Fertility-Sparing Option for Symptomatic Fibroids
38-year-old woman has heavy menstrual bleeding and pelvic pressure for 2 years. Hemoglobin is 9.4 g/dL despite oral iron. She has no prior pregnancy and wants to conceive within the next 2 years. Pelvic ultrasound shows three intramural fibroids, the largest 7 cm, with a normal endometrial cavity on saline infusion sonography; ovaries are normal. She has no history of surgery, and her PAP and endometrial sampling are normal. She asks about uterine artery embolization because a friend had it and avoided surgery. The gynecologist is recommending laparoscopic myomectomy but wants interventional radiology input. MRI is available before any procedure. The patient is otherwise healthy, takes no hormonal therapy, and has no contraindication to contrast.
1. How would you counsel her about UAE versus myomectomy for symptom control and fertility?
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UAE and myomectomy both improve bleeding and bulk symptoms, but the evidence for fertility after UAE is less robust than after myomectomy. Myomectomy may be preferred when future pregnancy is a priority, especially with a 7-cm intramural fibroid and a normal cavity, but it is not the only option. UAE is less invasive and has a shorter recovery, and many women conceive afterward; however, it is not a fertility treatment and carries risks of ovarian reserve decline, miscarriage, and placental complications. I would present both in a shared decision, recommend MRI for mapping, and involve reproductive endocrinology if she wants to optimize fertility.
2. What is the role of MRI before UAE, and what findings would change your recommendation?
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MRI maps the number, size, and location of fibroids and identifies adenomyosis, which can affect outcomes. A pedunculated subserosal fibroid with a narrow stalk is a relative contraindication to UAE because of risk of detachment and peritoneal bleeding. A submucosal fibroid that distorts the cavity might be better treated hysteroscopically, especially with fertility goals. If MRI shows significant adenomyosis or ovarian arterial supply to the fibroids, I would adjust counseling. MRI does not replace clinical judgment, but it changes the procedural plan.
3. If she chooses UAE, describe key technical and postprocedure considerations.
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For UAE, catheterize both uterine arteries and embolize until stasis, using calibrated microspheres or gelatin sponge; avoid non-target embolization. Provide aggressive pain control, antiemetics, and hydration; most patients have postembolization syndrome. Antibiotics are not routinely required. Document radiation dose and use pulsed fluoroscopy. Follow up for infection, fibroid expulsion, and symptom response. If she later conceives, counsel about high-risk obstetric surveillance.