Ovarian fibroid

Any consideration of major issues relating to the balance of benefit and harm, such as cancer or mortality rates, should be supplemented by a consideration of less prominent ones, for example, a reduction in disorders of the menstrual cycle (such as dysmenorrhea, menorrhagia, and the premenstrual syndrome) and the reduced risks of iron deficiency anemia, functional ovarian cysts, uterine fibroids, benign breast disease, pelvic inflammatory disease, and ectopic pregnancy (10,11). 

Case (v) A 35-year-old female had primary infertility with secondary amenorrhea, ceasation of ovarian function and uterine fibroid tumour on the posterior wall at the junction of upper one-third and lower two-third of the uterus. Symptoms Amenorrhea for the last two years, obase, sweaty palms and soles, craving for eggs, irregular menstruation earlier. 

Q4 Excessive bleeding during the menstrual period is called menorrhagia. The blood loss reduces levels of iron in the body and may result in iron-deficiency anaemia. The causes of excessive bleeding could be inflammation, fibroids, endometriosis, cervical polyps, adenomyosis, ovarian tumours, intrauterine devices (IUDs), inherited clotting disorders, endocrine dysfunction, such as thyroid dysfunction, or mental stress. In terms of drug therapy, oral ferrous... 

Chrisman HB, Saker MB, Ryu RK, et al. (2000) The impact of uterine fibroid embolization on resumption of menses and ovarian function. J Vase Interv Radiol 11 699-703... 

Razavi MK, Wolanske KA, Hwang GL, Sze DY, Kee ST, Dake MD (2002) Angiographic classification of ovarian artery-to-uterine artery anastomoses initial observations in uterine fibroid embolization. Radiology 224 707-712... 

Ahmad A, Qadan L et al (2002) Uterine artery embolization treatment of uterine fibroids effect on ovarian function in younger women. J Vase Interv Radiol 13 1017-20... 

Nikolic B, Spies JB et al (1999) Ovarian artery supply of uterine fibroids as a cause of treatment failure after uterine artery embolization a case report. J Vase Interv Radiol 10 1167-1170... 

Tropeano G, di Stasi C et al (2004) Uterine artery embolization for fibroids does not have adverse effects on ovarian reserve in regularly cycling women younger than 40 years. Fertil Steril 81 1055-1061... 

The anatomy of uterine fibroids and uterine artery embolization (UAE) consists of the fibroids, their position in the uterus, and the vasculature associated with the uterus. The vasculature of the ovarian arteries is also important because of the potential for collateral blood flow from the ovarian arteries supplying the fibroids. Communication between the uterine arteries and the ovarian arteries are also important because of the risk of embolization of the ovaries through uterine-ovarian anastomoses. 

Intramural fibroids are the most common type of fibroids. Their blood supply comes from one or more nutrient arteries. As the fibroid increases in size, the nutrient artery, and the arcuate artery enlarge [4]. Submucosal fibroids also obtain their blood supply from the nutrient arteries. However, with subserosal fibroids, the fibroid may adhere to other structures, and derive blood supply from those adjacent structures [4], including the ovarian arteries. 

Communications between the ovarian artery and the uterine artery has two potential adverse outcomes, it may allow continued blood supply to the fibroid, leading to failure of the procedure, and alternatively it can lead to permanent ovarian failure following embolization. Because of these potential problems, there has been considerable interest in how best to evaluate the ovarian arteries. Flush arteriography has been an approach to evaluating the ovarian arteries to determine if there is enlargement of the ovarian artery and supply to the fibroid [23]. In one study [23] of 294 aortograms, 75 ovarian... 

CiciNELLi et al. [5] described an interesting pattern of collateral flow between the uterine and ovarian arterial supply to the uterus. In doing measurements of blood flow in premenopausal women, this group found there is more blood flow to the uterus from the ovarian artery during the follicular phase, whereas in the luteal phase most of the uterus is supplied from the uterine artery. Whether this change in blood flow patterns is changed in patients with fibroids is not clear. No studies of the effect of the phase of the menstrual cycle on the effectiveness of uterine artery embolization have been performed at this point. 

My technique for embolization of uterine fibroids starts with placing a flush catheter that allows a contralateral approach (VCF or Omni Flush catheter) into the aorta and positioning it just below the level of the renal arteries. The image intensifier is centered over the pelvis and a angiogram is performed which allows for visualization of ovarian artery collaterals, and provides visualization of the iliac anatomy (Fig. 10.3.6a). The flush catheter is then positioned... 

Fig. 10.3.9. a Right ovarian artery supplying fibroid, b Post embolization, stasis in ovarian artery and no supply to fibroid... 

Hascalik S, Celik O, Sarac K, Hascalik M (2004) Transient ovarian failure a rare complication of uterine fibroid embolization. Acta Obstet Gynecol Scand 83 682-685... 

Pelage JP, Walker WJ, Le Dref 0, Rymer R (2003) Ovarian artery angiographic appearance, embolization and relevance to uterine fibroid embolization. Cardiovasc Intervent Radiol 26 227-233... 

Binkert CA, Andrews RT, Kaufman JA (2001) Utility of non-selective abdominal aortography in demonstrating ovarian artery collaterals in patients undergoing uterine artery embolization for fibroids. J Vase Interv Radiol 12 841-845... 

Another measure of outcome is the effectiveness of UFE in avoiding other treatments for fibroids, as measured by subsequent medical therapies or additional surgery. For example, hysterectomy or additional hysteroscopic resection or myomectomy for clinical failure or recurrence after UFE is an important measure of safety and a key outcome measure of UFE [2]. Spies et al. [9] reported nine (4.5%) hysterectomies out of 200 patients within 12 months of therapy. Seven of the patients underwent hysterectomy for clinical failure after UFE. The other two patients underwent incidental hysterectomy for treatment of a tubo-ovarian abscess and an adnexal mass. In a series of 400 women. Walker and Pelage [7] reported 23... 

There are some important anatomic variations associated with failure. These include tortuous artery, small uterine artery in one or both sides, absence of uterine arteries, ovarian artery supply of the fibroids and other less common variants such as a round ligament artery supply [7]. 

The role of ovarian arteries as a cause of failure is well known. Ovarian arteries may feed the fibroids through different pathways. The visualization of an ovarian artery is not systematically associated with failure. In one study, 25% of patients had large ovarian arteries before embolization [8]. Only arteries that directly participate in feeding the uterus cause failure. In cases of a small uterine artery or absence of one or both arteries, the ovarian artery supply should be suspected (Fig. 10.5.3). However, additional supply to the fibroids may come from the ovarian arteries, even if large sized bilateral uterine arteries are present [9, 10]. 

Fig. 10.5.3a-e. A 37-year-old patient with symptomatic fibroids. She was offered a hysterectomy as the only alternative. a,b Left uterine artery catheterization and embolization. The final angiogram at the termination of the embolization demonstrates the left ovarian artery (b). c Right internal iliac angiogram shows the absence of righf ufer-ine artery, d Catheterization of fhe righf ovarian arfery demonstrafes the supply to the uterus by this artery, e Distal catheterization and embolization of fhe ovarian arfery wifh successftil clinical oufcome... 

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