Pregnancy after uterine fibroid embolization: follow-up of 100 patients embolized using tris-acryl gelatin microspheres

Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?

BACKGROUND

Uterine artery embolisation is well established as a treatment for symptomatic fibroids, however, there remain some uncertainties. We have carried out a focused literature review on three particularly challenging aspects - post-procedure fertility, symptomatic adenomyosis and large volume fibroids and uteri, to enable operators to utilise evidence-based guidance in patient selection, consent, and management.

REVIEW

Literature searches were performed of the PubMed/Medline, Google scholar, EMBASE and Cochrane databases. The outcomes of our analysis of studies which recorded fertility rates in women desiring pregnancy following UAE for symptomatic fibroids found an overall mean pregnancy rate of 39.4%, live birth rate of 69.2% and miscarriage rate of 22%. The major confounding factor was patient age with many studies including women over 40 years who already have lower fertility compared to younger cohorts. Miscarriage rates and pregnancy rates in the studies analysed were comparable to the age matched population. Treatment of pure adenomyosis and adenomyosis with co-existing uterine fibroids with UAE has been shown to produce symptomatic improvement with better outcomes in those with combined disease. Although the effectiveness is not as high as it is in pure fibroid disease, UAE provides a viable and safe alternative for patients seeking symptom relief and uterine preservation. Our analysis of studies assessing the outcomes of UAE in patients with large volume uteri and giant fibroids (> 10 cm) demonstrate no significant difference in major complication rates demonstrating that fibroid size should not be a contraindication to UAE.

CONCLUSION

Our findings suggest uterine artery embolisation can be offered to women desiring pregnancy with fertility and miscarriage rates comparable to that of the age-matched general population. It is also an effective therapeutic option for symptomatic adenomyosis as well as for the treatment of large fibroids > 10 cm in diameter. Caution is advised in those with uterine volumes greater than 1000cm³. It is however clear that the quality of evidence needs to be improved on with an emphasis on well-designed randomised controlled trials addressing all three areas and the consistent use of validated quality of life questionnaires for outcome assessment to enable effective comparison of outcomes in different studies.

HIFU as an alternative modality for patients with uterine fibroids who require fertility-sparing treatment

OBJECTIVES

To compare pregnancy outcomes after high-intensity focused ultrasound ablation (HIFU), myomectomy and uterine artery embolization (UAE) for fertility-sparing patients with uterine fibroids and to investigate the possible mechanism of improving pregnancy by HIFU.

MATERIALS AND METHODS

A meta-analysis of 54 studies containing 12,367 patients was conducted to compare the pregnancy outcomes of three fertility-sparing therapies. And a retrospective self-control study of 26 patients with uterine fibroids from May 2019 to December 2020 was performed to assess the blood flow impedance of bilateral uterine arteries before and after HIFU.

RESULTS

In the analysis by treatment option, the pregnancy rate after myomectomy was 0.43 (95% CI 0.36-0.49), which was higher than 0.18 (95% CI 0.10-0.26) after HIFU, the latter was significantly higher than that after UAE (ratio 0.08, 95% CI 0.06-0.10). The miscarriage rate after HIFU was 0.08 (95% CI 0.04-0.12), which was similar to 0.15 (95% CI 0.09-0.21) after myomectomy and also similar to 0.16 after UAE (95% CI 0.01-0.30). In the subgroup analysis, women who received ultrasound guided HIFU (USgHIFU) were more likely to have ideal pregnancy outcomes than that after magnetic resonance imaging-guided HIFU. The pulsatility index and resistance index on the right side were significantly higher 3 months after HIFU than before (1.637 ± 0.435 vs. 1.845 ± 0.469; p = 0.033; 0.729 ± 0.141 vs. 0.784 ± 0.081, p = 0.039).

CONCLUSIONS

HIFU, especially USgHIFU, may be an alternative fertility-sparing modality for patients with uterine fibroids over 40 years old. HIFU may contribute to improving pregnancy rates by elevating uterine blood flow impedance.

Route of myomectomy and fertility: a prospective cohort study

OBJECTIVE

To assess prospectively the association between the myomectomy route and fertility.

DESIGN

Prospective cohort study.

SETTING

The Comparing Treatments Options for Uterine Fibroids (COMPARE-UF) Study is a multisite national registry of eight clinic centers across the United States.

PATIENT(S)

Reproductive-aged women undergoing surgery for symptomatic uterine fibroids.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

We used life-table methods to estimate cumulative probabilities and 95% confidence intervals (CI) of pregnancy and live birth by the myomectomy route during 12, 24, and 36 months of follow-up (2015-2019). We also conducted 12-month interval-based analyses that used logistic regression to estimate odds ratios and 95% CIs for associations of interest. In all analyses, we used propensity score weighting to adjust for differences across surgical routes.

