The impact of uterine fibroid embolization on resumption of menses and ovarian function

A combination of laparoscopy and bilateral uterine artery occlusion for the treatment of type II cesarean scar pregnancy: a retrospective analysis

OBJECTIVE

We investigated the efficacy of a combination of laparoscopy and bilateral uterine artery occlusion (BUAO) for the treatment of type II cesarean scar pregnancy (CSP).

METHODS

Patients with type II CSP underwent laparoscopy + bilateral uterine artery embolization (control group) or laparoscopy + BUAO (study group). Data regarding the duration of surgery, intraoperative hemorrhage, postoperative complications, the duration of the hospital stay, and the costs of hospitalization were retrospectively collected. One year later, the time to the return of the β-human chorionic gonadotropin (β-hCG) concentration to normal and to the return of menstruation were compared.

RESULTS

The duration of surgery, time to the return of menstruation, and incidence of postoperative complications in the study group were significantly less than in the control group, but there was no significant difference in the time for β-hCG to return to normal or the volume of intraoperative hemorrhage. The duration of hospitalization and costs for the control group were higher than those for the study group.

CONCLUSION

Laparoscopy in combination with BUAO is associated with minimal trauma, rapid recovery, a short duration of surgery, low cost of hospitalization, and a low postoperative complication rate. Thus, it represents a useful new surgical treatment for type II CSP.

Effectiveness of a hysteroscopic tissue removal system device for hysteroscopic myomectomy on patients' quality of life: a randomized clinical trial

PURPOSE

To evaluate the quality of life in patients treated for submucosal leiomyomas after hysteroscopic myomectomy compared to medical therapy. This is the first prospective randomized analysis comparing outcomes of medical therapy versus hysteroscopic myomectomy using the TruClear™ hysteroscopic tissue removal system to treat heavy menstrual bleeding from submucosal leiomyoma(s).

METHODS

Setting: private practice and community-based hospital; subjects: female patients with symptomatic submucosal leiomyomas from 2014 to 2017. A total of 69 patients enrolled, with 47 completed.

STATISTICAL ANALYSIS USED

randomization, linear mixed-effects modeling, hypothesis testing, and intent-to-treat analysis. Each patient was randomized to oral contraceptive pills/progesterone releasing intrauterine device or hysteroscopic myomectomy. Each patient was to complete the Uterine Fibroid Symptom and Health-related Quality of Life (UFS-QOL) questionnaire at baseline, one month, three months, and greater than or equal to six months after treatment.

MAIN OUTCOME MEASURED

Primary outcome was the health-related quality of life (HR-QOL), as reflected from UFS-QOL scores. Contrasts were constructed from a linear mixed-effects model to compare the two treatment groups for changes from baseline in UFS-QOL scores.

RESULTS

UFS-QOL scores were similar at baseline between the two treatment groups. There was an overall improvement in all UFS-QOL scores within each group. Higher improvement scores were noted in the surgical group compared to the medical group for almost all UFS-QOL scores. At ≥ 6 months, in comparison to the medically managed patients, the most considerable score improvements for the surgical group were reported in HR-QOL concern, activities, self-consciousness and symptom severity scores having mean change scores (95% CIs) of 35.3, 28.9, 28.6, and 32.2, respectively.

CONCLUSION

Although there was no statistical difference in the change degree of improvement of overall quality of life among patients with symptomatic submucosal leiomyomas who received medical or surgical treatments in the study, there were greater differences in improvements in health-related quality of life scores over time after surgical treatment.

Care Delivery for Patients with Leiomyomas: Failures, Real-Life Experiences, Analysis of Barriers, and Proposed Restorative Remedies

In this narrative review, we describe historical and contemporary influences that prevent patients with fibroids from getting appropriate medical care. Using patient stories as examples, we highlight how misogyny on all levels hurts patients and prevents medical teams from doing their best. Importantly, inequity and disparities result in massive gaps in care delivery. We suggest that we, as gynecologists and surgeons, must join public discourse on this topic to highlight the inadequacies of care delivery and the reasons behind it, suggest potential solutions, and join patients and communities in formulating and implementing remedies.

Efficacy of Embolization in Acquired Uterine Vascular Malformations: An Experience in Tertiary Care Centre in India

OBJECTIVE

 To determine the efficacy of Uterine Artery Embolization in patients with bleeding acquired uterine arteriovenous malformations (AVMs).

METHODS

 A prospective review of all patients who underwent Uterine Artery Embolization at our institution between July 2015 and April 2022 was performed. 225 patients were diagnosed with a uterine vascular malformation on doppler and corresponding MRI imaging. All patients underwent transcatheter embolization of the uterine arteries. Embolic agents in the 375 procedures included Histoacryl glue only (n = 326), polyvinyl alcohol (PVA) particles and Histoacryl glue (n = 29), PVA particles (n = 5), Gelfoam (n = 5), coils (n = 4), PVA particles and coils (n = 3), Histoacryl glue and Gelfoam (n = 2), and Histoacryl glue and coils (n = 1).

