Pregnancy and Uterine Artery Embolisation: Myth Busted

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 Looking at our own unpublished data, the mean age of 46.2 years in our cohort reinforces the notion that referrals are being selected, despite a legal and ethical requirement for UAE to form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.

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