Case note

A 39 year old woman under our care for 5 years for multiple uterine fibroids presented, requesting a review of her condition with a view to attempting pregnancy. Previous treatment included laparotomic myomectomy in 2006, GnRH agonist therapy (monthly leuprolide acetate injections in the PGL4001 [Ulipristal Acetate] Efficacy Assessment in Reduction of symptoms due to Uterine Leiomyomata II study ) in 2008, and hysteroscopic myomectomy in 2009 and had been asymptomatic on desogestrel treatment for 1 year.

On clinical examination, her uterine volume was equivalent to 20 weeks’ gestation, and magnetic resonance imaging (MRI) revealed multiple, disseminated, diffuse myomatosis ( Figure A ). Treatment was initiated with 5 mg oral ulipristal acetate (UPA) daily. MRI evaluation showed a significant decrease in fibroid volume after 3 months, continuing after 6 months ( Figure B and C). Without surgery, the patient proceeded with in vitro fertilization for andrological concern and age.

MRI follow up of the fibroids during UPA treatement and pregnancy

Multiple large myomas ( dark ovals ) and a distorted and reduced-capacity uterine cavity ( light area ) were visible before treatment (A) . Subsequent MRIs showed successive improvements after 3 months (B) and 6 months (C) of UPA, with no significant regrowth during early pregnancy ( D, 13 weeks’ gestation). Further shrinkage was observed in the third trimester ( E, 32 weeks’ gestation), with disappearance of most fibroids by 12 weeks after delivery (F) .

MRI , magnetic resonance imaging; UPA , ulipristal acetate.

Luyckx. UPA nonsurgical fibroids control. Am J Obstet Gynecol 2016 .

Pregnancy was confirmed following her first embryo transfer, 11 months after beginning and 3.5 months after ending UPA treatment. No significant fibroid regrowth was noted at the MRI performed during pregnancy ( Figure D and E). Because of previous laparotomy with myomectomy, cesarean delivery was planned and a healthy baby was delivered at 39 weeks. A follow-up MRI 12 weeks after delivery showed sustained regression of the myomas, both in number and size, also because of natural remodeling after pregnancy ( Figure F). The patient remains asymptomatic 1 year after delivery.