Hysteroscopy after uterine fibroid embolization in women of fertile age

Clinical investigation of fertility after uterine artery embolization combined with dilation and curettage(D&C) or D&C alone for cesarean scar pregnancies

Objective

The aim of this study was to compare the reproductive outcomes of patients with cesarean scar pregnancies (CSP) following uterine artery embolization (UAE) and dilation and curettage (D&C) treatments, and to evaluate the impact of UAE on fertility.

Materials

and methods: A retrospective case-control study was conducted. Patients diagnosed with CSP between 2019 and 2021 were included in the study. Clinical data and fertility outcomes were collected and reviewed retrospectively. Patients were divided into two groups based on their treatment option: the UAE combined with D&C group and the D&C alone group.

Results

A total of 91 CSP patients were enrolled in the study. Of these, 49 were treated with D&C, while 42 received UAE combined with D&C. The average gestational age in the UAE group was significantly longer than that in the D&C group. The average diameter of the gestational mass was significantly larger in the UAE group than in the D&C group (42.2 ± 19.8 mm vs 23.8 ± 15.9 mm). The other clinical features were not significantly different between the two groups. The average menstrual recovery time was 1.0 ± 0.20 months (range: 1-2 months) in the D&C group, and 2.0 ± 2.85 months (range: 1-18 months) in the UAE combined with D&C group, with a significant difference between the two groups. The average menstrual blood volume (MBV) decreased in 79 % of patients in the UAE group, compared to 18 % in the D&C group, with a significant difference between the two groups. There was no significant difference between the two groups in terms of pregnancy rate and birth rate (75 % vs 78 %, 63 % vs 56 %).

Conclusion

UAE combined with D&C is an efficient and safe treatment for CSP. Our study showed that decreased MBV and longer menstrual recovery time in UAE combined with D&C group, but there are no statistical difference in fertility outcomes between the two groups, which suggests probably a reversible impact on the reproductive function.

The Therapeutic Potential of Multipotent Mesenchymal Stromal Cell-Derived Extracellular Vesicles in Endometrial Regeneration

Disruption of endometrial regeneration, fibrosis formation, and intrauterine adhesions underlie the development of "thin" endometrium and/or Asherman's syndrome (AS) and are a common cause of infertility and a high risk for adverse obstetric outcomes. The methods used (surgical adhesiolysis, anti-adhesive agents, and hormonal therapy) do not allow restoration of the regenerative properties of the endometrium. The experience gained today with cell therapy using multipotent mesenchymal stromal cells (MMSCs) proves their high regenerative and proliferative properties in tissue damage. Their contribution to regenerative processes is still poorly understood. One of these mechanisms is based on the paracrine effects of MMSCs associated with the stimulation of cells of the microenvironment by secreting extracellular vesicles (EVs) into the extracellular space. EVs, whose source is MMSCs, are able to stimulate progenitor cells and stem cells in damaged tissues and exert cytoprotective, antiapoptotic, and angiogenic effects. This review described the regulatory mechanisms of endometrial regeneration, pathological conditions associated with a decrease in endometrial regeneration, and it presented the available data from studies on the effect of MMSCs and their EVs on endometrial repair processes, and the involvement of EVs in human reproductive processes at the level of implantation and embryogenesis.

Prevalence of intrauterine adhesions after myomectomy: a prospective multicenter observational study

OBJECTIVES

To evaluate intrauterine adhesion formation after laparoscopic and laparotomic myomectomy.

DESIGN

Prospective, multicenter, observational study (ClinicalTrials.gov ID: NCT04030273).

METHODS

We included patients after laparotomic and laparoscopic myomectomy. All patients underwent post-surgical diagnostic hysteroscopy, after three months. The intrauterine adhesion rate and associated factors were investigated.

RESULTS

Between January 2020 and December 2020, 38 and 24 consecutive patients underwent laparoscopic and laparotomic myomectomy, respectively. All diagnostic hysteroscopies were performed in the office setting without complications. Intrauterine adhesions were identified in 19.4% of women (95% CI of 9 - 29%). Factors univariately associated (p <0.2) with the presence of intrauterine adhesions after myomectomy were previous uterine surgery, the surgical approach (laparoscopic or laparotomic), the number of removed fibroids, the type and diameter of the largest myoma, and the opening of the uterine cavity. In the multivariable analysis, only the opening of the uterine cavity (OR 51.99; 95% CI, 4.53 - 596.28) and the laparotomic approach (OR, 16.19; 95% CI, 1.66 - 158.35) were independently associated with the identification of intrauterine adhesions after myomectomy.

