Fig. 13.1
(a) Axial MRI (T2 weighted), (b) Coronal maximum intensity projection of contrast enhanced MR Angiogram pre-embolisation shows enlarged uterine arteries, and (c) post embolisation shows reduction in size of fibroid and reduced compression of endometrial cavity
Following injection of local anaesthesia bilateral common femoral arterial approaches using Seldinger needle and guidewire approach is performed to allow insertion of vascular sheaths. Separate catheters are introduced on each side into the common iliac artery and the contralateral common iliac and then internal iliac arteries are catheterised. Following digital subtraction angiography the catheters are selectively advanced into the distal part of the uterine arteries. The aim is to place the catheter distal to the initial cervical branches. On confirmation of catheter placement on angiography, embolization is performed under fluoroscopic control to avoid non-target embolization (Fig. 13.2a). A particulate embolisation technique using preformed polyvinyl alcohol agent is commonly used between 500 and 700 μm in diameter. There are a number of different commercial particulates available for this use. There is no clear evidence to suggest one embolisation agent is better than the other. The embolisation procedure is monitored with imaging under fluoroscopy until cessation of flow is achieved in the mid and distal uterine arteries (Fig. 13.2b). The procedure is then repeated on the opposite side. After completion of bilateral embolisation the vascular sheaths are removed and haemostasis of the common femoral arteries by manual compression or by using arterial closure devices.
Fig. 13.2
Left uterine artery catheterisation and angiography (a) pre-embolisation, and (b) post embolization with polyvinyl alcohol particles 500–710 μm in size
Follow-up MRI is performed to assess the response to embolisation at 6 months. The reduction in size of the fibroids occurs after 2–3 months post embolization and can continue beyond 1 year after embolization (Fig. 13.3).
Fig. 13.3
Coronal MRI (T2 weighted fat saturated) (a) Pre and (b) 3 months post embolisation shows incomplete fibroid necrosis
Uterine Arterial Embolisation Complications
Although uterine arterial embolisation is generally safe there are three reports of fatalities, two due to septicemia, another due to pulmonary embolism. There has been a reported uterine rupture after uterine arterial embolisation [8]. In addition was reported initially to have a significant risk of premature menopause. The incidence of premature menopause after uterine arterial embolisation was reported as 1–2 % in women younger that 45 years. In addition, while it was recognised that the changes in menstrual function may be transient, by measuring basal FSH and antimullerian hormone levels, Hechencamp et al. found that uterine arterial embolisation decreased ovarian reserve in all women [9]. Therefore the ovarian damage might not necessarily result in menopause but may impair future fertility. However no such findings have been reported in other studies [10, 11]. The effect of uterine arterial embolisation on ovarian function and early ovarian failure is therefore not entirely clear.
Clinical Results of Uterine Arterial Embolisation in Infertility
While the value of uterine arterial embolisation in symptomatic fibroids has been established by randomised controlled trials [2, 4], there is minimal randomised controlled trial evidence based uterine arterial embolisation for infertility. There have been several case studies and limited cohort observational studies reporting the potential advantages of uterine arterial embolisation over existing treatments. The main comparator in terms of case studies and cohort observational studies has been with myomectomy. The reported advantages for the patient of uterine fibroid embolisation over myomectomy are that it can be performed under local anaesthesia, and that it has a limited requirement for hospital in-patient stay. Early cohort studies suggested that the miscarriage rate after uterine arterial embolisation was 17–30 % compared with 15 % after myomectomy, the rate of pre-term delivery was also reported as being higher after uterine arterial embolisation (16–22 %) compared with 3 % at myomectomy [12]. The rate of postpartum haemorrhage has also been reported to be higher after embolization (18 %) compared to the general obstetric population presumably due to abnormal placentation [12].
In terms of randomised controlled trial results of myomectomy and uterine arterial embolisation, Marra et al. reported results of uterine arterial embolisation for patients with intramural myoma larger than 4 cm [13]. They concluded that uterine arterial embolisation is as effective as myomectomy but found that myomectomy was associated with more pregnancies and deliveries and fewer miscarriages than uterine arterial embolisation. They did note however that uterine arterial embolisation avoided some of the complications of myomectomy by laparoscopy or laparotomy. This included adhesion formation and the more serious complications of laparoscopic myomectomy of haemorrhage, bowel injury, post operative haematoma and emergency hysterectomy [14].
Two more recent studies have indicated comparable fertility rates between uterine fibroid embolisation and surgical myomectomy. Pisco et al. reported 743 women where a future pregnancy was desired [15]. Uterine arterial embolisation had a fertility rate of 58.1 % compared to surgical myomectomy with a fertility rate of 57 %. In the reported 36 completed pregnancies with uterine arterial embolisation, the birth rate was 83 %, spontaneous abortion 11 %, pre-term delivery at 10 % and low birth weight at 13.3 %. The authors concluded this was not higher than the general population.
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