Uterine fibroid embolization versus myomectomy in women wishing to preserve fertility: Preliminary results of a randomized controlled trial

Impact of fibroids on reproductive function

There is debate regarding whether fibroids cause infertility or if they are simply an association. However, it is possible that fibroids are responsible for 2-3% of cases of infertility. The mechanisms by which these benign tumours could cause impaired reproductive function, both in terms of difficulty conceiving and early pregnancy loss, remain unclear. Myomectomy facilitates removal of a fibroid with preservation of reproductive potential. The procedure is associated with significant risks but, overall, some studies have suggested that this surgical option increases pregnancy rates significantly in women with fibroid-associated infertility. Miscarriage rates in women with fibroids and those who have undergone myomectomy vary considerably. It appears that miscarriage rates fall after myomectomy, although the overall rates of pregnancy loss remain higher than those seen in the general population. Fibroids affect 0.1-3.9% of pregnancies, and a number of complications encountered antenatally and post partum are thought to be directly related to the presence of these benign tumours. A number of contraceptive options exist for women with fibroids, with the choice depending on patient preference and both fibroid and patient characteristics.

[Interdisciplinary stratification of patients with myoma-related symptoms]

With the establishment of uterine artery embolization (UAE), the individualization of treatment of the symptomatic myomatous uterus showed a general progression. The concrete therapy decision is made in an interactive process between doctor and patient. A series of factors influence the choice of a suitable, operative or non-operative, therapeutic procedure. In the weighting of therapeutic options between surgery or UAE, in addition to current results of studies which compare both techniques,recommendations made by expert committees and guidelines are helpful for a competent counseling of patients and additionally supportive in decision processes such as interdisciplinary stratification.

Analysis of prognostic factors for patients with leiomyoma treated with uterine arterial embolization

OBJECTIVE

The objective of the study was to describe a clinically useful factors index predicting long-term efficacy of uterine artery embolization (UAE).

STUDY DESIGN

Newly diagnosed patients with uterine leiomyoma wishing to retain their uterus underwent UAE at our institution. Clinical demographics and 4 prognostic factors were recovered from the medical record. A regrowth-free interval (RFI) was calculated for all patients based on leiomyoma regrowth or recurrence of any previously reported symptoms. RFI by prognostic factor was analyzed by the Kaplan-Meier method.

RESULTS

Forty-three patients were identified. Two prognostic factors were identified by multivariate analysis: vascularity (dichotomized as hypervascular vs hypovascular; RFI at 2 years, 80% vs 20%, P = .001) and number of nodules (solitary vs multiple; RFI at 2 years, 72% vs 25% at 2 years, P = .001)

CONCLUSION

UAE success may be predicted by 2 preoperative parameters. Further investigation is warranted.

Sexuality and body image after uterine artery embolization and hysterectomy in the treatment of uterine fibroids: a randomized comparison

In this paper the effect of uterine artery embolization (UAE) on sexual functioning and body image is investigated in a randomized comparison to hysterectomy for symptomatic uterine fibroids. The EMbolization versus hysterectoMY (EMMY) trial is a randomized controlled study, conducted at 28 Dutch hospitals. Patients were allocated hysterectomy (n = 89) or UAE (n = 88). Two validated questionnaires (the Sexual Activity Questionnaire [SAQ] and the Body Image Scale [BIS]) were completed by all patients at baseline, 6 weeks, and 6, 12, 18, and 24 months after treatment. Repeated measurements on SAQ scores revealed no differences between the groups. There was a trend toward improved sexual function in both groups at 2 years, although this failed to reach statistical significance except for the dimensions discomfort and habit in the UAE arm. Overall quality of sexual life deteriorated in a minority of cases at all time points, with no significant differences between the groups (at 24 months: UAE, 29.3%, versus hysterectomy, 23.5%; p = 0.32). At 24 months the BIS score had improved in both groups compared to baseline, but the change was only significant in the UAE group (p = 0.009). In conclusion, at 24 months no differences in sexuality and body image were observed between the UAE and the hysterectomy group. On average, both after UAE and hysterectomy sexual functioning and body image scores improved, but significantly so only after UAE.