LIMITATIONS

One of the main limitations of our study is that we used uterine manipulator only in laparoscopic group; in addition, we did not perform a pre-operative hysteroscopy to evaluate the rate of intrauterine adhesions potentially present even before the myomectomy.

CONCLUSIONS

The prevalence of intrauterine adhesions after three months from surgery was significantly associated with the opening of the uterine cavity and the laparotomic approach.

Mini-Review of the New Therapeutic Possibilities in Asherman Syndrome-Where Are We after One Hundred and Twenty-Six Years?

Asherman syndrome is a multifaceted condition describing the partial or complete removal of the uterine cavity and/or cervical canal. It is a highly debatable topic because of its pronounced influence on both reproductive outcomes and gynaecologic symptoms. The latest reports demonstrated that trauma to the endometrium is the main cause of intrauterine adhesion formation. Left untreated, such adhesions gradually lead to a range of repercussions ranging from mild to severe. Considering the lack of non-invasive approaches, the advent of hysteroscopy has revolutionized the entire field, being otherwise considered the most efficient tool offering new directions and amplifying the chances of treating the Asherman syndrome.

Asherman syndrome in adenomyosis treated with uterine artery embolization: incidence predictive factors

PURPOSE

To investigate Asherman syndrome (AS) related to potential factors during uterine artery embolization (UAE) treatment of adenomyosis.

MATERIALS AND METHODS

This is a retrospective analysis of 195 women with adenomyosis who underwent UAE treatment from 2009 to 2016. All preoperative and intraoperative risk-related potential factors of AS were recorded. And AS events were carefully monitored during follow-up (range, 0-15 months). Potential risk-related factors of AS events were determined via univariate and multivariate logistic regression analyses.

RESULTS

The rate of AS events after UAE for adenomyosis was 12.82% (25/195). The univariate and multivariate analyses revealed the association of low vascularity with a significant risk for AS (P = 0.019).

CONCLUSION

Patients with low vascularity of adenomyosis at the time of UAE are more likely to have AS. And adenomyosis patients with low vascularity should be carefully selected to undergo UAE treatment.

Predicting the Fibroid-Migratory Impact of UAE: Role of Pre-embolization MRI Characteristics

Aim

To investigate potential factors on MR imaging that could be used to predict migration of uterine fibroids post-UAE.

Methods and Materials

We retrospectively reviewed patients referred for UAE having pre-procedural and 6 months post-procedural MRI, at a tertiary centre, over a 1-year period. Pre- and post-UAE images were reviewed in 64 women by two radiologists to identify the sub-type, dimensions, and infarction rate of each dominant fibroid. The shortest distance between the fibroid and the endometrial wall was measured to determine intramural fibroid movement. Paired sample T tests and two-sample T tests were used to compare between pre- and post-embolization variations and between migrated and non-migrated intramural fibroids, respectively. After preliminary results suggested potential predictors of intramural fibroids migration, we tested our findings against the non-dominant intramural fibroids in the same patients.

Results

Review of images revealed 35 dominant intramural fibroids, of which eight migrated to become submucosal fibroids, while five were either partially or completely expelled. These 13 migrated fibroids had a shorter pre-procedural minimum endometrial distance (range 1–2.4 mm) and greater maximum fibroid diameter (range 5.1–18.1 cm), when compared to non-migrating fibroids. On image reassessment, the migrated non-dominant intramural fibroids had a minimum endometrial distance and maximum fibroid diameter within the same range.

Conclusion

Intramural fibroids with a minimum endometrial distance less than 2.4 mm and a maximum fibroid diameter greater than 5.1 cm have a high likelihood of migrating towards the endometrial cavity after UAE.

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.

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.

Effect of myomectomy on endometrial cavity: A prospective study of 51 cases

CONTEXT

Fibroids are the most common tumors of the uterine cavity. Most of them are diagnosed during the reproductive age when the fertility is an important concern for the female. However, complications can occur after removal of fibroid (myomectomy) too for future pregnancy. Though myomectomy has been sighted as a cause of intrauterine adhesions data regarding the effect of myomectomy on endometrial cavity is lacking.

AIMS

Evaluate the incidence of intrauterine adhesion formation after myomectomy and to identify the associated factors.

MATERIALS AND METHODS

In this prospective observational study, hysteroscopy was done in 51 infertile patients who had undergone myomectomy 3 months before in a tertiary care center from 2012 to 2015. The presence of intrauterine adhesions noted on hysteroscopy was investigated on the basis of size, number, location and type of fibroid removed, along with intraoperative breach of the uterine cavity.

