The 1st French congress on uterine fibroids was held on June 9, 2023 in Paris on the initiative of Fibroma Info France. Professor Pr Claude Hocké, gynecologist, surgeon and head of the gynecological surgery and reproductive medicine department at the Bordeaux University Hospital, answers our questions about this female disease and its impact on fertility.
– Why Doctor: according to estimates, 1 in 4 women suffers from uterine fibroids, i.e. nearly 25 million women in Europe, what is this disease?
Professor Claude Hocké : the fibroid is a non-cancerous benign tumor developed at the expense of the muscular fibers of the uterus. It is hormone-dependent, which explains its rapid growth during female genital life, before menopause.
Moreover, its prevalence increases with age. At age 50, 50% of women have fibroids detected on ultrasound. The risk of developing a fibroid is also linked to ethnic origin. Indeed, women of origin Afro-Caribbean have a prevalence doubled compared to the Caucasian population. This disparity between populations has probable genetic origins, but the genes involved have not yet been found.
– What signs can reveal the existence of a uterine fibroid?
Small uterine fibroids usually cause little or no signs. However, those who are symptomatic give heavy bleeding, similar to heavy periods. This is also the leading cause of patient consultations.
These benign tumors can also cause pain (heaviness in the lower abdomen, pain during sexual intercourse, etc.) as well as fertility problems (implantation failure, miscarriage, etc.).
“Uterine fibroids are an isolated cause of infertility in only 2 to 5% of cases”
– When can a uterine fibroid be problematic for women who want children?
Uterine fibroids are rarely the main cause of infertility. The problems mainly come from ovulation or the fallopian tubes. On the other hand, fibroids make the situation worse. Especially since we now have older patients in France wishing to have children.
Fibroids are an isolated cause of infertility in only 2 to 5% of cases. It is considered a cause of failure when it is in the uterine cavity, larger than 4 cm or when the uterus is polymyomatous.
On the other hand, infertile women have three times more uterine fibroids than others. This causes a lot of problems in populations that have young and multiple fibroids because they are difficult to treat. The current difficulty comes mainly from the risk of recurrence after treatment (between 10 and 90%) depending on age and the number of fibroids.
Fibroid: “each treatment has advantages and disadvantages: it’s all about doing the right thing at the right time”
– What are the solutions for these patients with uterine fibroids who want to get pregnant?
Medical recommendations are to treat fibroids that are in the uterine cavity, and not too large, through hysteroscopic resection. If the fibroids are large – so-called intramural fibroids – myomectomy is preferred. This consists of surgical removal of the fibroid. Alternatively, it is possible to turn to embolization of the uterine arteries. This method – less tiring and less cumbersome than surgery – is generally proposed in cases of recurrence, because it is complicated to operate every two years. The disadvantage of embolization is that it does not make all the fibroids go away and it can lead to complications like ovarian failure or adhesions, which can reduce the chances of pregnancy. In addition, focused ultrasound and radiofrequency techniques, used in Asia, are being tested in Europe.
Each treatment has advantages and disadvantages: it’s all about doing the right treatment at the right time. For example, there is no ideal solution in a young woman with a poly-myomatous uterus (several uterine fibroids at the same time). Radiological treatment and surgical treatment are often alternated.
When women do not want children, it is possible to offer them symptomatic treatments to normalize menstruation, such as progestogen treatments which, among other things, block ovulation. Hysterectomy is also the radical treatment for patients with fibroids who do not want or want more children. Between 30 to 40% of hysterectomies in France are linked to fibroids.
Fibroid: “among infertile women treated, 50% of them were able to have a child one year after treatment”
– What are the chances of pregnancy for patients with fibroids?
As I have already indicated, uterine fibroids do not prevent pregnancy. On the other hand, studies show that in infertile women whose fibroids have been treated, 50% of them have been able to have a child one year after treatment. However, many factors come into play. The treatment is more likely to work if the patient is under 35 years old. Success rates will be lower for older patients who therefore have lower fertility.
– In the event of pregnancy, do the future mother or the fetus have greater risks?
Surgery is likely to increase the risk of uterine rupture, especially if the time between the operation and pregnancy is short (less than three months), or if the patient has had a poly-myomectomy. However, this risk being low base (0.5%), even a tripling of the risk does not entail a high risk for the mother-to-be.
Having a scarred uterus can also increase the risk of a caesarean section for the patient. The possibility of giving birth vaginally or by caesarean should then be studied during pregnancy with the practitioner.
Moreover, fibroids, at least those of the non-operated cavity, lead to a doubling of the risk of miscarriage. It is a risk for the pregnancy as well as a threat of premature delivery or hemorrhage of the issue. However, appropriate monitoring can reduce it.