RESULTS

 A total of 375 embolization procedures were performed in 225 patients. 90 patients required repeat embolization for recurrence of bleeding. The technical success rate of embolization was 100%. The clinical success rate was 92%: bleeding was controlled in 222 of 225 patients and three patients underwent a hysterectomy. 60 of the 225 patients had uneventful intrauterine pregnancies carried to term. The 210 patients who underwent successful embolization had no recurrence of bleeding at a median follow-up of 53 months (range, 5-122 months) after treatment. 15 patients were eventually lost to follow-up. One minor complication (0.4%) of non-flow-limiting dissection of the internal iliac artery occurred.

CONCLUSION

 Uterine Artery Embolization is a safe, effective, minimally invasive method to treat uterine AVMs with long-term efficacy, which can provide the preservation of fertility.

Acquired uterine arteriovenous malformation treated with superselective embolization: Case report

Acquired uterine arteriovenous malformation is a rare condition, sometimes provoking abnormal life-threatening uterine hemorrhage. Here, we present the case of a 30-year-old healthy woman who developed heavy vaginal bleeding after dilatation and suctioning of the placenta 1 month after the delivery of a nonviable fetus. An ultrasound was performed which showed the appearance of a large exacerbation of a vessel with positive fetal sounds, normal cardiac movement, and normal morphological analysis. The patient was successfully treated with unilateral superselective embolization, distal to the ovarian supply, maintaining normal supply to the uterus and ovaries restoring normal menstruation, and showed complete resolution of the arteriovenous malformation.

Contralateral and Ipsilateral Arterial Vasculature of the Human Uterus: The Pilot Results of an Anatomical Study

Arterial blood to the human uterus is provided by a pair of uterine arteries (UA) and supported by terminal branches of ovarian (OA) and vaginal arteries (VA). Literature reports the existence of ipsilateral and contralateral anastomoses between these arteries and the UA, but data on the prevalence of such anastomoses are discrepant. The aim of this trial is to study whether contralateral and ipsilateral anastomoses exist. We studied nine human uterine specimens, which were obtained from (i) human cadavers (n = 6), (ii) uterine transplant recipients (n = 2), and (iii) one altruistic uterine donor (n = 1). We injected India ink into the graft through the UA of each specimen (n = 8) or OA (n = 1). We semiquantitatively observed and evaluated the extent of the injection on horizontal, vertical, and transmural levels. The dye permeated beyond the midline in 9/9 (100 %) cases. Near-complete/complete permeation to the contralateral side was observed in 6/9 (66 %) cases. The dye permeated ipsilaterally throughout all uterine levels in 8/8 cases (100 %) of UA injection. The entire wall of the myometrium was permeated in 2/9 (22 %) cases. In 7/9 (78 %) cases, the wall of the myometrium was permeated less than halfway through. In conclusions, the preliminary results of this study prove the existence of ipsilateral and contralateral anastomoses. Complete transmural injection was observed in only 22 % of cases; however, this finding does not provide information about the functional capacity of these anastomoses. More data and studies are necessary to make definitive conclusions.

The impact on Anti-Mullerian Hormone (AMH), uterine fibroid size and uterine artery patency following Uterine Fibroid Embolization (UFE) with a resorbable embolic agent

The effect of Uterine Fibroid Embolization on fertility and ovarian reserve remains uncertain. We assessed the impact of a new resorbable, spherical particle (Gelbead) on concentration of Anti-Mullerian (AMH) hormone, fibroid volume and uterine artery patency. This prospective cohort study recruited consecutive patients from July 2017 to June 2018. Serum AMH, fibroid and uterine volume, UFS-QOL (uterine fibroid score-quality of life) scores were measured prior to and at 1 month and/or 3 months post embolization. Twenty-four participants were enrolled (median age 44 years, uterine volume 484 cm³, initial dominant fibroid volume 167 cm³). One patient was lost to follow-up. AMH (median ± SD) immediately prior to embolization was 3.2 ± 13.7 pmol/L. At 1-month postembolization, AMH was 4.1 ± 8.6 pmol/L and at 3 months 4.4 ± 8.6 pmol/L. We found no significant difference in AMH levels between baseline and at 1 month (p = 0.58) or baseline and 3 months (p = 0.17). The median dominant uterine fibroid volume decreased (167 to 64 cm³, p < 0.001). At 3 months post-embolization, 17/23 patients had patent uterine arteries bilaterally (73.9%). UFE with Gel-bead did not significantly affect AMH at 3 months post embolization, whilst maintaining a high rate of uterine artery patency.

Uterine artery embolization combined with ultrasound-guided dilation and curettage for the treatment of cesarean scar pregnancy: Efficacy and 5–8-year follow-up study

Objective

To evaluate the efficacy and safety of uterine artery embolization (UAE) combined with dilation and curettage (D&C) using ultrasound as a treatment for cesarean scar pregnancy (CSP) and assess its effect on ovarian and reproductive function.

Methods

A total of 54 patients with uterine CSP between January 2011 and December 2015 were included in this retrospective study. The patients were treated with UAE combined with D&C using ultrasound for the treatment of CSP and followed up for 5–8 years. Their medical records, medical histories, clinical manifestations, treatment courses, and treatment results were analyzed.

