PREGNANCY AFTER UTERINE FIBROID EMBOLIZATION (UFE) 14-04-2017 PREGNANCY AFTER UTERINE FIBROID EMBOLIZATION (UFE) João Martins Pisco, MD, PhD Interventional Radiologist Marisa Duarte, MD Tiago Bilhim, MD Saint Louis Hospital – Interventional Radiology Lisbon, Portugal www.hospstlouis.com St. Louis Hospital Faculty of Medical Sciences New University of Lisbon SIR 2010

UTERINE FIBROIDS UTERINE FIBROIDS OR MYOMAS ARE THE MOST FREQUENT BENIGN TUMOURS IN FERTILE AGE WOMEN 30% OF WOMEN OLDER THAN 35 YEARS OF AGE 50% OF AFRICANS SAME AGE

UTERINE FIBROIDS CLINICAL PRESENTATION HEAVY MENSTRUAL BLEEDING PELVIC PAIN A CAUSE OF INFERTILITY OR SPONTANEOUS ABORTION ASYMPTOMATIC

HOW TO TREAT UTERINE FIBROIDS? MEDICINE DRUGS: PILL ANTI - INFLAMMATORY HORMONES SURGERY: MYOMECTOMY HYSTERECTOMY UFE

INTRODUCTION DESIRE FOR FUTURE PREGNANCY, IS A RELATIVE CONTRAINDICATION TO UTERINE FIBROID EMBOLIZATION (UFE) MIOMECTOMY INDICATED SOME REPORTED PREGNANCIES HIGH COMPLICATION RATES SOME OBSTETRIC RISKS

PREGNANCY AFTER UFE A.C.O.G. (2004) – UFE CONTRAINDICATED IF PT WISHES CONCEPTION LIMITED DATA ON FERTILITY RATE AND PREGNANCY OUTCOMES AFTER UFE

MATERIAL – 743 PATIENTS 82 – PRESERVE FERTILITY 74 WANTED PREGNANCY NONE COULD GET A SUCCESSFUL PREGNANCY WOMEN INFORMED OF THE UNCERTAIN EFFECT OF UFE ON FERTILITY AND PREGNANCY AT LEAST 6 MONTHS BEFORE CONCEPTION

CLINICAL DATA OF SUCCESSFUL LIVE BIRTH PREGNANCIES (N=30) AGE – 27 – 43 YEARS (MEAN 36.2) UTERUS SIZE – 69 - 1450 CC (MEAN 343) DOMINANT FIBROID SIZE – 39 - 1280 CC (MEAN 151) SPONTANEOUS ABORTION BEFORE UFE – 11 (5 PATIENTS)

UFE (UTERINE FIBROID EMBOLIZATION) MAY BE THE UNIQUE EFFECTIVE TREATMENT FOR INFERTILE PATIENTS WITH UTERINE FIBROIDS IN THE FUTURE, UFE MAY BE A FIRST LINE TREATMENT OPTION FOR THESE PATIENTS

UFE 1ST - CASE SC, 33 YEARS OLD, WANTED TO GET PREGNANT SEVERAL UTERINE MYOMAS (THE LARGEST 2 HAD 10 AND 9 CM) HEAVY BLEEDING (MENSTRUATION 2 - 3 WEEKS), EXTREME ANEMIA (NEEDED PERIODICALLY IRON TRANSFUSION), PAIN AND LARGE BELLY SHE HAD 2 UNSUCCESSFUL MYOMECTOMIES AND 3 IN VITRO FERTILIZATION HYSTERECTOMY BOOKED!

UFE 1ST - CASE UFE: JUNE 24, 2004 BLEEDING AND PAIN FINISHED THE ANEMIA WAS CURED HER HUGE BELLY DECREASED MAY 2006 - PREGNANCY FEBRUARY 2007 - CESAREAN DELIVERY (38 WEEKS OF PREGNANCY); DAUGHTER CATARINA WITH 2.800KG

UFE 1ST - CASE “EMBOLIZATION CHANGED MY LIFE, THE BLEEDING IS FINISHED, I KEEP PART OF MY BODY THAT GYNECOLOGIST WANTED TO BE REMOVED. SINCE EMBOLIZATION I HAVE A COMPLETELY HEALTHY LIFE. THE EMBOLIZATION GAVE ME THE BEST PRIZE, MY DEAR DAUGHTER CATARINA”

