Uterine Artery Embolization for Treatment of Fibroids -- Effect on Fertility and Pregnancy Outcomes

Lev Kandinov, MD; Peter S. Bernstein, MD, MPH

Disclosures

January 03, 2005

Uterine fibroids are the most common uterine benign tumors. They are present in 20% of women of reproductive age and as many as 50% of women older than 35 years of age. Depending on their location, fibroids are divided into submucous, intramural, and subserosal. Subserosal fibroids usually do not cause infertility but can be the cause of severe pain. Submucous and intramural fibroids are seldom a cause of primary infertility.[1] More commonly, they cause second-trimester pregnancy loss (especially submucous myomas).[2] Approximately 10% of women with fibroids have other pregnancy complications, such as malpresentation, abruption, preterm labor, preterm rupture of membranes, fetus that is small for gestational age (SGA) or intrauterine growth restriction (IUGR), bleeding, and pain.[3] Patients with fibroids are also at higher risk for cesarean delivery. Although fibroids are estrogen-dependent tumors, no change in their size (measured sonographically) was noted in 70% to 80% of patients.[4]

In patients with infertility secondary to fibroids, fibroids are initially treated medically (oral contraceptives, gonadotropin-releasing hormone analogues), via hysteroscopic myomectomy (for submucous myomas), and via myomectomy (for intramural and submucous fibroids). Uterine artery embolization (UAE) has been used in the treatment of postpartum hemorrhage (PPH) since the 1970s, but it is a relatively new option for treatment of fibroids. It entails angiographically guided occlusion of the uterine artery with pellets, which decreases blood supply to the myomas and thus causes cell necrosis and decrease in the size of the fibroids. Complications arising from this procedure include those related to angiography (deep pelvic thrombosis, pulmonary embolism), amenorrhea, premature ovarian failure, perforation, infection, and tissue necrosis.[5] Although numerous pregnancies have been reported after this procedure, the fertility rate after UAE remains to be compared to that associated with myomectomy.

A study from France reviewed effects of UAE for treatment of PPH on menses, fertility, and future pregnancy. Of 31 patients studied, 4 had hysterectomy, and records were available for 25 of the 27 remaining patients. Of these 25, all had normal return of menses and 10 (40%) became pregnant. Of the 10 patients who became pregnant, there were 4 (14%) first-trimester spontaneous abortions. The rest of the pregnancies lasted to term without complications. This study suggested that patients who had UAE for obstetric hemorrhage should expect normal return of menses with preservation of future fertility.[6] These data suggest that, by itself, UAE has no negative effects on future fertility and pregnancy outcomes.

One of the first published studies that evaluated women's ability to become pregnant and to deliver after undergoing the procedure concluded that although there are small risks of hysterectomy, premature menopause, and infertility from radiation exposure following UAE, these compared favorably with the risks associated with myomectomy.[7]

There are multiple case reports of successful pregnancy outcomes after UAE for fibroids. However, numerous complications of pregnancy are reported as well. In one of the papers, authors reviewed 50 published cases of pregnancy after UAE and reported the following complications: malpresentation (17%), SGA (7%), cesarean section (56%), premature delivery (28%), and postpartum hemorrhage (13%).[8] In a different trial, the same authors then compared pregnancy outcomes after treatment with UAE vs laparoscopic myomectomy; 53 pregnancies after UAE were compared with 139 pregnancies after laparoscopic myomectomy. The rates of preterm delivery and malpresentation were significantly higher (6 times and 4 times, respectively) in patients treated with UAE. Likewise, the rates of spontaneous abortions and postpartum hemorrhage were higher in the UAE group, but they were not statistically significantly different.[9,10]

Although there is growing literature demonstrating that pregnancy after UAE is possible, there is not sufficient evidence that this treatment modality offers advantages over the traditional treatments. Whether UAE is safe for patients who wish to retain future fertility is controversial. In fact, an ACOG Committee Opinion from 2004 states: "...There is insufficient evidence to ensure its (UAE) safety in women desiring to retain their fertility, and pregnancy-related outcomes remain understudied. The ACOG considers this procedure investigational or relatively contra-indicated in women wishing to retain fertility..." Myomectomy remains the standard of care in patients who wish to retain their fertility. UAE's effect on fertility and pregnancy needs to be studied further. Meanwhile, this technique should only be used in patients desiring to remain fertile for whom there are no other feasible options.[11]

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