Keywords
fibroid - uterus - embolization - menorrhagia - interventional radiology
Objectives: Upon completion of this article, the reader will be able to describe the current
state of uterine artery embolization in the treatment of fibroids, including patient
selection, technical approaches, and clinical outcomes.
Uterine fibroids (leiomyomas) are the most common benign neoplasm of the female pelvis
and have a lifetime prevalence exceeding 80% among African American women and approaching
70% among Caucasian women.[1] Approximately 50% of women with fibroids experience symptoms which may include menorrhagia
that may result in anemia, bulk symptoms with bladder and bowel dysfunction and abdominal
protrusion, dysmenorrhea, and infertility.[2] Hysterectomy remains the most common treatment option for fibroids and concerns
have been raised about the overuse of this procedure.[3]
First reported in 1995 by Ravina et al,[4] uterine artery embolization (UAE) is now a well-established uterine preserving and
minimally invasive therapy for symptomatic fibroids. Since its introduction, strong
evidence for safety and efficacy of UAE has been generated with low rates of complications.[5] This review will discuss UAE for the management of symptomatic uterine fibroids
with special focus on emerging technical approaches and novel periprocedural patient
care.
Patient Selection
The majority of patients with symptomatic uterine fibroids who are candidates for
myomectomy or hysterectomy are also candidates for UAE. The interventional radiologist
can best determine if UAE is a recommended treatment option for a patient. However,
the decision to recommend UAE should not be made in isolation, but in collaboration
with a gynecologist who has already discussed the various medical and surgical options
with the patient.[6]
Most interventional radiologists prefer to see a patient for a clinic consultation
prior to UAE to determine whether she is a candidate for the procedure. During the
clinic visit, the interventional radiologist will review the patient's history, including
her symptoms, age, prior fibroid therapies, patient's preference regarding uterine
sparing therapy, desire for future pregnancy, assess patient's risks for the procedure,
and make a recommendation as to whether she is a candidate for UAE.[6]
The most common indications for UAE include heavy or prolonged menstrual bleeding
(menorrhagia); severe menstrual cramping (dysmenorrhea); pelvic pressure, discomfort,
excessive bloating, fullness, or bothersome abdominal wall distortion; pelvic pain;
pain during intercourse (dyspareunia); and urinary urgency, frequency, nocturia, or
retention.[7]
Absolute contraindications for UAE include viable pregnancy, active infection, and
suspected uterine, cervical, or adnexal malignancy. While not contraindications, there
are some conditions including severe contrast agent allergy, renal impairment, and
coagulopathy, which require special caution, but all of which can often be ameliorated
with appropriate management.[7]
Review of recent fibroid imaging is extremely important prior to proceeding with UAE.
While most patients with fibroids will likely have a pelvic ultrasound (US), a contrast-enhanced
magnetic resonance imaging (MRI) has been shown to be more accurate than US for characterizing
uterine fibroids.[8] As a result, MRI has become the preferred method of assessing the uterus and pelvis
prior to UAE as it evaluates for fibroid location, enhancement characteristics, and
the presence of ovarian artery (OA) supply to the fibroid, in addition to determining
other uterine pathologies which may mimic fibroid symptoms such as adenomyosis.[9] It may also help detect leiomyosarcoma if characteristic imaging parameters are
present, as discussed in a subsequent section below.
Uterine Artery Embolization and Adenomyosis
Adenomyosis is characterized by the diffuse or local growth of endometrial tissue
within the muscular layer of the uterus and has a prevalence of 5 to 70% among women
between 30 and 50 years of age.[10] This disease predominately affects the posterior uterine wall and can result in
diffuse uterine enlargement, widening of the junctional zone, and often coexists with
fibroids.[11] The symptoms of adenomyosis are similar to that of fibroids and include menorrhagia,
dysmenorrhea, and bulk-related symptoms such as pelvic pressure or urinary frequency.[12]
The presence of adenomyosis is not a contraindication to UAE. In fact, UAE has been
shown to result in clinical and symptomatic improvement for patients with isolated
adenomyosis. Long-term symptomatic relief may range from 64.5 to 82.4%.[7]
[10]
[12] In a subgroup of patients with adenomyosis and uterine fibroids, 82.4% of patients
reported symptom improvement at 34.2-month follow-up.[11]
UAE outcomes for adenomyosis are variable and depend on the extent and vascularity
of the adenomyosis, the degree of necrosis following UAE, and the presence and absence
of fibroids.[6]
[10] Better outcomes have been demonstrated in cases of adenomyosis with lower signal
intensity on T2-weighted imaging, focal areas of adenomyosis, and use of smaller particle
size for embolization.[2] While prospective, randomized trials evaluating the role of UAE for adenomyosis
are warranted, the current literature demonstrates durable symptom improvement in
patients with adenomyosis following UAE.
