Sepsis following hysteroscopic myomectomy.

Hysteroscopy and hysteroscopic myomectomy in general have low complication rates. Two patients underwent hysteroscopic myomectomy for prolapsing submucous myomas after UAE. The onset of prolapsing myoma occurred at varying times between completion of UAE and myomectomy, resulting in bacteremia for both patients. In Case 1, the patient recovered with intravenous antibiotic treatment. However, the patient in Case 2 had status improvement after undergoing an abdominal myomectomy, explorative laparotomy for removal of a necrotic myoma. Our two patient cases serve as a caution to clinicians regarding the rare incidence of septicemia occurring in patients undergoing hysteroscopic myomectomy with prior UAE treatment for prolapsing myomas.

Pain after uterine artery embolization with intrauterine device in situ.

Uterine artery embolization (UAE) is a minimally invasive option for females with symptomatic leiomyomas. Studies detailing a possible risk with an intrauterine device (IUD) in situ during UAE are limited. A 43-year-old female (Gravida 2, Para 2) underwent UAE with an IUD in situ. On post-procedure day 2, the patient presented with severe lower abdominal pain and mild leukocytosis. Following removal of her IUD, the patient experienced immediate pain relief. Caution is given to clinicians who wish to perform UAE with an IUD in situ.

Cervical intraepithelial neoplasia grade 3 in a patient following Gardasil vaccination.

Essentially all cervical dysplasia is caused by human papilloma virus (HPV). Three HPV vaccines have been available, with Gardasil-9 being the most recently approved in the USA. Gardasil-9 covers high-risk HPV strains 16, 18, 31, 33, 45, 52 and 58 as well as low-risk strains 6 and 11. A 33-year-old woman (Gravida 2, Para 2) received Gardasil in 2006. Subsequently, her pap smear revealed low grade squamous intraepithelial lesion. Cervical biopsies performed in 2015 and 2016 revealed cervical intraepithelial neoplasia grade 1 (CIN 1). She underwent loop electrosurgical excision procedure for persistent CIN 1, which demonstrated CIN 3. Genotyping revealed HPV type 56 infection. The advancement of Gardasil-9 vaccine only offers 90% protection to patients against HPV-related disease. Lay literature may mislead patients to think they have no risk of HPV infection.

Anti-Müllerian hormone levels before and after uterine artery embolization.

OBJECTIVE: To determine the effects of uterine artery embolization (UAE) on ovarian reserve as measured by Anti-Müllerian hormone (AMH) levels. MATERIAL AND METHODS: Non-randomized, observational study of 89 women 23-40 years of age who received UAE. Control hormone levels were measured prior to UAE and the first post-embolization measurement was taken at various times post-procedure (mean = 190 ± 229 days). RESULTS: Historical work verified by our earlier work has shown that AMH levels decline with age. Regression analysis allows us to determine whether UAE contributes to a greater decline in AMH values over that naturally occurring with aging. The effect of the procedure was found to contribute no deleterious effect to the natural decline in AMH levels. In addition, multiple blood draws were obtained from 32 patients up to 47 months post-UAE. Regression studies with these patients as their own controls showed no long-term diminishment of ovarian reserve due to the UAE procedure. CONCLUSIONS: Earlier reported data are consistent with larger sample size. UAE does not affect ovarian reserve in women <40 as evidenced by no significant change in AMH levels after embolization. Women who are of reproductive age and have uterine fibroids can consider UAE without concern for adverse effects on their fertility.

Pregnancy after uterine artery embolization using Gelfoam™.

We present a case study of a patient who underwent uterine artery embolization (UAE) using Gelfoam™ (Pfizer, New York, NY, USA) and had a subsequent pregnancy. Our patient, a 38-year-old female (4 Gravida/2 Para), underwent UAE for treatment of symptomatic myoma in September 2005. At the patient's seven-month post procedure visit, she experienced a 43.9% volume reduction in uterine size and 74.5% reduction in volume of the largest fibroid and relief of bulk symptoms and menorrhagia. The patient had a term delivery of healthy twin infants 15 months post embolization.