Results

The 54 patients were initially treated without severe complications. β-Human chorionic gonadotropin (β-hCG) normalization took 36.11 ​± ​10.73 days (range, 25–84 days), length of hospitalization was 6.6 ​± ​1.5 days (range, 4–10 days), and total blood loss was 18.48 ​± ​8.41 ​mL (range, 5–33 ​mL). All patients resumed normal menstruation after 33.48 ​± ​8.71 days (range, 26–70 days). At the 5–8-year follow-up after UAE combined with D&C by ultrasound for the treatment of uterine CSP, the menstrual volume in 32 (59.3%) patients decreased versus before the operation. Compared with pretreatment, the menstrual cycle was prolonged in two (3.7%) cases, shortened in 10 (18.5%) cases, irregular in one (1.9%) case, and unchanged in 39 (72.2%) cases. Three patients conceived naturally and successfully gave birth to healthy children. Seven (12.96%) patients with accidental natural pregnancies chose induced abortion with no significant change in their sex lives.

Conclusion

UAE combined with D&C using ultrasound for the treatment of uterine CSP is safe and effective and may not affect the fertility of patients aged <40 years. However, menstrual volume may be reduced in some patients.

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.

Application of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section

OBJECTIVE

This study aimed to investigate the clinical effects of abdominal aortic balloon occlusion followed by uterine artery embolization for the treatment of pernicious placenta previa complicated with placenta accreta during cesarean section.

METHODS

We performed a retrospective analysis of the clinical data for 623 patients who experienced pernicious placenta previa complicated with placenta accreta and received treatment in our hospital from January 2013 to January 2019. All patients underwent abdominal aortic balloon occlusion before their cesarean section. Seventy-eight patients received bilateral uterine artery embolization, and among them, placenta accreta was found at the opening of the cervix in 13 patients. Due to suturing difficulty after the removal of the placenta, gauze packing was used to temporarily compress the hemorrhage. As soon as the uterus was sutured, emergent bilateral uterine artery embolization was performed. Active bleeding was noted in the remaining 65 patients when the lower part of the uterus was pressed after the placenta was removed and the uterus was sutured, therefor, bilateral uterine artery embolization was performed urgently.

RESULTS

Of the 623 patients, 545 patients underwent only abdominal aortic balloon occlusion and 78 patients underwent additional emergent bilateral uterine artery embolization due to hemorrhaging during or after their cesarean section. No hysterectomies were performed. In the 78 patients, the amount of bleeding was 800-3,200 ml with an average of 1,650 ml during the operation; the volume of blood transfused was 360-1,750 ml (average: 960 ml). The fetal fluoroscopy time was 3-8 s (average: 5 s). The dose of radiation exposure was (4.2 ± 2.9) mGy. Fetal appearance, pulse, grimace, activity, and respiration (Apgar) score were normal. No serious complications were observed during or after the operation in the follow-up visits. Conclusion: For patients with pernicious placenta previa complicated with placenta accreta who experience active bleeding after cesarean section and abdominal aortic balloon occlusion, bilateral uterine artery embolization can effectively reduce blood loss and requirement of blood transfusion during the operation, and lowers the risk of hysterectomy.

Ovarian reserve after uterine artery embolization in women with morbidly adherent placenta: A cohort study

Objective

To evaluate ovarian reserve in women after preservative cesarean delivery using uterine artery embolization due to morbidly adherent placenta.

Study design

A historical cohort study including all women admitted to a single tertiary care center, with morbidly adherent placenta that had preservative cesarean delivery with bilateral uterine artery embolization. Inclusion criteria included gestational age >24 weeks, singleton pregnancy and placenta increta / percreta. Exclusion criteria included maternal age > 43 years old and cesarean hysterectomy. Control group included women attending the infertility clinic due to male factor or single women conceiving via sperm donation, matched by age. Blood samples were collected on day 2–5 of menstruations for hormonal profile and Anti Mullarian Hormone (AMH) levels. Primary outcome was ovarian reserve evaluated by the levels of AMH.

Results

59 women underwent preservative cesarean delivery using uterine artery embolization during the study period. 21 women met inclusion criteria (33.9%) and were matched controls (n = 40). Circulating levels of E2 and FSH did not differ significantly between the two groups (p = 0.665, p = 0.396, respectively). AMH was lower in the study group (median 0.8 IQR 0.44–1.80) compared to the controls (median 2.08 IQR 1.68–3.71) (p = 0.001). This finding was consistent in linear multivariate regression analysis where the group of cesarean delivery using bilateral artery embolization due to placenta accrete was significantly predictive for the levels of AMH (B = -1.308, p = 0.012).

Conclusion

Women post preservative cesarean delivery using uterine artery embolization due to placenta accrete have lower ovarian reserve compare to controls matched by age.

