If you have fibroids and you want to have children, you are facing one of the harder decisions in this area of medicine — and you deserve a straight answer rather than a sales pitch.
The short version: Both myomectomy and UFE are reasonable options for women who want to become pregnant. When the randomized trials are pooled, pregnancy, live birth and miscarriage rates are not significantly different between the two. Some observational data still show lower pregnancy rates and higher rates of certain obstetric complications after embolization, and the two procedures differ in other ways that matter — so the right choice depends on your fibroids, your surgical risk, your age and your timeline, not on a blanket rule.
You may have been told that embolization is off the table if you want children. That advice was standard for years, and it is no longer what the evidence supports. You may also be told by a clinic that performs only embolization that fertility is a non-issue. That is not quite right either. What follows is our attempt at the honest middle.
How Fibroids Can Affect Fertility
Fibroids are benign growths in the uterus. Whether they interfere with conception depends heavily on where they sit.
- Submucosal fibroids grow just beneath the uterine lining and bulge into the cavity. These are the most likely to interfere with embryo implantation. Women with cavity-distorting submucosal fibroids larger than 2 cm have shown higher pregnancy rates after hysteroscopic removal.
- Intramural fibroids develop within the muscular wall. Larger ones may distort the cavity or compress the fallopian tubes.
- Subserosal fibroids grow outward from the uterine surface. These generally have the least effect on fertility, though large ones can cause pain during pregnancy.
Location matters more than size alone, which is why imaging review is the starting point for any treatment conversation — and why a fibroid sitting inside the cavity may call for hysteroscopic removal regardless of what else you decide.
What the Research Actually Shows
Myomectomy surgically removes fibroids while leaving the uterus in place. Uterine fibroid embolization shrinks them by closing off their blood supply. Both preserve the uterus. For years the assumption was that myomectomy clearly produced better reproductive outcomes. The evidence has moved.
The randomized data show no significant difference
Two 2024 meta-analyses pooling randomized trials found no significant difference in live birth or miscarriage rates, and no significant difference in pregnancy rates, between embolization and myomectomy. A separate 2024 meta-analysis of 13 studies — including four randomized trials — likewise found no significant differences in pregnancy, live birth or miscarriage rates between the two procedures.
The largest comparison to date points the same way
A multicenter analysis presented in 2026, drawing on a national research network, matched 522 pairs of reproductive-age women treated with UFE or myomectomy. Pregnancy rates were 18.6% after UFE versus 21.5% after myomectomy — a difference that was not statistically significant. Ectopic pregnancy rates were identical at 1.9%. Postpartum hemorrhage was numerically higher after UFE (3.8% versus 2.3%) but did not reach significance. The one signal worth knowing about: time to pregnancy trended longer after UFE.
What pregnancy after UFE looks like on its own
A 2025 meta-analysis of 33 studies covering 4,287 women found a pooled pregnancy rate of 52% after UFE, with a mean time to conception of about 15 months. Age mattered a great deal: pregnancy rates were roughly 68% in women under 30 and 32% in women over 40.
What the major guidelines say
In its 2021 practice bulletin on symptomatic fibroids, the American College of Obstetricians and Gynecologists gives uterine artery embolization a Level A recommendation for patients who want to preserve the uterus, provided they are counseled about the limited data on reproductive outcomes. Notably, ACOG does not list a desire for future pregnancy as a contraindication to embolization — and in that same bulletin it explicitly states that a different fibroid procedure, radiofrequency ablation, “is not recommended for women planning future pregnancy.” The distinction is deliberate.
The American College of Radiology, in its 2023 Appropriateness Criteria, rates embolization “usually appropriate” for a reproductive-age woman with symptomatic fibroids who wants to preserve fertility.
Guidance is not unanimous internationally, and older documents from some societies are more restrictive than the current American ones. That is worth knowing if you are reading widely or getting conflicting advice.
What about my ovaries?
A common concern is whether cutting off blood supply to the uterus affects the ovaries. A 2020 systematic review and meta-analysis in Acta Obstetricia et Gynecologica Scandinavica, pooling six studies, found no significant change in AMH or FSH after uterine artery embolization — the two standard blood markers of ovarian reserve — and that held on subgroup analysis both under and over age 40. The FEMME trial likewise found no material difference in ovarian reserve hormones between embolization and myomectomy.
That is reassuring but not absolute. The same review found a significant decline in antral follicle count at three months, and a small risk of early menopause after embolization is generally acknowledged in women over 40. It is a reasonable thing to ask about directly at consultation.