Fertility after uterine artery embolization: a review.

Uterine artery embolization (UAE) research has largely been focused on women over 40 years, yet women of reproductive age undergo UAE without any increased morbidity. Some physicians refrain from recommending UAE to women in this age group because of some research findings showing a negative effect on fertility. This review presents a comprehensive discussion of the fertility potential of women undergoing UAE, in terms of pregnancy rates and complications as well as ovarian function and reserve. Findings indicate many benefits for women desiring fertility who undergo UAE over traditional myomectomy.

The effectiveness of combined abdominal myomectomy and uterine artery embolization.

OBJECTIVE: To evaluate the efficacy of abdominal myomectomy after uterine artery embolization (UAE-AM) among patients with myomas. METHODS: In a retrospective study, chart data were reviewed for patients attending a center in California, USA, who underwent UAE-AM between 1999 and 2012. Patients had been offered the combined procedure if the diameter of the myoma was at least 4cm, they wished to preserve fertility, or they were candidates for a traditional abdominal myomectomy. Estimated blood loss, fluoroscopy times, and hospital stay were recorded. Follow-up data on uterine volume and fibroid size had been collected via magnetic resonance imaging or ultrasonography approximately 3-6 months after UAE-AM. RESULT: Overall, 20 patients underwent UAE-AM. Approximately 6 months after the procedure, the mean decrease in uterine volume was 77.33%±14.25% and that in myoma diameter was 46.45%±25.61%. Six women subsequently became pregnant; one patient had two separate pregnancies. No patient required a conversion to hysterectomy or blood transfusion, and no recurrences were reported. CONCLUSION: UAE-AM was found to be an effective option available to women with large myomas who wished to preserve their uterus. With the combination procedure, patients had favorable outcomes with no fibroid recurrence.

Anti Müllerian hormone levels before and after uterine artery embolization: A preliminary report.

OBJECTIVE: To determine the effects of uterine artery embolization on Anti-Müllerian hormone levels for women under 40 years of age. MATERIAL AND METHODS: Non-randomized, observational study of women under 40 years of age and who received UAE. Twenty-seven women under the age of 40 who underwent UAE were included in the study. Hormone levels were measured prior to UAE, and at least six months post UAE. RESULTS: Statistical analysis from a paired t-test showed that the AMH levels pre- and post-embolization of these women fell within the normal range. The average AMH level prior to embolization was 2.54 ± 3.99 ng/mL. The mean AMH concentration after embolization was 2.33 ± 2.70 ng/mL. The average change in AMH levels between pre-and post-embolization was -0.21 ± 1.08 ng/mL. There is no statistically significant difference between the pre- and post- UAE AMH levels (95% CI -0.64 to 0.22, p=0.32). CONCLUSION: UAE does not affect ovarian reserve in women under 40 as evidenced by no significant change in AMH levels before and after embolization. Women who are of reproductive age and have fibroids can consider UAE without concern for adverse effects on their fertility.

Combined myomectomy and uterine artery embolization.

UNLABELLED: Objective: To evaluate the safety and efficacy of uterine artery embolization combined with endoscopic myomectomy. MATERIAL AND METHODS: We conducted a retrospective chart review of patients (n = 125) who underwent myomectomy concurrent with embolization within one month. We assessed two groups: 1) uterine artery embolization followed by hysteroscopic myomectomy and 2) uterine artery embolization followed by laparoscopic myomectomy. RESULTS: Following the combination procedures, 72% of the surveyed women reported symptom improvement. With the combined procedures, 92.5% of patients experienced reduction in myoma diameter and 87.5% of patients had decreased uterine size after an average of 4.70 months post subsequent procedure. The amount of decrease in the uterine volume (p = 0.39) and fibroid size (p = 0.23) were not significant between the two endoscopic myomectomy groups. CONCLUSIONS: Combining myomectomy with uterine artery embolization is a safe and effective procedure in treating symptoms and reducing myoma and uterine volumes.

Results of UAE in women under 40 years of age.