Successful pregnancy after uterine artery embolization for uterine arterovenous malformation: a rare case report

Objective

This paper reports on a rare case of pregnancy after uterine artery embolization (UAE) for uterine arteriovenous malformation (AVM). Debate exists about persistence of fertility in women after UAE. Adverse effects of this technique can modify both uterine echostructure, inducing necrosis and infarction, endometrial atrophy and uterine artery rupture, and ovarian reserve, causing persistent amenorrhea. Ovarian reserve appears to be affected by UAE in pre-menopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Case report

A 28-year-old woman was admitted to our department due to life-threatening uterine bleeding, resulting in tachycardia, pallor, and sweating. The patient came with a history of two spontaneous miscarriages. After sonography and computed tomography, AVMs were identified at uterine fundus and anterior wall.

Conclusion

The pathogenesis of infertility after UAE is not yet known. The peculiarity of this case was that, only few months later, the patient became pregnant and gave birth to a live fetus at 37 weeks with cesarean delivery.

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.

Anti-Müllerian hormone levels before and after uterine artery embolization

OBJECTIVE

To determine the effects of uterine artery embolization (UAE) on ovarian reserve as measured by Anti-Müllerian hormone (AMH) levels.

MATERIAL AND METHODS

Non-randomized, observational study of 89 women 23-40 years of age who received UAE. Control hormone levels were measured prior to UAE and the first post-embolization measurement was taken at various times post-procedure (mean = 190 ± 229 days).

RESULTS

Historical work verified by our earlier work has shown that AMH levels decline with age. Regression analysis allows us to determine whether UAE contributes to a greater decline in AMH values over that naturally occurring with aging. The effect of the procedure was found to contribute no deleterious effect to the natural decline in AMH levels. In addition, multiple blood draws were obtained from 32 patients up to 47 months post-UAE. Regression studies with these patients as their own controls showed no long-term diminishment of ovarian reserve due to the UAE procedure.

CONCLUSIONS

Earlier reported data are consistent with larger sample size. UAE does not affect ovarian reserve in women <40 as evidenced by no significant change in AMH levels after embolization. Women who are of reproductive age and have uterine fibroids can consider UAE without concern for adverse effects on their fertility.

One year symptom severity and health-related quality of life changes among Black African patients undergoing uterine fibroid embolisation

BACKGROUND

The main aim in the treatment of symptomatic fibroids by various modalities including uterine fibroid embolisation (UFE) is to alleviate symptoms and ultimately improve the quality of life. The efficacy of this modality of treatment in Black African women with significant fibroid burden and large uterine volumes is not clear. The main objective of the study was to examine potential changes in symptom severity among Black African patients 1 year following UFE for symptomatic uterine fibroids in a resource-constrained setting, rated using a validated questionnaire (UFS-QOL). Secondary outcomes examined were changes in quality of life and potential associations with age, parity, uterine volume and fibroid number prior to UFE. Additional interventions after UFE were also recorded.

METHODS

A prospective before and after study of Black African patients undergoing UFE was undertaken. Participants underwent pelvic MR imaging prior to UFE and completed the UFS-QOL, a validated condition-specific questionnaire at baseline and at 1 year. Ninety five participants were recruited and data from 80 completing 1 year of follow up were available for analysis of changes in the symptom severity scores.

RESULTS

The mean reduction in symptom severity score was 29.6 [95% CI 23.6 to 35.6, P < 0.001] and the mean improvement in HRQOL score was 35.7 [95% CI 28.4 to 42.9, P < 0.001]. A greater number of fibroids identified prior to UFE was associated with a more substantial improvement in symptom severity score (r_s = 0.28, n = 80, P = 0.013) and participants of higher parity reported a greater improvement in HRQOL score (r = 0.336, P = 0.002). Major and minor surgical interventions were needed in 5 (6.3%) and 10 (12.5%) participants respectively.

CONCLUSIONS

UFE is associated with clinically useful and statistically significant symptom relief in Black African patients. Symptom improvement following UFE is not compromised by a large fibroid burden and the rate of subsequent intervention is within an acceptable range. UFE is a safe alternative and efforts are needed to widen access to this non-surgical treatment modality.

Uterine Artery Embolization and Surgical Methods for the Treatment of Symptomatic Uterine Leiomyomas: A Systemic Review and Meta-analysis Followed by Indirect Treatment Comparison

PURPOSE

There is significant discussion and uncertainty about the optimal management of symptomatic uterine leiomyomas (SULs). Nonsurgical procedures such as uterine artery embolization (UAE) have been developed. The goal of this study was to conduct a meta-analysis and an indirect treatment comparison to examine the comparative efficacy and safety of the surgical procedures to treat SULs compared with UAE.

METHODS

MEDLINE, EMBASE, Lilacs, and the Cochrane Central Register of Controlled Trials databases were searched from inception to February 2016. Ten randomized controlled trials comparing UAE versus hysterectomy, myomectomy, and laparoscopic occlusion of the uterine arteries in patients with SUL published in a peer-reviewed journal were included. Two reviewers independently selected studies, assessed quality, and extracted data. Discrepancies were resolved through consensus.