STATISTICAL ANALYSIS

Chi-square test was used for the calculating significant difference in frequency of discrete variables in two groups. P < 0.05 was considered significant.

RESULTS

Intrauterine adhesions were seen in 11 out of 51 (21.57%) cases. No significant relationship between intrauterine adhesions and type, size or number of fibroid was observed. No statistical difference in the rate of adhesion formation was seen irrespective of breach of the uterine cavity during myomectomy.

CONCLUSION

Intrauterine adhesion formation after myomectomy is not related to the type of surgery or the nature of fibroid. However, in all cases desiring fertility postoperative hysteroscopy is highly recommended to diagnose and treat these adhesions early.

Intrauterine adhesions after open myomectomy: an audit

OBJECTIVE

To estimate the incidence of intrauterine adhesions after open myomectomy.

STUDY DESIGN

A prospective audit descriptive study was conducted involving thirty-six women who had undergone open myomectomy for symptomatic fibroids at a large undergraduate teaching hospital. A follow-up out-patient hysteroscopy was performed three months after surgery.

RESULTS

At hysteroscopy, eighteen patients (50%) were found to have mild to moderate intrauterine adhesions. The number of fibroids removed was significantly higher in patient who developed adhesions (median value 22 versus 9.5, p<0.05). Pre-operative GnRHa therapy, uterine size, opening of the uterine cavity during surgery, specimen weight, estimated blood loss, post-operative bleeding or pyrexia were similar whether or not adhesions were found.

CONCLUSION

Open myomectomy represents an important but currently underappreciated aetiological factor in the formation of intrauterine adhesions.

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.

High-Intensity Focused Ultrasound Ablation of Uterine Fibroids - Potential Impact on Fertility and Pregnancy Outcome

Laparoscopic myomectomy is regarded as the gold standard for women with symptomatic fibroids who wish to become pregnant. High-intensity focused ultrasound (HIFU or MRgFUS) ablation of uterine fibroids is also being discussed as a non-surgical, minimally invasive, therapeutic option. This review examines the available data on the impact of HIFU/MRgFUS on fertility and pregnancy, focusing particularly on potential direct side-effects of this type of intervention on ovaries, fallopian tubes and uterus and potential late effects on pregnancy and birth, based on the current literature. All pregnancies after HIFU/MRgFUS published to date (around 100 cases) were evaluated. The published case series suggest that HIFU/MRgFUS ablation has no impact on the rate of miscarriages or other obstetrical outcome parameters. Because no prospective studies exist which permit firm conclusions to be drawn on the impact of HIFU/MRgFUS on fertility and pregnancy outcome in women with symptomatic fibroids, this approach is currently only recommended for women with suspected fertility problems due to uterine fibroids who either decline surgery or who have an unacceptably high surgical risk.

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.

Uterine artery embolization complicated by uterine perforation at the site of previous myomectomy

A 46-year-old woman had an unusual complication from uterine myoma embolization by development of extensive necrosis with subsequent uterine perforation at the location of a previous myomectomy. We suggest that a scarred uterus may be a risk factor for uterine fibroid embolization complications, such as uterine necrosis.

Is myomectomy always the best choice for infertile women with symptomatic uterine fibroids?

Uterine artery embolization (UAE) is still regarded by most gynaecologists as contraindicated for women with symptomatic fibroids and otherwise unexplained infertility. For such patients, myomectomy is the usual option. We performed UAE as treatment of menorrhagia in an infertile woman with multiple subserosal and intramural fibroids who had previously failed multiple myomectomy. UAE resulted in durable symptom relief and substantial reduction of the uterine and fibroid size. The patient conceived spontaneously 20 months after UAE and progressed through pregnancy uneventfully. At 38 weeks of gestation, she underwent elective cesarean section and delivered a normal, healthy, 3180-g fetus without complications. The present case demonstrates that in symptomatic women with multiple subserosal and intramural fibroids and otherwise unexplained infertility, UAE may have symptomatic and reproductive outcomes superior to those of myomectomy.

Hysteroscopy after uterine fibroid embolization: evaluation of intrauterine findings in 127 patients

AIM

Several atypical hysteroscopy findings have been described in association with uterine artery embolization (UAE). The purpose of this study was to evaluate the types and frequency of these findings in the largest published series of patients.

MATERIAL AND METHODS

Premenopausal patients after bilateral UAE for symptomatic intramural fibroid underwent subsequent hysteroscopic examination 3-9 months following UAE. The uterine cavity was examined with focus on specific post-embolization changes. Biopsy of endometrium was obtained and evaluated together with a biopsy of abnormal foci if present.

