Benjamin Gocial, MD

 Good afternoon, I’m Dr.  Herbert Goldfarb from New York City and here we are with Dr. Benjamin  Gocial from Philadelphia. Dr. Gocial is a reproductive specialist who  also specializes in minimally invasive surgery. Dr Gocial, tell us a  little bit about your practice. You mentioned to me about normalizing  the uterine cavity.

  Yes, thank you. It is a pleasure to be  here. I primarily deal with fertility and reproductive endocrine issues.  I try to help women conceive and oftentimes fibroids are in the way,  one of the obstacles, especially when they involve the cavity. Doing  hysteroscopy and hysteroscopic techniques for evaluating the uterine  cavity and getting rid of uterine fibroids, so that they can conceive  normally, is my goal.  Oftentimes also the fibroids can cause abnormal uterine bleeding and  trying to correct that situation so that they have normal periods is  also my goal.

  I have had patients who say to  me, “I have a fibroid, and I want to have a child. Do I need to have the  fibroid removed before I have the child?” How do you approach these  patients and what do you tell them, and how do you make a decision as to  which fibroids need to be removed?

  That’s a great question because many  women have fibroids and most of them do not need treatment. Trying to  make that distinction is important, it’s critical. The main way is by  hysteroscopy to look inside the uterine cavity to see if the fibroid is  impacting the cavity or not. Another very important way is ultrasound to  see how large the fibroids are, how many there are, and where they are.

  An MRI, as we spoke about, is critical?

  I use an MRI often if I feel that I am  uncertain about the ultrasound imaging, or if I feel that surgery is  needed. It gives me the best possible information on categorizing and  identifying the size and depth of that fibroid, and how involved it is  in the uterus.

  Now, some of the groups that claim to  be advocates for women feel that a fibroid never needs to be removed in  a woman who is going to be pregnant. My concern is that these fibroids  can grow, and they can impact on the placental development. What is your  feeling about that?

  Well, I think it is hard in that area  to argue with the literature and the statistics. Clearly the presence of  a uterine fibroid does increase the risk of a miscarriage, a premature  delivery, sometimes so premature that the child is lost, and the  incidence of pain or bleeding during the pregnancy. Lastly, perhaps not  as important, it may be responsible for malpresentations so that the  woman is more likely to need a cesarian.

  You know today we have many  alternatives to hysterectomy. We have endometrial ablations, we have  myolysis, but for women who want to be pregnant none of these techniques  has really proven to be safe. We have to treat them very  conservatively. We have to make a decision as to which patients need  treatment. I think one of the greatest decision making problems is to  help the woman make a decision.   Not long ago I got a call from the daughter of a friend who had a 12 –  14 week sized fibroid, in other words, the size of a 14 week pregnancy.  It so impacted in the back of the uterus that she couldn’t void. The  physicians wanted to operate on her, and she was 14 weeks pregnant as  well. They wanted to operate on her and I said to her that even if she  had to self-catheterize every day, don’t let them operate on you.  Indeed, what happened was she just did this and eventually the fibroid  popped out of the bottom of the pelvis.   Just tell us in closing, how you approach the patient who comes in with  problems like bleeding and pain, and who want to be pregnant?

	 I think the most important thing is one  of the things you implied, individualizing the care. Every woman is  different, every uterus with fibroids is different, and trying to  determine which of the problems are most severe and which need treatment  and which don’t, is the key. Having a good overall idea of what is  likely, in other words, having experience with what fibroids will do,  and therefore what you can expect from them is key to deciding on which  treatment regimen is best.   For instance, in pregnancy, it is well known that the fibroids can grow  during pregnancy, but most of the growth occurs during the first  trimester. So, if you can do as you suggested for your patient, bide  their time through the first trimester, you are usually going to be  okay.

   One of the things we really worry  about of course is prematurity intervention and certainly we have to  treat the patient very, very tenderly. Bed rest sometimes helps  significantly.  In any case, both Dr. Gocial and I are on the fibroid panel. We welcome  your questions and will try to help you as much as we can. I’m in New  York City at the Downtown Hospital. Dr. Gocial is in Philadelphia, and  we can be reached through OBGYN.net. It was a pleasure talking to you  this afternoon.

Articles

From the 35th Annual Meeting - Las Vegas, Nevada- November 2006

Fibroids and Pregnancy

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Benjamin Gocial, MD

Articles

Fibroids and Pregnancy

Fibroids and Pregnancy Video