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Hysteroscopy after uterine fibroid embolization:Evaluation of intrauterine findings in 127 patients jog_1782 823..831

Michal Mara1, Petr Horak1, Kristyna Kubinova1, Pavel Dundr2, Tomas Belsan3 andDavid Kuzel1

1Department of Obstetrics and Gynecology and 2Institute of Pathology, First Faculty of Medicine, Charles University andGeneral Faculty Hospital, and 3Department of Radiology, Central Military Hospital, Prague, Czech Republic

Abstract

Aim: Several atypical hysteroscopy findings have been described in association with uterine artery emboliza-tion (UAE). The purpose of this study was to evaluate the types and frequency of these findings in the largestpublished series of patients.

Material andMethods: Premenopausal patients after bilateral UAE for symptomatic intramural fibroid under-went subsequent hysteroscopic examination 3–9 months following UAE. The uterine cavity was examinedwith focus on specific post-embolization changes. Biopsy of endometrium was obtained and evaluatedtogether with a biopsy of abnormal foci if present.

Results: UAE was performed in a total of 127 women with an average size of dominant fibroid 63.1 mm indiameter and an average patient age of 35.1 years. Even though the majority of patients were asymptomaticat the time of hysteroscopy (78.0%), the post-embolization hysteroscopic examination was normal in only51 patients (40.2%). The most frequent abnormalities included tissue necrosis (52 women, 40.9%), intracavitarymyoma protrusion (45 women, 35.4%), endometrium ‘spots’ (22.1%), intrauterine synechiae (10.2%) and‘fistula’ between the uterine cavity and intramural fibroid (6.3%). Histopathological examination showednormal, secretory or proliferative endometrium in 83.5% patients. Necrosis and/or hyalinization prevailed inthe results of biopsy of abnormal loci (45 cases, 35.4%).

Conclusion: Frequency of abnormal hysteroscopic findings several months after UAE for primary intramuralmyomas is high. Alarmingly high is the percentage of patients with a histopathologically verified necrosis.Performing hysteroscopy in selected patients after UAE is necessary before eventual surgical re-intervention,especially in women with reproductive plans.

Key words: endometrium, histopathology, hysteroscopy, necrosis, uterine artery embolization, uterinefibroid.

Introduction

In present society there is a trend to delay pregnancy

towards later age in women. It is accompanied with anincreasing incidence of uterine fibroids, which maycause infertility or contribute to severe complicationsduring pregnancy and delivery. Conservative, uterus-

sparing therapy is thus undoubtedly an up-to-datetopic.

Uterine artery embolization (UAE) is one of the

conservative treatments of uterine fibroids.1–3

Eventhough it is considered a minimally invasive therapy,it bears many possible complications, which can beserious, especially in women with reproductive plans.

Received: January 9 2011.Accepted: September 17 2011.Reprint request to: Dr Kristyna Kubinova, Department of Obstetrics and Gynecology, Charles University, Apolinarska 18, 128 00Prague, Czech Republic. Email: [email protected]

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doi:10.1111/j.1447-0756.2011.01782.x J. Obstet. Gynaecol. Res. Vol. 38, No. 5: 823–831, May 2012

© 2012 The Authors 823 Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology



Compared to infection and ovarian failure, which isseen rarely in patients younger than 40 years of age,intrauterine macroscopic as well as histopathologicalabnormalities are observed more frequently using hys-teroscopy and uterine cavity biopsy.4–9 The presence of intrauterine pathologies might be associated withhigher risk of early pregnancy loss in patients afterUAE .10–12 The aim of the present study was to examinethe frequency and type of post-embolization hystero-scopic findings in a large and homogenous group of patients.

