What is the risk of infertility after uterine artery embolization (UAE)?

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Risk of Infertility After Uterine Artery Embolization

UAE does not cause infertility, but pregnancy outcomes show concerning patterns: live birth rates of 73-81% among women who conceive, with miscarriage rates of 17.5-33%, which may be higher than after myomectomy. 1

Key Fertility Data After UAE

The most recent 2024 ACR guidelines 1 synthesize the evolving evidence on fertility after UAE and demonstrate a significant shift from earlier concerns:

Pregnancy and Live Birth Rates

  • Spontaneous pregnancy rates: 29.5% at 1 year and 40.1% at 2 years among women attempting conception 1
  • Live birth rate: 81% (148 live births from 182 pregnancies) in the largest retrospective cohort 1
  • Alternative data: 73% live birth rate (109/148 pregnancies) in another retrospective study of women with fibroids and/or adenomyosis 1

Miscarriage Risk

  • Contemporary data: 17.5-33% miscarriage rate across recent studies 1
  • FEMME trial: 33% miscarriage rate (5/15 pregnancies) at 4-year follow-up, though numbers were too small for statistical comparison with myomectomy 1
  • Prospective data: Low miscarriage rate of 8% (1/12 pregnancies) in one recent prospective study 1

Ovarian Reserve Preservation

UAE does impact ovarian reserve but not to the extent that causes infertility:

  • The FEMME trial found no significant difference in biomarkers of ovarian reserve between UAE and myomectomy 1
  • Anti-Müllerian hormone (AMH) levels decrease more with UAE than MRgFUS at 1 year, but this doesn't translate to infertility 1

Critical Context: The "Haunted" Evidence

The fertility question after UAE has been "haunted" by one early RCT showing 60% miscarriage rate (9/15) after UAE versus 18% (6/33) after myomectomy 1. This study should be disregarded because:

  • It excluded patients with submucosal fibroids from the myomectomy arm (selection bias)
  • Had very small numbers attempting conception in the UAE arm
  • Used short follow-up
  • Findings were inconsistent with all subsequent prospective data 1

Comparison with Myomectomy

UAE appears comparable to myomectomy for fertility preservation, though definitive RCT data remain limited:

  • FEMME trial showed majority of UAE pregnancies resulted in live births (9/15), similar pattern to myomectomy 1
  • Ovarian reserve markers equivalent between procedures 1
  • One prospective non-randomized trial comparing UAE to laparoscopic uterine artery occlusion (LUAO) showed no significant differences: pregnancy rates 69% vs 67%, live births 50% vs 46%, miscarriage rates 34% vs 33% 1

Clinical Pitfalls and Caveats

Patient Selection Matters

The poorest fertility outcomes occur in women with:

  • Extensive fibroid burden requiring multiple prior surgeries 2
  • Multiple associated infertility factors 2
  • One prospective study of women with extensive fibroids ineligible for myomectomy showed only 1/31 women conceived (monthly fecundability 0.1%), though this population had high rates of prior surgery and other infertility factors 2

Pregnancy Complications After UAE

Beyond conception, UAE pregnancies show:

  • Increased cesarean section rate: 66% vs 48.5% in fibroid controls (OR 2.1) 3
  • Increased postpartum hemorrhage: 13.9% vs 2.5% (OR 6.4) 3
  • No increased risk of preterm delivery, intrauterine growth restriction, or malpresentation compared to pregnancies with untreated fibroids 3

Counseling Recommendations

All patients considering UAE must be counseled that:

  1. Pregnancy remains possible after UAE—contraception is still required if pregnancy is not desired 1
  2. For women desiring future fertility, UAE appears to preserve fertility potential with live birth rates of 73-81% among those who conceive
  3. Miscarriage risk may be modestly elevated (17.5-33%) compared to baseline
  4. Cesarean delivery and postpartum hemorrhage risks are increased
  5. Women with extensive fibroids, multiple prior surgeries, or other infertility factors may have poorer outcomes

Evidence Quality Assessment

The guideline evidence is predominantly low to very low quality 1:

  • Most data comes from retrospective cohorts and case series
  • The single RCT (FEMME trial) had insufficient numbers for statistical fertility analysis
  • Prospective studies show promising results but lack randomization
  • Further randomized controlled trials comparing UAE versus myomectomy for fertility outcomes are urgently needed 1

Algorithmic Approach to Patient Selection

For women desiring future fertility:

  • Age <35, isolated fibroids, no prior surgery: Consider myomectomy first-line, but UAE is reasonable alternative with informed consent
  • Age 35-40, multiple fibroids, surgical risk factors: UAE and myomectomy appear equivalent—choose based on patient preference, fibroid characteristics, and surgical feasibility
  • Extensive fibroids with prior failed myomectomy: UAE may have reduced fertility potential; consider referral to reproductive endocrinology before proceeding
  • No desire for future fertility: UAE is appropriate option with lower morbidity than hysterectomy 1

References

1
Guideline

acr appropriateness criteria® management of uterine fibroids: 2023 update.

Journal of the American College of Radiology, 2024

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