RESULT(S)

Among 1,095 women who underwent myomectomy (abdominal = 388, hysteroscopic = 273, and laparoscopic = 434), 202 reported pregnancy and 91 reported live birth during 36 months of follow-up. There was little difference in the 12-month probability of pregnancy or live birth by route of myomectomy overall or among women intending pregnancy. In interval-based analyses, adjusted ORs for pregnancy were 1.28 (95% CI, 0.76-2.14) for hysteroscopic myomectomy and 1.19 (95% CI, 0.76-1.85) for laparoscopic myomectomy compared with abdominal myomectomy. Among women intending pregnancy, adjusted ORs were 1.27 (95% CI, 0.72-2.23) for hysteroscopic myomectomy and 1.26 (95% CI, 0.77-2.04) for laparoscopic myomectomy compared with abdominal myomectomy. Associations were slightly stronger but less precise for live birth.

CONCLUSION(S)

The probability of conception or live birth did not differ appreciably by the myomectomy route among women observed for 36 months postoperatively.

CLINICAL TRIALS REGISTRATION NUMBER

(NCT02260752, clinicaltrials.gov).

[Pregnancy after the first uterine fribrom embolization procedures in sub-saharian Africa in Côte d'Ivoire]

OBJECTIVE

To report the obstetrical outcome of patients wishing to conceive after embolization of uterine fibroids in Côte d'Ivoire.

MATERIALS AND METHOD

Over a 72-month period from February 2012 to February 2018, a prospective observational and descriptive longitudinal study focused on 181 non menopausal patients who had symptomatic uterine fibroids for which they had benefited from embolization of the uterine arteries. Among them, some were selected taking into account the inclusion criteria and were regularly monitored by their obstetrician-gynecologist.

RESULTS

The mean age of the 65 patients was 40.7 years and 16.3% of them had a history of myomectomy. The mean uterine volume and size of dominant myomas before and six months after embolization were 849.5cm³, respectively; 67.7cm and 584cm³; 45.4cm (all these measurements are in centimeters), i.e. a reduction rate of 33% and 43%. Of the 65 patients, eleven of them with an average age of 36.7 years were able to conceive, a rate of 16.9%. Among these 11 patients, 8 had had one pregnancy and three had had two each, for a total number of 14 pregnancies. The mean time from uterine fibroid embolization to pregnancy was 34 months with extremes ranging from 06 to 60 months. Among the obstetric complications, there was one case of placenta accreta which required hysterectomy and two cases of placenta previa which had progressed well after cesarean delivery.

CONCLUSION

The onset of pregnancy is possible after embolization of uterine fibroids. This less invasive procedure than myomectomy can also be offered to patients with a desire for motherhood. However, there is little agreement on fertility status after UFE and fertility rates after UFE have not yet been effectively quantified. Also, the decision to favor EFU over myomectomy in women wishing to maintain their fertility remains limited by the small size of our sample. We should analyze more patients who are trying to conceive after UFE and use longer follow-up.

Pregnancy and its Outcomes in Patients After Uterine Fibroid Embolization: A Systematic Review and Meta-Analysis

Uterine artery embolization (UAE) has been introduced for uterine fibroid treatment for two decades. Most of the patients are in reproductive age and many want future pregnancy. In this study, we will assess fertility, pregnancy and its outcomes in patients who have undergone UAE. In this systematic review, a systematic search was performed on important databases including PubMed and Medline, Web of Knowledge, Google Scholar, EMBASE and Scopus. Studies reported enough data about pregnancy after UAE were considered to be enrolled in the review. We assessed obstetric indices (pregnancy and delivery rates, pregnancy losses, complications and fetal outcomes). Study evaluation was done based on STROBE checklist by two reviewers. Totally, 24 original papers were included. Data were analyzed by Stata and MedCalc softwares. Among women wishing fertility, totally 40.5% experienced at least one pregnancy after UAE (95% confidence interval [CI]: 33.3%-48.2%). Pooled estimate of pregnancy loss rate was 33.5% (95% CI: 26.3-41%). Most pregnancy losses were due to spontaneous abortion (81.3% of all losses (95% CI = 76%-86.1%)). Rate of obstetrical complications was 25.4% (95% CI = 13-40.2%) among all finished pregnancies. Pooled estimate of preterm labor was 12.8% (95% CI = 8.7%-17.5%), and pooled estimate of low birth weight (LBW) was 10% (95% CI = 6.2-14.6%). Considering the findings of the study, a safe pregnancy after UAE is obviously possible resulting to a healthy and normal baby delivery. In addition, pooled obstetrical complication rates, pregnancy losses, preterm labor and LBW seem to be mostly similar to the general population. Registration: The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) on Nov 3, 2017, and was confirmed with a registration code of CRD42017076074.