Uterine Artery Embolization and Intrauterine Device
An intrauterine device (IUD) is one of the most widely used methods of long-acting
reversible contraception.[13] The presence of an IUD may be considered a risk factor for postprocedural infection
and some physicians may prefer to remove the IUD prior to UAE. The combination of
a foreign body within the uterine cavity and necrotic fibroid tissue following UAE
was thought to increase the rate of infection for some time.[14] However, in large follow-up studies of women with IUDs, the risk of pelvic inflammatory
disease attributed to the IUD is less than 1 in 1,300.[14] In addition, in a study of 20 women with IUDs undergoing UAE, Smeets et al[14] did not demonstrate any infectious complications after a mean follow-up of 20.5
months. The presence of an IUD should therefore not be a contraindication to UAE.
Leiomyosarcoma
Uterine leiomyosarcomas are extremely rare, comprising 1.3% of all uterine malignancies.
Less than 1% of women with uterine fibroids have leiomyosarcoma[15] and the presumed incidence of an occult malignancy in a patient undergoing surgery
or UAE is approximately 1 in 350 to 1,000 or less.[2]
Leiomyosarcoma can occur spontaneously or through malignant transformation of a preexisting
uterine fibroid, mostly in postmenopausal women in the fifth decade.[16] Clinical symptoms are similar to that of fibroids and include irregular vaginal
bleeding, abdominal pain, and palpable mass.[15]
On MRI, uterine leiomyosarcoma is a solid mass with irregular (not round), well-delineated
margins in an enlarged uterus. On T2-weighted imaging, the mass displays intermediate-to-high
signal intensity with bright signal on T1-weighted imaging, representing hemorrhagic
changes. On diffusion-weighted imaging, leiomyosarcoma demonstrates restricted diffusion
with hyperintensity at high b value and a low ADC value. There is also heterogeneous
enhancement and signal voids due to foci of calcification.[15] Given the overlap in imaging features between leiomyosarcoma and fibroids, comparison
to prior imaging is extremely important. A rapidly growing fibroid, specifically a
fibroid that has doubled in size within 3 to 6 months, should raise concern for possibility
of sarcoma. However, only approximately 0.27 to 2.6% of patients with a rapidly growing
uterus have been shown to have leiomyosarcoma.[15] Lastly, serum levels of lactate dehydrogenase (LDH) and LDH isozyme are usually
elevated in patients with uterine sarcomas.[16]
No morphological or functional criterion in imaging can discriminate between a degenerating
fibroid and a uterine leiomyosarcoma. Therefore, transcervical image-guided biopsy
may be considered as a problem-solving tool in cases of atypical imaging and careful
follow-up of such patients treated with UAE may be indicated to diagnose this extremely
rare malignancy.[16]
Uterine Artery Embolization in Postmenopausal Women
Uterine fibroids are thought to be hormonally responsive and typically regress after
menopause.[1]
[17] However, a subset of postmenopausal women continues to have symptomatic uterine
fibroids. Hormone replacement therapy and obesity have been linked to persistent or
new fibroid symptoms in the postmenopausal state.[17]
[18]
UAE for the treatment of bulk symptoms in postmenopausal women has been shown to be
safe and effective, resulting in 88.8 to 92% symptom improvement.[17]
[18] Fibroid-related bleeding in the postmenopausal state may also occur. However, in
this setting, prompt evaluation for underlying malignancy or endometrial hyperplasia
should be considered through an endometrial biopsy prior to proceeding with UAE.[1] In carefully selected postmenopausal women with symptomatic uterine fibroids, UAE
is a viable treatment option.
