UFE IN PATIENTS DESIRING FERTILITY

World Symposium on Endometriosis 2014

Jason R. Levy, M.D.Interventional Radiology

Northside HospitalAtlanta, GA

ACOG 2008 Practice BulletinAlternatives to hysterectomy

in management of leiomyomas

“Based on long and short-term outcomes, uterine artery embolization is a safe and

effective option for appropriately selected women who would like to retain

their uteri”

Level A Evidence:

Good and consistent scientific evidence.

ACOG Practice Bulletin: Clinical management guidelines for obstetricians-gynecologists. Number 96, August 2008. Obstet Gynecol 2008;112:387-400.

ACOG on UFE in patients interested in Fertility

Considered a relative contraindication

SHOULD IT BE?????

Fertility & UFE:What do we know? Not Enough!

There are no Level I evidence randomized controlled studies comparing UFE to myomectomy

Assessment of fertility following UAE is very complex and poorly understood with confounding factors Patients are of advanced age with

leiyomyoma- both of which can affect fertility.

Wide variability in age and interest in future fertility among patients treated with UAE.

Previous therapies

UFE: Issues to Address 1. Things that could effect Future Fertility

Ovarian failure/ function Radiation exposure Conversion to hysterectomy-less than 1% for

complications (far lower than myomectomy)

2. Creating higher risk pregnancies? Placental insufficiency? Abnormal placental location? IUGR? premature labor?

How do the Studies Assess Risk for Ovarian Failure post UFE

Hormonal: FSH, Estradiol and AMH

Ultrasound Doppler and ovarian size

Rates of amenorrhea

Ovarian Failure after UFE• Approximately 7% among women in the FIBROID

Registry, with nearly all older than age 45 years (1)

• Meta review of 15 randomized & prospective studies concluded no evidence of long term risk if under 40 based on US, hormonal analysis and amenorrhea (2)

• Women less 40 were followed 60 months post UFE no statistically significant difference in FSH, E2, follicle count, or ovarian volume compared with the control group

(1) Spies J, Myers ER, Worthington-Kirsch R, Mulgund J, Goodwin S, Mauro M, et al. The FIBROID Registry: symptom and quality-of-lifestatus 1 year after therapy. Obstet Gynaecol 2005; 106:1309–1318.

(2) Kaump GR, Spies J. The Impact of Uterine Artery Embolization on Ovarian Function. J Vasc Interv Radiol 2013; 24:459–467(3) Tropeano G, Di Stasi C, Amoroso S, Gualano MR, Bonomo L, Scambia G. Long-term effects of uterine fibroid embolization on ovarian

reserve: a prospective cohort study. Fertil Steril 2010; 94:2296–2300.

Ovarian Failure Rates UFE vs Surgery

Rates are identical to surgical therapies (1,2,3)

(1) Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol 2008; 31:73–85.(2) Hovsepian DM, Ratts VS, Rodriguez M, Huang JS, Aubuchon MG, Pilgram TK. A prospective comparison of the impact of uterine arteryembolization, myomectomy, and hysterectomy on ovarian function. J Vasc Interv Radiol 2006; 17:1111–1115.(3)Rashid S, Khaund A, Murray LS, Moss JG, Cooper K, Lyons D, et al. The effects of uterine artery embolisation and surgical treatmenton ovarian function in women with uterine fibroids. Br J Obstet Gynaecol 2010; 117:985–989.

Radiation Exposure• Mean ovarian dose from UFE is

9.38 cGy. Far less than the 375-400 cGy threshold for Ovarian dysfunction.

1)Nikolic et al. JVIR 2001; 12:39-44. 2)Halyard et al. J Natl Med Assoc.1996;88:391-3. 3)Horning et al. NEJM 1981; 23:1377-1382. 4)Dembo. The Ovary in Radiation Oncology 1994; 712-13.

• Estimated radiation exposure is about equivalent of 1 to 3 Barium Enemas depending on length of procedure.

1) Bradley et al. Br J Obstet Gynaecol 1998; 17:17-20. 2) Walker et al. Min Invas Ther Allied Technol 1998; 7(suppl):26.

Literature on Pregnancy rates and Risks post UFEThe BAD…The Neutral…

And The GOOD

Pregnancy after UAE-Toronto experience

Pron et al. Obstet Gynecol 2005; 105

• 24 pregnancies in 21 women

• 18/24 had successful delivery

• Rates for spontaneous abortion, abnormal placental location and babies small for gestational age higher than reported in general population.

• Study was flawed: The women assessed were older (most>40) and many had prior miscarriages and myomectomies

UAE versus Laparoscopic Myomectomy

Goldberg et al. Am J Obstet Gynecol 2004

• Retrospective review of 53 pregnancies after UAE; 139 pregnancies after laparoscopic myomectomy

• Increased risk for placental malpresentation and preterm delivery after UFE

• Study was flawed: The women assessed were older (most>40) and many had prior miscarriages and myomectomies

Randomized controlled trial comparing fertility outcomes of UAE versus myomectomy.

