Fertility after uterine artery embolization: Still an unsolved issue, CIRSE delegates heard

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fertility
Jean-Pierre Pelage presenting at CIRSE 2020

Fertility in patients who have had uterine artery embolization (UAE) is still a “hot topic,” Jean-Pierre Pelage (University Hospital and Medical Center, Caen, France) told delegates attending the online meeting of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE; 12–15 September, virtual). “We have confusing data in the literature—we know fertility after UAE is possible, and that UAE is a valuable alternative to hysterectomy and multiple myomectomy in symptomatic patients, but the role of embolization in the specific subset of women trying to get pregnant remains controversial.”

While some studies have demonstrated a 100% pregnancy rate following UAE, Pelage warned his audience that every patient is different, as is every procedure; there may be technical differences in how an embolization is conducted at different centres, for example. There are some reports in the literature of complications specifically associated with fertility after UAE. In the EMMY trial, the level of follicle-stimulating hormone (FSH)—used as a measure of ovarian impact, with higher values typically seen in patients with a diminished ovarian reserve—was seen to increase after embolization. However, this trend was more strongly observed in women over 45 years of age, and in those with higher FSH levels at baseline.

Complications from UAE include non-target embolization, mainly due to uterine-to-ovarian artery anastomoses, and extensive myometrial and endometrial ischaemic damage, largely due to an aggressive embolization technique. The latter complication can result in hysterectomy, which Pelage said “is obviously a disaster for women trying to get pregnant.” There are also reports of chronic endometriosis, which can also negatively impact fertility.

“There are some studies reporting very low pregnancy rates, including our initial experience: in 66 women offered embolization as a last resort treatment, there is virtually 0% pregnancy,” Pelage commented. He went on to give several examples of studies from other centres that also reported low fertility rates post-embolization.

“All these studies are confusing,” he said, “including the only randomised controlled trial dedicated to fertility [from Michal Mara (General Faculty Hospital and First Medical Faculty of Charles University, Prague, Czech Republic) et al, published in Cardiovascular and Interventional Radiology in 2008]. The pregnancy rate was lower after embolization, and the final term pregnancy rate was also very low.”

However, he did give the CIRSE audience some good news as well, informing them that embolization is known to be effective in the long-term for the treatment of heavy menstrual bleeding and pressure symptoms, and that the procedure leads to fully infarcted fibroids. “We know that you can expect spectacular volume reduction both of fibroids and of the uterus, which is good news for pregnancy. Embolization is a good alternative to myomectomy, which is the reference treatment for pregnancy-seeking women.”

In addition, Pelage’s group reported encouraging hormonal function following UAE, with no side effects of embolization on the ovarian reserve. Some studies have reported high rates of pregnancy: 61% (14 of 23 women) in a paper from Kavous Firouznia (Tehran University of Medical Sciences, Tehran, Iran) and colleagues published in American Journal of Roentgenology in 2009, which also reported no significant complications post-procedurally; and 59.5% (44 of 74 women) in a paper from João Pisco (St Louis Hospital, Lisbon, Portugal) et al, published in Fertility and Sterility in 2011.

Detailing his own institution’s recent experience, Pelage told registrants: “[We had a] 56% pregnancy rate in better-selected women, so younger than in our first cohort.” The 16 women included in this more recent study had an average age of 35 years, and nine of the group were actively trying to conceive. One-year post-embolization, five of the women were pregnant. Most of these pregnancies were not associated with any complications by the time of delivery.

Citing the July 2020 New England Journal of Medicine (NEJM) paper from Isaac Manyonda (St George’s, University of London, London, UK) detailing the results of the FEMME trial, Pelage highlighted the team’s fertility results: “They reported a significant number of pregnancies after embolization, even higher than in the surgery [myomectomy] group. Since it was not the primary objective, I well understand that you cannot draw definitive conclusions based on this paper.”

Attempting to make sense of these myriad results for fertility outcomes following UAE, Pelage summarised: “Pregnancy results are very variable, ranging from 14–61% from one study to another. The same [is true] for the miscarriage rate, obviously with miscarriage being more common in older women.

“From the existing literature, there seems to be an interest on the hormonal function [elevated FSH levels is more frequent after UAE], there seems to be a higher rate of pregnancy after myomectomy compared to embolization, and the rate of miscarriage seems to be higher after embolization. But again, most cases are not treated in a randomised trial, and treated women are older or have more fertility-confounding factors when treated with embolization.”

These summations led him to the conclusion that, “Despite the encouraging results of recent publications, we should still consider embolization with caution in pregnancy-seeking women. In our centre, we always discuss as a group with the referring gynaecologist to decide whether we should offer embolization or myomectomy, and we know that prospective randomised trials are very difficult to conduct in this group of women, especially in 2020, where women are well-aware of the potential interest of embolization as an alternative to surgery.”


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