Ovarian Failure with Uterine Artery Embolization

Author Information

Mirchandani AM*, Parulekar SV**, Samant PY***

(* Assistant Professor, ** Professor and Head of Department, *** Additional Professor
Department of Obstetrics and Gynaecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)

            Uterine artery embolization (UAE) has been performed to treat uterine leiomyomas conservatively. A case of premature ovarian failure resulting from UAE is presented and alternative treatment options are discussed.

            Uterine leiomyomas can be treated medically or surgically. The use of UAE by interventional radiology is on the rise. However it may cause amenorrhea by causing ovarian and uterine damage. A case of 32 years old woman who developed secondary amenorrhea after UAE for uterine leiomyoma is presented and alternative treatment options are discussed.

Case Report
            A 32 years old nulliparous woman presented with secondary amenorrhea for 1 year. She had undergone UAE for uterine leiomyoma measuring 12 cm in diameter 4 years ago by another consultant. She continued to menstruate normally for another year, developed oligomenorrhea for 1 year, and then amenorrhoea for one year. Her general condition was fair and vital parameters were normal. Systemic examination revealed no abnormality. Abdominopelvic examination and pelvic ultrasonography revealed a small uterus with nonmeasurable endometrial thickness and an absence of uterine leiomyoma. Her serum FSH level was 96 mIU/ml. She had no evidence of other endocrine gland dysfunction clinically as well as on investigations. She was put on hormone replacement therapy and did well on it.

            The blood supply of the uterus is through uterine arteries (branches of anterior divisions of internal iliac arteries) and ovarian arteries (branches of abdominal aorta). The uterine artery and ovarian artery anastomose with each other in the mesosalpinx near the uterine cornu. Three types of anastomoses are identified.[1] In type I (21.7%) flow from the ovarian artery to the uterus is through anastomoses with the main uterine artery. In type II (3.9%) the ovarian artery supplies the uterus directly. In type III (6.6%) the major blood supply to the ovary is from the uterine artery. The type III cases are classified as high risk of ovarian damage by UAE.
            Uterine leiomyomas can be treated medically with GnRH analogues or mifepristone. However the results are not lasting. Surgical treatment modalities include hysterectomy, myomectomy, myolysis, laparoscopic uterine artery occlusion, uterine artery embolization, and magnetic resonance imaging-guided focused ultrasound surgery.[2] UAE is an effective treatment alternative for uterine leiomyomas (98.97%).[3] However there are reports of ovarian damage with UAE.[3,4,5] The rate of ovarian failure after UAE is 1.23%[3] to 14%[6], which is lower than the rate of loss of ovarian perfusion demonstrated by doppler studies before and after UAE (54% total loss and 35% partial loss).[7] This is due to recovery of ovarian circulation. In the case presented, the patient had normal menses for two years after UAE. This was followed by oligomenorrhea for 1 year and then amenorrhea for 1 more year. She had suffered both ovarian damage and uterine damage from UAE. However the effects were delayed by 2 years after UAE, which is unusual. It is possible that her ovarian reserve was low at the initiation of treatment and UAE further depleted it. As a result, she got ovarian failure, which got initiated after a year and completed after two years.
            Amenorrhea after UAE is both of ovarian and uterine origin. Uterine damage is said to occur due to excessive embolization.[8] Ovarian damage appears to be due to nontarget organ embolization and possibly irradiation. Damage by embolization can be prevented by selective coil embolization of a uterine artery-to-ovarian artery communication before UAE. [9]
            We recommend that myomectomy should be the primary form of treatment of uterine leiomyomas in young women. If facilities are available, magnetic resonance imaging-guided focused ultrasound surgery may be used to achieve myolysis. UAE should be reserved for women when hysterectomy is the only option and it is not acceptable to the patient.
  1. Razavi MK, Wolanske KA, Hwang GL, Sze DY, Kee ST, Dake MD. Angiographic classification of ovarian artery-to-uterine artery anastomoses: initial observations in uterine fibroid embolization. Radiology. 2002 Sep; 224(3):707-12.
  2. Levy BS.Modern management of uterine fibroids. Acta Obstet Gynecol Scand. 2008; 87(8):812-23.
  3. Guo WB, Yang JY, Chen W, Zhuang WQ. Amenorrhea after uterine fibroid embolization: a report of six cases. Ai Zheng. 2008; 27(10):1094-9.
  4. Stringer NH, Grant T, Park J, Oldham L. Ovarian failure after uterine artery embolization for treatment of myomas.  J Am Assoc Gynecol Laparosc. 2000 Aug; 7(3):395-400.
  5. Hehenkamp WJ, Volkers NA, Broekmans FJ, de Jong FH, Themmen AP, Birnie E, Reekers JA, Ankum WM. Loss of ovarian reserve after uterine artery embolization: a randomized comparison with hysterectomy. Hum Reprod. 2007 Jul; 22(7):1996-2005.
  6. Payne JF, Robboy SJ, Haney AF. Embolic microspheres within ovarian arterial vasculature after uterine artery embolization. Obstet Gynecol. 2002 Nov;100(5 Pt 1):883-6.
  7. Ryu RK, Chrisman HB, Omary RA, Miljkovic S, Nemcek AA Jr, Saker MB, Resnick S, Carr J, Vogelzang RL. The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation. J Vasc Interv Radiol. 2001 Sep; 12(9):1071-4.
  8. Pelage JP, Cazejust J, Pluot E, Le Dref O, Laurent A, Spies JB, Chagnon S, Lacombe P. Uterine fibroid vascularization and clinical relevance to uterine fibroid embolization. Radiographics. 2005 Oct; 25 Suppl 1:S99-117.
  9. Wolanske KA, Gordon RL, Wilson MW, Kerlan RK Jr, LaBerge JM, Jacoby AF. Coil embolization of a tuboovarian anastomosis before uterine artery embolization to prevent nontarget particle embolization of the ovary.  J Vasc Interv Radiol. 2003 Oct; 14(10):1333-8.
Mirchandani A, Parulekar SV. Ovarian Failure with Uterine Artery Embolization. JPGO 2014 Volume 1 Number 1 Available from: http://jpgyob.blogspot.in/2014/01/ovarian-failure-with-uterine-artery.html