Material and Methods

Study design and recruitment of patients

A prospective observational cohort study was con-ducted in the Endoscopic Department of the UniversityTeaching Hospital. The indication for UAE was the

presence of symptomatic intramural fibroid or mul-tiple myomas (the dominant fibroid in intramural loca-tion) in patients who refused hysterectomy forreproductive or other reasons. Patients with furtherfertility plans were offered UAE only in cases not eli-gible (based on our best expert opinion) for standardtreatment (i.e. myomectomy). All candidates for UAEwere screened by vaginal and abdominal Dopplerultrasound (USG) examination and contrast-enhancedmagnetic resonance imaging (ceMRI). All examinationswere performed using one device (USG SiemensAcuson Antares, Siemens Medical Solutions, Malvern,

PA, USA, with vaginal probe at frequency 4–9 MHz,and abdominal probe at frequency 2–6 MHz; ceMRI onSigna Excite II (1.5 Tesla, General Electric, Milwaukee,WY, USA) by one gynecologist experienced in ultra-sonography and one radiologist experienced in gyne-cological indications for MRI. For the study purposesthe size and location of the dominant fibroid was deter-mined by USG, which is still more available and usedin clinical practice than MRI. The structure of thefibroids, their vascularization and relation to theuterine cavity, as well as the number of myomas wasdetermined by ceMRI, which is a more accurate andreliable method of assessing these parameters than

USG.13

All patients were fully informed of the principals andpurposes of UAE and hysteroscopy, as well as of pos-sible adverse effects and complications related to bothprocedures. The patients were also informed of thecharacter and goal of the study. All patients signed aninformed consent form for both procedures and par-ticipation in the study, and were also informed that

they could terminate their participation in the study atany time without stating a reason. The study wasapproved by The Institutional Review Board of theFirst Medical Faculty of Charles University in Prague.

Inclusion and exclusion criteria

Women between 18 and 45 years of age with a domi-nant intramural fibroid measuring 20–120 mm wereincluded in the study. Only patients wishing to pre-serve their uterus were included. Patients wereexcluded if they were completely asymptomatic, pre-ferred surgical treatment, had mainly subserous or sub-mucous location of dominant fibroid (all cases withany extent of intrauterine protrusion of the fibroid –according to pre-UAE ultrasound, MRI or hysteros-copy – were excluded) or with avascular dominantfibroid, had been diagnosed with adenomyosis (con-firmed by ceMRI), were suspected to have pelvic

malignancy, did not wish to undergo UAE or hysteros-copy, or who refused to participate or terminated theirparticipation in the study.

Uterine artery embolization

All of the embolizations were performed by one inter-ventional radiologist experienced in pelvic interven-tions. UAE was performed through the right femoralartery. First, local anesthesia was injected into the skinoverlying the femoral artery on the right groin. Theartery was then punctured and a microcatheter wasadvanced inside the ascending branch of the uterine

artery. Embolization was performed under skiascopicguidance using tris-acryl gelatin particles that were500–1200 mm in size. Free-flow embolization techniquewas used with a 5-F catheter (RUC, COOK, WilliamCook Europe, Bjeeverskov, Denmark). The interventionwas terminated when complete ischemia of the domi-nant fibroid was achieved maintaining a free flow inthe main branch and cervico-vaginal branches of theuterine artery.14 Following the procedure patientsreceived either intravenous opioid analgesia or epidu-ral anesthesia (sufentanyl) and a single dose of intra-venous antibiotics (sultamicillin 1.5 g) and alternativelyother analgesics, antiemetics and antipyretics if

needed. After UAE patients were observed for 24–48 hin the gynecological ward.

Hysteroscopy

Hysteroscopy was scheduled for the secretory phase of the cycle. The endometrium sample was always evalu-ated by a histopathologist related to the stated phase of the cycle. At the time of hysteroscopy patients received

M. Mara et al.

824 © 2012 The Authors Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology



a simple ‘yes/no’ questionnaire on myoma-relatedsymptoms. In cases of a positive answer, patients wereasked to state if these symptoms were of the sameintensity, worse, or better than before UAE.

Hysteroscopy was performed 3–9 months followingUAE by the same gynecologist specialized in gyneco-logical endoscopy. Hysteroscopy was performed witha 3.2-mm rigid hysteroscope with a direct opticalsystem and with 7-F bioptic forceps (Versascope, Gyn-ecare, Ethicon, Johnson and Johnson, Somerville, NJ,USA). Normal saline solution was used as distensionmedium. Pre-procedurally patients received 100 mgindomethacin suppository unless they had an allergyto indomethacin or a history of asthma. The procedurewas performed without anesthesia or with a paracervi-cal block with 8 mL 0.5% bupivacain or under a shortgeneral anesthesia using propofol 1.5–2 mg/kg andremifentanyl 0.1–0.5 ug/kg/min. Patients who did not

receive general anesthesia were discharged shortlyafter the procedure, other patients were discharged4–6 h after hysteroscopy.