Hysteroscopy after uterine fibroid embolization in women of fertile age

AIM

Uterine artery embolization for fibroids is a controversial issue for women with incomplete reproductive plans. Ovarian failure and uterine infection are the most dreaded complications of this procedure. The purpose of the present study was to assess the types and the frequency of intrauterine abnormalities and the histological features of the endometrium after embolization.

METHODS

Uterine artery embolization was performed on 51 women (average age 34.5 years) with intramural fibroid/s larger than 4 cm. Hysteroscopy and endometrial biopsy was performed from 3 to 9 months later in the luteal phase of the cycle.

RESULTS

Despite all women having no major symptoms prior to hysteroscopy, only 19 (37%) had completely normal hysteroscopic findings. There was intrauterine protrusion of fibroid/s in 19 cases (37%), yellowish coloration of the endometrium in 14 (28%), intrauterine or cervical adhesions in seven (14%), and communication between the myoma and the uterine cavity in five cases (10%). A normal, functional endometrium was histologically verified in 44 women of 49 (90%) who could be evaluated. Regressive changes (necrosis or hyalinization) of leiomyoma or of indefinite origin were found in 17 patients and embolization particles in five, including one patient with microspheres inside the endometrial vessel. No case of Asherman syndrome or endometrial atrophy was observed.

CONCLUSION

The frequency of abnormal hysteroscopic findings after embolization is surprisingly high. The clinical significance, reversibility, and impact on fertility of abnormal hysteroscopic findings after embolization remain unclear. Regardless, hysteroscopy should be strongly recommended to all patients after uterine fibroid embolization, prior to conception.

Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy

The purpose of this study was to compare the midterm results of a radiological and surgical approach to uterine fibroids. One hundred twenty-one women with reproductive plans who presented with an intramural fibroid(s) larger than 4 cm were randomly selected for either uterine artery embolization (UAE) or myomectomy. We compared the efficacy and safety of the two procedures and their impact on patient fertility. Fifty-eight embolizations and 63 myomectomies (42 laparoscopic, 21 open) were performed. One hundred eighteen patients have finished at least a 12-month follow-up; the mean follow-up in the entire study population was 24.9 months. Embolized patients underwent a significantly shorter procedure and required a shorter hospital stay and recovery period. They also presented with a lower CRP concentration on the second day after the procedure (p < 0.0001 for all parameters). There were no significant differences between the two groups in the rate of technical success, symptomatic effectiveness, postprocedural follicle stimulating hormone levels, number of reinterventions for fibroid recurrence or regrowth, or complication rates. Forty women after myomectomy and 26 after UAE have tried to conceive, and of these we registered 50 gestations in 45 women. There were more pregnancies (33) and labors (19) and fewer abortions (6) after surgery than after embolization (17 pregnancies, 5 labors, 9 abortions) (p < 0.05). Obstetrical and perinatal results were similar in both groups, possibly due to the low number of labors after UAE to date. We conclude that UAE is less invasive and as symptomatically effective and safe as myomectomy, but myomectomy appears to have superior reproductive outcomes in the first 2 years after treatment.

Uterine artery embolisation to treat symptomatic uterine fibroids

Women may now have another effective, safe, and minimally invasive treatment option for treating fibroids

The impact of uterine artery embolization on fertility and pregnancy outcome

PURPOSE OF REVIEW

Uterine artery embolization for management of symptomatic fibroids is an effective and increasingly popular treatment option. There are several studies evaluating the effects of uterine artery embolization on later pregnancies; however, the effects on fertility are still largely uncertain. This paper reviews the current literature on the effects of this technique on fertility and pregnancy outcome.