Pregnancy rates: UFE13/26 patients (50%) Myomectomy 31/40 who underwent myomectomy

becamepregnant (78%; Pvalue .04).

Abortion rate 9/17 following UAE 6/32 following myomectomy (Pvalue .05)

Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midtermclinical and first reproductive results of a randomized controlled trialcomparing uterine fibroid embolization and myomectomy. CardiovascIntervent Radiol 2008; 31:73–85.

Pregnancy after UAE versus Myomectomy-Mara et al

Small sample size,

Short duration of follow- up

Substantial variations in the number of patients who tried to conceive in each group

High rate of repeat interventions in the UAE group (much higher than most prospective UFE studies 32% myomectomy were kept in the UFE group) Higher rate of conversion than UFE literature suggests

operator bias to repeat operation These patients were kept in UFE group which confuses results.

Multiple procedures may influence pregnancy/abortion rates

Pregnancy after UAE vs Myomectomy-Mara et al-Limitations

Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midtermclinical and first reproductive results of a randomized controlled trialcomparing uterine fibroid embolization and myomectomy. CardiovascIntervent Radiol 2008; 31:73–85.

Pregnancy after UAE-UK Experience

Walker et al. Am J Obstet Gynecol 2006

• Retrospective UAE patients/ 108 desired pregnancy.

• 33/108 achieved pregnancy 30.5%• Lower than lap myomectomy numbers but many of these

patients were not candidates for myomectomy so more difficult population.

• Many of the pregnancies had prior problems with fertility. Some patients had prior myomectomy

• Of the women who achieved full term pregnancies 14 were previously only offered hysterectomy

Pregnancy after UAE-UK experience-contd

Walker et al. Am J Obstet Gynecol 2006

•No increased incidence of IUGR; placenta previa. Only 1 of each

•Higher rates than general population of:– Miscarriage-30.4%;mean age 38.75– Premature delivery-18.2%;mean age 36.8– Cesarean section-72.7%– Postpartum hemorrhage-not seen in other studies

» However this is not the “general population”

Prospectively followed 74 patients who wanted to become pregnant and treated with UFE

Followed a total of 4.5 years

44 pregnancies (59.5%). 33 live births(84.6%) 4 spontaneous abortions (9.1%). Time from UFE to pregnancy 10.8 months.

Higher proportion of younger patients (89.7% younger than 40 y) likely contributed to the better outcomes

Pregnancy After UAE-Portugal Experience Pisco et al 2011

Pisco JM, Duarte M, Bilhim T, Cirurgi~ao F, Oliveira AG. Pregnancy afteruterine fibroid embolization. Fertil Steril 2011; 95:1121.

Meta analysis Review on Fertility post UFE

Cumulative pregnancy rate 58.6% average age 35 Comparable to the age-adjusted pregnancy rates in the

general population. Considering that there is some degree of subfertility

associated with fibroid tumors this is a very positive result

Cumulative miscarriage rate 28% comparable to the rates quoted in patients with untreated

fibroid tumors.

Cumulative preterm delivery rate of 7.3% was similar to that in the general population.

PP. Mohan, MH Hamblin and RL. Vogelzang. J Vasc Interv Radiol 2013; 24:925–930

UFE-FERTILITY Results on UFE on fertility are preliminary and uncertain but not

an absolute contraindication.

Initial reproductive results may favor myomectomy over embolization in first 2 years after treatment.

Additional studies comparing the impacts of myomectomy and embolization on ovarian function and to better assess reproductive outcomes are needed. Conclusive studies with large numbers lacking

Uterus is maintained. This is not a hysterectomy

Hundreds of reported healthy pregnancies, without reports of any adverse outcome due to UAE

Role of UAE in patients with high desires for fertility

• Myomectomy (especially laparoscopic) remains the gold standard.

• UAE good option if:• Myomectomy inappropriate (i.e. >30 fibroids, likely to end with

scarring or hysterectomy)• Patient refuses myomectomy. • Surgical failures

• At NSH all patients fill out questionnaire on fertility

• All patients should understand the risks and lack of long term data

• Wait a minimum 6 months after embolization prior to conception

NSH INTERVENTIONAL RADIOLOGY CONSULTATION FOR UFE

(CLINIC VISIT)

On a scale of 0 to 10, what is your interest in having a baby in the future? (Although there have been successful

pregnancies after UAE, there is no guarantee that a patient can become pregnant after the procedure and

myomectomy may be preferred for those for women with a strong interest in pregnancy. These choices are

discussed in more detail at the time of the consultation)0= No Interest 10 = High Interest

0 1 2 3 4 5 6 7 8 9 10

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Thank You!