Hi everyone! Welcome to another episode of The Egg Whisperer Show. I am so excited about today’s topic. I get questions about fibroids and fertility all the time. This show is dedicated to everything you need to know about fibroids. Our invited guest is an expert on this topic. Dr. Banafsheh Kashani is board certified in OB/GYN and Reproductive Endocrinology and Infertility. She works at Eden Centers for Advanced Fertility and has been treating couples and individuals with infertility since 2014. After graduating with honors from UC Irvine, she graduated top of her class from University of South Alabama, College of Medicine. She completed her residency in OB/GYN at USC and her fellowship in Reproductive Endocrinology and Infertility at Rutgers New Jersey medical school.
Dr. Aimee: Welcome! Tell us about your practice.
Dr. Bana Kashani: My practice is here in Orange County and I treat couples with issues ranging from infertility to recurrent pregnancy loss. I do surgeries to treat conditions that can affect the uterus, like fibroids, polyps, and scar tissue. I love what I do.
Dr. Aimee: Thank you for being here. You have done some really interesting research work on the endometrium and freezing embryos. Can you tell us about that?
Dr. Bana Kashani: As a fellow, I looked at endometrial stromal cells. My research focus was on what we can do to optimize implantation. You can get a perfect embryo with IVF, but the endometrium and uterus need to be optimized to allow for implantation.
I spent a lot of time looking at that and then focused my research on patients undergoing frozen embryo transfers. We did a lot of work looking using SART databases to understand how to give patients the best pregnancy outcome.
Dr Aimee: Before I start getting into my questions, I want to read something I found on your website, and I love this.
I recognize each person or couple is unique and empathize with each and every patient. This allows me to help patients navigate all of their options and tailor my fertility treatment specific to their needs.
That’s pretty awesome. Thank you for saying that. Let’s get to my questions.
Dr. Aimee: What are fibroids?
Dr. Bana Kashani: Fibroids are benign tumors. They are made of smooth muscle cells, particularly thought to originate from the muscle layer of the uterus called the myometrium. 99% of the time, they are benign, but they are annoying and can cause so many problems.
Dr. Aimee: Love it. Annoying. They’re annoying. That’s true!
Dr. Bana Kashani: And they’re common. That’s another thing, they’re very common.
Dr. Aimee: And are all fibroids the same?
Dr. Bana Kashani: No. So fibroids vary by where they’re located within the uterus. Fibroids can be just hanging outside of the uterus. Those usually don’t cause problems, but the ones in the muscle are particularly bad, especially when they impinge on the uterine cavity. Those are the ones that are more problematic.
Dr. Aimee: Why do they grow?
Dr. Bana Kashani: Fibroids are hormonally responsive. Every female has hormones such as estrogen and progesterone. They fluctuate throughout your cycle and basically they’re food for fibroids. They feed them and make them grow. And this also happens during pregnancy.
Dr. Aimee: How would you know that you have a fibroid?
Dr. Bana Kashani: Some people just don’t know. It could be a completely incidental finding, meaning a finding that just happened to come up because they got a CT scan or MRI. But some of the main symptoms include things like: heavy menstrual bleeding, very heavy periods lasting many days. The other potential symptoms are: pelvic pain and pressure pain. Another common thing that comes up is progressively worsening constipation, having difficulty having bowel movements because there’s something there, putting pressure on the colon.
Dr. Aimee: Are there any risk factors that could increase someone’s risk of having fibroids?
Dr. Bana Kashani: Absolutely. I think the biggest recognized risk factor is in certain populations of patients, so African-Americans, are more prone to fibroids. In fact, at age 40 or 50 about 70 to 80% of African American women probably have a fibroid. That’s really high. Other risk factors are age, family history, high blood pressure, and low Vitamin D.
Dr. Aimee: What can someone do to prevent the growth of fibroids?
Dr. Bana Kashani: A healthy lifestyle is good because there are some dietary associations like alcohol consumption that can contribute to fibroids. In general, one of the things you can do, if you’re not trying to get pregnant, is to suppress your natural hormones using things like oral contraceptive pills. This could prevent fibroids from growing. There are medical management options that are available, but it really just depends on your goals.
Dr. Aimee: What are some of the medical management options that patients have?
Dr. Bana Kashani: There’s also an injection of called Lupron. It’s an injection that can last either a month or up to three months, and it basically puts you in a temporary menopause, and helps shrink fibroids.
Additionally, there’s a newer medication called Ulipristal Acetate, and that has been studied and has shown to potentially help decrease the size of fibroids.
Dr. Aimee: So we just talked about medical management options, and I know there are a lot of surgical management options. Can you talk to us about those?
Dr. Bana Kashani: Absolutely. So every surgery offered to patients depends on what kind of fibroid they have, and I usually offer the most minimally invasive option. For example, with hysteroscopy, a camera goes into the uterus, and this allows me to see if a fibroid is bulging into the uterine cavity, and you can then remove it.
The alternative surgery is laparoscopic. It’s a camera that goes through the belly button with other instrumentation to help remove fibroids. This type of surgery does require making small incisions on the abdomen. And then the other surgery is through something similar to a C-section scar. It’s called an open myomectomy. After removal of fibroids you then suture the muscle of the uterus back together.
Dr. Aimee: Patients ask me: if I go through the surgery, what are the chances that they’re going to come back? What do you tell your patients?
