Fibroid /C1Embolization /C1Pregnancy /C1
Adenomyosis
Uterine artery embolisation (UAE) is an effective option
for women with symptomatic fibroids and this has been
shown with level 1 evidence for over 20 years [ 1]. How-
ever, implementation of this treatment into mainstream
medicine has been an example of the incredibly difficult
path that Interventional Radiology (IR) treatments must
take when they disrupt the surgical status quo [ 2].
In the early days, rightful caution was exercised
regarding the use of UAE in women wishing to maintain
fertility. It was vital that safety and efficacy were proven
before issues such as ovarian reserve and placental
implantation could be assessed. However, this was often
misinterpreted as UAE being contra-indicated in women
desiring pregnancy, and embodies the anecdote of ‘ ‘ab-
sence of evidence does not mean evidence of absence’ ’.
There can be a somewhat reticence to approach pregnancy
at a local clinical level, reinforced by clinical guidelines
which are not sufficiently dynamic to reflect newer
evidence.
There are several problems with generating clinically-
relevant data in this space. Pregnancy as a study endpoint is
extraordinarily hard to measure due to the multifactorial
contribution of several patient and non-patient factors
which influence a successful live birth. In addition, women
with fibroids have a lower baseline rate of fertility. Existing
studies are under powered and yet it is near impossible to
study this when there is a reluctance to refer women under
40 to an IR. Looking at our own unpublished data, the
mean age of 46.2 years in our cohort reinforces the notion
that referrals are being selected, despite a legal and ethical
requirement for UAE to form a part of an informed consent
process for any uterine fibroid surgery.
However, things have changed in recent years. In 2024,
2 meta-analyses have been published, comparing preg-
nancy outcomes for women undergoing myomectomy and
UAE. The study of Peng et al. included 4 randomised trials,
and showed no difference in the rates of live birth and
miscarriage between the treatments [ 3]. The study of
Tzanis et al. included 2 randomised trials and showed no
difference in pregnancy rates between the treatments [ 4].
As these are meta-analyses of randomised controlled trials,
we now have level 1 evidence that shows pregnancy after
UAE is not just possible, but outcomes comparable to
myomectomy. Yet myomectomy for years has been touted
as the treatment to preserve or even increase fertility in
some women. It will take years for this data to be reflected
in guideline updates and maybe even longer for this to be
& Warren Clements
[email protected]
Gerard S. Goh
[email protected]
Matthew W. Lukies
[email protected]
1 Department of Radiology, Alfred Health, 55 Commercial
Road, Melbourne, VIC 3004, Australia
2 Department of Surgery, Monash University School of
Translational Medicine, Melbourne 3004, Australia
3 National Trauma Research Institute, Melbourne 3004,
Australia
4 Department of Medical Imaging, Monash Health, Melbourne,
Australia
123
Cardiovasc Intervent Radiol (2025) 48:583–584
https://doi.org/10.1007/s00270-024-03949-w
understood and acknowledged by non-IR stakeholders in
this clinical space.
There are both advantages and disadvantages to UAE,
and when considering future pregnancy it is always
important to consider the context of invasiveness, recovery,
time in hospital, and rate of complications of which dif-
ferent women value these uniquely. There are several
studies which show a higher rate of re-intervention after
UAE than for surgery, even though quality of life scores
may be similar [ 5]. We have to also acknowledge the
evolving unknowns such as the long-term impacts of per-
manent particles in the myometrium, similar to how our
understanding of the risks of myometrial scarring after
myomectomy or after caesarean section are also evolving.
These issues highlight the importance of the mandated
clinical outpatient IR consultation, including discussion
about obstetric history and desire for future pregnancy. The
content of that discussion should be framed around current
evidence, so that every patient is informed and able to
make her own decision based on the best available data.
While patient selection for UAE and informed consent
remain important topics, IRs must change their language to
reflect currently available level 1 evidence which supports
pregnancy after UAE at a similar rate to background age-
matched population and to women post-myomectomy. All
IRs have a mandate to end the concept that we only treat
peri-menopausal patients. In 2024, the pregnancy myth is
busted.
Funding This study was not supported by any funding.
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical Approval For this type of study ethical approval is not
required.
Informed Consent For this type of study formal consent is not
required.
Consent for Publication For this type of study, consent for publi-
cation is not required.