The main objectives of hysteroscopy were to: (i)evaluate the symmetry of the uterine cavity; (ii) macro-scopically evaluate the endometrium (thickness andcolor); and (iii) assess intrauterine abnormalities (if detected), such as intracavitary protrusion of myomaand its appearance, signs of regressive changes of thetissues inside the cavity, color abnormalities of theendometrium, signs of fistula (communication

between the cavity and the fibroid localized intramu-

rally), and synechiae. Based on our experience from aprevious study6 the evident signs of regressive changes(necrotic appearance of the fibroid protruding in orcommunicating with the uterine cavity) and the indi-rect signs of regression (distinct abnormalities inendometrium appearance, mucometra) were differen-tiated. Mere yellowish or dark coloring of small regionsof the endometrium (‘spots’) of an otherwise normalappearance were classified as a slightly abnormalfinding and not as a sign of tissue regression; and (iv)endometrial biopsy, plus biopsy of the abnormal foci inthe uterine cavity (if detected).

All the specimens were evaluated by one histo-

pathologist. The material was routinely processed and astandard histopathological evaluation was performedwith a description of the following: type of tissue(endometrium, including specification of its phaserelated to the cycle, myometrium, or myoma), and typeof any abnormality if present (necrosis and type,inflammation, and presence and localization of embo-lization particles).

Results

The study was conducted between June 2004 and Feb-ruary 2009. Based on inclusion and exclusion criteria atotal of 127 patients were enrolled. The total number of patients screened for the study was 162; 35 women met

the exclusion criteria and were not enrolled in thestudy, most frequently due to preference of anothertreatment alternative (19 patients) or submucosal loca-tion of myoma on MRI (11 patients). The characteristicsof the group are shown in Table 1.

Thirty-one patients (24.6%) underwent hysteroscopicexamination before UAE for hypermenorrhea or men-orrhagia (as requested by their private gynecologist) torule out uterine malignancy: all macroscopic and his-topathological findings were evaluated as normalexcept for nine patients (29.0%) with the cavitydescribed as slightly asymmetrical or dislocated possi-

bly due to presence of intramural myoma/s. There wasno case of intracavitary myoma protrusion, signs of regressive changes (in comparison with 11 patientswith histologically proven necrosis and/or hyaliniza-tion on post-UAE hysteroscopy, P < 0.001, c2 test), syn-echiae or other abnormalities later described in post-UAE hysteroscopy. The comparison of post-UAEhysteroscopic findings in two subgroups of patientswith pre-UAE hysteroscopy (with and withoutasymmetry of the uterine cavity) is presented inTable 2.

In 123 patients (96.9%) UAE was performedbilaterallyachieving complete ischemia of significant fibroids.Only in four women (3.1%) UAE was performed unilat-erally due to the presence of utero-ovariananastomoses.The radiologist did not perform embolization on the

Table 1 Baseline data of 127 patients undergoing hyst-eroscopy after uterine fibroid embolization

Mean age 35.1 years (20–46)Nulliparous women 67 (52.8%)Women wishing to retain fertility 93 (73.2%)Mean diameter of dominant

fibroid USG

63.1 mm (20–107)

†Mean number of fibroids

ceMRI

1.6†Patients with solitary myoma ceMRI 97 (76.4%)†Patients with 2–5 myomas ceMRI 25 (19.7%)†Patients with 6 myomas or

more ceMRI

5 (3.9%)

‡Patients with asymmetrical ordislocated uterine cavity ceMRI

65 (51.2%)

†Only myomas20 mm considered; ‡Without notable intrauter-ine prominence of myoma. USG base on ultrasonography,ceMRI base on contrast-enhanced magnetic resonance imaging.

