PREGNANCY AFTER UTERINE FIBROID EMBOLIZATION ( UFE)

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

2. 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

3. UTERINE FIBROIDSCLINICAL PRESENTATION • HEAVY MENSTRUAL BLEEDING • PELVIC PAIN • A CAUSE OF INFERTILITY OR SPONTANEOUS ABORTION • ASYMPTOMATIC

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

5. 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

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

7. 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

8. 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)

9. 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

10. 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!

11. 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

12. 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”

13. 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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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%)

22. TREATMENT PERFORMED OR OFFERED TO OUR PREGNANT WOMEN • PERFORMED: • 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

23. 5 PREGNANT WOMEN. WHOSE PREGNANCY WAS POSSIBLE ONLY AFTER UFE

25. 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