(* Senior Resident, ** Professor and Head of Unit, *** Assistant Professor, Department of Obstetrics and Gynecology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.)
The use of uterine artery embolization (UAE) in women who wish to retain their fertility is a controversy. There are concerns that premature ovarian failure and impaired decidual blood supply supposedly caused by UAE contribute to infertility and recurrent pregnancy loss. We report a case of a nulligravida with UAE done for fibroids that not only alleviated her symptoms but also resulted in a successful live birth.
UAE has been used successfully since three decades for the treatment of symptomatic uterine fibroids. However, its effects on the child bearing function have not been satisfactorily examined and need further evaluation.
Fig. 1: Ragged, unhealthy placenta.
Uterine artery embolization for treatment of symptomatic fibroids was first reported by Ravina et al in 1995. Today it is an established treatment option in women who do not want to undergo surgery. Relief of symptoms in 80-90% of women along with a reduction in the fibroid volume of 40-70% is seen at the end of one year. In this case there was a stupendous response with complete relief of symptoms and a reduction in fibroid volume by 94.3%. While there is no dilemma for women who have completed their families, experts deem it prudent to be cautious while offering this procedure to women who want to conceive in the future. The primary concern was UAE causing premature ovarian failure and hence infertility as suggested by earlier reports. However, a better designed study refuted these claims and showed that ovarian function remained unaltered, especially in women younger than 40 years of age. Indeed, there are several reports of successful pregnancies, most of them spontaneously conceived, as was seen in this case.[5-7] There is limited evidence on comparative fertility outcomes post myomectomy and UAE. In a randomized controlled trial, Mara et al have reported a comparable pregnancy rate in both groups.There are concerns regarding compromised decidual blood supply which may result in adverse pregnancy events such as implantation failure, miscarriage and intrauterine growth restriction. The miscarriage rate in the UAE group was significantly higher than the myomectomy group. However, these complications are also primarily associated with fibroids in pregnancy and hence to attribute them entirely to UAE may be erroneous. As in this case, pregnancy continued into the third trimester without hormonal support and delivered an appropriate for gestational age baby. An increased incidence of placenta previa and adherent placenta in pregnancies after UAE has been reported. This may be due to denudation of the endometrium as reported in a study that visualized the uterine cavity hysteroscopically post UAE. This case had grade 2 anterior placenta previa without adherence. Another anticipated complication is the risk of uterine rupture during pregnancy due to myometrial ischemia. However, there have been no such reported cases and this may be one of the advantages of UAE over myomectomy. In this case, integrity of the uterus was maintained and there were no areas of myometrial thinning as seen intra operatively. There are no definitive guidelines regarding the appropriate time to wait until conception so that healing occurs after UAE. It is generally recommended to wait for 3-6 months after myomectomy.
UAE is a promising modality of treatment for women with symptomatic fibroids who wish to retain their fertility. However, until more robust studies prove its safety for pregnancy, women should be cautioned regarding the risks of miscarriage and abnormal placentation. It may be a viable option for young women with multiple, scattered fibroids, small and large, where myomectomy may be difficult and could potentially end up in a hysterectomy or massive blood loss as in this case. Thus, careful patient selection is the key.
- Ravina JH, Ciraru-Vigneron N, Bouret JM, Herbreteau D, Houdart E, Aymard A, et al. Arterial embolisation to treat uterine myomata. Lancet 1995 Sep;346(8976):671-2.
- Royal College of Obstetricians and Gynaecologists. Clinical recommendations on the use of uterine artery embolisation (UAE) in the management of fibroids. 3rd ed. London: 2013.
- Tulandi T, Sammour A, Valenti D, Child TJ, Seti L, Tan SL. Ovarian reserve after uterine artery embolization for leiomyomata. Fertil Steril. 2002 Jul;78(1):197-8.
- Tropeano G, Di Stasi C, Amoroso S, Gualano MR, Bonomo L, Scambia G. Long-term effects of uterine fibroid embolization on ovarian study: a prospective cohort study. Fertil Steril. 2010 Nov;94(6):2296-300.
- Ravina JH, Vigneron NC, Aymard A, Le Dref O, Merland JJ. Pregnancy after embolization of uterine myoma: report of 12 cases. Fertil Steril. 2000 Jun;73(6):1241-3.
- McLucas B, Goodwin S, Adler L, Rappaport A, Reed R, Perrella R. Pregnancy following uterine fibroid embolization. Int J Gynaecol Obstet. 2001 Jul;74(1):1
- Pron G, Mocarski E, Bennett J, Vilos G, Common A, Vanderburgh L; Ontario UFE Collaborative Group. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol. 2005 Jan;105(1):67-76.
- Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008 Jan-Feb;31(1):73-85.
- Tropeano G, Litwicka K, Di Stasi C, Romano D, Mancuso S. Permanent amenorrhea associated with endometrial atrophy after uterine artery embolization for symptomatic uterine fibroids. Fertil Steril. 2003 Jan;79(1):132-5.
Shilotri M, Fonseca MN, Kapote D. A Successful Pregnancy Outcome following Uterine Artery Embolization for Fibroids. JPGO 2019. Vol.6 No.8. Available from: https://www.jpgo.org/2019/08/a-successful-pregnancy-outcome.html