Hysteroscopy after fibroid embolization




side of the anastomosis to prevent non-target emboliza-tion of the ovary. No serious complication associatedwith UAE (peri-procedural arterial injury, groinhematoma, deep venous thrombosis, significant pelvic

organ inflammation, sepsis, amenorrhea, hysterec-tomy) was observed. Six patients (4.7%) were hos-pitalized for more than 48 h due to protractedpost-embolization syndrome (pelvic pain, low-gradefever, generalized malaise). Only four (3.1%) patientswere re-admitted for transcervical myoma expulsion10, 11, 56, and 61 days after UAE (all before hysteros-copy). These patients presented with fever, pelvic painand elevation of serum inflammatory markers and werehospitalized and treated with intravenous antibiotics.All these patients were discharged within 72 h. Fourother patients experienced uncomplicated transcervical

myoma expulsion not requiring re-admission. Histo-pathological examination revealed complete necrotictissue of probably primarily leiomyoma in all of thesecases. In seven of these eight women, USG and ceMRIperformed pre-UAE showed asymmetry or dislocationof the uterine cavity by the myoma (however, withabsence of intracavitary myoma protrusion); one of thepatients underwent hysteroscopy before UAE withentirely physiological finding.

Hysteroscopy was performed as scheduled in all 127patients with the exception of nine women who wereexamined between days 10 and 15 of the cycle due tocycle irregularities. In 107 patients (84.3%) office hyst-

eroscopy was performed without the need for anyanesthesia, in 16 cases general anesthesia was usedand four patients required paracervical block. Theaverage interval between UAE and hysteroscopy was5.5 months. Ninety-nine patients (78.0%) were com-pletely asymptomatic at the time of hysteroscopy, andonly nine women (7.1%) reported myoma-relatedsymptoms to be the same or worse than before UAE.

Post-UAE hysteroscopic findings are shown andsub-classified in Table 3. Symmetric uterine cavity waspresent in 76 cases (59.8%), bilaterally visible ostium of fallopian tubes in 88 (69.3%) and normal, pinkish

homogenous endometrium in 106 (83.5%). The mosttypical abnormal finding after UAE was macroscopicsign of necrosis presenting as necrotic appearance of myoma (protruding into or communicating with thecavity – Fig. 1), or as mild, less-pronounced forms (so-called indirect signs of regression), where yellowish-whitish colorings cover larger area of the cavity, oftenwith a presence of thick mucus. One of the above-listedsigns of necrosis was present in 52 cases (40.9%). In 55women (43.3%) more than one intrauterine abnormal-ity was described.

In 28 patients hysteroscopy was followed by hystero-

scopic surgical intervention. In seven cases a simpleadhesiolysis of filmy adhesions was performed by blunt dissection using hysteroscope and distensionmedia. Dense adhesions that had to be lysed with scis-sors were present in six cases. In 15 patients (11.8%)myoma with more than 50% intracavitary protrusionwas resected under general anesthesia using a 8.5-mmrigid resectoscope, bipolar loop, and normal salinesolution for distension. The other 16 patients withreproduction plans who showed severe intrauterinepathology were referred for open or laparoscopic myo-mectomy. Of seven patients in whom hysteroscopy waspreceded by transcervical myoma expulsion (in one

patient expulsion occurred after hysteroscopy), twopatients had normal hysteroscopic finding, four pre-sented with mild abnormalities, and one with a residueof necrotic myoma protruding into the cavity, whichwas resected with bipolar loop.

Histopathological findings of endometrial biopsy aresummarized in Table 4. Morphologically normalendometrium was documented in 106 patients (83.5%).

Table 2 Correlation of pre-uterine artery embolization (UAE) and post-UAE hysteroscopic findings in 31 patients withpre-UAE hysteroscopy

Pre-UAE hysteroscopy Normal findingon post-UAEhysteroscopy

Minorabnormalitieson post-UAEhysteroscopy

Majorabnormalitieson post-UAEhysteroscopy

Necrosis and/orhyalinizationverified bypost-UAE

hysteroscopic biopsy

Normal finding (22 pts) 11 (50.0%) 8 (36.4%) 3 (13.6%) 6 (27.3%)Asymmetrical uterine

cavity (9 pts)2 (22.2%) 2 (22.2%) 5 (55.6%) 5 (55.6%)

P-value NS NS 0.05 NS

Tested by Fisher’s test. NS, statistically non-significant; pts, patients.

M. Mara et al.




In four patients histopathological findings were altered by hormonal therapy used by the patients against ourinstructions (oral contraceptives and nasal GnRH ago-nists in one, and Norethisteron orally in two patients).In six cases the histopathological examination showedregressive changes of the tissue (without furtherspecification). In one case biopsy was not performed

due to the patient’s discomfort and refusal of generalanesthesia.

