If you have fibroids, you may worry about future pregnancy. Uterine fibroids, aren’t usually cancerous, which is good news. But they grow in your womb, and they’re very common during your reproductive years. Fibroids develop as single tumors or as multiple growths. Depending on the type, size, and number of fibroids you have, they could affect your pregnancy.
Infertility is a major concern if you have non-cancerous uterine tumors. After all, your fertility is an important health marker, even if you don’t want a child right now. But fibroids aren’t the only cause of infertility. So, regardless of your family plan, it’s important to understand what’s causing your infertility. And, to help you investigate, here are some of the top culprits to explore if you’re dealing with infertility:
1. Infertility and Fallopian Tube Issues
When functioning properly, your fallopian tubes act as a highway for your eggs. During ovulation, eggs travel down the tubes; if an egg meets sperm at the end of its journey, it can become a fertilized embryo. If, however, your fallopian tubes become blocked or damaged, sperm can’t meet your eggs. And even if the sperm and egg do connect, the fertilized embryo will have a harder time travelling to your uterus for implantation. While many things can cause damage to your fallopian tubes, PID (pelvic inflammatory disease) and STIs or STDs are often responsible.
2. Endometriosis Impacts Fertility
Endometriosis is a painful condition in which endometrium, the tissue that’s normally found in the lining of your uterus grows outside the uterus. Often, this misplaced tissue develops in your ovaries or fallopian tubes. Endometriosis can be painful. It affects your menstrual cycle and, often, your ability to conceive.
PCOS, or Polycystic ovarian syndrome, is a hormonal disorder that causes your ovaries to become enlarged and covered in cysts at their edges. Another characteristic of this condition is that women produce more male hormones than is typical. Approximately 10% of women are affected by PCOS. Symptoms include irregular menstrual cycles, obesity, excess hair growth, higher risks of diabetes and acne.
4. Uterine Fibroids and Infertility
Uterine fibroids are non-cancerous tumors that develop in or on your uterus. Fibroids can develop inside your uterus, on its lining, inside its wall or even on the outer surface of your uterus. Fibroids can affect your menstrual cycle, your ability to conceive and your ability to carry a successful pregnancy to term.
Secondary infertility is often tied to fibroids. (This means you’ve had one baby, but are struggling to become pregnant again) Why? If you develop new fibroids after your first pregnancy, you may not conceive. The same could be true if an old fibroid got bigger after your first baby. If that’s your situation, discuss a fibroid exam with your doctor. We are also happy to offer remote fibroid consultations at this time.
5. Thyroid conditions
Thyroid hormones regulate, among other things, fertility and pregnancy in as much as they are a major part of human growth and development. Hypothyroidism, a condition in which your thyroid hormone levels are low, can stop your ovaries from releasing eggs for fertilization.
6. Egg problems
Every woman has a different number and quality of eggs that may be produced by her ovaries. Some women have fairly low egg counts. Other women have plenty of eggs, but the ones she has are not up to the task of creating a baby. Egg count and quality decrease with age, so women with advanced maternal age may be inclined to check their egg quality when grappling with infertility.
7. Uterine Polyps and Infertility
Polyps are uterine growths, but they are different than fibroids. (Learn the difference between polyps and fibroids here.) Still, like fibroids, polyps can lead to infertility. That’s because they have a stalk that attaches to the membrane lining your uterus and/or cervix.
Unfortunately, many different causes of infertility manifest with the same symptom—irregular or heavy menstrual cycles. In many cases, you can only pinpoint the cause of your infertility by ruling out all other possibilities. If you are concerned that fibroids may be the cause of your infertility issues, schedule a consultation with Dr. Fox or Dr. Hardee in our Houston area fibroid clinic today.
Have you ever wondered about problems with pregnancy and fibroids? When you learn that you have fibroids, it means that you have a non-cancerous tumor in your uterus. And, since your uterus is a large, layered organ, we classify and name fibroids based on where in your uterus they develop.
In case you need a review: your uterus has three layers: the outer serosa; the middle, muscular myometrium; and the inner lining—the endometrium. This endometrium is the lining that you shed each month during your period.
Now that you’ve got the anatomy down, we’ll get to classifying fibroids. There are three different types of fibroids.