Dr. Bana Kashani: That’s a tough one. So it depends on how many fibroids you have. The more fibroids you have removed, especially if they were big, the higher chance of recurrence. The recurrence rate could be anywhere from 30% all the way up to 50% 1–2 years after surgery. So it is possible that they will come back and you’ll have to be monitored for this after surgery too.
Dr. Aimee: How do you decide whether a fibroid should be removed or not?
Dr. Bana Kashani: First and foremost, if anyone has symptoms like bleeding or pressure symptoms, that tells you to consider removal. If there’s a fibroid that appears to affect the uterine cavity, then it absolutely should be removed. We don’t want to take any chances, of a fibroid impacting the chances of pregnancy.
Dr. Aimee: What are the risks of surgery?
Dr. Bana Kashani: If a patient is healthy with no other medical problems the risks are pretty low. Risks are: bleeding, infection, and possibility of scar tissue development inside and outside of the uterus. Very rarely, a surgery to remove many fibroids could result in a lot of bleeding during surgery that could require a blood transfusion, or in severe cases, having to have the uterus removed. But overall, I think that that risk is very, very small.
Dr. Aimee: How long do you tell patients to wait before they should try to get pregnant again?
Dr. Bana Kashani: I typically tell women to wait a six month time period if they had a major surgery, like a laparoscopy, robotic surgery or open surgery. If you’ve had a hysteroscopy and the fibroid was in the cavity, you can try right away. On average, I tell people six months. Everyone is different. In some women, they may consider proceeding to try to get pregnant as early as three months after surgery.
Dr. Aimee: Do you go through the pros and cons of doing surgery with your patients?
Dr. Bana Kashani: Yes. Every decision is individualized. We are trying to perfect everything prior to getting pregnant and reduce the risk of miscarriage.
For some people, a small fibroid may not make a big impact for them and they just want to proceed with trying. Every situation is unique. Major pros are the fact that it could help symptoms like bleeding, pelvic pain or pressure and optimize fertility and reduce the chance of miscarriage. The obvious cons are the time it takes to recovery from surgery, which will delay and postpone pregnancy which no one wants to do.
Dr. Aimee: What is the chance that fibroids will grow in pregnancy?
Dr. Bana Kashani: Unfortunately, fibroids can grow during pregnancy because estrogen and progesterone levels are so high. Only at the time of menopause do fibroids shrink and are not really problematic, but pregnancy, unfortunately, is when they can grow.
Dr. Aimee: How does someone find the right fibroid surgeon?
Dr. Bana Kashani: That’s so important. I’m so glad you brought that up. You need to be proactive and find out how many surgical procedures that doctor does. The more procedures they have done, the better equipped they will be to do your surgery. I also think it’s always wise to get a second opinion.
Dr. Aimee: Do you think MRIs are needed for every fibroid as part of the planning process?
Dr. Bana Kashani: Not for every case, but on a case-by-case basis, it can be very useful, but it’s not required. MRI can tell you if the fibroids are impinging on the uterine cavity. MRI helps delineate location and size of the fibroid(s) and can help determine the best surgical approach. It can also tell you if it appears like a fibroid is actually an adenomyoma. Removing those can be very tricky and challenging.
Dr. Aimee: What advice do you have for people who don’t live close to a fertility doctor.
Dr. Bana Kashani: I think the first thing you have to do is contact an OB/GYN. Be proactive and request a basic pelvic ultrasound, and ideally a transvaginal ultrasound. Iff there is anything concerning, then follow-up with more imaging, like with an MRI.
Dr. Aimee: Do you think there’s a role for fertility preservation (freezing eggs/embryos) for women with fibroids?
Dr. Bana Kashani: Oh, absolutely. I’m so glad you brought that up. So many people who have fibroids want to avoid surgery because they’re so worried about having to postpone trying to get pregnant for 6 months. This is especially important in women who are older, let’s say close 40, the best thing they can do is to freeze eggs or embryos prior to surgery. The biological clock can be paused and then you can proceed with transferring the embryo when the uterine cavity is corrected and everything is optimal.
Dr. Aimee: Is there a chance that IVF medications can cause fibroids to grow back?
Dr. Bana Kashani: Yes, they can. This is why you want to try to time transfer as close to fibroid removal as possible.
Dr. Aimee: How do you prepare your patients for transfer?
Dr. Bana Kashani: Every one of my patients before an embryo transfer will have a uterine cavity evaluation. I usually do a saline infused sonogram in the office. It’s a simple procedure and it takes about 10 minutes to complete. It gives me such a nice glimpse into the uterus and allows me to confirm there is no remaining scar tissue or fibroids that could be affecting the cavity. As long as I feel comfortable that the uterus is pristine, then we’ll proceed with transfer. If I have any question, we can proceed with a more helpful test, called a hysteroscopy, where a small camera is placed into the uterus to assess the cavity directly on a TV monitor.
Dr. Aimee: Do you do that in your office or do you do that in the operating room?
Dr. Bana Kashani: It depends on the patient. I do it both ways: in the office and in the operating room.
Dr. Aimee: Thank you for giving us all of this extremely helpful information about fibroids, fertility and pregnancy. Is there anything you want to tell our listeners about fertility?
Dr. Bana Kashani:
Be proactive with your fertility. It’s so precious. Age is so important and you just don’t want to lose out on your fertile window. Fertility docs are available and doing tele-health consults right now. Be proactive. I don’t want you to ever ever look back with regret.
Dr. Aimee: Where can patients find you?
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