RESEARCH ON FIBROID EMBOLIZATION (UFE OR UAE)

There is conflicting information in the media about the benefits and risks of fibroid embolization, also known as UFE or UAE. UFE is Uterine fibroid embolization. UAE is Uterine artery embolization.

This technique is performed by a radiologist, by inserting a catheter through a major artery either through the groin or through the wrist and directing plastic spheres into the blood supply that feeds a fibroid.


EMBOLIZATION IS NOT RECOMMENDED FOR WOMEN WHO WANT TO MAINTAIN FERTILITY

Studies on the effectiveness of embolization have been conducted over the past 14 years. Recommendations as a result of those studies is clear:

Women with fibroids who are of childbearing age, and who want to have the option to conceive, myomectomy (fibroid removal) is the only recommended option for women who plan to get pregnant. 

The risks associated with embolization include higher risk of birth complications and difficulty getting pregnant. Miscarriage or premature births are at a higher risk with embolization.

“Until recently, management of symptomatic fibroids refractory to medical treatment required surgical intervention.” UAE may be a viable option for some patient with symptomatic small fibroids (< 10 cm in diameter). However, to date, myomectomy is considered the only treatment option for women desiring future fertility.  The research on obstetric risks after UAE point to: prematurity, intrauterine growth restriction, abnormal placentation, and increased likelihood of cesarean delivery.

RESEARCH ON THE IMPACT OF UAE OR UFE ON FERTILITY

• Sukhbir S. Singh, Can Fam Physician. 2007 Feb; 53(2): 293–295. Pregnancy after uterine artery embolization for fibroids. 

CONCLUSION: Desired future pregnancy remains a relative contra-indication to UAE for symptomatic fibroids. Obstetric risks after UAE for fibroids include prematurity, intrauterine growth restriction, abnormal placentation, and increased likelihood of cesarean delivery.

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• Karlsen K1, Hrobjartsson A2, Korsholm M3, Mogensen O4, Humaidan P5, Ravn P3. Fertility after uterine artery embolization of fibroids: a systematic review. Arch Gynecol Obstet. 2018 Jan;297(1):13-25. doi: 10.1007/s00404-017-4566-7. Epub 2017 Oct 20.

CONCLUSION: Pregnancy rate was found to be lower and miscarriage rate higher after UAE than after myomectomy. However, we found very low quality of evidence regarding the assessed outcomes and the reported proportions are uncertain. There is a need for improved prospective randomized studies to improve the evidence base.

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• Keung JJ1, Spies JB2, Caridi TM2. Uterine artery embolization: A review of current concepts. Best Pract Res Clin Obstet Gynaecol. 2018 Jan;46:66-73. doi: 10.1016/j.bpobgyn.2017.09.003. Epub 2017 Sep 29.

CONCLUSION: Reproductive outcomes following uterine artery embolization have been described in several studies, predominantly in retrospective reviews. As uterine artery embolization became more widely performed, outcomes were initially investigated in small case series or case reports. A review by Goldberg et al. examined 53 pregnancies after UAE and 139 pregnancies after laparoscopic myomectomy, concluding that UAE was associated with higher rates of preterm labor and malpresentation [29,30]. However, the UAE patients included in the analysis were, on average, older and had larger uterine leiomyomata than those in the myomectomy group, potentially confounding the results of the review. In 2010, Homer and Saridogan published a review of 277 completed pregnancies after UAE and compared reproductive outcomes to fibroid-containing pregnancies, finding that UAE resulted in a higher rate of miscarriage, delivery by cesarean section, and post-partum hemorrhage [31].

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• Michal Mara and  Kristyna Kubinova. Embolization of uterine fibroids from the point of view of the gynecologist: pros and cons. Int J Womens Health. 2014; 6: 623–629.

CONCLUSION: Past studies have reported a high rate of miscarriage (27%–42%) following UAE. In patients desiring pregnancy, it is strongly recommended to consider the impact of UAE on fertility as well as poorer reproductive outcomes of patients after UAE in all prospective or controlled trials published up-to-date. Only carefully selected and appropriately counselled patients in this age group should be considered for UAE.

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• Torre A1, Paillusson B, Fain V, Labauge P, Pelage JP, Fauconnier A. Uterine artery embolization for severe symptomatic fibroids: effects on fertility and symptoms. Hum Reprod. 2014 Mar;29(3):490-501

CONCLUSION: Although UAE was effective in improving bleeding, bulking and pain symptoms, and in sparing the ovarian reserve, no woman in this study delivered successfully after UAE. In spite of 33.4 ± 14.5 months of attempts, only 1 in 31 women became pregnant and she finally miscarried (monthly fecundability rate 0.1% 95% CI 0-0.3%). The low reproductive outcomes reported in the present study suggest that UAE should not be performed routinely in young women of childbearing age with extensive fibroids.

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• Holub Z1, Mara M, Kuzel D, Jabor A, Maskova J, Eim J. Pregnancy outcomes after uterine artery occlusion: prospective multicentric study. Fertil Steril. 2008 Nov;90(5):1886-91. Epub 2007 Dec 26.

CONCLUSION: Pregnancies of women who were treated with uterine embolization were at significantly increased risk for spontaneous abortion when compared with pregnancies of women treated with LUAO.

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• Homer H1, Saridogan E. Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril. 2010 Jun;94(1):324-30.

CONCLUSION: The risk of miscarriage seems to be increased after UAE. Miscarriage rates were higher in  UAE  pregnancies (35.2%) compared with fibroid-containing pregnancies matched for age and fibroid location (16.5%) (odds ratio [OR] 2.8; 95% confidence interval [CI] 2.0-3.8). Pregnancies of women who were treated with uterine embolization were at significantly increased risk for spontaneous abortion when compared with pregnancies of women treated with LUAO.


RESEARCH ON UAE OR UFE & LARGE FIBROIDS

• Sanne M van der Kooij, MD, PhDWouter JK Hehenkamp, MD, PhD, UpToDate. Uterine leiomyomas (fibroids): Treatment with uterine artery embolization

Location – Subserosal or submucosal fibroids that are pedunculated and have a narrow stalk (stalk <50 percent in diameter in comparison with the largest diameter fibroid) are considered a relative contraindication [for UFE] because these fibroids may detach either intraperitoneally or within the uterine cavity; submucosal fibroids that detach may be expelled vaginally [21]. Detachment may be associated with sterile peritonitis or intrauterine infection.