Uterine Artery Embolization for Large Fibroids
For some time, UAE was not recommended for patients with fibroids greater than 10
cm, especially those located in the submucosal area and in women with uterine size
greater than 24 weeks.[19] The reasoning behind this was from a few case reports where UAE in patients with
large fibroid size and submucosal location resulted in infection, uterine injury,
sepsis, and death.[19] However, in the more recent years, several reports have demonstrated the safety
and efficacy of UAE in fibroids larger than 10 cm.[19]
[20]
[21] In fact, the safety and efficacy of UAE has also been demonstrated in patients with
a “megauterus,” measuring greater than 1,600 mL in volume.[2]
Gonadotropin-Releasing Hormone Agonists Prior to Uterine Artery Embolization
Gonadotropin-releasing hormone (GnRH) agonists may be used for short-term preoperative
treatment of uterine fibroids. Fibroid volume reduction (30–50%) and symptom improvement
is typically observed after GnRH agonist therapy for 3 to 6 months.[22] Due to the hypoestrogenic state, patients often experience menopausal symptoms such
as hot flashes, vaginal dryness, mood changes, and reduced bone density.[22] Following cessation of GnRH agonist therapy, fibroids typically regrow within 3
months and symptoms recur.
Treatment with GnRH agonist may cause a decrease in uterine vasculature which may
compromise the efficacy of UAE.[23] Prior reports have described deferring UAE for at least 3 months to allow for the
uterine arteries (UAs) to return to their normal caliber.[23]
[24] Kim et al[25] used GnRH agonist therapy for patients with large fibroids (>10 cm) and performed
UAE once the fibroid diameter had decreased to 8 cm. The authors demonstrated pre-UAE
GnRH agonist therapy of large fibroids was safe and did not compromise the UAE procedure.
Further studies are required to determine the effects of GnRH agonist therapy on the
uterine vasculature and whether simultaneous UAE can be performed without compromising
clinical efficacy.
Uterine Artery Embolization for Pedunculated Subserosal Fibroids
The presence of pedunculated subserosal fibroids, particularly those with an attachment
less than 50% of the diameter of the fibroid, had once been a relative contraindication
for UAE. This was due to the theoretical risk of stalk necrosis with fibroid detachment
from the uterus resulting in bowel or peritoneal inflammation requiring surgical intervention.[26] Katsumori et al[27] demonstrated that UAE can be safe and effective for patients with pedunculated subserosal
fibroids with a stalk diameter of 2 cm or greater. Margau et al[28] reaffirmed the safety and efficacy of UAE in patients with pedunculated subserosal
fibroids, including patients with stalk diameters less than 2 cm. Finally, Smeets
et al[29] demonstrated that UAE was safe and effective in the treatment of patients with pedunculated
subserosal fibroids with stalk diameters ranging from 1.6 to 5.2 cm. The authors did
not have any complications attributed to the pedunculated nature of the fibroid in
long-term follow-up of 33 months. In fact, the authors illustrated that the vascularity
of the fibroid stalk remained unchanged and unaffected by the UAE in all patients
who underwent postprocedural MRI. Based on the current evidence, pedunculated subserosal
fibroids are not a contraindication for UAE.
That said, Lacayo et al[30] demonstrated that regardless of the embolic material used, pedunculated serosal
fibroids were less likely to infarct than those deeper in the uterus (pedunculated
serosal fibroids had an odds ratio for complete infarction of 0.24 [p = 0.01]). Therefore, while the embolization of pedunculated fibroids may be safe,
the chance of successful treatment may be less compared with fibroids in other uterine
locations.
Technical Aspects
Access
UAE is traditionally performed with moderate sedation via a right common femoral artery
approach with embolization of bilateral UAs.[6] While most patients with fibroids have bilateral UA supply, a small subset does
present with unilateral disease and can benefit from unilateral UAE. Stall et al[31] demonstrated that unilateral UAE in appropriately selected patients who have isolated
unilateral UA supply to the entire fibroid has similar results when compared with
bilateral UAE. In addition, the authors demonstrated that unilateral UAE is associated
with reduced fluoroscopy time and postprocedural pain.
Bilateral femoral artery access with simultaneous angiography and embolization is
an alternative technique which has been shown to reduce procedural and fluoroscopy
time with no increase in complications.[32] More recently, transradial access (TRA) has gained popularity for UAE with the apparent
advantage of allowing patients to move freely following the procedure to assume the
most comfortable position.
Resnick et al[33] demonstrated that TRA UAE is safe and feasible with patent radial artery at 1-month
follow-up evaluation in all patients. While the technique of left TRA access has been
previously described,[34] some technical modifications for UAE are important to recognize prior to the procedure.
The left radial artery is accessed for subdiaphragmatic interventions and because
of the longer distance to the UAs from the wrist, an exchange length guidewire and
a longer catheter, such as a 4-Fr 120-cm Glidecath (Terumo, Somerset, NJ) should be
used to access the internal iliac arteries.[33] Conventional microcatheters such as the Renegade Hi-Flo (Boston Scientific, Natick,
MA) or Progreat (Terumo) can still be used to catheterize the UAs. In cases of OA
supply to the fibroid, the Sarah Radial catheter (Terumo) may be used for OA catheterization
(Aaron M. Fischman, personal communication, April 2017).
