In a woman of reproductive age with uterine fibroids who wishes to maintain fertility, is myomectomy the preferred treatment over uterine artery embolisation or other fibroid‑mobilization procedures?

Myomectomy vs Uterine Artery Embolization for Fertility Preservation

For women of reproductive age with uterine fibroids who desire future pregnancy, myomectomy is the preferred treatment over uterine artery embolization (UAE), with superior live birth rates, lower miscarriage rates, and fewer pregnancy complications. 1

Treatment Selection Based on Fibroid Location

Submucosal Fibroids (Cavity-Distorting)

• Hysteroscopic myomectomy is the definitive first-line treatment for submucosal fibroids <5 cm, as these fibroids significantly impair fertility through impaired implantation (pregnancy rates only 10% in ART cycles versus 30% without fibroids). 2
• Retrospective data demonstrate pregnancy rates of 85% with live birth rates of 65% after hysteroscopic myomectomy. 3
• Removal of submucosal fibroids should be performed to improve conception and pregnancy rates in women with otherwise unexplained infertility. 4

Intramural Fibroids

• Laparoscopic or open myomectomy is appropriate when intramural fibroids distort the cavity or are associated with unexplained infertility. 3
• Post-myomectomy pregnancy rates reach 54-59.5% in women with no other infertility factors. 2
• Intramural fibroids without cavity distortion reduce fertility (pregnancy rates 16.4% versus 30.1% in controls), but the benefit of removal remains controversial. 2
• Large prospective registries show no significant difference in fertility outcomes among hysteroscopic, laparoscopic, and open myomectomy approaches. 3

Subserosal Fibroids

• Do not remove subserosal fibroids as they do not affect fertility outcomes, with pregnancy and implantation rates equivalent to women without fibroids. 2, 4

Why Myomectomy Over UAE for Fertility

Superior Pregnancy Outcomes with Myomectomy

• Pregnancy rates following myomectomy are in the 50-60% range with most having good outcomes. 5
• The miscarriage rate after myomectomy is comparable to the general population at 14%. 3

Inferior Outcomes with UAE

• UAE has lower pregnancy rates, higher miscarriage rates, and more adverse pregnancy outcomes compared to myomectomy. 4, 5
• Pregnancies following UAE have higher rates of preterm delivery (odds ratio 6.2,95% CI 1.4-27.7) and malpresentation (odds ratio 4.3,95% CI 1.0-20.5) compared to laparoscopic myomectomy. 5
• One retrospective study showed a live birth rate of 73% (109/148) with miscarriage rate of 17.5% after UAE, but these outcomes are still inferior to myomectomy. 3
• UAE is associated with loss of ovarian reserve, especially in older patients. 4

Current Guideline Recommendations

The 2024 ACR Appropriateness Criteria lists laparoscopic/open myomectomy, medical management, MRgFUS, and UAE as "equivalent alternatives" for reproductive age patients with fibroids desiring pregnancy. 3 However, this equivalence designation conflicts with the actual evidence presented in the same guideline, which clearly demonstrates superior fertility outcomes with myomectomy.

Surgical Approach Selection for Myomectomy

Laparoscopic vs Open Myomectomy

• Both approaches demonstrate similar pregnancy and live birth rates in randomized controlled trials. 3
• Laparoscopic myomectomy is preferred when technically feasible due to decreased postoperative fever, shorter hospital stays, faster recovery, and smaller decrease in postoperative hemoglobin. 3
• Patient selection should be based on number, size, and location of fibroids and surgeon skill. 4

Technical Considerations

• Use an anterior uterine incision when performing abdominal myomectomy to minimize postoperative adhesions. 4

When UAE May Be Considered

Women seeking future pregnancy should not generally be offered UAE as a treatment option for uterine fibroids. 4 However, UAE can be offered to women who are not appropriate surgical candidates, with full disclosure of detrimental effects on future fertility including higher miscarriage rates (33% at 4-year follow-up in the FEMME trial versus 14% with myomectomy). 3, 1

Medical Management Role

Medical therapies (GnRH agonists/antagonists, hormonal contraceptives) suppress ovulation or disrupt endometrial development, so there is no role for medical therapy as stand-alone treatment for fibroids in the infertile population. 4 Ulipristal acetate showed promise with 41% fibroid volume reduction and pregnancy rates similar to controls, but this remains investigational. 3

Critical Pitfalls to Avoid

• Do not perform endometrial ablation in women desiring fertility—it is associated with elevated risk of extrauterine pregnancy, preterm delivery, and stillbirth. 3
• Do not use hysterosalpingogram to evaluate and classify fibroids; use transvaginal ultrasound, hysteroscopy, hysterosonography, or MRI instead. 4
• Do not assume all intramural fibroids require removal—if the endometrium is intact and there are no other fertility factors, the risks of myomectomy may outweigh uncertain benefits. 4