Systematic review of reproductive outcomes after High Intensity Focused Ultrasound treatment of uterine fibroids

Purpose: Myomectomy is currently the gold standard for the treatment of uterine fibroids in women who desire pregnancy. However, this surgical fibroid removal has a long convalescence. Promising alternatives may be noninvasive High Intensity Focused Ultrasound (HIFU) under either MRI (MR-HIFU) or ultrasound guidance (USgHIFU). In this systematic review, an overview is provided of reproductive outcomes after these two relatively new ablation techniques. Method: A systematic literature search was performed to identify studies reporting reproductive outcomes after HIFU treatment of fibroids. Only peer reviewed, full papers were included. Outcomes included pregnancy-, livebirth- miscarriage and caesarian section rate, time to conceive, reported complications, and possible prognostic factors. Results: In total 21 studies were included. Fourteen studies reported 124 pregnancies after MR-HIFU. Two placenta previas and no uterus ruptures were reported. Pregnancy rates were only retrospectively collected and ranged between 7% and 36%. Miscarriage rate in the oldest and largest prospective registry was 39%. After USgHIFU 366 pregnancies were reported with one fetal intrauterine death, six placenta previas and no uterus ruptures. The only prospective study reported a pregnancy rate of 47% and a miscarriage rate of 11%. Possible prognostic factors like age were not available in most studies. Conclusions: Based on the heterogeneous data currently available, reproductive outcomes after HIFU appear noninferior to outcomes after the current standard of care. However, a (randomized) controlled trial comparing reproductive outcomes after HIFU and standard care is necessary to provide sufficient evidence on the preferred fibroid treatment for women with a pregnancy wish.