Embolic Agents and Endpoints
In the United States and Europe, particulate material is the most common embolic agent
used for UAE. Several embolic agents are approved by the Food and Drug Administration
(FDA) for UAE, including tris-acryl gelatin microspheres (TAGM; Embospheres, Merit,
South Jordan, UT) and nonspherical polyvinyl alcohol (PVA) particles (various manufactures).
Spherical PVA which was developed in response to the extensive size variations of
nonspherical PVA and its tendency to clump the catheter was shown in numerous studies
to be less effective in fibroid necrosis and symptom improvement when compared with
TAGM.[35] Gelatin sponge is also an effective agent for UAE and widely used in Asia; however,
the inconsistent particle size due to its hand-preparation poses difficulties in quantitative
comparisons with the other available agents.[35]
Acrylamido polyvinyl alcohol microspheres (a-PVAM; Bead Block, BTG, West Conshohocken,
PA) are calibrated particles, which is FDA approved for UAE. Prior studies have demonstrated
reduced rates of fibroid infarction when using 500 to 700 μm particles.[36]
[37] In a prospective, randomized control trial, Worthington-Kirsch et al[38] showed that 700 to 900 μm a-PVAM was not inferior to TAGM as an embolic agent for
UAE.
Polyzene F–coated microsphere (Embozene, Boston Scientific) is the most recent addition
of embolic agents for UAE. This agent consists of a hydrogel core of polymethylmethacrylate
and a flexible shell of polyphosphazene which is a synthesized inorganic biostable
and biocompatible polymer.[39] The microspheres are also sieved to a high uniformity with narrow size range, are
color-coded, and available in sizes ranging from 40 to 1,300 μm. This agent has been
shown to be safe and effective in single-arm trials.[39]
[40] A prospective, randomized control trial comparing Polyzene F–coated microspheres
to TAGM for UAE is currently underway (ClinicalTrials.gov Identifier: NCT02884960).
Regardless of the particle choice, the goal of embolization is to occlude the vessels
supplying the fibroid leaving the UA patent yet with slow flow, typically near stasis.[6] The angiographic endpoint of near stasis is the sluggish flow in the main UA with
a persistent column of contrast through five heartbeats.
Aberrant Vascular Supply
Utero-ovarian anastomoses (UOA) have been considered the cause of treatment failure
after UAE and also contributing to the few cases of permanent amenorrhea and ovarian
dysfunction following UAE. Razavi et al[41] described three types of OA to UA anastomoses. In type I anastomosis, the OA supplies
the fibroid through anastomoses with the intramural UA. In type II, the OA supplies
the fibroid directly. In type III, the OA supply appears to be from the UA. The importance
of recognizing these patterns is the contribution of the OA to the fibroid arterial
supply and the potential effect of UAE on the OA supply. However, it should be noted
that nonvisualization of such UOA does not exclude small underlying connections. Therefore,
recognition of the particular type of UOA is important in identifying the potential
for nontarget ovarian embolization and instances of possible clinical failure following
UAE.
Despite the concern, there is little definitive evidence that any particular type
of UOA is linked to ovarian failure. For example, in one series, Lanciego et al[42] performed UAE in the setting of varying types of UOA. The authors concluded that
the recurrence rates, clinical failure, and amenorrhea after UAE did not seem to be
influenced by UOA. Other factors such as patient's age may be more important to ovarian
function. There is even evidence that direct embolization of the OAs in cases where
fibroids are supplied by those vessels may not impact ovarian function clinically.
Hu et al[43] reviewed the impact of OA embolization in addition to UAE on subsequent ovarian
function. The authors concluded that compared with standard UAE, the addition of OA
embolization did not precipitate the onset of menopause or increase menopausal symptom
severity. These data contradict the commonly held belief that OA embolization is associated
with ovarian failure.
The recurrence rate after UAE is approximately 20 to 28%.[43] Collateral supply from the OA to the fibroid can explain some of these cases of
recurrence. Therefore, it is imperative to perform an aortogram or have a good-quality
preprocedural MRI/MRA to evaluate for OA supply to the fibroid. In cases of dominant
OA supply, the OA can be catheterized and embolized with particulate agents in a similar
fashion to UAE.
