Reply: uterine artery embolization for severe symptomatic fibroids: effects on fertility and symptoms.

STUDY QUESTION Does uterine artery embolization (UAE) permit fertility in childbearing women who have extensive symptomatic fibroids and are not eligible for surgery? SUMMARY ANSWER Although UAE was effective in improving bleeding, bulking and pain symptoms, and in sparing the ovarian reserve, no woman in this study delivered successfully after UAE. WHAT IS KNOWN ALREADY Although pregnancies have been reported after UAE, the actual fertility rate after this treatment remains uncertain. STUDY DESIGN, SIZE, DURATION This prospective cohort study included 66 women who desired a future pregnancy and were treated with UAE for symptomatic fibroids. PARTICIPANTS/MATERIALS, SETTING, METHODS This cohort of consecutive patients had extensive symptomatic fibroids but were not eligible for abdominal myomectomy because of fibroid recurrence despite previous surgery, because of current risks of surgery, or because of patient refusal. The patients were enrolled in a tertiary referral center for fibroid treatment. All patients had a pre-operative ovarian function assessment and underwent bilateral superselective embolization of both uterine arteries using 500-1200 µm Tris acryl microspheres. MAIN RESULTS AND THE ROLE OF CHANCE Fibroid symptoms including menorrhagia (OR 0.08, 95% CI 0.02-0.27), metrorrhagia (OR 0.05, 95% CI 0.01-0.39), pain (OR 0.08, 95% CI 0.03-0.22) and bulk syndrome (OR 0.02, 95% CI 0.01-0.07) were significantly improved after UAE. According to magnetic resonance imaging, the dominant fibroid volume decreased by 31.8% (95% CI 12.2-51.3%). Ovarian reserve demonstrated no change after embolization. Thereafter the women were prospectively followed, and 31 of them (aged 37.3 ± 3.5 years) were actively trying to conceive. In spite of 33.4 ± 14.5 months of attempts, only 1 in 31 women became pregnant and she finally miscarried (monthly fecundability rate 0.1% 95% CI 0-0.3%). LIMITATIONS, REASONS FOR CAUTION The high rate of associated infertility factors in our population, and the high frequency of previous surgery, could in part explain these poor reproductive outcomes; however, they should not account for the total absence of ongoing pregnancy. Embolization might have had a negative impact on fertility in our population, which may not be related to ovarian function. WIDER IMPLICATIONS OF THE FINDINGS The low reproductive outcomes reported in the present study suggest that UAE should not be performed routinely in young women of childbearing age with extensive fibroids. Although this finding was established in a population for whom abdominal myomectomy was declined, a possible adverse effect of UAE on fertility potential should be considered for woman of childbearing age scheduled for embolization. STUDY FUNDING/COMPETING INTEREST(S) No particular funding was obtained for this study and the authors have no conflict of interest.