Once the egg is fertilised, the embryo must travel through the fallopian tube and embed in the uterine lining (endometrium). The endometrium is composed of cells that divide rapidly under the influence of progesterone and estrogen. Since the embryo implants in the endometrial layer, it must be thick and vascular to provide nutrients essential for embryonic development.

Sometimes the endometrium does not develop properly, and one cause can be a luteal phase defect. When a luteal phase defect is present, there is not enough progesterone to stimulate and support endometrial growth.

This condition can usually be treated by administering additional progesterone during the luteal phase or by giving fertility drugs such as Clomid or gonadotropins.

The uterus must be free of large polyps or fibroids that could interfere with embryonic growth and development. These conditions are usually diagnosed during the initial infertility workup with a hysterosalpingogram, hysteroscopy, or laparoscopy. The obstructions are removed before any type of fertility treatment, including IVF, is attempted. 

The uterus might also have congenital deformities such as a bicornuate uterus (which has “two horns”) or other problems such as a uterine septum. In many cases, the septum (a piece of scar tissue in the uterine cavity) can be successfully repaired using hysteroscopic surgery.

Uterine Fibroids

Myomas are non-cancerous (benign) tumours (growths) derived from the uterine muscle cells. These tumours develop when the muscle cells become extremely sensitive to normal estrogen levels and start dividing very rapidly. Uterine fibroids are common. As many as 1 in 5 women may have fibroids during their childbearing years. Half of all women have fibroids by age 50. Fibroids are rare in women under age 20. Fibroids can be so tiny that you need a microscope to see them. They can also grow very large. They may fill the entire uterus and may weigh several pounds. 

Although it is possible for just one fibroid to develop, usually there are more than one. Myomas are usually not solitary. More than one muscle fibre may be affected and therefore multiple myomas are usually present. They may differ in size with the result that very small myomas may not be seen at the time of surgery and for this reason myomas may recur following an operation.

Common symptoms of uterine fibroids are:

• Bleeding between periods
• Heavy bleeding during your period, sometimes with blood clots
• Periods that may last longer than normal
• Needing to urinate more often
• Pelvic cramping or pain with periods
• Feeling fullness or pressure in your lower belly
• Enlargement of the lower abdomen
• Pain during intercourse
• Lower back pain
• Infertility and miscarriages

Often, you can have fibroids and not have any symptoms. Your health care provider may find them during a physical exam or other test. Fibroids often shrink and cause no symptoms in women who have gone through menopause.

The localisation of the myomas in the uterus play an important role in causing symptoms. The ones directly below the uterine lining are the most important and can also be most easily missed by internal gynaecological examination by your doctor. They prevent pregnancy or cause miscarriages by taking up valuable space in or beneath the cavity of the uterus. This limits the blood supply to the foetus which does not grow or dies. A myoma may therefore mimic the function of an intra-uterine contraceptive device (“loop”).

Who gets fibroids?

There are factors that can increase a woman’s risk of developing fibroids.

• Age. Fibroids become more common as women age, especially during the 30s and 40s through menopause. After menopause, fibroids usually shrink.
• Family history. Having a family member with fibroids increases your risk. If a woman’s mother had fibroids, her risk of having them is about three times higher than average.
• Ethnic origin. African women are more likely to develop fibroids than white women.
• Obesity. Women who are overweight are at higher risk for fibroids. For very heavy women, the risk is two to three times greater than average.
• Eating habits. Eating a lot of red meat (e.g., beef) and ham is linked with a higher risk of fibroids. Eating plenty of green vegetables seems to protect women from developing fibroids.

Diagnosis

• The history of the symptoms of abnormal bleeding, pain, infertility and pregnancy loss may make your doctor suspicious of the presence of myomas.
• Uterine myomas can usually but not always be felt by gynaecological examination. 
• Ultrasound diagnosis is very accurate. Intra-vaginal (internal) ultrasound scans are much more accurate than the external ultrasound scanning done through a full bladder. 

Treatment

Not all fibroids need to be removed. Whether they need to be removed or not will depend on the position, size and growth rate as determined by regular follow-up evaluations.

• Open surgery: This has been the traditional way of removing myomas. Hospitalisation and a long period of time away from work has made this approach unfavoured. 
• Laparoscopic surgery: Most myomas can be removed very effectively through so called key whole surgery where the tumours are cut up in small pieces inside the pelvis and removed laparoscopically. The patient goes home the same day and back to work one week after surgery.
• Hysteroscopic surgery: During a very light anaesthetic a hysteroscope is passed through the cervix of the uterus. Under direct vision the myomas are cut away. This technique is only applicable to myomas being present inside the uterine cavity or directly below the uterine lining. This procedure is practically pain free and patients can go back to work within a few days.

When to Contact a Medical Professional

Call your health care provider if you have:

• Heavy bleeding, increased cramping, or bleeding between periods
• Fullness or heaviness in your lower belly area