Uterine artery embolisation (UAE) is a relative newcomer to the mainstream treatment modalities available for fibroid-related problems. The efficacy of UAE is indisputable and has been shown to be comparable to hysterectomy in the short term in large-scale trials. Moreover, compared with hysterectomy, UAE is less invasive, carries a superior risk profile, and, importantly, preserves the uterus. UAE therefore offers patients symptom relief whilst at the same time retaining reproductive potential. Notably however, although women can have successful pregnancies following UAE, it is becoming increasingly evident that pregnancies after UAE are more risky especially during the early stages. Long-term outcome data from randomised trials involving UAE have very recently become available and show that whilst high satisfaction rates previously identified during early-stage followup are sustained, one notable drawback is a substantial risk of reintervention. It remains to be seen how this facet of UAE will impact on its future uptake. 1. Introduction The occlusion of the vascular supply of uterine fibroids, uterine artery embolisation (UAE), was first described in 1995 [1] and is now firmly established as a minimally invasive organ-preserving approach for treating symptomatic uterine fibroids. Short term followup data from randomised controlled trials have established UAE as a safe and effective alternative to hysterectomy for alleviating fibroid-related disorders such as menorrhagia and pressure symptoms [2]. However, a fuller appreciation of the longer term efficacy and complications of UAE is only just becoming apparent. Therefore, although gaining in popularity, it is important that patients be apprised of these emerging data so that they will be well equipped to make informed decisions regarding the suitability of this treatment modality. This paper will summarise the reported side effects, complications, and symptom recurrence rate, not only in the short term but, as 5-year followup data are starting to emerge, also in the long term. We will also review the available evidence regarding the adverse effects of UAE on fertility and pregnancy outcome. 2. Technical Aspects and Periprocedural Side Effects of UAE UAE exploits the differential recovery ability between fibroids and normal uterine tissue in response to ischaemia that is induced at the arteriolar level [3]. Using a femoral artery approach, the uterine artery is catheterised thereby allowing for the injection of embolic particles, most often made of poly-vinyl alcohol (PVA), that disrupt the blood
References
[1]
J. H. Ravina, D. Herbreteau, N. Ciraru-Vigneron et al., “Arterial embolisation to treat uterine myomata,” The Lancet, vol. 346, no. 8976, pp. 671–672, 1995.
[2]
American College of Obstetricians and Gynecologists, “ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas,” Obstetrics & Gynecology, vol. 112, no. 2, part 1, pp. 387–400, 2008.
[3]
N. S. Banu, D. C. Gaze, H. Bruce, P. O. Collinson, A. M. Belli, and I. T. Manyonda, “Markers of muscle ischemia, necrosis, and inflammation following uterine artery embolization in the treatment of symptomatic uterine fibroids,” American Journal of Obstetrics and Gynecology, vol. 196, no. 3, pp. 213–e1, 2007.
[4]
M. M. Freed and J. B. Spies, “Uterine artery embolization for fibroids: a review of current outcomes,” Seminars in Reproductive Medicine, vol. 28, no. 3, pp. 235–241, 2010.
[5]
J. Bruno, K. Sterbis, P. Flick et al., “Recovery after uterine artery embolization for leiomyomas: a detailed analysis of its duration and severity,” Journal of Vascular and Interventional Radiology, vol. 15, no. 8, pp. 801–807, 2004.
[6]
T. C. Carrillo, “Uterine artery embolization in the management of symptomatic uterine fibroids: an overview of complications and follow-up,” Seminars in Interventional Radiology, vol. 25, no. 4, pp. 378–386, 2008.
[7]
R. Worthington-Kirsch, J. B. Spies, E. R. Myers et al., “The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: short-term outcomes,” Obstetrics and Gynecology, vol. 106, no. 1, pp. 52–59, 2005.
[8]
B. Radeleff, M. Eiers, N. Bellemann et al., “Expulsion of dominant submucosal fibroids after uterine artery embolization,” European Journal of Radiology, vol. 75, no. 1, pp. e57–e63, 2010.
[9]
G. Tropeano, S. Amoroso, and G. Scambia, “Non-surgical management of uterine fibroids,” Human Reproduction Update, vol. 14, no. 3, pp. 259–274, 2008.
[10]
A. Vashisht, J. Studd, A. Carey, and P. Burn, “Fatal septicaemia after fibroid embolisation,” The Lancet, vol. 354, no. 9175, pp. 307–308, 1999.
[11]
B. Nikolic, C. M. Kessler, H. M. Jacobs et al., “Changes in blood coagulation markers associated with uterine artery embolization for leiomyomata,” Journal of Vascular and Interventional Radiology, vol. 14, no. 9, pp. 1147–1153, 2003.
[12]
F. Czeyda-Pommersheim, S. T. Magee, C. Cooper, W. Y. Hahn, and J. B. Spies, “Venous thromboembolism after uterine fibroid embolization,” CardioVascular and Interventional Radiology, vol. 29, no. 6, pp. 1136–1140, 2006.
