Your patient has symptomatic fibroids and would like to have a baby: what treatment should you advise?

A 30-year-old woman with irregular menses is planning a pregnancy. Ultrasound shows a 6-cm intramural fibroid. She asks whether myomectomy or uterine artery embolization (UAE) is the treatment of choice. Friends of hers have had UAE, and she has looked at the Society of Interventional Radiology (SIR) Web site. What would you advise? Many women present in this fashion to general practitioners or gynaecologists or directly to interventional radiologists. Expert opinions differ. The SIR states that there have been numerous reports of pregnancies after UAE. The British Society of Interventional Radiology [1] is more cautious and states that there is insufficient data at this time to ensure that UAE is safe for women who may wish to become pregnant in the future, because few studies have assessed the effect of embolization on pregnancy-related outcomes. As radiologists, we wanted to establish the best current evidence. The McMaster/Oxford 'bottom-up' evidence based practice methodology was applied to this question. Initially, a focused clinical question or Patient Population, Intervention, Comparison, Outcomes (PICO) question was designed, as previously described by Staunton [2]: 'In women with symptomatic fibroids desiring future fertility, is uterine artery embolization or myomectomy associated with superior reproductive results?'. (author)