1. Uterine fibroids that develop beneath the outside covering of the womb are called sub-serosal.
2. If they form in your uterine muscle, they are intramural.
3. And if fibroids pop up in your uterine cavity, inside the endometrium, they are submucosal.
Many women find it difficult to become pregnant while they have untreated fibroids. But, if you do become pregnant, the location of your fibroids can make a major difference in your ability to carry your child to term.
Sub Mucosal Fibroids and Pregnancy
When it comes to pregnancy and fibroids, tumors that develop in your womb can have the greatest impact on your pregnancy. If the fibroid is large enough to change the shape of your womb, you may experience pregnancy complications. Common side effects include, spotting and pain. Your fetal growth could be limited, because fibroids take up too much space in your uterus. With pregnancy and fibroids, your risk for premature delivery and miscarriage also increases. And during your pregnancy, you’re also at risk for placental abruption (when your placenta detaches from your uterus.)
In some cases, your fibroid may require you to have a C-section. That’s because its growth can alter your baby’s position, or block off your delivery pathway.
Getting Pregnant with Fibroids
Sometimes, the location of your fibroid can make it difficult to become pregnant. In fact, we find fibroids in between 5% – 10% of women with infertility. The most common culprits? Fibroids that are inside your uterine cavity (submucosal). You may also have trouble getting pregnant with very large intramural fibroids (the ones within the wall of your uterus.)
Luckily, most women with fibroids can still become pregnant. But if you have fibroids and plan to get pregnant, you should receive a thorough medical evaluation. After all, fibroids can impact your fertility in several ways.
They can changes your cervix shape, limiting the number of sperm that enter your uterus. Depending on location, fibroids can also change your uterine shape, getting in the way of sperm or fertilized embryos. Some fibroids may block your fallopian tubes, which keeps your egg from traveling to your uterus for fertilization. Also, fibroids can impact your endometrial lining, making it harder for embryos to implant. This problem is further complicated if fibroid affect blood flow to your uterine cavity. Why? Limited blood makes it even tougher for embryos to implant in your uterus.
So, that’s what you need to watch out for when you’re trying to conceive. Or when you’re dealing with pregnancy and fibroids. But here’s some good news for you. Most fibroids don’t grow during pregnancy. In fact, with your changing hormone levels, some fibroids may even shrink while you’re pregnant. Still, given the potential risks to you and your growing baby, you should talk to your healthcare provider about your fibroids if you want to become or already are pregnant.
When choosing fibroid treatments, your two main choices will be surgery or UFE. Fibroid tumors are non-cancerous growths that develop in and on a woman’s uterus. While not a life threatening condition, because of their location, they can cause many negative symptoms, including problems with fertility, menstruation, and your bowel and bladder function.
Some women have a higher risk for developing fibroids. While we don’t know why these tumors form, we do know that certain factors are connected. That means if you have a family history, or are an African American women, you are more likely to develop fibroids in the future.
If your fibroid risk is high, now’s the time to think about your fertility. Women with fibroids who want to have children are often pushed into surgery treatment. Previously, we thought myomectomy, surgical fibroid removal, was a woman’s best option if she wanted to get pregnant. Now, research suggests that isn’t the case.
Quality of Life with Fibroid Treatments
There’s a new FEMME study, published in the New England Journal of Medicine, comparing myomectomy and UFE outcomes. Specifically, the study examines how each fibroid treatment affects your post-procedure quality of life. And the outcomes were very interesting.
After treating fibroids with surgery or UFE, each group of women rated their quality of life. Both groups of women reported significant improvements. And there was only an eight point difference between the two groups’ reported improvements. That difference is small enough to be considered statistically insignificant. Or, to put it simply, myomectomy and UFE provides almost identical improvements in your daily life. But their post-treatment recovery process is different: UFE has almost no down time. While myomectomy is still an invasive surgery, which may require a hospital stay.
Given these differences, the FEMME study should offer proof that you should explore UFE if you’re considering myomectomy. Since the two fibroid treatments offer similar benefits, and UFE comes with an easier recovery. Now, it’s important to remember that the FEMME study didn’t address fertility outcomes with either of these fibroid treatment options. So we’ll turn to that data in the next sections of this post.
Myomectomies Don’t Improve Fertility
Check this out. A study examining “the effect of myomectomy on fertility[discovered] no significant benefit,” according to a review in the Cochrane journal. In other words, even if you have surgery to remove your fibroid tumors, your chances of getting or staying pregnant may not improve.
