Non-surgical management of leiomyoma: impact on fertility

This review is designed to discuss the literature, published from December 2002 to January 2004, on the non-surgical treatment of fibroid. All established and new modalities are reviewed, and all new developments in the field are discussed. The resulting impact on the treatment of infertility will also be evaluated.

In the past year important advances occurred in the medical treatment of uterine fibroids. It was found, in a large randomized trial, that preoperative treatment with gonadotropin-releasing hormone analogue did not improve surgical results or decrease blood loss. However, important strides were made in understanding the molecular biology of the effect of the hormone analogue on fibroids. Other medical therapies investigated include danazol, raloxifene, mifepristone, aromatase inhibitors, and the levonorgestrel-containing intrauterine device. Most promising in terms of long-term usage for reduction of size and symptoms appears to be the combination of gonadotropin-releasing hormone analogue and raloxifene, although selective progesterone receptor modulators may also achieve this aim. However, none avoid producing an anovulatory state that inhibits fertility, and none have been shown to enhance fertility following discontinuation. Uterine artery embolization is another non-surgical technique under intense investigation. The year's literature suggests that while results are comparable with hysterectomy in terms of complication rate and patient satisfaction, there may be important issues for women who wish to undergo the procedure and retain future fertility. Specifically, there is a significant rate of premature ovarian failure, as well as occasional damage to the endometrial vasculature with resulting atrophy and adhesion formation. Improvements in technique, in particular the use of larger and more spherical microspheres for embolization, may reduce these unwanted effects. However, few data exist regarding the course of pregnancy and outcome following embolization.

A number of non-surgical treatments exist for uterine fibroids, but none has been shown to be of value in the patient desiring future fertility. Myomectomy remains the standard of care for such women, and all other therapies should be designated experimental and limited to appropriate investigational studies.