There are few questions about UFE that are more vexing than that of fertility after the procedure. While most of the indications and outcomes of UFE are settled science, the question of future fertility is not. We don’t have clear data to guide us on this question on a population basis and we certainly don’t for individual patients – unfortunately for many women, the answer is “it depends”.
What we can say is the following: women can and regularly do become pregnant after UFE and most will deliver without incident. The more important question is whether UFE is the best choice for women who are seeking to become pregnant. Are women more likely to have positive outcomes with a myomectomy or UFE if they wish to become pregnant? Should women who have fibroids try to get pregnant with no intervention? The answers to these questions are not simple and are complicated by considerations of age, level of interest in future pregnancy, extent of the fibroids, prior surgery, etc.
The best study we have is that by Mara et al [1, 2], which compared the two-year fertility outcomes of women randomly assigned to myomectomy or UFE. The study demonstrated better outcomes for myomectomy, but was confounded in that one third of the women who had UFE subsequently underwent myomectomy before outcomes were measured. Still, the Cochrane Review of UFE [3] concluded that there was weak evidence favouring myomectomy over UFE for women seeking to become pregnant.
Is there evidence that challenges that conclusion? Not from randomized trials. The recent FEMME Trial [4] had originally intended to help settle this question, but did not enrol sufficient patients to reach a conclusion. One of the largest non-randomized studies is a retrospective review of 359 women by Pisco et al [5]. This study showed a spontaneous pregnancy rate of 29.5% at one year and 40.1% at two years. The probability of successful live birth at one and two years was 24.4% and 36.7% respectively.
What is not known is whether these results are better than those that might be expected with no intervention or after myomectomy. In addition, there are clear reasons to avoid myomectomy, including in women who have had prior myomectomy or other pelvic surgery, those with contraindications to surgery and for those women who choose not to have surgery. The extent of the fibroids and their resectability is also an important consideration.
Given that the evidence is not clearly supporting one single approach, it is important to have a detailed discussion with the patient regarding what is known and unknown about pregnancy outcomes after UAE. With appropriate consideration of her specific circumstances and preferences, a decision can be reached that is best for her. The decision should tempered with the knowledge that there is much we do not know about the comparative outcomes and there is no guarantee of reproductive outcomes after UAE, just as there aren’t with myomectomy or conservative management. We can hope, as we gather more data over time, that we will be able to better answer these questions and better inform our patients.