Of course, this is just one study. We need more research to really prove the effect of fibroid surgery on fertility. It does, however, mean that women should carefully consider all their treatment options before rushing into surgery just to preserve their fertility dreams.
UFE and Pregnancy
Patients with fibroids who hope to get pregnant may also consider uterine fibroid embolization, a minimally invasive procedure that effectively kills fibroids by cutting off their blood supply. Many patients wishing to avoid myomectomy want to know if they can become pregnant after uterine fibroid embolization. There have been reports of many successful pregnancies in patients after UFE. Many studies show that fertility rates and miscarriage rates in UFE patients are no different than patients of the same age with fibroids who have had no treatment. But, if you are willing to have surgery, and you’re healthy enough for a myomectomy, discuss the advantages with your provider.
Early studies suggested a slight increase in pregnancy complications after UFE vs myomectomy. But newer science suggests that tweaks to the UFE process improved fertility and pregnancy outcomes. These pregnancy complications can include pre-term labor and pregnancy induced hypertension, also known as pre eclampsia. UFE can still help patients who aren’t good candidates for surgery. All this will be especially true if it turns out that myomectomy really can’t improve your fertility.
July is National Fibroid Awareness month, and that’s something we’re very serious about. So, today, we honor Tamika Gray Valburn, founder of The White Dress Project. For years, Tanika suffered with fibroids. Her mom lost two sets of twins because of her own fibroids. But even with the family history, Tamika didn’t make the connection to her own diagnosis!
In fact, Valburn’s fibroids were diagnosed in her late teens. At that point, she’d experienced years of painful symptoms. “You just think it will skip a generation,” she’s explained in interviews. “When you’re young, you’re not thinking it will be your story as well.” But, like so many women, Valburn discovered that fibroids do tend to run in families.
Living with Fibroid Symptoms
Because Valburn’s fibroids triggered heavy periods, she “learn[ed] how to pad myself [to keep from leaking through clothes.] I know the whole formula—what kind of underwear to wear, what kind of tights, what kind of Spanx. I’ve tried and tested everything. It’s become a way of life.”
Eventually, Tanika surgically removed 27 fibroids from her uterus. After her recovery, she wanted to help other women. So, in 2014, Tanika earned a Georgia state representative’s support in declaring July as Fibroid Awareness Month. The goal? Helping women get the crucial health information they need.
But she didn’t stop there. Tanika realized that she never bought white clothing. She said, “It’s a simple thing. Like, who cares, why not just wear black? But I love clothes, and the fact that I had to sacrifice wearing white for these benign tumors—I wasn’t feeling it.”
The White Dress Project
That same year, Tanika founded the White Dress Project, a nonprofit organization dedicated to promoting fibroid awareness, supporting research, and bringing together a community of women who work to empower one another. After all, this is crucial. According to the CDC, one in three women will have a hysterectomy by the time she turns 60. But, according to the American Journal of Obstetrics and Gynecology, 18.3% of those hysterectomies aren’t medically necessary. So, why do women have these surgeries? They don’t know about other options!
That’s where Tanika and her project want to make a difference. And they’ve made white dresses their symbol, as it signified a major milestone in Tanika’s recovery: the moment she could rock a white dress without any fear. (Because minimally invasive surgery helped resolve her painful fibroid symptoms.) Now, the white dress has become a symbol of strength and power to other women dealing with fibroids. And it’s just one more step in the crucial fight to take control of women’s menstrual health issues. Especially for Black women like Tanika, who are disproportionately at risk for avoidable hysterectomies. And for the serious complications that often come with open surgery.
As doctors involved in the daily battle against fibroids, we salute Tanika, our forever #WCW. We invite all women who are dealing with fibroids to slip on their white dresses and take control of their health by learning more about UFE, a minimally invasive treatment for fibroids!
Experiencing fibroid symptoms is far more common than you might think. According to the National Institutes of Health, 80 to 90 percent of African American women and 70 percent of Caucasian women will develop fibroids before the age of 50.
Since uterine fibroids are prevalent, can cause severe symptoms and can even lead to trouble getting or staying pregnant, it is important to know the warning signs of fibroid development.
