Dr. Paul MacKoul, MD: Watch and Wait and Fibroids – Don’t Let it Happen to YOU!


Fibroids are non-cancerous smooth muscle tumors that grow in the muscle of the uterus. They are more common than most people think and can cause problems with your menstrual cycle including pain, bleeding, frequency of urination, pelvic pressure and back pain. Fibroids can also cause infertility by preventing growth of the embryo – or pregnancy – into the uterine lining and by blocking the fallopian tubes.


Many women with pain and bleeding actually may have fibroids, which can be easily diagnosed by an ultrasound.  Ultrasound is convenient, inexpensive, much more accurate than a pelvic exam, and relatively easy to tolerate. When pain or bleeding occurs with the period, an ultrasound should always be performed since it is one of the most accurate ways to detect fibroids located anywhere in the uterus.

OBGYN’s are often the first doctors that identify fibroids in patients, and in many cases a “watch and wait” approach is used.  The OB may tell the patient that the fibroids are small and are not causing many problems at present, or they will be treated once they are interested in pregnancy.

The problem – fibroids grow because estrogen in the ovaries makes them grow.  This means that fibroids will continue to grow as long as your ovaries are making estrogen, and they will cause more symptoms the larger they become.   Heavier bleeding will cause anemia, pressure from the fibroids can affect your bladder and bowel causing you to “pee” more frequency as well as diarrhea or constipation.  Bloating and distension, pelvic pressure and back pain become worse as well.  Your menstrual cycle will often become more and more painful.

Your OBGYN may prescribe birth control pills to try and control bleeding.  Realize that this is only a temporary solution, since birth control pills have estrogen and the fibroids will continue to grow.

So what should you do?

  • First, if your symptoms are getting worse and the fibroids are getting larger, they need to be treated.  “Watch and Wait” only lets the fibroids grow, and is not a good treatment option.  It is that simple.
  • Second, there is no reason any patient should suffer because your OBGYN is not providing an option for your care.  Be proactive – get a second opinion with a specialist so that your fibroids can be treated early.
  • Third, realize that for most patients who desire to become pregnant, fibroid removal is always the best option.  Beware of treatment options that can damage the uterus or the ovaries, such as embolization, MRI guided ultrasound, or radiofrequency ablation.  Once you undergo a treatment that is not the best option for your care, you will have to deal with the consequences not only for poor control of symptoms, but possible infertility as well.

Treatment of Fibroids – What is the BEST Option?

Fibroid treatment depends on many factors.  The most important is whether or not the patient wants to become pregnant.   For those who are past childbearing or do not want pregnancy, there are more options available.  However, if pregnancy is desired, the options are very limited.  The following discussion will focus on those patients who desire fertility and preservation of the uterus.

Fibroid Removal Surgery – The Best Option

Removal of fibroids from the uterus, also called “myomectomy,” is the best option for immediate relief of symptoms and for preservation of fertility.  Fibroid removal surgery will preserve uterine structure and function, and immediately stops heavy bleeding, pain, frequency of urination, pelvic pressure and back pain.

Uterus Before Myomectomy

In this diagram, the fibroids are large and are pushing against the bladder, which is being pressed against the pubic bone.  The result is a decrease bladder capacity causing frequency of urination.   The fibroids also press against the back causing back pain, extend to the abdomen causing distension and bloating, and can also push against the colon causing constipation and diarrhea.  Fibroids impact the uterus by irritating the uterine lining and increasing the size of the uterus and the lining resulting in heavy bleeding and pain with cycles.   Fertility can be affected since the fibroids will prevent implantation of the embryo to form a pregnancy as they get larger, so removal often helps to increase pregnancy rates.


Uterus After Myomectomy

Fibroid removal brings the uterus back to normal size and shape and eliminates all the symptoms present before the surgery as noted above.  It is important that any fibroid removal surgeon ensures the patient that ALL fibroids will be removed, other than very small “seedling” fibroids.   Leaving moderate or large fibroids in the uterus does not help symptoms are fertility chances.  Always ask your OBGYN or Surgeon how they are removing fibroids from your uterus, and whether or not they are removing all of the fibroids during the procedure.


Less Effective Options

Embolization is a fibroid treatment option that has potential negative effects on the uterus.  With embolization, plastic particles are injected into the blood supply of the fibroids in an attempt to “kill” the fibroids.  Since embolization does not remove fibroids, they remain in the uterus and can increase the risk of miscarriage, or pregnancy loss.  Embolization also has the potential to decrease blood flow to the ovaries resulting in earlier menopause.