FINDINGS

Data from 986 patients submitted to UEA (n = 527) or surgery (n = 459) were analyzed. UAE had a lower risk of major complications (risk ratio [RR], 0.45 [95% CI, 0.22-0.95]; P = 0.04)and a higher risk of minor complications (RR, 1.65 [95% CI, 1.32-2.06]; P < 0.00001); UAE had a higher risk of re-intervention up to 2 years (RR, 3.74 [95% CI, 1.76-7.96]; P = 0.0006) and up to 5 years (RR, 5.01 [95% CI, 1.37-18.39]; P = 0.02); UAE had a similar risk of follicle-stimulating hormone levels >40 IU/L after 6 months (RR, 1.76 [95% CI, 0.24-12.95]; P = 0.58)and of recommending the procedure to another patient up to 5 years after treatment (RR, 1.00 [95% CI, 0.87-1.14]; P = 0.94). The indirect comparison between myomectomy and hysterectomy found that the 2 procedures were similar in the studied outcomes.

IMPLICATIONS

Compared with surgery, UAE had lower rates of major complications with an increased risk of re-intervention up to 2 and 5 years after the first procedure. UAE compared with surgery had a similar risk of ovarian failure and similar recommendation of the procedure to another patient. However, the number of trials was limited, and there was a high risk of bias in at least 2 domains. None of the trials blinded the participants and personnel or the outcome assessment. PROSPERO identifier: CRD42015026319.

Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

The influence of uterine artery embolisation on ovarian reserve, fertility, and pregnancy outcomes - a review of literature

Uterine fibroids are considered to be the most frequent female benign tumours. Fibroids affect mainly women of reproductive age. The most frequently reported signs and symptoms of fibroids include disturbances of the menstrual cycle such as heavy bleeding and painful menstruation, pelvic masses associated with pelvic pain, urinary problems or constipation, as well as infertility and recurrent pregnancy loss. The mainstay of fibroid treatment is still surgery. However, many patients seek alternative treatment options for fibroids, to preserve their uterus and fertility. One of the most important alternative treatment options for fibroids is uterine artery embolisation (UAE). However, there are some concerns that UAE may negatively influence ovarian function and even result in premature menopause. Moreover, the use of UAE in patients with future reproductive plans is still controversial, due to the possible pregnancy complications. The purpose of this review is to summarise the current knowledge regarding the possible influence of UAE on fertility, pregnancy outcome, and ovarian reserve.

The effects of uterine artery embolization on ovarian reserve

OBJECTIVE

To evaluate the effects of UAE for symptomatic uterine fibroids on ovarian reserve based on AMH.

STUDY DESIGN

This was a retrospective study conducted between March 2011 and October 2014. All women underwent UAE. At baseline and at the 3-month and 12-month follow-up visits, serum anti-Müllerian hormone (AMH), follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels were assessed, and ovarian volume and antral follicle count (AFC) were evaluated in each patient.

RESULTS

There were no statistically significant differences in serum E2, LH, or FSH levels or in ovarian volume 3 or 12 months after UAE (P=0.8194, P=0.3976, P=0.4766, and P=0.6822, respectively). However, AMH and AFC were significantly different 3 and 12 months after the procedure (P=0.00, P=0.029 and P=0.00, P=0.00, respectively). AMH levels remained low after 12 months of follow-up compared to the expected AMH levels. A statistically significant recovery of serum AMH at 12 months compared to at 3 months in those <40 years of age (P=0.00), but not in those ≥40 years (P=0.837).

CONCLUSIONS

Ovarian reserve appears to be affected by UAE in premenopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

Ovarian Changes After Abdominal Hysterectomy for Benign Conditions

OBJECTIVES

To investigate any change in the ovaries, including early follicular serum follicle-stimulating hormone (FSH) level, total ovarian volume, total antral follicle count, and ovarian stromal blood flow, in patients who had undergone abdominal hysterectomy for benign conditions.

METHODS

Fifteen women with abdominal hysterectomy and conservation of ovaries for benign conditions and who were between 29 and 44 years old were recruited to undergo three-dimensional ultrasound examination with power Doppler to assess total ovarian volume, total antral follicle count, and vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of ovarian stromal blood flow. Serum FSH, estradiol, and progesterone levels were checked on the same day. The results of the assessments were considered taken during the early follicular phase if the estradiol and progesterone levels were basal. Fifteen age-matched healthy women underwent the same assessments on the second day of menstruation.

RESULTS

Women with hysterectomy had significantly elevated serum FSH level and lower ovarian stromal blood flow indices, including VI, FI, and VFI, as compared with healthy women. The total antral follicle count and the total ovarian volume were similar between the two groups.

CONCLUSION

These changes may suggest altered ovarian function after hysterectomy.

Uterine Artery Embolization for Symptomatic Myomata

Fibroid disease is common and causes significant health problems in women of childbearing age. Over the past several years, uterine artery embolization (UAE) has emerged as a minimally invasive treatment for symptomatic uterine myomata. Embolotherapy is effective in relieving myoma-related symptoms in 80% to 90% of patients. It requires shorter hospitalizations than traditional surgical therapies for myoma disease and is associated with faster recovery and lower complication risks than surgery. Patient selection, the UAE procedure, and post-UAE management are reviewed.

