This case report presents a clinical pregnancy after ulipristal acetate (UA) to decrease uterine fibroid size. A 37-year-old patient, gravida 1, abortus 1, with uterine fibroids was treated with 5 mg of UA daily for 13 weeks starting eight months after a multiple laparotomic myomectomy. Fibroid shrinkage and restoration of the morphology of endometrial cavity were evaluated in order to allow a subsequent pregnancy. A decrease of the uterine fibroids and a normal morphology of the endometrial cavity were noted by transvaginal ultrasound after treatment. An endometrial biopsy excluded histologic endometrial changes. Three months after the end of UA the patient reported amenorrhea for 5 weeks and a clinical pregnancy was confirmed with transvaginal ultrasound. She underwent a subsequent uneventful pregnancy. Thus, the spontaneous pregnancy after UA to reduce fibroid size may support the potential clinical utility of this selective progesterone receptor modulator in the management of women with pregnancy desire and uterine fibroids after a prior myomectomy. Patients who refuse a new surgical procedure and/or those who are going to undergo assisted reproductive techniques would benefit from UA. It effectively shrinks fibroids, avoids risks of a new surgical procedure, and allows an immediate attempt at conception after the end of treatment.
Uterine fibroids, or leiomyomas, are benign uterine neoplasms that arise from the smooth-muscle tissue [
Ulipristal acetate is a selective progesterone receptor modulator (SPRM) already approved for the treatment of uterine fibroids in Europe [
There is a lack of evidence regarding the usefulness of ulipristal acetate to decrease fibroid size in order to avoid its impact on the endometrial cavity prior to pregnancy [
A 37-year-old woman with an unremarkable past medical and surgical history came to our gynecological clinic with lower abdominal pain. She had one pregnancy loss one year before. Transvaginal ultrasound revealed seven intramural uterine fibroids, with maximum diameters between 22 and 82 mm. Since the endometrial cavity was distorted by the fibroids, the patient underwent a laparotomic myomectomy, in which seven myomas were removed and one endometrial disruption was sutured. Both adnexa appeared normal. Her postoperative course was uneventful.
Eight months following the surgical procedure, the patient reported to have normal menstrual periods and she desired to become pregnant. Nevertheless, transvaginal ultrasound showed two intramural fibroids with maximum diameters of 21 and 25 mm, respectively. They were located in the posterior uterine wall and slightly deformed the endometrial cavity. The patient was therefore treated with a 5 mg daily dose of ulipristal acetate for 13 weeks. Pearls and pitfalls of the treatment were explained to the woman, and her informed consent was obtained.
Monthly follow-up visits were carried out. The patient persisted with amenorrhea from the beginning of the treatment, and no side effects were reported following treatment.
One month after the end of the treatment, she reported to have had one normal menstruation. Transvaginal ultrasound revealed a decrease in the two uterine fibroids to maximum diameters of 15 and 21 mm, respectively, and a normal morphology of the endometrial cavity. Actually, an endometrial biopsy obtained in the 22nd day of the menstrual cycle, before her second menstruation, revealed a normal secretory endometrium.
Three months after ending ulipristal acetate, the patient returned to the clinic complaining of amenorrhea for 5 weeks. Using transvaginal ultrasound, both intrauterine pregnancy and unmodified uterine fibroids were seen. The pregnancy was uneventful and subsequent obstetric ultrasounds revealed a discreet increase of the two uterine fibroids, with diameters of 27 and 45 mm, respectively, on the 28th week of pregnancy. The endometrial cavity did not appear to be distorted by the fibroids. An elective cesarean section was performed at 34 weeks of pregnancy because the patient had regular uterine contractions and prior myometrial damage with endometrial disruption during a laparotomic myomectomy in which seven myomas were removed. The healthy female newborn weighed 2432 g. Both the mother and the child were discharged 48 hours following the surgery, after an uncomplicated immediate postpartum period.
Uterine fibroids are present in approximately 70% and 80% of 50-year-old white and black women, respectively [
The optimal treatment for patients with symptomatic uterine fibroids and pregnancy desire remains unknown [
Treatment with 5 mg or 10 mg of the SPRM ulipristal acetate for 13 weeks controls excessive bleeding and reduces total fibroid volume [
Either a 5 mg or 10 mg daily dose of ulipristal acetate for 13 weeks has been associated with benign endometrial changes that are resolved within 6 months of treatment [
It is known that the sharp increases and decreases of estrogen and progesterone during pregnancy and the postpartum period have severe consequences for fibroid growth [
Ulipristal acetate 5 mg for 13 weeks successfully reduced fibroid size and allowed the reestablishment of the morphology of endometrial cavity. As soon as the anatomopathological study excluded endometrial changes after treatment, the patient was able to become pregnant. Three months after the end of ulipristal acetate treatment the woman came to our clinic at five weeks of spontaneous gestation and subsequently underwent an uncomplicated pregnancy. Since the patient had a previous endometrial disruption during a multiple laparotomic myomectomy, an elective cesarean section was carried out when she started labor.
The spontaneous pregnancy after ulipristal acetate to reduce fibroid size may support the potential clinical utility of this SPRM in the management of women with pregnancy desire and uterine fibroids after a prior myomectomy. In particular, patients who refuse a new surgical procedure and/or those who are going to undergo assisted reproductive techniques would benefit from this therapy. Since ulipristal acetate effectively shrinks fibroids and avoids risks of a new surgical procedure, it would allow an immediate attempt at conception at the end of treatment. Although no pregnancy-related complications or teratogenic effects have been reported to date, further series are required in order to establish the safety of ulipristal acetate as a treatment of symptomatic fibroids prior to pregnancy.
The authors have no conflict of interests and received no financial support for this work.