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

Abstract

Background Uterine artery embolisation is well established as a treatment for symptomatic fibroids, however, there remain some uncertainties. We have carried out a focused literature review on three particularly challenging aspects – post-procedure fertility, symptomatic adenomyosis and large volume fibroids and uteri, to enable operators to utilise evidence-based guidance in patient selection, consent, and management. Review Literature searches were performed of the PubMed/Medline, Google scholar, EMBASE and Cochrane databases. The outcomes of our analysis of studies which recorded fertility rates in women desiring pregnancy following UAE for symptomatic fibroids found an overall mean pregnancy rate of 39.4%, live birth rate of 69.2% and miscarriage rate of 22%. The major confounding factor was patient age with many studies including women over 40 years who already have lower fertility compared to younger cohorts. Miscarriage rates and pregnancy rates in the studies analysed were comparable to the age matched population. Treatment of pure adenomyosis and adenomyosis with co-existing uterine fibroids with UAE has been shown to produce symptomatic improvement with better outcomes in those with combined disease. Although the effectiveness is not as high as it is in pure fibroid disease, UAE provides a viable and safe alternative for patients seeking symptom relief and uterine preservation. Our analysis of studies assessing the outcomes of UAE in patients with large volume uteri and giant fibroids (> 10 cm) demonstrate no significant difference in major complication rates demonstrating that fibroid size should not be a contraindication to UAE. Conclusion Our findings suggest uterine artery embolisation can be offered to women desiring pregnancy with fertility and miscarriage rates comparable to that of the age-matched general population. It is also an effective therapeutic option for symptomatic adenomyosis as well as for the treatment of large fibroids > 10 cm in diameter. Caution is advised in those with uterine volumes greater than 1000cm3. It is however clear that the quality of evidence needs to be improved on with an emphasis on well-designed randomised controlled trials addressing all three areas and the consistent use of validated quality of life questionnaires for outcome assessment to enable effective comparison of outcomes in different studies.

Surgical evacuation combined with Shirodkar cervical suture and selective uterine artery embolization: A fertility preserving treatment for 10–15 weeks' live cesarean scar ectopic pregnancies

“…36 Additionally the findings of a recent systematic review of the impact of UAE on fertility concluded that fertility and miscarriage rates after UAE are comparable to that of the age-matched general population. 37 The main strength of our study was that it is the largest series of advanced CSEPs published in the English language literature.…”

“…The Royal College of Obstetricians and Gynecologists and the Royal College of Radiologists of the UK suggested some time ago that UAE may be offered to women who want to be able to become pregnant in the future, after an informed discussion 36 . Additionally the findings of a recent systematic review of the impact of UAE on fertility concluded that fertility and miscarriage rates after UAE are comparable to that of the age‐matched general population 37 …”

Clinical analysis of prophylactic uterine artery embolization combined with double balloon catheter for second-trimester pregnancy termination in cases of complete placenta previa: A retrospective study

“…[8] Prophylactic UAE is widely used to prevent bleeding in cases of abnormally invasive placenta with placenta previa, cesarean scar pregnancy, and large fibroids. [20][21][22] The use of prophylactic UAE for the termination of second-trimester pregnancy with placenta previa is controversial. [7,12] Wang et al [12] investigated 15 patients with placenta previa who underwent second-trimester pregnancy termination by prophylactic UAE.…”

Update on Endovascular Therapy for Fibroids and Adenomyosis

“…Unlike hysterectomy, minimally invasive interventions such as UAE may help preserve fertility, especially in cases of symptomatic adenomyosis and large fibroids, according to recent studies. 63 In fact, research indicates that even patients with larger uteri and fibroids greater than 10 cm do not experience significantly higher complication rates, suggesting that fibroid size should not be a contraindication for UAE. 63 However, one study found that miscarriage rates were highest in the UAE group compared to other minimally invasive techniques like HIFU and transcervical radiofrequency ablation.…”

“…63 In fact, research indicates that even patients with larger uteri and fibroids greater than 10 cm do not experience significantly higher complication rates, suggesting that fibroid size should not be a contraindication for UAE. 63 However, one study found that miscarriage rates were highest in the UAE group compared to other minimally invasive techniques like HIFU and transcervical radiofrequency ablation. 64 Nonetheless, this study identified maternal age as a confounding variable that could have contributed to the odds of fetal and maternal complications.…”