Is it safe to become pregnant after undergoing NovaSure (endometrial ablation) in the uterus?

Pregnancy After NovaSure Endometrial Ablation is Unsafe and Should Be Prevented

Pregnancy after NovaSure (or any endometrial ablation) is extremely dangerous and carries severe maternal and fetal risks including uterine rupture, maternal death, placenta accreta/increta requiring hysterectomy, preterm delivery, and stillbirth—therefore, reliable contraception is mandatory after this procedure. 1, 2, 3

Critical Safety Concerns

Endometrial Ablation is NOT Contraception

• Endometrial ablation destroys the uterine lining but does not prevent ovulation or conception 1, 2, 4
• The American College of Radiology explicitly states that endometrial ablation should only be performed in patients who do not desire future pregnancy 1, 2
• Pregnancy can occur regardless of the ablation technique used, even years after the procedure 3, 5, 6

Documented Maternal Risks

• Maternal death from uterine rupture: A 29-year-old woman with no prior uterine surgery died at 24 weeks gestation from spontaneous uterine rupture and massive hemorrhage after endometrial ablation 3, 5
• Placenta accreta/increta: 25% of continuing pregnancies develop abnormal placentation requiring emergency hysterectomy 5, 6
• Uterine rupture: Can occur in unscarred uteri, presenting as catastrophic hemorrhage 3, 5

Documented Fetal and Pregnancy Complications

• Ectopic pregnancy rate: 6.5% (8/123 pregnancies), including tubal, cornual, and cervical locations 5
• Spontaneous abortion: 28% of pregnancies that were not electively terminated 5
• Preterm delivery: 31% of continuing pregnancies, with 13-16% experiencing preterm premature rupture of membranes 5, 7, 6
• Perinatal mortality: 14% (9/64 continuing pregnancies) 5
• Stillbirth rate: 13.3 per 1000 births (significantly elevated compared to general population) 7
• Cesarean delivery: 43-44% of deliveries 5, 7
• Congenital anomalies: Reported cases include craniosynostosis, Down syndrome, corpus callosum agenesis, and malformations from intrauterine synechiae 5

Population-Based Evidence

A large Australian study of 18,559 women who underwent endometrial ablation found:

• 3.1% (575 women) had post-ablation pregnancies reaching at least 20 weeks gestation 7
• 85% of pregnancies from trial/observational studies ended in termination, miscarriage, or ectopic pregnancy 6
• Among continuing pregnancies, complication rates were dramatically elevated compared to the general obstetric population 7, 6

Risk Factors for Post-Ablation Pregnancy

Women at highest risk include:

• Nulliparity at time of ablation: 12-fold increased risk (aHR 12.2,95% CI 9.1-16.2) 7
• Younger age: Women under 35 have significantly higher pregnancy rates 7
• Lack of contraception: 80-90% of post-ablation pregnancies occurred in women not using contraception 6
• Relationship changes: New sexual partners after ablation increase pregnancy risk 3

Mandatory Contraception Counseling

All patients undergoing endometrial ablation must receive comprehensive contraception counseling and be advised to use reliable contraception indefinitely. 2, 3, 6

Recommended Approach

• For patients certain about completed childbearing: Consider concurrent tubal ligation/sterilization at the time of ablation 2, 3
• For patients who are not sexually active but may become active in the future: Concurrent sterilization should still be strongly considered given the catastrophic risks if pregnancy occurs 2
• For patients declining sterilization: Long-acting reversible contraception (IUD or implant) should be strongly recommended 6

Special Contraindications

• History of molar pregnancy: Endometrial ablation is contraindicated due to risk of undetected gestational trophoblastic disease recurrence masked by ablated endometrium 4
• Desire for future fertility: Endometrial ablation is absolutely contraindicated; alternative treatments (medical management, myomectomy, or uterine artery embolization) should be pursued instead 1

Clinical Management if Pregnancy Occurs

If pregnancy is diagnosed after endometrial ablation:

• Immediate obstetric consultation is required 3, 6
• Early ultrasound to exclude ectopic pregnancy (6.5% risk) 5
• Counsel regarding the significantly elevated risks of continuing the pregnancy 3, 6
• If pregnancy continues: High-risk obstetric care with close monitoring for placental abnormalities, preterm labor, and uterine rupture 5, 6
• Delivery planning should anticipate cesarean delivery and potential need for hysterectomy 5, 6

Alternative Treatments When Fertility Preservation Matters

For women who may desire future pregnancy:

• Medical management (hormonal therapies, tranexamic acid) 2
• Myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location) 1
• Uterine artery embolization (though pregnancy rates are lower than after myomectomy) 1
• Hysterectomy only for those with completed childbearing who decline other options 1