these
symptoms, and broids are often asymptomatic.
On examination, the uterus is often enlarged and
irregular with uterine broids due to the distor-
tion from the individual masses. A rectovaginal
examination may be helpful to identify posterior
broids. However, other conditions, such as adenomyosis, can cause uterine enlargement, and a
clinically signicant broid may be present, even
if the examination is normal. Diagnostic testing
with ultrasound is appropriate for any women
with infertility and is considered an important
component of the infertility evaluation.
Ultrasound
Transvaginal ultrasound provides better image
quality than abdominal ultrasound, but both methods might be necessary if the uterus is markedly
enlarged with uterine broids. Since overlying
bowel may limit the visualization of the uterus,
abdominal ultrasound is performed with the bladder full enough to provide a “window” for the
uterus. Vaginal ultrasound studies are performed
with an empty bladder for patient comfort.
Careful examination of the endometrium and
myometrium is needed to assess anatomic abnormalities. A submucous myoma is easily identied when the endometrium has a preovulatory
“triple stripe” pattern. If there is no endometrial
distortion, or deection of trilaminar endometrium, a submucous broid is unlikely. In the
early follicular phase and after ovulation, when
the endometrium is more homogeneous, endometrial distortion is more difcult to assess, and
saline infusion sonohysterography should be performed if a submucous broid is suspected [33].
Uterine broids have several variations in
ultrasound appearance, depending on the characteristics of the mass. For example, a calcied
myoma has a bright echogenic pattern and distortion or “artifact” beyond the mass (see Fig.9.7).
Although calcied broids are easily identied,
distortion that occurs beyond the mass may
“hide” the endometrium or other broids. Uterine
broids are sometimes visible as “hypoechogenic” oval masses in the myometrium. Less
often, a broid may have the same echogenic pattern as the surrounding myometrium and be identied by nding a deection of the endometrial or
the serosal surface of the uterus. Subtle or uncer-