Myoma necrosis dominated the biopsies from theatypical intrauterine findings (Table 5), and waspresent in a total of 42 cases, which represent 55.3% of patients with hysteroscopic abnormalities (both minorand major), and 33.1% of all patients respectively. Thecharacteristic type of necrosis in patients after UAE was

hyaline necrosis (37 cases), in two cases the resultsshowed mixed type (hyaline and coagulation orhyaline plus suppurative), two cases of suppurativeand one of coagulation necrosis. Embolization particles

Figure 1 Communication (fistula) between intramuralnecrotic myoma and uterine cavity (hysteroscopy).

Table 3 Hysteroscopic findings of 127 women afteruterine artery embolization (UAE)

I. Patients with normal finding 51 (40.2%)II. Patients with minor abnormalities 43 (33.8%)

1 abnormal finding 21Combination of 2 or more

abnormalities

22

Abnormal findings in this groupIntrauterine signs of necrosis 20

Pronounced (evident) 11Mild (indirect) 9

Spots on endometrium 15Yellowish 14Dark (brownish) 1

Mild intracavity protrusion of myoma 15Adhesions 7

Intrauterine filmy 3Intrauterine dense 3Intracervical filmy 1

Petite fistula (communication betweenmyoma and cavity)

2

III. Patients with major abnormalities 33 (26.0%)1 abnormal finding 0Combination of 2 or more

abnormalities33

Abnormal findings in this groupIntrauterine signs of necrosis 32

Pronounced (evident) 32Mild (indirect) 0

Protrusion of myoma into the cavity 30Pronounced 27Mild 3

Spots on endometrium 13Yellowish 12Dark (brownish) 1

Large fistula (communication between

myoma and cavity)

6

Adhesions 6Intrauterine filmy 3Intrauterine dense 3

Table 4 Histopathological results from hysteroscopicendometrial biopsy from 127 patients after uterineartery embolization (UAE)

Normal secretory endometrium 83 (65.4%)Proliferative endometrium 23 (18.1%)Unspecified corporal endometrium

(sample of the tissue too small)

7 (5.5%)

Regressively changed tissue only(vital endometrium not found)

6 (4.7%)

Hypoproliferative, dysfunctionalor inactive endometrium(in patients with hormonal therapy)

4 (3.1%)

Dysfunctional endometrium 2 (1.6%)Hyperplastic endometrium 1 (0.8%)Not taken 1 (0.8%)

Table 5 Histopathological results of biopsies from 76patients with hysteroscopic abnormalities

Regressive changes of tissues 45 (59.2%)

Necrosis 32Hyalinization and necrosis 10Hyalinization without necrosis 3

Other findings (without regressivechanges)

30 (39.5%)

Normal endometrium 26Myometrium or normal (vital)

leiomyoma (impossible to differentiate)3

Chronic endometritis 1Not taken 1 (1.3%)





were found in six patients (4.7% of all patients): fourtimes in the myoma, once in the endometrium andonce in the myometrium. Histopathological signs of inflammation were present in seven cases (5.5%): fivetimes described as endometritis and twice as pro-nounced multiplication of polymorphonuclei insidethe embolized myoma.

Tables 6 and 7 show the correlation betweenimaging, hysteroscopic, and histopathological find-ings. Regressive changes (necrosis and/or hyaliniza-tion) as well as embolization particles (Fig. 2) werehistopathologically diagnosed in a significantly higherpercentage of patients with severely abnormal hystero-scopic finding. In contrast, normal endometrium wasdescribed more often in patients with normal hystero-scopic finding. Finally, asymmetry or dislocation of theuterine cavity described on pre-UAE MRI predictedsignificantly higher risk of abnormal hysteroscopic

finding after UAE.

Discussion

UAE is an attractive minimally invasive alternative tosurgical treatment of leiomyomata. The advantages of

UAE are that there is no injury to the abdominal wall,no general anesthesia, and involves a shorter hospitalstay and recovery time.15–17 Unlike surgery, UAE is notlimited by obesity, previous abdominal surgeries, or

Figure 2 Leiomyoma with embolization particles (trisacryl gelatin microspheres) located outside the vesselsin fibrous tissue. Note the regressive changes (hyalin-ization) on the right side (HE ¥40).