Where genuine caution remains
The evidence is not uniform, and you should know the other side of it. A 2023 meta-analysis using trial sequential analysis found a lower pregnancy rate after embolization and higher rates of postpartum hemorrhage and placenta previa, while finding lower rates of preterm delivery and cesarean section. Much of that signal comes from observational studies, where women who chose embolization were often older or poorer surgical candidates to begin with — but it has not been explained away.
There is also a difference that has nothing to do with fertility directly: embolization carries higher rates of reintervention, including a substantially higher rate of eventual hysterectomy at four years. If your plans for pregnancy are several years out, that matters.
Which Way the Decision Usually Leans
Neither procedure wins on principle. These are the factors that tend to tip it one way or the other:
- A fibroid inside the uterine cavity often warrants hysteroscopic removal on its own merits, whatever else you choose.
- A small number of surgically accessible fibroids in a good surgical candidate is the classic case for myomectomy.
- Numerous fibroids, difficult surgical anatomy, prior myomectomy with recurrence, or significant surgical or anesthesia risk are the cases where UFE often makes more sense.
- Wanting to avoid a uterine incision is a legitimate consideration — myomectomy scars may lead your obstetrician to recommend a cesarean delivery.
- Your timeline matters in both directions. Average time to conception after UFE runs over a year, and pregnancy rates fall with age; recurrence after myomectomy is common, which can also cost you time.
Comparing the Two, Honestly
How We Perform Embolization at MIVA
There is a technical decision inside every fibroid embolization about where to stop, and it is worth understanding, because it is where the risk to your uterus is decided.
Our approach is deliberately conservative. The target endpoint is to completely shut down the vascularity feeding the fibroids while preserving sluggish forward flow in the main uterine artery — rather than embolizing the uterine artery to complete stasis. The fibroids lose their blood supply. The uterus keeps its own.
That distinction cuts in both directions, which is why it takes judgment rather than a rule. Under-treating the fibroids is what leaves symptoms behind and sends a woman back for a second procedure, so we do not stop short of devascularizing them. But carrying embolization past that point, to full occlusion of the uterine artery, adds risk to the uterus and the ovarian blood supply without adding benefit against the fibroids. Knowing where that line sits, case by case, is most of the craft of the procedure.
To be clear about what this is and is not: this is a statement about how we manage risk during the procedure. We are not aware of trial data comparing embolization endpoints head to head for pregnancy outcomes, and we would not claim this technique produces better fertility results than any other.
How We Approach This Conversation
At MIVA Medical in Independence, MO, we perform UFE. We do not perform myomectomy. That means we have an obvious interest in recommending our own procedure, and you should know that when weighing what any clinic tells you — including us.
Dr. Silas Williams reviews your imaging, asks about your timeline for pregnancy, and is direct about whether UFE is genuinely a good fit for your situation or whether you should be talking to a gynecologic surgeon first. We work with OB/GYNs across the Kansas City metro. If myomectomy is the better path for you, we will say so.
If fertility is not part of your decision — and for many women considering UFE it isn’t — the picture is simpler. You can read more about the procedure itself on our Uterine Fibroid Embolization page, and if you want the practical version — the questions to take into your appointment — we wrote that up at Kansas City Fibroid Center.
Sources
Ciortea R, et al. Impact of Uterine Artery Embolization on Subsequent Fertility Outcomes: A Meta-Analysis of 20 Years of Clinical Evidence. J Clin Med. 2025;14(20):7205. Link
Yan X, Zhou L, He G, Liu X. Pregnancy rate and outcomes after uterine artery embolization for women: a systematic review and meta-analysis with trial sequential analysis. Front Med. 2023;10:1283279. Link
Systematic review and meta-analysis of current evidence in uterine artery embolization vs myomectomy for symptomatic uterine fibroids. Sci Rep. 2024. Link
Pregnancy and Uterine Artery Embolisation: Myth Busted. Cardiovasc Intervent Radiol. 2024. Link
Fabre C, et al. Fertility outcomes after uterine artery embolization for symptomatic leiomyomas. CVIR Endovasc. 2025;8:83. Link
Bhatia A, et al. Fertility Outcomes Following Uterine Fibroid Embolization Versus Myomectomy: A Multicenter Observational Study. J Vasc Interv Radiol. 2026;37(4 Suppl):108093 (conference abstract).
El Shamy T, et al. The impact of uterine artery embolization on ovarian reserve: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2020. Link
American College of Obstetricians and Gynecologists. Practice Bulletin 228: Management of Symptomatic Uterine Leiomyomas. 2021. Link
American College of Radiology. ACR Appropriateness Criteria: Radiologic Management of Uterine Leiomyomas. Revised 2023. Link
Talk It Through With Someone Who Will Be Straight With You
Bring your imaging and your questions. If UFE is a good option for you, we will explain why. If it isn’t, we will tell you that too.