Uterine artery embolization angiography and fertility related aspects

Purpose. Uterine artery embolization is a minimally invasive technique. It applies the principle of targeted anatomical structure devascularisation with utility in fibroid conservative therapy, including for future fertility preserving status. The objective of our paper represents a description and evaluation of angiography utility as a predictive method for fertility maintenance. Material and Methods. The angiography and ultrasound aspects obtained from a prospective study in which selected patients have undergone uterine artery embolization for fertility preservation are detailed. Results. The following angiography aspects have been detected: left- right shunt and utero-ovarian collaterals; these have been compared with the ultrasound aspects related to the fibroid evolution form a volumetric and Doppler ultrasound point of view. The angiographical description predicts the impact on post embolization fibroid evolution and upon fertility. An analysis is made in order to assess the way in which angiography can contribute to fertility alteration. Conclusions. The angiography aspects during embolization and the following ultrasound aspects can represent predictive factors as to fertility evolution after uterine artery embolization.

Uterine artery embolisation for uterine fibroids: Our experience at a tertiary care service hospital

BACKGROUND

Uterine artery embolisation (UAE) has evolved as a minimally invasive and effective alternative, treatment modality for women with symptomatic fibroids. We discuss our initial experience of UAE in the management of symptomatic fibroids.

METHODS

Twenty five symptomatic patients of uterine fibroids were treated with UAE by selectively cannulating and injecting poly vinyl alcohol particles into the uterine arteries. Post treatment follow up was done at 2 and 6 months respectively.

RESULTS

Pre-treatment, the sizes of fibroids were between 3.9 and 10.9 cm (mean 7.4) on ultrasonography. Of the total 25 patients, 49 uterine arteries were embolised with a technical success rate of 98%. Menorrhagia persisted in 7 patients, dysmenorrhea in 4 patients and pressure symptoms in 2 patients respectively in follow up study of six months which corresponds to a reduction in symptoms by 68% for menorrhagia, 71% for dysmenorhoea and 75% for those with pressure symptoms respectively. At 2 months follow-up post embolisation, the mean diameter of the fibroid was 4.03 cm (range 2-5.2 cm) and at 6 months 3.2 cm (range 1.3-4.1 cm), corresponding to size reduction of 45.5% and 57%, respectively. Follow up with ultrasonography at 2 and 6 months period showed successful fibroid reduction in 24 patients with corresponding reduction in the symptomatology. One patient remained symptomatic with increase in fibroid size and had to undergo hysterectomy.

CONCLUSION

Uterine artery embolisation can be considered as an alternative to hysterectomy in appropriately selected symptomatic patients of uterine fibroids.

ART and uterine pathology: how relevant is the maternal side for implantation?

BACKGROUND

Assisted reproduction technology (ART) has become a standard treatment for infertile couples. Increased success rates obtained over the years have resulted primarily from improved embryo quality, but implantation rates still remain lower than expected. The uterus, an important player in implantation, has been frequently neglected. While a number of uterine pathologies have been associated with decreased natural fertility, less information exists regarding the impact of these pathologies in ART. This report reviews the evidence to help clinicians advise ART patients.

METHODS

An electronic search of PubMed and EMBASE was performed to identify articles in the English, French or Spanish language published until May 2014 which addressed uterine pathology and ART. Data from natural conception were used only in the absence of data from ART. Studies were classified in decreasing categories: RCTs, prospective controlled trials, prospective non-controlled trials, retrospective studies and experimental studies. Studies included in lower categories were only used if insufficient evidence was available. Pooled data were obtained from systematic reviews with meta-analyses when available. The summary of the evidence for the different outcomes and the degree of the recommendation for interventions were based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) statement recommendations.

RESULTS

There is strong evidence that surrogacy is effective for uterine agenesia. For the remaining pathologies, however, there is very little evidence that the established treatments improve outcomes, or that these pathologies have a negative effect on ART. In the presence of an apparently normal uterus, assessing endometrial receptivity (ER) is the goal; however diagnostic tests are still under development.

CONCLUSIONS

The real effect of different uterine/endometrial integrity pathologies on ART is not known. Moreover, currently proposed treatments are not based on solid evidence, and little can be done to assess ER in normal or abnormal conditions. No strong recommendations can be given based on the published experience, bringing an urgent need for well-designed studies. In this context, we propose algorithms to study the uterus in ART.

Uterine artery embolization: pre- and post-procedural evaluation using magnetic resonance imaging

Magnetic resonance (MR) imaging has become the preferred method in assessing the uterus and pelvis prior to and following uterine artery embolization (UAE). The multiplanar imaging capabilities, increased spatial and contrast resolution, anatomic detail and assessment of fibroid viability that MR provides over ultrasound allows for accurate pre-treatment planning and post-treatment assessment. The purpose of this article is to demonstrate the use of MR in the selection of patients, anatomic evaluation and procedural planning before UAE, describe the use of MR in evaluating treatment response after UAE and illustrate the use of MR in identifying post-UAE complications. An understanding of these principles is essential in guiding appropriate therapy, determining treatment effectiveness and identifying associated complications before and after UAE.

