For a woman who wants future pregnancy, is uterine fibroid embolization appropriate for preserving fertility compared to myomectomy?

Uterine Fibroid Embolization and Fertility Preservation

Myomectomy should be recommended as the treatment of choice over uterine fibroid embolization (UFE) for women desiring future pregnancy. 1, 2

Primary Recommendation

For women who want to preserve fertility, myomectomy (hysteroscopic, laparoscopic, or open depending on fibroid location) is the preferred surgical intervention over UFE. 3, 2, 4 The evidence consistently demonstrates superior reproductive outcomes following myomectomy compared to UFE, with higher clinical pregnancy rates (50-60% after myomectomy versus uncertain rates after UFE), higher live birth rates, and significantly lower rates of pregnancy complications. 2, 4

Evidence Supporting Myomectomy Over UFE

Pregnancy Outcomes

• Myomectomy achieves pregnancy rates of 50-60% in women without other infertility factors, with most pregnancies resulting in good outcomes. 3, 2
• UFE is associated with significantly 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. 2
• Pregnancies following UFE carry elevated risks of spontaneous abortion, abnormal placentation, and postpartum hemorrhage (up to 20% risk). 1, 2, 4
• Low birth weight, miscarriage, and prematurity have been specifically associated with UFE. 5

Fertility Considerations

• The actual fertility rate after UFE remains uncertain, with insufficient evidence to advocate UFE over myomectomy for women wishing to preserve fertility. 5, 6, 7
• Large prospective registries show no significant difference in fertility outcomes among different myomectomy approaches (hysteroscopic, laparoscopic, open). 3
• Among women attempting conception after myomectomy, fewer than 50% achieve pregnancy within 3 years, but this represents the best available surgical option for fertility preservation. 3

When UFE May Be Considered (With Significant Caveats)

UFE should only be offered to women desiring fertility if they are not appropriate surgical candidates, and only after full disclosure of detrimental effects on future fertility. 4, 7

Specific Scenarios

• Women with significant medical comorbidities precluding surgery 4
• Women who refuse surgical intervention despite counseling 7
• Critical caveat: UFE is relatively contraindicated in women unwilling to have hysterectomy under any circumstances, as emergency hysterectomy may be required for serious complications. 7

Required Counseling Before UFE

• Uncertain fertility rates after the procedure 5, 7
• Increased risks of preterm delivery, malpresentation, abnormal placentation, and postpartum hemorrhage in subsequent pregnancies 1, 2, 4
• Lack of long-term data on pregnancy outcomes 1, 7
• Possibility of requiring emergency hysterectomy for complications 7

Guideline Consensus

Multiple authoritative sources explicitly state that certain therapeutic options are not recommended for women who may wish to become pregnant, specifically citing uterine artery embolization due to known detrimental or undetermined effects on fertility. 1 The American College of Radiology guidelines frame myomectomy as the appropriate fertility-preserving intervention, while noting that UAE carries pregnancy risks. 1, 3

Surgical Approach Selection for Myomectomy

By Fibroid Type

• Hysteroscopic myomectomy: Submucosal fibroids ≤5 cm, especially pedunculated lesions 3
• Laparoscopic myomectomy: Subserosal or intramural fibroids with limited overall burden 3
• Open myomectomy: Multiple fibroids or markedly enlarged uterus precluding minimally invasive techniques 3

Recovery Timeline

• Hysteroscopic: 1-2 weeks to usual activities 3
• Laparoscopic: 2-3 weeks to usual activities 3
• Open: 3-4 weeks or longer to usual activities 3

Post-Operative Fertility Planning

Patients should wait 2-3 months after myomectomy before attempting conception to allow adequate uterine healing and minimize the risk of uterine rupture in subsequent pregnancy. 3 Both laparoscopic and open myomectomy carry measurable risk of uterine rupture in later pregnancies. 3

Common Pitfalls to Avoid

• Never recommend UFE as first-line treatment for women with strong desire for future pregnancy 2, 4
• Do not assume UFE preserves fertility equivalently to myomectomy—the evidence clearly demonstrates inferior reproductive outcomes 2, 4
• Avoid performing UFE without comprehensive counseling about pregnancy complications and uncertain fertility rates 5, 7
• Do not offer UFE to women unwilling to accept emergency hysterectomy as a potential complication 7

Quality of Life Considerations

While UFE demonstrates excellent symptom relief (71-92% effectiveness) and high patient satisfaction (>90%) for non-fertility outcomes, when fertility is the priority outcome, myomectomy's superior pregnancy and live birth rates outweigh UFE's advantages of shorter recovery and less invasive approach. 1, 6, 4