Addition aberrant arterial supply to the fibroid may arise from the inferior mesenteric
artery, the round ligament artery, and the internal pudendal artery.[44]
[45] In patients with an absent or diminutive UA, or in cases of prior pelvic surgery
or fundal fibroids, close attention to other sources of arterial supply must be given
to enhance the clinical success of UAE.
Periprocedural Pain Management
Periprocedural Pain Management
Superior Hypogastric Nerve Block
One of the main challenges of UAE is the management of postprocedural pain. While
70% of women have no pain during the actual procedure, greater than 90% of women report
pain after UAE.[46] The likely culprit for the pain in the immediate postprocedural setting is the ischemia
caused by the embolization process. This immediate postprocedural pain is different
from the postembolization pain which includes pain, fever, and fatigue for up to 72
hours, and is caused by the inflammatory reaction to the embolization.
Superior hypogastric nerve block (SHNB) is a technique which aims to reduce the ischemic
pain following UAE. In this technique, the entry site on the anterior abdomen is selected,
typically 2 to 5 cm below the umbilicus.[46] The skin is prepped and draped and following local anesthesia, a 21-gauge needle
is advanced under fluoroscopic guidance with a clamp to the anterior portion of the
fifth lumbar vertebral body. For optimal guidance, a cranio-caudal tilt of 5 to 15
degrees can be used. A catheter can be placed in the left common iliac artery from
the right transfemoral approach to delineate the bifurcation of the abdominal aorta
so the 21-gauge needle does not inadvertently penetrate through the aortic bifurcation.
Once the bony prominence is reached and confirmed on lateral view, a small amount
of dilute contrast (2–5 mL) is injected, which will opacify a crescent-shaped area
anterior to the vertebral body. If an unfavorable distribution is seen, the needle
should be repositioned. Following proper positioning, 10 m of 0.75% ropivacaine (Naropin,
AstraZeneca) is injected and the needle is withdrawn. Binkert et al[46] demonstrated that SHNB is a safe and minimally time-consuming way to reduce post-UAE
pain and opiate use, especially within the first 4 hours.
In a prospective, randomized controlled double-blinded trial comparing SHNB to placebo,
Yoon et al[47] demonstrated that SHNB resulted in reduced opioid analgesia and antiemetic use in
the immediate post-UAE period. However, no significant difference was noted in reduction
of hospital admission rate or duration of hospital stay following UAE.
Pre–Uterine Artery Embolization Steroid Administration
Following UAE, a substantial inflammatory process manifests resulting in the postembolization
syndrome consisting of pain, low-grade fevers, nausea, vomiting, and malaise. In a
prospective, randomized control trial, Kim et al[48] demonstrated that the administration of a single-dose intravenous dexamethasone
prior to UAE was effective in reducing inflammation and pain during the first 24 hours
following the procedure. In this trial, the patients in the steroid arm received 10 mg
of intravenous dexamethasone 1 hour prior to the UAE. The authors demonstrated that
while the opiate use was not different between the control and the dexamethasone groups,
the pain scores and the incidence of nausea and vomiting were lower in the group of
patients who had received dexamethasone. In addition, compared with the placebo group,
the patients who received dexamethasone had significantly lower elevations of inflammatory
makers such as C-reactive protein, interleukin-6, and cortisol during the first 24
hours following the UAE. While additional studies may be needed to evaluate the utility
of dexamethasone prior to UAE, its administration may be beneficial in reducing inflammation
in the immediate postprocedural setting.
Post–Uterine Artery Embolization Lidocaine Administration
Lidocaine is an intermediate-acting local anesthetic agent which has been used intra-arterially
during chemoembolization. With respect to UAE, intra-arterial administration prior
to embolization has been shown to cause moderate to severe vasospasm which may result
in clinical failure of UAE.[49] However, in a prospective, randomized control trial, Noel-Lamy et al[50] demonstrated that 10 mL of 1% lidocaine (100 mg) administered into the UA after embolization over a period of 15 seconds resulted in improved postprocedural pain
and opiate use. The authors also reaffirmed that intra-arterial lidocaine administration
prior to embolization resulted in more cases of incomplete necrosis, likely due to
vasospasm. Postembolization intra-arterial administration of lidocaine appears to
be a useful tool for reducing postprocedural pain and should be considered in every
case of UAE.
