doi:10.1111/j.1447-0756.2011.01779.x J. Obstet. Gynaecol. Res. Vol. 38, No.

4: 733736, April 2012

Is myomectomy always the best choice for infertile

women with symptomatic uterine fibroids? jog_1779 733..736

Giovanna Tropeano, Domenico Romano, Floriana Mascilini, Raffaele Gaglione,

Sonia Amoroso and Giovanni Scambia
Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy

Abstract
Uterine artery embolization (UAE) is still regarded by most gynaecologists as contraindicated for women
with symptomatic fibroids and otherwise unexplained infertility. For such patients, myomectomy is the usual
option. We performed UAE as treatment of menorrhagia in an infertile woman with multiple subserosal and
intramural fibroids who had previously failed multiple myomectomy. UAE resulted in durable symptom
relief and substantial reduction of the uterine and fibroid size. The patient conceived spontaneously
20 months after UAE and progressed through pregnancy uneventfully. At 38 weeks of gestation, she under-
went elective cesarean section and delivered a normal, healthy, 3180-g fetus without complications. The
present case demonstrates that in symptomatic women with multiple subserosal and intramural fibroids and
otherwise unexplained infertility, UAE may have symptomatic and reproductive outcomes superior to those
of myomectomy.
Key words: infertility, myomectomy, symptomatic fibroid, uterine artery embolization.

Introduction
Uterine artery embolization (UAE) is an increasingly
popular alternative to surgery for treating symptomatic
uterine fibroids.1,2 However, due to the uncertain effects
of this procedure on future fertility and pregnancy,
women seeking to become pregnant are generally dis-
couraged from treatment.3 For such women, myomec-
tomy remains the recommended option.4 Here, we
describe a case of successful spontaneous conception
and pregnancy following UAE in an infertile patient
with multiple symptomatic subserosal and intramural
fibroids who had previously failed myomectomy.
Case Report
A 29-year-old with a 5-year history of primary infertil-
ity presented to our department in 2008 complaining of
menorrhagia and anemia for the past two years. Her
menstrual periods lasted for 1015 days, with heavy
flow, and her hemoglobin level was 9.0 g/dL. Her
gynaecological history was significant for multiple sub-
serosal and intramural fibroids that had been diag-
nosed by transvaginal ultrasound in 2003 during a
diagnostic work-up for infertility. At that time, fibroids
were estimated to be the only possible factor for infer-
tility. Menstrual cycles had been regular until 2004,
when she experienced menorrhagia of 12 months
duration, for which several medical regimens were
tried unsuccessfully. In view of the patients desire to
conceive in the near future, an open myomectomy was
recommended by her gynecologist. A preoperative
transvaginal ultrasound scan demonstrated a polymyo-
matous uterus, 112 80 95 mm in size, with multiple
subserosal and intramural fibroids, with the largest
fibroid being intramural, 76 mm in diameter, and

Received: May 23 2011.

Accepted: September 17 2011.
Reprint request to: Dr Giovanna Tropeano, Department of Obstetrics and Gynecology, Universit Cattolica del Sacro Cuore,
Largo Gemelli 8, 00168 Roma, Italy. Email: giovanna.tropeano@rm.unicatt.it

2012 The Authors 733

Journal of Obstetrics and Gynaecology Research 2012 Japan Society of Obstetrics and Gynecology
G. Tropeano et al.
located in the uterine fundus. During myomectomy,
which was performed in April 2005, a total of 11
fibroids, including the dominant one, were removed
without entrance into the endometrial cavity. Pathol-
ogy confirmed the diagnosis of fibroids.
About 6 months after surgery, menorrhagia recurred
and new fibroids were identified on ultrasound. At that
time, the patient refused any further fibroid therapy
because she was actively trying to conceive. However,
she did not conceive. In 2008, because of worsening
symptoms and enlarging fibroids, a repeat myomec-
tomy was offered to the patient, but she wanted to
avoid another surgery and was referred to us for UAE.
On our initial assessment in January 2008, a trans-
vaginal ultrasound scan showed a 117 71 83-mm
uterus with innumerable intramural and subserosal
fibroids, with the dominant fibroid being intramural,
70 50 51-mm in diameter, and located on the ante-
rior lower wall. As part of our standard preprocedure
work-up in reproductive-aged women, a diagnostic
hysteroscopy was performed, which revealed normal
uterine cavity and normal appearance of the endo-
metrium (Fig. 1). In April 2008, the patient underwent
bilateral UAE with 355500-mm polyvinyl alcohol par-
ticles. After embolization, she experienced immediate
symptom relief. At 3 months follow-up, a hysteroscopy
was performed, which showed regular endometrial
Figure 1 Hysteroscopy performed (a) before and (b) 3 months after uterine artery embolization.
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Journal of Obstetrics and Gynaecology Research 2012 Japan Society of Obstetrics and Gynecology
cavity with no evidence of regressive changes (Fig. 1).
Endometrial biopsy confirmed normal functional
endometrium. Follow-up ultrasounds demonstrated a
progressive decrease in uterine and dominant fibroid
volumes as calculated using the formula for a prolate
ellipse (length width depth .5233). At 18 months
follow-up, ultrasound revealed a 50% reduction in
uterine volume (from 360.80 to 181.0 cm3) and a 70%
decrease in the dominant fibroid volume (from 93.41 to
27.84 cm3) (Fig. 2).
Two months later, the patient conceived spon-
taneously. An early ultrasound scan showed a viable
intrauterine pregnancy. Serial obstetric ultrasounds
documented stable uterine fibroids and normal fetal
development. The placenta was noted to be fundal in
position. The umbilical artery and uterine artery
Doppler waveforms at 30, 32, and 36 weeks of gestation
were within the normal ranges. The patient was fol-
lowed up regularly as an outpatient until 35 weeks of
gestation, when she experienced itching associated
with abnormal liver function tests on investigations
and was hospitalized for suspected obstetric cholesta-
sis. After 1 week of inpatient treatment with ursode-
oxycholic acid, the itching resolved and laboratory
values improved, and the patient was discharged.
At 38 weeks of gestation, the patient experienced
premature rupture of membranes. Because of her
2012 The Authors