But it’s also important to recognize that some uterine fibroids and endometriosis both cause similar symptoms. (Endometriosis is a condition in which tissue from your uterus, endometrium, grows in or on other parts of your body.) Like women with fibroids, women with endometriosis may experience heavy, painful periods as well as bleeding between periods.
The best way to diagnose the cause of your symptoms is to see your healthcare provider. But you can also narrow down the cause of your pelvic pain and heavy bleeding by better understanding your risk for developing fibroids.
Who is At Risk for Fibroid Symptoms en?
African American women are three times more likely than caucasian women to develop fibroids; they are also more likely to develop several fibroids at a time. Other factors that could increase a woman’s risk of developing fibroids include your age (being over 40) and your weight, since obesity increases your risk. You should also learn your family history of fibroids, and understand that high blood pressure, or never having a pregnancy, could also increase your risk.
Can I Lower My Fibroid Risk?
While many factors can increase your fibroid risk, there are steps you can take to lower your risk of developing these non-cancerous uterine tumors. Some measures include:
- Becoming pregnant
- Balancing your hormones
- Long-term use of birth control pills or shots
- Following a fibroid friendly diet (see more here)
What are the Symptoms of Uterine Fibroids?
Every case is different and some women may never experience symptoms, but a majority of women with fibroids experience at least one of these three common symptoms.
Excessive Menstrual Bleeding
The most common symptom for women with fibroid tumors is excessive bleeding while menstruating. Often times, the bleeding is prolonged, causing periods to last longer than normal. This can lead to soiling of clothing and may interfere with everyday activities.
Pelvic Pain & Pressure
Women with fibroids may feel pain in their lower abdomen. As fibroids grow larger, depending on their size and location, they may cause pain by putting pressure on organs. In addition, it could cause swelling that is often mistaken as weight gain or pregnancy.
Loss of Bladder Control
Fibroids can press against the bladder causing frequent urination and even loss of bladder control. Not only can this cause a great deal of pain, it can disrupt your everyday activities. In addition, fibroid growth can place pressure on the bowel, causing constipation and bloating.
Reaching a Uterine Fibroid Diagnosis
If you are experiencing any of the symptoms listed above, schedule an appointment with our fibroid specialists. Fibroids can usually be found during a simple abdominal or pelvic exam. If your doctor feels that you may have fibroids, an ultrasound or MRI may be used to confirm the diagnosis and proceed with treatment. And, if your provider rules out fibroids as the cause of your symptoms, he or she may recommend further testing to confirm or rule out an endometriosis diagnosis.
Sources: Bioidentical Hormone Health
For a while now on this blog, we’ve followed Real Housewives of Atlanta star Kandi Burrus’s struggles with fertility, fibroids and pregnancy. (And we’re so excited for her Season three of the Masked Singer win!) Fibroids (which disproportionately affect African American women like Burruss) are non-cancerous tumors. But they can still make it difficult for women to become pregnant or carry a baby to term. And because Kandi has stayed honest and open about her family’s journey, helping other fibroid sufferers feel heard, she is—once again—our Woman Crush Wednesday honoree.
Real Housewife Expands Her Family Via Surrogate
Kandi and her husband, Todd Tucker, share a three-year-old son, Ace, who they welcomed through IVF. While Kandi was able to carry and deliver Ace, her pregnancy was high-risk because of her fibroids. And she faced serious medical complications during her pregnancy.
That IVF cycle left the couple with some embryos which could expand their family. But given Kandi’s health struggles, they realized it would be too risky for her to try and make it through another pregnancy. That’s when they decided to explore surrogacy—when another woman carries your fertilized embryo—with the help of OBGYN Dr. Jackie Walters, who stars on Bravo TV’s Married to Medicine.
In a recent interview with The Daily Dish, Dr. Walters said, “I am so excited that Kandi wants to keep expanding her family because she is my patient, whether it’s with her or a surrogate. So, keep having babies. I love it. Have more babies!”
Struggling with an Alternative Pregnancy Journey
Even with the joy of anticipating her new baby’s arrival, Kandi’s surrogacy experience wasn’t easy. In fact, Kandi recently revealed that her surrogate was initially carrying twins, but lost one of her embryos.
“We actually was supposed to be having twins, and then one of them didn’t continue,” she said, continuing, “I was sad at first, but then I just had to be grateful that the one made it.”
