Embolization for Uterine Fibroids Has Benefits, But Still Impacts Reproductive Potential

A relatively new treatment for uterine fibroids, uterine artery embolization (UAE)-the injection of small particles into the artery to cause emboli-is effective, minimally invasive, and preserves the uterus. In a systematic review of how UAE compares with other surgical interventions for symptomatic uterine fibroids, researchers have concluded that UAE offers substantial improvements in symptoms of uterine fibroids but may not be the best therapy for women who want to retain their reproductive potential.¹

Included in the review were 5 randomized controlled trials: 3 studies compared UAE with abdominal hysterectomy, 1 compared UAE with surgery (43 hysterectomies and 8 myomectomies), and 1 compared UAE with myomectomy in women who wanted to preserve their fertility. At 2 years and 5 years, no significant differences in patient satisfaction rates between UAE and hysterectomy or myomectomy were found. The rates of major complications associated with surgery and UAE were similar. At long-term follow-up, there were no differences in ovarian failure rates.

There were several benefits unique to UAE, such as significantly shorter procedure time, fewer days needed in the hospital, and faster time to resumption of routine activities. Also, blood transfusions were needed less often in those who had UAE. However, women who underwent UAE had higher rates of minor short-term and long-term complications, more unscheduled readmissions after discharge, and higher surgical reintervention rates. Alone, the increased reintervention rates could nullify any initial cost advantages gained from the procedure’s benefits.

Because UAE is minimally invasive and preserves the uterus, it was expected that women would be able to conceive and have a successful pregnancy after the procedure. However, observational evidence has shown that although some women can have successful pregnancies following UAE, the reported miscarriage rates in women who conceive after undergoing UAE range from 18% to 64%, with a cumulative risk of miscarriage of about 35%, which is 3 times higher than the average miscarriage rate of the general population.^2-5 Myomectomy may be associated with slightly improved fertility outcomes compared with UAE, but the number of women (n=66) who tried to conceive in the study of hysterectomy versus myomectomy was too low to provide any meaningful evidence.

Pertinent Points:
- Overall patient satisfaction rates in women who underwent UAE to treat uterine fibroids are similar to those in women who had a hysterectomy or myomectomy.
- The very limited available evidence suggests that myomectomy may be the best option for women who wish to preserve their fertility. However, further research is needed to determine how UAE affects reproductive performance before more definitive conclusions can be made.

References:

1. Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2012;5:CD005073.
2. Pron G, Mocarski E, Bennett J, et al, for the Ontario UFE Collaborative Group. Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial. Obstet Gynecol. 2005;105:67-76.
3. Holub Z, Mara M, Kuzel D, et al. Pregnancy outcomes after uterine artery occlusion: prospective multicentric study. Fertil Steril. 2008;90:1886-1891.
4. Homer H, Saridogan E. Uterine artery embolization for fibroids is associated with increased risk of miscarriage. Fertil Steril. 2010;94:324-330.
5. Homer H, Saridogan E. Pregnancy outcomes after uterine artery embolisation for fibroids. The Obstetrician & Gynaecologist. 2009;11:265-270.