the method their fertility should return immediately. What we have to remember is that even in couples who are perfectly healthy and have no issue with their reproductive system even with adequate exposure i. e. regular sex, no use of contraception it can take them up to 1-2years to conceive.
A good number of people have the misguided notion that with a single encounter of intercourse the female partner will be pregnant. While this is feasible and does happen for some people for the vast majority this is not necessarily the case. I have often wondered why in couples, who have no intention of conceiving this is the scenario they often find themselves in … the proverbial oops moment. On the other hand, I also wonder why couples who badly want to have babies no matter how hard they try the baby appears to elude them. Not wanting to be blasphemous but I normally joke that the Good Lord should switch so that the scenarios change, but such is life very ironic indeed.
Back to serious things and our story for Wendy and Sam. Aside from their menstrual and sexual history, they both did not have any co-morbidities i. e. did not have any other illness and lead very healthy lifestyles. They both did not smoke and had occasional drinks with friends on the weekends. Wendy went to the Gym and Sam loved to run which he did at least twice a week. He had just completed the Nairobi Standard Chartered Marathon for the first time and was very proud of himself for this.
During physical exam the next red flag comes up, Wendy’ s uterus appears to be enlarged and is easily felt on abdominal examination, which is not normal. She reports that she noticed her clothes have gotten a bit tighter around the waist and has gotten comments from colleagues about being pregnant but she has been too ashamed to reply. One of the biggest challenges in fertility treatment is that it is a very private issue and the couple often walk alone, and find it extremely difficult to divulge their problem to anyone. Because of this they are unable to access care in a timely manner.
From her history I already suspect fibroids. The interesting thing is that fibroids do not necessarily cause infertility but can make infertility treatment challenging. The most important issue for fibroids with fertility is the location and subsequently the size. A very small fibroid located in the uterine cavity may cause infertility and is usually associated with torrential bleeding during the period, yet a huge fibroid on the outer surface of the uterus will not interfere with fertility but give other symptoms such as pelvic pressure or pain, constipation, frequent urination or defecation or inability to pass urine or stool and so on.
I send them for tests that include a semen count, hormones, STI screen, general health screen, pelvic ultrasound and assessment of her tubes. When the results come back as expected the only issue found was that she has fibroids. The fibroids were intramural with the largest being 6cm in diameter. From a fertility perspective we only treat the fibroids if they are submucosal( in the inner lining of the uterine cavity) or bigger than 4cm for intramural( in the wall of the uterus) fibroids.
We went through her treatment options. The first option is do nothing. The outcome will be worsening of symptoms and most probably status quo. As she had some heavy menstrual flow she could opt to take medication to reduce the flow that could range from anti-inflammatory drugs to hormones. She could also add blood builders to avert low blood levels.
As the issue was fertility the recommendation would be to remove the fibroids and options included surgery- open or laparoscopic surgery, uterine artery embolization, and High intensity focused ultrasound( HIFU). Uterine artery embolization is not recommended for those who intend to be pregnant in the future. So the options were surgery or HIFU.
As HIFU is less invasive we recommended she explore that option. Hold up Wendy is 36 and her Anti-Mullerian Hormone( AMH) which signifies the amount of eggs left are low. I explained this to her as regardless of treatment offered she would have a waiting period after the procedure which normally is 3-6months. In view of her low AMH we opted to retrieve her eggs first i. e. in-vitro fertilization( IVF), freeze the resultant embryos and do embryo transfer after HIFU.
I sent her to one of my colleagues who is a HIFU specialist after the IVF and results of her pap-smear and HPV testing, which were normal. By 3months she had not gotten enough resolution but at 6 months the fibroids were not visible. We did the embryo transfer and as we speak, she is currently 8 weeks pregnant.
Fibroids can be associated with many symptoms. The most common is heavy and / or prolonged menstrual flow, which makes majority of women to seek assistance. The bleeding can be so bad it warrants blood transfusion due to severe anaemia. This normally presents as headaches, dizziness and even fainting spells. Fortunately, Wendy had not reached this level. Some women also experience painful periods, other symptoms include abdominal pain, abdominal swelling with or without pressure symptoms. These present as bloating, constipation, frequent urination or defecation or the opposite, difficulty in passing urine or stool. Other women experience pain during intercourse and others lower back pain and in our case, fibroids can be associated with infertility.
We discussed treatment options with the case but the moral of the story is that there are several treatment options that can be explored based on the case presentation and preference of the patient. What we have to remember is that fibroids rarely undergo cancerous change and therefore can me managed conservatively.
I hope that by highlighting this case many women will be called to action and proactively seek help, and for those who do, feel welcome for a visit at Gynacare and we are sure to help you make informed decisions regarding your health.
May I take this early opportunity to wish you all a very Merry Christmas and a prosperous New year!!! May all your endeavors be fruitful in the coming years!
Dr. Maureen Owiti is a practicing Obstetrician Gynaecologist and fertility consultant based in Nairobi. You can commune with her on this or related matters via email at: Drmaureenowiti @ gmail. com.