Figure 2 Transvaginal ultrasound performed (a) before and (b) 18 months after uterine artery embolization.
history of multiple myomectomy, an elective lower-
segment caesarean section was performed. No pelvic
adhesions were noted. The uterus was found to have an
intramural 40-mm fibroid in the anterior lower wall,
and several subserosal fibroids, all <10 mm in diam-
eter, scattered throughout the anterior surface. A
normal 3180-g female neonatus, with an Apgar score of
9/10, was delivered. The placenta was removed manu-
ally without complications even though it was found to
be slightly adherent to a 2-cm area of myometrial thin-
ning in the uterine fundus. The estimated intraopera-
tive blood loss was 800 mL. Pathology showed normal
placenta. The patient and the newborn had an uncom-
plicated recovery and were discharged on postpartum
day 3. Currently, the patient is asymptomatic with
normal light periods.
Discussion
Women with multiple symptomatic fibroids and unex-
plained infertility pose exceptional difficulties in deter-
mining the optimal management.4,5 For such patients,
myomectomy is still regarded by most as the standard
of care.4 However, in the case of women with multiple
subserosal and intramural fibroids, currently there is
no clear evidence to support the efficacy of myomec-
tomy in terms of fertility enhancement.5 Additionally,
in these circumstances the efficacy of surgical treat-
ment in terms of symptom relief is often limited by
fibroid recurrence, and therefore the need for repeat or
additional therapy, which is common after removal of
multiple fibroids.6 In the case described here, multiple
2012 The Authors
Journal of Obstetrics and Gynaecology Research 2012 Japan Society of Obstetrics and Gynecology
Fibroid embolization and infertility
myomectomy had been resorted to on the premise that
it could provide both improvement of symptoms and
enhancement of fertility, but it failed to confer any ben-
efits to the patient.
UAE has proven to be an excellent treatment option
for most women with symptomatic fibroids.2 However,
mainly due to earlier reports of ovarian dysfunction,7
necrotic defects of the endometrial surface (uterine fis-
tula),8 and adverse obstetric outcomes9 after UAE, this
procedure is still considered by most as relatively con-
traindicated for women seeking to become pregnant.3
With regard to the possible ovarian impact of UAE,
currently available evidence is reassuring as the risk
of ovarian dysfunction after embolization has been
shown to be negligible in women younger than
40 years.10 However, fertility rates after UAE remain
unknown. The only available data derive from a ran-
domized trial comparing myomectomy and UAE in
women seeking to become pregnant.11 This study
found that during the first 2 years of follow-up, 50% (17
of 26) of women in the UAE group conceived com-
pared with 78% (33 of 40) in the myomectomy group,
suggesting superior reproductive outcomes after myo-
mectomy.11 The interpretability of this study, however,
is limited because the sample size was small, follow-up
was short, and UAE patients who had a fibroid >5 cm
still present 6 months after treatment underwent myo-
mectomy.11 In the case described here, the primary
indication for UAE was not to enhance fertility. None-
theless, UAE resulted in a substantial reduction in both
the uterine and the fibroid size, which is likely to have
increased the patients ability to conceive and carry a
pregnancy successfully to term.
735
G. Tropeano et al.
The exact pathogenesis of the focal abnormal placen-
tal adherence in our case is uncertain. Instances of
abnormal placentation after UAE have been reported.12
It has been hypothesized that this complication may
occur as a result of compromised endometrial perfu-
sion and endometrial damage caused by UAE.12 It
should be noted, however, that in our case the placenta
was found to be slightly adherent to an area of myo-
metrial thinning in the uterine fundus which corre-
sponded to the site of the largest fibroid removed
during previous myomectomy. In view of this, we
speculate that decidual defects in this site might
have developed as a result of reactive lesions of the
endometrium caused by surgical myometrial dissec-
tion and/or abnormal myometrial healing rather than
by UAE.
To the best of our knowledge, this is the first
reported case of successful spontaneous pregnancy in
an infertile woman with multiple symptomatic fibroids
who had previously failed myomectomy. This case
shows that in symptomatic women with multiple sub-
serosal and intramural fibroids and otherwise unex-
plained infertility, UAE may have symptomatic and
reproductive outcomes superior to those of myomec-
tomy. Although a case report does not allow us to draw
any conclusions, we believe that it may add support
to other data12,13 suggesting that it might be appropriate
to reconsider the contraindication of UAE for selected
patients seeking future pregnancy, for example those
with multiple fibroids or with previous failed fibroid
surgery.
Disclosure
No author has any potential conflict of interest.
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Journal of Obstetrics and Gynaecology Research 2012 Japan Society of Obstetrics and Gynecology
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2012 The Authors
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