Table 6 Comparison of three subgroups of patients (divided by post-uterine artery embolization (UAE) hysteroscopicevaluation) with regard to the results of imaging studies

Evaluation of post-UAE hysteroscopy Patients withasymmetricaluterine cavity

(pre-UAE MRI)†

Mean sizeof dominantmyoma in mm

(pre-UAEultrasound)‡

Meannumber of myomas

(pre-UAEMRI)‡

Mean sizeof dominantmyoma in mm

(post-UAEultrasound)‡

Normal finding (51 pts) 19 (37.3% of 51 pts) 61.0 1.4 44.7Minor abnormalities (43 pts) 24 (55.8% of 43 pts) 62.6 1.7 43.6Major abnormalities (33 pts) 22 (66.7% of 33 pts) 66.8 1.8 50.9P-value 0.01§ NS¶ NS¶ NS¶

†65 patients with asymmetrical uterine cavity on pre-UAE magnetic resonance imaging enrolled; ‡all 127 study patients enrolled. §c2 test,¶non-parametric Kruskal–Wallis’ test. NS, statistically non-significant; post-UAE ultrasound, ultrasound examination performed at the timeof post-UAE hysteroscopy; pts, patients.

Table 7 Comparison of three subgroups of patients (divided by post-UAE hysteroscopic evaluation) by histopathologicalresults of hysteroscopic biopsy

Evaluation of post-UAE

hysteroscopy

Morphologically

normal endometrium†

Necrosis and/or

hyalinization‡

Inflammatory

changes§

Presence of

embolizationparticles¶

Normal finding (51 pts) 50 (98.0% of 51 pts) 0 0 0Minor abnormalities (43 pts) 37 (86.0% of 43 pts) 14 (32.6% of 43 pts) 3 (7.0% of 43 pts) 0Major abnormalities (33 pts) 19 (57.6% of 33 pts) 31 (93.9% of 33 pts) 4 (12.1% of 33 pts) 6 (18.2% of 33 pts)P-value 0.001†† 0.001†† NS††,‡‡ 0.001††

†106 patients with morphologically normal (secretory or proliferative) endometrium enrolled; ‡45 patients with histological patterns of intrauterine regressive changes enrolled; §7 patients with histological patterns of intrauterine inflammatory changes enrolled; ¶6 patientswith embolization material verified from biopsy enrolled. ††c2 test; ‡‡Fisher’s test. NS, statistically non-significant; pts, patients.

M. Mara et al.




number and localization of myomas. However, thesafety concerns of UAE need to be divided intotwo categories depending on reproductive plans of the patient, if being compared to myomectomy orhysterectomy.18,19

In a group of patients without reproductive plans themain objective of UAE is to mitigate the symptoms,especially bleeding. The issue of shrinkage of myomasin these patients is secondary.20 Likewise, the impact of UAE on uterine cavity is unsubstantial in perimeno-pausal women and even amenorrhea (caused by theimpact on ovaries or the uterus) can be appreciated oreasily treated by hormonal therapy.

Patients wishing to conceive must be viewed from adifferent perspective, mainly because the ovarian orintrauterine effects of UAE may have grave conse-quences.21 While the risk of ovarian failure after UAE isquite low, especially in younger patients, the incidence

of intrauterine abnormalities associated with UAE issignificantly higher.5,6,8,22 Moreover, the gravity of somepost-embolization findings (intracavitary myoma pro-trusion, fistula between uterine cavity and intramuralmyoma, intrauterine synechiae) diagnosed by hyst-eroscopy makes successful pregnancy hardly imagin-able.4,6,7,9 It corresponds well with a high percentageof early pregnancy loss after UAE reported bysome authors.10–12 Similarly, published data regardinguneventful course of pregnancy in the second andthird trimesters and good perinatal outcome in patientsafter UAE suggest that if the uterine cavity is intact

(thus eliminating the cause of infertility or early abor-tion), vascular supply of the uterus and placental func-tions remain unaltered.12,23 However, other studies in asmall series of pregnant women point out the risks of preterm delivery, malpresentation, preeclampsia andplacenta previa more than at risk of abortion.24–26