RESULTS

UAE was performed in a total of 127 women with an average size of dominant fibroid 63.1 mm in diameter and an average patient age of 35.1 years. Even though the majority of patients were asymptomatic at the time of hysteroscopy (78.0%), the post-embolization hysteroscopic examination was normal in only 51 patients (40.2%). The most frequent abnormalities included tissue necrosis (52 women, 40.9%), intracavitary myoma protrusion (45 women, 35.4%), endometrium 'spots' (22.1%), intrauterine synechiae (10.2%) and 'fistula' between the uterine cavity and intramural fibroid (6.3%). Histopathological examination showed normal, secretory or proliferative endometrium in 83.5% patients. Necrosis and/or hyalinization prevailed in the results of biopsy of abnormal loci (45 cases, 35.4%).

CONCLUSION

Frequency of abnormal hysteroscopic findings several months after UAE for primary intramural myomas is high. Alarmingly high is the percentage of patients with a histopathologically verified necrosis. Performing hysteroscopy in selected patients after UAE is necessary before eventual surgical re-intervention, especially in women with reproductive plans.

Intrauterine Adhesions following Conservative Treatment of Uterine Fibroids

Uterine fibroids are common in women of reproductive age and various conservative treatments are available. In order to achieve a successful conservative treatment of fibroids, functional integrity of the uterus is as important as tumor removal or symptoms relief. In this context, intrauterine adhesions must be recognized as a possible complication of conservative management of uterine fibroids, but diagnostic pitfalls might justify an underestimation of their incidence. Hysteroscopic myomectomy can cause adhesions as a result of surgical trauma to the endometrium. The average reported incidence is around 10% at second-look hysteroscopy, but it is higher in certain conditions, such as the case of multiple, apposing fibroids. Transmural myomectomies also have the potential for adhesion, especially when combined with uterine ischemia. Uterine arteries embolization also carries a risk of intracavitary adhesions. Prevention strategies including bipolar resection, barrier gel or postoperative estradiol, might be useful, but stronger evidence is needed. In view of current knowledge, we would recommend a prevention strategy based on a combination of surgical trauma minimization and identification of high-risk cases. Early hysteroscopic diagnosis and lysis possibly represents the best means of secondary prevention and treatment of postoperative intrauterine adhesions.

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.

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.

Early results of magnetic resonance-guided focused ultrasound surgery of adenomyosis: analysis of 20 cases

STUDY OBJECTIVE

To evaluate the thermal ablative effects of magnetic resonance-(MR) guided focused ultrasound surgery (MRgFUS) on adenomyosis and to assess improvement in clinical parameters.

DESIGN

Twenty patients with adenomyosis were treated with MRgFUS. Extensive adenomyosis (6 cases) was treated with 2 applications. Uterine volume was evaluated by MR imaging before and immediately after MRgFUS. Ablation of adenomyosis and the architecture of nonperfused areas were evaluated immediately after MRgFUS. Improvement in patient symptoms was assessed through the symptom severity score questionnaire (Canadian Task Force classification II-3).

SETTING

Department of gynecology at a Japanese general hospital.

PATIENTS

Premenopausal women at least 18 years of age with symptomatic adenomyosis.

INTERVENTIONS

Thermal ablation by MRgFUS.

MEASUREMENTS AND MAIN RESULTS

We classified the nonperfused lesions on contrast-enhanced MR images immediately after MRgFUS into 3 types: lesions with round margins (type R), serrated margins (type S), and honeycomb architecture (type H). Type R was the most common (16/20 patients). Most adenomyosis lesions could be sufficiently ablated close to the serosal surface or to the endometrium by MRgFUS. The mean uterine volume 6 months after therapy was decreased by 12.7%. Symptom severity score improved significantly during 6 months of follow-up. No serious complications were observed.

CONCLUSION

These early results indicate the safe and effective ablation of adenomyosis tissue by MRgFUS. The procedure also resulted in the improvement in clinical symptoms during the 6 months of follow-up.

[Pregnancy after uterine-artery embolization for symptomatic fibroids: a case of placenta accreta with uterine rupture]

The evolution of pregnancies following uterine-artery embolisation (UAE) for symptomatic fibroids remains uncertain. We report a case of pregnancy after UAE, complicated of adherent placenta with uterine rupture, in a context of uterine leiomyomata with a prior cesarean delivery. Through a recent review of the literature, we discuss the main obstetrical complications following UAE. Appropriate management of these high-risk pregnancies, notably in case of risk of adherent placenta, seems to be necessary.