RECENT FINDINGS

Two recent studies have reported pregnancy rates following uterine artery embolization in women seeking pregnancy. A small, third study reported preliminary results in a randomized controlled trial comparing uterine artery embolization with myomectomy in women wishing to preserve fertility.

SUMMARY

The body of medical literature supports use of uterine artery embolization as an effective treatment for symptoms of vaginal bleeding and pelvic pressure from uterine fibroids. Patient selection is critical in determining the appropriateness of this treatment option. Myomectomy remains the standard of care for women with symptomatic fibroids seeking fertility preservation.

La chirurgie tubaire et utérine a-t-elle un effet délétère sur la fonction ovarienne?

Changes in menstrual pattern after tubal sterilisation have been reported for more than 50 years. Hence all tubal surgeries have been suspected of altering the ovarian reserve, by damage to the ovarian blood vessels. Recent studies showed that tubal surgery has no significant adverse effect on doppler flow indice and hormonal markers. Hysterectomy and uterine artery embolization seem to decrease ovarian reserve in perimenopausal women. Uterine artery embolization does not seem to have adverse effects on normally functioning ovaries.

Uterine artery embolization for symptomatic uterine fibroids

BACKGROUND

Uterine fibroids cause heavy and prolonged bleeding, pain, pressure symptoms and subfertility but are mostly benign. The traditional method of treatment has been surgery as long term medical therapies have not shown to be effective. Uterine artery embolization (UAE - complete occlusion of both the uterine arteries with particulate emboli) has been reported to be an effective and safe alternative in the treatment of menorrhagia and other fibroid-related symptoms in women not desiring future fertility, but thus far this evidence is based on case controlled studies and case reports.

OBJECTIVES

To review the benefits and/or harms from randomised controlled trials (RCTs) of uterine artery embolization (UAE) versus other interventions for symptomatic uterine fibroids.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group Trials register (searched 10 August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, Issue 3, 2004), MEDLINE (January 1966 to November 2005) and EMBASE (January 1980 to November 2005). We also contacted authors of potential ongoing studies.

SELECTION CRITERIA

RCTs of UAE versus any medical or surgical therapy for symptomatic uterine fibroids.

DATA COLLECTION AND ANALYSIS

Two of the authors (AS and JKG) assessed the trials and extracted the data independently. They also contacted the investigators of eligible RCTs for unpublished data.

MAIN RESULTS

Three trials were included in this review. Two RCTs compared UAE with abdominal hysterectomy in 234 women. Although the follow-up period was intended for two years, the available published results was only for six months follow-up. The second trial included 63 women comparing UAE with myomectomy in women who wished to preserve their fertility. The minimum follow-up reported was six months with a mean of 17 (+/- 9.3) months. The clinical success rate measured by improvement in fibroid-related symptoms e.g. menstrual loss was at least 85% in the UAE group from both trials. The mean dominant fibroid volume decreased by 30 to 46% in two trials. UAE significantly reduces length of hospital stay compared to surgery for either hysterectomy or myomectomy. Women undergoing UAE resumed routine activities sooner than those undergoing surgery. UAE was associated with a higher rate of minor post procedural complications such as vaginal discharge, post puncture haematoma and post embolization syndrome (pain, fever, nausea, vomiting), as well as higher unscheduled visits and readmission rates after discharge, compared with hysterectomy. There were no major complication differences between the two groups. Three women in the myomectomy trial had elevated FSH levels post UAE indicating possible ovarian dysfunction.

AUTHORS' CONCLUSIONS

UAE offers an advantage over hysterectomy with regards to a shorter hospital stay and a quicker return to routine activities. There is no evidence of benefit of UAE compared to surgery (hysterectomy / myomectomy) for satisfaction. The higher minor complications rate after discharge in the UAE group as well as the unscheduled visits and readmission rates require more longer term follow-up trials to comment on its effectiveness and safety profile. There is currently an ongoing trial (REST, U. K.) and EMMY trial yet to report on the long term follow up, the results of which are awaited with interest.