OBJECTIVE: To evaluate the success rate of uterine artery embolization for leiomyomata for women under 40 years of age. MATERIAL AND METHODS: This observational study of fibroid treatment in women under 40 years of age at the time of procedure was conducted at a private practice located in Los Angeles, CA. One hundred and four patients participated in the study. The study involved a pre- and post- UAE survey of symptoms evaluated on a scale of mild, moderate, or severe. The post UAE assessment also involved an indication of whether the patients would recommend UAE. Patients were surveyed concerning subsequent pelvic surgery and pregnancy. RESULTS: Comparison of pre- and post- survey data resulted in an overall success rate of 90.4% based on relief of symptoms. Patients reported no late onset failures. Several patients underwent full-term pregnancies. 6.7 % of patients underwent abdominal myomectomy following UAE. No patient underwent hysterectomy. CONCLUSION: No significant difference exists in the success rate of UAE for women under 40 and the entire cohort of women undergoing UAE. UAE is a suitable form of treatment for women in this age group.

Ovarian reserve following uterine artery embolization in women of reproductive age: a preliminary report.

OBJECTIVE: To evaluate the effect of uterine artery embolization (UAE) for leiomyomata on reproductive potential for women in their reproductive age group. MATERIAL AND METHODS: This non-randomized, cross-sectional, observational study of ovarian reserve in women under 40 years of age who underwent UAE was conducted at a private practice located in Los Angeles, California. Twenty four women under 40 years of age who underwent UAE at least four months prior to study interventions were recruited. The study involved a one-time serum blood test on day three of the menstrual cycle and measured early follicular phrase follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH) and estradiol (E2) levels. RESULTS: Descriptive analysis showed means of all outcome measures were within normal range of values [FSH = 6.67IU/L (SD = 2.3), AMH = 1.24 ng/ml (SD = 0.9), E2 = 58.8 pg/ml (SD = 18.0)]. CONCLUSION: Hormonal findings from this study were within normal ranges, suggesting that ovarian function is not adversely affected by UAE. Women with fibroids within reproductive age may consider UAE as a treatment option.

Pregnancy following uterine artery embolization: an update.

OBJECTIVE: This paper seeks to evaluate the ability to conceive and deliver term pregnancies following uterine artery embolization. METHODS: We conducted a retrospective chart review of patients under the age of 40 who indicated a desire for fertility prior to embolization. Patients were questioned regarding attempts to conceive, subsequent pregnancies, and outcomes of those pregnancies. Patients who identified fertility as a desired outcome were studied. All patients who conceived were asked about the details of the pregnancy. RESULTS: Forty-four women under the age of 40 embolized between 1996 and 2010 stated a desire for fertility. Twenty-two of these women have reported 28 pregnancies. Of these pregnancies, 20 live births, three miscarriages, and three instances of premature labor were reported. Seventeen of these pregnancies were delivered by caesarean section and six pregnancies were vaginal deliveries. And one woman is currently pregnant. No perfusion problems, either during pregnancy or labor, were reported. CONCLUSION: The course of pregnancy and delivery was largely normal after embolization with three cases of premature labor and three miscarriages reported. Forty-eight percent of women who were under 40 and desired pregnancies were able to have successful term pregnancies.

Repeat uterine artery embolization following technical failure.

This retrospective chart review was performed to evaluate the success of uterine artery embolization performed in two sessions due to initial technical failure. Patients undergoing embolization for symptomatic uterine myomata between 1997 and 2007 were included in the study. Patients who initially suffered unilateral technical failure were offered repeat embolization. This group was contrasted with patients who underwent bilateral embolization during the initial procedure. Success was defined as relief of symptoms based on pre- and post-procedure questionnaires, and/or > 30% shrinkage of the largest myoma. During the study period, 1078 uterine artery embolization procedures were performed. 1024 (94.9%) were initial bilateral procedures; 34 (3.2%) were unilateral procedures due to technical failure and 20 (1.9%) were unilateral procedures due to anatomical reasons. Twenty-two of the patients who experienced technical failure elected to undergo a repeat procedure. Sixteen patients who underwent repeat embolization were available for review. Eleven patients underwent post-embolization imaging; seven (63.6%) had successful shrinkage of the largest myoma. Three patients underwent post-embolization magnetic resonance imaging evaluation; none demonstrated enhancement of myomata. Fifteen patients completed questionnaires, fourteen (93.3%) reported symptom relief. Seven hundred and thirty-one of the patients who underwent initial bilateral embolization during the study period were available for review. Of the 582 patients with imaging data, 376 (64.6%) had successful shrinkage of the largest myoma. All 731 patients completed questionnaires. 728 patients (99.6%) reported symptom relief. Two-step bilateral embolization seems to be an effective management option after technical failure.