A matched cohort study comparing the outcome of intrauterine adhesiolysis for Asherman's syndrome after uterine artery embolization or surgical trauma

STUDY OBJECTIVE

To compare the outcome of hysteroscopic adhesiolysis in women who had Asherman's syndrome after uterine artery embolization (UAE) with those who had Asherman's syndrome caused by surgical trauma.

DESIGN

A retrospective cohort study matched for age and intrauterine adhesion score (Canadian Task Force classification II-2).

SETTING

A tertiary hysteroscopic center in a teaching hospital.

PATIENTS

Nineteen women with Asherman's syndrome after UAE and 57 women with Asherman's syndrome caused by surgical trauma.

INTERVENTIONS

Hysteroscopic adhesiolysis was followed by a second-look hysteroscopy 1 month later. The scoring system proposed by the American Fertility Society was used to evaluate intrauterine adhesion during hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

In the UAE group, only 42.1% of women experienced improvement in menstruation defined as a subjective increase in menstrual flow after surgery, which was significantly lower than that of 86.0% observed in the non-UAE group. In the UAE group, the reduction of the American Fertility Society (AFS) score after intrauterine adhesiolysis was 30%, which was significantly lower than that of 80% in the non-UAE group. The pregnancy rate and live birth rate in the UAE group (5% and 0%, respectively) were significantly lower than the corresponding rates in the non-UAE group (33% and 25%, respectively).

CONCLUSION

The outcome of hysteroscopic adhesiolysis in women with Asherman's syndrome after UAE was worse than in women with Asherman's syndrome caused by surgical trauma.

Uterine fibroids: clinical manifestations and contemporary management

Uterine fibroids (leiomyomata) are extremely common lesions that are associated with detrimental effects including infertility and abnormal uterine bleeding. Fibroids cause molecular changes at the level of endometrium. Abnormal regulation of growth factors and cytokines in fibroid cells may contribute to negative endometrial effects. Understanding of fibroid biology has greatly increased over the last decade. Although the current armamentarium of Food and Drug Administration-approved medical therapies is limited, there are medications approved for use in heavy menstrual bleeding that can be used for the medical management of fibroids. Emergence of the role of growth factors in pathophysiology of fibroids has led researchers to develop novel therapeutics. Despite advances in medical therapies, surgical management remains a mainstay of fibroid treatment. Destruction of fibroids by interventional radiological procedures provides other effective treatments. Further experimental studies and clinical trials are required to determine which therapies will provide the greatest benefits to patients with fibroids.

Usefulness of pelvic artery embolization in cesarean section compared with vaginal delivery in 176 patients

PURPOSE

To evaluate the efficacy and safety of transcatheter arterial embolization of the pelvic arteries for the treatment of postpartum hemorrhage (PPH) associated with cesarean section compared with vaginal delivery.

MATERIALS AND METHODS

A retrospective analysis of 176 patients undergoing transcatheter arterial embolization of the pelvic arteries for PPH from January 2006 through August 2011 was conducted at two institutions. The mean patient age was 33.9 years (range, 24-46 years). Data including delivery details, hematology and coagulation results, embolization details, and clinical outcomes were collected. Technical success was defined as cessation of bleeding on angiography or angiographically successful embolization of the bleeding artery. Clinical success was defined as the obviation of repeated embolization or surgical intervention.

RESULTS

The technical success rate was 98.8% (n = 174), and the clinical success rate was 89.7% (n = 158). Among 176 patients, 71 had cesarean sections, and 105 underwent normal vaginal deliveries. Of the 105 patients who underwent normal vaginal deliveries, 11 (10.5%) required repeat embolization or surgical intervention. Of the 71 patients who had cesarean sections, 7 (9.8%) required repeat embolization or surgical intervention. The clinical success rate and complication rate were not related to the mode of delivery. All women resumed menses after transcatheter arterial embolization, and most (n = 125) described their menses as unchanged. Subsequent spontaneous pregnancies occurred in 13 women.

CONCLUSIONS

The cesarean mode of delivery is not a predictor of poorer outcomes of transcatheter arterial embolization; however, further study is needed to clarify this relationship.

Risks for donors in uterus transplantation

Uterus transplantation (UTx) is an alternative to gestational surrogacy and adoption for patients with absolute uterine infertility. Studies have been conducted in animals, and UTx is now within the reach of clinical application in humans. Procedures in humans have been published, but many medical, ethical, and social problems and risks of UTx require discussion prior to widespread clinical application, from the perspectives of donors, recipients, families, and newborns. In this article, we summarize the burdens and risks of UTx, with a focus on donors who provide the uterus.

Fertility after "only B-Lynch" suture: a case report and literature review

OBJECTIVE

A new fertility assessment after a B-Lynch suture without a concomitant uterine devascularization is proposed.

