Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 1e2
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Editorial
Fertility outcomes after uterine artery occlusion in the management of women with symptomatic uterine fibroids In the last issue (Volume 51, Issue Number 3, Pages 331e335), Chang and colleagues published an excellent review article entitled Fertility and pregnancy outcomes after uterine artery occlusion with or without myomectomy, and concluded that conception and term pregnancy were possible after uterine artery occlusion (UAO) with and without myomectomy, but the evidence on whether the risk of abortion and preterm birth have been increasing simultaneously remains inconclusive [1]. The authors searched the MEDLINE biomedicine database, using uterine artery occlusion, myomectomy, and pregnancy as keywords, and found only a few articles (13 articles were found on the website: http://www.ncbi.nlm.nih.gov/pubmed?term¼uterine%20artery% 20occlusion%2C%20myomectomy%2C%20pregnancy) that focused on fertility and pregnancy outcomes after combined UAO and myomectomy procedures. The authors’ effort is worthy of encouragement, because the use of modern technology, including medical treatment, radiology-assisted therapy, and other less or minimally invasive procedures, has become much more popular for women with symptomatic uterine fibroids [2], based on the following considerations: these are very common diseases during the reproductive age; many women delay pregnancy, and wish to preserve their organs and remain sexually attractive [3,4]. However, there are some issues that need clarification. First, the nomenclature of UAO needs clarification, and UAO cannot include all the procedures. There are at least two distinct procedures for the blockage of the uterine in the management of uterine fibroidsdone is UAO and the other is uterine vessel occlusion [5]. The difference between UAO and uterine vessel occlusion is that the former is uterine artery blockage alone without simultaneous blockage of the uterine vessels and the anastomotic sites between the uterine vessels and the ovarian vessels, and the latter is UAO with simultaneous blockage of the uterine vessels and the anastomotic sites between the uterine vessels and the ovarian vessels [6,7]. In theory, the possibility of a negative impact on ovarian function is always a concern when using the uterine artery embolization procedure, and therefore, there is an argument about the deterioration of ovarian function after uterine artery embolization [6]. However, this negative impact on ovarian function may vary with the procedures, even though this procedure is called UAO. Kim et al [8] found that the use of uterine artery embolization in patients with anastomosis was associated with a greater risk of a significant increase in the follicular stimulating hormone (FSH) level than the use of uterine artery embolization in patients without anastomosis [8]. The former procedure is similar to the uterine vessel occlusion procedure and the latter is similar to the UAO procedure. It is reasonable to suppose that the two procedures
would have a different impact on the ovarian function and future fertility of patients who undergo them. In fact, a recent report studying the difference between the two proceduresdUAO and uterine vessel occlusiondin the management of symptomatic uterine myoma and assessing the effect on the FSH level of the application of the two different types of uterine vessel blockage in the management of women with fibroids showed that women treated with uterine vessel occlusion were associated with a greater risk of a significant increase in FSH levels during the 1st month after operation than those treated with UAO, which may be a reflection of diminished ovarian function [6]. In addition, the subsequent study [7] on the fertility outcome of these patients showed no statistical difference between the two groups, either in the item of pregnancy rate or in the item of successful delivery rate, with a 47% (n ¼ 8/17) pregnancy rate and a 41% (n ¼ 7/ 17) successful delivery rate in the uterine vessel occlusion group versus 66% (n ¼ 6/9) for both pregnancy and successful delivery rates in the UAO group. Second, although the authors tried their best to review all published articles and summarize the published data addressing the keywords uterine artery occlusion, myomectomy, and pregnancy, the omission of some data cannot be totally avoided. For example, one report showed that the overall pregnancy rate was 53.8% (14/ 26) and the overall live birth rate was 50% (13/26) [7] in those women with symptomatic uterine fibroids who were treated with a blockage of the uterine vessels. Based on these results, we believe that the basic differences in the procedures for the blockage of the uterine vessels in the management of women with symptomatic uterine fibroids might impair the consistency of the data presentation. A large prospective randomized study would be welcome in response to this uncertain issue. References [1] Chang KM, Chen MJ, Lee MH, Huang YD, Chen CS. Fertility and pregnancy outcomes after uterine artery occlusion with or without myomectomy. Taiwan J Obstet Gynecol 2012;51:331e5. [2] Su WH, Lee WL, Cheng MH, Yen MS, Chao KC, Wang PH. Typical and atypical clinical presentation of uterine myomas. J Chin Med Assoc 2012;75: 487e93. [3] Huang BS, Seow KM, Tsui KH, Huang CY, Lu YF, Wang PH. Fertility outcome of infertile women with adenomyosis treated with the combination of a conservative microsurgical technique and GnRH agonist: long-term follow-up in a series of nine patients. Taiwan J Obstet Gynecol 2012;51:212e6. [4] Horng HC, Wen KC, Su WH, Chen CS, Wang PH. Review of myomectomy. Taiwan J Obstet Gynecol 2012;51:7e11. [5] Wang KC, Chang WH, Liu WM, Yen YK, Huang N, Wang PH. Short-term advantages of laparoscopic uterine vessel occlusion in the management of women with symptomatic myoma. Taiwan J Obstet Gynecol 2012;51:539e44.
