Long-term fertility preservation and quality-of-life outcomes after high-intensity focused ultrasound ablation versus laparoscopic myomectomy in reproductive-aged women with uterine fibroids: a 5-year propensity-matched cohort study

High-intensity focused ultrasound ablation (HIFU-a) is a novel, non-invasive technique for treating uterine myoma. However, robust evidence comparing long-term multidimensional outcomes—including fertility trajectories, endocrine stability, and quality of life (QoL)—remain controversial. This study aimed to compare 5-year recurrence dynamics, re-intervention risks, hormonal profiles, pregnancy success rates, and longitudinal QoL changes between HIFU-a and laparoscopic myomectomy (LM) in this population. This propensity-score matched retrospective cohort included 332 symptomatic women (172 HIFU-a vs. 160 LM) followed for 5 years. Patients were enrolled between January 2016 and December 2019, with the last follow-up on December 31, 2024. Propensity score matching using a caliper width of 0.2 standard deviations of the logit was performed with covariates including age, BMI, fibroid size/location, and baseline fertility status. Structured assessments at baseline, 1, 3, and 5 years evaluated ultrasound-confirmed recurrence/re-intervention, endocrine function (FSH/LH/PRL/AMH), cumulative pregnancy rates, obstetric outcomes, and multidimensional QoL (SF-12). Time-to-event analyses with Kaplan-Meier curves and Cox proportional hazards models were applied to recurrence and pregnancy outcomes. Repeated SF-12 and hormone measurements were analyzed using linear mixed-effects models. Baseline characteristics were well balanced after propensity score matching (standardized mean differences 0.02–0.16). Kaplan-Meier analysis showed no statistically significant difference in recurrence or re-intervention rates between groups at 5 years (log-rank p = 0.601; HR 1.31, 95% CI 0.47–3.65). The HIFU-a group demonstrated a significantly higher cumulative pregnancy rate at 5 years compared with the LM group (59.9% vs. 50.6%; log-rank p = 0.043; HR 1.28, 95% CI 1.01–1.63). Obstetric outcomes—including live birth rate (72.1% vs. 68.4%, p = 0.518), miscarriage rate (19.2% vs. 22.8%, p = 0.401), preterm birth (8.7% vs. 10.3%, p = 0.682), and cesarean section rate (42.3% vs. 45.6%, p = 0.609)—did not differ significantly between groups. No uterine rupture cases were reported in either group. For quality of life, the HIFU-a group had a lower Physical Functioning score at 1 year, but longitudinal mixed-effects models revealed significantly greater improvements over time in Role Physical, Bodily Pain, Social Function, Vitality, Role Emotional, and General Health (significant group × time interactions, all p < 0.05). No significant differences were observed in the longitudinal trajectories of LH, FSH, PRL, or AMH. Over a 5-year follow-up period, HIFU-a demonstrated disease control comparable to LM, with a higher cumulative pregnancy rate and more favorable longitudinal QoL trajectories in reproductive-aged women with uterine fibroids. These findings support HIFU-a as a promising fertility-sparing treatment option for appropriately selected patients. Confirmation through a randomized controlled trial is warranted.