There is increasing recognition that infertility is a devastating problem for women with 70 per cent of black women developing fibroids. ROYAL IBEH unravels how open myomectomy has made many women unable to give birth.
She swallows hard. Her once-dreamy eyes when she got married have become sombre. The appetite for excitement seems lost in her soul. It is more difficult as the years roll by to look her husband in the eye. She does not even want to try. The desire to do so has been weakened by what they both desire most after their wedding.
“I was called a witch. Our family friends accused my husband of using our unborn babies for money ritual. At a point, my husband was frustrated that he wanted to marry another woman. That made me more desperate, more determined to give him a child.
“Being a mother is the only thing that matters to me; having that bundle of joy, would completely erase the insults from my in-laws, unsupportive husband and even the society.”
The above is the sad tale of Mrs. Gladys Umukoro, a 38-year-old woman who has been struggling to get pregnant in the past 10 years. She tells TOS Health Desk that the stigma that accompanies childlessness is devastating.
Regardless of the medical causes of infertility, women in most African societies suffer grief, social stigma, ostracism and often serious economic deprivation.
Mrs Umukoro said, “When I realised that time wasn’t on my side, I decided to go for IVF, and at the fertility clinic, I was told I have uterine fibroid that must be removed before I can commence IVF treatment.
“I couldn’t wait a minute, as I quickly told my gynaecologist to book the next day for the surgery. Getting pregnant was the only language and thing that mattered to me then. I underwent an open myomectomy. Few months after the surgery, I commenced IVF treatment. I started with three cycles, but all failed at the implantation stage. My gynaecologist then explained to me that it was normal to have failed cycles.
“Thereafter, I commenced another round of cycles which again failed. I decided to visit another fertility centre, where I was boldly told I have a scar in my womb due to the open surgery I did, and that is why I am having failed IVF.”
TOS HEALTH DESK explains that Umukoro is not alone. Many Nigerian women are silently in a similar insufferable situation. The psychological distress of infertile women is a reality with associated psychosocial stressors.
Another woman, Mrs Eno Ekanem who has been married for five years without a child, explained that her gynaecologist recommended a myomectomy to remove fibroids growing in her uterus if she ever considers having a baby.
In her words, “I did open myomectomy surgery in 2019, yet no pregnancy. I have been going from one fertility clinic to another. It’s the same story: there is a scar in my womb. That scar is preventing implantation from occurring. This period is like a nightmare to me. I plan to travel abroad soon, to repair the scar damage”.
According to Ekanem, “The reality of infertile women not fulfilling personal desires; meeting family expectation to become parents often lead to shame. Disappointment sometimes expressed by families of infertile women can as well amplify the guilt and shame felt by the infertile individual.
“The truth is, the moment other women start to talk about their children’s performance at school, I keep mute. I wonder what is it about for me to discuss.”
Another woman, Theresa Innocent who expressed her experience of shame remarked: “My husband now knows what the problem is with me. I heard the doctor talk about my blocked womb. Shame may, however, create a feeling of low esteem as I am experiencing now. Sometimes, frustration due to my infertility evoked anger in me.”
Another woman, Akpanke Okang who had fought infertility for 9 years said she was on the verge of giving up: “Every month is more saddening than the previous when the result would come negative. Should I give up wanting children?”
Yes! Hope delayed may result in weariness and doubts about efficacy of treatments may undermine hope. The loneliness of delayed hope may lead to feeling of hopelessness in situation when coping fails. The feeling of despondency arises when treatment efforts seem to be yielding little or no results. Previous infertility treatment of individuals without success results in experiencing severe level of hopelessness.
Fertility: Open surgery, No Silver Bullet -Study
What could lead to a scar in the uterus? A study, ‘Risk Factors for Intrauterine Adhesions in a Black African Population – Nigerians,’ revealed that intrauterine adhesions, also called areas of scar, are associated with certain uterine procedures such as dilatation and curettage (D&C), open myomectomy, caesarean section, and infections.
The study was conducted at the Nordica Fertility Center (NFC). A total of 905 patients from three cities, Lagos, Abuja, and Asaba, having infertility-related problems and on whom hysteroscopy was performed between January 2005 and November 2014, were studied. Among whom 264 were positive for intrauterine adhesions.
The overall mean number of myomectomy and D&C were significantly higher in intrauterine adhesions-positive women than in intrauterine adhesion-negative women.
Women with intrauterine adhesions were about two and a half times more likely to have had open myomectomy than those without and were just about twice as likely to have had D&C as those without intrauterine adhesions.
Correlation coefficient study indicates that intrauterine adhesions were significantly associated with performing all uterine and adnexal operations, especially open myomectomy, caesarean section, ovarian cystectomy, and salpingectomy.
Uterine procedures like open myomectomy, D&C and caesarean section, and adnexal surgeries are important risk factors for uterine adhesions in infertile black African women, says consultant gynaecologist, Dr. Victor Ajayi, at the 2021 Fibroids conference, organised by Nordica Fertility Centre in conjunction with the Physicians. He adds that mitigating these risk factors can help reduce the incidence of intrauterine adhesions in these women and improve their fertility.