http://dx.doi.org/10.1016/j.tjog.2012.10.006 1028-4559/Copyright Ó 2014, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
2
Editorial / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 1e2
[6] Lee WL, Liu WM, Fuh JL, Tsai YC, Shih CC, Wang PH. Basal FSH level changes after different types of uterine vessel occlusion in the management of uterine fibroids. Fertil Steril 2010;94:2286e90. [7] Lee WL, Liu WM, Fuh JL, Tsai YC, Shih CC, Wang PH. Use of uterine vessel occlusion in the management of uterine myomas: two different approaches. Fertil Steril 2010;94:1875e81. [8] Kim HS, Tsai J, Lee JM, Vang R, Griffith JG, Wallach EE. Effects of utero-ovarian anastomoses on basal follicle-stimulating hormone level change after uterine artery embolization with tris-acryl gelatin microspheres. J Vasc Interv Radiol 2006;17:965e71.
Hsiang-Tai Chao Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Peng-Hui Wang* Department of Obstetrics and Gynecology and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University Hospital, Ilan, Taiwan Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan Department of Medical Research, China Medical University Hospital, Taichung, Taiwan * Corresponding
author. Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei Veterans General Hospital, Taipei, Taiwan. E-mail addresses: [email protected], [email protected] (P.-H. Wang).
Contents lists available at ScienceDirect
Taiwanese Journal of Obstetrics & Gynecology journal homepage: www.tjog-online.com
Editorial
Fertility outcomes after uterine artery occlusion in the management of women with symptomatic uterine fibroids In the last issue (Volume 51, Issue Number 3, Pages 331e335), Chang and colleagues published an excellent review article entitled Fertility and pregnancy outcomes after uterine artery occlusion with or without myomectomy, and concluded that conception and term pregnancy were possible after uterine artery occlusion (UAO) with and without myomectomy, but the evidence on whether the risk of abortion and preterm birth have been increasing simultaneously remains inconclusive [1]. The authors searched the MEDLINE biomedicine database, using uterine artery occlusion, myomectomy, and pregnancy as keywords, and found only a few articles (13 articles were found on the website: http://www.ncbi.nlm.nih.gov/pubmed?term¼uterine%20artery% 20occlusion%2C%20myomectomy%2C%20pregnancy) that focused on fertility and pregnancy outcomes after combined UAO and myomectomy procedures. The authors’ effort is worthy of encouragement, because the use of modern technology, including medical treatment, radiology-assisted therapy, and other less or minimally invasive procedures, has become much more popular for women with symptomatic uterine fibroids [2], based on the following considerations: these are very common diseases during the reproductive age; many women delay pregnancy, and wish to preserve their organs and remain sexually attractive [3,4]. However, there are some issues that need clarification. First, the nomenclature of UAO needs clarification, and UAO cannot include all the procedures. There are at least two distinct procedures for the blockage of the uterine in the management of uterine fibroidsdone is UAO and the other is uterine vessel occlusion [5]. The difference between UAO and uterine vessel occlusion is that the former is uterine artery blockage alone without simultaneous blockage of the uterine vessels and the anastomotic sites between the uterine vessels and the ovarian vessels, and the latter is UAO with simultaneous blockage of the uterine vessels and the anastomotic sites between the uterine vessels and the ovarian vessels [6,7]. In theory, the possibility of a negative impact on ovarian function is always a concern when using the uterine artery embolization procedure, and therefore, there is an argument about the deterioration of ovarian function after uterine artery embolization [6]. However, this negative impact on ovarian function may vary with the procedures, even though this procedure is called UAO. Kim et al [8] found that the use of uterine artery embolization in patients with anastomosis was associated with a greater risk of a significant increase in the follicular stimulating hormone (FSH) level than the use of uterine artery embolization in patients without anastomosis [8]. The former procedure is similar to the uterine vessel occlusion procedure and the latter is similar to the UAO procedure. It is reasonable to suppose that the two procedures
