• If the fibroids indent into the cavity (i.e. Submucosal), no matter how big or small, you must have them removed by someone skilled in fertility-preserving techniques. Often they can be removed through a hysteroscope, so there’s no abdominal incision and the recovery time is short. You may need to wait a few months until cleared by the doctor to try to conceive, but you avoid much post-surgical discomfort.

• If the fibroid is in the wall (i.e. intramural), it is best to try to avoid surgery if possible. Why? Because removal will require a deep incision in the wall of the uterus. However, if the fibroid is greater than 4 centimeters, there are studies that recommend their removal. I prefer doing these surgeries through an abdominal incision because you get better closure of the uterine wall and minimize risk of the uterine scar failing in labor or even in late pregnancy. In the open procedure, I close the uterine wall carefully in layers to strengthen it. This is hard to do laparoscopically, although some report success with robotic surgery. While that decreases recovery time postoperatively, it does not shorten the time until the uterus will be ready for pregnancy – you’ll still need to wait 3 months before trying to conceive.

• If the fibroid is subserosal or pedunculated (explained in pt. 1 of my blog post), and they require removal, they can be removed laparoscopically. This ensures a quick recovery and no waiting to try for conception. Some of these fibroids can be huge and can present surgical challenges, but a skilled laparoscopic surgeon can almost always remove them.

Most importantly, if your OB/GYN suggests a hysterectomy and you still want to have children, run...don't walk to the nearest exit and get a second opinion. I truly believe every uterus is worth trying to preserve if the woman wants to have children. Sometimes, however, saving the uterus is impossible – sometimes a repair or attempt at repair just won’t safely allow for conception or a growing pregnancy, or the blood supply to the uterus has been unavoidably compromised during a myomectomy and caused irreversible damage. All in all, it's best to avoid surgery if at all advisable. Never, ever, undergo uterine artery vascular ablation if you have any desire at all to conceive again. A uterine ablation is touted as a way to avoid a more invasive surgery, but not all agree it is a good option, and everyone agrees it is a no-no before getting pregnant. The same goes for ultrasonic heating of the fibroids and other " noninvasive procedures.” If you are not sure how to proceed, get a second or even a third opinion from an experienced fertility doctor. You may also email me for my own thoughts any time at esimckes@fertilitypartnership.com.