Focused ultrasound surgery of intramural leiomyomas may facilitate fertility: A case report Miriam M. F. Hanstede, M.D., a Clare M. C. Tempany, M.D., b and Elizabeth A. Stewart, M.D. a a Department of Obstetrics, Gynecology, and Reproductive Biology, and b Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts Objective: To describe a successful pregnancy after a change in configuration of the endometrial cavity after magnetic resonance imaging-guided focused ultrasound surgery (MRgFUS) for leiomyomas. Design: Case report. Setting: University hospital. Patient: A 40-year-old woman with known leiomyomas and a history of secondary infertility. Intervention: Magnetic resonance imaging-guided focused ultrasound surgery treatment of two intramural myomas, one with a significant submucosal component. Main Outcome Measure: Change in conformation of the uterine cavity. Result(s): A viable intrauterine pregnancy, with full-term uneventful labor and vaginal delivery. Conclusion(s): Magnetic resonance imaging-guided focused ultrasound surgery changed the configuration of the endometrial cavity, and a subsequent pregnancy resulted in a term delivery. (Fertil Steril 2007;88:497.e5–7. © 2007 by American Society for Reproductive Medicine.) Key Words: MRgFUS, leiomyomas, fertility, pregnancy Uterine leiomyomas (fibroids) affect approximately 25% of women of reproductive age (1). The association between fibroids and infertility has been documented when there is distortion of the endometrial cavity (2–5). With the advent of hysteroscopic myomectomy, when there is an intracavitary fibroid, the cavity can be normalized in a minimally invasive fashion, thus enhancing fertility (6, 7). However, both large, nonhysteroscopically resectable sub- mucosal fibroids and intramural fibroids abutting the cavity can also cause cavitary distortion. The impact of these types of myomas on infertility and early pregnancy loss is more controversial. In addition, because these fibroids require abdominal myomectomy, the advantages of normalizing the cavity are outweighed by the morbidity of the surgery. We report on a case where treatment of two uterine fibroids by magnetic resonance imaging-guided focused ul- trasound surgery (MRgFUS) resulted in normalization of the endometrial cavity, and possibly facilitated a subsequent pregnancy. CASE REPORT A 40-year-old woman with three full-term deliveries and a history of secondary infertility presented for treatment of symptomatic uterine fibroids. She had a history of leiomyo- mas for 10 years, and experienced both abnormally heavy menstrual bleeding and pelvic pressure. In August 2003, she enrolled in a clinical trial of MRgFUS for treatment of uterine fibroid (8). She gave informed con- sent for the trial, and was deemed eligible for treatment. The protocol stated that women should have completed child- bearing before undergoing this investigational procedure. On preprocedure MRI with gadolinium, an enlarged uterus measuring 15.8  8.3  14.0 cm was seen. Multiple myomas were identified, and the two myomas believed to be most responsible for her symptoms were targeted for treat- ment. Both of these leiomyomas were located anterior and left of the endometrial cavity, causing a deviation of the cavity to the right. The larger fibroid was located superior and to the left of the endometrial cavity, and had a significant submucosal component. The latter caused considerable compression and distortion of the cavity. The smaller intramural myoma was located inferiorly (Fig. 1A, B). In September 2003, the patient underwent an uncompli- cated MRgFUS treatment. Posttreatment gadolinium MR images indicated thermal-induced necrosis in each treated fibroid. At 6-month follow-up examination, the overall size of the uterus was unchanged, but both treated fibroids were smaller. At 1 year, the superior treated fibroid was further decreased in size, and the inferior one had stabilized. A marked change in the configuration of the uterine cavity was noted at this time (Fig. 1C, D). Received June 20, 2006; revised November 14, 2006; accepted Novem- ber 17, 2006. Reprint requests: Elizabeth A. Stewart, M.D., Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Mayo Clinic and Mayo Medical School, 200 First Street, SW, Rochester, MN 55901 (FAX: 507 284-1774; E-mail: stewart.elizabeth@mayo.edu). 497.e5 0015-0282/07/$32.00 Fertility and Sterility Vol. 88, No. 2, August 2007 doi:10.1016/j.fertnstert.2006.11.103 Copyright ©2007 American Society for Reproductive Medicine, Published by Elsevier Inc.