[13]
A. C. Lai, S. C. Goodwin, S. M. Bonilla et al., “Sexual dysfunction after uterine artery embolization,” Journal of Vascular and Interventional Radiology, vol. 11, no. 6, pp. 755–758, 2000.
[14]
R. D. Edwards, J. G. Moss, M. A. Lumsden et al., “Uterine-artery embolization versus surgery for symptomatic uterine fibroids,” The New England Journal of Medicine, vol. 356, no. 4, pp. 360–370, 2007.
[15]
S. Dutton, A. Hirst, K. McPherson, T. Nicholson, and M. Maresh, “A UK multicentre retrospective cohort study comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy,” BJOG, vol. 114, no. 11, pp. 1340–1351, 2007.
[16]
W. J. K. Hehenkamp, N. A. Volkers, P. F. J. Donderwinkel et al., “Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial,” American Journal of Obstetrics and Gynecology, vol. 193, no. 5, pp. 1618–1629, 2005.
[17]
D. M. Hovsepian, G. P. Siskin, J. Bonn et al., “Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata,” CardioVascular and Interventional Radiology, vol. 27, no. 4, pp. 307–313, 2004.
[18]
M. Mara, J. Maskova, Z. Fucikova, D. Kuzel, T. Belsan, and O. Sosna, “Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy,” CardioVascular and Interventional Radiology, vol. 31, no. 1, pp. 73–85, 2008.
[19]
H. B. Chrisman, M. B. Saker, R. K. Ryu et al., “The impact of uterine fibroid embolization on resumption of menses and ovarian function,” Journal of Vascular and Interventional Radiology, vol. 11, no. 6, pp. 699–703, 2000.
[20]
W. J. Walker and J. P. Pelage, “Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up,” BJOG, vol. 109, no. 11, pp. 1262–1272, 2002.
[21]
A. Ahmad, L. Qadan, N. Hassan, and K. Najarian, “Uterine artery embolization treatment of uterine fibroids: effect on ovarian function in younger women,” Journal of Vascular and Interventional Radiology, vol. 13, no. 10, pp. 1017–1020, 2002.
[22]
G. Pron, E. Mocarski, J. Bennett, G. Vilos, A. Common, and L. Vanderburgh, “Pregnancy after uterine artery embolization for leiomyomata: the ontario multicenter trial,” Obstetrics and Gynecology, vol. 105, no. 1, pp. 67–76, 2005.
[23]
Z. Holub, M. Mara, D. Kuzel, A. Jabor, J. Maskova, and J. Eim, “Pregnancy outcomes after uterine artery occlusion: prospective multicentric study,” Fertility and Sterility, vol. 90, no. 5, pp. 1886–1891, 2008.
[24]
H. Homer and E. Saridogan, “Uterine artery embolization for fibroids is associated with an increased risk of miscarriage,” Fertility and Sterility, vol. 94, no. 1, pp. 324–330, 2010.
[25]
H. Homer and E. Saridogan, “Pregnancy outcomes after uterine artery embolisation for fibroids,” The Obstetrician & Gynaecologist, vol. 11, pp. 265–270, 2009.
[26]
H. Homer, “New insights into the genetic regulation of homologue disjunction in mammalian oocytes,” Cytogenetic and Genome Research, vol. 133, no. 2–4, pp. 209–222, 2011.
[27]
H. A. Homer, “aneuploidy and meiosis: eggs in a race against time,” in The Yearbook of Obstetrics and Gynaecology, T. Hillard, Ed., pp. 139–158, RCOG Press, 2007.
[28]
M. Mara, Z. Fucikova, D. Kuzel, J. Maskova, P. Dundr, and Z. Zizka, “Hysteroscopy after uterine fibroid embolization in women of fertile age,” Journal of Obstetrics and Gynaecology Research, vol. 33, no. 3, pp. 316–324, 2007.
[29]
S. M. van der Kooij, W. J. K. Hehenkamp, N. A. Volkers, E. Birnie, W. M. Ankum, and J. A. Reekers, “Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-Year outcome from the randomized EMMY trial,” American Journal of Obstetrics and Gynecology, vol. 203, no. 2, pp. 105–113, 2010.
[30]
J. G. Moss, K. G. Cooper, A. Khaund et al., “Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-Year results,” BJOG, vol. 118, no. 8, pp. 936–944, 2011.
[31]
J. Goldberg and L. Pereira, “Pregnancy outcomes following treatment for fibroids: uterine fibroid embolization versus laparoscopic myomectomy,” Current Opinion in Obstetrics and Gynecology, vol. 18, no. 4, pp. 402–406, 2006.
[32]
W. J. Walker and S. J. McDowell, “Pregnancy after uterine artery embolization for leiomyomata: a series of 56 completed pregnancies,” American Journal of Obstetrics and Gynecology, vol. 195, no. 5, pp. 1266–1271, 2006.
[33]
A. Hirst, S. Dutton, O. Wu et al., “A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study,” Health Technology Assessment, vol. 12, no. 5, pp. 1–248, 2008.