And even with her gratitude, Kandi acknowledged it was difficult to have another woman carry her child. “I just feel like this whole situation is strange,” she said. “[You] don’t get to be excited about the first kick… [or] about, ‘Oh now my baby bump is showing…’ You have this guilt [and] sadness,” she said, concluding, “So it’s a joyous, yet interesting experience.” Kandi’s baby is due this month.
Fertility and Fibroids: a Joyous Yet Interesting Experience
As Houston fibroid specialists, we think that Kandi described it perfectly. When you have fibroids, starting or expanding your family will still be joyous. And yes, it will almost always still be possible.
What you have to keep in mind is that your journey to reaching your family goals may be, well, a bit more interesting than other people’s. And that’s ok. Just follow Kandi’s example, and look for the joy wherever you can. Thanks, #WCW, Kandi: you’re an inspiration to any woman struggling with fertility and fibroids!
Sources: The Daily Dish
Two years ago, Real Housewives of Atlanta Star Porsha Williams was pregnant with her first child. At that time, she opened up about her fibroids struggle, making her one of our first Woman Crush Wednesday nominees! Well, once again, she’s talking fibroids and infertility, so we’re back to celebrate Porsha and her courage. Keep sharing those fibroid stories, ladies! Together, we’ll get through.
Early Fibroids and Fertility Challenges
Ms. Williams and her ex-husband, Kordell Stewart suffered one miscarriage during their marriage. For the next six years, Porsha struggled to get pregnant again. During this difficult period, Porsha found out she had uterine fibroids (non-cancerous tumors that grow in the uterus) that could be affecting her ability to carry a baby. Because of her age and hopes for a family, Porsha sought fertility-saving treatment. She ultimately had a myomectomy–a surgery that removed her fibroid but kept her uterus in place and in tact.
While her marriage ended, her hopes for a baby did not. She found new love with boyfriend Dennis McKinley. And then, in early 2019, the couple welcomed daughter PJ. At the time, Porsha told people, “It’s something we’ve both always wanted.”
Fear and Joy
Even hearing that she was finally pregnant was a tense moment for Porsha. On the way into her first pregnancy scan, she wondered, “Because I suffer with fibroids and had to have a myomectomy [I kept thinking] ‘Is the baby going to be okay? Will I make it full term?’ All those questions that you ask if you’ve had a miscarriage before.”
Today, as Porsha and now-fiance Dennis consider expanding their family, those fears remain. In fact, on a recent episode of RHOA, Porsha revealed that she implanted an IUD, a semi-permanent form of birth control. Her reason? Fear of pregnancy complications. And a newly-discovered fibroid regrowth.
On the show, Porsha explained to Denis: “It’s in the same place as my other fibroids were, [but] it’s much, much larger. [My doctor] was like, ‘To have the myomectomy again would make the whole thing difficult to deliver a baby.’ She was like, ‘Well, the other option would be to leave [the fibroid] and then if I got pregnant, see if the baby would possibly outgrow it.’”
For right now, however, that option is too frightening for Porsha. She told Dennis, “I don’t know. I’m scared to just roll the die and get pregnant, and not know what’s going to happen.”
Fertility, Pregnancy and Fibroid Care
As Houston fibroid doctors who work to give women alternatives to hysterectomies, we love helping couples like Dennis and Porsha. Too many women believe that they must undergo a hysterectomy in order to treat their uterine fibroids, but brave women like Ms. Williams are showing that pregnancy is possible, even after fibroids. As long as women know their fibroid treatment options and make their voices heard, uterine fibroids do not have to mean the end of their fertility! Thank you to Porsha and to all our other brave #WCWs for making their voices heard and giving fellow women the power of information.
Today, we want to highlight a feel-good story we saw in Essence magazine. It’s one woman’s experience with fibroids and infertility. But it’s also got a very happy ending: with the arrival of a healthy baby girl. Which means it’s the news we need to read right now. And, while you’re reading, don’t forget that treating your fibroids will be important if you want to start or grow your family. So we are here to help you start your treatment journey, even now, and even if we begin with a Telemedicine fibroids consultation. Now, let’s get to the good stuff: Rachel James, our Woman Crush Wednesday, sharing her story.
A Fibroid Diagnosis After Infertility
Rachel and her husband Terrence were married for a year when they realized fertility could be a challenge. They’d been trying, unsuccessfully, to conceive, so Rachel went to see her doctor. Quickly, she told Essence, she got her answer: “That’s when [I discovered that] I had ten fibroids.”