Clinical Outcomes
Clinical Success and Complications
The expected outcomes following a UAE include 50 to 60% fibroid size reduction, 40
to 50% uterine size reduction, 88 to 92% reduction of bulk symptoms, greater than
90% elimination of abnormal uterine bleeding, and 80 to 90% patient satisfaction.[7] At 3-year follow-up, the overall reintervention rate among patients who underwent
UAE was 14.4%.[7] This is in keeping with multiple prior studies which have concluded that UAE has
a similar patient satisfaction rate compared with the other surgical alternatives
and is associated with shorter length of hospital stay. However, patients undergoing
UAE have higher minor complications and higher likelihood of surgical reintervention
within 2 to 5 years.[51]
Compared with MR-guided focused ultrasound, UAE has been shown to have worse postprocedural
pain but significantly lower reintervention rate.[52]
[53]
Complications following UAE include permanent amenorrhea (0–3% for women younger than
45 years, 20–40% for women older than 45 years), prolonged vaginal discharge (2–17%),
fibroid expulsion (see section below), septicemia (1–3%), pulmonary embolus (<1%),
and nontarget embolization (<1%).[7] Less common complications include infection, delayed contrast material reactions,
urinary tract infection or retention, and nerve or vessel injury at the access site.
Less than 1% of patients require hysterectomy because of UAE complications. Three
fatalities have been reported following UAE, including pulmonary embolism, sepsis
from pyometrium, and death from ovarian cancer.[2]
Fibroid Expulsion
The reported incidence of fibroid expulsion following UAE ranges from 1.7 to 50%[54] with the presentation of pain, fever, or recurrent bleeding or discharge.[2] Expulsion may occur weeks to years following UAE, with a peak incidence at 3 months
following the procedure.[54] Fibroids most likely at risk for expulsion include submucosal fibroids which are
intracavitary, fibroids that are just beneath the endometrium, and transmural fibroids
that extend from the endometrium to the serosa. Patients may report passing pieces
of the fibroids or expel the entire tumor. If the necrotic components are not expelled
from the uterine cavity, the patient is at risk for ascending infection resulting
in life-threatening sepsis.[55] Treatment depends on the clinical status of the patient and can range from antibiotics,
hysteroscopic extraction, or hysterectomy. Nulliparous women are potentially at greater
risk to require hysterectomy compared with parous women.[54] The reported incidence of hysterectomy is appropriately 15% among patients expelling
fibroids.[7]
Fertility and Pregnancy following Uterine Artery Embolization
Little is truly known about the effects of UAE on fertility and future pregnancies.
Only one prospective, randomized controlled trial has compared reproductive outcomes
following UAE to myomectomy.[56] Based on a randomized group of 121 women who were followed up for 2 years, the authors
demonstrated that myomectomy resulted in better reproductive outcomes compared with
UAE. However, the trial suffered from several limitations. In addition to its strict
inclusion criteria which were not representative of a general population, the patients
in the UAE group were recommended to undergo a second intervention (myomectomy) if
their fibroids measured greater than 5 cm or in cases of regrowth of new fibroids
to that size. The technical failure rate of UAE was 11% which is unusually high. As
such, 33% of the UAE patients underwent a myomectomy and a 6-month interval was allowed
for recovery before pregnancy was attempted. Therefore, in the 2-year follow-up period,
the UAE patients had fewer opportunities to become pregnant compared with the patients
in the myomectomy group.
In a recent prospective, noncomparative trial, Torre et al[57] demonstrated that women without infertility factors who underwent UAE had a substantial
rate of subsequent fertility. The authors demonstrated that the annual fertility rate
after UAE (33.3% for the whole study population, 62.5% for women intending to conceive)
compared favorably with the 40 to 61% fertility outcomes after myomectomy.
Given the lack of robust data, the counseling of women considering fertility following
UAE should be individualized. When the fibroid is amenable to myomectomy and the patient
desires future pregnancy, then surgery should be the first recommended procedure.
If the patient's anatomy is not suitable for surgery, then UAE should be offered as
therapy. Lastly, following proper discussion of risks, benefits, and alternatives,
a woman who wants to avoid surgery should still be offered UAE, even if she desires
future fertility.[6]
Conclusion
The safety and efficacy of UAE for symptomatic uterine fibroids has been well-established.
More recently, advances in techniques with the addition of novel forms of periprocedural
patient care have resulted in improved postprocedural pain control. While reproductive
outcomes following UAE are not clearly known, all patients with symptomatic uterine
fibroids considering hysterectomy and myomectomy should be counseled about UAE by
an interventional radiologist.
