Recurrent miscarriage is defined as a condition where a woman suffers 3
or more consecutive miscarriages at less than 24 weeks gestation
. Though some patients have known cause like genetic, hormonal or
immunological, in many others, the cause is not known.
Fibroids are benign muscular
tumors arising from the wall of the uterus.
They may be submucosal i.e. arise just below the inner lining of the
uterus, intramural i.e. within the wall of the uterus or subserosal i.e. just
below the outer lining of the uterus.
Submucosal fibroids have been mainly associated with infertility.
Are fibroids associated with recurrent miscarriage? If so, does removal of a fibroid reduce the
chances of a repeat miscarriage
? A study
was carried out to answer these questions and the results were recently
published in the Human Reproduction Journal.
Women suffering repeated miscarriages
were included in the study. They
underwent two investigations to diagnose the presence of uterine abnormalities-
transvaginal ultrasonography (a procedure in which the ultrasound probe is
introduced into the vagina) and hysterosalpingography, (a procedure in which a
dye is introduced into the uterus and the structure of the uterus studied using
In the study, 8.2% women
with repeated miscarriages had fibroids.
Earlier studies indicate that fibroids are present in 1-2.4% women with
infertility. Thus, fibroids were more common in women with recurrent miscarriages
than with infertility.
The study found that 2.6% fibroids
were submucosal and 5.6% were intramural or subserosal. Submucosal fibroids tend to distort the
uterine cavity and may have to be removed.
In this study, only women with submucosal fibroids or with a mixed type
of submucosal plus intramural fibroids underwent surgery to remove the
a less invasive surgical procedure to remove fibroids was performed in 22
patients, whereas 3 patients underwent laparoscopy or laparotomy to remove the
In women with submucosal
fibroids, 16% suffered from painful menstruation and 32% suffered from heavy
bleeding prior to surgery. Improvement was
noted in these cases following surgery.
Women with fibroids
distorting the uterine cavity had a miscarriage rate of 76.7% and a live birth rate of
23.3%. The rates were similar in women
with fibroids not distorting the uterine cavity.
Fibroids distorting the uterine cavity resulted in a mid-trimester
miscarriage (between fourth to sixth months of pregnancy) rate of nearly 1 in
every 5 pregnancies. This implies that
any women with a mid-trimester miscarriage should be investigated for the
presence of fibroids.
After referral to a tertiary
center and undergoing surgery, women with fibroids distorting the uterus conceived
after a mean if 6.4 months. The
miscarriages in the mid-trimester dropped from 21.7 to 0.0%, thus resulting in
an increase in live birth rate from 23.3 to 52.0%. Thus, mid-trimester
miscarriages can be avoided with surgery for fibroids causing uterine
The live birth rates in women with fibroids not distorting the uterine
cavity also increased to 70.4% after referral to a tertiary center despite no
intervention. Thus, surgery may not be
required for these types of patients and the rate of successful pregnancies can
be improved with supportive care only.
The study also indicates
that women with large fibroids without distortion of the uterus can also have
A more detailed study should
be carried out to confirm the findings that surgery in patients with recurrent
miscarriages and distorting the uterine cavity is indeed beneficial.
Human Reproduction. 2011;26(12):3274-3279.; Sotirios H. Saravelos;
Junhao Yan; Hassan Rehmani; Tin-Chiu Li.