CASE REPORT

The case of a 37-year-old woman who experienced postpartum hemorrhage due to uterine atony during cesarean delivery of the previous pregnancy is reported. A B-Lynch brace suturing technique, not associated to any other hemostatic surgical procedure, was carried out. One year later and after an uncomplicated pregnancy of 39 weeks, the patient delivered a healthy infant by an elective cesarean section. Only omental adhesions were found on the anterior surface of the uterus as a consequence of the previous B-Lynch suture.

CONCLUSION

The B-Lynch hemostatic surgical procedure, alone, does not seem to have a negative impact on fertility. Additional clinical evidences in a greater case-series of patients are needed to assess the value of the method for fertility preservation.

Uterine Fibroid Embolisation - Potential Impact on Fertility and Pregnancy Outcome

The current standard therapy to treat myomas in women wishing to have children consists of minimally invasive surgical myomectomy. Uterine artery embolisation (UAE) has also been discussed as another minimally invasive treatment option to treat myomas. This review evaluates the literature of the past 10 years on fibroid embolisation and its impact on fertility and pregnancy. Potential problems associated with UAE such as radiation exposure of the ovaries, impairment of ovarian function and the impact on pregnancy and child birth are discussed in detail. Previously published reports of at least 337 pregnancies after UAE were evaluated. The review concludes that UAE to treat myomas can only be recommended in women with fertility problems due to myomas who refuse surgery or women with an unacceptably high surgical risk, because the evaluated case reports and studies show that UAE significantly increases the risk of spontaneous abortion; there is also evidence of pathologically increased levels for other obstetric outcome parameters. There are still very few prospective studies which provide sufficient evidence for a definitive statement on the impact of UAE therapy on fertility rates and pregnancy outcomes.

GnRH agonists: do they have a place in the modern management of fibroid disease?

In the management of women with fibroid disease, GnRH agonists (GnRHa) are frequently used to reduce volume and vascularity before myomectomy, apparently to render the operation easier and reduce operative blood loss, and to enable a transverse supra-pubic incision instead of a midline vertical one. They induce amenorrhoea and thus aid in the correction of pre-operative anaemia. Other gynaecologists use GnRHa to shrink sub mucous fibroids greater than 5 cm in diameter to facilitate access and reduce blood loss and operating time at transcervical resection. GnRHa are also occasionally used as a temporizing measure in women with symptomatic fibroids within the climacteric. We argue against the use of GnRHa in the management of fibroid disease because they are not cost effective, render myomectomy more difficult to apply because they destroy tissue planes, the more difficult enucleation in fact increasing rather than reducing peri-operative blood loss and operating time. When used before myomectomy, they increase the risk of 'recurrence' because they obscure smaller fibroids that 'recur' when the effects of the GnRHa wear off, and are associated with side effects in situations where they confer no benefits, or where alternative cheaper drugs with fewer side effects are available.

A case of placental polyp treated with an intraoperative injection of prostaglandin F2α followed by hysteroscopic resection

A 27-year-old woman had massive genital bleeding after an artificial abortion. Color Doppler ultrasonography showed a hypervascular mass. Hysteroscopy revealed a placental polyp. Serum hemoglobin level was decreased to 7.7 g/dl. Although uterine artery embolization (UAE) followed by hysteroscopic resection has been used for treatment of a placental polyp, UAE may not be an ideal option for patients with intent for future pregnancy because of the risk of ovarian function failure. This report presents a case of a placental polyp managed successfully with intracervical injection of prostaglandin F_2α, as an alternative UAE, followed by hysteroscopic resection.

Complications associated with uterine artery embolisation for fibroids

Uterine artery embolisation (UAE) is a relative newcomer to the mainstream treatment modalities available for fibroid-related problems. The efficacy of UAE is indisputable and has been shown to be comparable to hysterectomy in the short term in large-scale trials. Moreover, compared with hysterectomy, UAE is less invasive, carries a superior risk profile, and, importantly, preserves the uterus. UAE therefore offers patients symptom relief whilst at the same time retaining reproductive potential. Notably however, although women can have successful pregnancies following UAE, it is becoming increasingly evident that pregnancies after UAE are more risky especially during the early stages. Long-term outcome data from randomised trials involving UAE have very recently become available and show that whilst high satisfaction rates previously identified during early-stage followup are sustained, one notable drawback is a substantial risk of reintervention. It remains to be seen how this facet of UAE will impact on its future uptake.

Complications of uterine fibroid embolization

Uterine fibroid embolization (UFE) is an increasingly popular, minimally invasive treatment option for women with symptomatic fibroid disease. UFE therapy in qualified hands is an effective, well-tolerated procedure that offers relief of fibroid symptoms with a low risk of complications. In the acute postprocedural period, immediate complications may relate to vascular access, thromboembolic events, infection, and pain management. Reported major complications include but are not limited to pulmonary embolus, uterine ischemia, necrosis, sepsis, and death. Non-life-threatening complications include altered ovarian and sexual function, subcutaneous tissue necrosis, expulsion of fibroid tissue, and treatment failure. Awareness of the known complications of UFE may allow more rapid diagnosis and effective therapeutic responses to complications when they occur.