Fibroids and adenomyosis: the impact on reproductive outcomes and novel treatment options

Abstract

Introduction The symptoms of fibroids and adenomyosis can be severe and have significant impact on patients’ quality of life. Patients seek effective, minimally invasive treatments with the quickest recovery times which will cause the least disruption to their lives. This desire has driven the introduction of alternative treatments to the traditional myomectomy and hysterectomy. Importantly, many of these women wish to keep open the option of future fertility or to conserve their uterus. Many will ask if the fibroids or adenomyosis are impacting on their fertility and whilst it is established that submucosal fibroids can impact negatively on pregnancy, the effect of other fibroids is yet to be fully determined. The aims of this thesis are to explore: • whether the presence of fibroids and adenomyosis impact fertility outcomes in a cohort of patients suffering with recurrent miscarriage • through systematic review, the effectiveness, as measured by uterine and fibroid volume change, of three uterine sparing treatments, uterine artery embolization (UAE), high intensity focussed ultrasound (FUS) and radiofrequency ablation (RFA) • the effectiveness of magnetic resonance guided focussed ultrasound (MRgFUS) in the treatment of fibroids and if the introduction of strict patient selection criteria improves outcomes • whether radiofrequency ablation, a novel treatment for fibroids is clinically effective and describe the outcomes of the first UK cohort to have this treatment • whether radiofrequency ablation of uterine fibroids is a fertility-sparing treatment Results In a cohort of 429 patients with a history of recurrent miscarriage, neither small fibroids, less than 3cm, or adenomyosis increase the risk of miscarriage in the first trimester. First trimester miscarriage rates in those with fibroids was 5.9-7.4% and 7.2-7.8% in those without fibroids (p=1.000). UAE, FUS and RFA all result in a reduction in fibroid volumes with pooled fibroid volume reductions of 54%, 32% and 70% respectively at 6 months follow up. The introduction of strict selection criteria to choose patients suitable for treatment for MRgFUS improved non-perfused volumes from 44.0% to 59.4% (p=0.000). Treatment of fibroids with radiofrequency ablation, in a cohort of 24 patients, did show statistically significant improvements in symptom severity scores (baseline 64.0 ± 21.5, 6 months 37.5 ± 13.9, p=0.000) and quality of life scores (baseline 37.5 ± 13.9, 6 months 65.7 ± 20.8, p=0.001) compared to baseline, at 6 months follow up. However, rates of request for surgical re-intervention are high at 20.8% at 1 year follow up. Age greater than 45 years, GnRH analogue use and a primary symptom of heavy menstrual bleeding were associated with better outcomes. Greater fibroid volume reductions following treatment with radiofrequency ablation were associated with lower re-intervention rates. Radiofrequency ablation would appear to be safe for future fertility with no impact of ovarian reserve and no evidence of post treatment adhesiogenesis in the uterine cavity. Discussion There is a need for minimally invasive fertility sparing treatments for patients with fibroids and adenomyosis, for symptom control, even if the disease does not negatively impact on their fertility. MRgFUS is really only effective in the peri-menopausal woman. Whilst radiofrequency ablation appears to be effective and fertility sparing, re-intervention rates in this cohort were high and, like MRgFUS, further study may confirm that only a select few patients will see benefit from treatment.