While a fibroid diagnosis doesn’t automatically cause infertility, these non-cancerous uterine tumors can interfere with conception, pregnancy and delivery. Knowing this, Rachel decided to have her fibroids surgically removed. Even after three operations in three years, however, Rachel didn’t get pregnant—and her fibroids grew back, each and every time. So, she and Terrence decided to work with a fertility clinic.
After four rounds of failed interventions, Rachel finally got pregnant in December 2018—even though her fibroids returned. As a result, her pregnancy was difficult—after all, she had three fibroids surrounding her placenta and one underneath her uterus. Rachel told Essence, “I was on bed rest for the first 14 weeks and was at the doctor three times a week for my entire pregnancy.”
Still, there was a light at the end of the tunnel. In August 2019, the couple welcomed Reyna, their healthy baby girl. And, following this joy, Rachel shared her story publicly. Her goal? To help other women with fibroids find strength: “I felt inadequate while going through this,” she explains. “But I had to realize that we’re human, we’re flawed, and everything is not going to work perfectly every time. I had to give myself grace.”
Growing Your Family with Fibroids
As fibroid specialists, we are always thrilled to hear of happy endings like Rachel’s. Yet we are also pained to hear of her struggle—especially her three invasive surgeries. That’s why, in our practice, we offer a minimally invasive fibroid treatment.
Known as Uterine Fibroid Embolization (UFE), this procedure shrinks and kills fibroids by cutting off their blood supply. And we are able to do that by inserting a catheter (thin tube) through a vein in your wrist. You don’t have to stay overnight in the hospital. And you’re typically able to get up and walk within an hour of your procedure. Plus, having UFE doesn’t mean you can’t have a child, although we suggest discussing any fibroid treatment with your OB-GYN.
Are you staying home and dreaming of starting a family? We can start your fibroid treatment process right now! Even if you prefer to delay UFE, we can begin with a remote fibroid consultation, helping you clarify your options. So, if you’re ready to start your treatment journey, we’re ready to help. Reach out today and request a consultation—via Telemedicine or in our office. We can’t wait to help you get a happy ending of your own!
If you have fibroids—non-cancerous tumors that grow in your uterus—you may be worried about your fertility. Will you be able to get pregnant? Or, if you get pregnant, will the fibroids affect your baby’s growth and birth? Unfortunately, fibroids can impact your ability to become pregnant or deliver a healthy baby. But that doesn’t mean your dreams of having a family will never come true. Let’s take a closer look.
Will fibroids affect my fertility?
Depending on the size and location of your fibroids, the tumors can block sperm from reaching and fertilizing one of your eggs. Fibroids can also make it more difficult for a fertilized embryo to implant in your uterus. And, if you do become pregnant, fibroids may impact fetal development if they are located in a spot where your baby should be growing. For these reasons, you may want to treat fibroids before becoming pregnant. But your doctor can better advise you regarding fibroids and your fertility options.
What fibroid treatments should I choose to help my fertility?
Thankfully, you have many treatment options when it comes to fibroid tumors. It’s important to talk to a fibroid specialist about your family goals so you can choose the one that’s best for you.
In our Houston fibroid practice, we offer a treatment known as Uterine Fibroid Embolization (UFE). It is a minimally-invasive, non-surgical option that shrinks and kills fibroids by cutting off their blood supply. The procedure is performed through a catheter inserted through your arm. Particles are injected to the catheter to block the artery feeding your fibroids. Many women who undergo UFE go on to have healthy pregnancies.
Some women who still want to get pregnant may prefer a myomectomy—the surgical removal of your fibroid. If that’s the treatment option you select, you’ll need to give your uterus three to six months of healing time before trying to get pregnant.
One final word of warning, to help you manage your expectations: if you’ve had six or more fibroids removed surgically, research shows that you have a lower chance of getting pregnant than women with fewer fibroids. It’s also important to note that myomectomy may weaken your uterus, so it may be safer to deliver your baby via C-section following this fibroid treatment option.
While this information may seem frightening, it’s important to remember: pregnancy is possible, with and after fibroids. Stay positive, and be sure to discuss all your treatment options with your healthcare provider.
Sources: Clevelandclinic.org, Journal of Minimally Invasive Gynecology