WHAT IS UFE? UTERINE FIBROID EMBOLIZATION (UFE) IS A MINIMALLY INVASIVE PROCEDURE TINY NICK IN THE SKIN, THE CATHETER IS GUIDED BY X-RAYS TO THE UTERINE ARTERY AND BLOCKS BLOOD SUPPLY TO UTERINE FIBROIDS WITHOUT BLOOD THE MYOMA WILL SHRINK AND DIE CAN BE PERFORMED AS OUTPATIENT PROCEDURE

WHO PERFORMS UFE? AN INTERVENTIONAL RADIOLOGIST PERFORMS THE MOST ADVANCED AND LEAST INVASIVE TREATMENTS THAT REPLACE SURGERY LESS RISK, LESS PAIN, LESS RECOVERY TIME NO SCAR JUST A BANDAID www.sirweb.org

WHAT IS AN INTERVENTIONAL RADIOLOGIST ARE BOARD CERTIFIED PHYSICIANS WHO SPECIALIZE IN MINIMALLY INVASIVE TARGETED TREATMENTS USING CATHETERS GUIDED BY IMAGING EQUIPAMENT

HOW TO PERFORM UFE IF PATIENT WANTS TO GET PREGNANT? LOW X-RAY TIME EMBOLIZE THE LEAST POSSIBLE (ONLY TUMOR VESSELS) KEEP THE UTERINE ARTERIES PERMEABLE POLYVINYL ALCOHOL (PVA) EMBOZENE MICROSPHERES

IF I DON’T WANT TO DO A SURGERY PROPOSED BY GYNECOLOGIST WHAT TO DO? GET A 2ND OPINION WITH AN INTERVENTIONAL RADIOLOGIST INTERVENTIONAL RADIOLOGISTS ARE WIDELY AVAILABLE THROUGHOUT THE USA WWW.SIRWEB.ORG

WHY TO TREAT FIBROIDS BEFORE PREGNANCY UTERINE FIBROIDS: MAY BE A CAUSE OF INFERTILITY MAY INDUCE SPONTANEOUS ABORTION INCREASE IN SIZE DURING PREGNANCY HOWEVER, AFTER UFE, IN CASE OF PREGNANCY, THE FIBROIDS CONTINUE TO DECREASE IN SIZE

UFE MAY BE THE SINGLE EFFECTIVE TREATMENT AFTER UNSUCCESSFUL MYOMECTOMY OR IN VITRO FERTILIZATION HUGE OR MULTIPLE FIBROIDS HYSTERECTOMY (UTERUS REMOVAL) THE ONLY OFFERED TREATMENT MYOMECTOMY BUT EVENTUAL HISTERECTOMY CAN NOT BE RULED OUT

OUR RESULTS OF PREGNANCY AFTER UFE PREGNANCIES – SPONTANEOUS (WITHOUT ASSISTED REPRODUCTION TECHNIQUES) IN 43 OF 74 WOMEN WHO WANT TO CONCEIVE (58.1%) 36 FINISHED PREGNANCIES (83.7%) 30 SUCCESSFUL LIFE BIRTHS (83.3%) PRE TERM (36 WEEKS) 2 (6.6%) 5 ABORTIONS (13.8%) 1 INDUCED 4 SPONTANEOUS (13.3%) 1 STILLBIRTH (AFTER 5 MIOMECTOMIES, + 1 IVF CESAREAN AT 36 WEEKS) 7 ONGOING PREGNANCIES (16.3%)

TREATMENT PERFORMED OR OFFERED TO OUR PREGNANT WOMEN MYOMECTOMY 16 (1-4) – 6 PATIENTS FIV 7 (1-3) – 3 PATIENTS OFFERED: HISTERECTOMY – 9 PATIENTS MIOMECTOMY – 11 HISTERECTOMY COULD NOT BE EXCLUDED IN 5 PATIENTS

5 PREGNANT WOMEN. WHOSE PREGNANCY WAS POSSIBLE ONLY AFTER UFE

PREGNANCY AFTER UFE – CONCLUSION UFE IS NOT A CONTRAINDICATION TO PATIENTS WHO WANT TO CONCEIVE UFE MAY BE THE SINGLE EFFECTIVE TREATMENT FOR SUCCESSFUL PREGNANCIES IN SOME PATIENTS WITH UTERINE FIBROIDS OUR RESULTS OF SUCCESSFUL PREGNANCIES AFTER UFE ARE COMPARABLE TO THOSE OF MIOMECTOMY PATIENTS SHOULD BE ABLE TO CHOOSE BETWEEN SURGICAL OPTIONS AND UFE