While open myomectomy is one of the treatment options for fibroids, Ajayi says some challenges might arise with that procedure. “It can lead to infertility, damage to the fallopian tube, or cause a scar in the uterus and vaginal, which can affect implantation, leading to failed IVF, miscarriages, and the problem of bleeding during pregnancy. With all these challenges, the only option left for the woman who may want to go for IVF is surrogacy,” he adds.
Other treatment options with less complication, according to Ajayi, are minimally invasive methods like laparoscopy, which is the key-hole surgery.
Shedding light on that, he says, “With 1 to 1.5cm cut in the abdomen, you can have access to the inside of the abdomen, operate on the woman, and bring out the fibroid.
“The fibroids can be taken out of the womb with the help of the instrument called morcellation used to shred the fibroid into smaller pieces for easy removal, through the hole. To close the wound, we use surgical glue skin closure, and this gives the laparoscopic more hedge.
“We have done more than 100 cases with the laparoscopic and some of the benefits are it is minimally invasive, less scarring, it is more cosmetically and acceptable, with shorter hospital stay in that patient go home in 72 hours, a quick return to normal activity, less blood loss or no need for blood transfusion and less complications.”
According to Ajayi, the possible drawbacks of using laparoscopy are longer duration than the non-invasive method, a patient may need to convert to abdominal myomectomy and this occurs in one out of nine women.
He says the next treatment option is the hysteroscopy myomectomy, used to treat sub-mucous fibroids inside the uterine cavity, adding that there is also the non-invasive method called the High-Intensity Focused Ultrasound (HIFU).
Treating Fibroids without A Knife, Now Feasible
The HIFU treatment option is for patients who want to preserve their uterus, do not want to go for surgery, and do not want blood products, says the director, HIFU Center, Bara Hospital, South Africa, Dr. Raymond Setzen.
Setzen, explains, “With HIFU, we selectively destroy tissues at depth without harming overlying, adjacent structures within path of beam. With the method, the skin is untouched in that you will see no cut or mark from the surgery.”
He adds that HIFU could be used to treat benign and malignant solid tumours, prostate cancer, liver cancer, breast cancer, for pancreatic cancer; it is used for pain control and not for a cure, bone cancer, renal cancer, and benign gynaecological conditions like uterine fibroids and adenomyosis.
How HIFU Destroy The Fibroids?
“The fibroid is destroyed with the conversion of mechanical energy, which is the ultrasound waves, into thermal energy, which is heat. Immediately, thermal toxicity occurs if tissue temperature raised above the threshold of 56 degree Celsius.
“Another way that we get the fibroids damaged is a process called the inertial cavitation in that once the ultrasound waves are deposited into the fibroids, we get alternating cycles of compression and rarefaction. During the rarefaction, gas bubbles are drawn out of solution, and they will fluctuate inside and eventually collapse, releasing energy which causes a temperature increase,” he discloses.
The director says the HIFU is a day procedure, and because it is a non-invasive procedure, it does not affect normal uterine tissue.
Speaking further on that, he notes, “Also, because of the precise ablation to the target area, it allows for normal vaginal delivery in future pregnancies. There is no general anaesthetic, patients recover faster, return to work within days, there is no ionising radiation, which makes the procedure to be repeated, especially if the patient has multiple fibroids, and no damage to ovaries, it is cost-effective in that it decreases hospital stay and no blood transfusion required. HIFU provides a safe and effective alternative in the management of patients with symptomatic fibroids.”
In a bid to alleviate the agony of women living with fibroids in Nigeria, Nordica Fertility Center’s Managing Director, Dr. Abayomi Ajayi, purchased the HIFU machine. It is expected to become operational by the end of March 2021.
“Besides South Africa and Egypt,” he points out, “we will be the third Africa country to be using HIFU in treating fibroid.”
However, Ajayi noted that not all fibroids need treatment, adding that there are certain things to be considered before one decides if the fibroid should be treated or not.
“If the fibroid is 4.5cm or larger and if the fibroid is the intramural type, then you may consider treatment. In terms of location, all fibroids that are inside the cavity of the uterus should be treated no matter how small, because it can affect your chance of getting pregnant, cause miscarriages.
“If the fibroid is in the way of reaching the ovaries, then it must be treated because it can prevent the doctor from retrieving the eggs during IVF or if the fibroid is disturbing the lining of the womb, such fibroid should be treated,” Ajayi stated.
Then, he says further, “If there is no need for treatment, the advice is let the fibroid be. This is to my fellow doctors and patients because, sometimes, fibroid treatment may do more harm than good. It is better to leave the fibroids that are not causing a problem to remain while you keep observing the woman.
“If the fibroid must be treated, then the best treatment options are the minimally invasive like the laparoscopy and the non-invasive method like the HIFU.”