would have a different impact on the ovarian function and future fertility of patients who undergo them. In fact, a recent report studying the difference between the two proceduresdUAO and uterine vessel occlusiondin the management of symptomatic uterine myoma and assessing the effect on the FSH level of the application of the two different types of uterine vessel blockage in the management of women with fibroids showed that women treated with uterine vessel occlusion were associated with a greater risk of a significant increase in FSH levels during the 1st month after operation than those treated with UAO, which may be a reflection of diminished ovarian function [6]. In addition, the subsequent study [7] on the fertility outcome of these patients showed no statistical difference between the two groups, either in the item of pregnancy rate or in the item of successful delivery rate, with a 47% (n ¼ 8/17) pregnancy rate and a 41% (n ¼ 7/ 17) successful delivery rate in the uterine vessel occlusion group versus 66% (n ¼ 6/9) for both pregnancy and successful delivery rates in the UAO group. Second, although the authors tried their best to review all published articles and summarize the published data addressing the keywords uterine artery occlusion, myomectomy, and pregnancy, the omission of some data cannot be totally avoided. For example, one report showed that the overall pregnancy rate was 53.8% (14/ 26) and the overall live birth rate was 50% (13/26) [7] in those women with symptomatic uterine fibroids who were treated with a blockage of the uterine vessels. Based on these results, we believe that the basic differences in the procedures for the blockage of the uterine vessels in the management of women with symptomatic uterine fibroids might impair the consistency of the data presentation. A large prospective randomized study would be welcome in response to this uncertain issue. References [1] Chang KM, Chen MJ, Lee MH, Huang YD, Chen CS. Fertility and pregnancy outcomes after uterine artery occlusion with or without myomectomy. Taiwan J Obstet Gynecol 2012;51:331e5. [2] Su WH, Lee WL, Cheng MH, Yen MS, Chao KC, Wang PH. Typical and atypical clinical presentation of uterine myomas. J Chin Med Assoc 2012;75: 487e93. [3] Huang BS, Seow KM, Tsui KH, Huang CY, Lu YF, Wang PH. Fertility outcome of infertile women with adenomyosis treated with the combination of a conservative microsurgical technique and GnRH agonist: long-term follow-up in a series of nine patients. Taiwan J Obstet Gynecol 2012;51:212e6. [4] Horng HC, Wen KC, Su WH, Chen CS, Wang PH. Review of myomectomy. Taiwan J Obstet Gynecol 2012;51:7e11. [5] Wang KC, Chang WH, Liu WM, Yen YK, Huang N, Wang PH. Short-term advantages of laparoscopic uterine vessel occlusion in the management of women with symptomatic myoma. Taiwan J Obstet Gynecol 2012;51:539e44.
http://dx.doi.org/10.1016/j.tjog.2012.10.006 1028-4559/Copyright Ó 2014, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
2
Editorial / Taiwanese Journal of Obstetrics & Gynecology 53 (2014) 1e2
[6] Lee WL, Liu WM, Fuh JL, Tsai YC, Shih CC, Wang PH. Basal FSH level changes after different types of uterine vessel occlusion in the management of uterine fibroids. Fertil Steril 2010;94:2286e90. [7] Lee WL, Liu WM, Fuh JL, Tsai YC, Shih CC, Wang PH. Use of uterine vessel occlusion in the management of uterine myomas: two different approaches. Fertil Steril 2010;94:1875e81. [8] Kim HS, Tsai J, Lee JM, Vang R, Griffith JG, Wallach EE. Effects of utero-ovarian anastomoses on basal follicle-stimulating hormone level change after uterine artery embolization with tris-acryl gelatin microspheres. J Vasc Interv Radiol 2006;17:965e71.
Hsiang-Tai Chao Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Peng-Hui Wang* Department of Obstetrics and Gynecology and Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan Department of Obstetrics and Gynecology, National Yang-Ming University Hospital, Ilan, Taiwan Immunology Center, Taipei Veterans General Hospital, Taipei, Taiwan Infection and Immunity Research Center, National Yang-Ming University, Taipei, Taiwan Department of Medical Research, China Medical University Hospital, Taichung, Taiwan * Corresponding
author. Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei Veterans General Hospital, Taipei, Taiwan. E-mail addresses: [email protected], [email protected] (P.-H. Wang).
