Advanced Reproductive Specialists

Uterine Fibroids

​Uterine fibroids (also known as leiomyomas) are extremely common muscle tumors (or growths) that develop from a single muscle cell within the womb. It is stated in the literature that up to 75% of women develop a fibroid prior to menopause (1). That being said, not all women require intervention. The questions that need to be answered include: Do I really need this fibroid removed? If it needs to be removed, how can that be accomplished?

​Recommendations for fibroid removal or myomectomy hinge on size, location, symptoms and the desire for future fertility. Fibroids may be located anywhere in the uterus. Tumors located within or close to the uterine cavity may impact bleeding and cramping even if they are small. Some women may suffer from anemia or low blood counts. Larger fibroids can cause pressure symptoms and discomfort. Decisions regarding management in these cases are fairly straightforward since surgery should be able to resolve or significantly improve these symptoms. The big question is a woman with no symptoms that is attempting to conceive.

​It is well known that any fibroid that distorts or disrupts the uterine cavity has a negative impact on one’s ability to conceive both naturally and with in vitro fertilization (IVF) (2). In addition, pregnancy complications may be increased including miscarriage, preterm labor/delivery, postpartum bleeding, C-section risk and malpresentation (where the baby is positioned differently in the uterus). Some controversy exists regarding fibroids that are “close to” but not within the uterine cavity. According to multiple studies, there is some evidence that fibroids that exist in close proximity to the cavity (where the baby will be developing) do pose a negative impact on success. A recent study published in March of this year found that fibroids located close to the uterine cavity were associated with reductions in live birth rates in women undergoing IVF (3). How then do fibroids impact fertility?

​Fibroids that impact the uterine cavity have an obvious mechanical impact but what about fibroids not immediately within the cavity. What other mechanisms have been proposed? Impacts on blood flow have been proposed as well as the potential for fibroids to produce substances that may have a significant impact on the receptive nature of the nearby endometrium or uterine lining (4). Other theories have focused on the impact on the fallopian tube and the possible deleterious effect on the tubal transport of the s***m, egg or embryo. It is our belief that fibroids causing cavity distortion or larger fibroids in close proximity to the cavity should be removed.

​Since fibroid size and location are the most important characteristics that dictate how we counsel our patients, we recommend uterine imaging to assist us in our ability to recommend the best course of action. Saline ultrasound offers excellent visualization of uterine fibroids and furthermore, allows the physician to determine distance from the cavity as well as the best surgical approach for smaller fibroids that may not be directly visible from the outside when performing minimally invasive surgery.

​The technique of myomectomy may be performed in several different ways, depending on fibroid size, number and patient characteristics. Smaller fibroids located within the uterine cavity may be approached with a hysteroscope (an instrument placed through the cervix) while the patient is under anesthesia. This technique does not require incisions and most patients return to normal activity the following day. Larger fibroids or fibroids where all or the majority of the tumor is located outside the cavity are treated either with laparoscopy (small incisions) with approximately 5-7 days out of work or with laparotomy which requires longer recovery times. By far, the majority of cases can be handled in a minimally invasive way without a hospital stay. Laparoscopic management requires advanced laparoscopic skills and has been shown to be associated with reductions in post-operative complications and blood loss. Our experience has been that patients undergoing laparoscopic myomectomy recover faster and return to work sooner with minimal scars.

​Although fibroids are very common, the first step is to determine whether an intervention is necessary. This is based on symptoms and fertility desires. Furthermore, your physician, through very basic testing, can determine whether the fibroid(s) are hindering your ability to conceive and carry a child. If one desires to proceed with myomectomy, most can be accomplished in a minimally invasive way. We would encourage anyone with symptoms of painful periods, cramping, pelvic pressure or infertility to seek an evaluation for anatomic causes. There are multiple options available and outcomes after myomectomy are excellent.