Pregnancy success and outcomes after uterine fibroid embolization: updated review of published literature

Females with symptomatic leiomyomas (fibroids) wishing to maintain fertility are faced with difficult treatment choices. These include uterine fibroid embolization (UFE), myomectomy, hormonal therapy, MRI high intensity focused ultrasound, and myolysis. This review focuses on UFE, one of the most commonly accepted minimally invasive procedural choices among patients with symptomatic fibroids wishing to retain the option of becoming pregnant in the future, and makes comparisons to myomectomy which has historically been the surgical choice for fertility-preserving fibroid treatment. Pubmed and Google Scholar searches using keywords such as: uterine artery embolization, uterine fibroid embolization, pregnancy, complications, infertility were performed between Jan 1, 2019 and May 10, 2019. Publications were chosen based on their inclusion of information pertaining to fertility or pregnancy after UFE without being limited to single case reports.Randomized controlled trials comparing myomectomy and UFE are limited due to study size and confounding variables, but through registry data and familiarity with referring clinicians, UFE has gained wide acceptance. Healthy pregnancies following UFE have been sporadically reported but the actual fertility rate after UFE remains uncertain. Conversely, low birth weight, miscarriage and prematurity have been associated with UFE. Despite inherent risks of possible fertility issues after UFE, the procedure remains an option for females with clinically symptomatic fibroids who desire pregnancy. However, additional research regarding rates of conception and obstetrical risks of infertility following UFE is necessary.

Knuttinen MG, Stark G, Hohenwalter EJ, Bradley LD, Braun AR, Gipson MG, Kim CY, Pinchot JW, Scheidt MJ, Sella DM, Weiss CR, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Uterine Leiomyomas

Uterine fibroids, also known as leiomyomas, are the most common benign tumor in women of reproductive age. When symptomatic, these patients can present with bleeding and/or bulk-related symptoms. Treatment options for symptomatic uterine leiomyomas include medical management, minimally invasive treatment such as uterine artery embolization, and surgical options, such as myomectomy. It is important to understand the role of these treatment options in various clinical scenarios so that appropriate consultation is performed. Furthermore, patients should be presented with the outcomes and complications of each of these treatment options. A summary of the data and clinical trials of the treatment options for symptomatic uterine leiomyomas is outlined in this article. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Uterine fibroid embolization efficacy and safety: 15 years experience in an elevated turnout rate center

OBJECTIVE

To evaluate effectiveness and safety of UFE as alternative to surgery, in treatment of uterine fibromatosis.

METHODS/MATERIALS

255 patients (aged 26-55) with symptomatic UF, indication for surgery, followed in our center (2000-2014), single or multiple fibroids, pain and/or functional/compressive disorders, underwent embolization: injection of PVA particles (150-900 μm) from distal portion of uterine arteries (ascending section). Primary end-point: flow-stop distally to injection site, disappearance of lesion design, preservation of flow in main trunk of UA. Secondary end-point: control of pain and functional/compressive disorders during follow-up (2-7 years).

RESULTS

Procedure was performed bilaterally in 250 patients (98%). Mean duration: 47 min (average fluoroscopy: 10:50 min). Post-embolization pelvic pain (according with VAS score) was on average 2.2 at discharge (24 h). Follow-up at 2 years: resolution of menstrual disorders in 78% of patients and improvement in 14%; pain disappeared in 66%; significant improvement of menstrual flow and HCT/HB levels, decrease in total uterine (57.7%)/dominant fibroid (76.1%) volume. Recurrence in 18 patients.

CONCLUSIONS

UFE represents an excellent alternative to surgical treatment: it is safe, tolerable and effective both in short and long term, with evident advantages in economic and social terms.

Fertility after uterine artery embolization of fibroids: a systematic review

PURPOSE

The impact of uterine artery embolization (UAE) for the purpose of diminishing the effect of uterine fibroids on fertility is unclear. We have investigated the reported rates of pregnancy and miscarriage after treatment of uterine fibroids with UAE.

MATERIALS AND METHODS

We searched for relevant information in PubMed and Embase for randomized controlled trials (RCT), controlled clinical trials, comparative before-after trials, cohort studies, case-control studies and case series where UAE treatment of premenopausal women was performed for uterine fibroids with and where a control intervention was included. The PRISMA guideline was used to do a systematic review using the main outcomes pregnancy rate and miscarriage rate. Risk of bias was assessed by the Cochrane risk of bias tool or by ROBINS-I. The quality of evidence was assessed by the GRADE approach.

RESULTS

We included 17 studies (989 patients): 1 RCT, 2 cohort studies, and 14 case series. Pregnancy rates after UAE were 50% in the RCT and 51 and 69% in the cohort studies. Among the case series median pregnancy rate was 29%. Miscarriage rates were 64% in the RCT. Miscarriage rates at 56 and 34% were found in the cohort studies after UAE. The median miscarriage rate was 25% in the case series.

