HIFU for Intramural Myoma in Reproductive-Age Women
For reproductive-age women with intramural myomas desiring future pregnancy, myomectomy should be offered as the first therapeutic choice, not HIFU, due to significantly superior fertility outcomes and live birth rates. 1, 2
Critical Fertility Considerations
HIFU has concerning reproductive outcomes that make it inappropriate as first-line therapy for women of reproductive age:
- Only 41% of pregnancies after HIFU result in live births, compared to 65-85% with myomectomy 2
- Spontaneous abortion rate reaches 28% after HIFU, nearly double the general population rate 2
- Registry data from 54 pregnancies in 51 women showed 43% had associated complications, though no specific pattern emerged 1
- Long-term fertility data remains severely limited with insufficient evidence to recommend HIFU for women planning pregnancy 1, 2
HIFU Technical Efficacy and Limitations
HIFU achieves modest fibroid volume reduction but has significant technical restrictions:
- Approximately 50% volume reduction at 1 year and 40% at 24 months 1, 2
- Viable tumor cells persist in 26% of specimens after treatment, indicating incomplete ablation 1, 2
- Restricted to patients with fewer than 6 leiomyomas and total fibroid volume <900 cm³ 1, 2
- Each treatment session requires several hours to complete 1, 2
Treatment Algorithm for Intramural Myomas in Reproductive-Age Women
First-line approach:
- Laparoscopic or open myomectomy for women desiring future fertility 2
- Wait 2-3 months after myomectomy before attempting pregnancy to allow proper healing 2
- Recurrence risk is approximately 27% at 10 years, higher with multiple fibroids 2, 3
Alternative considerations when myomectomy is not feasible:
- HIFU may be considered only for poor surgical candidates or patients who refuse surgery after thorough counseling about inferior fertility outcomes 2
- Uterine artery embolization (UAE) should also not be first-line due to increased miscarriage (35%), cesarean sections (66%), and postpartum hemorrhage (13.9%) 1, 2
Comparative Safety Profile
HIFU demonstrates lower short-term morbidity than surgery:
- Major adverse events occur in only 0.2% of HIFU cases versus 12.6% of surgical cases 4
- Median hospital stay is 4 days for HIFU versus 8-10 days for surgery 4
- Quality of life improves more rapidly after HIFU than surgery at 6 months, though absolute differences are small 4
Important Caveats and Complications
Serious complications can occur with HIFU, particularly with large fibroids:
- Rapid myoma enlargement and heavy vaginal bleeding have been reported, especially with huge fibroids 5
- Intramural fibroids may protrude into the endometrial cavity after HIFU treatment (observed 5-73 days post-treatment), potentially requiring subsequent hysteroscopic myomectomy 6
- Not all fibroids are suitable for HIFU due to risks of serious complications 5
When HIFU May Be Appropriate
HIFU can be considered in specific clinical scenarios:
- Women who have completed childbearing and desire uterine preservation 4
- Poor surgical candidates with significant comorbidities 1, 2
- Patients who refuse surgery despite comprehensive counseling about alternatives 2
- Symptomatic relief is the primary goal rather than fertility preservation 4, 7
In these cases, 65% of women achieve at least 10-point reduction in symptom severity scores, though 19% require subsequent invasive interventions within the first year. 7