Fibroids Before Embolization


Fibroids After Embolization

Embolization does NOT remove fibroids, but blocks their blood supply in an attempt to “kill” fibroids.  Dead fibroids cause significant pain, with most patients indicating that embolization often causes much more pain than the LAAM surgery for fibroid removal, and it lasts longer.  Embolization will NOT result in immediate relief of symptoms, and may take months or years to resolve symptoms.  Further, embolization can affect rates of miscarriage by increasing them since the fibroids are not removed, and can also potentially impact blood flow to the ovaries and affect fertility.


Radiofrequency ablation is a technique where a probe is placed into the fibroid and the fibroid is heated up in an attempt to kill the fibroid.  This technique also should not be used for fertility since it can damage the uterus.

MRI guided ultrasound is another technique that relies on destruction of the fibroid while the fibroid is in the uterus.

For any procedure that is used to treat fibroids, it is always best to remove the fibroid rather than use a procedure that keeps the fibroid in place if fertility is desired.

The Best Fertility Option

There are certain types of fibroid removal procedures that can result in recovery times and results with less pain that are actually BETTER than embolization, radiofrequency ablation (Accessa, Sonata) and other types of procedures that attempt to kill a fibroid rather than remove it.  LAAM – Laparoscopic Assisted Myomectomy – is an example of a fibroid removal procedure that removes ALL fibroids from the uterus of ANY size, immediately relieves symptoms,  uses a very small incision with a recovery of 7 to 10 days, and allows for less pain and better outcomes.







Always consider fibroid removal procedures when fertility is a consideration.   It is your best option for the fastest recovery, immediate relief of symptoms, the least amount of pain, and will preserve the uterus and ovaries.

The LAAM Procedure – Laparoscopic Assisted Myomectomy – and Why it is the BEST Option for Fibroid Removal

There are many ways to perform fibroid removal from the uterus.

Open Myomectomy (Laparotomy – Large Incision)

The standard way is to make an open incision, remove the uterus from the pelvis so that it is “sitting” on the tummy, and then remove the fibroids.  With the fibroids removed the uterus is much smaller, and is replaced back through the large incision.   With this approach, a large incision is required to remove the large uterus, since the fibroids are making the uterus much bigger than normal.  For example, a uterus with three large fibroids each at 7 cm is roughly THREE TIMES LARGER than a normal uterus, and a large incision is required to remove it to perform open myomectomy.   Open myomectomy requires a recovery time of three days in the hospital, and then 8 weeks before most patients are at 80% normal.

Laparoscopic Myomectomy (Minimally Invasive – two to five+ smaller incisions)

There are three main ways to perform laparoscopic myomectomy – standard, robotic, and LAAM.


Robotic myomectomy is not a great option.  With all the technology used to develop robotics and the higher cost to the patient and the healthcare system, robotics just are not well matched for fibroid removal.