Christopher W. Lipari, M.D.
Board Certified Reproductive Endocrinologist and Infertility Specialist
Jacksonville Center for Reproductive Medicine



1. Baird DD, Dunson DB, Hill MC, Cousins D, Schectman JM. High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence. Am J Obstet Gynecol 2003; 188: 100-7.
2. Farhi J, Ashkenazi J, Feldberg D, Dicker D, Orvieto R, Ben Rafael Z. Effect of uterine leiomyomata on the results of in-vitro fertilisation treatment. Hum Reprod 1995; 10: 2576-8.
3. Yan L, Yuq Zang Y, Guo Z, Lee Z, Niu J, Ma J. Effect of type 3 intramural fibroids on endometrial fertilization – intracytoplasmic s***m injection outcomes as: a retrospective cohort study. Fertil Steril 2018; 109: 817-22.
4. Rackow B, Taylor HS. Submucosal uterine leiomyomas have a global effect on molecular determinates of endometrial receptivity. Fertil Steril 2010; 93: 2027-34.

Uterine Fibroids - Jacksonville Center For Reproductive Medicine ​Uterine fibroids (also known as leiomyomas) are extremely common muscle tumors (or growths) that develop from a single muscle cell within the womb. It is stated in the literature that up to 75% of women develop a fibroid prior to menopause (1). That being said, not all women require intervention....

Adenomyosis is a condition in which the lining of the uterus appears to grow within the muscle of the uterus (myometrium). The term utilized in the past was "endometriosis interna" due to location of this tissue within the myometrium. The only way to diagnose adenomyosis with absolute certainty would be through pathologic confirmation (where a physician inspects the tissue with a microscope). This condition is very common and usually presents in the mid 30's but can be present at other times. Symptoms consist of heavy, painful cycles so many women and physicians may overlook it during the treatment of endometriosis. There are certain changes on imaging such as ultrasound in conjunction with a thorough history and exam that allow us to increase our clinical suspicion. We feel confident that we are able to predict its presence. Many times adenomyosis is diffuse, however, it can also appear similar to a fibroid when it is consolidated in one area. We evaluate women for both endometriosis and adenomyosis because it is extremely important to treat both conditions in women electing to proceed with surgical intervention. Although hysterectomy has been the treatment many have recommended in the past for the management of adenomyosis, it is not an option for women desiring to retain their ability to have children. We have had great success with peritoneal excision of endometriosis and pre sacral neurectomy, a procedure designed to "interrupt" one of the pathways for pain transmission from the uterus. It has allowed many women to proceed with building their family without struggling with pain from month to month. Other medical therapies have included continuous birth control pills or an IUD when not contraindicated; of course, these options are not useful in women while attempting to conceive.

Christopher W. Lipari, M.D.
Reproductive Endocrinology and Infertility
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine

I get questions every day regarding endometriosis recurring in the future. Also, a common question is "will the disease pop up in other organs and locations in the body." I think we need to go back to: Where does endometriosis come from. While the prevailing opinion is Sampson's theory or retrograde menstruation meaning the menstrual flow goes backwards through the tubes. Under this theory, the living cells land on the peritoneum and then begin to grow. Based on my experience / opinion, and I think the majority of the Excision surgeons nationally, this can't be true for many reasons. My belief is a person is born with changes in the embryonic cell placement of endometrial cells (outside the uterus) and later the pubertal hormones activate the development of the endometrial cell cluster of endometriosis. If one focuses on this theory, then once excised or completely destroyed in any way, that endometriosis lesion is not coming back and because birth was the start, there will be no "new disease" popping up anywhere else.

Another myth that should be addressed here is spreading or invading. In all my years of doing surgery for endometriosis, I have never felt that the disease invades a tissue. The lesion can grow in size (with limitations) and the fibrosis can cause decreased blood flow compromising adjacent tissues such as bowel or bladder resulting in wall breakdown and the lesion ending up inside the bladder or bowel cavity. This is extremely unusual, therefore disproving any sort of primary invasion. In addition, I have never seen evidence of spreading or seeding like cancer in a metastatic way. The lesions they are born with are the ones they live with throughout their life unless excised and they don't multiply like weeds! Hope this clears some of the mystery as patients repeatedly ask these questions. Those that experience "recurrence" with ablation really have persistence as the lesions were not successfully eradicated with the prior surgery(ies).

Michael D. Fox, MD
Advanced Reproductive Specialists
Jacksonville Center for Reproductive Medicine
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