Pregnancy after endometrial ablation: a systematic review

Background: Pregnancies have been reported after endometrial ablation but there is little data regarding subsequent pregnancy outcomes. Objective: To review systematically the available evidence regarding pregnancy outcomes after endometrial ablation, in order to equip physicians effectively to counsel women considering endometrial ablation. Search strategy: MEDLINE, Embase, Cochrane, and ClinicalTrials.gov were searched through January 2017. Selection criteria: Published and unpublished literature in any language describing pregnancy after endometrial ablation or resection was eligible. Data collection and analysis: Data about preconception characteristics and pregnancy outcomes were extracted and analysed according to study design of source and pregnancy viability. Main results: We identified 274 pregnancies from 99 sources; 78 sources were case reports. Women aged 26–50 years (mean 37.5 ± 5 years) conceived a median of 1.5 years after ablation (range: 3 weeks prior to 13 years after). When reported, 80–90% had not used contraception. In all, 85% of pregnancies from trial/observational studies ended in termination, miscarriage or ectopic pregnancy. Pregnancies that continued (case report and non-case report sources) had high rates of preterm delivery, caesarean delivery, caesarean hysterectomy, and morbidly adherent placenta. Case reports also frequently described preterm premature rupture of membranes, intrauterine growth restriction, intrauterine fetal demise, uterine rupture, and neonatal demise. Conclusions: An unexpectedly high rate of pregnancy complications is reported in the available literature (which may reflect publication bias) and high-quality evidence is lacking. However, based on the existing evidence, women undergoing endometrial ablation should be informed that subsequent pregnancy may have serious complications and should be counselled to use reliable contraception after the procedure. Tweetable abstract: Systematic review – pregnancies reported after endometrial ablation have an increased risk of adverse outcomes.