In our previous study in 51 women with intramuralmyoma we reported a high percentage of abnormalhysteroscopic findings after successful, symptomati-cally efficient UAE.6 Some of these findings were highlyspecific or bizarre, which made the classification andevaluation of these findings difficult. For that reason wedecided to continue this work with the notion that

more experience will lead to better understanding,classification and assessment of the particular findings.The main goal of the present study conducted in asignificantly higher number of patients was to moreaccurately establish the prevalence of abnormal intrau-terine findings following UAE and to clarify if UAE, ina highly selected group of patients ineligible for surgi-cal treatment, can be safely recommended to patients

with reproductive plans. The secondary objective wasto determine if abnormal intrauterine findings can

be predicted preoperatively using standard imagingmethods.

The strength of the present work is that both UAEand hysteroscopy were performed in a single special-ized center using standardized technique and method-ology. However, our study has several limitations, suchas lack of pre-UAE hysteroscopy in the majority of thepatients, subjectivity of evaluation of hysteroscopy, andambiguous classification of myomas (and especially inlarger myomas) regarding uterine layers.

Our study confirmed the presence of severe intrau-terine pathologies in patients after UAE in more thanone-quarter of the women. The majority of these find-ings are unquestionably a consequence of rapid regres-sive changes in myomas after embolization (hyalinenecrosis in most of the cases) and with proximity of

necrotic tissue to the uterine cavity forming intrauter-ine protrusion (more often) or fistula. However, basedon our experience, even if UAE causes a large protru-sion of necrosis into the cavity, it seems to be a highlyselective procedure, focused on devitalization of myoma/s and leaving healthy tissues of the uteruswith a non-tumor vascularization intact. This applies atleast to so-called limited UAE, which was used in allpatients in our study.14

The question is whether UAE, given the high percent-age of intrauterine pathologies, can still be considered asafe alternative treatment for women with fertility

plans. The comparison of reproductive outcome of patients after UAE who underwent further surgicalre-intervention (transcervical or transabdominal myo-mectomy) with a control group might be theanswer. Nodata is available on this subject. Hysteroscopic findingsin patients after surgical re-intervention after UAE are,in our experience, satisfactory, giving patients a goodchance of a successful pregnancy, at least from the ana-tomic point of view. Some authors note that a propor-tion of these lesions may heal spontaneously in a longertime interval from UAE.27

Another important question is if post-UAE disorderof uterine cavity can be predicted. It seems logical that

the closer to the cavity the fibroid is before emboliza-tion, the higher the chance of abnormal post-procedureintrauterine findings. Our results show that womenwith post-UAE regressive changes had uterine cavitydescribed as asymmetrical on pre-UAE MRI morefrequently (28 of 45, 62.5%) than patients withoutnecrosis and/or hyalinization (37 of 82, 45.1%) butthe difference was not significant (P = 0.0652, c2 test).





Intrauterine regressive changes have also been foundin six patients with completely normal pre-UAE hyst-eroscopy (Table 2). Migration of the embolized fibroidsthrough the muscular layer of the uterine wall is aprobable explanation.4 Even though complete necrosisis a fairly common histological finding in myomasremoved after pregnancy by laparoscopy or laparo-tomy, it is interesting and difficult to explain whywe have never seen regressive changes similar topost-UAE findings in these patients on hysteroscopy.

Nevertheless it is evident that given the high preva-lence of severe intrauterine pathologies with potentialreproductive consequences, UAE cannot be recom-mended as a first-choice treatment for patients withintramural myomas. This recommendation appliesespecially to women who are planning pregnancysoon, women with a cavity compressed by myoma(greater chance of contact of necrosis with the cavity) or

patients eligible for standard myomectomy. For a smallgroup of women who are excluded from the above-listed groups, UAE remains an option. It is thereforenecessary to inform patients planning pregnancy of allthe possible risks and complications, and high prob-ability of need for surgical re-intervention.

Acknowledgments

The present study was supported by the Internal GrantAgency of the Ministry of Health Care of the CzechRepublic (NS 9798-4).

Disclosure

The authors report no conflicts of interest. The authorshave no relationships with the companies that mayhave a financial interest in the information contained inthe manuscript.

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