Three-dimensional reconstruction of the uterine vascular supply through vascular casting and thin slice computed tomography scanning.

It was the objective of this study to construct a model of the uterine vascular supply through vascular casting and thin slice computed tomography scanning. This will provide a teaching aide for the understanding of uterine artery embolization (UAE) procedures, as well as normal uterine and ovarian arterial anatomy. Using 20% chlorinated poly vinyl chloride, we infused and cast a set of a normal uterus, vagina and bilateral adnexa through the uterine artery and ovarian artery. After thin slice CT scanning, we obtained the three-dimensional (3D) reconstruction by maximum intensity projection (MIP) and surface-shaded display (SSD), and then observed its figure and characteristics. A model of the uterine vascular supply can be successfully reconstructed by vascular casting and thin slice CT scanning. The 3D reconstruction offers a clear view of the course of the uterine artery and its blood supply distribution. It has two major branches: The intramuscular uterine branch and the cervicovaginal branch (1). Blood supply is generally unilateral, with communicating branches between the two sides and possible anastomoses between the arterial blood supply of the uterus and the ovaries. The major blood supply of the cervix comes from the cervicovaginal branch of the uterine artery, while the vaginal arterial supply derives directly from the internal iliac artery. The CT technique allows real-time 360 degrees rotation and changes in model for in-depth study of the vascular network and its adjacent tissues. It is possible to construct an in vitro uterine arterial network by vascular casting and CT scanning, which can provide unique insight into the female genitourinary system arterial network. Based on this, we can create reconstructions as well as models for different diseases such as leiomyomata, adenomyosis, and endometrial cancer. These models will provide morphological evidence to the interventional therapy and UAE teaching in Obstetrics and Gynecology.

Computed tomography angiogram for failed uterine artery embolization.

It was the aim of this study to discuss the efficacy of computed tomography angiography after failed uterine artery embolization. We performed a review of cases where embolization of myomata failed to relieve symptoms, or shrink myomata. If MRI showed continued uptake, patients were offered CT angiograms to better direct therapy. Repeat embolization details were compared with findings on CT angiogram. During the study, 675 patients underwent uterine artery embolization. 229 patients underwent follow-up MRI with intravenous contrast, 29 of which showed persistent uptake into myomata. Twelve patients had CT angiogram of the abdomen following MRI and six elected to undergo repeat UAE after CT angiogram. There was a 75% concurrence between CT angiograms and live studies (angiogram during repeat uterine artery embolization). With CTA, five patients showed a unilateral non-uterine blood supply, one showed a bilateral non-gonadal supply to the uterus, and two showed a normal blood supply, with all but two cases confirmed on live angiogram. Based on post-repeat MRI, one of the six repeat UAE patients shows no continued uptake of intravenous contrast to myomata. Four show continued uptake, however, one patient did show decreased size of myomata. CT angiography is a valuable tool to identify collateral and persistent uterine artery supply, and offers great potential for accurate identification and evaluation of extra-gonadal supply to the uterus. It will allow for pre-operative planning, as well as discussion of risks and benefits with patients.

Collateral supply to uterine leiomyomata from an unnamed vessel: a case report.

Uterine leiomyomata are most often supplied solely by the uterine arteries. However, myomata have been reported to recruit collateral supply, usually from the ovarian arteries, which may contribute to clinical failure of uterine artery embolization. This case report describes a patient in whom a uterine myoma developed collateral supply de novo. The aberrant vessel was identified using computed tomographic angiography (CTA) and was selectively occluded in a successful embolization procedure.