CONCLUSION

Pregnancy rate was found to be lower and miscarriage rate higher after UAE than after myomectomy. However, we found very low quality of evidence regarding the assessed outcomes and the reported proportions are uncertain. There is a need for improved prospective randomized studies to improve the evidence base. Systematic review registration number: CRD42016036661.

Uterine rupture after uterine artery embolization for symptomatic leiomyomas

BACKGROUND

There are few data regarding safety of pregnancy after uterine artery embolization. However, numerous women desire future fertility after this procedure. Uterine rupture without a history of cesarean delivery or uterine scarring is an exceedingly rare complication in pregnancy.

CASE

We report a case of uterine rupture in a primigravid woman after uterine artery embolization. Her pregnancy was also complicated by placenta previa with placenta increta, resulting in a favorable neonatal outcome in an otherwise life-threatening situation for mother and fetus.

CONCLUSION

Uterine artery embolization is a risk factor for abnormal placentation and uterine rupture in subsequent pregnancies.

[Uterine artery embolization for myomas treatment]

Myoma treatment by uterine artery embolisation (UAE) using non-spherical PVA particles or calibrated tris-acryl microspheres>500μm is effective in more than 90 % of cases in the short-term. In the long-term, menorrhagia, bulk-related symptoms and pelvic pain are significantly improved or eliminated in 75 % of cases at 5 to 7 years. At 6 months, uterine volume reduction and larger myoma volume reduction varies between 30 to 60 % and 50 to 80 % respectively. During hospital stay the complication rate is very low, less than 3 % mostly urinary infection and pain. Secondary hysterectomy for complication is less than 2 % at 3 months. Definitive amenorrhea is reported in less than 5 % of cases in women of more than 45-year of age. No significant impact of embolization on hormonal function has been reported in women less than 45 years with normal baseline function. UAE is not indicated for submucous myomas. Randomized studies comparing embolization to hysterectomy demonstrate that reinterventions are more frequently performed after embolization. Secondary hysterectomy is performed in 13 to 24 % of cases at 2 years and in up to 28 % of cases at 5 years. Hospital stay, duration of recovery and time off work are shorter after embolization compared to hysterectomy. Embolization is cheaper than hysterectomy at 12 and 24 months even taking into consideration the additional costs of imaging and reinterventions. UAE is a good alternative treatment in women with unique myoma of less than 10cm and multiple myomas around 15cm. This treatment should be proposed to women each time possible. Randomized studies comparing embolization to myomectomy demonstrate that in the short and mid-term there is no difference in terms of control of menorrhagia and bulk-related symptoms. Uterine volume reduction and quality of life were not different at 6 months. Periprocedural and 30-day complication rates are not different. At 6 months, the rate of complications is higher after myomectomy. Reinterventions are more frequent after embolization compared to myomectomy. Hospital stay, duration of recovery and time off work are shorter after embolization compared to myomectomy. UAE is less aggressive than myomectomy and should be proposed as a conservative alternative treatment. Embolization should be considered with caution in pregnancy-seeking women since there is still a lack of good quality data available in the specific group of patients. FSH level is more frequently elevated after embolization compared to myomectomy. Pregnancy rate and term pregnancy rate are higher after myomectomy compared to embolization. Spontaneous abortion is more frequent after embolization than after myomectomy. At this time, UAE is not indicated excepted in studies or in specific cases when the woman want a pregnancy. Embolization performed before myomectomy (preoperative or combined procedures) can be discussed for an individual patient but there is not enough data to support its routine use.

Reproductive ability after uterine artery embolization in a sheep model: observation over 2 seasons

OBJECTIVE

To investigate the mid-term effect of uterine artery embolization (UAE) on fertility after bilateral UAE with either tris-acryl gelatin microspheres (TAGM) or gelatin particles (GP).

MATERIALS AND METHODS

Fertility was compared in 6 ewes that underwent UAE with TAGM, 6 ewes that underwent UAE with GP, and 6 control ewes. All ewes were artificially inseminated or naturally bred for 2 consecutive breeding seasons after UAE. Pregnancies in each breeding season were investigated.

RESULTS

Overall, 36 lambs, all normal in appearance, were delivered after 2 breeding seasons. All 18 ewes delivered lambs in at least the first or second breeding season, with 13 having lambs in both the first and second breeding seasons. In the first breeding season after UAE, all 12 ewes in the UAE group delivered lambs, while 5 (83.3%) of the 6 ewes in the control group did. In the second breeding season, 9 (90%) of the 10 ewes that were alive in the UAE group delivered lambs, while 5 (83.3%) of 6 ewes in the control group did. There were no significant differences in the rate of ewes delivering in the first and second breeding season between control and UAE groups (P = .3333; first season, P > .9999; second season, Fisher exact probability test).

CONCLUSION

The mid-term influence of UAE on reproductive ability in sheep was minimal.