  • The Robot Does not DO the Surgery.  Patients need to realize that the robot does not “think” or do the surgery – the technology is not nearly advanced enough at this time for any mechanical device to take the place of the surgeon.  Instead, the robot is controlled by the operator using a set of controls.  If the operator is a skilled surgeon, the robot will perform well.  If the operator is not as skilled, the robot will lead to higher complications.  There are multiple studies in the literature that have looked at robotic complications for all types of GYN surgery, most of which have identified a higher complication rate than with other types of minimally invasive surgery.
  • Time of Surgery. The surgery takes a very long time, sometimes more than four hours, with the patient in the “head down” position on the operating room table for this extended time.  The anesthesia exposure is longer.  Risks associated with the longer length of surgery are increased as well.
  • Recovery and Incisions.  Robotics require at least 4 and up to 6 incisions fibroid removal.  The incisions are NOT cosmetic – they are located throughout the abdomen and quite visible.  They are also larger in size.  Recovery with robotic myomectomy can be almost as along as open surgery, depending on the number of fibroids removed and the skill of the operator.  Four to six weeks is usually required.  Pain is also increased due to the larger size and number of incisions used.
  • Deep Fibroids.  Robotics cannot remove fibroids deep within the muscle of the uterus very well.  This is because robotics cannot “see” or “feel” fibroids deep in the uterine muscle, so often these fibroids are missed.   This is a serious issue for patients desiring fertility since those deep fibroids are often the ones that will cause problems with implantation of the embryo into the uterine lining and can increase the risk of miscarriage.  Those deeper fibroids also are the main cause of heavy bleeding.
  • Tactile Sense is LOST.  Robots cannot feel fibroids.  The best option for fibroid removal procedures requires the ability to “feel” for fibroids deep within the muscle to locate them and remove them.  Robotics relies on MRI and other studies which miss medium and even smaller fibroids all the time.  Smaller fibroids become larger ones, and deep fibroids lead to heavier bleeding and fertility problems.
  • Large Fibroids.  Robotics have a difficult time removing very large fibroids in the uterus.  Whereas open and LAAM approaches have the ability to removal any size fibroid, robotics cannot do so with ease.  Those patients with multiple larger fibroids should consider other options that will provide a better outcome and faster recovery with complete removal of ALL fibroids, such as the LAAM procedure.
  • Multiple Fibroids.  The greater the number of fibroids, the more difficult and time consuming the robotic procedure becomes.  Removal of one or two fibroids is very different from removal of more than 10 fibroids.  Patients with larger number of fibroids often do not have them removed by the robotic approach.  The result is persistant symptoms and growth of the fibroids.  It is not that the fibroids “grew back” but that the smaller fibroids continued to grow since they were not removed, causing more symptoms as they became larger.
  • Uterine Muscle Closure. The uterine muscle closure – the defect created when the fibroids are removed – is not as good as “open” or LAAM procedures.  With robotics or laparoscopic approaches, the closure is with small needles and takes significant time with a closure that is not nearly as strong as standard “open” type closures.  This is very important to make sure that the uterus has healed well to prevent complications during pregnancy such as uterine rupture.
  • Conversion to Open Surgery.  Robotics have a high conversion rate to open surgery, meaning that during the procedure a decision was made to “convert” the incisions to larger ones in order to remove the fibroids or control bleeding.  Nothing is more disconcerting to patients than when they wake up after the procedure with a larger incision, more pain, and a much longer recovery time.
  • Cost.  Robotics cost more.  The robot is a $2 million dollar device that uses expensive disposable instruments.  Add to that the longer time of the surgery – OR time is very expensive – and robotics become the most expensive surgical option available for removal of fibroids.  The  more expensive the surgery, the more patients will pay for the procedure.

The LAAM Procedure

LAAM is a “hybrid” approach to fibroid removal, using the best results with open surgery matched with incisions that are smaller in number in size than either robotic or other laparoscopic approaches.  LAAM provides a “revolutionary” way to remove fibroids that is safe, very effective, and has the fastest recovery of ANY fibroid removal procedure.  These results have been published in a comparison trial between open, robotic, and laparoscopic approaches, with the references here.

  • The Technique.  LAAM uses only two incisions – one quarter inch incision at the belly button, and a second incision in the bikini line – the CS line – for removal of the fibroids and closure of the uterine muscle.  The incisions are cosmetic since they are placed in locations that are not very visible, and cause less pain as well.  LAAM also uses a tourniquet placed laparoscopically that is used to temporarily control blood supply to the uterus. This ensures safety, and almost completely eliminates the need to convert the surgery to open due to bleeding.
  • Fibroid Removal.  One of the most powerful attributes of LAAM is its ability to remove any size fibroid from any size uterus and any number of fibroids as well.  LAAM has been used to remove up to 160 fibroids in one patient!
  • Length of the Surgery.  LAAM is completed in about 1 to 1.5 hours, about one third the time of robotic procedures for the same size uterus.  The “head down” position is only used for about 15 minutes of the procedure.  Anesthesia exposure is limited as well.
  • Cost.  LAAM has been proven to be the lowest cost option for fibroid removal surgery.  In a comparision trial, LAAM saved up to $5,000 dollars compared to robotics mainly due to decrease OR times and no need to use expensive disposable instruments.

Why isn’t LAAM Used MORE?

LAAM is a highly specialized procedure that requires a significant amount of training and expertise to perform properly.  Once mastered, LAAM becomes a superior option for patients requiring fibroid removal for both symptomatic relief and for fertility.  Other options simply do not compare.

The surgeons at the Center for Innovative GYN Care developed and perfected LAAM procedures with the application of a laparoscopic tourniquet, and with time and experience have been able to improve and refine the procedure to  provide almost all patients with the LAAM option to greatly improve their condition and outcome.   There really is no substitute for training and experience in surgery.  LAAM is an example of a procedure that when performed properly results in amazing outcomes.  When performed improperly by those who have do not have the experience and training, the results are not optimal.

Realize that OBGYN’s do not perform enough surgery to master the technique and training that LAAM requires.   The same is true for many “Specialists.”  Consider a consult to the surgeons of CIGC for more information and a discussion of the LAAM option for treatment of your condition.

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