Less Pregnancy Risk After UAE Than Suspected?


LONDON — The strongest data yet on pregnancies after uterine artery embolization suggest that the procedure poses less risk to subsequent pregnancies than was previously suspected, according to British researchers.

“It would be scientifically invalid to suggest that no patient wishing to become pregnant in the future should undergo uterine artery embolization [UAE],” said Woodruff J. Walker, M.D., who presented the data at the annual congress of the International Society for Gynecologic Endoscopy.

“This evidence suggests the risks of pregnancy after UAE are less than first feared,” commented Franklin D. Loffer, M.D., medical director and executive vice president of AAGL, an association formerly known as the American Association of Gynecologic Laparoscopists.

“This is a very large, long series. And it is the type of information that, as it accumulates, sets opinions,” he told this newspaper.

Dr. Walker, an interventional radiologist at Royal Surrey County Hospital in Guildford, England, also presented prospective long-term follow-up data on uterine artery embolization (UAE). The prospective study included 174 women who were followed for 5ndash;7 years after undergoing UAE for symptomatic fibroids.

Out of 98 patients who expressed a desire for future pregnancy, 42 reported a total of 53 pregnancies making this the largest series of post-UAE pregnancies from a single center worldwide, Dr. Walker said.

One pregnancy was conceived through in vitro fertilization. The rest were spontaneous conceptions. In addition to 29 live births, there were 4 ongoing pregnancies, 13 miscarriages, 4 terminations, 1 ectopic pregnancy, and 1 stillbirth due to a knotted umbilical cord. There also was another stillbirth resulting from uterine rupture through the cesarean scar in a woman with her second pregnancy after UAE.

The spontaneous miscarriage rate in this series was 24.5%, said Dr. Walker, which is within the normal range for women of this age. The mean age of women who miscarried was 42; the mean age of women with live births was 36.

Two terminations were chosen for social reasons, while one was chosen because of a diagnosis of trisomy 21. Another one was chosen because of abnormal growth at 15 weeks' gestation.

There were four categories of obstetric complications that occurred more frequently in the study group than the normal obstetric population of the same age, Dr. Walker said. (See table.)

Eighteen women had experienced subfertility ranging from 18 months to 8 years before undergoing UAE. Eleven of those women reported successful pregnancies after the procedure.

There was a high cesarean section rate —22 out of the 29 live births. Twelve of the sections were elective, and the other 10 were emergency, 4 of which were performed after attempted vaginal delivery.

According to Dennis Hidlebaugh, M.D., a gynecologic surgeon at Cleveland Clinic Florida, Naples, the pregnancy results after UAE in this study are reassuring.

“They seem no different from any other results in a slightly older population,” he told this newspaper. “In all, this study helps define better outcomes and risks so that patients can be better counseled.”

The one patient whose second post-UAE pregnancy resulted in uterine rupture through her C-section scar “might imply that prior C-section might increase the risk,” Dr. Hidlebaugh said.

In terms of patient satisfaction after UAE, 75% of the 174 women experienced a normalization of heavy menstrual flow, Dr. Walker said.

Eighty-seven percent of women said they would recommend the procedure to others, 61% said they were satisfied with the procedure, and 85% reported an improved quality of life.

Persistent vaginal discharge after UAE occurred in 5.2% of the women.

Among those women for whom the procedure did not reduce symptoms adequately, five subsequently underwent hysteroscopic resection; one, a laparoscopic myomectomy; and nine, hysterectomies.

Ovarian failure remains a potential risk of UAE, but it is rare—reported in 7.6% of women, although only one of these patients was under age 45, Dr. Walker said.

“In older patients, there is some suggestion that UAE can bring on menopause earlier,” he said. In a larger series of 1,200 women, 5 women younger than 45 years have experienced ovarian failure, although 2 had predisposing factors, he added.

In conclusion, Dr. Walker noted that patients with failed hysteroscopic or laparoscopic myomectomies or those with large submucous or numerous interstitial fibroids can be successfully treated with UAE and should be offered this option, even if they desire future fertility.

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