Key Points

• Uterine artery embolization (UAE) was the first image-guided technique for the management of bleeding and pressure symptoms related to uterine leiomyomas, and has robust evidence supporting its use as an alternative to hysterectomy.
• Appropriateness of the use of UAE in women with infertility or who wish to become pregnant in the future is unclear as there is less evidence relating to fertility and pregnancy performance, particularly that which is specific to the various leiomyoma phenotypes (FIGO Type, number, volume).
• Hysteroscopic myomectomy remains the most appropriate surgical intervention for those with FIGO Type 0, 1, and 2 tumors that can be removed safely using the intrauterine approach.
• UAE may have a role, even in women who wish further pregnancy, in specific instances where hysteroscopic myomectomy is not feasible, or when there exist risks to an abdominal approach to myomectomy because of comorbidities.
• The relative value of UAE compared to targeted leiomyoma ablative procedures such as microwave, radiofrequency, or focused ultrasound ablation remains unclear.

The Procedure

Uterine artery embolization (UAE) is an interventional radiologic procedure that involves temporary occlusion of the uterine arteries using biocompatible particles. In most instances, UAE is performed under moderate sedation and local anesthetic. After accessing the right femoral artery, a radiopaque catheter is guided to one of the uterine arteries under fluoroscopic direction. After injecting the particles into the artery to the point of occlusion, the catheter is repositioned in the opposite uterine artery, where the process is repeated. This bilateral uterine artery occlusion results in ischemia from which the uterus recovers, but the fibroids do not, resulting in their infarction. 

First described by Ravina from France in 1995 (Ravina 1995), UAE has since been demonstrated to generally provide sustained relief of leiomyoma-associated symptoms, most notably pressure and abnormal uterine bleeding (AUB). It has similar rates of patient satisfaction to myomectomy and hysterectomy (Cochrane ?, Others?). The procedure has also been reported from low- and middle-income regions in Africa and Asia, with reports of success even with large fibroids as are common in Africa. There are several reports of good outcomes, and overall, its introduction has been a positive experience for many women in both Africa and Asia (Mariara et al. 2017; Mutai et al. 2015; Subrmaniam et al. 2010) 

While UAE has been demonstrated to be an effective, uterine-sparing alternative to hysterectomy, its role as an alternative to abdominal approaches to myomectomy, either laparoscopic or laparotomic, or other image-guided leiomyoma ablation techniques is less clear. Uterine artery embolization should not be seen as an alternative to hysteroscopic myomectomy when removal of types 0, 1, and 2 tumors is feasible.

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Clinical Outcomes

Summary

Following occlusion of the uterine arteries by embolization, fibroid infarction generally occurs with subsequent shrinkage and symptom resolution for most women. It is suspected that the molecular expressions associated with leiomyomas, such as TGF-𝛽3, described in the pathogenesis section (LINK), are also diminished or eliminated, but data supporting this hypothesis are unavailable. The expected outcomes following a UAE include a mean 50 to 60% fibroid size reduction, [MM1] 40 to 50% reduction in uterine volume, 88 to 92% reduction of bulk symptoms, greater than 90% elimination of abnormal uterine bleeding, and 80 to 90% patient satisfaction (Stewart et al. 2015) When compared with the abdominal approaches to myomectomy, UAE appears to improve the quality of life of women with symptomatic uterine fibroids to a similar degree (Need appropriate citation). 

Given the similar outcomes from laparotomic or laparoscopic myomectomy and embolization, the choice of therapy should be based on patient preferences, patient-specific factors, and the availability of appropriately skilled providers. For those with infertility or who wish for future fertility, the issue is somewhat more complex as the comparative impact of UAE and laparoscopic or laparotomic myomectomy on fertility and subsequent pregnancy is not clear.

The lack of clarity regarding the impact of UAE on fertility is related to the fact that the randomized studies published to date have been plagued by small sample sizes and differing results. There had been concerns about the impact of UAE on ovarian function based on earlier studies of women who had undergone the procedure in their later forties (Reference?), However, randomized trials in younger patients have not demonstrated a diminution of ovarian reserve (Mara 2008, Sirkeci 2023). There are fewer data available on uterine function after UAE, and this suggests caution is warranted in recommending UAE to those seeking to become pregnant. While pregnancy can regularly occur after UAE, myomectomy may have better outcomes (Mara 2008). However, the data are weak and further study is needed, particularly comparing leiomyoma phenotypes such as number, volume, and location with respect to the myometrium and other features defined by the FIGO leiomyoma classification system (Link).

Complication Rates 

The overall complication rate after UAE differs from the published report and can be as high as 40% to as low as 5%. Much of this difference is due to varying definitions of adverse events, post-procedure pain management, and experience in treating patients. With appropriate post-procedure protocols, complications leading to re-admission post-procedure are well less than 5% (Worthington-Kirsch 2005) above.

 The overall complication rate differs by published report and can be as high as 40% to as low as 5%. 

Patient Selection

UAE is appropriate for most patients with uterine fibroid symptoms, including abnormal and heavy bleeding, pain during sex, pelvic pain and pressure, constipation, urinary issues, and erratic menstrual cycles. UAE may be a preferred choice over surgery in the following circumstances:

Relative Contraindications or Special Care Considerations

For patients with a severe allergy to iodinated contrast used in arteriography, appropriate prophylaxis with corticosteroids is indicated. Similarly, where there is a history of vascular surgery or vascular injury in the pelvis, caution with vascular access and embolization is needed. 

There are certain fibroid types or locations that may not respond as well to embolization and therefore, surgery can be a better option. For example, small intra-cavity fibroids are usually better treated with hysteroscopic resection and very large sub-serosal fibroids can have a better outcome with myomectomy. Cervical fibroids are more difficult to treat with embolization, but in a woman where uterine retention is important, it may be a better choice than myomectomy. For women with very large fibroid uteri (those with a greater than a 24-28 week size or greater) may not have sufficient shrinkage after UAE to return abdominal girth to normal and those women, may prefer surgery. 

There are specific circumstances when surgical resection has been planned but due to the size and/or number of fibroids, excessive blood loss is a concern. In this setting, pre-operative UAE followed by surgery can dramatically reduce blood loss and facilitate surgery.